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2011 HSR&D National Meeting Abstract

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2011 National Meeting

3068 — Organizational Interventions to Improve Chronic Illness Care: Utilization of Chronic Care Model Elements

Noel PH (VERDICT/South Texas Veterans Health Care System), Lawrence VA (VERDICT/South Texas Veterans Health Care System), Cornell JE (UT Health Science Center at San Antonio), Arar NH (VERDICT/South Texas Veterans Health Care System), Leykum LK (VERDICT/South Texas Veterans Health Care System), Mortensen EM (VERDICT/South Texas Veterans Health Care System), Pugh MJ (VERDICT/South Texas Veterans Health Care System), Bollinger MJ (VERDICT/South Texas Veterans Health Care System), Parchman ML (VERDICT/South Texas Veterans Health Care System)

Objectives:
According to the Chronic Care Model (CCM), six elements contribute to effective management of chronic illness. Three primarily target individuals (patient self-management, provider decision support, and community linkages). The other three [clinical information systems (CIS), delivery system redesign (DSR), organizational support and leadership (OSL)] fundamentally differ in that they explicitly seek to change organizational structures and processes. We performed a systematic review to characterize evidence regarding use of these organizational elements in controlled trials to improve quality of care or outcomes for chronic illness.

Methods:
Using a modification of the Cochrane Collaboration’s Effective Practice and Organization of Care (EPOC) search strategy, we performed disease-specific searches of MEDLINE 1989-2008. Inclusion criteria included: randomized or controlled clinical trials; published in English; conducted in developed countries; targeting: type 2 diabetes (DM), congestive heart failure (CHF), ischemic heart disease (IHD), chronic obstructive lung disease (COPD), or human immunodeficiency virus disease (HIV); and using intervention strategies employing any of the three CCM organizational elements (with or without strategies targeting individuals). Studies reporting patient/provider knowledge, satisfaction, or attitudes only were excluded. Two investigators independently screened potentially eligible titles and jointly abstracted eligible studies into an electronic database. We coded intervention strategies using a modification of EPOC’s taxonomy, which were then mapped onto the 6 CCM elements.

Results:
Of 27,342 publications, 142 studies were eligible: DM–66/8,126; CHF–40/2,559; IHD–20/5,113; COPD–13/1,979; HIV–3/1,988. The number of studies using the organizational elements was: DSR (25 alone/105 in combination), CIS (13/64), and OSL (2/17). Only 2 studies utilized all 3 organizational elements. The most frequently used combinations included patient self-management (PSM): PSM+DSR (31 studies) and PSM+CIS+DSR (19 studies). No studies utilized all 6 organizational and individual strategies.

Implications:
Among the 5 chronic illnesses targeted by our systematic review, controlled trials to improve quality of care or outcomes for DM tested organizational strategies most frequently. Although the CCM suggests that each of the six elements is necessary, but not sufficient, to provide effective chronic illness care, no studies utilized all six elements.

Impacts:
Recently published controlled trials test incomplete operationalizations of the CCM. Organizational interventions are underutilized.


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