Appendix E. Selected Findings From Research on the Chronic Care Model
Asthma Health Disparities Collaborative Coalition Guide
This appendix presents highlights from the scientific literature on each of the six components of the Chronic Care Model, as well as on the Chronic Care Model overall. The information presented here is not meant to be a comprehensive review of the literature but rather to illustrate various health system changes and their related impact or outcomes.
Chronic Care Model
Tsai and colleagues completed a meta-analysis of interventions to improve care for chronic illnesses. This analysis was to determine whether interventions that incorporate at least one element of the Chronic Care Model result in improved outcomes for specific chronic illnesses and if any elements were essential for improved outcomes. The meta-analysis on 112 studies revealed that interventions with at least one element of the model had consistently beneficial effects on clinical outcomes and processes of care across all conditions studied. The effects on quality of life were mixed, with only the congestive heart failure and depression studies showing benefit.
Source: Tsai AC, Morton SC, Mangione CM, Keeler EB. A meta-analysis of interventions to improve care for chronic illnesses. Am J Manag Care 2005 Aug;11(8):478-88.
Wagner and colleagues analyzed descriptive and pre-post data from 23 health care organizations participating in the 13-month (August 1998-September 1999) diabetes collaborative. Both chart review and self-report data on care processes and clinical outcomes suggested improvements were based on health system changes made during the collaborative. Many of the organizations with the greatest improvements were community health centers, which had the fewest resources and the most challenged populations.
Source: Wagner EH, Glasgow RE, Davis C, et al. Quality improvement in chronic illness care: a collaborative approach. Seattle, WA: MacColl Institute for Healthcare Innovation. Accessed at http://www.improvingchroniccare.org on December 12, 2006.
Health Care Organization
Although little research is currently available linking health care organization components to direct improvement in health outcomes, there is evidence that shows an indirect relationship. Evidence that implementation of the Chronic Care Model does result in improved quality of care and improved health outcomes has been noted elsewhere. The following are some examples of the indirect linkage.
Visible leadership support. Ovretveit and colleagues noted in their comprehensive review of research in quality collaboratives that health care systems would be unlikely to achieve quality improvement that would be significant or sustained in the absence of visible and real support from senior leaders. Some examples of senior leader support include visiting clinical sites, reviewing monthly reports, providing resources, and problem-solving for innovators. Eventually, the support of change in pursuit of better quality care should become part of the organization's culture.
Source: Ovretveit J, Bate P, Cleary P, et al. Quality collaboratives: lessons from research. Qual Saf Health Care 2002;11:345-51.
Provider incentives. A 2002 report from the National Health Care Purchasing Institute noted that provider incentives can be used effective to improve health care quality and delivery. A range of incentive models was examined. Although financial incentive models were the most well known, there were several nonfinancial models, especially those that leveraged the power of peer pressure. Organizations also combined several incentive models to create a stronger motivation force for health care improvement.
Source: Bailit Health Purchasing LLC. Provider Incentive Models for Improving Quality of Care. Washington, DC: National Health Care Purchasing Institute; March 2002.
Asthma action plan and other self-management strategies. Lieu and colleagues examined opportunities for intervention by identifying outpatient management practices associated with increased risk of hospitalization or emergency department (ED) visits among children under age 14 with asthma. Parents of children hospitalized during the study period were less likely than those with no hospitalization or ED visit to have a written asthma management plan and to report washing bed sheets in hot water at least twice a month. Children with hospitalization were also more likely to have a nebulizer.
Source: Lieu TA, Quesenberry CP Jr, Capra AM, et al. Outpatient management practices associated with reduced risk of pediatric asthma hospitalization and emergency department visits. Pediatrics 1997;100(3 Pt 1):334-41.
Asthma action plan. All asthma consensus statements recommend the use of a written action plan as a central part of asthma management, but a recent systematic review of randomized trials examined the independent effect of a written action plan in children and adolescents and compared the effect of different written action plans. Four trials involving 355 children were reviewed. Children using symptom-based action plans had lower risk of exacerbations which required an acute care visit. Children assigned to peak flow-based action plans reduced by a half day the number of symptomatic days per week.
Source: Bhogal S, Zemek R, Ducharme FM. Written action plans for asthma in children. Cochrane Database Syst Rev 2006 Jul 19;3:CD005306.
Self-management education. This Cochrane review of 36 trials was conducted to examine the strength of evidence to test whether health outcomes are influenced by education and self-management programs when coupled with regular health practitioner review. Self-management education reduced hospitalizations, emergency room visits, unscheduled visits to the doctor, days off work or school, and nocturnal asthma. Researchers concluded that education in asthma self-management which involves self-monitoring by either peak flow or symptoms, coupled with regular medical review and a written action plan, improves health outcomes for adults with asthma. Also, training programs that enable people to adjust their medication using a written action plan appear to be more effective than other forms of asthma self-management.
Source: Gibson PG, Powell H, Couglan J, et. al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev 2003;(1):CD001117.
Health coaching. This study tested the efficacy of coaching to reduce environmental tobacco smoke (ETS) exposure among Latino children with asthma. After asthma management education, families were randomly assigned to no additional service (control condition) or to coaching for ETS exposure reduction (experimental condition). Approximately 1½ hours of asthma management education was provided; experimental families also obtained seven coaching sessions (approximately 45 minutes each) to reduce ETS exposure. At 4 months post-coaching, parents in the coached group reported their children exposed to significantly fewer cigarettes than parents of control children. Reported prevalence of exposed children decreased to 52% for the coached families but only to 69% for controls.
Source: Hovell MF, Meltzer SB, Wahlgren DR, et. al. Asthma management and environmental tobacco smoke exposure reduction in Latino children: a controlled trial. Pediatrics 2002 Nov;110(5):946-56.
Delivery System Design
Physician education and nurse-led planned care. This study compared two interventions (peer-led physician education vs. nurse-led planned care plus peer leader education) across a 2-year period in real-world primary care practices. Results demonstrated that an organized approach to pediatric asthma care that includes the services of a nurse plus peer leader education (planned care intervention) can significantly reduce asthma symptom days by 12%, or an average of 13 days per year. According to parent reports, planned care subjects also had greater controller adherence compared with usual care subjects.
Source: Lozano P, Finkelstein JA, Carey V, et. al. A multisite randomized trial of the effectiveness of physician education and organizational change in chronic asthma care: health outcomes of the pediatric asthma care patient outcomes research team II study. Arch Pediatr Adolesc Med 2004;158:875-83.
Group visits. The group visit model is one possible solution to the limitations observed in the current primary care structure and to the demands of the growing chronic illness load. An electronic review of all group visit articles published from 1974 to 2004 was conducted via the PubMed® and MEDLINE® databases. Although the heterogeneity of the studies presented some limitations, there was sufficient data to support the effectiveness of group visits in improving patient and physician satisfaction, quality of care, quality of life, and in decreasing emergency department and specialist visits.
Source: Jaber R, Braksmajer A, Trilling JS. Group visits: a qualitative review of current research. J Am Board Fam Med 2006 May-Jun;19(3):276-90.
Clinician prompting. This randomized controlled trial examined whether clinician prompting regarding a child's symptom severity and guideline recommendations at the time of an office visit improved the delivery of preventive asthma care. Children were randomly assigned to a clinician-prompting group (single-page prompt) or a standard-care group (no prompt given). Children in the clinician-prompting group were more likely to have had preventive measures at the visit compared with children in the standard-care group. These measures included delivery of an action plan, discussions about asthma, and recommendations for an asthma followup visit.
Source: Halterman JS, Fisher S, Conn KM, et al. Improved preventive care for asthma: a randomized trial of clinician prompting in pediatric offices. Arch Pediatr Adolesc Med 2006 Oct;160(10):1018-25.
Referral to asthma specialist. Asthma-specialist care was compared to generalist care on the rate of relapse of asthma ED visits and hospitalizations as well as on asthma control. Subjects ages 6-59 with asthma presenting for acute ED care for asthma received either referral to an asthma specialist in the allergy department with comprehensive ongoing asthma care (experimental group) or continued outpatient management from generalist physicians (control group). Compared with the control group, the intervention group had a 75% reduction in the number of subjects with asthma awakenings per night, an almost 50% reduction in asthma ED relapses, and a greater use of inhaled corticosteroids and cromolyn.
Source: Zeiger RS, Heller S, Mellon MH, et al. Facilitated referral to asthma specialist reduces relapses in asthma emergency room visits. J Allergy Clin Immunol 1991 Jun; 87(6):1160-8.
Provider (resident) training. Researchers conducted a pre- and post-training survey of 41 intervention residents to assess residents' implementation of the Chronic Care Model. The change in implementation for intervention residents was compared with that of 77 primary care residents not receiving this training. Asthma-related ED use by patients cared for by intervention residents was compared with that of other asthma patients. At baseline, residents in both groups reported inconsistent application of key elements of the model. At post-test, intervention-group residents reported significantly greater increases in access to asthma guidelines, the proportion of patients receiving written asthma management plans, and residents' access to information on community asthma programs, than did comparison-group residents. The number of asthma-related ED visits dropped significantly among patients treated by intervention residents.
Source: Green J, Rogers VW, Yedidia MJ. The impact of implementing a chronic care residency training initiative on asthma outcomes. Acad Med 2007 Feb;82(2):161-7.
Clinical Information Systems
There is a shortage of published research linking this component to direct improvement in health outcomes and quality of care, but some evidence, as in the following example, shows an indirect relationship.
Bates and colleagues reported that an information system was useful for measuring care. In addition, it served as a useful tool for improving quality of care when used for decision support. Investigators reported significant benefits in reducing the unnecessary use of laboratory testing, quickly reporting abnormal test results to key providers, preventing and detecting adverse drug events, changing prescription patterns to reduce drug costs, and providing critical pathways to providers.
Source: Bates DW, Pappius E, Kuperman GJ, et al. Using information systems to measure and improve quality. Int J Med Inform. 1999 Feb-Mar;53(2-3):115-24 .
Community Resources and Policies
Community partnerships. This study evaluated the effectiveness of a school-based asthma case management approach with medically underserved inner city children. Fourteen elementary schools with high rates of asthma-related hospital use were randomized to either a nurse case-management intervention or a usual care condition. In intervention schools, nurse case managers conducted weekly group sessions incorporating the "Open Airways" curriculum, followed up on students' school absences, and coordinated students' asthma care. In usual-care schools, students received routine school nursing services. Students in the intervention schools had fewer school absences than their usual-care counterparts (4 vs. 8 days, respectively) and experienced significantly fewer ED visits and fewer hospital days.
Source: Levy M, Heffner B, Stewart T, Beeman G. The efficacy of asthma case management in an urban school district in reducing school absences and hospitalizations for asthma. J Sch Health 2006 Aug;76(6):320-4.
Lay workers. Use of community health workers to obtain health, social, and environmental information from Black inner city children with asthma was one component of a larger intervention study designed to reduce morbidity in this group. A subset of 140 school-aged children with asthma was recruited and enrolled in a program to receive home visits by health workers for the purposes of obtaining medical information and teaching basic asthma education to the families. Data gathered by the workers led researchers to conclude that appropriately recruited and trained lay workers were effective in obtaining useful medical information and providing basic asthma education in the home.
Source: Butz AM, Malveaux FJ, Eggleston P, et. al. Use of community health workers with inner-city children who have asthma. Clin Pediatr (Phila) 1994 Mar;33(3):135-41.