Implementation of a Population Health Chronic Disease Management Program

NCT02812303 | Completed

• 1 other identifier: 2009P002079
• Study Type: observational
• Target: 108,000
• Locations: 1 country
• Sites: 1

Brief Summary

A pilot program was created by the network's primary care leadership team at Massachusetts General Hospital. A population health management program was implemented for chronic disease management. The investigators evaluated quality of care process and outcome measures over the first six months of the program and compared practices assigned a central population health coordinator to those not assigned this support.

Conditions

Diabetes Mellitus; Cardiovascular Diseases; Hypertension

Outcome Measures

Primary Outcomes (3)

• Difference in differences in Low density lipoprotein (LDL) goal achievement over the follow-up period comparing PHC to non-PHC practices

  Among patients with diabetes and cardiovascular disease

  6 months

• Difference in differences in Hemoglobin A1c (HbA1c) goal achievement over the follow-up period comparing PHC and non-PHC practices

  Among patients with diabetes

  6 months

• Difference in differences in Blood pressure (BP) goal achievement over the follow-up period comparing PHC and non-PHC practices

  Among patients with diabetes and hypertension

  6 months

Secondary Outcomes (3)

• Difference in differences in proportion of patients completing breast cancer screening over the follow-up period comparing PHC and non-PHC practices

  6 months

• Difference in differences in proportion of patients completing cervical cancer screening over the follow-up period comparing PHC and non-PHC practices

  6 months

• Difference in differences in proportion of patients completing colorectal cancer screening over the follow-up period comparing PHC and non-PHC practices

  6 months

Study Arms (2)

Population Health Coordinator Support

8 practices received the support of central population health coordinators (PHCs). PHCs utilized a population health management (PHM) information technology (IT) tool and performed administrative tasks including appointment scheduling, ordering overdue laboratory testing, chart reviews, and obtaining outside tests/labs. In addition, PHCs regularly met with physicians to review those patients who required clinical intervention to develop an action plan. The network did not have sufficient resources to implement a PHC in all of the 18 network practices. So PHCs were allocated by responses from the practice leader, baseline quality scores, size of the practice, nature of the practice (health center vs not), and location of the practice. These decisions were made in a way that sought to equitably distribute available PHC resources within the practice network as a way to get network buy-in and maximize the impact of the program, both for practices with and without PHCs.

Other: Centralized support for population health management activities

No Population Health Coordinator Support

Ten practices without PHC support were provided training on how to use the PHM IT tool. The staff in these practices remained primarily responsible for managing administrative tasks.

Interventions

Centralized support for population health management activities OTHER

Population Health Coordinator Support

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)
• Sampling Method: Non-Probability Sample

Study Population

Adult adult (age ≥ 18 years) patients who had at least one visit to a study practice within the prior 3 years at baseline or had a visit during the 6-month study evaluation period and were connected with a specific network physician or practice.

You may qualify if:

• Diabetes mellitus (type 1 or type 2), or cardiovascular disease (including coronary artery disease, peripheral vascular disease, and cerebrovascular disease), or hypertension
• Breast cancer: women 50-74 years of age
• Cervical cancer: women 21-64 years of age
• Colorectal cancer: men or women 52-75 years of age

You may not qualify if:

• Patients not connected with a specific network physician or practice
• Patients who switched between PHC and non-PHC practices during the follow-up period
• Breast: bilateral mastectomy
• Cervical: total hysterectomy Colorectal: total colectomy

Sponsors & Collaborators

• Massachusetts General Hospital: lead

Study Sites (1)

Massachusetts General Hospital

Boston, Massachusetts, 02114, United States

Location

Related Publications (1)

• James A, Berkowitz SA, Ashburner JM, Chang Y, Horn DM, O'Keefe SM, Atlas SJ. Impact of a Population Health Management Intervention on Disparities in Cardiovascular Disease Control. J Gen Intern Med. 2018 Apr;33(4):463-470. doi: 10.1007/s11606-017-4227-3. Epub 2018 Jan 8.

  PMID: 29313223 DERIVED

MeSH Terms

Conditions

Diabetes Mellitus; Cardiovascular Diseases; Hypertension

Condition Hierarchy (Ancestors)

Glucose Metabolism Disorders; Metabolic Diseases; Nutritional and Metabolic Diseases; Endocrine System Diseases; Vascular Diseases

Study Officials

• Steven J Atlas, MD, MPH

  Massachusetts General Hospital

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: observational
• Observational Model: COHORT
• Time Perspective: PROSPECTIVE
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Assistant Professor

Study Record Dates

• First Submitted: June 20, 2016
• First Posted: June 24, 2016
• Study Start: July 1, 2014
• Primary Completion: December 1, 2014
• Study Completion: December 1, 2014
• Last Updated: June 24, 2016

Record last verified: 2016-06

Data Sharing

• IPD Sharing: Will not share

Locations

US (1)