Implementation of a Population Health Chronic Disease Management Program

Implementation of a Population Health Chronic Disease Management Program in a Primary Care Network

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.

Study Overview

• Status: Completed
• Conditions: Cardiovascular Diseases; Hypertension; Diabetes Mellitus
• Intervention / Treatment: Other: Centralized support for population health management activities

Detailed Description

A pilot program was created by the network's primary care leadership team at Massachusetts General Hospital. They hired and allocated 4 population health coordinators (PHCs) as part of a pilot project to centralize population health management efforts to improve quality of care for chronic disease management. The network did not have sufficient resources to implement a PHC in all of the 18 network practices. So the program's team invited practice leaders to participate and the PHCs were allocated by program's leadership team based on a variety of factors including 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 (on campus or community based). 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. In this study, the investigators evaluated quality of care process and outcome measures over the first six months of the chronic disease management program. The investigators hypothesized that practices assigned a central PHC would have greater performance increases in quality measures compared to practices that were not assigned a PHC.

• Study Type: Observational
• Enrollment (Actual): 108000

Contacts and Locations

Study Locations

• United States
  • Massachusetts
    • Boston, Massachusetts, United States, 02114
      • Massachusetts General Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• 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.

Description

Inclusion Criteria:

• 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

Exclusion Criteria:

• 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

Study Plan

How is the study designed?

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
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.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
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 Outcome Measures

Outcome Measure	Time Frame
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

Collaborators and Investigators

• Sponsor: Massachusetts General Hospital

Publications and helpful links

General Publications

• 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.

Study record dates

Study Major Dates

• Study Start: July 1, 2014
• Primary Completion (Actual): December 1, 2014
• Study Completion (Actual): December 1, 2014

Study Registration Dates

• First Submitted: June 20, 2016
• First Submitted That Met QC Criteria: June 21, 2016
• First Posted (Estimate): June 24, 2016

Study Record Updates

• Last Update Posted (Estimate): June 24, 2016
• Last Update Submitted That Met QC Criteria: June 21, 2016
• Last Verified: June 1, 2016

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Pathologic Processes; Disease Attributes; Cardiovascular Diseases; Chronic Disease
• Other Study ID Numbers: 2009P002079

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO