Clinical trial NCT02812303: Implementation of a Population Health Chronic Disease Management Program
Official title: Implementation of a Population Health Chronic Disease Management Program in a Primary Care Network
Study type: OBSERVATIONAL
Overall status: COMPLETED
Conditions: Diabetes Mellitus
Cardiovascular Diseases
Hypertension
Lead sponsor: Massachusetts General Hospital
Sponsor class: OTHER
First posted: 2016-06-24
Enrollment: 108000
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Observational model: COHORT
Time perspective: PROSPECTIVE
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.

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.

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.

Eligibility criteria: 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

Primary outcomes:
measure: Difference in differences in Low density lipoprotein (LDL) goal achievement over the follow-up period comparing PHC to non-PHC practices
timeFrame: 6 months
measure: Difference in differences in Hemoglobin A1c (HbA1c) goal achievement over the follow-up period comparing PHC and non-PHC practices
timeFrame: 6 months
measure: Difference in differences in Blood pressure (BP) goal achievement over the follow-up period comparing PHC and non-PHC practices
timeFrame: 6 months
Secondary outcomes:
measure: Difference in differences in proportion of patients completing breast cancer screening over the follow-up period comparing PHC and non-PHC practices
timeFrame: 6 months
measure: Difference in differences in proportion of patients completing cervical cancer screening over the follow-up period comparing PHC and non-PHC practices
timeFrame: 6 months
measure: Difference in differences in proportion of patients completing colorectal cancer screening over the follow-up period comparing PHC and non-PHC practices
timeFrame: 6 months
Other outcomes:
Locations:
city: Boston
country: United States
facility: Massachusetts General Hospital
state: Massachusetts
Study officials:
affiliation: Massachusetts General Hospital
name: Steven J Atlas, MD, MPH
role: PRINCIPAL_INVESTIGATOR
References:
citation: 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.