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Implementation of a Population Health Chronic Disease Management Program

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ClinicalTrials.gov Identifier: NCT02812303
Recruitment Status : Completed
First Posted : June 24, 2016
Last Update Posted : June 24, 2016
Sponsor:
Information provided by (Responsible Party):
Steven Atlas, Massachusetts General Hospital

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.

Condition or disease Intervention/treatment
Diabetes Mellitus Cardiovascular Diseases Hypertension 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.

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Study Type : Observational
Actual Enrollment : 108000 participants
Observational Model: Cohort
Time Perspective: Prospective
Official Title: Implementation of a Population Health Chronic Disease Management Program in a Primary Care Network
Study Start Date : July 2014
Actual Primary Completion Date : December 2014
Actual Study Completion Date : December 2014

Resource links provided by the National Library of Medicine


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.



Primary Outcome Measures :
  1. Difference in differences in Low density lipoprotein (LDL) goal achievement over the follow-up period comparing PHC to non-PHC practices [ Time Frame: 6 months ]
    Among patients with diabetes and cardiovascular disease

  2. Difference in differences in Hemoglobin A1c (HbA1c) goal achievement over the follow-up period comparing PHC and non-PHC practices [ Time Frame: 6 months ]
    Among patients with diabetes

  3. Difference in differences in Blood pressure (BP) goal achievement over the follow-up period comparing PHC and non-PHC practices [ Time Frame: 6 months ]
    Among patients with diabetes and hypertension


Secondary Outcome Measures :
  1. Difference in differences in proportion of patients completing breast cancer screening over the follow-up period comparing PHC and non-PHC practices [ Time Frame: 6 months ]
  2. Difference in differences in proportion of patients completing cervical cancer screening over the follow-up period comparing PHC and non-PHC practices [ Time Frame: 6 months ]
  3. Difference in differences in proportion of patients completing colorectal cancer screening over the follow-up period comparing PHC and non-PHC practices [ Time Frame: 6 months ]


Information from the National Library of Medicine

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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
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.
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

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT02812303


Locations
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United States, Massachusetts
Massachusetts General Hospital
Boston, Massachusetts, United States, 02114
Sponsors and Collaborators
Massachusetts General Hospital
Investigators
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Principal Investigator: Steven J Atlas, MD, MPH Massachusetts General Hospital
Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):
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Responsible Party: Steven Atlas, Assistant Professor, Massachusetts General Hospital
ClinicalTrials.gov Identifier: NCT02812303    
Other Study ID Numbers: 2009P002079
First Posted: June 24, 2016    Key Record Dates
Last Update Posted: June 24, 2016
Last Verified: June 2016
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: No
Additional relevant MeSH terms:
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Cardiovascular Diseases
Chronic Disease
Disease Attributes
Pathologic Processes