236983 Chronic Disease Management Program. Does It Improve Health Outcomes? Preliminary Results

Wednesday, November 2, 2011: 10:30 AM

Roger Zoorob, MD, MPH , Department of Family and Community Medicine, Meharry Medical College, Nashville, TN
Medhat Kalliny, MD, PhD , Department of Family Medicine and Community Medicine, Meharry Medical College, Nashville, TN
Mohammad Sidani, MD, MS , Department of Family Medicine and Community Medicine, Meharry Medical College, Nashville, TN
Kristy Durkin, MSW , Department of Family Medicine and Community Medicine, Meharry Medical College, Nashville, TN
Sylvie Akohoue, PhD , Family and Community Medicine, Meharry Medical College, Nashville, TN
Robert S. Levine, MD , Department of Family and Community Medicine, Meharry Medical College, Nashville, TN
BACKGROUND & PURPOSE: Chronic illness especially cardio-metabolic diseases have had a profound effect on both utilization and cost of health-care. More than 75% of the nation's health-care resources are consumed by chronic disease. A multidisciplinary chronic disease management program is currently being implemented at the Meharry Medical College Family and Community Medicine centers for the management of cardiac and metabolic diseases. The main purpose of this study is evaluation of the effectiveness of this chronic disease care model on health outcomes in patients with cardio-metabolic chronic diseases in an academic setting. DESIGN & METHODS: Patients with chronic cardiac and metabolic diseases have received standardized evidence-based medical care from a physician-led team in a Family Medicine Residency based clinic. The team includes a Family Medicine physician, a nurse practitioner, a social worker, and a nutritionist. The implemented chronic care model is a multidisciplinary system that involves case management, multidisciplinary care, nutritional counseling, life style modification, behavioral intervention and self management. Among many other health outcome measures, baseline levels of low density lipoproteins (LDL), high density lipoproteins (HDL), body mass index (BMI), blood pressure (BP) and hemoglobin A1C (HbA1c) have been collected at the time of enrollment into the program. These outcomes have been assessed at three, six and nine month post-enrollment and compared to the pre-enrollment baseline levels. RESULTS: Up to date, about two hundred patients with chronic cardiac and metabolic diseases are enrolled into Meharry Family Medicine Chronic Disease Management Program. Preliminary analysis of data shows that there are significant differences between pre-enrollment baseline levels of HbA1C, body weight, and LDL and those measured at 6-9 month post-enrollment (p< 0.0001, 0.05, and 0.01; respectively). The pre-enrollment mean and standard deviation were 8.1% + 2.2, 223.3 lb + 57.7 and 108.0 mg/dL + 42.5 for HbA1C, body weight, and LDL; respectively. However, the 6-9 post-enrollment mean and standard deviation were 7.1% + 1.9, 211.7 lb + 46.1 and 95.8 mg/dL + 331.1 for HbA1C, body weight, and LDL; respectively. CONCLUSION: Implementing chronic disease management care model in primary care setting improves health outcomes in patients with cardiac and metabolic diseases. Our goal is to expand this program to recruit more patients, and evaluate other health outcome measures. It is our goal also to imply this model of care to patients with other chronic diseases such as asthma and COPD. Research supported by Health Resources and Service Administration (HRSA) Grant # D54MP05469.

Learning Areas:
Chronic disease management and prevention
Clinical medicine applied in public health
Implementation of health education strategies, interventions and programs
Provision of health care to the public

Learning Objectives:
This study evaluates the effectiveness of a chronic disease management program. The specific aims of this study are: 1. Establish baseline pre-intervention values based on traditional care. 2. Implement a chronic care management model for care of cardio-metabolic disease 3. Perform a quality assessment evaluation to determine the effectiveness of chronic care model in a primary care indigent practice

Keywords: Chronic Diseases, Managed Care

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am a tenured professor and oversee programs such as chronic disease management and prevention, outreach programs, health disparities research programs.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.

See more of: Chronic Diseases Research
See more of: Medical Care