Implementation of a Population Health Chronic Disease Management Program

Hypertension Clinical Trial

Official title:

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

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT02812303
• Other study ID #: 2009P002079
• Status: Completed
• Phase: N/A
• First received: June 20, 2016
• Last updated: June 21, 2016
• Start date: July 2014
• Est. completion date: December 2014

Study information

• Verified date: June 2016
• Source: Massachusetts General Hospital
• Contact: n/a
• Is FDA regulated: No
• Health authority: United States: Institutional Review Board
• Study type: Observational

Clinical Trial 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.

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.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 108000
• Est. completion date: December 2014
• Est. primary completion date: December 2014
• Accepts healthy volunteers: No
• Gender: Both
• Age group: 18 Years and older

Eligibility

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 Design

Observational Model: Cohort, Time Perspective: Prospective

Related Conditions & MeSH terms

• Cardiovascular Diseases
• Chronic Disease
• Diabetes Mellitus
• Hypertension

Intervention

Other:
• Centralized support for population health management activities

Locations

Country	Name	City	State
United States	Massachusetts General Hospital	Boston	Massachusetts

Sponsors (1)

Lead Sponsor	Collaborator
Massachusetts General Hospital

Country where clinical trial is conducted

United States, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	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	No
Primary	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	No
Primary	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	No
Secondary	Difference in differences in proportion of patients completing breast cancer screening over the follow-up period comparing PHC and non-PHC practices		6 months	No
Secondary	Difference in differences in proportion of patients completing cervical cancer screening over the follow-up period comparing PHC and non-PHC practices		6 months	No
Secondary	Difference in differences in proportion of patients completing colorectal cancer screening over the follow-up period comparing PHC and non-PHC practices		6 months	No