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Biomedical subjects

E H Wagner

Publications and source records attributed to E H Wagner.

At least 19 recordsLinked to original sources
PubMed2004

Improving the quality of health care for chronic conditions.

Chronic conditions are increasingly the primary concern of health care systems throughout the world. In response to this challenge, the World Health Organization has joined with the MacColl Institute for Healthcare Innovation to adapt the Chronic Care Model (CCM) from a global perspective. The resultant effort is the Innovative Care for Chronic Conditions (ICCC) framework which expands community and policy aspects of improving health care for chronic conditions and includes components at the micro (patient and family), meso (health care organisation and community), and macro (policy) levels. The framework provides a flexible but comprehensive base on which to build or redesign health systems in accordance with local resources and demands.

Chronic Disease↗
PubMed2001

Effect of improved glycemic control on health care costs and utilization.

CONTEXT: Because of the additional costs associated with improving diabetes management, there is interest in whether improved glycemic control leads to reductions in health care costs, and, if so, when such cost savings occur. OBJECTIVE: To determine whether sustained improvements in hemoglobin A(1c) (HbA(1c)) levels among diabetic patients are followed by reductions in health care utilization and costs. DESIGN AND SETTING: Historical cohort study conducted in 1992-1997 in a staff-model health maintenance organization (HMO) in western Washington State. PARTICIPANTS: All diabetic patients aged 18 years or older who were continuously enrolled between January 1992 and March 1996 and had HbA(1c) measured at least once per year in 1992-1994 (n = 4744). Patients whose HbA(1c) decreased 1% or more between 1992 and 1993 and sustained the decline through 1994 were considered to be improved (n = 732). All others were classified as unimproved (n = 4012). MAIN OUTCOME MEASURES: Total health care costs, percentage hospitalized, and number of primary care and specialty visits among the improved vs unimproved cohorts in 1992-1997. RESULTS: Diabetic patients whose HbA(1c) measurements improved were similar demographically to those whose levels did not improve but had higher baseline HbA(1c) measurements (10.0% vs 7.7%; P<.001). Mean total health care costs were $685 to $950 less each year in the improved cohort for 1994 (P =.09), 1995 (P =.003), 1996 (P =.002), and 1997 (P =.01). Cost savings in the improved cohort were statistically significant only among those with the highest baseline HbA(1c) levels (>/=10%) for these years but appeared to be unaffected by presence of complications at baseline. Beginning in the year following improvement (1994), utilization was consistently lower in the improved cohort, reaching statistical significance for primary care visits in 1994 (P =.001), 1995 (P<.001), 1996 (P =.005), and 1997 (P =.004) and for specialty visits in 1997 (P =.02). Differences in hospitalization rates were not statistically significant in any year. CONCLUSION: Our data suggest that a sustained reduction in HbA(1c) level among adult diabetic patients is associated with significant cost savings within 1 to 2 years of improvement.

Adult↗
PubMed2001

Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings.

BACKGROUND: Diabetes is a common chronic disease that is increasingly managed in primary care. Different systems have been proposed to manage diabetes care. OBJECTIVES: To assess the effects of different interventions, targeted at health professionals or the structure in which they deliver care, on the management of patients with diabetes in primary care, outpatient and community settings. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, the Cochrane Controlled Trials Register (Issue 4 1999), MEDLINE (1966-1999), EMBASE (1980-1999), Cinahl (1982-1999), and reference lists of articles. SELECTION CRITERIA: Randomised trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITS) analyses of professional, financial and organisational strategies aimed at improving care for people with Type 1 or Type 2 diabetes. The participants were health care professionals, including physicians, nurses and pharmacists. The outcomes included objectively measured health professional performance or patient outcomes, and self-report measures with known validity and reliability. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. MAIN RESULTS: Forty-one studies were included involving more than 200 practices and 48,000 patients. Twenty-seven studies were RCTs, 12 were CBAs, and two were ITS. The studies were heterogeneous in terms of interventions, participants, settings and outcomes. The methodological quality of the studies was often poor. In all studies the intervention strategy was multifaceted. In 12 studies the interventions were targeted at health professionals, in nine they were targeted at the organisation of care, and 20 studies targeted both. In 15 studies patient education was added to the professional and organisational interventions. A combination of professional interventions improved process outcomes. The effect on patient outcomes remained less clear as these were rarely assessed. Arrangements for follow-up (organisational intervention) also showed a favourable effect on process outcomes. Multiple interventions in which patient education was added or in which the role of the nurse was enhanced also reported favourable effects on patients' health outcomes. REVIEWER'S CONCLUSIONS: Multifaceted professional interventions can enhance the performance of health professionals in managing patients with diabetes. Organisational interventions that improve regular prompted recall and review of patients (central computerised tracking systems or nurses who regularly contact the patient) can also improve diabetes management. The addition of patient-oriented interventions can lead to improved patient health outcomes. Nurses can play an important role in patient-oriented interventions, through patient education or facilitating adherence to treatment.

Ambulatory Care↗
PubMed2001

Quality improvement in chronic illness care: a collaborative approach.

BACKGROUND: Despite rapid advances in the clinical and psycho-educational management of diabetes, the quality of care received by the average patient with diabetes remains lackluster. The "collaborative" approach--the Breakthrough Series (BTS; Institute for Healthcare Improvement [IHI]; Boston)--coupled with a Chronic Care Model was used in an effort to improve clinical care of diabetes in 26 health care organizations. METHODS: Descriptive and pre-post data are presented from 23 health care organizations participating in the 13-month (August 1998-September 1999) BTS to improve diabetes care. The BTS combined the system changes suggested by the chronic care model, rapid cycle improvement, and evidence-based clinical content to assist teams with change efforts. The characteristics of organizations participating in the diabetes BTS, the collaborative process and content, and results of system-level changes are described. RESULTS: Twenty-three of 26 teams completed participation. Both chart review and self-report data on care processes and clinical outcomes suggested improvement based on changes teams made in the collaborative. Many of the organizations evidencing the largest improvements were community health centers, which had the fewest resources and the most challenged populations. DISCUSSION: The initial Chronic Illness BTS was sufficiently encouraging that replication and evaluation of the BTS collaborative model is being conducted in more than 50 health care systems for diabetes, congestive heart failure, depression, and asthma. This model represents a feasible method of improving the quality of care across different health care organizations and across multiple chronic illnesses.

Aged↗
PubMed2001

Population-based health principles in medical and public health practice.

Traditionally, medical education, research, and practice have focused on the care of the individual but an increasing emphasis on the care of populations has raised awareness among academic medical centers, integrated delivery systems, and managed care organizations of the value of embracing population-based health principles. Five principles are relevant in this regard: a community perspective, a clinical epidemiology perspective, evidence-based practice, an emphasis on outcomes, and an emphasis on prevention. This article describes these interrelated concepts together with specific strategies to effect implementation. Widespread awareness and adoption of these principles will have a profound impact on medical and public health education, practice, and ultimately the public's health.

Community Health Planning↗
PubMed2001

Does the chronic care model serve also as a template for improving prevention?

Practical models of ways to enhance service delivery are sorely needed to help close the gap between research and practice. An evidenced-based model of chronic-illness management is shown to apply equally to preventive interventions. Successful examples of prevention programs in cancer screening and counseling for health behavior change illustrate the utility of the model for prevention and across different types of health care organizations. Although there are some important differences between interventions required for chronic disease management and prevention, there are a greater number of common factors. They share the need to alter reactive acute-care-oriented practice to accommodate the proactive, planned, patient-oriented longitudinal care required for both prevention and chronic care.

Chronic Disease↗
PubMed2001

Interventions to improve the management of diabetes in primary care, outpatient, and community settings: a systematic review.

OBJECTIVE: To review the effectiveness of interventions targeted at health care professionals and/or the structure of care in order to improve the management of diabetes in primary care, outpatient, and community settings. RESEARCH DESIGN AND METHODS: A systematic review of controlled trials evaluating the effectiveness of interventions targeted at health care professionals and aimed at improving the process of care or patient outcomes for patients with diabetes was performed. Standard search methods of the Cochrane Effective Practice and Organization of Care Group were used. RESULTS: A total of 41 studies met the inclusion criteria. The studies identified were heterogeneous in terms of interventions, participants, settings, and reported outcomes. In all studies, the interventions were multifaceted. The interventions were targeted at health care professionals only in 12 studies, at the organization of care only in 9 studies, and at both in 20 studies. Complex professional interventions improved the process of care, but the effect on patient outcomes remained less clear because such outcomes were rarely assessed. Organizational interventions that facilitated the structured and regular review of patients also showed a favorable effect on process measures. Complex interventions in which patient education was added and/or the role of a nurse was enhanced led to improvements in patient outcomes as well as the process of care. CONCLUSIONS: Multifaceted professional interventions and organizational interventions that facilitate structured and regular review of patients were effective in improving the process of care. The addition of patient education to these interventions and the enhancement of the role of nurses in diabetes care led to improvements in patient outcomes and the process of care.

Ambulatory Care↗
PubMed2001

Chronic care clinics for diabetes in primary care: a system-wide randomized trial.

OBJECTIVE: To evaluate the impact of primary care group visits (chronic care clinics) on the process and outcome of care for diabetic patients. RESEARCH DESIGN AND METHODS: We evaluated the intervention in primary care practices randomized to intervention and control groups in a large-staff model health maintenance organization (HMO). Patients included diabetic patients > or = 30 years of age in each participating primary care practice, selected at random from an automated diabetes registry. Primary care practices were randomized within clinics to either a chronic care clinic (intervention) group or a usual care (control) group. The intervention group conducted periodic one-half day chronic care clinics for groups of approximately 8 diabetic patients in their respective doctor's practice. Chronic care clinics consisted of standardized assessments; visits with the primary care physician, nurse, and clinical pharmacist; and a group education/peer support meeting. We collected self-report questionnaires from patients and data from administrative systems. The questionnaires were mailed, and telephoned interviews were conducted for nonrespondents, at baseline and at 12 and 24 months; we queried the process of care received, the satisfaction with care, and the health status of each patient. Serum cholesterol and HbA1c levels and health care use and cost data was collected from HMO administrative systems. RESULTS: In an intention-to-treat analysis at 24 months, the intervention group had received significantly more recommended preventive procedures and helpful patient education. Of five primary health status indicators examined, two (SF-36 general health and bed disability days) were significantly better in the intervention group. Compared with control patients, intervention patients had slightly more primary care visits, but significantly fewer specialty and emergency room visits. Among intervention participants, we found consistently positive associations between the number of chronic care clinics attended and a number of outcomes, including patient satisfaction and HbA1c levels. CONCLUSIONS: Periodic primary care sessions organized to meet the complex needs of diabetic patients imrproved the process of diabetes care and were associated with better outcomes.

Adult↗
PubMed2001

Improving depression care: barriers, solutions, and research needs.

Potential solutions for barriers to improved organization of care of depressive illness were identified. These included (1) aligning efforts to improve depression care with broader strategies for improving care of other chronic conditions; (2) increasing the availability of depression case management services in primary care; (3) developing registries and reminder systems to ensure active follow-up of depressed patients; (4) achieving agreement on how depression outcomes should be measured to provide outcomes-based performance standards; (5) providing greater support from mental health specialists for management of depressed patients by primary care providers; (6) campaigns to reduce the stigma associated with treatment of depressive illness; (7) increased dissemination of interventions that activate and empower patients managing a depressive illness; (8) redefining the lack of time of primary care providers for high-quality depression care as issues in organization of care and provider training; and (9) development of incentives (organizational or financial) for high-quality depression care. Research needs were identified according to what has been learned to date. Identified research needs included: studies of approaches to organization of case management, research in new populations (e.g., new diagnostic groups, rural populations, the disadvantaged, the elderly, and those with chronic medical illnesses), research on stepped care and relapse prevention strategies, evaluation of the societal benefits of improved depression care, and multisite trials and meta-analytic approaches that can provide adequate statistical power to assess societal benefits of improved care.

Case Management↗
PubMed2000

What can we do to improve physical function in older persons with type 2 diabetes?

BACKGROUND: Older persons with type 2 diabetes are at higher risk for functional impairment than are their age-matched counterparts without-diabetes. We therefore sought to identify factors associated with impaired physical function in older persons with type 2 diabetes by using a cross-sectional study design. METHODS: We studied 1238 persons with type 2 diabetes who were 55 years of age or older and enrolled in the Type II Diabetes Patient Outcomes Research Team (PORT) project. Subjects were primary care patients at a large staff model health maintenance organization who had completed a mailed survey that collected information about demographics (age, race, marital status, income, education, gender, and body mass index [BMI]), health behaviors (exercise, smoking, and alcohol), care and control of diabetes (therapy, self-reported glucose control, home glucose monitoring, and disease duration), mood (Center for Epidemiologic Studies--Depression Scale [CES-D]), comorbidity, and the Short-Form-36 health survey (SF-36). We evaluated the bivariate relationships between the PFI- 10, a 10-item measure of physical function from the SF-36, and candidate independent variables from the domains described previously. Variables that were significant at an a level of .10 were entered into a multiple linear regression model. RESULTS: There were eight independent predictors of impaired physical function (all p < .05, R2 = .40). Factors associated with impaired function in order of their relative importance were as follows: a higher comorbidity score, older age, obesity, lack of regular exercise, CES-D score higher than 20, taking insulin, lower formal education, and abstinence from alcohol. CONCLUSIONS: Increased comorbidity and older age are associated with poorer function, as is the severity of diabetes and less formal education. Exercise, lower BMI, and better mood are associated with better function. Therefore, promoting regular exercise and weight loss, in addition to treating depression, are likely to preserve or even improve the functional status of older persons with type 2 diabetes. Moderate alcohol use may be beneficial as well. The extent to which these relationships persist in prospective studies or clinical trials remains to be evaluated.

Activities of Daily Living↗
PubMed2000

The Kaiser Family Foundation Community Health Promotion Grants Program: findings from an outcome evaluation.

OBJECTIVES: To present results from an outcome evaluation of the Henry J. Kaiser Family Foundation's Community Health Promotion Grants Program (CHPGP) in the West, which represented a major community-based initiative designed to promote improved health by changing community norms, environmental conditions, and individual behavior in 11 western communities. METHODS: The evaluation design: 14 randomly assigned intervention and control communities, 4 intervention communities selected on special merit, and 4 matched controls. Data for the outcome evaluation were obtained from surveys, administered every two years at three points in time, of community leaders and representative adults and adolescents, and from specially designed surveys of grocery stores. Outcomes for each of the 11 intervention communities were compared with outcomes in control communities. RESULTS: With the exception of two intervention communities-a largely Hispanic community and a Native American reservation-we found little evidence of positive changes in the outcomes targeted by the 11 intervention communities. The programs that demonstrated positive outcomes targeted dietary behavior and adolescent substance abuse. CONCLUSIONS: Improvement of health through community-based interventions remains a critical public health challenge. The CHPGP, like other prominent community-based initiatives, generally failed to produce measurable changes in the targeted health outcomes. Efforts should focus on developing theories and methods that can improve the design and evaluation of community-based interventions.

Adolescent↗
PubMed1999

The unreliability of individual physician "report cards" for assessing the costs and quality of care of a chronic disease.

CONTEXT: Physician profiling is widely used by many health care systems, but little is known about the reliability of commonly used profiling systems. OBJECTIVES: To determine the reliability of a set of physician performance measures for diabetes care, one of the most common conditions in medical practice, and to examine whether physicians could substantially improve their profiles by preferential patient selection. DESIGN AND SETTING: Cohort study performed from 1990 to 1993 at 3 geographically and organizationally diverse sites, including a large staff-model health maintenance organization, an urban university teaching clinic, and a group of private-practice physicians in an urban area. PARTICIPANTS: A total of 3642 patients with type 2 diabetes cared for by 232 different physicians. MAIN OUTCOME MEASURES: Physician profiles for their patients' hospitalization and clinic visit rates, total laboratory resource utilization rate and level of glycemic control by average hemoglobin A1c level with and without detailed case-mix adjustment. RESULTS: For profiles based on hospitalization rates, visit rates, laboratory utilization rates, and glycemic control, 4% or less of the overall variance was attributable to differences in physician practice and the reliability of the median physician's case-mix-adjusted profile was never better than 0.40. At this low level of physician effect, a physician would need to have more than 100 patients with diabetes in a panel for profiles to have a reliability of 0.80 or better (while more than 90% of all primary care physicians at the health maintenance organization had fewer than 60 patients with diabetes). For profiles of glycemic control, high outlier physicians could dramatically improve their physician profile simply by pruning from their panel the 1 to 3 patients with the highest hemoglobin A1c levels during the prior year. This advantage from gaming could not be prevented by even detailed case-mix adjustment. CONCLUSIONS: Physician "report cards" for diabetes, one of the highest-prevalence conditions in medical practice, were unable to detect reliably true practice differences within the 3 sites studied. Use of individual physician profiles may foster an environment in which physicians can most easily avoid being penalized by avoiding or deselecting patients with high prior cost, poor adherence, or response to treatments.

Benchmarking↗
PubMed1999

If diabetes is a public health problem, why not treat it as one? A population-based approach to chronic illness.

It is increasingly acknowledged that diabetes and other chronic illnesses are major public health problems. Medicare and many managed health care organizations have recognized the enormous personal and societal costs of uncontrolled diabetes in terms of complications, patient quality of life, and health care system resources. However, the current system of reactive acute-episode focused disease care practiced in many settings does not adequately address this public health problem. An alternative proactive, population-based approach to chronic illnesses such as diabetes is proposed and illustrated. This multilevel systems approach addresses supportive and inhibitory social-environmental factors at multiple levels (personal, family, health care team, work, neighborhood, community). Key disciplines contributing to a population-based approach to diabetes include epidemiology, behavioral science, health care services, public health, health economics, and quality of life professions. Current and potential contributions of each of these disciplines are illustrated and an integrative, population-based systems approach to diabetes management and prevention of complications is proposed. This approach is also seen as applicable to other chronic illnesses.

Chronic Disease↗