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(7) Chronic Disease Management in Illinois


Janae D. Price, MPH – Epidemiologist, Centers for Disease Control and Prevention


In the U.S., 75 million adults aged 20 and older have been told by a health care provider that they have hypertension (HTN), 30.2 million indicated being told they have type 2 diabetes (T2D), and an estimated 3 million indicate both, with the number of adults increasing. Interventions employed by health systems to address HTN, T2D and other chronic diseases have shifted in recent years toward using a population health management approach as interventions are more likely to be effective for hypertension and diabetes prevention given the current resource-constrained environment. As such, a comprehensive approach that incorporates a multi-disciplinary care team and point of care resources, within and outside of the health care walls, is critical to address the multiple co-morbidities and risk factors that are routinely addressed in the primary care setting. Given the variability of resources, organizational supports, community linkages and information technology (IT) infrastructure, the ability of health care systems to implement evidence-based interventions can vary widely. The aim of this study was to understand evidence-based interventions used to manage chronic diseases in Illinois using CDC Health Systems Scorecard (HSSC) results. In 2018, the CDC HSSC was deployed state-wide to >250 private and public health plans, hospitals, provider groups, federally qualified health centers, and independent practitioners. This study focused on evidence-based strategies and interventions used to manage 3 chronic conditions (high blood pressure, high blood cholesterol, and diabetes) across 7 domains. Policy, systems and processes (P/S/P) scores were generated based on the number of interventions the organization had in place for each strategy. Responses were direct-matched with the national clinical quality improvement (QI) measure scores for controlled high blood pressure, cholesterol management and hemoglobin A1c >9% (poor glycemic control). Clinical QI percent scores are national measures reported by health systems, to monitor and improve the quality of perinatal, chronic, and preventative care services. Descriptive statistics were generated as well as cumulative and within domain scores. Interventions were most common among Electronic Health Record Systems (67.5%), followed by team-based care (66.3%) and self-management (58.8%) The total number of interventions in place across all domains ranged from 5 – 37 (high blood pressure), 0 – 36 (high blood cholesterol), and 0 – 38 (diabetes) with a mean of 14.1 (95% CI 11.8, 16.4), 6.9 (95% CI 5.1, 8.7), and 11.3 (95% CI 8.6, 14.0) interventions, respectively. Preliminary results indicate a positive relationship between the number and type of interventions and overall clinical quality scores across health systems in Illinois. Within each intervention category, there was a positive association between the percent of health systems that had P/S/P's in place and met or exceeded the Healthy People 2020 target for all HTN, high cholesterol and diabetes. There is growing evidence that strategies such as use of P/S/P's across health systems to improve the quality of chronic care are effective and vital to improving health outcomes. Although this study focused on a sub-set of elements that address systematic supports for quality improvement, there are other elements that would benefit from being studied. These could include, but are not limited to; availability of community resources, the level of leadership and decision support, and systems of care design to ensure productive interactions between health systems, care teams and patients. In Illinois, assessments of organizational infrastructure and P/S/P's that support evidence-based interventions for chronic disease management is a novel concept. Evidence-based system-wide interventions for the management of HTN, high blood cholesterol and T2D are routinely reviewed and recommended by national organizations. Aligning these public health recommendations with clinical guidelines while accounting for the variability of cost, resources, partnerships, and patient engagement can be more of an art than a science for healthcare systems. Further study in this area would assist Illinois health systems with identifying universal and targeted interventions to improve QI strategies in support of HTN, high blood cholesterol and T2D prevention and control.



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