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Using Evidence

Federal Initiatives


Tricia L. Trinité, N.P., M.S.P.H., Director, Health Disparities Collaboratives, Bureau of Primary Health Care (BPHC), Health Resources and Services Administration (HRSA), Denver, CO.

Autumn Dawn Galbreath, M.D., Director, University of Texas Disease Management Center, San Antonio, TX.

This session described leading initiatives sponsored by the Federal Government to develop or implement programs related to disease management.

Dr. Autumn Dawn Galbreath stated that disease management is a population-based, systematic approach to identify people at risk for specific diseases, intervene with a program of care, and measure outcomes. Disease management emphasizes providing a continuum of care for those with chronic illness.

Important characteristics of disease management include:

  • Incorporating best medical practices throughout the continuum of care.
  • Developing clinical guidelines through the review of medical literature.
  • Improving measurable outcomes in the quality of care.
  • Providing the care at reduced cost.

Dr. Galbreath noted that disease management assumes that medical practice varies and that this variation is related to differences in outcomes. It also assumes that it is possible to develop a system that optimizes patient care and improves outcomes, resulting in decreased costs.

HRSA's Health Disparities Collaborative Project is a major effort of the BPHC to involve clinicians in a national quality-improvement initiative for chronic diseases. The project provides an opportunity for healthcare organizations to participate in a team approach to implementing best practice models of care for their chronic disease patients. It incorporates a change model created by the Institute for Healthcare Improvement and a chronic care model developed by the MacColl Institute for Healthcare Innovation.

Teams at participating health centers are implementing these models to improve care in five areas of health disparities designated by the U.S. Department of Health and Human Services:

  • Diabetes.
  • Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS).
  • Cardiovascular disease.
  • Infant mortality.
  • Immunizations and cancer.

(Asthma and depression are being added to the list).

The population-based model of care relies on identifying which patients have an illness and ensuring that they receive evidence-based care. The model is patient-centered, in that it helps patients to participate in their own care.

Health centers participate in teams and attend learning sessions by experts on a particular topic (i.e., diabetes). Over the course of a 1-year period, the teams set goals (data collection on certain outcomes, e.g., blood tests), and develop, test, and implement community-specific strategies following evidence-based recommendations for improving the delivery of healthcare for a specific clinical area (e.g., best practice standards of care for diabetic patients).

Eighty-five centers have completed the initial phase of the collaborative and continue to measure outcomes quarterly, and an additional 120 centers are beginning the next round. Results of the first year indicate the rate of glycosolated hemoglobin testing in diabetic patients increased significantly at the participating centers over the course of a 1-year period.

Ms. Trinité shared some of the project's guiding principles of generating positive change:

  • Commitment to mission.
  • Joint community of learners.
  • Focus on outstanding results for patients.
  • Continuously experiment, design, and implement.
  • Provide rationale and support for collaborative.
  • Build relationships and collectively manage the project.
  • Establish collaboration as a prerequisite for participation.

A second Federal disease management initiative is the South Texas Congestive Heart Failure (CHF) Demonstration Project. This project is a collaboration among the Department of Defense (DoD), the Department of Veterans Affairs (VA), and the University of Texas Health Science Center in San Antonio, Texas, and is funded through a congressional appropriation. It is the first demonstration of its kind for a CHF population and the first major Federal evaluation of a disease management program. The patient base for the study totals 1,500, including veterans, Medicaid, Medicare, and military populations.

The demonstration project is a prospective 3-year randomized study beginning January 2000. Its premise is to evaluate the integration of traditional clinical guidelines with usual delivery of care. The study design involves collaboration among patients, physicians, and nurse disease managers (critical care nurses). The patients are separated into three groups:

  • Traditional physician care.
  • Comprehensive disease management.
  • Comprehensive disease management with technology.

The "with technology" group involves greater self-management by patients using technology such as blood pressure cuffs that patients can use in their homes.

The project's objectives include:

  • Improved clinical outcomes.
  • Patient and provider satisfaction.
  • Economic outcomes such as decreasing total healthcare resource utilization and projected cost savings with long-term use of a disease management protocol.

Results are expected in early 2003.

Disease management is an important innovative concept that remains to be proven conclusively. Further evidence is needed as to its clinical and economic effectiveness. Dr. Galbreath concluded her presentation by sharing the important lesson that the effectiveness of a disease management program depends upon adequate infrastructure, information sharing, and cooperation among institutions.


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