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 greater than or equal to 30);ears 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-halt day chronic care clinics for groups of similar to 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 tor 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 HbA(1c) levels and health care use and cost data was collected from HMO administration 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 HbA(1c) levels. CONCLUSIONS - Periodic primary care sessions organized to meet the complex needs of diabetic patients improved the process of diabetes care and were associated with better outcomes.