Annals Topics Include Chronic Care Model, Syndromic Surveillance

Articles in the July/August issue of Annals of Family Medicine shed light on the challenges of implementing a chronic care model and indicate that primary care offices could serve as useful surveillance centers for emerging infections, including those possibly tied to bioterrorism. Here's a summary of Annals articles on these topics and a list of titles of several other articles in the issue.

Chronic care model. Two research articles portray efforts to implement the chronic care model, or CCM, that internist Edward Wagner, M.D., proposed in 1998. Eighteen multispecialty clinics in the Minneapolis-St. Paul metropolitan area in Minnesota began implementing the CCM in 2001, and the two Annals of Family Medicine articles analyze the resulting changes that had occurred in some of the clinics by 2004.

"Care Quality and Implementation of the Chronic Care Model: A Quantitative Study" notes significant improvements in outcomes for patients with diabetes and heart disease. However, it was hard to correlate the use of the CCM with improvements in such measures as LDL and glycated hemoglobin levels, numbers of cardiac events, and numbers of follow-up visits by patients with depression. Out of six CCM components, only two correlated with an improvement in health measures, and the improvement applied to patients with diabetes.

"Despite implementation of the CCM and improvements in quality measures for three chronic diseases (diabetes, heart disease and depression), there were few significant correlations between these changes. Demonstrating such a relationship may require larger changes, a larger number of clinics, changes in other CCM elements or a more sensitive measurement tool," say the authors.

"Challenges of Change: A Qualitative Study of Chronic Care Model Implementation" reports on the results of CCM implementation by five out of 18 clinics. The authors identified many barriers to CCM implementation, including "too many competing priorities, a lack of specificity and agreement about the care process changes desired, and little engagement of physicians."

The authors call for a blueprint more specific than the CCM and note, "Effective models of organizational change and detailed examples of proven, feasible care changes still need to be demonstrated if we are to transform care."

Syndromic surveillance. "Syndromic Surveillance for Emerging Infections in Office Practice Using Billing Data" shows how Dayspring Family Medicine in Eden, N.C., submitted its ICD-9 codes for one year to the University of North Carolina at Chapel Hill. The practice and the university tracked 10 clinical syndromes the CDC says could constitute signs and symptoms of infection with category A bioterrorism agents, (i.e., infections that can be easily disseminated or that are highly transmissible, cause high mortality, and are likely to cause public panic and social disruption). Emergency department visit data provided comparative information. During the 2003-04 influenza season, "the occurrence of spikes (in codes related to influenza) in the practice before (spikes in) the emergency department suggest that the practice may have seen influenza earlier," say the authors.

They conclude, "This preliminary study showed the feasibility of implementing syndromic surveillance in an office setting at a low cost and with minimal staff effort. Although many implementation issues remain, further development of syndromic surveillance systems should include primary care offices."

Other articles. Here are the titles of some other articles in this issue of Annals.