Family Medicine Research

Chronic Disease Management Tied to Provision of Preventive Care Services, Study Finds

July 23, 2013 03:14 pm Sheri Porter

New research in the July/August issue of Annals of Family Medicine(
suggests that time-strapped primary care physicians can, indeed, deliver preventive services recommended by the U.S. Preventive Services Task Force (USPSTF) to patients with chronic conditions.

[Stock photo of doctor and obese woman standing on scale]

Furthermore, study authors concluded that "Rather than a barrier, the presence of chronic illness was positively associated with receipt of recommended preventive services" among a majority of the 667,379 adult patients whose data were studied. The148 practices that participated in the study -- 77 percent of which were family medicine practices -- all were members of the same large national practice-based research network (PBRN).

The study's corresponding author, Steven Ornstein, M.D., a professor of family medicine at the Medical University of South Carolina, Charleston, told AAFP News Now that although he wasn't surprised by the findings after his nearly 20 years of being immersed in quality improvement research, "It was important to demonstrate the findings because the prevailing attitudes -- including much of the literature -- suggested otherwise."

Indeed, study authors pointed out that according to some researchers, primary care physicians need 7.4 hours each day just to provide patients with all USPSTF-recommended services.

Story Highlights
  • New research suggests that the presence of chronic illness is associated with receipt of recommended preventive care services.
  • The findings debunk a common perception that primary care physicians don't have time to provide such services to patients with chronic illness.
  • Study authors theorize that inclusion in a practice-based research network, use of electronic health records and other strategies prompted physicians in the study to deliver preventive care when treating patients with chronic illness.

The newly published research debunks that idea, according to Ornstein. "When a practice designs a system to take good care of patients with chronic illnesses, it carries over to taking care of their prevention, as well," he said.

"There's no 'magic wand,' but physicians actually can achieve the same success (seen in this study) -- despite what others say and irrespective of who the patient is -- by developing the right systems," said Ornstein. For example, physicians involved in the study received regular reports from the research network that allowed them to track their progress in providing preventive care.

"Obviously, the AAFP's patient-centered medical home (PCMH) principles and TransforMED activities( around the PCMH are intended to help other family physician practices do exactly the same," added Ornstein.

Specific Findings

Study researchers analyzed the cross-sectional association of 10 USPSTF-recommended preventive services and the prevalence of 24 chronic conditions using patient data updates entered into the Practice Partner Research Network database as of Oct. 1, 2011. That database is derived from Practice Partner electronic health record (EHR) systems previously implemented in each practice.

The preventive services researchers looked at were screening for high blood pressure; lipid disorders; urogenital chlamydial infection; breast, cervical and colorectal cancers; type 2 diabetes mellitus in adults with elevated blood pressure; alcohol misuse; depression; and osteoporosis. The 24 chronic conditions chosen for the study "represent a broad spectrum of illnesses relevant to primary care practice and are conditions of priority for comparative effectiveness research," said the authors.

Of the more than 667,000 patients whose data were studied, 34.6 percent had no chronic disease, 20.1 percent had one chronic condition, 14.9 percent had two, 11.2 percent had three, 7.7 percent had four, and 11.5 percent had five or more chronic conditions.

For each preventive service, there existed a curvilinear relationship with the number of chronic conditions, "with an increased likelihood of being up-to-date with a preventive service as the number of chronic conditions increases from zero to four or five," after which the association plateaued, the authors wrote.

Furthermore, for each preventive service except screening for urogenital chlamydial infection, there were "strong associations between the odds of being up-to-date and the presence of chronic illness," they said.

The researchers pointed out that their findings of "strong positive associations between receipt of clinical preventive services and the presence of chronic illnesses" were very different from "oft-expressed concerns" that the additional time required to care for complex patients with one or more chronic conditions hindered the delivery of preventive services.

Moreover, they said, the fact that their findings persisted even after adjustment for age and encounter frequency suggest that something in the nature of the care provided to those patients accounted for physicians' increased attention to prevention.

Moving Forward

The reasons for the findings remain unclear, according to the authors, but they speculated that perhaps the practices used periodic practice reports supplied by the PBRN as chronic disease registries, which, in turn, prompted attention to preventive care.

The authors also theorized that activities commonly associated with chronic disease management -- such as ordering tests and arranging follow-up care -- "provide the context for provision of preventive services."

Acknowledging that study participants shared commonalities -- namely, they all used the same EHR product and voluntarily participated in the PBRN -- the researchers admitted that the study's results might not be readily generalizable to the general population.

"Despite these limitations, we believe that our findings support the notion that modern primary care practices, facilitated by tools like EHRs and joined in learning networks such as PBRNs, can overcome competing demands and effectively deliver preventive services to the growing number of patients with multiple chronic illnesses," wrote the authors.

Noting that previous studies have suggested that strategies such as EHR-based reminders and PCMH participation have a positive impact on the overall delivery of preventive care services, the authors said that future research could focus on whether these approaches confer the same benefit among patients with chronic illnesses.