1. Chronic Disease Management

This page contains additional references for Chapter 1 of Responding to Healthcare Reform: A Strategy Guide for Heatlhcare Leaders.  The most current additions are at the top of the page.  It also includes the annotated references from the book and their associated hyperlinks.

Current References

Begley. Sharon, The Best Medicine: Cutting Health Costs with Comparative Effectiveness Research: A quiet revolution in comparative effectiveness research just might save us from soaring medical costs, Scientific American, July 11 2011.

First Paragraphs: It was the largest and most important investigation of treatments for high blood pressure ever conducted, with a monumental price tag to match. U.S. doctors enrolled 42,418 patients from 623 offices and clinics, treated participants with one of four commonly prescribed drugs, and followed them for at least five years to see how well the medications controlled their blood pressure and reduced the risk of heart attack, stroke and other cardiovascular problems. It met the highest standards of medical research: neither physicians nor their patients knew who was placed in which treatment group, and patients had an equal chance of being assigned to any of the groups. Such randomized controlled trials have long been unmatched as a way to determine the safety and efficacy of drugs and other treatments. This one, dubbed ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial), cost an estimated $120 million and took eight years to complete.

The results, announced in December 2002, were stunning: the oldest and cheap­est of the drugs, known as thiazide-type diuretics, were more effective at reducing hypertension than the newer, more expensive ones. Furthermore, the diuretics, which work by ridding the body of excess fluid, were better at reducing the risk of developing heart failure, of being hospitalized and of having a stroke. ALLHAT was well worth its premium cost, argued the National Heart, Lung, and Blood Institute (nhlbi), which ran the trial. If patients were prescribed diuretics for hypertension rather than the more expensive medications, the nation would save $3.1 billion every decade in prescription drug costs alone—and hundreds of millions of dollars more by avoiding stroke treatment, coronary artery bypass surgery and other consequences of high blood pressure.


Improving Patient Decision-Makingin Health Care: A 2011 Dartmouth Atlas Report Highlighting Minnesota
First Paragraph:  For patients whose conditions can be treated with elective surgery, location matters. In this Dartmouth Atlas report, the first in a series looking at individual states and regions, we show the wide regional variation in the likelihood that patients with similar conditions receive elective procedures. This report highlights Minnesota and shows the variation across the state. For example, if you have heart disease and live in St. Cloud, Minnesota, you are half as likely to undergo cardiac bypass surgery than if you live in Detroit Lakes, and more than twice as likely to undergo back surgery than if you live in Rochester. If you have gallstones and live in Wadena, you are three times more likely to have your gall bladder removed than if you live in Minneapolis.

AHRQ Innovations Exchange (2011)

The Innovations Exchange helps solve problems, improve health care quality, and reduce disparities through the application of evidence based medicine and comparative effective research.

  • Find evidence-based innovations and QualityTools.
  • View new innovations and tools published biweekly.
  • Learn from experts through events and articles

The Shared Decision Making National Resource Center at the Mayo Clinicadvances patient-centered medical care by promoting shared decision making through the development, implementation, and assessment of patient decision aids and shared decision making techniques

It contributes to achieving shared decision making goals expressed in the Patient Protection and Affordable Care Act by:

  • Developing and evaluating patient decision aids
  • Contributing to defining international decision aid standards
  • Defining high performance organizations using shared decision making
  • Educating and training care providers in communication techniques
  • Adopting and using patient decision aids at the point of care
  • Contributing to statewide implementation efforts
  • Certifying patient decision aids through collaboration with external partners

Paul Sullivan, MD; Don Goldmann, MD.   “The Promise of Comparative Effectiveness Research.” JAMA. 2011;305(4):400-401. doi: 10.1001/jama.2011.12
Introduction: The American Recovery and Reinvestment Act will provide an unprecedented stimulus for translational and health services research. A $1.1 billion investment in comparative effectiveness research (CER)1​ should produce a torrent of new information about the effectiveness of drugs, technologies, and interventions. For this to result in better, more cost-effective health care, better evidence is needed to address the translational gap between clinical studies and everyday practice.2 In essence, this is CER for implementation strategies (a type of CER seriously underrepresented in current discourse, but necessary to deliver on the Institute of Medicine’s goals for improved health care quality).

Laraque,Danielle ; Sia,Calvin C.J. “Health Care Reform and the Opportunity to Implement a Family-Centered Medical Home for Children.” JAMA, 2010, 303, 23, 2407-2408

Extract: The passage of the Patient Protection and Affordable Care Act (PPACA) formalized the concept of the medical home and primary care as a vital part of effective health care delivery. The PPACA comes closer to providing universal access to care and seeks evidence-based models to improve maternal child health programs such as home visiting, Emergency Medical Services for Children, and community health teams in support of the medical home system of care. Implemented correctly, the critical components of an integrated system could evolve to improve quality, efficiency, and cost-effective care that allows appropriate payment for a model of optimal health care delivery. It may be instructive to review the roots of the medical home concept and its application over decades as the family-centered medical home (FCMH).


Dentzer,Susan.  “Geisinger Chief Glenn Steele: Seizing Health Reform’s Potential To Build A Superior System.”  Health Affairs., 2010, 29, 6, 1200-1207

Intro: National health reform clearly poses challenges for all types of health care providers, from the smallest rural hospital to the largest integrated system. Some institutions clearly see the coming changes mainly as a threat to business as usual, while others embrace them as an opportunity to move to a superior system. In the latter category are Glenn Steele, M.D., and Geisinger Health System, where Steele has been president and chief executive officer since 2001.

Margolius,David; Bodenheimer,Thomas. “Transforming Primary Care: From Past Practice To The Practice Of The Future.” Health Affairs., 2010, 29, 5, 779-784

Abstract: The gap between the supply of primary care physicians and the demand for primary care continues to grow. Primary care practices must find a way to increase their patient capacity without sacrificing quality of care or adding more work to already overburdened physicians. A transformed primary care practice addressing these issues must redefine the physician role such that the physician no longer sees all patients assigned to the practice but acts as a leader for a well-trained, highly functioning primary care team. The team’s overall goal would be to advance the health of an entire patient panel. New payment models are among changes that will be central to this transformation.

Bohmer,Richard M.J.  “Managing The New Primary Care: The New Skills That Will Be Needed.”  Health Affairs., 2010, 29, 5, 1010-1014

Abstract: Developing new models of primary care will demand a level of managerial expertise that few of today’s primary care physicians possess. Yet medical schools continue to focus on the basic sciences, to the exclusion of such managerial topics as running effective teams. The approach to executing reform appears to assume that practice managers and entrepreneurs can undertake the managerial work of transforming primary care, while physicians stick with practicing medicine. This essay argues that physicians currently in practice could be equipped over time with the management skills necessary to develop and implement new models of primary care.

Schoen,Cathy; Osborn,Robin; How,Sabrina K.H.; Doty,Michelle M.; Peugh,Jordon. “In Chronic Condition: Experiences Of Patients With Complex Health Care Needs, In Eight Countries, 2008″. Health Affairs. 2009, 28, 1, w1-16

Abstract:This 2008 survey of chronically ill adults in Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States finds major differences among countries in access, safety, and care efficiency. U.S. patients were at particularly high risk of forgoing care because of costs and of experiencing inefficient, poorly organized care, or errors. The Dutch, who have a strong primary care infrastructure, report notably positive access and coordination experiences. Still, deficits in care management during hospital discharge or when seeing multiple doctors occurred in all countries. Findings highlight the need for system innovations to improve outcomes for patients with complex chronic conditions.

Larson,Eric B. “Group Health Cooperative — One Coverage-and-Delivery Model for Accountable Care.”  N.Engl.J.Med., 2009, 361, 17, 1620-1622

Intro: “On January 1, 1947, Group Health Cooperative of Puget Sound began delivering a new kind of healthcare. Consumers paid flat monthly dues for comprehensive care. Members elected the board of trustees and bought bonds to fund new facilities. Doctors and nurses devoted as much energy to promoting wellness as they did to treating illness. Group Health Cooperative’s founders believed that health was everybody’s business and everybody’s right. They prescribed democracy to cure an expensive and inefficient health care system.”

Group Health is one of just two large consumer-governed health plans in the United States (HealthPartners in Minneapolis is the other). A board of trustees composed of 11 Group Health patients, who are elected by other patients, works with management and doctors to set policies and the direction for the nonprofit organization, which integrates care and coverage. Of about 600,000 Group Health members in Washington State and northern Idaho, nearly two thirds get care through an integrated network of facilities owned and operated by the co-op; the network comprises 26 primary care centers, 6 specialty care units, and 1 hospital. The other third of the membership gets care through contracted providers.

Annotated References from Responding to Reform

American Academy of Family Physicians (AAFP). 2010. “Joint Principles of a Patient-Centered Medical Home Released by Organizations Representing More Than 300,000 Physicians.” [Online press release; retrieved 12/30/10.] www.aafp.org/online/en/home/media/releases/2007/20070305pressrelease0.html

Community Care of North Carolina. 2011. [Online information; retrieved 1/3/11.] http://www.communitycarenc.com/
The Community Care of North Carolina program (formerly known as Access II and III) is building community health networks organized and operated by community physicians, hospitals, health departments, and departments of social services. By establishing regional networks, the program is establishing the local systems that are needed to achieve long-term quality, cost, access, and utilization objectives in the management of care for Medicaid recipients.

Health Information Management Systems Society (HIMSS). 2010. “Meaningful Use Onesource.” [Online information; retrieved 12/30/10.] www.himss.org/EconomicStimulus/
The American Recovery and Reinvestment Act of 2009 (ARRA), included significant Medicare and Medicaid incentive payments to providers and hospitals for the “meaningful use” of certified health IT products. The legislation requires the US Department of Health and Human Services to take regulatory action in several areas, including electronic health record (EHR) incentives for eligible professionals and hospitals (Meaningful Use), standards and certification criteria, an HHS Certification Program, and privacy and security. The Health Information Management Systems Society’s website contains extensive documentation of this new federal resource.

Improving Chronic Illness Care. 2010. Website. [Online information; retrieved 12/30/10.] http://www.improvingchroniccare.org/.
This website, provided by the American Academy of Family Physicians provides resources and information for practitioners on the implementation of the Chronic Care Model. The site includes an exploration of the elements of the Chronic Care Model (www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2); a step-by-step video that walks professionals through the model ( www.improvingchroniccare.org/index.php?p=The_Model_Talk&s=27 ); and a practice assessment tool to gauge how a practice is performing on the six dimensions of the Chronic Care Model (www.improvingchroniccare.org/index.php?p=ACIC_Survey&s=35 )

Milstein, A., and E. Gilbertson. 2009. “American Medical Home Runs.” Health Affairs 28 (5): 1317.

Wagner, E. H. 2000. “The Role of Patient Care Teams in Chronic Disease Management.” BMJ: British Medical Journal 320(7234): pp. 569.

Wennberg, J. E., A. M. O’Connor, E. D. Collins, and J. N. Weinstein. 2007. “Extending the P4P Agenda, Part 1: How Medicare can Improve Patient Decision Making and Reduce Unnecessary Care.” Health Affairs 26(6): 1564.

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