1. Michael L. Parchman, MD, MPH
STAR
Net
Is the Structure of Primary Care Clinics Associated with A1c? A STARNet Study
Michael L. Parchman, MD, MPH
Raquel L. Romero, MD
Jacqueline A. Pugh, MD

2. Type 2 Diabetes and Glucose
Intensity of Therapy
Self-care behaviors
Diet
Exercise
SMBG
Med Adherence

3. The Chronic Care Model (CCM)

4. Objective
To determine if strength of the CCM in small autonomous primary care clinics is associated with A1c control after controlling for patient self-care behaviors

5. Methods 20 Primary Care Clinics
South Texas Ambulatory Research Network (STARNet)
“Snowball” recruitment
Diversity
Solo (single-handed) practices (n=11)
Group practices (n=3, physicians=10)
Community Health Center (n=1; physician=1)
VA Primary Care clinics (n=2; physicians=11)
City/county health clinics (n=3; physicians =12)

6. Methods
30-32 consecutive adult patients presenting with an established dx of type 2 DM
Data collection
Patient survey (demographics, self-care behaviors)
Chart Abstraction (up to 5 most recent values)
Clinician survey (Assessing Chronic Illness Care, ACIC, Survey)

7. Self Care Behaviors “I have followed my diet as instructed…”
No, and I do not intend to
No, and I do not intend to for the next 6 months
No, but I plan to within the next 6 months
Yes, but for less than the past 6 months
Yes, for more than the last 6 months

8. ACIC Survey
A validated measure of the presence of the elements of the CCM in primary care settings (Bonomi AE, HSR 2002)
Scale for each item 0 to 11
0-2 “limited support”
3-5 “basic support”
6-8 “good support”
9-11 “fully developed support”

9. HLM Level-1: repeated measure of A1c within patient
Level-2: patient characteristics and self-care behaviors
Level-3: ACIC survey score for each clinic

10. Results Mean (SD) or % (n=618) Age 58.6 (12.9) %Male 51.5 %Hispanic
57.3
%Maintenance Stage of Change
Diet
Exercise
SMBG
Meds 46 45 85 61
Most recent A1c
7.7(2.1)
ACIC (possible range 0 to 11)
6.3 (1.7)

11. Model 1
Model 2
Model 3
Age
-0.018
(0.004)
<.001
-0.014
-0.013
<0.001
Male
-0.212
(0.086)
0.014
-0.235
(0.087)
0.007
-0.192
(0.088)
0.030
Hispanic
0.714
0.677
0.659
Diet
-0.383
(0.098)
-0.403
Exercise
0.0189
(0.097)
0.846
0.050
0.612
SMBG
-0.017
(0.101)
0.865
0.864
Med adhere
-0.285
(0.153 )
0.062
-0.300
(0.152)
0.049
ACIC Score
-0.073
(0.025)
0.004

12. Results
For every 1 point increase in ACIC score, 0.07 decrease in A1c.
If a clinic were to move from “limited” to “fully supported” may require as much as a 6 point increase in ACIC score
Such and increase would be associated with a decrease in A1c of 0.42, similar to decreases seen when adding additional class of oral meds such as TZD.

13. What about Elements of the CCM? Top 5 Clinics: A1c Values
Clinic A
Clinic B
Clinic C
Clinic D
Clinic E
Delivery System
Community Linkage
Decision Support
Organization Support
Self-manage support
Clinical Info Support

14. Conclusions
As seen through the “lens” of the CCM, the “structure” of the primary care clinic is associated with A1c control
If primary care clinics are “complex adaptive systems” then elements of the CCM may be part of their internal “fitness landscape”
Effective and efficient methods for helping clinics implement elements of the CCM model are needed

15. Acknowledgments
Funding for this study was provided by AHRQ, Grant # K08 HS ; HRSA Grant # 5D12HP ; and the South Texas Health Research Center.
Special thanks to the physicians and office staff of the South Texas Ambulatory Research Network (STARNet)
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