Chronic care clinics: a randomized controlled trial of a new model of primary care for frail older adults.
OBJECTIVE
To determine whether a new model of primary care, Chronic Care Clinics, can improve outcomes of common geriatric syndromes (urinary incontinence, falls, depressive symptoms, high risk medications, functional impairment) in frail older adults.


METHODS
Randomized controlled trial with 24 months of follow-up. Physician practices were randomized either to the Chronic Care Clinics intervention or to usual care.


METHODS
Nine primary care physician practices that comprise an ambulatory clinic in a large staff-model HMO in western Washington State.


METHODS
Those patients aged 65 and older in each practice with the highest risk for being hospitalized or experiencing functional decline.


METHODS
Intervention practices (5 physicians, 96 patients) held half-day Chronic Care Clinics every 3 to 4 months. These clinics included an extended visit with the physician and nurse dedicated to planning chronic disease management; a pharmacist visit that emphasized reduction of polypharmacy and high-risk medications; and a patient self-management/support group. Control practices (4 physicians, 73 patients) received usual care.


METHODS
Changes in self-reported urinary incontinence, frequency of falls, depressive symptoms, physical function, and satisfaction were analyzed using an intention-to-treat analysis adjusted for baseline differences, covariates, and practice-level variation. Prescriptions for high-risk medications and cost/utilization data obtained from administrative data were similarly analyzed.


RESULTS
After 24 months, no significant improvements in frequency of incontinence, proportion with falls, depression scores, physical function scores, or prescriptions for high risk medications were demonstrated. Costs of medical care including frequency of hospitalization, hospital days, emergency and ambulatory visits, and total costs of care were not significantly different between intervention and control groups. A higher proportion of intervention patients rated the overall quality of their medical care as excellent compared with control patients (40.0% vs 25.3%, P = .10).


CONCLUSIONS
Although intervention patients expressed high levels of satisfaction with Chronic Care Clinics, improved outcomes for selected geriatric syndromes were not demonstrated. These findings suggest the need for developing greater system-wide support for managing geriatric syndromes in primary care and illustrate the challenges of conducting practice improvement research in a rapidly changing delivery system.
Division of Geriatric Medicine, University of Colorado Health Sciences Center, Denver 80206, USA.
E A
EA
Coleman
L C
LC
Grothaus
N
N
Sandhu
E H
EH
Wagner
D000368:Aged; D000554:Ambulatory Care Facilities / Q000458:organization & administration*; D002908:Chronic Disease / Q000523:psychology / Q000628:therapy*; D019468:Disease Management; D005260:Female; D005500:Follow-Up Studies; D016330:Frail Elderly / Q000523:psychology; D015577:Geriatric Assessment; D006279:Health Maintenance Organizations / Q000458:organization & administration*; D006302:Health Services Research; D006801:Humans; D008297:Male; D017146:Models, Organizational; D020380:Needs Assessment; D017060:Patient Satisfaction; D011320:Primary Health Care / Q000458:organization & administration*; D016896:Treatment Outcome; D014861:Washington