Multilevel analysis of the chronic care model and 5A services for treating tobacco use in urban primary care clinics.
OBJECTIVE
To examine the chronic care model (CCM) as a framework for improving provider delivery of 5A tobacco cessation services.


METHODS
Cross-sectional surveys were used to obtain data from 497 health care providers in 60 primary care clinics serving low-income patients in New York City. A hierarchical generalized linear modeling approach to ordinal regression was used to estimate the probability of full 5A service delivery, adjusting for provider covariates and clustering effects. We examined associations between provider delivery of 5A services, clinic implementation of CCM elements tailored for treating tobacco use, and the degree of CCM integration in clinics.


RESULTS
Providers practicing in clinics with enhanced delivery system design, clinical information systems, and self-management support for cessation were 2.04-5.62 times more likely to perform all 5A services ( p<.05). CCM integration in clinics was also positively associated with 5As delivery. Compared with none, implementation of one to six CCM elements corresponded with a 3.69-30.9 increased odds of providers delivering the full spectrum of 5As ( p<.01).


CONCLUSIONS
Findings suggest that the CCM facilitates provider adherence to the Public Health Service 5A clinical guideline. Achieving the full benefits of systems change may require synergistic adoption of all model components.
Hung
Dorothy Y
DY
Mailman School of Public Health, Columbia University, 722 W. 168th Street, Suite 548, New York, NY 10032, USA. dh2237@columbia.edu
Shelley
Donna R
DR
D000328:Adult; D002908:Chronic Disease; D003430:Cross-Sectional Studies; D003661:Decision Support Techniques; D005260:Female; D006302:Health Services Research; D006801:Humans; D008297:Male; D008875:Middle Aged; D017146:Models, Organizational; D009519:New York City; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011320:Primary Health Care; D012044:Regression Analysis; D011795:Surveys and Questionnaires; D020340:Tobacco Use Cessation / Q000379:methods*; D014029:Tobacco Use Disorder / Q000628:therapy*; D017749:Total Quality Management; D014505:Urban Population
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