Can a Chronic Care Model Collaborative Reduce Heart Disease Risk in Patients with Diabetes?

  • Roberto B. Vargas
  • Carol M. Mangione
  • Steven Asch
  • Joan Keesey
  • Mayde Rosen
  • Matthias Schonlau
  • Emmett B. Keeler
Original Article


There is a need to identify effective practical interventions to decrease cardiovascular disease risk in patients with diabetes.


We examine the impact of participation in a collaborative implementing the chronic care model (CCM) on the reduction of cardiovascular disease risk in patients with diabetes.


Controlled pre- and postintervention study.


Persons with diabetes receiving care at 13 health care organizations exposed to the CCM collaborative and controls receiving care in nonexposed sites.

Measurements and Main Results

Ten-year risk of cardiovascular disease; determined using a modified United Kingdom Prospective Diabetes Study risk engine score. A total number of 613 patients from CCM intervention sites and 557 patients from usual care control sites met the inclusion criteria. The baseline mean 10-year risk of cardiovascular disease was 31% for both the intervention group and the control group. Participants in both groups had improved blood pressure, lipid levels, and HbA1c levels during the observation period. Random intercept hierarchical regression models showed that the intervention group had a 2.1% (95% CI −3.7%, −0.5%) greater reduction in predicted risk for future cardiovascular events when compared to the control group. This would result in a reduced risk of one cardiovascular disease event for every 48 patients exposed to the intervention.


Over a 1-year interval, this collaborative intervention using the CCM lowered the cardiovascular disease risk factors of patients with diabetes who were cared for in the participating organization’s settings. Further work could enhance the impact of this promising multifactorial intervention on cardiovascular disease risk reduction.

Key words

chronic care diabetes cardiovascular disease collaborative intervention 


  1. 1.
    Sowers JR. Diabetes mellitus and cardiovascular disease in women. Arch Intern Med. 1998;158:617–21.PubMedCrossRefGoogle Scholar
  2. 2.
    Tedesco JV, Wright RS, Williams BA, et al. Effect of diabetes on the mortality risk of cardiogenic shock in a community-based population. Mayo Clin Proc. 2003;78(5):561–6.PubMedCrossRefGoogle Scholar
  3. 3.
    Haffner SM, Lehto S, Ronnemaa T, Pyorala K, Laakso M. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med. 1998;339(4):229–34.PubMedCrossRefGoogle Scholar
  4. 4.
    Winer N, Sowers JR. Cardiovascular risk factors in diabetic patients with hypertension. Curr Diab Rep. 2002;2(3):263–6.PubMedCrossRefGoogle Scholar
  5. 5.
    Almdal T, Scharling H, Jensen J, Vestergaard H. The independent effect of type 2 diabetes mellitus on ischemic heart disease, stroke, and death: a population-based study of 13,000 men and women with 20 years of follow-up. Arch Intern Med. 2004;164(13):1422–6.PubMedCrossRefGoogle Scholar
  6. 6.
    Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet. 1998;351(9118):1755–62.PubMedCrossRefGoogle Scholar
  7. 7.
    American Diabetes Association: clinical practice recommendations 2000. Diabetes Care. 2000;23 Suppl 1:S1–116.Google Scholar
  8. 8.
    The sixth report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Arch Intern Med. 1997;157(21):2413–46.Google Scholar
  9. 9.
    United Kingdom Prospective Diabetes Study (UKPDS) Group. Intensive blood–glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352(9131):837–53.CrossRefGoogle Scholar
  10. 10.
    Pyorala K, Pedersen TR, Kjekshus J, Faergeman O, Olsson AG, Thorgeirsson G. Cholesterol lowering with simvastatin improves prognosis of diabetic patients with coronary heart disease. A subgroup analysis of the Scandinavian Simvastatin Survival Study (4S). Diabetes Care. 1997;20(4):614–20.PubMedCrossRefGoogle Scholar
  11. 11.
    Gaede P, Vedel P, Larsen N, Jensen GV, Parving HH, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med. 2003;348(5):383–93.PubMedCrossRefGoogle Scholar
  12. 12.
    The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329(14):977–86.CrossRefGoogle Scholar
  13. 13.
    Snow V, Aronson M, Hornbake ER, Mottur-Pilson C, Weiss KB; The Clinical Efficacy Subcommittee of the American College of Physicians. Lipid control in the management of type 2 diabetes mellitus: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2004;140(8):644–9.PubMedGoogle Scholar
  14. 14.
    California Healthcare Foundation/American Geriatrics Society Panel on Improving Care for Elders with Diabetes. Guidelines for improving the care of the older person with diabetes mellitus. J Am Geriatr Soc. 2003;51(5s):S265–80.CrossRefGoogle Scholar
  15. 15.
    Vinik AI, Vinik E. Prevention of the complications of diabetes. Am J Manag Care. 2003;9(3 Suppl):S63–80; quiz S81–4.PubMedGoogle Scholar
  16. 16.
    United Kingdom Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ. 1998;317(7160):703–13.Google Scholar
  17. 17.
    Garfield SA MS, Chin MH, Venkat Narayan KM, et al. Considerations for diabetes translational research in real-world settings. Diabetes Care 2003;26(9):2670–4.PubMedCrossRefGoogle Scholar
  18. 18.
    Renders CM, Valk GD, Griffin SJ, Wagner EH, Eijk Van JT, Assendelft WJ. Interventions to improve the management of diabetes in primary care, outpatient, and community settings: a systematic review. Diabetes Care. 2001;24(10):1821–33.PubMedCrossRefGoogle Scholar
  19. 19.
    Berwick DM. Disseminating innovations in health care. JAMA. 2003;289(15):1969–75.PubMedCrossRefGoogle Scholar
  20. 20.
    Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA. 2002;288(15):1909–14.PubMedCrossRefGoogle Scholar
  21. 21.
    Wagner EH, Glasgow RE, Davis C, et al. Quality improvement in chronic illness care: a collaborative approach. Jt Comm J Qual Improv. 2001;27:63–80.PubMedGoogle Scholar
  22. 22.
    Chin MH, Cook S, Drum ML, et al. Improving diabetes care in midwest community health centers with the health disparities collaborative. Diabetes Care. 2004;27(1):2–8.PubMedCrossRefGoogle Scholar
  23. 23.
    Mangione-Smith R, Schonlau M, Chan KS, et al. Measuring the effectiveness of a collaborative for quality improvement in pediatric asthma care: does implementing the chronic care model improve processes and outcomes of care? Ambul Pediatr. 2005;5(2):75–82.PubMedCrossRefGoogle Scholar
  24. 24.
    Asch SM BD, Keesey JW, Broder M, et al. Does the collaborative model improve care for chronic heart failure? Med Care. 2005;43(7):667–75.PubMedCrossRefGoogle Scholar
  25. 25.
    Piatt GA, Orchard TJ, Emerson S, et al. Translating the chronic care model into the community: results from a randomized controlled trial of a multifaceted diabetes care intervention. Diabetes Care. 2006;29(4):811–7.PubMedCrossRefGoogle Scholar
  26. 26.
    Institute for Healthcare Improvement. The breakthrough series: IHI’s collaborative model for achieving breakthrough improvement,, 2005. Accessed 10.12.06
  27. 27.
    Landon BE, Wilson IB, McInnes K, et al. Effects of a quality improvement collaborative on the outcome of care of patients with HIV infection: the EQHIV study. Ann Intern Med. 2004;140(11):887–96.PubMedGoogle Scholar
  28. 28.
    Horbar JD, Rogowski J, Plsek PE, et al. Collaborative quality improvement for neonatal intensive care. Pediatrics. 2001;107(1):14–22.PubMedCrossRefGoogle Scholar
  29. 29.
    Solberg L, Kottke T, Brekke M, et al. Failure of a continuous quality improvement intervention to increase the delivery of preventive services a randomized trial. Eff Clin Pract. 2000;3(3):153–5.PubMedGoogle Scholar
  30. 30.
    Pearson ML WS, Schaefer J, Bonomi AE, et al. Assessing the implementation of the chronic care model in quality improvement collaboratives. Health Serv Res. 2005;40(4):978–96.PubMedCrossRefGoogle Scholar
  31. 31.
    Cretin S, Shortell SM, Keeler EB. An evaluation of collaborative interventions to improve chronic illness care. Framework and study design. Eval Rev. 2004;28(1):28–51.PubMedCrossRefGoogle Scholar
  32. 32.
    Stevens RJ, Kothari V, Adler AI, Stratton IM. The UKPDS risk engine: a model for the risk of coronary heart disease in type II diabetes (UKPDS 56). Clin Sci (Lond). 2001;101(6):671–9.CrossRefGoogle Scholar
  33. 33.
    Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83.PubMedCrossRefGoogle Scholar
  34. 34.
    Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension. 2003;42(6):1206–52.PubMedCrossRefGoogle Scholar
  35. 35.
    Vijan S, Hayward RA. Treatment of hypertension in type 2 diabetes mellitus: blood pressure goals, choice of agents, and setting priorities in diabetes care. Ann Intern Med. 2003;138(7):593–602.PubMedGoogle Scholar
  36. 36.
    Collins R, Armitage J, Parish S, Sleigh P, Peto R; Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placebo-controlled trial. Lancet. 2003;361(9374):2005–16.PubMedCrossRefGoogle Scholar
  37. 37.
    Khaw K-T, Wareham N, Bingham S, Luben R, Welch A, Day N. Association of hemoglobin A1c with cardiovascular disease and mortality in adults: the European prospective investigation into cancer in Norfolk. Ann Intern Med. 2004;141(6):413–20.PubMedGoogle Scholar
  38. 38.
    Sung NS, Crowley WF, Jr., Genel M, et al. Central challenges facing the national clinical research enterprise. JAMA. 2003;289:1278–87.PubMedCrossRefGoogle Scholar
  39. 39.
    Tunis SR, Stryer DB, Clancy CM. Practical clinical trials: increasing the value of clinical research for decision making in clinical and health policy. JAMA. 2003;290:1624–32.PubMedCrossRefGoogle Scholar
  40. 40.
    National Committee for Quality Assurance. The State of Health Care Quality. 2003. 2000 L Street, NW Suite 500, Washington D.C. 20036. Page 50.Google Scholar
  41. 41.
    Bowman MA, Konen JC. Quality of outpatient care: diabetes. JAMA. 1995;274:1584; author reply 1585.PubMedCrossRefGoogle Scholar
  42. 42.
    Clemenson N. Quality of outpatient care: diabetes. JAMA. 1995;274(20):1584; author reply 1585.PubMedCrossRefGoogle Scholar
  43. 43.
    Frijling BD, Lobo CM, Keus IM, et al. Perceptions of cardiovascular risk among patients with hypertension or diabetes. Patient Educ Couns. 2004;52(1):47–53.PubMedCrossRefGoogle Scholar
  44. 44.
    Nelson K, Garcia RE, Brown J, et al. Do patient consent procedures affect participation rates in health services research? Med Care. 2002;40:283–8.PubMedCrossRefGoogle Scholar
  45. 45.
    U.S. Department of Health and Human Services Center for Disease Control and Prevention. National Diabetes Fact Sheet: General Information and National Estimates on Diabetes in the United States 2003. Atlanta, GA: 2004.Google Scholar

Copyright information

© Society of General Internal Medicine 2007

Authors and Affiliations

  • Roberto B. Vargas
    • 1
    • 2
  • Carol M. Mangione
    • 1
    • 2
  • Steven Asch
    • 2
    • 3
  • Joan Keesey
    • 2
  • Mayde Rosen
    • 2
  • Matthias Schonlau
    • 2
  • Emmett B. Keeler
    • 2
  1. 1.Division of General Internal Medicine and Health Services ResearchDavid Geffen School of Medicine at UCLALos AngelesUSA
  2. 2.RAND HealthSanta MonicaUSA
  3. 3.Division of General Internal Medicine, West Los Angeles Veteran’s Administration HospitalDavid Geffen School of Medicine at UCLALos AngelesUSA

Personalised recommendations