Disease Management and Health Outcomes

, Volume 9, Issue 12, pp 691–698 | Cite as

Primary Care Clinic-Based Chronic Disease Care

Features of Successful Programs
  • Patrick J. Os’Connor
  • JoAnn M. Sperl-Hillen
  • Nicolaas P. Pronk
  • Terry Murray
Original Research Article



To identify common features of primary care clinics that have successfully achieved improvement in chronic disease care.


We analyzed seven primary care practices that have achieved significant improvement in chronic disease care provided to adults with diabetes mellitus, hypertension, lipid disorders, or heart disease. Strategies used to improve care were mapped across categories of the Enhanced Primary Care (EPC) model, and common features were identified.


The seven practices achieved significant improvement in health outcomes of adults with diabetes mellitus, hypertension, or lipid disorders within 1 to 2 years. Outcome measures typically included all people in the practice with the conditions of interest. Improvement was sufficient to substantially reduce risk of major cardiovascular events by over 20% on a population basis. In the majority of successful primary care practices, combinations of ten key strategies were used: leadership; resources; clinical guidelines; organized care teams; patient activation; information systems; identification of population at risk; monitoring; prioritization; and active outreach to patients.


The results support the existence of an EPC model capable of achieving significant improvements in chronic disease care over a relatively short period of time. Health systems and primary care practices interested in improving the care of patients with chronic diseases may consider simultaneous use of the various improvement strategies identified in this study.


Medical Group Primary Care Clinic Primary Care Practice Improvement Strategy Active Outreach 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



This work was supported in part by RO1 grant HS09946 from The Agency for Health Care Research and Quality. The authors report no conflict of interest related to the content of this article.


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Copyright information

© Adis International Limited 2001

Authors and Affiliations

  • Patrick J. Os’Connor
    • 1
  • JoAnn M. Sperl-Hillen
    • 1
  • Nicolaas P. Pronk
    • 1
  • Terry Murray
    • 2
  1. 1.HealthPartners Research FoundationMinneapolisUSA
  2. 2.Quello Medical GroupBloomington, MinneapolisUSA

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