O RIGINAL A RTICLE Improving Chronic Illness Care A Longitudinal Cohort Analysis of Large Physician Organizations Stephen M. Shortell, PhD, MBA, MPH,* Robin Gillies, PhD,* Juned Siddique, DrPH,† Lawrence P. Casalino, MD, PhD,‡ Diane Rittenhouse, MD, MPH,§ James C. Robinson, PhD,* and Rodney K. McCurdy, MHA* Background: An increasing number of people suffer from chronic illness. Processes exist to provide better chronic illness care and yet for the most part, they are not used. Objective: To examine the change in use of commonly recom- mended chronic illness care management processes (CMPs) in large medical groups between 2000 and 2006 and the factors associated with the change. Design and Measures: Cohort analysis of data from a national telephone survey in year 2000 and again in 2006. Participants provided information on their organizations’ ownership, size, use of defined chronic illness CMPs, financial incentives, quality improvement in- volvement, profitability, and use of electronic medical records. Setting: Medical groups and independent practice associations of 20 physicians or more (N ⫽ 369) that treat patients with asthma, congestive heart failure, depression, and diabetes, and that re- sponded to the survey in 2000 and 2006. Results: Use of CMP increased from 6.25 to 7.67 (of a total of 17; P ⱕ 0.001), that is, by 23%, between 2000 and 2006. Increases were greatest for those practices receiving financial rewards for quality; those participating in quality improvement activities; and those practices that were profitable. Most of the increase was in use of registries and in patient self-management support services. Conclusions: There is significant opportunity for improving chronic illness care even in larger physician organizations. Public policies that promote financial rewards for improving quality and that en- courage quality improvement initiatives are likely to be associated with improved chronic illness care. Key Words: chronic illness, chronic care model, quality improvement, financial incentives (Med Care 2009;47: 932–939) From the *Division of Health Policy and Management, School of Public Health, University of California, Berkeley, CA; †Department of Preven- tive Medicine, Northwestern University, Chicago, IL; ‡Department of Public Health, Weill Cornell Medical College, New York, NY; and §Department of Family and Community Medicine, University of Cali- fornia, San Francisco, CA. Supported by Robert Wood Johnson Foundation, grant 51573; the Common- wealth Fund, grant 20050334; and California Healthcare Foundation, Reprints: Stephen M. Shortell, PhD, MBA, MPH, School of Public Health 50 University Hall, Berkeley, CA 94720. E-mail: shortell@berkeley.edu. Copyright © 2009 by Lippincott Williams & Wilkins ISSN: 0025-7079/09/4709-0932 | www.lww-medicalcare.com A pproximately, 20 million Americans suffer from asthma; 5 million from congestive heart failure; 26 million from depression; and 21 million from diabetes. 1– 4 Collectively, these 4 chronic illnesses amount to $149 billion in direct costs and $286 billion in total costs annually. 1– 4 In recent years evidence has begun to emerge that the use by medical groups of organized care management processes (CMPs) to care for patients with these diseases improves the quality and out- comes of care. 5–9 Yet, many Americans do not receive such care 10 and many physician practices do not use recommended processes for managing patients with chronic illness. 11 These processes include use of disease registries that enable physician organizations to identify their patients with chronic illnesses; development of patient education programs to help patients better manage their illnesses; use of nurse care managers for the sickest patients with the most complex needs; providing feedback to physicians on their performance; providing physicians and patients with reminders and decision support information at the time of care; and related items. These processes are key elements of the chronic care model. 12–15 We examine whether greater use of these processes occurs when physician organizations have the capabilities to create and maintain them and when they are given incentives to invest in improving quality. In 2000, we created a national database to survey all large medical groups (20 or more physicians) and independent practice associations (IPAs) in the United States. We conducted a follow-up survey in 2006 to address 2 questions: has the use of CMPs increased among these organizations since 2000; and, if it has, what have been the factors associated with the increase? We hypothesized that organizations that became or remained owned by a hospital/health maintenance organiza- tion (HMO)/or health system, as opposed to independent physician ownership, would increase their CMP use due to the greater financial resources likely to be available to them. We predicted that those that became or remained medical groups would increase their use of CMPs more than IPAs due to the medical groups’ tighter degree of integration than the gen- erally more loosely organized IPAs. We also hypothesized that organizations that became or remained profitable, increased their participation in organized quality improvement efforts, and/or increased their electronic medical record (EMR) ca- pability would be more likely to increase their use of CMPs than organizations remaining less profitable, those not partic- Medical Care • Volume 47, Number 9, September 2009