According to a new study, a population health management program (PHM) using a health information technology (IT) tool could significantly improve the process and outcome measures for patients with diabetes, cardiovascular disease, and hypertension.

Researchers developed and implemented a health information technology-enabled population health management program for chronic disease management in academic hospital-affiliated primary care practices.

The researchers conducted a quasi-experimental evaluation of the program and compared quality-of-care process and outcome measures over the first 6 months of the PHM program in practices assigned a central population health coordinator (PHC) with those not assigned a PHC.

Central PHCs were non-randomly assigned to 8 of 18 practices. They met with physicians, managed lists of patients not at goal in chronic disease registries, and performed administrative tasks.

In non-PHC practices, existing staff remained responsible for these tasks. The primary outcome was difference-in-differences over the 6-month follow-up period between PHC and non-PHC practices.

The primary outcomes included diabetes (low-density lipoprotein cholesterol [LDL-C], glycated haemoglobin [A1C], and blood pressure [BP] goal attainment), cardiovascular disease (LDL-C goal attainment), and hypertension (BP goal attainment).

The secondary outcomes included process measures only (obtaining LDL-C, A1C, and BP readings) and cancer screening test completion.

The difference in the percentage point (PP) increase in outcome measures over follow-up was greater in PHC practices than non-PHC practices for all measures among patients with diabetes, cardiovascular disease, and hypertension.

The PHCs did not focus on cancer screening, and during the same time period, there were similar changes in cancer screening rates between PHC and non-PHC practices.

The study findings revealed that a PHM program using a health IT tool improved process and outcome measures for patients with diabetes, CVD, and HTN over short-term follow-up.

Further, utilizing central PHCs who worked closely with practice personnel led to greater improvement in outcome measures in those practices’ patients compared with patients in practices not assigned central coordinators.

The results support the use of central personnel working with practice-based staff on PHM programs. However, longer-term follow-up is required to evaluate outcomes over time. New funding mechanisms are needed to support such practice- and network-based efforts to improve population-based chronic disease management.