skip navigation

Volume 14, Issue 1
Winter 2002

• Feature Article
• Center News
• Research Highlights
• Recent Presentations
• Recent Publications
• Research Newsletter Page

Feature Article

The MacColl Institute:

Closing the gap between what we know and what we do

By Katie Saunders

Health care quality represents an area of longstanding interest for Ed Wagner, MD, director of the MacColl Institute for Healthcare Innovation at Group Health Center for Health Studies.

"I’ve always been distressed by the gap between what we know and what we do," says Wagner. He points out that the gap between "what is possible" and "what is" has only gotten bigger over time because treatments have become so much more effective. Wagner is not alone in his concern about health care quality. A 2001 report issued by the Institute of Medicine (IOM) concluded that "between the health care we have and the care we should have lies not just a gap, but a chasm."

Sub-optimal treatment of chronic conditions is one of the major emphases of the report. These conditions, such as diabetes, heart disease, and asthma, impact almost half the U.S. population and account for the majority of health care expenses. However, according to the report, most people with chronic diseases do not receive the care they need. Ed Wagner, one of six reviewers of the IOM report, shares this perspective. "Meeting the complex needs of patients with chronic illness or impairment is the single greatest challenge facing organized medical practice," he says.

What accounts for the "quality chasm" related to the care for chronic conditions? According to Wagner, health care is largely organized around the treatment of acute diseases. The acute care model is founded on a one-time exchange of information between the patient and physician during which the physician identifies and fixes the disease. In contrast to this single encounter, management of chronic conditions requires planned, regular interactions with providers, with an emphasis on functioning and prevention of complications. Systematic assessments, adherence to treatment guidelines and support for patient self-management are key elements of successful chronic illness care. At Group Health, this systematic approach to caring for patients with chronic illness is referred to as "population-based care."

Top

Diabetes care was the first success
Wagner was one of the first people at Group Health to articulate the concept of population-based care. He and the MacColl Institute staff had the opportunity to pilot test some of these ideas in the early to mid 1990s, specifically for the treatment of diabetes. "Diabetes care was our laboratory where we were privileged to take these ideas and really try them out," he says. For example, the prototype for the diabetes registry, now used throughout Group Health Cooperative, was built in the MacColl Institute in the early 1990s. The Institute also introduced the concept of the "diabetes expert team." Comprised of diabetologist David McCulloch, MD, and diabetes nurse specialist Martha Price, this team shares expertise with primary care providers through the mechanism of joint visits with diabetes patients. Emphasizing the collaborative nature of this work, Wagner credits Institute staff Brian Austin, Connie Davis, Mike Hindmarsh, Melissa Parkerton, Nimi Sandhu, and Judith Schaefer for their contributions, as well as the cooperation of members of Group Health’s delivery system.

These early efforts in diabetes were a major influence on the subsequent creation of Group Health’s Clinical Roadmap framework. The Roadmaps provide direction for clinical improvement efforts for defined populations of patients, such as patients with heart disease or asthma. Group Health currently supports the following 12 Roadmaps: asthma, breast care, cervical cancer, depression, diabetes, healthy adults and children, heart care, HIV, immunization, pregnancy, senior care, and tobacco use. These efforts related to population-based care have put Group Health on the map. Group Health was featured relatively prominently in the IOM report on health care quality. Among other things, Group Health is recognized for its commitment to evidence-based medicine and its well-structured primary care system that enhances population-based care.

Top

ICIC impacts care nationally
Wagner hopes that other health care systems will emulate Group Health’s historical commitment to improving the treatment of chronic conditions. He points out that the ultimate success of clinical-improvement efforts depends not only on their effectiveness, but also on their "reach," or the number of people who are positively impacted. To that end, the MacColl Institute is currently the site of "Improving Chronic Illness Care (ICIC)," a national program office of The Robert Wood Johnson Foundation.

The goal of ICIC is to help people with chronic diseases by "teaching health care systems to keep patients as healthy as possible through planning, proven strategies, and management." (ICIC Web site). ICIC grew out of Group Health’s experience with population-based care. At the heart of ICIC is the Chronic Care Model, which summarizes the fundamental components for improving care in health systems at the community, organization, practice, and patient levels. The Model focuses on six areas: organization of health care, community linkages, self-management support, delivery system design, decision support, and information systems. ICIC sponsors "collaboratives" which assemble dozens of organizations in year-long efforts to improve care for a specific chronic illness, based on elements of the Chronic Care Model.

ICIC’s biggest success story to date has been the participation of the Bureau of Primary Health Care, part of the federal Health Resources and Services Administration. According to MacColl Institute Deputy Director Brian Austin, the Bureau operates over 700 community health centers nationwide that serve people who have no other sources of care, such as the uninsured or working poor. Nationally, all health centers have committed to the Chronic Care Model and to the goal of eliminating disparities in care by 2005. Austin points out that while the demographic groups served by these centers typically receive substandard care, in many cases they now will be the recipients of the best available chronic-disease care in their communities.

Top

WHO collaboration may influence care globally
The Institute is also collaborating with the World Health Organization (WHO) on chronic illness care. As life expectancies have increased in developing countries, the relative burden of chronic disease has also grown. By 2020, chronic conditions are predicted to be the primary cause of death and disability in the world. In light of this, WHO is working with the MacColl Institute to sponsor a chronic disease initiative—"Innovative Care for Chronic Conditions"—to help spread examples of good, affordable care for people with chronic illness. The WHO initiative and other global efforts to improve chronic illness care are encouraging the Institute to place more emphasis on assessing how the Chronic Care Model translates internationally, says Austin.

Wagner is encouraged by these and other developments on the health care quality front. He points out that people have been aware of deficiencies in health care quality for at least the last two decades, but little has been done to remedy the situation. That might be changing. "I’m modestly optimistic that our society is beginning to see that something’s got to change and we are making some efforts that we weren’t making before," says Wagner. For example, the IOM report recommends that the federal Agency for Healthcare Research and Quality identify at least 15 priority conditions, most of them chronic. Then health care professionals, health plans, purchasers and others would develop strategies to improve care for these conditions over a five-year period.

Meanwhile, Wagner and the MacColl Institute have their own plans for the next five years. "Our goal is to help improve the care of patients around the world who are suffering from major chronic illness," says Wagner.

For more information on Improving Chronic Illness Care, go to www.improvingchroniccare.org.

Top

Download feature
article in .pdf format.