Chronic Care Clinics for Diabetes in Primary Care

A system-wide randomized trial

  1. Edward H. Wagner, MD, MPH,
  2. Louis C. Grothaus, MS,
  3. Nirmala Sandhu, MPH,
  4. Mary Sue Galvin, RN, MN,
  5. Mary McGregor, RN, MN,
  6. Karen Artz, RN, MS and
  7. Eric A. Coleman, MD, MPH
  1. W.A. MacColl Institute for Healthcare Innovation, Center for Health Studies, Group Health Cooperative of Puget Sound, Seattle, Washington


    OBJECTIVE—To evaluate the impact of primary care group visits (chronic care clinics) on the process and outcome of care for diabetic patients.

    RESEARCH DESIGN AND METHODS—We evaluated the intervention in primary care practices randomized to intervention and control groups in a large-staff model health maintenance organization (HMO). Patients included diabetic patients ≥30 years of age in each participating primary care practice, selected at random from an automated diabetes registry. Primary care practices were randomized within clinics to either a chronic care clinic (intervention) group or a usual care (control) group. The intervention group conducted periodic one-half day chronic care clinics for groups of ∼8 diabetic patients in their respective doctor’s practice. Chronic care clinics consisted of standardized assessments; visits with the primary care physician, nurse, and clinical pharmacist; and a group education/peer support meeting. We collected self-report questionnaires from patients and data from administrative systems. The questionnaires were mailed, and telephoned interviews were conducted for nonrespondents, at baseline and at 12 and 24 months; we queried the process of care received, the satisfaction with care, and the health status of each patient. Serum cholesterol and HbA1c levels and health care use and cost data was collected from HMO administrative systems.

    RESULTS—In an intention-to-treat analysis at 24 months, the intervention group had received significantly more recommended preventive procedures and helpful patient education. Of five primary health status indicators examined, two (SF-36 general health and bed disability days) were significantly better in the intervention group. Compared with control patients, intervention patients had slightly more primary care visits, but significantly fewer specialty and emergency room visits. Among intervention participants, we found consistently positive associations between the number of chronic care clinics attended and a number of outcomes, including patient satisfaction and HbA1c levels.

    CONCLUSIONS—Periodic primary care sessions organized to meet the complex needs of diabetic patients improved the process of diabetes care and were associated with better outcomes.


    • Address correspondence and reprint requests to Edward H. Wagner, M.D., M.P.H., Center for Health Studies, Group Health Cooperative, 1730 Minor Ave., Suite 1290, Seattle, WA 98101. E-mail: wagner.e{at}

      Received for publication 27 June 2000 and accepted in revised form 7 November 2000.

      A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

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