Heart-Related Multiple Chronic Conditions in Primary Care: Behavioral Technology

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PROJECT SUMMARY/ABSTRACT This R01 proposal seeks to test a computer technology (C-CHESS) that offers a common approach to multiple chronic conditions (MCCs). Among Medicare beneficiaries, 65% have 3 or more MCCs and 23% have 5 or more. People with MCCs account for 90% of Medicare spending. MCCs are usually addressed in primary care. Increasing workloads in primary care often prevent clinicians from addressing self-management skills with patients, though such skills as goal-setting and tracking are important for managing chronic conditions. Behavioral interventions such as cognitive behavioral therapy, self-monitoring, and social support can improve both self-management skills and health outcomes, and technology can effectively deliver such interventions. C-CHESS (Chronic Condition Health Enhancement Support System) provides tools, motivation, and social support to help patients with MCCs better manage their conditions, including interactions that arise among the combination of conditions. C-CHESS is built on elements of success behavioral interventions: long duration, ongoing outreach, monitoring, prompts, action planning, problem solving, self-tailoring, and peer support. C-CHESS addresses clinician burden by promptly communicating important changes in patient status and—by improving patient-self-management—reducing primary care visits. C-CHESS will be tested in a randomized clinical trial in 5 primary care clinics in southern Wisconsin. The trial will involve 330 patients age 65 and older with 3 or all 4 of these conditions: hypertension, hyperlipidemia, diabetes, and osteoarthritis. Patients will be assigned to treatment as usual + C-CHESS or treatment as usual + access to the Internet. The trial will last 12 months with a 6-month follow up. The goal of the trial is to detect differences between the 2 groups in quality of life and use of primary care. Secondarily, the trial aims to detect differences between the 2 groups in (1) measures for each condition (blood pressure, LDL, blood sugar, and pain); (2) a composite score that combines the individual measures; and (3) number of symptoms patients have from a list of 8. The trial will also examine factors that may mediate the relationship between the interventions and outcomes: adherence to medications and appointment attendance, as well as the 3 components of self-determination theory (patient competence, relatedness to others, and motivation). Finally, the trial will examine factors that may affect the strength of the relationship between C-CHESS and outcomes: gender, age, and number of chronic conditions. If successful, C-CHESS will improve the health and reduce the burden on primary care of a large, growing, expensive group of patients whose conditions are not now well addressed. Successful implementation may point to a shift from care that is place-based, focused on medical management, and periodic to care focused on helping patients manage their own conditions through a system built on the proven principles of effective behavioral interventions made easy for both patients and clinicians to use.