Nov. 13, 2003
UNC Health Care establishes Center for Excellence in Chronic Illness Care
BY REBEKAH TEMPLE
UNC Health Care
CHAPEL HILL, N.C. – It’s a tradition and a standing appointment for several University of North Carolina at Chapel Hill School of Medicine faculty and UNC Hospitals staff. No latex gloves, stethoscopes, pens or agendas are required. The only order of business is to celebrate Floyd “Buddy” Davis’ birthday.
At some point, most people try to forget their birthday, but not Davis. For the last 20 years, the Moncure resident has been celebrating his Aug. 11 birthday by throwing a barbecue at his home. Family, friends and neighbors all come, sometimes more than 100 strong, bringing with them all the “fixins” – potato salad, baked beans, ,corn, fried chicken and fish are among the feast..
Davis invites “everyone who wants to come” to his party, and for the last half dozen years his invitation list has included his physicians and other providers at UNC Hospitals.
Now 76, Davis has been cared for by many over his years of coming to UNC, including Dr. Michael Pignone and pharmacist Dr. Robb Malone, both of the Division of General Medicine. For the last four years, Pignone and Malone have been on the forefront of a movement to change the way care is delivered to patients like Davis with chronic illness.
Through the General Internal Medicine Practice at the Ambulatory Care Center on the UNC-Chapel Hill campus, Pignone and Malone have developed a comprehensive program for patients with chronic illness, particularly diabetes. The program has been so successful that Pignone and Malone have been given UNC Health Care funding to establish the Center for Excellence in Chronic Illness Care, a performance improvement initiative.
Pignone and Malone, co-directors of the center, believe that the chronic illness program is one of the main reasons Davis still is well enough to host his birthday parties. And Davis agrees.
“They had doubts about ol’ Buddy (back) then,” said Davis who has been a patient of the practice’s diabetes program since it was established in 1999..
According to Malone, Davis’ health is better now than it was when he started the program. “For all the health issues he has, he’s doing very well,” Malone said.
In addition to diabetes, Davis has high cholesterol, hypertension, congestive heart failure and renal insufficiency. He takes 23 medications on a daily basis. Davis was an obvious candidate for the diabetes program.
The program was started to try to improve care for patients with diabetes. Two pharmacists were hired to lead the program, Malone one of them, and they had one year to show results without increasing patient visits. So, they got on the telephone.
They selected patients not doing particularly well with glucose control and called them to ask about their blood sugar and blood pressure. They discussed and encouraged lifestyle modifications, including diet and exercise, adjusted medications according to pre-specified algorithms and reminded patients of their appointments.
They also created a database to keep track of all the patients in the program and to document how they were doing. “What is unique about disease management is it is systematic approach for patient care. It takes at risk patients and then intervenes with specific programs of care and it measures the clinical outcomes,” Pignone said.
Their pilot study of the program found that participants had an average reduction in hemoglobin A1c, a measure of blood sugar control, of 1.9 percentage points, from 10.8 percent to 8.9 percent. The results were so promising that Pignone and Malone, along with others, decided to pursue a randomized trial, which was completed this past May.
The trial confirmed the result of their previous work. Again, hemoglobin A1c decreased by an average of 1.9 percentage points in patients enrolled in the program compared to those receiving routine care. They also saw large improvements in blood pressure and aspirin use. Based on these changes, patients in the program will have over a 50 percent decrease in heart attacks and strokes, the major causes of death for patients with diabetes. Patient satisfaction increased significantly as well.
The results have gotten the attention of others. The group had an article published in the spring in the American Journal of Medical Quality on the pilot study and have submitted the results of the randomized trial to Annals of Internal Medicine. Additionally, Dr. Russell Rothman who worked with
the team during his fellowship in the Robert Wood Johnson Clinical Scholars Program, presented the results of the randomized trial at a meeting of the national Society of General Internal Medicine, where it won an award for best research project.
The initial success of the diabetes program also led to the creation of other programs within the General Internal Medicine Practice. In 2001, an anticoagulation program was started. “We were seeing such great results with the diabetes program, that we decided to use the same approach to treat patients with blood clotting disorders,” Pignone said.
A year ago, a chronic pain program also was started and this year is being expanded to patients with osteoarthritis. These programs still are in pilot phases, but the results suggest similarly large improvements in the quality of care. The hope is to expand to other conditions, such as depression and asthma/chronic obstructive pulmonary disease, both within the General Internal Medicine Practice and in other specialties.
“We have established a multidisciplinary, disease management approach that we think can be modified and tailored to work with many different chronic illnesses,” Pignone said.
According to Pignone, the benefits of using systematic approaches to actively manage chronic disease are numerous. “As a provider in the practice, I have found that our programs for chronic illness make providing care more enjoyable, make our patients more satisfied and improve outcomes. It is really a win-win situation. I am excited to help bring this model of care to patients throughout UNC Health Care.”
Note to media: A photograph of Davis with Drs. Pignone and Malone is available for downloading at www.unchealthcare.org/images/chronic_disease.jpg.
Suggested photo caption:
Michael Pignone, MD, (left) and Robb Malone, PharmD, (right) chat with Floyd Davis during one of his recent appointments. Davis has been a patient of the Division of General Internal Medicine Practice’s Diabetes Program since it was established in 1999. Because of the program, Davis’ health is better now than it was four years ago.
To request an interview with Davis, Pignone or Malone, call Stephanie Crayton-Robinson at (919) 966-2860.