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Improving Chronic Disease Care by Adding Laypersons to the Primary Care Team: A Parallel Randomized Trial

Richard Adair, MD; Douglas R. Wholey, PhD; Jon Christianson, PhD; Katie M. White, EdD; Heather Britt, PhD; and Suhna Lee, MPA
[+] Article, Author, and Disclosure Information

From Allina Health and the University of Minnesota, Minneapolis, Minnesota.

Acknowledgment: The authors thank Lori Boland, MPH (study concept and design); Kimberly Radel, MHA, Deborah Elumba, RN, Sana Iverson, RN, Allison Shipley, BA, and Tamara J. Winden, MBA (study supervision and data acquisition); Sochenda Nelson, BS (manuscript revision); and Jean Marie Berquist, RN, BSN (development of EHR reporting tools).

Financial Support: By the Robina Foundation.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-3106.

Reproducible Research Statement: Study protocol and statistical code: Available from Kimberly Radel (e-mail, kimberly.radel@allina.com). Data set: Not available.

Requests for Single Reprints: Kimberly Radel, MHA, Allina Health, 2925 Chicago Avenue, Minneapolis, MN 55407; e-mail, kimberly.radel@allina.com.

Current Author Addresses: Dr. Adair: Medicine Clinic, 2800 Chicago Avenue South, #250, Minneapolis, MN 55407.

Drs. Wholey, Christianson, and White and Ms. Lee: University of Minnesota, Division of Health Policy & Management, Mail Code 8729A, 420 Delaware Street SE, Minneapolis, MN 55455.

Dr. Britt: Allina Health, 2925 Chicago Avenue, Minneapolis, MN 55407.

Author Contributions: Conception and design: R. Adair, D.R. Wholey, J. Christianson, K.M. White, H. Britt.

Analysis and interpretation of the data: R. Adair, D.R. Wholey, J. Christianson, K.M. White, S. Lee.

Drafting of the article: R. Adair, K.M. White, S. Lee.

Critical revision of the article for important intellectual content: R. Adair, D.R. Wholey, J. Christianson, K.M. White, H. Britt, S. Lee.

Final approval of the article: R. Adair, D.R. Wholey, J. Christianson, K.M. White, H. Britt.

Statistical expertise: D.R. Wholey, S. Lee.

Obtaining of funding: R. Adair, H. Britt.

Administrative, technical, or logistic support: R. Adair, J. Christianson, H. Britt, S. Lee.

Collection and assembly of data: R. Adair, S. Lee.

Ann Intern Med. 2013;159(3):176-184. doi:10.7326/0003-4819-159-3-201308060-00007
Text Size: A A A

Background: Improving the quality and efficiency of chronic disease care is an important goal.

Objective: To test whether patients with chronic disease working with lay “care guides” would achieve more evidence-based goals than those receiving usual care.

Design: Parallel-group randomized trial, stratified by clinic and conducted from July 2010 to April 2012. Patients were assigned in a 2:1 ratio to a care guide or usual care. Patients, providers, and persons assessing outcomes were not blinded to treatment assignment. (ClinicalTrials.gov: NCT01156974)

Setting: 6 primary care clinics in Minnesota.

Patients: Adults with hypertension, diabetes, or heart failure.

Intervention: 2135 patients were given disease-specific information about standard care goals and asked to work toward goals for 1 year, with or without the help of a care guide. Care guides were 12 laypersons who received brief training about these diseases and behavior change.

Measurements: The primary end point for each patient was change in percentage of goals met 1 year after enrollment.

Results: The percentage of goals met increased in both the care guide and usual care groups (changes from baseline, 10.0% and 3.9%, respectively). Patients with care guides achieved more goals than usual care patients (82.6% vs. 79.1%; odds ratio, 1.31 [95% CI, 1.16 to 1.47]; P < 0.001); reduced unmet goals by 30.1% compared with 12.6% for usual care patients; and improved more than usual care patients in meeting several individual goals, including not using tobacco. Estimated cost was $286 per patient per year.

Limitations: Providers' usual care may have been influenced by contact with care guides. Last available data in the electronic health record were used to assess end points.

Conclusion: Adding care guides to the primary care team can improve care for some patients with chronic disease at low cost.

Primary Funding Source: The Robina Foundation.

Chinese translation


Grahic Jump Location

Study flow diagram.

* Includes all nonpregnant patients aged 18 to 79 y with diabetes, hypertension, or heart failure seen during the enrollment period.

† The last available data for patients who moved or changed clinics were included in the analysis because these patients could (and sometimes did) return.

‡ Data were removed at the request of the 9 patients who withdrew and for the pregnant patient because she discovered that she was pregnant soon after enrollment.

§ Used last available data in the electronic health record.

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Submit a Comment/Letter
Improving the U.S. Health Care System
Posted on August 15, 2013
Justin D. Lee, Daniel G. Arkfeld
USC Keck School of Medicine
Conflict of Interest: None Declared
It is with much interest that I have reviewed Dr. Adair et. al. improving chronic disease care article. This study provides an interesting and innovative way to utitilize laypersons with less training than the traditional doctor or nurse in order to improve health care for patients suffering from chronic illness. With looming future healthcare reforms where universal healthcare will create the need for more primary care physicians, this article provides an option to not only curtail the need for more highly trained, expensive medical staff but also to improve the quality of chronic illness treatment. It is recommended that further research is done on the cost of these care guides in order to see if costs per patient can be lowered without affecting the overall results and if a change in the overall training time of two weeks alters the effectiveness of the percent goals met. Further research should also be done on whether the patient's attitude and trust changes between these laypersons and a fully trained doctor and if the benefits of these laypersons truly outweigh the costs.
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Summary for Patients

Does Adding Laypersons to Primary Care Teams Improve Care for Chronic Diseases?

The full report is titled “Improving Chronic Disease Care by Adding Laypersons to the Primary Care Team. A Parallel Randomized Trial.” It is in the 6 August 2013 issue of Annals of Internal Medicine (volume 159, pages 176-184). The authors are R. Adair, D.R. Wholey, J. Christianson, K.M. White, H. Britt, and S. Lee.


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