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      Research Area: Managing Chronic Health Conditions

      Chronic diseases are the leading drivers of healthcare costs and account for most illness, disability, and death in the United States. Ninety percent of the $4.5 trillion spent on healthcare costs annually in the U.S. is for people with chronic and mental health conditions. AMGA works with members to help them identify patients with gaps in care and prioritize outreach and intervention to high-risk populations, especially those with one or more chronic conditions. With these insights, AMGA members can proactively intervene on behalf of patients providing better overall population health.

      Endocrine, nutritional, and metabolic 

      Obesity

      • Diagnosing obesity as the first step to weight loss. Controlling for other patient demographics, insurance status, health utilization, and prescribing anti-obesity medication, documentation of an obesity diagnosis remained independently predictive of >10% total Body Weight Loss. Learn More

      • Quality analysis of data collected during site visits conducted as part of a national learning collaborative in which 10 AMGA members implemented interventions in primary care to improve care for patients with obesity. Learn More
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      • Measuring What Matters study confirmed the feasibility and perceived value of 7 operational performance and patient-centered measures, collected in primary care practices in 10 AMGA member organizations over 18 months. Measures included documented obesity diagnosis, change in weight over time, and prescription of anti-obesity medication. Learn More

      • More information on AMGA obesity resources. Learn More

      Diabetes

      • Evaluation of a multi-site telehealth diabetes prevention program (DPP) demonstrates no observable differences in the effectiveness of the DPP when delivered via telehealth to multiple remote rural communities from a single urban site, compared with face-to-face intervention. Learn More

      • Use of telemedicine for diabetes and hypertension care and impact on patient outcomes and racial/ethnic health disparities. Analysis of changes in clinical care for patients with type 2 diabetes during COVID. In January 2020, <1% of visits were conducted via telehealth, by April 2020 this increased to 64%. Black patients had the smallest declines in visits and the greatest use of telehealth during this time. Learn More

      • Therapeutic inertia in type 2 diabetes management. Retrospective data base study with 22 AMGA members found 50% of T2DM patients after 6 months and 10% after 24 months lacked treatment intensification to control blood glucose levels. Learn More

      • Clinician knowledge and attitudes on guidelines for treatment of T2DM patients with or at high risk for a major adverse cardiac event (MACE). AMGA interviewed clinicians at 4 AMGA member organization and found only 20% were “extremely familiar” with new ADA guidelines recommending new agents for glucose control with cardiac benefits.

      • Enabling T2DM patients to monitor their blood glucose using Continuous Glucose Monitors (CGMS). Link to poster Real-Time Continuous Glucose Monitors found that CGM use in primary care can significantly improve glycemic control in certain T2DM patients. Learn More

      • More information on AMGA obesity resources. Learn More 

      Heart and vascular diseases 

      • PREVENT equations accurately and precisely predict risk for incident cardiovascular disease (CVD) and CVD subtypes in a large, diverse sample of U.S. adults using clinical variables such as smoking status, systolic blood pressure, cholesterol, glomerular filtration rate, antihypertensive or statin use, and diabetes. Learn More

      Hypertension

      • Less precision was observed in diastolic blood pressure (BP) reading and stratifying by practice or provider/care team can lead to more efficient quality improvement. Learn More

      • Patients who received home BP monitoring increased mean BP control rates from 42% to 67% in comparison to matched control patients who improved from 59% to 67%. Learn More

      • Disparities, medication adherence, and therapeutic inertia contributing to disparities in treatment and outcomes across patient and provider characteristics

      • Million Hearts Hypertension Prevalence Estimator tool can predict hypertension prevalence based on demographic and comorbidity characteristics and identify potential underdiagnosed hypertension. Learn More

      • Cardiologists and primary care physicians were interviewed on hypertension and BP control and expressed diverse perspectives on the importance of BP targets (organization wide vs patient level), treatment and escalation, and medication adherence. Learn More

      Peripheral Artery Disease (PAD)

      • An AMGA analysis found almost two-thirds of patients with ulceration related to lower-extremity PAD had no prior PAD diagnosis. AMGA examined the factors driving these health disparities in early diagnosis and treatment of PAD. Learn More

      Atrial Fibrillation (Afib)

      • Patient-, provider-, and health system-level interventions to improve medication adherence to direct oral anticoagulants for patients with non-valvular Afib

      • Primary adherence to oral anticoagulants 

      Venous Thromboembolism (VTE)

      • Creating safe care transitions for patients with VTE throughout their ED, hospital, and outpatient experience. Six AMGA members used implementation science-informed approaches to identify gaps, develop, and implement methods for improved management of patients with VTE during critical times of transition between emergency departments, inpatient, and outpatient settings. Learn More

      Kidney disorders and disease

      • Novel prediction equations for a decline of ≥40% in estimated glomerular filtration rate (eGFR) can be applied successfully for use in the general population in persons with and without diabetes with higher or lower eGFR. Learn More

      • eGFR testing rates are uniformly high among people with type 2 diabetes for whom annual testing for chronic kidney disease is recommended; however, testing rates for urinary albumin-to-creatinine ratio (uACR) are suboptimal although uACR testing may increase detection of CKD. Learn More

      • Home-based urine screening tests were used as a population health screening tool to assess renal function among patients with diabetes and/or hypertension. Screening tests were highly rated by patients and found 60% were in normal range, 36% abnormal, and 4% high abnormal. Learn More

      • uACR is the preferred measure of albuminuria; however, if ACR is not available, predicted ACR from PCR or urine dipstick protein may help in CKD screening, staging, and prognosis. Learn More

      • Equations for predicting 5-year risk of incident chronic kidney disease included age, sex, race/ethnicity, eGFR, history of cardiovascular disease, ever smoker, hypertension, BMI, albuminuria concentration, and diabetes medications (for patients with diabetes only). Learn More

      • Change in albumin-to-creatinine ratio (ACR) consistently associated with subsequent risk of end-stage kidney disease across groups, especially those with ACR 300mg/g or higher. A 30% decrease in ACR over 2 years estimated to confer a more than 1% absolute reduction in 10-year risk of end-stage kidney disease. Learn More 

      Opioid use disorder

      • Over 5% of osteoarthritis patients experience a new period of chronic opioid use (COU) within a given year, however these patients can be identified using EHR data allowing more timely intervention. Learn More
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      • EHR data from 13 healthcare organizations was used to evaluate machine learning models estimating risk of COU within 1 year among patients with osteoarthritis newly prescribed an opioid. Models showed high variable discrimination across organization. Learn More

      • Among patients with incident opioid use disorder, a high medical deductible ($1000+) is associated with lower odds of initiation of medication for opioid use disorder (MOUD) compared with no deductible. Initial 30-day out-of-pocket costs ranged from $100 (methadone) to $710 (extended release naltrexone). Learn More

      • Among patients with a new diagnosis of OUD who had a prescription written for buprenorphine or oral naltrexone, 70% filled the prescription within 30 days with 57% filling on the day it was written. Fill rates were greater for patients with copays at or below the mean. Learn More

       

       
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