Introduction: Chronic diseases are the leading cause of death and disability in almost all over the world; in Europe causing over 9 million deaths per year according to WHO estimates. A promising health organization model for chronic disease management is represented by the Chronic Care Model (CCM). In the 12th district of the ASL Roma 2 since 4 years was implemented a CCM for the management of patients affected by diabetes and/or at high cardiovascular risk.
Objective: Aim of this study is to evaluate the effectiveness of the Chronic Care Model (CCM) for the management of chronic disease in terms of mortality reduction, avoidable hospitalizations reduction and improvement of clinical parameters.
Materials and methods: A retrospective cohort study will involve patients of 12th district of the ASL Roma 2 affected by diabetes and at high cardiovascular risk assisted through the CCM. Their health outcomes will be compared with those of patients in the same clinical conditions, residents in the same district but not assisted with CCM. The sample will be composed by adults (> 18 years) with a diagnosis of diabetes mellitus type 2 (DM2) or metabolic syndrome and / or arterial hypertension (IT) and two or more risk factors. Outcomes will be mortality from all causes and from causes related to DM and IT, preventable hospitalizations as defined in the Prevention Quality Indicators (PQI) by the Agency for Healthcare Research and Quality, and 10 clinical parameters. The data sources will be the records of causes of death (RENCAM), the hospital discharge records (SDO) and information systems for primary healthcare.
Conclusion: Data from the experience of CCM in Tuscany seem promising especially in the evaluation of patient satisfaction and clinical outcomes particularly on cardiovascular and neurological complications and long-term mortality.
Keywords: Chronic care model; Chronic disease; Community care; Diabetes; Hypertension; Primary care.