Protocol for the evaluation of a chronic care model experience in Rome.

Area of Science:

• Public Health
• Healthcare Management
• Chronic Disease Epidemiology

Background:

• Chronic diseases are a leading global cause of death and disability.
• The Chronic Care Model (CCM) is a recognized framework for managing long-term health conditions.
• ASL Roma 2's 12th district has implemented CCM for diabetes and high cardiovascular risk patients for four years.

Purpose of the Study:

• To assess the effectiveness of the Chronic Care Model (CCM) in chronic disease management.
• To evaluate CCM's impact on reducing mortality rates.
• To measure CCM's effect on decreasing avoidable hospitalizations and improving clinical parameters.

Main Methods:

• A retrospective cohort study comparing CCM-assisted patients with non-CCM-assisted patients.
• Inclusion criteria: adults (>18) with type 2 diabetes mellitus (DM2), metabolic syndrome, or arterial hypertension (IT) and ≥2 risk factors.
• Outcomes measured: all-cause mortality, DM/IT-related mortality, preventable hospitalizations (PQI), and 10 clinical parameters using RENCAM, SDO, and primary healthcare data.

Main Results:

• Preliminary data from Tuscany suggest CCM improves patient satisfaction and clinical outcomes.
• CCM shows potential in mitigating cardiovascular and neurological complications.
• Long-term mortality reduction is a key area of promise for CCM implementation.

Conclusions:

• The Chronic Care Model (CCM) demonstrates potential for improving chronic disease management outcomes.
• Further evaluation is needed to confirm CCM's impact on mortality and hospitalizations in the ASL Roma 2 cohort.
• CCM implementation may lead to better clinical results and reduced healthcare utilization for chronic conditions.