Of the more than 160,000 patients cared for in the network, there were 12,316 with diabetes, 12,591 with cardiovascular disease and 41,591 with hypertension. For each group of patients, the researchers compared outcomes – such as whether patients were receiving appropriate and timely testing and monitoring and whether they achieved clinical goals, such as target A1C levels for patients with diabetes or cholesterol levels for those with cardiovascular disease – at practices with centralized population health coordinators to those at practices without coordinators.

While all of the network practices showed significant increases in chronic disease outcomes during the six-month study period from July through December 2017, those improvements were measurably greater at practices where central population health coordinators worked closely with practice staff. Practices with coordinators showed greater improvement in the percentages of patients who received appropriate testing and in those who achieved clinical targets. As a control measure, the researchers also compared the percentages of patients who received appropriate cancer screenings during the study period, which the central coordinators did not focus effort on these registries, and found no significant differences between the practices with and without coordinators.


“Since our study was limited to six months, after which the program was expanded to all MGH primary care practices, we need longer-term follow-up to assess outcomes over time,” says Ashburner, who is an instructor in Medicine at Harvard Medical School. “But our results clearly show that a population health management program in which centralized coordinators work closely with practice staff provides even greater improvement in clinical outcomes for patients with diabetes, cardiovascular disease or hypertension.”

Co-authors of the American Journal of Managed Care report are senior author Steven Atlas, MD, MPH, MGH Division of General Internal Medicine; Daniel Horn, MD and Yuchiao Chang, PhD, MGH General Internal Medicine; Sandra O’Keefe, MPH, Mass. General Physician’s Organization; Adrian Zai, MD, PhD, MGH Laboratory of Computer Sciences; and Neil Wagle, MD, MBA, Brigham and Women’s Hospital.

Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH Research Institute conducts the largest hospital-based research program in the nation, with an annual research budget of more than $900 million and major research centers in HIV/AIDS, cardiovascular research, cancer, computational and integrative biology, cutaneous biology, genomic medicine, medical imaging, neurodegenerative disorders, regenerative medicine, reproductive biology, systems biology, photomedicine and transplantation biology. The MGH topped the 2015 Nature Index list of health care organizations publishing in leading scientific journals and earned the prestigious 2015 Foster G. McGaw Prize for Excellence in Community Service. In August 2017 the MGH was once again named to the Honor Roll in the U.S. News & World Report list of "America's Best Hospitals."

Back to HCB News

Population Health Homepage