The case for "outsourcing" diabetes care

A Novel Patient-oriented Tool for Evaluating Quality Measurements

Quality measurements (QMs) have emerged as quantitative tools for measuring “quality”, an elusive term that has been historically difficult to define and quantify. However, current literature has demonstrated that these measurements are flawed. The purpose of this study was to identify the strengths and weaknesses of quality measurements and provide a novel scorecard for evaluating quality measurements. In this retrospective analysis, 246 quality measurements that are integrated into the most significant payer-provider contracts within our institution were analyzed. Each measurement was dissected based on type of measurement, evidence, precision, data exchange, alignment, and how patient-oriented. Our research showed a significant lack of quality measurement alignment across payer-provider contracts. As such, we developed and proposed a Quality Measurement Evaluation Tool (QMET) that scores a quality measurement’s ability to 1) reflect population health and 2) promote patient-oriented goals. Our research demonstrated the majority of quality measurements scored in the inadequate range (i.e., QMET score <6) and only few in the optimal range (i.e., QMET score 10-12). QMET provides a standardized and comprehensive method for appraising quality measurements, promoting continued use of QMs that accurately reflect population health and promote patient-oriented measurements. Future research into the application and reliability of QMET is needed.

Multistrategic approach to improve quality of care of people with diabetes at the primary care level: Study design and baseline data

AIM

To test the one year-post effect of an integrated diabetes care program that includes system changes, education, registry (clinical, metabolic and therapeutic indicators) and disease management (DIAPREM), implemented at primary care level, on care outcomes and costs.

METHODS

We randomly selected 15 physicians and 15 nurses from primary care units of La Matanza County to be trained (Intervention-IG) and another 15 physicians/nurses to use as controls (Control-CG). Each physician-nurse team controlled and followed up 10 patients with type 2 diabetes for one year; both groups use structured medical data registry. Patients in IG had quarterly clinical appointments whereas those in CG received traditional care. DIAPREM includes system changes (use of guidelines, programmed quarterly controls and yearly visits to the specialist) and education (physicians' and nurses' training courses). Statistical data analysis included parametric/nonparametric tests according to data distribution profile and Chi-squared test for proportions.

RESULTS

Baseline data from both groups showed comparable values and 20-30% of them did not perform HbA1c and lipid profile measurements. Majority were obese, 59% had HbA1C ≥7%, 86% fasting blood glucose ≥100mg/dL, 45%, total cholesterol ≥200mg/dL, and 92% abnormal HDL- and LDL-cholesterol values. Similarly, micro and macroangiopathic complications had not been detected in the previous year. Most patients received oral antidiabetic agents (monotherapy), and one third was on insulin (mostly a single dose of an intermediate/long-acting formulation). Most people with hypertension received specific drug treatment but only half of them reached target values; dyslipidemia treatment showed similar data.

CONCLUSIONS

Baseline data demonstrated the need of implementing an intervention to improve diabetes care and treatment outcomes.

Diabetes Nurse Educators' Prioritized Elder Foot Care Behaviors

Purpose

The purpose of this study was to identify diabetes nurse educators' perceptions of the most important foot care behaviors for elderly people to enact in daily care.

Methods

A structured, open-ended questionnaire was mailed to a regionally stratified random sample of 90 diabetes nurse educators. Subjects were asked to identify and rank order 8 foot care behaviors perceived important for elderly people with diabetes to enact daily. Data were transcribed and coded into categories and domains using descriptive content analysis.

Results

Forty-seven diabetes nurse educators responded with a total of 346 foot care behaviors perceived important for elders. Twenty-one major foot care behavior content categories were grouped into 4 domains of descending importance: foot/nail care, footwear/shoes, general health, and foot emergencies.

Conclusions

Diabetes nurse educators generated a range of baseline data for developing a reliable, valid, and patient foot care knowledge outcome measure to support national diabetes patient education and self-management program guidelines.

Building Capacity to Reduce Disparities in Diabetes

Purpose

The purpose of this study is to determine whether an innovative interactive distance training program is an effective modality to train community health workers (CHWs) to become members of the diabetes health care team. The University of New Mexico Health Sciences Center has developed a rigorous diabetes training program for CHWs involving both distance and hands-on learning as part of Project ECHO™ (Extension for Community Healthcare Outcomes).

Methods

Twenty-three diverse CHW participants from across New Mexico were enrolled in the first training session. Participants completed surveys at baseline and at the end of the program. They attended a 3-day hands-on training session, followed by weekly participation in tele/video conferences for 6 months. Wilcoxon signed-rank statistics were used to compare pre- and posttest results.

Results

Participants demonstrated significant improvements in diabetes knowledge ( P = .002), diabetes attitudes ( P = .04) and confidence in both clinical and nonclinical skills ( P < .001 and P = .04, respectively). Additionally, during focus group discussions, participants reported numerous benefits from participation in the program.

Conclusions

Community health worker participation in the Project ECHO diabetes training program resulted in significant increases in knowledge, confidence, and attitudes in providing care to patients with diabetes. Studies are ongoing to determine whether the training has a positive impact on patient outcomes.

Use of RE-AIM to develop a multi-media facilitation tool for the patient-centered medical home

Background

Much has been written about how the medical home model can enhance patient-centeredness, care continuity, and follow-up, but few comprehensive aids or resources exist to help practices accomplish these aims. The complexity of primary care can overwhelm those concerned with quality improvement.

Methods

The RE-AIM planning and evaluation model was used to develop a multimedia, multiple-health behavior tool with psychosocial assessment and feedback features to facilitate and guide patient-centered communication, care, and follow-up related to prevention and self-management of the most common adult chronic illnesses seen in primary care.

Results

The Connection to Health Patient Self-Management System, a web-based patient assessment and support resource, was developed using the RE-AIM factors of reach (e.g., allowing input and output via choice of different modalities), effectiveness (e.g., using evidence-based intervention strategies), adoption (e.g., assistance in integrating the system into practice workflows and permitting customization of the website and feedback materials by practice teams), implementation (e.g., identifying and targeting actionable priority behavioral and psychosocial issues for patients and teams), and maintenance/sustainability (e.g., integration with current National Committee for Quality Assurance recommendations and clinical pathways of care). Connection to Health can work on a variety of input and output platforms, and assesses and provides feedback on multiple health behaviors and multiple chronic conditions frequently managed in adult primary care. As such, it should help to make patient-healthcare team encounters more informed and patient-centered. Formative research with clinicians indicated that the program addressed a number of practical concerns and they appreciated the flexibility and how the Connection to Health program could be customized to their office.

Conclusions

This primary care practice tool based on an implementation science model has the potential to guide patients to more healthful behaviors and improved self-management of chronic conditions, while fostering effective and efficient communication between patients and their healthcare team. RE-AIM and similar models can help clinicians and media developers create practical products more likely to be widely adopted, feasible in busy medical practices, and able to produce public health impact.

Introducing the health coach at a primary care practice: impact on quality and cost (Part 1)

The cost of healthcare in U.S. is a poor value proposition. One of the primary goals of the healthcare reform act is to reduce cost while improving healthcare quality. We believe that adding a health coach will help in achieving this goal. The health coach is a medical professional who supports both the physician and the patient by meeting previously established goals. This research presents and analyzes the key roles of a health coach in a primary care practice.

Clinical inertia in management of T2DM

Diabetes is highly prevalent and serious chronic debilitating disease and reported to be the fourth main cause of death in Europe. Despite extensive evidence of benefits of tight glycemic control, large proportions of people with diabetes do not achieve target glycemic control. One major reason for this is clinical inertia which is "recognising the problem but failure to act" by health care professionals in primary care. The key issues in the management of people with T2DM include early detection of problems, realistic goal setting, improved patient adherence, better knowledge and understanding of pharmacotherapeutic treatment options and prompt intervention. Health care professionals must need to overcome clinical inertia and need to intensify therapy in an appropriate and timely manner.

The impact of an assisted diabetes care programme on a private practice

AIMS

Specially trained nurses who follow detailed protocols and algorithms under the supervision of a diabetologist can markedly improve diabetes outcomes in community health centres. We aimed to study the impact of a nurse-assisted diabetes care (NADC) model on diabetes and clinic's financial outcomes in a private practice setting.

METHODS

Nurse-assisted diabetes care was provided to the diabetic patients referring to a Monday private diabetes clinic in Shiraz. 107 patients who had received such care were hierarchically matched with 107 diabetic patients receiving usual endocrinologist care in the same clinic during the rest of the week. At the end of 6 months of follow-up, outcomes [glycosylated haemoglobin (HbA1c), serum triglycerides, low-density lipoprotein (LDL) cholesterol, duration of patient's visit and net clinic's income] for patients under NADC were compared with those of usual care patients and also with those derived from the 6 months before receiving NADC.

RESULTS

Under NADC, HbA1c levels had a more significant fall (p < 0.03), significantly smaller proportions of patients had triglyceride levels of > 1.69 mmol/l (150 mg/dl) and LDL cholesterol of > 2.58 mmol/l (100 mg/dl) (both p < 0.05), the time for one patient's visit decreased by an average of 9.3 min (p = 0.000) while the clinic's net income increased by 21.25%.

CONCLUSION

Nurse-assisted diabetes care, while improving diabetes outcomes significantly, spares time for the physician and allows more patients to be seen per clinic hours. The excess income from extra visits much outweighs the expenditures including the nurses' wages. NADC is profitable for private diabetes clinics or offices.

A nurse-managed diabetes care programme

AIMS

To compare diabetes outcomes in patients under endocrinologist-directed diabetes care with those in patients in a nurse-managed diabetes care (NMDC) programme.

METHODS

NMDC was provided to the diabetic patients referring to a Wednesday diabetes clinic in Shiraz. A total of 159 patients who had received such care were hierarchically matched with 159 diabetic patients receiving usual endocrinologist care in the same clinic during the rest of the week. Outcomes in patients who completed 1 year under NMDC were compared with those of usual endocrinologist care patients and also with those derived from the year before receiving NMDC.

RESULTS

For patients in NMDC programme, the process measures recommended by the American Diabetes Association (ADA) were carried out more frequently than for the appropriate control patients. Under NMDC, HbA(1c) levels fell 3.2% in the 117 patients who were followed for at least 6 months, when compared with a 2.5% fall under usual endocrinologist care (p < 0.001). During the year before the study, in 73 patients mean HbA(1c) levels decreased by 2.6%. At the end of a year under the NMDC programme, the values fell further by 0.65% (p < 0.001). Also, the proportions of patients with TG levels > 150 mg% and LDL levels > 100 mg% decreased from 31% and 36% to 16% and 20%, respectively (p < 0.04 and p < 0.05, respectively).

CONCLUSION

NMDC programme improves diabetes outcomes more significantly than endocrinologist-directed care.

PRODIACOR: A patient-centered treatment program for type 2 diabetes and associated cardiovascular risk factors in the city of Corrientes, Argentina

OBJECTIVE

To implement a controlled clinical trial (PRODIACOR) in a primary care setting designed 1) to improve type 2 diabetes care and 2) to collect cost data in order to be able to measure cost-effectiveness of three system interventions (checkbook of indicated procedures, patient/provider feedback and complete coverage of medications and supplies) and physician and/or patient education to improve psychological, clinical, metabolic and therapeutic indicators. All three Argentinean health subsectors (public health, social security and the private, prepaid system) are participants in the study. Patients of participating physicians were randomly selected and assigned to one of four groups: control, provider education, patient education, and provider/patient education; the system interventions were provided to all four groups.

BASELINE RESULTS

Mean BMI was 29.8 kg/m(2); most subjects had blood pressure, fasting glucose and total cholesterol above targets recommended by international standards. Only 1% had had microalbuminuria measured, 57% performed glucose self-monitoring, 37% had had an eye examination and 31% a foot examination in the preceding year. Ten percent, 26% and 73% of people with hyperglycemia, hypertension and dyslipidemia, respectively, were not on medications. Most patients treated with either insulin or oral antidiabetic agents were on monotherapy as were those treated for hypertension and dyslipidemia. WHO-5 questionnaire scores indicated that 13% of the subjects needed psychological intervention.

CONCLUSIONS

Baseline data show multiple deficiencies in the process and outcomes of care that could be targeted and improved by PRODIACOR intervention.

Use of chronic care model elements is associated with higher-quality care for diabetes

PURPOSE

In 30 small, independent primary care practices, we examined the association between clinician-reported use of elements of the Chronic Care Model (CCM) and diabetic patients' hemoglobin A(1c) (HbA(1c)) and lipid levels and self-reported receipt of care.

METHODS

Ninety clinicians (60 physicians, 17 nurse-practitioners, and 13 physician's assistants) completed a questionnaire assessing their use of elements of the CCM on a 5-point scale (never, rarely, occasionally, usually, and always). A total of 886 diabetic patients reported their receipt of various diabetes care services. We computed a clinical care composite score that included patient-reported assessments of blood pressure, lipids, microalbumin, and HbA(1c); foot examinations; and dilated retinal examinations. We computed a behavioral care composite score from patient-reported support from their clinician in setting self-management goals, obtaining nutrition education or therapy, and receiving encouragement to self-monitor their glucose. HbA(1c) values and lipid profiles were obtained by independent laboratory assay. We used multilevel regression models for analyses to account for the hierarchical nature of the data.

RESULTS

Clinician-reported use of elements of CCM was significantly associated with lower HbA(1c) values (P = .002) and ratios of total cholesterol to high-density lipoprotein cholesterol (P = .02). For every unit increase in clinician-reported CCM use (eg, from "rarely" to "occasionally"), there was an associated 0.30% reduction in HbA(1c) value and 0.17 reduction in the lipid ratio. Clinician use of the CCM elements was also significantly associated with the behavioral composite score (P = .001) and was marginally associated with the clinical care composite score (P = .07).

CONCLUSIONS

Clinicians in small independent primary care practices are able to incorporate elements of the CCM into their practice style, often without major structural change in the practice, and this incorporation is associated with higher levels of recommended processes and better intermediate outcomes of diabetes care.

Treating diabetes to accepted standards of care: A 10-year projection of the estimated economic and health impact in patients with type 1 and type 2 diabetes mellitus in the United States

OBJECTIVE

The aim of this study was to investigate the health-economic impact of maintaining glycosylated hemoglobin (HbA(1c)) values in all US patients with currently uncontrolled type 1 or type 2 diabetes mellitus at the American Diabetes Association (ADA) standard of 7.0% and the American Association of Clinical Endocrinologists (AACE) target of 6.5% compared with maintenance at current population-based values.

METHODS

The CORE-Center for Outcomes Research Diabetes Model was used to predict costs and outcomes for patients with uncontrolled type 1 and type 2 diabetes who remain at established population mean HbA(1c) values in comparison with those for patients who maintain the standard value of 7.0% or the target value of 6.5%. The analysis was run from a societal perspective over a 10-year time horizon. The costs of treating complications and medication costs were retrieved from published sources. Costs and clinical outcomes were discounted at 3% per annum. Sensitivity analyses were performed on the discount rate and time horizon.

RESULTS

This analysis found that maintaining HbA(1c) at the ADA standard value of 7.0% and the AACE target value of 6.5% in patients with uncontrolled type 1 and type 2 diabetes could achieve total direct medical cost savings of nearly 35 US dollars and 50 billion US dollars , respectively, over 10 years. When indirect cost savings were included, the total savings increased to between nearly 50 billion US dollars and 72 billion US dollars for these respective HbA(1c) targets, corresponding to 4% and 6% of the total annual US health care costs of 1.3 trillion US dollars. Reduced savings were observed with a higher discount rate and shorter time horizon, but savings increased as the time horizon became longer. These cost savings must be weighed against the cost of reaching the HbA(1c) goals and the likelihood of achieving the clinical objectives.

CONCLUSIONS

Efficient targeting of financial resources toward the goal of lowering HbA(1c) in line with published guidelines could lead to financial savings in the range from nearly 35 billion US dollars to 72 billion US dollars over the next 10 years.

Effect of nurse-directed diabetes care in a minority population

OBJECTIVE

To determine whether diabetes care directed by nurses following detailed protocols and algorithms and supervised by a diabetologist results in meeting the evidence-based American Diabetes Association (ADA) process and outcome measures more often than care directed under usual care in a minority population.

RESEARCH DESIGN AND METHODS

Studies were mainly conducted in two Los Angeles County clinics. In clinic A, nurse-directed diabetes care was provided to 252 patients (92% Hispanic and 2% African-American) referred by their primary care providers. These patients were hierarchically matched with 252 diabetic patients in clinic B (79% Hispanic and 19% African American). When nurse-directed care was abruptly discontinued in clinic A for administrative reasons, it was reestablished in clinic B. Those patients were randomly selected from a teaching clinic, and the outcomes in 114 patients who completed 1 year were compared with outcomes derived the year before receiving nurses' care. The following process and outcome measures were assessed in the study: 1) number of visits, 2) diabetes education, 3) nutritional counseling, 4) HbA(1c), 5) lipid profiles, 6) eye exams, 7) foot exams, 8) renal evaluations, and 9) ACE inhibitor therapy in appropriate patients.

RESULTS

For patients under nurse-directed diabetes care in both clinics A and B, almost all process measures were carried out significantly more frequently than for the appropriate control patients. Under the care of nurses in clinic A, HbA(1c) levels fell 3.5% from 13.3 to 9.8% in the 120 patients who were followed for at least 6 months, as compared with a 1.5% fall from 12.3 to 10.8% under usual (physician-directed) care in clinic B. During the year before enrolling in nurse-directed care in clinic B, mean HbA(1c) levels decreased from 10.0 to 8.5%. At the end of a year under the nurses' care, the values fell further to 7.1%. The median value fell from 8.3 to 6.6%.

CONCLUSIONS

Specially trained nurses who follow detailed protocols and algorithms under the supervision of a diabetologist can markedly improve diabetes outcomes in a minority population. This approach could help blunt the increased morbidity and mortality noted in minority populations.