Best Practices in Diabetes Management: Getting More Patients to Goal

The need for improved diabetes carehas never been more evident. The"State of Diabetes in America" studyjust released by the American Association ofClinical Endocrinologists (AACE) indicatesthat 2 of every 3 individuals with type 2 diabetesstill do not have their glycosylatedhemoglobin A_1C (A_1C) levels under control.¹The report, which analyzed a laboratorydatabase of more than 157 000 people in 39states in 2003 and 2004, found that 67% ofpatients had A_1C levels above the AmericanCollege of Endocrinology goal of ≤6.5%(Table 1). In none of the states were morethan half of the patients controlled. In sharpcontrast, a related national survey reportedby AACE found that 84% of those with type2 diabetes thought they were doing a goodjob controlling their blood sugar. Thesesobering results show that most Americanswith diabetes are at risk for serious andcostly complications because of inadequatelycontrolled blood glucose values.

Key recommendations for improved diabetescare are well accepted and involve earlyand aggressive control of glycemia, dyslipidemia,and blood pressure, what the NationalDiabetes Education Program (http://www.ndep.nih.gov/campaigns/BeSmart/BeSmart_index.htm) and the American DiabetesAssociation (ADA) call the ABCs (A_1C, Bloodpressure, and Cholesterol) of diabetes(Table 2).² Most believe that adoption ofcommon elements endorsed by the chroniccare model,³ including team care, improvedinformation technology, clinical decisionsupport, self-management education, anddelivery system redesign, will provide thebest opportunities to achieve these goals.

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Journal of Managed Care

In this supplement to , Drs Sperl-Hillenand O'Connor from the HealthPartnersMedical Group (HPMG) in Minneapolis analyzetheir diabetes care outcomes over thepast decade. Compared with diabetes controlreported in many settings, the datacollected by this multispecialty groupdemonstrate considerable success in reducingtheir median A_1C levels below 7% and themean low-density lipoprotein cholesterollevels to <100 mg/dL. To their credit, HPMGis seeking to understand the determinants ofthese results in hopes of further improvingthem. They have now examined the fluctuationsin their A_1C and lipid results from 1994to 2003 and tried to identify the correlates ofthose year-to-year movements.

As noted in their discussion, intensificationof pharmacotherapy was a primary factorin A_1C and lipid improvement over thisperiod. The willingness of clinicians to combine2 or more agents to achieve A_1C treatmentgoals was apparently essential. Othercritical success factors included institutionalleadership commitment to diabetesimprovement, participation in diabetes careimprovement initiatives, and allocation ofmultidisciplinary resources at the cliniclevel to improve diabetes care. Resourceswere devoted to nurse and dietitian educators,active outreach to high-risk patientsfacilitated by registries, physician opinionleader activities including clinic-based educationalprograms, and financial incentivesto primary care clinics.

HPMG has maintained recognition statuswith the Diabetes Physician RecognitionProgram (DPRP) since 1999. This joint programof the ADA and the National Committeefor Quality Assurance (NCQA) maybe one new factor that allows health systemsto reach that next level of quality improvement. Pilot DPRP programs enhancing reimbursementfor recognized physicians andsimilar "pay-for-performance" programshave received increasing attention.Improved outcomes have been demonstratedamong DPRP-recognized physicians (eg, a98% rate of A_1C testing vs 82% amongMedicare providers and 81% among othercommercial providers).⁴ However, as pointedout by Drs Sperl-Hillen and O'Connor, wemust find the appropriate mechanisms tofund these programs and also guard againstpenalizing clinicians with the most ill, complexdiabetes patients. The results to date ofa pilot program (Bridges to Excellence) indicatethat rewarding DPRP recognition withfinancial incentives does appear to be associatedwith large increases in the number ofphysicians who become DPRP-recognized,thus demonstrating they are providingquality diabetes care. One can learn moreabout these programs at www.ncqa.org/dprpand http://www.ncqa.org/Programs/bridgestoexcellence/bridgesq-a.htm.

The paper by Dr Mahoney at PitneyBowes offers an innovative approach tomanagement of the pharmacy benefit forcompany employees with diabetes. Asemphasized by Dr Mahoney, increasedadherence to pharmacologic therapy is a keyto improved disease control and reducedlonger term costs. Although the connectionbetween adherence and control is well documented,⁵ it was an internal company studyrevealing a link between poor adherence andhigh next-year costs that convinced this corporatemedical director to take aggressivesteps to attempt to enhance medication adherence.By shifting all diabetes medicationsfrom tier 2 or 3 formulary status to tier 1,the potential financial disincentives topatient acquisition and use of diabetes medicationsand supplies were significantlydiminished. The result has been increases inmedication possession rates and use offixed-combination drugs, a decrease in totalper-patient pharmacy costs, a 26% decreasein emergency department visits, a 6%decrease in costs per employee with diabetes,and a slowing of the increases in overallper-patient health costs.

The company simultaneously institutedother enhancements to its diabetes diseasemanagement programs that could have contributedto the observed improvement incosts, including distribution of free glucosemeters to employees with diabetes. However,the authors contend that the benefitredesign was the truly novel component oftheir overall disease management efforts.Dr Mahoney's paper provides healthcareadministrators and their pharmacy benefitmanagement partners with one more potentialmechanism for improving diabetes care.

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American Journal of Managed Care

Both papers in this supplement to demonstratethe importance of taking a chroniccare model³ approach to improving managementfor people with diabetes. One or bothemphasize the benefits of team care (addingnurse and dietitian educator and physicianopinion leader efforts to the activities of primaryhealthcare professionals), improvedinformation technology (use of registries toidentify patients needing interventions),clinical decision support (clinic-based trainingprograms for healthcare professionals),self-management education (diabeteseducation), and delivery system redesign(medication benefit redesign and financialincentives integrated into other diseasemanagement efforts).

Suboptimal healthcare delivery systemsare major barriers to achieving the diabetestreatment goals that would reduce the developmentand progression of diabetic complicationsas well as their resultant human andeconomic costs. Systems improvementshould be a focus of all diabetes care settingsfrom solo clinical practices to large integratedhealthcare delivery systems. To assist healthcareprofessionals and administrators seekingto structure better systems and improve theefficiency and effectiveness of their diabetescare delivery, the National Diabetes EducationProgram has recently developed a Website (www.betterdiabetescare.nih.gov) withextensive information and resources.

Ideally, like the authors of the papers inthis supplement, all who accept the challengeto improve the care of their patientswith diabetes will display a willingness toinvest in new ideas, to measure the results,to modify programs in response to measuredresults, and to share their experiences withcolleagues. We, and especially our patients,will all benefit from these efforts.

1. American Association of Clinical Endocrinologists.State of diabetes in America: a new report revealsAmerica's diabetes health is in jeopardy. Press release,May 18, 2005. Available online at: www.aace.com/pub/press/release. Accessed May 22, 2005.

Diabetes Care.

2. American Diabetes Association. Standards of medicalcare in diabetes. 2004;27(suppl 1):S15-S35.

Eff Clin Pract.

3. Wagner EH. Chronic disease management: what willit take to improve care for chronic illness? 1998;1:2-4.

4. Diabetes Physician Recognition Program (DPRP).The State of Health Care Quality, 2002. NationalCommittee for Quality Assurance. Available online at:www.ncqa.org/sohc2002/. Accessed March 14, 2005.

Am J Manag Care.

5. Hepke KL, Martus MT, Share DA. Costs and utilizationassociated with pharmaceutical adherence in a diabeticpopulation. 2004;10:144-151.

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