Improving Diabetes Treatment Quality in Managed Care Organizations

The majority of patients with diabetes mellitus in the United States receive suboptimal medical care. A plethora of reports have documented inadequacies in diabetes care processes and poor clinical outcomes among patients with diabetes.^1-4 The gap between our current knowledge of effective diabetes treatments and their implementation is especially troubling in light of the high and rapidly growing prevalence of diabetes and the significant morbidity, mortality, and healthcare costs resulting from poorly treated diabetes.⁵ Yet, the state of diabetes care is emblematic of broader systemic deficiencies in outpatient chronic disease care: A recent study of ambulatory care practices in 12 metropolitan areas, for example, found that patients with chronic conditions received less than 60% of recommended care for their conditions.⁶

It is especially important to understand sources of deficiencies in and mechanisms to improve the quality of diabetes care in managed care organizations, which are increasingly the main source of healthcare services for persons with diabetes in the United States.^7,8 Moreover, managed care organizations, whether staff models with integrated delivery systems or loose networks of providers, are often well positioned to institute the necessary system reforms to improve chronic disease care.

In the face of increased awareness of deficiencies, progress has been made in delineating necessary mechanisms at the patient, provider, and healthcare system levels to improve the quality of diabetes care. At the health system level there is growing evidence that improvements in 6 interrelated components of primary care for patients with chronic illnesses–clinical information systems, delivery system redesign, decision support, healthcare organization, patient self-management support, and community resources–can significantly improve clinical processes and outcomes.^9-14 This Chronic Care Model incorporates strategies for system improvements in each of these areas and has guided improvement efforts in more than 1000 healthcare organizations.¹⁵ The benefits of implementing these system changes in clinical practice are currently being assessed in a range of practice settings. Moreover, these principles have underpinned the major reengineering of healthcare systems such as the Veteran's Affairs and Indian Health Services since the mid-1990s, which have led to stunning improvements in diabetes and other chronic disease care processes.^16-19 The papers in this theme issue provide useful new insights into the current state of diabetes care in managed care. Several papers document progress in implementing evidence-based treatment guidelines, and others evaluate current efforts to coordinate care and highlight approaches to direct further improvements in diabetes care strategies.

The extent and speed with which a health system's providers translate evidence about effective medical therapies and clinical guidelines into practice are important benchmarks for evaluation. Nau et al and Timpe et al, in their papers addressing this question in 3 different managed care systems, document encouraging trends from 1997 to 2001 (eg, increased percentages of patients receiving multidrug hypoglycemic therapy, on angiotensin—converting enzyme inhibitors or angiotensin-receptor blockers, and on antilipemic medications).^20,21 Yet they also found that the percentages of eligible patients on recommended therapies (in all cases less than 50%) continued to be relatively low. A third paper by Fuke et al similarly found a high prevalence of inadequate lipid control among patients with diabetes, both among those with and without documented coronary artery disease, in a primary care practice- based research network.²² Equally concerning, they found that only 20% of patients with diabetes had received a prescription for any lipid-lowering treatment. These papers reinforce the continued, pressing need both to delve into the barriers to effective translation of research into clinical practice and to test system change strategies.

The existence in each of the studied managed care systems of at least rudimentary computerized clinical information data bases provides a foundation for such strategies. Clinical information systems quantify quality gaps and monitor progress in the implementation of evidence- based care, as these 3 papers did. They also enable practice teams to have ready access to data on individual patients, timely reminders and feedback, and to develop comprehensive registries of specific populations of patients.

Also central to improving diabetes care are the health system's leadership and managerial policies for coordinating care within and across medical specialties and strategies to support patients' diabetes self-management. Managed care strategies to limit medically unnecessary use of specialty services in particular have been a lightning rod for patients' concerns about managed care. In an important contribution to the debate about the effect of such policies, Kim et al found no relationship between either prospective or retrospective referral management strategies and receipt of dilated eye exams, patient-reported specialist use, or patient perceptions of difficulty in seeing a specialist.²³ And Hepke et al's paper reinforces the importance of investing in programs to promote patients' self-management and adherence to medications.²⁴ Their findings of decreased use of medical services among patients who had higher adherence to hypoglycemic medications builds on prior research showing significant costs savings within 1 to 2 years of sustained improvements in diabetes disease control.^25,26 While increased patient adherence and more intensive pharmaceutical treatment (as Nau et al found) will increase pharmaceutical costs in the short term, these increases likely will be offset by the savings from decreased hospitalizations and emergency department visits.

Another crucial means to improve diabetes care is the development and implementation of effective population- based approaches. Three papers in this issue address critically important issues for the design of such approaches. As Piette and colleagues point out, a deficiency in most diabetes management algorithms is the failure to incorporate treatment of comorbid medical conditions often linked to diabetes.²⁷ In light of the high prevalence of depression among patients with diabetes and the interactions between these 2 conditions, Piette et al develop a conceptual framework for integrating depression management with diabetes care. Their approach, however, is equally valid for guiding care for patients with multiple chronic conditions in general. The management challenges they outline for patients with both diabetes and depression forcefully illustrate the need to move beyond single-disease interventions to disease management approaches that address multiple disorders.

Selby et al's paper further reinforces this point.²⁸ They found that approximately 90% of adult patients with diabetes in Kaiser Permanente in Northern California also met criteria for either hypertension or elevated low-density lipoprotein cholesterol; 50% of all patients with diabetes had all 3 conditions. As they argue, identification of any one of these conditions should trigger a search for the other two. Moreover, programs aimed at managing any of these conditions should be designed to evaluate and manage all 3 conditions. Indeed, multifactorial programs targeting all 3 of these conditions have been shown to dramatically lower the incidence of cardiovascular disease and other complications of diabetes.²⁹

Pogach et al evaluate coordination strategies for foot care delivery at 10 Veterans Affairs medical centers, an important but often overlooked aspect of diabetes management. 30 In an earlier study they found that VA sites with greater coordination of foot care delivery had significantly lower amputation rates.³¹ Their current paper reinforces the importance of incentive structures in shaping disease management programs. All the sites had effectively responded to VA policy mandates for preventive foot screening and referral, performance of which was directly measured and feedback given. Yet less progress had been made in developing activities in the unmeasured areas of surveillance and salvage. Moreover, the number of coordination strategies implemented by any site was relatively low, and, despite the strength of VA information systems, no integrated electronic registries to allow tracking of patients with highrisk feet had been developed. Pogach et al's meticulous analysis emphasizes that an organized system of care and ready availability of data are necessary but not sufficient for outstanding chronic disease care. In particular, their findings argue for the need to move beyond a narrow focus on performance measurement to include evaluation of coordination of care. Their paper reminds us how poorly we still understand the organizational factors that lead to successful disease management programs and provides a useful road map to guide future research.

The papers in this theme issue examine the efforts of a variety of organized healthcare systems to improve the care of their patients with diabetes. In sum, they reinforce the growing base of evidence indicating that there are no simple fixes to improving the quality of diabetes care. Rather, improved outcomes follow integrated system changes involving more concerted leadership, clinical information system enhancements, better coordination and follow-up, more consistent and collaborative self-management support, and attention to comorbid conditions. There are exciting, promising initiatives throughout the country, and we have made progress in certain areas. Yet, this issue also reminds us that there is much more to do.

From the From the Ann Arbor Veteran's Affairs (VA) Center for Practice Management and Outcomes Research and Division of General Internal Medicine, University of Michigan, Ann Arbor (MH) and and the W. A. Sandy MacColl Institute for Healthcare Innovation and Group Health Cooperative, Seattle, Wash (EHW).

Address correspondence to: Michele Heisler, MD, MPA, HSR and D, Mail Stop 11H, PO Box 130170, Ann Arbor, MI 48113-0170. E-mail: mheisler@umich.edu

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