Addressing the Quality Gaps in Diabetes Prevention and Care
Despite the complexity of managing diabetes, health care organizations are finding ways to improve the quality of care. Although each plan will encounter its own unique barriers, research has demonstrated that the following obstacles are common:
- The health care system and most current methods of reimbursement are not designed for managing chronic diseases optimally; they may fail to meet the needs both of patients and physicians in coordinating caregivers, information, interventions, and providing incentives to physicians.
- Physicians may be challenged to develop the skills and find time to teach patients behavioral strategies, may be unclear about how to reach treatment goals, and may lack the organizational support and information systems to track patient care and outcomes.
- Patients must overcome their personal barriers to managing their disease successfully, which they may perceive as severe and numerous.
- Cultural differences, poor reading skills, or low health literacy are frequently impediments.[2,5]
In its 2004 State of Health Care Quality Report, NCQA defines quality gap as the difference in performance between the top 10% of organizations and average national performance. Quality gaps can be examined in any industry; for example, in the airline industry, the difference in safety performance between the top 10% of airlines and the national average is less than 1%. In the health care system, however, the quality gap is much larger. For some HEDIS® measures related to diabetes and prediabetes, the difference in performance between the top 10% of plans and the national baseline of usual care is greater than 10 percentage points (Table 1).
Table 1. Comparison of National Baselines and Commercial Health Plans in the 90th Percentile of Care Quality (HEDIS® Measures)
||National Baseline (%)
||90th Percentile (%)
||Spread (Percentage Points)
|Controlling High Blood Pressure
|Advising Smokers to Quit
Across the total United States population, each year an estimated 4,300 to 9,600 deaths from diabetes could be prevented in the U.S. if all patients with diabetes received the care that top plans provide.In addition, best care could prevent an estimated 14,000 heart attacks, strokes, or amputations at a cost savings of $573 million, and patients could avoid 6.8 million reduced-capacity days or sick days.
Physician and Patient Barriers to Quality Diabetes Care
Health care organizations can provide support for both physicians and patients that promotes adherence to evidence-based guidelines, such as educational materials, patient tracking tools, and feedback mechanisms, as well as systemic support for communication and care coordination. Groups that recognize and reward physicians for excellence reinforce initiatives physicians undertake to improve their quality of care.
Addressing Medication Adherence
Many patients with diabetes have difficulty managing their medication regimens. Research has found that adherence to oral hypoglycemic agents ranges widely from 36% to 93% in patients treated for six months to two years.
Adherence to insulin therapy among patients with type 2 diabetes is 62% to 64%. Young patients fill prescriptions for only one third of their prescribed insulin doses.
A first step in improving adherence is identifying when patients are not adhering to the drug regimen. To achieve desired blood glucose goals, it is essential to distinguish poor glycemic control due to poor adherence from a failure of the type of drug or dosage. Indications that adherence may be the problem include:
- Patients with a poor record of appointment-keeping are also likely to have difficulties with blood glucose self-management.
- Patients who are not responding to treatment, particularly to an increasing intensity of treatment, may not be adhering to treatment recommendations.
The complexity of drug therapy may be an adherence barrier for patients. Physicians also need to be aware of all the medications a patient is taking. Simplifying the drug regimen by switching to once-daily dosing or combining multiple medications into one regimen can help. For example, allowing the patient to take several drugs before meals, instead of some before and some after, can be helpful. Educating patients about what to do if they miss a dose or if side effects bother them also improves compliance. Table 2 lists some interventions that research has shown can improve adherence.
Table 2. Some Interventions That Improve Adherence
|Type of Intervention
- Teaching by nurse and psychologist supplemented with audiotapes
- Home visits to increase family support, group sessions to increase patient confidence and skills
- Frequent follow-up by nurse at work-site clinic until treatment goals achieved
- Feedback through patient recording of medications and blood pressure response
- Combination medication chart and pill organizer
- Prescription refill reminder and special packaging
- Nurse counseling plus reminder chart, structured counseling by pharmacist
- Phasing in patient responsibility for medication administration at the end of hospitalization
- Telephone reminders and monitoring using a computerized telephone system
- Educational videotape or picture book*
|*Subjects were asthmatic children.
Addressing Resistance to the Use of Insulin
Insulin is an effective and often underused treatment option for type 2 diabetes. Research has shown that 53% of people with type 2 diabetes needed insulin within six years of beginning sulfonylureas and 80% within nine years.
Both people with type 2 diabetes and their physicians may resist the move from oral medications to insulin. So-called “psychological insulin resistance” affects 57% of patients with diabetes, who say they are very worried about taking insulin. Just 23% thought insulin would help them control their diabetes, according to one survey.
The same survey found that 59% of PCPs and 47% of diabetes specialists delayed using insulin until absolutely necessary.. The traditional approach to managing type 2 diabetes is first lifestyle changes, then oral agents, then combinations of oral agents, and finally insulin. Oral medications can control blood glucose for years, but in most cases the disease eventually progresses, and oral agents are no longer effective. The question being asked today is when to begin insulin therapy in type 2 diabetes. Endocrinologists warn that waiting too long increases the risk of complications, and some believe that type 2 diabetes should be treated aggressively with insulin when A1c approaches 8%.[10,14]
Studies show that patients are fearful of beginning insulin therapy for many reasons, including fear that insulin therapy will restrict their lives, lack of confidence that they can handle the regimen, feeling that using insulin indicates their personal failure to manage their disease, and fear of injections. Few expect any benefits from starting insulin therapy. See Table 3 for strategies for patients who are reluctant to take insulin.
Table 3. Strategies to Consider When Patients Express Reluctance to Start Taking Insulin
|Identify a patient’s personal obstacles before reassuring them or jumping to another strategy
||Ask an open-ended question such as, “Can you tell me why you feel so strongly about not taking insulin?”
Administer a brief, self-report questionnaire about insulin resistance
|Give the patient a sense of control
||Offer a trial period of therapy
|Help the patient gain confidence
||Demonstrate insulin use and allow the patient to practice before leaving the clinic or office
Limit the self-care regimen at first
Follow up quickly with initial dosage adjustments
|Frame the message carefully
||Focus on A1c results and the critical goal of protecting long-term health
Stress that they have not failed, but that diabetes is a progressive disease that may require more and stronger medications over time
|Explain the risk of hypoglycemia
||Tell patient that hypoglycemia is uncommon in type 2 diabetes
Tell patient that moderate vigilance and learning to recognize and treat it can reduce the risk further
|Help patient overcome fear of injections
||Refer patient to a mental health expert in cognitive behavioral therapy
Consider insulin pens rather than syringes
|Review the benefits the patient can expect to see from insulin therapy
||Tell the patient of potential improvements in mood, sleep, and energy levels, as well as how improving glycemic control protects their long-term health
An important concern of physicians, as well as patients, with the use of insulin is the risk of hypoglycemia. Hypoglycemia is a fact of life for many people with type 1 diabetes. Data about hypoglycemia events are not available for patients with type 2 diabetes treated to near-normal glycemic levels, but hypoglycemia became progressively more limiting to glycemic control in the United Kingdom Prospective Diabetes Study (UKPDS) subjects. Frequent self-monitoring of blood glucose levels reduces the risk of hypoglycemia.
Both patients and physicians may fear such side effects as weight gain.Using metformin as an adjunct to insulin therapy may prevent weight gain.
Another barrier for physicians to beginning insulin therapy may be finding the time to train a patient on how to manage the therapy. In some areas, physicians can refer their patients with diabetes to community diabetes educational programs. Where there are no community resources, or where practices wish to provide this service themselves, the ADA has developed an educational tool for use in small primary care practices that treat patients with diabetes called “Insulin Therapy and Your Practice Subscription Series.”
Beating the Benchmark: A Disease Management Program Improves HEDIS® Results Already at Goal
A Midwestern health plan reached the conclusion that its HEDIS® results for diabetes had reached a plateau in 2000 and decided that new strategies were necessary to continue improving outcomes.
The organization demonstrated the following baseline HEDIS® results for its commercial and Medicare populations:
Table 4. Commercial and Medicare Risk Rates 2000
|HEDIS® Measure for Comprehensive Diabetes Care
|Poor HbA1c Control
|Lipid Control (LDL <130 mg/dL)
The plan realized that many of its HEDIS® outcomes for diabetes had reached or surpassed the national benchmark as reported by Quality Compass. Even though outcomes were consistent with national benchmarks, there was still room for improvement, and incremental gains (even small ones) would be worthwhile from quality of life, utilization, and financial perspectives. The plan decided that if the Quality Compass benchmark for a HEDIS® measure had been exceeded, a new goal would be established. The health plan determined the difference between the current rate and 100%, then set the goal based on improving this difference by 10%.
Prior to 1999, the health plan addressed diabetes care through individual efforts to educate members about the importance of eye examinations, cholesterol testing, and other similar approaches. In addition, case management was provided to members with diabetes meeting specific utilization parameters. To this point, the MCO had not used a fully integrated approach to coordinate care and services. The health plan wanted to develop a consistent program that would include targeted outreach based on individual needs. After examining gaps in existing interventions, the plan determined the need for a diabetes disease management (DM) program, using a DM vendor.
Implementing a Comprehensive Disease Management Approach
The decision to contract with an outside DM vendor was based on the ability of the vendor to apply systematic means of reaching every member with diabetes using a stratification model that divided the population into risk classifications. The program uses an opt-out approach, so the plan expected participation to be high. The program includes the following services:
- Systems to track members with diabetes and their health status, including outcome reports
- Outbound telephone assessments by nurses to all members with diabetes for identification of health concerns, patient education, and assistance with self-management (results communicated to physicians)
- Regular conference calls with the plan’s case managers, conducted by call center staff from the DM vendor, to coordinate care of select members
- Testing reminders mailed two to three times per year (see Appendix 6)
- Interactive health assessments and member educational tools, including personalized action plan to share with physicians, offered on the Web site
- Quarterly and annual educational mailings
- Yearly calendars and reminder stickers (see Appendix 7)
In addition to the vendor interventions, the plan worked with a medical device company to provide free glucose meters.
The health plan relied on the DM vendor to conduct the majority of interventions for members so it could focus its attention on outreach to practitioners. The health plan wanted to cultivate its own relationships with physicians, so the majority of outbound communication about the program came directly from the plan. Practitioner interventions were developed with an emphasis on controlling A1c levels and improving microalbumin testing, two areas that would have a significant impact on identifying and limiting diabetes complications. Microalbumin testing demonstrated the greatest opportunity for improvement at baseline. Barrier identification revealed that:
- Practitioners were assuming a regular urinalysis would provide the microalbumin results (which is not accurate).
- Some physicians assumed that if the patient was already on an ACE inhibitor, further testing for microalbuminuria was not needed (also not accurate).
The health plan developed interventions with these barriers in mind.
Physician interventions included:
- Physician educational packets that included standards of care, a diabetes flow sheet (see Appendix 8), a foot poster to remind members with diabetes to remove their shoes during a doctor visit, and microalbumin testing information
- Letters to individual physicians whose members had poorly controlled A1c (>9.5%) or had not been tested for A1c level
- Recommendation to add a microalbumin dipstick test to the regular urine dipstick. Doctors were also provided with reimbursement information.
- Practitioner Web site with clinical practice guidelines and print-ready medical record tools to track treatment progress
- Reports to all physicians identifying missing tests, or A1c and LDL levels that were above goals
- Onsite education for select physicians (those demonstrating less than optimal results for individual members) by the medical director to discuss standards of care and performance goals
- Pharmacologic algorithm for type 2 diabetes published in formulary for practitioners to improve medication management
The outreach to members and practitioners was intense, and the effort paid off. Two years after the implementation of the disease management program, the health plan was able to achieve significant outcomes.
The health plan was confronted with a challenge: what to do when outcomes approach benchmark performance? The organization considered its HEDIS® results and decided that continued improvement was possible for all measures and was also worthwhile, considering the clinical and financial consequences associated with complications of diabetes. In this case, the health plan determined that it needed to develop a comprehensive disease management program. The plan utilized the services of a DM vendor, along with its own internal resources, to stage interventions based on identified needs of each member enrolled in the program and to address practitioner barriers related to standards of care. Interventions focused heavily on controlling blood sugar levels and monitoring for kidney nephropathy. In a partnership with the DM vendor, the organization ultimately achieved significant gains in all HEDIS® diabetes measure results for both its commercial and Medicare populations.
Table 5. Commercial and Medicare Risk Rates 2001
|HEDIS Measure for Comprehensive Diabetes Care
|Poor HbA1c Control
|Lipid Control (LDL <130 mg/dL)
Closing the Gap
Diabetes is a disease in which patient self-management plays a central role. Research has shown that people need guidance in overcoming their personal barriers to making significant lifestyle changes, especially when trying to integrate a prescribed regimen into their existing lifestyle. Barriers that both patients and physicians may have to contend with include varied literacy skills, cultural differences, difficulty making behavioral changes, and lack of adherence to medications. Making changes in the way care is delivered, patient support for self-management strategies, physician support for using clinical guidelines, and database use are chronic care model (CCM) elements that can overcome these barriers.
Addressing Low Literacy
Literacy is the ability to understand and use printed information in daily activities. Health literacy is the ability to obtain, understand, and use health information to improve one’s own health or the health of others.
Both low literacy and low health literacy can cause patients to make mistakes with general health and medication regimens. Even when physicians think they are speaking clearly and simply, many people, whether they read well or not, do not understand the information their doctors give them. People with poor reading skills have more health problems, require more frequent and longer hospital visits, and have difficulty using the health care system and understanding health care information.
Over 21% of adults—more than 40 million people—in the United States demonstrated the lowest level of literacy skills in the 2003 National Adult Literacy Survey. Of these:
- 62% did not finish high school
- 33% were 65 years of age or older
- 25% were immigrants learning to speak English
- 26% had physical or mental health conditions that prevented them from participating fully in work, school, housework, or other activities
- 19% had visual difficulties
Over half of people with inadequate health literacy levels did not know how to take medication on an empty stomach, compared to 16% with adequate health literacy, and 68% did not know how to interpret low blood sugar values, compared to 24% with adequate health literacy. It is worth noting that written information given to patients often requires a higher literacy level than most patients have.
Health and literacy studies have demonstrated that the following strategies can help health care professionals communicate better:
- Use of plain language
- Use of pictures
- Use of videos
- Combinations of written and visual presentation of information
Addressing Cultural Differences
Because the prevalence of diabetes is higher among African Americans, Hispanic Americans, and Native Americans, health care professionals need to be aware of cultural differences that can affect what strategies are effective. Values associated with food, body weight, and biomedical interventions are not always the same across racial and ethnic groups. For example, studies have shown.:
- African American women do not, as a group, value slimness and exercise.
- Mexican American women tend to place family and economic issues over self-management of diabetes.
- Hispanic Americans report that feeling well is more important than lowering blood glucose levels.
The Centers for Disease Control and Prevention (CDC) has produced a CD of Latin music created to help prevent and control type 2 diabetes by encouraging Hispanic Americans to incorporate more movement into their lives. More information about this CD can be obtained by going to www.cdc.gov/pcd/announcements.htm.
The American Diabetes Association (ADA) has a number of resources for African Americans, Latin Americans, Native Americans, and Asian Americans. See www.diabetes.org and search by race or ethnic group for culturally appropriate publications, recipes, and community programs.
Addressing Behavioral Change
As discussed in the chapter titled Diabetes Prevention: A Unique Opportunity, strategies patients can use to achieve lasting behavioral change include self-monitoring, stimulus control, and problem-solving. These interventions are available from specialists, e.g., psychologists or community programs. Physicians also have a great effect on patients’ ability and willingness to pursue change; more so than they may believe.
Physicians may believe that their advice to patients about lifestyle changes is not effective. However, an analysis of data from the 1998 National Health Interview Survey (NHIS) showed that physicians’ advice can help change behavior in people with diabetes:
- The advice of a physician may be effective in encouraging people with diabetes to lose weight and take medications to help control their high blood pressure.
- Counseling by clinicians can be very effective in motivating smokers to quit.
- People with diabetes appear more likely than people without diabetes to adhere to a physician’s advice to take medications.
Using Technology to Improve Quality of Care
An important tool physicians can use to track behavioral changes is a clinical database that monitors treatment strategies, the problems a patient has with self-management, and outcomes over time. Records such as these allow the physician to identify which interventions are effective for a particular clinical goal or patient.
CD-ROM technology offers an intervention tool for easing the time and knowledge burden on PCPs and diabetes teams. Clinics and offices that provide an interactive CD-ROM self-management program for patients to use onsite can integrate it into a regular office visit. For example, one such program automates some of the components of self-management to help patients create a personalized action plan:
- Patients answer questions about what medical care they have received (based on NCQA/ADA Provider Recognition Program guidelines) and their current diet, physical activity level, and smoking behavior.
- Based on the answers, the program allows patients to select from choices of activities for changing behavior.
- Patients then select from a list of perceived barriers and from a list of strategies to overcome these barriers.
- Patients receive a printout of a personalized plan, physicians receive a summary to review and endorse, and case managers receive a detailed printout of the session and briefly counsel the patient.
This type of intervention, along with follow-up support to review and revise the plan if needed, allows more patients to receive support for self-management activities, while saving the care provider time while delivering a consistent, high-quality message.
Research has provided substantial evidence that Web-based interventions improve outcomes resulting from behavioral changes such as increasing exercise time, improving knowledge of nutritional status, maintaining weight loss, and increasing participation in health care. Sites that direct the participant to individually tailored materials report longer session times and more visits. A wide variety of resources on the Internet provides tools for health care professionals to use to improve diabetes care (Table 6).
Table 6. Resources for Patients and Diabetes Professionals on the Internet
|American Diabetes Association
- Patient information, Web links, publications, recipes, and programs
- Professional meetings/education
- Clinical practice recommendations
- Links to other resources
- Professional membership
- Books for professionals
- Research grants
- Physician and self-management education recognition programs
- Professional section councils and newsletter
|American Heart Association
- Patient support program
- Online lifestyle planner
- Online interactive tool for tracking A1c, blood pressure, cholesterol
- Diabetes information for newly diagnosed patients
- Speakers kit
- American Association of Diabetes Educators
|American Association of Clinical Endocrinologists
- Patient educational publications
- Clinical guidelines and research
- Links to other resources
- Professional meetings and education
- Professional membership
|National Center for Chronic Disease Prevention and Health Promotion
- Diabetes fact sheets and statistical data
- Links to diabetes projects
- Links to state-based programs
- Links to other resources
- National Diabetes Education Program
- Publications and products in English and Spanish
|Michigan Diabetes Research and Training Center
- Educational materials
- Survey instruments
- Training and resources for professional research
- Research grants
- Links to other resources
|Joslin Diabetes Center
- Patient educational materials, including culturally sensitive and age-appropriate information
- Professional education
- Research programs
- Disease management
|National Institute of Diabetes & Digestive and Kidney Disease
- Support for clinical research
- Diabetes information and publications
- Web links
Promoting Physician Adherence to ADA Guidelines
An analysis by the CDC suggested that fewer than 5% of patients with diabetes receive care that conforms with ADA guidelines. Physician feedback is an effective method of increasing the proportion of patients who reach treatment goals. Interventions that work include self-audit forms, reports that compare performance to peers, and educational materials. The following paragraphs describe examples of these interventions.
Providing physicians with a roster of patients and a tracking tool can improve compliance with the ADA standards for diabetes care. One health maintenance organization (HMO) identified all members over 20 years old with diabetes (except gestational diabetes) over a two-year period, and mailed self-audit forms along with a registry of their patients with diabetes to an intervention group of PCPs. The forms were filled out with patients’ names and had spaces to fill in results from two A1c tests, a lipid profile, a urine exam for proteinuria, and a dilated retinal exam. Practitioners could fill in the data or request a provider representative to complete it at the end of the year. All the studied parameters except the retinal exam rate improved more in the intervention group than in the control group, who were not mailed the self-audit forms and registry.
In a physician education project, practitioners, family practitioners, internists, and endocrinologists who cared for Medicare patients with diabetes, and patients received the following interventions:
- A report to each physician comparing his/her performance to other physicians in the form of a bar graph
- Personal contact with each physician by a knowledgeable colleague regarding the importance of A1c testing
- Patient educational tools for the office such as brochures, posters, and A1c stickers
- Scientific literature about the validity of A1c testing
- Educational materials
- Instructions to request A1c testing
- Offer for a free home glucose monitor
A1c testing rates increased 62%, and the number of patients whose A1c values were below 8% increased from 44% to 57%. These interventions worked better for endocrinologists and internists than for family practice physicians.
In another study, physician-developed guidelines and yearly audits with feedback improved all measures of adherence to clinical guidelines. However, some results returned to pre-intervention levels after the second year, even though physicians requested and received practice aids such as chart stickers to remind nurses of each patient’s complications; flow sheets for tracking lab results; and examinations, educational sessions, and support for developing meal plans for patients.
The barriers that emerged after the first year were:
- A perception by physicians that patients would not comply with nutritional therapy, insulin therapy, or intensified insulin therapy
- Lack of time to carry out multiple interventions in a single visit
- Difficulty in finding or communicating with specialists
Addressing these barriers requires changes to the system of care:
- Use of computerized reminders and tracking systems
- Use of clinicians other than physicians to perform some examinations or follow-up care
- Use of protocols and standing orders
Pay for Performance Versus Fee for Service
Lack of reimbursement for interventions that improve chronic disease care is a serious barrier for physicians treating patients with diabetes, particularly: nonvisit methods of interaction, group interactions, and self-management support.
The national Improving Chronic Illness Care program implemented quality improvements based on the Chronic Care Model (CCM) in more than 100 health care organizations, including 12 health plans. In spite of fee-for-service payment in most organizations, both small and large systems were able to successfully implement comprehensive system changes and demonstrate improvements in care. However, fee-for-service payment created disincentives for testing, for using existing personnel in different ways, and for organizing visits or follow-up. One of the factors mentioned most often as a barrier to chronic disease improvement by the organization involved in this program was reimbursement policies.
California’s Pay-for-Performance plan (P4P) is a quality incentive program for physicians involving six health plans, seven million commercial HMO enrollees, 215 physician groups, and 45,000 doctors. The incentives are based on performance on clinical quality, patient experience, and investment in information technology. It has recently announced its first-year results:
- There was a wide variation in clinical quality for diabetes screening; however, 18,000 more members (than the previous year) received a diabetes test.
- Larger physician groups tended to have better clinical quality scores.
- Greater use of information technology was linked to better clinical performance.
For more information on NCQA's PPC, go to www.ncqa.org/ppc.
Physician Recognition Can Address Diabetes Quality Gaps
Recognizing physicians and medical groups who develop and implement systems to improve care delivery can reinforce feedback and distinguish them from others in the marketplace. The NCQA/ADA Diabetes Physician Recognition Program® (DPRP) was developed in 1997 to identify physicians who demonstrate provision of diabetes care based on HEDIS measures of testing and outcomes.
It also provides products and tools to help patients with diabetes become engaged in their own care and achieve better outcomes. To date, over 1,800 physicians have received recognition through the program. Program participants have continued to improve their performance even after meeting the thresholds for recognition, mostly without financial incentives to do so. All recognized physicians are listed on NCQA’s and ADA’s Web sites and may receive other publicity such as recognition in health plan provider directories.
Bridges to Excellence is a nonprofit organization dedicated to advancing the quality of health care, by addressing the need to redesign payment in a way that encourages health care professionals to make the changes needed to improve quality. To this end, the organization has created reward programs, including Diabetes Care Link, in which physicians can receive recognition and financial rewards for high levels of care. Diabetes Care Link tracks physician performance on measures that have been developed by the ADA and NCQA in the Diabetes Physician Recognition Program.
To search the list of physicians recognized for providing high-quality diabetes care, go towww.ncqa.org/PhysiciansQuality_Reports.htm.
Participating employers and plans in some geographic areas are providing financial bonuses to physicians who earn recognition; physicians can receive up to $80 per patient with diabetes in their practice covered by a participating employer and plan. The cost to employers is no more than $175 per patient with diabetes per year with a savings of $350 per patient per year.
NCQA’s newest physician recognition program is Physician Practice Connections (PPC), which assesses physician office performance in the areas of clinical information systems, patient education and support, and care management. Processes that are examined include the clinical information systems used to track patients and their care needs, the patient education and referral resources used to help patients manage their conditions, and care management processes to help patients with chronic conditions. More than 1600 physicians have earned PPC recognition at the time this report was posted to the Web.
Clinics Will Test the Effectiveness of a Team-Based Approach to Diabetes Care
Persons with diabetes manage their condition 24 hours a day, seven days a week. Historically, physicians have assumed the primary role for managing patients and have referred their patients to other clinicians, such as diabetes educators and dietitians, for specific needs and education. The Chronic Care Model (CCM) encourages the use of a team-based approach to care management because it spreads the many responsibilities over a larger group of health care professionals and leverages the individual strengths of the diabetes team members to provide more comprehensive care to patients.
A medical group association awarded a grant to two affiliated clinics in a rural area in the northern United States to test the impact of an approach that shifts some responsibilities for patient education on diabetes preventive care and monitoring from the physician to other office staff. This coordinated care approach will be implemented in one office, while usual care will be delivered in a geographically separate clinic as a control.
The clinic plans to implement the coordinated care approach on a quarterly basis over a 12-month period. Each quarter, the clinic will implement one of four diabetes preventive modules and the associated restructured patient care workflow. The modules, based on AACE and ADA guidelines, focus on retinal screening, microalbumin testing, macrovascular risk control, and peripheral neuropathy screening. Each module has patient educational materials and defined tasks for the receptionist, nurse, physician, and medical records staff. The nurse has the main accountability for providing patient education, which is reinforced by the physician. The coordinated care approach is designed to promote adherence to evidence-based guidelines, increase patients’ knowledge and self-management of their condition, and improve communication among health care team members.
A variety of metrics will be used to assess the impact of the coordinated care approach and compare its effectiveness to the usual care approach. Medical record abstraction will be completed at baseline, three, six, nine, and 12 months postimplementation to determine A1c, blood pressure, and lipid levels, as well as whether patients received the appropriate preventive services designated by each module. Staff knowledge will be assessed through an office staff questionnaire completed at baseline and after each module. The baseline assessment allows for further training prior to implementing each module. Patient knowledge will be assessed through a Diabetes Knowledge Questionnaire at baseline, at six months (after the first two modules are completed), and at 12 months (after all four modules are completed). Comparing the coordinated care approach to usual care will allow the clinics to determine which approach is most effective at providing high-quality diabetes care that helps patients reach AACE and ADA targets. Early data reveal that the outcomes are promising.
To help physicians and health care professionals refocus, health plans can:
- Support or provide disease management programs
- Use databases to track behavioral changes, treatment, and physician adherence to guidelines and to automate reminders, guideline information, treatment protocols, and communication among team members
- Emphasize adherence to guidelines
- Support the use of team care, increased use of nonphysician team members, and links to community resources
- Identify and make available tools that help physicians establish frequent contact and follow-up with patients
- Recognize and reward improvements in physician performance
- Reimburse physicians for screening for prediabetes and diabetes and for the time needed to implement behavioral strategies to prevent and manage diabetes
To help patients, health plans can:
- Encourage and support lifestyle changes to prevent diabetes through assessing risk perception, education, and group and individual interventions
- Use visual presentations and patient education materials that are simple to read
- Use culturally relevant educational materials
- Promote use of the Internet and other interactive treatment planning tools
- Identify patients having difficulty adhering to treatment and inform their physicians so they can get help with behavioral changes
Through QI activities, health plans can facilitate the changes that improve diabetes care and outcomes for their members and create a more efficient health care system.
Compensating Pharmacists Expands Patients’ Access to Care
Part of the challenge for any MCO is making sure that members with diabetes are seen by practitioners at regular intervals. Consistent and timely visits promote early identification of complications and can help prevent exacerbation of the disease. Access for members who need physician appointments quickly, particularly when symptoms appear suddenly, is an ongoing challenge for many health plans. One organization decided to address this concern by developing a care process (modeled on the Asheville Project) involving health care professionals who are often underutilized: pharmacists.
A preferred provider organization (PPO) model health plan responsible for the health and life insurance benefits of over 200,000 state, county, and university workers examined medical expenses and determined that care for members with diabetes cost three times more than members without diabetes. The plan responded by developing an intervention program onsite at members’ pharmacies. This initiative was developed with support from the state university’s school of pharmacy and the health education and research affiliate of a local tertiary care facility, and was based on a structured model including:
- Specified services based on clinical practice guidelines
- Scheduled appointments with members with diabetes that take place at the pharmacy
- Establishment of health care goals for each member and ongoing measurement of progress in achieving those goals
- Online tracking of health care outcomes through a proprietary Internet-based system
- Sharing of outcomes data with the member’s physician via quarterly reports
- Identification and coordination of care for services the member needs (e.g., equipment, supplies, and medications)
- Incentives for pharmacists and members to participate
This program engaged the services of local pharmacists in retail settings to work directly with patients with diabetes to monitor health status, provide education, and communicate outcomes to physicians. The program took advantage of the convenient location of pharmacies (the population is largely rural) and the clinical expertise of the pharmacists, who normally were limited to providing patients with information about medications.
How Does the Diabetes Pharmacy Program Work?
Eligible members were identified as having diabetes by reviewing claims and pharmacy data. The plan sent all of these members a letter introducing the program and a list of pharmacies that were participating. The plan encouraged the members to join the program by offering to waive all co-payments associated with diabetes medications, providing some diabetes supplies, and covering laboratory tests once the annual deductible was met. Members enrolled in the program using an application that was enclosed with the introductory letter. They identified the pharmacist they wanted to work with and returned the application to the plan. Upon receipt, the plan entered the new enrollees in the database and sent a confirmation letter to the members’ physicians and the selected pharmacists. Reports identifying new members with diabetes and letters to potential participants were sent on a quarterly basis.
Pharmacists were invited to participate in the program based on their location in the six-county pilot area. Pharmacists agreed to comply with all program services and practice requirements. The pharmacist was required to have completed a nationally recognized diabetes certification program, a 27-hour course that includes a seminar and self-study work. They were also required to complete additional training on the secure Internet database program that was used to maintain records on each member. As part of the program, members were required to get appropriate laboratory testing, and the pharmacist could either refer the member to a participating laboratory or perform the testing at the pharmacy. In the latter case, the pharmacist was required to possess a certificate of registration through the Clinical Laboratory Improvement Act of 1988.
In exchange for participating in the program, the pharmacist was paid for each member visit as follows:
|HCPCS/ CPT Code
||Diabetes program initial assessment
||1 per patient, per lifetime
||Diabetes program, follow-up 15 min
||Limit of 2 units per visit
The pharmacist acquired, via the Internet database, a list of members who had selected his or her pharmacy, and initiated a telephone call to the member to schedule the initial one-hour assessment. During this first visit, the pharmacist conducted a baseline health assessment and provided counseling about medications, diet and exercise, and possible complications of diabetes. Subsequent follow-up visits occurred either monthly or less frequently, depending on the member’s health issues. These follow-up appointments lasted an average of 15 to 30 minutes.
The pharmacist was required to document the level of services provided at each encounter in the Internet database; at minimum, blood pressure, cholesterol level, A1c values, review of medications, meal and exercise planning, and referrals to appropriate health care providers were tracked. The pharmacist also completed the online Education/Goals Summary Form that identified goals established with the member and a log of the education provided to support attainment of these goals.
Out of 2,200 eligible members with diabetes in the six county pilot areas, 540 were participating (25%) in the diabetes pharmacy program. There were 19 pharmacies and 24 pharmacists in the program, including both independents and large chains. The pharmacists had member caseloads that ranged from 10 to 50 patients. More than 30 different results were tracked in the database, including:
- Percentage with A1c level tested in previous six months
- Percentage with A1c level tested in previous 12 months
- Average A1c value
- Percentage with urine protein test in previous 12 months
- Percentage with blood pressure taken in previous six months
- Average systolic and diastolic levels
- Percentage with low-density lipoprotein (LDL) cholesterol <100 mg/dL
- Percentage with high-density lipoprotein (HDL) cholesterol >40 mg/dL
- Percentage with self-measured blood glucose
- Average self-monitored glucose level
- Percentage with retinal eye examination in previous 12 months
The program is less than a year old, so outcomes data are limited. However, data in the first nine months demonstrated the following
- Percentage with A1c testing in previous six months increased from 62.2% to 70.3%
- Percentage with A1c level <7% improved from 43. 1% to 54.8%
- Percentage with lipid panel obtained in last 12 months increased from 63.3% to 70.5%
- Percentage with LDL <100 mg/dL improved from 41.9% to 47.8%
Preliminary indications show that the program has resulted in improved performance in screening and outcomes for A1c and lipid levels.
Feedback from the pharmacists was very positive. The program helps create member loyalty, resulting in repeat business for the pharmacy and an opportunity for pharmacists to use their clinical expertise beyond dispensing medications. Members appreciated the ease of access to a health care professional when they had questions or concerns about their diabetes and the reduced out-of-pocket costs for drugs, supplies, and laboratory services.
Overall, the diabetes pharmacy program afforded this organization an opportunity to expand access to health care services and track specific outcomes data for their members with diabetes, thereby reducing costs of diabetes care and improving the quality of patients’ lives. Based on the initial success of the pilot, the plan and its partners have scheduled training sessions for pharmacists interested in participating in the planned statewide expansion of the program.
20. Egede LE. Lifestyle modification to improve blood pressure control in individuals with diabetes: is physician advice effective? Diabetes Care. 2003;26:602-607.