Diabetes Management: An Approach That Improves Outcomes and Reduces Costs

April 2, 2008
Edward J. Shahady, MD
Edward J. Shahady, MD

As many as 10% of Americans older than 20 years have type 2 diabetes, and more than 20% of the total population has the metabolic syndrome. Type 2 diabetes will develop in many of those with the metabolic syndrome.

As many as 10% of Americans older than 20 years have type 2 diabetes, and more than 20% of the total population has the metabolic syndrome.1,2 Type 2 diabetes will develop in many of those with the metabolic syndrome. In the United States, diabetes is the sixth leading cause of death; the leading cause of end-stage renal disease, non-traumatic limb amputations, and blindness; and the leading contributor to cardiovascular disease.3-6

The physical, fiscal, and psychological burden of diabetes can be significantly reduced if evidence-based goals are achieved for hemoglobin A1c, low-density lipoprotein (LDL) cholesterol levels, and blood pressure. Based on strong evidence, the American Diabetes Association (ADA) has set the following goals for management of the disease:

• Hemoglobin A1c < 7%.
• LDL cholesterol level < 100 mg/dL.
• Blood pressure < 130/80 mm Hg.

However, diabetes is a complex chronic disease that has proved difficult to manage effectively in the primary care setting. Despite our increased knowledge of the pathophysiology of the disease and of effective treatment strategies, patient outcomes have not shown a parallel improvement.7,8 Nationally, only 48% of patients have reached the ADA's hemoglobin A1c goal, just 33% have met the LDL cholesterol goal, and only 33% have met the blood pressure goal. Only 7% have reached goal for all 3 parameters at the same time.9

This article describes a program that has significantly improved the percentages of patients who meet ADA goals. It also offers resources and tips that can help you implement a similar strategy in your practice.

The Diabetes Master Clinician Program (DMCP) was created by the Florida Academy of Family Physicians Foundation (FAFPF) in 2003 to address the performance gap in diabetes care. The DMCP was designed to help clinicians implement approaches that have been shown to improve outcomes in the management of chronic disease. The program is funded through grants, and there is no charge for participation.

Of the 8657 patients in the 58 practices participating in the DMCP, the percentages that have achieved ADA goals have been significantly better than the national average: 54% of the patients have achieved the hemoglobin A1c goal; 53% have achieved the LDL cholesterol goal; 54% have achieved goal blood pressure; and 19% have met all 3 goals. Several participating practices report figures as high as 75% for individual measures and 44% for all 3 together.

Moreover, these improved performance statistics translate into considerable cost savings. A national program, the Diabetes Physician Recognition Program (DPRP), which is cosponsored by the ADA and the National Committee for Quality Assurance, provides recognition for physicians who achieve certain performance measures in their care for patients with diabetes. An independent actuarial firm, Towers Perrin, was asked to calculate the per-patient savings accrued by physicians who achieve DPRP recognition. The firm estimated the following savings for every additional patient in a practice who was able to achieve the following goals10:

• Hemoglobin A1c < 7.0%: $248 saved per patient.
• Blood pressure < 130/80 mm Hg: $494 saved per patient.
• LDL cholesterol level < 100 mg/dL: $369 saved per patient.

Using these estimates and the numbers of patients in the DMCP at each goal beyond what would be projected based on national average percentages, the following annual program-wide savings can be calculated:

• Hemoglobin A1c < 7.0%: $98,704 total savings.
• Blood pressure < 130/80 mm Hg: $825,234 total savings.
• LDL cholesterol level < 100 mg/dL: $499,257 total savings.

In fact, in the opinion of this author, these numbers are quite conservative.

The DMCP uses 3 principal tools to help primary care physicians and their patients attain the ADA goals:

• A diabetes registry.
• Group visits.
• A team approach.

These tools are accompanied by ample training and support for both clinicians and assistants.

Diabetes registry. The diabetes registry used in the DMCP is an Internet-based relational database created in consultation with an information technology expert. Evidence-based quality indicators culled from the published guidelines of the ADA,11 the National Cholesterol Education Project,12 and the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure13 were used to guide the creation of the database fields. The DMCP registry generates excellent reports that both enhance the care provided in one-on-one office visits and facilitate management of all patients with diabetes in the participating practices.

Time-saving physician reports. Between 15 and 20 minutes of a physician's time is allotted for a typical one-on-one office visit with a patient with diabetes. Often, some of that time is spent searching for laboratory results and other information from past visits. The diabetes registry provides a report that can save physicians up to 5 minutes by organizing all of the patient's pertinent diabetes information for their review (Table 1).

Easy-to-understand patient "report cards." The most valuable report generated by the DMCP registry is the patient report card (Table 2). The simple language that is used to explain the items in the report empowers and educates patients and encourages self-management. If a practice chooses, a medical assistant or nurse can review and explain the report to the patient. These reports enhance the effectiveness of the one-on-one visit; reduce frustration; save time; and increase patient, staff, and physician satisfaction.


Identifying specific care needed by patients. The registry can also generate lists of patients who have not returned to the office for periodic diabetes evaluations; lists of those who may have been to the office but have not had the recommended periodic evaluations; and lists of others who lack documentation for a specific annual laboratory test, examination (eg, ophthalmological exam), immunization, or therapy. The reports facilitate notifying patients of the need to come in for these services; they can also make it easier to recognize when a strategy such as arranging for an optometrist to visit a clinic may be productive. Electronic medical records (EMRs) may not provide reports of this nature.

Still other reports identify high-risk patients based on their hemoglobin A1c, LDL cholesterol level, non-HDL cholesterol level, or blood pressure. These reports make it easier to determine which patients require more aggressive management strategies (eg, group visits).

Tracking a practice's overall performance in diabetes care. Because the DMCP registry is Internet-based and involves all participating practices, it can generate reports that allow clinicians to compare their practice's ability to achieve the ADA goals for hemoglobin A1c, LDL cholesterol, and blood pressure with the results achieved by other practices in the program (Table 3). Practices are also able to track their performance in achieving goals over time (Table 4).

Group visits. These are an integral and important part of the program. Group visits empower patients to better self-manage their diabetes. Clinicians are encouraged to invite their high-risk patients (those who are not at goal for hemoglobin A1c, LDL cholesterol, or blood pressure) to participate; the diabetes registry helps them identify these patients. Group visits are usually 2 hours long, with the first hour conducted by the medical assistant or nurse and the second hour led by the physician.

Team approach. A key component of the DMCP is the empowering of medical assistants and nurses to help ensure that all elements of quality care are provided for each patient. Use of the registry-generated reports makes it easier for assistants to assume responsibility for certain aspects of care. For example, a medical assistant or nurse can give patients their "patient report cards" and review these reports with them. Assistants or nurses can also use the registry's population reports and reminders to order needed tests in a timely fashion. In addition, group visits are structured to take advantage of the special assistance a trained medical assistant or nurse can provide.

Training and support. The DMCP provides evidence-based training for a team of a clinician and a medical assistant or nurse from each participating practice. The training consists of interactive group seminars, visits to the clinician's office, and educational e-mails over an 8- to 12-month period. It includes information about current clinical standards of care, how to enter data into the registry, how to produce and interpret quality assessment reports, and how to conduct group visits. The office manager and other office staff also receive an orientation to the project. Alumni meetings are held yearly.

The guidelines for group visits include forms for privacy protection and documentation of the visit, appropriate ICD 9 and CPT coding, roles for the medical assistant or nurse and the clinician, suggested curriculum, and information on how to prepare for and follow up the group visit.

The heartening results achieved by practices involved in the FAFPF's DMCP can be replicated in most any practice that is willing to invest the time and effort. Resources that can help clinicians implement the tools of a diabetes registry and group visits are available at no cost or for a modest investment. In some cases, training and support are available for free as well.

Setting up a registry. There are several public domain software programs that allow practices to set up a diabetes registry at no cost (Box). Most of these are relatively simple to use, based on well-known programs such as Microsoft Excel or Microsoft Access. Various commercial registry software products are also available. Compared with the cost of an EMR, these are quite modestly priced.

For a slightly more substantial investment (but still far less than is required for an EMR), practices may want to consider a chronic disease management system. These products can be used for the management of multiple chronic diseases and can be especially helpful in the care of patients with more than 1 chronic condition. Finally, practices that have already switched to an EMR-or that plan to do so-will usually find that these systems include most of the functionality of a registry and can be readily used to assist in the management and tracking of patients with diabetes.

Instituting group visits. Getting a group visit program off the ground can seem daunting to clinicians whose careers have been measured in one-on-one patient visits. However, no-cost resources are available to help with this as well (see Box).





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