A systematized, team-based approach to type 2 diabetes management really can reduce vascular complications. In this study, by the Geisinger Health System, it took just 3 years.
Improving care for patients with a chronic, multisystem disease like diabetes, which requires coordination of multiple providers, can be very complicated. But does all the hard work to coordinate that care really pay off in terms of outcomes?
The short answer is: Yes-and fairly quickly according to a new study by researchers at Geisinger Health System in Pennsylvania. The study, published online on June 26, 2014 in the American Journal of Managed Care, showed how a systematized, team-based approach to diabetes management in primary care clinics can reduce microvascular and macrovascular complications of type 2 diabetes in just 3 years.
“The study showed that a system of care with an all-or-none bundled measure used in primary care for patients with diabetes may reduce the risk of myocardial infarction, stroke, and retinopathy over just a 3-year period,” commented Thomas Graf, MD, Chief Medical Officer for Population Health at Geisinger Health System. “Prior work had shown that improving individual measures could be accomplished quickly,” he notes, “but this is the first time that a system of care has been shown to reduce the incidence of diseases that complicate diabetes, and it does so in a short time period.”
Drawing on elements of the American Diabetes Association’s Standard of Care in Diabetes Geisinger in 2006 implemented its Diabetes System of Care in select clinics. Equal numbers of patients with diabetes were either exposed to the Diabetes System of Care (n=4095), or were not exposed (n=4095) if they received care in clinics where the system was not implemented.
The Geisinger Diabetes System of Care consisted of:
* 9-component bundle of diabetes measures (Table)
* Delegated responsibilities for each team member
* A workflow redesign independent of input from individual providers, which included standing orders for influenza and pneumococcal vaccinations, diabetes lab work, eye exam referrals, and diabetic foot screenings
* EHR decision support for HbA1c, LDL, and blood pressure management
* Patient report cards and monthly performance reports for team members
* “All-or-none” financial incentives awarded only when all 9 parts of the bundle were completed
The small financial incentives used in this study garnered the attention of the primary care team, while also rewarding them for generating change, Graf explained. These incentives, though, were not intended to be in exchange for longer, more intensive work hours. The Diabetes System of Care introduced new workflows that providers were able to sustain, Graf pointed out, because the procedures made it easier for physicians to focus on complex medical decision making. The new workflows also streamlined completion of routine tasks necessary for comprehensive diabetes care.
Analyses included patients age 40 years and older and were based on insurance claims data. Chronic kidney disease was not included because reliable reports were not available in claims data.
Key results included:
* Incident cases: 714 MI, 445 stroke, 519 retinopathy, 17 amputations
* Myocardial infarction: HR 0.77, 95% CI 0.65-0.90
* Stroke: HR 0.79, 95% CI 0.65-.097
* Retinopathy: HR 0.81, 95% CI 0.68-0.97
* Amputation: HR 1.32, 95% CI 0.45-3.85
Graf highlighted the numbers-needed-to-treat results. After investing time and energy to implement the Diabetes System of Care, the study showed that only 82 patients with diabetes would need to be treated over 3 years to prevent one myocardial infarction.
“Many primary care physicians have more than 82 patients with diabetes, and could save lives in their practice by using this system of care,” Graf emphasized.
To prevent one stroke over 3 years, only 178 patients with diabetes would need to be treated. And to prevent one case of retinopathy, only 151 patients would need to be treated.
“We accomplished these results without increased office staff, by changing roles and responsibilities to a team based-model,” Graf pointed out.
Among this study’s most reassuring news, perhaps, is that payback is relatively fast.
“Payers and health systems can innovate and invest together in the infrastructure to build similar systems of care, knowing that the benefit for their patients with diabetes will be prompt,” the authors concluded.
Table. Diabetes Bundle Protocol in the Diabetes Bundle Sites on January 1, 2006,
Geisinger Health System Diabetes Bundle Care Model
|Bundle Element||Quality Standard|
|A1c||Every 6 months|
|A1c control-patient specific goal||<7 or 7%-8%|
|LDL-C control-patient specific goal||<70 or <100 mg/dL|
|Blood pressure measurement (mm Hg)||<140 SBP, <80 DPB|
|Urine protein testing||Annually|
|Penumococcal immunization||Once before and once after age 65y|
|Smoking status assessment||Nonsmoker|
Bloom FJ, Yan X, Stewart WF, et al. Primary care diabetes bundle management: 3-year outcomes for microvascular and macrovascular events.Am J Manag Care. 2014;20(6):e175-e182. Published Online June 26, 2014 at:
American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2014;37:S14-S80.