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The sponsors of a recently concluded diabetes disease management pilot study hope that the results of their work will bring primary care providers the tools and information they need to provide better diabetes care.
The 17-month study was a joint effort by two major health care concerns:
1. Diagnostics Division of The Roche Group, the international pharmaceuticals company, whose products include the Accu-Check blood glucose monitoring system.
2. Sierra Health Services, a Las Vegas-based health care services company that operates HMOs, indemnity and workers’ compensation insurers, PPOs, and a multispecialty medical group.
The focus of their efforts was on improving the methods of managing patient populations with diabetes mellitus. According to the Diabetes Quality Improvement Project (DQUIP) diabetes mellitus currently affects some 16 million Ameri-cans, and over 150,000 people die from diabetes and its complications each year. "The annual cost of diabetes has been reported to be nearly $100 billion," according to DQUIP, making it "one of the deadliest and most costly diseases known." The coalition includes the American Diabetes Association, the Foundation for Accountability, the Health Care Financing Administration, and the National Committee for Quality Assurance (NCQA), the American Academy of Physicians, the American College of Physicians, and the Department of Veterans Affairs.
Most of the morbidity and mortality of diabetes is due to the complications associated with the disease, according to a recent DQUIP statement, including blindness, kidney failure, nerve damage, and cardiovascular disease. "Studies show that many, if not all, of the complications of diabetes can be slowed or even prevented by better management on the part of the health care team and the patient. Improved blood glucose control, regular eye examinations, and reduction in cholesterol and blood pressure are some of the practices that have been unequivocally shown to reduce complications and the heavy personal and financial toll of the disease."
Roche Diagnostics has historically invested heavily in medical research activities at the consumer, physician, and managed care plan levels, according to Ron Peyton, the company’s director of managed care and health management. And Sierra wanted to improve its approach to diabetes care.
When the two organizations joined forces in late 1997, the result was the Diabetes Advantage Program (DAP). "We worked with Sierra to put together a comprehensive health management approach to improve diabetes care among its population. What we wanted to do was build a program that combined risk stratification and patient education, along with software reporting and tracking tools, to assist Sierra in better meeting patient needs," he explains. "At the same time, we also wanted to enable Sierra to better meet the various managed care benchmarks that are being applied to the treatment of diabetes through NCQA, DQUIP, The Health Care Financing Administration, [the Joint Commission on Accreditation of Healthcare Organizations], and others."
"Overall, we wanted to improve the quality of patient outcomes in terms of HbA1c levels, lipid levels, and blood pressure management," says Linda Stutz, manager of health management development for Roche Diagnostics. In addition, "We wanted to increase the level of patient satisfaction with Sierra’s diabetes care program, as well as with the overall level of service from the health plan."
And, importantly, "We wanted to create a program that would not increase the workload of the primary care physician," says Stutz, "but, in fact, could increase his or her ability to deliver quality care within the existing outpatient clinic setting." This final point is an important one, she notes, because research has shown that 90% of all diabetes care is done by primary care physicians, as opposed to specialists.
Program’s care standards set by physicians
Although approximately 600 total Sierra diabetes patients were enrolled in the DAP, only about 250 of them were "academically enrolled" and included in the actual study, according to Peyton. This latter group met the study’s inclusion/exclusion criteria: ages 21 to 75, no major health risks, no end-stage renal disease, and no current involvement in any other studies. Other enrollees, who did not necessarily meet these criteria, came on board "due to physician excitement about the program," he notes.
At least some of this excitement may have been due to the large role participating Sierra physicians played in setting the standards for the program. "We brought the physicians together so that they could establish exactly what their standards of care are for diabetes," says Peyton. "We asked them to put these standards in terms of what factors they felt were most important to monitor." Those factors included HbA1c levels, lipid levels, and blood pressure, as well as foot condition and complications of diabetes such as retinopathy and nephropathy.
The various factors were then rank-ordered by the physicians to provide a stratified classification system for placing diabetic patients in categories for high, medium, and low risk of serious complications. The physician group then determined what they felt were the appropriate medical responses, coming up with definitions of appropriate treatment/intervention options for diabetes patients within each risk category.
These options, or "standing orders" for each risk category, were entered into a computer software program specially designed for the DAP, according to Peyton. Meanwhile, the clinical characteristics and/or lab profiles of participating diabetes patients were entered into the same program. A designated staff person — called a tracker — was charged with the responsibility of getting diabetes patients in for appropriate lab testing as well as entering all data into the software program.
Constructing a better world’
Having a physician-generated risk classification system, individual patient lab profiles, and standing orders for treatment/intervention linked within a computer database created what Peyton calls "a better world" for both physicians and diabetics in the DAP study.
Once brought into the program, each patient received a report stating where they were on the risk continuum and what course of action they should follow, according to Peyton. And at the same time, physicians got reports for each patient stating lab results and where they fell in terms of risk, along with the standing orders/recommendations for appropriate treatment — as formulated by the participating physicians at the beginning of the program. And in the DAP study, these events occurred before any patient/physician encounter took place — a situation that is not the norm in today’s health care environment.
For a patient, a visit to a physician’s office is typically a starting point, kicking off a series of events including observation, testing, diagnosis, and treatment. But, "in the better world we have constructed with Sierra, by the time the diabetic patient hits the physician’s office with a complaint, explains Peyton, "the lab profiles, the results of previous examinations, and the standing orders are already there."
In short, there’s magic in having the physician, the patient, and the necessary knowledge all in the same room at the same time, he says. "There’s no time lag, no waiting for test results." Freed from basic patient information gathering, "Physicians become empowered to try to find out what is unique about this patient and can expend their efforts on creative thought on how they can uniquely intervene."
The Roche/Sierra DAP concluded in October. A preliminary look at the results showed that the program had positive impacts on meeting Health Plan Employer Data and Information Set requirements, as well as on patient and physician satisfaction levels. At press time, the official results from the first six months of program operation were slated for presentation at the 35th annual meeting of the European Association for the Study of Diabetes (EASD) in Brussels in late September. Full results are scheduled for tabulation and release in early 2000.
[For more information, contact:
• Linda Stutz, Manager of Health Management Development, Roche Diagnostics. Telephone: (317) 576-3312. E-mail: firstname.lastname@example.org.
• The American Diabetes Association, 1701 N. Beauregard St., Alexandria, VA 22311. Telephone: (800) 342-2383. Web site: http://www.diabetes.org.]