This Physician’s Weekly feature was completed in cooperation with the experts at the American Diabetes Association.
Over the last decade, healthcare providers in primary care settings and endocrinology practices have seen significant and steady improvements in the number of patients with diabetes who are achieving recommended levels of A1C, blood pressure (BP), and cholesterol. National data show that average A1C levels have declined from 7.82% in 1999-2000 to 7.18% in 2004, based on information collected in the National Health and Nutrition Examination Survey. Improvements in lipids and BP control have accompanied improvements in A1C, which in turn have led to substantial reductions in end-stage microvascular complications in individuals with diabetes.
While these improvements are significant, data continue to suggest that there are areas for improvement in diabetes care. “Medications, technology, and enhanced insulin pens and pumps have had an important role in improving the management of diabetes,” says Martha M. Funnell, MS, RN, CDE. “However, some studies have shown that a substantial number of people with diabetes still have A1C, BP, and cholesterol levels that need to improve. Complicating the matter is that the quality of diabetes care varies considerably across providers and practice settings.”
Examining Diabetes Intervention
Over the years, researchers have implemented numerous interventions to improve adherence to recommended diabetes care standards, but care delivery systems are often fragmented and lack clinical information capabilities. In many cases, care delivery systems are poorly designed to manage this chronic disease. “Ideally, patients with chronic conditions like diabetes should be cared for by collaborative, multidisciplinary teams to facilitate self-management and self-care strategies for patients,” says Funnell.
In the American Diabetes Association’s Standards of Medical Care in Diabetes-2011, experts describe implementing the Chronic Care Model (CCM), which utilizes six core elements as a strategy to help providers optimize diabetes care. The CCM focuses on delivery system design, self-management support, decision support, clinical information systems, community resources and policies, and health systems.
“To improve diabetes care, clinicians need to move from a reactive to a proactive care delivery system, where planned visits are coordinated through team-based approaches,” Funnell explains. “Use of consistent, effective care guidelines is paramount. In addition, clinicians should use registries and electronic medical records that provide patient-specific and population-based support to the diabetes care team. Efforts to create a qualityoriented culture are also critical.”
In order to achieve desired outcome goals in diabetes, it is likely that reimbursement for care will need to be altered so that clinicians are rewarded for providing quality care (which is defined by the attainment of evidence-based quality measures). To successfully implement the CCM model, the roles of staff may need to be redefined.
Funnell adds that promoting patient self-management is fundamental to improving outcomes. “Patient education about nutrition, diet and exercise, behavior change and coping strategies, pharmacotherapy, and comorbidities is essential. Efforts are needed to ensure that gaps in quality of care are reduced and eliminated. Greater efforts to implement chronic care models may further enable clinicians to achieve these goals.”
Three Key Objectives to Improve Diabetes Care
According to the American Diabetes Association, there are three major strategies to successfully improve the quality of diabetes care that is delivered by providers (Table). The first objective is to enact provider and team behavior changes. The National Diabetes Education Program provides an online resource (http://www.betterdiabetescare.nih.gov) to help healthcare professionals design and implement more effective delivery systems for those with diabetes. “Providers need to facilitate timely and appropriate lifestyle and/or drug therapies—and intensify those efforts when necessary—for patients who haven’t reached their appropriate A1C, BP, and cholesterol goals,” says Funnell.
The second objective is to facilitate patient behavior changes, and Funnell says this is an especially important consideration. “Systematically supporting behavior changes so that patients engage in healthy lifestyles is critical. Patient education on physical activity, healthy eating, smoking cessation, weight management, effective coping, and medication taking can go a long way toward optimizing diabetes care. It can also help with the prevention of diabetes-related complications and enable patients to achieve appropriate BP, lipid, and glucose goals and quality of life.”
The third objective to improving diabetes management is to redesign the system of care. Specifically, providers are encouraged to utilize the CCM and critically assess other efforts and strategies to improve diabetes care. “The most successful practices have an institutional priority for quality of care improvements,” says Funnell. “This may require expanding the role of diabetes care teams and staff, redesigning delivery systems, involving and educating patients, and using electronic health record tools. Optimal diabetes management requires an organized, systematic approach. That means having a coordinated team of dedicated healthcare professionals in an environment that prioritizes and encourages patient-centered, high-quality care.”
American Diabetes Association. Standards of Medical Care in Diabetes—2011. Diabetes Care. 2011;34:S11-S61. Available at: http://care.diabetesjournals.org/content/34/Supplement_1/S11.full.
Hoerger TJ, Segel JE, Gregg EW, Saaddine JB. Is glycemic control improving in U.S. adults? Diabetes Care. 2008;31:81-86.
Beaulieu N, Cutler DM, Ho K, et al. The business case for diabetes disease management for managed care organizations. Forum for Health Economics and Policy. 2006;9:article 1.
Cheung BM, Ong KL, Cherny SS, Sham PC, Tso AW, Lam KS. Diabetes prevalence and therapeutic target achievement in the United States, 1999 to 2006. Am J Med. 2009;122:443-453.