Intensive diabetes management yields positive results

Increasing diabetes awareness and integrating a multi-faceted, approach to improve patient care and education, results in significantly improved patient outcomes, according to a report in the April issue of Clinical Diabetes, a publication of the American Diabetes Association.

The article reports the results of the first two years of an initiative to increase diabetes awareness among the University of Pittsburgh Medical Center's (UPMC) 220 primary care physician practices, called UPMC Community Medicine, Inc. (CMI), and the implementation of a structured program to improve care and outcomes.

"This is a rather extraordinary accomplishment," said Francis X. Solano Jr., M.D., vice president, physician services division and chief medical officer of CMI. "Our physicians have provided interventions on more than 15,000 patients that have exceeded outcome measures reported in The New England Journal of Medicine last year. The dramatic accomplishments in such a large population of patients is remarkable and demonstrates the UPMC physician service division's commitment to leading edge quality care in diabetes mellitus."

"At the beginning of the initiative, we found that primary care physicians were not uniformly delivering diabetes care based on evidence-based guidelines. Since over 90 percent of patient visits were to primary care providers (PCPs), it became critical to determine if PCPs could adopt a process delivery system that included use of evidence-based guidelines," according to Linda Siminerio, Ph.D., executive director of the University of Pittsburgh Diabetes Institute and assistant professor of medicine and nursing at the University of Pittsburgh. "After two years we found that physicians made major strides in the improvement of health care practices and patient outcomes," Dr. Siminerio continued.

A review of 15,687 laboratory test results found that, at the end of the two-year period, the patients' average HBA1C (which indicate a person's blood sugar control over the past 2 to 3 months) was reduced to 6.97 percent, which is better than the national average HBA1C of 7.8 percent.

There were 4,598 patients tracked with respect to blood pressure and cholesterol management. Some 51 percent of these patients lowered their blood pressure below 130/80 mm and 78 percent lowered their blood pressure below 140/90 mm. A total of 71 percent of patients were placed on an ACE inhibitor or beta-blocker for heart disease. More than 42.8 percent of patients lowered their LDL cholesterol level below 100 mg and 76.4 percent lowered LDL to less than 130 mg. A total of 77 percent of patients were put on a lipid-lowering drug. Physician compliance with a prospective tracking form that focused on lipid and blood pressure management was over 95 percent.

These figures are impressive when compared to national statistics, according to Dr. Solano. Nationally, according to a 2002 study in the Annals of Internal Medicine, just 65.7 percent of people with diabetes have blood pressure lower than 140/90, only 11 percent have LDL less than 100 mg and only 42 percent have LDL less than 130 mg.

The Focus on Diabetes initiative began by laying the foundation for improved diabetes care practices through implementation of the American Diabetes Association (ADA) Standards of Care, supporting education efforts and creating community awareness. ADA Standards with companion flow sheets were disseminated to the practices. Presentations to physicians on diabetes care focused on ADA guidelines, rationale and strategies for treatment and diabetes self-management education. This was a major challenge since the UPMC physician network extends across a radius of 250 miles. Physician education was delivered through a variety of venues including telecommunicated programs for outlying rural practices, regional physician meetings and lectures from the academic endocrine faculty.

One of the major factors for success has been getting physicians involved in the quality improvement process and making them responsible for collecting their data in a prospective manner. By asking them to track their patient interventions, physicians were not only assessing their results but also responding to them at the time of encounter. It was also critical to give physicians data on their population of patients and tools to facilitate patient management, according to Drs. Solano and Siminerio.

Physicians received quarterly reports on the laboratory data pertinent to the care of their diabetes patients. Laboratory results along with patient demographics, visits and charges were captured into a large UPMC clinical data repository called Medical Archival Retrieval System (MARS).

The initiative began as a voluntary participation project; but physician participation eventually was mandated. At the start of the initiative approximately 120-130 physicians (50 to 60 percent) participated in tracking and reporting data based on the project guidelines, by the end of the study period 95 percent participated.

In addition, diabetes educators were hired to provide diabetes education at physician practices on "diabetes days," in order to maximize efficiency with the added benefit of the focused visits for the practice. Education was promoted through the practices and public awareness campaigns.

"Diabetes care is becoming a priority for health systems as costs and health outcomes are being closely scrutinized. Because the traditional health care system is designed to provide a symptom-driven response to acute illnesses, it is poorly configured to meet the needs of the chronically ill," said Dr. Siminerio. "Although it may take years to see significant impacts on micro- and macro-vascular disease, our results would lead us to believe our patients have been best served by these ongoing quality efforts."