Managing diabetes and preventing microvascular and macrovascular complications requires a more holistic approach that goes beyond glucose, and includes careful management of other risk factors.
Affecting more than 25.8 million Americans, diabetes is one of the most far-reaching epidemics facing the United States. Type 2 diabetes (T2D) is the most common type, accounting for an estimated 90% to 95% of all diabetes cases.
From 2009 to 2034, the number of Americans living with T2D is expected to nearly double, bringing with it additional cost burdens related to the management of the disease and related complications, according to the Centers for Disease Control and Prevention (CDC). Diabetes is a complex disease characterized by multiple modifiable risk factors, including obesity and high blood glucose levels, as well as non-modifiable risk factors such as age, race and family history.
Currently, clinical management of diabetes in professional-based guidelines from the American Diabetes Assn. and other organizations have clinical practice recommendations addressing different aspects of diabetes management. However, these various guidelines heavily center on the management of hemoglobin A1c (A1C) levels. The guidance documents from these organizations are reflected in the National Committee for Quality Assurance’s (NCQA) HEDIS performance measures, which is what Accountable Care Organizations (ACOs) and other organizations use to assess diabetes care performance.
This focus on A1C is grounded in the knowledge that epidemiological evidence indicates a continuous relationship between glycemia (A1C) and diabetes-related complications-among them many debilitating and devastating complications, including vision loss, renal impairment and failure, amputation, and cardiovascular events. Generally, every one percentage point reduction in A1C translates into a 40% decrease in microvascular complications and an 18% decline in combined fatal and nonfatal myocardial infarction, therefore targeting A1C is important when making clinical decisions in T2D.
However, a singular focus on A1C does not fully align with what the medical community understands about the multi-factorial nature of the disease. Managing diabetes and preventing microvascular and macrovascular complications requires a more holistic approach that goes beyond glucose, and includes careful management of other risk factors.
These include managing blood pressure, controlling blood lipids, and incorporating preventive care for the eyes, feet and kidneys. People with diabetes who maintain a normal blood pressure reading can reduce their chances for complications of the eyes, kidneys and nerves by about 33%, as well as their risk for cardiovascular disease by up to 50%, according to CDC. Preventive foot care programs, including assessing risk and educating patients on proper care, can significantly lower their risk of amputation.
While some organizations have adopted this type of holistic treatment model for other major disease categories, including cardiovascular disease and respiratory care, diabetes care continues to lag behind.
That may be changing, however, with healthcare reform driving the industry toward outcomes-based care where reimbursement and other incentives will be more closely tied with patient results. Given this change, organizations are beginning to shift their focus in the direction of a more inclusive care approach that accounts for the whole patient, rather than one aspect.
Few, if any, disease management programs place a clear emphasis on the prevention of complications like nephropathy and other microvascular issues beyond reductions in A1C levels. A1C is important only to the extent that reducing those levels and achieving guideline-recommended goals reduces the risk for complications. However, there is more that can be done to drive awareness among physicians and patients to pay attention to those complications before they occur.
One of the roots of the problem is diabetes management guidelines are very generic and focused on individualized treatment (non-prescriptive), and are anchored primarily to A1C control alone.
Guidelines from the National Asthma Education and Prevention Program, for instance, provide a more regimented treatment algorithm on asthma management for clinicians, providing a more stepwise approach to which therapies to initiate and at what point. This is not the case with current diabetes care guidelines, which recommend a more tailored approach.
For that reason, organized customers are anchored to what seems consistent in the guidelines and that is achieving an A1C of less than 7%, compliance with A1C testing, and managing side effects like hypoglycemia that impact outcomes and drive up cost. However, the CDC’s recent Diabetes Report Card notes about one in three patients with diabetes are not receiving at least two A1C tests a year or an annual foot exam, nearly four in 10 patients are not receiving an annual eye exam, and half do not get an annual flu vaccine. What is concerning is many patients are not receiving preventive care.
Improving diabetes care requires a more collaborative model, one that better aligns with where healthcare is heading in this country. In 2010, the Group Practice Forum worked in partnership with Boehringer Ingelheim Pharmaceuticals, Inc. and Eli Lilly and Company to begin developing such a model for organized customers. The Group Practice Forum is an independent, physician-led organization designed to provide health systems with a variety of solutions to increase their knowledge depth and achieve maximum efficiency and effectiveness.
The joint initiative, called the Diabetes Education Engagement Program (DEEP), is one of the first programs of its kind with the aim of providing a commonsense approach to diabetes care, which has not previously been rigorously applied to the disease. DEEP is based on a patient-centered collaborative care model promoting patient engagement, patient activation and patient self-management with the goal of improving outcomes in adult patients with type 2 diabetes. It incorporates evidence-based protocols and best practices in a standardized approach to optimally manage adults with type 2 diabetes in an out-patient setting. The Group Practice Forum serves as the steering committee.
The tools and resources associated with DEEP are aligned with key health reform initiatives and can be easily integrated at the point of care. This is not a complex program as it can be tailored into organized customers’ existing platforms. It is more a philosophical shift in thinking and not difficult to implement.
The centerpiece of the DEEP customer-facing materials is the Diabetes Patient Journey-a workflow process that highlights clinical considerations and best practices for patients with diabetes, emphasizing a standardized, team-based approach. This is a “blueprint” for patient care, outlining the course-from the physician’s office visit, to other aspects of care the practitioner should consider, such as the timing of when to bring in a nutritionist, diabetes educator or nurse practitioner to provide additional care.
The Diabetes Patient Journey not only provides a combination of evidence-based protocols and best practices for better managing A1C and other markers but also addresses the myriad of diabetes-related complications, providing the clinician with reminders to check kidney function, cardiovascular issues (for example, lipid profile, blood pressure), and even the feet for signs of neuropathy. It also provides alerts for healthcare practitioners to pay closer attention to medication side effects, even mild hypoglycemic events.
Organizations can easily adapt the Patient Journey into workflow processes they currently have in place for other disease states, which should help to reduce any barriers to adoption.
DEEP has gained acceptance from organizations who believe this collaborative effort between Group Practice Forum and Boehringer Ingelheim and Eli Lilly and Company could help improve outcomes for patients with diabetes. Group Practice Forum has had success with other collaborations to improve the management of patients with chronic conditions.
One such example is their work with the Consortium for Southeastern Hypertension Control (COSEHC), an organization with over thirty cardiovascular (CV) Centers of Excellence, and its cornerstone program, IMPACT (The Integrated Medical Processes to Achieve Care Transformation). Although IMPACT focuses on cardiovascular/metabolic care, some of its fundamental principles align with DEEP, including its integration of evidence-based clinical expertise with team-based care processes to improve primary care population management.
COSEHC’s assessment of IMPACT showed improvements in a number of measures, including patient outcomes, processes, emergency room usage, and overall costs, one year after implementing this more integrated care model. For example, the number of patients receiving eye exams increased by 19% after implementing the program. Emergency room visits were almost one-third lower and inpatient hospital days declined by 10.4% for every 1,000 patients enrolled in IMPACT versus control patients. Among patients with diabetes, the percentage of patients achieving goal systolic blood pressure improved by 28 percentage points after one year (from 37% to 65%), and the number achieving LDL cholesterol target goals also improved by 13 percentage points (from 66% to 79% at one year). Overall, nearly 30% of patients with diabetes enrolled in IMPACT reached goals for A1C as well as other important measures, such as systolic blood pressure and lipids.
Equally important to patient outcomes is the annual cost savings of the program. Two-year results showed an annual savings of more than $178,000 for medical and prescription spending among managed patients with diabetes. Considering many of these patients are managed by rebundling of hospital payments, the direct net savings could be twice that amount.
IMPACT is one of many volume-to-value models that are looking at the management of chronically-ill populations who are high healthcare users, and attempting to find solutions for improving care while curtailing rising costs. Collectively, these models illustrate that a more collaborative, holistic approach to disease management has the potential to greatly impact not only patient care but also total medical expenditure for the medical provider and customer organizations.
This is important in today’s changing healthcare landscape as it aligns well with the dual efforts to improve patient care while lowering the cost of the care. Recognizing the need for this type of model in diabetes, many organized customers have already begun adopting the DEEP model. Based on the initial successes of IMPACT, such an integrated care model will be helpful in moving the U.S. healthcare system, and patient care, in a more positive direction.
This information is provided for use by individuals responsible for making decisions regarding pricing and formulary availability only. This information is not for use by medical professionals in a medical practice setting.
Scott Willover is the Director of Diabetes Payor Brand Marketing for Boehringer Ingelheim Pharmaceuticals, Inc.