GLUCOSE CONTROL IN MEMBERS WITH DIABETES

Enhancing Care With a Team Approach

This health plan served several ethnic populations known to have a relatively high incidence of diabetes, and therefore it was particularly concerned with the health impact of this disease.

The plan performed an analysis that showed that members with diabetes used more than twice the outpatient services and nearly four times the inpatient resources of nondiabetic patients. While diabetic patients totaled only 5% of the membership, they consumed 13% of medical care resources. Studies such as the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) have shown that improved outcomes result from better control of blood glucose levels in both type 1 and type 2 diabetic patients. With this information, the plan realized that there was ample opportunity to improve the overall health status of its members by improving glucose control in its diabetic population.

The targeted population consisted of all members with diabetes. The plan used pharmacy, automated laboratory, and hospital claims data to identify the targeted population. The plan used three inclusion criteria:

• receipt of a prescription for an antidiabetic medication or
• HbA1c result greater than 6.9% or
• a hospital admission with a primary or secondary ICD-9-CM diagnosis code of 250.xx

The plan chose two performance measures based on the improvement of HbA1c results. (For this reason, patients with not HbA1c results in the laboratory system were excluded from the study. These patients made up 4% of the identified population.) The two measures used were:

• the percentage of diabetic patients in good control as evidenced by an HbA1c level of less than 8%
• the population's mean HbA1c level

The plan used members' most recent test results to determine these measures. No sampling techniques were used; the entire population was included in the measurement.

Automated laboratory data from 1995 revealed that 43% of diabetic patients were in good control with an HbA1c level of less than 8%. The baseline mean HbA1c result was found to be 8.51%. Quantitative analysis revealed that there was considerable variation among clinic sites with regard to both measures.

For a benchmark, the plan looked at national best practices among its organization's other regions. For the percentage of members with an HbA1c level of less than 8%, it identified a benchmark of 53%. No benchmark was identified for the mean HbA1c level. Based on its baseline results, and the identified benchmark, the plan identified two performance goals:

• to improve the rate of diabetic patients with glucose control (HbA1c less than 8%) to 50%
• to reduce the mean HbA1c of the diabetic population to 8.3%

The plan conducted a brainstorming session with its practitioners to identify a number of barriers to good glucose control. It learned that primary care physicians (PCPs) were often mired in the acute needs of their patients. These physicians felt that they did not have sufficient time to focus on the ongoing needs of their patients with diabetes, including their preventive health needs. In order to free up physician time for those aspects of care that most demand their level of training, some responsibilities needed to be delegated. But physicians were reluctant to hand over care, even if it could be more effectively and efficiently managed by others. This inefficient use of resources contributed to fragmented care. Nurse practitioners, clinical registered nurses, and physicians were not working together as a team.

There also was a lack of consistency among practitioners regarding management. There was no process to ensure that appropriate testing and counseling were done every visit. The doctors felt that this inconsistency was reflected in the measurements of glucose control.

The plan also found that there was no process in place to assess the risk for an individual diabetic patient. Clinicians found it difficult to make decisions and to implement strategies to successfully improve glucose control according to individual risk factors. If information specific to a patient's individual risk was available, resources could be applied more effectively to where they would yield the most benefit.

Also, physicians had no organized way to track their own panel of patients for care management. There was no systematic feedback mechanism for physicians to determine which patients were currently in need of specific services.

PHYSICIAN LEADERSHIP From the beginning, the plan sought input and leadership from its medical staff. Physician leadership is essential to quality improvement. It creates the vision and momentum necessary to drive the process forward. It helps practicing physicians see the value of the activity and the positive effect of quality improvement on their patients' lives.

The plan began by forming a work group. The plan scheduled extra administrative time to allow four physicians, two to three clinical staff, and supporting analysts to attend. The information systems department also allocated resources to assist in the effort. A facilitator aided this group in identifying a number of key processes that would assist with the enhanced management of the diabetic population. The group focused on processes of screening, enrollment in the diabetes management program, appropriate treatment, consistent monitoring, and continual measurement.

The plan implemented its initial interventions in a stepwise fashion. It adopted a well-accepted, already existing diabetes practice guideline. By using an existing guideline, the plan eliminated the time and effort involved in creating a new guideline. Training sessions emphasized this guideline. PCPs were trained in the management of diabetes in three two-hour sessions. Case managers were given similar training sessions on diabetes management. This clinical training was followed by additional training specific to diabetes case management.

The plan redefined the diabetes case manager and PCP roles to enhance a collaborative approach to care. The case manager's role was revised to include the responsibility for much of the routine care an monitoring of assigned diabetic patients. The plan established a diabetes hotline to allow practitioners to call and seek case management services for their diabetic patients at any time.

A diabetes registry was designed as a simple paper process to track glucose management. With this process, individual laboratory results could be used to stratify patients with diabetes according to HbA1c level. Patients could then be assigned to a case manager based on their level of risk. Depending on acuity and need, the process assigned members to certified diabetes educators, clinical pharmacists, nurse practitioners, or clinical registered nurses.

A TEAM APPROACH Teams assigned to care for a panel of patients allowed individual healthcare providers to care for patients in a more integrated and efficient manner. At the same time, defined roles created an increased sense of accountability and responsibility for individual patients. Because the team concept helped physicians manage their time, and also decreased the ''hassle factor,'' doctors were strongly supportive.

These case managers initiated contact with their assigned patients. They also screened new members using a questionnaire. This allowed for the identification of new patients with diabetes, the development of a treatment plan, and the subsequent assignment of patients to a diabetes care team.

The first remeasurement, using 1996 data, showed that the percentage of diabetic patients with good glucose control increased to 53%. The mean HbA1c decreased to 8.13%. Both of these improvements were statistically significant.

Generally, improvements were made across clinic locations and provider types. However, the plan identified five clinic sites where lower-than-average HbA1c testing rates were found. Additionally, a number of PCPs whose patients had low rates were identified.

The work group conducted another barrier analysis. This analysis identified a number of outstanding issues. There continued to be a need for more dedicated time in the primary care setting to provide for routine diabetes care. Also, the staged diabetes management clinical practice guidelines were not being consistently followed. This was particularly true in relation to periodic monitoring of the HbA1c level. Finally, healthcare providers needed improved access to HbA1c data on their paneled patients. Physician performance was related directly to the amount of feedback they were given.

In response to this analysis, the plan took a number of focused actions. The plan offered training for PCPs in staged diabetes management that focused on glycemic control guidelines. Additional training sessions for nonphysician diabetes case managers discussed staged diabetes management, including glucose control and case management principles.

The plan increased its efforts to ensure that patients were assigned to appropriate case managers. By the end of 1997, 78% of patients with diabetes had been assigned to case managers. Case managers had seen 42% of their patients at least once.

An on-line diabetes registry was implemented. This database could be accessed at any clinic computer terminal. Case managers could use new data entry fields to document relevant patient information. The registry provided information on lab results that was updated daily. Training was provided to staff members to encourage the appropriate use of the new on-line system.

In the fall of 1997, the plan distributed the first diabetes performance report to PCPs for review and comment. Measures related to glucose control included:

• percentage of patients who had an HbA1c performed in the past six months
• mean HbA1c
• percentage of patients with good glucose control (HbA1c less than 8%)
• screening rate for impaired glucose tolerance
• screening rate for patients older than 45 years
• percentage of patients seen by a case manager

These reports stratified data by PCP, case manager, and clinic location.

FEEDBACK Physicians need critical feedback about their individual performance. The implementation of performance reports for diabetes was a key factor in encouraging accountability and identifying where further training and resources were needed. The plan felt that feedback was missing early in the initiative, and the reports should have been implemented earlier.

The second remeasurement, using 1997 data, revealed that the rate of diabetic patients with glucose control was 47.7% and the mean HbA1c was 8.35%. These rates appeared to be worse than those of the prior year.

Concerned about the results, the plan found that an upgraded testing method introduced in late 1996 created a significant change in the reference range for the HbA1c test. To identify the effects of this change, the reference laboratory looked at several blood samples using both the old and upgraded methods. The upgraded method yielded results that averaged 0.6 mg/dL higher than the old test. From this, the plan's staff inferred that perhaps the mean HbA1c level did improve from 1996 to 1997, although there was no way to calculate the significance of the change.

The plan continues this quality initiative. In 1998, the plan refined the diabetes registry by adding additional data fields to provide more detailed patient data online at all clinic terminals. The registry includes the most recent dispensing date of insulin and oral hypoglycemic agents, as well as a complete pharmacy dispensing history. Other enhancements allow case managers to input disease stage and treatment regimen.

The case management and team approach is a well-established model of care for the entire organization. This initiative serves as framework for creating similar models around other disease processes and aspects of care.