Impact of Population Management With Direct Physician Feedback on Care of Patients With Type 2 Diabetes

Abstract

OBJECTIVE -Population-level strategies may improve primary care for diabetes. We designed a controlled study to assess the impact of population management versus usual care on metabolic risk factor testing and management in patients with type 2 diabetes. We also identified potential patient-related barriers to effective diabetes management.RESEARCH DESIGN AND METHODS -We used novel clinical software to rank 910 patients in a diabetes registry at a single primary care clinic and thereby identify the 149 patients with the highest HbA 1c and cholesterol levels. After review of the medical records of these 149 patients, evidence-based guideline recommendations regarding metabolic testing and management were sent via e-mail to each intervention patient's primary care provider (PCP). Over a 3-month follow-up period, we assessed changes in the evidence-based management of intervention patients compared with a matched cohort of control patients receiving usual care at a second primary care clinic affiliated with the same academic medical center.RESULTS -In the intervention cohort, PCPs followed testing recommendations more often (78%) than therapeutic change recommendations (36%, P ϭ 0.001). Compared with the usual care control cohort, population management resulted in a greater overall proportion of evidencebased guideline practices being followed (59 vs. 45%, P ϭ 0.02). Most intervention patients (62%) had potential barriers to effective care, including depression (35%), substance abuse (26%), and prior nonadherence to care plans (18%).CONCLUSIONS -Population management with clinical recommendations sent to PCPs had a modest but statistically significant impact on the evidence-based management of diabetes compared with usual care. Depression and substance abuse are prevalent patient-level adherence barriers in patients with poor metabolic control. Diabetes Care 26:2275-2280, 2003M anagement of type 2 diabetes in the U.S. is expensive (representing 25% of the Medicare budget) (1), complex (patients often have hypertension, hyperlipidemia, and other comorbidities) (2-4), and generally falls short of evidence-based goals (most diabetic patients do not reach recommended levels of glycemic, blood pressure, or cholesterol control) (5,6). Patient-related factors such as adherence to medications and healthy lifestyle changes and societal factors such as costs and access to care are important but difficult-to-modify elements of diabetes management (7-10). In contrast, interventions directed toward primary care providers (PCPs) may be more likely to improve quality of diabetes care (11,12).Prior interventions to improve quality of care by changing physician practice patterns have mostly been either physician-centered (e.g., intensive academic detailing, physician report cards) (13-15) or patient-specific and centered on clinic visits (e.g., computerized reminder systems) (12,16 -20). In contrast, population-based diabetes management takes an overview perspective to monitor and deliver patient care (21,22). Population management...

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“…There have been reports describing improvements in diabetes clinical process measures in these settings using population-based approaches, but many of these studies suffer from limitations such as a single-institution setting, lack of physiologic outcomes, short duration, or observational design. [52][53][54][55][56][57] Like many of these studies, our quarterly population reports provide a current roster of patients for each PCP, sorted by level of control of A1C, lipids and urinary albumin excretion. This allows the provider to identify patients who may benefit from a more intensive intervention.…”

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“…57 Population management approaches the DM task with a broader perspective, focusing on the entire patient cohort with the condition with a given condition rather than on an individual patient. 58,59 This approach, particularly useful for practices that employ multiple members of a care team or have an expanded locus of care, 60,61 enables providers to identify patients for further intervention based on acuity and circumvents the time constraints that may limit changes in management during time-constrained individual clinic visits. This approach is most appropriate for interventions that do not require face-to-face visits and facilitates surveillance and intervention for patients without pending follow-up appointments.…”

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“…This approach has been well evaluated for its role in improving rates of preventive health screening such as mammograms, vaccinations, and screening questionnaires [28][29][30][31]. CCRs have received less study for use in chronic care, but evaluations show that CCRs can help keep clinicians better "informed" and facilitate practice consistent with clinical practice guidelines in the management of chronic diseases such as diabetes [4][5][30][31][32].…”