Improving Diabetes Processes of Care in Managed Care

Abstract

OBJECTIVE -To evaluate the impact of systematic patient evaluation and patient and provider feedback on the processes and intermediate outcomes of diabetes care in Independent Practice Association model internal medicine practices.RESEARCH DESIGN AND METHODS -Nine practices providing care to managed care patients were randomly assigned as intervention or comparison sites. Intervention-site subjects had Annual Diabetes Assessment Program (ADAP) assessments (HbA 1c , blood pressure, lipids, smoking, retinal photos, urine microalbumin, and foot examination) at years 1 and 2. Comparison-site subjects had ADAP assessments at year 2. At Intervention sites, year 1 ADAP results were reviewed with subjects, mailed to providers, and incorporated into electronic medical records with guideline-generated suggestions for treatment and follow-up. Medical records were evaluated for both groups for the year before both the year 1 and year 2 ADAP assessments. Processes and intermediate outcomes were compared using linear and logistic mixed hierarchical models.RESULTS -Of 284 eligible subjects, 103 of 173 (60%) at the Intervention sites and 71 of 111 (64%) at the comparison sites participated; 83 of 103 (81%) of the intervention-site subjects returned for follow-up at year 2. Performance of the six recommended assessments improved in intervention-site subjects at year 2 compared with year 1 (5.8 vs. 4.3, P ϭ 0.0001) and compared with comparison-site subjects at year 2 (4.2, P ϭ 0.014). No significant changes were noted in intermediate outcomes. Shortcomings in self-management support, clinical information systems, and decision support contribute to suboptimal diabetes care in primary care (23). The Annual Diabetes Assessment Program (ADAP) was designed as a population-based program of evaluation and feedback to support diabetes clinical practice guidelines (24,25). During a 1-h focused encounter with nonphysician providers within the primary care setting, key diabetes and cardiovascular health parameters were measured and discussed with the patient by a certified diabetes educator. A tailored report with guidelinedriven recommendations for care (25) was then sent to the patient's primary care provider (PCP) and incorporated into the electronic medical record. We hypothesized that implementing the ADAP would improve processes and intermediate outcomes of diabetes care. CONCLUSIONSTo rigorously assess whether the ADAP would improve measures of diabetes care, we conducted a randomized, controlled clinical trial. RESEARCH DESIGN AND METHODS Clinical settingNine university-affiliated primary care internal medicine (IM) practices affiliated with a managed care organization (MCO) were paired by size and type and then randomly assigned as intervention or comparison sites. One unpaired practice was assigned as an intervention site. Most of the PCPs in the practices were working full-time and there were no residents in the practices. ParticipantsDiabetic members of the MCO who were aged Ն18 years and had been members for at least 1 year wer...

Effectiveness of Interventions to Promote Screening for Diabetic Retinopathy

“…Hand searches did not yield additional studies. Forty-eight eligible studies with seven companion papers [65][66][67][68][69][70][71] were identified, including 12 RCTs, 18,21,30,32,35,39,40,44,[52][53][54]56 four nonrandomized studies, 23,29,31,38 and 32 pre-post studies. 17,19,20,22,24 -28,33,34,36,37,41-43,45-51,55,57-64 The 48 studies had a total of 162,157 participants (range, 30 to 27,270) and follow-up periods ranging from 4 months to 4 years.…”

“…Attrition ranged from 0% to 14.9% among the seven studies reporting these data. 19,28,32,39,40,43,53 The leading sources of attrition were as follows: (1) moved out of the area, (2) death, (3) poor health, (4) loss of interest, and (5) transportation difficulties. Table 2 shows the intervention focus, the RRs, and absolute retinal screening rates for each study.…”

“…21 Similar results were noted among the nonrandomized study designs, 28,34,51,63,64 the RR ranged from 1.12 (95% CIϭ1.02-1.22) 63 to 1.80 (95% CIϭ1.59 -2.03). 64 Five RCTs focusing on the healthcare system infrastructure and processes also demonstrated that interventions increased screening significantly 30,39,40,52,54 ; the RR ranged from 1.12 (95% CIϭ1.03-1.22) 39 to 5.56 (95% CIϭ2. 19 -14.10).…”

“…This review revealed that the rate of retinal screening could be improved through improving access to primary care. 18,20,29,38,40,45,48,49,65 In the systematic review, the identified inadequate access included financial constraints, 20,38,65 cultural tensions, 18,45 and maldistribution of the healthcare workforce or geographic components. 29,48,49 One study 66 found that for under-served ethnicminority populations, the lack of health insurance or healthcare availability hindered intervention to further increase recommended screening.…”

“…30 A mobile diabetes clinic was used to improve access in a geographically spread-out population. 40,48 A program of training, credentialing, and ongoing professional development for retinal practitioners was found to be effective in a remote rural area in which providers were scarce. 50 This review has several limitations.…”