Will a risk-based approach improve diabetes care?
Pilot looks beyond blood sugar to guide care plans
How well physician practices manage diabetes will soon be a marker of primary care performance. With its heavy toll in health care expenditures, lost productivity, mortality, and suffering, diabetes is the focus of national health care assessment efforts.
Against that backdrop, a pilot project at Sierra Health Services in Las Vegas seeks to prove that focusing resources on high-risk patients and addressing the needs of patient subgroups could result in better outcomes.
Stratifying patients by risk of developing complications is critical, says James W. Snyder, MD, medical director for clinical process improvement and chief of endocrinology at Southwest Medical Associates, a large multispecialty practice and subsidiary of Sierra Health Services.
"The real problem is that diabetes is such a common disease," says Snyder. "There are not that many endocrinologists and certified diabetes educators [to go around]. We're trying to develop a strategy that ensures that the specialty clinic will be better used with people who have sufficient risk to warrant special attention and care."
The Diabetes Advantage Program will enroll up to 1,200 patients of 20 clinicians. It involves two active sites and one control site among the 13 Southwest Medical Associates clinics in Nevada. The program will track clinical and cost outcomes: glycohemoglobin and other laboratory parameters, patient and provider satisfaction, hospital admissions, and urgent care and medical office visits.
The results may serve as a model not just for diabetes care, but for other chronic illnesses, says Rob Wishnowsky, MBA, director of disease management development for Roche Diagnostics/ Boehringer Mannheim in Indianapolis, which supported the yearlong project. "We want to learn from this and refine our own approach to disease management," says Wishnowsky. "This is a real-world learning laboratory for us."
Blood sugar isn't always the main concern
Glyceric control is a focal point for managing diabetes. But for some patients, it may not be the critical issue in their care, says Snyder. The Diabetes Advantage Program involves individual treatment plans that tailor services to the patients' needs.
Diabetes patients are actually a diverse group. At Sierra Health, some 48% of diabetics are older than 70. "For many of those patients, their sugar control may not be that important," says Snyder. "They've got reasonable blood sugars. But their main problems are cardiovascular issues, a recent stroke, or high blood pressure.
"Because diabetes is so prevalent among the elderly, that focus [on glyceric control] is too narrow," he asserts.
Avoiding serious complications of diabetes requires vigilance, from screening to monitoring. The average patient with Type II diabetes has the disease five to seven years prior to diagnosis, Snyder says.
Nationally, an estimated 16 million people have diabetes; about half of them remain undiagnosed. Last year, the American Diabetes Association in Alexandria, VA, recommended a lower threshold of 126 mg/dl on the fasting plasma glucose test (from the previous level of 140 mg/dl) in an effort to begin managing Type II patients at an earlier stage.
Meanwhile, clinicians struggle to control the disease in more severe diabetics. For example, at Sierra Health Systems, the average diabetic patient has a one in four chance of being hospitalized each year despite more than five primary care office visits each year, Snyder says.
Patients participating in the Diabetes Advantage Program first receive an intake assessment, which includes a nursing assessment, lab work-up, a psychosocial screen with the PAID (Problem Areas in Diabetes) questionnaire, and a physical assessment conducted by a primary care physician. (For more information on the PAID questionnaire, see related story, p. 44.)
"When that data are available, we apply the risk-stratification algorithms and come up with risk-based interventions," says Snyder. "Those become the care plan for that particular patient."
The risk stratification assigns a low, medium, or high risk for conditions such as retinopathy, neuropathy, risk for amputation, nephropathy, cardiovascular disease and lipid status, glyceric control, hypoglycemia, as well as coping problems as identified by the PAID instrument.
Tracker manages ongoing care
A team care coordinator or "tracker" works with an RN to manage the ongoing patient care, says Snyder. "Those two individuals have the primary responsibility for maintaining the registry and following the patients as they interact with the primary care doctor who is responsible for the overall care of the patient," he says.
The treatment protocols evolved from physician input, notes Wishnowsky. "We have worked with the providers to develop standards of care that they feel are appropriate as interventions based on risk categories," he says.
Snyder hopes to reduce utilization through better control of the disease and targeted use of referral services. Low-risk patients also will see nurses, who can carry out standing orders with the approval of a physician. "We're looking for cost savings in addition to better outcomes," he says.
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