Measuring outcomes for diabetes DM
Collaboration invitation for QI/TQM readers
By Janice Schriefer, Continuous Improvement Department, and Pat Spoelhof and Mark Huizenga, Care Management Group, Spectrum Health
Tom Peterson, MD, and Laurie Levknecht, Michigan Medical, P.C.
Grand Rapids, MI
Over the last year, Spectrum Health and Michigan Medical, P.C. (MMPC) in Grand Rapids, MI, established a diabetes disease management pilot program. This is a collaborative effort between Spectrum Health Care Management Group; Michigan Medical P.C., a multispecialty physician group; and the local HMO, Priority Health. The primary goal of the program is to improve glycemic control and complication monitoring in diabetic patients. Another program goal is to educate MMPC physicians about recent changes recommended for the care of the diabetic patient.
Improvement efforts include increased patient and staff education and case management of high-risk diabetic patients. The aim is to move diabetic patient management toward nationally recognized diabetic management standards established by the American Diabetic Association1 and HEDIS (Health Care Employer Data and Information Set). Also, we hope to improve patient satisfaction and reduce preventable complications of diabetes.
The clinical leaders of Spectrum Health Care Management Group and MMPC jointly identified the need for this project. Diabetes is a prevalent and serious disease with the potential for multiple complications. We based our decision to pursue a diabetes disease management program on patient volume data derived from claims data. On average, diabetes patients cared for by MMPC physicians use more resources than other patient populations.
The following research studies supported some of our interventions:
• Rubin, Dietrich, and Hawk2 note that diabetes places a significant burden on the U.S. health care system and is the target of many disease management programs. The authors found that intensive patient education and case management of diabetic patients resulted in savings of more than $50 per patient per month. Hospital admissions were reduced by more than 18% and bed days by 21%.
• Gilmer, Manning, O’Connor, and Rush3 note the importance of maintaining HbA1c levels below 8%. Using regression analysis, the researchers found that the cost for medical care was closely associated with HbA1c levels.
Medical charges increased significantly for every 1% increase above a HbA1c of 7%:
— Patients with levels between 7-8 had 10% more health expenses;
— between 8-9, 20% more health expenses;
— over 9, 30% more health expenses.
• Testa and Simonson4 performed a double-blind, randomized, controlled trial of 569 Type 2 diabetic patients. The researchers found that improved glycemic (blood sugar) control of Type 2 diabetics is associated with substantial short-term symptomatic, quality of life and health economic benefits. Favorable health economic outcomes included higher retained employment, less absenteeism, greater productive capacity, fewer bed days, and fewer restricted activity days.
• Eastman et al.5 used simulation models and discovered that comprehensive diabetes treatment that maintains a HbA1c value of 7.2% or less is predicted to reduce the cumulative incidence of blindness, end-stage renal disease, and lower-extremity amputation by 72%, 87%, and 67% respectively. Life expectancy increased by 1.39 years.
The ultimate result and goal of the diabetes disease management program is an improved medical condition for diabetes patients. The following outcome measures are based primarily on the Provider Recognition Program (PREP) measures, which are national standards from the American Diabetes Association:
| PREP Measure | Frequency |
| 1. HbA1c | 1 time/year |
| 2. Dilated retinal exam | 1 time/year |
| 3. Foot exam | 1 time/year |
| 4. Blood pressure check | 2 times/year |
| 5. Urinary protein/micro-albuminuria check | 1 time/year |
| 6. Lipid profile | 1 time/year |
| 7. Self-management education | Annual |
| 8. Medical nutrition therapy | Annual |
| 9. Self-monitoring blood glucose | Annual |
| 10. Tobacco status and counseling referral | Annual |
The success of the project will be determined by the improvement in specific measurable outcomes. Implementation will take place in three stages:
Stage 1: Continued development of the outcomes measurement system.
Stage 2: Launch of the patient education program and case management of complicated patients.
Stage 3: Re-measurement of outcomes.
Project evaluation: Through application of the measurable objectives listed above.
Our purpose in writing this article is to assist other integrated delivery systems in the clarification of outcomes measures for diabetes disease management programs. The most important point of the entire study is to demonstrate that a collaborative effort between physicians, HMOs, patient educators, social workers, nurses, and diabetic patients can work to improve the care of the diabetic patient. The collaborative feature is what makes this type of program truly unique.
[Editor’s note: For more information on the Spectrum Health Diabetes Disease Management Outcome Measures and to explore collaboration with other QI/TQM readers, contact Janice Schriefer, Mail Code 74, 100 Michigan St., Grand Rapids, MI 49503. Telephone: (616) 391-2974. Fax: (616) 391-3570. E-mail: [email protected].
Also, more information on diabetes disease management can be found at the following Web sites:
• www.ncqa.org (National Committee on Quality Assurance and HEDIS);
• www.diabetes.org (American Diabetes Association and DQIP);
• www.facct.org (Foundation for Accountability).]
References
1. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care 1999; 22(supp 1):S32-S41.
2. Rubin RJ, Dietrich KA, Hawk AD. Clinical and economic impact of implementing a comprehensive diabetes management program in managed care. J Clin Endocrinol Metab 1998; 83:2,635-2,642.
3. Gilmer TD, Manning WG, O’Connor PJ, et al. The cost to health plans of poor glycemic control. Diabetes Care 1997; 20:1,847-1,853.
4. Testa MA, Simonson DC. Health economic benefits and quality of life during improved glycemic control in patients with type 2 diabetes mellitus. JAMA 1998; 280:1,490-1,496.
5. Eastman RC, Javitt JC, Herman WH, et al. Model of complications of non-insulin dependent diabetes mellitus. Diabetes Care 1997; 20:735-744.
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