Diabetes: 8 Strategies to put into Practice

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Applied Evidence

Diabetes: 8 Strategies to put into Practice

J Fam Pract. 2013 October;62(10):542-547

By

Ronald N. Adler, MD

David M. Harlan, MD

In search of ways to improve the way you approach diabetes care in your practice? Consider these strategies, which have worked for us—and have evidence to support them.

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References

1. Danaei G, Finucane MM, Lu Y, et al. National, regional, and global trends in fasting plasma glucose and diabetes preva- lence since 1980. Lancet. 2011;378:31-40.

2. Nathan DM, Cleary PA, Backlund JY, et al. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med. 2005;353:2643-2653.

3. Ford ES. Trends in the risk for coronary heart disease among adults with diagnosed diabetes in the U.S.: findings from the National Health and Nutrition Examination Survey, 1999- 2008. Diabetes Care. 2011;34:1337-1343.

4. Golden SH. Emerging therapeutic approaches for the manage- ment of diabetes mellitus and macrovascular complications. Am J Cardiol. 2011;108(3 suppl):59B-67B.

5. American Diabetes Association. Diabetes statistics. Edited Au- gust 20, 2013. Available at: http://www.diabetes.org/diabetes- basics/diabetes-statistics/. Accessed September 11, 2013.

6. Economic costs of diabetes in the U.S. in 2007. Diabetes Care. 2008;31:596-615.

7. Standards of medical care in diabetes—2013. Diabetes Care. 2013;36(suppl 1):S11-S66.

8. Stark Casagrande S, Fradkin JE, Saydah SH, et al. The preva- lence of meeting A1C, blood pressure, and LDL goals among people with diabetes, 1988-2010. Diabetes Care. 2013;36:2271- 2279.

9. Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998;1:2-4.

10. Wagner EH, Austin BT, Davis C, et al. Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001;20:64-78.

11. Coleman K, Austin BT, Brach C, et al. Evidence on the chronic care model in the new millennium. Health Aff (Millwood). 2009;28:75-85.

12. Bojadzievski T, Gabbay RA. Patient-centered medical home and diabetes. Diabetes Care. 2011;34:1047-1053.

13. Anderson RJ, Freedland KE, Clouse RE, et al. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001;24:1069-1078.

14. Katon W, Von KM, Ciechanowski P, et al. Behavioral and clini- cal factors associated with depression among individuals with diabetes. Diabetes Care. 2004;27:914-920.

15. Katon W, Russo J, Lin EH, et al. Diabetes and poor disease control: is comorbid depression associated with poor medica- tion adherence or lack of treatment intensification? Psychosom Med. 2009;71:965-972.

16. Bogner HR, Morales KH, de Vries HF, et al. Integrated manage- ment of type 2 diabetes mellitus and depression treatment to improve medication adherence: a randomized controlled trial. Ann Fam Med. 2012;10:15-22.

17. Pignone MP, Gaynes BN, Rushton JL, et al. Screening for de- pression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;136:765- 776.

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19. Executive summary: standards of medical care in diabe- tes—2013. Diabetes Care. 2013;36(suppl 1):S4-S10.

20. Ismail-Beigi F. Clinical practice. Glycemic management of type 2 diabetes mellitus. N Engl J Med. 2012;366:1319-1327.

21. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hy- perglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012;35:1364-1379.

22. Greene J, Hibbard JH, Sacks R, et al. When seeing the same physician, highly activated patients have better experi- ences than less activated patients. Health Aff (Millwood). 2013;32:1299-1305.

23. Battersby M, Von KM, Schaefer J, et al. Twelve evidence-based principles for implementing self-management support in pri- mary care. Jt Comm J Qual Patient Saf. 2010;36:561-570.

24. Watson S. The 13 best diabetes iPhone & Android apps of 2013. Healthline Web site. Available at: http://www.healthline.com/ health-slideshow/top-iphone-android-apps-diabetes. Published August 8, 2013. Accessed September 16, 2013.

PRACTICE RECOMMENDATIONS

› Develop a diabetes registry and use it to identify patients in need of intervention. B
› Adopt routine depression screening for patients with diabetes. A
› Individualize HbA1c targets based on the patient’s comorbidities and duration of diabetes, among other patient factors. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

The prevalence of diabetes, particularly type 2 (T2D), continues to grow at an unprecedented rate,¹ largely because Americans are eating more than in years past and exercising less. At the same time, improvements in treatment are resulting in lower rates of cardiovascular (CV) comorbidities and increased longevity for those with T2D.^2,3

Most patients with diabetes are cared for in a primary care setting. With more than a quarter of those who have diabetes (an estimated 7 million Americans) unaware that they have it,^4,5 primary care physicians typically see many patients with undiagnosed T2D, as well.

Diabetes care is extremely costly; approximately 20 cents of every health care dollar is spent on those with the disease.⁶ As a result of this expenditure and increasing adherence to annually updated evidence-based guidelines,⁷ control is improving, but slowly: Between 2007 and 2010, only 18.8% of patients with diabetes achieved all 3 American Diabetes Association (ADA) goals—for glycemia, blood pressure, and low-density lipoprotein (LDL) cholesterol.⁸

Part of the problem, experts agree, is that the US health care system is not well suited to manage chronic conditions. This has prompted efforts to develop enhanced delivery modes like the Chronic Care Model and the Patient-Centered Medical Home,^9,10 but none has been widely adopted. While groups that have implemented such changes have had significant success,^11,12 practices already operating at full capacity often find the work of practice transformation to be daunting.

Difficult as the task may be, we’ve been able to identify—and follow—a number of strategies that serve us well in caring for patients with diabetes. Whether you have the resources to undertake a major practice transformation or simply wish to sharpen your focus, adopting any (or all) of the strategies detailed here will help you optimize diabetes care.

1. Develop a diabetes registry

To have the greatest possible impact on a particular type of patient, you need a way to reliably identify those with a specific condition or set of symptoms. A diabetes registry—a database that starts with basic demographic information for all the patients in your practice with a diabetes diagnosis and is populated with relevant lab results and dates, immunization status, and date of last visit—serves such a function. Some EHRs have this built-in functionality, but most spreadsheet software packages, such as Excel, have the necessary features, as well.

The ideal registry is accurate and up to date, comprehensive, sortable by any of the parameters, and easily accessed, ideally at the point of care. In addition to being able to generate reports for individual patients, the registry should have the ability to track providers—showing, for example, how many (or what percentage) of a provider’s patients have had a diabetes foot exam within the past 12 months. A registry should also be able to pull such statistics for the practice as a whole.

Population management, in which the same standards are applied to all the patients in your practice with a particular diagnosis, is made possible by a registry. Because the registry can be searched by any of the parameters, office staff can use it to identify patients in need of interventions—eg, because of an HbA1c >8%, LDL cholesterol >100 mg/dL, or no recent visit. Medical assistants can then reach out to such patients to ensure that they receive the interventions they need.

Often the greatest challenge associated with the creation of a useful registry is the ability to populate it with accurate and continuously updated data. Using the presence of diabetes on the problem list is a reasonable place to start. But this can create difficulties if any clinicians in the practice have coded for T2D when they were simply testing for it. To avoid such problems, develop clearly defined inclusion criteria before trying to populate the registry.

2. Analyze (and streamline) workflow

Practices that undertake a critical analysis of their workflow often find, as we did, that some staff members are not working to the full capacity of their license. Medical assistants, for example, could give routine immunizations following protocols and standing orders.

To learn more about the workflow in your practice, consider establishing a “change team,” with at least one Teams that conduct “waste walks” to analyze practice workflow often find that some staff members are not working to the full capacity of their license. representative from each position (eg, front office clerk, medical assistant, RN, physician assistant, and family physician). The team can then conduct “waste walks”—literally walking through the workspace to assess office processes from a fresh perspective.