The Effectiveness of Diabetes Care Management in Managed Care

Published Online: May 07, 2009
Julie A. Schmittdiel, PhD; Connie S. Uratsu; Bruce Fireman, MA; and Joe V. Selby, MD, MPH

Objectives: To evaluate the effectiveness of the diabetes care management (CM) program in Kaiser Permanente Northern California (KPNC) by determining the proportion of enrollees that met program entry criteria and by comparing intermediate outcomes trajectories of enrollees versus similar patients who did not receive CM.

Study Design: Observational study with propensity score matching of CM patients to control subjects.

Methods: Care management program entry criteria were assessed for 179,249 adult patients with diabetes mellitus in 2003 and were compared between CM and non-CM patients in that year. Propensity score matching was used to match CM patients with comparable non-CM controls. Preprogram and postprogram glycosylated hemoglobin (A1C), low-density lipoprotein cholesterol (LDL-C), and systolic blood pressure levels, as well as medication adherence, and treatment intensification rates of CM patients, were compared for enrollees versus controls.

Results: Sixteen percent of CM patients were ineligible by program entry criteria. Small but statistically significant differences in A1C and LDL-C levels favoring CM patients were observed during 15 months of postprogram follow-up. Care management patients were more likely to receive treatment intensification for poorly controlled hyperglycemia, hyperlipidemia, and hypertension. Improvements in all 3 cardiovascular risk factor levels were observed for all KPNC patients with diabetes regardless of CM participation.

Conclusions: Eligibility guidelines for diabetes CM were not strictly adhered to in this program. Nevertheless, in a population with improving risk factor control, patients entering CM experienced slightly greater improvement.

(Am J Manag Care. 2009;15(5):295-301)

The chronic care model highlights delivery system design as a key element in providing quality care to patients with chronic illness.1 One system design innovation that has taken hold in the past decade is the use of nonphysician care managers for selected patients with chronic illnesses such as diabetes mellitus. Clinical trials have examined the effect of care management (CM) programs2,3 (often led by nurses) on diabetes care quality and outcomes. Most have found positive associations between CM interventions and improved process measures (such as glycosylated hemoglobin [A1C] level testing rates) and patient satisfaction.2,4-7 It is controversial whether CM improves critical outcomes such as blood pressure and glycemic and lipid control.2,4-6,8-14 A recent effectiveness evaluation of CM found no association between the intensity of CM use and A1C level, blood pressure, or low-density lipoprotein cholesterol (LDL-C) level in the diabetic populations of 10 health plans and 71 provider groups.15 Almost all evaluations of CM to date have been randomized controlled trials.8,12,16,17 There have been few studies of how nurse CM programs and protocols from these trials translate into everyday care delivery settings18 or how they affect patient outcomes after implementation on a wide scale. Chronic condition CM usually is designed to target a small segment of higher-risk patients; however, there is little published information on the extent to which CM programs appropriately succeed in reaching their intended population.

Kaiser Permanente Northern California (KPNC) implemented a large-scale primarily nurse-led diabetes CM program beginning in 1999. More than 150 diabetes nurse care managers offered intensive counseling on medication management (including appropriate titration) and adherence, diet, and lifestyle to patients with diabetes referred to CM by their primary care physician. Care management was designed to help provide additional individualized patient support beyond primary care for improving self-management and cardiovascular disease (CVD) risk factor control. Control of glycemia was a central focus from the program’s inception; emphasis on blood pressure and lipid control was

added in later years. This program was designed to treat patients for 3 to 6 months and then to place the patients back into the primary care system once (ideally) CVD risk factors and self-management behaviors had improved.

The objectives of this study were 3-fold: (1) to describe the population of patients enrolled in this program, (2) to assess correspondence of program enrollment with stated entry criteria, and (3) to evaluate program effectiveness for improving A1C level, LDL-C level, systolic blood pressure (SBP), medication adherence, and appropriate treatment intensification.


Study Population

This study was developed and approved by the steering committee of the Translating Research in Action for Diabetes (TRIAD) study15 and was conducted in KPNC, which is 1 of 6 TRIAD translational research centers. As an integrated healthcare delivery system, KPNC provides comprehensive medical care to a diverse population of approximately 3.2 million members in Northern California. Patients with diabetes were selected for the study from the KPNC diabetes registry19 if they were identified as having diabetes before December 31, 2002; were aged 20 to 85 years as of January 2003; and were continuously enrolled with an active drug benefit in January 2003. A small number of patients (n =

2609) who were likely to have type 1 diabetes mellitus (age <40 years as of January 1, 2003, and taking insulin only) were excluded. Initial SBP and A1C, LDL-C, and albumin levels for CM patients and for patients with diabetes not in CM were compared using the first value for 2003 found in the registry database. Patients were identified as CM participants if they had a diabetes CM entry date between January 1, 2003, and December 31, 2003, in the automated “Alert Note” CM database and had at least 1 day of enrollment in the program. Official eligibility criteria for the KPNC CM program state that patients entering diabetes CM should meet 1 or more of the following criteria: (1) an A1C level of at least 8.5%, (2) an albumin level exceeding 3.0 g/dL, or (3) a diabetes-related hospitalization or emergency department (ED) visit. All patients with diabetes were assessed for whether they met CM program entry criteria between July 1, 2002, and December 31, 2003.

Matching CM Patients to Control Subjects

PDF is available on the last page.

Issue: May 2009
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