Primary Care Diabetes Bundle Management: 3-Year Outcomes for Microvascular and Macrovascular Events | Page 2

Published Online: June 26, 2014
Frederick J. Bloom Jr, MD; Xiaowei Yan, PhD; Walter F. Stewart, PhD; Thomas R. Graf, MD; Tammy Anderer, PhD; Duane E. Davis, MD; Steven B. Pierdon, MD; James Pitcavage, MS; and Glenn D. Steele Jr, MD
Because patients were not randomized, we used a 2-step method to protect against inferential threats attributable to baseline differences in risk factors. First, logistic regression was used to calculate a propensity score20 for each eligible diabetes patient to balance disease burden for members of the DS and NDS groups at the beginning of intervention (January 1, 2006), which was denoted as the index date. If patients had pure postintervention exposure, then the index date was set to be the same as the baseline date. Claims data from the date of enrollment to the index date were used to derive the propensity score based on patient gender and age at index date, as well as claims documentation of comorbidities (mild liver disease, peripheral vascular disease, heart failure, cerebrovascular accident, pulmonary disease, severe liver disease, renal disease, malignant cancer, cardiovascular disease, and dialysis) up to the index date. The propensity score was used to match DS and to NDS diabetes patients (± 0.2 of SD of the propensity score, an optimal caliper usually used in propensity score–matching studies21) and to balance both groups on future risk of events of interest. Second, to account for differences in person-time of observation in the postsystem-of-care periods, we calculated the probability of being “exposed” to the post-system period. To this end, each patient’s age at diabetes baseline date, duration of person-time in the preintervention period, and comorbidities documented before the index dates were included in the conditional logistic regression model. Conditional logistic regression was used to control for matched pair variation. A score obtained for each subject represented the likelihood of postsystem-of-careexposure.

Person-time was excluded until a patient reached 40 years of age. Cumulative risk was estimated using the weighted Cox Proportional Hazards regression model, which combined a traditional Cox Proportional Hazard regression model with inverse probability weighting (IPW). The inverse of the previously described postsystem exposure score was used as a weight, along with age at the index date and gender. A patient was censored from observation if they discontinued as a GHP member, died as a GHP member, or incurred their first unique major microvascular or macrovascular event as previously described. The C statistic was used to measure discriminatory capability of the model and calculated as described by Pencina and colleague’s method.22 The cumulative hazard of each outcome was predicted by the model. Statistical analyses were performed using SAS version 9.2 (SAS Institute Inc, Cary, North Carolina) for the time-to-event analysis and relative risk comparison.

The number of patients needed to treat (NNT) was calculated based on risk reduction, which was estimated from the above Cox proportional hazard model; that is, the 3-year survival rate was estimated from the model for DS and NDS group, respectively, and the difference represented the 3-year risk reduction. The NNT is the inverse of the risk reduction.


The initial study cohort of 16,086 GHP members met the criteria for diabetes diagnosis. (Figure 1). After applying exclusion criteria (<180-day follow-up, age <40, only preintervention exposure or prevalent outcome), the sample was reduced by 3421 of the 8355 patients in the DS group clinics and by 3634 of the 7734 in the NDS group clinics. After applying propensity score–matching criteria, 4095 DS subjects were matched to 4095 NDS subjects. Before matching (Table 2), DS group members were significantly older, had proportionately more of their person- time in the postintervention period, and had a longer follow-up period than NDS members. After matching, DS and NDS members still differed on duration of follow-up time in the postintervention period. The 2 groups were similar on the risk score derived at baseline and up to the time of the index date. The adjusted hazard ratio (Table 3) for MI was 0.77 (95% CI, 0.65-0.90); for stroke, 0.79 (95% CI, 0.65-0.97); and for retinopathy, 0.81 (95% CI, 0.68- 0.97). The risk of the macrovascular and microvascular events were significantly lower among DS patients compared with NDS patients (Figure 2 includes cumulative hazard plots). These hazard plots show that the reduction in macrovascular outcomes (MI and stroke) is most pronounced after year 1 of the DS, and that the microvascular outcome retinopathy is evident after approximately 18 months. The risk of developing retinopathy, MI, and stroke among DS patients was significantly less than that of NDS patients in the 3-year follow-up period. The NNT to prevent 1 event over 3 years was 82 (95% CI, 37-133) for MI; 178 (95% CI, 57-681) for stroke; and 151 (95% CI, 47- 512) for retinopathy.


This analysis of claims data from a propensity-matched observational design shows a statistically significant lower risk of macrovascular and microvascular disease end points in the first 3 years of a diabetes system of care that included an all-or-none bundled measure compared with primary care without this intervention. The impact was substantial, with only 82 patients needed to treat to prevent 1 MI event, 178 to prevent 1 stroke, and 151 to prevent 1 case of retinopathy. Perhaps the most notable finding is the apparent early impact of the care model. The findings suggest an impact in the first 3 years with the possibility that a reduction in risk began to emerge after the first year. This finding is consistent with prior randomized controlled trials indicating that reduction in risk of cardiovascular outcomes can be achieved. 4-7,10 However, the early impact of an all-ornone diabetes system of care on microvascular and macrovascular conditions has not been previously described.

The finding of a reduction of MI, stroke, and retinopathy in only 3 years through a risk factor intervention is supported by prior studies on individual risk factors such as smoking cessation, BP control, and influenza immunization. 12,23-26 Multiple trials have also shown statistically significant improvements in microvascular and macrovascular outcomes in 3 to 5 years of follow-up in programs designed to reduce cardiovascular risk.4-7,10 This study showed improvement in a shorter period of followup. Observing statistically significant differences strongly depends on sample size, and showing statistically significant differences does not indicate when the benefits of an intervention first emerge. These previous trials were designed to show that the intervention had an effect, not to determine the earliest point at which the effect occurred. The current observational study included multiple simultaneous interventions which could have amplified the early benefits in risk reduction when compared with other studies using a single intervention.

A limitation of this study is that the DS group intervention did not occur in isolation.After the initiation of the DS, other performance improvement projects were initiated, including reporting of diabetic foot examination rates, diabetic eye examination rates, aspirin use, and angiotensin- converting enzyme inhibitor/angiotensin II receptor blocker use. However, it is unlikely that these other initiatives contributed to the early separation in risk observed in the DS clinics compared with the NDS clinics. The NDS sites also had other ongoing care improvements sponsored by the health plan. These included Web-based registry tools and outreach programs based on HEDIS measures for diabetes, which could have resulted in improved diabetes outcomes, but in a less substantial manner than in the DS sites. The DS intervention included many interventions, including physician and staff monetary incentives. These were used at the DS sites to focus attention and promote team attainment of goals. NDS sites also received a Physician Quality Summary bonus from GHP, but the monetary incentives were less than what was provided the DS sites and not related to an all-or-none improvement. The extent to which these varying monetary incentives contributed to the success of the intervention was not studied.

Finally, patients in the DS care arm were more likely to be cared for in practices that are a part of an integrated health system and in sites that have an EHR. While we used propensity score matching at the time of the index date to balance the “intervention” and control arms, there is the possibility that the separation of the time-toevent curves for micro- and macrovascular disease risk was explained by unmeasured confounding attributable to a host of factors that are simply correlated with the effectiveness of delivering the diabetes care.15,27

This diabetes system of care had multiple interventions, and the impact of each will require further research. Determining the best combination of bundled measures, work flow redesign, financial incentives, and the relative impact of each aspect of the system of care are ongoing.28,29 Analysis of the impact of the system of care on overall mortality and total cost of care is planned.

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Issue: June 2014
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