Primary Care Diabetes Bundle Management: 3-Year Outcomes for Microvascular and Macrovascular Events | Page 3
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
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.
Prior evidence indicates that it is possible to improve process of care measures for diabetes in clinical practice, 30 and document small to modest improvements in glycemic control.31 There is a single report of reduced adverse events (amputations, retinopathy, and MI) using a diabetes disease management program.32 If substantiated, our findings that a DS reduces the microvascular and macrovascular complications of diabetes in only 3 years have potentially important implications for patients, providers, and payers. 33
Author Affiliations: Geisinger Health System, Danville, PA (FJB, TRG, TA, DED, SBP, GDS); Sutter Health, Sacramento, CA (XY, WFS, JP).
Source of Funding: Geisinger Health Plan.
Author Disclosures: Drs Bloom and Graf report accepting fees from the Merck Speaker’s Bureau. Dr Davis reports employment with a group practice that operates as part of Geisinger Health System, from which data were used as part of this study. The other authors (XY, WFS, TA, SBP, JP, GDS) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (FJB, XY, WFS, TA, SBP, GDS); acquisition of data (FJB, XY, TA, SBP, JP, GDS); analysis and interpretation of data (FJB, XY, WFS, TA, JP, GDS); drafting of the manuscript (FJB, WFS, TA, DED, JP, GDS); critical revision of the manuscript for important intellectual content (FJB, XY, WFS, TA, DED, JP, GDS); statistical analysis (XY); obtaining funding (DED); administrative, technical, or logistic support (FJB, TA, SBP, JP, GDS); supervision (FJB, WFS, JP, GDS).
Address correspondence to: Frederick J. Bloom Jr, 100 N. Academy Ave, Danville, PA 17822-3836. E-mail: firstname.lastname@example.org.
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