The Future of Diabetes Disease Management: Integrating Lessons Learned from Clinical, Health Services, and Policy Research

The American Journal of Managed Care, April 2005, Volume 11, Issue 4

Journal

Our understanding of diabetes and its managementis evolving rapidly based on informationfrom researchers and the world of healthcaredelivery about "what works" to improve outcomes.This theme issue of the includes studies thatcan inform efforts to improve diabetes care on manylevels, including more effective clinical decision-making,improvements in health systems that promotetreatment quality, and health policies that encouragethe best disease management practices.

Despite years of research on diabetes managementand quality improvement, these new studies are worthwhilebecause, unfortunately, diabetes treatmentprocesses and outcomes remain disappointing in manyhealthcare systems. The study by Godley and colleagues1highlights the gap between guideline recommendationsand the care many patients with diabetesreceive. Through a review of claims data and charts,the authors found that less than 20% of patients withdiabetes achieved blood pressure goals, and many hadadditional cardiovascular risk factors. Perhaps mostdisturbing, 42% of patients with poor blood pressurecontrol were on only 1 antihypertensive agent or noblood pressure treatment at all, suggesting significantroom for improvement via appropriate medicationintensification. The problem of "clinical inertia" in thecontext of poor physiologic outcomes has been documentedin glucose management as well,2 and mayrequire system-level changes to ensure that patientsare prescribed drug regimens that can reduce the riskof costly complications.

Fortunately, the quality of diabetes care in manyhealthcare systems is improving, and this is shownclearly in the study by McBean and colleagues.3 Theseresearchers demonstrate that most Medicare beneficiarieswith diabetes now receive guideline-recommendedservices such as testing for regular hemoglobin(HbA1c) and low-density lipoprotein (LDL) tests.However, rates of other recommended care processesremain unacceptably low. The investigators also foundthat treatment processes vary across racial groups andhealth plan types. This variation provides importantclues about how to foster further quality improvements,and suggests opportunities for healthcare managersto learn from one another about how best toachieve goals set by the National Committee for QualityAssurance and other organizations.

Lessons about developing more effective models ofdiabetes care sometimes are best learned by examininghealthcare systems that seem to have gotten it right.The US Department of Veterans Affairs (VA) healthcaresystem provides better diabetes care than many privatemanaged care organizations,4 through a structure thatpromotes and rewards quality via information systemsand management incentives. Jackson and colleagues5linked organizational-level data from 177 VA clinics topatient outcomes and identified a number of organizationalcharacteristics associated with improved diabetescontrol. Their study reinforces prior findings about theimportance of system changes, such as electronicreminders, and identifies other provocative correlates ofglycemic control, such as managerial autonomy and theextent to which physicians as well as nurses participatein quality improvement efforts. These results shouldfoster discussion within non-VA health systems (aswell as in poorly performing VA facilities) about howthey can adopt managerial practices that promotemore effective diabetes management.

Much of the focus in chronic disease care has beenon disease management programs, and Knight et al6provide a systematic review of programs for patientswith diabetes. These researchers report that overall,diabetes disease management can lead to modestimprovements in patients' glycemic control, as well asimprovements in related care such as retinal examinations.The authors also rightly caution readers againstadopting programs without critically appraising theircharacteristics and goals. Publication bias may welllead to an overly optimistic picture of these programs'benefits, and even in the published literature, rigorousstudies have not been uniformly positive.7 As theauthors point out, many innovations in disease managementare occurring without public evaluation ofprogram effects.8 Nevertheless, the generally positiveeffects demonstrated by this review are encouraging.Health plans should continue to innovate in this area,taking what has been shown to be feasible and effectivein other settings and adapting it to their own practicesand patients.

Pharmaceutical researchers have developed a fullmenu of medications that can improve glycemic control,blood pressure, and lipid levels in patients withdiabetes. Medication management is central to mostpatients' care, and pharmacists may play an importantrole in achieving physiologic targets. Choe and colleagues9conducted a randomized trial of diabetes diseasemanagement delivered by a clinical pharmacist.After more than a year of follow-up, patients whoreceived the service had greater improvements in bloodglucose levels than those receiving usual care.Intervention patients also had more frequent LDL testing,retinal examinations, and monofilament footscreening, suggesting that the pharmacist fosteredimproved treatment quality that extended beyond medicationuse. This study illustrates 1 specific strategy forachieving improvements in diabetes care, even withoutmore global changes in the way health systems areorganized.

The study by Karter and colleagues10 also supportsthe need for greater attention to patients' medicationmanagement, demonstrating that many patients withdiabetes need insulin plus insulin-sensitizing agents toachieve target blood glucose levels. The study was conductedwithin the Kaiser Permanente (KP) healthcaresystem, which (like the VA) has become a model ofhow to evaluate and improve chronic illness care.Nevertheless, many patients with diabetes and poorglycemic control who were treated in the KP systemreceived monotherapy with sulfonylureas (in agreementwith current practice guidelines), which appearsto be less effective in achieving glucose level targets.Karter and other KP researchers provide a valuableservice to that system's patients, and their studiesoften provide the evidence base for quality improvementinitiatives both within and outside of the KPsystem. Other health systems should consider encouraginghealth services research that leverages the enormouspotential of their own data systems for improvingthe knowledge base available to their clinicians andmanagers.

Finally, the article by Herman and colleagues11 addsto the growing body of evidence that appropriate medicationuse may not only improve the health status ofpatients with diabetes, but may also reduce their use ofcostly health services. The investigators compared outcomesfor patients with type 2 diabetes who were randomizedto either monotherapy with sulfonylureas orcombination therapy with rosiglitazone. After 2 years offollow-up, patients in the combination therapy groupexperienced fewer emergency department visits andhospitalizations and lower per-patient treatment costs.In addition to the study's important clinical implications,findings such as these provide an important contextfor payer decisions about out-of-pocket drug costsand the influence they may have on the behavior ofpatients taking multiple medications. Too often, thesecosts inhibit appropriate adherence and foster poorerhealth outcomes.12

Collectively, these studies provide an exciting pictureof where we have come in diabetes clinical andhealth services research. They also highlight the workthat remains to be done in order to ensure that as manypatients with diabetes as possible can lead healthy andproductive lives. We must continue to develop newstrategies for designing health systems that foster qualitydiabetes care. Given the demonstrated benefit ofmedication intensification for diabetes as well as othercommon chronic illnesses, future work should identifythe barriers to appropriate prescribing, regimen adjustments,and patient adherence. Redesigning prescriptiondrug benefits so that patients' out-of-pocket costs reflecttheir expected benefit from pharmacotherapy is an ideathat has been championed by Fendrick and others foryears.13 Studies such as those in this special issue add tothe growing evidence supporting this innovativeapproach. The "business case" for effective diseasemanagement is growing. The challenge to researchers,health systems, and payers will be to take the bold stepsneeded to redesign treatment and benefit structures inways that foster the gains suggested here.

From the Center for Practice Management and Outcomes Research, VA Ann ArborHealth Care System; Department of Internal Medicine and Michigan Diabetes Research andTraining Center, Ann Arbor, Mich.

Dr. Piette is a VA Research Career Scientist. The views expressed in this article do notnecessarily reflect those of the US Department of Veterans Affairs.

Address correspondence to: John D. Piette, PhD, Center for Practice Management andOutcomes Research, VA Ann Arbor Health Care System, PO Box 130170, Ann Arbor, MI,48113-0170. E-mail: jpiette@umich.edu.

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1. Godley PJ, Maue SK, Farrelly EW, Frech F. The need for improved medical managementof patients with concomitant hypertension and type 2 diabetes. 2005;11:206-210.

Diabetes Care.

2. Shah BR, Hux JE, Laupacis A, Zinman B, van Walraven C. Clinical inertia inresponse to inadequate glycemic control: do specialists differ from primary care physicians?2005;28:600-606.

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3. McBean AM, Jung K, Virnig BA. Improved care and outcomes among elderlyMedicare managed care beneficiaries with diabetes. 2005;11:213-222.

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4. Kerr E, Gerzoff RB, Krein SL, et al. Diabetes care quality in the Veterans AffairsHealth Care System and commercial managed care: the TRIAD study. 2004;141:272-281.

Am J Manag Care.

5. Jackson GL, Yano EM, Edelman D, et al. Veterans Affairs primary care organizationalcharacteristics associated with better diabetes control. 2005;11:225-237.

Am J Manag Care.

6. Knight K, Badamgarav E, Henning J, et al. A systematic review of diabetes diseasemanagement programs. 2005;11:242-250.

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7. Krein SL, Klamerus ML, Vijan S, et al. Case management for patients with poorlycontrolled diabetes: a randomized trial. 2004;116:732-739.

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8. Casalino LP. Disease management and the organization of physician practice. 2005;293:485-488.

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9. Choe HM, Mitrovich S, Dubay D, Hayward RA, Krein SL, Vijan S. Proactive casemanagement of high-risk patients with type 2 diabetes by a clinical pharmacist: a randomizedcontrolled trial. 2005;11:253-260.

Am J Manag Care.

10. Karter AJ, Moffet HH, Liu J, et al. Achieving good glycemic control: Initiation ofnew antihyperglycemic therapies in patients with type 2 diabetes from the KaiserPermanente Northern California Diabetes Registry. 2005;11:262-270.

Am J Manag Care.

11. Herman WH, Dirani RG, Horblyuk R, et al. Reduction in use of healthcare serviceswith combined sulfonylurea and rosiglitazone: findings from the rosiglitazone earlyversus sulfonylurea titration (RESULT) study. 2005;11:273-278.

Med Care.

12. Piette JD, Wagner TH, Potter MB, Schillinger D. Health insurance status, cost-relatedmedication underuse, and outcomes among diabetes patients in three systems ofcare. 2004;42:102-109.

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13. Fendrick AM, Smith DG, Chernew ME, Shaw SN. A benefit-based copay for prescriptiondrugs: patient contribution based on total benefits, not drug acquisition cost.2001;7:861-867.