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Evidence suggests that diabetes is inadequately managed in the United States.
Reviewed by Rui Li, MM
Additionally, data from the 1999 to 2000 National Health and Nutrition Examination survey showed that 37% of diabetic patients reached the goal of HbA1c <7% and 37% had values >8%. Only 36% had normal blood pressure, 40% had elevated blood pressure and >50% had total cholesterol 200 mg/dL. Only 7% of adults with diabetes achieved recommended goals of HbA1c, blood pressure and total cholesterol.
ADOPTION OF CARE PROCESSES
Researchers reporting in Diabetes Care sought to describe the extent of the adoption of diabetes care management processes.1 Rui Li, MM, from the School of Public Health at the University of California, Berkeley, and colleagues, derived data from the National Survey of Physicians Organizations (NSPO) and the Management of Chronic Illness conducted in 2000 to 2001.
“The locus of actual care delivery for much of diabetes management is the physician organization,” Li and colleagues wrote. “No large-scale surveys have previously been conducted to determine the extent to which physician organizations have adopted innovations known to improve the care of diabetes.”
The NSPO telephone survey called medical groups and independent practice associations (IPAs) with ≥20 physicians. The collected data determined the prevalence of diabetes care management processes as well as explored what characteristics of physician organizations are associated with greater adoption of the improvements, the team reported. A total of 1,104 of the 1,590 identified physician organizations responded; 987 were included. Of these, 645 were medical groups and 342 were IPAs.
CARE MANAGEMENT PROCESSES
Previous work describes the Chronic Care Model, created to address deficiencies in the management of chronic disease.2-4 It includes six components: two that involve the larger health care system surrounding the physician organization and four internal components. Four care management processes (CMP), derived from the internal Chronic Care Model components, were the basis of data obtained by the NSPO. The CMP consisted of 1) the use of clinical practice guidelines in conjunction with physician reminder systems, 2) case management, 3) performance feedback to individual physicians, and 4) disease registries.
The survey asked whether the organization had implemented the four diabetes CMPs; all of which are significantly correlated with each other (P<.001), they reported. “We created a diabetes care management index using these four CMPs to measure the extent of the adoption of diabetes CMPs in each physician organization,” Ms. Li wrote. The index range used was 0 to 4, each CMP was scored as 1 point. The internal consistency reliability of the index was 0.64.
FOUR GROUPS OF VARIABLES
The four groups of independent variables used were 1) external incentives for a physician organization to im-prove quality, 2) computerized clinical information technology infrastructure, 3) relationship with health maintenance organizations (HMOs), and 4) ownership of the physician organizations.
The survey asked seven questions to assess external incentives. The first three were defined as categorical variables, coded as 0 or 1. The last four were measured compositely, from 0 to 4. Clinical information technology (IT) was measured by a single IT index, values ranged from 0 to 6.
The investigators categorized ownership of physician organizations as by a HMO or a hospital system, ownership by physicians in the organization or ownership by nonphysician managers or others.
“Of the 987 medical groups and IPAs surveyed that treat patients with diabetes, the average score on the diabetes care management index was 1.7,” Ms. Li and colleagues wrote. “In other words, physician organizations on average used fewer than two of the four components of the diabetes care management index.”
They found that 26% of the physician organizations used none of the processes, 22% used one, 20% used two, 19% used three and 13% used all four. The most commonly reported CMP was physician performance feedback, used by 48% of the physician organizations; 43% used diabetes case managers, 40% had a diabetes registry and 39% used physician guidelines and tied to reminder systems.
“Our study is the first to provide national data on the use of diabetes CMPs among physician organizations,” the investigators said. “Our results demonstrate that external incentives for quality, clinical IT capability and group ownership by an HMO or hospital system are associated with increased use of diabetes CMPs.”
The average physician organization has adopted fewer than two of the four components of the diabetes care management index, and more than 25% of those studies do not use any at all, they said. “This is unfortunate because the CMPs have been shown, in most studies, to be associated with improved diabetes outcomes.”
The investigators went on to say that these findings are consistent with others that have found a large gap between scientific knowledge and routine practice in diabetes treatment. A report by the Institutes of Medicine (IOM) said that the low quality is more a result of failure at the organizational level, than that of individual physicians.5
IOM REPORT SUPPORTED
“The IOM proposed the implementation of organization processes for quality and emphasized the importance of providing physician organizations with incentives for quality-enhancing processes,” Ms. Li said. “Our regression results support the conclusions of the IOM report.”
The current investigation also found that the role played by IT is critical. “IT facilitates better chronic illness care by giving physicians access to patient information, enabling identification of at-risk populations, and providing decision support at the point of care,” the team wrote. “Without IT infrastructure, it is difficult to generate a registry of diabetic patients and to provide tools for patient tracking and follow-up.”
Physician organizations owned by HMOs or hospital systems used more diabetes CMPs than physician-owner physician organizations. This may be explained by the availability of resources, they said.
“CMPs – the institution of physician reminder systems based on clinical practice guidelines, case management, performance feedback to individual physicians and the use of disease registries – have been associated with improved glycemic control in patients with diabetes,” Ms. Li and colleagues wrote.
This survey found that few medium and large physician organizations have adopted all of these processes and almost half have only instituted none or just one.
The study identifies some factors that may increase the likelihood of the adoption of CMPs for diabetes, factors like external quality reporting, additional payment for better quality, sophisticated clinical information systems, organization size and HMO ownership.
“Policies and practices that promote these characteristics may help spread improvement in diabetes care,” they concluded.
Rui Li, MM, is from the School of Public Health at the University of California, Berkeley. She can be reached at rli@uclink.berkeley.edu.
1. Li R, Simon J, Bodenheimer T, et al. Organizational factors affecting the adoption of diabetes care management processes in physician organizations. Diabetes Care. 2004;27:2312-2316.
2. Wagner EH, Austin BT Davis C, et al. Improving chronic illness care: translating evidence into action. Health Affairs. 2001;20:64-78.
3. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002;288:1775-1779.
4. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the Chronic Care Model, Part 2. JAMA. 2002;288:1775-1779.
5. Institute of Medicine: Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC. National Academies Press. 2001.
