Improved Patient Outcomes in 3 Years with a System of Cure for Diabetes
Diabetes mellitus (DM) and associated complications are increasing in the United States, with prevalence up 40 percent from 2002 to 2010. [1] Randomized controlled studies have shown reductions in the increased cardiovascular disease risk associated with diabetes when glucose, cholesterol, and blood pressure are better controlled and there are standards of care for improving patient outcomes, including recommendations for medical care from physician-coordinated teams. [2]
In spite of this evidence, provision of state-of-the-art care is rare, and it is unclear how quickly patient-level impact is achieved. [3] To confront this discrepancy, Geisinger Health System designed a team-based system of care to consistently provide evidence-based diabetes care. [4,5] This system used an all-or-none bundle of diabetes measures and electronic health record (EHR) tools to improve the consistency with which patients receive all elements of care. These measures resulted in reduced risk of retinopathy, stroke, and myocardial infarction (MI) within 3 years. [6]
Geisinger Health System is an integrated health system with 38 Community Practice Service Line (CPSL) sites in central and northeast Pennsylvania. The DM bundled system of care was instituted in CPSL in 2005 after a multispecialty, multidisciplinary group redesigned care for patients with diabetes based on evidence-based guidelines. [7] The workgroup defined nine measures that comprised an all-or-none diabetes bundle (Table 1). Workflows were developed that were measurable, scalable, reliable, and not dependent on the diligence of individuals. The system includes team-based care with delegated accountable responsibilities, EHR decision support, autogenerated patient report cards, and auto-updating of patient registry. The individual metrics and all-or-none bundle results for each office-based team and for each individual provider are reported monthly and shared transparently. Physician and team quality and innovation incentives are based on all-or-none care performance and are up to 20 percent of total cash compensation.
Analysis of claims data from our propensity-matched observational design shows a statistically significant lower risk of macrovascular and microvascular disease endpoints in the first 3 years in the new system compared to primary care outside the system. [6] This impact is substantial. Only 82 treated patients are needed to prevent 1 MI, 178 to prevent 1 stroke, and 151 to prevent 1 case of retinopathy. Perhaps the most notable finding is the apparent early impact of system implementation. The findings suggest that this occurs within the first 3 years, with the possibility that a reduction in risk begins 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. However, the early impact of a diabetes system of care has important clinical implications.
If reproducible, these implications for patients, providers, and payers are substantial. Patients will know that the difficult changes required to manage chronic disease will improve their health in ways they can appreciate. Payers and health systems can innovate and invest together to build similar systems of care, knowing that the benefit for their patients with diabetes will be prompt. [8] The ability to control the total cost of care by improving the quality of care and health of patients is key. The promising success of this new system hinged on creating a culture of team-based care, judicious use of EHR tools, having accurate clinical information, and aligning team incentives.
References
- U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. 2011. Health, United States, 2010: With special feature on death and dying. Available at: http://www.cdc.gov/nchs/data/hus/hus10.pdf (accessed February 3, 2020).
- American Diabetes Association. 2011. Standards of medical care in diabetes—2011. Diabetes Care 34 (Suppl 1):S11-S61. https://doi.org/10.2337/dc11-S011
- Saaddine, J. B., B. Cadwell, E. W. Gregg, M. M. Engelgau, F. Vinicor, G. Imperatore, and K. M. Narayan. 2006. Improvements in diabetes processes of care and intermediate outcomes: United States, 1988-2002. Annals of Internal Medicine 144(7):465-474. https://doi.org/10.7326/0003-4819-144-7-200604040-00005
- Bloom, Jr., F. J., T. Graf, T. Anderer, and W. F. Stewart. 2010. Redesign of a diabetes system of care using an all-or-none diabetes bundle to build teamwork and improve intermediate outcomes. Diabetes Spectrum 23(3):165-169. https://doi.org/10.2337/diaspect.23.3.165
- Weber, V., F. Bloom, S. Pierdon, and C. Wood. 2008. Employing the electronic health record to improve diabetes care: A multifaceted intervention in an integrated delivery system. Journal of General Internal Medicine 23(4):379-382. https://doi.org/10.1007/s11606-007-0439-2.
- Bloom, Jr., F. J., X. Yan, W. F. Stewart, T. R. Graf, T. Anderer, D. E. Davis, S. B. Pierdon, J. Pitcavage, and G. D. Steele, Jr. 2014. Primary Care Diabetes Bundle Management: Three-Year Outcomes for Microvascular and Macrovascular Events. The American Journal of Managed Care. Available at: https://www.ajmc.com/journals/issue/2014/2014-vol20-n6/primary-care-diabetes-bundle-management-3-year-outcomes-for-microvascular-and-macrovascular-events?p=1 (accessed February 3, 2020).
- American Diabetes Association. 2005. Standards of medical care in diabetes. Diabetes Care 28(Suppl 1):S4-S36. https://doi.org/10.2337/diacare.28.suppl_1.S4
- Paulus, R. A., K. Davis, and G. D. Steele. 2008. Continuous innovation in health care: Implications of the Geisinger experience. Health Affairs 27(5):1235-1245. https://doi.org/10.1377/hlthaff.27.5.1235
