Combination of Intensive Therapy and Team Approach Promotes Good Outcomes
Even though the treatment of diabetes is complex and major barriers to achieving good outcomes exist, AHRQ-funded research has shown that glycemic control can be achieved and complications of diabetes postponed through a combination of intensive drug therapy and a team approach (Table 3).
In a retrospective study, academic endocrinologists in Atlanta examined the clinical records of 151 diabetes patients (121 with type 2 diabetes and 30 with type 1) in their own practice.16 Most of these patients had complications as a result of their diabetes, including peripheral neuropathy (78 percent), retinopathy (22 percent), hypertension (80 percent), hyperlipidemia (64 percent), coronary heart disease (27 percent), and peripheral vascular disease (14 percent)—not unusual for patients who had had diabetes, on average, for 12 years.
Investigators found that half the patients made at least four visits during the study year. Patients alternated between visits that included both a physician and a nurse practitioner and visits with a nurse practitioner alone. Nurse practitioners, who were also directly available at other times for phone contact, were able to facilitate more frequent adjustment of therapy when necessary. The average HbA1c of patients with type 2 diabetes was 6.9 percent; 87 percent achieved good control of blood sugar (8 percent or less HbA1c) by the use of complex treatment regimens, 78 percent were managed with more than diet alone or a single oral agent, and many patients received either two oral hypoglycemics or one oral hypoglycemic plus insulin injections. The average HbA1c of patients with type 1 diabetes was 7.1 percent; 80 percent achieved good control of blood sugar with an average of 3.4 injections of insulin per day (Figure 1; Text Version). In addition, screenings were performed at recommended intervals for major complications, including eye and foot problems, high lipid levels, and hypertension.
Table 3. Components of intensive therapy and a team approach in treatment of diabetes
- More frequent use of 2 oral medications (a hypoglycemic and an antihyperglycemic) or 1 oral medication plus insulin.
- Greater likelihood of 3 or more daily injections for insulin recipients.
- 4 or more visits per year for many patients.
- Visits with both physicians and nurse practitioners alternating with visits with a nurse practitioner.
- Direct telephone availability of nurse practitioners.
- Dietitian visits with patients.
- Screening for complications.
Source: Adapted from Miller CD, Phillips LS, Tate MK, et al. Meeting American Diabetes Association guidelines in endocrinologist practice. Diabetes Care 2000; 23(4):444-8.
The Atlanta researchers reviewed several earlier studies that focused mostly on patients in primary care settings and found that significant percentages of patients had HbA1c levels above 8 percent.17,18 When comparing their own study to one of these earlier studies,19 the AHRQ-funded Atlanta team found that patients in their study were more likely than those in the earlier studyd to be using oral hypoglycemic medications plus insulin (31 percent vs. 3 percent). Also, the Atlanta patients taking insulin were more likely to be injecting three or more times per day (42 percent vs. 4 percent).
d. This study was based on persons with diabetes in the Third National Health and Nutrition Examination Survey (NHANES III). In this study, participants who received either oral hypoglycemics or insulin had average HbA1c levels of 8 percent or above.
The Atlanta researchers stated that "the discrepancies between our data and those of primary care studies (showing less success in achieving glycemic control) may be because of factors other than the type of treating physician."16
The following factors were mentioned by the researchers:
- The earlier primary care studies date from the early 1990s and may not reflect current practices.
- Patient motivation may have differed.
- A broader array of medications was available at the time of the Atlanta study.
- The ability to do rapid on-site HbA1c measurements was available for the Atlanta physicians.
The researchers emphasized that "good glycemic outcomes are attributable to a commitment to achieving normal metabolic status that is reinforced through multiple contacts, including not only physician appointments but also nurse practitioner visits, dietitian visits, and telephone calls."16
In a study describing the results of diabetes therapy for type 2 patients in their own clinic, the Atlanta-based research team identified "clinical inertia" (not intensifying therapy when glycemic levels are high) as a barrier to care in a small group of cases (40 visits, or 6 percent, out of 636 visits). This phenomenon occurred either because patients were not adhering to their meal plan or for no stated reason.20 A related study, by the same researchers, found that clinical inertia could be reduced by the use of a step-sequence treatment intensification plan. The sequence of steps started with diet alone, advanced to the medications glyburide or glipizide, and then added insulin in varying strengths and frequencies of administration. The study, conducted from 1992 to 1996, found that when providers used this sequence of steps, the percentage of type 2 diabetes patients with good glycemic control (an HbA1c of <7 percent) increased from under 40 percent to close to 60 percent over a 12-month period.21 The researchers considered these results even more significant since they were achieved in an underserved minority population (urban African-Americans) that tends to have poor rates of glycemic control and high rates of diabetic complications. As part of the study, the researchers emphasized to providers that patients were to remain in a given treatment category only if their glycemic control was good.
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Preventive Care Can Help To Postpone or Avoid Complications
Diabetes can lead to partial or total blindness as a result of proliferative retinopathy, a complication that occurs when new blood vessels that grow to replace older defective ones leak blood into the retina. Blindness can also result from macular edema, a complication that occurs when blood vessels in the eye balloon and malfunction, leading to a swelling of the retina.
For vision-related complications to be treated promptly, the American Diabetes Association recommends that diabetic patients have comprehensive periodic dilated eye and vision examinations by an ophthalmologist or optometrist.2 An AHRQ-funded study reinforces these recommendations. Researchers, using a computer model, estimated that screening and prompt treatment for eye disease in all appropriate patients with type 2 diabetes, by virtually eliminating severe vision loss for patients with proliferative diabetic retinopathy and macular edema, would preserve the sight of thousands of diabetic patients.22 Nearly all of the benefits would come from the early detection and prompt treatment of macular edema in patients whose type 2 diabetes began before age 45.
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Provider Questionnaires Improve Adherence to Treatment Protocols
Other strategies oriented toward assisting the provider can help patients receive needed care. An AHRQ-funded study showed that one way in which providers increased their ability to follow protocols was through completing questionnaires that served as a self-survey about the appropriateness of glycemic goals and whether their patients were well controlled.14
Both physicians and nurses were asked to fill out one-page multiple-choice questionnaires after each office visit over a 3-month period. In this study, conducted at a diabetes clinic treating African-American patients, adherence to protocols calling for intensification of therapy when indicated (e.g., putting patients previously treated by diet alone on medication or adding sulfonylurea medication to insulin) increased from 55 percent to 63 percent when providers completed a questionnaire after every patient visit.
This study is part of a series of ongoing AHRQ projects that will be providing further evidence about other interventions to assist providers in rendering effective care. Two interventions being tested include:
- The use of computerized reminders and flow sheets to track blood sugar levels, performance of tests, and test results for each of a provider's diabetic patients.
- Face-to-face discussions between primary care providers and endocrinologists to review patient management.
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Barriers to Patient Adherence Can Be Reduced
As discussed earlier (Table 2), both providers and patients have identified barriers that prevent patients from following the advice given to them about their treatment. Research funded by AHRQ and others can assist providers in helping their patients to overcome some of these barriers. For example, studies have shown that social support networks help elderly patients and African-American adults to comply with certain recommended practices.23,24
Also, automated telephone disease management (ATDM) with nurse followup has been found to be a successful strategy for helping diabetic patients manage their care.25 ATDM increased the number of patients who achieved glycemic control and avoided diabetic symptoms.
In addition, a new program aimed at primary prevention in minority children at risk for developing diabetes has shown promise in one study.26 Finally, a chronic disease self-management program developed for chronic conditions other than diabetes and now being used in a number of diabetes clinics around the country may yield positive results for diabetic patients.27
Social Support Assists Vulnerable Populations in Improving Adherence
An AHRQ-funded study of family members of persons with diabetes age 70 and over found that more than one-third went with older diabetics on their doctor visits. In addition, 22-50 percent of family members reported helping with various aspects of diabetes care, with the top two categories being "keeping enough medication on hand" and "following a diet."23 Such participation, as well as help with the daily management of diet and medications, was more likely if the patients were functionally disabled. Researchers found that those patients who received more family assistance were more likely both to take their medications as prescribed and to follow their diets.
Another AHRQ-funded study, a literature review of studies reporting on the effects of social support among African-American adults with diabetes, found that African-Americans relied more heavily than whites on informal social networks to meet their disease management needs.24 The social support consisted of help with the day-to-day management of diabetes, including:
- Help with diet supervision.
- Medication assistance.
- General support.
- Blood sugar monitoring.
- Foot care.
In findings that parallel the study on social support and the elderly,23 the review found that social support is significantly associated with improved diabetes management among this population.
Automated Telephone Disease Management (ATDM) Improves Patient Outcomes
An AHRQ-funded literature review of studies on the effects of interactive voice response systems in the diagnosis and management of chronic disease found that these systems can positively affect health and health behavior outcomes.25 In a randomized controlled trial, 272 diabetic patients in the Department of Veterans Affairs (VA) health system received biweekly calls from an automated telephone-messaging computer that enabled patients to provide a recorded assessment of their health status and health behaviors in 5-8 minutes. Patients used their phone's touch-tone keypad to report self-monitored blood glucose readings and various symptoms. Based on the automated assessment reports, a nurse made followup calls to address reported problems. The patients who received ATDM calls with nurse telephone followup had better glycemic control and self-care along with fewer diabetic symptoms than patients who did not receive these calls.28
After a 12-month trial period, among patients with HbA1c values above 9 percent, the average values were 9.1 percent for those receiving ATDM calls and 10.2 percent for those who did not. The entire group receiving ATDM calls had HbA1c levels at followup that were 0.3 percent lower than those of the control group (8.1 percent vs. 8.4 percent). The researchers estimated that if the reduction in glycemic values achieved in this study could be replicated throughout the VA system, the government could save $100 million each year. The results of this study replicated those from a previous ATDM trial conducted among English- and Spanish-speaking patients in county clinics. In that study, the investigators found that ATDM improved patients' glycemic control, symptoms, and self-care, and decreased depressive symptoms.29
Primary Prevention Can Lower Risk Factors for Mexican-American Children
To learn more about how to prevent diabetes from occurring in the Mexican-American population, AHRQ funded a pilot study of an intervention program for children at risk for type 2 diabetes.26 The 3½-month program had a threefold emphasis on understanding of diabetes, diet, and exercise and was designed to be culturally and age-appropriate for Mexican-American children. Thirty-seven at-risk children 7-12 years of age (those with at least one diabetic parent or grandparent) and their parents were enrolled in an eight-session educational program intended to inform them about diabetes and its complications and to teach the essentials of a healthy lifestyle. Health screenings for the children were given before and after the program.
Post-program analysis of individual risk factors showed a trend toward more normal values. For example, the percentage of children whose consumption of protein, total fat, saturated fat, and cholesterol fell within the recommended daily requirement increased. Also, 94 percent of parents and 67 percent of children began reading food labels, 83 percent of parents began to use fat-modified recipes, and 83 percent of children began exercising regularly. Parental involvement also resulted in parents making progress toward adopting healthier lifestyles.
Chronic Disease Self-Management Program May Improve Adherence
The Chronic Disease Self-Management Program (CDSMP) is now being used by health organizations in 31 States and 9 countries (including diabetes treatment facilities).27 The CDSMP could eventually have a significant impact on the health status and health care use of persons with diabetes. The program originated in an AHRQ-funded study that tested a 7-week community-based patient education program for people with heart disease, lung disease, stroke, and arthritis. A premise of the program is that many chronic diseases, such as diabetes, heart disease, lung disease, arthritis, and high blood pressure, pose similar problems in patient self-management. The CDSMP focuses on improving people's self-efficacy in taking care of their own health. In the initial 6-month followup, the study found positive results for self-reported health, disability, fatigue, and hospital use indicators.
The CDSMP consists of seven weekly 2½-hour sessions (later changed to six weekly sessions) focusing on nutritional change, adoption of exercise programs, use of medications and community resources, health-related problem solving, and decisionmaking.e Preliminary followup studies (covering a 2-year period) indicate that participants have improved health, more energy, and fewer hospitalizations and doctor visits.
e. For sites using the program for diabetes and other conditions, go to http://patienteducation.stanford.edu/
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Research Is Currently Underway to Improve Diabetes Care
AHRQ is continuing its efforts to find the most effective means of treating diabetes and improving outcomes of care. Currently, AHRQ-funded researchers are testing new technologies to improve patient care, enhancing existing treatment modalities, making care more culturally sensitive, testing interventions to improve provider performance, delineating the impact of managed care on patients with diabetic retinopathy, and tracing the indirect economic impact of diabetes. For example, AHRQ funds are being used to:
- Examine variation in outcomes for diabetic patients using an automated telephone disease management system and extend the use of ATDM to Spanish-speaking patients.
- Test the impact of a culturally sensitive multimedia computer education program in a clinical setting on diabetes-related knowledge, attitudes, self-efficacy (the belief that what you do makes a difference), and self-care for African-American and Latino populations.
- Measure the effects of increased self-monitoring of blood glucose on the cost, quality, and outcomes of diabetes care in patients enrolled in a managed care program.
- Test a more intensive collaborative approach to disease management vs. a more traditional approach in 40 midwestern community health centers serving a medically underserved population in rural and urban areas. The "collaborative" approach involves intensive, extended training of providers in total quality management as well as improvement of skills in provider-patient communication, as compared to the "traditional" approach of basic, brief training in total quality management.
- Test the effect of interpreters on diabetes outcomes for Navajo patients.
- Examine methods for helping physicians follow recommended treatment modalities.
- Study the organizational and financing arrangements in managed care and their effects on eye care for working-age patients with diabetic retinopathy.
- Identify the extent of the indirect costs of diabetes, as represented by reduced on-the-job productivity. (This is the first study to consider this type of productivity loss for diabetes.)
- Pilot-test methods for improving the treatment of low-income diabetic patients in community health centers.
- Pilot-test methods for developing a claims-based quality measure for ambulatory diabetic care.
- Study how features of managed care affect outcomes of patients with diabetes and, in a related study, outcomes for patients with diabetic retinopathy.
Diabetes Quality Improvement Project (DQIP)
The Diabetes Quality Improvement Project, a coalition of public and private entities, has developed a set of diabetes-specific performance and outcome measures based in part on AHRQ-funded research. These new measures, by replacing a number of current conflicting standards, will allow accurate comparisons of
care within and across health care settings. Once valid comparisons can be drawn, providers will be able to further improve care, either by broader use of intensive therapy using a team approach or by adopting specific innovations that will assist providers and patients in achieving treatment objectives.
Health care professionals, purchasers of health care, and consumers are gradually adopting the DQIP measures nationwide. These measures focus on HbA1c testing, eye and foot exams, blood pressure control, and monitoring for kidney disease.
The DQIP coalition is comprised of seven organizations: the American Diabetes Association (ADA), the Foundation for Accountability (FACCT), the Centers for Medicare and Medicaid Services (CMS, formerly HCFA), and the National Committee for Quality Assurance (NCQA), the American Academy of Physicians,
the American College of Physicians, and the Department of Veterans Affairs.30-32
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AHRQ-funded research shows that patients can achieve good diabetic control if providers recommend intensive therapies, use a team approach, furnish appropriate preventive care, and put into practice proven strategies that help patients better manage their care. Few patients have type 2 diabetes without other diagnoses.33 Generalists, in treating multiple chronic illnesses in a single patient, may balance glycemic control with other interventions in order to achieve a treatment plan responsive to the most pressing needs of the patient. The barriers to implementing these methods and strategies are challenging, but improvements in patient outcomes are both important and achievable. In addition, new technologies for assisting the patient in self-management show considerable promise. An example is customized modules for personal digital assistants (electronic handheld appliances known as PDAs) for managing diet and exercise. The results of these studies have set the stage for dramatic improvements needed to improve care and outcomes for all patients with diabetes.
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For More Information
This synthesis was written by Mark W. Stanton, M.A. (Mark.Stanton@ahrq.hhs.gov).
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1. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Disorders. Diabetes Statistics of the United States, Nov. 1, 1998. NIH Publication No. 99-3892.
2. American Diabetes Association. Clinical practice recommendations 2001. Position statement. Standards of medical care for patients with diabetes mellitus. Diabetes Care 2001 Jan;24 Suppl 1:S1-S133.
3. Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion. Frequently Asked Questions. http://www.cdc.gov/diabetes/faqs.htm.
4. American Diabetes Association. Facts and Figures. http://www.diabetes.org.
5. Stratton IM, Adler AI, Neil HA, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): Prospective observational study. BMJ 2000;321:405-12.
6. Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977-86.
7. UK Prospective Diabetes Study (UKPDS), VIII. Study design, progress and performance. Diabetologia 1991 Dec;34(12):877-90.
8. UK Prospective Diabetes Study (UKPDS 33). Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352:837-53.
9. Testa M, Simonson D. Health economic benefits and quality of life during improved glycemic control in patients with type 2 diabetes mellitus. JAMA 1998;280(17):1490-6.
*10. Hayward RA, Manning WG, Kaplan SH, et al. Starting insulin therapy in patients with type 2 diabetes. JAMA 1997;278(20):1663-9.
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*12. Greenfield S, Rogers W, Mangotich M, et al. Outcomes of patients with hypertension and non-insulin-dependent diabetes mellitus treated by different systems and specialties. Results from the Medical Outcomes Study. JAMA 1995;274(18):1436-44.
*13. Larme AC, Pugh JA. Attitudes of primary care providers toward diabetes. Barriers to guideline implementation. Diabetes Care 1998;21(9):1391-6.
*14. El-Kebbi IM, Ziemer DC, Gallina, DI, et al. Diabetes in urban African-Americans. XV. Identification of barriers to provider adherence to management protocols. Diabetes Care 1999;22(10):1617-20.
*15. Kravitz RL, Hays RD, Sherbourne CD, et al. Recall of recommendations and adherence to advice among patients with chronic medical conditions. Arch Intern Med 1993;153:1869-78.
*16. Miller CD, Phillips LS, Tate MK, et al. Meeting American Diabetes Association guidelines in endocrinologist practice. Diabetes Care 2000;23(4):444-8.
17. Martin TL, Selby JV, Zhang D. Physician and patient prevention practices in NIDDM in a large urban managed-care organization. Diabetes Care 1995;18:1124-32.
18. Weatherspoon LJ, Kumanyika SK, Ludlow R, et al. Glycemic control in a sample of black and white clinic patients with NIDDM. Diabetes Care 1994;17:1148-53.
19. Harris MI, Eastman RC, Cowie CC, et al. Racial and ethnic differences in glycemic control of adults with type 2 diabetes. Diabetes Care 1999;22:403-8.
20. El-Kebbi IM, Ziemer DC, Musey VC, et al. Diabetes in urban African-Americans. IX. Provider adherence to management protocols. Diabetes Care 1999;20(5):698-703.
*21. Cook CB, Ziemer DC, El-Kebbi IM, et al. Diabetes in urban African-Americans. XVI. Overcoming clinical inertia improves glycemic control in patients with type 2 diabetes. Diabetes Care 1999;22(9):1494-1500.
*22. Javitt JC, Aiello LP, Chiang Y, et al. Preventive eye care in people with diabetes is cost-saving to the federal government. Diabetes Care 1994;17(8):909-17.
*23. Silliman RA, Bhatti S, Khan A, et al. The care of older persons with diabetes mellitus: families and primary care physicians. J Am Geriatr Soc 1996;44(11):1314-21.
*24. Ford ME, Tilley BC, McDonald PE. Social support among African-American adults with diabetes, Part 2: a review. J Natl Med Assoc 1998;90(7):425-32.
*25. Piette JD. Interactive voice response systems in the diagnosis and management of chronic disease. Am J Manag Care 2000;6(7):817-27.
*26. McKenzie SB, O'Connell J, Smith LA, et al. A primary intervention program (pilot study) for Mexican American children at risk for type 2 diabetes. Diabetes Educator 1998;24(20):180-6.
*27. Lorig KR, Sobel DS, Stewart AL, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization. Med Care 1999;37(1):5-14.
28. Piette JD, Weinberger M, Kraemer FB, et al. Impact of automated calls with nurse follow-up on diabetes outcomes in a Department of Veterans Affairs health care system. Diabetes Care 2001;24(2):202-8.
29. Piette JD, Weinberger M, McPhee SJ, et al. Do automated calls with nurse follow-up improve self-care and glycemic control among vulnerable patients with diabetes? Am J Med 2000;108(1):20-7.
30. Health Care Financing Administration. Quality of Care: National Projects. Diabetes Quality Improvement Project (DQIP). http://www.hcfa.gov/quality/3.htm.
31. American Diabetes Association. The Diabetes Quality Improvement Project. http://www.diabetes.org/main/info_news/news/dqip.jsp.
32. Fleming B, Greenfield S, Engelgau MM, et al. The Diabetes Quality Improvement Project. Moving science into health policy to gain an edge on the diabetes epidemic. Diabetes Care 2001;24:1815-20.
33. Glasgow RE, Wagner EH, Kaplan RM, et al. If diabetes is a public health problem, why not treat it like one? A population-based approach to chronic illness. Ann Behav Med 1999;21(2):159-70.
* AHRQ-funded/sponsored research
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AHRQ Publication Number 02-0005
Current as of November 2001
Improving Care for Diabetes Patients Through Intensive Therapy and a Team Approach. Research in Action, Issue 2. AHRQ Publication Number 02-0005, November 2001. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/diabria/diabetes.htm