CliniCal Diabetes Volume 26, number 1, 2008. B r i d g E s t o E x c E l l E n c E Table 1. Yearly Cost Savings for Diabetes Care of 8,657 patients in the DMCP …
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The Florida Diabetes Master Clinician Program: Facilitating Increased Quality and Significant Cost Savings for Diabetic Patients
Edward Shahady, MD, ABCL, ABFM, FAAFP Up to 10 of Americans 20 years of age have type 2 diabetes, and 20 have the metabolic syndrome1,2 The prevalence of both has increased by 33 during the past decade as a result of an increasingly sedentary lifestyle, the epidemic of obesity, the growth of ethnic groups at risk for the disease, and the aging of the population The prevalence of the metabolic syndrome increases dramatically with age, and 45 of people 60 years of age have the syndrome Type 2 diabetes will develop in many of these individuals1,2 In the United States, diabetes is the sixth leading cause of death; the leading cause of renal failure end-stage renal disease, nontraumatic limb amputations, and blindness; and the leading contributor to cardiovascular disease CVD CVD accounts for 70 of deaths in adults with diabetes The complications associated with diabetes lead to excessive suffering, increased use of health care resources, and excessive costs36 Despite our increased knowledge and understanding of the pathophysiology
and management of diabetes, patient outcomes have not shown a parallel improvement A large gap exists between our knowledge and our performance7,8 Based on excellent evidence, the American Diabetes Association ADA has set the following goals: hemoglobin A1c A1C 7, LDL cholesterol 100 mg/dl, and blood pressure 130/80 mmHg Nationally, only 48 of patients are able to reach the A1C goal, and only 33 are at the LDL and blood pressure goals Only 7 are able to reach the goal for all three at the same time9 The 58 Florida practices that participate in the Diabetes Master Clinician Program DMCP of the Florida Academy of Family Physicians Foundation FAFPF have been able to help patients attain better control of their diabetes than the national averages The 8,657 patients 27,920 visits in the 58 practices average 54 goal achievement for A1C, 53 goal achievement for LDL, and 54 goal achievement for blood pressure Significantly, 19 are achieving all three goals at the same time Several practices have achieved goals as high as 75 for the individual measures and 44 for all three measures together A cost savings of 1,122 per year can be achieved if a patient is at goal for all three of these
diabetes goals The yearly cost savings for all patients in the DMCP is estimated to be 14 million This estimation is based on information obtained from the Bridges to Excellence website,10 which provides an actuarial evaluation of the estimated per-patient savings for physicians who achieve recognition through the Diabetes Physician Recognition Program Table 1 provides information about how this estimate was calculated The number of patients at the published national goal in the DMCP database was subtracted from the number at goal for the Florida project eg, A1C 48 total patients vs 54 total patients The DMCP was created by the FAFPF in 2003 to address the performance gap that exists in diabetes care The program started with four practices, and currently 58 practices participate Each practice team of a clinician and medical assistant MA or nurse receives evidence-based training through interactive group seminars, visits to the clinicians office, and educational
Table 1 Yearly Cost Savings for Diabetes Care of 8,657 patients in the DMCP
Number of DMCP Patients at Goal Greater Than National Average 398 1,353 1,741
ADA Quality Indicator A1C LDL Cholesterol Blood Pressure
Total
Cost Savings Per Patient 27900 36900 47400 1,12200
Total Cost Savings 111,04200 499,25700 825,23400 1,435,53300
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e-mails during an 8- to 12-month period Alumni meetings are held yearly The office manager and other office staff also receive an orientation to the project Training includes information about current published clinical standards of care, how to enter data into the Internetbased electronic diabetes registry, how to produce and interpret quality assessment reports, and how to conduct group visits The program is funded through grants, and there is no charge for participation A guideline for group visits is provided that includes forms for privacy protection, documentation of the visit, appropriate International
Classification of Diseases and Current Procedural Terminology coding, roles for the MA or nurse and the clinician, suggested curriculum, and information about how to prepare and follow up the group visit Group visits are usually 2 hours long, with the first hour conducted by the MA or nurse and the second hour led by the physician Practices are encouraged to invite their high-risk
patients those who are not at goal for A1C, LDL, or blood pressure to the group visits The diabetes registry helps them identify these high-risk patients A CPT code of 99214 is appropriate for most of these
Table 2 Report Card Given to Clinician at Each Visit A Male Patient
Goal Weight lb BMI kg/m
2
October 2007 185 31
July 2007 201 34 44 155/88
January 2007 201 34 44 149/89
Waist Size inches Blood Pressure mmHg Eye Check Foot Check A1C Total Cholesterol mg/dl LDL Cholesterol mg/dl HDL Cholesterol mg/dl Non-HDL Cholesterol mg/dl Triglycerides mg/dl Urine Microalbumin Flu Shot Aspirin Group Visit
40 120/80 Once a year Once a year 6 135 70 40
42 135/80 Done Done 70 185 105 44
85 222 145 33
79 222 144 35
100 150 Once a year Once a year Daily Once, or twice if first is before age 65
141 144 Not done Done Yes Yes
189 188
187 200
No Yes
Yes No
Pneumovax
First one given
patients because they are of moderate complexity and high risk The Internet-based diabetes registry is a relational database created in consultation with an information technology expert Evidence-based quality indicators were obtained from the published guidelines of the ADA,11 National
Cholesterol Education Project,12 and Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure13 These guidelines were used to guide the creation of the database fields Practices are required to have a high-speed Internet connection and must agree to have an independent research assistant enter all of their patients into the database Subsequent updating of the database is done by the practices and the research assistants The diabetes registry provides excellent reports that enhance care for one-on-one office visits and facilitate population management of all diabetic patients in the participating practices The typical one-on-one office visit for a diabetic patient takes 1520 minutes of a physicians time Some of that time is spent searching for lab results and other information from past visits The diabetes registry provides a report Table 2 that saves physicians up to 5 minutes by organizing all of the pertinent diabetes information for physician review In addition to saving time, it reduces the frustration and exhaustion that accompanies the hunt for information The most valuable report is the patient report card Table 3 This is given to
patients by the MA or nurse The language that is used to explain the items is intended to empower and educate patients and encourage selfmanagement If empowered to do so, the MA or nurse can reduce physicians time and frustration by reviewing the reports, ordering needed laboratory tests and immunizations, and explaining the importance of items in the report to patients Some MAs and nurses have been taught how to do the monofilament
0
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exam of the feet These reports, along with empowered staff, enhance the effectiveness of the one-on-one visit, reduce frustration, save time, and increase patient, staff, and physician satisfaction The other reports in the diabetes registry focus on population management Population management tools aid physicians with identifying patients
who have not returned to the office for periodic diabetes evaluations, as well as those who may have been to the office but have not had the recommended periodic evaluations Patients may be asked to obtain laboratory tests or go to see an ophthalmologist but fail to do so Physicians have no way of recognizing this without a registry Reminder
systems are only of value if patients are being seen
Population management tools facilitate management when patients are not in the office Unfortunately, electronic health records do not contain disease registries that provide these types of reports Reports that place patients in different risk categories aid with developing creative strategies for management Table 4 shows the number of patients a physician has who have different A1C
Table 3 Report Card Given to Patient at Each Visit
Goal Weight lb Blood Pressure mmHg Tests A1C Sugar for 3 months LDL Cholesterol Lousy Cholesterol mg/dl HDL Cholesterol Happy Cholesterol mg/dl Triglycerides another bad fatty substance mg/dl Medication Aspirin to prevent heart attacks Important Yearly Activities Eye Check to prevent blindness Foot Check for sores and numbness Urine Microalbumin to check for kidney failure Flu Shot to prevent pneumonia Special Vaccine Pneumovax to prevent a special pneumonia One time, or two times if first before age 65 Once a year Done Take daily Yes No Yes 120/80 October 2007 185 135/80 July 2007 201 155/88 January 2007 201 149/89
6
70
85
79
70
105
145
144
40
44
33
35
150
144
188
200
Once a
year
Not done
Once a year Once a year
Not done Done
First one given
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Table 4 Report to Identify Patients Average A1C Also Available for LDL, Non-HDL, and Blood Pressure: Aids Identification of High-Risk Patients
Dr Samples Clinic A1C Patients at Each Level n 8 43 8 to 65 133 65 49
Patient List
Medical Record 89493 56473 33347 12358 12356 Name Jones, Bubba Charming, Prince Jones, Mary Simpson, Bart Dean, James Average A1C 124 113 112 110 109 Visits n 2 4 2 3 2
helps providers focus on the patients who are in the most need Table 6 permits physicians to compare their practices ability to achieve the ADA goals for A1C, LDL, and blood pressure Some practices care for more disadvantaged patients and will not achieve goals as high as others Practices are also able to track their performance in achieving goals over time Table 7 demonstrates changes over time for four practices All of the practices improved their numbers after they had been in the program for 18 months or longer Summary Diabetes is a complex disease that may be the most difficult of all chronic diseases to manage in primary care settings
The fiscal and psychological burden of diabetes can be significantly reduced if evidence-based goals are achieved for A1C, LDL cholesterol, and blood pressure The FAFPFs DMCP has developed tools to help primary care physicians and their patients attain these goals These tools include an Internet diabetes registry and group visits The registry produces reports that facilitate population management of patients and make one-on-one office visits more efficient
Table 5 List of Patients Who Have Not Had a Given Test or Exam in the Past 365 Days Available for Eye and Foot Exams and Urine Microalbumin Test
Patient Name Charming, Prince Jones, Bubba Kong, King Jones, Mary Simpson, Bart Dean, James Dough, Lotta Pincher, Penny Date Last Done 8/2006 12/2005 2/2006 1/2006 4/2006 9/2006 11/2005 7/2005
sample reports are not real patients but rather fictious ones that were entered in the registry for training purposes Table 5 aids physicians in recognizing patients who lack documentation for specific yearly tests or immunizations and daily aspirin use These patients could be contacted and asked to return for this care Special days can also be arranged to help increase goal achievement An
optometrist may be willing to come to a clinic to conduct eye exams, or a clinic could choose to schedule a flu shot day on a Saturday The registry
levels Those patients with levels 8 are at the greatest risk for complications, and more aggressive management strategies are required Group visits are one strategy that can be employed Patients in the high-risk group can be invited to attend group visits Clinic staff and physicians can also click on patients names to see when they were last seen in the office; if it has been more than 3 months since the last visit, the patients can be asked to return as soon as possible for a follow-up visit These reports are also available for LDL cholesterol, non-HDL cholesterol, and blood pressure All names shown in the
Table 6 Samples of Various Practices Average Achievement of ADA Goals on Most Recent Tests Compared to All Practices and National Average
A1C 7 48 54 68 44 75 58 66 45 64 LDL 100 mg/dl 33 55 64 46 75 55 56 51 43 Systolic Blood Pressure 130 mmHg 33 55 53 52 69 71 74 46 48 All Three Goals at the Same Time 7 19 30 14 44 30 33 14 15
Practice Name National All 58 Practices 6 11 20 22 37 48 56
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Table 7 Percentage of Four Clinics Patients Meeting Goals for A1C, LDL Cholesterol, Blood Pressure, and All Three at Once
All Three Goals at the Same Time 10 18 9 18 9 39 20 29
5 Brown JB, Nichols GA, Glauber HS, Bakst AW: Type 2 diabetes: incremental medical care costs during the first 8 years after diagnosis Diabetes Care 22:11161124, 1999 6 Selby JV Ray GT, Zhang D, Colby CJ: Excess , costs of medical care for patients with diabetes in a managed care population Diabetes Care 20:1396 1402, 1997 7 Shahady EJ: Medical research in the 21st century [Letter] JAMA 286:1834, 2001 8 Institute of Medicine: Crossing the Quality Chasm: A New Health System for the 21st Century Washington, DC, National Academy Press, 2001 9 Saydah SH, Fradkin J, Cowie CC: Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes JAMA 291:335342, 2004 10 Bridges to Excellence website http:// wwwbridgestoexcellenceorg/assets/Documents/ Program_Evaluation_Documents/DCL_ analysis1207051pdf Accessed 5 August 2007 11 American Diabetes Association: Standards of medical care in diabetes [Position Statement] Diabetes Care 30 Suppl 1: S4S41,
2007 12 The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JAMA 289:25602571, 2003 13 Grundy SM, Cleeman JI, Merz NB, Brewer HB, Clark LT, Hunninghake DB, Pasternak RC, Smith SC, Stone NJ: Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines Circulation 110:22272239, 2004
A1C Clinic 4 1/06 7/07 Clinic 5 1/06 7/07 Clinic 20 1/06 7/07 Clinic 22 1/06 7/07 46 59 45 70 51 54 45 57
LDL Cholesterol 45 55 46 60 34 67 41 49
Blood Pressure 38 49 36 52 45 69 48 74
and of higher quality Group visits empower patients to better self-manage their diabetes ACkNOWLEDGEMENTS Pfizer, Inc, and Blue Cross Blue Shield have provided financial support for the Diabetes Master Clinician Program REFERENCES
1 Ford ES, Giles WH, Dietz WH: Prevalence of the metabolic syndrome among US adults JAMA
287:356359, 2002 Boyle JP, Honeycutt AA, Narayan KM, Hoerger T, Geiss LS, Chen H, Thompson TJ: Projection of diabetes burden through 2050: impact of changing demographic and disease prevalence in the US Diabetes Care 24:19361940, 2001
3 Mokdad AH, Ford ES, Bowman BA,
Nelson DE, Engelgau MM, Vinicor F, Marks JS: Diabetes trends in the US 19901998 Diabetes Care 23:12781283, 2000 4 Selby J, Grumbach K, Quesenberry CJ, Schmittdiel JA, Truman AF: Differences in resource use and costs of primary care in a large HMO according to physician specialty Health Serv Res 34:503518, 1999 2
Edward Shahady, MD, ABCL, ABFM, FAAFP is director of the Diabetes , Master Clinician Program of the Florida Academy of Family Physicians Foundation in Jacksonville
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