Barriers to tight control
There are many reasons tight blood glucose control is not more widespread, despite its clear benefits. “Some people have access problems,” Dr. Spann says, “such as insurance that doesn’t cover extensive treatment. It also is difficult to get many people to a point where they’re willing and able to make lifestyle changes to improve their control.”
Since diabetes is a progressive condition, it can become increasingly difficult to achieve treatment targets. Several studies have noted that the percentage of people achieving targets diminishes with duration of diabetes.
What’s more, the “system” of medical care may be a problem in itself, according to Dr. Spann and others. The way primary care is organized and reimbursed by insurance companies probably serves as a barrier to achieving optimal blood glucose control for many people. Dr. Spann points to the “Chronic Care Model” developed by Dr. Ed H. Wagner at Improving Chronic Illness Care (ICIC), a national program of the Robert Wood Johnson Foundation based in Seattle, as a way to change the system.
“I think that the proponents of the Chronic Care Model are right on,” Dr. Spann says. “There have been a number of studies that have shown that practices that have most of the elements of the model in place do better in getting more of their patients to treatment targets.” Those elements include electronic registries that track and report important patient information, multidisciplinary treatment teams, and care management. “The doctor can’t do it all,” Dr. Spann says. “We know that nurses and diabetes educators probably do better health education than we do.”
One health system that has adopted the Chronic Care Model and applied it to diabetes is MaineHealth in Portland, Maine. In conjunction with its physician–hospital organization, the MMC PHO, MaineHealth has developed an Internet-based Clinical Improvement Registry for primary-care doctors. The doctors enter information about their patients, and the system provides current clinical data at each visit, including the latest laboratory results, status of key tests (for example, HbA1c and blood pressure), and problems to be addressed. The system can also be used to generate notices for patients and doctors, to remind them of overdue examinations or laboratory tests. Data may be viewed for each patient or for a doctor’s overall practice.
The MMC PHO also employs 14 Chronic Illness Care Managers, who are embedded in primary-care practices as part of the patient care team (they manage not just diabetes, but asthma and heart failure). These nurse specialists provide patients with intensive education and motivational support, even paying home visits if that will help.
The most recent data from the program covers the experience of 15 primary-care practices over a period from the program’s inception to the end of its first year. Before the program existed, 80% of people with diabetes had received an HbA1c test within the past year. After a year, 93% of people had received one. The percentage of people with HbA1c values less than 7% rose from 41% to 49%—a 20% increase. The percentage of people with HbA1c values above 8% decreased from 31% to 24%, and the percentage of people with HbA1c values above 9.5% decreased from 13% to 9%. There were similar results in measures of LDL (or “bad”) cholesterol and blood pressure.
“This is not a question of bad doctors or bad patients,” says Larry Anderson, M.D., Senior Director for Quality Improvement and Medical Affairs at the MMC PHO. “It is a question of a care model that is focused on illness instead of prevention, and systems that have been created that don’t accommodate a change in focus. We’re changing the focus, including offering financial incentives for physicians whose patients do better.”