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Authors: Margaret Zupa, MD, clinical fellow, Division of Endocrinology and Metabolism, and Linda Siminerio, RN, CDE, PhD, professor of medicine, Division of Endocrinology and Metabolism, executive director, University of Pittsburgh Diabetes Institute
Models that address the needs of patients with diabetes mellitus (DM) in primary care (PC) are being explored as health systems move to value-based care. A paradigm change is underway that focuses on patient-centered, team-care that aims for high-value, high-quality health care delivery at the PC level. While the number of patients with DM in the United States continues to rise, with 1.5 million new cases diagnosed per year,1 there is an inverse number of providers to deliver comprehensive, quality care.
While serving as the front line of care for patients with DM, PC requires additional assistance to optimize quality and value in the care of these patients. Studies have shown that primary care physicians (PCPs) consider DM more difficult to treat than other chronic diseases, as more monitoring and medication adjustment is required to achieve treatment goals.2,3 Meanwhile, physicians also report that they feel ill-equipped to counsel patients regarding behavior change.4,5 In a survey of physicians and nurses regarding DM care responsibilities, nurses reported that they felt capable and ready to assume these responsibilities. They were reported to have more time to spend with patients, were better listeners, knew patients better, and provided better education than physicians.6 Although specialty endocrinology clinics traditionally have been a referral resource for comprehensive team care, the current national shortage of endocrinologists often limits access to this service. Endocrinologists will need to serve as a critical resource for their DM expertise while PC will continue to be the mainstay of care for patients with increasingly complex DM needs.
Insurers, who ultimately are responsible for services and costs, are keenly aware of the current PC challenges and limitations. For payers, suboptimal DM care translates into higher expenditures. UPMC is an integrated health system that includes more than 40 academic, community, and specialty hospitals and 600 outpatient sites serving diverse populations throughout western Pennsylvania and beyond. The reach and impact of UPMC are extended through its Insurances Services Division (ISD) and UPMC Health Plan, which partners with UPMC and additional community network providers to provide high-quality care. For these reasons, UPMC provides an ideal “community laboratory” to examine methods that promote access and best practice to the patients it serves.
Diabetes education is recognized as an essential component of DM care. It has been shown to reduce health care costs, increase adherence, and improve glycemia among patients with DM.7 It is not always feasible, however, for the individual PC practice to employ a diabetes educator (DE) to provide this service. To address health care gaps and improve DM outcomes in remote community practices, the UPMC Health Plan partnered with members of the Division of Endocrinology and Metabolism to implement and evaluate a DE-driven high-risk initiative. DEs were employed by the UPMC Health Plan under the direction of the Division of Endocrinology and Metabolism and took an active role in supporting PCPs to meet the complex demands of diabetes management.
DEs worked with care managers within PC practices to identify and target DM patients at high risk, specifically those with HbA1c > 9 percent, DM-related ER visits and hospitalizations, and self-reported barriers to care. A practice-based visit included an individualized assessment and self-management education with treatment recommendations shared with the PCP. Patients referred for the DE intervention during the first year of the program had a mean reduction in HbA1c from 9.6 to 8.4 over six months (108 patients, p < 0.001) and 9.2 to 8.1 percent over 12 months (80 patients, p < 0.001). While the decrease in HbA1c seen at six months was encouraging, the persistent improvement in glycemic control at 12 months indicated that this change was durable. The sustainability likely is due to both the DE intervention and the implementation of a process in which the PC team also gained skills in providing ongoing support. In addition, the program has influenced PCP’s ability to meet quality measures and has been well received. The demonstrated success of the intervention has prompted continued support of the program.
Furthermore, this project has spurred continued interest in models of care delivery for patients with DM for Margaret Zupa, MD, a first-year endocrine fellow. Motivated by the success of this program and the desire to find additional ways to improve the care of patients with diabetes at a system level, Dr. Zupa plans to pursue the T32 research fellowship track with a focus on health systems research. Working in collaboration with a mentor in the UPMC Department of General Internal Medicine, Anne-Marie Rosland, MD, Dr. Zupa will examine the impact of a patient activation and family supporter engagement intervention in the PC setting on medication adherence and health care utilization patterns among patients with DM. Linda Siminerio, RN, CDE, PhD, and the Diabetes Medical Home team also are collaborating in designing a DE-driven patient-centered model. This interdepartmental collaboration will contribute to the Division’s ability to develop and evaluate novel models of care for patients with DM, and advance the quality and value goals of the Division in collaboration with partners at the UPMC Health Plan and in primary care.
1 Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta.
2 Anderson RM, Fitzgerald JT, Gorenflo DW, Oh MS. A Comparison of the Diabetes-related Attitudes of Health Care Professionals and Patients. Patient Educ Couns. 1993 Jun; 21(1–2): 41–50.
3 Zgibor JC, Songer TJ. External Barriers to Diabetes Care: Addressing Personal and Health Systems Issues. Diabetes Spectrum. 2001 Jan 1; 14(1): 23–8.
4 Orlandi MA. Promoting Health and Preventing Disease in Health Care Settings: An Analysis of Barriers. Prev Med. 1987 Jan; 16(1): 119–30.
5 Beaven DW, Scott RS. The Organisation of Diabetes Care. In: Alberti KGM, Krall LP, Editors. The Diabetes Annual: 2. New York: Elsevier; 1986. p. 39–48.
6 Siminerio LM, Funnell MM, Peyrot M, Rubin RR. US Nurses’ Perceptions of Their Role in Diabetes Care: Results of the Cross-National Diabetes Attitudes Wishes and Needs (DAWN) Study. Diabetes Educ. 2007 Feb; 33(1): 152–62.
7 Duncan I, Ahmed T, Li QE, Stetson B, Ruggiero L, Burton K, et al. Assessing the Value of the Diabetes Educator. Diabetes Educ. 2011 Oct; 37(5): 638–57.