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Innovations in Managing Diabetes: UPMC/UPMC Health Plan Program Focused on Proactive Identification, Outreach, and Management of High-Risk Patients

May 17, 2024

Optimally managing diabetes can be complex and challenging for many patients with the disease. The complexity and challenges of successful diabetes management is also affected by the fact that primary care physicians (PCPs), rather than endocrinologists, handle the bulk of routine care and evaluation following a diabetes diagnosis.

There simply are not enough endocrine and diabetes specialists in the U.S. to handle the rapidly increasing percent of the population living with the disease, and as one would expect, this lack of providers can have downstream consequences for some patient populations.

From an insurance perspective, diabetes also represents a major challenge to the health care systems in the U.S. and around the world where the disease is on the increase. More than 30 million Americans are affected by some form of diabetes, and this number continues to rise. A striking 25% of total Medicare spending each year is allocated to diabetes care because many patients fail to reach the necessary clinical benchmarks for glucose control and other important health indicators, such as lipid and blood pressure levels, all of which are critical for achieving good long-term outcomes.

"Diabetes that is not well-controlled can lead to a rapid decline in a patient's health and long-term prognosis," says Esra Karslioglu French, MD, MBA, ECNU, clinical associate professor of Medicine and clinical chief at the UPMC Division of Endocrinology and Metabolism. "When serious comorbidities like heart disease, kidney disease, and retinopathy develop, they are usually irreversible and greatly impact a patient's health, lifespan, and quality of life. Additionally, they are very costly to treat. Therefore, our focus is not only on maintaining healthy glucose levels through various strategies but also on preventing these severe downstream effects that arise from poor diabetes control."

Dr. Karslioglu French advocates for immediate intervention if a newly diagnosed diabetes patient is not moving toward optimal control within six months or if an existing patient struggles with glucose management. This intervention could involve new medications, advanced tools like continuous glucose monitors and insulin pumps, or more intensive education and coaching. Unfortunately, many patients facing difficulties in managing their diabetes don’t follow this recommended path, or face challenges and barriers for which they need focused help for assistance.

A Multifaceted, Proactive Approach to Identifying and Treating Diabetes Patients at High Risk of Negative Health Outcomes

The UPMC Division of Endocrinology and Metabolism, in collaboration with UPMC Health Plan, has developed an innovative, multi-pronged program to proactively identify and address the needs and health care complexities of high-risk patients with diabetes.

Dr. Karslioglu French defines high-risk diabetes patients based on two criteria. The first is a HbA1c level over 8%. The second is the occurrence of unplanned diabetes-related health care events, such as hospital admissions or emergency department visits due to hypo- or hyperglycemia.

This program consists of two core components designed to improve the management of patients who are not optimally controlling their blood glucose levels or are at risk for serious adverse health events.

The first component employs what are called Targeted Automatic eConsults (TACos). The second component leverages the expertise of Certified Diabetes Care and Education Specialists (CDCES) to conduct proactive outreach and management primarily through virtual or phone-based visits with patients.

The development of these programs has been led by Dr. Karslioglu French and her collaborators at UPMC Health Plan, including Ellen Beckjord, PhD, MPH, vice president of Population Health and Clinical Transformation, and James Schuster, MD, MBA, chief medical officer of the Insurance Services Division.

The clinical implementation of these initiatives began in 2020 and 2021, respectively, and have achieved positive, measurable successes in the more than 2,000 patients actively followed every year by the programs and their clinicians.

Targeted Automatic eConsults (TACos): Prompting PCPs on the Need for Intervention

TACos represent a novel digital health intervention aimed at overcoming clinical inertia in primary care settings. Clinical inertia, the hesitation or delay in intensifying treatment when clinically necessary, is a significant barrier to optimal diabetes management. This intervention uses electronic health record (EHR) data to proactively identify patients at risk for poor diabetes outcomes and suggests unsolicited specialist recommendations to PCPs immediately before a patient’s scheduled visit.

The TACos intervention utilizes a machine learning predictive model developed by the UPMC Clinical Analytics Department to identify high-risk patients with current HbA1c levels greater than 8% and who are predicted to continue to have uncontrolled HbA1c within the next 12 months. Endocrinologists review the medical history of identified patients and provide specific recommendations electronically to the PCPs. This approach facilitates timely treatment adjustments and supports evidence-based decision-making in primary care.

In a 2023 study published by Dr. French Karslioglu and colleagues, the TACos intervention was shown to be effective in improving diabetes management. The study included 196 individuals receiving TACos matched with 392 control participants. Recommendations from TACos were enacted 65% of the time, leading to a significant median percent change in HbA1c levels (-10.9%) in the intervention group compared to controls (-10.2%). Additionally, the intervention group saw lower median total costs by 7.9%.

Certified Diabetes Care and Education Specialists (CDCES) Intervention

The second component of the program involves CDCES conducting direct, proactive outreach and management of patients fitting a high-risk profile. This intervention focuses on virtual and phone-based visits, enabling more frequent interaction between patients and CDCES, essentially at whatever level of frequency or intensity the patient needs or wants. The CDCES work under the supervision of an endocrinologist and assist patients in managing their diabetes, making necessary treatment changes, and providing education on lifestyle modifications or other needs. The CDCES and the patients work together frequently until the patients' blood sugars are under good control. This differs from traditional in-person visits where there may be restrictions on the number of times a provider can see a patient. Additionally, the CDCES are able to review patients' glucose data remotely and make adjustments to their treatment regimen through remote patient monitoring programs.

“This proactive approach allows for more frequent monitoring and adjustment of diabetes management plans compared to traditional in-person visits,” says Dr. French Karslioglu. “Our team of CDCES help patients achieve better blood sugar control by evaluating and adjusting medication regimens, assisting with the use of continuous glucose monitors, and providing guidance on diet and exercise.”

As Dr. French Karslioglu explains, the CDCES intervention program has shown significant success in improving patient outcomes. Approximately 2,000 high-risk patients are managed annually through this intervention.

“We have documented our results in decreased HbA1c levels, reduced total medical costs, and prevention of hospital readmissions,” says Dr. French Karslioglu. “These outcomes highlight the effectiveness of frequent, personalized care and the utilization of technology in diabetes management.”

Dr. French Karslioglu and colleagues are continuing to gather data on the effectiveness of the CDCES’ intervention and will be publishing their results in the future.

Successes and Future Directions

The combined efforts of the TACos and CDCES interventions have led to notable improvements in diabetes care at UPMC. Both components of the program have demonstrated success in decreasing HbA1c levels and reducing health care costs for high-risk patients. These interventions have also facilitated timely treatment adjustments and supported primary care providers in managing complex diabetes cases.

Future plans for the program include expanding the use of clinical analytics to identify other vulnerable populations who could benefit from similar interventions. This expansion aims to address the growing burden of diabetes and ensure that high-risk patients receive the necessary care to prevent adverse health outcomes.

Dr. French Karslioglu and her team are also exploring the potential for integrating additional digital health tools and resources to further enhance patient engagement and self-management. The goal is to create a comprehensive, scalable model of diabetes care that leverages technology and personalized interventions to improve outcomes for patients across diverse health care settings.

“As the program continues to evolve, we see much promise for expanding its impact to other high-risk populations and setting a new standard for diabetes care. At UPMC, we have the advantage of being an IDFS (integrated healthcare delivery system). Insurance and health services divisions’ collaborations, like the high-risk diabetes program, enable us to create efficient and effective care models for chronic disease management,” says Dr. French Karslioglu.

Further Reading and References