Better diabetic control works in research, practice

Close monitoring reduces complications

Almost four years ago, a large-scale diabetes study produced an unequivocal message: Intensive therapy of insulin-dependent diabetics reduces the occurrence and severity of serious complications of the disease.1 But could those results be duplicated in the real world of cost and time pressures?

Two quality improvement programs are, in fact, translating the clinical research success story into better diabetes care.

The Staged Diabetes Management program, developed by the International Diabetes Center of Minneapolis, produced a reduction of up to 2% in glycosylated hemoglobin (HbA1c) and a doubling in the frequency of dilated eye exams after one year on the program. The American Medical Group Association in Alexandria, VA, is launching a program that encourages practices to monitor and normalize glycohemoglobin, implement patient education and other interventions, and expand outcomes measurements.

"We can really make a difference in diabetes care," says Julie Sanderson-Austin, RN, vice president of quality management and research for AMGA. "We have narrowed this down to just what we think is very important in the management of diabetes."

Fewer complications, less costly

In the multisite Diabetes Control and Complications Trial, the reduction of blindness, end-stage renal disease, lower extremity amputation, and mortality promised long-term savings of both health care dollars and patient suffering. But it came at a labor-intensive price of about $14,000 per patient per year.

Staged Diabetes Management, which is a system of practice guidelines, road maps, and flowcharts as well as professional and patient education, costs about $3,000 per patient in labor and materials and provides better blood glucose control for both insulin-dependent and non-insulin-dependent diabetics and patients with gestational diabetes mellitus.2

Still, patients in Staged Diabetes Management will receive more office visits for the closer monitoring, with an average of four visits per year vs. three in traditional care, says Gregg Simonson, PhD, manager of research and development for the International Diabetes Center, which was one of the DCCT research sites.

"In the short term, staged diabetes management does cost more for care," he says. "Improving care and managing diabetes better will save money in the long term."

Those savings can be substantial. Indian Health Service sites in northern Minnesota recorded a 48% reduction in lower extremity amputation after using the Staged Diabetes Management program for three years, Simonson says. Early intervention and better monitoring of gestational diabetes leads to fewer cesareans and less neonatal intensive care, he says.

This is accomplished through "decision paths" that identify stages of therapy, such as meal planning, oral agents, and insulin doses. "The goal is to reduce variation in practice so everyone is managing diabetes in a unified way," says Simonson.

Still, Simonson stresses that the Staged Diabetes Management program is customized for each site. Implementation begins with an assessment of current care using chart audits and training of the staff, including primary care physicians, patient educators, nurse practitioners, physician assistants, dietitians, and pharmacy personnel.

"It’s a team approach," says Simonson. "The patient is an important part of that team, too."

More widespread use of the glycohemoglobin test in itself would improve screening and monitoring of diabetics, says Matthew Riddle, MD, professor of medicine and head of the diabetes section of the Oregon Health Sciences University in Portland.

The American Diabetes Association recommends that insulin-dependent diabetics receive the test every three to four months and non-insulin dependent diabetics receive the test every six months. Yet many diabetics do not receive the tests with that frequency.

Riddle worries that managed care, particularly capitated plans, actually provides disincentives for primary care physicians to closely monitor glycohemoglobin. "Primary care physicians are being strongly advised to do no superfluous tests," he says. "They’re being graded on how little money they spend."

Several organizations are trying to change the incentive toward greater accountability for outcomes. The American Diabetes Association and National Committee for Quality Assurance (NCQA) have teamed up to offer a Provider Recognition Program that publicizes physicians and groups that monitor diabetic care. (See related story, above.)

Some organizations, such as the California Cooperative HEDIS Reporting Initiative, a statewide collaboration of health plans, purchasers, and providers, has urged the NCQA to include the glycohemoglobin measure in its data set.

The American Medical Group Association made the glycohemoglobin test the centerpiece of its Diabetes Quality Improvement Consortium, a program for the association’s member practices that involves monitoring and improving care.

Practices that opt for Level One of the outcomes data collection will identify diabetics receiving care from the group and record the HbA1c at least once a year. Levels two, three, and four provide additional measures, including the Health Status Questionnaire and Diabetic Functioning Scale. (Copies of the diabetes-related patient questionnaire and physician forms have been inserted in this issue.)

Reports will allow groups to compare their measures to an aggregated benchmark as well as to individual groups. (Physicians and groups are coded, and identities remain confidential.) Physicians also can view graphs showing their own trends over time, which will enable them to monitor the effect of quality improvement interventions, says Sanderson-Austin. They can then share effective strategies with other physicians, she says.

Sanderson-Austin notes that while employers previously focused solely on cost and patient satisfaction, they are beginning to ask for information about outcomes. For diabetics, clinical outcomes directly influence both cost and satisfaction, as well, she notes.

"The time is right for providers to begin to put more emphasis on outcomes," she says.


1. The 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. Engl J Med 1993; 329:977-986.

2. Ginsberg BJ and Mazze R. Clinical consequences of the diabetes control and complications trial. N J Med 1994; 91:221-224.

For more information on the Staged Diabetes Management program, contact Renea Bradley, International Diabetes Center, 3800 Park Nicollet Blvd., Minneapolis, MN 55416-2699. Telephone: (612) 993-2721.

For more information about the Diabetes Quality Improvement Consortium, contact Julie Sanderson-Austin, vice president, quality management and research, American Medical Group Association, 1422 Duke Street, Alexandria, VA 22314-3430. Telephone: (703) 838-0033.