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'Bundled' management reduced diabetes-related vascular complications
A team-based model with an all-or-none or “bundled” approach to primary care reduced the risk for myocardial infarction, stroke and retinopathy for patients with diabetes, according to research published in The American Journal of Managed Care.
Frederick J. Bloom Jr., MD, and colleagues from Geisinger Health System evaluated the nine-component bundle of diabetes measures, workflow redesign, electronic health record tools and financial incentives included in the Geisinger Health Plan over 3 years.
“Given that diabetes is more and more common and has a disproportionate impact on cost as well as morbidity and mortality, it is imperative that we find ways to reliably deliver better care,” Thomas Graf, MD, chief medical officer for population health at Geisinger and a researcher on the study, told Endocrine Today.
Through a parallel pre-post observational design, the researchers compared 4,095 primary care patients in the Diabetes System of Care (DS) group — developed by the integrated health services organization in 1996 — against 4,095 propensity score-matched primary care patients in the non-Diabetes System of Care (NDS) group.
The researchers calculated cumulative hazard rate for retinopathy, amputation, stroke and MI to determine whether the primary care diabetes bundled system would reduce the risk for microvascular and macrovascular complications more than usual care.
Patients in the DS cohort showed significantly lower adjusted hazard ratios for MI (HR=0.77; 95% CI, 0.65-0.9), stroke (HR=0.79; 95% CI, 0.65-0.97), and retinopathy (HR=0.81; 95% CI, 0.68-0.97).
No difference in adjusted HR was seen between groups for major amputations (HR=1.32; 95% CI, 0.45-3.85); however, only 17 major amputations occurred during follow-up.
The investigators determined that to prevent a single event during 3 years, it would be necessary to treat 82 for MI, 178 for stroke and 151 for retinopathy.
With multiple interventions required for the DS, however, the system-wide change did not come without challenge.
“Much of the work involved redesigning workflows, creating electronic accelerators to support just-in-time information targeted to the level of the staff person to allow everyone to work at the top of license and increase efficiency,” Graf said.
The researchers continue their work to determine the best combination of bundled measures, redesign and financial incentives, according to the study; further analysis on how the system of care affects overall mortality and total cost of care is planned.
Shifting to a bundled care system is feasible by any size practice, Graf said.
“Larger practices often have an easier time with creating the infrastructure to do this with near perfect reliability, but the speed of change with smaller practices is often greater, and so results can sometimes be seen quicker.” — by Allegra Tiver
Disclosure: The study was funded by Geisinger Health Plan. Two researchers report accepting fees from the Merck Speaker’s Bureau.
Perspective
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Diabetes affects a growing number of people with the current numbers estimated at nearly 29 million in the United States. Optimizing levels of glucose, blood pressure and cholesterol can reduce the risk of developing related complications. Adhering to the American Diabetes Association standards of care such as retinal screening, smoking cessation and obtaining influenza and pneumococcal vaccines can further prevent associated disease risks. Yet studies demonstrate that across the nation we fail to attain the recommended targets for most of these individual risk factors. As a matter of fact, in any one individual with diabetes it would be optimal to achieve target levels for all the measures combined.
Yet, studies such as NHANES reveal that in patients with diabetes, targets for a bundle of three measures (glucose, blood pressure and cholesterol) are achieved only 18% of the time. The clinicians in Geisinger’s integrated health delivery system use nine discrete evidence-based care elements, including HbA1c, low-density lipoprotein (LDL), and blood pressure testing and target levels; nonsmoking status; urine protein measurement; and influenza and pneumococcal vaccination to determine adherence to current diabetes standards of care. Geisinger tracks performance using an “all-or-none bundle approach,” where only full compliance with all individual performance metrics is scored a success. Processes and workflows have been established to optimize the achievement of the entire bundle.
This recent study in the American Journal of Managed Care reveals that using an “all or none bundle” together with the team based models of care results in reduced rates of myocardial infarction, stroke and retinopathy. This approach can be successful for lowering complication rates across a population of patients which is important as many health systems take on more full risk payment models. This approach can be successful for lowering complication rates across a population of patients, which is important as many health systems take on more full risk payment models. It is a good solution and shown in this study to be effective; perhaps more practices could look to implement this into their daily routines.