Primary care model linked to improvements in diabetes care

A new diabetes care model could increase the percentage of patients who meet a composite quality indicator without requiring incremental resources, according to a study published in Annals of Family Medicine.

Joseph R. Herges, PharmD, of the Mayo Clinic’s pharmacy services, and colleagues wrote that “primary care practices manage most patients with diabetes and face considerable operational, regulatory, and reimbursement pressures to improve the quality of this care.” So, they developed the Enhanced Primary Care Diabetes (EPCD) model “to leverage the expertise of care team nurses and pharmacists to improve diabetes care.”

“We developed and implemented a comprehensive approach to diabetes management that is centered around care team nurses and activates, as needed, other members of the multidisciplinary care team,” they wrote. “This nurse-led ... model was designed to be implemented within existing team infrastructure without requiring incremental resources.”

The researchers noted that this model “is distinguished from previously published nurse-led primary care models for diabetes management” in two important ways: it is multidisciplinary and team-centered, “allowing all members of the primary care team to work cohesively and in real time to meet the patients’ needs,” and it is focused on “addressing all components of the D5 indicator, and not glycemic control alone as is the focus of many diabetes quality improvement programs.”

According to the Herges and colleagues, D5 is “a publicly reported composite quality measure of diabetes care” that tracks blood pressure control, low-density lipoprotein control, glycemic control, aspirin use and tobacco abstinence.

The researchers conducted a retrospective trial with an interrupted-time series design to evaluate the model’s effect on D5. The analysis included electronic health record data from 32 primary care practices — 13 Mayo Clinic Rochester practices and 19 Mayo Clinic Health System practices, all of which provide care for people who have diabetes. The researchers categorized the practices as:

• staff clinician practices with access to EPCD (5,761 patients);
• resident physician practices with access to EPCD (1,887 patients); or
• staff clinician practices without access to EPCD (10,079 patients).

Primarily looking for the percentage of patients meeting the D5 measure compared with a 7-month pre-implementation period and a 10-month post-implementation period, the researchers found that, after implementing EPCD, staff clinician practices significantly improved the percentage of patients who met the D5 composite quality indicator (change in incident rate ratio from 0.995 to 1.005).

“On the basis of the improvement in the composite D5 indicator attainment in the EPCD staff practices without increasing incremental resources, we hypothesize that care team nurses, with the trust of a primary care clinician, can effectively manage diabetes panels,” the researchers wrote.

Additionally, the D5 attainment trends did not significantly change among resident physician practices with access to EPCD. They worsened in staff clinician practices without EPCD access (change in incident rate ratio from 1.001 to 0.994; P = .05)

“At a time when patients cared for with the usual care approach saw a decline in their diabetes care quality, patients in the EPCD staff practices saw significant improvements and patients in the EPCD trainee practices were able to reverse their prior decline and remain stable,” Herges and colleagues wrote. “Importantly, the EPCD model promotes and facilitates comprehensive diabetes care beyond glycemic control alone.”

They concluded that implementing the EPCD model was linked to improvements in diabetes care quality, and that “further study of proactive, multidisciplinary chronic disease management led by care team nurses and integrating clinical pharmacists is warranted.”

“The EPCD model, which leverages the expertise of nurses, pharmacists, and other members of the multidisciplinary care team, and does not require new resources, provides a successful template that health care systems can build on to improve the quality of diabetes care they provide to patients.”