August 2006 - With diabetes disease-management programs becoming more commonly used among physician groups, the question arises: Just how effective are they at improving patient care? The answer, according to UCLA researchers, is that they lead to better examination and testing--but not to better control of key factors associated with diabetes complications, such as blood pressure, cholesterol or blood sugar levels.
A new study, to be published in the July 18 issue of Annals of Internal Medicine, finds that health care providers' use of management programs resulted in higher rates among their patients of recommended examinations, such as eye and foot exams, testing for kidney function or damage due to the disease, cholesterol checks, and getting influenza vaccinations.
These management strategies, however, had no impact on good medication management and were not linked to improved sugar, blood pressure or cholesterol levels.
The three disease-management strategies include physician reminders (reminders that health plans or physician groups can send to their clinicians, including preprinted guidelines, flow sheets, and flags or customized alerts for medical records); regular feedback from physician groups to their doctors on the care they provide; and structured care management, which is when patients also see case managers, attend diabetes education classes and/or receive reminders about the care they need, such as eye examinations or flu shots, between doctor visits.
"The good news is that physician groups that are investing in care-management strategies are doing a better job of delivering eye care, screening for kidney problems and high cholesterol, and providing regular foot exams to more of their patients with diabetes," said Dr. Carol Mangione, professor of medicine in the department of medicine at the David Geffen School of Medicine at UCLA and in the department of health services at the UCLA School of Public Health. "These results also suggest that it is much more challenging to achieve better control of the factors that are most strongly associated with the long-term complications of diabetes that patients care about, such as heart attacks and strokes. To prevent these serious complications, disease management programs may need to directly monitor the levels of blood pressure, cholesterol and glucose, and the treatments used to control them."
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The researchers studied 8,661 patients from 63 physician groups in several health plans, seven of them sponsored by Translating Research Into Action for Diabetes (TRIAD), a multi-center study of diabetes care within managed care systems, and four plans with individual physician contracts. The patients were recruited between July 2000 and October 2001.
The study shows that use of any of the three disease-management strategies resulted in higher rates of retinal screening, kidney checks, foot examinations and hemoglobin measurements. These are important because diabetes can lead to blindness, kidney failure and loss of limbs when not properly controlled.
Additionally, the researchers found that greater use of structured care management and performance feedback were linked with serum lipid level testing and influenza vaccine administration. They also found a correlation between the use of performance feedback and increased rates of foot examinations, and between physician reminders and increased rates for microalbuminuria checks, which test for small but abnormal amounts of the protein albumin in the urine.
Over the past 10 years, disease-management programs have focused on improving processes of care rather than outcomes. The study's findings suggest that to achieve better control of blood pressure, cholesterol and sugar--and ultimately reduce the risk of complications such as heart attacks and strokes--these programs will need to actively engage the participation of doctors and patients and will need to measure and report on the levels of these outcomes on a regular basis.
UCLA researchers in addition to Mangione are Dr. W. Neil Steers and Dr. Arleen F. Brown. Other researchers include Robert B. Gerzoff, David F. Williamson, Eve A. Kerr, Beth E. Waitzfelder, David G. Marrero, R. Adams Dudley, Catherine Kim, William Herman, Theodore J. Thompson, Monika M. Safford and Joe V. Selby. The Centers for Disease Control and the National Institute of Diabetes and Digestive and Kidney Diseases funded the study.
Source: University of California, Los Angeles
