Disease management (DM) has come a long way, especially when it comes to diabetes. It began with the American Diabetes Association (ADA) Standards of Care, which started with general practice recommendations and definitions about quality and expanded to develop specific clinical goals related to blood glucose, blood pressure, and lipid management. Next was the introduction of care measures established through a collaboration of quality-based organizations, and which eventually became known as the Comprehensive Diabetes Care measure used in HEDIS. Ongoing work with stakeholder organizations continues to refine approaches to diabetes care. For example, the National Diabetes Quality Improvement Alliance makes recommendations to the National Quality Forum regarding improvements in diabetes measures that are incorporated into many pay-for-performance quality programs.
Richard G. Stefanacci, DO
HEDIS data show that diabetes care is improving over time, but slowly. Twenty-one million Americans have the disease, but almost half of them do not keep their blood glucose under control. The National Committee for Quality Assurance suggests that gaps in diabetes prevention and care relate to poor reimbursement for managing chronic conditions. Also, many physicians simply do not have the time or skills to teach patients behavioral strategies. There’s also a lack of programs that address cultural differences and low health literacy of patients, not to mention a need for innovative tools and products to help patients overcome barriers to managing their diabetes.
Scott Guerin, PhD
Along with the evolution of the measures has come a revolution in treatments. Innovative treatments in the pipeline include a drug/device combination being developed by Intarcia Therapeutics for treatment of type 2 diabetes. This product is a matchstick-sized, miniature osmotic pump (ITCA 650), placed subdermally to provide continuous and consistent dispersion of the glucagon-like peptide-1 (GLP-1) receptor agonist, exenatide. Upon its approval, ITCA 650, which is currently in phase 3 clinical trials, will be the first injection-free GLP-1 therapy that will be active for up to a full year from the time of placement.
Technological advances are wonderful, but a population health approach should be encouraged as well, as illustrated in a study of 23,000 diabetic patients. Most of the quality and pay-for-performance programs centered on poorly controlled patients with HbA1c ≥9%. However, this analysis showed that the typically targeted high-risk population was highly dynamic, had sizable turnover and—importantly—was a relatively small subpopulation of patients.
Two other studies showed that increased interactions with a clinical pharmacist; regular primary care visits; and screenings for blood glucose, cholesterol levels, kidney function, and eye exams that include some incentives can significantly affect diabetes management in patient populations. In turn, this can lower health risks and reduce related health care costs.
If you haven’t guessed it by now, physics come in to play in this last example in the form of the observer effect. Physicists have demonstrated that a beam of electrons can be affected by the act of being measured, and as the “watching” increases, so does the influence of the act of observing. This phenomenon has also been documented in behavioral experiments such as in the Hawthorne effect, where researchers documented changes in subjects simply as a result of those subjects being studied.
As the management of diabetes care improves due to continuing efforts to refine quality measures, implementation of pay-for-performance programs, and the development of innovative products, additional advancements can be made by simply expanding the scope of the target populations, increasing discussions with diabetic patients, and implementing appropriate screening. Together, these are a leap forward for disease management into true population health.