CURRENT ISSUES

--------------------------------------------------------------------------Diabetes mellitus programmes taste sweet success

-Amanda Cameron-

D iabetes mellitus was among the first diseases to be targeted for disease management programmes when they were first introduced. Now, there is experience aplenty with

programmes designed to prevent and treat this common, serious and costly condition. Presentations at the Second Annual Disease Management Congress [Washington, DC, US; September 1998] revealed considerable variety in the approaches taken by different diabetes programmes designed for specific populations in specific funding environments.

When a small l83-bed hospital north of Boston, US, discovered that its 350 OOO-resident catchment area contained an alarming 17 000 patients with undiagnosed diabetes, it decided that it had do something, and fast. And so the Winchester Hospital Community Health Institute 'Diabetes Casefinder Program' was developed.

Catching patients who slip through the net Eight months to 1 year after the programme was

established, the institute had reviewed a total of 5486 patient records and had identified 1506 patients who were at risk for diabetes and 344 who were known to have diabetes. 616 tests later, the programme had newly diagnosed diabetes in 42 patients and had detected 136 patients with diabetes who had inadequate blood glucose control.

Institute director Ms Kathleen Beyerman, who presented the results at the meeting, told how these patients showed some 'pretty good process outcomes' 6-8 months after receiving diabetic counselling. Among 170 patients, 72% had embarked on a successful exercise programme, 67% had successfully lost weight, 60% regularly monitored their blood glucose levels, and 59% took their medication as prescribed. Further­more, among 65 patients, 75% showed improved glycosylated haemoglobin levels (HbA,c).

'Train wreck' prevention Ms Beyerman described the casefinder programme

as a way to prevent patients who are the equivalent of 'train wrecks' from coming through the physician's door. By actively finding previously undiagnosed patients with diabetes, patients with uncontrolled diabetes, and those who are at risk for diabetes, the programme aims to provide early detection and inter­vention, help patients with diabetes maintain their blood glucose within the recommended range, and reduce the incidence of diabetes.

r~~ll t.."ris is achieved in a very simple ma.'lner. TJsing a system designed to cause minimal disruption to a particular general practice, the casefinder checks each medical record for diabetes risk factors and sends letters and laboratory slips to patients who need to be tested (those at moderate to high risk). Once the laboratory results have been returned, they are reviewed by the physician and a diabetes educator and a final report is produced detailing the diagnosed and undiagnosed patients.

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Physicians who participate in the programme provide community service and free visits in exchange for the benefits provided by the programme.

Early detection a 'win-win' process Ms Beyerman also described another of the institute's

programmes that aims to catch a wide range of potential health problems as early as possible through compliance with recommended screening guidelines.

Billed as being easily implemented in any physician practice and requiring' little time for great rewards', 'Putting Prevention into Practice' looks similar to the casefinder programme in that a medical record review is followed by a mailout of letters to patients, inviting them to book in for recommended tests and examina­tions. When the tests have been completed - an initial response rate of 9% was boosted up to 24% with the aid of a telephone reminder system - the results are entered into a customised database and a built-in 'tickler system' generates a letter reminding patients when it is time for their next visit.

According to Ms Beyerman, 'Putting Prevention into Practice' has thus far screened nearly 9800 patients. Of these, > 1700 have been recalled, and > 500 have been newly diagnosed with diabetes (n = 50), hyper­tension (133), hypercholesterolaemia (316) or skin cancer (16). The programme is supported by additional revenue of $US60 OOO/physician/year (gross) that is generated via extra physician procedures and visits.

As an added bonus, patients like the extra attention paid to them as a result of the programme, and physicians report high satisfaction with: the system's ability to bring patients in for physical examinations and/or screening; the usefulness of the screening tool; their ability to meet professional standards; and an improvement in their HEDIS* measurements. Moreover, the programme helps physician practices that are predominantly fee-for-service operations to prepare for the emerging capitated environment.

Joslin 'does it' for the elderly Elderly patients, who have otten had diabetes for up

to 30 years, present an especially difficult and costly problem to healthcare providers as they are starting to develop complications that can ultimately lead to blindness, kidney failure, amputation and death if left untreated. Thus, foot and eye care, as well as glycaernic control and cardiovascular risk reduction, are important components of care for elderly patients with diabetes.

* Health Plan Employer Data and lnfonnation Set

PharmacoEconomics & Outcomes News 31 Oct 1998 No. 186

3

4 CURRENT ISSUES

Diabetes mellitus programmes - continued

Providers are also faced with finding healthcare solutions for a group of patients who very often have limited mobility and vision.

Dr James Rosenzweig of the Joslin Diabetes Center, Boston, US, described several of the centre's program­mes that have been 'very helpful' in the management of Medicare patients with diabetes.

Keeping the elderly infonned ... The 'Diabetes Outpatient Intensive Treatment' or

'DO-IT' programme is a 3.5-day intensive educational programme that was initially devised to help improve glycaemic control among patients with type I (insulin­dependent) diabetes. Each patient who joins the programme - an increasing number of whom have type 2 (non-insulin-dependent) diabetes - undergoes an initial evaluation by an endocrinologist and receives an individualised care plan. In the days that follow, patients attend one-on-one and group classes about self-management and self-monitoring, and practice healthy eating and exercise habits under the guidance of a dietitian and an exercise physiologist.

According to Dr Rosenzweig, the first 175 patients who completed the programme showed significant and sustained improvements in glycaemic control. Notably, patients with starting HbA}c values of> 10% had average HbA}c reductions of 2.5% that lasted for up to 15 months. In addition, patients needed fewer emergency room (ER) visits and hospitalisations as a result of the programme, and experienced improved quality of life, less daily stress from diabetes, and greater productivity.

'We feel the programme is cost effective as well', commented Dr Rosenzweig. 'So wefeel that a one-time intervention can have long-term results and [that] patient management is the most successful approach.'

... and 'Fit and Healthy' Experience with the 'Fit and Healthy' lifestyle

modification programme developed at Joslin convinced Dr Rosenzweig that intensive diet and exercise management can 'significantly decrease cardiovascular risk factors and nearly normalize glycemic control in Type 2 diabetic patients without significant side effects'.

The 16-week programme, comprising weekly educational, nutritional and exercise sessions as well as a daily exercise regimen, significantly reduced patients' bodyweight (by 6.5-71b), body mass index, fasting glucose levels, HbA}c levels (by 0.6%), fasting insulin levels, triglyceride levels, total cholesterol levels, and diastolic BP (by 8mm Hg), as well as significantly increased their V02max levels.

Perceiving a large need for more supervision of diabetes education of patients in the home setting, the disease management team at Joslin also developed their 'Home Care' programme to assist visiting nurses in diabetes education and care. Eleven months after implementing 'Home Care' at the Joslin-affiliated McNeil Hospital in Chicago, the group found that

PhannacoEconomics & OutcOrmlS News 31 Oct 1998 No. 186

there was a 23% reduction in hospitalisations and a 7% decrease in ER visits due to a significant decline in acute diabetes complications. Better patient self-management also meant that 30% fewer skilled nursing visits were required, producing cost savings of $US712/patient or a total of $US 114000 over the II-month period.

The key to the success of the programme was the use of a diabetes nurse educator to teach home health­care nurses about diabetes medications, glucose monitoring and insulin injections. The educator also acted as a case manager and advisor to the nurses, and as an information resource for patients. Patients could also consult a diabetes resource manual.

Prirnary-care for capitated patients The Joslin disease management team has also

developed a 'Primary Care Initiative' for 858 patients with diabetes for whom a managed-care company has provided a capitated budget. Using Joslin internists as primary-care providers and a case manager, patients are triaged to different clinical-care pathways depending on their specific comorbidities and under­lying disease severity. This means that the impact of individual comorbidities on treatment costs can be assessed.

Dr Rosenzweig explained how the team developed a 4-level diabetes disease severity index for 6 different organ-based diabetes-related healthcare categories: glycaemic control; cardiovascular disease; peripheral vascular disease/peripheral neuropathy/foot problems; eye disease; kidney disease; and autonomic neuropathy. Within each of these categories, each of the 4 disease severity levels corresponds to a different intensity of care required [see boxed text] .

Joslin Disease Severity Index for the Glycaemic Control Category

• Levell (low risk): patients with an HbA1c of < 8% • Level 2 (moderate risk): an HbA1C of 8-9% or hypogiycaemic symptoms > 3 times per week or a history of diabetic ketoacidosis « 2 episodes in the past year) • Level 3 (moderate-high risk): an HbA1cOf ~10% or a history of frequent diabetic ketoacidosis (~ 2 timeslyear) • Level 4 (high risk): an HbA1c of> 10% or recurrent episodes of severe hypoglycaemia

Once a patient has been classified by healthcare category and disease severity, he/she is then triaged to a specific therapeutic pathway. For example, patients in the glycaemic control category who are in disease severity level 3 have an educational needs assessment conducted by the case manager, whereas those in level 4 are referred for inclusion in the 'DO-IT' programme.

Over the past year, the programme has saved money through a significant reduction in both inpatient and outpatient care costs, according to Dr Rosenzweig. However, pharmaceutical costs increased substantially.

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