Optimizing adult diabetes care in community health

Elizabeth Nelson, CNP, Rohit Bobade, MS, Vicki Hunt, MD, & Manpreet S. Mundi, MD

Journal of the American Association of Nurse Practitioners


Abstract

Background and purpose: Diabetes mellitus is an epidemic. Many organizations and states have established reportable quality care measures. Our organization explored novel ways of chronic disease management. The purpose of this article is to decrease the percentage of patients with a hemoglobin A1c (HbA1c) more than 8%.

Methods: Prospective, pre- and postintervention, quality improvement project was implemented in the Employee and Community Health Clinic using an endocrinology nurse practitioner (NP) to coordinate and provide care to adult patients with diabetes. A convenience sample of 103 patients with diabetes was selected for this project. Patients were excluded from the project if they did not complete preintervention satisfaction surveys or did not sign research release forms.

Conclusions: One hundred three patients were referred, and two met exclusion criteria. Of those patients, 51% were female with an average HbA1c of 9.1%. Eighty-one of the referred patients attended their appointment. The patients who sought care had a reduction in HbA1c from 9.0% ± 1.8% to 8.3% ± 1.7% (p value < .001). Patients who did not appear had no significant change in their HbA1c from 9.8% ± 3.1% to 9.4% ± 2.7% (pvalue = .61).

Implications for practice: Incorporating specialty trained NPs can lead to improvements in HbA1c, patient-reported control of diabetes, and a reduction in the frequency of hypoglycemia.


Introduction

Diabetes mellitus (DM), specifically type 2 DM (DM2), is an epidemic with 422 million adults diagnosed with diabetes throughout the world (World Health Organization [WHO], 2016). In the United States alone, 30.3 million people have diabetes, and in 2015, diabetes was the seventh leading cause of death (Centers for Disease Control and Prevention [CDC], 2017). Of those with diabetes, only 14.4% are able to manage their disease without antidiabetic medications (CDC, 2017). Additionally, DM2 is a chronic progressive disease that is often associated with depression and other comorbidities, such as obesity, hypertension, and hyperlipidemia (Goff et al., 2007), and it contributes to the development of complications, such as renal disease, eye disease, and cardiovascular disease (CVD) (Action to Control Cardiovascular Risk in Diabetes Study Group, 2008). Patients with DM2 die from CVD at rates 2–4 times higher than those without diabetes (Stamler, Vaccaro, Neaton, & Wentworth, 1993). Worldwide, it is estimated that 3.4 million people per year die from consequences of hyperglycemia (WHO, 2016).

The disease burden of diabetes alone is not the only reason there is growing concern in the medical community on how to appropriately manage this disease. The estimated total costs related to diabetes was $245 billion in the United States in 2012, indicating that patients with a diagnosis of diabetes carry average medical expenditures 2.3 times higher than those without (CDC, 2017). There are also concerns over the aging population. Between 2005 and 2020, the population younger than 65 years is expected to grow by approximately 9%, whereas the population aged 65 years and older is projected to grow by approximately 50% (Association of American Medical Colleges [AAMC], 2008). Older patients often diagnosed with multiple chronic diseases use greater levels of physician services, therefore placing a greater demand on already strained health care resources (AAMC, 2008). This, coupled with the projected shortage of primary care physicians and endocrinologists, places the quality of care provided at risk (AAMC, 2008 Stewart, 2008). In fact, recent review of medical records and telephone interviews revealed that most patients had received 56.1% of recommended care for chronic conditions, whereas those with diabetes had only received 45.4% of recommended care (McGlynn et al., 2003).

To ensure quality and improve the care received by patients with DM2, many organizations and states, including the state of Minnesota, have established reported quality care measures (MN Community Measurement, 2017). These often focus on established key measures for patients with diabetes, such as glycemic control (based on hemoglobin A1c [HbA1c]), blood pressure control, lipid control (based on low-density lipoprotein [LDL]), tobacco use, and aspirin usage (MN Community Measurement, 2017). Additional incentive is provided by publicly reporting these care measures, allowing one medical center to be compared with others locally as well as statewide.

Faced with similar challenges in the management of DM, our organization began to explore novel ways of chronic disease management. This process began with the review of current gaps in quality and meetings with key stakeholders in areas of primary care and endocrinology for the assessment of areas for improvement. It was identified that there were approximately 8,380 patients in Employee and Community Health (ECH) with a diagnosis of diabetes. Of these, 1,546 patients had an HbA1c greater than 8% and would not meet the Minnesota Community Measures (MCM). Additionally, the current treatment process relied heavily on utilization of specialty care for the management of diabetes, whether it was indicated or not, leading to a backlog of patients. In the 15 months prior to the initiation of the current care model, approximately 37% of patients with diabetes seen in the Division of Endocrinology had an HbA1c of less than 8%. Key stakeholders in primary care identified that patients referred to the Division of Endocrinology often remained in the care of endocrinologist for extended periods of time. Endocrinologist, on the other hand, noted that they were often not comfortable sending patients back to primary care until they were more stable in their DM management. In an effort to provide cost-effective and optimum care for ECH patients, with a focus on developing a care-team model, the ECH endocrine diabetes care model was developed.

Methods

Setting

The ECH diabetes clinic (EDC) was instituted at Mayo Clinic, Rochester, MN. It was started in the department of ECH, which treats more than 140,000 patients. Employee and Community Health includes the departments of family medicine and primary care internal medicine (PCIM). Of the patients, 8,380 have been identified with a diagnosis of diabetes, and of those, 1,546 have an HbA1c greater than 8%.

Design and implementation

A prospective, pre- and postintervention, quality improvement project was implemented in the EDC using an endocrinology nurse practitioner (ENP) to coordinate and provide care to adult patients with uncontrolled DM. This nurse practitioner (NP) worked in conjunction with a diabetic educator. The study design was conducted using quality improvement methodology of DMAIC (define, measure, analyze, improve, and control). The model/clinic design was the result of multiple meetings with key stakeholders within the departments of endocrinology, family medicine, and PCIM. The study used several formal quality tools, including a stakeholder analysis, critical to quality discussion, and process mapping. Implementation of the clinic took place between August 2011 and March 2012.

Sample

A convenience sample of 103 patients with DM was selected for this project. Inclusion criteria were patients who were seen in the EDC from August 2011 to March 2012, diagnosed with diabetes according to the International Classification of Diseases, Ninth Revision codes, and participated in preintervention satisfaction surveys. Patients were excluded from the project if they did not complete preintervention satisfaction surveys or did not sign a research release. There were two patients who met exclusion criteria.

Intervention

Patients who were included in the EDC were those referred to the clinic by their primary care providers (PCPs). The PCPs approached patients who were eligible for the intervention during a usual office visit or over the phone. Patients who agreed to participate in the study were accepted by verbal informed consent obtained at the first office visit by the ENP. Patients who declined participation were still seen by the ENP for diabetic care, but no information was collected or used for research purposes. The ENP conducted initial office visits with patients, which included review of the electronic medical records, preintervention patient satisfaction surveys, and discussion of treatment plan. Once the treatment plan was determined, patients were seen by the diabetic educator to receive further education on the new treatment plan. Depending on the treatment plans, some patients were followed over the phone by the diabetic educator for review of treatment and adjustments. Communications of patient treatment plans were sent via electronic messaging to PCPs following every appointment with the ENP. Patients were not billed for specialist services.

Follow-up care was provided by the ENP every 4–8 weeks, depending on the treatment plans, through office visits. Follow-up appointments were used to review laboratory results and initiate, change, or adjust medications. Education was provided at follow-up visits, if needed, based on treatment plan changes. Patients were then mailed follow-up postintervention satisfaction surveys 6 months after their first visit.

Measures

Sources of data included the electronic medical record, population health software, manual chart review (for clinical information), billing data, Office of Access Management for appointment information, and patient satisfaction surveys. Data gathered was categorized as follows: clinical measures, appointment data, utilization data, and flow data.

Clinical data included the following: patient demographics, HbA1c at baseline (within 3 months prior to first visit) and postintervention (approximately 6 months following intervention), percent of patients meeting goal of HbA1c < 8%, change in HbA1c pre- versus postintervention, diabetic therapy, and frequency of hypoglycemia. Appointment data included the following: total number of visits to the Division of Endocrinology with diagnosis code of diabetes and number of patients referred to diabetic educators. Utilization data included the following: “no-show” rates for patients with diabetes in the department of endocrinology, no-show data for the EDC, and fill rates for the ENP clinic. Flow data included the number of patients referred to the Department of Endocrinology from ECH, the number of patients from Endocrinology referred back to ECH, and the number of ECH-empaneled patients who were seen in the Department of Endocrinology without direct referral from the ENP or PCPs. For the patients who did not appear for their initial visit, laboratory results (including HbA1c and lipid panel) were gathered with their next laboratory draw by their PCP. We used JMP Pro 10.0 for statistical analysis of data. Differences in proportions were determined by Student t-test.

Ethical considerations

Formal ethics approval was not required for this program evaluation.

Results

After initial meetings with key stakeholders, an NP-led diabetes clinic was established with data collection for the pilot study taking place between August 2011 and March 2012. During that time, 103 patients were referred, and 2 met exclusion criteria. Patients with an average age of 64 ± 13.7 years were referred (Table 1). Of those patients, 51% were female and had an average HbA1c of 9.1% ± 2.1%. Eighty-one of the referred patients appeared for their visit and obtained their diabetes-related care through this newly established clinic. Twenty patients did not appear despite multiple contacts. Of note, these individuals tended to be younger at baseline (Table 1). These same 20 patients had a history of not showing for visits; during the 4 years prior to the project, they were responsible for 869 no-show visits, defined as not appearing for a scheduled visit and making no attempt to reschedule and/or cancel the visit.

 

The patients who sought care in the EDC had a significant reduction in HbA1c from 9.0% ± 1.9% to 8.3% ± 1.7% (p value < .001), with an average of 1.9 visits per patient (Table 2). The patients who did not appear had no significant change in their HbA1c from 9.8% ± 3.1% to 9.4% ± 2.7% (p value = .61) (Table 2). There was no statistical difference in lipids pre- and postintervention, but this was not targeted for this study (Table 2). The number of patients meeting the MCM for HbA1c of 8% or less increased from 26% to 49.3%. There was statistical significance in the age of no-show patients (p value = .004), noting that the no-show patients tended to be younger (56 ± 13.1 years) (Table 1).

 

There was also a positive impact in terms of new patient access for the Division of Endocrinology. In the 15 months prior to the intervention, 370 patients were seen in Endocrinology from ECH with a HbA1c of less than 8.0%, whereas 627 patients were seen with a HbA1c of ≥8%. In the 15 months after the intervention, these numbers were reduced to 268 and 506, respectively. It was estimated that the creation of this care model had increased subspecialty access by approximately 200 appointments per year.

Patients responded positively to the clinic with 58% feeling that their diabetes was controlled, a significant improvement from the prepilot mark of 29% (Figure 1). The percent of patients reporting daily, weekly, and monthly hypoglycemia improved from 4% to 0%, 26% to 19%, and 26% to 10%, respectively (Figure 2). Patients also overwhelmingly preferred the location of the clinic to be embedded within the same area as their primary care location (78%), as opposed to closer proximity to a subspecialist (11%) (Figure 3).

 

Discussion

The prevalence of diabetes continues to increase, leading to the growing increase in health expenditures with standard waits to be seen by a subspecialist up to 3–9 months and many practices being closed to new patients (CDC, 2017 Stewart, 2008). This is prompting many institutions to evaluate the use of alternative models for care of patients with diabetes in an effort to improve quality of care provided, reduce costs, and improve patient outcomes. Our institution faced similar issues leading to the development of the EDC using an ENP to coordinate and provide care to adult patients with uncontrolled diabetes. This NP worked in conjunction with a diabetic educator to provide care for patients.

Our results indicate that patients who sought care in the EDC had a significant reduction in HbA1c, decrease in reported hypoglycemia, and an increase in patient-reported diabetescontrol. The EDC also increased subspecialty appointment availability by approximately 200 appointments per year. The percent of patients meeting MCM goals for a HbA1c of 8% or less also increased from 26% to 49.3%.

There have been numerous studies in primary care that have looked at the differences between physician provided care and NP care that found no differences in health outcomes for patients, suggesting that NPs provide high-quality care and achieve good outcomes (Wale, Belizán, Nadel, Jeffrey, & Vij, 2013). With an increasing number of patients with chronic illnesses, health care systems are challenged to provide care, and NPs can play a key role in helping meet those challenges (Watts et al., 2009). Some studies have looked at incorporating NPs and physician assistants along with physicians to manage patients with diabetes (Jackson, Lee, Edelman, Weinberger, & Yano, 2011 Jessee & Rutledge, 2012 Richardson, Derouin, Vorderstrasse, Hipkens, & Thompson, 2014). One of these studies reported that staffing NPs in primary care programs was associated with better control of diabetes based on modeled associations between staffing of midlevel providers and last HbA1c taken from 88,682 patients; of those patients, they had a HbA1c reduction of 0.31% (Jackson et al., 2011). Another study of 28 patients noted that using an NP to provide care for patients with type 2 diabetes led to improvements in HbA1c with 50% of patients meeting goal (8% or less), 95.6% meeting blood pressure goal (<140/90 mm Hg), and 57.8% meeting LDL goal (<100 mg/dl) (Richardson et al., 2014). There was also another study that assessed the effectiveness of NPs care of type 2 diabetes in group visits for 26 patients, noting that of the 11 patients in the NP groups, HbA1c levels decreased on average of 2% (Jessee & Rutledge, 2012). Additionally, there was a study that included 149 pregnant patients with diabetes managed by NPs, which resulted in a 24% decrease in adverse neonatal outcomes (Murfet, Allen, & Hingston, 2014). These studies not only used NPs but also looked at creative process models. Some used group visits, electronic visits, and telephone calls. In all of these studies, they noted improved outcomes in their patients with diabetes (Jackson et al., 2011 Jessee & Rutledge, 2012 Richardson et al., 2014).

We also used a diabetic nurse educator in our intervention. Seventy percent of our patients in the EDC were referred to our diabetic nurse educator. The educator provided initial education and followed up with these patients between appointments with the ENP. We did not account for these patient's separately in our analysis. There have been other studies that looked into using diabetic nurse educators in care process models. One open, controlled trial performed in Australia used a nurse educator in a diabetes clinic and found that of the 185 patients enrolled with the intervention model, there was a 0.8% reduction in HbA1c at 12 months versus 0.2% of usual care patients (Russell et al., 2013). A Cochrane Database review of 6 trials with 1,382 participants (patients with type 1 and type 2 diabetes) looked at usual care versus care provided by a nurse educator, pediatric NP, automated education calls, outpatient nurses, or nurse care coordinators (Loveman, Royle, & Waugh, 2003); it noted that despite improvement in glycemic control in many of the intervention groups in the studies, there was no significant difference in control groups over a 12-month period, leading to the conclusion that the presence of a diabetesspecialist nurse may improve diabetic control over a short time, but it is not evident over a longer period based on current trials (Loveman et al., 2003).

The difference between our study versus previous studies is a larger sample size than some previous studies that also provided an intervention. We also specifically used an NP who worked in endocrinology along with a diabetic educator nurse. Previous studies used NPs with no noted training in endocrinology, and in many of the studies, there was no mention of also using a diabetic nurse educator (Jackson et al., 2011 Jessee & Rutledge, 2012 Richardson et al., 2014). We also examined the impact the EDC had on increasing appointment availability in the Division of Endocrinology. This is important given increased need for subspecialist appointments with the projected shortage of endocrinologists. There have also been a few diabetic managementmodels that have incorporated costs (Schofield, Cunich, & Naccarella, 2014). Patients who were seen in the EDC were not charged for specialty visits but were provided with specialist care. The patient was billed as if they had seen their own PCP. This could be one way to cut down the burden of diabetic costs for patients, which is estimated at expenditures of approximately $13,700 per year, with nearly $7,900 attributed to diabetes (American Diabetes Association [ADA], 2013). Using different care process models has the potential to decrease the cost of care while still improving patient outcomes.

Despite the positive results, there were limitations to the study. Although it was a prospective design, patients were not randomized to EDC or standard care. We were also not able to control patients who presented to the EDC versus those who did not. Patients who did not appear tended to no-show for other appointments as well, creating an inherent difference between the two groups and possibly explaining the significant findings. In the present study, the interventions were also targeted specifically to glycemic control and did not include hypertension or hyperlipidemia. Clearly, a prospective, randomized, control trial is necessary to further delineate the impact of endocrinology-trained or diabetes-trained NPs. Ideally, these studies would be long-term trials to assess outcomes past 12 months. We also would recommend more research that includes diabetic nurse educators and specific measures to see if care provided improves outcomes.

Conclusions

Increasing rates of diabetes have placed significant strain on the health care system. Our institution, faced with similar strains, developed an endocrinology-trained NP-led clinic that was embedded within primary care. For patients seeking care, the clinic was successful in improving diabetes control. Additional trials are necessary to further delineate which components of this clinic led to the positive outcomes noted.


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