Quality of care
Landmark studies completed during the 1990s proved that diabetes complications could be prevented by proper medical care. These findings led to the establishment of standards of medical care for individuals with diabetes. But the first report cardbased on surveys (Third U.S. National Health and Nutrition Examination Survey and the Behavioral Risk Factors Surveillance System) from 1988 and 1995"found there is a huge gap between the care people with diabetes are getting and the recommended care," said Jinan Saaddine, M.D., division of diabetes translation, National Center for Chronic Disease Control and Health Promotion, Centers for Disease Control & Prevention (see table below).
|Standard||% of patients who meet ADA standards|
|Yearly foot exam||54.8%|
|Yearly dilated eye exam||63.3|
|Blood pressure < 140/90||65.7|
|Test blood glucose daily**||38.0|
The study by Saaddine and colleagues found care varied consistently across groups by two factors, health insurance and use of insulin. Not having health insurance was associated with poorer status for several indicators. The use of insulin was associated with better preventive care, perhaps because insulin use is linked to diabetes severity, and providers are more likely to follow recommendations when managing patients with severe disease, according to experts.
Because of its timing (relative to studies documenting the need for "tight control"), results from the period evaluated by Saaddine and colleagues (Annals of Internal Medicine, April 16, 2002) are regarded as a benchmark by many diabetes experts.
But Saaddine noted that the studies showed "we have lots to do." Clinical trials have shown that better adherence to standards would reduce complications. Decreasing hemoglobin A1c (HbA1c) levels by one percentage point would reduce microvascular complications by 25% to 30%. Reducing blood pressure by 10 mm Hg would decrease macrovascular and microvascular complications and mortality rates by 25% to 55% and the risk of death by 43%.
Saaddine remarked that despite what we know about preventing complications, diabetes remains the leading cause of blindness, and of nontraumatic lower limb amputation. "That shouldn't be, because all the trials have proven we can prevent this from happening," she said. To close the gap between the standard of care and current medical practice, "we need to work hard on three very important levelsthe patient level, the provider level, and the healthcare system," she added.
Leonard Egede, M.D., Medical University of South Carolina, began studying the attitudes of healthcare providers about diabetes after observing that "there seemed to be a disconnect between the gravity of the diabetes problem and the response of a lot of residents to it."
A recent study, authored by Egede and Yvonne Mitchell, Ph.D., concluded that internists harbor negative attitudes about Type 2 diabetes. As assessed by the standardized test Diabetes Attitude Scale-3, participants in the study scored lower than the standardized mean on the need for special training in teaching, counseling, and behavior change techniques; on understanding the seriousness of Type 2 diabetes and the value attached to tight diabetes control; and on the value attached to patient autonomy regarding daily self-care of their diabetes.
Egede commented, "I don't think it's lack of interest; I think it is several problems." He explained that during training, diabetes is just one of multiple problems residents encounter, so many may not know the guidelines and what needs to be done. "The bigger problem is the time and resources required to deal with the problem in primary care," he said. His research has shown that residents and physicians perceive diabetes as very difficult to treat.
"It takes a lot of time, it takes a lot of resources, and many physicians don't think they have the time nor the resources to provide the quality of care that is required," said Egede. He also noted, "Of course, the third problem is the issue of reimbursement." The 15 to 30 minutes most physicians have available to provide patient care is inadequate to educate diabetes patients about self-management. "Physicians don't get reimbursed for the extra time they spend with patients, so there is really no incentive to devote that amount of time to patients. Only recently has the government begun to pay for diabetes education, and then only limited reimbursement," he said.
To better meet the standard of care, Egede and others advo-cate the team approach to dia- betes management. Joan Rider, Pharm.D., CDE, professor of pharmacy practice at Ferris State University in Big Rapids, Mich., believes a specialized practice setting such as hers is key to narrowing the gap. St. Mary's Center for Diabetes and Endocrinology in Grand Rapids, Mich., offers "one-stop shopping," making it more likely individuals with diabetes obtain quality care.
"Patients are either established patients with an endocrinologist or they're referred to an endocrinologist by our internists or family medicine practitioners," said Rider. The entire team, including physicians, CDE dietitians, physician assistants, and pharmacists, participate, she said. On some afternoons podiatrists rotate in. In addition, the clinic is working with Ferris' college of optometry to get some optometry students in with instructors to do eye exams.
But Egede pointed out, "If you look at the data that are coming out, at the very minimum, 70% of patients with diabetes are seen in primary care, primary care being general physicians in practice." So, it's going to be impossible to absorb all the patients into academic medical centers or the care of specialists. "I think reimbursement drives a lot of these issues. So, if there is this notion that people are getting reimbursed for diabetes care at a different rate, you begin to see more primary care physicians being interested," he said.
While physicians are waiting for reimbursement changes, they need to be efficient with the available resources, he continued, suggesting that they set aside certain times to see diabetes patients, recognizing that these patients take more time than most others. He also believes patient education is key. "I think the more educated patients are, the more empowered they are, either to comply with the recommendations physicians give or even demand what is reasonable care."
Pharmacists' roles in bettering medical care for individuals with diabetes will vary according to practice setting. At the clinic, Rider and her pharmacy students field questions about drug interactions, herbal products, and other OTC medicines. They work along with the nurses to ensure people are getting their every three-month HbA1c reading and that they are monitoring effectively at home. They troubleshoot by checking meters to determine they are accurate. Rider and her students also look at blood sugar levels.
"I think pharmacists should be expected to look at blood sugars and to know what to change in the regimen to try to make it work better," Rider said. "I don't think the general pharmacist or the general practitioner gets that type of background." But somebody who is a diabetes educator, she noted, is trained to sit down and look at blood sugars, and say, 'Yes, their morning dosage should be adjusted or this should be moved back,' or whatever. That's what I try to do when I have labs with individual students, to give them a bunch of blood sugars and say, 'OK, what do we do for this patient?' And I give them different scenarios."
Rider believes obtaining CDE credentials is beneficial to pharmacists because doing so develops and demonstrates expertise as well as assists in obtaining reimbursement for pharmacist services.
Francine Kaufman, M.D., president of the American Diabetes Association (ADA) and head of the endocrinology division at Children's Hospital in Los Angeles, thinks a lot of progress has been made in diabetes care since 1995. While she acknowledges that management of diabetes is getting more complicated, with a greater number of agents available and used, she stated, "I think the gap between the standard of care and what's actually going on out there is getting narrower."
Kaufman believes the gap has been narrowed as a result of tremendous efforts by associations like ADA and the other groups involved with diabetes care. The pharmaceutical industry has helped by educating physicians. In her opinion, there is more public awareness, perhaps driven in part by the patients themselves. She noted, "We've gotten a lot of play on the fact there's an epidemic of diabetes in the country, and, therefore, people and primary care providers are trying to keep up. But there are many forces still making it difficult. The economics of medicine at this point is probably the biggest one."
Saaddine and associates plan to continue to monitor the quality of diabetes care. She is presently working on the data from the Behavioral Risk Factors Surveillance System (2001-2002) but awaiting release of data from the Fourth United States Health and Nutrition Examination Survey. The publication date for the release of those data has not been determined.
Kathy Hitchens. Diabetes care: Closing the gap between standards and practice. Drug Topics 2002;24:26s.