Vol. 16 •Issue 11
• Page 47
Pressed For Time
Treating Type 2 Diabetes in the Real World
by Dawn Bucher, NP
Do you work in a small primary care office or a clinic that has frequent staff turnover? Are you struggling to improve functional and clinical outcomes in your patients with diabetes because there just don't seem to be enough hours in the day? If so, this article may help. I have developed outcome monitoring tools based on established practice guidelines. Although I work in a rural health clinic, these tools can be modified for any setting that treats patients with diabetes.
Clinical Background
Diabetes mellitus is the sixth leading cause of death in the United States and affects nearly 21 million U.S. residents.1,2Rising obesity, sedentary lifestyles and an expanding older adult population are the root contributors to a rapid increase in diabetes cases over the past 5 years.3-5
Diabetes is a chronic condition that is challenging to manage and costly to treat. The highest costs are largely the result of debilitating complications related to macrovascular and microvascular conditions such as coronary artery disease, stroke, end-stage renal disease, nephropathy, retinopathy, neuropathy and foot ulcers.6,7In the United States, diabetes costs more than $130 billion per year — an amount representing nearly 14% of health care expenditures.7
Tight glycemic control and lifestyle improvement can reduce the complications of diabetes.8Control of blood sugar levels, lipid levels and blood pressure reduces heart attack and stroke risk.9,10These strategies also reduce retinopathy, neuropathy and nephropathy.2Reducing lipid levels in patients with diabetes can reduce cardiovascular complications.2 And annual comprehensive foot exams and good foot care can reduce lower extremity amputations.2
In addition to direct complications of diabetes, patients face other types of health risks as a result of this disorder. One of these is a higher-than-average risk for vaccine-preventable illness. But in 2005, only 37% of patients with diabetes were vaccinated against pneumococcal disease, and close to 40% were vaccinated against influenza.11
Self-management of diabetes, along with thorough education about the disease, is essential for patients to successfully manage their condition. Recent trends show that patients are improving in these areas, but much remains to be done. In 2000, for example, more than 50% of diabetes patients reported attending diabetes self-management classes, and nearly 62% reported performing daily foot self-examinations. Sixty-five percent reported undergoing regular A1ctesting. Four years later, these numbers had not increased much: 63.7% performed daily foot self-examinations, 68.8% underwent A1ctesting, and 56.6% attended diabetes self-management classes.11
Although 80% of diabetes patients saw health care providers for their diabetes at least once in 1994, less than 50% had annual foot exams, close to 58% had annual dilated eye exams, and just 35% performed daily self-monitoring of blood glucose.11By 2004, these statistics had improved slightly. Annual foot exam rates increased by 18.5%, daily self-monitoring rates increased by 24.7%, annual provider visits rose less than 10%, and annual dilated eye exams increased only a few percentage points.11
Theoretical Foundation
Suboptimal care of diabetes leads to poor patient outcomes.12,13Many deficiencies in our health care system influence the management of chronic diseases such as diabetes. Among them are failure to follow practice guidelines, lack of care coordination, lack of active follow-up and inadequate patient education and training.14
Use of the Chronic Care Model can improve patient outcomes. This model, promoted by the Robert Wood Johnson Foundation, is a systematic guide to improve health outcomes and clinical processes. One study found that patients who received the chronic care model intervention experienced improvements in physical and psychological outcomes.15To achieve better outcomes, patients must have adequate access to health care providers, have the necessary tools and skills for self-management, and have regular laboratory evaluations, appropriate medications and medical nutrition therapy.16
The Chronic Care Model encompasses community resources and policies, health care organizations, patient self-management support, decision support, delivery system design and clinical information systems.17In combination, these elements promote informed, activated patients and prepared, proactive clinical teams. This model is evidenced-based, patient-centered, efficient, coordinated and safe. Figure 1 provides a visual representation of the Chronic Care Model.
Standards of Care
Standards of care for diabetes have evolved. The American Diabetes Association (ADA) recommends a comprehensive medical evaluation for all newly diagnosed patients. For patients with an established diagnosis of diabetes, it supports a review of the comprehensive evaluation, including previous treatments and past and present glycemic values.11 he comprehensive diabetes evaluation encompasses a medical history, a physical examination, laboratory evaluation and appropriate referrals.11
Although the ADA recommends a collaborative integrated team approach for the management of diabetes, rural health clinics and health clinics in underserved areas lack many resources. The Clinical Information Systems portion of the Chronic Care Model can help address some of these shortcomings. Comprehensive evaluation guides for health care providers, nurses, laboratory technicians and patients are potential solutions that meet the goals of the Chronic Care Model. These guides, which I developed for use in my rural health clinic setting, can assist health care staffs in providing comprehensive care to patients with type 2 diabetes.
Table 1 shows a guide for health care providers. Although most providers perform these tasks, many do not document them or sometimes forget to incorporate them into each visit. Using the checklist can help providers remember everything from the need to check the patient's feet for sensation to documenting findings in the patient's chart.
Table 2 is a guide for nursing staff, and Table 3 is a guide for laboratory staff. In the typical clinical setting, members of the laboratory staff do not make testing decisions. But in our rural setting, these professionals follow standing orders we put in place for our patients with diabetes. This allows patients to undergo testing prior to their appointments, making the relevant information available for office visits.
The information in the tables represents guidelines only. Some providers may want patients to achieve lower glycemic values or want their staff to perform other routine tasks. I developed these guides based on my review of ADA guidelines, U.S Preventive Services Task Force (USPSTF) recommendations and Cochrane review data, and in consultation with my collaborating physician.14,18
Because standards of care change often, review these guides annually to determine whether any information requires revision. In our small rural health clinic, I review evidence-based literature and then update the guidelines when necessary. Our clinic physician, nurse and laboratory technician review any updates and make suggestions. After we agree on all changes, I create the new documents, and we begin using them.
Informed, Activated Patient
Another component of the Chronic Care Model is an informed, activated patient. Good functional and clinical outcomes will not occur if the patient or family members are not involved. Patient involvement is imperative to the management of any chronic disease. Incomplete education of patients with diabetes is a common problem. Ninety percent of patients with diabetes are treated by their primary care providers, meaning that thorough diabetes education is often impractical with limited staff and resources. Access to diabetes education is particularly a problem in rural areas.19When patients are informed and actively participate in its management, the interaction between provider and patient is more productive and leads to healthier patients, more satisfied providers and lower costs.14
In our rural health clinic, all diabetes patients receive a personal education package. We instruct them to read and review all information contained in the package, and we discuss it during the follow-up visit and subsequent visits. We encourage patients in our clinic to know everything there is to know about their disease.
One way to get patients more involved in their disease management is to give them a "report card" that shows their progress. In our clinic, this card has areas for laboratory data and other test results on one side and areas to record immunizations, other exams and measurements on the opposite side.
Patients who see multiple specialists can use the card to give data to other providers, thus improving overall clinical outcomes. Figure 2 shows an example of the two sides of a card. For the purpose of this article, the card is shown larger than the actual wallet size we use in our clinic.
Putting It Into Practice
Type 2 diabetes is a chronic illness that requires comprehensive and ongoing medical care, along with patient self-management and patient education, to prevent long-term complications. Many factors inhibit the achievement of good clinical outcomes for affected patients. Using concise guides and checkoff lists to ensure continuity of care, testing and services can help improve outcomes in patients with diabetes. The case study included as a sidebar to this article illustrates the use of these guides in real-life practice.
References
1. McCulloch DK. Overview of medical care in adults with diabetes mellitus. Available with subscription at http://www.uptodate.com. Accessed Aug. 11, 2008.
2. Centers for Disease Control and Prevention. Number of Americans with diabetes continues to increase. Available at: http://www.cdc.gov/od/oc/media/pressrel/fs051026.htm. Accessed Aug. 11, 2008.
3. Glazier RH, Bajcar J. A systematic review of interventions to improve diabetes care in socially disadvantaged populations. Diabetes Care. 2006;29(7):1675-1688.
4. Geiss LS, et al. Changes in incidence of diabetes in U.S. adults, 1997-2003. Am J Prev Med. 2006;30(5):371-377.
5. CDC National Diabetes Fact Sheet: United States, 2005. Available at: http://www.cdc.gov/diabetes/pubs/factsheet05.htm. Accessed Aug. 11, 2008.
6. Ettaro L, et al. Cost-of-illness studies in diabetes mellitus. Pharmacoeconomics. 2004;22(3):149-164.
7. Sacks DB, et al. Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Clin Chem. 2002;48(3):436-472.
8. Harmel AP, et al. Diabetes Mellitus: Diagnosis and Treatment. 5thed. Philadelphia, Pa.: W.B. Saunders; 2004.
9. Pedersen O, Gaede P. Intensified multifactorial intervention and cardiovascular outcome in type 2 diabetes: the Steno-2 study. Metabolism: Clinical & Experimental. 2003;52(8 Suppl 1):19-23.
10. Stratton IM, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ. 2000;321(7258):405-412.
11. CDC Data and Trends. National Diabetes Surveillance System. Age-adjusted rates of ever receiving a pneumococcal vaccination per 100 adults with diabetes, United States, 1993-2005. Available at: http://www.cdc.gov/diabetes/statistics/preventive/fZ_pneum.htm Accessed Aug. 11, 2008.
12. Harris M. Health care and health status and outcomes for patients with type 2 diabetes. Diabetes Care. 2000;23(6):754-758.
13. Saydash S, et al. Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA. 2004;291(3):335-342.
14. Improving Chronic Illness Care: The Chronic Care Model. Promoting effective change in provider groups to support evidenced-based clinical and quality improvement across a wide variety of health care settings. Available at: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2. Accessed Aug. 11, 2008.
15. Piatt J, et al. Translating the chronic care model into the community: results from a randomized controlled trial of a multifaceted diabetes care intervention. Diabetes Care. 2006;29(4):811-817.
16. American Diabetes Association. Standards of medical care in diabetes-2006. Diabetes Care. 2006;29(Suppl 1):S4-S42.
17. Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998;1(1):2-4.
18. United States Preventive Services Task Force. Guide to Clinical Preventive Services. Washington, D.C.: Agency for Healthcare Research and Quality; 2006.
19. Siminerio LM, et al. Deploying the Chronic Care Model to implement and sustain diabetes self-management training programs. Diabetes Educat. 2006;32(2):253-260.
Dawn Bucher is a family nurse practitioner at Ivanhoe Clinic in Ivanhoe, Minn., and the Flandreau Santee Sioux Tribal Health Clinic in Flandreau, S.D. She recently earned a doctorate in nursing practice from Columbia University in New York City.
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