December 10 , 2007

Curbing the Diabetes “Outbreak”
By Thomas G. Dolan
For The Record
Vol. 19 No. 25 P. 26

Disease management programs and professional organizations are counting on a team-oriented approach to stymie the growing incidence of diabetes.

Health authorities are more frequently referring to the rapidly growing numbers of people with diabetes in the United States as an epidemic.

Epidemic? Isn’t that a term used for diseases such as tuberculosis, malaria, and HIV, which are prevalent in impoverished countries with poor healthcare systems?

Although the quoted numbers often vary, they are universally high. In a recent USA Today article, Catherine Cowie, MPH, PhD, of the National Institute of Diabetes and Digestive and Kidney Diseases reports that 73 million adults are currently suffering from diabetes. Additionally, Cowie says 26% of adults have impaired glucose or above-normal blood sugar levels but have not yet been diagnosed with diabetes. What this means, according to Cowie, is that roughly one third of the population has diabetes or is at high risk of being diagnosed. However, these numbers don’t include children with the disease.

There are two types of diabetes. Type 2, which accounts for 95% of the cases and typically begins in middle age, is caused by the inability to produce enough insulin and is associated with obesity. Type 1, which is caused by the loss of insulin-producing cells, is usually diagnosed in children or young adults. Statistics indicate that both types are becoming more common in young adults and children, who are also showing an increased incidence of related problems, including obesity, kidney failure, and heart disease.

According to an article in the American Heart Association Journal by lead author Caroline S. Fox, MD, of the National Lung, Heart, and Blood Institute in Framingham, Mass., the diabetes rate has doubled in the last 30 years, with most of the increase occurring in people who were obese. Research also shows that the risk of developing diabetes in the 1980s and 1990s increased by 40% and 105%, respectively.

The reasons behind the sharp increase in diabetes cases can be traced to lifestyle changes, according to Nico Pronk, PhD, vice president of health and disease management at HealthPartners.

“When you look back over time, we didn’t have sedentary lives. That really started after World War II and became more and more prevalent as technology replaced manual effort,” he says. “Now, 55% of the population is overweight, 30% to 35% are obese, and severe obesity is the fastest growing cause of diabetes. But it’s built over the years, one generation over the next, so it’s now reaching epidemic proportions.”

At the same time, it’s not as if the healthcare community has been unaware of this trend or has not been trying to cope with it. “Disease management programs have been around for the past 10 to 15 years, and the diabetes plans have been the most robust. Almost every managed care facility has been offering diabetes care plans for the past five years,” says Marissa Schlaifer, MS, RPh, director of pharmacy affairs at the Academy of Managed Care Pharmacy.

Richard Hellman, MD, FACP, FACE, of Hellman and Rosen Endocrine Associates in North Kansas City, Mo., and president of the American Association of Clinical Endocrinologists (AACE), agrees that “the general concept of having a coordinated team approach, especially over the long term, has had fine results; we published our own plan 10 years ago. That said, the question is do these programs always have beneficial results? The answer, sadly, is no and often not. The reason is that the goals of these insurance-based programs are often not the same as those of the consumer, who wants to reduce complications and improve their health. The goal of the insurance programs has been to reduce short-terms costs, which ends up prolonging the disease and making it worse.”

Hellman says that the new AACE guidelines are drawn from a broader, primarily European perspective, and have the input from 84 different countries. He says the results of recent European studies show that, as opposed to starting treatment in a modest and convenient manner, it’s better to start with optimal treatment, controlling the three main factors affecting diabetes: glucose, blood pressure, and cholesterol.

“What’s been shown is that if you give comprehensive and more intensive care at the start and maintain it for six to eight years, then the advantages appear to be long-lasting,” Hellman says. “This represents a huge breakthrough in the model of care. Giving the optimal amount of care from the start, as opposed to gradually increasing it as the disease gets worse, provides far better outcomes and costs far less. But it does cost more at the start. I would challenge these plans to realign their priorities, to spend more short-term to provide optimal care, as opposed to simply looking at costs.”

Another problem with diabetes control is that there are many authorities establishing different guidelines, some of which may not be sufficient. For example, Hellman says while it is recognized that glucose must be kept low, the new AACE guidelines “are somewhat more stringent than those of the American Diabetes Association. We want to get blood sugars as low as we can.”

Among the myriad of diabetes guidelines, Hellman points out that the AACE’s differs in one area. “As far as I know—and I’ve read a lot of guidelines for diabetes control—this is the first to focus on patient safety issues,” he says.

Chief among patient safety concerns are blood glucose levels, regardless of whether a patient has been diagnosed with diabetes. “The evidence has accumulated that when people go into the hospital undiagnosed, that without attention being paid to the blood glucose levels prior to surgery, you greatly increase the risk of infection, heart failure, poor healing, greater mortality, or longer hospitalization and increased costs,” Hellman says. “There is significant scientific evidence which shows that patients, health professionals, and doctors create unintentional hazards for patients in hospitals. Studies show that even if you don’t have diabetes, high blood glucose levels can put you at risk. Moreover, one third of the people who have diabetes are undiagnosed. That means that out of every three people with diabetes, there is one that nobody knows has it. That’s a huge number.”

Also contributing to rising diabetes rates is the failure of patients to adhere to treatment plans. According to a study published in the January 2004 issue of Diabetes, only 7% of people with diabetes over the age of 20 followed their treatment regimens to maintain acceptable blood glucose, blood pressure, and cholesterol levels.

“This shows you how difficult it is to manage this complex disease state,” says John Zrebiec, MSW, CDE, associate director of mental health services at Joslin Diabetes Center in Boston, adding that it’s a problem not only for patients but also for professionals assigned to monitor care.

Why are these patients so lax in following their treatment plans? “How would you feel if you had to take four insulin shots a day, check your blood sugar five times a day, stop smoking and drinking, change your diet, and exercise?” Zrebiec asks.

Because there are so many stakeholders—patients, families, doctors, pharmacists, hospitals, managed care facilities, insurance companies, employers—it’s not surprising that diabetes management plans can vary considerably. There are different standards of care. Some measure standards, while others consider short- or long-term results, and so on.

The good news is these diabetes management plans are converging in terms of standards, care, and measurements, as well as how to more quickly identify patients or those at risk and provide support to help patients stick to their regimes.

HealthPartners, the largest consumer-governed nonprofit healthcare organization in the nation, established its diabetes management plan in 1994 but didn’t start measuring compliance until four years ago. During that time, however, compliance rates have tripled, according to Pronk.

He explains that the plan identifies the disease through a variety of data, claims reviews, health risk appraisals, and pharmacy records. Patients are identified as being at different levels of risk. Some may be sent a newsletter or contacted through periodic outreach programs, while others receive more attention. “We try to overlay the program on top of clinical care and support so people can manage themselves,” Pronk says. “We want to optimize the outcome of the program but first and foremost, we want to make it an exceptional experience. Otherwise, people won’t come back.”

The plan focuses on five different standards to help patients control blood pressure, cholesterol, and blood glucose, take an aspirin a day, and quit smoking. “We use the measurements recommended by the Institute of Medicine,” Pronk says.

Seattle’s Group Health Cooperative operates a diabetes management program at 25 clinics with an emphasis on being proactive. David K. McCulloch, MD, the group’s medical director of clinical improvements, explains that the cooperative’s extensive database in a sophisticated system results in patients being tracked individually.

Contact with the patient is based on need and performed in a coordinated fashion. For example, birthday cards sent to patients may contain friendly reminders, or a member who comes to a clinic for a sprained ankle may be asked, “By the way, did you know that this might be a good time for a blood pressure check?”

Part of a good outreach system, McCulloch explains, is targeting individuals without overdoing it. “Patients are justifiably ticked off if they get a reminder for an eye exam today, for a breast exam tomorrow, and diabetes the next day,” he says. “We don’t track results. The studies have been done that show if you take the right drugs and treatment, you’ll see a 40% improvement over the next five years. We don’t have to prove what’s already been proven. What we do is have the systems in place to track the health of our members and to intervene and support when necessary.”

A new and somewhat different approach was recently initiated by the Dallas-Fort Worth Business Group on Health, which has developed a comprehensive plan designed to include all stakeholders. A 130-member coalition of area employees committed to market-based healthcare reform, the group features members American Airlines, Neiman Marcus, and Texas Instruments, and four participating healthplans: Aetna, Blue Cross and Blue Shield of Texas, Cigna Humana, and UnitedHealthcare. Approximately 80% of the nearly 4,100 primary care physicians in the area are involved in the project, as are a variety of consumer advocacy groups and community centers. Key program components include the use of performance measures using nationally recognized and endorsed outpatient care standards for the treatment of diabetes and public reporting of the results.

“Our primary goal is to improve the quality of care,” says Executive Director Marianne Fazen, PhD. “The cost analyses will come later, and we believe the cost savings will take care of itself.”

— Thomas G. Dolan is a medical/business writer based in the Pacific Northwest.