Care: New Clinical Guidelines and Leadership Council |
"Diabetes remains at the leading edge of opportunity for improving the health of Kaiser Permanente members," says Paul Wallace, MD, Care Management Institute (CMI) Executive Director. There are many reasons why this is the case.
In 2002, Kaiser Permanente (KP) delivered care to more than 500,000 adults with diabetes,1 comprising 9.1% of KP's adult membership.a If all the adult KP members with diagnosed diabetes lived in one city, it would be larger than Boston, Portland, Denver, Long Beach, Virginia Beach, or Oakland and would be growing as rapidly as a Sunbelt retirement haven. The prevalence of diabetes in the United States as a whole increased by 33% between 1990 and 1998, marching in lockstep with the growing epidemic of overweight and obesity.2
is costly; estimated US direct medical costs in 2002 were $92 billion.3
Indirect costs due to disability, lost productivity, and premature mortality
consumed an estimated additional $40 billion.3 Long-term complications--heart
disease, hypertension, stroke, kidney disease, retinopathy, and neuropathy--account
for the high costs. Adults with diabetes have heart disease death rates
and stroke mortality rates two to four times those of adults without diabetes.
Together, heart disease and stroke are responsible for 65% of deaths among
adults with diabetes.4
Many costs cannot be quantified. Diabetes, like other chronic conditions, extracts an incalculable toll of pain and suffering from patients, family, and friends. For all these reasons--high prevalence and mortality rates, high direct and indirect costs, and negative impact on quality of life--it was one of the first clinical priority areas identified by the CMI several years ago. At the time, diabetes care centered on physicians managing patients' blood glucose levels by prescribing medications and dietary modifications.
"Over time, we've moved from thinking mainly about controlling disease to a framework of population-based care, the stratification of needs, adaptation of care delivery to individual needs, the importance of managing comorbid conditions well, and, most recently, the engaged patient as the locus of control for pursuing health in the face of a chronic condition," says Dr Wallace.
Good glycemic management is still a key part of diabetes management. But revised diabetes clinical guidelines released by the CMI in March include both a major revision and a pivotal new topic area. Together, they signal a sea change in caring for KP members with diabetes.
The guideline for using cholesterol-lowering medications in diabetic patients has been substantially simplified. Prior to the revision, statin use was predicated on baseline cholesterol levels.
"It's been clearly shown that the use of statins in diabetics lowers the risk of cardiovascular disease by at least 25%, regardless of baseline cholesterol level, with a middose statin regimen like 40 mg of lovastatin. Titrating statins has also been shown to be extraordinarily difficult," says Jim Dudl, MD, endocrinologist (KP-SCR) and leader of a newly formed CMI diabetes leadership council (see sidebar).
"With the data from the Heart Protection Study,5 we were able to simplify the whole process. Every diabetic patient is offered a midlevel statin dose with a single lab test to follow up. The concept is safer than aspirin use, and we can have a much higher percentage of diabetic patients on statins," he says.
The Heart Protection Study, a randomized controlled trial of nearly 6000 adults, showed that cholesterol-lowering pharmacotherapy offers significant cardiovascular risk reduction for adults with diabetes without manifest coronary artery disease or high cholesterol levels, thus obviating the need for baseline cholesterol testing.5
Relocating the Hub of Care
A new topic area in the guidelines addresses the rapidly changing health care environment. "Two forces are making the way we practiced diabetes care a few years ago both obsolete and dysfunctional," says Dr Dudl.
"The level of care necessary for a diabetic patient to have good medical care has increased many times over from ten years ago. It used to be the case that a member with diabetes would come into the clinic and get blood drawn. A week later, we'd get the results and call the patient to adjust one thing or another. Now, good diabetes care means fine-tuning blood glucose daily or more frequently."
Secondly, he says, technology has moved the essentials of treatment from the clinic setting to the patient's home. Dr Dudl continues, "Now the hub of care is in the patient's home, because that's where the data are. Patients do fingerstick testing. They go into the lab and get blood drawn, then call and get the results."
Targets and tools empower patients by defining a desirable blood glucose range and then providing the necessary means to assess and achieve it. Titration schedules for insulin dosages, for instance, put patients in control of their blood glucose levels.
The guidelines workgroup reviewed the literature and found that self-care works well for a number of conditions. "Self-management is the way to address the fact that the hub of care is shifting. We included a self-management guideline so that good diabetes self-care becomes the standard, not the exception," he concludes.
Recommending a Longer Look at Gestational Diabetes
A second new area in the guidelines addresses the risk that women with gestational diabetes will progress to Type 2 diabetes. "Women with gestational diabetes are at increased risk for developing Type 2 diabetes and should be offered weight control and lifestyle modification advice," says Michelle Wong, CMI Care Management Consultant and co-leader of the guidelines workgroup.
To keep pace with emerging evidence, clinical guidelines are revised every two years.