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OffLine Fall 1999

Volume 12 Number 2

In 1994 Group Health formally embraced the tenets of "population-based care." This concept involves the systematic delivery of health care to populations of patients with the same condition. Key components of population-based care involve identifying patients at risk, intervening with specific programs of care shown to be effective by scientific studies and measuring clinical and other outcomes. This planned, proactive, approach to providing health care for patients with chronic conditions contrasts with the more prevalent acute care model—a model in which providers, for the most part, react to health crises. Population-based care is the driving force behind Group Health's Clinical Roadmap effort, a program designed to improve care for enrollees with selected conditions, including depression, asthma and diabetes.

Diabetes, one of the original conditions targeted by the Roadmap, is described by Group Health Center for Health Studies investigator and diabetes roadmap co-chair Ed Wagner as a "prototype" condition for disease management. This label derives from the enormous patient suffering and high health care costs associated with diabetes-related complications, which include blindness, foot amputation, and cardiac disease. Diabetes is characterized by the body's inability to manage blood glucose or sugar. High blood glucose levels, especially in combination with high blood pressure (a relatively common condition among diabetic patients), can cause serious damage to the small blood vessels of the kidneys and eyes, the arteries surrounding the heart and the nerves. Reassuringly, research has shown that maintaining blood glucose (and blood pressure) levels in normal ranges most of the time can substantially reduce this damage.

Following a proper diet, exercising and not smoking are some of the steps a diabetic patient can take to maintain appropriate blood glucose levels and to prevent serious diabetes-related complications. In addition to these self- management tasks, routine preventive health care, and in many cases, medications, are critical to the management of blood glucose levels and the identification of early, and often treatable, signs of trouble. Primary care is an ideal setting for provision of this routine health care and for enhancing and supporting patient self-management. Indeed, CHS investigator Ed Wagner and colleagues have applied the principles of population-based care to improve primary care management of Group Health's 18,000 diabetic patients for the last 7 years.

Has management of diabetes improved? The definitive positive indicator would be a reduction in diabetes-related complications and mortality. However, since complications usually take many years to develop, the Diabetes Roadmap has identified "intermediate" process of care" indicators to measure the Roadmap's effectiveness. These process measures, which are detailed in clinical guidelines adopted by the Roadmap, include annual retinal and foot exams and glucose testing. Microalbuminuria screening is also recommended annually. This test examines the urine for evidence of kidney damage; patients testing positive can be treated with ACE-inhibitors. Finally, the Cooperative adopted a guideline in 1997 detailing effective glycemic management that should result in lower blood sugar (Hb1Ac) levels. Theoretically, the higher the compliance with these process measures, the fewer future complications among diabetic patients.

Group Health diabetologist David McCulloch reported that in 1997, 70 percent of Group Health's diabetic patients had a dilated retinal eye exam compared to only 56 percent in 1995. Rates of annual foot exams have risen from less than 20 percent before 1995 to 82 percent in 1998. Seventy percent of diabetic patients underwent microalbuminuria screening in 1998 and 92 percent had a HbA1C test, rates which reflect steady increases in compliance since 1996. Normal HbA1c levels range between 5 and 6 percent—below 8 percent is considered good for diabetic patients. The overall mean HbA1c level for the diabetic population fell below 8 percent for the first time in 1996 and has decreased slightly since then. Stated another way, two-thirds of diabetic patients had an HbA1c level below 8 in 1998. Diabetes care at Group Health has also fared well on a more subjective level—patient satisfaction. Between 1996 and 1997 patients reported statistically significant greater satisfaction with four aspects of their diabetes-related care: overall quality, thoroughness of treatment, doctor's skill/experience and coordination of services.

What brought about these dramatic changes? Globally, they are the result of a successful collaboration between the Diabetes Steering Committee, Group Health providers and Group Health patients. Specifically, improvements in diabetes management introduced through the Roadmap process can be reduced to 4 key elements. First, a diabetes registry implemented in in 1995 (online since 1996) supplies health care teams with up-to-date patient information which can be used to identify patients with diabetes, guide visits and initiate patient contact. Second, a diabetes expert team (DET), consisting of a diabetologist (Dr. David McCulloch) and a diabetes nurse specialist (Dr. Martha Price), shares expertise with primary care providers through the mechanism of joint visits with diabetes patients. By the end of 1997, 259 primary care teams had had at least one visit with the DET, with 167 of those practices having 2 or more such visits. Data from 1996 showed that practices that had consulted with the DET had a higher proportion of patients in compliance with certain process of care measures compared to practices that had not received expert advise. Clinical guidelines, founded on a rigorous review of the scientific literature (i.e., "evidence-based medicine"), are the third key element of diabetes population-based care. And lastly, patient self-management is supported and encouraged primarily through "Right Track", a patient notebook which is distributed through Group Health pharmacies free of charge by physician prescription.

Of course, costs are associated with these system changes. Furthermore, policymakers might be concerned that the documented improvements in diabetes care may actually result in increased health care costs due to the greater number of preventive visits. To address these concerns, the Roadmap has examined health care utilization and costs for diabetic patients between 1995 and 1997. In this time period, total health care costs for diabetic patients decreased by 11 percent compared to a 4 percent increase for Group health patients as a whole. Inpatients admits for diabetic patients were down by 17 percent, inpatient days by 25 percent and average hospital length of stay by 10 percent, reductions not observed among the entire Group Health population. Between 1995 and 1997, diabetic patients made an average of one less specialty visit per year. These cost reductions are even more striking in light of the concomitant increase in diabetes-related medication costs—monthly drug costs per diabetic patient rose from an average of $70.16 in 1995 to $82.36 in 1997.

These are not the only cost data that bolster the work of the Diabetes Roadmap and provide support for preventive programs and early intervention. UW researcher Scott Ramsey, in collaboration with Wagner, CHS investigator Katherine Newton and others, used Group Health automated data to estimate the excess health care costs associated with six diabetes-related complications—heart attack, hypertension, foot disease, eye disease, stroke and end-stage renal disease. In reporting the results, the researchers caution that relying on automated data to identify complications is a potential limitation. In a separate validation study comparing automated data to the "gold standard" medical record, Newton found that automated data were generally good at identifying those diabetic patients who had complications. But computerized data were more problematic in terms of "false positives"—that is, identifying diabetic patients as having a complication which they do not have.

Noting these limitation, Ramsey and colleagues reported that, in the year following diagnosis of the complication, health care costs for diabetic patients aged 65+ were roughly twice those for age-gender matched diabetic patients without the complication. This relative difference in costs was greater in younger cohorts. Consider foot ulcers, which are six times more prevalent in diabetics compared with non-diabetics. In the year after diagnosis, diabetic patients with new foot ulcers incurred costs up to 5.4 times greater than those for diabetics who had not developed foot ulcers; in the second year the increment was as much as 2.8. Ramsey calculated that a male aged 40 to 64 with a new foot ulcer incurs an extra $28,000 in health care costs during the two years following diagnosis.

While consideration of costs is a reality in today's health care world, the overarching goal of Group Health Diabetes Roadmap is to improve care for patients. This point was brought home by a recent editorial in the New England Journal of Medicine by Thomas Bodenheimer of the U.C.S.F. Medical School. Group Health and Wagner were featured prominently in this editorial. Bodenheimer contrasted disease management programs like Group Health's, that are centered in primary care, with "carve-out" programs in which health care institutions contract with outside firms to provide care for populations of patients. He had several concerns with carve-out programs, not the least of which was that they are often motivated by cost and therefore, tend to focus on severe patients where the potential for cost-savings is greatest. Bodenheimer contrasted this more entrepreneurial focus with Group Health's population-based care approach in which cost savings are of secondary importance to the well-being of patients, whether low or high utilizers.

Despite this national attention, Group Health is not resting on its laurels. For example, McCulloch has identified the need for improved strategies to support patient self-management. Further, the work on the Diabetes Roadmap and its success served as the basis for an ongoing Robert Wood Johnson-funded national program based at the McColl Institute entitled "Improving Chronic Illness Care."

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