The Affordable Care Act and Diabetes

Harvey W. Kaufman and colleagues just published an excellent analysis of the impact of the Affordable Care Act in Diabetes Care. Using laboratory testing orders sent to Quest Diagnostics (a large national clinical laboratory provider), they found how many patients were newly diagnosed with diabetes since the Act went into effect. The 26 states and District of Columbia that took advantage of Medicaid expansion under the Act saw a substantial 13% increase in the number of diabetics identified. The 24 states that limited Medicaid expansion saw only 0.4% more diabetics.

An accompanying editorial by William H. Herman and William T. Cefalu reminds us that this lost opportunity to improve health in half the states is due to a Supreme Court decision allowing states to opt out of Medicaid expansion. Thanks, Supreme Court!

Using phone and fax to improve diabetes care

The Journal of Diabetes and Its Complications just published a study on "Diabetes self-management support using mHealth and enhanced informal caregiving" by a team of VA researchers from Michigan and Stanford. The team set up an IVR phone system for veterans with diabetes. The vets received phone calls every week to assess their status and generate automatic tailored messages about how to deal with their disease. The system was designed to also engage family members and other informal caregivers as well as the clinician. This was a fairly sophisticated system with multiple tree-structured algorithms that took 5 to 10 minutes per call to complete and covered a wide range of issues including hypoglycemia, hyperglycemia, medication adherence, foot self-care, self-monitoring of blood sugar and blood pressure, and so forth. Clinicians received a fax if the system detected a concern.

The paper reports very positive short-term outcomes.  72% of patients agreed to try it and 84% of the scheduled calls were completed. On average, the system detected about one problem for every 5 weeks of patient participation. Patients who had informal caregivers tended to have fewer problems. Of course, the Pareto Principle applies here as everywhere and almost half of the problems were concentrated in 15% of patients. The best news is that the number of problems seemed to decrease over time, suggesting that the patients were achieving better stability.

At this time, there are no data on whether the patients actually got better in terms of physiologic control, complications, utilization or satisfaction with care. However, it looks like the relatively old fashioned technologies of phone and fax still have great potential to enhance care by engaging patients, caregivers and clinicians.

Aikens JE, Zivin K, Trivedi R, Piette JD. Diabetes self-management support using mHealth and enhanced informal caregiving. J Diabetes Complications. 2014;28: 171-6.

Individualizing content for patient engagement efforts

I'm struck by the wise comments presented in this recent piece from mHealthNews. Editor Eric Wicklund wrote about the efforts of Kyra Bobinet, MD, MPH to increase the "emotional intelligence" of communications between provider and patient. "If it's personal and relevant," says Bobinet, "that should work." 

I couldn't agree more. Generic messaging of the "everybody ought to get a flu shot" variety has little resonance with the patient and is unlikely to impact behavior in a big way. Specific, tailored messages along the lines of "Because your last A1C diabetes test was high, you need to recheck again now" are more motivating. Of course, they are much harder to produce if you don't have an automated system to scan the information you have about the patient, identify the most important opportunities to improve care, and reach out to the patient in language they will understand via media they will accept.

This is not the sort of process that most practices can do on their own. It requires some infrastructure and more than a little staff time to do all that communicating and engaging! Patient Engagement Systems offers a software-as-a-service solution that allows you to connect to your patients, keep them engaged in their care, and has been proven to improve outcomes and reduce the total cost of care. As more and more practices, payers and Accountable Care Organizations realize they need to increase engagement on a large scale to improve quality and reduce costs, they are turning to automated systems to do the job.

Diabetes prevalence goes up - again!

The good folks at the Centers for Disease Control recently put out the 2014 National Diabetes Statistics Report. They estimate that over 29 million Americans have diabetes. That puts the overall prevalence at 9.3% or more than one in 11 people. The vast majority of them are adults, with prevalence rising to over 25% after age 65. There are 1.7 million new cases per year. In addition to the huge burden of illness, disability and premature death, the current cost of the diabetes epidemic is $245 trillion per year.

But there is some good news. Patients with diabetes who are engaged in their care, especially with primary care services, have better outcomes and require a lot less time in the hospital. Their costs are thousands of dollars lower per patient. The tools to do this are available at remarkably low cost in just about any kind of primary care setting.

New payment structures mean that the incentives to reduce costs and improve quality are in place. Accountable Care Organizations (ACOs) can't just pass the costs of bad quality along; they need to capture the savings that have been proven to occur with this kind of Patient Engagement, and they are starting to do it.

If you know of an ACO (or other practice setting) that is motivated to reduce total utilization for diabetes and other chronic conditions without disrupting provider workflow, please let them know about Patient Engagement Systems. Call Toll-free: (855) 870-4337 or email contactus@ptengage.com.

Winning the war against kidney failure

Ed Gregg, the master of diabetes epidemiology, and his team from the CDC, just published their latest report on the state of the nation's epidemic of diabetes. The good news is that the rates of diabetic complications - heart attacks, amputations, kidney failure, fatal hyperglycemic crisis, stroke - have fallen quite a bit since 1990. This is almost certainly do to the widespread application of practice guidelines by specialists and especially primary care providers. Monitoring and managing A1C, blood pressure, lipids and early renal damage is paying off at the national scale.

What about adults without diabetes?

"Trends in the population of adults without diabetes were generally not as promising as those in the population with diabetes, with smaller reductions in the rate of acute myocardial infarction, no significant change in rates of stroke and lower-extremity amputation, and an increase in the rate of end-stage renal disease."

An increase in end-stage renal disease? At the same time that we were making significant inroads against renal failure in diabetes (-28% drop in the rate), we see a swelling of the rates in non-diabetic adults by a whopping 65%. Why is this?

First, early stage chronic kidney disease is often un-noticed by providers who may not understand the implications of apparently small increases in serum creatinine. Second, proteinuria, the hallmark of treatable early renal damage, may not even be sought. Third, blood pressure is hard to reduce, often requiring multiple medications and persistent, frequent monitoring. You can't prevent the progression of early chronic kidney disease with once-a-year visits.

These problems in the quality of care are very much like those that beset diabetes 20 years ago, but we have made great strides by becoming aware of the problem, deciding as a profession that we should and shall do something about it, and marshalling all our resources - guidelines, educators, non-physician providers, reminders, lifestyle changes, new medications - and building them into our ongoing processes of care. In many practices, the optimal care of diabetes is a stated goal and the office uses standing orders, automated reminders and all the tricks of modern systems management to reliably deliver state-of-the-art care for diabetes. It's time to do that for early kidney disease.

Changes in Diabetes-Related Complications in the United States, 1990–2010
Edward W. Gregg, Ph.D., Yanfeng Li, M.D., Jing Wang, M.D., Nilka Rios Burrows, M.P.H., Mohammed K. Ali, M.B., Ch.B., Deborah Rolka, M.S., Desmond E. Williams, M.D., Ph.D., and Linda Geiss, M.A.
N Engl J Med 2014; 370:1514-1523 April 17, 2014 DOI: 10.1056/NEJMoa1310799

Patient Engagement for Suicide Prevention

You can't manage what you can't measure is a truism in quality improvement. In mental health, it goes even further: You can't manage what you won't even talk about. Although lots of barriers have fallen in the realm of acceptable topics for conversation between doctors and patients - we no longer avoid saying "cancer" like the word itself was the disease - suicide is still a particularly difficult topic for providers to broach. No doubt training the doctors to deal with this sticky area head on can help, but it takes two to tango, and physicians hate to initiate a difficult discussion as much as anyone else.

So, Ruby Shah, Richard Kravitz and the good folks at UC Davis went at the problem from the other end. They used patient engagement techniques - a tailored interactive media program shown in the waiting room - to activate the patient to discuss their symptoms (both emotional and physical) including thoughts of self-harm, and the possibility that those symptoms were due to depression. Among patients with mild depression, there was little impact, perhaps because there was little need. But among patients with moderate to severe depression, the probability that suicide would at least be discussed went from 40% to 58%. 

Is this enough to make a difference? Talking about the issue is only the first step. Did it result in appropriate action? Kravitz and company already reported in JAMA that the engagement approach increased treatment (or referral for treatment) from 16% to 26%. So, the intervention works in the sense that it sometimes stimulates the necessary discussion and appropriate treatment. However, the depression scores 12 weeks later were not better in the engagement group and were even a bit worse. Increased prescribing for non-depressed patients raises the possibility that the engagement program actually made things worse for some patients.

This study was excellent science, but not a clear cut success for patient care. The tailored messaging had an impact on behavior and resulted in treatment changes. However, some of those treatment changes could have made things worse, not better. Twelve weeks later, there was little evidence that the patients felt better - probably because depression is hard to treat, especially with medications.

Shah R, Franks P, Jerant A, Feldman M, Duberstein P, Y Garcia EF, Hinton L,
Strohecker L, Kravitz RL. The Effect of Targeted and Tailored Patient Depression 
Engagement Interventions on Patient-Physician Discussion of Suicidal Thoughts: A 
Randomized Control Trial. J Gen Intern Med. 2014 Apr 8. [Epub ahead of print]
PubMed PMID: 24710994.

Kravitz RL, Franks P, Feldman MD, et al. Patient Engagement Programs for Recognition and Initial Treatment of Depression in Primary Care: A Randomized Trial. JAMA. 2013;310(17):1818-1828. doi:10.1001/jama.2013.280038

Is depression a link between diabetes and kidney disease?

A team of epidemiologists and nephrologists led by Margaret K. Yu from the University of Washington and the VA recently published strong evidence that among diabetics, depression raises the risk of End-Stage Renal Disease (ESRD or renal failure) by 85%. This is a very big deal. There are lots of diabetics and lots of them have major depression.

Although it is not yet clear if treatment for depression can avert or delay ESRD for these folks, there are plenty of other reasons to identify and treat them. Even if treating depression doesn't prevent ESRD, it probably saves money, improves productivity, averts suicides, reduces morbidity and makes life better for the patient, the family, the neighbors and the rest of us. Given that the most effective treatment for depression is non-pharmacologic (Cognitive Behavioral Therapy) and doesn't impair glucose metabolism or renal function, the main issue is how so we get these patients into therapy?

Endocrinologists have a role, but they only see a small fraction of diabetic patients, and they often aren't equipped to diagnose and manage depression. This is one of those things that Primary Care does - and is getting better at all the time. More and more PCPs are routinely screening their patients for depression (often with the PHQ-9 - the same instrument used in Yu's study) and are developing systems to provide therapy either in the practice or by referral.

However, PCPs are prone to the same tunnel vision as every other doctor. If the patient isn't in the office, often nothing happens - no diagnosis, no treatment, no prevention. So, here is one more reason to use systematic patient engagement strategies to make sure that the PCP and the patient are interacting. Because that's when the good stuff happens!

Yu MK, Weiss NS, Ding X, Katon WJ, Zhou XH, Young BA. Associations between Depressive Symptoms and Incident ESRD in a Diabetic Cohort. Clin J Am Soc Nephrol. 2014 Mar 27. [Epub ahead of print]