The impact of diabetes counseling and education: clinical and cost outcomes from a large population of US managed care patients with type 2 diabetes

Effects of conformance to type 2 diabetes guidelines on health care resource utilization, clinical outcomes, and cost: A retrospective claims analysis

OBJECTIVES

To determine if there is a difference in the outcomes of diabetes patients managed with high, intermediate, or low conformance to diabetes guidelines.

STUDY DESIGN

Retrospective database analysis.

METHODS

This was a retrospective database analysis of adults diagnosed with type 2 diabetes and with glycated hemoglobin (HbA1c) ≥7% (53 mmol/mol) who were commercially insured by, or receiving Medicare benefits through, Aetna. Subjects were classified as having high, intermediate, or low conformance to current guidelines. Six, 12, and 18 months later, health care resource utilization, clinical outcomes, and costs were assessed using multivariable regression analysis to determine whether differences existed between patients with high, intermediate, and low conformance. Regression models were adjusted using pre-index variables, and the results were expressed as incidence rate ratios (IRRs) with 95% confidence intervals (CIs).

RESULTS

A total of 21,171 individuals were included in the analysis. In analyses of patients with low versus high conformance, pharmacy costs were significantly lower over 18 months of outcome assessment (P < 0.001), but diabetes-related outpatient costs were significantly higher (P < 0.001). In analyses of patients with intermediate versus high conformance, diabetes-related outpatient costs were significantly greater at 12 and 18 months (P < 0.001 for both).

CONCLUSIONS

Reduced conformance to guidelines leads to higher diabetes-related costs.

A quality improvement project to increase compliance with diabetes measures in an academic outpatient setting

BACKGROUND

American Diabetes Association (ADA) sets annual guidelines on preventative measures that aim to delay the onset of severe diabetes mellitus complications. Compared to private internal medicine clinics, resident clinics provide suboptimal diabetic preventative care as evidenced by decreased compliance with ADA guidelines. The purpose of our study is to improve diabetic care in resident clinics through quality improvement (QI) projects, with A1C value as primary outcome and other ADA guidelines as secondary outcomes.

METHODS

Our resident clinic at Beaumont Hospital, Royal Oak consists of 76 residents divided in 8 teams. In November 2016, baseline data on ADA guideline measures was obtained on 538 patients with diabetes mellitus. A root cause analysis was conducted. 5 teams developed a QI intervention plan to improve their diabetes care and 3 teams served as comparisons without intervention plans. In November 2017, post-intervention data was collected.

RESULTS

Baseline characteristics demonstrate mean age of intervention groups at 60.9 years and of comparison groups at 58.9 years. The change in A1C value from baseline to post-intervention was + 0.09 vs. + 0.322 in the intervention and comparison groups respectively (p = 0.174). As a group, the changes in secondary outcome measures were as follows: eye examinations (+ 5% in intervention vs. -7% in comparison, p < 0.01), foot examinations (+ 13% vs. + 5%, p = 0.09), lipid panel testing (+ 7% vs. -5%, p < 0.01), micro-albumin/creatinine ratio testing (+ 4% vs. + 1%, p = 0.03), and A1C testing (+8% vs. + 5%, p = 0.24).

CONCLUSIONS

While the QI project did not improve A1C value, it did have significant improvement in several secondary outcomes within intervention groups. One resident team implemented an intervention involving protected half-day blocks to identify overdue examinations and consequently had the largest improvements, thus serving as a potential intervention to further study. Given our study results, we believe that QI interventions improve preventative care for patients with diabetes in resident clinics.

Diabetes Education Impact on Hypoglycemia Outcomes: A Systematic Review of Evidence and Gaps in the Literature

PURPOSE

The primary purpose of this study is to report a systematic review of evidence and gaps in the literature among well-conducted studies assessing the impact of diabetes education on hypoglycemia outcomes and secondarily reporting the impact on other included target outcomes.

METHODS

The authors used a modified Cochrane method to systematically search and review English-language titles, abstracts, and full-text articles published in the United States between January 2001 and December 2017, with diabetes education specified as an intervention and a directly measurable outcome for hypoglycemia risk or events included.

RESULTS

Fourteen quasi-experimental, experimental, and case-control studies met the inclusion criteria, with 8 articles reporting a positive impact of diabetes self-management education and support (DSMES) on hypoglycemia outcomes; 2 of the 8 reported decreased hypoglycemia events, and 1 reported decreased events in both the intervention and control groups. In addition, 5 studies targeted change in reported hypoglycemia symptoms, with all 5 reporting a significant decrease. DSMES also demonstrated an impact on intermediate (knowledge gain, behavior change) and long-term (humanistic and economic/utilization) outcomes. An absence of common hypoglycemia measures and terminology and suboptimal descriptions of DSMES programs for content, delivery, duration, practitioner types, and participants were identified as gaps in the literature.

CONCLUSIONS

Most retained studies reported that diabetes education positively affected varied measures of hypoglycemia outcomes (number of events, reported symptoms) as well as other targeted outcomes. Diabetes education is an important intervention for reducing hypoglycemia events and/or symptoms and should be included as a component of future hypoglycemia risk mitigation studies.

Impact of pharmacotherapeutic education on medication adherence and adverse outcomes in patients with type 2 diabetes mellitus: a prospective, randomized study

AIM

To evaluate the impact of pharmacotherapeutic education on 30-day post-discharge medication adherence and adverse outcomes in patients with type 2 diabetes mellitus (T2DM).

METHODS

The prospective, randomized, single-center study was conducted at the Medical Department of University Hospital Dubrava, Zagreb, between April and June 2018. One hundred and thirty adult patients with T2DM who were discharged to the community were randomly assigned to either the intervention or the control group. Both groups during the hospital stay received the usual diabetes education. The intervention group received additional individual pre-discharge pharmacotherapeutic education about the discharge prescriptions. Medication adherence and occurrence of adverse outcomes (adverse drug reactions, readmission, emergency department visits, and death) were assessed at the follow-up visit, 30 days after discharge.

RESULTS

The number of adherent patients was significantly higher in the intervention group (57/64 [89.9%] vs 41/61 [67.2%]; χ2 test, P=0.003]. There was no significant difference between the groups in the number of patients who experienced adverse outcomes (31/64 [48.4%] vs 36/61 [59.0%]; χ2 test, P=0.236). However, higher frequencies of all adverse outcomes were consistently observed in the control group.

CONCLUSION

Pharmacotherapeutic education of patients with T2DM can significantly improve 30-day post-discharge medication adherence, without a significant reduction in adverse clinical outcomes. ClinicalTrial.gov identification number: NCT03438162.

A Patient-Facing Diabetes Dashboard Embedded in a Patient Web Portal: Design Sprint and Usability Testing

Background

Health apps and Web-based interventions designed for patients with diabetes offer novel and scalable approaches to engage patients and improve outcomes. However, careful attention to the design and usability of these apps and Web-based interventions is essential to reduce the barriers to engagement and maximize use.

Objective

The aim of this study was to apply design sprint methodology paired with mixed-methods, task-based usability testing to design and evaluate an innovative, patient-facing diabetes dashboard embedded in an existing patient portal and integrated into an electronic health record.

Methods

We applied a 5-day design sprint methodology developed by Google Ventures (Alphabet Inc, Mountain View, CA) to create our initial dashboard prototype. We identified recommended strategies from the literature for using patient-facing technologies to enhance patient activation and designed a dashboard functionality to match each strategy. We then conducted a mixed-methods, task-based usability assessment of dashboard prototypes with individual patients. Measures included validated metrics of task performance on 5 common and standardized tasks, semistructured interviews, and a validated usability satisfaction questionnaire. After each round of usability testing, we revised the dashboard prototype in response to usability findings before the next round of testing until the majority of participants successfully completed tasks, expressed high satisfaction, and identified no new usability concerns (ie, stop criterion was met).

Results

The sample (N=14) comprised 5 patients in round 1, 3 patients in round 2, and 6 patients in round 3, at which point we reached our stop criterion. The participants’ mean age was 63 years (range 45-78 years), 57% (8/14) were female, and 50% (7/14) were white. Our design sprint yielded an initial patient-facing diabetes dashboard prototype that displayed and summarized 5 measures of patients’ diabetes health status (eg, hemoglobin A_1c). The dashboard used graphics to visualize and summarize health data and reinforce understanding, incorporated motivational strategies (eg, social comparisons and gamification), and provided educational resources and secure-messaging capability. More than 80% of participants were able to successfully complete all 5 tasks using the final prototype. Interviews revealed usability concerns with design, the efficiency of use, and content and terminology, which led to improvements. Overall satisfaction (0=worst and 7=best) improved from the initial to the final prototype (mean 5.8, SD 0.4 vs mean 6.7, SD 0.5).

Conclusions

Our results demonstrate the utility of the design sprint methodology paired with mixed-methods, task-based usability testing to efficiently and effectively design a patient-facing, Web-based diabetes dashboard that is satisfying for patients to use.

Evaluation of a Diabetes Self-Management Program: Claims Analysis on Comorbid Illnesses, Health Care Utilization, and Cost

Background

An estimated 30.3 million Americans have diabetes mellitus. The US Department of Health and Human Services created national objectives via its Healthy People 2020 initiative to improve the quality of life for people who either have or are at risk for diabetes mellitus, and hence, lower the personal and national economic burden of this debilitating chronic disease. Diabetes self-management education interventions are a primary focus of this initiative.

Objective

The aim of this study was to evaluate the impact of the Better Choices Better Health Diabetes (BCBH-D) self-management program on comorbid illness related to diabetes mellitus, health care utilization, and cost.

Methods

A propensity score matched two-group, pre-post design was used for this study. Retrospective administrative medical and pharmacy claims data from the HealthCore Integrated Research Environment were used for outcome variables. The intervention cohort included diabetes mellitus patients who were recruited to a diabetes self-management program. Control cohort subjects were identified from the HealthCore Integrated Research Environment by at least two diabetes-associated claims (International Classification of Diseases-Ninth Revision, ICD-9 250.xx) within 2 years before the program launch date (October 1, 2011-September 30, 2013) but did not participate in BCBH-D. Controls were matched to cases in a 3:1 propensity score match. Outcome measures included pre- and postintervention all-cause and diabetes-related utilization and costs. Cost outcomes are reported as least squares means. Repeated measures analyses (generalized estimating equation approach) were conducted for utilization, comorbid conditions, and costs.

Results

The program participants who were identified in HealthCore Integrated Research Environment claims (N=558) were matched to a control cohort of 1669 patients. Following the intervention, the self-management cohort experienced significant reductions for diabetes mellitus–associated comorbid conditions, with the postintervention disease burden being significantly lower (mean 1.6 [SD 1.6]) compared with the control cohort (mean 2.1 [SD 1.7]; P=.001). Postintervention all-cause utilization was decreased in the intervention cohort compared with controls with −40/1000 emergency department visits vs +70/1000; P=.004 and −5780 outpatient visits per 1000 vs −290/1000; P=.001. Unadjusted total all-cause medical cost was decreased by US $2207 in the intervention cohort compared with a US $338 decrease in the controls; P=.001. After adjustment for other variables through structural equation analysis, the direct effect of the BCBH-D was –US $815 (P=.049).

Conclusions

Patients in the BCBH-D program experienced reduced all-cause health care utilization and costs. Direct cost savings were US $815. Although encouraging, given the complexity of the patient population, further study is needed to cross-validate the results.

Insurance coverage and diabetes quality indicators among patients with diabetes in the US general population

This study explores associations between health insurance and diabetes quality indicators. Data were obtained from 8305 patients with diabetes who reported no insurance, Medicaid or private insurance in the 2013 BRFSS in 26 states in the US. Six diabetes quality indicators were assessed: HgbA1c testing, foot exam, eye exam, influenza immunization, pneumococcal immunization and diabetes education. Logistic regression was performed comparing quality indicators by insurance group adjusting for covariates. Subjects with private insurance or Medicaid were more likely than the uninsured to have HgbA1c testing (OR=2.60, 95%CI: 2.02-3.35; OR=2.04, 95%CI: 1.55-2.69, respectively), a foot exam (OR=1.72, 95%CI: 1.32-2.25; OR=1.64, 95%CI: 1.23-2.18, respectively) and an eye exam (OR=2.01, 95%CI: 1.56-2.58; OR=2.50, 95%CI: 1.91-3.27, respectively). Those with private insurance were more likely than the uninsured to have influenza immunization (OR=1.75, 95%CI: 1.37-2.25) and diabetes education (OR=1.36, 95%CI: 1.06-1.74). Uninsured persons with diabetes are less likely to receive standard diabetes services compared to the insured, but most quality indicators were similar in publicly and privately insured groups.

Effect of a structured diabetes education programme in primary care on hospitalizations and emergency department visits among people with Type 2 diabetes mellitus: results from the Patient Empowerment Programme

AIM

To assess whether a structured diabetes education programme, the Patient Empowerment Programme, was associated with a lower rate of all-cause hospitalization and emergency department visits in a population-based cohort of patients with Type 2 diabetes mellitus in primary care.

METHODS

A cohort of 24 250 patients was evaluated using a linked administrative database during 2009-2013. We selected 12 125 patients with Type 2 diabetes who had at least one Patient Empowerment Programme session attendance. Patients who did not participate in the Patient Empowerment Programme were matched one-to-one with patients who did, using the propensity score method. Hospitalization events and emergency department visits were the events of interest. Cox proportional hazard and negative binomial regressions were performed to estimate the hazard ratios for the initial event, and incidence rate ratios for the number of events.

RESULTS

During a median 30.5 months of follow-up, participants in the Patient Empowerment Programme had a lower incidence of an initial hospitalization event (22.1 vs 25.2%; hazard ratio 0.879; P < 0.001) and emergency department visit (40.5 vs 44%; hazard ratio 0.901; P < 0.001) than those who did not participate in the Patient Empowerment Programme. Participation in the Patient Empowerment Programme was associated with a significantly lower number of emergency department visits (incidence rate ratio 0.903; P < 0.001): 40.4 visits per 100 patients annually in those who did not participate in the Patient Empowerment Programme vs. 36.2 per 100 patients annually in those who did. There were significantly fewer hospitalization episodes (incidence rate ratio 0.854; P < 0.001): 20.0 hospitalizations per 100 patients annually in those who did not participate in the Patient Empowerment Programme vs. 16.9 hospitalizations per 100 patients annually in those who did.

CONCLUSIONS

Among patients with Type 2 diabetes, the Patient Empowerment Programme was shown to be effective in delaying the initial hospitalization event and in reducing their frequency.

Real-world evaluation of the effects of counseling and education in diabetes management

Background. Patient education has long been recognized as a component of effective diabetes management, but the impact of counseling and education (C/E) interventions on health care costs is not fully understood. Objectives. To identify the incidence and type of diabetes C/E received by type 2 diabetes patients and to evaluate associated economic and clinical outcomes. Methods. This retrospective cohort study used the Premier-Optum Continuum of Care database (2005-2009) to compare adult patients with type 2 diabetes receiving C/E to those not receiving C/E (control). The index date was the first C/E date or, in the control cohort, a randomly assigned date on which some care was delivered. Patients had at least 6 months' pre-index and 12 months' post-index continuous health plan coverage. Health care costs and glycemic levels were evaluated over 12 and 6 months, respectively, with adjustment for differences in baseline characteristics using propensity score matching (PSM). Results. Of 26,790 patients identified, 9.3% received at least one C/E intervention (mean age 53 years, 47% men) and 90.7% received no C/E (mean age 57 years, 54% men). Standard diabetes education was the most common form of C/E (73%). After PSM, C/E patients had some improvements in glycemic levels (among those with laboratory values available), without increased risk for hypoglycemia, and incurred $2,335 per-patient less in diabetes-related health care costs, although their total health care costs increased. Conclusions. Despite the low uptake of C/E services, C/E interventions may be associated with economic and clinical benefits at 12 months. Further analyses are needed to evaluate the long-term cost-effectiveness of such initiatives.