In the JournalsPerspective

Population management program improves CV risk factor control in diabetes

Jamal S. Rana

A comprehensive population management program that was implemented into a health care delivery system improved CV risk factor control in patients with diabetes, according to a study published in The American Journal of Medicine.

“People with diabetes face a higher risk of stroke and heart attack, but controlling key risk factors is a real challenge,” Jamal S. Rana, MD, PhD, cardiologist at Oakland Medical Center and adjunct investigator in the division of research at Kaiser Permanente Northern California in Oakland, California, said in a press release.

CV risk in diabetes

Researchers assessed temporal trends and prevalence of LDL, HbA1c and BP in patients with diabetes from the National Committee for Quality Assurance from 2004 to 2013. The number of patients ranged from 98,345 to 122,177, and the mean age ranged from 52 to 54 years.

Patients received care from Kaiser Permanente Northern California, which implemented a quality improvement program in 2014 to care for patients with diabetes.

The program, called Preventing Heart Attacks and Strokes Everyday (PHASE), consisted of the following:

  • a diabetes registry to identify patients with diabetes who require cardiac risk reduction activities;
  • a report of annual prevalence of LDL, hypertension and HbA1c control;
  • an evidence-based CV risk factor control algorithm for step therapy to aid clinicians; and
  • nurse and pharmacist care managers who worked under certain protocols to reach out to patients with diabetes and require CV risk factor management.

The CV risk factor control outcome of interest was quality measures for LDL (< 100 mg/dL) and HbA1c (> 9%).

Improvements in risk factors

During the study period, poor glycemic control worsened nationally (31% to 34%; average annual percent change [AAPC] = 0.3; P = .8), but it improved in patients who participated in the program (28% to 18%; AAPC = –4.8; P < .05).

Lipid control also increased in patients from the program (47% to 71%; AAPC = 4.3; P < .05). The improvement was not as significant on a national level (40% to 44%; AAPC = 1.4; P = .2).

From 2007 to 2013, more patients in the program had controlled BP (77% to 82%; AAPC = 1.1; P < .05) compared with those on a national level during the study period (57% to 62%; AAPC = 1.9; P < .05).

“Major benefits of adoption and use of standardized, evidence-based protocols include reduced clinical variability that is outside the bounds of evidence-based practice, participation of qualified health care team members in medication titration, incorporation of treatment algorithms into clinical decision support, facilitation of the development of registries and quality improvement measurements, promotion of efficient and cost-effective medications and treatments, and demonstration to clinical staff that risk factor control is a priority,” Rana and colleagues wrote. “We believe that PHASE was successful in providing such framework to manage risk factor control by utilizing linear care pathways that facilitated consistent implementation and enabled care managers and primary care providers to operate efficiently.” – by Darlene Dobkowski

Disclosures: The study was supported by a Kaiser Permanente Northern California Community Benefit grant. The authors report no relevant financial disclosures.

Jamal S. Rana

A comprehensive population management program that was implemented into a health care delivery system improved CV risk factor control in patients with diabetes, according to a study published in The American Journal of Medicine.

“People with diabetes face a higher risk of stroke and heart attack, but controlling key risk factors is a real challenge,” Jamal S. Rana, MD, PhD, cardiologist at Oakland Medical Center and adjunct investigator in the division of research at Kaiser Permanente Northern California in Oakland, California, said in a press release.

CV risk in diabetes

Researchers assessed temporal trends and prevalence of LDL, HbA1c and BP in patients with diabetes from the National Committee for Quality Assurance from 2004 to 2013. The number of patients ranged from 98,345 to 122,177, and the mean age ranged from 52 to 54 years.

Patients received care from Kaiser Permanente Northern California, which implemented a quality improvement program in 2014 to care for patients with diabetes.

The program, called Preventing Heart Attacks and Strokes Everyday (PHASE), consisted of the following:

  • a diabetes registry to identify patients with diabetes who require cardiac risk reduction activities;
  • a report of annual prevalence of LDL, hypertension and HbA1c control;
  • an evidence-based CV risk factor control algorithm for step therapy to aid clinicians; and
  • nurse and pharmacist care managers who worked under certain protocols to reach out to patients with diabetes and require CV risk factor management.

The CV risk factor control outcome of interest was quality measures for LDL (< 100 mg/dL) and HbA1c (> 9%).

Improvements in risk factors

During the study period, poor glycemic control worsened nationally (31% to 34%; average annual percent change [AAPC] = 0.3; P = .8), but it improved in patients who participated in the program (28% to 18%; AAPC = –4.8; P < .05).

Lipid control also increased in patients from the program (47% to 71%; AAPC = 4.3; P < .05). The improvement was not as significant on a national level (40% to 44%; AAPC = 1.4; P = .2).

From 2007 to 2013, more patients in the program had controlled BP (77% to 82%; AAPC = 1.1; P < .05) compared with those on a national level during the study period (57% to 62%; AAPC = 1.9; P < .05).

“Major benefits of adoption and use of standardized, evidence-based protocols include reduced clinical variability that is outside the bounds of evidence-based practice, participation of qualified health care team members in medication titration, incorporation of treatment algorithms into clinical decision support, facilitation of the development of registries and quality improvement measurements, promotion of efficient and cost-effective medications and treatments, and demonstration to clinical staff that risk factor control is a priority,” Rana and colleagues wrote. “We believe that PHASE was successful in providing such framework to manage risk factor control by utilizing linear care pathways that facilitated consistent implementation and enabled care managers and primary care providers to operate efficiently.” – by Darlene Dobkowski

Disclosures: The study was supported by a Kaiser Permanente Northern California Community Benefit grant. The authors report no relevant financial disclosures.

    Perspective
    Darren McGuire

    Darren McGuire

    While analyzing secular trends in health care performance in general and for type 2 diabetes targeted risk factors specifically, as done here, is not new, there are a few added bells and whistles here that are noteworthy. No. 1, using the national contemporary data for comparison and contrast is useful in supporting the likelihood that the measured changes in quality performance were driven at least in part by the PHASE program and not just a sign of the evolving care in American medicine.

    No. 2, except for the nurse/pharmacist navigator effort, the remainder of the PHASE intervention can largely be automated within a common electronic medical record system, so there is little effort required beyond the programming — and likely substantial clinical benefits for patients and for populations.

    I particularly like the quarterly reporting of metrics to each center. When reported in the context of the program average and the top performing centers, this can prove a potent instrument to raise the level of care at each center performing below the top tier. We have used inpatient and outpatient cardiology registries in this way for decades with consistently good results.

    Single clinics or centers could relatively easily apply some facets of the PHASE program, but only with the assumption that the results are attributable in part to each of the four parts of the intervention. For example, if a clinic applies all but the nurse/pharmacist part, one cannot be certain from these data what proportion of the improvement might be affected, or is all of the change observed exclusively attributable to the added role/interventions of these dedicated providers? Providers, clinics and systems can be and should be tracking the key evidence-based metrics and feeding back results for continued improvements in such interventions.

    Programs like Kaiser Permanente Northern California have tremendous potential to embed research like this into everyday practice. For future such programs, the system might consider “cluster randomization,” with clinics being the unit of randomization to be able to more clearly separate effects of the program from secular trends within the health care system, which may not necessarily be present in the nationwide experience. Then among those randomized to the program, a secondary randomization to apply one, two, three or all four of the components would make it possible to see which is/are most important and which did not contribute at all.

    First, though hyperglycemia is a prognostic risk factor for atherosclerotic vascular disease, pharmacological interventions targeting improved blood glucose have not yielded atherosclerotic CVD benefits. While important for microvascular disease risk mitigation, and in that context, quality patient care, the reporting, as is done here, tends to perpetuate the misperception that glycemic control is a metric of quality CV care. This bias of the authors is reflected in the ordered presentation throughout the report: “glucose, cholesterol and blood pressure.”

    Also, acknowledging the intervention began in the early 2000s, the thresholds used to identify targeted LDL and BP are debatable — which was the case even when the program started. Most would consider LDL < 70 mg/dL and BP below 130 mm Hg systolic/80 mm Hg diastolic more evidence-based and more potent atherosclerotic CVD prevention targets. The authors might have addressed this by meeting in the middle and, in addition to the data presented that they selected a priori, could have also reported the frequency of achieving these more aggressive targets. Capitalizing on what are missed opportunities for a more global assessment of atherosclerotic CVD prevention in type 2 diabetes would have meant analyzing the frequency of use of ACE inhibitors or angiotensin receptor blockers  independent of BP, the frequency of use of daily aspirin for the highest-risk patients at least for those with prevalent atherosclerotic CVD and the frequency of smoking abstinence or, for those actively smoking, the frequency of counseling or referral for cessation programs.

    • Darren McGuire, MD
    • Cardiology Today Editorial Board Member UT Southwestern Medical Center

    Disclosures: McGuire reports he consults for AstraZeneca, Boehringer Ingelheim, Lilly USA, Merck, Metavant, Novo Nordisk, Pfizer and Sanofi Aventis and has clinical trial leadership with AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Janssen, Lexicon Pharmaceuticals, Merck, Novo Nordisk and Sanofi Aventis.