July 03, 2014
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'Bundled' management reduced diabetes-related vascular complications

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A team-based model with an all-or-none or “bundled” approach to primary care reduced the risk for myocardial infarction, stroke and retinopathy for patients with diabetes, according to research published in The American Journal of Managed Care.

Frederick J. Bloom Jr., MD, and colleagues from Geisinger Health System evaluated the nine-component bundle of diabetes measures, workflow redesign, electronic health record tools and financial incentives included in the Geisinger Health Plan over 3 years.

“Given that diabetes is more and more common and has a disproportionate impact on cost as well as morbidity and mortality, it is imperative that we find ways to reliably deliver better care,” Thomas Graf, MD, chief medical officer for population health at Geisinger and a researcher on the study, told Endocrine Today.

Through a parallel pre-post observational design, the researchers compared 4,095 primary care patients in the Diabetes System of Care (DS) group — developed by the integrated health services organization in 1996 — against 4,095 propensity score-matched primary care patients in the non-Diabetes System of Care (NDS) group.

The researchers calculated cumulative hazard rate for retinopathy, amputation, stroke and MI to determine whether the primary care diabetes bundled system would reduce the risk for microvascular and macrovascular complications more than usual care.

Patients in the DS cohort showed significantly lower adjusted hazard ratios for MI (HR=0.77; 95% CI, 0.65-0.9), stroke (HR=0.79; 95% CI, 0.65-0.97), and retinopathy (HR=0.81; 95% CI, 0.68-0.97).

No difference in adjusted HR was seen between groups for major amputations (HR=1.32; 95% CI, 0.45-3.85); however, only 17 major amputations occurred during follow-up.

The investigators determined that to prevent a single event during 3 years, it would be necessary to treat 82 for MI, 178 for stroke and 151 for retinopathy.

With multiple interventions required for the DS, however, the system-wide change did not come without challenge.

“Much of the work involved redesigning workflows, creating electronic accelerators to support just-in-time information targeted to the level of the staff person to allow everyone to work at the top of license and increase efficiency,” Graf said.

The researchers continue their work to determine the best combination of bundled measures, redesign and financial incentives, according to the study; further analysis on how the system of care affects overall mortality and total cost of care is planned.

Shifting to a bundled care system is feasible by any size practice, Graf said.

“Larger practices often have an easier time with creating the infrastructure to do this with near perfect reliability, but the speed of change with smaller practices is often greater, and so results can sometimes be seen quicker.” — by Allegra Tiver

Disclosure: The study was funded by Geisinger Health Plan. Two researchers report accepting fees from the Merck Speaker’s Bureau.