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Back: A Look Ahead Approach to Treating Diabetes

Dr. Fromer

 Len Fromer, MD, FAAFP
 Steering Committee
 Primary Care Metabolic Group

In early June over 15,000 people gathered in New Orleans for five days of sharing and learning about our state of knowledge on diabetes. The annual meeting of the American Diabetes Association is an opportunity for the world’s great diabetes researchers to teach the world evidence discovered about the tsunamic epidemic of this disease state. Amazing science is shared. Tremendous amounts of current knowledge is exchanged with audiences eager to advance diabetes care.

We have a problem.

There is an urgent need to embark on an additional journey, one that recognizes the imperative to always intersect great science with caring for patients. Integrating state of the art evidence from scientific endeavor into practice is one of the fundamental pillars of the patient centered medical home and chronic care models.

There now exists a wide gap between the science and clinical outcomes. Research on the clinical aspects of diabetes generally falls into 5 broad categories:         

1. Risk factors for diabetes

2. Prediction and screening for diabetes

3. Therapeutic lifestyle change and its impact on diabetes risk and control

4. Health literacy and its role in diabetes care

5. Models to improve care

As we look at each category it becomes apparent that the powerful data and science being presented at ADA is our roadmap for the patient journey through care. This plays out via workflow redesign in our practices as we transform away from urgent rescue of diabetics towards a regular planned care model.

One research project presented at ADA as a poster session illustrates these points. An analysis was presented that had looked at a network of primary care practices in Minnesota and how each performed on achieving better A1C levels in their diabetic patient populations. Specifically, the researchers found the highest performing practices and asked a simple question: what did these practices do differently that enabled them to achieve strikingly better outcomes? What they found was quite enlightening: high performing practices had instituted a regular planned care model for diabetes that included routine scheduled follow up visits, and on each visit the best practices utilized a proactive ‘treat forward’ approach: how was the patient’s A1C on that visit, what is the target they wanted to achieve on the next visit, and how do they get there. This look ahead approach was in stark contrast to the average or underperforming practices, which routinely would look backwards on each visit to see if the patient had improved from the previous encounter. The focus on the future and targeted goals made an enormous difference and enabled the high performing practices to avoid clinical inertia (Rush, WA et al, presented at ADA, New Orleans, June 5-9 2009, poster session #1206)

In another example of how we can and need to integrate research into practice, Hoerger et al presented results of their analysis of the impact of risk factor control on the quality of life and mortality rates for diabetics. Their work found that as we achieve helping patients control the three key risk factors of hyperglycemia, blood pressure, and cholesterol, we do indeed see a beneficial effect on quality of life, micro and macrovascular complications, and mortality rates (Hoerger et al, ADA New Orleans June, 2009, 41-OR).
Integration of this information into practice empowers better physician-patient education and adherence and would have a powerful effect on improving outcomes.

Informed, activated patients working with teams of clinical and non-clinical staff in our offices are necessary to implement this model of care. Health information technology enables access to data whenever and wherever it is needed. Registries to analyze and take action on a disease state and population based model of care drive us to best in class center of excellence care.

So, how do we make the right choices in this journey to the most effective diabetes care? The answers are before us, packaged in the research presented at the ADA. It informs us with evidence, helping us to make the correct decisions as we redesign and continuously create a culture of practice improvement every day. Bridging the gap between great science and taking care of our patients is exactly what we need as the singular most important take away from 5 days at ADA.

Share your thoughts on PCMG’s Blog!

Do you plan to make any changes in your practice to integrate a ‘look ahead’ approach  to treat your patients with diabetes? If so, what plans do you have?