2.3.0.0 Strategies for System-Level Improvement
Optimal diabetes management requires an organized, systematic approach and the involvement of a coordinated team of dedicated health care professionals working in an environment where patient-centered high-quality care is a priority (7,14,15). While many diabetes processes of care have improved nationally in the past decade, the overall quality of care for patients with diabetes remains suboptimal (3). Efforts to increase the quality of diabetes care include providing care that is concordant with evidence-based guidelines (16); expanding the role of teams to implement more intensive disease management strategies (7,17,18); tracking medication taking behavior at a systems level (19); redesigning the organization of the care process (20); implementing electronic health record tools (21,22); empowering and educating patients (23,24); removing financial barriers and reducing patient out-of-pocket costs for diabetes education, eye exams, diabetes technology, and necessary medications (7); assessing and addressing psychosocial issues (25,26); and identifying, developing, and engaging community resources and public policies that support healthy lifestyles (27). The National Diabetes Education Program maintains an online resource (www.betterdiabetescare.nih.gov) to help health care professionals design and implement more effective health care delivery systems for those with diabetes.
The care team, which centers around the patient, should avoid therapeutic inertia and prioritize timely and appropriate intensification of lifestyle and/or pharmacologic therapy for patients who have not achieved the recommended metabolic targets (28-30). Strategies shown to improve care team behavior and thereby catalyze reductions in A1C, blood pressure, and/or LDL cholesterol include engaging in explicit and collaborative goal setting with patients (31,32); identifying and addressing language, numeracy, or cultural barriers to care (33-35); integrating evidence-based guidelines and clinical information tools into the process of care (16,36,37); soliciting performance feedback, setting reminders, and providing structured care (e.g., guidelines, formal case management, and patient education resources) (7); and incorporating care management teams including nurses, dietitians, pharmacists, and other providers (17,38). Initiatives such as the Patient-Centered Medical Home show promise for improving health outcomes by fostering comprehensive primary care and offering new opportunities for team-based chronic disease management (39).
Telemedicine is a growing field that may increase access to care for patients with diabetes. Telemedicine is defined as the use of telecommunications to facilitate remote delivery of health-related services and clinical information (40). A growing body of evidence suggests that various telemedicine modalities may be effective at reducing A1C in patients with type 2 diabetes compared with usual care or in addition to usual care (41). For rural populations or those with limited physical access to health care, telemedicine has a growing body of evidence for its effectiveness, particularly with regard to glycemic control as measured by A1C (42-44). Interactive strategies that facilitate communication between providers and patients, including the use of web-based portals or text messaging and those that incorporate medication adjustment, appear more effective. There is limited data available on the cost-effectiveness of these strategies.
Successful diabetes care also requires a systematic approach to supporting patients’ behavior change efforts. High-quality diabetes self-management education and support (DSMES) has been shown to improve patient self management, satisfaction, and glucose outcomes. National DSMES standards call for an integrated approach that includes clinical content and skills, behavioral strategies (goal setting, problem solving), and engagement with psychosocial concerns (26). For more information on DSMES, see Section 5 “Lifestyle Management.”
In devising approaches to support disease self-management, it is notable that in 23% of cases, uncontrolled A1C, blood pressure, or lipids were associated with poor medication-taking behaviors (“medication adherence”) (19). At a system level, “adequate” medication taking is defined as 80% (calculated as the number of pills taken by the patient in a given time period divided by the number of pills prescribed by the physician in that same time period) (19). If medication taking is 80% or above and treatment goals are not met, then treatment intensification should be considered (e.g., uptitration). Barriers to medication taking may include patient factors (financial limitations, remembering to obtain or take medications, fear, depression, or health beliefs), medication factors (complexity, multiple daily dosing, cost, or side effects), and system factors (inadequate follow-up or support). Success in overcoming barriers to medication taking may be achieved if the patient and provider agree on a targeted approach for a specific barrier (12).
The Affordable Care Act has resulted in increased access to care for many individuals with diabetes with an emphasis on the protection of people with preexisting conditions, health promotion, and disease prevention (45). In fact, health insurance coverage increased from 84.7% in 2009 to 90.1% in 2016 for adults with diabetes aged 18–64 years. Coverage for those ≥65 years remained near universal (46). Patients who have either private or public insurance coverage are more likely to meet quality indicators for diabetes care (47). As mandated by the Affordable Care Act, the Agency for Healthcare Research and Quality developed a National Quality Strategy based on the triple aims that include improving the health of a population, overall quality and patient experience of care, and per capita cost (48,49). As health care systems and practices adapt to the changing landscape of health care, it will be important to integrate traditional disease-specific metrics with measures of patient experience, as well as cost, in assessing the quality of diabetes care (50,51). Information and guidance specific to quality improvement and practice transformation for diabetes care is available from the National Diabetes Education Program practice transformation website and the National Institute of Diabetes and Digestive and Kidney Diseases report on diabetes care and quality (52,53). Using patient registries and electronic health records, health systems can evaluate the quality of diabetes care being delivered and perform intervention cycles as part of quality improvement strategies (54). Critical to these efforts is provider adherence to clinical practice recommendations and accurate, reliable data metrics that include sociodemographic variables to examine health equity within and across populations (55).
In addition to quality improvement efforts, other strategies that simultaneously improve the quality of care and potentially reduce costs are gaining momentum and include reimbursement structures that, in contrast to visit-based billing, reward the provision of appropriate and high-quality care to achieve metabolic goals (56) and incentives that accommodate personalized care goals (7,57).