A Controlled Trial of Population Management

Abstract

OBJECTIVE—Population-level strategies to organize and deliver care may improve diabetes management. We conducted a multiclinic controlled trial of population management in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS—We created diabetic patient registries (n = 3,079) for four primary care clinics within a single academic health center. In the intervention clinic (n = 898), a nurse practitioner used novel clinical software (PopMan) to identify patients on a weekly basis with outlying values for visit and testing intervals and last measured levels of HbA1c, LDL cholesterol, and blood pressure. For these patients, the nurse practitioner e-mailed a concise patient-specific summary of evidence-based management suggestions directly to primary care providers (PCPs). Population changes in risk factor testing, medication prescription, and risk factor levels from baseline (1 January 2000 to 31 August 2001) to follow-up (1 December 2001 to 31 July 2003) were compared with the three usual-care control clinics (n = 2,181). RESULTS—Patients had a mean age of 65 years, were mostly white (81%), and the majority were insured by Medicare/Medicaid (62%). From baseline to follow-up, the increase in proportion of patients tested for HbA1c (P = 0.004) and LDL cholesterol (P < 0.001) was greater in the intervention than control sites. Improvements in diabetes-related medication prescription and levels of HbA1c, LDL cholesterol, and blood pressure in the intervention clinic were balanced by similar improvements in the control sites. CONCLUSIONS—Population-level clinical registries combined with summarized recommendations to PCPs had a modest effect on management. The intervention was limited by good overall quality of care at baseline and temporal improvements in all control clinics. It is unknown whether this intervention would have had greater impact in clinical settings with lower overall quality. Further research into more effective methods of translating population registry information into action is required.

Diabetes care among veteran women with disability

“…However, subgroup differences by age in testing and by race/ethnicity in HbA 1c testing and outcomes among disabled women suggest that subgroup-specific interventions may be needed to improve diabetes care. This is also consistent with a larger body of literature suggesting the lack of efficacy of global quality improvement programs for diabetes and hypertension (Grant et al, 2004;Murray et al, 2004;O'Connor et al, 2005).…”

Effect of a Nurse-Directed Diabetes Disease Management Program on Urgent Care/Emergency Room Visits and Hospitalizations in a Minority Population

“…Unfortunately, most approaches used to improve diabetes outcome measures have been ineffective in practice. These include: 1) reminding patients about appointments (5,6); 2) providing feedback information on patients to their treating physicians (7)(8)(9)(10), even when treatment recommendations for the patient were included (11,12); 3) case management (when the case manager could not make treatment decisions) (13,14); 4) physician education (15,16); and 5) multifaceted quality improvement interventions in the practice setting (17,18).…”

The Vermont Diabetes Information System: A Cluster Randomized Trial of a Population Based Decision Support System

“…Another study in 24 practices in Minnesota, which included a case manager function, showed improvements in both process and outcome 15 . Other interventions have resulted in improvement in process but not laboratory outcomes 8,10,16 . Systematic reviews suggest that quality improvement strategies in diabetes care produce modest results 45,46 .…”

“…The Chronic Care Model highlights the importance of a population-based approach; involving community, patients and providers; and information technology [4][5][6] . Various combinations of population management, practice support, and patient outreach have been used for diabetes care in a variety of settings with mixed results [7][8][9][10][11][12][13][14][15][16] . Many practice interventions for diabetes have been carried out in academic and urban centers.…”