Redesigning Primary Care to Improve Diabetes Outcomes (The UNITED Study) 

The UNITED Study examines the question: what if improving diabetes care was as easy as changing the way we interact with patients? 

Diabetes education has been slowly improving, according to national standardized quality measures. One possible solution for improving the delivery of care is the patient-centered medical home (PCMH). These are meant to promote active management and care coordination to increase health, as well as to improve patient satisfaction and decrease cost. However, what precisely a PCMH is, is unclear; the principles are there, but the operations can vary widely, and the effects have remained inconclusive. The PCMH is a practice where the primary care physician coordinates patient treatment, ensuring the patient receives the care they need when and where they need it, delivered in a way that they can understand. In Minnesota, the legislation was adopted in 2008 that added additional reimbursement to PCMHs and required primary care practices to report their annual diabetes performance measures.  

The Understanding Infrastructure Transformation Effects on Diabetes (UNITED) study takes advantage of this wealth of information. By 2017, 355 of the 585 primary care practices used in the cohort of this study were licensed PCMHs. To assist in improving patient care, the UNITED study looked to identify specific actions and infrastructure changes that were associated with high-quality diabetes care. Primary care practices eligible for this study were those that practiced in Minnesota or provided primary care to patients in Minnesota and had thirty or more patients with diabetes in 2016. An 82-question “practice connections-research survey” was used to evaluate the presence of 62 systems of care management used at each practice. This survey was created and tested for reliability by the National Committee for Quality Assurance to assess: Clinical information systems, decision support, delivery system redesign, health care organization, and clinical quality improvement. While these do not directly monitor diabetes care, they do assess the quality of care and utilization for patients with diabetes. Practice groups were considered small if they had one practice site, medium if they had 2-11 practice sites, or large if they had 12 or more practice sites. The National Quality Forum-Endorsed Maintenance Standard Optimal Diabetes Care (NFQ#0729) was used to evaluate performance. This measures endpoints as a composite measure that includes achieving all the following: Last A1C <8%, last blood pressure <140-90 mmHg, a prescribed statin (unless contraindicated), documentation in the past two years of no tobacco use, and one daily aspirin or antiplatelet in patients with an ischemic vascular disease (unless contraindicated). The results of this performance measure were recorded as a simple “yes” or “no.” These results were modeled using a logit framework. Predictors were the 62 systems of care management. Effects were controlled for variables such as age, sex, type of diabetes, and rurality of practice, among others.  

Of the 585 possible primary care practices, 395 completed this study, resulting in data from 215,842 individual patients with type 1 or type 2 diabetes. Among these, 45.8% achieved the composite endpoint in 2017. This was slightly higher in large urban practices (46.8%) than in small urban (45.8%) or rural (42.9%) practices (P < 0.001). As reported by the practice leaders, improvement in diabetes care was ranked a higher priority than depression, asthma, or cardiovascular disease. Three systems of care management were found to result in significant increases in the achievement of the composite endpoint of NQF#0729: Shared decision making with patients, checklists of tests or interventions needed, and guideline-based reminders of risk assessments. The shared decision making with patients increased achievement of the composite endpoint by 2.6% (P < 0.001), checklists by 3.2% (P < 0.003), and guideline-based reminders by 5% (P < 0.005). Together, these improved achievement by 10.8% (P < 0.001). While all three systems resulted in improvement, the impact of each varied among subgroups. Shared decision making had a larger impact in large practices, while reminders for risk assessments had a larger impact on small practices. It was found that 36 systems of care management had either no significant effect on or a negative effect on diabetes quality measures.  

Comprehensive changes to primary care practice are often expensive and may dissuade changes to how care is provided. The UNITED study looked at systems of care management to see which, if any, showed improvement in composite endpoints of diabetes care. It found that three systems of care resulted in significantly higher results in diabetes quality measures. A systematic process to conduct shared decision making with patients, checklists of tests or other interventions that are needed for prevention or monitoring in diabetes, and guideline-based reminders of age-appropriate risk assessments were found to be the most important. When all of these were combined, the result was a 10.8% increase in the probability of a patient achieving the studied performance measures.  

Practice Pearls: 

• Not all changes to patient care must be big. Significant improvements in diabetes quality measures were seen by implementing a checklist of tests or interventions needed. 
• The UNITED study found that a 10.8% increase in achievement of the composite endpoint resulted from implementing three systems of care.  

• Shared decision making was found to work better for large practices, while reminders for risk assessments were found to work best for small practices.  

“Defining the PCMH.” Agency for Healthcare Research and Quality, U.S. Department of Health & Human Services, pcmh.ahrq.gov/page/defining-pcmh. 

Peterson, Kevin A., et al. “Redesigning Primary Care to Improve Diabetes Outcomes (The UNITED Study).” Diabetes Care, American Diabetes Association, 27 Dec. 2019, care.diabetesjournals.org/content/early/2019/12/26/dc19-1140. 

“What Is the Patient-Centered Medical Home?” ACP, American College of Physicians, www.acponline.org/practice-resources/business-resources/payment/delivery-and-payment-models/patient-centered-medical-home/understanding-the-patient-centered-medical-home/what-is-the-patient-centered-medical-home. 

George McConnell, PharmD. Candidate, LECOM School of Pharmacy