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Diabetes Patients Do Better with Medical Home

Jul 21, 2011

Diabetes patients enrolled in a medical home program supported by multiple payers saw improvements in several aspects of their care.

According to Robert Gabbay, MD, PhD, of Penn State University, a study of 10,000 patients who had been in the program for a year found that the percentage of patients who had yearly foot assessments for neuropathy rose from a baseline 50% to 69%. In addition, more patients got yearly screenings for nephropathy and diabetic retinopathy, and there was also an increase in pneumonia and flu shots over baseline, the investigators reported. 


Providers also made greater use of therapies shown to reduce morbidity and mortality: the proportion of patients on statins jumped from 36% to 57% after initiation of the program, while those on either an ACE inhibitor or an angiotensin receptor blocker (ARB) rose from 42% to 56% (P<0.05 for both).

Gabbay and colleagues lamented the fact that only 7% of diabetes patients currently achieve evidence-based goals for key predictors of morbidity and mortality, including glycated hemoglobin (HbA1c), blood pressure, and lower LDL cholesterol.

Further improvements likely require a paradigm shift, they said, which may be found in the Chronic Care Model incorporated into the Patient-Centered Medical Home.

The patient-centered medical home concept involves a team-based model of care, led by a primary care doctor who provides coordinated care throughout a patient’s lifetime. The chronic care model focuses on multiple elements that enhance the relationship between patients with chronic conditions and their medical team, including greater support for self-management, improved clinical information systems, making community resources available, and offering decision support.

Gabbay and colleagues initiated one of the first medical home centers that incorporated the chronic care model for diabetes patients, initially encompassing 25 practices and 143 primary care providers covering about 10,000 diabetes patients in southeast Pennsylvania. Their model was unique, they said, because it incorporates multiple payers — six of the state’s private insurers.

Since there haven’t been any data reported on this type of medical home, Gabbay and colleagues analyzed the program’s first year, from May 2008 to May 2009.

During that time, they said they saw significant improvement in both evidence-based care guideline adherence and clinical outcomes.

Gabbay and colleagues also reported “small but statistically significant” improvements in key clinical parameters such as blood pressure and cholesterol, although they noted the greatest improvements occurred in the highest-risk patients:

  • An 8.5% absolute increase in the percentage of patients with an LDL cholesterol level under 130
  • A 4% absolute increase in those with blood pressure under 140/90
  • A 2.5% drop in the proportion of patients with HbA1c above 9%

They noted that these effects may have been the result of the fact that the initiatives focused on high-risk patients in order to reduce the number of people with the poorest diabetes quality measures. It’s also possible that “some of the assessed performance improvement could be attributed to better data collection, documentation, and reporting,” they wrote.

As well, improvements in complication screening resulted, in many cases, from distributing tasks among the healthcare team, they said.

The study was also limited by self-reported data, but overall the researchers said the program has already been expanded to include 152 practices and 644 providers.

Similar, multi-payer initiatives began after this initiative — in Colorado, Rhode Island, and Vermont — but Gabbay and colleagues noted that there are differences in their design and said it “will be important to understand how these differences affect the effectiveness of the patient-centered medical home efforts.”

Practice Pearls:

  • Explain that diabetes patients enrolled in a medical home program supported by multiple payers saw improvements in several aspects of their care.
  • Note that providers also made greater use of therapies shown to reduce morbidity and mortality, including prescribing statins as well as either angiotensin-converting enzyme inhibitors or angiotensin-receptor-blocking agents

Gabbay RA, et al “Multipayer patient-centered medical home implementation guided by the chronic care model” Joint Comm J Quality Patient Safety 2011; 37(6): 265-273