Redesigning ambulatory care management for uncontrolled type 2 diabetes: a prospective cohort study of the impact of a Boot Camp model on outcomes.
Redesigning ambulatory care management for uncontrolled type 2 diabetes: a prospective cohort study of the impact of a Boot Camp model on outcomes.
- 2019
Conclusions: Redesigning diabetes care management using a pragmatic technology-enabled approach supported translation of evidence-based best practices across a mixed-payer regional healthcare system. Diabetes educators successfully participated in medication initiation and titration. Improvement in glycemic control, reduction in hospitalizations and potential for monetization was demonstrated in a high-risk cohort of adults with uncontrolled type 2 diabetes. Objective: Type 2 diabetes care management (DCM) is challenging. Few studies report meaningful improvements in clinical care settings, warranting DCM redesign. We developed a Boot Camp to provide timely, patient-centered, technology-enabled DCM. Impact on hemoglobin A1c (HbA1c), emergency department (ED) visits and hospitalizations among adults with uncontrolled type 2 diabetes were examined. Research design and methods: The intervention was designed using the Practical Robust Implementation and Sustainability Model to embed elements of the chronic care model. Adults with HbA1c>9% (75 mmol/mol) enrolled between November 2014 and November 2017 received diabetes education and medication management by diabetes educators and nurse practitioners via initial clinic and subsequent weekly virtual visits, facilitated by near-real-time blood glucose transmission for 90 days. HbA1c and risk for ED visits and hospitalizations at 90 days, and potential savings from reducing avoidable medical utilizations were examined. Boot Camp completers were compared with concurrent, propensity-matched chart controls receiving usual DCM in primary care practices. 086 annually per participant for averted hospitalizations were calculated. Results: A cohort of 366 Boot Camp participants plus 366 controls was analyzed. Participants were 79% African-American, 63% female and 59% Medicare-insured or Medicaid-insured and mean age 56 years. Baseline mean HbA1c for cases and controls was 11.2% (99 mmol/mol) and 11.3% (100 mmol/mol), respectively. At 90 days, HbA1c was 8.1% (65 mmol/mol) and 9.9% (85 mmol/mol), p<0.001, respectively. Risk for 90-day all-cause hospitalizations decreased 77% for participants and increased 58% for controls, p=0.036. Mean potential for monetization of US Trial registration number: NCT02925312. Copyright (c) Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
English
2052-4897
10.1136/bmjdrc-2019-000731 [doi] bmjdrc-2019-000731 [pii] PMC6861097 [pmc]
*Ambulatory Care/og [Organization & Administration]
*Diabetes Mellitus, Type 2/bl [Blood]
*Diabetes Mellitus, Type 2/th [Therapy]
*Models, Organizational
Adult
Aged
Ambulatory Care Facilities/og [Organization & Administration]
Ambulatory Care Facilities/st [Standards]
Ambulatory Care/ec [Economics]
Ambulatory Care/st [Standards]
Blood Glucose Self-Monitoring
Blood Glucose/me [Metabolism]
Cohort Studies
Cost Savings
Diabetes Mellitus, Type 2/ec [Economics]
Diabetes Mellitus, Type 2/ep [Epidemiology]
District of Columbia/ep [Epidemiology]
Emergency Service, Hospital/ec [Economics]
Emergency Service, Hospital/sn [Statistics & Numerical Data]
Female
Glycated Hemoglobin A/me [Metabolism]
Hospitalization/ec [Economics]
Hospitalization/sn [Statistics & Numerical Data]
Humans
Long-Term Care/ec [Economics]
Long-Term Care/og [Organization & Administration]
Long-Term Care/st [Standards]
Male
Maryland/ep [Epidemiology]
Medicaid/ec [Economics]
Medicaid/sn [Statistics & Numerical Data]
Medicare/ec [Economics]
Medicare/sn [Statistics & Numerical Data]
Middle Aged
Patient-Centered Care/ec [Economics]
Patient-Centered Care/og [Organization & Administration]
Patient-Centered Care/st [Standards]
Treatment Outcome
United States/ep [Epidemiology]
MedStar Health Research Institute
MedStar Heart & Vascular Institute
MedStar Institute for Quality and Safety
MedStar Union Memorial Hospital
MedStar Washington Hospital Center
Medicine/Endocrinology
MedStar Diabetes Institute
MedStar Health, Columbia
Journal Article
Conclusions: Redesigning diabetes care management using a pragmatic technology-enabled approach supported translation of evidence-based best practices across a mixed-payer regional healthcare system. Diabetes educators successfully participated in medication initiation and titration. Improvement in glycemic control, reduction in hospitalizations and potential for monetization was demonstrated in a high-risk cohort of adults with uncontrolled type 2 diabetes. Objective: Type 2 diabetes care management (DCM) is challenging. Few studies report meaningful improvements in clinical care settings, warranting DCM redesign. We developed a Boot Camp to provide timely, patient-centered, technology-enabled DCM. Impact on hemoglobin A1c (HbA1c), emergency department (ED) visits and hospitalizations among adults with uncontrolled type 2 diabetes were examined. Research design and methods: The intervention was designed using the Practical Robust Implementation and Sustainability Model to embed elements of the chronic care model. Adults with HbA1c>9% (75 mmol/mol) enrolled between November 2014 and November 2017 received diabetes education and medication management by diabetes educators and nurse practitioners via initial clinic and subsequent weekly virtual visits, facilitated by near-real-time blood glucose transmission for 90 days. HbA1c and risk for ED visits and hospitalizations at 90 days, and potential savings from reducing avoidable medical utilizations were examined. Boot Camp completers were compared with concurrent, propensity-matched chart controls receiving usual DCM in primary care practices. 086 annually per participant for averted hospitalizations were calculated. Results: A cohort of 366 Boot Camp participants plus 366 controls was analyzed. Participants were 79% African-American, 63% female and 59% Medicare-insured or Medicaid-insured and mean age 56 years. Baseline mean HbA1c for cases and controls was 11.2% (99 mmol/mol) and 11.3% (100 mmol/mol), respectively. At 90 days, HbA1c was 8.1% (65 mmol/mol) and 9.9% (85 mmol/mol), p<0.001, respectively. Risk for 90-day all-cause hospitalizations decreased 77% for participants and increased 58% for controls, p=0.036. Mean potential for monetization of US Trial registration number: NCT02925312. Copyright (c) Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
English
2052-4897
10.1136/bmjdrc-2019-000731 [doi] bmjdrc-2019-000731 [pii] PMC6861097 [pmc]
*Ambulatory Care/og [Organization & Administration]
*Diabetes Mellitus, Type 2/bl [Blood]
*Diabetes Mellitus, Type 2/th [Therapy]
*Models, Organizational
Adult
Aged
Ambulatory Care Facilities/og [Organization & Administration]
Ambulatory Care Facilities/st [Standards]
Ambulatory Care/ec [Economics]
Ambulatory Care/st [Standards]
Blood Glucose Self-Monitoring
Blood Glucose/me [Metabolism]
Cohort Studies
Cost Savings
Diabetes Mellitus, Type 2/ec [Economics]
Diabetes Mellitus, Type 2/ep [Epidemiology]
District of Columbia/ep [Epidemiology]
Emergency Service, Hospital/ec [Economics]
Emergency Service, Hospital/sn [Statistics & Numerical Data]
Female
Glycated Hemoglobin A/me [Metabolism]
Hospitalization/ec [Economics]
Hospitalization/sn [Statistics & Numerical Data]
Humans
Long-Term Care/ec [Economics]
Long-Term Care/og [Organization & Administration]
Long-Term Care/st [Standards]
Male
Maryland/ep [Epidemiology]
Medicaid/ec [Economics]
Medicaid/sn [Statistics & Numerical Data]
Medicare/ec [Economics]
Medicare/sn [Statistics & Numerical Data]
Middle Aged
Patient-Centered Care/ec [Economics]
Patient-Centered Care/og [Organization & Administration]
Patient-Centered Care/st [Standards]
Treatment Outcome
United States/ep [Epidemiology]
MedStar Health Research Institute
MedStar Heart & Vascular Institute
MedStar Institute for Quality and Safety
MedStar Union Memorial Hospital
MedStar Washington Hospital Center
Medicine/Endocrinology
MedStar Diabetes Institute
MedStar Health, Columbia
Journal Article