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Redesigning ambulatory care management for uncontrolled type 2 diabetes: a prospective cohort study of the impact of a Boot Camp model on outcomes.

by Baker, Kelley M; Evans, Stephen R; Fernandez, Stephen J; Huang, Chun-Chi; Magee, Michelle; Mete, Mihriye; Montero, Alex R; Nassar, Carine M; Sack, Paul A; Smith, Kelly; Youssef, Gretchen A.
Citation: ; BMJ Open Diabetes Research & Care. 7(1):e000731, 2019..Journal: BMJ open diabetes research & care.Published: ; 2019; ISSN: 2052-4897.Full author list: Baker KM; Evans SR; Fernandez SJ; Huang CC; Magee MF; Mete M; Montero AR; Nassar CM; Sack PA; Smith K; Youssef GA.UI/PMID: 31798894.Subject(s): Adult | United States/ep [Epidemiology] | Treatment Outcome | Patient-Centered Care/st [Standards] | Patient-Centered Care/og [Organization & Administration] | Patient-Centered Care/ec [Economics] | *Models, Organizational | Middle Aged | Medicare/sn [Statistics & Numerical Data] | Medicare/ec [Economics] | Medicaid/sn [Statistics & Numerical Data] | Medicaid/ec [Economics] | Maryland/ep [Epidemiology] | Male | Long-Term Care/st [Standards] | Long-Term Care/og [Organization & Administration] | Long-Term Care/ec [Economics] | Humans | Hospitalization/sn [Statistics & Numerical Data] | Hospitalization/ec [Economics] | Glycated Hemoglobin A/me [Metabolism] | Female | Emergency Service, Hospital/sn [Statistics & Numerical Data] | Emergency Service, Hospital/ec [Economics] | District of Columbia/ep [Epidemiology] | *Diabetes Mellitus, Type 2/th [Therapy] | Diabetes Mellitus, Type 2/ep [Epidemiology] | Diabetes Mellitus, Type 2/ec [Economics] | *Diabetes Mellitus, Type 2/bl [Blood] | Cost Savings | Cohort Studies | Blood Glucose Self-Monitoring | Blood Glucose/me [Metabolism] | Ambulatory Care Facilities/st [Standards] | Ambulatory Care Facilities/og [Organization & Administration] | Ambulatory Care/st [Standards] | *Ambulatory Care/og [Organization & Administration] | Ambulatory Care/ec [Economics] | AgedInstitution(s): MedStar Health Research Institute | MedStar Heart & Vascular Institute | MedStar Institute for Quality and Safety | MedStar Union Memorial Hospital | MedStar Washington Hospital CenterDepartment(s): Medicine/Endocrinology | MedStar Diabetes Institute | MedStar Health, ColumbiaActivity type: Journal Article.Medline article type(s): Journal ArticleOnline resources: Click here to access online Digital Object Identifier: https://dx.doi.org/10.1136/bmjdrc-2019-000731 (Click here) ORCID: Magee, Michelle F https://orcid.org/0000-0002-4692-3201 (Click here) Abbreviated citation: ; BMJ open diabetes res. care. 7(1):e000731, 2019.Abstract: 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.Abstract: 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.Abstract: 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.Abstract: 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 USAbstract: 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.

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