Diabetes outcomes within integrated healthcare management programs

Diabetes outcomes within integrated healthcare management programs

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Contents lists available at ScienceDirect

Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd

Original research

Diabetes outcomes within integrated healthcare management programs V. Baldo b,∗, S. Lombardi a,1, S. Cocchio b, S. Rancan a,1, A. Buja b, S. Cozza a,1, C. Marangon a,1 , P. Furlan b , M. Cristofoletti a,1 Distretto Socio Sanitario, Local Health District n◦ 5 “Vicentino Ovest”, Veneto Region, Italy Department of Molecular Medicine, Institute of Hygiene, Laboratory of Public Health and Population Studies, University of Padua, Italy

a

b

a r t i c l e

i n f o

a b s t r a c t

Article history:

Aim: The aim of this observational study was to assess mortality of patients with type 2

Received 25 September 2013

diabetes by type of healthcare delivery system, i.e. through specialist centers or generalist

Received in revised form

doctors, or integrated care.

13 March 2014

Methods: The study was conducted at the “Vicentino Ovest” Local Health District in the

Accepted 19 March 2014

Veneto Region (north-eastern Italy) from January 1, 2008 to December 31, 2010. Patients

Available online xxx

with diabetes (≥20 years old) were identified using different public health databases. They were grouped as: patients followed up by specialists at diabetes clinics (DS); patients seen

Keywords:

only by their own general practitioner (GP); and patients receiving integrated care (DS-GP).

Integrated care

Cox’s regression analysis was used to estimate adjusted hazard ratios for available potential

Diabetes

predictors of death by level of care.

Health care research

Results: The crude mortality rate was highest in the GP group (26.1 per 1000 person-years), the difference being minimal when compared with the DS group (21.7 per 1000 personyears) and more marked when compared with the DS-GP group (8.8 per 1000 person-years). Patients followed up by their GPs had a 2.7 adjusted RR for mortality by comparison with the DS-GP group. Conclusions: The findings of the present study could demonstrate that it is safe and costeffective, after a first specialist assessment at a diabetes service, for low-risk diabetic patients to be managed by family physicians as part of a coordinated care approach, based on the specialist’s clinical recommendations; GPs can subsequently refer patients to a specialist whenever warranted by their clinical condition. © 2014 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

∗ Corresponding author at: Department of Molecular Medicine, Institute of Hygiene, Laboratory of Public Health and Population Studies, University of Padua, 35121 Padova, Italy. Tel.: +39 0498275389; fax: +39 0498275392. E-mail address: [email protected] (V. Baldo). 1 Local Health District “Vicentino Ovest”, Veneto Region.

http://dx.doi.org/10.1016/j.pcd.2014.03.005 1751-9918/© 2014 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: V. Baldo, et al., Diabetes outcomes within integrated healthcare management programs, Prim. Care Diab. (2014), http://dx.doi.org/10.1016/j.pcd.2014.03.005

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1.

Introduction

The increasing burden of diabetes worldwide highlights the urgency of ensuring that appropriate services are accessible to this kind of patient. The social and economic cost of diabetes is related to chronic complications, and timely care is essential to ensure their effective prevention [1,2]. Appropriate and timely care is difficult to achieve, however, and a variety of health care setting have been implemented in recent years. Monitoring the quality of care by analyzing administrative data is feasible and inexpensive, and enables large population samples to be considered. In the last decade, the use of electronic medical records has been widely recommended as a method for reducing errors, improving the quality of health care, and cutting costs in ambulatory healthcare settings. In particular, electronic medical records have been shown to improve the quality of care for patients with chronic diseases, such as diabetes [3]. Surveillance based on administrative data helps to simplify the management of diabetes based on an organized, proactive and integrated approach, focusing on preventing the complications of this disease. Analyzing the available electronic data can facilitate the coordination of the different members of the healthcare teams involved, leading to lower rates of omissions in clinical information, and supporting evidence-based clinical decisionmaking. Given the rising prevalence of diabetes and the high frequency and severity of the related complications, preventing such complications latter must be considered a national public health goal [4] and fundamental to containing the social costs of diabetes. Inpatient costs for diabetes are reportedly far higher than outpatient costs, due to the higher level of medical care needed to cope with the complications of this disease, and the likelihood of multiple complications can multiply the costs of treating diabetes several times over [2]. Strict disease management is needed for diabetics and there has been longstanding debate on the roles of generalists and specialists in the management of these patients. More recently, there has increasingly been a tendency to shift the management of chronic diseases from specialist outpatient clinics to a more GP-based service [5]. A coordinated care model, involving both primary care physicians and specialist diabetes services, could assure both an early diagnosis of diabetes type 2 in the population at risk and a continuous monitoring of diabetic patients. In our area, an integrated healthcare delivery system has been developed, which involves specialist diabetes center and general practitioners, relying on an integrated electronic data recording system; an open-door policy operates between the specialist service and routine primary care so that patients can be referred back and forth as necessary. This approach is still in the experimental phase, however, and applied only to a minority of patients [2]. The aim of the present observational study was to assess mortality among patients with type 2 diabetes grouped by type of healthcare delivery system, i.e. specialist center or generalists alone, or integrated care.

2.

Material and method

2.1.

Context

Briefly, in our Local Health District (LHD), patients first see their GP and, if diabetes is suspected on the strength of glucose metabolism tests, they are referred by the GP to the Diabetes Service to confirm the diagnosis and stage their diabetes. The specialist and GP together complete a personal information sheet in a web-compatible format (EURO TOUCH) that contains all the patient’s details. All patients with compensated diabetes 2 and with no diabetes-related complications, whose HbA1c levels are <7.5, are enrolled in the protocol for integrated management with the GP. All patients receiving integrated care are re-examined once every two years by a specialist at the diabetes center. Care provided exclusively by specialist diabetes centers is reserved for all patients with type 1 diabetes, newly-diagnosed diabetes, insulin-treated diabetes with poor glycemic control requiring stabilization; non-insulin-treated diabetes treated with maximum doses of oral therapy and with twice determination of HbA1c >7.5%. Patients with special needs, such as preconception care, during pregnancy, or with renal, eye or foot problems, or a cardiovascular-related disease risk >20% are also managed at the diabetes clinic. Other diabetic patients not referred by their GPs to the Diabetes Service, i.e. who only received generalist care, were identified by means of the drug prescription and prescription charge exemption database.

2.2.

Study population

This study was conducted at the “Vicentino Ovest” Local Health District in the Veneto Region (north-eastern Italy) from January 1, 2008 to December 31, 2010. The area has a population of approximately 182,000 (143,000 ≥20 years old); about 13% of this population are immigrants, mainly from Asian countries. Patients with diabetes (≥20 years old) were identified using three data sources, i.e. hospital discharge records, drug prescriptions, analyzing the records of anti-diabetic drugs prescribed for residents (only people with at least two antidiabetic drug prescriptions were considered as having diabetes), and exemptions for individuals not liable to prescription charges because they had been diagnosed with diabetes. The data sources were matched with a deterministic linkage procedure using a unique identifier; the study population included all individuals included in at least one of the three public health data sources. The question of the validity of the deterministic record linkage procedure applied in our study to identify cases of diabetes had previously been addressed in a paper showing that this strategy enables individuals with known diabetes to be identified and the prevalence of the disease to be estimated just as well as in other studies conducted in Italy using more costly and time-consuming methods [6]. This database was further linked to the Diabetes Service’s integrated database of diabetic patients, which confirms the diagnosis and provides details of other patients’ not cached with the previously described record linkage source (see Table 1).

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(6.0) (6.9) (4.2) (27.6) (20.4) (52.0) 3590 2652 6756 (7.4) (6.4) (3.9) (21.2) (38.2) (40.5) 998 1795 1904 (6.5) (11.2) (7.4) (41.9) (10.6) (47.5) 1985 500 2248 (17.0) (10.0) (73.0) 607 357 2604

(2.1) (3.4) (1.6)

(5.7) (0.5) (91.5) (8.5) 11,889 1109 (6.1) (0.9) (91.0) (9.0) 4275 422 (8.2) (0.4) (90.0) (10.0) 4260 473 (94.0) (6.0) 3354 214

(2.0) (0.0)

(0.0) (0.5) (0.9) (3.8) (12.9) (1.8) (10.4) (21.5) (39.1) (27.2) 240 1356 2793 5079 3530 (0.0) (1.3) (1.0) (4.7) (12.0) (0.5) (8.0) (23.0) (40.8) (27.7) 22 374 1082 1916 1303 (0.0) (0.1) (1.3) (5.7) (16.7) (4.4) (16.1) (17.5) (28.7) (33.4) 206 762 828 1358 1579 (0.3) (6.2) (24.7) (50.6) (18.2) 12 220 883 1805 648

(0.0) (0.5) (0.5) (1.3) (5.7)

(5.1) (5.4) (52.9) (47.1) 6871 6127 (5.5) (5.8) (54.7) (45.3) 2568 2129 (7.5) (7.3) (48.0) (52.0) 2270 2463 (1.9) (1.8)

Fatality rate % (%)

Fatality rate %

n

(%)

4733

(57.0) (43.0)

We identified 12,978 individuals ≥20 years old with diabetes residing in the “Vicentino Ovest” Local Health District as at 1 January 2008. They were a mean 64.8 ± 15.2 years old (males 62.8 ± 13.6; females 67.0 ± 16.5); 8.5% of this diabetic population originated from outside the European Union (and 61.0% of these came from Asian countries). The overall interval prevalence of diabetes was 8.8% (9.3% in males, 8.3% in females). The age-specific prevalence in 2010 by gender is given in Fig. 1.

2033 1535

Results

n

3.

3568

The causes of deaths were ascertained from the causes of death register and classified according to the International Classification of Diseases, 10th Revision (ICD-10) or 9th Revision (ICD-9). Individuals were followed up to calculate all-cause mortality and cause-specific mortality rates for diabetes-related metabolic disorders (ICD-10, E11), cardiovascular diseases (ICD-10, I00-I99), stroke (ICD-10, I60-I69) and cancer.

MMG

Outcomes

GI

2.4.

Total

The study period was considered as of January 1, 2008, and ended at the time of any patient’s death or transfer elsewhere, or on December 31, 2010. Mortality rates were calculated by dividing the number of deaths by the total person-time and expressed in terms of events per 1000 person-years. Cox’s regression analysis was used to estimate adjusted hazard ratios (HR) for available potential predictors of death by type of healthcare delivery system, considering age, hospitalization, gender, type of treatment (insulin, oral anti-diabetics, or dietary restrictions alone), and nationality. The statistical analyses were performed using the SPSS, version 14.

n

Statistical analysis

Table 1 – Case fatality rates by characteristic of the study population.

2.3.

Gender Males Females Age group 18–30 31–45 46–60 61–75 76+ Nationality EU Non-EU Therapy Diet alone Insulin Oral therapy

Fatality rate % Fatality rate % (%)

4697

SD

n

(%)

Total

We considered a diagnosis of type 2 diabetes beyond the age of 20 years, since 98–99% of children 0–18 years of age at the time of their diagnosis of diabetes are cases of type 1 diabetes [7]. The study population was grouped according to the type of care they received: patients with unstable diabetes who were followed up by the Diabetes Service (DS); patients with compensated diabetes who were examined at the DS, then followed up mainly by their general practitioner (DS-GP); and patients seen by their GPs but not referred to a diabetes clinic (GP). Treatment was divided into three groups, i.e. dietary restrictions alone, oral anti-diabetic drugs, and insulin. Information on patients’ therapy was retrieved from their antidiabetic drug prescriptions. Patients prescribed both insulin and oral anti-diabetic drugs were assigned to the “insulin treatment” group; and all diabetic patients not prescribed any anti-diabetic drugs were placed in the “dietary restrictions alone” group. The Ethical Review Board of the Vicenza Province examined the study design and approved the survey.

12,998

p r i m a r y c a r e d i a b e t e s x x x ( 2 0 1 4 ) xxx–xxx

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4.

Fig. 1 – Proportion of cases identified by means of the Diabetes Service’s integrated database and not from the record linkage source (drug prescriptions + prescription charge exemptions + hospital discharge records).

Diabetes was more prevalent in males than in females at all ages (Fig. 2). The baseline characteristics of the study population are shown in Table 1. As for their management, 63.7% of the patients were seen by the Diabetes Service (DS and DS-GP groups) and were screened for complications. More than a third of the patients were not referred to the DS (GP group); these cases were more likely to be older and not receiving pharmacological treatment. During the 3-year follow-up, the all-cause mortality rate was 20.6 per 1000 person-years, 4.4 for cardiovascular disease, 1.5 for stroke, 5.2 for cancer, and 2.4 for related metabolic disorders. The mortality rate was higher in the GP group (26.1 per 1000 person-years), and the difference was minimal vis-à-vis the DS group (21.7 per 1000 person-years), but considerable when compared with the DS-GP group (8.8 per 1000 person-years) (Table 2). Table 3 shows the adjusted HRs for mortality: the patients followed-up only by their GPs had a 2.7 adjusted HR for mortality by comparison with the DS-GP group.

Fig. 2 – Prevalence of diabetes type 2 by age, gender and nationality.

Discussion

This study identified a higher mortality rate among diabetes patients followed up only at primary care level than among patients receiving an integrated primary plus specialist care. After adjusting for age, sex, insulin treatment and place of residence, the all-cause mortality rate rose by 270% in patients who never attended the diabetes service. Furthermore as expected, the patients who were managed exclusively by the specialist service (because they had more severe disease) had a higher mortality rate than those receiving integrated care. Similar results were reported in a previous Italian paper, which showed that attending a diabetes clinic reduced cardiovascular and, to a lesser extent, digestive mortality among diabetic patients [8]. The degree of glycemic control is an important determinant of cardiovascular diseases in diabetic patients [9,10], while satisfactory metabolic control is essential to preventing long-term complications and improving survival [11]. We have no information on the blood glucose levels of patients not attending the diabetes service, but a number of studies have documented that patients attending the diabetes service have a better metabolic control than those seen only by family physicians [12,13]. Diabetes management is complex and involves addressing many issues, not just glycemic control. A large body of evidence supports the need for a number of actions to improve diabetic patient outcomes. Screening, diagnostic and therapeutic actions are recommended that are known, or believed, to favorably affect health outcomes in patients with diabetes. Better care relating to a number of factors other than hyperglycemia may therefore help to explain why we found a lower mortality risk for diabetic patients receiving integrated care, which combines the advantages of expert, evidence-based care at a diabetic service with the closer, more readily accessible and customized care provided by GPs. Our data nevertheless show that patients cared for by GPs alone have the worst outcome, confirming previous findings that patients who saw their family doctor irregularly just to obtain drug prescriptions, with no structured monitoring of their risk factors, were associated with a higher mortality risk [14]. It would be unwise to generalize on the strength of the present findings because healthcare systems differ considerably. In addition, the present report is based on an observational study, not an interventional trial, so we cannot rule out the possibility of our results being influenced by factors other than the quality of diabetes care, such as a self-selection bias [15]. For instance, patients attending a diabetes clinic might have a higher level of formal education, or better compliance with therapy, while patients not attending the diabetes clinic might be more severely ill [16]. It has been demonstrated, in fact, that profiling and comparing the quality of care provided by different groups of physicians may be inaccurate if careful attention is not paid to the case mix, or patients’ compliance with therapy, for instance, and adjusting for such patient-related characteristics could reduce the statistical significance of the differences emerging for some outcome measures [17]. On the other hand, by means the

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Table 2 – Mortality rate (per 1000 person years) for outcomes by level of care. GP-DS n All-cause mortality Cancer mortality Cardiovascular mortality Metabolic disorders mortality Stroke mortality

GP

1000 py

66 20 13 6 6

8.8 2.7 1.7 0.8 0.8

n 352 87 75 40 28

DS 1000 py

n

26.1 6.4 5.6 3.0 2.1

1000 py

263 67 60 36 17

21.7 5.5 5.0 3.0 1.4

Table 3 – Adjusted Rates ratios (HR) and 95% confidence intervals for all-cause mortality by characteristic. HR GP (ref GP-DS) DS (ref GP-DS) Previous hospitalization Age Gender (males vs females) Nationality (UE vs non-EU) Insulin (ref only diet) Oral drugs (ref only diet)

2.71 1.77 9.49 1.08 1.56 1.08 .81 .63

adjustment for hospitalizations and type of therapy our data do partially take into account the different case-mix distribution by type of healthcare delivery system. Another limitation of the present study lies in that the validity of the information on the cause of death has not been tested precisely. Quality control on the information provided in death certificates concerning cause of death and other details is an important issue that all epidemiologists have to deal with [18,19]. When the Italian Statistics Institute [20] conducted a quality control using an automated error-finding procedure, it reported a proportion of error of 4 per thousand. In addition a recent Italian study found that crude prevalence estimates of diabetes in administrative databases were lower than the corresponding GP and survey-based estimates [21]. Our study used an additional source, however, i.e. the Diabetes Service’s integrated database of diabetic patients, which confirms diagnoses and provides details of other patients not cached with the previously described record linkage source. The present study showed that a higher proportion of elderly diabetics was not identified by means of the administrative databases: a possible explanation for this is that the main contribution to the diagnoses in the administrative database comes from drug prescriptions, and elderly diabetics living in rest homes would go undetected because rest homes obtain and distribute any drugs needed by residents, without using prescriptions for named patients.

5.

Conclusion

Diabetes mellitus is a chronic illness that requires continual medical care and ongoing patient self-management training and support to prevent acute complications and reduce the risk of long-term complications [22]. The findings of the present study could demonstrate that it is safe and cost-effective, after a first specialist assessment at a diabetes service, for low-risk diabetic patients to be managed by family physicians as part of a coordinated care approach, based on the specialist’s clinical recommendations; GPs can

IC 95.0% 2.07 1.34 7.74 1.08 1.33 .47 .65 .52

p 3.6 2.3 11.63 1.09 1.83 2.45 1.01 .76

subsequently refer patients to a warranted by their clinical condition.

.000 .000 .000 .000 .00 .86 .06 .000

specialist

whenever

Conflict of interest statement The authors state that they have no conflict of interest.

Acknowledgments We thank everyone who helped with this project, particularly Liliana Lora, Natalino Bianco, Giampietro Stefani and Luigi Lago for support with data collection.

references

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