Time to Treat

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T3 logoThe Time to Treat (T3) project focuses on raising awareness among primary care providers of clinical inertia in diabetes care management, and emphasizes the importance of early and intensive treatment for people who have been newly diagnosed with diabetes.  The overarching  goal of this project is to increase the number  of people with newly diagnosed diabetes who meet evidence-based clinical target measures for the ABCs of diabetes: Blood Glucose (HbA1c <8%)), Blood Pressure (<130/80 mm/Hg), LDL Cholesterol (<100), and Tobacco-Free (non-smoking) status.  Failure to reach these target measures within one year of diagnosis is an example of clinical inertia, as defined in the literature.  The T3 project provides primary care providers and clinic staff with the rationale for addressing physician-, practice management-, and patient-related factors related to clinical inertia in order to positively impact quality of care and improve health outcomes for people newly diagnosed with diabetes.

Early achievement of diabetes clinical management goals depends on a multidisciplinary, collaborative treatment approach.  Active engagement of all parties involved in the care process as well as linkages to supportive community resources are necessary for optimal diabetes outcomes, as depicted in the following diagram:

Figure 1: Factors Influencing Early Achievement of Diabetes Clinical Management Goals

Clinical Inertia 1

Program objectives for healthcare providers:

• Increased understanding of the importance of early intensive treatment for patients newly diagnosed with diabetes
• Improved knowledge of treatment strategies and needed systems changes to enable newly diagnosed patients to meet target measures
• Increased intervention  with effective treatment strategies when people do not meet target measures

Program objectives for patients newly diagnosed with diabetes:

• Early achievement of diabetes control and management goals (ideally within one year of diagnosis)
• Overall improved control of the ABCs of diabetes – HbA1c, Blood Pressure, LDL Cholesterol, and Smoking Cessation

The major components of the Time to Treat project included a Literature Review, Development of Provider Education Tools, Clinic-Based Health System Change initiatives using the Chronic Care Model framework, and  plans for dissemination of evaluation results.
 

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As part of the Time to Treat project, a Literature Review was conducted in January 2013 in order to assess current evidence around issues related to early and effective care for people with newly diagnosed type 2 diabetes, and to establish a scientific context for funded Diabetes Prevention and Control Program (DPCP) initiatives.  The specific purpose of this literature review was to inform and support participating DPCPs and their National Association of Chronic Disease Directors (NACDD) consultants in developing and implementing evidence-based health systems interventions. The literature review summarizes the scientific literature in three areas:

1. Rationale for immediacy in newly diagnosed diabetes treatment and management, including early achievement of HbA1c/blood glucose, blood pressure, cholesterol/lipids, diabetes self-management, and tobacco cessation goals;

2. Clinical inertia in diabetes management, including physician, patient, and office system factors as well as potential strategies to reduce clinical inertia in diabetes care; and

3. Treatment algorithms and guidelines for diabetes management with an emphasis on guidelines for patients newly diagnosed with diabetes.
 

Key References from Literature Review
1. Joy SV. Clinical pearls and strategies to optimize patient outcomes.  Diabetes Educ  2008;34(Suppl 3):54S-59s. Abstract available from  http://www.ncbi.nlm.nih.gov/pubmed/18525065

2. O’Connor PJ, Sperl-Hillen JAM, Johnson PE, Rus WA, Biltz G. Clinical inertia and outpatient medical errors. Advances in Patient Safety: From Research to Implementation (Volume2: Concepts and Methodolgy). Editors: henriksen K, Battles JB, Marks ES, Lewin DI. Rockville (MD): Agency for Healthcare Research and Quality.  Feb 2005.  Retrieved from  http://www.ncbi.nlm.nih.gov/books/NBK20513/pdf/ch22.pdf

3. Phillips LS, Branch Jr. WT, Cook CB, Doyle JP, El-Kebbi IM, Gallina DL, Miller CD, Ziemer DC, Barnes CS. Clinical Inertia. Ann Intern Med 2001;135:825-834. Retrieved from  http://www.sbc-sc.org.br/sistema/categorias/materias/assets/palestras/20-09-2006/estudos/extras/02-clinicalinertia.pdf

For a complete list of references, see the link to the Literature Review above.

Chronic Care Model

The state Diabetes Prevention and Control Programs (DPCPs) participating in the Time to Treat project used the Chronic Care Model (CCM)(1), shown below, as an evidence-based foundation to guide and evaluate their work.  The Chronic Care Model was developed by Ed Wagner, MD, MPH, Director of the MacColl Institute for Healthcare Innovation, Group Health Cooperative.

The DPCPs reviewed the CCM with clinical and administrative staff at the partnering health clinics and provided guidance as to how this framework could be used to drive health systems changes related to early and intensive control of diabetes and cardiovascular risks to slow pancreatic dysfunction and prevent complications.  This included identifying patients who were newly diagnosed with diabetes and making practice improvements to help them reach the recommended clinical targets for A1c, blood pressure, cholesterol, and smoking status (ABCs) as soon as possible after diagnosis.

Other frameworks may also help guide health systems change work related to early and intensive treatment for people newly diagnosed with diabetes, such as the Patient-Centered Medical Home (PCMH) model(2) or the National Center for Quality Assurance (NCQA) diabetes recognition program(3).

A 2013 systematic review of the CCM and diabetes management concluded that the CCM is in use in primary care settings in the U.S. with positive outcomes reported(4).  For example, the support of health care leaders stimulated organizational change in a number of studies reviewed4.   In two other reviewed studies, redefining health care team roles improved the quality of diabetes care and rates of eye exams and was associated with improved levels of A1C, blood pressure, cholesterol and weight(4).

Figure 1. The Chronic Care Model


Copyright 1996-2014 The MacColl Center. The Improving Chronic Illness Care program is supported by The Robert Wood Johnson Foundation, with direction and technical assistance provided by Group Health's MacColl Center for Health Care Innovation

Core Elements of the Chronic Care Model
 (As described by the Chronic Illness Care program)

        • Health System 
                o Create a culture, organization and mechanisms that promote safe, high quality care(5)
                Possible strategies:
                        ► Cultivate support for improvement in the organization at all levels(5)
                        ► Encourage open-handling of errors and quality problems to improve care(5)

        • Delivery System Design
                o Assure the delivery of effective, efficient clinical care and self-management support(5)
                Possible strategies:
                        ► Redesign the healthcare team and redefine their roles to promote  effective care which has been proven to help positively impact the delivery of high quality care(4,5)
                        ► Distribute clinical tasks among team members for more efficient and effective care(6)
                        ► Pre-planning and preparation  prior to visit to support evidence-based, patient-centered care(5)
                        ► Integrate Diabetes Self Management Education and Diabetes Self-Management Support  into the primary care setting (group- and/or individual-level)(4,7)
                        ► Provide care that is culturally and linguistically appropriate as well as accessible to individual patients with a wide variety in  levels of health literacy(5)

        • Decision Support
                o Promote clinical care that is consistent with scientific evidence and patient preferences(5)
                Possible strategies:
                        ► Provide Electronic Health Record prompts for healthcare providers  to support clinical-decision making(8)
                        ► Offer problem-based learning meetings among healthcare staff(6)
                        ► Train primary care providers on evidence-based guidelines(5)
                        ► Share information regarding evidence-based guidelines with patients(5)
                        ► Utilize telemedicine technology allowing for a greater quantity of data with which to make clinical decisions(8)

        Clinical Information Systems
                o Organize patient and population data to facilitate efficient and effective care(5)
                Possible strategies:
                        ► Establish an outpatient electronic health records system that has the following important tracking and supportive actions
                        ► Document the date of diagnosis, as part of a comprehensive diabetes evaluation as defined by the ADA, in order to encourage and inform early and intensive treatment, to facilitate tracking of individual progression of disease, and to assist with population-based assessments of incidence of diabetes and complications for research and policy purposes(9)
                        ► Establish a diabetes registry to monitor patient progress and lapses in patient care(4)
                        ► Provide Electronic Health Record prompts to support clinical-decision making(8)
                        ► Offer  timely reminders to providers and staff on needed services(5)

        • Self-Management Support
                o Empower and prepare patients to manage their health and health care(5)
                Possible strategies:
                        ► Reinforce patient’s central role in their care at each clinic visit(5)
                        ► Embrace a collaborative approach to problem-solving between the provider and the patient(5)
                        ► Promote self-management skills and behaviors(5)
                        ► Refer to evidence-based chronic disease self-management programs meeting the ADA recommendations for Diabetes Self-Management Education(4,7,10)
                        ► Encourage sustainment self-management behaviors and skills  through Diabetes Self-Management Support(7,10)
                        ► Goal setting with patients and documenting goals as well as action plans in the patient record for follow-up(11)
                        ► Referral to evidence-based chronic disease self-management programs affiliated with the clinic or in the community(5)

        • Community
                o Mobilize community resources to meet needs of patients(5)
                Possible strategies:
                        ► Encourage patients to participate in effective community programs or organizations(5)
                        ► Inform patients of available resources in the community pertaining to their medical conditions(6)
                        ► Partner with community organizations or centers to help fill gaps in needed services for more comprehensive care(5,6)

Applying the Chronic Care Model to Diabetes Care (see Figures 2 and 3 below)

The interdependence of clinical, social, and environmental factors to support optimal diabetes care and improved outcomes is depicted in the diagram below. 

Figure 2. Collaborative Partnerships Promote Early Achievement of Diabetes Clinical Management Goals :
Applying the Chronic Care Model to Diabetes Care.

Figure 3. Care Transformation Strategies for Early Achievement of Diabetes Clinical Management Goals :
Applying the Chronic Care Model to Diabetes Care

References

1. Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Effective Clinical Practice 1998;1(1):2-4. Retrieved from http://ecp.acponline.org/augsep98/cdm.pdf

2. Agency for Healthcare Research and Quality. Defining the PCMH. Patient Centered Medical Home Research Center.  Retrieved from http://pcmh.ahrq.gov/page/defining-pcmh

3. National Committee for Quality Assurance. Diabetes Recognition Program. Retrieved from http://www.ncqa.org/tabid/139/Default.aspx

4. Stellefson M, Dipnarine K, Stopka C. The chronic care model and diabetes management in US primary care settings: a systematic review. Prev Chronic Dis 2013;10:1-21. Retrieved fromhttp://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf   

5. Improving Chronic Illness Care program.  The Chronic Care Model: Model elements.  Improving Chronic Illness Care.  Retrieved from www.improvingchroniccare.org
Copyright 1996-2014 The MacColl Center. The Improving Chronic Illness Care program is supported by The Robert Wood Johnson Foundation, with direction and technical assistance provided by Group Health's MacColl Center for Health Care Innovation

6. Sevin C, Moore G, Shepher J, Jacobs T, Hupke C. Transforming care teams to provide the bets possible, patient-centered collaborative care. J Ambulatory Care Manage 2009;32(1):24-31. Retrieved from https://www.familycarenetwork.com/.../Transforming%20Care%20Teams.pdf

7.  American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care January 2014;37:Supplement 1 S14-S80. doi:10.2337/dc14-S014 Retrieved from http://care.diabetesjournals.org/content/37/Supplement_1/S14.full.pdf+html

8. Reed M, Huan J, Graetz I, Brand R, Hsu J, Fireman B, Jaffe M. Outpatient electronic health records and the clinical care and outcomes of patients with diabetes mellitus. Ann Intern Med 2012;157(7):482-489.
Retrieved from  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3603566/pdf/nihms436283.pdf

9. Stolar MW. Defining and achieving treatment success in patients with type 2 diabetes mellitus. Mayo Clinic Proceedings 2010;85(Suppl 12):S50-9. Retrieved from  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2996162/pdf/mayoclinproc_85_12_suppl_006.pdf

10. Funnell M, Brown T, Childs B, Haas L, Hosey G, Jensen B, Maryniuk M, Peyrot M, Piette J, Reader D, Siminerio L, Weinger K, Weiss M. National standards for diabetes self-management education. Diabetes Care  2008;31(S1):S97-S104. Retrieved from http://care.diabetesjournals.org/content/31/Supplement_1/S97.full.pdf+html

11. Simons L, Baker NJ, Schaefer J, Miller D, Anders S. Activation of patients for successful self-management.  J Ambulatory Care Manage 2009; 32(1):16-23. Retrieved from http://journals.lww.com/ambulatorycaremanagement/fulltext/2009/01000/activation_of_patients_for_successful.4.aspx (PDF available)
 

Additional Resources

American Association of Clinical Endocrinologists Comprehensive Diabetes Algorithm 2013 https://www.aace.com/publications/algorithm

Chronic Disease Self-Management Program from Stanford Patient Education Research Center: http://patienteducation.stanford.edu/programs/cdsmp.html

National Diabetes Education Program website:  http://ndep.nih.gov/publications/PublicationDetail.aspx?PubId=113#main

Being proactive soon after a diabetes diagnosis is important for fostering a healthy future. Primary care providers play a critical  role in 1) helping patients understand the seriousness of their disease, 2) providing education and support for making lifestyle changes, 3) prescribing appropriate medications, 4) monitoring therapy and response against evidence-based clinical management goals, 5) providing information on community-based resources, and 6) adding or changing treatment options, including medications, if the patient is not at goal.  Active engagement of all parties involved in the care process as well as linkages to supportive community resources are necessary for optimal diabetes outcomes.


Key Resources

American Diabetes Association Standards of Medical Care in Diabetes 2014 http://professional.diabetes.org/ResourcesForProfessionals.aspx?typ=17&cid=84160&pcid=84160

Improving Chronic Illness Care website: http://www.improvingchroniccare.org/index.php?p=The_Community&s=19

Summary of the Carlas  or Summary of early managed Carla’s and passively managed Carla’s course of care and health outcomes
Visual representation of the Carla’s

Key Messages from the Time to Treat Video

⇒  What is the prevalence of diabetes in the U.S.?
In 2012, an estimated 29.1 million people had diabetes, 8.1 millon of the total remaining undiagnosed.

⇒  What is the incidence of diabetes in the U.S.?
In 2012, 1.7 million American adults were newly diagnosed with diabetes.

⇒  What four treatment goals are the recommended targets for optimizing control in individuals with diabetes?
1) Glycemic control as measured by HbA1c
2) Blood pressure control
3) Optimization of lipid or cholesterol profile
4) Abstinence from all tobacco products

The four targets above are referred to as the ABCs of diabetes care by the Centers for Disease Control and Prevention Division of Diabetes Translation.

⇒  Are individuals with diabetes receiving care that meets ADA goals?
Of all U.S. adults with diabetes, 80% did not meet ADA recommendations for preventive services and 86% did not meet recommended targets for all four measures of good control (hemoglobin A1c, blood pressure, cholesterol, and smoking status).

On average, a patient’s hemoglobin A1c (HbA1c) remains uncontrolled for more than 7 years before intensification of treatment.

⇒  Why is early achievement of glycemic control so important for patients with newly diagnosed with diabetes?
It may be possible to change the course of disease progression with early control through creating positive “metabolic memory” and preserving beta-cell function.

⇒  Why might an individual with diabetes not receive the recommended care?
Among many reasons, clinical inertia has been identified as a factor in individuals with diabetes not achieving treatment goals.

⇒  What is clinical inertia?
Clinical inertia is defined as the lack of treatment intensification in a patient not at evidence-based goals for care.  It is a complex phenomenon influenced by the interplay of the healthcare provider, patient and office system factors:
      • Healthcare Provider Factors
            ►  Overestimation of care provided
              Soft reasons to avoid intensification of therapy
              Lack of education, training, tools, and practice support
      • Patient Factors
              Denial
              Perception of disease as not serious
              Medication non-adherence
      • Office System Factors
              Lack of decision support
              Absence of patient care team approach or coordination of care
              Poor provider-staff communication
              No visit planning
              No active patient outreach
              Lack of availability of clinical guidelines
              No data to monitor care to determine need for instensification

  What can be done to combat clinical inertia?
Due to the complexity the causes of clinical inertia, combatting clinical inertia requires multilevel and multidimensional approaches often referred to as health systems changes.  Health systems changes or “care transformation strategies” are changes in office policies, procedures, structures, and supports that make it easier for healthcare providers to provide quality care and help patients to become engaged and activated in their care.

⇒  What are some examples of care transformation strategies?
•  Creation of multidisciplinary team-based care focusing on outlining and redefining staff roles, communicating objectives about the new workflow clearly, providing training regarding the roles for each team member, and creating a visual of the clinic process flow.
•  Utilization of clinical decision support tools to provide information shortly before or during a clinic visit to guide providers to appropriately intensify therapy.  The tools may take the form of pre-printed flow sheets or electronic health record prompts.
•  Utilization of visit resolution and accountability tools that direct attention to proper drug intensification and requests the provider give useful documentation if recommended changes were not made.
•  Offering patient support  to include tools to help patients set the agenda for each visit, educational resources and videos to help the patient understand treatments and lab values, and positive feedback and strategies to motivate the patient at each visit.
•  Encouraging education and training that will enhance provider-patient communication  


References from the Time to Treat Video

1. American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care January 2014;37:Supplement 1 S14-S80. doi:10.2337/dc14-S014 Retrieved from http://care.diabetesjournals.org/content/37/Supplement_1/S14.full.pdf+html

2. Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA: U.S. Department of Health and Human Services; 2014. Retrieved from http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf

3. Improving Chronic Illness Care program.  The Chronic Care Model: Model elements.  Improving Chronic Illness Care.  Retrieved from www.improvingchroniccare.org
Copyright 1996-2014 The MacColl Center. The Improving Chronic Illness Care program is supported by The Robert Wood Johnson Foundation, with direction and technical assistance provided by Group Health's MacColl Center for Health Care Innovation

4. O’Connor PJ, Sperl-Hillen JAM, Johnson PE, Rus WA, Biltz G. Clinical inertia and outpatient medical errors. Advances in Patient Safety: From Research to Implementation (Volume2: Concepts and Methodolgy). Editors: henriksen K, Battles JB, Marks ES, Lewin DI. Rockville (MD): Agency for Healthcare Research and Quality. February 2005.  Retrieved from  http://www.ncbi.nlm.nih.gov/books/NBK20513/pdf/ch22.pdf

5. Phillips LS, Branch Jr. WT, Cook CB, Doyle JP, El-Kebbi IM, Gallina DL, Miller CD, Ziemer DC, Barnes CS. Clinical Inertia. Ann Intern Med 2001;135:825-834. Retrieved from  http://www.sbc-sc.org.br/sistema/categorias/materias/assets/palestras/20-09-2006/estudos/extras/02-clinicalinertia.pdf

6. Sevin C, Moore G, Shepher J, Jacobs T, Hupke C. Transforming care teams to provide the bets possible, patient-centered collaborative care. J Ambulatory Care Manage 2009;32(1):24-31. Retrieved from https://www.familycarenetwork.com/sites/default/files/Transforming%20Care%20Teams.pdf

7. Simons L, Baker NJ, Schaefer J, Miller D, Anders S. Activation of patients for successful self-management.  J Ambulatory Care Manage 2009; 32(1):16-23. Retrieved from http://journals.lww.com/ambulatorycaremanagement/Fulltext/2009/01000/Activation_of_Patients_for_Successful.4.aspx

8. Stellefson M, Dipnarine K, Stopka C. The chronic care model and diabetes management in US primary care settings: a  systematic review. Prev Chronic Dis 2013;10:1-21. Retrieved from http://www.cdc.gov/pcd/issues/2013/pdf/12_0180.pdf