Diabetes monitoring reaches new levels

Diabetes Care Quality in the Veterans Affairs Health Care System and Commercial Managed Care

From Auckland, New Zealand, and the Australian island state of Tasmania to New York City, Oregon and Washington state, health care professionals have started to wield information technology to identify, treat and manage patients with diabetes, whose treatment in the United States costs $132 billion a year.

The New York City Department of Health and Mental Hygiene has taken the boldest step to identify and manage the treatment and health of diabetics. It plans to electronically collect A1c hemoglobin blood sugar levels from all 127 laboratories in the city that are connected to the Electronic Clinical Laboratory Reporting System (ECLRS), run by New York state.

Dr. Diana Berger, medical director of New York's Diabetes Prevention and Control Program, said the project — the first of its kind in the world — will help the department better manage the city's 530,000 diabetics and reach out to more than 250,000 people in the city who have yet to be diagnosed.

The department will use those lab results to develop a diabetic patient registry, which will help it focus on areas with many patients with diabetes and work on intervention and treatment projects with local clinicians, Berger said.

The department will test an intervention project in the South Bronx, where 48,000 diabetics live, she said. Public health workers will visit clinicians there and provide information gathered from ECLRS reports to help them manage their patients with diabetes.

Using the ECLRS data, department employees can alert doctors when patients' A1c blood sugar levels have risen to 8 percent or higher. They can follow the alert with a letter to patients, who can opt out of the project at any time, Berger added.

The Department of Veterans Affairs' Veterans Health Information Systems and Technology Architecture has been better at helping the VA better manage diabetics than commercial health care systems have been, according to a report published in August 2004 in the Annals of Internal Medicine.

That report states that of eight commercial health care plans participating in the study, only two generated automated feedback to providers on quality of care, three maintained a diabetes registry and three generated patient reminders. But at the VA, the report states, the five facilities studied had most or all of those activities in place.

As a result, 93 percent of patients at VA facilities receive annual hemoglobin tests vs. 83 percent of patients at commercial facilities. And 91 percent at VA facilities have annual eye examinations — critical for diabetics because the condition can cause blindness — compared with 75 percent at commercial facilities.

The study states that if commercial health care systems want to achieve the VA's level of diabetes management, they need to invest in several areas: IT, care integration and performance monitoring.

The Counties Manukau District Health Board in Auckland, which operates Middlemore Hospital and serves 400,000 people, had similar results with electronically tracking and managing at-risk diabetic patients. The region includes a large Maori and Pacific Islander population, which has a high incidence of diabetes.

Mike Lee, an application developer at HealthAlliance, an IT services company that supports Middlemore, said the process begins when a general practitioner registers a patient with diabetes in a practice management system provided by Orion Systems International.

Orion's Integrated Care Server compares diabetic patients' information with best practice rules and sends a message to the general practitioner to recommend treatment.

According to the New Zealand Ministry of Health, those automated systems have helped the Manukau board reduce from 34 percent to 7 percent the number of diabetic patients who had an A1c level higher than 9 percent, which is dangerous.

Capt. Charles Davis, a pediatrician and neonatologist who serves as deputy commander of the Naval Medical Center San Diego, said the center uses the Defense Department's standard Composite Health Care System to help identify, manage and treat diabetics, who account for 9,000 of the 120,000 active duty and retired employees and their families the center and its clinics serve.

Early identification of diabetes allows the medical center's clinicians to better manage patients' blood sugar levels, which alleviates the need for additional treatment, Davis said. Collating data about diabetic patients also allows doctors to determine which treatments work best.

In Tasmania, officials at HealthConnect, an agency backed by the Australian government, tested a program that let diabetics participate in health care management through secure, Web-based access to their medical records. The two-year trial ended in 2004. It gave clinicians and consumers access to a diabetes task list, which helped decrease the number of visits to the doctor. Patients were also able to upload their at-home blood sugar test results into their records.

The U.S. Centers for Medicare and Medicaid Services (CMS) has taken this approach a step further with a three-year home health monitoring project for patients with diabetes and congestive heart disease.

"This demonstration project will focus on Medicare beneficiaries who have the most to gain from our health care system but who too often don't get the best possible prevention-oriented care," said Dr. Mark McClellan, administrator of CMS.

Steve Brown, chief executive officer of Health Hero Network, said the consortium will install the Health Buddy network in the homes of about 2,000 patients in Bend, Ore., and Wenatchee, Wash.

Brown said the Health Buddy runs on the same type of Samsung Electronics processor used in personal digital assistants. It connects via a dial-up modem to Health Hero's iCare Desktop, a secure, Web-based system that nurses and doctors use to monitor and manage patients.

Patients can answer clinicians' questions on the Health Buddy by pushing buttons, Brown said, adding that they can also plug electronic blood pressure cuffs and blood glucose meters into the device's data ports.

Clinicians can scan patients through the iCare console, which identifies patients who need more coaching or intervention, he added.

Brown said Health Hero and its partners have guaranteed CMS that the demonstration will save the centers at least 5 percent in patient health care costs. He said home health technologies can help CMS cut the nation's $30 trillion health budget by providing alternative care management for the 15 percent of Medicaid patients who account for 80 percent of Medicare costs.

The high cost of diabetes

Dr. Diana Berger, medical director of New York's Diabetes Prevention and Control Program, said the United States faces an epidemic of diabetes largely caused by obesity resulting from a fast-food diet.

That quick and often cheap fast-food fix comes at a high price, Berger said. She estimated that costs to treat diabetes in the United States run $132 billion a year, with New York City's share of the bill about $8.3 billion a year.

In New York, diabetes takes a grim toll annually: 1,891 deaths and 1,731 amputations plus uncounted cases of stroke, heart disease, blindness and kidney failure.

— Bob Brewin

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