Wednesday, August 29, 2007

Diabetes care - Measuring and Control;ing Diabetic Outcome

Three themes dominate the literature on quality – how to measure it, how to apply it to chronic disease, and how to achieve better outcomes.

No chronic disease preoccupies quality experts more than type 2 adult diabetes, which is closely related to the obesity epidemic and to over-ndulgence in eating the wrong foods and under-ndulgence in exercise.

Diabetes is the most costly chronic disease ($15,000 per patient per year). It is the easiest to track with measurable quality indicators (eye exams, foot inspections, hemoglobin A1C, lipids, and glucose). And its incidence has reached epidemic proportions( afflicting 10 in 1000 Americans, growing by 65% over the last ten years, and being closely linked to obesity, which itself has grown by 75% over the same time period).

Surely diabetes outcomes ought to be manageable through meticulous attention to diabetic regimens and life style adjustments.

But measuring diabetic outcomes and stemming the epidemic tide has two major problems: 1) how to measure the long-term outcomes once the disease has been diagnosed and treated; and 2) how to persuade diabetics to change the habits (overeating, eating the wrong foods, not exercising) that led to the disease in the first place.

Two types of metrics, process and outcome metrics, exist. Process metrics measure the means of getting a desired result, i.e. measurements that track the state of the disease. Outcome metrics measure the things that really matter-- rates of morbidity and mortality, good patient experience, patient understanding and control of their disease.

Most quality reporting today focuses on process. Did doctors use an EMR? Did they give the right pill? Did they check on a body part or a sign or blood test associated with the disease?

Unfortunately, while process metrics is an essential and good first step, process metrics take place in a narrow clinical window--what took place in the doctor’s office. Process metrics may overlook the big picture – what happened to the patient in the larger context of their lives? Did the treatments really work? Did the patients truly comply and adhere to the doctors’ orders? Did the patients fundamentally understand their control their disease over time?

Answers to these questions are often intangible and difficult to measure, often fall outside the doctor’s control, and may control long-term studies by independent observers outside to the doctor’s office to triangulate in on answers, and may only be addressed negatively – reduced rates of hospitalization, blindness, kidney failure, and amputations.

But the questions, though answerable, will take time to resolve. And they may take intense education support teams and psychological techniques to persuade patients to change habits and life styles.

One technique is forestalling insulin therapy. A young diabetic friend of mine confided to me,” My hemoglobin A1C is 6.6%. I keep it there because my doctor told me if it goes above 7.0%, she may have to put me on insulin.” Clear authoritative orders may also work. A nationally known endocrinologist has diabetic patients sign a contract saying they will abide by his rules. He also espouses group support. His group stages pep rallies for diabetics at which patients wear T-shirts bearing the message “In Control.”

Controlling diabetes will require all the educational campaigns all the media publicity, all the best doctor-patient relationships and counseling, and all the measurements and educational techniques we can muster.

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