The Role of Disease Management in Diabetes Care

Approximately 16,600 health care professionals hold the title of certified diabetes educator (CDE).¹ With > 24 million people living with diabetes in the United States,² this translates into roughly one CDE for every 1,500 individuals with diabetes.

Because of the chronic nature of diabetes and its associated complications, diabetes requires constant attention and regular follow-up. It is well documented that keeping blood glucose and blood pressure levels at near-normal levels significantly reduces diabetes-related complications.^3,4 According to National Health and Nutrition Examination Survey data, the age-adjusted percentage of people achieving glycemic, blood pressure, and cholesterol targets (i.e., all three targets) increased from 7.0% in the period from 1999 to 2002 to 12.2% in the period between 2003 and 2006.⁵ Although the proportion of those achieving these three targets appears to be increasing, there remains a significant proportion of individuals with diabetes who fail to achieve recommended A1C, blood pressure, and cholesterol levels.

Given the rapid rise of diabetes during the past several decades and the immense opportunity to improve diabetes-related measures, the need for health care professionals with diabetes expertise is crucial to improve the health of the population. In addition to specialized educator availability, other barriers that may limit the amount of preventive or follow-up care patients receive include cost of care, access to care (e.g., because of rural location or lack of transportation), appointment-scheduling constraints, time away from work, and low level of education.⁶

Disease management may be able to bridge some of this gap. In fact, a growing number of health plans are trying to manage their diabetes population through in-house disease management programs, with the intent of improving health outcomes and reducing the population's risk of developing serious long-term complications. Although health plans are a major adopter of disease management programs, other sources for disease management include employers, private companies, and hospital- and community-based clinics.

Key reasons identified for adopting disease management programs include improving clinical outcomes, reducing medical costs and utilization, and improving member satisfaction.⁷ The specific goals of a particular disease management program may vary, but in the broadest sense, disease management programs provide patient education and support by using evidence-based practice guidelines to prevent complications and improve patients' overall health. This, in turn, reduces unnecessary health care utilization, driving down costs.

Disease management first became known in the late 1980s, with more widespread implementation occurring in the mid- to late 1990s. Because there was no recognized governing body for such efforts, programs were designed with varying features, and there was very little consistency among the programs.⁸

To remedy this problem, the Disease Management Association of America (DMAA), a nonprofit trade association representing stakeholders in the disease management industry, created a definition for disease management and defined core program components. The DMAA defined disease management as “a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant.”⁹ To be classified as a disease management program, the program must implement six core components. These include population identification, collaborative practice models to include physicians and support service providers, patient self-management education, process and outcomes measurement, evaluation and management, and routine reporting.⁹

Aside from the core components, other features of the interventions offered through disease management programs, including educational content, intensity/duration/frequency of the program, and delivery mode (e.g., face-to-face vs. telephone, mail, or Internet-based) vary greatly. Additionally, some programs are described as “opt-in,” in which individuals actively decide to participate, whereas others use an “opt-out” model, in which all individuals are counted as “in” the program unless they proactively contact the program to state that they do not want to participate.

Regardless of their particular design, disease management programs have the opportunity to reach patients at a “teachable moment,” perhaps through a live referral or after a significant event, such as a disease-related hospitalization or a new diagnosis. Telephone-based programs are able to mitigate some of the previously noted barriers to care, such as inaccessibility, inconvenience, and high costs.

Typically, nurses have facilitated disease management interventions; however, as disease management evolves, those in the field are recognizing the importance of a multidisciplinary approach. Professionals providing disease management services may include nurses, registered dietitians, social workers, pharmacists, or physical therapists.⁸

Programs may incorporate education and counseling techniques such as motivational interviewing and facilitation of patient self-management. This type of approach usually involves having individuals with diabetes setting goals, with guidance as needed from their health professional or “disease manager.” In subsequent encounters, providers and patients revisit the goals and discuss next steps of future goals.

Health care providers also address preventive service reminders (e.g., to get a foot exam, flu and pneumonia vaccines, a dental exam, or a retinal eye exam) and clinical guidelines (e.g., for checking A1C, blood pressure, and cholesterol levels) during patient encounters.

Some disease management programs allow disease managers to make independent medication adjustments, usually with predetermined protocols. As expected, patients who are able to adjust medications with the help of their disease manager are able to get closer to goal than patients who do not have such a service.^10,11 Referrals back to patients' primary care provider or other diabetes care team members (e.g., diabetes nurse, registered dietitian, and pharmacist) are made for routine follow-up appointments or for times when a need arises (e.g., when a patient is taking medication incorrectly or experiences adverse side effects or complications).

Of crucial importance to the success of disease management interventions is the link back to patients' diabetes care team. Disease management is often referred to as “between-visit care,” because it provides education and support that reinforces the messages patients receive from their primary care provider and clinic-based diabetes care team. Providing consistency and reinforcement of such messages allows for more patient buy in and illustrates that all parties are collaborating for the best interests of patients, enhanced patient care services, and better health outcomes.

Systematic reviews have looked at the impact of disease management programs on diabetes care.^12,13 The results show modest improvements in glycemic control and improved screening rates. A study of > 500 patients found that intensive telephone follow-up resulted in better adherence to preventive measures recommended by the American Diabetes Association, including annual eye exams, professional foot exams, foot self-exams, and pneumonia vaccinations.¹⁴ A health plan–based disease management program demonstrated that program participants achieved lower A1C levels and better adherence to A1C testing recommendations than nonparticipants and had fewer hospitalizations and emergency room visits, resulting in cost savings.¹⁵ A study of patients who receive care through the U.S. Department of Veterans Affairs patients found that automated disease management calls coupled with live telephone-based nurse follow-up care resulted in improved A1C levels, fewer reported symptoms of poor glycemic control, and higher rates of specialty care utilization.¹⁶

The sparse use of electronic medical records (and lack of consistency among them) can pose a barrier to truly integrated care. Additionally, it is difficult to compare and contrast independent disease management programs because of the high degree of variation in program designs. Despite these problems, current research shows that disease management can have a positive impact on the health of people with diabetes.

As disease management programs continue to evolve and expand, more research will be needed to determine their long-term effectiveness. Future research should specifically assess which individual components are essential to the success of disease management programs. This information will allow health care organizations and employer groups to make informed decisions regarding program design and structure to achieve the maximum benefit for more individuals with diabetes. In addition to diabetes disease management programs, which can reach a larger segment of the diabetes population, efforts should be made to increase the number of health care professionals with diabetes expertise. Specific focus should involve increasing the number of CDEs because they possess specialized knowledge in providing diabetes care and self-management skills.

• American Diabetes Association(R) Inc., 2010