Use of a Disease Registry and Primary Care Office Teams to Improve Lipid Goal Achievement in Patients with Diabetes

Introduction
Most diabetes care occurs in a primary care setting. Standards of diabetes care from several professional organizations include setting specific lipid goals for diabetic patients. Recommendations include medication and lifestyle changes to achieve lipid and glucose goals. Several studies indicate that about 50% of patients with diabetes achieve their goals and far fewer achieve all of their goals at the same time.^7,8,9 Addressing these gaps in quality requires system changes. A disease registry and a primary care office team that implements population-based care strategies for diabetes can help. This article describes how the Diabetes Master Clinician Program (DMCP) has addressed this issue.

The DMCP started in 2003 and currently has 115 offices, greater than 700 clinicians, including family physicians, general internists, nurse practitioners and physician assistants. Demographic and quality-of-care information metrics for each patient are entered into an Internetbased registry. The registry currently contains information on 22,262 patients and 130,263 visits; and from it patient report cards are produced reflecting clinic performance, individual clinician performance, and population reports for segments such as those with low-density lipoprotein (LDL). The primary care office team - composed of a clinician, nurse, medical assistant and front office staff – reviews all of these reports and, with the help of the DMCP program, is part of team-based solutions to decrease gaps in care.¹

Functioning as a team is a major challenge. Traditional training and experience for clinicians is oriented toward one-on-one care. Training is not usually oriented toward care of at-risk populations within a practice. Population management requires registries to manage chronic disease, experience with using registry reports to create population approaches to chronic disease and skills to empower office team members to assume significant responsibility for resolving gaps in quality of care.² Healthcare reform and the patient-centered medical home will be no more than rhetoric if robust registries and effective primary care teams are not part of the solution. Current patientcentered medical home guidelines stress the importance of registries and teams but do not require documentation of their effective utilization.³ Decreasing the cost of care for chronic disease will benefit from registries and team care.⁴

The Patient Report Card
Patients receive their report (report 1) from the medical assistant/nurse before they see the clinician. The MA/nurse will provide a brief explanation of the results in patient terms to prepare the patient for the clinical encounter. The explanation for each of the quality metrics enables the MA/nurse and patient to understand why these items are important. Feedback about this report card indicates that patients are more likely to accept a test, immunization or medication because of the report card. MAs/nurses contribute a lot.

Clinic Report Cards
Clinic report cards (Report 2) provide a clinic/office with an indication of its level of goal achievement for all of its patients with diabetes. Staff members can use these numbers to motivate their team to improve the percentage of patients at goal. The report also compares their clinic’s data with the average for all 115 practices that participate in the DMCP. The team can use additional reports to identify which patients are not at goal. Indicators include A1C, LDL, blood pressure, non-highdensity lipoprotein HDL and triglycerides (Report 3 is an example for LDL). Additional reports are available that list patients who have not had other important items evaluated like urine microalbumin, flu shots etc. The office team meets periodically to review these reports and to create strategies to communicate with patients. Strategies include phone calls, text messages, emails, group visits and additional office visits. These activities help develop a participatory office.⁵

Value of Registries and Teams
Health-care reform is changing the reimbursement system for primary care. Volume-based systems will be replaced by value-based systems. Reimbursement will be based on the quality of care provided. Registries and functioning participatory teams are keys to an effective value-based system. There will be challenges, especially when it comes to the benchmarks for quality. Standards of care change and different professional organizations have different standards. Other variables include the type of population within a practice, health insurance coverage, percent of disadvantage patients and level of health literacy. These influence the ability of a practice to increase the percentage of patients at goal.⁶ Practice registries may help. Practices in this scenario are able to identify their patient characteristics and metrics at base line (before treatment) and then are able to use improvements over baseline to judge goal achievement and reimbursement. This requires innovation, patience, political/emotional intelligence, and drive.

Disclosure statement: Dr. Shahady has received honorarium from Merck, Janssen and Lilly/Boehringer Ingelheim.