Two primary care clinics in Israel compared MDT outcomes to standard care in patients with poor glucose control (A1C levels ≥10%); the patients were studied for 6 months.11 One clinic was randomly chosen to provide patients with standard medical care, delivered by physicians and nurses (control group), while another clinic provided patients with an MDT approach that included care from a diabetes specialist, a dietician, and a diabetes nurse educator. At the 6-month follow-up, patients at the intervention clinic had significantly lowered mean A1C levels (–1.8%, P=.00001) and plasma glucose readings (–1.5 mmol/L [~27 mg/dL], P=.003), with no significant changes seen in either measure at the control clinic.11 Patients in the intervention group also had twice the response rate to treatment (defined as a ≥0.5% decrease in A1C at 6-month follow-up) vs the control group (71% vs 35%, respectively). Additionally, patients in the intervention group had a higher rate of follow-up (attendance at 6-month visit) than patients in the control group (82% vs 35%, respectively).
Another study evaluated (over 1 year) a community-based family medicine residency program that implemented MDT care for 105 patients with type 2 diabetes and compared pre- and post-intervention outcomes.12 Successful disease management was defined as having A1C <7%, low-density lipoprotein (LDL) cholesterol <100 mg/dL, and blood pressure <130/80 mm Hg. At 1 year following program implementation, patients improved in all metabolic and process measures. Additionally, 17.1% of patients achieved successful disease management, defined as meeting all 3 criteria, as compared with 5.7% prior to the intervention.12 The patients who did not meet all 3 criteria, however, would still benefit from care coordination and targeted intervention to help them manage the disease and achieve goals.
Individual and group diabetes management education approaches are also integral parts of centralized care, and are associated with proven patient benefits. A meta-analysis that included data from 31 randomized, controlled trials evaluating self-management education showed that, at immediate follow-up after the last educator-patient contact, patients who had received self-management education decreased their A1C levels by 0.76% more than patients who did not receive self-management education (95% confidence interval, 0.34–1.18).13 Patient outcomes further improved as more time was spent with educators.
Another meta-analysis of 11 studies showed that group-based education for diabetes was related to A1C decreases of 1.4% after 4–6 months of follow-up; these decreases endured at 1 year (0.8%) and 2 years (1.0%) of follow-up (P<.00001 for all 3 time points).14 Patients who received group-based education also had reduced body weight (1.6 kg; P=.02) and improved diabetes knowledge (P<.00001) at 12–14 months of follow-up, and reduced systolic blood pressure (5 mm Hg; P=.01) at 4–6 months of follow-up. Lastly, about 1 in 5 patients who received group-based education were able to decrease their doses of diabetes-related medications at 12–14 months (P<.00001).14
Outcomes data from a subset of patients from the Diabetes America clinics showed that after 4 visits, the average patient A1C value was 7.0%. Overall, 59% of patients had A1C values <7.0% and only 9% had A1C values >9.0%. Additionally, 62% of patients had LDL cholesterol values <100 mg/dL, and only 14% had values >130 mg/dL. A total of 64% of patients sustained systolic blood pressure levels <130 mm Hg, and only 14% had values >140 mm Hg. Lastly, 62% of patients sustained diastolic blood pressure levels <80 mm Hg, and only 5% had values >90 mm Hg.15 All of these outcomes surpass recommended guidelines from the National Committee for Quality Assurance (NCQA) Diabetes Physician Recognition Program (DPRP).16
Cost-effectiveness analyses from a 3-year study of Diabetes America clinics were performed by Aetna, a health insurance provider. Outcomes and costs were monitored for 4 large, public-sector employers who provided their employees with incentives (co-payment waivers) to use an SDC center (in this case, Diabetes America clinics).17 Costs were then compared between patients who did and did not use Diabetes America clinics. For the first 2 years of the study, outcomes were similar, but in the third year the SDC patients had average monthly medical costs that were $226 less per member.17 These cost savings appeared to be due to fewer emergency room visits and shorter hospital stays. Although prescription costs for the clinic patients were on average $40 more per month than for patients not accessing care at these sites, the higher cost was offset by lower medical costs in the long run. Additionally, patients at the Diabetes America centers were more compliant with disease maintenance requirements (such as regular eye exams and blood screenings).
Reasons for success and key challenges