Specialty Diabetes Care Research Articles

1169-P: Democratizing Type 1 Diabetes Specialty Care in the Primary Care Setting: Project ECHO T1D

Project ECHOTM (Extension for Community Healthcare Outcomes) is a hub-spoke telehealth outreach model that democratizes specialty knowledge to reduce disparities and improve health outcomes. Limited access to endocrinologists forces many primary care providers (PCPs) to manage patients with type 1 diabetes (T1D) without specialty support. As such, Stanford and the University of Florida partnered to develop and pilot “ECHO T1D”, a teleECHOTM clinic focused on T1D in California (CA) and Florida (FL), respectively. Our goal was to demonstrate the feasibility of ECHO T1D and improve PCPs’ abilities to manage patients with T1D. Primary care spokes were recruited targeting Federally Qualified Health Centers (FQHCs) where vulnerable T1D patient populations more likely rely on PCPs for care. In CA, 11 spokes enrolled with 37 clinics serving ∼900 patients with T1D who do not receive routine specialty T1D care. In FL, 12 spokes enrolled with 67 clinics serving ∼1,000 patients with T1D. Multidisciplinary hub team specialists were recruited and a 6-month curriculum was developed. Weekly 1-hour teleECHO sessions consisting of didactic presentations and case reviews were offered for 27 sessions. Weekly engagement of the 70 participating PCPs (69% in CA) ranged from 0 to 27 (mean 14) sessions and 65 completed both baseline and exit surveys. Baseline data demonstrated low confidence in providing T1D care, especially related to diabetes technology. Pre/post surveys demonstrated statistically significant improvements in provider confidence in T1D management and knowledge (p=0.02). PCPs who attended ≥ 50% sessions had the largest improvements. Over 90% of PCPs reported changes in medical practice (e.g., insulin and pump adjustments) and 95% would recommend the program to colleagues. The ECHO model can be applied to T1D to improve PCPs’ ability to manage patients with T1D. Future directions include evaluating influence on patient level outcomes and applying the model to insulin-requiring T2D patients. Disclosure N. Cuttriss: None. C. Anez-Zabala: None. L.G. Baer: None. S.L. Filipp: None. M. Basina: None. M.J. Gurka: None. L. Figg: None. M.J. Haller: Advisory Panel; Self; SAB Biotherapeutics, Inc. K.K. Hood: Research Support; Self; Dexcom, Inc. Speaker’s Bureau; Self; LifeScan, Inc., MedIQ. X. Roque: None. R. Lal: Consultant; Self; Abbott, Biolinq. S.C. Westen: None. D.M. Maahs: Advisory Panel; Self; Eli Lilly and Company, Insulet Corporation, Medtronic, Novo Nordisk A/S. Consultant; Self; Abbott, Sanofi. Research Support; Self; Bigfoot Biomedical, Dexcom, Inc., Roche Diabetes Care, Tandem Diabetes Care. M. Town: Other Relationship; Self; Insulet Corporation. C. Wang: None. J.J. Wong: None. K. Yabut: None. A.F. Walker: None. Funding The Leona M. and Harry B. Helmsley Charitable Trust

334-OR: Project ECHO T1D Tackles Complexity of Diabetes Cases in Primary Care

Primary care providers (PCPs) manage type 1 diabetes (T1D) and complex diabetes for people who lack access to multispecialty care. Project ECHOTM (Extension for Community Healthcare Outcomes) is a low-dose, high frequency workforce development hub-spoke model that leverages telehealth to connect multidisciplinary specialists (“hub”) with PCPs across regional clinic sites (“spokes”). Applying the ECHO model, we piloted the model for T1D (Project ECHO T1D) in the states of California (CA) and Florida (FL) targeting PCPs managing adult and pediatric patients with T1D. Weekly hour-long teleECHOTM sessions were led by each hub in CA and FL over a 6 month pilot period. Each session included 1 to 2 case presentation. Prior to each teleECHO session, PCPs uploaded de-identified case presentations for discussion via REDCap®. Recommendations were provided by other participants and the multidisciplinary hub teams. Characteristics of case presentations were tracked in CA and FL. During the 6 month intervention, 47 new and follow-up cases were presented in CA and 45 in FL. Middle age adults (33.9±17.4 years-old, 20% pediatric) with poorly controlled diabetes (HbA1c 9.6±2.2% in CA and 10.4±2.8% in FL) were frequent cases. Common thematic questions submitted by PCPs in CA and FL, respectively, included: insulin dose adjustments (49%, 47%), social concerns (37%, 47%), behavioral health (29%, 34%), diabetes devices (44%, 13%), and diabetes education (15%, 38%). Patients commonly had depression (29.3%, 28.1%), recent hospitalizations (27%, 17%) and ER visits (33%, 26%) in the past year. Greatest barriers to care were social support (34%, 28%), financial (29%, 22%), diabetes knowledge (22%, 25%), attitudes and beliefs (27%, 16%) and psychiatric issues (20%, 19%). Findings illustrate the complexity of diabetes being managed by PCPs and the need for healthcare delivery innovation in diabetes education to support PCPs and primary care clinics who manage patients with complex diabetes who lack access to diabetes specialty care. Disclosure N. Cuttriss: None. C. Anez-Zabala: None. L.G. Baer: None. S.L. Filipp: None. M. Basina: None. M.J. Gurka: None. L. Figg: None. M.J. Haller: Advisory Panel; Self; SAB Biotherapeutics, Inc. K.K. Hood: Research Support; Self; Dexcom, Inc. Speaker’s Bureau; Self; LifeScan, Inc., MedIQ. X. Roque: None. R. Lal: Consultant; Self; Abbott, Biolinq. S.C. Westen: None. D.M. Maahs: Advisory Panel; Self; Eli Lilly and Company, Insulet Corporation, Medtronic, Novo Nordisk A/S. Consultant; Self; Abbott, Sanofi. Research Support; Self; Bigfoot Biomedical, Dexcom, Inc., Roche Diabetes Care, Tandem Diabetes Care. M. Town: Other Relationship; Self; Insulet Corporation. C. Wang: None. J.J. Wong: None. K. Yabut: None. A.F. Walker: None. Funding The Leona M. and Harry B. Helmsley Charitable Trust

1313-P: Comparison of Diabetes Health-Care Quality between Endo ECHO and the Academic Medical Center

Background: Patients receiving diabetes specialty care experience higher quality care, fewer complications and improved survival; however, access to specialists is limited in medically underserved areas. The Endo ECHO program connects specialists at academic medical centers with PCPs through virtual clinics. We report the comparability of quality measures between Endo ECHO patients and those receiving diabetes specialty care. Methods: Patients with complex diabetes from 10 Endo ECHO clinics in NM completed surveys assessing healthcare quality one year after program enrollment. Patients at the University of New Mexico Diabetes Comprehensive Care Center (DCCC) served as a comparison group and completed the same survey. Results: Five hundred thirty-three ECHO patients and 139 DCCC patients completed surveys. ECHO patients were much less likely to identify English as their primary language (69% ECHO vs. 91% DCCC, p<0.0001) and reported lower levels of educational attainment (40% ECHO with at least some college vs. 60% DCCC, p<0.0001). DCCC patients were more likely to report a positive overall health status (42% ECHO vs. 68% DCCC, p<0.0001), yet there was no difference in overall concern about health across groups. ECHO patients reported more frequent visits to their usual source of diabetes care (72% ECHO with 4 or more annual visits vs. 58% DCCC, p<0.0001). There were no differences in the frequency of A1C testing or feet checks by a provider; however, more DCCC patients reported regular eye exams (69% ECHO vs. 87% DCCC, p<0.0001) and that their provider had assessed smoking status (70% ECHO vs. 82% DCCC, p<0.0001). Conclusions: Endo ECHO patients faced greater medical literacy barriers yet reported similar outcomes for several, but not all, diabetes care quality measures as compared to those reported by patients at the DCCC. Endo ECHO may be a suitable alternative to specialty care for patients in medically underserved areas; ongoing evaluation will determine its impact on clinical outcomes. Disclosure M.M. Paul: None. A. Davila Saad: None. J. Billings: None. S. Blecker: Advisory Panel; Self; Medtronic. M.F. Bouchonville: None. B. Hager: None. S. Arora: None. C. Berry: None. Funding The Leona M. and Harry B. Helmsley Charitable Trust

1264-P: Predictors of Success in Usual and Intensive Specialty Diabetes Programs

Intensive management (IM) is recognized as an important approach in treatment of poorly controlled diabetes. However, it is unknown what factors determine response to usual diabetes specialty care (UC) vs. IM and understanding these will improve allocation of costly resources. We sought to identify predictors of response in UC and IM, a high-resource 6-month service designed for those who fail UC that includes telemedicine, remote data sharing, and in-person visits. A response metric was defined as an A1c reduction of >/=0.5 within 12 months of the initial visit. We analyzed two groups with baseline A1c >8: 1) UC patients referred to a diabetes specialty clinic between 12/2016 and 8/2017 (N= 163) and 2) IM patients, who were referred after failing metric between 10/2015 and 6/2018 (N=62). The majority met metric (UC-Met: 74%, IM-Met: 61%). In UC and IM, there were no differences between those who met metric and those who did not in age, gender, race or ethnicity. The UC-Met vs. UC-Notmet were similar across quality parameters (SBP, statin prescription, LDL), prior A1c pattern (peak and nadir A1c), and the presence of cognitive impairment. However, IM-Notmet had more cognitive dysfunction (20% vs. 2.6%, p=0.04) and substance abuse (16% vs. 5%, p=0.35) than IM-Met. Those in IM-Met had a lower A1c nadir in the last decade (6.87 vs. 7.26, p=0.04). Prevalence of psychiatric disease was high in both IM groups (60% IM-Notmet and 53% IM-Met). In conclusion, specialty diabetes services delivered via UC was effective in 74% of patients. The majority of those who fail to achieve clinically significant A1c lowering benefit from resource-intensive programs, especially those who achieved lower A1c levels in the past. However, cognitive impairment and active substance abuse appear to be risk factors for lack of response to high intensity programs, suggesting that resources designed to manage these conditions should be prioritized in affected individuals with diabetes. Disclosure K.L. Del Valle: None. A. Grizales: None. M. Donahue: None. A. Turchin: Advisory Panel; Self; Monarch Medical Technologies. Research Support; Self; Eli Lilly and Company. Stock/Shareholder; Self; Brio Systems. M.E. McDonnell: None.

Reduced Impact of Diabetes Clinic Referral on High-Frequency Emergency Department Users

The patterns of emergency department (ED) visits in patients with diabetes are not well understood. The Emergency Department Diabetes Rapid-referral Program (EDRP) allows direct booking of ED patients presenting with urgent diabetes needs into a diabetes specialty clinic within 1 day of ED discharge. The objective of this secondary analysis was to examine characteristics of patients with diabetes who have frequent ED visits and determine reasons for revisits. A single-center analysis was conducted comparing patients referred to the EDRP (n = 420) to historical unexposed controls (n = 791). The primary outcome was the proportion of patients in each frequency group of ED revisits (none, 1 to 3 [infrequent], 4 to 10 [frequent], or >10 [superfrequent]) in the year after the ED index visit. Secondary outcomes were hospitalization rates and International Classification of Diseases-Ninth Revision (ICD-9) diagnoses at ED revisits. Superfrequent users, responsible for >20% of total ED visits, made up small but not significantly different proportions of EDRP and control populations, 3.6% and 5.2%, respectively. Superfrequent groups had lower hospital admission rates at ED revisits compared to frequent groups. Mental health disorders (including substance abuse) were the primary, secondary, or tertiary ICD-9 codes in 30.6% (95% confidence interval [CI], 27.7% to 33.5%) and 6.6% (95% CI, 5.1% to 8.2%) in the superfrequent and infrequent groups, respectively. Direct access to diabetes specialty care from the ED is effective in reducing ED recidivism but not amongst a small subgroup of superfrequent ED users. This group was more likely to have mental health disorders recorded at ED revisits, suggesting that more comprehensive approaches are needed for this population. EDRP = Emergency Department Diabetes Rapid-referral Program; ED = emergency department; HbA1c = hemoglobin A1c; ICD-9 = International Classification of Diseases-Ninth Revision.

Attitudes Regarding Technology and Weight Loss in Patients with Diabetes and Prediabetes in a Military Health System

Background: Military dependents and veterans have obesity, prediabetes and diabetes rates similar to the general U.S. population. This project examined the attitudes of patients with prediabetes and diabetes regarding weight loss and the use of technology in weight management. Method: A survey was distributed to three primary care clinics and a diabetes specialty care clinic in the San Antonio Military Health System (SAMHS) over a two week period in February 2017. Demographics included age, sex, and presence of medical diagnoses including prediabetes and diabetes. Access to and attitudes regarding multiple types of personal technology were assessed. Data analysis was completed using SPSS version 22. Results: There were 424 surveys collected. Prediabetes was self-reported by 25 (6.6%) respondents and 151 (39.6%) respondents self-reported a diabetes diagnosis. Interest in weight loss was high for patients with prediabetes (100%) and diabetes (73.5%); of those with diabetes that also self-identified as obese, 50 (96%) were interested in losing weight. Patients with prediabetes and diabetes were interested in using fitness trackers (65.5%), online videos (57.1%), receiving text messages (53.9%), fitness apps (53.3%), and the existing patient online portal (52.1%). Access to technology was high; many patients owned a personal computer or tablet (76.6%), used text messaging (75%), or owned a smart phone (64.5%). A majority (59.7%) believed technology was helpful for weight loss, but relatively few had used technology in past weight loss efforts (32.4%). Conclusions: This survey showed that SAMHS patients with prediabetes and diabetes have significant interest in weight loss, access to personal technology devices, and interest in using technology to assist with weight loss. These results will be used to augment existing weight management and health interventions for people with prediabetes and diabetes. Disclosure A. Beauvais: None. J.L. Wardian: None. T.J. Sauerwein: Speaker's Bureau; Self; Merck & Co., Inc., AstraZeneca.

Telemedicine in the Management of Type 1 Diabetes.

BackgroundVeterans with type 1 diabetes who live in rural Alabama and Georgia face barriers to receiving specialty diabetes care because of a lack of endocrinologists in the Central Alabama Veterans Health Care System. Telemedicine is a promising solution to help increase access to needed health care. We evaluated telemedicine’s effectiveness in delivering endocrinology care from Atlanta-based endocrinologists.MethodsWe conducted a retrospective chart review of patients who were enrolled in the Atlanta VAMC Endocrinology Telehealth Clinic from June 2014 to October 2016. Outcomes of interest were hemoglobin A1c levels, changes in glycemic control, time savings for patients, cost savings for the US Veterans Health Administration, appointment adherence rates, and patient satisfaction with telehealth.ResultsThirty-two patients with type 1 diabetes received telehealth care and in general received the recommended processes of diabetes care. Patients trended toward a decrease in mean hemoglobin A1c and glucose variability and a nonsignificant increase in hypoglycemic episodes. Patients saved 78 minutes of travel time (one way), and the VA saved $72.94 in travel reimbursements per patient visit. Patients adhered to 88% of scheduled telehealth appointments on average, and 100% of surveyed patients stated they would recommend telehealth to other veterans.ConclusionsSpecialty diabetes care delivered via telemedicine was safe and was associated with time savings, cost savings, high appointment adherence rates, and high patient satisfaction. Our findings support growing evidence that telemedicine is an effective alternative method of health care delivery.

Patient, Primary Care Provider, and Specialist Perspectives on Specialty Care Coordination in an Integrated Health Care System.

Successful coordination of specialty care requires understanding the perspectives of patients, primary care providers, and specialists-that is, the specialty care "triad." This study used qualitative methods to compare these perspectives in an integrated health care system, using diabetes specialty care as an exemplar. Primary care providers and endocrinologists relied on interclinician relationships to coordinate care. Clinicians rarely included patients or other staff in their conceptualization of specialty care coordination. Patients often assumed responsibility for specialty care coordination but struggled to succeed. We identified several opportunities to improve coordination across the triad. In an integrated medical system, the shared organizational structure can facilitate these efforts.

Specialty Group Medical Visits for Patients With Diabetes.

Diabetes remains a major public health problem that affects ∼29 million Americans, or 9.3% of the U.S. population. Diabetes and its complications account for ∼$176 billion in annual direct medical costs (1). The burden of diabetes is disproportionate among the medically underserved, in particular African-American and Hispanic patients, as well as patients with Medicaid (2,3). Disparities in diabetes care among racial and ethnic minorities can be attributed to a number of factors, including reduced access to care and poorer quality of care (4). Quality diabetes care requires a patient-centered, organized, systematic approach by a coordinated interdisciplinary team of health care professionals (5). Despite advances in diabetes care through the years, 30–50% of patients do not meet their glycemic, blood pressure, or lipid targets (6). Notably, patients with Medicaid tend to have a lower percentage of goal attainment than those with private insurance or Medicare (3). Further complicating these issues is the shortage of adult endocrinologists to treat complex diabetes cases, resulting in overwhelming patient volumes and limited access to care (7). Addressing these barriers is crucial to providing optimal, patient-centered diabetes care. To overcome these challenges, we pioneered a novel specialty diabetes group medical visit (GMV) model at the Cooper University Hospital Urban Health Institute (UHI) in Camden, NJ. Camden has a medically underserved, resource-poor population that is largely African American and Hispanic (8). Our patient population with diabetes is medically complex, with high rates of hypertension, hyperlipidemia, and insulin use. The diabetes GMV model for providing specialty diabetes care serves as a means of solving two intertwined business and clinical problems faced with traditional one-on-one office visits. The clinical rationale for GMVs was based on poor patient experiences, lack of self-management support, and the endocrinologist’s frustration at his inability to offer high-quality, comprehensive care in …

Interactive Video Telehealth Models to Improve Access to Diabetes Specialty Care and Education in the Rural Setting: A Systematic Review.

The burden of diabetes is complex and growing in epidemic proportions. According to the American Diabetes Association (ADA), ∼29.1 million Americans (9.3% of the population) were diagnosed with diabetes as of 2015, and >1 million new cases of diabetes are diagnosed in people ≥20 years of age in the United States each year (1). Diabetes is also on the rise globally. The International Diabetes Federation has predicted that the number of people with diabetes worldwide will rise from the present 415 million to 642 million in 2040 (2). Diabetes is the seventh leading cause of death in the United States and kills more people every year than AIDS and breast cancer combined (1). Patients with diabetes often have comorbid conditions of hypertension, dyslipidemia, retinopathy, neuropathy, kidney failure, lower limb amputations, and cardiovascular disease (3). Alarmingly, in the past decade, research has shown an increased risk for pancreatic, liver, colorectal, endometrial, and breast cancer among people living with diabetes (4). Although additional studies are needed to determine the causes of this risk, cancer screening is a necessary standard of diabetes care. Increased diabetes incidence in the United States is attributed to an aging population, increased diabetes risk among expanding minority groups (i.e., non-Hispanic blacks, Asians, Hawaiians/Pacific Islanders, and Native Americans/Alaska Natives), sedentary lifestyle, and high rates of obesity (5). In 2012, the ADA reported that diabetes accounted for $245 billion in public costs, including $176 billion in direct costs and $69 billion in indirect costs (i.e., disability, work loss, and premature mortality). In the absence of an improved diabetes management strategy, escalating costs will create an enormous economic burden for the already strained U.S. health care system. The prevalence of diabetes is 17% higher in adults living in rural areas than in the population as a whole (6). Rural populations …

Effects of professional autonomy and approval from others on job satisfaction in nurses qualified as a Certified Diabetes Educator of Japan: Focus on the presence or absence of responsibility for outpatient specialty diabetes care

Effects of professional autonomy and approval from others on job satisfaction in nurses qualified as a Certified Diabetes Educator of Japan: Focus on the presence or absence of responsibility for outpatient specialty diabetes care

Endocrinology Telehealth Consultation Improved Glycemic Control Similar to Face-to-Face Visits in Veterans.

Rates of diabetes for veterans who receive health care through the Veterans Health Administration are higher than rates in the general population. Furthermore, many veterans live in rural locations, far from Veterans Affairs (VA) hospitals, thus limiting their ability to readily seek face-to-face endocrinology care for diabetes. Telehealth (TH) technologies present an opportunity to improve access to specialty diabetes care for such patients; however, there is a lack of evidence regarding the ability of TH to improve glycemic control in comparison to traditional face-to-face consultations. This was a retrospective cohort study of all new endocrinology diabetes consultations at the Denver VA Medical Center over a 1-year period. A total of 189 patients were included in the analysis. In all, 85 patients had received face-to-face (FTF) endocrinology consultation for diabetes and 104 patients had received TH consultation. Subjects were mostly males (94.7%) and the mean age was 62.8 ± 10.1 years old. HbA1c improved from 9.76% (9.40% to 10.11%) to 8.55% (8.20% to 8.91%) (P < .0001) for the TH group and from 9.56% (9.16% to 9.95%) to 8.62% (8.22% to 9.01%) (P < .0001) for the FTF group after 1 visit. This change in HbA1c was not significantly different in the TH and FTF groups (P = .24). TH visits were associated with a hypothetical savings in median distance traveled of 231.2 miles per trip (which equates to $94.79 saved per trip). Endocrinology TH consultations improved short-term glycemic control as effectively as traditional FTF visits in a veteran population with diabetes.

Abstract #232: Stardm: A Model of Care in Specialty Diabetes Care

Abstract #232: Stardm: A Model of Care in Specialty Diabetes Care

Your Diabetes Care Provider in the Future Is Probably an NP or PA!

I t is well known that the physician shortage is bad and getting worse with an influx of newly insured patients. To make matters worse for people with diabetes, the numbers of endocrinologists treating people with diabetes is decreasing. Some estimate that there are only ~ 4,000 practicing endocrinologists, and the number is dropping.1 The need for qualified health care professionals (HCPs) has never been greater. The rapidly aging population, coupled with longer life expectancies, will result in an increasing number of people with diabetes who will need both primary and specialty diabetes care. The current health care system is challenged to ensure accessibility to quality, affordable care for people with diabetes. Some health care organizations, HCPs, and government officials believe at least part of the solution lies in expanding the scope of practice of nurse practitioners (NPs) and physician assistants (PAs). A key message in the Institute of Medicine (IOM)'s The Future of Nursing: Leading Change, Advancing Health 2 is that NPs should be used to the full extent of their education and training and that they need to become full partners with physicians and other HCPs. As stated in that document, “The United States has the opportunity to transform the health care system, and nurses can and should play a fundamental role in this transformation.” To achieve this transformation, “Nurses should practice to the full extent of their education and training.” One reason many NPs are unable to practice to the full extent of their education and training is rooted in history and traditions that are no longer appropriate for today's rapidly advancing health care system. Physicians were the first …

Impact of Comprehensive Diabetes Specialty Care in the Management of Older Adults with Stage 3 or 4 Nephropathy

Impact of Comprehensive Diabetes Specialty Care in the Management of Older Adults with Stage 3 or 4 Nephropathy

171: Comprehensive Co-Management of Older Adults With Diabetes and Stage 3 or 4 Kidney Disease: Impact of Diabetes Specialty Care

171: Comprehensive Co-Management of Older Adults With Diabetes and Stage 3 or 4 Kidney Disease: Impact of Diabetes Specialty Care

Primary and Specialty Medical Care Among Ethnically Diverse, Older Rural Adults With Type 2 Diabetes: The ELDER Diabetes Study

Residents in rural communities in the United States, especially ethnic minority group members, have limited access to primary and specialty health care that is critical for diabetes management. This study examines primary and specialty medical care utilization among a rural, ethnically diverse, older adult population with diabetes. Data were drawn from a cross-sectional face-to-face survey of randomly selected African American (n=220), Native American (n=181), and white (n=297) Medicare beneficiaries > or =65 years old with diabetes in 2 rural counties in central North Carolina. Participants were asked about utilization of a primary care doctor and of specialists (nutritionist, diabetes specialist, eye doctor, bladder specialist, kidney specialist, heart specialist, foot specialist) in the past year. Virtually all respondents (99.0%) reported having a primary care doctor and seeing that doctor in the past year. About 42% reported seeing a doctor for diabetes-related care. On average, participants reported seeing 2 specialists in the past year, and 54% reported i seeing >1 specialist. Few reported seeing a diabetes specialist (5.7%), nutritionist (10.9%), or kidney specialist (17.5%). African Americans were more likely than others to report seeing a foot specialist (P < .01), while men were more likely than women to have seen bladder specialist (P = .02), kidney specialist (P = .001), and heart specialist (P = .004), after adjusting for potential confounders. Predictors of the number of specialists seen include gender, education, poverty status, diabetes medication use, and self-rated health. These data indicate low utilization of specialty diabetes care providers across ethnic groups and reflect the importance of primary care providers in diabetes care in rural areas.

Specialist and Generalist Care for Type 1 Diabetes Mellitus

The incidence of diabetes mellitus (both type 1 and type 2) is growing to epidemic proportions, with an expected combined worldwide prevalence of 220 million by the year 2010. A subsequent increase in the incidence of diabetes complications is likely to follow if present trends continue, placing an increased burden on already troubled healthcare systems. While there are many identified biologic mechanisms for the development of diabetes complications, there has been little exploration of healthcare provider issues and their contribution to these outcomes. One area of research with few data is the influence of diabetes specialty care on outcomes in type 1 diabetic patients. Evidence demonstrates that both process delivery and outcomes are better in individuals with typel diabetes who are cared for by diabetes specialists compared with generalists. For example, those receiving care from diabetes specialists were more likely to receive diabetes education, to be treated with intensive insulin therapy (>2 injections/day), and to receive an eye examination compared with those receiving generalist care. Additionally, lower rates of proliferative retinopathy were observed in those receiving specialist care. Recent evidence also demonstrates that there are lower incidences of neuropathy, overt nephropathy, and coronary artery disease in those patients who spend a higher proportion of the duration of their diabetes in specialist care. Based on these observations, it is recommended that attempts be made to replicate the favorable characteristics of specialty care in the primary care setting. Healthcare systems should ensure the availability of access to diabetes specialists, as well as ancillary healthcare professionals including diabetes educators, with increased emphasis placed on coordinated care.

Examining diabetes health benefits in health plans of large employers.

Components of the contract specifications (also known as model purchasing specifications) for diabetes care that were developed by George Washington University (Washington, D.C.) and the Centers for Disease Control and Prevention were applied to 20 health plans from two Fortune 500 companies as well as the Federal Employee Health Benefits Plan to investigate the extent of diabetes-related benefits available to employees. Diabetes-related benefits covered a range of services and supplies that include insulin, physician visits, immunizations, diabetes preventive assessments, foot and eye exams, hemoglobin A1c tests, orthotics, diabetes self-management education, case management, smoking cessation, obesity treatment, and exercise training. The 20 health plans included health maintenance organizations, preferred provider organizations, point of service plans, and one indemnity plan. Services and supplies were assigned to three tiers: tier 1, general diabetes care; tier 2, specialty diabetes care; tier 3, lifestyle services. Services and supplies were considered covered even if they required authorization by the provider (e.g., doctor referral, recommendation, or prescription) or the health plan. Tier 1 services and supplies received more comprehensive coverage by all health plans. Differences in coverage were more notable in tiers 2 and 3 than in tier 1. Tier 3 (lifestyle services) received less coverage than tiers 1 and 2.

Searching for glycemic control in pediatric type 1 diabetes: A long way to go

Searching for glycemic control in pediatric type 1 diabetes: A long way to go