"Patients who received the chronic care model, or CCM, intervention experienced substantial improvements both physically and psychologically," said Gretchen Piatt, M.P.H., a doctoral candidate in the department of epidemiology at the University of Pittsburgh Graduate School of Public Health (GSPH) and the study's first author. "As a result of this study, the University of Pittsburgh Medical Center has redesigned the way in which diabetes care is delivered."
Using state-of-the-art education and other training tools, the CCM was designed to guide systematic efforts to improve health care for people with chronic illness. The idea is to motivate patients, caregivers and health care professionals to work as a team toward a goal of better outcomes.
"Not everyone will be able to see a diabetes specialist," noted Janice Zgibor, Ph.D., senior author of the study, assistant professor of epidemiology at GSPH and director of evaluation at the University of Pittsburgh Diabetes Institute. "Most people with diabetes, especially those in smaller communities, are managing their illness in the primary-care setting. The CCM intervention gives them, and their providers, better tools with which to do this."
The study involved diabetic patients who visited 11 primary care physician practices located in one of Pittsburgh's eastern suburbs between 1999 and 2003. The 11 practices encompassed 24 health care professionals providing care for a primarily elderly, disadvantaged population with a higher incidence of chronic illness compared to the general population. Physician practices were randomized to the CCM intervention, provider education about diabetes or standard diabetes care. Ultimately, 119 patients took part in the study – 30 receiving the CCM intervention, 38 whose providers received a single diabetes education session and the remaining received standard care.
In the CCM intervention group, in which patients and their providers received diabetes-control education, there were significant improvements in clinical, behavioral and psychological indicators compared to the other patient groups. For example, several important indicators of diabetes control, including average blood glucose measures, levels of HDL (good) cholesterol and non-HDL (bad) cholesterol and knowledge about diabetes control, improved significantly for patients receiving the CCM intervention but were little changed in the other two groups.
Hemoglobin A1c, a measure of average blood glucose levels over three months that is a key assessment of overall diabetes control, declined by 7.9 percent for patients receiving the CCM intervention, the study authors reported. Other significant measures included a 14.1 percent improvement in HDL cholesterol, a 7 percent decline in non-HDL cholesterol, a 12 percent improvement in diabetes knowledge test scores and a 28.5 percent increase in the number of patients reporting that they self-monitor blood glucose.
According to Dr. Zgibor, the results confirm what many people in the field have suspected for some time, that optimal diabetes care requires comprehensive education for both patients and providers.
Indeed, although all participants in the study benefited to some degree, those in the CCM intervention group got more comprehensive attention. Most took advantage of weekly ADA-approved diabetes self-management training sessions provided by a certified diabetes educator. In addition, they attended monthly support group sessions to discuss issues such as foot care, healthy diet, alternative treatments and problem-solving skills for a one-year follow-up period.
In addition, providers for the CCM intervention patients were encouraged to schedule diabetic patients' routine appointments to coincide with "diabetes days" so they could take advantage of the services of a visiting certified diabetes educator on site. They also were encouraged to refer their diabetic patients to the on-site diabetes educator for more information whenever possible. Patients in the provider-education only group benefited from diabetes care knowledge shared with other clinicians during a provider-education session.
Although a diabetes educator was not placed in these practices, an educator was available for consultation over a six-month study period. The remaining patients received standard care.
"These results are important, as they demonstrate that a multifaceted intervention can improve diabetes outcomes in an underserved urban community," the authors write. "This study suggests that this model for improving diabetes care in the community is feasible and effective and could be applied to other chronic illnesses."
Currently, the University of Pittsburgh Medical Center hosts 21 ADA-approved diabetes self-management training programs during which diabetes educators also rotate to primary care practices on a routine basis.
Nationally, diabetes is the fifth leading cause of death, according to the ADA. Many people first become aware of the disease when confronted with one of its life-threatening complications such as heart disease, blindness, high blood pressure, stroke, kidney disease or circulatory problems leading to amputation. Women who develop gestational diabetes during pregnancy have a substantially increased risk of acquiring the disorder later in life, and women who have diabetes before becoming pregnant face a higher risk of complications for themselves and their babies. One out of every 10 health care dollars is spent on diabetes and its complications, for an estimated total of $132 billion a year in the U.S.
Today, the U.S. Centers for Disease Control and Prevention estimates that 20.8 million Americans – 7 percent of the U.S. population – already have diabetes. Because diabetes risk is associated with increased age and obesity – itself becoming epidemic – the number of people being affected by the disorder is expected to grow to 30 million by 2050.
Funding for the study was provided by the Lions Clubs, the University of Pittsburgh Medical Center's Division of Community Health Services and the local hospital foundation.
Additional study authors include Trevor Orchard, M.D., Sharlene Emerson, C.R.N.P., Thomas Songer, Ph.D., Maria Brooks, Ph.D., Mary Korytkowski, M.D., Linda Siminerio, Ph.D., and Usman Ahmad, M.D., all of the University of Pittsburgh; and David Simmons, M.D., of the University of Auckland, New Zealand.
Founded in 1948 and fully accredited by the Council on Education for Public Health, GSPH is world-renowned for contributions that have influenced public health practices and medical care for millions of people. For more information, visit http://www.publichealth.pitt.edu.
The mission of the University of Pittsburgh Diabetes Institute, in partnership with the University of Pittsburgh Medical Center, is to provide and support diabetes prevention, detection, education, treatment and research. For more information, visit http://diabetesinstitute.upmc.com.
Last reviewed: By John M. Grohol, Psy.D. on 21 Feb 2009
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