The American Diabetes Association (ADA)(www.diabetes.org) reports that as of January 2011, nearly 26 million people in the United States -- or 8.3 percent of the population -- had diagnosed or undiagnosed diabetes. During 2012, costs related to the disease were $245 billion, according to ADA figures. Of that total, $176 billion was attributed to direct medical costs and $69 billion to reduced worker productivity.
According to the CDC's National Center for Health Statistics FastStats Web page on diabetes(www.cdc.gov), the disease caused 69,071 deaths in the United States in 2010 and ranked seventh on the nation's mortality list.
Those statistics leave little doubt that there's room for continuing study on creative approaches to enhancing the medical care of patients with diabetes. Two potential approaches are reported on in separate research studies in the March/April issue of Annals of Family Medicine. One of the studies looks at using peer health coaches to help patients with diabetes, and the other looks at how a care management team can complement the medical care provided by a patient's primary care physician.
Researchers for the Annals study "Impact of Peer Health Coaching on Glycemic Control in Low-Income Patients With Diabetes: A Randomized Controlled Trial"(annfammed.org) noted the challenges primary care physicians face in providing care for a growing number of patients with diabetes. "Many primary care practices have no one available to provide the time-consuming counseling and teaching of self-management skills that have been shown to improve diabetes outcomes," said study authors.
- Taking care of patients with diabetes demands a lot of time from primary care physicians.
- Two recent studies offer creative ways to complement the physician's work: peer health coaching and care management teams.
- Authors of both studies reported significant reductions in hemoglobin A1c levels in patients who had access to the enhanced care.
Researchers selected and trained 23 patients from six public health clinics in San Francisco to serve as health coaches. These peer coaches -- all with glycated hemoglobin (HbA1c) levels of less than 8.5 percent -- completed the curriculum for the eight-week, 36-hour health coach training class and passed written and oral exams.
Researchers also recruited from the same six clinics 299 patients with HbA1c levels greater than 8 percent and then randomly assigned 148 of those patients to receive health coaching; the other 151 patients received "usual care" provided to patients with diabetes.
At six months, the researchers found that HbA1c levels decreased by 1.07 percent in the peer-coached group compared to a decrease of 0.3 percent in the group that received usual care.
Corresponding author David Thom, M.D., Ph.D., told AAFP News Now that patients with a chronic disease benefit greatly from having an ongoing relationship with someone who can provide resources, support and encouragement. "Using peers is one way of doing that, and it's important to get evidence for how it works so that peer coaching can be part of the toolbox," said Thom, a professor and director of research in the University of California-San Francisco (UCSF) School of Medicine's Department of Family and Community Medicine.
Thom, who is a member of the core faculty at the UCSF Family and Community Medicine Residency Program at San Francisco General Hospital, said the study was conducted in a safety net clinic system beset with common economic, language and cultural barriers. Peer coaches -- trained in English or Spanish and assigned to patients accordingly -- shared the same chronic condition as the patients being coached.
"I think having the same condition adds an important dimension," said Thom. "It gives more credibility, certainly, to peer coaches as they seek to establish a relationship, a bond and a sense of trust with patients." In addition, peer coaches uniquely understand the challenges faced by the patients they are coaching, he said.
Thom noted that coaches were given basic patient education on diabetes, as well as an introduction to the general principles on creating action plans and setting goals. But he said the coaching they provided to patients went beyond that.
"We know that social stressors and access to services affect patients' health, and, as a medical system, we seldom address those things," said Thom. But the peer coaches were in a position to address -- one-on-one with individual patients -- social determinants of health, such as family stress, child care needs and access to healthy food.
"The important point is that patients (serving as peer health coaches) can also be part of the solution -- part of the plan," said Thom. "We have an untapped resource out there with patients who have the (chronic) condition, who have the motivation and personal skills to be effective coaches for other patients."
Thom said setting up a structure for that to happen within family medicine practices could be very beneficial to improving clinical outcomes for patients with diabetes.
In describing the study "Improved Outcomes in Diabetes Care for Rural African Americans,"(annfammed.org) a second group of researchers noted that many minority patients with diabetes who live in rural areas do not receive recommended levels of care for the disease and frequently have poorer clinical outcomes than patients who have access to state-of-the art diabetes care.
Researchers wanted to test the effectiveness of restructuring a primary care practice to include care management intervention provided by a three-person team: a nurse, a pharmacist and a dietitian.
Three rural primary care practices were selected and asked to implement new elements, including behavioral coaching and point-of-care management, into the care of randomly selected black patients with diabetes. An additional five practices served as the control group.
Each patient in the redesign model was seen an average of four times in a 12-month period by a member of the care management team and in conjunction with the patient's traditional office visit with the physician. Patients had scheduled visits with the care manager and physician for an additional two years.
Authors reported significantly greater intermediate and long-term improvement in glycemic control among patients supported by the care management team. Specifically, mean HbA1c levels decreased in intervention practice patients by 0.5 percent at 18 months and maintained that decrease at 36 months.
By comparison, HbA1c levels among control practice patients decreased by only 0.2 percent at 18 months and maintained only a 0.1 percent decrease at 36 months.
Corresponding author Paul Bray said in an interview that the research team wanted to reframe the national discussion on patient care.
"There's been a history of blame around the topic of delivering quality care for patients who don't usually get better," said Bray, who serves as the quality program manager for regional clinics operated by North Carolina-based Vidant Medical Group.
For years, he said, health care stakeholders and policymakers have pointed fingers at physicians, patients and the health care system for not achieving better diabetes care outcomes. But they were missing the point, according to Bray. "What we have is really a delivery design problem," he said.
To address the problem, practices made a seemingly simple improvement in care delivery by ensuring that patients were seen by the primary care physician and the nurse, who was serving as the health coach, on the same day at the same location. This integrated visit expedited and improved patient care, said Bray, an outcome he and his colleagues expected.
However, the team did not anticipate the enormous benefits derived from what Bray characterized as impromptu "hallway conversations," or brief two-minute to three-minute encounters, between the health coach and the physician during which quick facts and challenges related to the patient's care were exchanged.
Those brief interludes of information-sharing often led to a modification of the patient's treatment plan, said Bray.
Bray, who also is affiliated with the East Carolina University Department of Family Medicine in Greenville, said family physicians should not underestimate the work that goes into team building and, in particular, the challenges associated with smoothing the patient flow between the family physician and the health coach.
"That whole dance between the two of them really needs some practice, but the outcome is very much worth it," said Bray.