Redesigning Primary Care to Improve Diabetes Outcomes (the UNITED Study)

Diabetes Care. 2020 Mar;43(3):549-555. doi: 10.2337/dc19-1140. Epub 2019 Dec 27.

Abstract

Objective: The effective redesign of primary care delivery systems to improve diabetes care requires an understanding of which particular components of delivery consistently lead to better clinical outcomes. We identified associations between common systems of care management (SysCMs) and the frequency of meeting standardized performance targets for Optimal Diabetes Care (NQF#0729) in primary care practices.

Research design and methods: A validated survey of 585 eligible family or general internal medicine practices seeing ≥30 adult patients with diabetes in or near Minnesota during 2017 evaluated the presence of 62 SysCMs. From 419 (72%) practices completing the survey, NQF#0729 was determined in 396 (95%) from electronic health records, including 215,842 patients with type 1 or type 2 diabetes.

Results: Three SysCMs were associated with higher rates of meeting performance targets across all practices: 1) a systematic process for shared decision making with patients (P = 0.001), 2) checklists of tests or interventions needed for prevention or monitoring of diabetes (P = 0.002), and 3) physician reminders of guideline-based age-appropriate risk assessments due at the patient visit (P = 0.002). When all three were in place, an additional 10.8% of the population achieved recommended performance measures. In subgroup analysis, 15 additional SysCMs were associated with better care in particular types of practices.

Conclusions: Diabetes care outcomes are better in primary care settings that use a patient-centered approach to systematically engage patients in decision making, remind physicians of age-appropriate risk assessments, and provide checklists for recommended diabetes interventions. Practice size and location are important considerations when redesigning delivery systems to improve performance.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Diabetes Mellitus, Type 2 / diagnosis*
  • Diabetes Mellitus, Type 2 / epidemiology
  • Diabetes Mellitus, Type 2 / therapy*
  • Electronic Health Records / statistics & numerical data
  • Female
  • Humans
  • Male
  • Middle Aged
  • Minnesota / epidemiology
  • Nurse Practitioners / organization & administration
  • Nurse Practitioners / standards
  • Nurse Practitioners / statistics & numerical data
  • Outcome Assessment, Health Care
  • Physician Assistants / organization & administration
  • Physician Assistants / standards
  • Physician Assistants / statistics & numerical data
  • Physicians / organization & administration
  • Physicians / standards
  • Physicians / statistics & numerical data
  • Practice Patterns, Physicians' / organization & administration
  • Practice Patterns, Physicians' / standards
  • Practice Patterns, Physicians' / statistics & numerical data
  • Primary Health Care / organization & administration*
  • Primary Health Care / standards
  • Prognosis
  • Quality Improvement / organization & administration*
  • Quality Improvement / standards
  • Standard of Care / organization & administration
  • Standard of Care / standards
  • Surveys and Questionnaires
  • Young Adult