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In its 2001 report, Crossing the Quality Chasm: A New Health System forthe 21st Century, the Institute of Medicine (IOM) described thedifference between what health care should be and what it is now as not a gap,but a chasm.1 TheIOM identified six attributes around which the health care system should beredesigned: Health care needs to be safe, timely, effective, efficient,equitable, andpatient-centered.
Despite our efforts to shift care in these directions over the past 4years, we have learned that crossing the divide is not easy to do on our own.In fact, closing the chasm will require changes at every level of the healthcare delivery system. Diabetes is one clinical condition where we know thedifference between current care and perfect care is large, but we also knowthe disparity is avoidable. This makes diabetes care an ideal target forquality-improvementefforts.2
Many evidence-based strategies to prevent or delay diabetes complicationshave emerged during the past decade. Yet despite the evidence and relativecost-effectiveness of these treatments, translation of the research intopractice remains suboptimal.
Still more research has identified numerous barriers to care at multiplelevels that may explain why diabetes care in the U.S. continues to fall shortof ourexpectations.3 Atthe provider level, forgetfulness and time constraints, a perception ofpatients as nonadherent, and inadequate knowledge all act as barriers. Forpatients, barriers include incomplete understanding of the seriousness ofdiabetes, lack of motivation toward prevention, and insufficient time,resources, and support. At the system level, the status of diabetes as achronic disease constitutes a major obstacle for a system designed to deliveracute episodic care.
Too many health care organizations continue to lack information supportsystems that can identify and track diabetes patients and prompt cliniciansabout the ongoing care and preventive needs of individual patients. Andalthough a number of small studies have successfully tested provider-,patient-, and system-level interventions to improve diabetes care, meaningfulsystemwide changes have yet to emerge.
Breakthrough improvements clearly require redesigning the health caresystem to meet the six characteristics of high-quality care described by theIOM. The changes needed include:
FINANCIAL INCENTIVES
Already we have begun to see changes in the mechanism of payments toproviders. In recent years, insurers and purchasers of health care haveembraced a concept that encourages clinicians to improve the quality of carewith pay-for-performance programs. By attempting to reward clinicians forproviding high-quality care, payers and employers hope these programs willsignificantly improve quality ("Look Before You Leap: Examining Pay forPerformance," see page1).
For pay for performance to work, however, the areas targeted must actuallyimprove care and lead to fewer complications, thereby reducing costs. Targetsmust be clinically meaningful, based on evidence, and cost-effective. Inaddition, the measures used to determine who is delivering quality care needto be standardized across health plans so that clinicians can more efficientlyalign their efforts.
Physicians have begun to respond positively to pay-for-performanceincentives, which shows promise for this approach that puts performancemeasurement in the forefront of their practices. Even without the financialincentive, performance measurement forces physicians to focus on improvingquality. These efforts are still in their infancy, however, and only time willtell if the incentives advance quality and if cost savings follow.
PRACTICE-FLOW CHANGES
Organization and workflow within a medical-group practice influencetremendously its quality of care. Combining automated reminders with clinicalpractice guidelines and performance feedback could create a breakthrough inquality improvement. Information technology can help create patient-trackingsystems that prompt providers to achieve treatment and preventive-care goals,and electronic medical records may improve communication among providers andreduce medical errors. For computerized reminders to work, however, they mustbe part of an overall continuous quality improvement effort.
In practices that have yet to launch electronic systems, even nonautomatedapproaches, such as telephone reminders, chart stickers, and flow sheets, canhelp prompt both providers and patients to get needed tests and treatments.Another way to reorganize practice flow is to create a diabetes clinic blockschedule, which allows primary care providers to focus the visit entirely ondiabetes-related issues.
CONTINUING PATIENT EDUCATION
Finally, we need to educate and support our diabetes patients in asystematic way. Teaching patients about the goals of therapy and the need forpreventive care will help make the patient a partner in the process.
Small steps can make a difference. More than 10 years ago, a study foundthat a community-care model that sent reminders directly to patients improvedadherence to many preventivemeasures.4 Otherspecific teaching programs, such as skill building, have shown improvements inquality of life, glycemic control, and adherence to screeningrecommendations.5
Building in these kinds of crucial systematic approaches to patienteducation can be accomplished at the practice level without a major financialinvestment.
We have evidence of how to reduce diabetes complications, and thesystems-based research is coming. We must make changes in our own practices tohelp redesign health care in a way that creates a safe, effective, efficient,timely, patient-centered, and equitable system. We can and we must do this.The time is now. 
Footnotes
References
2. Saaddine JB, Engelgau MM, Beckels GL, et al.: A diabetes reportcard for the United States: Quality of care in the 1990s. Ann InternMed 136:565–574, 2002.
3. Narayan KM, Benjamin E, Gregg EW, et al.: Diabetes translationresearch: Where are we and where do we want to be? Ann InternMed 140:958–963, 2004.
4. Hurwitz B, Goodman C, Yudkin J: Prompting the clinical care ofnon-insulin dependent (type II) diabetic patients in an inner city area: Onemodel of community care. BMJ 306:624–630, 1993.
5. Gruesser M, Bott U, Ellermann P, et al.: Evaluation of a structuredtreatment and teaching program for non-insulin-treated type II diabeticoutpatients in Germany after the nationwide introduction of reimbursementpolicy for physicians. Diabetes Care 16:1268–1275, 1993.[Abstract]
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| DOC News | Diabetes | Diabetes Care | Clinical Diabetes | Diabetes Spectrum |
