Carol M. Mangione, MD, MSPH; Robert B. Gerzoff, MS; David F. Williamson, PhD; W. Neil Steers, PhD; Eve A. Kerr, MD; Arleen F. Brown, MD, PhD; Beth E. Waitzfelder, PhD; David G. Marrero, PhD; R. Adams Dudley, MD, MBA; Catherine Kim, MD, MPH; William Herman, MD; Theodore J. Thompson, MS; Monika M. Safford, MD; Joe V. Selby, MD, MPH; for the TRIAD Study Group*
Disclaimer: The contents of this paper are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention and the National Institute of Diabetes and Digestive and Kidney Diseases.
Acknowledgment: The authors acknowledge the participation of their health plan partners.
Grant Support: This study was jointly funded by Program Announcement no. 04005 from the Centers for Disease Control and Prevention (Division of Diabetes Translation) and the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Kerr's role was supported by the Department of Veterans Affairs Health Services Research and Development Service.
Potential Financial Conflicts of Interest: None disclosed.
Corresponding Author: Carol M. Mangione, MD, MSPH, Department of Medicine, David Geffen School of Medicine at UCLA, 911 Broxton Plaza, Room 119, Los Angeles, CA 90095-1736; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Mangione, Steers, and Brown: Department of Medicine, David Geffen School of Medicine at UCLA, 911 Broxton Plaza, Room 119, Los Angeles, CA 90095-1736.
Mr. Gerzoff, Dr. Williamson, and Mr. Thompson: Division of Diabetes Translation, Centers for Disease Control and Prevention, 4770 Buford Highway Northeast, MS K-10, Atlanta, GA 30341.
Dr. Kerr: Ann Arbor Veterans Affairs Center for Practice Management and Outcomes Research, 2215 Fuller Road (11H), Ann Arbor, MI 48105.
Dr. Waitzfelder: Pacific Health Research Institute, 846 South Hotel Street, Suite 303, Honolulu, HI 96813.
Dr. Marrero: Diabetes Training and Research Center, Indiana University, 250 University Boulevard, Room 122, Indianapolis, IN 46202.
Dr. Dudley: University of California, San Francisco, 3333 California Street, Suite 265, San Francisco, CA 94118.
Dr. Kim: University of Michigan, 300 NIB, 7C13, Box 0429, Ann Arbor, MI 48109-0429.
Dr. Herman: University of Michigan Medical Center, 1500 East Medical Center Drive, 3920 TC, Ann Arbor, MI 48109-0354.
Dr. Safford: Department of Preventive Medicine, University of Alabama at Birmingham, MT 643, 1717 11th Avenue South, Birmingham, AL 35294-4410.
Dr. Selby: Division of Research, Kaiser Permanente, 2000 Broadway, Oakland, CA 94612.
Although disease management programs are widely implemented, little is known about their effectiveness.
To determine whether disease management by physician groups is associated with diabetes care processes, control of intermediate outcomes, or the amount of medication used when intermediate outcomes are above target levels.
Patients were randomly sampled from 63 physician groups nested in 7 health plans sponsored by Translating Research into Action for Diabetes (87%) and from 4 health plans with individual physician contracts (13%).
8661 adults with diabetes who completed a survey (2000–2001) and had medical record data.
Physician group and health plan directors described their organizations' use of physician reminders, performance feedback, and structured care management on a survey; their responses were used to determine measures of intensity of disease management. The current study measured 8 processes of care, including most recent hemoglobin A1c level, systolic blood pressure, serum low-density lipoprotein cholesterol level, and several measures of medication use.
Increased use of any of 3 disease management strategies was significantly associated with higher adjusted rates of retinal screening, nephropathy screening, foot examinations, and measurement of hemoglobin A1c levels. Serum lipid level testing and influenza vaccine administration were associated with greater use of structured care management and performance feedback. Greater use of performance feedback correlated with an increased rate of foot examinations (difference, 5 percentage points [95% CI, 1 to 8 percentage points]), and greater use of physician reminders was associated with an increased rate of nephropathy screening (difference, 15 percentage points [CI, 6 to 23 percentage points]). No strategies were associated with intermediate outcome levels or level of medication management.
Physician groups were not randomly sampled from population-based listings, and disease management strategies were not randomly allocated across groups.
Disease management strategies were associated with better processes of diabetes care but not with improved intermediate outcomes or level of medication management. A greater focus on direct measurement, feedback, and reporting of intermediate outcome levels or of level of medication management may enhance the effectiveness of these programs.
*See Appendix 1 for a complete list of the TRIAD Study Group.
Little is known about the effects of quality-of-care improvement programs on the process of care and outcomes of diabetes.
The study involved 8661 patients with diabetes, 63 provider groups, and 3 disease management strategies (provider feedback, reminders, and structured care). The quality measures included 8 processes of care, 3 intermediate diabetes outcomes, and medication management of these outcomes. More intense disease management strategies predicted higher measures of many processes of care but only 1 intermediate outcome and 1 medication management outcome.
The disease management strategies improved processes of care but not outcomes. Experts in quality improvement may need to refocus their efforts.
Description of sampling and response rate.xx
Table 1. Selected Item-Level Responses for Provider Groups for Each Disease Management Strategy*
Appendix Table 1. Descriptive Statistics for Each Clinical Care Strategy Composite
Table 2. Clinical Management Measures for Hemoglobin A1c, Systolic Blood Pressure, and Serum Low-Density Lipoprotein Cholesterol*
Table 3. Distributions of Patient Demographic Characteristics and Clinical Predictors across Physician Groups*
Table 4. Distribution of Quality Indicators, Mean Intermediate Outcome Levels, and Clinical Management Variables across Physician Groups*
Table 5. Adjusted Association of Physician Group Disease Management with Quality Indicators, Intermediate Outcome Levels, and Medical Management of Intermediate Outcomes*
Appendix Table 2. Adjusted Association of Physician Group Disease Management with Quality Indicators, Intermediate Outcome Levels, and Medical Management of Intermediate Outcomes (Third, Second, and First Tertiles)*
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Mangione CM, Gerzoff RB, Williamson DF, et al, for the TRIAD Study Group*. The Association between Quality of Care and the Intensity of Diabetes Disease Management Programs. Ann Intern Med. 2006;145:107–116. doi: 10.7326/0003-4819-145-2-200607180-00008
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Published: Ann Intern Med. 2006;145(2):107-116.
Cardiology, Coronary Risk Factors, Diabetes, Endocrine and Metabolism.
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