Reaching Goals:
It’s as Easy as A1C, Blood Pressure and LDL Cholesterol!
Your FAFP Foundation at Work
Edward Shahady, MD
Medical Director Diabetes Master Clinician Program
Florida Academy of Family Physicians Foundation

Excellent studies (1, 2) indicate that lowering A1C below 7 and LDL
below 100 reduces the incidence of retinopathy, nephropathy, neuropathy,
stroke and cardiovascular disease. Other studies indicate
that patients who know their actual laboratory values and understand
their significance will achieve better overall management of their
diabetes. (3) The America Diabetes Association (ADA) has set the
goals for quality diabetes management at goals of an A1C of ≤ 7,
LDL ≤ 100 and blood pressure of ≤ 130/80. Unfortunately the
majority of patients are not successful in achieving these goals. Only
30 to 35% of diabetic patients nationally are reaching any of the
ADA quality indicators individually and only 7% achieve goal in all
three indicators at the same time. (4) A reduction in the morbidity
and mortality associated with diabetes is not possible more patients
achieving goal for all diabetes quality indicators.

Diabetes is the fifth leading cause of death in the US; the leading
cause of kidney failure, non-traumatic limb amputations and blindness;
and the leading contributor to cardiovascular disease. The economic
and emotional burden associated with diabetes is enormous
and will not decrease without an increase in the number of patients
achieving diabetes quality goals. Goal achievement is enhanced in
systems that emphasize early recognition and treatment of diabetes.
Unfortunately, current systems of clinical care and medical education
emphasize care in the later stages of the disease. Newer systems
are needed to effectively address this issue. A major shift in the way
we care for patients and teach is crucial to reduce the burden of suffering
associated with diabetes. (5)

Responding to the challenge of creating a new system of clinical
care and medical education the Florida Academy and its foundation
created the Diabetes Master Clinician Program (DMCP) in
November of 2003. The program uses small group teaching techniques
and visits to the clinicians’ offices to train clinicians and their
staff to conduct diabetic group visits and use an Internet-based disease
registry. Group visits are more effective than individual office
visits. They provide an environment for group education, patient
sharing of solutions and more time for the clinician to be with the
patient. The registry is an innovative electronic tool that enhances
individual and population patient management. The registry produces
individual patient report cards that inform patients of the reasons
for diabetes goals and their level of goal achievement.
Clinicians and staff use the report cards to teach and motivate
patients during their visits. Additional reports are provided to the
practice that (a) describe practice achievement of goals compared to
the other practices in the DMCP and (b) identify practice patients
who are at higher risk for developing diabetes complications. These
reports serve as practice report cards and guides for focusing practice
resources and energy.

The master clinician registry currently contains 3,378 patients and
9,368 visits. Achievement rate for the individual quality indicators
varies from 56% for A1C to 49% for LDL. Eighteen percent of patients
in the database are achieving goal for all three quality indicators at the
same time. This increased success over the national 7% is most likely
due to the patient report card and group visits. Patients are pleased to
have the report card because it educates, informs and motivates. The
group visit adds the power of peers and the patient’s health-care
providers to the power of the report card. Patient feedback indicates
they are very pleased with the report cards and group visits.

Although 18% achievement is better than the national achievement
of 7%, it still leaves 82% not at goal. Several barriers (Table 1) exist
that make achieving goals difficult. The DMCP addresses the last
two barriers listed in the table by creating better systems of care, a
different way of educating physicians and their staff, and addressing
many of the patient adherence issues. Reimbursement is a more
complex issue and will require a political solution.

The current reimbursement system favors care in the later stages of
disease and not diabetes care in the early stages of disease. The
January third issue of USA Today (6) highlighted the absurdity of
reimbursement issue. It pointed out that new hospital construction
was focusing on creating facilities for the end stages of disease and
its complications because third-party reimbursement paid better for
end stage disease care. The article also noted that this construction
would increase costs and not increase overall quality of care for
these diseases.

The Florida Academy plans to increase the number of offices that
use the DMCP and demonstrate the quality of care that can be provided
by family physicians who are diabetes master clinicians.

Table 1. Barriers to Quality Care for Diabetes
1. Reimbursement systems that favor care in the later stages of diabetes
and not recognition, early treatment and prevention of complications
2. Patient adherence to treatment is limited by level of literacy,
understanding of their disease, inability to pay, depression and lack
of transportation.
3. Physician frustration secondary to lack of office systems for
chronic disease care and prior training that focuses care in the later
stages of diabetes

References
1. UK Prospective Diabetes Study (UKPDS) Group: Intensive blood-glucose
control with sulphonylureas or insulin compared with conventional treatment
and risk of complications in patients with type 2 diabetes (UKPDS 33).
Lancet:1998; 352:837–853
2. Colhoun H, Betteridge J, Durrington P Hitman G. et al Primary Prevention of
Cardiovascular Disease With Atorvastatin in Type 2 Diabetes in the Collaborative
Atorvastatin Diabetes Study (CARDS): Lancet 2004;364:685-696
3. Heisler M, Piette J, Spencer M, Kieffer E, et al The Relationship Between
Knowledge of Recent HbA1c Values and Diabetes Care Understanding and Self-
Management, Diabetes Care 2005;28:816-822
4. Saydah SH, Fradkin J, Cowie CC. Poor control of risk factors for vascular disease
among adults with previously diagnosed diabetes. JAMA. 2004;291:335-342.
5. Shahady EJ, Type 2 Diabetes, the metabolic syndrome, inflammation and arteriosclerosis.
Consultant December 2005 Vol. 45 #14 pp 1579-86
6. Cauchon D, Appleby J. Hospital building booms in ‘burbs, USA Today Jan 3,
2006 A. 1