CLINICAL DIABETES
VOL. 18 NO. 2 Spring 2000


PRACTICE PROFILES


Mastering Diabetes at Medicare


Claresa Levetan, MD


Editor's note: In the "Practice Profiles" department of Clinical Diabetes, we spotlight clinicians who have chosen to dedicate a significant portion of their time to the care of patients with diabetes. Suggestions for clinicians to interview in the future are welcome and can be e-mailed to levetan@juno.com.

Who? Barbara Fleming, MD, PhD, 1999 recipient of the American Diabetes Association's Charles Best Award for Distinguished Service in the Cause of Diabetes.

What? General internist at Walter Reed Army Hospital, senior clinical advisor at the Health Care Financing Administration, and founder of the Diabetes Quality Improvement Project (DQIP).

Where? Washington, D.C.

When did you first get interested in public health?
Long before I attended medical school, I was interested in population health and prevention, and I earned a master's degree and a doctorate focusing on the preventive health aspects of nutrition. It seemed to me then, and it still does, that if we really want to have a significant impact on the health of the public, we are talking about changing health behaviors, not coming up with a new antibiotic, as valuable as that is.

When did you first get interested in medicine?
I completed my doctorate in nutritional biochemistry and first got interested in medicine when I was exposed to the science of medicine during a postdoctoral fellowship at the National Institutes of Health (NIH). Then, I went to medical school and fell in love with clinical medicine. I went on to do my internal medicine residency at the University of Maryland and Johns Hopkins.

When did you develop an interest in diabetes?
As an internist, such a large percentage of the patients I see have diabetes that this disease literally commanded my attention. I found diabetes fascinating because so many organ systems are affected, and I think it is possibly one of the most challenging diseases because so many critical outcomes are under patients' control. From a public health perspective, I became interested in diabetes while at the Health Care Financing Administration (HCFA), where we see the huge impact of this disease on individual Medicare beneficiaries.

Your name is synonymous with diabetes at HCFA, but what exactly do you do?
HCFA, which administers the Medicare program, is the nation's largest purchaser of health care. As a senior clinical advisor in the Office of Clinical Standards and Quality, I have an opportunity to work on a number of exciting initiatives, from our diabetes activities to a project on performance measurement for medication use to our hospital performance measurement initiatives. My activities are in the area of quality measurement and improvement, although I occasionally get involved in regulatory activities at the agency.

What is the connection between HCFA and diabetes?
Through administration and oversight of quality in Medicare, HCFA is responsible for health care for about 40% of the individuals with diabetes in this country. Using an estimated prevalence of 10% in the population over age 65, we have more than 4 million diagnosed patients with diabetes. Therefore, we are very concerned with how you measure quality of care in diabetes, how you improve that care, and how high quality care can be rewarded.

What is the Diabetes Quality Improvement Project (DQIP)?
DQIP is a comprehensive set of performance measures for diabetes. This project grew out of concern that the proliferation of measure sets for diabetes would result in mass confusion for consumers and purchasers and a huge burden for physicians. There seemed to me to be a compelling need to standardize performance measurement in this country, since we seemed to be heading toward a situation in which multiple purchasers of health care would be requiring multiple measure sets for the same disease.

Within the diabetes community, there was a group of individuals who felt this as intensely as I did. Dr. Richard Eastman, Director of Diabetes at the National Institute for Diabetes and Digestive and Kidney Diseases, and I convened the first meeting of these like minds in December 1995. By the time I was able to get funding in 1997, support from the American Diabetes Association, National Committee for Quality Assurance (NCQA), the Foundation for Accountability, and other key groups made the effort possible.

The hope was that consensus around a single set of performance measures would allow meaningful use of the measures for comparison of care across settings of care and for optimal quality improvement by allowing identification and dissemination of best practices in an apples-to-apples comparison.

Who is using the DQIP measures?
HCFA is using DQIP to assess care provided in all Medicare managed care plans and in fee-for-service settings. In addition, all of HCFA's peer review organizations in all 50 states are working with practices and practitioners to develop and implement quality improvement activities. And, very importantly, we are exploring options for rewarding high-quality care using both economic and noneconomic incentives.

The measure set is also widely used in the United States, so we are closer to achieving our initial goals that we thought we would be at this point in time. Medicare, NCQA, the Veteran's Affairs Health System, and many other health systems are using the DQIP measures. In fact, I was contacted last week by the Taiwanese government about using the DQIP measures for their country.

What is the biggest challenge to DQIP?
The biggest challenge to DQIP has been the lack of understanding on the part of the health care community in general of the difference between performance measures and guidelines. Guidelines are directives for how care should be performed for individual patients, whereas measures are "snapshots" of the care that is being provided to populations of patients.

Misconstruing the DQIP measures as guidelines has led to much confusion and consternation. The DQIP measures are evidence-based performance measures that perform well, i.e., are feasible, can be collected reliably, show a wide range among sites and thus discriminate among sites, and demonstrate lots of opportunity for improvement in care.

We are working to keep the measures current with the state of evidence and state of practice and to reduce the burden associated with their collection.

Given your doctorate in nutritional biochemistry, what is your perspective on the role of diet in the development of chronic diseases such as diabetes and heart disease?
I earned a doctorate in nutritional biochemistry because I was so interested in the role of nutrition in disease at the cellular and molecular level. The evidence is even more convincing today now that lifestyle issues such as nutritional choices are key components in health and disease, with diabetes and heart disease being the classic and most compelling examples.

I use my background in nutrition extensively in my medical practice and often spend 10 minutes doing a quick dietary recall just to give patients with or at high risk for diabetes an idea of calorie and fat content, in particular. That is followed by referral for more extensive evaluation, but I find that I can validate the work patients then do with the educator or dietitian and follow-up effectively with them.

What do you recommend for physicians in practice who want to keep up with the latest in diabetes?
For generalists who see the entire spectrum of disease, the answer to keeping up is the Internet, with sites such as Medscape, the American Diabetes Association (ADA), and others providing meeting summaries, article summaries, and reviews that are really, truly invaluable. I listen to medical audiotapes during my 2-hour daily commute and find that to be a really valuable use of time. Of course, journals round out that menu. ADA membership (with meetings, newsletters, and journals) is also a great way for doctors to keep up.

What do you believe are among the biggest strides that have been made in the field of diabetes over the past decade?
For generalists, the United Kingdom Prospective Diabetes Study provided a very important link between type 2 diabetes and glycemic control. Given that link, the armamentarium of new and exciting drugs has been a huge step forward. Of course, basic science continues to provide the underpinnings we need to understand important components of diabetes, e.g., the role of postprandial glucose control. I would like to think that DQIP has stimulated an interest in diabetes and in quality improvement as a result of the significant increase in public reporting and accountability as a result of widespread use of the measure set.

What is your hope for the future of Americans with diabetes who are over the age of 65?
Hopefully, as we learn more about behavior modification, the number of those individuals will decrease. Advances in the management of obesity and lifestyle change are going to be critical for reducing the incidence of diabetes and the prevalence of complications.

As an avid exercise enthusiast, how do you encourage patients—particularly those who have never exercised—to begin an exercise program?
Luckily, it's true: I love exercise, from swimming to sculling. However, as a result of participation in activities such as aerobics, spinning, and weight training with a great personal trainer, I understand the importance of excellent coaching. So, in getting patients to commit, I have been most effective by providing encouragement and follow-up as their "coach."

Is it ever too late for someone to start an exercise program, even a low-intensity workout such as walking?
No! I have patients in their 80s who have started doing weight training, and I have a set of balance exercises that I try to get all of my elderly patients to do. The problems I have are that there is no easy way to refer patients to programs that are age-specific, and there is not enough time to do a good job of teaching balance, flexibility, and strength training. Still, I try.

What message would you give to general internists and family practitioners who are doing their best given all the changes in medicine and are trying to provide optimal care for patients with diabetes?
Taking care of patients with this complex disease, so much of which is dependent on patients' lifestyle choices, is about as challenging as it gets for generalists. For doctors in fee-for-service settings, the "planned visit" championed by Drs. Wagner and McCullough at Group Health and others is such a good idea. That way, diabetes can be handled intensively separately from acute issues that arise. In managed care, the challenges may be even tougher given more serious time limitations.

Relying on other health care professionals from podiatrists to educators is so important—physicians just cannot do it all for patients with diabetes. In spite of all the challenges, it is critical to remember, as I have heard it said, that "the secret to taking care of the patient is caring for the patient." That is the true joy of medicine that keeps us motivated to do the best we can for every patient.

Do you feel that your practice at Walter Reed Army Medical Center keeps you in touch with the changing complexities of medicine and health care delivery?
I think it is essential for physicians in government to maintain an active medical practice. At Walter Reed, we have just converted to a managed care system and have faced those challenges. However, my earlier experiences in private practice have been invaluable in helping me to understand the challenges that the medical community faces on a daily basis. I greatly enjoy the practice of medicine, and while I cannot imagine any profession more satisfying, it is also one of the most challenging and difficult. The commitment and sacrifices of doctors "in the trenches" are truly commendable.

We are fortunate to have someone like you working to better the lives of patients with diabetes on a global scale. You must put in 100 hours a week—do you have time for play?
Luckily, I love my job at HCFA and really enjoy taking care of patients at Walter Reed. So the work hours seem like play, most of the time. In my spare time, my husband and I like to bike, hike, swim, and go antiquing. I am also passionate about the arts, and I dabble in watercolors, acrylics, pastels, and sculpture. This summer, I hope to take my first course in glass blowing.


Claresa Levetan, MD, is director of diabetes education at MedStar Research Institute in Washington, D.C. She is an associate editor of Clinical Diabetes.


New reports on the Scientific Evidence for Behavior Change in Clinical Settings

The Center for the Advancement of Health has just released a series of reports from its Health Behavior Change in Managed Care initiative, Funded by the Robert Wood Johnson Foundation, the initiative assessed the availablilty, access, and integration of health behavior change strategies in managed care in 1999.  As part of this initiative, the center critically reviewed the scientific literature on behavior change interventions in clinical settings.  Detailed descriptions of several hundred clinical settings are avialable on the following topics: asthma, depression, diabetes, back pain, cardiovascular disease, smoking, physical inactivity, dietary practices, and alcohol and other drug misuse,  To obtain these resources free of charge, visit the Center's Website (http://www.cfah.org) or send an e-mail request to cfah@cfah.org.  You can also access PDF files of all the reports from our website.


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