Diabetes Care: New Clinical Guidelines and Leadership Council

“Diabetes remains at the leading edge of op-
portunity for improving the health of Kaiser Permanente members,” says Paul Wallace, MD,
Care Management Institute (CMI) Executive Di-
rector. There are many reasons why this is the case.
In 2002, Kaiser Permanente (KP) delivered care to more than 500,000 adults with diabe-
tes, 1 comprising 9.1% of KP’s adult
membership.a If all the adult KP members with
diagnosed diabetes lived in one city, it would
be larger than Boston, Portland, Denver, Long
Beach, Virginia Beach, or Oakland and would be growing as rapidly as a Sunbelt retirement
haven. The prevalence of diabetes in the United
States as a whole increased by 33% between
1990 and 1998, marching in lockstep with the
growing epidemic of overweight and obesity.2
Diabetes is costly; estimated US direct medi-
cal costs in 2002 were $92 billion.3 Indirect

Setting Up a System for Setting Policy

The process of guidelines revision involves a working group of clinical experts and method-
ologists. The workgroup is devoted to creating excellent content within the domain of diabetes
care as members identify rigorous evidence and consider its practical implementation.
However, CMI also identified the need to address
issues beyond content development: identifying clini-
Diabetes Leadership
cal targets, influencing policy, and guiding the direc-
Council members include:
tion of CMI’s diabetes-related work. To fulfill those func-
Chair:
Jim Dudl, MD
tions, the Diabetes Leadership Council was formed,
Colorado: John Merenich, MD
comprising a member from each Region.
Georgia: Willie Rainey, MD
“The goal of the Diabetes Leadership Council is to
GHC:
David McCulloch, MD
bring together regional diabetes leaders to improve the
Hawaii: Brian O’Connor, MD
health of KP’s members with diabetes,” says Michelle
MAS:
Howard Tracer, MD
Wong, CMI Care Management Consultant. “We want
NCR:
Fred Hom, MD
to use the experience of the regions to ensure that dia-
NW:
Michael Herson, MD
betes care within KP evolves in the best possible di-
Ohio:
Mark Roth, MD
rection.” The group will meet quarterly.
SCR:
Frederick Ziel, MD, CDE

costs due to disability, lost productivity, and
premature mortality consumed an estimated
additional $40 billion.3 Long-term complica-
tions—heart disease, hypertension, stroke,
kidney disease, retinopathy, and neuropa-
thy—account for the high costs. Adults with
diabetes have heart disease death rates and
stroke mortality rates two to four times those
of adults without diabetes. Together, heart
disease and stroke are responsible for 65%
of deaths among adults with diabetes.4
Many costs cannot be quantified. Diabetes,
like other chronic conditions, extracts an in-
calculable toll of pain and suffering from pa-
tients, family, and friends. For all these rea-
sons—high prevalence and mortality rates,
high direct and indirect costs, and negative
impact on quality of life—it was one of the
first clinical priority areas identified by the

CMI several years ago. At the time, diabetes
care centered on physicians managing pa-
tients’ blood glucose levels by prescribing
medications and dietary modifications.
“Over time, we’ve moved from thinking
mainly about controlling disease to a frame-
work of population-based care, the stratifica-
tion of needs, adaptation of care delivery to
individual needs, the importance of manag-
ing comorbid conditions well, and, most re-
cently, the engaged patient as the locus of
control for pursuing health in the face of a
chronic condition,” says Dr Wallace.
Good glycemic management is still a key part
of diabetes management. But revised diabetes
clinical guidelines released by the CMI in March
include both a major revision and a pivotal new
topic area. Together, they signal a sea change
in caring for KP members with diabetes.

Rethinking Statins
The guideline for using cholesterol-lowering
medications in diabetic patients has been substan-
tially simplified. Prior to the revision, statin use
was predicated on baseline cholesterol levels.
“It’s been clearly shown that the use of
statins in diabetics lowers the risk of cardio-
vascular disease by at least 25%, regardless of
baseline cholesterol level, with a middose statin
regimen like 40 mg of lovastatin. Titrating statins
has also been shown to be extraordinarily
difficult,” says Jim Dudl, MD, endocrinolo-
gist (KP-SCR) and leader of a newly formed
CMI diabetes leadership council (see sidebar).

“With the data from the Heart Protection
Study,5 we were able to simplify the whole
process. Every diabetic patient is offered a
midlevel statin dose with a single lab test to
follow up. The concept is safer than aspirin
use, and we can have a much higher percent-
age of diabetic patients on statins,” he says.
The Heart Protection Study, a randomized con-
trolled trial of nearly 6000 adults, showed that
cholesterol-lowering pharmacotherapy offers
significant cardiovascular risk reduction for adults
with diabetes without manifest coronary artery
disease or high cholesterol levels, thus obviat-
ing the need for baseline cholesterol testing.5

Relocating the Hub of Care
A new topic area in the guidelines addresses
the rapidly changing health care environment.
“Two forces are making the way we prac-
ticed diabetes care a few years ago both ob-
solete and dysfunctional,” says Dr Dudl.
“The level of care necessary for a diabetic
patient to have good medical care has in-
creased many times over from ten years ago.
It used to be the case that a member with
diabetes would come into the clinic and get
blood drawn. A week later, we’d get the re-
sults and call the patient to adjust one thing or
another. Now, good diabetes care means fine-
tuning blood glucose daily or more frequently.”
Secondly, he says, technology has moved
the essentials of treatment from the clinic set-
ting to the patient’s home. Dr Dudl continues,
“Now the hub of care is in the patient’s home,
because that’s where the data are. Patients do
fingerstick testing. They go into the lab and
get blood drawn, then call and get the results.”
Targets and tools empower patients by de-
fining a desirable blood glucose range and
then providing the necessary means to as-
sess and achieve it. Titration schedules for
insulin dosages, for instance, put patients in
control of their blood glucose levels.
The guidelines workgroup reviewed the
literature and found that self-care works well
for a number of conditions. “Self-manage-
ment is the way to address the fact that the
hub of care is shifting. We included a self-
management guideline so that good diabe-
tes self-care becomes the standard, not the
exception,” he concludes.

CMI Diabetes Guidelines Project Management Team

Jim Dudl, MD
Michelle Wong, MPH, MPP
Jill Bowman

CMI Diabetes Guidelines Workgroup

Colorado

Georgia
Group Health Cooperative
Hawaii

Mid-Atlantic States

Northwest

Northern California

Clinical Lead, KP Southern California
Project Manager, CMI
Evidence-Based Medicine Methodologist, CMI

Ohio

Southern California

Larry Ballonoff, MD
John Merenich, MD
Mongthuong Tran, PharmD
Willie Rainey, MD
David McCulloch, MD
Ivie Kumura, PharmD, CDE
Brian O Connor, MD
Susan McDonough, MS, RD, CDE
Howard Tracer, MD
Radhika Breaden, MD (Prevention Partners)
Michael Herson, MD
Dean Klopfenstein, RPh, CDE
Jennifer Day, PharmD (California Division)
Rick Dlott, MD
Fred Hom, MD
Nancy Moline, RN, MEd, CDE
Denise Portello, MPH, RD
Laura Skabowski, MS
Mary Ann Dzurec, PharmD
Mark Roth, MD
Catharina Wong, MPH
Frederick Ziel, MD, CDE

Recommending a Longer Look
at Gestational Diabetes
A second new area in the guidelines ad-
dresses the risk that women with gestational
diabetes will progress to Type 2 diabetes.
“Women with gestational diabetes are at in-
creased risk for developing Type 2 diabetes
and should be offered weight control and
lifestyle modification advice,” says Michelle
Wong, CMI Care Management Consultant and
co-leader of the guidelines workgroup.
To keep pace with emerging evidence, clini-
cal guidelines are revised every two years. ?

a

The case identification rate within KP is
slightly higher than the 8.7% prevalence rate
of diagnosed diabetes in the US adult
population, which may reflect a true higher
prevalence rate among KP members or superior
case identification practices.

References
1. Kaiser Permanente Medical Care Program.
Care Management Institute. Kaiser Permanente
diabetes outcomes report. Seventh annual
report, data from 2002. Oakland (CA): Care
Management Institute, Kaiser Permanente
Medical Care Program; 2003. Available from:

http://pkc.kp.org/national/cmi/dept/measure-

ment/reports/diabetes VII/Diabetes VII
Outcomes.pdf (Accessed June 28, 2004).
Mokdad AH, Ford ES, Bowman BA, et al.
Diabetes trends in the US :1990-1998. Diabetes
Care 2000 Sep;23(9):1278-83.
Hogan P, Dall T, Nikolov P; American Diabetes
Association. Economic costs of diabetes in the US
in 2002. Diabetes Care 2003 Mar;26(3):917-32.
American Diabetes Association. National
diabetes fact sheet (Web site). Available from:
www.diabetes.org/diabetes-statistics/national-
diabetes-fact-sheet.jsp (accessed May 20, 2004).
MRC/BHF Heart Protection Study of cholesterol-
lowering therapy and of antioxidant vitamin
supplementation in a wide range of patients at
increased risk of coronary heart disease death:
early safety and efficacy experience. Eur Heart J
1999 May;20(10):725-41.