Quality Improvement Project

Diabetes — Chronic Condition Background

Type 1 and Type 2 Diabetes

Risk factors for type 1 diabetes

Risk factors for prediabetes and type 2 diabetes

Risk factors for gestational diabetes

The Rationale for Selection

The Target Population

Intervention Plans

Target Goals

It has been estimated that in New York there is roughly two million people, or over twelve percent of the population, that have diabetes; furthermore, of this population, over half a million people have the condition but are not aware that they have it (American Diabetes Association, N.d.). It is further estimated that nearly five and a half million people, or over a third of the population, have prediabetes. Diabetes and diabetes-associated cardiovascular diseases have become the leading cause of death in the region accounting for roughly two-thirds of the deaths and the rates of diabetes has lead this trend to be referred to as the diabetes epidemic (Frieden, 2006).

Diabetes does not affect the general population evenly. Some communities are affected more severely (disparately impacted) by diabetes but do not receive a commensurate share of diabetes research, treatment and education; these communities include (American Diabetes Association, N.d.):

Latinos/Hispanics (English)

Latinos/Hispanics (Spanish)

African-Americans

Asian-Americans

Native Hawaiians and Pacific Islanders

American Indian/Alaskan Natives

It has been estimated that African-Americans are from 1.4 to 2.2 times more likely to have diabetes than white persons, prevalence of diabetes among American Indians is 2.8 times the overall rate, and Asian and Pacific Islanders also have increased rates of diabetes in comparison to whites (U.S. Department of Health and Human Services, 2001). In addition, racial and ethnic minority populations have a higher risk of complications of diabetes, such as lower limb amputations, retinopathy and kidney failure, than non-Hispanic Whites (American Diabetes Association, N.d.).

Figure 1 – Rates of Diabetes in NY (CDC, 2013)

Many people who are diagnosed with diabetes do not find out they have the disease until the symptoms have progressed and the patients have reached a point in which there is less of an opportunity to mitigate the consequences of the disease with lifestyle interventions. Therefore there is an increased rate of hospitalization among this population that drives up total healthcare costs while it also decreases the patients’ quality of life. Estimates of the total costs attributable to diabetes were approximately $100 billion per year in the United States and in 2000, the average length of a diabetes-related hospital stay was 7.9 days, with the average charge of $17,800 per stay (New York State, 2015). Other estimates place the total cost closer to two billion dollars per year in 2007 with one out of every five U.S. federal health care dollars is spent treating people with diabetes; the average yearly health care costs for a person without diabetes is $2,560; for a person with diabetes, that figure soars to $11,744 (U.S. Department of Health and Human Services, 2001).

Given the presence of diabetes has reached epidemic proportions in New York, the disease contributes costly additions to the state’s healthcare system, and health outcomes can be significantly improved with effective treatment, this analysis will propose a quality improvement program (QIP) that focuses on reducing the readmission rates of patients that have been hospitalized for diabetes related conditions. The QIP’s goals will include reducing unplanned inpatient hospital readmission(s), improve medication adherence, and ensure Care Management adheres to following-up with member assessment education and care plan implementation. These objectives will help prevent complications and development of comorbidities, which will improve members’ quality of life and contribute to the reduction of disease progression. The primary goal of the QIP will be to achieve an overall 9% reduction in all cause readmissions within 30 days after discharge for diabetes all cause admissions within the 3 years span that this study will be conducted.

Diabetes — Chronic Condition Background

Diabetes is the fastest accelerating condition that represents a chronic disease of our time. This epidemic is expected to affect one out of every twelve New Yorkers and since 1994, that number has more than doubled, and it is expected that the number will double again by the year 2050 (Department of Health, N.d.).

Type 1 and Type 2 Diabetes

All forms of diabetes are related to the body’s natural production of insulin. With type 1 diabetes, the body’s immune system attacks part of its own pancreas, usually developing in childhood or adolescence (Diabetes Research Institute, N.d.). The explanation for this autoimmune disease is not clearly understood. However, the cells that sense glucose in the blood, islets, respond to sugar ingested into the body with the appropriate amount of insulin (in a healthy adult) to normalize the blood sugar level by allowing the glucose to enter the cells and be converted to energy. However, when the immune system mistakenly attacks the islets, the body can no longer produce insulin on its own and the glucose levels begin to rise. To treat the elevated glucose levels, insulin injections must be administered to prevent the buildup of glucose in the body.

As opposed to Type 1 diabetes, individual’s bodies with Type 2 diabetes can still produce insulin naturally. However, the body either does not produce enough insulin or the body is unable to use the insulin efficiently to lower the body’s glucose levels (PubMed Health, N.d.). This condition is far more common than the autoimmune version. Furthermore, in Type 2 diabetes the condition of the disease can have a great deal of variability associated with it — from being treatable with minor lifestyle changes to needing to take insulin injections similar to individuals with Type 1 diabetes. The lower amounts of glucose that are associated with this condition can be the product of a damaged pancreas. Also, if the body has problem efficiently absorbing and use the insulin, it can also led to a buildup in glucose levels.

Although the exact causes of diabetes are not clear, the risk factors associated with the disease have been well researched. The following sections represent an overview of the risk factors that are known to be associated with the most common forms of diabetes (Mayo Clinic, N.d.):

Risk factors for type 1 diabetes

Family history. Your risk increases if a parent or sibling has type 1 diabetes.

Environmental factors. Circumstances such as exposure to a viral illness likely play some role in type 1 diabetes.

The presence of damaging immune system cells (autoantibodies). Sometimes family members of people with type 1 diabetes are tested for the presence of diabetes autoantibodies. If you have these autoantibodies, you have an increased risk of developing type 1 diabetes. But not everyone who has these autoantibodies develops diabetes.

Dietary factors. These include low vitamin D consumption, early exposure to cow’s milk or cow’s milk formula, and exposure to cereals before 4 months of age. None of these factors has been shown to directly cause type 1 diabetes.

Geography. Certain countries, such as Finland and Sweden, have higher rates of type 1 diabetes.

Risk factors for prediabetes and type 2 diabetes

Weight. The more fatty tissue you have, the more resistant your cells become to insulin.

Inactivity. The less active you are, the greater your risk. Physical activity helps you control your weight, uses up glucose as energy and makes your cells more sensitive to insulin.

Family history. Your risk increases if a parent or sibling has type 2 diabetes.

Race. Although it’s unclear why, people of certain races — including blacks, Hispanics, American Indians and Asian-Americans — are at higher risk.

Age. Your risk increases as you get older. This may be because you tend to exercise less, lose muscle mass and gain weight as you age. But type 2 diabetes is also increasing dramatically among children, adolescents and younger adults.

Gestational diabetes. If you developed gestational diabetes when you were pregnant, your risk of developing prediabetes and type 2 diabetes later increases. If you gave birth to a baby weighing more than 9 pounds (4 kilograms), you’re also at risk of type 2 diabetes.

Polycystic ovary syndrome. For women, having polycystic ovary syndrome — a common condition characterized by irregular menstrual periods, excess hair growth and obesity — increases the risk of diabetes.

High blood pressure. Having blood pressure over 140/90 millimeters of mercury (mm Hg) is linked to an increased risk of type 2 diabetes.

Abnormal cholesterol and triglyceride levels. If you have low levels of high-density lipoprotein (HDL), or “good,” cholesterol, your risk of type 2 diabetes is higher. Triglycerides are another type of fat carried in the blood. People with high levels of triglycerides have an increased risk of type 2 diabetes. Your doctor can let you know what your cholesterol and triglyceride levels are.

Risk factors for gestational diabetes

Age. Women older than age 25 are at increased risk.

Family or personal history. Your risk increases if you have prediabetes — a precursor to type 2 diabetes — or if a close family member, such as a parent or sibling, has type 2 diabetes. You’re also at greater risk if you had gestational diabetes during a previous pregnancy, if you delivered a very large baby or if you had an unexplained stillbirth.

Weight. Being overweight before pregnancy increases your risk.

Race. For reasons that aren’t clear, women who are black, Hispanic, American Indian or Asian are more likely to develop gestational diabetes.

The Rationale for Selection

This population was selected because it represents one of the best opportunities in healthcare to reduce costs and improve patient outcomes. Diabetes, similar to other chronic medical conditions, is associated with increased risk of hospital readmission and some of the risk factors include previous hospitalization, extremes in age, and socioeconomic barriers (Dungan, 2012). There have been major scientific advances in the management of diabetes and many readmissions are entirely preventable. However, to prevent readmissions, it takes a comprehensive effort that includes multiple aspects of the patient’s life. It can include factors such as education, economic factors, access to follow-up care and medications, social and/or family support, diet support and access to quality foods, access to exercise facilities, access to diabetes related equipment, and many more. The QIP must account for all of the patients’ limitations regarding the effective management of diabetes that could prove to be obstacles.

The Target Population

It has been estimated that in New York there is roughly two million people, or over twelve percent of the population, that have diabetes; furthermore, of this population, over half a million people have the condition but are not aware that they have it (American Diabetes Association, N.d.). It is further estimated that nearly five and a half million people, or over a third of the population, have prediabetes. On a national level, it is currently estimated that 26 million people in the United States (8.3% of the population) have diabetes, and another 7 million people have undiagnosed diabetes; furthermore, estimates indicate an additional 2 million people 20 years and older are diagnosed with diabetes each year and the total estimates of people at risk for diabetes or people with pre-diabetes are approximately 79 million (Saccomano, 2014).

Intervention Plans

The QIP intervention plan will take a holistic and patient centered approach that targets the reduction of readmission rates. With this focus in mind, it will be important to create a multidisciplinary team that includes registered nurses, nurse practitioners, physicians, physician assistants, registered dietitians, pharmacists, social workers, nursing assistants, and certified diabetes educators (CDEs) to plan the individual interventions (Saccomano, 2014). One study found that formal inpatient diabetes education was associated with a reduction in the rate of hospital readmission for patients with poorly controlled diabetes and another study, of Medicare beneficiaries with type 2 diabetes, found that major risk factors for readmission are patient complexity, older age, and longer duration of initial hospital stay (Tucker, 2013).

“Certified diabetes educators (CDE) focus on patient education and self-management. CDEs commonly work in hospital outpatient clinics, inpatient hospital settings, and in community practices; however, the American Association of Diabetic Educators (AADE) reports that CDEs are underutilized … Even if fully utilized, because there are only about 18,000 CDEs in the United States, the bulk of the education will fall to other members of the healthcare team. Registered nurses, pharmacists, and other clinicians must be familiar with strategies for patient-centered care and diabetes self-management (Saccomano, 2014).”

The team should also follow the recommendation from the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE) to conduct a needs assessment so the education plan can be individualized to the patient. Both the ADA and the AACE make recommendations as to what should be in the plan, including (Saccomano, 2014):

understanding the diagnosis of diabetes recognition of symptoms such as hypoglycemia and hyperglycemia information on constant eating patterns medication management incorporating physical activity into their daily plan setting strategies to reach psychosocial and behavioral goals.

One of the key intervention strategies is to start early. Early discharge planning can be especially important to high-risk patients such as those who (Saccomano, 2014):

have elevated glucose levels or poor glycemic control

have been newly diagnosed as having diabetes

are starting insulin therapy

have comorbidities

had a recent hospital admission for diabetes ketoacidosis (DKA) or hypoglycemia have a readmission diagnosis of hypoglycemia or hyperglycemia.

Furthermore, some of the individual factors that will need to be accounted for in the individual intervention plans include (Saccomano, 2014):

functional abilities or limitations

economic factors, such as lack of health insurance or inability to afford prescriptions

follow-up access to care (ensuring that patients have a primary care provider for follow up)

barriers to learning, such as language and motor skills

how well diabetes was controlled before hospital admission

readmission within 30 days of a previous admission comorbid conditions psychosocial evaluation primarily for depression, a common problem in patients with diabetes.

Communication during the patients visit, during transition, and after discharge have also been identified as one of the critical success factors. The ADA recommends keeping the outpatient care provider fully informed about the patient’s hospital stay and during the transition of care, information regarding the patient’s hospital stay and treatment plan must be communicated to the outpatient provider to ensure continuity of care once the patient is discharged (Saccomano, 2014).

Target Goals

The QIP’s goals will include reducing unplanned inpatient hospital readmission(s), improve medication adherence, and ensure Care Management adheres to following-up with member assessment education and care plan implementation. These objectives will help prevent complications and development of comorbidities, which will improve members’ quality of life and contribute to the reduction of disease progression. The primary goal of the QIP will be to achieve an overall 9% reduction in all cause readmissions within 30 days after discharge for diabetes all cause admissions within the 3 years span that this study will be conducted.

References

American Diabetes Association. (N.d.). Health Disparities. Retrieved from American Diabetes Association: http://www.diabetes.org/advocacy/advocacy-priorities/health-disparities.html

American Diabetes Association. (N.d.). New York, New York. Retrieved from American Diabetes Association: http://www.diabetes.org/in-my-community/local-offices/new-york-new-york/

CDC. (2013). Diagnosed Diabetes, Age Adjusted Rate (per 100) Adults – Total 2013. Retrieved from Center for Disease Control: http://gis.cdc.gov/grasp/diabetes/DiabetesAtlas.html

Department of Health. (N.d.). Diabetes. Retrieved from New York State: https://www.health.ny.gov/diseases/conditions/diabetes/

Diabetes Research Institute. (N.d.). What is Type 1 Diabetes? Retrieved from Diabetes Research Institute: http://www.diabetesresearch.org/what-is-type-one-diabetes

Dungan, K. (2012). The Effect of Diabetes on Hospital Readmissions. Journal of Diabetes Science and Technology, 1045-1052.

Frieden, T. (2006). Diabetes in New York City: Public Health Burden and Disparities. Retrieved from New York City Department of Health and Mental Hygiene: http://home2.nyc.gov/html/doh/downloads/pdf/epi/diabetes_chart_book.pdf

Mayo Clinic. (N.d.). Diabetes Risk Factors. Retrieved from Mayo Clinic: http://www.mayoclinic.org/diseases-conditions/diabetes/basics/risk-factors/con-20033091

New York State. (2015). New York State Strategic Plan for the Prevention and Control of Diabetes. Retrieved from New York State: https://www.health.ny.gov/diseases/conditions/diabetes/strategicplan.htm

PubMed Health. (N.d.). Type 2 Diabetes. Retrieved from PubMed Heatlh: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0024703/

Saccomano, S. (2014, April). Taking steps in the hospital to prevent diabetes-related readmissions. Retrieved from American Nurse Today: http://www.americannursetoday.com/taking-steps-in-the-hospital-to-prevent-diabetes-related-readmissions/

Tucker, M. (2013). Inpatient Diabetes Education Seems to Reduce Readmissions. Medscape Medical News, 1-2.

U.S. Department of Health and Human Services. (2001). Diabetes Disparities Among Racial and Ethnic Minorities. Retrieved from Agency for Healthcare Research and Quality: http://archive.ahrq.gov/research/findings/factsheets/diabetes/diabdisp/diabdisp.html