How Do We Measure Successful Diabetes Care?

This content originally appeared on diaTribe. Republished with permission.

By Arvind Sommi, Andrew Briskin

Quality measures are tools to evaluate the effectiveness and quality of healthcare. Measures such as A1C, blood pressure, and cholesterol are used to understand health at the population level to ensure people with diabetes are getting the best care possible. At The diaTribe Foundation, we believe that Time in Range would be a valuable addition to the quality measures for diabetes care.

During a routine office visit, your healthcare provider may check certain health measures such as your A1C, blood pressure, and cholesterol. These tests are primarily used to assess your individual health and the effectiveness of your diabetes treatment plan. They are also used to evaluate the overall quality of care provided when these results are combined across all patients in a healthcare professional’s office, healthcare system, or health plan.

Recent advances in glucose monitoring, and the increasing use of continuous glucose monitors (CGM), has led to wider use of the metric Time in Range (TIR), which is a helpful supplement to A1C in assessing your glucose management. Because of this, TIR could be a valuable addition to the quality measures for diabetes care if it became a more widespread metric – a feat that is challenged by barriers to accessing CGM and integrating it into electronic health records.

What is a quality measure?

Quality measures can encompass many things but generally include different types of measurement domains, as outlined below.

Diabetes care

Source: diaTribe

Some tests, such as A1C screening or blood pressure monitoring, can serve as both a healthcare process and an outcome measure.

At the population level, outcome measures evaluate whether certain established goals are reached for a group of people. For example, this might be the percentage of patients in a healthcare practice with an A1C greater than or less than 9.0%. Quality measures, in this way, are used by insurance providers, people with diabetes looking for the best healthcare professionals to use, researchers, employers, and reporting agencies to better understand the effectiveness of diabetes treatments and evaluate how effective healthcare professionals or health systems are.

How are quality measures used in diabetes care?

Quality measures are important in diabetes care because achieving these goals can decrease the risk of diabetes complications and lead to improved health outcomes for everyone. There are several quality measures in diabetes care, many of which you may be familiar with through routine office visits with your healthcare team, such as:

Primarily, the combined data from these tests across many people with diabetes is used to determine if certain treatment methods are effective for the entire population. The data can also be used to reinforce or dispute established standards of diabetes care and respond to new care innovations (such as the latest technology or treatments).

Along with their use in evaluating treatments and standards of care, quality measures can also be used to evaluate healthcare professionals. In some cases, healthcare provider reimbursements from Medicare or other insurance providers may be tied to results, particularly under a value-based care model (learn more about value-based care here). For example, A1C screenings might be reimbursed only if enough patients meet A1C targets below certain thresholds.

Why might including Time in Range in quality measures be helpful to you?

While A1C is the current quality measure used to assess glucose management in people with diabetes, A1C has limitations. The accuracy of A1C measurements can vary based on factors such as race/ethnicity or chronic kidney disease. A1C tests are also generally limited to every two to three months and only represent an average blood glucose level over that time, which means daily highs and lows are not explicitly captured. Additionally, while low blood sugar may lower your A1C, it can also increase your risk of severe hypoglycemia – meaning a lower A1C may be dangerous if you experience frequent low blood sugars or mild hypoglycemia.

Time in Range is a glucose metric typically measured by a CGM. It is the amount of time you spend in the target range – generally between 70 and 180 mg/dL. The goal for most people with diabetes is to have at least 70% of your glucose readings within this range. Understanding your TIR as well as your time above and below range can help you and your healthcare provider assess how your body responds to medications, food choices, daily activities, stress, and a variety of other factors that affect your glucose. The increased use of TIR could help equip people with diabetes and their healthcare team with the information they need to make vital healthcare decisions and experience better diabetes care.

Time in Range allows for quick, actionable steps to improve diabetes management and corresponding health outcomes,” said Dr. Diana Isaacs, a diabetes care and education specialist from the Cleveland Clinic. “Time in Range can be assessed more frequently and provides more actionable insight into glucose management. Making it a quality measure would increase the utilization of this powerful tool. It has the potential to revolutionize how we take care of people with diabetes.”

Increases in TIR have been associated with a reduced risk of microvascular complications such as eye (retinopathy) and nerve disease (neuropathy), with similar evidence emerging for other macrovascular complications such as heart disease. Plus, the use of CGM has increased dramatically over the last few years (for example in people with type 1 diabetes in the T1D Exchange registry, this number rose from 6% in 2011 to 38% in 2018), allowing more people with diabetes to use TIR data on a regular basis.

However, there are still barriers to integrating TIR as a quality measure for diabetes care. One major challenge is the many barriers to using a CGM. For instance, most insurers cover CGM only for a limited number of people with diabetes (for example, those with type 1 diabetes who take insulin). Until access is substantially expanded and more people are able to use CGM who wish to, TIR adoption into the standard quality measures will be difficult.

An additional challenge is that TIR data is not integrated into most electronic health records (EHR) used by clinicians, making it difficult for providers to analyze TIR data for all patients and to assess TIR at the community level. Efforts are currently underway to change these systems so that TIR can be integrated into her systems, similar to metrics like A1C and blood pressure; at the ADA Scientific Sessions this year Dr. Amy Criego spoke to the success that the International Diabetes Center in Minnesota has had with integrating Abbott LibreView data into their EHR.

Through the efforts of the Time in Range Coalition, diaTribe is working to increase awareness and hopefully the eventual adoption of TIR as a meaningful quality measure in diabetes care.

Source: diabetesdaily.com

Your Eye Health During COVID-19 — What You Should Know

This content originally appeared on diaTribe. Republished with permission.

By Kira Wang

While the global pandemic has interrupted many healthcare services, eye care is still essential and available under certain circumstances

Diabetes can lead to changes or problems in your vision, making annual eye appointments a necessity for every person with diabetes. One can prevent complications with vision for many years, even many decades, with some luck – it’s about glucose management as well as genes. For people who already have eye complications, treatment may be required as often as every few months in order to keep eyesight as strong as possible. But COVID-19 has disrupted many aspects of our daily lives, including the ability to visit eye care professionals for regular appointments. Although providers may not be able to see you in person at this time, there are still ways for you to access the care you need and keep your eyes as healthy as possible.

Can I still see my eye care provider in person?

We reached out to diaTribe’s network of healthcare professionals and learned that eye care providers are still treating emergencies and people with advanced cases of diabetes-related retinopathy and diabetes-related macular edema. Emergencies might include cases of trauma, infection, or sudden changes in vision (e.g., flashing lights, floaters, blurriness) – if you have experienced any of these situations, talk to your healthcare team right away.

If you have been diagnosed with diabetes-related retinopathy or diabetes-related macular edema, delaying treatment can risk worsening vision, and you may need to receive in-person care. If your treatment has been rescheduled, double-check with your healthcare team to make sure your vision is not at risk. For more mild cases of diabetes-related retinopathy or diabetes-related macular edema, your healthcare professional may consider the risks of exposure to COVID-19 versus how your vision will be affected without scheduled treatment.

Planning ahead is important, and every person is different – ask your doctor in advance about what specific plan works for you. If you do visit your eye care provider in person, remember to wear a face covering—this will help keep you and your healthcare team safe!

Telemedicine and eye care: when can I talk to my healthcare professional virtually? 

For problems with the outside of your eye, video visits can help you connect with your provider right from your home. Issues outside your eye might include redness, discharge, or swollenness. Explaining your symptoms to your provider over video can help them determine whether you’ll need to be seen in person.

What should I know about scheduling eye appointments in the midst of COVID-19?

For those who already have regularly scheduled eye appointments, your check-ups may be delayed during these times. If your visit is delayed, you should still pay attention to any changes in your vision. You can do this by giving yourself an at-home eye test.  If you don’t already have annual visits with an eye care professional, try to set up an appointment as soon as eye care clinics are back up and running.

Remember: keeping your blood sugar levels in range is central to maintaining healthy eyes.

In these challenging times, we are impressed by the use of telemedicine, for eye care and beyond. For more information on telemedicine during COVID-19, check out these nine tips by longtime diaTribe advisor Dr. Francine Kaufman. To the many healthcare professionals out there, we are grateful for your service and support. Mark your calendars—July is Healthy Vision Month, and we’ll have more articles on eyes coming your way soon!

About Kira

Kira Wang graduated from Duke University summa cum laude with a degree in psychology and minors in biology and chemistry. She wrote a senior thesis on the transactional coping strategies of parents and youths with chronic illness and spent time researching eye imaging techniques in the Duke Eye Center.

Source: diabetesdaily.com

Diabetes Eye Screenings: Why They Are Important and Challenging

This content originally appeared on diaTribe. Republished with permission.

By Renza Scibilia and Chris ‘Grumpy Pumper’ Aldred

Regular eye screenings are important for people with diabetes. Learn more about diabetes-related retinopathy screenings from diabetes advocates Renza and Grumpy

What Causes Diabetes-Related Retinopathy?

Diabetes-related retinopathy occurs when many years of high blood sugar levels cause damage to blood vessels in the eye. This damage triggers your body to make more blood vessels – but these new vessels are fragile and easily damaged, which can result in bleeding or scarring in the eye that worsens vision. Fortunately, there are medications available that can improve symptoms. For more background on diabetes-related retinopathy, see here.

There is more to developing a diabetes-related eye condition than just A1C. Time in range also plays a role, as seen by recent research – diaTribe will be updating readers on this in the coming months!  Blood pressure also plays an important role in our risk, as can rapid fluctuations in glucose levels. Family history of eye conditions, such as glaucoma and age-related macular degeneration (AMD), may increase the risk of diabetes-related eye issues, so knowing and sharing your family history is important when discussing your eyes at screening appointments.

The importance of eye screenings

In diaTribe’s past interview with ophthalmologist (eye doctor) Dr. Ivan Suñer of Memorial Hospital of Tampa, we learned that people with retinopathy often have no noticeable symptoms until they are at high risk for losing their vision. Early detection of diabetes-related retinopathy is crucial to prevent vision loss. Thus, his number one piece of advice was to see a doctor regularly for eye screenings. The American Diabetes Association (ADA) recommends that people with diabetes get a comprehensive eye exam every two years if there is no evidence of retinopathy. For those with retinopathy, the ADA recommends an eye exam every year.

Given the importance of eye screenings, Renza and Grumpy – within a few days of each other – both recently tweeted about our upcoming eye screening checks. (Renza has annual visits to her private ophthalmologist as suggested by Australian guidelines; Grumps receives a screening every three to four months to monitor some damage in his left eye.)

Both of us (Renza and Grumpy) are fortunate that we live in countries with national eye screening programs for people with diabetes. (Australia’s program was launched just this year; the UK program has been around for a number of years now.)

In Australia, KeepSight operates as a “recall and reminder” system. People with diabetes register with the program and are sent prompts to make appointments. The frequency of these reminders is individually tailored, determined by how frequently screening checks are required.

In the UK, the Diabetic Eye Screening Program (time for a rename and some #LanguageMatters attention!) is overseen by the National Health Service (NHS). Screening appointments are made for people with diabetes, and follow up letters are sent with the results.

National screening programs work because they offer a coordinated and consistent approach that has the potential to reach a wide number of people. In an ideal world, they capture all people living with diabetes, ensuring screening occurs at the right time, changes to the eyes are identified early, and appropriate treatment is started immediately.

When implemented properly, the results of screening programs can be staggering. Before the UK program was established, diabetes-related eye conditions were the leading cause of preventable blindness in the UK. That is no longer the case.

The challenges of eye screenings

Not many people with diabetes look forward to their eye screenings. And many of us will look for any excuse to put off making or going to our screening appointment. There are a number of reasons for that.

While it may be one of the least invasive checks on our screening list, it can be one of the most disruptive. If pupil dilating drops are required, the rest of the day is often a write-off. Even when the blurred vision goes, we are often left feeling tired or with a headache from the bright light and eye strain caused by the drops.

On top of organizing time off work or school for ourselves, we may need to involve a friend or family member to take us to the appointment. All of these things can make coordination of our appointment difficult and become a reason that we postpone or cancel.

But logistics are only one reason we may decide to put off our appointment. Many of us are anxious about results from screening checks. Diabetes-related complications are often presented to us in such a scary and threatening way that we are frightened to organize and attend appointments. (Renza recently wrote this piece, “Why Scare Tactics Don’t Work in Diabetes” for diaTribe about how her introduction to diabetes-related complications when she was diagnosed with diabetes scared her so much that she was simply unable to face the thought of diabetes screenings.)

And those of us who have missed an appointment or two, or have never been screened before, become worried that we will be “told off” when we do eventually gather the courage to attend.

What works and how can we do better?

  • Making the process of actually having a diabetes eye check as easy and smooth as possible will always mean more uptake. Bringing screening to the people, rather than expecting people to travel long distances, will reduce a significant barrier to keeping up-to-date with screening checks. There are a number of different initiatives that are working toward making screening checks more convenient.
  • Pharmacies are being used in some areas to provide initial screening checks (using a retinal scanning camera), with any necessary follow-up being conducted by specialist eye health care professionals. This works well because it means the initial screening check – which will pick up any changes – is done somewhere convenient and familiar, and without the need for dilating drops. Hopefully this will reduce some of the nervousness people may feel about going to a clinic or hospital setting.
  • Coordinated reminder systems are great! Anything that helps ease the weight of “diabetes administration” is welcome to help with the daily tasks demanded by diabetes.
  • Counselling around the visit would also be helpful for some!

Having any sort of diabetes-related complications screening is never just about the process of attending and completing the screening. Just the thought of, and planning for, the appointment can be distressing for people, especially for those who have had complications presented to them in a scary or threatening manner. Offering counselling before and/or after screening is a great idea to help address some of those anxieties, and provide people with practical tips for coping.

Screening checks are part of the process of managing diabetes-related complications

We’d urge healthcare professionals to acknowledge just how difficult it can be for someone to simply show up for a screening appointment, and commend those that do. A little word of understanding can go a very long way!

As ever, peer support can be hugely beneficial. Whether it be sharing stories about how people manage to navigate anxieties and nervousness about eye screening checks, or how people have dealt with a diagnosis, speaking with others who have walked a similar path can be useful and can help reduce the isolation many people feel.

And finally, most people with diabetes do know the importance of regular complications screening, and that early detection and treatment will likely result in better outcomes. (In Grumps’ case, this early detection has meant that the issues have not progressed for several years and that, to date, no treatments have been required.) But that is not enough. We need to follow messages and campaigns that highlight the importance of screening with advice on how to make the process easier and more comfortable for people with diabetes, while recognizing how difficult it can be. Humanizing the experience of screening, and giving results and follow- up, is all an important part of the story.

Source: diabetesdaily.com

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