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March 11, 2010 Volume VI, No. 41

HIN Communications Editor Jessica Papay

Dear Healthcare Intelligence Network Client,

Diabetes affects approximately 8 percent of people in the United States, and adults with diabetes have heart disease death rates two to four times higher than adults without diabetes, according to the American Diabetes Association. In this week's issue, you will discover how sugar-sweetened drinks are contributing to this problem, along with the link between diabetes, depression and dementia.

You will also learn about two doctors' prescriptions that could help improve diabetes care.

Your colleague in the business of healthcare,
Jessica Papay
Editor, Disease Management Update

This week's DM news:

Table of Contents

  1. Diabetes & Sugar-sweetened Drinks
  2. Depression, Dementia & Diabetes
  3. Achieving Medication, Care Plan Adherence
  4. Patient Engagement in the Diabetes Medical Home
  5. Healthcare Trends: Prescription for Primary Care
  6. Two Recommendations to Improve Diabetes Care
  7. Medical Homes in 2010

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Have Sugar-sweetened Beverages Led to an Increase in Diabetes, Heart Disease and Healthcare Costs?

More Americans now drink sugar-sweetened sodas, sport drinks and fruit drinks daily, and this increase in consumption has led to more diabetes and heart disease over the past decade, researchers reported at the American Heart Associationís (AHA) 50th annual conference on cardiovascular disease epidemiology and prevention. Using the coronary heart disease (CHD) policy model, researchers estimate that the increased consumption of sugar-sweetened beverages between 1990 and 2000 contributed to 130,000 new cases of diabetes, 14,000 new cases of CHD and 50,000 additional life-years burdened by CHD over the past decade. Sugar-sweetened soda, sport and fruit drinks (not 100 percent fruit juice) contain equivalent calories, ranging from 120 to 200 per drink, and thus play a role in the nationís rising tide of obesity, researchers said. Previous research has linked daily consumption of these sugary beverages to an increased risk of diabetes, even apart from excessive weight gain.

Through the CHD model, the researchers estimate the additional disease caused by the drinks has increased CHD healthcare costs by $300-$550 million between 2000 and 2010. This figure likely underestimates the true costs researchers found because it does not account for the increased costs associated with the treatment and care of patients with diabetes alone. Over the last decade, at least 6,000 excess deaths from any cause and 21,000 life-years lost can be attributed to the increase in sugar-sweetened drinks. Health policy experts suggest curbing the consumption of sugared drinks through an excise tax of 1 cent per ounce of beverage, which would be expected to decrease consumption by 10 percent.

The authors are currently examining the impact of various approaches to reducing consumption of sugary beverages. "The AHA recommends a dietary pattern that is rich in fruit, vegetables, low-fat or fat free dairy products, high-fiber whole grains, lean meat, poultry and fish," said Robert H. Eckel, M.D., past president of the AHA and professor of medicine at the Anschutz Medical Campus of the University of Colorado Denver. "Always consider overall diet in the context of energy balance and make sure foods and drinks high in added sugars are not taking the place of foods with essential nutrients." The AHA recommends an upper limit of half of the discretionary calorie allowance from added sugars, which for most American women is no more than 100 calories per day and for most American men is no more than 150 calories per day from added sugars. Sugar-sweetened beverages should be limited to 450 calories or less per week (36 oz), based on a 2000-calorie-per-day diet.

To learn more about this research, please visit:

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Major Depression More Than Doubles Risk of Dementia Among Adult Diabetics

Adults who have both diabetes and major depression are more than twice as likely to develop dementia, compared to adults with diabetes only, according to a study published in the recent Journal of Internal Medicine. Various other population studies, the researchers noted, have shown that the risk of Alzheimer's disease, vascular dementia and other types of dementia is from 40 to 100 percent higher in people with diabetes, compared to people without diabetes. A history of depression more than doubles the subsequent risk of Alzheimer's disease and other forms of dementia in the general population. According to one researcher, "We wanted to determine the effects of both conditions — diabetes and major depression — occurring together. Our analysis suggests that major depression more than doubles the risk of dementia in adults with diabetes."

The research team on this project tracked the outcomes of adults from Group Health Cooperative's diabetes registry who agreed to participate. They were patients from nine Puget Sound area primary-care clinics in western Washington state. The clinics were chosen for their socioeconomic and racial/ethnic diversity and were demographically similar to the area's population. Initial enrollment of patients took place between 2000 and 2002, and the patients were studied for five years. Patients already diagnosed with dementia were excluded from the study. Over the five-year period, 36 of 455, or 7.9 percent, of the diabetes patients with major depression were diagnosed with dementia. Among the 3,382 patients with diabetes alone, 163 or 4.8 percent developed dementia. The researchers calculated that major depression with diabetes was associated with a 2.7-fold increase of dementia, compared to diabetes alone. Because the onset of dementia can sometimes be marked by depression, the researchers also adjusted their hazard model to exclude patients who developed dementia in the first two years after their depression diagnosis.

The exact manner in which diabetes and depression interact to result in poorer outcomes is not certain. Some studies suggest that a genetic marker for dementia is associated with a faster cognitive decline. Depression may also raise the risk of dementia, the authors noted, because of biological abnormalities linked to this affective illness, including high levels of the stress hormone cortisol, poor regulation in the hypothalamus-pituitary system or autonomic nervous system problems that can affect heart rate, blood clotting and inflammatory responses. Depression, they added, might also raise the risk of dementia because of behaviors common in the condition, such as smoking, over-eating, lack of exercise, and difficulty in adhering to medication and treatment regimens. In the current study, patients with both diabetes and major depression were more likely to be female, single, smokers, physically inactive and treated with insulin. They also had more diabetes complications and a higher BMI, a ratio calculated from height and weight. However, these differences were controlled for in the analysis and depression remained an important risk factor.

Diabetes, the authors noted, is a risk factor for dementia because of blood vessel problems and also may accelerate the decline of Alzheimer's disease. Many factors linked to diabetes might also increase the odds of developing dementia, including tissue damage from high blood sugar levels, episodes of low blood sugar and insulin resistance. Also, depression is common among people who have diabetes. Until more research is available on the exact mechanisms behind the links between depression, diabetes and dementia, the researchers say, "It seems prudent for clinicians to add effective screening and treatment for depression to other preventive measures such as exercise, weight control and blood sugar control, to protect against the development of cognitive deficits in patients with diabetes."

To learn more about this research, please visit:

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Achieving Medication and Care Plan Adherence Through an Integrated Care Team

While neither colocation of team members nor an electronic health record is a prerequisite for a successful integrated care team, explains Dr. Jan Berger, chief medical officer of Silverlink Communications Inc., there are four essential factors that contribute to the confidence and comfort levels of both patients and team members.

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Patient Engagement in the Diabetes Medical Home

Each week, healthcare professionals respond to a reader's query on an industry issue. This week's experts are Dr. James E. Barr, medical director at Partners in Care, and Roberta Burgess, CCNC nurse case manager with Heritage Hospital in Tarboro, North Carolina.

Question: The Medicaid population has many social barriers to care. How do you increase their engagement to allow the diabetes medical home model to be successful?

Response: (Roberta Burgess) It is hard, but population management is something I do with my diabetic population or any other population that we work with. I send out materials on a monthly basis to my diabetics, and most of the time itís just education. I'll say that this is an educational flier about your diabetes. Iíll also have at the bottom, "If you would like more information, contact me, and I can come see you one-on-one and we can talk about some other things." I get responses back from those letters saying, ďI got a letter from you about my diabetes. I need to know more about it." I also pick up the phone and call them, one at a time until I get somebody. There is a barrier, but I pick up the phone and say, "My name is Roberta and Iím your case manager. I work for your medical home. Is there anything I can help you do today? How are you doing with your diabetes? Are you having any other problems that I might be able to help you with? I know all about the resources." That opens the door and lets them know they can get care or help. Many times they may not get out because of transportation. I can provide them with transportation. But it is one-by-one, and itís treacherous.

(Dr. James Barr) The process map that we utilize identifies every person that is in contact with this patient. The list includes the medical home doctor, all the specialists involved and a case manager if one exists. That list can continue and can involve the family member who might have the most influence over this patient or will help with compliance, transportation or finances. There may be a financial assistance plan that can be implemented inside that patient's profile in order for them to get certain medications. It could involve a faith-based organization, a minister, or somebody with whom they have a relationship. It's good to include anybody who has had a relationship with that patient so that when youíre having a problem, the map indicates resources to use to help this patient obtain the type of care they need.

For more information on the diabetes medical home, please visit:

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Healthcare Trends & Studies: Prescription for Primary Care — Initiatives for Change

There are rumblings about the state of primary care at each step of the healthcare continuum: hospitals and health plans want primary care physicians (PCPs) to accept a larger role in DM and care transitions, including patient education and follow-up. Meanwhile, PCPs struggle to provide quality care and devote adequate time to patients in the face of reduced reimbursements and increased reporting. In an online survey, the Healthcare Intelligence Network (HIN) asked healthcare organizations how they are affected by the state of primary care and how they are handling the deficiencies.

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Doctors Recommend Two Ways to Improve Diabetes Care

In a new study, physicians recommend two ways to help patients with diabetes to fight through barriers that prevent them from having a healthy lifestyle, as well as to assist those physicians who become frustrated over not being able to help their diabetic patients. The joint study from UMDNJ-Robert Wood Johnson Medical School, University of Hawaii and University of Michigan shows that PCPs believe the barriers that put patients with uncontrolled diabetes at risk for cardiovascular disease are either patient-related or system-related.

Their recommendations include training physicians and other healthcare providers in effective strategies that will allow them to work collaboratively with patients to address the barriers, and at the system level, developing more team-based strategies with health plan partners included in those teams to address payment reform for physicians. Some physicians noted that spending more time with diabetes patients is not cost-effective and that there is a lack of reimbursement from health insurers for time spent counseling patients.

Physiciansí perceptions that they were unable to help patients overcome these barriers resulted in high levels of frustration. According to the study, this response was consistent among physicians in all four areas of the country included in the study. The frustration arose from a perceived inability to address patients' motivation for maintaining good health, patientsí resistance to treatment recommendations and a belief that the barriers faced by patients are outside of physicians' control.

The study interviewed 34 PCPs in diverse practices in California, Indiana, Michigan and New Jersey who provided outpatient care to adult diabetic patients. Many of the physicians responded that patient-related socioeconomic concerns proved to be a significant barrier to maintaining good diabetic health. This included financial struggles by patients that kept them from maintaining the challenging lifestyle and diet that diabetes requires, such as buying healthy but often more expensive food. Family-related concerns, such as a lack of support or caring for other family members before themselves, also proved a significant barrier for patients. The study also found that other medical conditions such as pain or depression competed with patientsí efforts to control cardiovascular risk factors.

System-related barriers fell into two categories: the physician's ability to deliver care and the patient's ability to access care. Physicians identified the cost of transportation to get to appointments and the high cost of medication to treat diabetes as significant barriers for their patients. The health system presented other barriers such as difficulties obtaining referrals and making convenient appointments. System-related barriers preventing physicians from delivering care included the failure to utilize technology to make a patient's health record readily accessible at the point of care. Poor coordination of care among healthcare providers also was noted as a significant barrier. "Ideally, a multidisciplinary team of nurses, diabetes educators, pharmacists and endocrinologists would greatly improve a primary care doctor's ability to assist patients who face significant barriers to controlling diabetes and its complications," said lead study author Jesse Crosson, Ph.D., assistant professor of family medicine and director of the New Jersey Primary Care Research Network at UMDNJ-Robert Wood Johnson Medical School.

To learn more about this research, please visit:

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Medical Homes in 2010

Patient-centered medical home (PCMH) pilots are in high gear around the country and high on the healthcare reform agenda. Recent studies indicate that the PCMH can deliver quality care at little or no added cost. Complete HIN's fourth annual survey on your organization's PCMH experience and get a FREE executive summary of the compiled results. Nearly 60 organizations have responded so far; your responses will be kept confidential.

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