What We Want to Achieve Through Systems Changes

Team Care: Advantages

Short-term cost savings associated with team care can result from shorter length of hospital stay, reduced rate of hospital readmission, or reductions in disabilities and associated costs. For example, in one study the average length of stay for patients with a primary diagnosis of diabetes was 56% shorter for team-managed patients than for patients managed by an internist alone and 35% shorter than for patients seen only by an endocrinologist. The reduction in length of stay was largest when consultation was obtained early in the hospital stay.13 Another study showed significant reductions in readmission rates for team-managed patients.14 An outpatient team can deal with management issues or potential complications early, before they develop into serious problems that warrant a costly emergency room visit or hospital admission.

A study of patients who maintained an average hemoglobin A1C value of 7.5% reported improved quality of life on five scales, including symptom distress, general perceived health, and cognitive functioning. Compared with the control group, this group also had higher retained employment, greater productive capacity, and less absenteeism, resulting in significant short-term cost savings.15

Long-term benefits

Both the DCCT16 (Diabetes Control and Complications Trial conducted by the NIDDK) and the UKPDS17 (United Kindom Prospective Diabetes Study) improved health outcomes by providing intensive management that involved team care, frequent patient follow-up care, counseling, and ongoing patient education. Intensively treated patients achieved an HbA1c value of 7.2% in the DCCT and 7% in the UKPDS, compared with 8.9% and 7.9%, respectively, for conventionally treated patients. Although these trials did not study aspects of the team care they practiced, it is unlikely that their results could have been achieved without a team approach.

The DCCT found that intensive treatment for patients with type 1 diabetes reduced the risk for microvascular complications for eye disease by 76%, kidney disease by 65%, and nerve damage by 64%. A follow-up study indicated that the reduction in risk for progressive eye and kidney disease persisted for at least 4 years after the DCCT ended, despite increasing blood glucose values.

The UKPDS showed that intensive treatment maintained over time for patients with type 2 diabetes reduced the risk for retinopathy by 21%, cataract extraction by 24%, microvascular endpoints by 25%, and albuminuria by 33%. Lowering blood pressure in a subset of UKPDS subjects to a mean of 144/82 mm Hg reduced the risk of strokes, diabetes-related deaths, heart failure, microvascular complications, and visual loss up to 56%.

Although almost every patient can be expected to benefit from any increment in improved glycemic regulation, blood glucose control is more effective in preventing the initial development of microvascular complications than in preventing their progression once they have become established. Early therapeutic intervention also is more cost-effective. There is a marked correlation between glycemic control and the cost of medical care, with medical charges increasing significantly for every 1% increase in A1C above 7%.18 In fact, the increase in medical charges accelerates as the A1C value increases. These findings underscore the need for early diagnosis and treatment of type 2 diabetes.

Resources

Team Care: Comprehensive Lifetime Management
www.ndep.nih.gov/resources/health.htm

This report was developed by the National Diabetes Education Program to help organizational leaders in health care systems, health care providers, and purchasers of health care to implement team care for people with diabetes in all clinical settings.

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