November is National Diabetes Month, when patients, clinicians, and advocacy groups come together to sound the alarm on one of the country’s most common chronic health conditions. The staggering numbers show there’s good reason to be alarmed:
- 37 million people—11% of the U.S. population—carried a diagnosis of diabetes in 20191
- 1 in 5 people don’t know they have the disease2
- 96 million Americans have pre-diabetes2 (blood glucose levels higher than normal but not yet high enough to be diagnosed as diabetes)
Despite the statistics, there’s also reason for hope. Proven maintenance medications and new monitoring technologies are helping patients better manage their diabetes. In hospitals and health systems, a shift toward proactive care is helping clinicians identify patients who may be at risk for complications and poor health outcomes.
Identifying and Intervening With At-Risk Patients
Stillwater Medical Center in Oklahoma recently launched an initiative to track patients’ adherence to their medications. While non-adherence is a challenge in treating many conditions, it is particularly troubling among patients with diabetes because it can result in serious health complications, including heart disease, chronic kidney disease, and irreversible nerve damage. There are effective therapies in combating diabetes, such as insulin therapy and oral medications such as metformin, sulfonylureas, and thiazolidinediones. Unfortunately, one year after diagnosis, adherence to non-insulin medications is less than 80% and then drops precipitously.3
To improve care quality and decrease diabetes-related complications and readmissions, a multidisciplinary team at Stillwater Medical Center is tracking diabetes patients using medication history and adherence data in the electronic health record (EHR) system. With DrFirst’s MedHx™ PRM (Population Risk Management) and the hospital’s MEDITECH EHR, the team identifies high-risk patients and facilitates clinical interventions and discussions with those who aren’t filling their prescriptions on a timely basis.
Chris Roark, the health system’s Chief Information Officer, recently appeared on This Week Health’s podcast to discuss the project.
In light of the immense challenges the diabetes epidemic poses for patient outcomes and healthcare resources, population health initiatives like this one at Stillwater Medical Center are essential to providing the best possible care to the most vulnerable patients—this month and every month.