Diabetes Registry Enables Safer, More Thorough Care for Patients

**By Nicholas Moy, MD**

MD PatientAccording to a landmark study published in 2016 in The Lancet, 422 million adults worldwide have diabetes. In the United States alone, diabetes statistics are staggering. According to the Centers for Disease Control and Prevention, in 2015:

  • More than 100 million Americans have diabetes or prediabetes, which if not treated can lead to type 2 diabetes within five years.
  • The percentage of adults with diabetes increased with age, reaching a high of 25.2 percent among those aged 65 years or older.
  • An estimated 1.5 million new cases of diabetes were diagnosed among U.S. adults, with more than half between the ages of 45 and 64.
Understanding diabetes by type

In type 1 diabetes, the body does not produce insulin. Insulin is a hormone the body needs to get glucose (sugar) from the bloodstream into cells. Type 1 is usually diagnosed in children and younger people. However, it can develop at any age. Only about 5 percent of people with diabetes have type 1. Currently, there is no known way to prevent type 1. People with it must inject or pump insulin to survive.

In type 2 diabetes, sometimes called “adult onset,” the body does not use insulin properly, which is called insulin resistance. At first, the pancreas makes extra insulin to make up for it. But, over time, it isn’t able to keep up and can’t make enough insulin to keep blood glucose at normal levels. People with type 2 can manage the disease with diet, exercise and medications. In some cases, insulin is needed for management.

Preventing type 2 diabetes

Before people develop type 2 diabetes, they almost always have prediabetes – blood glucose levels that are higher than normal, but not yet high enough to be diagnosed as diabetes. This condition puts you at a higher risk for developing type 2 diabetes and cardiovascular disease.

While there is still no cure for diabetes, there is good news: The progression from prediabetes to type 2 diabetes is not inevitable. The National Institutes of Health clinical trial, the Diabetes Prevention Program, found that for people with prediabetes, modest lifestyle changes led to weight loss of 5 to 7 percent in participants and reduced the risk of type 2 diabetes by 58 percent in individuals at high risk.

Diabetes Registry

This is why primary care physicians with Virginia Mason, including myself, developed a Diabetes Registry, which does three important things to help ensure the right care is delivered to the right patients at the right time. First, it identifies patients with diabetes. Second, it identifies how well they are doing. And third, it pulls them back into care when needed.

Although the American Diabetes Association recommends that people with diabetes see a primary care or endocrinology provider every three to six months, life doesn’t always allow that to happen. This is why Virginia Mason’s  Diabetes Registry software is so helpful. It uses algorithms to regularly analyze electronic medical records and alert care teams about who may need follow-up, whether through an appointment or a report to their care team on recent changes, such as with blood pressure, weight loss, etc.

Virginia Mason team members, including medical assistants and nurses, then know to check in with these patients to make sure they are on track. This ensures the care they receive is aligned with their current needs.

“Recently, I was able to get several out-of-care patients in for an appointment and labs with one of our providers,” said Certified Medical Assistant Courtney Yates. “Patients are responding well to the simple reminders we’re sending them, whether they are messages though the patient portal, calls, or mailed letters. Our goal is to get 100 percent of our out-of-care patients back in care.”

Dr Nicholas MoyNicholas Moy, MD, is board certified in Internal Medicine and practices Primary Care at Virginia Mason Hospital and Seattle Medical Center. His special interests include quality improvement and geriatrics.


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