Diabetes in the United States
Diabetes is rapidly emerging as a significant healthcare concern in the United States. According to the latest statistics from the Centers for Disease Control and Prevention, approximately 11% of the U.S. population has been diagnosed with diabetes1. Additionally, over a million Americans receive a new diabetes diagnosis each year2. Without proper management, diabetes can lead to severe health complications such as nerve damage, cardiovascular disease, and stroke.
For patients living with diabetes, regular monitoring of A1c is important. There is a considerable volume of research which suggests that proper glycemic management results in a significant reduction in the risk of developing many diabetes-related complications, ranging from microvascular complications to cardiovascular disease. Regular A1c testing gives the provider key information necessary to set and track treatment goals, helping to ensure the best outcomes possible for their patients.
Managing Patient Populations Living with Diabetes
One method of managing a patient’s blood sugar levels is via an A1c hemoglobin test. This simple lab test measures the amount of glycated hemoglobin in the blood, providing an accurate estimate of the patient’s blood sugar levels over the last 2-3 months. Regular monitoring of A1c levels is crucial for healthcare providers to track the disease and adjust treatment plans as needed. It also helps patients stay informed and actively involved in their own care. The American Diabetes Association’s Standards of Care recommend that A1c hemoglobin tests be conducted at least twice a year.3
Given its importance in diabetes management, there is a specific UDS measure (eCQM CMS122) designed to assess how well-controlled patients’ A1c levels are. The measure evaluates adult patients with a diabetes diagnosis and determines the percentage who either had an A1c greater than 9% or did not have an A1c test result recorded within the measurement period. The latter group of patients, those without a recent test result, is who we will focus on.
So, how does one ensure that A1c lab tests are being completed? Naturally, providers encourage their patients to complete the test in a timely manner, but with limited face time at the point of care, this can only do so much. Alternatively, other clinic staff can be utilized in outreach efforts, following up with patients who have not yet completed their labs. However, this process can be cumbersome and time-consuming, particularly given the many other demands on staff’s time. It is because of these very challenges that we created Azara Patient Outreach (APO).
How APO Works: Set It and Forget It
APO utilizes EHR data to identify which patients are due for an A1c lab test, and automatically sends reminders via an automated text message. Setting up an APO campaign is simple and quick, requiring only a minimal investment of staff time. Azara currently has two types of APO campaigns related to the A1c UDS measure: one that focuses on patients who have a visit scheduled soon and another for patients who do not have an upcoming visit. Both are customizable and can be individually started, stopped, or paused at any time.4 Once enabled, APO campaigns essentially run themselves – “Set It and Forget It”.
Tracking Campaign Effectiveness in DRVS
Eligible patients are automatically identified by back-end campaign criteria, and custom text reminders will start being sent using the selected cadence. When a patient completes their A1c test and the results are recorded in the EHR, they are automatically removed from the campaign. These patients are considered to have met the “Campaign Success Criteria”, effectively adding to the percentage of patients who closed the care gap. As new patients meet the campaign criteria over time, they are automatically added without requiring any action from staff. That is one of the beauties of APO's “Set It and Forget It” technology – set up the campaign and let it work for you!
For patients who respond to the campaign message, whether it be a pre-defined response option (Yes, No, etc.), or a personally written response, staff can review those patients’ responses within the DRVS system via the “APO Campaign Responses” measure. For instance, a patient might respond to a diabetes A1c campaign with details like, “I am out of testing supplies”, or “Which locations are available”. Being able to view these types of responses can help practice staff conduct targeted 1-1 follow-up to help the patient with their specific needs.
An Analysis of Practices Running APO Diabetes A1c Campaigns
Figure 1 - Example of APO Reporting in DRVS: APO Campaign Performance Measure
Using APO campaigns to remind patients they are due for an A1c lab test should lead to more labs being completed, and thus improvements in the A1c UDS measure. To test this hypothesis, we sampled 20 practices who had either one or both A1c APO campaigns active. Next, we examined measure data for the 3 months prior to, and 12 months after, initial campaign activation to determine improvements that occurred.
The Results: Improvements in UDS Measure CMS 122
Our analysis showed that practices that utilized Azara Patient Outreach saw a mean improvement in their A1c UDS measure of 2.5 percentage points. The median improvement (an indicator that is less sensitive to outlier values) showed an improvement of 2.1 percentage points.
While the magnitude of the measure improvement may feel small, this particular UDS measure is commonly considered difficult to move. One reason is due to the way the numerator criteria is handled. As mentioned above, the measure calculates the percentage of patients who had a high (> 9%) A1c or no result at all. So, even if a patient reacts to the APO campaign by completing their A1c lab, the result of that test may be too high and not impact the UDS measure result. In other words, the APO-defined care gap is closed and marked as a success for the patient because they completed the lab, but the result of the A1c is what ultimately “moves the needle” of the UDS measure. In other words, the APO Diabetes A1c reminder campaign encourages regular testing, but does not influence the results of those tests.
Results: Improvements for Practices Utilizing One or Both APO A1c Campaigns
Our analysis also yielded another interesting result regarding practices that used either one or both APO campaigns. The below visualization displays a dot for each of the 20 practices in the sample, grouped into two columns: the left column for practices that only had one of the A1c APO campaigns enabled, and the right column for practices that had both enabled. The y-axis of the graph shows how much (if any) the practice’s measure improved in the 12 months after enabling the APO campaign(s).
Figure 2 - Analysis Results
The graph above shows practices that utilized both APO campaigns saw greater overall improvements in the measure (2.5 percentage points on average). By comparison, practices that used only one of the two A1c APO campaigns saw a mean improvement of 1.5 percentage points. If we exclude a single-center outlier, the results shift and show us that centers utilizing both campaigns at once have double the improvement that a single APO campaign would see – a mean improvement of 3.3 percentage points compared to 1.5 percentage points for those utilizing one campaign.
In conclusion, the data in this analysis strongly suggests that using APO campaigns can meaningfully contribute to improving A1c UDS measure results—and patient health. Considering that APO requires only minutes to set up, and doesn’t demand constant attention from staff, this approach is particularly appealing.
Contact your client success manager or solutions@azarahealthcare.com to learn more about how Azara Patient Outreach can improve patient outcomes and drive quality improvement at your organization.
[1] Centers for Disease Control and Prevention. National Diabetes Statistics Report website. https://www.cdc.gov/diabetes/php/data-research/index.html. Accessed Aug 8, 2024.
[2] https://diabetes.org/ “Diabetes by-the-numbers”
[3] American Diabetes Association Professional Practice Committee; 6. Glycemic Goals and Hypoglycemia: Standards of Care in Diabetes—2024. Diabetes Care 1 January 2024; 47 (Supplement_1): S111–S125. https://doi.org/10.2337/dc24-S006
[4] HgA1c Introduction and Analysis: 2021. Diabetes Care 1 November 2022; 32: S111–S125. https://doi.org/10.2337/dc24-S006
