AMGA Diabetes Risk Model Development Project

AMGA worked with twelve medical groups to develop a diabetes risk model that will improve the care of high-risk diabetes patients. The data collected in this project was used to gain more detailed knowledge on relationships among severity of illness, resource utilization, patients’ perceptions of quality of life, and treatment protocols.

The model helps medical groups identify high risk diabetes patients, and institute changes in care processes that produce better quality of life, improved clinical values, and lead to a decrease in unnecessary utilization of health care resources. The project was funded through an educational grant from Parke-Davis.

Each of the twelve medical groups who participated agreed to identify 411 diabetes patients and collect survey data, lab, and utilization data on the population. One group collected data on an additional sample of 411 African-American patients. In 1999, each group administered a baseline survey to all 411 patients (with the exception of one group which needed to get patient consent prior to administering the survey, limiting their sample to under 200 patients.) In addition to collecting baseline survey data, each group collected lab, hospitalization data and outpatient billing data on each of the 411 patients. In 2000, each group administered a follow-up survey to the same patient population and collected the same lab and utilization data collected in 1999.

The data sets are described below:

• Physical functioning
• General Health
• Depression screener
• Disability days
• Diabetes Self-Management
• Number of Hospitalizations, ER visits, and office visits
• Diabetes Care (foot exams, retinal eye exams, nutritionist)
• Comorbidities
• Body Mass Index
• Smoking Status
• Personal Characteristics (Age, gender, education, marital status)

• HbA_1c (date of test and value)
• Microalbuminuria (date of test and if results are normal or abnormal)
• Macroalbuminuria (date of test and if results are normal or abnormal)
• Total Serum Cholesterol (date of test)
• LDL Cholesterol (date of test)
• HDL Cholesterol (date of test)
• Serum Triglyceride (date of test)
• Lipid Profile (date of test)

• Blinded Patient ID
• Date of Birth
• Sex
• Provider Type
• Date of Service
• Place of Service
• ICD-9 Diagnoses Codes
• CPT Procedure Codes

• Blinded Patient ID
• Date of Birth
• Sex
• Hospital Admission and Discharge dates
• Physician Type
• ICD-9 Diagnosis Codes
• CPT Procedure Codes
• Disposition of patient

AMGA has developed several nomograms that allow clinicians to help identify their high-risk patients in the office setting. These tools can be used in the office setting with data provided directly from the patient. Based on their responses, clinicians can determine the patient’s level of risk and better determine necessary follow-up.

There are different models for identifying patients at risk for disability, for elevated HbA1c and for increased hospitalizations.

The nomograms are available to AMGA members and to the general public. If you have any questions about this study, or would like more information about the project, please contact Joyce Jones, (703) 838-0033 ext. 340 or jjones@amga.org.

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