33AMGA.ORG NOVEMBER/DECEMBER 2019
The national prevalence of diabetes mellitus (DM) was 8.5% in 2016–17.1 The prevalence of DM in Pennsylvania, home to UPMC Pinnacle,
is currently around 10% and is
increasing. 2 The total direct and
indirect estimated cost of diagnosed diabetes in the United States
is $327 billion, which equates to 1 in 7 dollars
spent on diabetes. 3
Diabetes control is assessed by an HbA1C
(A1C) blood test, which is a marker for average
blood glucose level over a three-month period.
An A1C value of from 7% to 8% is considered
optimal based on several national guidelines. 4, 5
Worsening diabetes control as indicated by
an A1C value greater than 9% is well known
to be associated with significant increases
in both microvascular and macro-vascular
The United Kingdom Prospective Diabetes
Study7 and the Diabetes Control and Complications Trial8 found that a 1% reduction in A1C levels
for a diabetes patient results in as much as a
35% reduction in risk for future complications.
Ideally, all patients with uncontrolled diabetes
should be cared for by an endocrinologist; however, primary care providers (PCPs) manage 80%
of such patients due to a shortage of endocrinologists across the country. In addition, some
patients are reluctant to follow up with specialists for financial and other reasons.
UPMC Pinnacle in Harrisburg, Pennsylvania,
had a strong program in place for inpatient
glycemic control since 2002 (see “The Setting”).
In 2009, UPMC was recognized as a Center of
Diabetes Excellence, the first institution in
Pennsylvania recognized as such by
the Joint Commission. It has also
remained in the top 10th percentile
for ICU glycemic control for many
years when compared with 100
other hospitals across the nation,
as reported by Medical Decision
In 2014, it was observed that the
hospital readmission rate was directly propor-
tional to an A1C level, measured at the time of
admission, with significant increases in patients
with A1C greater than 9% (see Table 1). Further-
more, patients with high A1C levels (>9%) had
30% more emergency department visits com-
pared to patients with A1C levels lower than 9%.
Across the primary system, approximately 25%
of diabetic patients had an A1C greater than 9%.
Diabetes care in the outpatient clinics was
fragmented. Patients were not consistently
referred to diabetes educators and nutritionists,
the two most important components for suc-
cessful management of diabetes. There was also
an observed gap in knowledge among physicians
to help improve diabetes control, especially
related to new medications and technology.
The Intervention Program
The innovative UPMC Pinnacle outpatient diabetes control program is endocrinologist-led.
The physician who led the inpatient glycemic
control program was identified as a champion
for the outpatient program. The principal mission of the program was to enable the primary
care sites to provide the best diabetes care to
improve glycemic control. Six key interventions
A team approach for
populations in a large
By Renu Joshi, M.D.
25% of diabetic
patients had an
A1C greater than