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Redesigning ambulatory care management for uncontrolled type 2 diabetes: a prospective cohort study of the impact of a Boot Camp model on outcomes
  1. Michelle F Magee1,2,3,
  2. Kelley M Baker4,
  3. Stephen J Fernandez5,
  4. Chun-Chi Huang5,
  5. Mihriye Mete5,
  6. Alex R Montero2,3,
  7. Carine M Nassar1,3,
  8. Paul A Sack6,7,
  9. Kelly Smith4,
  10. Gretchen A Youssef3,
  11. Stephen R Evans8
  1. 1MedStar Health Research Institute, Hyattsville, Maryland, USA
  2. 2Department of Medicine, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
  3. 3MedStar Diabetes Institute, MedStar Health, Columbia, Maryland, USA
  4. 4MedStar Institute for Quality and Safety, Columbia, Maryland, USA
  5. 5Biostatistics and Biomedical Informatics, MedStar Health Research Institute, Hyattsville, Maryland, USA
  6. 6Department of Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
  7. 7School of Medicine, University of Maryland, Baltimore, Maryland, USA
  8. 8MedStar Health, Columbia, Maryland, USA
  1. Correspondence to Dr Michelle F Magee; Michelle.F.Magee{at}


Objective Type 2 diabetes care management (DCM) is challenging. Few studies report meaningful improvements in clinical care settings, warranting DCM redesign. We developed a Boot Camp to provide timely, patient-centered, technology-enabled DCM. Impact on hemoglobin A1c (HbA1c), emergency department (ED) visits and hospitalizations among adults with uncontrolled type 2 diabetes were examined.

Research design and methods The intervention was designed using the Practical Robust Implementation and Sustainability Model to embed elements of the chronic care model. Adults with HbA1c>9% (75 mmol/mol) enrolled between November 2014 and November 2017 received diabetes education and medication management by diabetes educators and nurse practitioners via initial clinic and subsequent weekly virtual visits, facilitated by near-real-time blood glucose transmission for 90 days. HbA1c and risk for ED visits and hospitalizations at 90 days, and potential savings from reducing avoidable medical utilizations were examined. Boot Camp completers were compared with concurrent, propensity-matched chart controls receiving usual DCM in primary care practices.

Results A cohort of 366 Boot Camp participants plus 366 controls was analyzed. Participants were 79% African-American, 63% female and 59% Medicare-insured or Medicaid-insured and mean age 56 years. Baseline mean HbA1c for cases and controls was 11.2% (99 mmol/mol) and 11.3% (100 mmol/mol), respectively. At 90 days, HbA1c was 8.1% (65 mmol/mol) and 9.9% (85 mmol/mol), p<0.001, respectively. Risk for 90-day all-cause hospitalizations decreased 77% for participants and increased 58% for controls, p=0.036. Mean potential for monetization of US$3086 annually per participant for averted hospitalizations were calculated.

Conclusions Redesigning diabetes care management using a pragmatic technology-enabled approach supported translation of evidence-based best practices across a mixed-payer regional healthcare system. Diabetes educators successfully participated in medication initiation and titration. Improvement in glycemic control, reduction in hospitalizations and potential for monetization was demonstrated in a high-risk cohort of adults with uncontrolled type 2 diabetes.

Trial registration number NCT02925312.

  • delivery of care
  • education and behavioral interventions
  • treatment algorithms
  • outcome research

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  • Contributors MFM, CMN, GAY and SRE are responsible for the conception and design of the study. MFM, SJF, C-CH, MM, ARM, CMN, PAS and GAY acquired, analysed and interpreted the data. MFM, MM, C-CH, CMN, GAY and SRE drafted the manuscript. MFM, KMB, MM, ARM, CMN, PAS, KS and GAY participated in critical revision of the manuscript for important intellectual content. MFM, MM, CMN and GAY supervised the study. MFM had full access to all study data and final responsibility for the decision to submit for publication.

  • Funding MedStar Health provided funding and participated in the conception and design of the study and in review of the manuscript but did not participate in the decision to submit the manuscript for publication. The District of Columbia Department of Health and the American Diabetes Association each provided funding for initial pilot studies that generated preliminary data for this work. BioTel (Telcare) provided starter blood glucose monitoring system kits to enrolled patients and trained study staff but did not participate in the design and conduct of the study or the writing and submission of the manuscript.

  • Disclaimer The content of this manuscript is solely the responsibility of the authors.

  • Competing interests MFM received funding on behalf of MedStar Health Research Institute during the study period from Eli Lilly for the REWIND Study, from the Patient-Centered Outcomes Research Institute (NCT-02093234), from the National Institutes of Health (NIH DK-109503) and from Mytonomy. She served as a speaker for the American Diabetes Association and for PRIMED. KMB has no interests to declare. SJF received funding on behalf of MedStar Health Research Institute during the study period from the National Institutes of Health. CMN received funding on behalf of MedStar Health Research Institute during the study period from Eli Lilly for the REWIND Study and from the Patient-Centered Outcomes Research Institute. KS received funding from the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1-TR001409, the Agency for Healthcare Research and Quality and the National Institutes of Health (NIH DK-109503). GAY was a speaker for the American Diabetes Association during the study period. No other potential conflicts of interest relevant to this article were reported. C-CH, MM, ARM, PAS and SRE have no interests to declare.

  • Patient consent for publication Not required.

  • Ethics approval The study was reviewed and approved by the MedStar Health Research Institute’s Institutional Review Board (IRB) and was conducted from November 2014 to February 2018.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request.