Virginia Mason’s registry helps better manage diabetes patients | Guest editorial

  • Thursday, December 21, 2017 11:21am
  • Opinion
Nicholas Moy. Courtesy of Virginia Mason

Nicholas Moy. Courtesy of Virginia Mason

By Nicholas Moy

Special to the Reporter

According to the largest ever study of diabetes levels across the world published in 2016 in The Lancet, 422 million adults worldwide have diabetes and the global cost of the autoimmune disease is now $825 billion per year.

In the United States alone, diabetes statistics are staggering. According to the Centers for Disease Control and Prevention, in 2015:

An estimated 30.3 million people of all ages — or 9.4 percent of the U.S. population — had diagnosed or undiagnosed diabetes.

This total included 30.2 million adults aged 18 years or older (12.2 percent of all U.S. adults), of which 7.2 million (23.8 percent) were not aware of or did not report having diabetes.

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 (6.7 per 1,000 people) were diagnosed among U.S. adults aged 18 years or older.

More than half of these new cases were among adults from 45-64 years old, and the numbers were about equal for men and women.

These figures emphasize the importance of awareness and prevention when it comes to this chronic — but often preventable and certainly manageable — disease.


In type 1 diabetes, the body does not produce insulin. The body breaks down sugars and starches into a simple sugar called glucose, which it uses for energy. Insulin is a hormone the body needs to get glucose from the bloodstream into cells. Type 1 is usually diagnosed in children and younger people. However, it can develop at any age. Only about five 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,” a 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.


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. Doctors sometimes refer to prediabetes as impaired glucose tolerance or impaired fasting glucose, depending on what test was used when it was detected. This condition puts you at a higher risk for developing type 2 diabetes and cardiovascular disease.

The hemoglobin A1c test measures average blood glucose for the past two to three months. The advantages of being diagnosed this way are that you don’t have to fast or drink anything.

Diabetes is diagnosed at a hemoglobin A1c of greater than or equal to 6.5 percent.


Normal: Less than 5.7 percent

Prediabetes: 5.7 percent to 6.4 percent

Diabetes: 6.5 percent or higher

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 5-7 percent in participants and can reduce the risk of type 2 diabetes by 58 percent in individuals at high risk.

Since it’s not uncommon for busy primary care physicians, such as myself, to have panels of 1,500 patients or more, I hope you can appreciate the importance of using a team approach and effective tools to assist clinicians with tracking and managing people who are at risk for — or already diagnosed with — diabetes so it can be prevented, when possible, and managed effectively as often as possible.


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 usually see a primary care, internal medicine or endocrinology provider every 3-6 months, depending on how well their diabetes is controlled, life circumstances don’t always allow for that to happen. This is why Virginia Mason’s proprietary registry software is so helpful. It uses algorithms to automatically and regularly analyze electronic medical records and alert care teams about who needs to be contacted or followed up with and whether they need to come in for an appointment or just to report on blood pressure, exercise, weight loss, etc.

Virginia Mason team members, including medical assistants and nurses, then know to call and or email these patients to make sure they are doing the right things. It helps match care services with how well — or not — someone with diabetes is doing.

“The diabetes registry has been helping us keep a close eye on patients at Virginia Mason Kirkland Medical Center with a hemoglobin A1c between eight and nine,” said certified medical assistant Courtney Yates. “Recently, I was able to get seven out of nine out-of-care patients in for an appointment and labs with one of our primary care providers and six out of eight patients in for an appointment and labs with one of our internists. Patients are responding well to the simple reminders we’re sending them, whether they are messages though the patient portal,, calls or mailed letters. In fact, we recently started to contact patients who are out of care for all our providers at Virginia Mason Kirkland. Our goal is to get 100 percent of our out-of-care patients back in care.”

Currently, primary care providers who practice at Virginia Mason Hospital and Seattle Medical Center and Virginia Mason Kirkland Medical Center are trialing and refining the diabetes registry. Once the tool is proven, it will be used at Virginia Mason’s other Puget Sound area medical centers starting sometime in 2018.

Nicholas Moy 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. Moy is a Bellevue resident.

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