NYC Health + Hospitals on Nov 30, 2022, announced its highest-ever rate of A1C control among the nearly 64,000 primary care patients with diabetes. More than two-thirds (68.0%) of patients with diabetes have an A1C level, or blood sugar level, below 8%, meaning their diabetes is at or near goal, and only 16.5% of patients have significantly uncontrolled diabetes with an A1C level over 9%, the system’s lowest ever rate. In addition, the system increased teleretinal screenings by 20% from 10,000 per year in 2021 to 12,000 in 2022. Annual teleretinal screenings are a critical tool in catching diabetic retinopathy, the leading cause of blindness in U.S. adults aged 20-74, before symptoms develop. Patients with diabetes also have the highest ever rate of blood pressure control at 80.5%, in part due to the distribution of home blood pressure monitors and measuring and documenting home blood pressure. Most diabetes-related deaths are due to cardiovascular disease, and diabetes doubles the risk of heart attack or strokes. High blood pressure is an independent risk factor for these outcomes. Since it is common for patients with diabetes to have high blood pressure, it is even more critical to control blood pressure in patients with diabetes.
These results follow the health system’s expansion of diabetes services in 2021, which included 36 additional pharmacists to help patients manage their medications, additional teleretinal machines, and peer mentoring for patients with diabetes. In addition, NYC Health + Hospitals nurses and outreach staff contact over 1,000 patients each month with high blood pressure or diabetes to keep them engaged in primary care, with a focus on patients who are uncontrolled and do not have an upcoming visit scheduled.
“A diabetes diagnosis can be frightening, but NYC Health + Hospitals is here to help you every step of the way,” said NYC Health + Hospitals Vice President and Chief Population Health Officer Nichola Davis, MD. “We’ve made it easy to get tested for diabetes during a primary care appointment, and if you have diabetes, you’ll have a team of people on your side, from your provider and nurse, to patient support groups and a peer mentor who’s been there.”
“The Primary Care Diabetes Program supports patients who have fallen out of care,” said Yesehac Araya, Diabetes Program Coordinator, Bellevue Primary Care Diabetes Program. “This involves monthly outreach to patients overdue for A1C testing. Once contact is established the diabetes team assists patients along the path of care coordination, bringing them in for a focused diabetes recall visit, with the ultimate goal of re-establishing connections to their primary care doctors.”