Challenges and Opportunities for Value-Based Healthcare Delivery and Real-World Research in Diabetes During and Post-COVID-19

Blog Posts  |  18 November 2020  |  By John M. Farah, PhD

Healthcare expenditures in the US continue to trend upward, with total costs reaching a staggering $3.6 trillion—nearly 17% of GDP—in 2018.1 Accounting for a substantial proportion of this economic burden are chronic medical conditions that are principal causes of death and long-term disability.2

Preventing the onset, slowing the progression, and reducing the burden of chronic conditions are essential to managing costs and optimizing outcomes in the transition from fee for-service payment models to patient centric, value-based health care.

Diabetes Contributes Substantially to Healthcare Costs

In the US, diabetes mellitus is among seven chronic conditions identified as leading drivers of healthcare costs.2

  • An estimated one in seven healthcare dollars is spent on treating diabetes and its complications.3
  • Patients with diabetes have higher medical costs than individuals without diabetes, not only following but for many years prior to a diabetes diagnosis.4

Of the 34 million Americans living with diabetes,5 most (95%) have type 2 diabetes. Many of the additional 88 million adults who have prediabetes are unaware they have elevated risk for a diagnosis of type 2 diabetes.5

Cardiovascular Risk and Care Gaps in Diabetes

Diabetes care is often complicated by the presence of multiple chronic conditions. For individuals with type 2 diabetes, the combination of hypertension, hyperlipidemia, and obesity constitutes a major comorbidity cluster.6 Diabetes, specifically hyperglycemia, is a predisposing factor for cardiovascular disease and a predictor of all-cause and cardiovascular mortality.7,8

More patients are achieving their care plan goals owing to the availability of newer glucose-lowering drug classes that reduce cardiovascular risk and the implementation of quality-oriented chronic care delivery models that offer a coordinated, team-based approach that promotes adherence to standards of medical care and supports shared decision-making and patient self-management.9

Others, meanwhile, continue to struggle to meet glycemic and cardiovascular targets.

  • Real-world evidence (RWE) registry and survey studies have reported fewer than one-quarter of patients attained control over four major risk factors—blood glucose, blood pressure, LDL cholesterol, and smoking status—recommended for evaluation by the American Diabetes Association.10,11
  • In one study, being male or white or having middle or high income was associated with meeting all four targets.10 In the other study, gaps in diabetes care were associated with being younger, female, or non-white.11

The Intersection of Diabetes with COVID-19

Impact of COVID-19 on Hospitalizations and Mortality

While there does not appear to be increased risk of contracting COVID-19 for individuals with diabetes, there is greater likelihood for negative outcomes should they become ill from SARS-CoV-2.

  • Investigators reported significantly increased odds of in-hospital death for patients with diabetes.12 Having cardiovascular and cerebrovascular comorbidities further amplifies the risk of severe illness from COVID-19.13

From March through July 2020, US deaths increased 20% beyond what would be expected for a given place and time, with one-third of additional deaths attributed to causes other than COVID-19.14

  • Some of these deaths may have resulted from disruptions to usual healthcare delivery. Notably, a significant increase in the US mortality rate for heart disease, the most common cause of death for individuals with diabetes,15 was reported during the COVID-19 spring surge.14

Findings from a newly published Global Burden of Disease (GBD) study which identified diabetes as a top ten driver of years lost to ill health, disability, or early death illustrate how chronic disease and related risk factors coupled with public health shortcomings over decades have “created a perfect storm fueling COVID-19 deaths.”16,17

The editor-in-chief of the medical journal that published the GBD study characterized the current COVID-19 public health crisis not as a pandemic but as a syndemic and asserted “the harm caused by SARS-CoV-2 will demand far greater attention to [non-communicable diseases like hypertension, obesity, diabetes, cardiovascular and chronic respiratory diseases, and cancer] and socioeconomic inequality than has hitherto been admitted.”18

Impact of COVID-19 on Care Coordination and Continuity

The COVID-19 public health crisis has created care gaps by interrupting coordination and continuity of team-based care essential to ensuring a quality environment and positive treatment outcomes. To compensate for disruptions in care arising from COVID-19–related office closures and shelter-at-home recommendations, adoption of telehealth services and tools—among these, secure virtual visits between healthcare professionals and their patients, wearable devices and mobile apps for remote patient monitoring, and patient portals for purposes of engagement and education—has increased dramatically over pre-syndemic levels.19

  • Telehealth services and tools hold the potential not only to assist in care coordination and continuity but also to drive down healthcare delivery costs.20

That outcomes for individuals with diabetes may be suboptimal for months beyond the course of natural emergencies—particularly for individuals with socioeconomic risk and those who take insulin21—speaks to a pressing need to leverage health information and communications technology to establish and maintain equitable diabetes care across all groups, including vulnerable populations and underserved communities.22

The Centers for Medicare and Medicaid Services (CMS) has broadened access to telehealth services, many for the duration of the COVID-19 public health emergency.23,24 Likewise, a growing number of commercial payers are extending cost-share waivers for telehealth visits to reduce barriers to patient use during the syndemic.25 CMS is also providing expanded telehealth support to state agencies and the Children’s Health Insurance Program.24

Electronic Health Record-Enabled Quality Care

Veradigm®, an integrated data systems and analytics services company, is helping to establish and maintain continuity of care for patients with chronic diseases by enabling communication with their physicians via telemedicine tools built into its electronic health record (EHR) system, while patients remain securely at home.26

Veradigm is also supporting patient engagement and education through patient portals and personalized health records, supporting physicians in prescribing medications electronically, and enabling quality management, outcomes reporting, and infectious disease surveillance.26

During the COVID-19 syndemic, Veradigm continues to offer EHR services, without charge, to the local free clinics serving on the front line.26

Leveraging Real-World Data to Inform Innovation and Quality of Diabetes Care

Real-World Evidence Study

Using de-identified patient data from a nationwide EHR system (offered as part of its Health Insights database), Veradigm together with academic and pharmaceutical collaborators recently published an RWE study that demonstrated lowered glycated hemoglobin following initiation with a fixed-ratio combination of a long-acting human insulin analog and a glucagon-like peptide receptor agonist in patients with type 2 diabetes.27 Further, the combination offered a more efficient approach to therapy for patients on more than one daily injection of antidiabetic medications.

Registries and Electronic Health Records

As organized systems that use observational study methods, registries collect real-world data (RWD) from populations defined by a condition, disease, or exposure to evaluate specified outcomes. Registries can monitor the safety and effectiveness of a treatment, track care patterns, uncover disparities in care delivery, and inform quality improvement.28 As one of six core elements of chronic care delivery models, registries are endorsed by the American Diabetes Association as a means of providing population-based and patient-specific support to diabetes care teams.7,9

The American College of Cardiology (ACC) has partnered with the pharmaceutical company Novo Nordisk to launch Transforming Cardiovascular Risk in Diabetes (TRANSFORM CVRiD), a two-year, quality improvement initiative that aims to reduce cardiovascular risk for individuals living with type 2 diabetes.29 The study will use RWD from the ACC/Veradigm PINNACLE Registry® and Diabetes Collaborative Registry® (DCR) “to identify patterns that lead to optimal care and develop tools and education to support clinicians.” The initiative “will identify gaps in care, [and] spur quality improvement in treating vulnerable patients.”29

The ACC/Veradigm PINNACLE registry, the largest outpatient cardiovascular registry and the first to evaluate outcomes in patients with heart disease, provides insight into guidelines and medications, helping practices meet quality reporting requirements.30 As the first global, cross-specialty clinical registry established to document and improve quality and management of diabetes and metabolic disease across the continuum of care, the DCR facilitates coordinated care, prevention, and treatment of diabetes, providing benchmark reports and identifying opportunities for outcomes improvement.31,32

In its partnership with the ACC, Veradigm operates both the PINNACLE Registry and the DCR.33 The partnership is integrating Veradigm’s EHR datasets and analytic capabilities with the ACC registries and leveraging Veradigm’s network of primary care and specialist practitioners.34

With a focus on simplifying healthcare to help manage costs and patient outcomes, Veradigm is supporting life sciences stakeholders, health plans, health technology partners, healthcare practitioners, and their patients throughout and beyond the COVID-19 public health emergency.


  1. CDC. Health and economic costs of chronic diseases. Centers for Disease Control and Prevention 15 September 2020;

  2. CDC. Chronic diseases in America. Centers for Disease Control and Prevention 24 September 2020;

  3. ADA. The cost of diabetes. American Diabetes Association 24 March 2020;

  4. Shrestha SS, Zhang P, Hora IA, et al. Trajectory of excess medical expenditures 10 years before and after diabetes diagnosis among US adults aged 25-64 years, 2001-2013. Diabetes Care 2019;42(1):62-68.

  5. CDC. National diabetes statistics report, 2020. Centers for Disease Control and Prevention 28 August 2020;

  6. Lin P-J, Kent DM, Winn AN, et al. Multiple chronic conditions in type 2 diabetes mellitus: prevalence and consequences. Am J Manag Care 2015;21(1):e23-e34.

  7. Davies MJ, D’Alessio DA, Fradkin J, et al. Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia 2018;61(12):2461-2498.

  8. Raghaven S, Vassy JL, Ho Y-L, et al. Diabetes mellitus-related all-cause and cardiovascular mortality in a national cohort of adults. J Am Heart Assoc 2019;8(4):e011295.

  9. ADA. 1. Improving care and promoting health in populations: standards of medical care in diabetes. American Diabetes Association 2020;

  10. Fan W, Song Y, Inzucchi SE, et al. Composite cardiovascular risk factor target achievement and its predictors in US adults with diabetes: the Diabetes Collaborative Registry. Diabetes Obes Metab 2019;21(5):1121-1127.

  11. Kazemian P, Shebl F, McCann N, et al. Evaluation of the cascade of diabetes care in the United States, 2005-2016. JAMA Intern Med 2019;179(10):1376-1385.

  12. Barron E, Bakhai C, Kar P, et al. Associations of type 1 and type 2 diabetes with COVID-19-related mortality in England: a whole-population study. Lancet Diabetes Endocrinol 2020;8:813-822.

  13. CDC. People with certain medical conditions. Centers for Disease Control and Prevention 16 October 2020;

  14. Woolf SH, Chapman DA, Sabo RT, et al. Excess deaths from COVID-19 and other causes, March-July 2020. JAMA 2020;324(15):1562-1564.

  15. Johns Hopkins Medicine 2020. Diabetes and heart disease. Johns Hopkins University, Johns Hopkins Hospital, and Johns Hopkins Health System 2020;,death%20in%20people%20with%20diabetes

  16. University of Washington. Chronic disease, poor public response fuels COVID-19. 16 October 2020;

  17. Melillo G. Diabetes risk factors dominate top causes of global mortality, heighten COVID-19 risks. 15 October 2020;

  18. Horton R. Offline: COVID-19 is not a pandemic. Lancet 2020;396:871.

  19. Robinson J, Borgo L, Fennell K, et al. The Covid-19 pandemic accelerates the transition to virtual care. NEJM Catalyst 10 September 2020;

  20. AHA. Why telehealth is critical to healthcare transformation. American Hospital Association 26 February 2019;

  21. Hartman-Boyce, Morris E, Goyder C, et al. Diabetes and COVID-19: risks management, and learnings from other national disasters. Diabetes Care 2020.

  22. Cutter C, Berlin NL, Fendrick AM. Establishing a value-based ‘new normal’ for telehealth. Health Affairs 8 October 2020;

  23. CMS. Medicare telemedicine health care provider fact sheet. Centers for Medicare and Medicaid Services 17 March 2020;

  24. CMS. Trump administration drives telehealth services in Medicaid and Medicare. Centers for Medicare and Medicaid Services 14 October 2020;

  25. AHIP. Health insurance providers respond to coronavirus (COVID-19). America’s Health Insurance Plans 27 October 2020;

  26. Veradigm. Electronic health records doing their part in fighting coronavirus. 7 April 2020;

  27. Egede LE, Bogdanov A, Fischer L, et al. Glycemic control among patients newly prescribed IDegLira across prior therapy group in US real-world practice. Diabetes Ther 2020;11:1579-1589.

  28. Gliklich RE, Dreyer NA, Leavy MB, editors. Registries for Evaluating Patient Outcomes: A User’s Guide. Chapter 15. Interfacing Registries and Electronic Health Records. 3rd edition. Rockville (MD): Agency for Healthcare Research and Quality (US); 2014;

  29. PRNewswire. ACC, Novo Nordisk partner to improve cardiovascular disease management in patients with type 2 diabetes. 10 September 2020;

  30. ACC. PINNACLE Registry celebrates 10 years. American College of Cardiology 6 March 2018;

  31. Arnold SV, Goyal A, Inzucchi SE, et al. Quality of care of the initial patient cohort of the Diabetes Collaborative Registry. J Am Heart Assoc 2017;6:e005999.

  32. NCDR. The Diabetes Collaborative Registry: Transforming the future of diabetes care. American College of Cardiology National Cardiovascular Data Registry 2020;

  33. Allscripts. Veradigm® Partners with American College of Cardiology to develop next-generation research network: NCDR PINNACLE and Diabetes Collaborative Registries. 2 July 2019;

  34. Veradigm. American College of Cardiology, Veradigm partner to accelerate heart disease, diabetes treatment. 7 June 2019;

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