Performance Performance Improvement: Improvement: Continuing - - PowerPoint PPT Presentation

Performance Performance Improvement: Improvement: Continuing Continuing Medical Education Medical Education

Lara Zisblatt, MA Lara Zisblatt, MA Assistant Director Assistant Director Boston University Boston University School of Medicine School of Medicine Continuing Medical Education Continuing Medical Education

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MENTOR QI MENTOR QI™ ™ Diabetes Performance Diabetes Performance Improvement Initiative, Improvement Initiative, Getting Patients Getting Patients to Goal in to Goal in Glycemic Glycemic Control Control

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Type 2 Diabetes Performance Type 2 Diabetes Performance Improvement Program: Improvement Program: Clinical Overview Clinical Overview

Elliot Sternthal, MD, FACP Elliot Sternthal, MD, FACP Clinical Director of Clinical Director of Diabetes Services Diabetes Services Boston Medical Center Boston Medical Center Boston, MA Boston, MA

Overview of Diagnosed and Undiagnosed Overview of Diagnosed and Undiagnosed Diabetes in the United States Diabetes in the United States— —2008 2008

Adapted from American Diabetes Association. Available at: Adapted from American Diabetes Association. Available at: http:// http://www.diabetes.org www.diabetes.org. Accessed . Accessed June 25, June 25, 2008. 2008.

People Without People Without Diabetes Diabetes Diagnosed: Diagnosed: 18 million 18 million Undiagnosed: Undiagnosed: 6 million 6 million People With Diabetes: 24 million People With Diabetes: 24 million (8.0% of the population) (8.0% of the population)

• Incidence: 1.5 million new cases diagnosed yearly

Incidence: 1.5 million new cases diagnosed yearly

• Number of adult patients predicted to grow to ~22 million by 20

Number of adult patients predicted to grow to ~22 million by 2025 25

• Vast majority (>90%) of cases are type 2 diabetes

Vast majority (>90%) of cases are type 2 diabetes

The Dual Epidemic: The Dual Epidemic: Obesity and Diabetes Obesity and Diabetes

• 65% of US adults are overweight (BMI >25) and

65% of US adults are overweight (BMI >25) and 30% are obese (BMI >30) 30% are obese (BMI >30)

• 24% have the Metabolic Syndrome

24% have the Metabolic Syndrome

• There are now an estimated 24 million people

There are now an estimated 24 million people with diabetes mellitus (DM) in the US; 57 million with diabetes mellitus (DM) in the US; 57 million have pre have pre-

• diabetes

diabetes

• The lifetime risk of developing DM for people

The lifetime risk of developing DM for people born in 2000 is 33% for men and 39% for women born in 2000 is 33% for men and 39% for women

– – For Hispanic women, the lifetime risk is 50% For Hispanic women, the lifetime risk is 50%

• In this population, cardiovascular disease (CVD)

In this population, cardiovascular disease (CVD) is the major cause of mortality is the major cause of mortality

Obesity Trends* Among US Adults Obesity Trends* Among US Adults

*BMI *BMI ≥ ≥30. 30. Adapted from Centers for Disease Control and Prevention. Adapted from Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance Behavioral Risk Factor Surveillance System

• System. Available at: http://

. Available at: http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/index.htm www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/index.htm. . Accessed June 20, 2008. Accessed June 20, 2008.

Role of Obesity in Metabolic Role of Obesity in Metabolic Syndrome (MS) Syndrome (MS)

• NHANES III Population

NHANES III Population

– – Normal weight Normal weight – – 5% had MS 5% had MS – – Overweight Overweight – – 22% had MS 22% had MS – – Obese Obese – – 60% had MS 60% had MS

• Framingham Population

Framingham Population

– – Obese w/o MS Obese w/o MS – – no significant no significant risk of DM2 or risk of DM2 or CVD CVD – – Obese with MS Obese with MS – – 10 x 10 x risk DM2, 2 x risk DM2, 2 x risk CVD risk CVD – – Normal weight with MS Normal weight with MS – – 4 x 4 x risk DM2, 3 x risk DM2, 3 x

• risk CVD

risk CVD

Metabolic Syndrome and Metabolic Syndrome and Type 2 Diabetes Type 2 Diabetes

• Botnia

Botnia Study (large, high Study (large, high-

• risk family study in

risk family study in Finland & Sweden) Finland & Sweden)

– – 84% men & 78% women with DM2 had MS 84% men & 78% women with DM2 had MS – – 64% men & 42% women with pre 64% men & 42% women with pre-

• DM had MS

DM had MS – – 15% men & 10% women with normal glucose tolerance 15% men & 10% women with normal glucose tolerance had MS had MS

• Prospective Observational Studies

Prospective Observational Studies

– – Non Non-

• diabetic Pima Indians with MS: 2.1

diabetic Pima Indians with MS: 2.1-

• 3.6 x

3.6 x risk risk DM2 DM2 – – Caucasians with MS: 7 Caucasians with MS: 7-

• 34 x

34 x risk DM2 risk DM2

• MS components without impaired fasting

MS components without impaired fasting glucose still at glucose still at risk of DM2 risk of DM2

Isomaa Isomaa B, et al. B, et al. Diabetes Care Diabetes Care. 2001;24:683 . 2001;24:683-

• 689.

689.

Primary Care Providers Must Be Involved Primary Care Providers Must Be Involved in the Care of Patients With Diabetes in the Care of Patients With Diabetes

• Approximately 20% of primary

Approximately 20% of primary-

• care patients have

care patients have diabetes diabetes

• >90% of individuals with diabetes are managed by PCPs

>90% of individuals with diabetes are managed by PCPs

• PCPs refer <10% of patients with diabetes to

PCPs refer <10% of patients with diabetes to endocrinologists endocrinologists

• ~60% referrals for insulin

~60% referrals for insulin-

• replacement Rx

replacement Rx

• Majority of PCPs have <4 hr diabetes

Majority of PCPs have <4 hr diabetes-

• related education in

related education in medical school medical school

• Need for continuous supplementary education

Need for continuous supplementary education

• ~5000 endocrinologists in US, 66% office

~5000 endocrinologists in US, 66% office-

• based

based

• 12% fewer endocrinologists than needed; gap to worsen

12% fewer endocrinologists than needed; gap to worsen from 2010 onward from 2010 onward

Unger J. Primary Care Network, Unger J. Primary Care Network, Primary Issues Primary Issues. 2002;4:1 . 2002;4:1-

• 3.

3. Unger J. Unger J. Female Patient Female Patient. 2003;28:12 . 2003;28:12-

• 16.

16.

Costs Associated With Diabetes Costs Associated With Diabetes

• DM + CAD + HTN (x 3 yr) is 300% > DM

DM + CAD + HTN (x 3 yr) is 300% > DM alone ($46,000 alone ($46,000 vs vs $14,000) $14,000)

• A1C from 6%

A1C from 6%→ →10%: 10%: 11% in 11% in

• verall costs per patient
• verall costs per patient
• If each PCP

If each PCP A1C by 2% in 100 pts = A1C by 2% in 100 pts = savings of $150,000 per provider x 3 yr savings of $150,000 per provider x 3 yr

DM, diabetes mellitus; CAD, coronary artery disease, HTN, hypert DM, diabetes mellitus; CAD, coronary artery disease, HTN, hypertension. ension. Gilmer TP, et al. Gilmer TP, et al. Diabetes Care Diabetes Care. 2005;28:59 . 2005;28:59-

• 64.

64.

Level of Glycemic Control in Level of Glycemic Control in Type 2 DM Patients: NHANES Database Type 2 DM Patients: NHANES Database

• 12.4% have A1C >10%

12.4% have A1C >10%

• 20.2% have A1C >9%

20.2% have A1C >9%

• 37.2% have A1C >8%

37.2% have A1C >8%

• 64.2% have A1C >7%

64.2% have A1C >7%

• Treated to <7% (NHANES 1988

Treated to <7% (NHANES 1988-

• 1994

1994 vs vs 1999 1999-

• 2000)

2000)

– – 1994 1994 – – 44.5% 44.5% – – 2000 2000 – – 35.8% (improved in 2002) 35.8% (improved in 2002)

Koro Koro CE, et al. CE, et al. Diabetes Care Diabetes Care. 2004;27:17 . 2004;27:17-

• 20.

20.

Prevalence of Retinopathy vs Prevalence of Retinopathy vs Duration of Type 2 Diabetes Duration of Type 2 Diabetes

Patients with retinopathy (%) Patients with retinopathy (%)

Harris MI, et al. Harris MI, et al. Diabetes Care Diabetes Care. 1992;15:815 . 1992;15:815-

• 819.

819.

Years Years

20 20 40 40 60 60 80 80

• 10

10

• 6.5

6.5

• 4.2

4.2 5 5 10 10 15 15 20 20

Wisconsin population Wisconsin population Australian population Australian population Apparent onset Apparent onset prior to prior to diagnosis diagnosis Time of diagnosis Time of diagnosis

Adapted from Ramlo Adapted from Ramlo-

• Halsted BA, Edelman SV.

Halsted BA, Edelman SV. Prim Care. Prim Care. 1999;26:771 1999;26:771-

• 789.

789.

Natural History of Type 2 Diabetes Natural History of Type 2 Diabetes– – Implications of Delayed Diagnosis Implications of Delayed Diagnosis

Macrovascular complications Microvascular complications

Insulin resistance Insulin resistance

Impaired Impaired glucose tolerance glucose tolerance Undiagnosed Undiagnosed diabetes diabetes Known diabetes Known diabetes

Insulin secretion Insulin secretion Postprandial glucose Fasting glucose Fasting glucose

Microvascular Microvascular Complications Occur With Complications Occur With Glycemia Below Pre Glycemia Below Pre-

• diabetic Range

diabetic Range

• Meta

Meta-

• analysis of Blue Mountains Eye Study (n=3162),

analysis of Blue Mountains Eye Study (n=3162), Australian Diabetes, Obesity, and Lifestyle Study (n=2182) Australian Diabetes, Obesity, and Lifestyle Study (n=2182) & Multi & Multi-

• Ethnic Study of Atherosclerosis (n=6079)

Ethnic Study of Atherosclerosis (n=6079)

• Retinopathy now more accurately diagnosed with multiple

Retinopathy now more accurately diagnosed with multiple-

• field retinal photographs

field retinal photographs

• >60% retinopathy cases found among patients with fasting

>60% retinopathy cases found among patients with fasting plasma glucose (FPG) <126 mg/ plasma glucose (FPG) <126 mg/dL dL

• 7.4% to 13.4% had retinopathy at glucose level <100 mg/

7.4% to 13.4% had retinopathy at glucose level <100 mg/dL dL (previous studies: 2% (previous studies: 2%-

• 4% prevalence)

4% prevalence)

• 17.8% to 34.7% had retinopathy at glucose level >126 mg/

17.8% to 34.7% had retinopathy at glucose level >126 mg/dL dL

• Results

Results c/w c/w gradual gradual in retinopathy prevalence with in retinopathy prevalence with FPG FPG

Wong TY, et al. Wong TY, et al. Lancet

• Lancet. 2008;371:736

. 2008;371:736-

• 743.

743.

DCCT Research Group. DCCT Research Group. N Engl J Med N Engl J Med. 1993;329:977 . 1993;329:977-

• 986.

986. Ohkubo Y, et al. Ohkubo Y, et al. Diabetes Res Clin Diabetes Res Clin Pract Pract. . 1995;28:103 1995;28:103-

• 117.

117.

Intensive Insulin Therapy: Intensive Insulin Therapy: Microvascular Risk Reduction in Two Trials Microvascular Risk Reduction in Two Trials

* * Albuminuria Albuminuria >300 mg/24 hr. >300 mg/24 hr.

† † Worsening of

Worsening of albuminuria albuminuria >300 mg/24 hr. >300 mg/24 hr.

Significantly improved Significantly improved 60% 60% Neuropathy Neuropathy 70% 70%†

†

54%* 54%* Nephropathy Nephropathy 69% 69% 63% 63% Retinopathy Retinopathy

Kumamoto Kumamoto DCCT DCCT Study Study Reduction in Risk with 2% Reduction in Risk with 2% Reduction of A1C Reduction of A1C Complication Complication

United Kingdom Prospective Diabetes Study (UKPDS) United Kingdom Prospective Diabetes Study (UKPDS) Group.

• Group. Lancet.
• Lancet. 1998;352:837

1998;352:837-

• 853

853.

9 8 7 6 3 6 9

Years

Median A1C (%)

Glycemic Responses in the UKPDS Glycemic Responses in the UKPDS

12 Conventional therapy Intensive therapy

10 10-

• Year Cohort

Year Cohort

10-year median 7.9% 10-year median 7.0%

United Kingdom Prospective Diabetes Study (UKPDS) Group. United Kingdom Prospective Diabetes Study (UKPDS) Group. Lancet

• Lancet. 1998;352:837

. 1998;352:837-

• 853.

853.

Intensive Therapy Policy Intensive Therapy Policy Various Endpoints in the UKPDS Various Endpoints in the UKPDS

P P<.03 <.03 12% 12% All diabetes All diabetes-

• related

related endpoints studied endpoints studied P P=.052 =.052 16% 16% Myocardial infarction Myocardial infarction P P<.01 <.01 P P<.02 <.02 P P<.0001 <.0001 25% 25% 21% 21% 33% 33% All All microvascular microvascular

• Retinopathy progression

Retinopathy progression

• Microalbuminuria

Microalbuminuria

Reduction in Risk With Reduction in Risk With 0.9% Reduction of A1C 0.9% Reduction of A1C Complication Complication

Does Normalizing Glycemia Does Normalizing Glycemia Reduce CV Risk? Reduce CV Risk?

• ADVANCE

ADVANCE (n=11,140); 5 yr; baseline A1C 7.2%; A1C 6.5 (n=11,140); 5 yr; baseline A1C 7.2%; A1C 6.5 vs vs 7.3% 7.3%

– – No significant reduction in CV endpoints or all No significant reduction in CV endpoints or all-

• cause mortality;

cause mortality; 21% 21% new/worsening nephropathy (48% on new/worsening nephropathy (48% on statin statin, 57% on aspirin) , 57% on aspirin)

• ACCORD

ACCORD (n=10,251); 3.5 yr (terminated early); baseline A1 (n=10,251); 3.5 yr (terminated early); baseline A1C C 8.1%; 8.1%; A1 A1C C 6.4% 6.4% vs vs 7.5% 7.5%

– – No significant reduction in composite CV endpoint; lower signifi No significant reduction in composite CV endpoint; lower significant cant nonfatal MI rate; significantly higher rate of death from CV cau nonfatal MI rate; significantly higher rate of death from CV causes; ses; significant increase in all significant increase in all-

• cause mortality (54 extra deaths)

cause mortality (54 extra deaths)

• Critique

Critique: trials too short; late intervention in atherosclerotic process : trials too short; late intervention in atherosclerotic process; ; those with shorter duration of diabetes did better with intensiv those with shorter duration of diabetes did better with intensive e glucose therapy; rapid rate of A1C reduction in ACCORD (1.4% wit glucose therapy; rapid rate of A1C reduction in ACCORD (1.4% within 4 hin 4 months); difference in weight gain: 3.5 kg in ACCORD months); difference in weight gain: 3.5 kg in ACCORD vs vs 0.7 kg in 0.7 kg in ADVANCE; difficulty in showing additional improvement in CV outc ADVANCE; difficulty in showing additional improvement in CV outcome

• me

when overall cardiac care is optimized when overall cardiac care is optimized

ADVANCE Collaborative Group. ADVANCE Collaborative Group. N N Engl Engl J Med J Med. 2008;358:2560 . 2008;358:2560-

• 2572.

2572. ACCORD Study Group. ACCORD Study Group. N N Engl Engl J Med J Med. 2008;358:2545 . 2008;358:2545-

• 2559.

2559.

Type 2 DM and CV Disease Risk Reduction: Type 2 DM and CV Disease Risk Reduction: Lessons From ADVANCE & ACCORD Lessons From ADVANCE & ACCORD

• Lowering blood glucose primarily prevents

Lowering blood glucose primarily prevents microvascular microvascular complications complications

• Individualize glucose goals for patients with advanced

Individualize glucose goals for patients with advanced CV disease CV disease

• In older, high

In older, high-

• risk patients, maintain A1C close to 7%,

risk patients, maintain A1C close to 7%, not necessarily <7% not necessarily <7%

• More intense blood glucose control may modestly

More intense blood glucose control may modestly reduce CVD risk in those with early DM w/o advanced reduce CVD risk in those with early DM w/o advanced atherosclerotic disease: may be appropriate to reduce atherosclerotic disease: may be appropriate to reduce A1C <7% A1C <7%

• Avoid hypoglycemia

Avoid hypoglycemia

• Focus on proven therapies: lipid

Focus on proven therapies: lipid-

• lowering, BP

lowering, BP reduction, anti reduction, anti-

• platelet therapy, & smoking cessation

platelet therapy, & smoking cessation

Clinical Inertia: Why Is There Confusion Clinical Inertia: Why Is There Confusion in Treating Type 2 Diabetes? in Treating Type 2 Diabetes?

• Until 1995, only sulfonylureas and

Until 1995, only sulfonylureas and insulin were available insulin were available

• Now

Now – – many new agents many new agents

• Lack of

Lack of “ “big picture big picture” ” context of context of treatment treatment

• “

“Niche Niche” ” agents agents

• Failure to understand metabolic

Failure to understand metabolic staging of decompensation of staging of decompensation of type 2 DM type 2 DM

Clinical Inertia: Why Is There Confusion Clinical Inertia: Why Is There Confusion in Treating Type 2 Diabetes? in Treating Type 2 Diabetes? (cont

(cont’ ’d) d)

• Lack of prospective

Lack of prospective RCTs RCTs – –“ “seat of the seat of the pants pants” ” advice advice

• What agent to start? How to combine? When

What agent to start? How to combine? When to use insulin as add to use insulin as add-

• on/replacement?
• n/replacement?
• DAWN study: 50%

DAWN study: 50%-

• 55% of PCPs delayed

55% of PCPs delayed insulin therapy in type 2 diabetes until insulin therapy in type 2 diabetes until absolutely necessary absolutely necessary

• Effect beyond glycemic control,

Effect beyond glycemic control, ie ie, TZDs, , TZDs, incretin incretin mimetics mimetics

DAWN, Diabetes Attitudes, Wishes, and Needs; RCT, randomized con DAWN, Diabetes Attitudes, Wishes, and Needs; RCT, randomized controlled trial; trolled trial; TZD, TZD, thiazolidinedione thiazolidinedione. .

Clinical Inertia: Clinical Inertia: Contributing Factors Contributing Factors

• Delayed diagnosis

Delayed diagnosis

• Inadequate attention to & control of postprandial

Inadequate attention to & control of postprandial hyperglycemia hyperglycemia

• Underestimate seriousness of type 2 DM

Underestimate seriousness of type 2 DM

• Acceptance of fair

Acceptance of fair-

• poor A1C levels

poor A1C levels

• Fear of hypoglycemia

Fear of hypoglycemia

• Inability to perform self

Inability to perform self-

• care

care

• Formulary restrictions

Formulary restrictions

• Ambiguous and

Ambiguous and “ “failure failure-

• driven

driven” ” treatment protocols treatment protocols

• Lack of familiarity with new oral agents and insulin

Lack of familiarity with new oral agents and insulin

Clinical Inertia: Clinical Inertia: Resulting Practice Pitfalls Resulting Practice Pitfalls

• Oral agents being used interchangeably

Oral agents being used interchangeably

• Inappropriate choice of initial agent

Inappropriate choice of initial agent

– – SU for IR SU for IR excessive hypoglycemia excessive hypoglycemia – – Metformin for insulin deficiency Metformin for insulin deficiency

• sustained hyperglycemia

sustained hyperglycemia

SU, sulfonylurea; IR, insulin resistance. SU, sulfonylurea; IR, insulin resistance.

Clinical Inertia: Clinical Inertia: Resulting Practice Pitfalls Resulting Practice Pitfalls (cont (cont’ ’d) d)

• Monotherapy

Monotherapy for too long for too long – –

– – Type 2 DM is progressive Type 2 DM is progressive

• Trying to

Trying to “ “squeeze squeeze” ” too much out of SU too much out of SU

– – 70% 70%-

• 80% effect seen at 10

80% effect seen at 10-

• mg dose

mg dose glyburide glyburide

• Switching rather than combining

Switching rather than combining

– – SU SU↔ ↔metformin metformin – – SU SU→ →meglitinide meglitinide – – Metformin Metformin↔ ↔TZD TZD

SU, sulfonylurea, TZD, SU, sulfonylurea, TZD, thiazolidinedione thiazolidinedione. .

Clinical Inertia: Clinical Inertia: Resulting Practice Pitfalls Resulting Practice Pitfalls (cont (cont’ ’d) d)

• Non

Non-

• recognition of subtle hypoglycemia

recognition of subtle hypoglycemia after after ∆ ∆ therapy, therapy, glucotoxicity glucotoxicity

– – Hunger, snacking, weight gain Hunger, snacking, weight gain

• Failure to

Failure to SU or insulin SU or insulin

• Insulin

Insulin

– – Too much, too infrequent, inadequate Too much, too infrequent, inadequate prandial coverage prandial coverage

SU, sulfonylurea. SU, sulfonylurea.

Diabetes Scorecard Diabetes Scorecard

Achieving ADA Recommendations Achieving ADA Recommendations

NHANES 1999 NHANES 1999-

• 2002: 998 adults

2002: 998 adults ≥ ≥ 18 yr old 18 yr old

% % Characteristic Characteristic

39.6 39.6

Blood Pressure Blood Pressure

< 130/80 mm Hg < 130/80 mm Hg 65.8 65.8 24.0 24.0 10.1 10.1

Urine Urine Microalbumin/creatinine Microalbumin/creatinine (mg/g) (mg/g)

Normal <30 Normal <30 Microalbuminuria 30 Microalbuminuria 30-

• 299

299 Macroalbuminuria Macroalbuminuria ≥ ≥300 300 49.8 49.8 20.5 20.5 29.7 29.7

A1C: A1C:

<7% <7% 7% 7%-

• <8%

<8% ≥ ≥8% 8%

Diabetes Scorecard Diabetes Scorecard (cont

(cont’ ’d) d)

Achieving ADA Recommendations Achieving ADA Recommendations

NHANES 1999 NHANES 1999-

• 2002: 998 adults

2002: 998 adults ≥ ≥ 18 yrs old 18 yrs old

65.0 65.0 28.8 28.8 6.3 6.3 <200 <200 200 200-

• 399

399 ≥ ≥130 130 TG TG (mg/ (mg/dL dL) ) Low risk Low risk Borderline risk Borderline risk High risk High risk 36 36 30.8 30.8 33.3 33.3 <100 <100 100 100-

• 130

130 ≥ ≥130 130 LDL LDL (mg/ (mg/dL dL) ) Low risk Low risk Borderline risk Borderline risk High risk High risk 27.4 27.4 35.3 35.3 37.3 37.3 W W >55 >55 45 45-

• 55

55 <45 <45 M M >45 >45 35 35-

• 45

45 <35 <35 HDL HDL (mg/ (mg/dL dL) ) Low risk Low risk Borderline risk Borderline risk High risk High risk

% % Characteristic Characteristic

Diabetes Scorecard Diabetes Scorecard (cont (cont’ ’d) d)

Achieving ADA Recommendations Achieving ADA Recommendations

NHANES 1999 NHANES 1999-

• 2002: 998 adults

2002: 998 adults ≥ ≥ 18 yr old 18 yr old

% % Characteristic Characteristic

28.2 28.2

Recommended physical activity Recommended physical activity

≥ ≥5 moderate 5 moderate– –vigorous activities x 30 min/wk vigorous activities x 30 min/wk ≥ ≥3 vigorous activities x 30 min/wk 3 vigorous activities x 30 min/wk 81.2 81.2

Nonsmoker Nonsmoker

18.3 18.3

Daily fiber intake Daily fiber intake 20 g

20 g-

• 35 g

35 g 64.0 64.0 48.3 48.3 28.3 28.3

Daily Caloric Intake Daily Caloric Intake

Protein 10% Protein 10%-

• 20%

20% Saturated fat <10% Saturated fat <10% Unsaturated fat <10% Unsaturated fat <10%

Resnick Resnick HE, et al. HE, et al. Diabetes Care Diabetes Care. 2006;29:531 . 2006;29:531-

• 537.

537.

Systems and Processes: Systems and Processes: Remedy for Clinical Inertia Remedy for Clinical Inertia

• Step

Step-

• wise interventions

wise interventions

• Incremental changes in patient behavior

Incremental changes in patient behavior

• Customized therapy

Customized therapy

• Treatment guided by metabolic stage

Treatment guided by metabolic stage

• Better control of postprandial hyperglycemia

Better control of postprandial hyperglycemia

• Less hypoglycemia in early type 2 DM

Less hypoglycemia in early type 2 DM

• CV risk reduction

CV risk reduction

• Good for the beta cell?

Good for the beta cell?

• Better A1C ?

Better A1C ?

How to Initiate and How to Initiate and Advance Changes Advance Changes in Your Practice in Your Practice

Elaine Fleck, MD Elaine Fleck, MD

Columbia University Columbia University Director, Internal Medicine Director, Internal Medicine Ambulatory Care Practice Ambulatory Care Practice New York New York-

• Presbyterian Hospital

Presbyterian Hospital

Improving Care Improving Care

• Recognize that there is a gap between

Recognize that there is a gap between type 2 diabetes care as it is and care as type 2 diabetes care as it is and care as it could and should be for patients it could and should be for patients

• Identify an action plan that you/your

Identify an action plan that you/your practice would like to accomplish to practice would like to accomplish to improve this care improve this care

• Understand and implement an

Understand and implement an intervention that can change the nature intervention that can change the nature

• f care delivery in your practice
• f care delivery in your practice

Tips for Success I Tips for Success I

• Improvement occurs in small steps

Improvement occurs in small steps

• Repeated attempts needed to

Repeated attempts needed to implement new ideas implement new ideas

• Failed attempt = Learning opportunity!

Failed attempt = Learning opportunity!

• Assess regularly to improve plan

Assess regularly to improve plan

Tips for Success II Tips for Success II

• Communicate: Involve your medical

Communicate: Involve your medical team team

• Collect data before and after making

Collect data before and after making changes changes SHARE AND BORROW IDEAS SHARE AND BORROW IDEAS

Tour of Suggested Interventions Tour of Suggested Interventions

• Go to:

Go to: http:// http://www.mentorqi.com www.mentorqi.com/ / Apps/System/ Apps/System/Logon.aspx Logon.aspx

• User name: diabetes

User name: diabetes Password: diabetes Password: diabetes

• Six selected interventions for Action Plan

Six selected interventions for Action Plan

– – A1C Testing A1C Testing – – Exercise Exercise – – Glucose Self Glucose Self-

• Monitoring

Monitoring – – Goal Setting Goal Setting – – Nutrition Nutrition – – Proper Therapy Proper Therapy

Example Intervention Example Intervention

• Provider Reminder Systems

Provider Reminder Systems to Increase A1C Testing to Increase A1C Testing “ “There is excellent evidence There is excellent evidence that tracking/reminder systems that tracking/reminder systems can improve quality of care. can improve quality of care.” ”

– – Flow sheets added to charts of patients Flow sheets added to charts of patients with diabetes with diabetes – – Paper/prompt for every chart of patients Paper/prompt for every chart of patients with diabetes with diabetes

Closing the Quality Gap: Agency for Healthcare Research and Qual Closing the Quality Gap: Agency for Healthcare Research and Quality. Available at:

• ity. Available at:

http:// http://www.ahrq.gov/clinic/epc/qgapfact.htm www.ahrq.gov/clinic/epc/qgapfact.htm. .

Example of Example of A1C Prompt A1C Prompt on Chart

• n Chart
• Use bright yellow sheet

Use bright yellow sheet

• Make very simple reminder

Make very simple reminder

– – ID # ID # – – Date of most recent A1C Date of most recent A1C – – Most recent A1C level Most recent A1C level

• Meet with everyone remotely involved

Meet with everyone remotely involved

– – Suggest lunch with a pizza Suggest lunch with a pizza – – Explain this is a Explain this is a “ “pilot pilot” ” – – Identify another team member to assist Identify another team member to assist

• Try it for one provider for one day/one week

Try it for one provider for one day/one week

• Re

Re-

• evaluate and learn from the process

evaluate and learn from the process

Promoting Promoting Diabetes Self Diabetes Self-

• Care:

Care: Asking the Right Asking the Right Questions Questions

Jane Jeffrie Seley Jane Jeffrie Seley MPH, MSN, GNP, CDE MPH, MSN, GNP, CDE Diabetes Nurse Practitioner Diabetes Nurse Practitioner

Diabetes Is a Self Diabetes Is a Self-

• Care Disease

Care Disease

• Requires multiple daily self

Requires multiple daily self-

• care

care activities activities that change over time that change over time… …

• Decisions need to be made on an

Decisions need to be made on an

• ngoing basis regarding meals,
• ngoing basis regarding meals,

physical activity, and medications physical activity, and medications

• This requires education, motivation,

This requires education, motivation, and support and support

Funnell Funnell MM, Anderson RM. MM, Anderson RM. Clin Clin Diabetes

• Diabetes. 2004;22:123

. 2004;22:123-

• 127.

127.

Building relationships with patients with Building relationships with patients with diabetes promotes self diabetes promotes self-

• care

care

Diabetes Self Diabetes Self-

• Care Survival Skills

Care Survival Skills

Diabetes Self Diabetes Self-

• Care Assessment

Care Assessment

Meal Planning: Meal Planning:

• Is patient spacing meals and

Is patient spacing meals and snacks throughout the day? snacks throughout the day?

• Does patient measure

Does patient measure portion sizes? portion sizes?

• Does patient know how to

Does patient know how to identify/count carbohydrates? identify/count carbohydrates?

• Does patient know how to read a Nutrition Facts label?

Does patient know how to read a Nutrition Facts label?

• Have you discussed specific weight

Have you discussed specific weight-

• loss strategies?

loss strategies?

• Has the patient ever received individualized meal

Has the patient ever received individualized meal planning education? planning education?

Diabetes Self Diabetes Self-

• Care

Care Assessment Assessment (cont

(cont’ ’d) d) Physical Activity: Physical Activity:

• Does patient have physical

Does patient have physical activity plan? activity plan?

• Which activities? Aerobic

Which activities? Aerobic vs vs anaerobic? anaerobic?

• How often and for how long?

How often and for how long?

• Time of day?

Time of day?

• Need to adjust meals/meds?

Need to adjust meals/meds?

• Where do they exercise? Do they need an alternative

Where do they exercise? Do they need an alternative plan for bad weather? plan for bad weather?

• Any hypoglycemia?

Any hypoglycemia?

• Does patient carry medical ID, hypo

Does patient carry medical ID, hypo tx tx? ?

Diabetes Self Diabetes Self-

• Care

Care Assessment Assessment (cont

(cont’ ’d) d) Medication: Medication:

• When does patient take each

When does patient take each diabetes medication in relation diabetes medication in relation to food? to food?

• Does patient know mechanism of action of each

Does patient know mechanism of action of each medication? medication?

• Have you observed technique for injections?

Have you observed technique for injections?

• Does patient know how to store medications?

Does patient know how to store medications?

• Does patient know open expiration dates?

Does patient know open expiration dates?

• Does patient know what to do with syringes, pen

Does patient know what to do with syringes, pen needles once used? needles once used?

Diabetes Self Diabetes Self-

• Care

Care Assessment Assessment (cont

(cont’ ’d) d) Blood Glucose Monitoring: Blood Glucose Monitoring:

• Do patients have working meter?

Do patients have working meter?

• Have you observed their technique?

Have you observed their technique?

• When are they checking BG?

When are they checking BG?

• Do they know their targets? What do they do when

Do they know their targets? What do they do when they are too high or low? they are too high or low?

• Do they log results?

Do they log results?

• Have you reviewed their results and made

Have you reviewed their results and made treatment changes based upon them? treatment changes based upon them?

3 Ways to Be Sure Patient 3 Ways to Be Sure Patient Understands Understands… …

Reassure Reassure

• “

“I want to be sure that I explained I want to be sure that I explained this clearly to you, so . . . this clearly to you, so . . .” ”

Teach Back Teach Back

• “

“In your own words, In your own words, can you tell me . . .? can you tell me . . .?” ”

Show Me Show Me

• Survival skills require demonstration and practice

Survival skills require demonstration and practice

http://www.npsf.org/askme3/PCHC/. http://www.npsf.org/askme3/PCHC/.

CME Credit Information CME Credit Information

To receive 1 To receive 1 AMA PRA Category 1 AMA PRA Category 1 Credit Credit™ ™ for this teleconference, go to: for this teleconference, go to: http://www.bu.edu/cme/seminars/DIAB http://www.bu.edu/cme/seminars/DIAB HAY08/teleconferences.html HAY08/teleconferences.html