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Managing Type 2 Diabetes

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Managing Diabetes Type 2 by Meneghini

Managing Diabetes Type 2 by Meneghini

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    • 1. Interventions to Improve Quality of Care Luigi Meneghini, MD, MBA Diabetes Research Institute (DRI) University of Miami School of Medicine II PAHO-DOTA Workshop on Quality of Diabetes Care DRI, 14–16 May 2003
    • 2. Outline
      • Introduction.
      • Diabetes prevalence & burden.
      • Metabolic goals to reduce illness.
      • Benchmarks and recognition programs.
      • Economic impact of improving diabetes control.
      • Model for promoting intensive insulin therapy at the primary-care level.
        • Basal/bolus insulin therapy & patient education.
    • 3. Purpose of Optimizing Care
      • Reduce burden of illness.
        • Microvascular and macrovascular complications.
        • Acute complications (hypoglycemia, hyperglycemia, DKA).
      • Enhance quality of life.
      • Reduce fiscal burden.
    • 4. Macro & Micro-Vascular Endpoints Source: Stratton IM et al. for the UK Prospective Diabetes Study Group. UKPDS 35. BMJ 2000; 321: 405–412.
      • Adjusted for age, sex, and ethnic group.
      • White men ages 50–54 years at diagnosis; mean duration of diagnosis of 10 years.
      Updated mean hemoglobin A 1c concentration (%) 80 60 40 20 0 5 6 7 8 9 10 11 Adjusted* incidence per 1000 person-years (%) Myocardial infarction Microvascular end points
    • 5. Mastering Your Diabetes Metabolic & Psychosocial Outcomes Diabetes Empowerment Scale (DES) The DES is a valid and reliable survey of patient empowerment which yields an overall empowerment score based on all 28 items and three subscale scores (range for all scales: 1.0-5.0). Improvement was evident on all DES scales for participants in the MYD pilot study, despite high baseline values. Diabetes Empowerment Scale Pretest Posttest 3mF/U Overall empowerment 4.1 4.2 4.3* Managing psychosocial aspects 3.9 4.2 4.2 Dissatisfaction/readiness to change 4.3 4.5 4.6* Setting/ achieving diabetes goals 4.0 4.0 4.1 (*P<0.05 v. baseline) Quality of Life & Self-Efficacy Measures of both Quality of Life (QOL) and Self-Efficacy showed statistically significant improvement following the intervention. At the three month follow-up the most significant improvement in QOL sub-scales was for Satisfaction (p=0.0113). 8.84 8.01 7.65 8.10 7.50 6.80 7.00 7.20 7.40 7.60 7.80 8.00 8.20 8.40 8.60 8.80 Mean HbA1c % Mo 1-3 Pre-MYD * p<0.05 v. pre-MYD Mo 4-6 Mo 7-9 Mo 10-12 * * *
    • 6. Healthcare Costs Increase With Worsening Glycemic Control *In patients with Type 2 diabetes alone (no cardiovascular complications). Increase in medical costs associated with rising HbA 1c levels compared to costs for patients with HbA 1c of 6%* 3-Year Medical Costs, 1993–1995 ($) 12,000 10,000 9,000 8,000 6 7 8 9 10 Baseline HbA 1c (%), 1992 5% 11% 21% 36% 11,000 Source: Gilmer TP et al. Diabetes Care 1997; 20: 1847-1853.
    • 7. Increase of Diabetes & Gestational Diabetes in the USA
    • 8. Global Projections of Diabetes (in millions, 1995-2010) 13.0 17.5 35% 12.4 22.5 81% 22.0 32.9 50% 0.9 1.3 44% 7.3 14.1 93% World 1995 = 118 million 2010 = 221 million Increase of 87% 62.8 132.3 111%
    • 9. Diabetes Mellitus in the USA: Health Impact of the Disease Diabetes Blindness* Kidney failure* Amputation* Life expectancy reduced by 5–10 years Heart disease ­ 2X to 4X *Diabetes is the #1 cause of renal failure, new cases of blindness, and non-traumatic amputations. Nerve damage in 60% to 70% of patients 6th leading cause of death Sources: Diabetes Statistics . October 1995 (updated 1997). NIDDK publication NIH 96-3926. Harris, MI. In: Diabetes in America ( 2nd ed.) 1995: 1-13.
    • 10. The Cost of Diabetes Diabetes costs the United States ~$132 billion annually! Total = $91.8 Billion Total = $39.8 Billion Source: American Diabetes Association. Diabetes Care 2003; 26: 917-932. $44.1 $23.2 $24.6 Direct Medical Expenses General Medical Conditions Diabetes & Acute Metabolic Complications Chronic Diabetes Complications Indirect Medical Expenses $21.6 $7.5 $10.8 Mortality Lost work days Restricted activity Permanent disability
    • 11. Projected Costs of Diabetes (USA, in billions) $200 $100 $0 1997 2002 2010 2020 $98 $192 $156 $132
    • 12.
      • Complication Prevalence (%)*
      • Any complication 50
      • Retinopathy 21
      • Abnormal ECG 18
      • Absent foot pulses (  2) and/or ischemic feet 14
      • Impaired reflexes and/or decreased vibration sense 7
      • Myocardial infarction/angina/claudication 2–3 †
      • Stroke/transient ischemic attack 1
      *Some patients had more than 1 complication at diagnosis † Prevalence of each individual condition UKPDS Group. Diabetologia 1991;34:877-890. Prevalence of Complications at Time of Diagnosis
    • 13. Percentage of Adults with Type 2 Diabetes by HbA 1c Level % of Subjects Source: Harris MI et al. Diabetes Care 1999; 22: 403-408. NHANES III (1988–1994) 0% 20% 40% 60% 80% 100% Oral Insulin All >9% 8%–9% 7%–8% <7% 38% 27% 45% 20% 15% 27% 22% 19% 32% 18% 14% 23%
      • 62% of patients on oral therapy are not at ADA goal of HbA 1c < 7%.
      HbA 1c
    • 14. Metabolic Goals to Reduce Illness
      • Macrovascular disease
        • Peripheral vascular disease
        • Coronary artery disease
        • Stroke
      • Microvascular disease
      • Nephropathy
      • Retinopathy
      • Neuropathy
      Blood Glucose
      • Blood Pressure
      • Lipids
      • Other risk factors
    • 15.  
    • 16. NCQA/ADA Diabetes Physician Recognition Program 
    • 17. NCQA/ADA Diabetes Physician Recognition Program 
    • 18. Recognized Physicians Provide High-Quality Care Physicians achieving Recognition through the NCQA/ADA Diabetes Provider Recognition Program (DPRP) % of patients with Diabetes Provider Recognition Program, average performance of applicants, 2001 data. Health plan average, 2000 average performance data for plans, as reported in NCQA’s The State of Managed Care Quality - 2001 report, pp. 46 - 47. Medicare, 1998-99 fee-for-service data for the median state, JAMA,10/4/00 , Vol. 284, No. 13, p. 1674. * Lower is better for this measure.
    • 19. Measurement Leads to Improvement
      • For DPRP applicants between 1997 and 2001:
      • The average rate of diabetes patients who had hba1c levels < 8% increased from 50 to 70%.
      • The rate of diabetes patients who had LDLc < 130 mg/dl increased by 35%.
      • The rate of diabetes patients monitored for kidney disease rose from 60% to 84%.
    • 20. Short-Term Economic Impact of Managing Diabetes Is there a financial incentive for insurance plans and governments?
    • 21. Incremental Cost/QALY Gained When Compared to Standard Care Source: Leroith (ed.) Diabetes Mellitus , 1996, pp. 621-630.
    • 22. Excess Costs for Patients with Diabetes in a MCO
      • 1994 costs of medical care in 85,209 members of the diabetes registry of Kaiser Permanente.
      • 85,209 age- and gender-matched non-diabetic controls.
      • Costs categorized as inpatient care, outpatient care, pharmacy and out-of-plan referrals.
      • Costs also categorized as due to short-term complications, long-term complications and remaining excess costs.
      Source: Selby JV. Diabetes Care 1997; 9: 1396.
    • 23. Yearly Costs of Care for Members with and without Diabetes Source: Selby JV. Diabetes Care 1997; 9: 1396.
    • 24. Excess Cost of Care for Diabetes (by site of care) Source: Selby JV. Diabetes Care 1997; 9: 1396.
    • 25. Standardized Cost Differential for 1% Change in HbA1c Source: Gilmer TP et al. Diabetes Care 1997;20:1847-1853.
    • 26. Impact of Comprehensive Diabetes Management Program
      • DTCA NetCare management program
        • Population based approach.
        • Multidisciplinary team works with plan physicians and patients to effect behavioral change.
        • Stratify/profile both patients & physicians to target level of support.
      • Seven MCO plans with 360,000 covered lives and 7,000 patients with diabetes.
      • Evaluate short-term impact.
        • Care coordination.
        • Guideline adherence.
      Rubin RJ, et al. J Clin Endocrinol Metab 1998; 83: 2635
    • 27. Impact of Comprehensive Diabetes Management Program Source: Rubin RJ, et al. J Clin Endocrinol Metab 1998; 83: 2635. * Total costs decreased by $44 per member/month (10.9%) which would translate into savings of $528,000 in the first year for a plan with 1000 members with diabetes. Break-even at 1,265 members with diabetes as per DTCA. $406 $362 $182 $135 $84 $76 $44 $45 $66 $76 $29 $30 $0 $50 $100 $150 $200 $250 $300 $350 $400 $450 Average Cost per member/month Total Inpatient Outpatient MD Drugs Other Baseline (54,186 member months) Follow-up (55,879 member months)
    • 28. Approach to Insulin-Requiring Patients with Type 2 Diabetes
    • 29. Physiologic Insulin Replacement The Basal/Bolus Approach
      • Identifying appropriate candidates for insulin therapy.
      • Calculating insulin replacement algorithms.
        • Basal insulin.
        • Bolus insulin.
          • Prandial and corrective.
      • Coordinating patient education support.
    • 30. Identifying the Glycemic Burden Fasting Pre-prandial Post-prandial Hepatic Glucose Output Glucose Disposal Prandial Insulin Secretion
    • 31. Indications for Insulin Therapy
      • Poor glycemic control.
        • Symptom control.
        • Prevention of chronic complications.
      • Fasting hyperglycemia on oral agents.
        • Basal insulin replacement.
      • Post-prandial glucose elevations.
        • Bolus insulin replacement.
      • Adverse effects of oral agents.
      • Cost.
    • 32. Physiology of Insulin Secretion Muscle Gut Liver Hepatic Glucose Output Intestinal CHO Absorption Plasma Glucose Basal insulin Bolus Insulin (-) Pancreas
    • 33. 4:00 25 50 75 16:00 20:00 24:00 4:00 Plasma Insulin µ U/ml) 8:00 12:00 8:00 Time Near-Physiologic Insulin Replacement Lispro Aspart Regular Ultralente Glargine CSII Prandial replacement Basal Replacement
    • 34. Translating the Basal/Bolus Prescription PCP Carbohydrate counting Correction (supplemental) scale Insulin algorithms Insulin administration Glucose monitoring Psychosocial issues Special situation adjustments Diabetes Overview Knowledge & skills assessment Prandial insulin coverage Insulin Prescription Lantus 20 u HS CHO ratio 1/10 Correction ratio 1/40 BG target 120 mg/dl ?
    • 35. Components of the Diabetes Team The Ideal Scenario Dietitian Endocrinologist Nurse Educator Exercise Therapist Case Manager PCP         
    • 36.  
    • 37. Success of Program Depends on
      • Getting primary-care physicians (PCPs) to attend the program.
      • Inviting key diabetes educators.
        • May need to set up additional training to certify competency in basal/bolus therapy.
      • Facilitating network opportunities between PCPs and educators.
      • Evaluate impact of program.
        • Pre- & post-program questionnaires.
    • 38. The End                                      
    • 39. Calculating Insulin Ratio & Doses
      • Calculate total daily insulin dose (TDI)
        • Based on current insulin doses
        • Based on weight in kg (weight x 0.5 u/kg/day)
      • TDI is approximately ½ basal and ½ bolus replacement
      • Example: A 80 kg patient would require ~ 40 units of insulin per day, of which 20 units are for basal replacement and 20 units to cover meal carbohydrates
    • 40. Calculating Insulin Ratio & Doses
      • Calculate corrective ratio (supplemental insulin)
        • For Lispro or Aspart use 1800  TDI = fall in glucose (mg/dl) per 1 unit of insulin
        • For Regular insulin use 1500  TDI = fall in glucose (mg/dl) per 1 unit of insulin
      • Example: A patient requiring 40 units of insulin per day would expect a 45 mg/dl drop per unit of Lispro/Aspart insulin
    • 41. Basal/Bolus Insulin Prescription
      • Basal insulin replacement
        • Insulin Glargine 20 units at bedtime
      • Prandial insulin replacement
        • 7 units Lispro or Aspart before meals
      • Correction (supplemental) insulin
        • 1 unit per 45 mg/dl above target
      • Pre-meal target: 120 mg/dl