The document discusses various interventions to improve quality of care for patients with diabetes. It describes goals for metabolic control to reduce complications, benchmarking and recognition programs, and the economic impacts of improved diabetes management. It also discusses a model for promoting intensive insulin therapy at the primary care level using basal-bolus insulin regimens along with patient education.

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

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

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.

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.

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.

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

30. Identifying the Glycemic Burden Fasting Pre-prandial Post-prandial Hepatic Glucose Output Glucose Disposal Prandial Insulin Secretion

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

38. The End