IMPROVING DIABETES CARE FOR ADULTS

IMPROVING DIABETES CARE FOR ADULTS: A Population-Based Approach Patrick J. O’Connor, MD, MPH Senior Clinical Investigator HealthPartners Research Foundation Today’s Objectives – Leadership and Resources: The Burden of Diabetes and the Cost of Doing Nothing – Population Health Impact and Cost of Competing Diabetes Improvement Priorities – The “Enhanced Primary Care Model” – Results and Future Challenges Burden of Diabetes in the US Morbidity and Mortality – Mortality: #3 cause, with 182,000 deaths each year – Prevalence doubling every 10-15 years – The death rate in the diabetic population is slowly decreasing for men but increasing for women – 70% of deaths in adults with DM are related to MI or CVA – Clinical trials provide evidence that control of hyperglycemia, dyslipidemia, and hypertension and use of ASA lower the risk of macro and micro complications. CDC, 1998. Primary Prevention of Type 2 Diabetes – Physical Activity – Weight Management – Finnish Study 57% Reduction in Incidence - mean age around 60 years with IGT - dietary instruction 8 weekly sessions, then q 3 mo - structured physical activity 3 x a week - lost about 5 Kg. Economic Burden of Diabetes in Adults The Cost of Doing Nothing 3 Year Charges $50,000 $40,000 $30,000 $20,000 $8,600 $10,000 $0 6% 7% $9,000 $40,200 $42,500 $38,700 $45,600 $49,700 CHD & DM $9,600 $10,400 $11,600 DM only 8% 9% > 10% HBA1c Selecting Improvement Goals All Goals Are Not Equal Prioritizing Diabetes Treatment Goals – Gap Analysis – Consider Population Health Benefits--NNT, Events – Consider Incremental Direct Costs to Payers – Clinical Strategies: Glycemic control Lipid control Blood pressure control Aspirin use Percent of Adult Diabetes Patients NOT at Goal Eye Exam in 2 Years Kidney Test - 1 Year HBA1c < 7 Aspirin Use BP < 130/85 HBA1c < 8 LDL < 100 in CHD LDL < 130 Non-CHD 0% 20% 40% 40% 60% 60% 60% 80% 50% Bar 1 60% 10% 10% 70% Number Needed to Treat for 5 Years to Prevent Progression of One Microvascular Complication 80 70 72 NNT 60 50 40 30 20 10 0 BP Control Glycemic Control 28 - 10/5 mm Hg - 1% HBA1c Micro Events Averted 150 100 50 0 107 56 14 BP Control HBA1c Improved < 8% HBA1c Improved < 10% Relative Impact of Various DM Improvement Strategies on Population Health Outcomes Events Averted per 10,000 Adults with DM Over 5 Years Time Number Needed to Treat for 5 Years to Prevent One Heart Attack or Stroke 60 50 40 40 60 30 20 10 6 12 20 0 LDL <100 Lower BP mg/dl in CHD 10/5 mm Hg Patients Lower A1c 1% ASA LDL <130 mg/dl in NonCHD Patients Macro Events Averted 500 450 400 350 300 250 200 150 100 50 0 500 250 200 111 58 50 LDL <100 BP Control HBA1c Aspirin Use LDL <130 HBA1c mg/dl in Improved mg/dl in Improved CHD <8% Non-CHD <10% Patients Patients Relative Impact of Various DM Improvement Strategies on Population Health Outcomes Events Averted per 10,000 Adults with DM Over 5 Years Time Direct Costs of DM Improvement Strategies Literature Cost/Pt/Yr Lower BP 50% of Pts need $630 3+ drugs Lower HBA1c Intensive $1600 - $3600 Management with Monitoring, Oral Agents, insulin Use Aspirin 325 mg ec po QD $20 Lower LDL Statins, Fibrates $700 - $1400 5-Year Net Cost to Health Plan for Every 10,000 Adults with Diabetes for Selected Diabetes Care Improvement Strategies (Increased Treatment Costs - Savings from Averted Events) COST (SAVINGS) BP Control Aspirin Use Control HBA1c to < 10% Control HBA1c to < 8% LDL <100 mg/dl in CHD Patients ($4,800,000) ($3,300,000) $5,700,000 $64,800,000 $4,100,000 LDL <130 mg/dl in Non-CHD Patients $11,400,000 Diabetes Improvement Goals – Various evidence-based diabetes clinical care recommendations have very different costs and very different benefits, calculated on a population basis – Aspirin use and blood pressure control have the most favorable ratio of benefits to costs Diabetes Improvement Goals – Lipid control in heart patients gives more benefit at lower cost than lipid control in patients without heart disease. – Glycemic control is an important element of diabetes care. Costs and benefits of glycemic control are sensitive to the HBA1c goal of care. The Enhanced Primary Care Model Better than Carve Out Disease Management Enhanced Primary Care Model--Advantages - Invest in Care System - -Extend Benefits to Multiple Clinical Domains - Strengthen, not Weaken Continuity and Coordination of Care - Seamless to Patients - Better Population Penetration Successful Chronic Disease Care: Messages to Docs – Do This, or Die (Economic and Breadth of Practice Issues) – Don’t Blame Patients---Solve Problems – Doing things together is more important than doing things alone - Partner with the Patient - Team up with nurses, educators, other docs The Enhanced Primary Care Model-Foundations Data and Information Systems Support Activated Patient CQI Road Map Guidelines Effective Care Team The Enhanced Primary Care Model-Operation Registry Planned Care & Active Outreach Monitor CQI Prioritize Active Registry or Risk List – For each doc and each clinic, new every 3 months – List of DM patients from highest to lowest HBA1c (later added CHD status and LDL-levels) – Permits proactive, population-based management – ID diabetes is 91% sensitive with 94% positive predictive value – Generally positive response from docs Monitor Clinical Status or Risk – HBA1c, LDL, CHD status – Want BP control, aspirin use, smoking status – Key Decision: What clinical domain to emphasize - Do what is easy? Or - Do what is right? Prioritize Patients Based on Risk – Novel concept to many nurses and educators – Use both clinical status and “readiness to change” – Focus most energy on those ready to change (varies by specific issue--smoking, diet, activity, DM care in general) – Those in worst shape most ready to change – Do NOT ignore those who are doing well--if so, doomed to clinical success and financial disaster (pipeline effect) Active Outreach -- Proactive Care – Need more than just docs to do this – Empower nurses and educators – – – – Respect patient’s constitutional rights and privacy Calls come directly from clinic, usually a nurse pt knows First check: Medication intensity Second check: Motivational and educational needs Visit Planning – A form of decision support – Do the hard way, by hand--too expensive – Do the easy way AMR/automated systems – Flow sheets are the poor clinic’s solution to this problem – Have not done yet, but results better than those who have made this a primary emphasis of improvement – AMR clinic with DM GL is good, but not best clinic Median HBA1c Cross-Section 10.0 Median HBA1c 9.6 9.1 8.3 7.2 7.9 6.9 1995 8.9 7.8 6.8 1996 8.9 7.7 6.9 1997 8.6 7.5 6.7 1998 8.2 7.1 6.3 1999 N = 6238 HBA1c Test Rate 9.0 8.0 7.0 6.0 1994 N = 4782 85.2% 85.1% 25th percentile Median HBA1c 75th percentile Cross-Sectional Change in Mean HBA1c 9.0 8.8 8.6 8.4 8.2 8.0 7.8 7.6 7.4 7.2 7.0 8.55 8.16 8.02 8.03 7.82 7.45 1994 1995 1996 1997 1998 1999 Cohort LDL Changes 140 135 130 125 120 115 110 1995 1996 1997 1998 1999 132 129 124 118 113 Chronic Disease Care – Identify Problems – Prioritize Problems in Partnership with Patient – Initiate Treatment – Monitor Response – Titrate to Goal Summary – 40% reduction in macrovascular risk – 25% reduction in microvascular risk – In well organized (enhanced) primary care clinics with a part time on-site DM nurse educator (not necessarily CDE) – Patient Education NOT associated with significantly better A1c – Improvement NOT due to: carve out disease management, endocrinology consults (<5% per year), less than 2% of patients use either TZD, alpha glucosidase, or meglitamides Key Components – Medical Group Physician Involvement and Leadership – Resources--show ”cost of doing nothing” – Intelligent use of information: identify patients with diabetes, monitor, prioritize, proactive outreach & visit planning – Organize clinics to give proactive, population-based care – Intensify Treatment--Titrate to Goal – Consider Evidence AND Value when selecting improvement goals Future Directions – Variation Continues--Plenty of room for more improvement – Ascertain most appropriate level for QI intervention – – – – Focus on blood pressure reduction Focus on “Patient Activation” Focus on Visit Planning Focus on Physician decision making process and methods to change physician behavior – Development of “Patient Archetypes” to advance care