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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. Outline. Introduction. Diabetes prevalence & burden.

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Interventions to improve quality of care l.jpg

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


Outline l.jpg
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.

II Workshop on Quality of Diabetes Care, Miami, May 2003


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Purpose of Optimizing Care

  • Reduce burden of illness.

    • Microvascular and macrovascular complications.

    • Acute complications (hypoglycemia, hyperglycemia, DKA).

  • Enhance quality of life.

  • Reduce fiscal burden.

II Workshop on Quality of Diabetes Care, Miami, May 2003


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Macro & Micro-Vascular Endpoints

80

60

40

20

0

Myocardial infarction

Microvascular end points

  • Adjusted for age, sex, and ethnic group.

  • White men ages 50–54 years at diagnosis; mean duration of diagnosis of 10 years.

Adjusted* incidence per 1000 person-years (%)

5 6 7 8 9 10 11

Updated mean hemoglobin A1c concentration (%)

Source: Stratton IM et al. for the UK Prospective Diabetes Study Group. UKPDS 35. BMJ 2000; 321: 405–412.

II Workshop on Quality of Diabetes Care, Miami, May 2003


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8.84

8.80

8.60

* p<0.05 v. pre-MYD

8.40

8.20

*

8.10

8.01

Mean HbA1c %

8.00

*

7.50

7.80

*

7.65

7.60

7.40

7.20

7.00

6.80

Mo 1-3

Mo 4-6

Mo 7-9

Mo 10-12

Pre-MYD

Mastering Your DiabetesMetabolic & 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 ScalePretestPosttest3mF/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).

II Workshop on Quality of Diabetes Care, Miami, May 2003


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Healthcare Costs Increase With Worsening Glycemic Control

Increase in medical costs associated with rising HbA1c levels compared to costs for patients with HbA1c of 6%*

36%

12,000

11,000

21%

*In patients with Type 2 diabetes alone (no cardiovascular complications).

10,000

11%

3-Year Medical Costs, 1993–1995 ($)

5%

9,000

8,000

6

7

8

9

10

Baseline HbA1c (%), 1992

Source: Gilmer TP et al. Diabetes Care 1997; 20: 1847-1853.

II Workshop on Quality of Diabetes Care, Miami, May 2003


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Increase of Diabetes & Gestational Diabetes in the USA

II Workshop on Quality of Diabetes Care, Miami, May 2003


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Global Projections of Diabetes

(in millions, 1995-2010)

22.0

32.9

50%

62.8

132.3

111%

13.0

17.5

35%

7.3

14.1

93%

12.4

22.5

81%

0.9

1.3

44%

World

1995 = 118 million

2010 = 221 million

Increase of 87%

II Workshop on Quality of Diabetes Care, Miami, May 2003


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Diabetes Mellitus in the USA:Health Impact of the Disease

6th leading cause of death

Kidney failure*

Life expectancy reduced by

5–10 years

Blindness*

Heart disease

­ 2X to 4X

Diabetes

Nerve damage in 60% to 70% of patients

Amputation*

*Diabetes is the #1 cause of renal failure, new cases of blindness, and non-traumatic amputations.

Sources: Diabetes Statistics. October 1995 (updated 1997). NIDDK publication NIH 96-3926. Harris, MI. In: Diabetes in America (2nd ed.) 1995: 1-13.

II Workshop on Quality of Diabetes Care, Miami, May 2003


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Indirect Medical Expenses

Mortality

$10.8

$21.6

Lost work days

Restricted activity

$7.5

Permanent

disability

The Cost of Diabetes

Diabetes costs the United States ~$132 billion annually!

Total = $91.8 Billion

Total = $39.8 Billion

Direct Medical Expenses

General Medical

$24.6

Conditions

$44.1

Diabetes & Acute

$23.2

Metabolic

Complications

Chronic Diabetes

Complications

Source: American Diabetes Association. Diabetes Care 2003; 26: 917-932.

II Workshop on Quality of Diabetes Care, Miami, May 2003


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Projected Costs of Diabetes (USA, in billions)

$192

  • $200

  • $100

  • $0

$156

$132

$98

1997 2002 2010 2020

II Workshop on Quality of Diabetes Care, Miami, May 2003


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Prevalence of Complications at Time of Diagnosis

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.

II Workshop on Quality of Diabetes Care, Miami, May 2003


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Percentage of Adults with Type 2 Diabetes by HbA1c Level

NHANES III (1988–1994)

100%

23%

  • 62% of patients on oral therapy are not at ADA goal of HbA1c < 7%.

27%

32%

80%

HbA1c

14%

15%

>9%

60%

19%

8%–9%

18%

% of Subjects

20%

7%–8%

40%

22%

<7%

38%

20%

45%

27%

Source: Harris MI et al. Diabetes Care 1999; 22: 403-408.

0%

Oral

Insulin

All

II Workshop on Quality of Diabetes Care, Miami, May 2003


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Metabolic Goals to Reduce Illness

Macrovascular disease

  • Peripheral vascular disease

  • Coronary artery disease

  • Stroke

  • Microvascular disease

  • Nephropathy

  • Retinopathy

  • Neuropathy

  • Blood Pressure

  • Lipids

  • Other risk factors

Blood Glucose

II Workshop on Quality of Diabetes Care, Miami, May 2003



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NCQA/ADA Diabetes Physician Recognition Program

II Workshop on Quality of Diabetes Care, Miami, May 2003


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NCQA/ADA Diabetes Physician Recognition Program

II Workshop on Quality of Diabetes Care, Miami, May 2003


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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.

II Workshop on Quality of Diabetes Care, Miami, May 2003


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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%.

II Workshop on Quality of Diabetes Care, Miami, May 2003


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Short-Term Economic Impact of Managing Diabetes

Is there a financial incentive for insurance plans and governments?


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Incremental Cost/QALY Gained When Compared to Standard Care

Source: Leroith (ed.) Diabetes Mellitus, 1996, pp. 621-630.

II Workshop on Quality of Diabetes Care, Miami, May 2003


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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.

II Workshop on Quality of Diabetes Care, Miami, May 2003


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Yearly Costs of Care for Members with and without Diabetes

Source: Selby JV. Diabetes Care 1997; 9: 1396.

II Workshop on Quality of Diabetes Care, Miami, May 2003


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Excess Cost of Care for Diabetes (by site of care)

Source: Selby JV. Diabetes Care 1997; 9: 1396.

II Workshop on Quality of Diabetes Care, Miami, May 2003


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Standardized Cost Differential for 1% Change in HbA1c

Source: Gilmer TP et al. Diabetes Care 1997;20:1847-1853.

II Workshop on Quality of Diabetes Care, Miami, May 2003


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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.

II Workshop on Quality of Diabetes Care, Miami, May 2003

Rubin RJ, et al. J Clin Endocrinol Metab 1998; 83: 2635


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Impact of Comprehensive Diabetes Management Program

Baseline (54,186 member months)

Follow-up (55,879 member months)

$450

$406

$400

$362

$350

$300

Average Cost per member/month

$250

$200

$182

$150

$135

$100

$84

$76

$76

$66

$45

$44

$50

$30

$29

$0

Total

Inpatient

Outpatient

MD

Drugs

Other

* 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.

Source: Rubin RJ, et al. J Clin Endocrinol Metab 1998; 83: 2635.

II Workshop on Quality of Diabetes Care, Miami, May 2003


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Approach to Insulin-Requiring Patients with Type 2 Diabetes

II Workshop on Quality of Diabetes Care, Miami, May 2003


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Physiologic Insulin ReplacementThe Basal/Bolus Approach

  • Identifying appropriate candidates for insulin therapy.

  • Calculating insulin replacement algorithms.

    • Basal insulin.

    • Bolus insulin.

      • Prandial and corrective.

  • Coordinating patient education support.

II Workshop on Quality of Diabetes Care, Miami, May 2003


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Identifying the Glycemic Burden

Fasting

Hepatic Glucose

Output

Post-prandial

Pre-prandial

Prandial Insulin

Secretion

GlucoseDisposal

II Workshop on Quality of Diabetes Care, Miami, May 2003


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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.

II Workshop on Quality of Diabetes Care, Miami, May 2003


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Gut

(-)

Hepatic Glucose Output

Intestinal CHO Absorption

Liver

Muscle

Plasma Glucose

Bolus Insulin

Basal insulin

Pancreas

Physiology of Insulin Secretion

II Workshop on Quality of Diabetes Care, Miami, May 2003


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Near-Physiologic Insulin Replacement

Lispro

Aspart

Regular

75

Prandial

replacement

Ultralente

Glargine

CSII

50

Plasma Insulin µU/ml)

Basal

Replacement

25

4:00

8:00

12:00

16:00

20:00

24:00

4:00

8:00

Time

II Workshop on Quality of Diabetes Care, Miami, May 2003


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?

Insulin

Prescription

Lantus 20 u HS

CHO ratio 1/10

Correction ratio 1/40

BG target 120 mg/dl

Translating the Basal/Bolus Prescription

PCP

Knowledge & skills assessment

Diabetes Overview

Glucose monitoring

Insulin administration

Insulin algorithms

Carbohydrate counting

Prandial insulin coverage

Correction (supplemental) scale

Special situation adjustments

Psychosocial issues

II Workshop on Quality of Diabetes Care, Miami, May 2003


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Components of the Diabetes TeamThe Ideal Scenario

PCP

Case Manager

Endocrinologist

Dietitian

Nurse Educator

Exercise Therapist

II Workshop on Quality of Diabetes Care, Miami, May 2003



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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.

II Workshop on Quality of Diabetes Care, Miami, May 2003


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The End

II Workshop on Quality of Diabetes Care, Miami, May 2003


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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

II Workshop on Quality of Diabetes Care, Miami, May 2003


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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

II Workshop on Quality of Diabetes Care, Miami, May 2003


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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

II Workshop on Quality of Diabetes Care, Miami, May 2003


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