Svensk familj medicin 10 november 2010
This presentation is the property of its rightful owner.
Sponsored Links
1 / 48

Chronic Disease Management: the Diabetes PowerPoint PPT Presentation


  • 76 Views
  • Uploaded on
  • Presentation posted in: General

Svensk Familj Medicin 10 November 2010. Chronic Disease Management: the Diabetes. The Case of the brothers: K.K. & G.K. Two brothers , ages 36 & 38, musicians and roustabouts Methadone Percocet Xanax Cigarettes DM. Month 1 - 3. D/C perc & benzos Decrease Methadone to 30/d

Download Presentation

Chronic Disease Management: the Diabetes

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Svensk familj medicin 10 november 2010

SvenskFamiljMedicin

10 November 2010

Chronic Disease Management:the Diabetes


The case of the brothers k k g k

The Case of the brothers: K.K. & G.K.

  • Two brothers, ages 36 & 38, musicians and roustabouts

  • Methadone

  • Percocet

  • Xanax

  • Cigarettes

  • DM


Month 1 3

Month 1 - 3

  • D/C perc & benzos

  • Decrease Methadone to 30/d

  • A1c: 9.2 & 9.7

  • How to improve their DM?

  • What would constitute success?

  • What would be the consequence of failure?

  • For them….and for me?


Ghc s experiment

GHC’s experiment

  • If the brothers get their HgA1c down…

  • The doctor get bucks.

  • How did we get here?


History of all this

History of all this…..

  • 1800s

    • “Doctors”

    • Charged what the market would bear

    • No insurance

    • Doctors provided hospital care for free


Early 1900s

Early 1900s

  • Enter the AMA

  • Doctors charge for hospital work

  • Still no insurance


1920s

1920s

  • GM insures auto workers

  • Start of national struggle to insure all…

  • Doctors charge what they want


1940s 1950s

1940s & 1950s

  • Low post war unemployment

  • Wage control

  • More companies offer health insurance as an benefit

  • Work based health insurance

  • Doctors still charged whatever


Medicare is born july 30 1965

Medicare is born July 30, 1965

  • Huge expansion of health care

  • Insurers & govgain power

  • Docs still paid for each widget


1980s

1980s

  • DRGs invented

  • Widgets need to be standardized

  • Doctors begin to cede authority to insurers

  • HMOs mostly function to control cost


1990s

1990s

  • Healthcare grows to ~ 15% of GDP

  • ~44 Million uninsured


How doctors are paid determine what patients get

How doctors are paid determine what patients get.

  • If doctors are free to do what they want – variance in quantity & quality.

  • If doctors are free to charge what they want -- variance in fees.

Regional Variations in Total Knee Replacement Surgery

January 4th, 2010 by 

Variation in the Average Cost Per Medicare Recipient by Region, August 15, 2007


2000s

2000s

  • Pay for performance P4P

  • Quality measures

  • HEDIS

  • Obama-care


2010s

2010s

  • End of Obama-care?

  • How many steps back?

  • We get what we pay for…


Prices matter

Prices matter

lobotomy

lobotomy

lobotamy

5 cents

10 cents


Quality matter

Quality matter

lobotomy

and

lobotomy

lobotamy

And FRIES!!

10 cents

10 cents


Insurance pay doctors for widgets

Insurance pay doctors for widgets


Quantity of widgets v quality

Quantity of widgets v quality


Pay is often not for quality

Pay is often not for quality


Measuring quality

Measuring quality

  • Process: % of patients that have yearly HgA1c.

  • Outcomes: % of patients that avoid hospitalizations or postpone death.

  • Process much easier to measure than outcomes.


Measuring quality1

Measuring quality

  • Individual doctors v systems.

  • Systems are few:

  • GHC

  • UW?

  • Swedish?

  • Patients see many different doctors


Diabetes 2 management how can we improve quality of life and decrease cost

Diabetes 2 Management:how can we improve quality of life, and decrease cost?

  • Screening?

  • What labs?

  • What frequency?

  • What are goals for labs?

  • What other measures and referrals?


Should we screen for diabetes

Should we screen for diabetes?

  • Disease:

    • Real health problem w M&M

    • Treatment that works

  • Test:

    • Detects preclinical disease

    • Safe, cheap, available

http://virtualmentor.ama-assn.org/2006/01/cprl1-0601.html


Should we screen adults for dm

Should we screen adults for DM?

  •  9.3% of adults have DM.

    • Cowie CC, Rust KF, Byrd-Holt DD, et al. Prevalence of diabetes and impaired fasting glucose in adults in the U.S. population: National Health And Nutrition Examination Survey 1999-2002. Diabetes Care2006;29(6):1263-1268

  • 43% of diabetics not identified in 2005

    • Cowie CC, Rust KF, Ford ES, et al. Full accounting of diabetes and pre-diabetes in the U.S. population in 1988-1994 and 2005-2006. Diabetes Care 2009;32(2):287-294. Published Online: November 18, 2008.

  • CDC 2004-2005 data


    Does it matter to screen

    Does it matter to screen?

    • Prevalence of complications higher in diabetics with delayed diagnosis:

      • 14. Hu FB, Stampfer MJ, Haffner SM, et al. Elevated risk of cardiovascular disease prior to clinical diagnosis of type 2 diabetes. Diabetes Care 2002;25(7):1129-1134.

      • 15. Meigs JB, Nathan DM, Wilson PW, et al. Metabolic risk factors worsen continuously across the spectrum of nondiabetic glucose tolerance. The Framingham Offspring Study. Ann Intern Med1998;128(7):524-533.


    Hga1c

    HgA1c

    • 30-35% reduction in incidence of microvascular complications / 1% decrease in HgA1c.

      • UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive blood-glucose control with metformin on com-plications in overweight patients with type 2 diabetes(UKPDS 34) [erratum in Lancet. 1998;352:1557]. Lancet.1998;352:854-865.

  • 14% reduction in macrovascular complications / 1% decrease in HgA1c.

    • Stratton IM, Adler AI, Neil HA, et al. Association ofglycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective obser-vational study. BMJ. 2000;321:405-412.

  • Target: < 7% (with exceptions)

    • American Diabetes Association. Standards of medical care in diabetes—2010 [published correction appears in Diabetes Care 2010;33(3):692]. Diabetes Care 2010;33(suppl 1):S11-S61

  • Quality measures: % of diabetics w

    • < 7% (the higher, the better)

    • > 9% (the lower, the better)


  • Bp goals in db

    BP goals in DB

    • Evidence? Mixed

    • ACCORD trial BP <120/80 not associated with meaningful outcomes.

    • UKPDS trial BP < 130/80, and Rx w ACE or BB, NNT 14 prevents one MI

      • ACCORD, a systolic blood-pressure goal below 120 mmHg had no significant effect on the primary composite outcome of nonfatal myocardial infarction, nonfatal stroke, or cardiovascular mortality compared with a goal below 140 mmHg. The trial was conducted in 4,733 patients with type 2 diabetes and a high risk for cardiovascular events, and the results were published early online by the New England Journal of Medicine and presented at the American College of Cardiology's 59th Annual Scientific Session.

      • Now we did see a 41% reduction in stroke rate, which was statistically significant, but because it was a secondary outcome—part of the composite but a secondary outcome—and one of a number of different secondary outcomes we looked at, it can't drive the interpretation of the trial by itself.

      • Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. BMJ 1998 Sep 12;317(7160):703-13


    Bp goals in db1

    BP goals in DB

    • ACP: 130-135/80

    • ADA: < 130/80

    • AGS: 130-140/80

    • PQRI: < 140/80

    • HEDIS: <130/80


    Diabetes and nephropathy

    Diabetes and nephropathy

    • 30% of diabetics (DM2)

    • Leading cause of ESRD

    • DM w albuminuria: 20% ESRD (after 20 y)

    • ACE-I markedly reduce progression of nephropathy: 24% RRR

      • Heart Outcomes Prevention Evaluation Study Investigators. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: Results of the HOPE study and MICRO-HOPE substudy. Lancet. 355: 2000; 253-259


    Ace i in dm one cv risk factor

    ACE-I in DM + one CV risk factor

    • Based on the HOPE trial 1800 patients over 5y

      • NNT      37         prevents one MI

      • NNT      53         prevents one stroke

      • NNT      29         prevents one CV related death

      • NNT      32         prevents one death (all causes)

        • Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Heart Outcomes Prevention Evaluation Study Investigators. Lancet 2000 Jan 22;355(9200):253-9.


    Lipids in db

    Lipids in DB

    • Several studies confirm reduced CHD events in diabetics treated w Statins.

    • Reduced rate 27-48% (events, not mortality) in 4 years.

      • Colhoun HM, Betteridge DJ, Durrington PN, Hitman GA, Neil HA, Livingstone SJ, Thomason MJ, Mackness MI, Charlton-Menys V, Fuller JH: Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomized placebo-controlled trial. Lancet364:685 -696,2004

  • LDL < 100 (rec by ACP, ADA, PQRI,HEDIS)


  • Diabetics without occlusive arterial disease

    Diabetics without occlusive arterial disease


    Diabetics with occlusive arterial disease

    Diabetics with occlusive arterial disease


    Asa and dm

    ASA and DM

    • Recommended

      • ADA

      • ACC

      • HQF

      • AMA-PCPI

    • No recommendation

      • PQRI

      • HEDIS


    Asa in diabetics

    ASA in diabetics

    • Evidence mixed and benefit small

    • Meta-analysis

      • 9% reduction in MI (fatal and non fatal)

      • 15% reduction in strokes

      • Both non significant

      • Increased GI bleeding: 1-5 events / 1000 patients / year

      • NNT if CV risk < 10% in 10 years: 50

        • Pignone M, et al "Aspirin for primary prevention of cardiovascular events in people with diabetes: A position statement of the American Diabetes Association, a scientific statement of the American Heart Association, and an expert consensus document of the American College of Cardiology Foundation" Circulation 2010; 121.


    Asa in diabetics w 10 10y risk

    ASA in diabetics w > 10% 10y risk

    • Men > 50 years

    • Women > 60 y

    • Plus one additional risk factor

      • Smoking

      • HTN

      • Dyslipidemia

      • FH premature CAD

      • Renal disease


    Diabetes and retinopathy

    Diabetes and retinopathy

    • Evidence supports screening

    • In 100 patients w diabetes over 10 years.

    • Without screening: 55 blind

    • With screening and treatment: 13 blind

      • Bachmann M, Nelson SJ. Screening for Diabetic Retinopathy: A quantitative overview of the evidence, applied to the populations of health authorities and boards. Bristol: Health Care Evaluation Unit, University of Bristol, 1996:1 – 46

      • http://www.library.nhs.uk/diabetes/viewResource.aspx?resid=387102


    Diabetes and neuropathy

    Diabetes and neuropathy

    • Monofilament exam recommended by:

      • ADA

      • PQRI

      • APMA (Podiatrists)

    • No recommendation

      • HEDIS

    • No evidence yet that screening reduces disease


    The diabetes other parameters to monitor

    The Diabetes: other parameters to monitor

    • Exercise?

    • Weight loss?

    • Smoking?


    The 4p game

    The $4P Game

    • 1000 patients with DM

    • 10 years

    • Goals: fewest hospitalizations, fewest deaths, fewest dollars.

    • Prize:


    Chronic disease management the diabetes

    $4P

    • Assumptions:

    • Average life span: 78y (2006, USA)

    • Average life span of a diabetic: 70y (2007)

    • Average diabetic spends 5 days in the hospital (5.3, v 4.1 in non diabetic)

    • Average cost of hospital care is $2000/d


    4p yearly hga1c screening and response

    $4P -- Yearly HgA1c screening and response

    • Cost: $200/p

    • reduces hospitalization by 10%.

    • Increases longevity by 0.5y.

    • If 50% reach HgA1c< 7 =


    Hedis

    HEDIS

    • 1991: HMO Employer Data & Information Set

    • 1993: Health Plan Employer Data & Information Set

    • 2007: Healthcare Effectiveness Data and Information Set

    • NCQA

    • National Committee for Quality Assurance

    • http://www.ncqa.org/tabid/675/Default.aspx


    Diabetes hedis

    Diabetes & HEDIS

    • HbA1c testing yearly

    • % HbA1c > 9.0

    • % HbA1c < 7.0

    • LDL testing yearly

    • % LDL < 100

    • Retinal exam yearly

    • Nephropathy screening yearly (or on ACE (GHC))

    • BP yearly, and % < 140/90 & <130/80


    Back to our brothers

    Back to our brothers…

    • What would you want to do for them now?

    • They remained non compliant and never got their HgA1c down below 9.

    • They left our practice when drug requests escalated.


    P4p usually works depends on details

    P4P: usually works, depends on details

    • Are there any risks?

      • Disenrollment

      • Cherry picking

      • Increasing the variance in medical care

      • Wrong goals

      • Doctor centered medical home

      • Marginal real life benefits


    Chronic disease management the diabetes

    http://www.clinicalgeriatrics.com/articles/Quality-Improvement-Diagnosis-and-Management-Diabetes-Mellitus-Older-Adults

    http://www.annals.org/content/144/7/465.abstractImprovements in Diabetes Processes of Care and Intermediate Outcomes: United States, 1988–2002

    Jinan B. Saaddine, MD; 

    Betsy Cadwell, MS; 

    Edward W. Gregg, PhD;

    Michael M. Engelgau, MD; 

    Frank Vinicor, MD; 

    GiuseppinaImperatore, MD; and 

    K. M. VenkatNarayan, MD

    http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/nephrology/diabetic-nephropathy/#bib15

    http://conferences.und.edu/primarycare/documents/Brosseau_PPT.pdf

    http://clinical.diabetesjournals.org/content/24/1/27.full

    http://www.fchp.org/providers/resources/hedis-measures.aspx

    http://www.theheart.org/article/1041287.do

    http://www.jaoa.org/cgi/content/full/110/7_suppl_7/eS2

    http://www.clinicalgeriatrics.com/articles/Quality-Improvement-Diagnosis-and-Management-Diabetes-Mellitus-Older-Adults

    http://www.sciencenews.org/view/generic/id/62299/title/The_high_cost_of_diabetes


  • Login