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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


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

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

    4. 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

    5. 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

    6. 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

    7. Increase of Diabetes & Gestational Diabetes in the USA II Workshop on Quality of Diabetes Care, Miami, May 2003

    8. 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

    9. 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

    10. 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

    11. 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

    12. 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

    13. 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

    14. 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

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

    16. NCQA/ADA Diabetes Physician Recognition Program II Workshop on Quality of Diabetes Care, Miami, May 2003

    17. NCQA/ADA Diabetes Physician Recognition Program II Workshop on Quality of Diabetes Care, Miami, May 2003

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

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

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

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

    23. 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

    24. 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

    25. 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

    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. II Workshop on Quality of Diabetes Care, Miami, May 2003 Rubin RJ, et al. J Clin Endocrinol Metab 1998; 83: 2635

    27. 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

    28. Approach to Insulin-Requiring Patients with Type 2 Diabetes II Workshop on Quality of Diabetes Care, Miami, May 2003

    29. 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

    30. 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

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

    32. 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

    33. 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

    34. ? 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

    35. 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

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

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

    38. The End II Workshop on Quality of Diabetes Care, Miami, May 2003

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

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

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