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Building a Diabetes Alliance: The Role of Provider Education

Building a Diabetes Alliance: The Role of Provider Education. Robert E. Jones, MD, FACP, FACE Professor of Medicine University of Utah School of Medicine and Friend of the UDPCP. The Problem. Distribution of Glycemic Abnormalities in US. US Population: 275 million in 2000.

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Building a Diabetes Alliance: The Role of Provider Education

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  1. Building a Diabetes Alliance:The Role of Provider Education Robert E. Jones, MD, FACP, FACE Professor of Medicine University of Utah School of Medicine and Friend of the UDPCP

  2. The Problem

  3. Distribution of Glycemic Abnormalities in US US Population: 275 million in 2000 Undiagnosed diabetes 5.9 million Diagnosed type 1 diabetes ~1.0 million Additional 16 million with prediabetes Diagnosed type 2 diabetes 10 million CDC. Available at:http://www.cdc.gov/diabetes/pubs/estimates.htm ADA. Facts and Figures. Available at: www.diabetes.org/main/application/commercewf?origin=*.jsp&event=link(B1)

  4. Coronary Artery Disease: -3 to 6 fold increased risk compared to non-diabetics -Major cause of death in all people with diabetes -10 to 20 year reduction in life expectancy Neuropathy: -Types 1 and 2: >50% lifetime risk (approaches 100% with nerve conduction studies) Retinopathy: -Type 1: 60% at 10 years and ~100% at 20 years -Type 2: 20% at diagnosis and 60-80% at 20 years Peripheral Vascular Disease: -Lifetime risk of amputation is 8/1000 Nephropathy: -Type 1: 40-50% at 20 years -Type 2: 5-10% at 20 years Diabetes Complications

  5. Building a Coalition • Diabetes and it’s complications are expensive and both the suffering and expense might be avoidable • Stakeholders must be identified and all should benefit from participation • Patients, providers, insurers and government agencies • There is a common mistrust between all

  6. Diabetes Alliance • Must involve a commitment of all those affected by diabetes: • Patients • Providers • Insurers • Government agencies • Do any of these groups benefit from a bad outcome? • In the short term, they all do • In the long term, they all suffer

  7. The Importance of Early, Aggressive Glucose Control

  8. DCCT: Change in A1C Over Time Conventional Group A1C (%) Intensive Group Years DCCT. N Engl J Med. 1993;329:977

  9. Conventional Intensive DCCT: Diabetic ComplicationEvent Rates 76% Risk Reduction 60 • 55.0 50 59% Risk Reduction 40 39% Risk Reduction Cumulative Incidence (%) 30 29.8 64% Risk Reduction • 23.9 20 54% Risk Reduction 16.4 10 • 13.4 13.0 7.9 • 5.1 5.0 2.5 0 Retinopathy Laser Rx1 Micro- Albuminuria2 Clinical Progression1 albuminuria2 Neuropathy3 1. DCCT Research Group. Ophthalmology. 1995;102:647; 2. DCCT Research Group.Kidney Int. 1995;47:1703; 3. DCCT Research Group. AnnIntern Med. 1995;122:561

  10. DCCT: Lifetime Benefits of Intensive Therapy Gain inComplications-Free Living* 15.3 Gain in Length of Life 5.1 0 5 10 15 20 Years *Significant microvascular or neurologic complication DCCT. JAMA. 1996;276:1409

  11. DCCT: Average A1C 4 Years After Trial Conventional Therapy A1C (%) Intensive Therapy EDIC Year DCCT/EDIC Research Group. N Engl J Med. 2000;342:381

  12. DCCT: Progression of Retinopathy 4 Years After Trial Conventional Therapy Cumulative Incidence (%) Intensive Therapy EDIC Year Reprinted with permission from DCCT/EDIC Research Group. N Engl J Med. 2000;342:381

  13. EDIC Reduction in CV Disease Events were reduced 57% (12-79% [95% CI]; P=0.02) DCCT EDIC NEJM 2005;353:2643-2654

  14. UK Prospective Diabetes Study Group: A1C 9 Conventional Group Intensive Group 8 A1C (%) Subjects with A1C <7%: 3 years 45% 6 years 30% 9 years 15% 7 6 0 1 2 3 4 5 6 7 8 9 10 Years Reprinted with permission from UKPDS. Lancet. 1998;352:837-853.

  15. Control: Reduction In Complications Complications DCCT1,2 Kumamoto3 UKPDS4 9% 7% 9% 7% 8% 7% Retinopathy 63% 69% 17%–21% Nephropathy 54% 70% 24%–33% Neuropathy 60% – – Macrovascular disease 41%* – 16%* *Not statistically significant 1DCCT Research Group. N Engl J Med. 1993;329:977; 2DCCT Research Group. Diabetes. 1995;44:968; 3Ohkubo Y et al. Diabetes Res Clin Pract. 1995;28:103; 4UKPDS Group. Lancet. 1998;352:837

  16. UKPDS 10 Year Poststudy Followup • Following completion of UKPDS, therapy was left to the discretion of providers • The difference in A1C disappeared (like EDIC) • Results: • Microvascular Disease (RR=0.76; p=0.001) • Diabetes Endpoint (RR=0.91; p=0.04) • Death from Diabetes (RR=0.83;p=0.01) • All Cause Mortality (RR=0.87;p=0.007) • Myocardial Infarction (RR=0.85;p=0.01) Holman RR et al. NEJM 2008;359:1577-1589

  17. Pre-Study Glyemic Exposure and Microvasular Outcomes ** Nephropathy 40 Retinopathy Neuropathy ** 30 ** ** Complication Risk Reduction (%) 20 10 ** UKPDS ADVANCE VADT 7.1 57.6 108.1 Glycemic Exposure* *Glycemic Exposure=Duration of Diabetes x Study Entry A1C ** Statistically Significant Jones RE, Wadweker D. In press, 2010.

  18. Utah Diabetes Prevention and Control Program:Provider Education

  19. First Attempt (~1995) Over 50 providers licensed in Utah were given the primary literature (DCCT and UKPDS plus derivative articles) and asked to establish treatment goals for glucose, lipids and blood pressure in people with diabetes

  20. First Attempt (~1995) 7.2---It’s Up to You! BP 140/90 mm Hg LDLc 130 mg/dl

  21. Introduction • 1997 was a unique year: • DCCT was “4 years old” and UKPDS was “2 years old” • The ADA had just defined goals for diabetes management • Insulin lispro, metformin and troglitazone were recently approved by the FDA • The Expert Committee redefined the diagnostic criteria for diabetes (FBS 126 vs 140 mg/dl) • Utah Diabetes Control Program initiated a process for certification of Diabetes Self Management Programs

  22. The Perfect Storm

  23. Phase 1 (1999-2002)Defining Diabetes, Targets and Complications CME events were by invitation of the local certified diabetes educators in order to highlight their skills Topics centered on the diagnosis of diabetes, setting targets, the management of diabetes and diabetes complications plus treatment of HTN and lipids Attendees were given copies of the Utah Diabetes Management Handbook (1999)

  24. Phase 2 (2003-2006)The Utah Diabetes Practice Recommendations Again, CME events were by invitation of the local providers or the diabetes educators Topics centered on the management of diabetes in a variety of settings (outpatient, inpatient and pregnacy) Providers were given a “Chinese Menu” for topics Attendees were given copies of the Utah Diabetes Management Handbook (2003) and applicable UDPRs

  25. ADA/EASD Consensus Statement (2008) Lifestyle + Metformin+Basal Insulin Lifestyle + Metformin+Intensive Insulin At diagnosis: Lifestyle+Metformin Tier 1: Well-validated core therapies Step 2 Lifestyle + Metformin+Sulfonylurea Step 2 Step 3 Step 1 Tier 2: Less well-validated therapies Lifestyle + Metformin+Pioglitazone Lifestyle + Metformin+Pioglitazone+Sulfonylurea Step 2 Reinforce lifestyle interventions at every visit and check A1C every 3 months until A1C is <7% and then at least every 6 months. Lifestyle + Metformin+Basal Insulin Lifestyle + Metformin+GLP-1 agonist Adapted from Nathan DM et al. Diabetes Care. 2008:31;1-11.

  26. ADA/EASD Consensus Statement (2008) Lifestyle + Metformin+Basal Insulin Lifestyle + Metformin+Intensive Insulin At diagnosis: Lifestyle+Metformin Tier 1: Well-validated core therapies Step 2 Lifestyle + Metformin+Sulfonylurea Step 2 Step 3 Step 1 Tier 2: Less well-validated therapies Lifestyle + Metformin+Pioglitazone Lifestyle + Metformin+Pioglitazone+Sulfonylurea Step 2 Reinforce lifestyle interventions at every visit and check A1C every 3 months until A1C is <7% and then at least every 6 months. Lifestyle + Metformin+Basal Insulin Lifestyle + Metformin+GLP-1 agonist Adapted from Nathan DM et al. Diabetes Care. 2008:31;1-11.

  27. UDPRs Glycemic Algorithm Diagnosis; initiate lifestyle modifications (education) and start metformin Individually Assess Patient Possible weight increase, Greater A1C lowering (>1%), Principally reduce FPG Possible weight loss (or neutral), Lesser A1C lowering (<1%), Principally reduce PPG -Patient’s Goals -Fasting v Postprandial Target (A1C) -Weight Effects -Cost -Relative Efficacy -Age -Cardiac, Renal and Hepatic Function Basal insulin (most effective) Incretomimetics (most weight loss) Sulfonylureas (least expensive) DPP-IV inhibitors (least effective) Not included: Amylomimetics; Meglitinides; AGIs TZDs (no hypoglycemia) UDPRs, 2009

  28. Hypertension Algorithm UDPRs, 2009

  29. Measurables • UDPRs • 38,500 downloads • Interest and inquiries throughout the country • Provider education • Independent reviews, insurers and patient surveys • The frequency of target measurement/documentation (lipids, BP, microalbumin, A1C, foot exam) has significantly increased • Meeting established targets cannot be ascertained or has not changed

  30. Are We Having an Impact?

  31. Current State of Diabetes Management • Targets • A1C < 7% • BP < 130/80 mm Hg • Total cholesterol < 200 mg/dL or LDL < 100 mg/dL 1 Saydah et al. JAMA 2004;291:335-342 2 BARI 2D Study Group. NEJM 2009;360:2503-25-2515.

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