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Creating Models for Health Care Delivery that Address Chronic Disease. Linda Siminerio, PhD Senior Vice President, IDF University of Pittsburgh Diabetes Institute Associate Professor School of Medicine. Presentation Objectives:. Describe the Problem and Urgency

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creating models for health care delivery that address chronic disease

Creating Models for Health Care Delivery that Address Chronic Disease

Linda Siminerio, PhD

Senior Vice President, IDF

University of Pittsburgh Diabetes Institute

Associate Professor

School of Medicine

presentation objectives
Presentation Objectives:
  • Describe the Problem and Urgency
  • Present the Chronic Care Model
    • Report on the “Pittsburgh Regional Initiative for Diabetes Education (PRIDE)”
  • Present the Innovative Care for Chronic Diseases Model
    • Highlight Global Projects
diabetes worldwide
Diabetes Worldwide

Estimated number (in Millions) of people with diabetes, worldwide:*

Increase in deaths from diabetes over next 10 years:†

India 35%

The Americas 80%

the western Pacific and eastern Mediterranean regions 50%

Africa >40%

*Diabetes Prevalence. International Diabetes Federation, 2003.

†Preventing Chronic Diseases: a vital investment, World Health Organization, 2005.

1985: 30 million

1995: 135 million

2003: 194 million

2025: 330 million

us diabetes facts

Million

2003

2005

Pre-diabetes

US Diabetes Facts
  • 20% increase past 20 yrs
  • 70% increase 30-39 yr. age range
  • 1 in 3 children born in 2003 will get diabetes
  • Type 2 in children is increasing
  • 14 million lost work days
  • Annual costs -- $132 billion
epidemiologic transition
Epidemiologic Transition

Omran, A. The Epidemiologic Transition: A theory of the epidemiology of a population change. Milbank Q. 1971:49:509-538.

Non-Communicable Disease

Mortality Rates

Infectious Disease

Epidemiologic Transition

More information available at http://www.pitt.edu/~super1/lecture/lec0022/007.htm

organization of health care what it should be
Organization of Health Care(What it should be)
  • Evidence-based, planned care
    • Clinical Guidelines
  • Reorganization of practice (team approach)
    • Includes ancillary professionals with the patient as the most important member
  • Attention to patient needs (information)
    • Counseling, education, information feedback
  • Access to clinical expertise
    • Patient and provider education, access to specialists
  • Supportive information systems
    • Patient registries
    • Provider feedback on preventive service utilization
organization of health care what it is
Organization of Health Care(What it is)
  • Care is not necessarily based on evidence, but experience and training
  • Seldom is there a team approach…care is mainly driven by the physician alone
  • Paternalistic and directive approach with little attention to patients’ behavioral needs
  • Limited access to diabetes specialists
    • Insurer limitations
    • Reluctance of primary care referral
    • Fragmented access
  • Poor information systems
    • No computers
    • Poor tracking
slide8

Transition in Health Care

PARADIGM SHIFT

ACUTE CARE CHRONIC CARE

Focus: prevention

Care: coordinated

Focus: illness

Care: fragmented

quality of care for people with diabetes in the united states
Quality of Care for People with Diabetes in the United States

A Diabetes Report Card for the United States: Quality of Care in the 1990’s.

%

(2.6mmol/L)

Saaddine JB: Ann Intern Med. 136: 565-574, 2002

university of pittsburgh medical center the challenges of providing access and quality
University of Pittsburgh Medical Center The Challenges of Providing Access and Quality
  • 19 hospitals/ 200 primary care practices
  • 90,000 patients with diabetes
  • 90% diabetes care provided by PCPs
  • Poor adherence to guidelines
  • Lack of integrated technology
  • Daily decisions made by patient
  • Poor access for education and nutrition
  • Undefined relationships to the community
objective
Objective
  • By implementing a model for health care delivery we could:
    • Gain health system support
    • Demonstrate improvements in clinical outcomes, A1C, BP and Lipids
    • Demonstrate reimbursement for services
    • Expand number of resources in communities
health system
Health System
  • UPMC board initiative
  • Presentations to leadership
  • Pittsburgh Regional Initiative for Diabetes Education (PRIDE)
    • Patient/Provider/Community

Community

Health System

Resources and Policies

Organization of Healthcare

Self-Management Support

Delivery System Design

Decision Support

Clinical Information Systems

Prepared, Proactive Practice Team

Informed, Activated Patient

Productive Interactions

Functional and Clinical Outcomes

community
Community
  • Resource Identification
    • Focus groups with providers and patients
    • Community leaders
    • Local physicians
    • Government

Functional and Clinical Outcomes

decision support
Decision Support

Evidence Based Guidelines

  • ADA Medical & Education Standards

Functional and Clinical Outcomes

clinical information systems
Clinical Information Systems
  • Paper Charts
  • Excel spread sheets
  • Laboratory feedback
  • Electronic Medical Records
  • Management systems
clinical information decision support
Clinical Information / Decision Support
  • Instituted ADA Guidelines
  • Physician education
    • Regional programs
    • System seminars
    • Integrating CDEs into practices
    • Office staff education
  • Clinical information
    • Continuous feedback
    • Comparative reports to peers
community medicine inc cmi versus national data
Community Medicine Inc. (CMI)versus National Data

DM Report Card for USA Annals Internal Medicine 2002;136 (8) 565-574

cmi vs national data
CMI vs National Data

DM Report Card for USA Annals Internal Medicine 2002;136 (8) 565-574

proportion of patients with hba1c levels 8 0 7 0 2003 2006
Proportion of Patients with HbA1c Levels < 8.0% & 7.0% (2003-2006)

%

Time

proportion of patients with ldlc levels 130 mg dl 100 mg dl 2003 2006
Proportion of Patients with LDLc Levels < 130 mg/dL & 100 mg/dL (2003-2006)
delivery system design
Delivery System Design
  • Diabetes Educators in Primary Care
  • Diabetes “Mini Clinics”
proportion of people educated at pcp office compared to hospital based outpatient dsme
Proportion of People Educated at PCP Office Compared to Hospital Based Outpatient DSME

p<0.0001

%

n=686/4332

n=9,334/89,760

nurse directed protocols
Nurse-directed protocols
  • Approved protocols for glycemic, hypertension and cholesterol management
  • Nurses used these protocols in management
  • Intervention in high-risk Hispanic community
  • Significant improvement in provider processes and patient outcomes

Davidson, M., et al Effect of nurse-directed diabetes care in minority populations: Diabetes Care, 2003.

process measures
Process measures

Measure ADA guidelines Nurse-directed care Usual care P

HbA1c Goal-yes, 1 per 6 months; Goal-no, 1 per 3 months 227/252 (90) 66/252 (26) <0.001

Lipid profile At least yearly 244/252 (97) 148/252 (59) <0.001

Eye exam At least yearly 240/252 (95) 200/252 (79) <0.001

Renal profile* Yearly 215/252 (85) 148/209 (71)

<0.001

If dipstick negative/trace, measure albumin-to- creatinine ratio 54/183 (30) 76/174 (44) <0.01

If dipstick negative/trace, or albumin-to-creatinine ratio >30 mg/g, ACE treatment 19/28 (68) 59/93 (63) NS

Foot exam At least biannually 245/252 (97) 202/252 (80) <0.001

2 visits

At least biannually 248/252 (98) 241/252 (96) NS

Diabetes education No frequency stated 239/252 (98) 122/252 (48) <0.001

Nutritional counseling No frequency stated 224/252 (89) 14/252 (6) <0.001

Davidson, M., et al Effect of nurse-directed diabetes care in minority populations: Diabetes Care, 2003.

hba1c sd outcome measure
HbA1c (% ± SD) outcome measure

Nurse-directed care Usual care P

All patients

 Percent of patients 249/252 (99) 201/252 (80) <0.001

 Initial 13.5 ± 3.7 12.1 ± 3.1 <0.001

2 tests

 Percent of patients 201/249 (81)* 145/201 (72) <0.05

 Initial 13.3 ± 3.5 12.3 ± 3.4 <0.02

 Final 10.3 ± 6.0 10.8 ± 3.2 NS

 Change -3.0 ± 6.6 -1.5 ± 2.9 <0.01

6 months

 Number of patients 120 145

 Initial 13.3 ± 3.4 12.3 ± 3.4 <0.02

 Final 9.8 ± 3.0 10.8 ± 3.2 <0.01

 Change -3.5 ± 3.8 -1.5 ± 2.9 <0.001

Data are n (%) or means ± SD.

* Some of these patients were followed for <3 months.

self management support
Self-Management Support
  • Expanded Education sites
  • CDE in Primary Care
  • Traveling educator
  • AADE Outcomes System
slide33

Behavior

Learning

ClinicalIndicators

Health

Status

AADE Outcome System (IMPACT)

System Measures Changes In…

slide34

Healthy eating

Being active

Monitoring

Taking medication

Problem-solving

Healthy coping

Reducing risks

AADE 7 Self-Care Behaviors

diabetes prevention program
Diabetes Prevention Program
  • 150 minutes of exercise/week
  • Healthy eating program
  • 7% reduction in weight
  • Results in:
    • Decreases in Blood pressure ( 130/85 mmHg)
    • Decreases in Waist circumference
      • Men < 40 inches; Women < 35 inches
    • Decreases in Triglyceride levels (< 150 mg/dL)
    • Decreases in Glucose (< 100 mg/dL)
    • Decreases in HDL cholesterol
      • Men > 40 mg/dL; Women > 50 mg/dL
average weight loss over time diabetes prevention program braddock
Average Weight Loss Over TimeDiabetes Prevention Program-Braddock

Lifestyle Modification Program150 minutes of physical activity per week and a healthy eating program

pounds

average decrease in bmi over time diabetes prevention program braddock
Average Decrease in BMI Over TimeDiabetes Prevention Program-Braddock

Lifestyle Modification Program150 minutes of physical activity per week and a healthy eating program

slide40

Decreases in the Proportion of Subjects with Abdominal Obesity, Hypertension, and Hypertriglyceridemia Over TimeDiabetes Prevention Program - Braddock

%

conclusions
Conclusions
  • The CCM provided a good framework for quality improvements in primary prevention and treament
    • Gained health system and community attention
    • Increased number of resources
    • Captured attention of state and federal policy makers
    • Improved insurance coverage
  • Decision support – clinical improvements
  • Clinical information systems afforded the opportunity for tracking populations
  • Self-management support – facilitated diabetes education and behavior change
  • System redesign
    • Improved access for education
    • Physicians and patients reported increased communication and satisfaction.
slide43

MICRO LEVEL

  • Informed
  • Motivated
slide44

MESO LEVEL

  • Organize & Equip
  • Coordinate
  • Community
slide45

MACRO LEVEL

  • Leadership& Advocacy
  • Integrate policies
  • Consistent financing
  • Human Resources
  • Legislative frameworks
  • Partnerships
global projects
Global Projects
  • Canada – Vancouver expanded CCM
  • Mexico – Veracruz project
  • Morocco – Nat’l. Government used ICCC
  • Russian Federation – ICCC for secondary prevention with 56 teams
  • Rwanda – ICCC HIV/AIDS project
  • United Kingdom – 10 yr. quality project
key messages
Key Messages
  • Burden of chronic disease increasing
  • Most health systems not equipped
  • Patients do better with integrated system
  • Evidence supports organized systems of care
  • CCM has been successful in US
  • ICCC depicts complimentary process
  • CCM & ICCC need to be disseminated, implemented & evaluated

Eppinger-Jordan, JE; Pruitt, SD, Bengoa, R., Wagner, E. Improving the quality of health care fore chronic conditions. Quality Safe Hl Care, 2004.

special acknowledgement
Special Acknowledgement
  • Project team
    • Janice Zgibor, RPh, PhD
    • Sharlene Emerson, CRNP, CDE
    • Gretchen Piatt, PhD, CHES
    • Janis McWilliams, MSN, CDE
    • Kristine Ruppert, DrPH
    • Francis Solano, MD
  • University of Pittsburgh Diabetes Institute
  • University of Pittsburgh Division of Endocrinology and Metabolism
  • University of Pittsburgh Medical Center

“This research was partially sponsored by funding from the United States Air Force administered by the U.S. Army Medical Research Acquisition Activity, Fort Detrick, Maryland, Award Number W81XWH-04-2-0030."

slide49
WHO
  • JoAnne Eppinger-Jordan, PhD
  • Contact: K. Thompson
  • thompsonk@who.int