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IMPROVING DIABETES CARE FOR ADULTS: A Population-Based Approach. Patrick J. O’Connor, MD, MPH Senior Clinical Investigator HealthPartners Research Foundation. Today’s Objectives. Leadership and Resources: The Burden of Diabetes and the Cost of Doing Nothing

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improving diabetes care for adults a population based approach

IMPROVING DIABETES CARE FOR ADULTS: A Population-Based Approach

Patrick J. O’Connor, MD, MPH

Senior Clinical Investigator

HealthPartners Research Foundation

today s objectives
Today’s Objectives
  • Leadership and Resources: The Burden of Diabetes and the Cost of Doing Nothing
  • Population Health Impact and Cost of Competing Diabetes Improvement Priorities
  • The “Enhanced Primary Care Model”
  • Results and Future Challenges
burden of diabetes in the us morbidity and mortality
Burden of Diabetes in the USMorbidity and Mortality
  • Mortality: #3 cause, with 182,000 deaths each year
  • Prevalence doubling every 10-15 years
  • The death rate in the diabetic population is slowly decreasing for men but increasing for women
  • 70% of deaths in adults with DM are related to MI or CVA
  • Clinical trials provide evidence that control of hyperglycemia, dyslipidemia, and hypertension and use of ASA lower the risk of macro and micro complications.

CDC, 1998.

primary prevention of type 2 diabetes
Primary Prevention of Type 2 Diabetes
  • Physical Activity
  • Weight Management
  • Finnish Study 57% Reduction in Incidence
    • mean age around 60 years with IGT
    • dietary instruction 8 weekly sessions, then q 3 mo
    • structured physical activity 3 x a week
    • lost about 5 Kg.
economic burden of diabetes in adults

Economic Burden of Diabetes in Adults

The Cost of Doing Nothing

slide6

CHD & DM

DM only

HBA1c

selecting improvement goals

Selecting Improvement Goals

All Goals Are Not Equal

prioritizing diabetes treatment goals

Prioritizing Diabetes Treatment Goals

Gap Analysis

Consider Population Health Benefits--NNT, Events

Consider Incremental Direct Costs to Payers

Clinical Strategies:

Glycemic control

Lipid control

Blood pressure control

Aspirin use

number needed to treat for 5 years to prevent progression of one microvascular complication
Number Needed to Treat for 5 Years to Prevent Progression of One Microvascular Complication

7 2

NNT

2 8

- 10/5 mm Hg

- 1% HBA1c

micro events averted
Micro Events Averted

1 0 7

5 6

1 4

Relative Impact of Various DM Improvement Strategies on Population Health Outcomes

Events Averted per 10,000 Adults with DM Over 5 Years Time

macro events averted
Macro Events Averted

5 0 0

2 5 0

2 0 0

1 1 1

5 8

5 0

Relative Impact of Various DM Improvement Strategies on Population Health Outcomes

Events Averted per 10,000 Adults with DM Over 5 Years Time

slide15

5-Year Net Cost to Health Plan for Every 10,000 Adults with Diabetes for Selected Diabetes Care Improvement Strategies(Increased Treatment Costs - Savings from Averted Events)

diabetes improvement goals
Diabetes Improvement Goals
  • Various evidence-based diabetes clinical care recommendations have very different costs and very different benefits, calculated on a population basis
  • Aspirin use and blood pressure control have the most favorable ratio of benefits to costs
diabetes improvement goals1
Diabetes Improvement Goals
  • Lipid control in heart patients gives more benefit at lower cost than lipid control in patients without heart disease.
  • Glycemic control is an important element of diabetes care. Costs and benefits of glycemic control are sensitive to the HBA1c goal of care.
the enhanced primary care model

The Enhanced Primary Care Model

Better than Carve Out

Disease Management

enhanced primary care model advantages
Enhanced Primary Care Model--Advantages
  • Invest in Care System
  • -Extend Benefits to Multiple Clinical Domains
  • Strengthen, not Weaken Continuity and Coordination of Care
  • Seamless to Patients
  • Better Population Penetration
successful chronic disease care messages to docs
Successful Chronic Disease Care: Messages to Docs
  • Do This, or Die (Economic and Breadth of Practice Issues)
  • Don’t Blame Patients---Solve Problems
  • Doing things together is more important than doing things alone
    • Partner with the Patient
    • Team up with nurses, educators, other docs
slide21

The Enhanced Primary Care Model--Foundations

Data and Information

Systems Support

Activated

Patient

Effective

Care Team

CQI

Road Map

Guidelines

slide22

The Enhanced Primary Care Model--Operation

Registry

Planned

Care & Active

Outreach

Monitor

CQI

Prioritize

active registry or risk list
Active Registry or Risk List
  • For each doc and each clinic, new every 3 months
  • List of DM patients from highest to lowest HBA1c (later added CHD status and LDL-levels)
  • Permits proactive, population-based management
  • ID diabetes is 91% sensitive with 94% positive predictive value
  • Generally positive response from docs
monitor clinical status or risk
Monitor Clinical Status or Risk
  • HBA1c, LDL, CHD status
  • Want BP control, aspirin use, smoking status
  • Key Decision: What clinical domain to emphasize
    • Do what is easy? Or
    • Do what is right?
prioritize patients based on risk
Prioritize Patients Based on Risk
  • Novel concept to many nurses and educators
  • Use both clinical status and “readiness to change”
  • Focus most energy on those ready to change (varies by specific issue--smoking, diet, activity, DM care in general)
  • Those in worst shape most ready to change
  • Do NOT ignore those who are doing well--if so, doomed to clinical success and financial disaster (pipeline effect)
active outreach proactive care
Active Outreach -- Proactive Care
  • Need more than just docs to do this
  • Empower nurses and educators
  • Respect patient’s constitutional rights and privacy
  • Calls come directly from clinic, usually a nurse pt knows
  • First check: Medication intensity
  • Second check: Motivational and educational needs
visit planning
Visit Planning
  • A form of decision support
  • Do the hard way, by hand--too expensive
  • Do the easy way AMR/automated systems
  • Flow sheets are the poor clinic’s solution to this problem
  • Have not done yet, but results better than those who have made this a primary emphasis of improvement
  • AMR clinic with DM GL is good, but not best clinic
slide28

N = 4782

85.2%

N = 6238

85.1%

HBA1c Test Rate

chronic disease care
Chronic Disease Care
  • Identify Problems
  • Prioritize Problems in Partnership with Patient
  • Initiate Treatment
  • Monitor Response
  • Titrate to Goal
summary
Summary
  • 40% reduction in macrovascular risk
  • 25% reduction in microvascular risk
  • In well organized (enhanced) primary care clinics with a part time on-site DM nurse educator (not necessarily CDE)
  • Patient Education NOT associated with significantly better A1c
  • Improvement NOT due to: carve out disease management, endocrinology consults (<5% per year), less than 2% of patients use either TZD, alpha glucosidase, or meglitamides
key components
Key Components
  • Medical Group Physician Involvement and Leadership
  • Resources--show ”cost of doing nothing”
  • Intelligent use of information: identify patients with diabetes, monitor, prioritize, proactive outreach & visit planning
  • Organize clinics to give proactive, population-based care
  • Intensify Treatment--Titrate to Goal
  • Consider Evidence AND Value when selecting improvement goals
future directions
Future Directions
  • Variation Continues--Plenty of room for more improvement
  • Ascertain most appropriate level for QI intervention
  • Focus on blood pressure reduction
  • Focus on “Patient Activation”
  • Focus on Visit Planning
  • Focus on Physician decision making process and methods to change physician behavior
  • Development of “Patient Archetypes” to advance care