Making your office a diabetes center of excellence

1
Making your office a diabetes center of excellence

• Edward Shahady MD, ABFM, ABCL, FAAFP
• Clinical Professor of Family Medicine
• Medical Director Diabetes Master Clinician
  Program (DMCP)
• Florida Academy of Family Physicians (FAFP)

2
Objectives

• Discuss the 4 year experience of the DMCP with
  using a diabetes registry and group visits
• Identify clinical practice guidelines for care
  and recognize how well we are (not) meeting the
  guidelines
• Recognize barriers to achieving excellence in
  Diabetes Care
• Discuss current and emerging pharmacological
  agents used in the treatment of diabetes

3
How good is our care

• Nationally only 48 of patients are at ADA goal
  of lt7 HBA1C ?
• Only about 1/3 of diabetics are at goal of LDL
  OFlt100 and 1/3 at B/P goal of lt130/80 ?
• Our current system is not working
• Need something different
• DMCP created by Florida FAFP 2003 as a way to
  achieve excellence in diabetes care in the Family
  Physicians office
• ? Mokdad AH, Ford ES, Bowman BA, et al. Diabetes
  trends in the US 1990 1998. Diabetes Care.
  2000231278-1283.

4
DMCP

• Funded -grants from BCBS, Pfizer and Astra Zeneca
• 1 year of training includes classroom and visits
  to clinician site
• Taught patient and staff empowerment, diabetes
  standards, how to use a diabetes registry, group
  visits.
• Periodic Alumni meetings
• 49 practices-over 6000 patients and 22,000 visits
  May 2007)
• Frequent communication via email and telephone.
• Partner with Community Health Workers (Big Bend
  Rural Health Network)

5
Goal of the DMCP is to reduce patient, clinician,
staff and office barriers to achieving excellence
in diabetes care.
6
Noncompliance Defined as two people working
towards different goals
7
Why a Diabetes Registry ?

• Can not manage what you can not measure
• Registry provides clinicians total practice
  information as well as individual patient
  information.
• We know reduction in A1C, LDL and BP reduces
  mortality and morbidity If patients know their
  numbers and their goals they have a greater
  chance of reaching goal.
• Give Physicians and Staff a report card on how
  their practice is doing compared to others. P4P
• Provide Physicians rapid access to their high
  risk and moderate risk patients

8
Diabetes Master Clinician Program Florida Academy
of Family Physicians Foundation
9
(No Transcript)
10
Given to Dr. at the visit
11
150
Given to patient at visit
12
(No Transcript)
13
Patient lists also available for flu shots,
microalbumin and foot checks.
This list was used to generate names for the
Healthy Vision Project in Taylor county
14
(No Transcript)
15
Towers Perrin actuarial evaluation 2006-Bridges
to Excellence
16
(No Transcript)
17
Evidence that Rx Matters

• A 1 decrease in HbA1C decreases the chances of
  blindness, amputations and renal disease by 35
  (DCCT-UKPDS-Kumamoto) (Level A)
• Reduction of LDL (lousy cholesterol) less than
  100 or 70, and systolic blood pressure less than
  130-decreases CVD 50 TO 60 (CARDS, 4S, TNT,
  PROVE-IT) (Level A)
• 75 of the deaths and disability from diabetes
  associated with cardiovascular disease (CVD)
  (Level A)

18
HBA1C ADA Recommendations

• Lowering A1C associated with a ?in microvascular
  complications of diabetes (A) and possibly
  macrovascular disease (B).
• The general A1C goal is 7. (B)
• The A1C goal for the individual patient is an A1C
  as close to normal (6) as possible without
  significant hypoglycemia. (E)
• Less stringent goals appropriate for patients
  with a history of severe hypoglycemia, limited
  life expectancies, very young children or older
  adults, and individuals with comorbid conditions.
  (E)
• ADA 2007 Clinical Practice recommendations
  Diabetes Care 200730S3-41

19
Lipid Management ADA Recommendations

• Lifestyle modification focusing on the reduction
  of saturated fat, trans fat, and cholesterol
  intake weight loss, increased physical activity
  improve the lipid profile in patients with
  diabetes. (A)
• The primary goal is an LDL lt100 mg/dl (A) if
  high risk lt70 (A)
• For those gt 40 years old statin therapy to
  achieve an LDL reduction of 30 40 regardless of
  baseline LDL levels is recommended (A)
• Lower triglycerides to150 mg/dl and raise HDL
  cholesterol to gt 40 mg/dl in men and gt 50 mg/dl
  in women, should be considered. (C)
• ADA 2007 Clinical Practice recommendations
  Diabetes Care 200730S3-41

20
Guidelines (Goals) for Lipids

• Total Cholesterol lt135 ADA (E)
• LDL lt100 (ADA) lt70 ATP3- (A E)
• Can not use LDL if triglycerides gt200 (ATP3)-use
  Non-HDL cholesterol (E)
• Non-HDL cholesterol TC-HDL-it represents the
  small dense atherogenic particles-goal is 30gtthan
  LDL (ATP3) (E)
• DMCPreccomends all of above with individual goal
  of lt70 for LDL and lt100 for Non-HDL

21
Hypertension ADA Recommendations

• Treat Systolic BPlt130 (C), Treat Diastolic BP to
  lt80 (B)
• If BP gt140/90 should receive drug Rx as well as
  TLC (A)
• More than one drug often needed (B)
• Initial drug Rx should be with a drug that
  reduces CV events-ACE, ARB, Diuretics and CCB (A)
• All diabetics should receive an ACE or ARB (E)
• ADA 2007 Clinical Practice recommendations
  Diabetes Care 200730S3-41

22
Blood Pressure Goals

• The Patient should be seated quietly for 5
  minutes in a chair (not on an exam table), feet
  on the floor, and arm supported at heart level
  -two measurements (JNC7) (E)
• Goal lt130/80 ADA
• JNC7 gt140/90 Hypertension lt119/79 ideal, in
  between the two is pre-hypertension (B, E)
• DMCP individual goal of 119/79
• Joint National Committee on Prevention,
  Detection, Evaluation, and Treatment of High
  Blood Pressure. (The JNC 7 Report. JAMA.
  20032892560-2572.)

23
Anti-platelet ADA Recommendations

• Use aspirin (75162 mg/day) as a secondary
  prevention strategy in those with diabetes with a
  history of CVD. (A)
• Use aspirin as a primary prevention strategy in
  Type 2 patients 40 years of age who have
  additional risk factors (family history of CVD,
  hypertension, smoking, dyslipidemia, or
  micro-albuminuria). (A) Type 1 (C)
• Aspirin not recommended for patients lt 21
  because of the increased risk of Reyes syndrome.
  (E)
• ADA 2007 Clinical Practice recommendations
  Diabetes Care 200730S3-41

24
Influenza ADA Recommendations

• ADA recommends yearly Flu Shots (Level E)
• One case controlled study (Level B)-Vaccination
  was associated with a 56 reduction in any
  complication ,a 54 reduction in hospitalizations
  ,and 58 reduction in deaths
• Among study subjects aged 1864 years-higher
  reductions in the occurrence of any complication
  observed compared to those aged gt65 years (72
  vs. 39 reduction).
• In first-time vaccinated subjects, the primary
  end point was reduced by 47, and in those who
  received vaccination the year before, the
  reduction was 58.
• Diabetes Care 2006291771-1776,

25
Pneumovax (Pneumonia Shot)

• ADA recommends one shot is enough protection for
  a lifetime for most people. (E)
• People under 65 who have a chronic illness or a
  weakened immune system should obtain another
  injection 5-10 years after their first one.
• You can give Pneumovax anytime during the year.

26
Physical Activity ADA Recommendations

• To improve qlycemic control, assist with weight
  maintenance, and reduce risk of CVD, 150 min/week
  of moderate-intensity aerobic physical activity
  (5070 of maximum heart rate) and/or at least 90
  min/week of vigorous aerobic exercise (gt70 of
  maximum heart rate) is recommended. The physical
  activity should be distributed over at least 3
  days/week. (A)
• To maintain muscle strength perform resistance
  exercise three times a week, targeting all major
  muscle groups, progressing to three sets of 8 10
  repetitions at a weight that cannot be lifted
  more than 810 times. (A)
• ADA 2007 Clinical Practice recommendations
  Diabetes Care 200730S3-41

27
Nephropathy Screening ADA Recommendations

• To reduce the risk and/or slow the progression of
  nephropathy, optimize glucose and blood pressure
  control. (A)
• Perform an annual test for of micro-albuminuria
  in type 1 diabetic patients with diabetes
  duration of 5 years and in all type 2 diabetic
  patients, starting at diagnosis. (E)
• Serum creatinine should be measured annually for
  the estimation of glomerular filtration rate
  (GFR) in all adults with diabetes regardless of
  the degree of urine albumin excretion. (E)
• Continued surveillance of micro-albuminuria/protei
  nuria to assess response to therapy and
  progression of disease is recommended. (E)
• ADA 2007 Clinical Practice recommendations
  Diabetes Care 200730S3-41
• ADA 2007 Clinical Practice recommendations
  Diabetes Care 200730S3-41

28
Urine Microalbumin

• Micro-albuminuria (MA) may be a marker of
  cardiovascular risk.
• Excretion rate related to carotid artery
  intima-media thickness, large artery stiffness,
  and LVH
• MA reflects a state of diffuse endothelial
  dysfunction, low grade inflammation and vascular
  disease burden
• Tsioufis et al Am J Hypertension 200417470-476

29
Retinopathy Screening ADA Recommendations

• Patients with Type 1 diabetes should have an
  initial dilated eye examination by an
  ophthalmologist or optometrist within 35 years
  after the onset of diabetes. (B)
• Patients with type 2 diabetes should have an
  initial dilated eye examination by an
  ophthalmologist or optometrist shortly after the
  diagnosis of diabetes. (B)
• Subsequent examinations should be repeated
  annually by an ophthalmologist or optometrist.
  (E)
• Less frequent exams (every 23 years) may be
  considered in the setting of a normal eye exam.
  (E)
• Examinations will be required more frequently if
  retinopathy is progressing. (B)
• ADA 2007 Clinical Practice recommendations
  Diabetes Care 200730S3-41

30
Neuropathy Screening ADA Recommendations

• All patients should be screened for distal
  neuropathy at diagnosis and at least annually
  thereafter by the primary care office. Not a
  referral to podiatrist( A)
• Tests for sensation like 10-g monofilament
  pressure sensation and vibration perception using
  a 128-Hz tuning fork are excellent tools for
  detecting neuropathy. Use of both tests is 87
  sensitivity in detecting distal peripheral
  neuropathy. (B)
• Simple inspection of insensate feet should be
  performed at 3- to 6-month intervals. (B)
• Education of patients about self-care of the feet
  and referral for special shoes/inserts are vital
  components of patient management. (B)
• ADA 2007 Clinical Practice recommendations
  Diabetes Care 200730S3-41

31
Neuropathy Nephropathy Screening Pre-Diabetes
(Level B)

• The prevalence of a positive test when screening
  for nephropathy among those with undiagnosed
  diabetes was 26.5 compared with 7.1 in those
  with no diabetes ( P lt.01).
• For peripheral neuropathy, 21.5 with undiagnosed
  diabetes had positive screening tests compared
  with 10.1 with no diabetes ( P lt.01)
• NHANES data Ann Fam Med 20064427-432.

32
How well are we doing in implementing these
standards?
33
Diabetes Master Clinician Program Florida Academy
of Family Physicians Foundation
34
Barriers to effective Care
35
Noncompliance Defined as two people working
towards different goals
36
Patient Barriers to Goal Achievement

• Lack of trust in physician and office staff
• Lack of confidence in their ability to reach goal
• Lack of understanding of treatment regimen
• Costs and side effects greater than benefit
• Lack of transportation (25 in Quincy Study)
• Inability to pay for medication (30 in Quincy
  Study)
• Depression (25 in Quincy Study)
• Other emotional issues consume patients energy
• Shahady E, Barriers to Care in Chronic Disease
  Whos to Blame? Consultant Sept 2006

37
Physician/Staff Barriers

• Lack of time and system support
• Lack of reimbursement for counseling
• Major focus on acute medical problems
• Rewards for acute care are immediate-rewards for
  chronic care are delayed-medical school and
  residency teaches rewards of acute care.
• Not able to make chronic disease exciting
• Not trained to deal with chronic disease
  (cultural and literacy issues)
• Shahady E, Barriers to Care in Chronic Disease
  Whos to Blame? Consultant Sept 2006

38
System Barriers

• High Co-pay
• Frequent refill requirements
• Frequent staff turnover
• Established policies not promoting treatment to
  goal
• Limited staff for patient teaching
• Ineffective communication systems between
  different care providers
• Shahady E, Barriers to Care in Chronic Disease
  Whos to Blame? Consultant Sept 2006

39
Dealing with Barriers

• Need to empower patients and staff
• Patient is an equal member of the team-Patient
  the expert in the illness-physician expert in the
  disease.
• Patient identifies problems and learning needs
• Patient is the problem solver and caregiver,
  physician/clinician/staff the resource
• Patient has to feel the power and ability to
  change.
• Be a listener and facilitator
• Shahady E, Barriers to Care in Chronic Disease
  Whos to Blame? Consultant Sept 2006

40
Discuss current and emerging pharmacological
agents used in the treatment of diabetes
41
Metabolic Defects in Type 2 Diabetes
Glitizones
Glitizones
Skeletal Muscle Decreased Glucose uptake
Adipose Tissue lipolysis gtgtFFA
Glucotoxicity
Metformin
Lipotoxicity
Liver Increased glucose production (Glucagon
not suppressed)
Sulfonylurea
Pancreas a ß cell
Insulin
Incretin drugs
Incretin drugs Glitizones- ß cell preservation
Increased
Gut Carb Absorption
Inzucchi SE. JAMA. 2002287.360-72.
Serum Glucose
42
Nathan Diabetes Care 2006 291963-72
43
Downloaded from www.nejm.org May 21 2007
44
Obtained on line May 22, 2007 at
www.theheart.org/viewArticle.do?primaryKey792251
nl_idtho22may07
45
Meta-analysis of MI risk with rosiglitazone
n 15,560 on rosiglitazone n 12,283 on
comparator drug or placebo
Nissen SE, Wolski K. N Engl J Med. 2007356.
46
(No Transcript)
47
Januvia Galvis
Byetta
Clin Invest Med. 199518247254, Am J Physiol
Endocrinol Metab. 2003284E716E725, Diabetes
Care. 19847491502. Diabetologia.
20054817001713.
48
Incretin memetics

• Exenatide (Byetta FDA approved) given subcut-5 to
  10 mcg bid with sulfonylurea or metformin-reduced
  A1C .8 to .9, reduced weight 1.6 to 2.8 kg over
  a 30 week period (1)
• Negative effects-nausea in up to 40 of patients
  that decreases over time (only 3 stopped the
  drug)-hypoglycemia most significant with 10 mcg
  bid combined with sulfonylurea
• Liraglutinide-in phase 3 trials not FDA
  approved-is a once a day injectable agent with
  similar positive effects as exenatide in small
  studies(2)
• Kendall DM Diabetes Care 2005281083-91
• Madsbad S, Diabetes Care 2004271335-42

49
DPP-4 Inhibitors

• These drugs increase the level of endogenous
  GLP-1 by inhibiting DPP4
• Januvia (Sitaglipin) and Galvus (Vildaglipin)
• They are oral agents given once a day-
• Several trials (1,2) found a reduction in A1C of
  0.5 to 1 after a year (1), and an increase in
  beta cell mass (2)
• Both are weight neutral
• Use as monotherapy or as second and third oral
  agent
• Ahren B, Diabetes Care 2004272874-80
• Duttaroy, Diabetes 200554(suppl 1)A141

50
RIO clinical trial program Efficacy overview
RIO-Europe, RIO-Lipids, RIO-NA Placebo-corrected
change from baseline at 1 year
Van Gaal LF et al. Lancet. 2005. Després J-P et
al. N Engl J Med. 2005.Pi-Sunyer FX et al. JAMA.
2006.
P 0.002 vs placebo P 0.02 vs placebo
51
RIO-Diabetes Treatment effectsChange from
baseline at 1 year
Scheen AJ et al. Lancet. 20063681660-72.
52
Thanks for your attention