IMPROVING DIABETES CARE FOR ADULTS: A PopulationBased Approach

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IMPROVING DIABETES CARE FOR ADULTS A
Population-Based Approach

• Patrick J. OConnor, MD, MPH
• Senior Clinical Investigator
• HealthPartners Research Foundation

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Todays 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

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Burden of Diabetes in the US Morbidity 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.
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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.

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Economic Burden of Diabetes in Adults

• The Cost of Doing Nothing

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CHD DM
DM only
HBA1c
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Selecting Improvement Goals

• All Goals Are Not Equal

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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

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Percent of Adult Diabetes Patients NOT at Goal
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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
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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
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Number Needed to Treat for 5 Years to Prevent One
Heart Attack or Stroke
6 0
4 0
2 0
1 2
6
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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
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Direct Costs of DM Improvement Strategies
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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)
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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

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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.

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The Enhanced Primary Care Model

• Better than Carve Out
• Disease Management

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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

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Successful Chronic Disease Care Messages to
Docs

• Do This, or Die (Economic and Breadth of
  Practice Issues)
• Dont 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

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The Enhanced Primary Care Model--Foundations
Data and Information Systems Support
Activated Patient
Effective Care Team
CQI
Road Map Guidelines
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The Enhanced Primary Care Model--Operation
Registry
Planned Care Active Outreach
Monitor
CQI
Prioritize
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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

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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?

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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)

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Active Outreach -- Proactive Care

• Need more than just docs to do this
• Empower nurses and educators
• Respect patients constitutional rights and
  privacy
• Calls come directly from clinic, usually a nurse
  pt knows
• First check Medication intensity
• Second check Motivational and educational needs

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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 clinics 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

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N 4782 85.2
N 6238 85.1
HBA1c Test Rate
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Cross-Sectional Change in Mean HBA1c
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Cohort LDL Changes
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Chronic Disease Care

• Identify Problems
• Prioritize Problems in Partnership with Patient
• Initiate Treatment
• Monitor Response
• Titrate to Goal

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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 (lt5 per
  year), less than 2 of patients use either TZD,
  alpha glucosidase, or meglitamides

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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

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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