New Frontiers in Diabetes Prevention

1
New Frontiers in Diabetes Prevention
Management Technology Enabled Behavior Changes
Interventions

• Linda M. Siminerio, RN, PhD, CDE
• University of Pittsburgh
• School of Medicine Nursing
• Neal Kaufman, M.D., M.P.H
• Founder and Chief Executive Officer DPS Health
• Professor of Pediatrics and Public Health UCLA
• Co-founder, UCLA Center for Healthier Children,
  Families and Communities
• Malinda M Peeples RN, MS, CDEVice President
  Healthcare IntegrationWellDoc, Inc.

This research was sponsored by funding from the
US Air Force, administered by the US Army Medical
Research Acquisition Activity, Fort Detrick, MD
W81XWH-04-2-003 and W81XWH-07-2-0080
2
Objectives

• Role of technology in public health
• Benefits and limitations of new technology
• What new technologies are being employed
• What new technologies are being employed for type
  2 prevention

3
Presidents Health Care Reform

• Universal coverage
• Modernizing health care system
• Promoting wellness prevention

4
Epidemiologic Transition
Omran, A. The Epidemiologic Transition A theory
of the epidemiology of a population change.
Milbank Q. 197149509-538.
Non-Communicable Disease
Mortality Rates
Infectious Disease
Epidemiologic Transition
More information available at http//www.pitt.edu/
super1/lecture/lec0022/007.htm
5
Transition in Health Care
PARADIGM SHIFT
ACUTE CARE CHRONIC CARE
Focus prevention Care coordinated
Focus illness Care fragmented
6
Americas Diabetes Facts

• 20 increase in past 20 years
• 70 increase in diabetes in ages 30-39 1990-1998
  (CDC)
• Expected to increase 165 in 50 yrs
• Annual costs 174 billion
• Type 2 in children is increasing
• 30 of hospital admissions

7
Organization of Diabetes Care in US(What we
know)

• An acute care approach is not effective for
  chronic disease management
• Team care is best predictor of improvements in
  glucose control
• Shortages of endocrinologists, PCPs, CDEs
• Diabetes care delivery is primarily paternalistic
  with little attention to patients behavioral
  needs
• Diabetes education improves outcomes/needs follow
  up

8
Paradigm shift Patient-Centered Self-Management

• Too many patients too little time
• Lifestyle Disease and Patient Decisions
• Patients with diabetes provide about 98 of their
  own care
• patient-related factors contribute 98 of the
  effect on glycemic outcomes, while
• physician related factors contribute the
  remaining 2
• Funnell MM., et al Empowerment an idea whose
  time has come. The Diabetes Educator, 1991,
  1737-41.
• Tuerk, PW, et al. Estimating physician effects
  on glycemic control in the treatment of diabetes
  methods, effects sizes, and implications for
  treatment policy. Diabetes Care, 2008,
  31869-873.

9
Challenges Supporting Healthy Lifestyles

• Education is necessary but not sufficient and
  needs to be based on behavioral performance
• Individuals need different types of support
• Support from many places and many people
• Environments vary in ability to support
• Healthcare providers cant meet most needs
• Patients needs change during illness journey
• Solution Support patient self-management

10
Overall Objectives for Pittsburgh Projects

• Develop and evaluate web-based technological
  approaches that
• Promote self-management team care
• Are evidence-based
• Link health care providers to their patients
• Increase access
• Provide follow up

11
Using Technologyfor chronic disease management
The Chronic Care Model
Community
Health System
Resources and Policies
Organization of Healthcare
Delivery System Design
Decision Support
Clinical Information Systems
Self- Management Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Functional and Clinical Outcomes
12
Physician-Patient Portal

• Hypothesis
• Use of a patient portal directly linked to an EMR
  will facilitate communication between the
  physician and patient to improve outcomes
• Patients would be highly satisfied and would be
  willing to pay for use

13
(No Transcript)
14
Patient Satisfaction
15
Impact on Diabetes Process Measures

• Patients achieved more process measures and more
  likely to be at goals for diabetes related
  intermediate outcomes.
• Compared to patients over the same time period
  not using HealthTrak, there was no difference in
  the trend

Hess R, et al. Exploring challenges and
potentials of personal health records in diabetes
self management Implementation and initial
assessment. Telemedicine and e-Health. 2007.
16
HealthTrak focus group results

• Reluctant to pay for HealthTrak
• Reasons for reluctance to assign a monetary value
  included
• diabetes educators and calls are already provided
  free of charge
• preference for telephone communication
• and potential for the system to realize savings
  as a result of improvements (so the system should
  bear the costs)

Hess R, et al. Exploring challenges and
potentials of personal health records in diabetes
self management Implementation and initial
assessment. Telemedicine and e-Health.
2007. Bryce CL, et al. Value versus user fees
Perspectives of patients before and after using a
web-based portal for management of diabetes.
Telemed J E Health. 2008141035-43.
17
Conclusion

• Led to hypothesis that providing passive access
  to information and reminders is inadequate to
  change health outcomes and that future work
  should test more active self-management systems
• Patients reluctant to pay believe that benefit
  is for payor/system

18
Self-Care BehaviorsOutcome System

• Purpose
• Assess
• Gather
• Track
• Aggregate
• outcomes measures of behavior changes from
• diabetes self-management education (DSME)

19
Patient data Self-Care Framework
D-SMART Diabetes Self Management Assessment and
Reporting
20
Location
21
Overall Satisfaction
22
Diabetes Educator Patient Communication
23
Healthy Behaviors for Life

• Web-Based Interactive Educational Tools to
  Prevent Pediatric Obesity and Promote Lifelong
  Healthy Behaviors

Weight Management and Wellness Center
24
Program Description

• HB4Life is an evidence-based clinical program
  developed and implemented at Childrens Hospital
  of Pittsburghs Weight Management and Wellness
  Center to address pediatric obesity from
  prevention to early intervention and evaluation
  of treatment strategies.
• An integral part of the HB4Life is educating
  patients and families about healthy food choices
  and lifestyle behaviors.
• Interactive web-based educational tools allow
  patients and providers to track behaviors,
  enhances program exposure and reduces paper and
  printing costs.

25
Healthy Plate
26
Tracker
27
Conclusions and Implications

• To date, 84 children ages 3 to 19 years (median
  age 10 years) have registered on the web site and
  accessed tools in Pittsburgh.
• HB4Life.com will be implemented as part of the AF
  Wilford Hall Pediatric Wellness Centers program
  to address pediatric obesity the beneficiary
  population.
• Web-based tools will be compared to standard
  treatment for patients in a 6-month randomized
  controlled trial.

28
Why use Technologyfor health care?

• 75 of the US population had home Internet access
  in 2004 (vs. 66 in 2003)
• In 1998, 47 of female 26 of male users looked
  for health information online
• The kinds of information they look for include
• 62 an illness or disease
• 20 nutrition or fitness information
• 12 drug-related information
• 4 a doctor or hospital
• 2 online medical support

29
Benefits and limitations of new technology

• Reduce complications and morbidity
• Potential to improve access
• Societal shifts opportunities for remote
  support
• Enhance patient-provider relationships
• Improve communication
• Saves time
• Reduce healthcare utilization and cost
• Offers opportunity to track data -Improve
  population outcomes

30
Limitations of new technology

• Unanswered questions
• Does age affect use?
• Will technology broaden the gap with disparities?
• Limited computer availability
• Who pays?

31
Consider Who Pays?

• No/ Limited reimbursement for telephone consults,
  e-health and telemedicine
• Services for underserved Geographic locations
  with limited specialists and access issues are
  covered by CMS
• Insurers usually cover emergency/episodic care,
  stroke, dermatology
• E-visits email with physicians pilot with
  insurance plans
• Medicaid law does not recognize telemedicine as
  distinct service.
• Reimbursement for telemedicine is available at
  the state's option 18 states recognize service

32
Technology in Summary

• Shown to improve clinical outcomes
• Improves communications in regard to behavioral
  themes and processes (appts)
• Patients have access to systems and are satisfied
• Patients reluctant to pay
• Needs continued study
• Need to advocate for reimbursement

33
Virtual Lifestyle Management (VLM)

• Developed as a UPMC Portal enhancement
• Builds upon behavioral theory suggesting that
  efforts to promote long-term behavior change
  should include
• Information
• Behavioral tips
• Support
• Focus on weight loss, diet and physical activity
  patterns, for cardiovascular prevention
• Neal Kaufman, MD, MPh