Transcript Diabetes Master Clinician Program Florida Academy of

The Diabetes Registry: A CostEffective Approach to Practicing
Quality Medicine
Edward Shahady, MD
Medical Director, Diabetes Clinician Program
Florida Academy of Family Physicians
“Diabetes is the 6th leading cause of death, leading
cause of blindness, chronic renal disease,
amputations and a major contributor to coronary
artery disease and strokes.
Florida with its aging population has a large number
of diabetic and pre-diabetic patients that require
extensive medical attention.
The extent of this care demands time, knowledge,
compassion and commitment from all members of the
clinician’s office, the patient, families and other care
givers. Simply stated it takes a village to care for a
diabetic.”
More Diabetes Facts
• 20% of Medicare population has diabetes
• 30% of the Medicare Budget is spent on diabetes
• Leading cause of blindness is diabetic retinopathy
and it is 90% preventable - National Eye Institute
• Diabetic nephropathy is the leading cause of end
stage renal disease - most is preventable - NIDDKD
• Diabetes accounts for 60% of all non-traumatic
amputations - 85% preventable - ADA CDC
Epidemic of Diabetes
• Between 2009 and 2034, # with diagnosed and
undiagnosed diabetes is anticipated to increase
from 23.7 million to 44.1 million.
• During the same period, annual diabetes-related
spending is expected to increase from $113 billion to
$336 billion (2007 dollars).
• Medicare - the diabetes population is expected to
rise from 8.2 million in 2009 to 14.6 million in 2034
“Excellent evidence documents that when patients
achieve control of their HbA1c, LDL and Blood
pressure through life style changes and medication,
obtain recommended immunizations, eye exams, foot
exams, urine microalbumin and take aspirin daily,
significant reduction in complications will be
achieved.
Practices that measure individual and practice
achievement of these evidenced based activities and
share that information with clinicians, staff and
patients achieve better diabetes control and reduce
costs and complications.”
Background Information
• DMCP Florida Academy of Family Physicians started in
November 2003
• Funded by grants
• Now have 84 offices and over 250 clinicians and 450
nurses; MA’s have received training and use the
registry
• Partnering with ADA, JADE, and Rural Health Networks
- St John’s, Big Bend, and Heartlands
Background Information
(Training)
• After all their diabetes data are entered into the registry the
clinician and staff (MA/LPN) receive initial training of 4.0
hours followed by two 2-hr sessions over one year.
• Follow-up training consists of visits to clinicians office and
of emails sharing data and recent articles
• Training includes(evidenced based CME credit)
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Evidence Based standards of care
How to use patient reports from diabetes registry
How to use population reports from the registry
How to conduct group visits
Up-to-date knowledge about diabetes, lipids and hypertension
How to address clinician and patient barriers to standards
adherence - clinical inertia
Value of DMCP
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Increased quality of care for diabetics in your practice
Decreased complications and suffering for your patients
Entry into the Medical Home concept
Increased reimbursement for quality of care
Increased prestige through recognition and certification
– Office recognized as a center of diabetes excellence
– Clinicians certified as Diabetes Master Clinicians
– Staff certified as Diabetes Master Clinician Associates
DMCP Diabetes Registry
• Is Internet based - all data and reports on the
web
• Research assistant places initial data for all
diabetic patients from a practice into the
registry.
• Staff then keeps up data entry
• Initial training begins once data from practice is
entered
In addition to the registry,
taught how to do group
visits.
Actual group visit - patients completing
first part of medical record
Registry Reports (Tools)
• Point of Care Reports for the clinician and the
Patient - report cards
• Population-based Reports that identify
• Patients at increased risk because of
increased HbA1c, LDL, B/P, non-HDL,
triglycerides
• Patients who do not have documented
annual recommendations or daily ASA
Barriers to Quality Achievement
• Most clinicians believe they are achieving better
goal attainment than they are
• Do not have a feel for the patients who are not
being seen
• Office staff not used to aiding quality
achievement-push to the limit of their license
• Reimbursed for volume and ability to code - not
quality
Lets look at the
evidenced-based
goals for diabetes
care that are used in
our registry.
What does reaching goals accomplish?
• 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 risk of CVD 40-50%
(CARDS, 4S, TNT, PROVE-IT) (Level A)
A1C goals?
• For patients in general, is an A1C goal of 7% (B)
• For the individual patient, as close to normal (6%)
as possible without hypoglycemia (E, A)
• Less stringent goals if patient has history of
severe hypoglycemia, older, prior CV event, etc.
• Obtain A1C every 3 months (not controlled - every
6 months controlled)
– (2010) ADA Clinical Practice Recommendations
Diabetes Care. Available at: www. diabetes.org
Lipid goals?
• Obtain lipid profile at least 1 time a year (E)
• The primary goal is an LDL <100 mg/dl (A) if high risk <70 (E)
Recent suggestion is <70 if diabetes plus one risk factor
(smoking, >BP, Fam Hx).
• For those >40 years old statin therapy to achieve an LDL
reduction of 30-40% regardless of baseline LDL levels is
recommended (A)
• Lower triglycerides to 150 mg/dl and raise HDL cholesterol to
>40 mg/dl in men and >50 mg/dl in women
•
(2010) ADA Clinical Practice Recommendations Diabetes Care. Available at: www. diabetes.org
B/P goals?
• Treat systolic BP<130 (B), treat diastolic BP to <80 (B)
• Drug Rx as well as TLC (A)
• More than 1 drug often needed (B) usually add a diuretic
to ACE or ARB
• Measure B/P with feet on floor and arm supported at
heart level: two measurements (JNC7) (E)
• ADA goal 130/80
– (2010) ADA Clinical Practice Recommendations Diabetes Care.
Available at: www.diabetes.org , Chobanian AV et al. (2003)
JAMA 289(19):2560-2572
Other goals?
• Yearly flu shots (B)
• Pneumovax (1 shot): if first shot before 65, another 5-10
years after first
• Dilated eye exam yearly in T2D, T1D 3-5 years after the
onset , then yearly (B)
• Annual test for of micro-albuminuria even if on ACE or
ARB (E)
• Annual test for sensation like 10-g monofilament
pressure sensation and vibration perception using a 128Hz tuning fork excellent tools for detecting neuropathy feet (B)
– (2010), ADA Clinical Practice Recommendations Diabetes Care.
Available at: www. diabetes.org
Let’s look at some
reports from the
registry.
Saves
Clinician 5
Minutes
Patient
Report
Care
Also in
Spanish
Report
informs
practice of
goal
achievement.
Report informs
each clinician
of goal
achievement.
Report
informs each
clinician of
goal
achievement.
Reports identify
patients at high
risk - not at goal
- all names
fictitious.
Patients not
at goal for
LDL
How many patients with CKD are at LDL
goal? Don’t know without a registry
• National Kidney foundation goal for LDL in CKD is
<100
• 4541 patients in Kaiser Colorado System - with GFR
<60
– 1384 - 30% no lipid profile in last 365 days
– 3157 - 70% of those that had a lipid profile at LDL goal
– 72% of those at goal on a statin (only drug with evidence of
↓ of CAD in patients with CKD and ↓ in progression of loss
of renal function
• Stadler et al J. Clin Lipidology 2010;4;298-304
Diabetics
at-risk
smokers
Patients who
have not had
recommended
quality measure
for 5 items
Use this
report to
improve
screening
for CKD in
diabetes
Office staff are the missing link to
reaching quality goals.
Need to push them to limit of their
licensure.
Impact of Medical Assistants
Over 8-month period for 140 patients
1. MA gave
patients and
physicians
report cards
2. MA Ordered
tests per
protocol and
3. MA did the
monofilament
exams
Sample of Best Practices
Towers Perrin actuarial evaluation
2006 Bridges to Excellence
ADA Quality
Yearly Cost
Indicator
Savings if
indicator achieved
HBA1C ≤ 7
$279.00
LDL
≤ 100
Syst BP ≤ 130
Total yearly
savings
$369.00
$474.00
$1122.00
http://www.bridgestoexcellence.org
Yearly Cost Savings using Bridges to
Excellence data as of June 2009
# Patients reaching
goal for quality
indicator above
national average in
2002
HbA1c 1079 patients
Yearly Cost Savings if
indicator achieved
$301,041.00
LDL
3582 patients
$1,321,758.00
BP
3938 patients
$1,866,612.00
Total yearly savings
$3,489,411.00
www.bridgestoexcellence.org
http://www.fafp.org/diabetes_mc.html
Other information
• Dr. Shahady can be contacted at
[email protected].
Questions
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