Diabetes Care begins with Diabetes Prevention · 2018. 4. 3. · reduced their risk of developing type 2 diabetes (at average follow -up of 3 years) compared to placebo. And the lifestyle

Neha Sachdev, MDJanet Williams, MA

Diabetes Care begins with Diabetes Prevention

© 2018 American Medical Association. All rights reserved.

Objectives

• Describe the clinical practice burden and trends in type 2 diabetes

• Review evidence for diabetes prevention

• Describe AMA’s Stages of Engagement

2


Epidemiology and Clinical Burden of Prediabetes

3


Alex

4

• 2003 Prediabetes age 55

© 2018 American Medical Association. All rights reserved.5


• 2006 Type 2 Diabetes

GlucometerLancetsTest StripsDiabetes EducationMetforminStatinAspirin?ACE-I?Referral OphthalmologyReferral PodiatryOffice Visit q 3 monthsLabs and Urine

Alex




• 2016 Retinopathy

Alex




• 2016 Retinopathy

• 2020 CKD

Referral NephrologyPrior authorizationsOngoing refillsOngoing labsMedical complicationsAnemiaOsteoporosisEdema

Alex

© 2018 American Medical Association. All rights reserved.National Center for Chronic Disease Prevention and Health PromotionDivision of Diabetes Translation

Adults with Diagnosed Diabetes, Age-Adjusted Percentage

Disclaimer: This is a user-generated report. The findings and conclusions are those of the user and do not necessarily represent the views of the CDC.www.cdc.gov/diabetes/dataSource:

Americans have diabetes

30+MILLION

http://www.cdc.gov/diabetes

© 2018 American Medical Association. All rights reserved.National Center for Chronic Disease Prevention and Health PromotionDivision of Diabetes Translation

Adults Diagnosed with Diabetes in Ohio, Age-Adjusted Percentage

Disclaimer: This is a user-generated report. The findings and conclusions are those of the user and do not necessarily represent the views of the CDC.www.cdc.gov/diabetes/dataSource:

http://www.cdc.gov/diabetes


Health burden of diabetes

10

100%more likely to

develophypertension1

80%more likely to

be hospitalized for heart attack2

50%more likely to

be hospitalized for a stroke2

70%more likely todie from heart

disease or stroke2

Compared to people without diabetes, those with diabetes are:


Cost of diabetes


Total Medical Expenditure In The Years Leading to Diabetes Diagnosis

12

$ prior to diabetes diagnosis

(2010-2013)

Diabetes Diagnosis (2014)

$ over same 5 year period

(2010-2013)

No Diabetes Diagnosis (2014)

Ongoing research at the American Medical Association


Current burden of prediabetes

13

84 MILLION ADULTS HAVE PREDIABETES1

9 OF10 DON'T KNOW THEY HAVE PREDIABETES2

1 IN 3 ADULTS HAS PREDIABETES1

1 IN 2 65+age

A reversible condition in which plasma glucose levels are higher than normal but not high enough to diagnose type 2 diabetes

https://preventdiabetesstat.org/#reference1-1




Prediabetes diagnosis


Progression from prediabetes to type 2 diabetes

15


Prevention: need to engage the rising risk

Only 3% of our national health expenditure is spent on prevention1

Move beyond keeping the healthy well to target those with identifiable risk factors to prevent progression = rising risk

Stratifying a population

High cost/ utilization

Rising Risk e.g., 15% to 30% chance of progressing from prediabetes to diabetes†

Risk factors

Healthy / low risk

% o

f a P

opul

atio

n

Evidence Base for Diabetes Prevention


One solution: National Diabetes Prevention Program

18

Prediabetes is a reversible condition.

The National DPP can help patients lower their risk of developing type 2 diabetes and reduce the likelihood of:

ILLNESS MEDICATION EXPENSE


What is the National DPP?

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Examples of sessions:

1. Eat Well to Prevent T22. Get Active to Prevent T23. Shop and Cook to Prevent T24. Find Time for Fitness5. Eat Well Away from Home6. Stay Motivated to Prevent T27. Manage Stress8. Have Healthy Food You Enjoy


Historical starting point: DPP randomized controlled trial

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DPP Research Study: People with prediabetes who took part in a structured lifestyle change program reduced their risk of developing type 2 diabetes (at average follow-up of 3 years) compared to placebo.

And the lifestyle change program was nearly twice as effective as metformin.

DPPIntensive Lifestyle Change Program

(71% reduction for patients over age 60)

METFORMINGlucose Lowering Drug

(Currently, there is no FDA approval for metformin for the indication of diabetes prevention)

31%riskreduction58%risk

reduction


National DPP Lifestyle Change Program

21

Program goal

5%MINIMUM BODYWEIGHT LOSS IN 6 MONTHS

MONTHS OF MAINTENANCE6+

In-person program•Peer-to-peer camaraderie•Group support•Progress reports•CDC-recognized

Online program•Patient flexibility•Complete modules on own schedule•Web/mobile enabled dashboards •CDC-recognized

• Emphasis on prevention, and empowerment

• Lifestyle coach motivates and supports individuals


Benefits of the DPP

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15 FEWER NEW CASES OF DIABETES1

8 FEWER PATIENTS USING ANTI-HYPERTENSIVE MEDICATION2

4 FEWER PATIENTS USING ANTI-LIPID MEDICATION2

DPP clinical impact:(over 3 years, after program completion per 100 high-risk adults)

1. Knowler et al. N Engl J Med 2002;346:393-403.2. The DPP Research Group. Impact of lifestyle and metformin therapy on cardiovascular disease risk factors in the diabetes prevention program.

Diabetes Care 2005:28(4):888-894.


USPSTF abnormal glucose screening recommendation

23

USPSTF standards suggest testing patients every 3 years.

AGE & BMI

Grade B recommendation• 40-70 age AND• BMI ≥ 25* The American Diabetes Association encourages screening for diabetes at a BMI of ≥ 23 for Asian Americans



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Family historyFamily history of type 2 diabetes includes first-degree relatives (a person’s parent, sibling or child)

Medical history• Gestational diabetes

• Polycystic ovary syndrome

Racial and ethnic minorities• African Americans

• American Indians or Alaskan Natives• Asian Americans

• Hispanics or Latinos• Native Hawaiians or Pacific Islanders



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Grade B recommendation

• Screen for abnormal blood glucose with a fasting glucose, hemoglobin A1C or oral glucose tolerance test

• Refer patients with abnormal glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity


DPP Benefits Practicing Physicians & Health Systems

Why prioritize diabetes prevention?

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Allows physicians to offer our patients the intensive lifestyle change counseling they need, but that we don’t have the time/capacity to give

Aligns to value based care trends• Included as

Improvement Activities under QPP (MIPS)

• Aligns with PCMH standards

Medicare reimbursement scheduled to begin 2018

Achieves the IHI Triple (Quadruple) Aim• Better care: Adheres to evidence-based

guidelines for diabetes prevention• Better outcomes: Lowers incidence of

diabetes by 58 percent• Lower cost: Medicare estimated savings

at $2,650 per beneficiary• Improving Care Giver Experiences:

Reduce prevalence of diabetes


National Movement

27


Challenges Facing Clinical Team

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The current and growing volume of chronic disease

Lack of time to effectively deliver the intensive counseling needed for lifestyle changes

Social determinants of health often fall outside our scope of influence

Lack of adequate information about community-based resources for diabetes prevention




AMA Efforts to Prevent Diabetes

Goal:

Galvanize efforts to increase screening for prediabetes and raise participation in evidence-based diabetes prevention programs

Approach:

• Engage health systems across the U.S. in diabetes prevention

• Help link clinical practices to diabetes prevention programs

• Develop, test and disseminate relevant tools and resources

• Advocate for inclusion of lifestyle interventions in health benefits

31

www.preventdiabetesstat.org


Changing Clinical Practice

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AMA diabetes prevention offeringsThe AMA offers a comprehensive program to guide implementation of clinical practice change in order to prevent type 2 diabetes.

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Engagement Consulting Implementation support (admin)Services

Walk through core decisions

Tools and solutions(examples, not comprehensive)


Determine DPP offering

Internal DPP

Partner with community organization

Virtual DPP

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Something else


Physician and care team engagement• Clinic awareness

• Grand rounds

• Online modules

• PI CME (Part IV MoC)

35

www.preventdiabetesstat.org


STEPS Forward® and PI CME

36

www.stepsforward.org www.ama-assn.org/education


Patient identification

37


Patient communications

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preventidiabetesstat.org and doihaveprediabetes.org

http://www.preventidiabetesstat.org/

http://www.doihaveprediabetes.org/


Referral process and feedback loop

39


MONTH 1 MONTH 2 MONTH 3 MONTH 4

Secure Organizational

Buy-in

LaunchDPP

Submit CDC Application

Create Snapshot of

Potential Costs/

Benefits

Meeting/Phone Conference with the AMA

Identify Eligible Patients

Initiate Patient Communication

& Messaging

Identify Physician Champion

Develop Physician

Engagement & Education

Development Plan

Develop Referral

Process to DPP

Milestones

CLIENT JOURNEY MAP

AMA Facilitate

Webinar or Co-Present to Physician

Team

Define Reporting Metrics

Secure Class Location/Time

*Visual example; not fully comprehensive of the process in its entirety

Final Class Preparation

Identify and Train DPP Coaches


Evaluation

41

Identification

DPP Referral

DPP Enrollment

DPP Participation

CostOutcomesAttendance and Retention

Weight Loss Physical Activity HbA1c Blood Pressure Medications


System-wide Diabetes Prevention Strategic Plan

Purpose:

Intermountain will develop and implement a systematic and comprehensive approach to identify individuals at-risk for

diabetes and match them with evidence-based interventions in

an effort to prevent type 2 diabetes.

PROPRIETARY


Impact of Coverage:The Case Avoidance Equation

Target 1949 individuals for enrollment (total n=6495)

Cumulative DM incidence at 1 yrs:• DPP vs Controls (2.1% vs 5.0%)• 3% reduction

$6030 difference in healthcare costs for those with T2DM compared to those with prediabetes*

By hitting our enrollment goal, avoid 58 cases of diabetes......indicating a $349,723 savings to the system

*Internal analysis of Intermountain health plan claims

Could Intermountain target a 2018 enrollment goal for our Medicare capitated insurance product?


Shared Decision Making Tools

• The use of a decision aid (DA), defined as a tool that makes the clinical decision explicit, describes the options available, and helps people to understand these options as well as their possible benefits and harms, is one way to frame preference-sensitive decisions.

• This is particularly critical for patients with prediabetes, who are often confused about the short-term and long-term risks associated with their asymptomatic condition, are uncertain “what else they can do” to prevent diabetes, and feel “left in mid-air” to fend for themselves PROPRIETARY


Shared Decision Aid for Prediabetes

D E L I B E R A T I O N (45 to 60 minute clinical encounter with the pharmacist).

Initial Preferences Informed Preferences

PROPRIETARY

STAGE 1: Talk About Choice

• Step back & describe problem• Offer choice• Justify choice (explain uncertainty,

concept of personal preferences).• Check patient reaction

STAGE 2: Talk About Options

• Check knowledge ①• List options (lifestyle, metformin)

①• Describe options, including harms

and benefits ②• Provide decision support ②• Summarize

STAGE 3: Talk About Decision

• Focus on preferences ③• Elicit a preference ③• Leaning toward decision ④• Offer review ⑤• Make decision ⑥


Final Thoughts

46


Best practices for enabling physicians and care teams to refer• Raise awareness amongst physicians, care teams and patients through

Ad Council campaign, grand rounds, webinars and CME

• Approach as a process or quality improvement initiative

• “Automate” screening and referrals• Retrospective query to identify those at risk

• Criteria to identify those most at risk/likely to act/likely to be successful

• Referral through EMR

• Build feedback loops so that physicians can discuss progress with their patients

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Neha Sachdev – [email protected] Sill – [email protected]

Janet Williams – [email protected]

mailto:[email protected]




Questions

49

Documents

Diabetes Care begins with Diabetes Prevention · 2018. 4. 3. · reduced their risk of developing type 2 diabetes (at average follow -up of 3 years) compared to placebo. And the lifestyle