Performance Performance Improvement: Improvement:

Continuing Continuing Medical EducationMedical Education

Lara Zisblatt, MALara Zisblatt, MAAssistant DirectorAssistant DirectorBoston University Boston University

School of MedicineSchool of MedicineContinuing Medical EducationContinuing Medical Education

Welcome!Welcome!

To register: To register: www.mentorqi.comwww.mentorqi.com

To preview the site, please go to: To preview the site, please go to: http://http://www.mentorqi.comwww.mentorqi.com/Apps//Apps/System/System/Logon.aspxLogon.aspx–– User name: diabetesUser name: diabetes

–– Password: diabetesPassword: diabetes

MENTOR QIMENTOR QI™™ Diabetes Performance Diabetes Performance Improvement Initiative, Improvement Initiative, Getting Patients Getting Patients to Goal in to Goal in GlycemicGlycemic ControlControl

Performance Improvement CMEPerformance Improvement CME

Performance Improvement: 20 Performance Improvement: 20 AMA AMA PRA Category 1 CreditsPRA Category 1 Credits™™

Teleconferences: 1 Teleconferences: 1 AMA PRA Category AMA PRA Category 1 Credit1 Credit™™ for each teleconference, total for each teleconference, total of 6 teleconferencesof 6 teleconferences

Total of 26 Total of 26 AMA PRA Category 1 CreditsAMA PRA Category 1 Credits™™

MENTORQI.comMENTORQI.com StepsSteps

On left side bar, click on:On left side bar, click on:2. Practice Assessment2. Practice Assessment

–– Survey of 23 questions to get a snapshot of Survey of 23 questions to get a snapshot of your practiceyour practice

3. My Patient Chart Review (Baseline)3. My Patient Chart Review (Baseline)–– Complete 10 chart reviews of patients with a Complete 10 chart reviews of patients with a

diagnosis of type 2 diabetesdiagnosis of type 2 diabetes

4. Assess My Performance4. Assess My Performance–– Review a feedback report of your baseline data, Review a feedback report of your baseline data,

your peersyour peers’’ data, and national benchmarksdata, and national benchmarks

MENTORQI.comMENTORQI.com StepsSteps

On left side bar click on:On left side bar click on:5. Build Action Plan5. Build Action Plan

–– Choose from a menu of intervention options that include Choose from a menu of intervention options that include building a patient registry or creating a patient reminder building a patient registry or creating a patient reminder system for A1C testingsystem for A1C testing

–– Implement your Action Plan and wait 3 months before Implement your Action Plan and wait 3 months before reassessmentreassessment

6 & 7. Chart Review and Practice Assessment 6 & 7. Chart Review and Practice Assessment (Follow(Follow--up)up)

–– After the 3After the 3--month waiting period, you will be invited back to month waiting period, you will be invited back to the site to complete your followthe site to complete your follow--up practice assessment and up practice assessment and chart reviewchart review

–– After completing the followAfter completing the follow--up activities, you will receive up activities, you will receive your certificate for 20 your certificate for 20 AMA PRA Category 1 CreditsAMA PRA Category 1 Credits™™..

Maintenance of CertificationMaintenance of Certification

Approved by the American Board of Approved by the American Board of Family Medicine (ABFM) for Part IV Family Medicine (ABFM) for Part IV Credit required for Maintenance of Credit required for Maintenance of Certification for Family Physicians Certification for Family Physicians

If you are interested in Part IV credit, If you are interested in Part IV credit, please eplease e--mail BUSM CME at mail BUSM CME at mentorqi@bu.edumentorqi@bu.edu or call us at or call us at 800.688.2475800.688.2475

ParticipantsParticipants

8080GRAND TOTALGRAND TOTAL

22STUDENTSTUDENT

22REGISTERED NURSEREGISTERED NURSE

1717PHYSICIAN ASSISTANTPHYSICIAN ASSISTANT

1414PHYSICIANPHYSICIAN

22PHARMACISTPHARMACIST

22NUTRITIONIST/DIETITIANNUTRITIONIST/DIETITIAN

4141NURSE PRACTITIONERNURSE PRACTITIONERTOTALTOTALPROFESSIONPROFESSION

Thank You!Thank You!

Please complete chart reviews as soon Please complete chart reviews as soon as possibleas possible

If you are having trouble completing If you are having trouble completing the chart reviews, please let us know. the chart reviews, please let us know. We can help!We can help!

If you have any questions, please If you have any questions, please ee--mail us at mail us at mentorqi@bu.edumentorqi@bu.edu or call or call us at 800.688.2475us at 800.688.2475

Type 2 Diabetes Performance Type 2 Diabetes Performance Improvement Program:Improvement Program:

Clinical OverviewClinical Overview

Elliot Sternthal, MD, FACPElliot Sternthal, MD, FACPClinical Director of Clinical Director of Diabetes ServicesDiabetes Services

Boston Medical CenterBoston Medical CenterBoston, MABoston, MA

Overview of Diagnosed and Undiagnosed Overview of Diagnosed and Undiagnosed Diabetes in the United StatesDiabetes in the United States——20082008

Adapted from American Diabetes Association. Available at: Adapted from American Diabetes Association. Available at: http://http://www.diabetes.orgwww.diabetes.org. Accessed. AccessedJune 25, June 25, 2008. 2008.

People Without People Without DiabetesDiabetes

Diagnosed: Diagnosed: 18 million18 million

Undiagnosed: Undiagnosed: 6 million6 million

People With Diabetes: 24 million People With Diabetes: 24 million (8.0% of the population)(8.0% of the population)

Incidence: 1.5 million new cases diagnosed yearlyIncidence: 1.5 million new cases diagnosed yearlyNumber of adult patients predicted to grow to ~22 million by 20Number of adult patients predicted to grow to ~22 million by 202525Vast majority (>90%) of cases are type 2 diabetesVast majority (>90%) of cases are type 2 diabetes

The Dual Epidemic:The Dual Epidemic:Obesity and DiabetesObesity and Diabetes

65% of US adults are overweight (BMI >25) and 65% of US adults are overweight (BMI >25) and 30% are obese (BMI >30)30% are obese (BMI >30)24% have the Metabolic Syndrome24% have the Metabolic SyndromeThere are now an estimated 24 million people There are now an estimated 24 million people with diabetes mellitus (DM) in the US; 57 million with diabetes mellitus (DM) in the US; 57 million have prehave pre--diabetesdiabetesThe lifetime risk of developing DM for people The lifetime risk of developing DM for people born in 2000 is 33% for men and 39% for womenborn in 2000 is 33% for men and 39% for women–– For Hispanic women, the lifetime risk is 50%For Hispanic women, the lifetime risk is 50%

In this population, cardiovascular disease (CVD) In this population, cardiovascular disease (CVD) is the major cause of mortalityis the major cause of mortality

Obesity Trends* Among US AdultsObesity Trends* Among US Adults

*BMI *BMI ≥≥30.30.Adapted from Centers for Disease Control and Prevention. Adapted from Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance Behavioral Risk Factor Surveillance SystemSystem. Available at: http://. Available at: http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/index.htmwww.cdc.gov/nccdphp/dnpa/obesity/trend/maps/index.htm. . Accessed June 20, 2008.Accessed June 20, 2008.

Role of Obesity in Metabolic Role of Obesity in Metabolic Syndrome (MS)Syndrome (MS)

NHANES III PopulationNHANES III Population–– Normal weight Normal weight –– 5% had MS5% had MS–– Overweight Overweight –– 22% had MS22% had MS–– Obese Obese –– 60% had MS60% had MS

Framingham PopulationFramingham Population–– Obese w/o MS Obese w/o MS –– no significant no significant risk of DM2 or risk of DM2 or

CVDCVD–– Obese with MS Obese with MS –– 10 x 10 x risk DM2, 2 x risk DM2, 2 x risk CVDrisk CVD–– Normal weight with MS Normal weight with MS –– 4 x 4 x risk DM2, 3 x risk DM2, 3 x

risk CVDrisk CVD

Metabolic Syndrome and Metabolic Syndrome and Type 2 DiabetesType 2 Diabetes

BotniaBotnia Study (large, highStudy (large, high--risk family study in risk family study in Finland & Sweden)Finland & Sweden)–– 84% men & 78% women with DM2 had MS84% men & 78% women with DM2 had MS–– 64% men & 42% women with pre64% men & 42% women with pre--DM had MSDM had MS–– 15% men & 10% women with normal glucose tolerance 15% men & 10% women with normal glucose tolerance

had MShad MSProspective Observational StudiesProspective Observational Studies–– NonNon--diabetic Pima Indians with MS: 2.1diabetic Pima Indians with MS: 2.1--3.6 x 3.6 x risk risk

DM2DM2–– Caucasians with MS: 7Caucasians with MS: 7--34 x 34 x risk DM2risk DM2

MS components without impaired fasting MS components without impaired fasting glucose still at glucose still at risk of DM2risk of DM2

IsomaaIsomaa B, et al. B, et al. Diabetes CareDiabetes Care. 2001;24:683. 2001;24:683--689.689.

Primary Care Providers Must Be Involved Primary Care Providers Must Be Involved in the Care of Patients With Diabetesin the Care of Patients With Diabetes

Approximately 20% of primaryApproximately 20% of primary--care patients have care patients have diabetesdiabetes>90% of individuals with diabetes are managed by PCPs>90% of individuals with diabetes are managed by PCPsPCPs refer <10% of patients with diabetes to PCPs refer <10% of patients with diabetes to endocrinologistsendocrinologists~60% referrals for insulin~60% referrals for insulin--replacement Rxreplacement RxMajority of PCPs have <4 hr diabetesMajority of PCPs have <4 hr diabetes--related education in related education in medical schoolmedical schoolNeed for continuous supplementary educationNeed for continuous supplementary education~5000 endocrinologists in US, 66% office~5000 endocrinologists in US, 66% office--basedbased12% fewer endocrinologists than needed; gap to worsen 12% fewer endocrinologists than needed; gap to worsen from 2010 onwardfrom 2010 onward

Unger J. Primary Care Network, Unger J. Primary Care Network, Primary IssuesPrimary Issues. 2002;4:1. 2002;4:1--3.3.Unger J. Unger J. Female PatientFemale Patient. 2003;28:12. 2003;28:12--16.16.

Costs Associated With DiabetesCosts Associated With Diabetes

DM + CAD + HTN (x 3 yr) is 300% > DM DM + CAD + HTN (x 3 yr) is 300% > DM alone ($46,000 alone ($46,000 vsvs $14,000)$14,000)

A1C from 6%A1C from 6%→→10%: 10%: 11% in 11% in overall costs per patientoverall costs per patient

If each PCP If each PCP A1C by 2% in 100 pts = A1C by 2% in 100 pts = savings of $150,000 per provider x 3 yrsavings of $150,000 per provider x 3 yr

DM, diabetes mellitus; CAD, coronary artery disease, HTN, hypertDM, diabetes mellitus; CAD, coronary artery disease, HTN, hypertension.ension.

Gilmer TP, et al. Gilmer TP, et al. Diabetes CareDiabetes Care. 2005;28:59. 2005;28:59--64.64.

Level of Glycemic Control in Level of Glycemic Control in Type 2 DM Patients: NHANES DatabaseType 2 DM Patients: NHANES Database

12.4% have A1C >10%12.4% have A1C >10%

20.2% have A1C >9%20.2% have A1C >9%

37.2% have A1C >8% 37.2% have A1C >8%

64.2% have A1C >7%64.2% have A1C >7%

Treated to <7% (NHANES 1988Treated to <7% (NHANES 1988--1994 1994 vsvs19991999--2000)2000)–– 1994 1994 –– 44.5%44.5%

–– 2000 2000 –– 35.8% (improved in 2002)35.8% (improved in 2002)KoroKoro CE, et al. CE, et al. Diabetes CareDiabetes Care. 2004;27:17. 2004;27:17--20. 20.

Prevalence of Retinopathy vs Prevalence of Retinopathy vs Duration of Type 2 DiabetesDuration of Type 2 Diabetes

Patie

nts

with

retin

opat

hy (%

)Pa

tient

s w

ith re

tinop

athy

(%)

Harris MI, et al. Harris MI, et al. Diabetes CareDiabetes Care. 1992;15:815. 1992;15:815--819.819.

YearsYears

00

2020

4040

6060

8080

--1010 --6.56.5 --4.24.2 00 55 1010 1515 2020

Wisconsin populationWisconsin population

Australian populationAustralian population

Apparent onsetApparent onsetprior to prior to

diagnosisdiagnosis

Time of diagnosisTime of diagnosis

Adapted from RamloAdapted from Ramlo--Halsted BA, Edelman SV. Halsted BA, Edelman SV. Prim Care. Prim Care. 1999;26:7711999;26:771--789.789.

Natural History of Type 2 DiabetesNatural History of Type 2 Diabetes––Implications of Delayed DiagnosisImplications of Delayed Diagnosis

Macrovascular complicationsMicrovascular complications

Insulin resistanceInsulin resistance

ImpairedImpairedglucose toleranceglucose tolerance

UndiagnosedUndiagnoseddiabetesdiabetes Known diabetesKnown diabetes

Insulin secretionInsulin secretionPostprandial glucose

Fasting glucoseFasting glucose

MicrovascularMicrovascular Complications Occur With Complications Occur With Glycemia Below PreGlycemia Below Pre--diabetic Rangediabetic Range

MetaMeta--analysis of Blue Mountains Eye Study (n=3162), analysis of Blue Mountains Eye Study (n=3162), Australian Diabetes, Obesity, and Lifestyle Study (n=2182) Australian Diabetes, Obesity, and Lifestyle Study (n=2182) & Multi& Multi--Ethnic Study of Atherosclerosis (n=6079)Ethnic Study of Atherosclerosis (n=6079)

Retinopathy now more accurately diagnosed with multipleRetinopathy now more accurately diagnosed with multiple--field retinal photographsfield retinal photographs

>60% retinopathy cases found among patients with fasting >60% retinopathy cases found among patients with fasting plasma glucose (FPG) <126 mg/plasma glucose (FPG) <126 mg/dLdL

7.4% to 13.4% had retinopathy at glucose level <100 mg/7.4% to 13.4% had retinopathy at glucose level <100 mg/dLdL(previous studies: 2%(previous studies: 2%--4% prevalence)4% prevalence)

17.8% to 34.7% had retinopathy at glucose level >126 mg/17.8% to 34.7% had retinopathy at glucose level >126 mg/dLdL

Results Results c/wc/w gradual gradual in retinopathy prevalence with in retinopathy prevalence with FPGFPG

Wong TY, et al. Wong TY, et al. LancetLancet. 2008;371:736. 2008;371:736--743. 743.

DCCT Research Group. DCCT Research Group. N Engl J MedN Engl J Med. 1993;329:977. 1993;329:977--986.986.Ohkubo Y, et al. Ohkubo Y, et al. Diabetes Res Clin Diabetes Res Clin PractPract.. 1995;28:1031995;28:103--117.117.

Intensive Insulin Therapy:Intensive Insulin Therapy:Microvascular Risk Reduction in Two TrialsMicrovascular Risk Reduction in Two Trials

* * AlbuminuriaAlbuminuria >300 mg/24 hr.>300 mg/24 hr.†† Worsening of Worsening of albuminuriaalbuminuria >300 mg/24 hr.>300 mg/24 hr.

Significantly improvedSignificantly improved60%60%NeuropathyNeuropathy

70%70%††54%*54%*NephropathyNephropathy

69%69%63%63%RetinopathyRetinopathy

KumamotoKumamotoDCCTDCCTStudyStudy

Reduction in Risk with 2%Reduction in Risk with 2%Reduction of A1CReduction of A1CComplicationComplication

United Kingdom Prospective Diabetes Study (UKPDS)United Kingdom Prospective Diabetes Study (UKPDS) Group. Group. Lancet.Lancet. 1998;352:8371998;352:837--853853.

9

8

7

60

0 3 6 9

Years

Median A1C (%)

Glycemic Responses in the UKPDSGlycemic Responses in the UKPDS

12

Conventional therapyIntensive therapy

1010--Year CohortYear Cohort

10-year median7.9%

10-year median7.0%

United Kingdom Prospective Diabetes Study (UKPDS) Group. United Kingdom Prospective Diabetes Study (UKPDS) Group. LancetLancet. 1998;352:837. 1998;352:837--853.853.

Intensive Therapy Policy Intensive Therapy Policy Various Endpoints in the UKPDSVarious Endpoints in the UKPDS

PP<.03<.0312%12%All diabetesAll diabetes--related related endpoints studiedendpoints studied

PP=.052=.05216%16%Myocardial infarctionMyocardial infarction

PP<.01<.01PP<.02<.02PP<.0001<.0001

25%25%21%21%33%33%

All All microvascularmicrovascular•• Retinopathy progressionRetinopathy progression•• MicroalbuminuriaMicroalbuminuria

Reduction in Risk WithReduction in Risk With0.9% Reduction of A1C0.9% Reduction of A1CComplicationComplication

Does Normalizing Glycemia Does Normalizing Glycemia Reduce CV Risk?Reduce CV Risk?

ADVANCE ADVANCE (n=11,140); 5 yr; baseline A1C 7.2%; A1C 6.5 (n=11,140); 5 yr; baseline A1C 7.2%; A1C 6.5 vsvs 7.3% 7.3% –– No significant reduction in CV endpoints or allNo significant reduction in CV endpoints or all--cause mortality; cause mortality;

21% 21% new/worsening nephropathy (48% on new/worsening nephropathy (48% on statinstatin, 57% on aspirin), 57% on aspirin)

ACCORD ACCORD (n=10,251); 3.5 yr (terminated early); baseline A1(n=10,251); 3.5 yr (terminated early); baseline A1CC 8.1%; 8.1%; A1A1CC 6.4% 6.4% vsvs 7.5%7.5%–– No significant reduction in composite CV endpoint; lower signifiNo significant reduction in composite CV endpoint; lower significant cant

nonfatal MI rate; significantly higher rate of death from CV caunonfatal MI rate; significantly higher rate of death from CV causes; ses; significant increase in allsignificant increase in all--cause mortality (54 extra deaths)cause mortality (54 extra deaths)

CritiqueCritique: trials too short; late intervention in atherosclerotic process: trials too short; late intervention in atherosclerotic process; ; those with shorter duration of diabetes did better with intensivthose with shorter duration of diabetes did better with intensive e glucose therapy; rapid rate of A1C reduction in ACCORD (1.4% witglucose therapy; rapid rate of A1C reduction in ACCORD (1.4% within 4 hin 4 months); difference in weight gain: 3.5 kg in ACCORD months); difference in weight gain: 3.5 kg in ACCORD vsvs 0.7 kg in 0.7 kg in ADVANCE; difficulty in showing additional improvement in CV outcADVANCE; difficulty in showing additional improvement in CV outcome ome when overall cardiac care is optimizedwhen overall cardiac care is optimized

ADVANCE Collaborative Group. ADVANCE Collaborative Group. N N EnglEngl J MedJ Med. 2008;358:2560. 2008;358:2560--2572.2572.ACCORD Study Group. ACCORD Study Group. N N EnglEngl J MedJ Med. 2008;358:2545. 2008;358:2545--2559.2559.

Type 2 DM and CV Disease Risk Reduction: Type 2 DM and CV Disease Risk Reduction: Lessons From ADVANCE & ACCORDLessons From ADVANCE & ACCORD

Lowering blood glucose primarily prevents Lowering blood glucose primarily prevents microvascularmicrovascular complicationscomplicationsIndividualize glucose goals for patients with advanced Individualize glucose goals for patients with advanced CV diseaseCV diseaseIn older, highIn older, high--risk patients, maintain A1C close to 7%, risk patients, maintain A1C close to 7%, not necessarily <7%not necessarily <7%More intense blood glucose control may modestly More intense blood glucose control may modestly reduce CVD risk in those with early DM w/o advanced reduce CVD risk in those with early DM w/o advanced atherosclerotic disease: may be appropriate to reduce atherosclerotic disease: may be appropriate to reduce A1C <7% A1C <7% Avoid hypoglycemiaAvoid hypoglycemiaFocus on proven therapies: lipidFocus on proven therapies: lipid--lowering, BP lowering, BP reduction, antireduction, anti--platelet therapy, & smoking cessationplatelet therapy, & smoking cessation

Clinical Inertia: Why Is There Confusion Clinical Inertia: Why Is There Confusion in Treating Type 2 Diabetes?in Treating Type 2 Diabetes?

Until 1995, only sulfonylureas and Until 1995, only sulfonylureas and insulin were available insulin were available Now Now –– many new agentsmany new agentsLack of Lack of ““big picturebig picture”” context of context of treatmenttreatment““NicheNiche”” agentsagentsFailure to understand metabolic Failure to understand metabolic staging of decompensation of staging of decompensation of type 2 DMtype 2 DM

Clinical Inertia: Why Is There Confusion Clinical Inertia: Why Is There Confusion in Treating Type 2 Diabetes? in Treating Type 2 Diabetes? (cont(cont’’d)d)

Lack of prospective Lack of prospective RCTsRCTs ––““seat of the seat of the pantspants”” adviceadvice

What agent to start? How to combine? When What agent to start? How to combine? When to use insulin as addto use insulin as add--on/replacement?on/replacement?

DAWN study: 50%DAWN study: 50%--55% of PCPs delayed 55% of PCPs delayed insulin therapy in type 2 diabetes until insulin therapy in type 2 diabetes until absolutely necessary absolutely necessary

Effect beyond glycemic control, Effect beyond glycemic control, ieie, TZDs, , TZDs, incretinincretin mimeticsmimetics

DAWN, Diabetes Attitudes, Wishes, and Needs; RCT, randomized conDAWN, Diabetes Attitudes, Wishes, and Needs; RCT, randomized controlled trial; trolled trial; TZD, TZD, thiazolidinedionethiazolidinedione..

Clinical Inertia: Clinical Inertia: Contributing FactorsContributing Factors

Delayed diagnosisDelayed diagnosisInadequate attention to & control of postprandial Inadequate attention to & control of postprandial hyperglycemiahyperglycemiaUnderestimate seriousness of type 2 DMUnderestimate seriousness of type 2 DMAcceptance of fairAcceptance of fair--poor A1C levelspoor A1C levelsFear of hypoglycemiaFear of hypoglycemiaInability to perform selfInability to perform self--carecareFormulary restrictionsFormulary restrictionsAmbiguous and Ambiguous and ““failurefailure--drivendriven”” treatment protocolstreatment protocolsLack of familiarity with new oral agents and insulinLack of familiarity with new oral agents and insulin

Clinical Inertia: Clinical Inertia: Resulting Practice PitfallsResulting Practice Pitfalls

Oral agents being used interchangeablyOral agents being used interchangeably

Inappropriate choice of initial agentInappropriate choice of initial agent–– SU for IR SU for IR excessive hypoglycemiaexcessive hypoglycemia

–– Metformin for insulin deficiency Metformin for insulin deficiency sustained hyperglycemiasustained hyperglycemia

SU, sulfonylurea; IR, insulin resistance.SU, sulfonylurea; IR, insulin resistance.

Clinical Inertia: Clinical Inertia: Resulting Practice Pitfalls Resulting Practice Pitfalls (cont(cont’’d)d)

MonotherapyMonotherapy for too long for too long –––– Type 2 DM is progressiveType 2 DM is progressive

Trying to Trying to ““squeezesqueeze”” too much out of SUtoo much out of SU–– 70%70%--80% effect seen at 1080% effect seen at 10--mg dose mg dose glyburideglyburide

Switching rather than combiningSwitching rather than combining–– SUSU↔↔metforminmetformin

–– SUSU→→meglitinidemeglitinide

–– MetforminMetformin↔↔TZDTZD

SU, sulfonylurea, TZD, SU, sulfonylurea, TZD, thiazolidinedionethiazolidinedione..

Clinical Inertia: Clinical Inertia: Resulting Practice Pitfalls Resulting Practice Pitfalls (cont(cont’’d)d)

NonNon--recognition of subtle hypoglycemia recognition of subtle hypoglycemia after after ∆∆ therapy, therapy, glucotoxicityglucotoxicity–– Hunger, snacking, weight gainHunger, snacking, weight gain

Failure to Failure to SU or insulinSU or insulin

InsulinInsulin–– Too much, too infrequent, inadequate Too much, too infrequent, inadequate

prandial coverageprandial coverage

SU, sulfonylurea.SU, sulfonylurea.

Diabetes ScorecardDiabetes ScorecardAchieving ADA RecommendationsAchieving ADA Recommendations

NHANES 1999NHANES 1999--2002: 998 adults 2002: 998 adults ≥≥ 18 yr old18 yr old

%%CharacteristicCharacteristic

39.639.6Blood PressureBlood Pressure

< 130/80 mm Hg< 130/80 mm Hg

65.865.824.024.010.110.1

Urine Urine Microalbumin/creatinineMicroalbumin/creatinine (mg/g)(mg/g)Normal <30Normal <30Microalbuminuria 30Microalbuminuria 30--299299MacroalbuminuriaMacroalbuminuria ≥≥300 300

49.849.820.520.529.729.7

A1C:A1C:<7%<7%7%7%--<8%<8%≥≥8%8%

Diabetes Scorecard Diabetes Scorecard (cont(cont’’d)d)Achieving ADA RecommendationsAchieving ADA Recommendations

NHANES 1999NHANES 1999--2002: 998 adults 2002: 998 adults ≥≥ 18 yrs old18 yrs old

65.065.028.828.86.36.3

<200<200200200--399399≥≥130130

TG TG (mg/(mg/dLdL))Low riskLow riskBorderline riskBorderline riskHigh riskHigh risk

363630.830.833.333.3

<100<100100100--130130≥≥130130

LDL LDL (mg/(mg/dLdL))Low riskLow riskBorderline riskBorderline riskHigh riskHigh risk

27.427.435.335.337.337.3

WW>55>55

4545--5555<45<45

MM>45>45

3535--4545<35<35

HDL HDL (mg/(mg/dLdL))Low riskLow riskBorderline riskBorderline riskHigh riskHigh risk

%%CharacteristicCharacteristic

Diabetes Scorecard Diabetes Scorecard (cont(cont’’d)d)Achieving ADA RecommendationsAchieving ADA Recommendations

NHANES 1999NHANES 1999--2002: 998 adults 2002: 998 adults ≥≥ 18 yr old18 yr old

%%CharacteristicCharacteristic

28.228.2Recommended physical activityRecommended physical activity≥≥5 moderate5 moderate––vigorous activities x 30 min/wkvigorous activities x 30 min/wk≥≥3 vigorous activities x 30 min/wk3 vigorous activities x 30 min/wk

81.281.2NonsmokerNonsmoker

18.318.3Daily fiber intakeDaily fiber intake 20 g20 g--35 g35 g

64.064.048.348.328.328.3

Daily Caloric IntakeDaily Caloric IntakeProtein 10%Protein 10%--20%20%Saturated fat <10%Saturated fat <10%Unsaturated fat <10%Unsaturated fat <10%

ResnickResnick HE, et al. HE, et al. Diabetes CareDiabetes Care. 2006;29:531. 2006;29:531--537.537.

Systems and Processes: Systems and Processes: Remedy for Clinical InertiaRemedy for Clinical Inertia

StepStep--wise interventionswise interventionsIncremental changes in patient behaviorIncremental changes in patient behaviorCustomized therapyCustomized therapyTreatment guided by metabolic stageTreatment guided by metabolic stageBetter control of postprandial hyperglycemiaBetter control of postprandial hyperglycemiaLess hypoglycemia in early type 2 DMLess hypoglycemia in early type 2 DMCV risk reductionCV risk reductionGood for the beta cell?Good for the beta cell?Better A1C ?Better A1C ?

How to Initiate and How to Initiate and Advance Changes Advance Changes in Your Practicein Your Practice

Elaine Fleck, MDElaine Fleck, MDColumbia UniversityColumbia University

Director, Internal Medicine Director, Internal Medicine Ambulatory Care Practice Ambulatory Care Practice

New YorkNew York--Presbyterian HospitalPresbyterian Hospital

Improving CareImproving Care

Recognize that there is a gap between Recognize that there is a gap between type 2 diabetes care as it is and care as type 2 diabetes care as it is and care as it could and should be for patientsit could and should be for patients

Identify an action plan that you/your Identify an action plan that you/your practice would like to accomplish to practice would like to accomplish to improve this careimprove this care

Understand and implement an Understand and implement an intervention that can change the nature intervention that can change the nature of care delivery in your practiceof care delivery in your practice

Tips for Success ITips for Success I

Improvement occurs in small stepsImprovement occurs in small steps

Repeated attempts needed to Repeated attempts needed to implement new ideasimplement new ideas

Failed attempt = Learning opportunity!Failed attempt = Learning opportunity!

Assess regularly to improve planAssess regularly to improve plan

Tips for Success IITips for Success II

Communicate: Involve your medical Communicate: Involve your medical teamteam

Collect data before and after making Collect data before and after making changeschanges

SHARE AND BORROW IDEASSHARE AND BORROW IDEAS

Tour of Suggested InterventionsTour of Suggested Interventions

Go to: Go to: http://http://www.mentorqi.comwww.mentorqi.com//Apps/System/Apps/System/Logon.aspxLogon.aspx

User name: diabetesUser name: diabetes Password: diabetes Password: diabetes

Six selected interventions for Action PlanSix selected interventions for Action Plan–– A1C TestingA1C Testing

–– ExerciseExercise

–– Glucose SelfGlucose Self--MonitoringMonitoring

–– Goal SettingGoal Setting

–– NutritionNutrition

–– Proper TherapyProper Therapy

Example InterventionExample Intervention

Provider Reminder Systems Provider Reminder Systems to Increase A1C Testingto Increase A1C Testing““There is excellent evidence There is excellent evidence that tracking/reminder systems that tracking/reminder systems can improve quality of care.can improve quality of care.””–– Flow sheets added to charts of patients Flow sheets added to charts of patients

with diabeteswith diabetes

–– Paper/prompt for every chart of patients Paper/prompt for every chart of patients with diabeteswith diabetes

Closing the Quality Gap: Agency for Healthcare Research and QualClosing the Quality Gap: Agency for Healthcare Research and Quality. Available at: ity. Available at: http://http://www.ahrq.gov/clinic/epc/qgapfact.htmwww.ahrq.gov/clinic/epc/qgapfact.htm..

Example of Example of A1C PromptA1C Prompt on Charton Chart

Use bright yellow sheet Use bright yellow sheet Make very simple reminderMake very simple reminder–– ID #ID #–– Date of most recent A1CDate of most recent A1C–– Most recent A1C levelMost recent A1C level

Meet with everyone remotely involved Meet with everyone remotely involved –– Suggest lunch with a pizzaSuggest lunch with a pizza–– Explain this is a Explain this is a ““pilotpilot””–– Identify another team member to assist Identify another team member to assist

Try it for one provider for one day/one weekTry it for one provider for one day/one weekReRe--evaluate and learn from the processevaluate and learn from the process

PromotingPromotingDiabetes SelfDiabetes Self--Care:Care:

Asking the Right Asking the Right QuestionsQuestions

Jane Jeffrie SeleyJane Jeffrie SeleyMPH, MSN, GNP, CDEMPH, MSN, GNP, CDE

Diabetes Nurse PractitionerDiabetes Nurse Practitioner

Diabetes Is a SelfDiabetes Is a Self--Care DiseaseCare Disease

Requires multiple daily selfRequires multiple daily self--care care activities activities that change over timethat change over time……

Decisions need to be made on an Decisions need to be made on an ongoing basis regarding meals, ongoing basis regarding meals, physical activity, and medicationsphysical activity, and medications

This requires education, motivation, This requires education, motivation, and supportand support

FunnellFunnell MM, Anderson RM. MM, Anderson RM. ClinClin DiabetesDiabetes. 2004;22:123. 2004;22:123--127.127.

Building relationships with patients with Building relationships with patients with diabetes promotes selfdiabetes promotes self--carecare

Diabetes SelfDiabetes Self--Care Survival SkillsCare Survival Skills

Diabetes SelfDiabetes Self--Care AssessmentCare Assessment

Meal Planning:Meal Planning:Is patient spacing meals and Is patient spacing meals and snacks throughout the day?snacks throughout the day?

Does patient measure Does patient measure portion sizes?portion sizes?

Does patient know how to Does patient know how to identify/count carbohydrates?identify/count carbohydrates?

Does patient know how to read a Nutrition Facts label?Does patient know how to read a Nutrition Facts label?

Have you discussed specific weightHave you discussed specific weight--loss strategies?loss strategies?

Has the patient ever received individualized meal Has the patient ever received individualized meal planning education?planning education?

Diabetes SelfDiabetes Self--Care Care Assessment Assessment (cont(cont’’d)d)

Physical Activity: Physical Activity: Does patient have physical Does patient have physical activity plan?activity plan?Which activities? Aerobic Which activities? Aerobic vsvs anaerobic?anaerobic?How often and for how long?How often and for how long?Time of day?Time of day?Need to adjust meals/meds?Need to adjust meals/meds?Where do they exercise? Do they need an alternative Where do they exercise? Do they need an alternative plan for bad weather?plan for bad weather?Any hypoglycemia?Any hypoglycemia?Does patient carry medical ID, hypo Does patient carry medical ID, hypo txtx??

Diabetes SelfDiabetes Self--Care Care Assessment Assessment (cont(cont’’d)d)

Medication: Medication: When does patient take each When does patient take each diabetes medication in relation diabetes medication in relation to food?to food?Does patient know mechanism of action of each Does patient know mechanism of action of each medication?medication?Have you observed technique for injections?Have you observed technique for injections?Does patient know how to store medications?Does patient know how to store medications?Does patient know open expiration dates?Does patient know open expiration dates?Does patient know what to do with syringes, pen Does patient know what to do with syringes, pen needles once used?needles once used?

Diabetes SelfDiabetes Self--Care Care Assessment Assessment (cont(cont’’d)d)

Blood Glucose Monitoring:Blood Glucose Monitoring:Do patients have working meter?Do patients have working meter?

Have you observed their technique?Have you observed their technique?

When are they checking BG?When are they checking BG?

Do they know their targets? What do they do when Do they know their targets? What do they do when they are too high or low?they are too high or low?

Do they log results?Do they log results?

Have you reviewed their results and made Have you reviewed their results and made treatment changes based upon them?treatment changes based upon them?

3 Ways to Be Sure Patient 3 Ways to Be Sure Patient UnderstandsUnderstands……

ReassureReassure““I want to be sure that I explained I want to be sure that I explained this clearly to you, so . . .this clearly to you, so . . .””

Teach BackTeach Back““In your own words, In your own words, can you tell me . . .?can you tell me . . .?””

Show MeShow MeSurvival skills require demonstration and practiceSurvival skills require demonstration and practice

http://www.npsf.org/askme3/PCHC/.http://www.npsf.org/askme3/PCHC/.

CME Credit InformationCME Credit Information

To receive 1 To receive 1 AMA PRA Category 1 AMA PRA Category 1 CreditCredit™™ for this teleconference, go to:for this teleconference, go to:

http://www.bu.edu/cme/seminars/DIABhttp://www.bu.edu/cme/seminars/DIABHAY08/teleconferences.htmlHAY08/teleconferences.html