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The Impact of Diabetes on Hospital Readmissions. New York State Regional Family Medicine Conference. James Desemone , MD Director of Medical Staff Quality Ellis Medicine October 15, 2011. Dr. Desemone has no financial disclosures nor conflicts of interest to declare. - PowerPoint PPT Presentation
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The Impact of Diabetes on The Impact of Diabetes on Hospital ReadmissionsHospital Readmissions
James Desemone, MDJames Desemone, MDDirector of Medical Staff QualityDirector of Medical Staff Quality
Ellis MedicineEllis Medicine
October 15, 2011October 15, 2011
New York State RegionalNew York State RegionalFamily Medicine Conference Family Medicine Conference
Dr. Desemone has no Dr. Desemone has no financial disclosures financial disclosures
nor conflicts of nor conflicts of interest to declareinterest to declare
The Impact of Diabetes on The Impact of Diabetes on Hospital ReadmissionsHospital Readmissions
With Special Thanks to:With Special Thanks to:
Nancy LandorNancy LandorSenior Director, Strategic Quality Initiatives, HANYSSenior Director, Strategic Quality Initiatives, HANYS
Amy JonesAmy JonesManager, Quality Initiatives, HANYSManager, Quality Initiatives, HANYS
Karen PirigyiKaren PirigyiAssistant to the Director, Quality Services, Ellis MedicineAssistant to the Director, Quality Services, Ellis Medicine
Impact of Diabetes on Impact of Diabetes on Hospital ReadmissionsHospital Readmissions
By attending this conference, the participant By attending this conference, the participant should be able to:should be able to:
1.1. Name 3 of the measures in the National Committee Name 3 of the measures in the National Committee for Quality Assurance (NCQA) Diabetes for Quality Assurance (NCQA) Diabetes Recognition ProgramRecognition Program
2.2. Explain how diabetes education reduces the cost Explain how diabetes education reduces the cost of careof care
3.3. Name the percentage of patients with diabetes that Name the percentage of patients with diabetes that physicians refer to diabetes educationphysicians refer to diabetes education
Hospital ReadmissionsHospital Readmissions
CHFCHF
COPDCOPD
PneumoniaPneumonia
AMIAMI
Hospital ReadmissionsHospital Readmissions
What about Diabetes?What about Diabetes?
• Keeps a low profileKeeps a low profile
• Frequently a secondary Frequently a secondary diagnosisdiagnosis
Estimated Adult Diabetes Estimated Adult Diabetes Prevalence in NYS, 2002-2008Prevalence in NYS, 2002-2008
Past and projected prevalence Past and projected prevalence of overweight (BMI >25 kg/m²)of overweight (BMI >25 kg/m²)
Wang YC, et al. Lancet Wang YC, et al. Lancet 378: 815–25 (2011)378: 815–25 (2011)
New York StateNew York StateEmergency Department UtilizationEmergency Department Utilization
Diabetes Patients Admitted as Inpatient as a % of Total ED VisitsDiabetes Patients Admitted as Inpatient as a % of Total ED Visits
Healthcare Association of New York State, July 2010Healthcare Association of New York State, July 2010
726,553 7,146,817
Percentage of NYS Admissions Percentage of NYS Admissions with Diabetes as 1with Diabetes as 1oo or 2 or 2oo Dx Dx
Healthcare Association of New York State, July 2010Healthcare Association of New York State, July 2010
NYS Readmission Rates, 2008NYS Readmission Rates, 2008
Healthcare Association of New York State, July 2010Healthcare Association of New York State, July 2010
Healthcare Association of New York State www.hanys.org
Survey : NYS Systems/Hospitalsn=70
Do you have discharge planning criteria for referring any type of diabetes patient to a Certified Diabetes Educator (CDE) or ADA/AADE Certified Education Program post-discharge?
Criteria in PlaceCriteria in Place No Criteria in PlaceNo Criteria in Place
Healthcare Association of New York State www.hanys.org
HANYS’ Study—NYS DataIdentifying Routine Diabetes Care
Room for Improvement
There are 33,327 diabetes patients on the 5% SAF Carrier File or Medicare patients.
Of those, 3,327 (10%) did not receive any preventive care.
Only 12,969 (38.9%) received all of the recommended procedures in the year.
Source: 2007 Medicare Limited Data Set Standard Analytic Files 5% version
Healthcare Association of New York State www.hanys.org
National Committee for Quality Assurance Diabetes Recognition Program
National National Committee for Committee for
Quality Quality AssuranceAssurance
Diabetes Diabetes Recognition Recognition
ProgramProgram
Healthcare Association of New York State, July 2010Healthcare Association of New York State, July 2010
Reducing ReadmissionsReducing Readmissions
• Improved Diabetes Treatment by Improved Diabetes Treatment by the Provider?the Provider?
• Referral to a Diabetes Self-Referral to a Diabetes Self-Management Training and Management Training and Education (DSMT/E) Program?Education (DSMT/E) Program?
• PhiladelphiaPhiladelphia• January 1994 to December 2001January 1994 to December 2001• 80,218 unique patients with diabetes80,218 unique patients with diabetes• 224,818 hospital discharges to self-care224,818 hospital discharges to self-care
Robbins JM, et al. J Health Care for the Poor and Underserved 19:562-573 (2008)Robbins JM, et al. J Health Care for the Poor and Underserved 19:562-573 (2008)
Odds ratio for Hospital Readmission Odds ratio for Hospital Readmission within 30 days within 30 days
Maybe…Maybe……….for patients who are discharged without a recorded diagnosis of .for patients who are discharged without a recorded diagnosis of
diabetesdiabetes
•Caveats:Caveats:– Administrative data are prone to errorAdministrative data are prone to error– Did not examine transition of care from inpatient to outpatient Did not examine transition of care from inpatient to outpatient
What We WantWhat We Want
Safe, Positive Clinical QualitySafe, Positive Clinical Quality
Cost SavingsCost Savings
Hospital Costs Account for Majority Hospital Costs Account for Majority of Total Costs of Diabetesof Total Costs of Diabetes
0
1000
2000
3000
4000
5000
6000
7000
Inpatient Nursing Home Physician’sOffice
OutpatientPrescription
Insulin andSupplies
Do
llar
s
Per Capita Health Care Expenditures (2002)
Diabetes Without Diabetes
Hogan P, et al. Diabetes Care. 2003;26:917–932.
Duncan et al, Duncan et al, The Diabetes Educator. The Diabetes Educator. 35:752-761 (2009)35:752-761 (2009)
Assessing the Value ofAssessing the Value ofDiabetes EducationDiabetes Education
• 2005, 2006, 20072005, 2006, 2007
• InsuranceInsurance– Commercial or MedicareCommercial or Medicare
• Purpose:Purpose:– Evaluate the impact of Diabetes Self-Evaluate the impact of Diabetes Self-
Management Training and Education Management Training and Education (DSMT/E) on the cost of care(DSMT/E) on the cost of care
Duncan et al, Duncan et al, The Diabetes Educator. The Diabetes Educator. 35:752-761 (2009)35:752-761 (2009)
Number of Patients with Number of Patients with Diabetes Who Received Diabetes Who Received
EducationEducation
7.3%7.3% 3.8%3.8%
Commercial
482,571Medicare
152,074
Preliminary ConclusionPreliminary Conclusion
The The CARECARE with with DSMT/E is better.DSMT/E is better.
Duncan et al, Duncan et al, The Diabetes Educator. The Diabetes Educator. 35:752-761 (2009)35:752-761 (2009)
Duncan et al, Duncan et al, The Diabetes Educator. The Diabetes Educator. 35:752-761 (2009)35:752-761 (2009)
Duncan et al, Duncan et al, The Diabetes Educator. The Diabetes Educator. 35:752-761 (2009)35:752-761 (2009)
Duncan et al, Duncan et al, The Diabetes Educator. The Diabetes Educator. 35:752-761 (2009)35:752-761 (2009)
Assessing the Value ofAssessing the Value ofDiabetes Education, 2008Diabetes Education, 2008
Tucker ME. Hospitalist News Digital Network, 2010-08-31Tucker ME. Hospitalist News Digital Network, 2010-08-31
Duncan et al, Duncan et al, The Diabetes Educator. The Diabetes Educator. 35:752-761 (2009)35:752-761 (2009)
Assessing the Value ofAssessing the Value ofDiabetes Education, 2008Diabetes Education, 2008
Tucker ME. Hospitalist News Digital Network, 2010-08-31Tucker ME. Hospitalist News Digital Network, 2010-08-31
Duncan et al, Duncan et al, The Diabetes Educator. The Diabetes Educator. 35:752-761 (2009)35:752-761 (2009)
Assessing the Value ofAssessing the Value ofDiabetes Education, 2008Diabetes Education, 2008
Tucker ME. Hospitalist News Digital Network, 2010-08-31Tucker ME. Hospitalist News Digital Network, 2010-08-31
Duncan et al, Duncan et al, The Diabetes Educator. The Diabetes Educator. 35:752-761 (2009)35:752-761 (2009)
Assessing the Value ofAssessing the Value ofDiabetes Education, 2008Diabetes Education, 2008
Tucker ME. Hospitalist News Digital Network, 2010-08-31Tucker ME. Hospitalist News Digital Network, 2010-08-31
Duncan et al, Duncan et al, The Diabetes Educator. The Diabetes Educator. 35:752-761 (2009)35:752-761 (2009)
Assessing the Value ofAssessing the Value ofDiabetes Education, 2008Diabetes Education, 2008
Tucker ME. Hospitalist News Digital Network, 2010-08-31Tucker ME. Hospitalist News Digital Network, 2010-08-31
Duncan et al, Duncan et al, The Diabetes Educator. The Diabetes Educator. 35:752-761 (2009)35:752-761 (2009)
Assessing the Value ofAssessing the Value ofDiabetes Education, 2008Diabetes Education, 2008
Tucker ME. Hospitalist News Digital Network, 2010-08-31Tucker ME. Hospitalist News Digital Network, 2010-08-31
Duncan et al, Duncan et al, The Diabetes Educator. The Diabetes Educator. 35:752-761 (2009)35:752-761 (2009)
The Impact of The Impact of Diabetes EducationDiabetes Education
ConclusionsConclusions
1.1. Reduction in cost of care was driven by Reduction in cost of care was driven by reducing admissionsreducing admissions
– Two or more DSMT/E sessions per year is better Two or more DSMT/E sessions per year is better than 0 or 1 sessions per yearthan 0 or 1 sessions per year
2.2. DSMT/E DSMT/E – Physicians refer to DSMT/E infrequentlyPhysicians refer to DSMT/E infrequently– Patients of physicians who refer to DSMT/E Patients of physicians who refer to DSMT/E
receive better carereceive better care
TREATMENT MODALITIESTREATMENT MODALITIESTREATMENT MODALITIESTREATMENT MODALITIES
DIET
EXERCISE INSULIN
DIET
EXERCISE INSULIN
Assessing the Value ofAssessing the Value ofDiabetes EducationDiabetes Education
……in patients with significant in patients with significant diabetes complicationsdiabetes complications
McMurray SD, et al. Am J Kid Dis. 40:566-575 (2002)McMurray SD, et al. Am J Kid Dis. 40:566-575 (2002)
Diabetes Education During DialysisDiabetes Education During Dialysis
• Hemodialysis PatientsHemodialysis Patients– Educators met with patient during each Educators met with patient during each
dialysis visitdialysis visit• M-W-F: study groupM-W-F: study group• T-R-S: control group (no education)T-R-S: control group (no education)
• Peritoneal Dialysis PatientsPeritoneal Dialysis Patients– Met with educator once a monthMet with educator once a month
Diabetes Education During DialysisDiabetes Education During Dialysis
Dialysis TypeDialysis Type Control GroupControl Group(n=38)(n=38)
Study GroupStudy Group(n=45)(n=45)
HD 33 37
PD 5 8
Type 2 DM 90% 84%
McMurray SD, et al. Am J Kid Dis. 40:566-575 (2002)McMurray SD, et al. Am J Kid Dis. 40:566-575 (2002)
Diabetes Education During DialysisDiabetes Education During Dialysis
McMurray SD, et al. Am J Kid Dis. 40:566-575 (2002)McMurray SD, et al. Am J Kid Dis. 40:566-575 (2002)
Diabetes Education During DialysisDiabetes Education During Dialysis
McMurray SD, et al. Am J Kid Dis. 40:566-575 (2002)McMurray SD, et al. Am J Kid Dis. 40:566-575 (2002)
Diabetes Education During DialysisDiabetes Education During Dialysis
McMurray SD, et al. Am J Kid Dis. 40:566-575 (2002)McMurray SD, et al. Am J Kid Dis. 40:566-575 (2002)
Control GroupControl Group(n=38)(n=38)
Study GroupStudy Group(n=45)(n=45)
Amputations2 pts toes2 pts BKA1 pt AKA
0
Admissions(PVD, infections,
amputations)10 1
Diabetes Education During DialysisDiabetes Education During DialysisConclusionsConclusions
McMurray SD, et al. Am J Kid Dis. 40:566-575 (2002)McMurray SD, et al. Am J Kid Dis. 40:566-575 (2002)
1.1. Fewer AmputationsFewer Amputations
2.2. Fewer HospitalizationsFewer Hospitalizations
3.3. Better ABetter A1c1c
Medicare ReimbursementMedicare ReimbursementDiabetes Self Management TrainingDiabetes Self Management Training
Medical Nutrition TherapyMedical Nutrition Therapy
Diabetes Education Services, Reimbursement Tips for Primary Care Practice Am Assoc Diab Educators, Revised February 2009
ConclusionsConclusions
DSMT/E DSMT/E 1.1. is an underutilized is an underutilized
treatment modalitytreatment modality
2.2. improves Quality of Careimproves Quality of Care
3.3. reduces the Cost of Carereduces the Cost of Care by reducing admissionsby reducing admissions
Impact of Diabetes on Impact of Diabetes on Hospital ReadmissionsHospital Readmissions
By attending this conference, the participant By attending this conference, the participant should be able to:should be able to:
1.1. Name 3 of the measures in the National Committee Name 3 of the measures in the National Committee for Quality Assurance (NCQA) Diabetes for Quality Assurance (NCQA) Diabetes Recognition ProgramRecognition Program
2.2. Explain how diabetes education reduces the cost Explain how diabetes education reduces the cost of careof care
3.3. Name the percentage of patients with diabetes that Name the percentage of patients with diabetes that physicians refer to diabetes educationphysicians refer to diabetes education
Thank Thank youyouThank Thank youyou
James Desemone, MDJames Desemone, MDDirector, Medical Staff QualityDirector, Medical Staff Quality
Ellis MedicineEllis Medicine
James Desemone, MDJames Desemone, MDDirector, Medical Staff QualityDirector, Medical Staff Quality
Ellis MedicineEllis Medicine