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Chronic Disease Management: the Diabetes

Svensk Familj Medicin 10 November 2010. Chronic Disease Management: the Diabetes. The Case of the brothers: K.K. & G.K. Two brothers , ages 36 & 38, musicians and roustabouts Methadone Percocet Xanax Cigarettes DM. Month 1 - 3. D/C perc & benzos Decrease Methadone to 30/d

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Chronic Disease Management: the Diabetes

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  1. SvenskFamiljMedicin 10 November 2010 Chronic Disease Management:the Diabetes

  2. The Case of the brothers: K.K. & G.K. • Two brothers, ages 36 & 38, musicians and roustabouts • Methadone • Percocet • Xanax • Cigarettes • DM

  3. Month 1 - 3 • D/C perc & benzos • Decrease Methadone to 30/d • A1c: 9.2 & 9.7 • How to improve their DM? • What would constitute success? • What would be the consequence of failure? • For them….and for me?

  4. GHC’s experiment • If the brothers get their HgA1c down… • The doctor get bucks. • How did we get here?

  5. History of all this….. • 1800s • “Doctors” • Charged what the market would bear • No insurance • Doctors provided hospital care for free

  6. Early 1900s • Enter the AMA • Doctors charge for hospital work • Still no insurance

  7. 1920s • GM insures auto workers • Start of national struggle to insure all… • … • Doctors charge what they want

  8. 1940s & 1950s • Low post war unemployment • Wage control • More companies offer health insurance as an benefit • Work based health insurance • Doctors still charged whatever

  9. Medicare is born July 30, 1965 • Huge expansion of health care • Insurers & govgain power • Docs still paid for each widget

  10. 1980s • DRGs invented • Widgets need to be standardized • Doctors begin to cede authority to insurers • HMOs mostly function to control cost

  11. 1990s • Healthcare grows to ~ 15% of GDP • ~44 Million uninsured

  12. How doctors are paid determine what patients get. • If doctors are free to do what they want – variance in quantity & quality. • If doctors are free to charge what they want -- variance in fees. Regional Variations in Total Knee Replacement Surgery January 4th, 2010 by  Variation in the Average Cost Per Medicare Recipient by Region, August 15, 2007

  13. 2000s • Pay for performance P4P • Quality measures • HEDIS • Obama-care

  14. 2010s • End of Obama-care? • How many steps back? • We get what we pay for…

  15. Prices matter lobotomy lobotomy lobotamy 5 cents 10 cents

  16. Quality matter lobotomy and lobotomy lobotamy And FRIES!! 10 cents 10 cents

  17. Insurance pay doctors for widgets

  18. Quantity of widgets v quality

  19. Pay is often not for quality

  20. Measuring quality • Process: % of patients that have yearly HgA1c. • Outcomes: % of patients that avoid hospitalizations or postpone death. • Process much easier to measure than outcomes.

  21. Measuring quality • Individual doctors v systems. • Systems are few: • GHC • UW? • Swedish? • Patients see many different doctors

  22. Diabetes 2 Management:how can we improve quality of life, and decrease cost? • Screening? • What labs? • What frequency? • What are goals for labs? • What other measures and referrals?

  23. Should we screen for diabetes? • Disease: • Real health problem w M&M • Treatment that works • Test: • Detects preclinical disease • Safe, cheap, available http://virtualmentor.ama-assn.org/2006/01/cprl1-0601.html

  24. Should we screen adults for DM? •  9.3% of adults have DM. • Cowie CC, Rust KF, Byrd-Holt DD, et al. Prevalence of diabetes and impaired fasting glucose in adults in the U.S. population: National Health And Nutrition Examination Survey 1999-2002. Diabetes Care2006;29(6):1263-1268 • 43% of diabetics not identified in 2005 • Cowie CC, Rust KF, Ford ES, et al. Full accounting of diabetes and pre-diabetes in the U.S. population in 1988-1994 and 2005-2006. Diabetes Care 2009;32(2):287-294. Published Online: November 18, 2008. CDC 2004-2005 data

  25. Does it matter to screen? • Prevalence of complications higher in diabetics with delayed diagnosis: • 14. Hu FB, Stampfer MJ, Haffner SM, et al. Elevated risk of cardiovascular disease prior to clinical diagnosis of type 2 diabetes. Diabetes Care 2002;25(7):1129-1134. • 15. Meigs JB, Nathan DM, Wilson PW, et al. Metabolic risk factors worsen continuously across the spectrum of nondiabetic glucose tolerance. The Framingham Offspring Study. Ann Intern Med1998;128(7):524-533.

  26. HgA1c • 30-35% reduction in incidence of microvascular complications / 1% decrease in HgA1c. • UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive blood-glucose control with metformin on com-plications in overweight patients with type 2 diabetes(UKPDS 34) [erratum in Lancet. 1998;352:1557]. Lancet.1998;352:854-865. • 14% reduction in macrovascular complications / 1% decrease in HgA1c. • Stratton IM, Adler AI, Neil HA, et al. Association ofglycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective obser-vational study. BMJ. 2000;321:405-412. • Target: < 7% (with exceptions) • American Diabetes Association. Standards of medical care in diabetes—2010 [published correction appears in Diabetes Care 2010;33(3):692]. Diabetes Care 2010;33(suppl 1):S11-S61 • Quality measures: % of diabetics w • < 7% (the higher, the better) • > 9% (the lower, the better)

  27. BP goals in DB • Evidence? Mixed • ACCORD trial BP <120/80 not associated with meaningful outcomes. • UKPDS trial BP < 130/80, and Rx w ACE or BB, NNT 14 prevents one MI • ACCORD, a systolic blood-pressure goal below 120 mmHg had no significant effect on the primary composite outcome of nonfatal myocardial infarction, nonfatal stroke, or cardiovascular mortality compared with a goal below 140 mmHg. The trial was conducted in 4,733 patients with type 2 diabetes and a high risk for cardiovascular events, and the results were published early online by the New England Journal of Medicine and presented at the American College of Cardiology's 59th Annual Scientific Session. • Now we did see a 41% reduction in stroke rate, which was statistically significant, but because it was a secondary outcome—part of the composite but a secondary outcome—and one of a number of different secondary outcomes we looked at, it can't drive the interpretation of the trial by itself. • Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. BMJ 1998 Sep 12;317(7160):703-13

  28. BP goals in DB • ACP: 130-135/80 • ADA: < 130/80 • AGS: 130-140/80 • PQRI: < 140/80 • HEDIS: <130/80

  29. Diabetes and nephropathy • 30% of diabetics (DM2) • Leading cause of ESRD • DM w albuminuria: 20% ESRD (after 20 y) • ACE-I markedly reduce progression of nephropathy: 24% RRR • Heart Outcomes Prevention Evaluation Study Investigators. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: Results of the HOPE study and MICRO-HOPE substudy. Lancet. 355: 2000; 253-259

  30. ACE-I in DM + one CV risk factor • Based on the HOPE trial 1800 patients over 5y • NNT      37         prevents one MI • NNT      53         prevents one stroke • NNT      29         prevents one CV related death • NNT      32         prevents one death (all causes) • Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Heart Outcomes Prevention Evaluation Study Investigators. Lancet 2000 Jan 22;355(9200):253-9.

  31. Lipids in DB • Several studies confirm reduced CHD events in diabetics treated w Statins. • Reduced rate 27-48% (events, not mortality) in 4 years. • Colhoun HM, Betteridge DJ, Durrington PN, Hitman GA, Neil HA, Livingstone SJ, Thomason MJ, Mackness MI, Charlton-Menys V, Fuller JH: Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomized placebo-controlled trial. Lancet364:685 -696,2004 • LDL < 100 (rec by ACP, ADA, PQRI,HEDIS)

  32. Diabetics without occlusive arterial disease

  33. Diabetics with occlusive arterial disease

  34. ASA and DM • Recommended • ADA • ACC • HQF • AMA-PCPI • No recommendation • PQRI • HEDIS

  35. ASA in diabetics • Evidence mixed and benefit small • Meta-analysis • 9% reduction in MI (fatal and non fatal) • 15% reduction in strokes • Both non significant • Increased GI bleeding: 1-5 events / 1000 patients / year • NNT if CV risk < 10% in 10 years: 50 • Pignone M, et al "Aspirin for primary prevention of cardiovascular events in people with diabetes: A position statement of the American Diabetes Association, a scientific statement of the American Heart Association, and an expert consensus document of the American College of Cardiology Foundation" Circulation 2010; 121.

  36. ASA in diabetics w > 10% 10y risk • Men > 50 years • Women > 60 y • Plus one additional risk factor • Smoking • HTN • Dyslipidemia • FH premature CAD • Renal disease

  37. Diabetes and retinopathy • Evidence supports screening • In 100 patients w diabetes over 10 years. • Without screening: 55 blind • With screening and treatment: 13 blind • Bachmann M, Nelson SJ. Screening for Diabetic Retinopathy: A quantitative overview of the evidence, applied to the populations of health authorities and boards. Bristol: Health Care Evaluation Unit, University of Bristol, 1996:1 – 46 • http://www.library.nhs.uk/diabetes/viewResource.aspx?resid=387102

  38. Diabetes and neuropathy • Monofilament exam recommended by: • ADA • PQRI • APMA (Podiatrists) • No recommendation • HEDIS • No evidence yet that screening reduces disease

  39. The Diabetes: other parameters to monitor • Exercise? • Weight loss? • Smoking?

  40. The $4P Game • 1000 patients with DM • 10 years • Goals: fewest hospitalizations, fewest deaths, fewest dollars. • Prize:

  41. $4P • Assumptions: • Average life span: 78y (2006, USA) • Average life span of a diabetic: 70y (2007) • Average diabetic spends 5 days in the hospital (5.3, v 4.1 in non diabetic) • Average cost of hospital care is $2000/d

  42. $4P -- Yearly HgA1c screening and response • Cost: $200/p • reduces hospitalization by 10%. • Increases longevity by 0.5y. • If 50% reach HgA1c< 7 =

  43. HEDIS • 1991: HMO Employer Data & Information Set • 1993: Health Plan Employer Data & Information Set • 2007: Healthcare Effectiveness Data and Information Set • NCQA • National Committee for Quality Assurance • http://www.ncqa.org/tabid/675/Default.aspx

  44. Diabetes & HEDIS • HbA1c testing yearly • % HbA1c > 9.0 • % HbA1c < 7.0 • LDL testing yearly • % LDL < 100 • Retinal exam yearly • Nephropathy screening yearly (or on ACE (GHC)) • BP yearly, and % < 140/90 & <130/80

  45. Back to our brothers… • What would you want to do for them now? • They remained non compliant and never got their HgA1c down below 9. • They left our practice when drug requests escalated.

  46. P4P: usually works, depends on details • Are there any risks? • Disenrollment • Cherry picking • Increasing the variance in medical care • Wrong goals • Doctor centered medical home • Marginal real life benefits

  47. http://www.clinicalgeriatrics.com/articles/Quality-Improvement-Diagnosis-and-Management-Diabetes-Mellitus-Older-Adultshttp://www.clinicalgeriatrics.com/articles/Quality-Improvement-Diagnosis-and-Management-Diabetes-Mellitus-Older-Adults http://www.annals.org/content/144/7/465.abstractImprovements in Diabetes Processes of Care and Intermediate Outcomes: United States, 1988–2002 Jinan B. Saaddine, MD;  Betsy Cadwell, MS;  Edward W. Gregg, PhD; Michael M. Engelgau, MD;  Frank Vinicor, MD;  GiuseppinaImperatore, MD; and  K. M. VenkatNarayan, MD http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/nephrology/diabetic-nephropathy/#bib15 http://conferences.und.edu/primarycare/documents/Brosseau_PPT.pdf http://clinical.diabetesjournals.org/content/24/1/27.full http://www.fchp.org/providers/resources/hedis-measures.aspx http://www.theheart.org/article/1041287.do http://www.jaoa.org/cgi/content/full/110/7_suppl_7/eS2 http://www.clinicalgeriatrics.com/articles/Quality-Improvement-Diagnosis-and-Management-Diabetes-Mellitus-Older-Adults http://www.sciencenews.org/view/generic/id/62299/title/The_high_cost_of_diabetes

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