Jolene Johnson, MD Associate Clinical Professor of Medicine, LSU School of Medicine

1. Jolene Johnson, MD Associate Clinical Professor of Medicine, LSU School of Medicine Head, Statewide Diabetes Disease Management, LSU HCSD

2. Benefits of LSU ICON for Diabetes Disease Management • Project Design and Protocol Development • IRB Submissions and Approvals • Database Development and Management • Data Analysis/Statistical Support • Dedicated Patient Interaction Specialists to Assist in Recruitment and Data Collection

3. Benefits of LSU ICON for Diabetes Disease Management • Diabetes Interest Group • Assisting Diabetes Management Group in the development and testing of procedures associated with the expansion of the scope of its programs and services • Diabetes Screening Techniques • Treatment Strategies for Pre-Diabetes • Hepatitis B Immunization

4. Current LSU ICON Diabetes Disease Management Projects Implementing Screening for Diabetes and Pre-Diabetes within the LSU HCSD Medical Home Clinics Jolene Johnson, MD and Ronald Horswell, PhD Principal Investigators Jay Besse, BS and Rob Leonhard, MBA Co-Investigators Designing Screening Algorithms for Diabetes and Pre-Diabetes Ronald Horswell, PhD Principal Investigator Gang Hu, MD, PhD and Jolene Johnson, MD Co-Investigators

5. Implementing Screening for Diabetes and Pre-Diabetes within the LSU HCSD Medical Home Clinics Overview: • This Quality Improvement project pilots a specific diabetes screening protocol and follow-up program. • This pilot was conducted at three LSU HCSD medical home clinics. • If the pilot protocol and follow-up program prove feasible and sustainable, they will be implemented at other LSU HCSD medical home clinics.

6. Implementing Screening for Diabetes and Pre-Diabetes within the LSU HCSD Medical Home Clinics Specific Aims: • Aim 1:Pilot at three LSU HCSD Medical Home clinics a new diabetes screening program that consists of using the newly-developed LSU Diabetes/Pre-diabetes Screening Protocol (“Screening Protocol”) to identify previously undiagnosed diabetes patients and pre-diabetes patients.   • Aim 2:Assess the feasibility and sustainability of the screening program. If Aim 2 demonstrates feasibility and sustainability of the screening program, or suggests feasibility and sustainability can be achieved with only minor modifications, the project will move on to Aims 3 and 4. • Aim 3:Implement (via a phased roll-out) the screening program (“Screening Protocol” and “Follow-up Protocol”) across LSU Health medical home clinics. • Aim 4:Evaluate the clinical effectiveness of the screening program.

8. Implementing Screening for Diabetes and Pre-Diabetes within the LSU HCSD Medical Home Clinics Project was piloted for 2,830 patients who visited three Medical Home Clinics at Earl K. Long from January 14, 2013 to February 28, 2013. • North Baton Rouge • South Baton Rouge • Family Practice Clinic

9. Implementing Screening for Diabetes and Pre-Diabetes within the LSU HCSD Medical Home Clinics Group Name (# of subjects) Unique visitors (2830) A Legend Diabetes (817) Exclusion by Administration Data ? Yes Decision B Cancer,HIV or ESRD (299) No C Visitors (1714) D Yes Screened (841) Screened? No F Not screened (873) Screening stop boxes for exclusion? No Risk Factors Assessed (344) Yes E J Existing Diabetes Diagnosis (75) Less than 2 Risk Factors (132) 2+ Risk Factors (212) G Recently Tested (371) L K Not Ordered (22) Ordered (190) H Age<45 & BMI<25 (51) M N I Done (130) Pending (60) O P Normal (55) Pre-diabetes (63) Diabetes (12) Q R S

10. Implementing Screening for Diabetes and Pre-Diabetes within the LSU HCSD Medical Home Clinics Results: 5.7% Prevalence of previously undiagnosed patients with diabetes identified among those with two or more risk factors visiting the pilot clinics Based upon the LSU HCSD Medical Home volume of 101,000 unique adult patients annually, 1420patients would be identified by the screening protocol as having diabetes if conducted for one year

11. Implementing Screening for Diabetes and Pre-Diabetes within the LSU HCSD Medical Home Clinics Results: 29.9% Prevalence of previously undiagnosed pre-diabetic patients among those with two or more risk factors visiting the pilot clinics. Based upon the LSU HCSD Medical Home volume of 101,000 unique adult patients annually, 7,470 patients would be identified by the screening protocol as having pre-diabetes if conducted for one year

12. Overall Impact of Projects on Improvement of Health Outcomes The identification of a large number of undiagnosed patients with pre-diabetes highlights the need for a treatment strategy. Therefore, feasible and inexpensive interventions for patients with pre-diabetes should be defined and tested.

13. Current LSU ICON Diabetes Disease Management Projects Implementing Screening for Diabetes and Pre-Diabetes within the LSU HCSD Medical Home Clinics Jolene Johnson, MD and Ronald Horswell, PhD Principal Investigators Jay Besse, BS and Rob Leonhard, MBA Co-Investigators Designing Screening Algorithms for Diabetes and Pre-Diabetes Ronald Horswell, PhD Principal Investigator Gang Hu, MD, PhD and Jolene Johnson, MD Co-Investigators

14. Designing Screening Algorithms for Diabetesand Pre-Diabetes Overview: • This Quality Improvement Project is gathering data necessary to evaluate alternative screening algorithms for identifying previously undiagnosed patients with diabetes and pre-diabetes. • The immediate application of these results will be the development of a cost effective screening algorithm(s) for use within the LSU Health delivery system.

15. Designing Screening Algorithms for Diabetes and Pre-Diabetes Specific Aims • Aim 1: Estimate and compare the achievable combinations of sensitivity and specificity obtainable by the candidate screening protocols involving single or multiple component tests. • Aim 2: Determine if risk factor assessment via either the American Diabetes Association’s risk factor instrument and/or the FINDRISC instrument improves screening algorithm performance. • Aim 3: Conduct cost effectiveness analysis comparing the candidate algorithms.

16. Designing Screening Algorithms for Diabetes and Pre-Diabetes DETERMINING CLINICAL DIABETES DIAGNOSIS

17. Designing Screening Algorithms for Diabetes and Pre-Diabetes

18. Designing Screening Algorithms for Diabetes and Pre-Diabetes

19. Designing Screening Algorithms for Diabetes and Pre-Diabetes

20. Designing Screening Algorithms for Diabetes and Pre-Diabetes

21. Designing Screening Algorithms for Diabetes and Pre-Diabetes Results: • Risk factor screening instruments, utilized as typically recommended (e.g.: ADA 2+ risk factors), reduce the cost per person screened, but have a maximum sensitivity of 80%. • Suggests the need to be selective in establishing screening instrument cut off points.

22. Overall Impact of Project on Improvement of Health Outcomes To maximize the sensitivity and minimize the cost of diabetes screening

23. Proposed LSU ICON Diabetes Disease Management Project Comparing Cost Effectiveness of Two Methodologies for Assessing Diabetic Patients for Hepatitis B Vaccines Within the Medical Home Clinic Jolene Johnson, MD and Ronald Horswell, PhD Principal Investigators

24. Proposed LSU ICON Diabetes Disease Management Project Overview: • Two general strategies for Hepatitis B vaccination • Test for immunity prior to vaccination • Immunize all patients • Critical information for determining optimal strategy includes: • Cost of immunity testing • Cost of immunization • Baseline prevalence of immunity in the population