Cost Effective Management of Diabetes

1. Cost Effective Management of Diabetes New Jersey Academy of Family Physicians May 30, 2003 Robert Eidus MD, MBA

2. www.eidushealth.com/solutionsNJAFP presentation button • Powerpoint presentation • Tools • Word and Excel: modifiable • PDF • Spreadsheet of literature review summary • Exercise • Smoking • Diabetes • Diet

3. Goals of Cost Effective Management • Prevent microvascular complications • Aggressive hypoglycemic management ( also helps renal, retinal, neuropathy, QOL) • HbA1C reduction • Prevent Cardiac Complications • Aggressive management of hypertension, hyperlipidemia • ASA • Lifestyle modification • Tobacco • Exercise • Prevent renal complications • Screen for microalbuminuria • ACEI (ARB) • Prevent vision loss • Retinal screening • Prevent other co-morbidities • Immunizations • Foot surveillance

4. Type II Diabetes • An illness of: • Genetics • Lifestyle issues

5. The Magnitude of Cost EffectivenessDiabetes Related Costs (three year estimates) Gilmer, Todd, et. al., Diabetes Care, 1997; Vol 20, No 12

6. Cost-effectiveness • Medical costs savings per year for reduction of HbA1C of 1% point range from $135 to $1400 • Other estimates range as high as $8000 per year • Savings begin to accrue within the first year and are greater in subsequent years if reductions are sustained • Hypertension management: Incremental costs per life year gained (£720) – UKPDS 40

7. Cost Effectiveness • Smoking • Smoking increases relative risk for stroke by a factor of 2.5 • 30% of all CHD deaths in US attributable to smoking • These risks are accentuated in the diabetic • Smoking cessation is the most effective management intervention and the results begin to accrue in year 1 • Smoking cessation has been estimated to be 40 times more cost effective than cholesterol management

8. Cost effectiveness • Exercise • Exercise cuts overall post-MI risk by 25% • Diabetes is now considered to be a coronary artery disease equivalent (ACC/AHA Stage A) • Regular walking among diabetic women is associated with substantially reduced risk for cardiovascular events • Exercise helps improve sensitivity to insulin

9. Medication Effectiveness “In Vitro” vs System Ineffectiveness • There are few studies pointing to the superiority of one oral hypoglycemic over another. When they are done, they are done in controlled environments • Medication superiority A vs. B, may be on the order of 2,3, or 4% • System inefficiency is on the order of 40-60% • If one had to choose, a “C” treatment regimen with a “A” implementation and management plan is preferable over the reverse

10. A Different Paradigm • Focus on systems and the process of care, rather than on minute nuances in medication management • Use office management tools • Lifestyle and behavioral issues govern morbidity and mortality • Use behavioral change principles • Treat lifestyle issues aggressively • Treat Co-morbidities aggressively • Focus on prospective social issues rather than severity of illness issues in determining who will consume large amount of health care resources in the year to come • Design interventions around this new risk profile • People with chronic illness of different types which impact the quality of life have more in common than people with homogeneous conditions but who have varying degrees of severity of illness and QOL impact • There is a commonality among people who have chronic illness with common management issues

11. Examples of System Inefficiency • 41% of people with heart failure for whom a beta blocker are indicated are receiving it (www.heartfailure.org) • Beta blocker post MI (1996) 62%, (2000) 92% • HbA1C testing in diabetics (2001) 80% • LDL screening in diabetic (2001) 86% • LDL control in diabetics (2001) 55% • Urine microalbuminuria in diabetics (2001) 42% • HEDIS Poor HbA1C control- (2001) 41%* * > 9.5%

12. Gaps in Care in Diabetes • Prevention of Renal Disease • ACE inhibitors • Prevention of Coronary Artery Disease • Lipid and Hypertension management, ASA • Smoking • Exercise • Immunizations • Retinal Vascular Surveillance

13. Physician/Provider Centric Care is fragmented No reminder system, no disease registry No risk management safeguards Behavioral change theory not used Disorganized charting Missed opportunities Time constraints Lack of use of tools, flowcharts, etc. Patient Centric Patient not aware, not educated Faulty data bases Cost of meds Motivation Lifestyle issues Lack of support Confusing or contradictory information Managing Type II DiabeticsCauses for system inefficiency and ineffectiveness

14. Hypoglycemic Agents • Management is largely empiric • Little evidence pointing to the superiority of one agent vs. another • Choice based on economics, frequency of administration, side effect profile, drug-drug interactions • Excellent monograph from Illinois Academy of Family Physicians (630-435-0257)

15. Other Medication Issues • ACE or ARB are renal protective and vasculoprotective • Consider using unless there is a contraindication • Beta-blockers are effective in reducing incidence of new coronary events • Statins are drug class of choice for most diabetics who have elevated lipids • Diet, achievement of ideal body weight, and exercise is the foundation of cost effective management

16. Computer Based Systems Reminders to physicians Online registries Patient profiles Smart systems Appointment reminder systems to patients Lab results in flow sheet format Non-automated Letter and postcard reminders Telephone reminders Chart sticker prompts Flow sheets Use of other tools Diabetes Best Practices (HCFA-2001)

17. Adherence • Major Causes of Non Adherence • Not knowing why you are taking the medications • Not knowing about potential side effects in advance • Side effects impairing quality of life • Cost • Timing issues • Depression

18. Diabetes Medication Use • % of diabetics with > 1 rx per year= 99% • Mean number rx per pt. per yr.= 31.5 Tools to support improving patient adherence • Living With Diabetes Daily Diary • Red Light Green Light Tool • Medication Use Questionnaire • Goal setting form

19. Living With Diabetes Daily Diary

20. People may miss taking their medications for various reasons. Here is a list of possible reasons why you may have missed taking any medications within the past month

21. When was the last time you missed taking any of your medications? ڤWithin the past week ڤ1-2 weeks ago ڤ2-4 weeks ago ڤ1-3 Months ago ڤMore than 3 months ago ڤNever skip any medications

22. Red Light Green Light Signals

23. Your Diabetic Management Goals • Adherence Goals • Lifestyle Goals • QOL Goals • Format as a contract • One page check off • Physician and Patient Signature

24. Albert Einstein (paraphrased) • When you are having trouble solving a problem, the answer is invariably 1800 from where you are looking

25. The High Cost Tetralogy Social Isolation Low Self Esteem Depression Low Self-efficacy

26. Coping With Your Illness

27. Coping With Your Illness

28. Coping With Your Illness

29. Interventions for High Cost Tetralogy Patients • See them frequently • Community resources • Religious community support • Pets • Telephonic support • Brief counseling • Diagnose and Treat Depression

30. Effect of Phone Counseling Source:: Problem-solving counselling or phone call support for outpatients with chronic illness: Effective for whom? Roberts, J., Brwone, GB, et.al., Can J. Nurs Res,Fall 1995; 27(3):111-37

31. Assessing motivationUseful questions? • How do you feel about smoking? About stresses in your life? • How do you feel about stopping smoking? • What reasons would you have for making this change? • Are you thinking about stopping smoking in the next 6 months?

32. The Prochaska Model of Behavioral Change

33. Smoking Cessation • Advise change (personalize risks of coronary artery disease and benefits of altering behaviors • Assess motivation • Assess past experiences with smoking cessation • Discuss problems/ barriers • Discuss resources • Develop a plan for change • Schedule follow up contact • Monitor progress Adapted from DHHS guidelines If one has a 33% impact on smoking cessation in diabetics, the number needed to treat could be less than or equal to six

34. Other useful things to do • Aspirin: NNT 16 (CI 12-47) in preventing AMI • Set lower BP thresholds (diastolic < 80) • Exercise: • Prevention of renal disease (screen for microalbuminuria; use of ACEI or ARB • Estimate lifetime savings of $9900 for type II diabetics

35. Reimbursement Issues • Patients • Supplies • Insulin Pump • Physicians • E&M coding • EKG • Diabetic education • Extended time

36. Diabetes: E&M Coding 99213: 1-3 HPI questions; ROS- 2 or more systems reviewed 1-5 exam items plus medication management or >6 exam items and no medication management 99214: HPI: 4 or more questions; ROS: 2-9 systems reviewed; Social Hx reviewed Exam: > 12 exam items Medication management 99215: Presence of serious co-morbidity (e.g. TIA, aneurysm, ischemia) HPI: 4 or more questions; ROS: 2-9 systems; Social Hx reviewed Exam: 2+ exam items on 9 systems

37. Physical Exam: Appropriate areas to review • Vitals: Weight and BP • Skin: look for atrophy, diabetic lesions • Eyes: fundus, cataract • Oral cavity: dentition, gingiva • Neck: Thyroid, bruits • Heart: Signs is IHD, vasculature • Musculoskeletal: Gait, feet • Neurologic: DTR, vibration, monfilament • Psychiatric: Cognition, depression screen

38. Cost-effective Medicine “A billion here, a billion there, pretty soon you are talking about real money” Everett Dirkson, US Congress