We have an epidemic of diabetes

1. We have an epidemic of diabetes!!! R. Patrick Devereux, Pharm.D The Institute for Wellness and Education Woodstock, Georgia June 8, 2006

2. Add Diabetes Forecast beginning here.Add Diabetes Forecast beginning here.

3. We Have an Epidemic of Diabetes !

4. Diabetes a Human Drama

5. Rationale for a Diabetes Program Only 55% of people with diabetes remain on therapy after 12 months There are significant knowledge deficits in 50-80% of individuals with diabetes Each $1 spent on outpatient diabetes education saves $2-3 in hospitalization costs

6. Diabetes Control Not at ADA Goal

7. AACE states May 18 2005: Diabetes is Worsening 2 out of 3 patients do not reach A1c of 6.5% 98% of people diagnosed with type 2 diabetes agree that blood sugar control is important 84% of Americans with type 2 diabetes feel they are doing a good job of managing their diabetes 61% do not know what the A1C test is 51% do not know what their last A1C number was The medical community needs to intervene earlier and more aggressively to control blood sugar

9. Diabetes: Huge Cost to Society Diabetes costs $132 billion/year* = 10% of HC spending (< 7% are drugs) 25% of all Medicare budget Individual healthcare costs for diabetes $13,243/yr* 2.4 times higher than non-diabetes Better glycemic control can lead to $685-950 annual savings per patient** Co-payments doubled, 23% reduction consumption: +17% emergency room; +10% hospital stay

10. �A Progressive Disease NEEDS  Aggressive Treatment" 1. Diagnose Early 2. Establish baseline 3. Implement aggressive treatment 4. TREAT TO TARGET1. Diagnose Early 2. Establish baseline 3. Implement aggressive treatment 4. TREAT TO TARGET

11. Goal of Diabetes Treatment Mimic physiologic insulin release Intensively treat to goals Control FPG levels from ?80 to ?120* mg/dL PPG levels from ?100 to ?140 mg/dL A1C to <7%1 (<6.5%2) Intensively treat diabetes comorbidity

12. �Diabetes Intensive Management Program� Presented by: R. Patrick Devereux, PharmD The Institute for Wellness and Education June 8, 2006

13. Advantages of the GHLC Project Model

14. GHLC Participating Companies City of Roswell Coca Cola GA Dept of Comm Health (DCH) GA State Merit System Home Depot Interland Lockheed Verizon Alpharetta Verizon Ashford Dunwoody

15. Georgia Healthcare Leadership Council - Diabetes Initiative

16. Enrollment Metrics (Aggregate Data) Number of patients 97 patients enrolled 47 completed program Patient demographics Gender Age Ethnicity Education distribution

17. Enrollment Metrics (Aggregate Data) Average duration of enrollment 9.043 months Provider time spent on patient care Visit 1: 42.76 minutes Visit 2: 48.70 minutes Visit 3: 47.11 minutes Visit 4: 43.30 minutes* Visit 5: 45.00 minutes* *not all patients received visits 4 and 5

18. Demographics Patient demographics (for 47 completing program) Age <35: 3; 36-45: 9; 46-55: 23; 56-65: 11; >66: 1 Gender Female 26; Male 21 Ethnicity African American 23; Asian 2 Caucasian 20; Hispanic 2 Education No high school diploma or equivalent: 1 High school diploma or equivalent: 24 Some college, no degree: 8 College diploma: 14

19. Clinical Outcomes � A1C A1C Initial visit A1C: 7.62 Last visit A1C: 7.15 Only 12 out of 47 patients (25%) new or had A1C when started program 28% of patients decreased A1C by >1% 6 > 2%, 2 >3% decrease

20. Clinical � A1c Values �through Dec 31 2005 (comparison of 47 patients) Visit 1 A1c Values Average = 7.62 Visit 5 (9 month mean) Average = 7.15

21. A1C examples worth mentioningBest 5 A1c Decreases 8.5 down to 5.7 9.1 down to 6.4 8.3 down to 5.6 9.6 down to 6.2 14 down to 11.2

22. Clinical Outcomes LDL Initial visit LDL: 133 mg/dL Last visit LDL: 100 mg/dL LDL examples worth mentioning: 210 down to 151 156 down to 64 139 down to 88

23. Clinical Outcomes Blood Pressure (aggregate) Initial visit BP: 139.5/85.9 mmHg Last visit BP: 123.7/82.7 mmHg How many knew there BP ?? Most patients knew BP None of the patients knew goal BP of 130/80 mmHg or lower prior to program

24. Blood Pressures worth mentioning 139/94 down to 100/70 160/100 down to 126/82 140/70 down to 112/66 194/98 down to 160/88 145/80 down to 114/70 145/90 down to 120/80 140/89 down to 120/80 132/86 down to 120/80 150/110 down to 140/88

25. Did the patient achieve their goals?? Major Program Goals Tracked in Patients Learn more about diabetes, avoid complications Feel better Lower A1c, get better control of BG Lower BP Daily foot exam Regular eye and dental exams Monitor blood glucose Learn more about diet to follow

26. Flu Vaccine, Foot exam Flu Vaccination Program onset: 7 patients received flu shot annually (7/47 = 14.8%) Program end: 38 patients receive flu shot (38/47 = 80.8%) Foot Exam Program onset: 5 patients admit to daily self foot exam (5/47 = 10.6%) Program end: 47 patients admit to daily self foot exam (100%)

27. Medication Use Breakdown of Patient Use of Antidiabetic Medications No medications, diet and exercise only: 5 Oral DM meds only: 35 Oral DM meds plus insulin: 4 Insulin only: 3 Worth mentioning: 4 patients were able to come off of medications as a result of education and training they received as part of this program, improved BG, A1c, etc.

28. Medication Use ACE Inhibitor Therapy Patients on ACE at program onset: 20 Patients on ACE at program end: 30 Able to get 10 patients on ACE therapy Lipid Lowering Therapy Patients on LLRx at program onset: 19 Patients on LLRx at program end: 24 Able to get 5 patients on LLRx

29. Medication Use Daily Aspirin Therapy Patients on daily ASA at program onset: 7 Patients with CI to daily ASA therapy: 4 Patients on daily ADA at program end: 20 Able to get 13 patients on daily ASA therapy Used for cardioprotection ADA Standard for all DM pts >30yoa

30. Medication Compliance Program Onset (self rated) N/A: 1 Not very well: 2 Poor: 0 Fair: 5 Good: 25 Very well: 14

31. Medication Compliance Program End (self rated) N/A: 2 Not very well: 1 Poor: 0 Fair: 1 Good: 17 Very well: 26

32. BG Monitoring Compliance Program Onset (self rated) N/A: 6 Not very well: 9 Poor: 4 Fair: 3 Good: 16 Very well: 9

33. BG Monitoring Compliance Program End (self rated) N/A: 0 Not very well: 2 Poor: 1 Fair: 5 Good: 19 Very well: 20

34. Humanistic Outcomes:Patient Perceptions �After we met Thursday I went home and opened my new insulin and my high BGs started dropping. Thanks for your help!� -pt at Home Depot (this pt was using expired insulin and we were able to catch that and get him on the right track)

35. Humanistic Outcomes:Patient Perceptions �I wanted to thank you for meeting with me and providing the meter. I�ve been using it every day and found that it really helps to know my blood glucose level in order to keep it under control. Thanks again.� -pt at Verizon Alpharetta

36. Humanistic Outcomes:Patient Perceptions �I just wanted to express how delighted I am to have the invaluable services provided by your agency. I really needed someone to fill in the gap. I have been using a local health services clinic and have seen a different physician each visit. You have been the only constant health professional since we started. I look forward to your visit and getting very needed information to manage my health care. I feel I need someone who will monitor me and hold me accountable for corrective actions. Thank you for your excellent health care procedures and practices.� -pt at Verizon Ashford Dunwoody

37. Humanistic Outcomes:Patient Perceptions �Thank you for coming to the facility and teaching me and other employees about diabetes. I am so glad I was at the Health Fair to have my blood sugar tested. I have learned so much about eating properly and monitoring my blood sugar daily. Learning about diabetes and how to control it has made a difference in my lifestyle and my husbands as well.� -pt at Lockheed

38. Humanistic OutcomesPatient Perceptions �Thanks so much for the opportunity to participate in the diabetes wellness program. Thanks again for your concern and time dedicated to those who suffer from diabetes. The program has not only motivated me to continuously monitor my diabetes, but also to successfully manage my overall health. Thanks to you as I continue to launch my success story.� -pt at Verizon Ashford Dunwoody

39. Humanistic OutcomesPatient Perceptions �I am interested in continuing the diabetes program. It has been a great help.� -pt at Dept of Comm Health

40. Guidelines that are Not Implemented Do NOT Work !!

41. What Next ???

43. Measuring The Clinical Effectiveness Of Disease Management Programs:Are Members Getting Healthier?

44. Why Do Employers Have Disease Management Programs?

45. Most Frequently Offered Disease Management Programs

46. Why Diabetes?

47. Using HEDIS Data To Measure Effective Diabetic Care

48. Florida HMO HEDIS Data - HbA1c Screening

49. Pennsylvania HMO HEDIS Data - HbA1c Screening

50. Atlanta HMO HEDIS Data - HbA1c Screening

51. Florida HMO HEDIS Data � Poorly Controlled HbA1c

52. Pa. HMO HEDIS Data - Poorly Controlled HbA1c

53. Atlanta HMO HEDIS Data - Poorly Controlled HbA1c

54. Florida HMO HEDIS Data � Diabetes LDL-C Screening

55. Pa. HMO HEDIS Data - Diabetes LDL-C Screening

56. Atlanta HMO HEDIS Data - Diabetes LDL-C Screening

57. Fla. HMO HEDIS Data � Diabetes LDL-C <130mg/dl

58. Pa. HMO HEDIS Data - Diabetes LDL-C <130mg/dl

59. Atlanta HMO HEDIS Data - Diabetes LDL-C <130mg/dl

60. Florida HMO HEDIS Data � Cholesterol Mgmt. After Acute Cardiac Event � LDL-C <100mg/dl

61. Pennsylvania HMO HEDIS Data � Cholesterol Mgmt. After Acute Cardiac Event � LDL-C <100mg/dl

62. Atlanta HMO HEDIS Data � Cholesterol Mgmt. After Acute Cardiac Event � LDL-C <100mg/dl

63. In Summary

64. In Summary (cont�d)