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We have an epidemic of diabetes!!!

We have an epidemic of diabetes!!!. Why Diabetes ? ? ?. We Have an Epidemic of Diabetes !. Diabetes a Human Drama. 20+ million Americans have diabetes; - 44 million are obese - 6+ million undiagnosed 25 million increase projected by 2010 > 998,000 new cases yearly

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We have an epidemic of diabetes!!!

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  1. We have an epidemic of diabetes!!!

  2. Why Diabetes ? ? ?

  3. We Have an Epidemic of Diabetes !

  4. Diabetes a Human Drama • 20+ million Americans have diabetes; - 44 million are obese - 6+ million undiagnosed • 25 million increase projected by 2010 • > 998,000 new cases yearly • >200,000 deaths • 54,750 amputations • 29,200 develop kidney failure • 25,550 become blind

  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 APhA Foundation 2003 Statistics

  6. Diabetes Control Not at ADA Goal Oral Insulin A1c 100 27 32 >9% 80 • 62% of oral patients • 73% of insulin patients 15 60 19 8%–9% % of Subjects 20 40 22 7%–8% 20 38 27 <7% 0

  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 157,000 people with type II diabetes; 12 states

  8. Percentage of Diabetes Patients with A1C Above Goal (6.5%) by State: 2003-2004 RED: Top 11 worst-ranked BLUE: All other states WHITE: No data

  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"

  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 1ADA. Diabetes Care. 2002;25(suppl 1):S1; 2AACE/ACE. Endocr Pract. 2002;8(suppl):5

  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 GHLC Project Model“Traditional” Disease Management Programs Face-to-face counseling is customized for individual patients. Caregiver is a specially trained pharmacist/CDE who knows the patient’s history. Patient and caregiver work together to set and follow up on specific goals. Educational counseling is targeted to each patient’s needs and individual goals. Impersonal counseling is generic and for a mass audience. Service is often limited to information about the prescription without the benefit of a complete medical history. Follow-up on generic benchmarks is often conducted via postcard/impersonal telemarketing techniques. Educational materials are often irrelevant to many patients and inappropriate for low literacy levels. Adapted from DiabetesCommunity Health Project, North Carolina Center for Pharmaceutical Care

  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. March ------------April----------May-June-July---August-Sept-Oct----November 1)Results given 2)Invited to Lunch & Learns Georgia Healthcare Leadership Council - Diabetes Initiative No Screening BG/BP/BMI BG> 140 Lunch&Learn1 Nutrition and Exercise Lunch&Learn2 Behavior Modification Lunch&Learn3 Avoiding Complications Yes Intensive Mgmt 1: 1)Results given 2)Consult with CDE 3)A1C – immediately. 4)Set Goals 5)BG Meter 6)KWWD 7)Invited to Lunch/Learns 8)Informed Consent 9)Knowledge Base Test Intensive Mgmt 2: 1) Consult 2)Review Goal 3)KWWD 4)Letter to Provider Intensive Mgmt 3 Award/Recognition: 1) Certificates 2) Recognize those that meet goal with Employer incentive. 3)Final A1c 4)Retest Diabetes Knowledge Base

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

  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 • “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

  37. 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

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

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

  40. What Next ???

  41. Thank You ! ! !

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

  43. Why Do Employers Have Disease Management Programs? • Improve member health • Reduce absenteeism and increase employee productivity • Help better manage the cost of healthcare benefits in order to • keep those programs affordable and sustainable • Add value, not just costs to the benefit plans!

  44. Most Frequently Offered Disease Management Programs • The Big Five: • Diabetes • Asthma & COPD • Heart Disease – CAD & CHF • Back Pain • Depression • Obesity? A growing problem and getting bigger!

  45. Why Diabetes? • One out of every 10 healthcare dollars spent in the U.S is on • diabetes and its complications • $92 billion in direct costs; $40 billion of indirect costs (2002) • $13,243 average annual healthcare costs for patients with • diabetes vs. $2,560 for patients without it (2002) • 88 million disability days due to diabetes (2002) • 16.9 million diabetes related hospitalizations (2002) • 62.6 million physician office visits Source: Centers for Disease Control and Prevention, 2005

  46. Using HEDIS Data To Measure Effective Diabetic Care • Comprehensive Diabetic Care Measures • HbA1c Screening • Poorly Controlled HbA1c Levels • Diabetic Retinal Eye Exam • LDL-C Screening • LDL-C Level <130mg/dl (new measure is <100mg/dl) • Nephropathy Screening • It’s more than just managing blood sugar; diabetes is a complex • and complicated disease state that affects many different areas • of the body

  47. Florida HMO HEDIS Data - HbA1c Screening

  48. Pennsylvania HMO HEDIS Data - HbA1c Screening

  49. Atlanta HMO HEDIS Data - HbA1c Screening

  50. Florida HMO HEDIS Data – Poorly Controlled HbA1c Note: Lower Is Better

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