Dr. Strangelove or: How I Learned to Stop Worrying and Love Taking Care of Diabetics in Clinic

1. Dr. Strangelove or: How I Learned to Stop Worrying and Love Taking Care of Diabetics in Clinic September 5, 2012 Kevin Wang

2. What This Is Not … • A rehash of the treatment of diabetes • A discussion on the LDL and BP goals for diabetes • A long discussion of random studies showing this, that and the other • A discussion on gestational diabetes (sorry) • Boring … I hope

3. Goals • To discuss why diabetes care management is important • To discuss some of the common complications in diabetes and how we can facilitate the care of our diabetics in clinic • What’s actually measured by insurance companies and other quality assurance groups?

4. Diabetes Again?!?! • Why is diabetes such a big deal? • Prevalence of diabetes in adults is up to almost 18% • Accounts for 14% of US healthcare expenditures due to the many associated comorbidities • Despite new advances in treatment, no major improvement in the treatment of diabetes over the last three decades • Measurable improvement with A1C goal • < 10% of patient actually meet all recommended goals for treatment • Even prediabetes is associated with its own issues

5. Basic Overview of Diabetes • Just kidding! • But seriously, let’s talk a bit about screening and diagnosis first • Screening • Diagnosis

6. Complications of Diabetes • Audience participation

7. Coronary Artery Disease • Screening for CAD • ASA • ADA Recommendations • Framingham Risk Calculator • http://www.mcw.edu/calculators/Coronary-Heart-Disease-Risk.htm

8. Peripheral Arterial Disease

9. Risk Reduction • Diet & Exercise • Swedish Nutrition (Yes, they accept Medicaid and Medicare!) • YMCA • 9140 California Ave SW, Seattle, WA 98136206 344 3181 • http://www.seattleymca.org/locations/WestSeattle/pages/program-details.aspx?progid=5202 • Smoking • .avsquitsmoking

10. Diabetic Retinopathy

11. Diabetic Nephropathy

12. Diabetic Neuropathy

13. Screening for Neuropathy

14. Foot Care .KWDIABETICFOOTCARE

15. Community Foot Care Clinics • Swedish First Hill Family Medicine with Dr. Grabowski • Podiatric Physicians & Surgeons • 1101 Madison St Suite 1120, Seattle, WA 98104(O) 206 447 0302 • Priority Foot Wear & Pedorthoic Services • 2150 North 107th Street Suite 204, Seattle, WA 98133(O) 206 957 7772 • Advanced Foot & Ankle Clinics • 10564 5th Ave NE Suite 103, Seattle, WA 98125(O) 206 361 2255

16. Diabetic Foot Ulcers

17. Foot Ulcer Management .WOUNDCARECENTER

18. Dental Screening

19. But My Patient Has Medicaid or No Insurance! • http://www.kingcounty.gov/healthservices/health/locations/dental.aspx • http://www.skcds.org/for-the-community/general/clinics-and-programs-providing-reduced-cost-dental-care/ • http://dental.washington.edu/patient/dental-student-clinics.html

20. Quality Measures • Hemoglobin A1C Testing • Poor Control: > 9% • Control: < 8% • Control for Certain Populations: < 7% • Eye Exam • LDL Screening • LDL Control

21. Quality Measure (Cont.) • Medical attention for nephropathy • Influenza vaccination • Pneumococcal vaccination • At diagnosis • If age < 65, give second dose 5 years after initial dose • Assessment of tobacco use • Assistance with tobacco cessation

22. Why do we have so much trouble treating our diabetic patients? • Systems Problems (a.k.a. Challenges due to the design of the health care system) • Increase in the number of people with diabetes which results in a decrease in the attention and resources available per person • Clinical Inertia

23. What can we do to improve delivery of care? • The Chronic Care Model • ADA Objectives • Optimize provider & team behavior • Support patient behavior change • Change the system of care • Other Ideas?

24. Should we be managing our diabetics? • Medical Outcomes Study • Short Answer – YES!

25. What we are doing to improve the health of our diabetic patients • Team Meetings and Patient Panel Review (ICSI Recommendation) • Who has diabetes? • Who has high blood pressure? • Who has had a diabetic eye exam? • Who has an LDL > 100 mg/dL? • Who has had a foot exam? • Calling patients who haven’t had a diabetes check in “a while” • http://www.icsi.org/guidelines_and_more/gl_os_prot/other_health_care_conditions/diabetes_mellitus__type_2/diabetes_mellitus__type_2__management_of___6.html

26. Healthy People 2020 • Reduce the annual number of new cases by 10% (8/1000 to 7.2/1000 aged 18-84 years) • Improve glycemic control by reducing the proportion of diabetics with an A1C > 9% from 16.2% to 14.6% • Increase proportion of diabetics with an A1C < 7% from 53.5% to 58.9% • And much much more! • http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=8

27. Take Home Points • There are lots of different guidelines for screening/treatment of the complications associated with diabetes • Don’t forget to take advantage of your community resources • Systems changes should help us monitor and give additional support for our patients with diabetes • Current quality indicators for diabetes may change! • Don’t forget about screening recommendations to treat those who don’t know they have diabetes!

28. Thank You!