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The Diabetes Registry: A Cost-Effective Approach to Practicing Quality Medicine

The Diabetes Registry: A Cost-Effective Approach to Practicing Quality Medicine. Edward Shahady , MD Medical Director, Diabetes Clinician Program Florida Academy of Family Physicians.

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The Diabetes Registry: A Cost-Effective Approach to Practicing Quality Medicine

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  1. The Diabetes Registry: A Cost-Effective Approach to Practicing Quality Medicine Edward Shahady, MD Medical Director, Diabetes Clinician Program Florida Academy of Family Physicians

  2. “Diabetes is the 6th leading cause of death, leading cause of blindness, chronic renal disease, amputations and a major contributor to coronary artery disease and strokes. Florida with its aging population has a large number of diabetic and pre-diabetic patients that require extensive medical attention. The extent of this care demands time, knowledge, compassion and commitment from all members of the clinician’s office, the patient, families and other care givers. Simply stated it takes a village to care for a diabetic.”

  3. More Diabetes Facts • 20% of Medicare population has diabetes • 30% of the Medicare Budget is spent on diabetes • Leading cause of blindness is diabetic retinopathy and it is 90% preventable - National Eye Institute • Diabetic nephropathy is the leading cause of end stage renal disease - most is preventable - NIDDKD • Diabetes accounts for 60% of all non-traumatic amputations - 85% preventable - ADA CDC

  4. Epidemic of Diabetes • Between 2009 and 2034, # with diagnosed and undiagnosed diabetes is anticipated to increase from 23.7 million to 44.1 million. • During the same period, annual diabetes-related spending is expected to increase from $113 billion to $336 billion (2007 dollars). • Medicare - the diabetes population is expected to rise from 8.2 million in 2009 to 14.6 million in 2034

  5. “Excellent evidence documents that when patients achieve control of their HbA1c, LDL and Blood pressure through life style changes and medication, obtain recommended immunizations, eye exams, foot exams, urine microalbumin and take aspirin daily, significant reduction in complications will be achieved. Practices that measure individual and practice achievement of these evidenced based activities and share that information with clinicians, staff and patients achieve better diabetes control and reduce costs and complications.”

  6. Background Information • DMCP Florida Academy of Family Physicians started in November 2003 • Funded by grants • Now have 84 offices and over 250 clinicians and 450 nurses; MA’s have received training and use the registry • Partnering with ADA, JADE, and Rural Health Networks - St John’s, Big Bend, and Heartlands

  7. Background Information(Training) • After all their diabetes data are entered into the registry the clinician and staff (MA/LPN) receive initial training of 4.0 hours followed by two 2-hr sessions over one year. • Follow-up training consists of visits to clinicians office and of emails sharing data and recent articles • Training includes(evidenced based CME credit) • Evidence Based standards of care • How to use patient reports from diabetes registry • How to use population reports from the registry • How to conduct group visits • Up-to-date knowledge about diabetes, lipids and hypertension • How to address clinician and patient barriers to standards adherence - clinical inertia

  8. Value of DMCP • Increased quality of care for diabetics in your practice • Decreased complications and suffering for your patients • Entry into the Medical Home concept • Increased reimbursement for quality of care • Increased prestige through recognition and certification • Office recognized as a center of diabetes excellence • Clinicians certified as Diabetes Master Clinicians • Staff certified as Diabetes Master Clinician Associates

  9. DMCP Diabetes Registry • Is Internet based - all data and reports on the web • Research assistant places initial data for all diabetic patients from a practice into the registry. • Staff then keeps up data entry • Initial training begins once data from practice is entered

  10. In addition to the registry, taught how to do group visits.

  11. Actual group visit - patients completing first part of medical record

  12. Registry Reports (Tools) • Point of Care Reports for the clinician and the Patient - report cards • Population-based Reports that identify • Patients at increased risk because of increased HbA1c, LDL, B/P, non-HDL, triglycerides • Patients who do not have documented annual recommendations or daily ASA

  13. Barriers to Quality Achievement • Most clinicians believe they are achieving better goal attainment than they are • Do not have a feel for the patients who are not being seen • Office staff not used to aiding quality achievement-push to the limit of their license • Reimbursed for volume and ability to code - not quality

  14. Lets look at the evidenced-based goals for diabetes care that are used in our registry.

  15. What does reaching goals accomplish? • A 1% decrease in HbA1C decreases the chances of blindness, amputations and renal disease by 35% (DCCT-UKPDS-Kumamoto) (Level A) • Reduction of LDL (lousy cholesterol) less than 100 or 70, and systolic blood pressure less than 130 decreases risk of CVD 40-50% (CARDS, 4S, TNT, PROVE-IT) (Level A)

  16. A1C goals? • For patients in general, is an A1C goal of 7% (B) • For the individual patient, as close to normal (6%) as possible without hypoglycemia (E, A) • Less stringent goals if patient has history of severe hypoglycemia, older, prior CV event, etc. • Obtain A1C every 3 months (not controlled - every 6 months controlled) • (2010) ADA Clinical Practice Recommendations Diabetes Care. Available at: www. diabetes.org

  17. Lipid goals? • Obtain lipid profile at least 1 time a year (E) • The primary goal is an LDL <100 mg/dl (A) if high risk <70 (E) Recent suggestion is <70 if diabetes plus one risk factor (smoking, >BP, FamHx). • For those >40 years old statin therapy to achieve an LDL reduction of 30-40% regardless of baseline LDL levels is recommended (A) • Lower triglycerides to 150 mg/dl and raise HDL cholesterol to >40 mg/dl in men and >50 mg/dl in women • (2010) ADA Clinical Practice Recommendations Diabetes Care. Available at: www. diabetes.org

  18. B/P goals? • Treat systolic BP<130 (B), treat diastolic BP to <80 (B) • Drug Rx as well as TLC (A) • More than 1 drug often needed (B) usually add a diuretic to ACE or ARB • Measure B/P with feet on floor and arm supported at heart level: two measurements(JNC7) (E) • ADA goal 130/80 • (2010) ADA Clinical Practice Recommendations Diabetes Care. Available at: www.diabetes.org , Chobanian AV et al. (2003) JAMA 289(19):2560-2572

  19. Other goals? • Yearly flu shots (B) • Pneumovax (1 shot): if first shot before 65, another 5-10 years after first • Dilated eye exam yearly in T2D, T1D 3-5 years after the onset , then yearly (B) • Annual test for of micro-albuminuria even if on ACE or ARB (E) • Annual test for sensation like 10-g monofilament pressure sensation and vibration perception using a 128-Hz tuning fork excellent tools for detecting neuropathy -feet (B) • (2010), ADA Clinical Practice Recommendations Diabetes Care. Available at: www. diabetes.org

  20. Let’s look at some reports from the registry.

  21. Saves Clinician 5 Minutes

  22. Patient Report Care

  23. Also in Spanish

  24. Report informs practice of goal achievement.

  25. Report informs each clinician of goal achievement.

  26. Report informs each clinician of goal achievement.

  27. Reports identify patients at high risk - not at goal - all names fictitious.

  28. Patients not at goal for LDL

  29. How many patients with CKD are at LDL goal? Don’t know without a registry • National Kidney foundation goal for LDL in CKD is <100 • 4541 patients in Kaiser Colorado System - with GFR <60 • 1384 - 30% no lipid profile in last 365 days • 3157 - 70% of those that had a lipid profile at LDL goal • 72% of those at goal on a statin (only drug with evidence of ↓ of CAD in patients with CKD and ↓ in progression of loss of renal function • Stadler et al J. Clin Lipidology 2010;4;298-304

  30. Diabetics at-risk smokers

  31. Use this report to improve screening for CKD in diabetes Patients who have not had recommended quality measure for 5 items

  32. Office staff are the missing link to reaching quality goals. Need to push them to limit of their licensure.

  33. Impact of Medical Assistants Over 8-month period for 140 patients • MA gave patients and physicians report cards • MA Ordered tests per protocol and • MA did the monofilament exams

  34. Sample of Best Practices

  35. Towers Perrin actuarial evaluation 2006 Bridges to Excellence http://www.bridgestoexcellence.org

  36. Yearly Cost Savings using Bridges to Excellence data as of June 2009 www.bridgestoexcellence.org

  37. http://www.fafp.org/diabetes_mc.html

  38. Other information • Dr. Shahady can be contacted at eshahady@att.net.

  39. Questions Comments

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