a-l-l: care team approach to diabetic medication management...a-l-l: care team approach to diabetic...

A-L-L: Care Team Approach to Diabetic Medication Management Aspirin Lisinopril and lipid lowering

Anna Cosyleon, MD * Physician Lead Diabetes Kaiser Permanent Colorado

Department Population and Prevention Services. *No Financial Disclosures

2 | © Kaiser Permanente 2010-2011. All Rights Reserved.May 27, 2014

Objectives: A-L-L use and Team approachin Diabetes Care

Defining the Problem

Foundation

Tools

Support Systems

?


Overwhelming Burden for Millions

CDC Statistics– 25.8 million with diabetes – 18.8 Million Diagnosed– 7 million undiagnosed– Estimated 79 million with pre-

diabetes

Burden of Diabetes

Major cause blindness, renal failure, amputation and CVD Total cost in the US in 2013 = $245 billion 1 out of every 3 Medicare dollars spent on

diabetes Prevalence of 11.3% in US adults in 2011

CDC. National diabetes fact sheet, United States 2013ADA Diabetes Care 2003;26:917

– Leading cause kidney failure, blindness, amputation– Risk cardiovascular disease 2 to 4 fold– 7th leading Cause of Death– 30% of Diabetics over 40 y/o have impaired

sensation in their feet

Complications


Aspirin, Lisinopril, and Lipid Lowering (statin)

A-L-L Therapy is our best option for mitigating the risks associated with having diabetes

How Can We Reduce this Burden?

What is ALL?

In all eligible DM patients, use: Aspirin

– Recommended dose of 81 mg qd Lisinopril

– Target dose of ≥ 20 mg qd Lipid-lowering agents

– Simvastatin 40 mg for risk <7.5% and Atorvastatin 40 for >7.5%

? 25%

22%MI

33%CVA

Cardiovascular Risk Reduction with A-L-L

Benefit of combined treatment


Average Annual Risk per Event

0

0.005

0.01

0.015

0.02

0.025

0.03

0.035

0.04

0.045

MI Stroke ESRD Blind Dying

Nothing

A1c control

ALL

Based on Archimedes model

71% decline with ALL

11 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.

May 27, 2014

Cholesterol Levels as a Trigger for Statin Rx

Cholesterol Levels as trigger for Statin are not relevant

If a patient falls within the four groups most likely to benefit from statin therapy, he/she should be prescribed a statin

Titration is no longer necessary

Monitoring LDL start levels religiously, is no longer necessary

Take Home Points: ALL Therapy

Combination lowers CV events Low risk Low cost Low monitoring

– Glycemic control– Blood pressure- Lisinopril (ACEI) or Losartan (ARB)– Statin Simvastatin or atorvastatin dose based on risk– Aspirin based on risk for cardiovascular disease– Nephropathy– Eye exam– Foot exam

How can the busy Primary Care provider address all the quality goals of this enlarging population?

Problem Defined: There are too many issues to be addressed for each diabetic patient to consistently expect them to be adequately covered at each visit one patient at a time

14 © Kaiser Permanente 2010-2011. All Rights Reserved.May 27, 2014

Team approach to increase both medication & guideline adherence

Foundation

Building a new strategy to care for all of the needs for a diabetic patient.

It takes a team

Foundation of Team Approach

Leadership with clear and measurable goals Whole team engagement Culture of Transparent Accountability Clear communication between teams Sharing of successful practices

Foundation Tools

Registry –Know who are our patients

Data analysis –how are our patients doing?

Actionable quality lists/alerts–Scheduled List monitoring and outreach

• Defining the Problem• Foundation

• Tools• Support Systems• Provider Incentive

Accurate list of patients–Define and track who has DM–Track medication prescriptions and lab

reports– Ideally automated administrative process

Registry

Two A1c ≥ 6.5% Two Fasting Blood Sugars ≥ 126Diagnosis DM On insulin or Oral Hypoglycemic medicationDiagnosis DM and on metformin

Registry: Criteria for inclusion

Ability to extract and arrange information from the patient record, lab, radiology, hospital and pharmacy Present in format that is actionable Needs to be current: “real time”

Data Systems

Diabetes Gap Report Other lists

– No visit in 12 month list– No Statin list– No A1c in 10 month list– Ace/ARB/Micro albumin list

Quality Lists/Care Gap Identification

Team Can Identify

individuals who could

benefit from ALL

Summary Tab in chart indicating testing/quality gaps– viewed by whole care team at each visit & phone call

Electronic prompts for whole care team – A1c, chemistry, urine tests or Retinal exam due– Automatic lab ordering

Blood Pressure alerts

Electronic Medical Record Alerts

1. Defining the Problem2. Foundation3. Tools

4. Support Systems5. Provider Incentive

A centralized team of RNs and support staff Analytic chart review Uses guidelines and tools Outreach patients who have care needs (gap) Focus on total patient care needs PCP works with care delivery team to deliver on

recommendations

Quality Support Team

50% have completed the recommended lab work or prevention screening within 90 days 75% who required an office visit have had an office visit

within 90 days 20% with A1c >8.0% will have an A1c < 8.0% within 12

months of chart review

Quality Support Team outreach success

12 FTE RN’s who specialize in diabetes care◦ Focus on insulin titration and self management

Phone/email based care◦ Patients with A1c ≥ 8.0% on insulin◦ Patients new to insulin or short acting meal time insulin◦ Patients on insulin with recurrent hypoglycemia◦ Consult support Whole Patient care address all care needs◦ address A-L-L

Diabetes Care Team

Clinical Pharmacy support Free walk in BP appointments Free scheduled RN BP appointments BP alert signaling staff to check second BP if BP

greater than goal

Blood Pressure Control

Clinical Pharmacy Specialists- outreach for A-L-L Registered dieticians DM Basics class DM insulin class Webinars Other on-line education support

Other Ancillary Support

1) Defining the Problem2) Foundation3) Tools4) Support Systems

5) Provider Incentive

Monthly regional and individual reports

Selected quality goals set by our Primary Care Quality Council

Quality Dashboards

Successful Adherence to ALL

Barriers ALL

Cost of medications Patient/provider does not understand value of ALL Fear of medication side effects Multiple drug therapies

Not takenas prescribed

Long-Term

Not FinishedNot Started

Not Filled

Take Home Points: ALL Therapy Registry Ability to collect and analyze data Tools identify quality gaps and provide an actionable list Team Approach to increase adherence Incentives to the PC team to continue to address quality

goals

a-l-l: care team approach to diabetic medication management...a-l-l: care team approach to diabetic...

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