c2/d2: diabetes care at kaiser permanente population-based ... · clinical strategic goals results...

C2/D2: Diabetes Care at Kaiser Permanente Population-based Approach

Alide Chase, Senior Vice President, Medicare Clinical Operations & Population Care and Executive Director, Care Management Institute

Objectives

2

• Review a large system’s approach to population-based care with a

focus on pre-diabetes and diabetes

• Appreciate the need to “focus on the few” treatments most

impactful

• Appreciate the use of segmentation to customize approach to

different people’s care needs

• Review the importance of measurement and use of dashboards

from a system level to individual level

• Share successful use of technology to increase compliance and

self care

Today’s Focus

Tactics

1. Prevention

2. Treatment Intensification

3. Prevention of Complications

4. Segmentation

5. Technology

6. Metrics

7. Outcomes

3

Evolution of Population Care

1997 Disease Management 2010 Complete Care

Chronic Conditions

Lifestyle/Behavior

Prevention

Oth

er D

isea

ses

Co

ron

ary

Art

ery

Dis

ease

Dys

lipid

emia

Dia

bet

es

Old Days New Approach

4

5

NEW THINKING: Population Care “Complete Care”

Key themes People

Patient centered care and focus

Make the right thing easier to do

Get the right person to do the right job

Need for sponsorship at all levels

6

Systems

Focus on “what” needs to be improved

Metrics

Integration of members of the healthcare team

Emphasis on process improvement techniques

Technology

Electronic Medical Record: Delivering the right information at the right time

Registries

Panel management tools

Web and smart phone applications

Interactive voice responses

Diabetes Basics and Facts

7

8

Diabetes Basics

Most diabetes develops in people with inherent insulin resistance (high prevalence in the Middle Eastern

population) Obesity adds to the risk due to excess food and lack

of exercise This leads to:

• Cardiovascular disease (heart attacks & strokes) and

• Hyperglycemia (excessive blood sugar) which can lead to blindness, kidney failure, amputations, and coma

Middle East & North Africa Diabetes Facts

IDF estimates suggest that one in five people in the Middle East are now living with diabetes, a number expected to increase to 1 in every 3 by 2030*

• Two out of every five respondents are at risk of developing diabetes,. However, almost 40% of those at risk have never had a blood glucose test**.

Six out of the world’s top ten countries for highest prevalence of diabetes are in the Middle East and North Africa Region

Kuwait, Lebanon, Qatar, Saudi Arabia, Bahrain and the United Arab Emirates ranks #2 in the world at 19.5% prevalence ***.

The region spends $5.5 billion annually treating diabetes****

9

*International Diabetes Federation’s (IDF) World Diabetes Congress (WDC)

** Novo Nordisk’s diabetes awareness survey in the MENA region November 2010

***PLoS One. 2012; 7(8): e40948

**** International Diabetes Foundation 2012 fifth edition

Why Behavior Change Now? Kaiser Permanente diabetes burden to surge over time

Pre-diabetes

20121

1.67 million

1 – Preliminary data; CMI Analysis October 2012. Pre-diabetes defined according to ADA definition using lab values.

2 – Diabetes Prevention Research Group; Diabetes Prevention Program

3 – Preliminary data; CMI Analysis, as of March 31 2012. CORE KP HEDIS Diabetes cohort, minus expected % of Type 1 diabetes per CDC national prevalence

4 – Based on average annual medical expenditure estimates, Vojta et al, Hlth Aff, Jan 2012. Effective Interventions for Stemming Diabetes and Pre-Diabetes

New cases of diabetes by 2015

482,630

New cases of diabetes by 2022

868,400

= $6.3 B/year4

29% develop diabetes over 3 years2

52% develop diabetes over 10 years2

KP members with type 2 DM in 20123

477,383

= $3.48 B/year4

10

How does KP Apply a Population-based Approach to Diabetes Care?

11

• Prevention of both Pre-Diabetes and Diabetes (DM):

Weight control & exercise

• Prevention and Treatment of DM complications:

“focus on the few” most impactful treatments

customize approach

measurement (metrics) and dashboards from a system to individual level

Use technology

12

Kaiser Permanente’s Approach

Total Population l

Obesity

Complicated

Uncomplicated

Diabetes

Population View with Sub-Populations

• 8% KP

• 11-20% ME

• 20% KP

• ME 40%, but ½ not tested

Pre-Diabetes

To Prevent Pre-DM and DM Evidence: Decrease weight and increase exercise in obese and

pre-diabetes individuals prevents diabetes

• The Diabetes Prevention Trial (DPT) showed that a combination of:

150 min of exercise and 7% weight loss will lead to 30% less progression of pre- diabetes in 10 yrs. as compared to Metformin, an oral glucose control medication that led to an 18% reduction in progression to diabetes.

Diabetes may be reduced to pre-diabetes or normal state with weight loss

14

Action: Using Diabetes Programs, educate people how to lose weight and exercise

Approach:

Public health messages on TV & radio; create walking paths, work with schools to remove sugared drinks from vending machines, healthy choices in cafeteria, and promote exercise

Patient Engagement: interactive online education programs, education classes, individual counseling by health coaches and dietitians

Prevention of DM complications: “focus on the few” most impactful treatments

We must know:

• What are the biggest causes of morbidity, mortality and cost of care of diabetes complications?

it is not what most people think

• If treatments are used that decrease morbidity & mortality, then what is the cost of care?

best to model the result with a program like Archimedes

15

Costs of Diabetes Complications

5.1

2.4

1.10.7

0.2

0

1

2

3

4

5

6

MI, Stroke Kidney Disease Coma Amputation Blindness

CVD is the biggest cost of care in diabetes

Unfortunately sugar control doesn’t help

Sugar control [A1C] prevents

Based on Northern Cal KP 1996 data

16

BP & cholesterol treatments decrease

In M

illio

ns $

What Works: BP & Lipid Meds Prevent CVD ACE-I fixed dose

22%

0%

5%

10%

15%

20%

25%

Decreased CVD

17

Heart Protection Study

MRC/BHF Heart Protection Study of cholesterol-

lowering therapy and of antioxidant vitamin

supplementation in a wide range of patients at

increased risk of coronary heart disease death:

early safety and efficacy experience. Eur Heart J

1999;20:725-41.

HOPE Study

Effects of an Angiotensin-Converting–Enzyme

Inhibitor, Ramipril, on Cardiovascular Events

in High-Risk Patients.The Heart Outcomes

Prevention Evaluation Study Investigators

N Engl J Med 2000; 342:145-153

Ful

l Adh

eren

ce

Ful

l Adh

eren

ce

Kaiser Permanente’s ALL Approach

Start all three drugs at fixed dose at once:

• Aspirin,

• Lisinopril or other ACE Inhibitor/ARB

• Lipid Lowering (statins)

In member s with diabetes above age 55 (ASA optional ) and those with CAD

Then repeat BP and Cholesterol test and if still elevated,…

Treat BP & Lipids until normal

18

19

Archimedes Model: Benefit of just starting a fixed dose of ALL

Average annual risk of various events

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

HbA1c control

ALL

71% decline

Which Segment of the Population with Diabetes do you focus on?

Which segment is easy to identify for treatment with ALL?

• People with diabetes who are over 55 have a 94% chance of having either high BP or cholesterol, * the criteria proven in HOPE to benefit from Lisinopril **

Therefore consider all people with DM over 55 for ALL & treat high BP and cholesterol at any age****

Which people are at highest risk for sugar sensitive complications like blindness amputations and kidney failure?

• The higher the A1C the more likely each of those complications are*** . American Diabetes Association and NCQA both agree HgbA1c should be <9****

All patients should be below Hgb A1C 9, and all should be as near normal as possible without producing significant low blood sugars.

20

* Selby ** Mircohope *** DCCT, **** ADA glucose targets NCQA HEDIS targets

>55yo Use

ALL Meds

Complicated

Diabetes

How do the Few Actions Fit into KP Diabetes:

Step 1, consider ALL medications

Uncomplicated Diabetes

21

ALL Meds

Complicated

Diabetes

Treat to

Target

Then BP, LDL, A1c Ctrl

Kaiser Permanente Diabetes: Step 2 Focus on Treatment

Intensification of the Other 3 Treatments : BP, LDL

Cholesterol, & A1C

Focus on

the Few

Uncomplicated Diabetes

Not in control

22

Technology: Make the “Right Thing” Easier

In-Reach: to patients during clinic visit

• Electronic Medical record organizes the opportunities

• Patient Panels:

Panel Management

Panel support Tool

• In Reach at time of visit: Maximizing use of the medical assistant

Out reach: to patients at home

• Automated electronic contacts

Medication adherence: automated letters & calls

Email:

• Automated lab results

• Patient contacts provider

23

Making the Right Thing Easier

Physician Education

Tools

Panel Support Tool

Physician Member

Visit

HEDIS Performance

24

South Bay Beta Blocker Adherence Program Clinical Strategic Goals Results

CSG Results - Persistence of Beta Blocker Treatment

post Heart Attack

84.0

85.0

86.0

87.0

88.0

89.0

90.0

91.0

92.0

pe

rio

d 1

-

Fe

bru

ary

20

09

pe

rio

d 2

-

Ap

ril 2

00

9

pe

rio

d 3

-

Jun

e 2

00

9

pe

rio

d 4

-

Au

gu

st

20

09

pe

rio

d 5

-

Oct

ob

er

20

09

South Bay

SC REGION

Intern started South

Bay BB adherence

program - June 2009

In-Reach: Electronic Medical Record Data Organization

25

Panel Support Tool

26

A Team Approach to Care

• Identify missing labs, screenings, kp.org status, etc.

• Provide member instructions

• Contact member and document encounter in HealthConnect™

• Vital sign collection & documentation

• Identify and flag alerts for provider

• Prepare patient for exams

• Pre-encounter follow-up

• After visit summary, care instructions, follow-up appt, educational materials, access to kp.org

• Follow-up contact and appointments

27

Outreach: Medication adherence: Refill Call/Letter Reminder

19%

28

Automated Communication: Email - 4.5 Million Members Viewed Their Test Results in 1 year

29

29

Email: 3.1 Million Members Emailed their Doctor

30

And . . . Email Improved OUTCOMES

31

Health Affairs. 2010;29:1370. 31

What Metrics Do We Need at Provider Level to Drive Improvement?

Principle: metrics alone do not decrease diabetes or its complications

• Therefore those that lead to ACTIONS are most important: “ACTIONABLE” is the test of value of use of a metric at any given time

Items to titrate: BP, LDL, Cholesterol, and A1C

Medication dispensed and refilled that are on the “ABC” list : Adherence drops 50% in one year so adherence is a major issue

• Others that are helpful for other preventative measures annually:

Fasting Blood Sugar: to diagnose DM, and following at home glucose testing if results will be ACTIONABLE

Eye exams

Kidney: urine microalbumin,

Nerve: Foot exams

What to display at each level to drive action towards improvement?

32

Metrics: All Start With a Registry

A list of who is in your population that has diabetes

Criteria: usually based on a diagnosis of diabetes or use of medications for sugar control

Optimal to have just a few metrics:

• Best with results of BP, lipids, A1c, and their medications including last refill

This registery & its metrics allow for assessing:

• If BP, lipid, A1C treatments initiation & adherence, and if contact patients by

In-reach: reminders to providers to consider treatment or

Out-reach: reminders to patients to get treatments advised

• Adherence: the percent on a medication over time.

33

For Comparisons with the Nation and Regions, Ambulatory Metrics are used

34

75t h

N on-

PPOs

9 0 t h

N on-

PPOs

HED IS

2 0 12

(PY 2011)

HED IS

A dmin.

'12 3rd Qtr

N ort hern

C alif o rnia

Sout hern

C alif o rnia

C o lorado Georg ia Hawaii M id -

A t lant ic

St at es

N ort hwest

( 9 0 0 3 )2

Ohio

   LDL-C Screening 92.70% 94.91% 90th 75th 97.49% 96.51% 94.81% 96.70% 98.92% 95.82% 97.43% 95.23%

   LDL-C Level <100 65.82% 72.51% 90th 90th 82.22% 82.26% 81.25% 78.95% 84.49% 78.11% 76.44% 75.18%

Controlling High Blood Pressure 70.90% 75.55% 75th 90th 87.03% 89.47% 83.38% 81.08% 84.85% 85.81% 83.32% 78.43%

Persistence of Beta-Blocker Treatment After a Heart 90.82% 94.25% 90.53% 94.39% 93.45% 84.91% 83.33% 84.67% 94.06% 87.50%

Comprehensive Diabetes Care

   HbA1c Testing 93.92% 95.62% 90th 75th 96.99% 97.49% 95.60% 95.14% 98.87% 95.51% 97.62% 94.60%

   HbA1c Control >9% (low rate better) 15.93% 11.68% 90th 75th 9.91% 8.74% 15.00% 13.83% 8.49% 10.78% 8.50% 12.60%

   HbA1c Control <8% 75.46% 79.51% 79.51% 81.75% 73.33% 74.09% 79.95% 78.59% 80.43% 73.67%

   Retinal Exam 74.70% 80.78% 90th 82.18% 85.40% 79.61% 48.38% 86.59% 78.43% 84.05% 70.45%

   LDL-C Screening 91.97% 94.38% 96.72% 96.23% 91.55% 95.08% 98.26% 95.29% 96.59% 95.44%

   LDL-C Level <100 60.61% 66.43% 90th 90th 79.87% 77.16% 71.91% 69.35% 81.98% 73.98% 72.85% 74.01%

   Medical Attention for Nephropathy 92.09% 94.16% 90th 90th 96.82% 97.92% 94.55% 94.72% 95.01% 96.82% 97.38% 96.65%

   Blood Pressure Control <140/80 54.01% 63.02% 90th 90th 76.28% 81.34% 72.94% 70.07% 75.22% 76.78% 75.58% 72.37%

   Blood Pressure Control <140/90 71.13% 76.64% 90th 90th 86.04% 88.24% 85.87% 81.97% 84.99% 84.50% 83.90% 83.13%

Adult BMI Assessment 80.31% 88.58% 90th 90th 99.00% 98.97% 96.00% 99.00% 95.99% 96.82% 98.27% 94.40%

Breast Cancer Screening - Ages 42-69 75.40% 80.63% 90th 90th 87.93% 90.91% 88.49% 86.21% 81.36% 90.35% 88.06% 84.70%

Colorectal Cancer Screening 68.93% 76.02% 90th 90th 87.90% 87.28% 85.26% 84.97% 82.26% 87.72% 87.29% 86.78%

Most Effective Cardiovascular Care

Cardiovascular

Cholesterol Management for Patients With Cardiovascular Conditions

Diabetes

High Impact Measure - Prevention

Major InitiativesHED IS 2 0 12

N at ' l Percent iles

Programwide

Perf o rmance

HED IS 2 0 12 ( Perf o rmance Y ear 2 0 11)

Kaiser Permanet e

1 2 3 4 5 6 7 8

Outcomes: What Did We Accomplish?

Targeted medication utilization

Intermediate outcomes: how did we do with BP lipid & A1C control compared to the nation?

Targeted outcomes: Heart attacks & strokes

• In the Diabetic & CVD populations using ALL

• Total population in a large region

35

We Achieved >77% Medication Initiation & Adherence on Heart Attack & Stroke Prevention Meds…

85.477.3

% DM Pts in Southern California

Chart Title

On Statin On ACE/ARB

36

Ambulatory Strategic Subscale 2012 (Performance Year 2011) Compared to 2011 National Percentiles

37 DUC 20110211_001

At/above 90th percentile

At/above 75th percentile

Medicare Ambulatory 2012 (Performance Year 2011)

75t h

N on-

PPOs

9 0 t h

N on-

PPOs

HED IS

2 0 11

(PY 2010)

HED IS

2 0 12

(PY 2011)

N ort hern

C alif o rnia

Sout hern

C alif o rnia

C o lorado Georg ia Hawaii M id -

A t lant ic

St at es

N ort hwest

( 9 0 0 3 )2

Ohio

   LDL-C Screening 92.22% 94.40% 90th 90th 97.78% 97.67% 98.50% 96.39% 98.84% 95.74% 97.12% 95.86%

   LDL-C Level <100 66.38% 72.15% 90th 90th 81.61% 82.57% 86.28% 79.34% 85.55% 78.36% 75.98% 80.54%

Controlling High Blood Pressure 68.86% 74.42% 75th 90th 84.02% 86.37% 88.33% 75.08% 87.83% 85.97% 80.29% 88.81%

Persistence of Beta-Blocker Treatment After a Heart 88.03% 91.58% 90.50% 91.81% 98.61% 70.97% 90.00% 85.54% 90.97% 98.51%

Comprehensive Diabetes Care

   HbA1c Testing 93.93% 95.95% 75th 75th 97.76% 97.61% 97.82% 97.32% 98.30% 95.79% 98.29% 96.59%

   HbA1c Control >9% (low rate better) 16.11% 11.31% 75th 90th 8.95% 8.66% 10.90% 9.49% 9.73% 11.15% 7.96% 10.71%

   HbA1c Control <8% 75.43% 80.18% 79.87% 81.04% 78.50% 76.89% 75.91% 79.85% 81.37% 75.43%

   Retinal Exam 73.66% 79.28% 90th 90th 82.43% 83.88% 87.23% 86.37% 85.40% 81.01% 82.97% 87.83%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%    LDL-C Screening 91.48% 94.07% 75th 75th 98.40% 97.91% 91.90% 97.08% 97.57% 95.43% 96.96% 95.62%

   LDL-C Level <100 60.10% 65.37% 90th 90th 84.03% 80.00% 79.44% 73.97% 81.27% 72.56% 73.99% 75.91%

   Medical Attention for Nephropathy 91.56% 93.92% 75th 90th 98.40% 97.91% 99.07% 96.84% 96.59% 96.58% 97.31% 94.65%

   Blood Pressure Control <140/80* N/A N/A N/A N/A 77.64% 78.66% 77.88% 82.97% 79.56% 72.29% 73.19% 71.78%

   Blood Pressure Control <140/90 69.74% 75.06% 75th 90th 90.10% 87.91% 92.21% 91.24% 88.56% 82.01% 81.79% 84.43%

Adult BMI Assessment 65.69% 80.23% 90th 90th 99.00% 98.97% 96.00% 99.00% 95.99% 96.82% 98.27% 94.40%

Breast Cancer Screening - Ages 42-69 75.13% 80.92% 75th 90th 88.55% 89.68% 85.75% 83.43% 89.02% 90.04% 88.78% 86.56%

Colorectal Cancer Screening 68.71% 75.57% 90th 90th 91.30% 88.61% 84.02% 85.59% 78.61% 82.26% 85.65% 86.15%

* First Year M easure HEDIS 2011.

HED IS 2 0 11

N at ' l Percent iles1

Programwide

Perf o rmance

HED IS 2 0 12 ( Perf o rmance Y ear 2 0 11)

Kaiser Permanet e

Cholesterol Management for Patients With Cardiovascular Conditions

Cardiovascular

Diabetes

1 HEDIS 2011 National Percentiles. HEDIS 2012 benchmarks will be available in Aug. for Commercial, Oct. for M edicare.

Major Initiatives

Most Effective Cardiovascular Care

High Impact Measure - Prevention

1 2 3 4 5 6 7 8

Achieved 75th-90th Percentile in Testing and

Treating for AC1C, BP, and Lipid control

37

We Decreased Myocardial Infarcts in Northern California Kaiser Members

38

~60% drop

24% decline

N Engl J Med. 2010;362:2155-65.

38

39

Diabetes & CVD Patients Decreased MI’s & Strokes over 60% with Use of ALL

-15

-26-30

-25

-20

-15

-10

-5

0

Decrese in MI & Strokes/1000 persons/yr

low util

High Util

Even 1 day of 5 utilization was significant, but taking it

2/3 of the time was much more beneficial.

RR 60% decrease

39

Summary

Use a large systems approach to population care

Focus on the “few” who will benefit most using segmentation to find those at highest risk of heart attacks & strokes, and use:

• Simplified, inexpensive “Treat To Target” protocols,

• Registry and dashboard of metrics of medication adherence, BP, cholesterol and A1C to a few targets and corrective action until achieved, and

• Technology, including a panel support tool, proactive office encounter, automatic call/letter reminders, email communication,

KP achieved

• >77% of the critical medication initiation/adherence,

• >75% ile A1C, lipid and bp control compared to the nation, and

• The major outcome of decreasing severe heart attacks & or strokes in >60%

in both the diabetes and entire Northern California population

40

Ask Alide

Questions?

41

Alide Chase

Senior Vice President, Medicare Clinical Operations & Population Care

Executive Director, CMI

alide.l.chase@kp.org, 510-271-5817

Presenter

42

APPENDIX

43

44

Step 1

if >55yo or

CVD start ALL

Step 2

After ALL,

If still high, Add Then add Then add

ASA A: 81-325 1/d

B:BP

meds L: Lisinopril 20 if SBP>140 Prinzide 20/25

Add

Amlodipine Add Atenolol

C: Chol

L: atorvastatin

20-40 if LDL>100 atorvastatin 40 Atorva 80

S: Sugar

Control

Diet &

Exercise

pre meal

Sugar>120 metformin

skip or add

glipizide add Insulin

Treatment Algorithm: ABC's of DM