creating models for health care delivery that address chronic disease linda siminerio, phd senior...

Creating Models for Health Care Delivery that Address Chronic Disease

Linda Siminerio, PhDSenior Vice President, IDF

University of Pittsburgh Diabetes InstituteAssociate Professor School of Medicine

Presentation Objectives:

Describe the Problem and Urgency Present the Chronic Care Model

Report on the “Pittsburgh Regional Initiative for Diabetes Education (PRIDE)”

Present the Innovative Care for Chronic Diseases Model Highlight Global Projects

Diabetes WorldwideEstimated number (in Millions) of people with diabetes, worldwide:*

Increase in deaths from diabetes over next 10 years:†

India 35%The Americas 80%the western Pacific and eastern Mediterranean regions 50%Africa >40%

*Diabetes Prevalence. International Diabetes Federation, 2003.

†Preventing Chronic Diseases: a vital investment, World Health Organization, 2005.

1985: 30 million1995: 135 million2003: 194 million2025: 330 million

0

50

100

150

200

250

300

350

1985 1995 2003 2025

US Diabetes FactsUS Diabetes Facts

20% increase past 20 yrs 70% increase 30-39 yr. age range 1 in 3 children born in 2003 will get diabetes Type 2 in children is increasing 14 million lost work days Annual costs -- $132 billion

18.220.8

52

10

20

30

40

50

Mill

ion

Mill

ion

20032003 20052005 Pre-diabetesPre-diabetes

Epidemiologic Transition

Non-Communicable Disease

Infectious Disease

Epidemiologic Transition

Mo

rta

lity

Ra

tes

More information available at http://www.pitt.edu/~super1/lecture/lec0022/007.htm

Omran, A. The Epidemiologic Transition: A theory of the epidemiology of a population change. Milbank Q. 1971:49:509-538.

Organization of Health Care(What it should be)

Evidence-based, planned care Clinical Guidelines

Reorganization of practice (team approach) Includes ancillary professionals with the patient as

the most important member Attention to patient needs (information)

Counseling, education, information feedback Access to clinical expertise

Patient and provider education, access to specialists Supportive information systems

Patient registries Provider feedback on preventive service utilization

Organization of Health Care(What it is)

Care is not necessarily based on evidence, but experience and training

Seldom is there a team approach…care is mainly driven by the physician alone

Paternalistic and directive approach with little attention to patients’ behavioral needs

Limited access to diabetes specialists Insurer limitations Reluctance of primary care referral Fragmented access

Poor information systems No computers Poor tracking

PARADIGM SHIFT

ACUTE CARE CHRONIC CAREFocus: illness

Care: fragmented

Focus: prevention

Care: coordinated

Transition in Health Care

Quality of Care for People with Diabetes in the United States

3845.7

68.5

11

42.9

28.8

0102030405060708090

100

at least 1HbA1c test

HbA1c < 7% LDLc<100mg/dl

SBP<140mmHg

Annual fluvaccine

SMBG>1/day

%

Saaddine JB: Ann Intern Med. 136: 565-574, 2002

A Diabetes Report Card for the United States: Quality of Care in the 1990’s.

(2.6mmol/L)

University of Pittsburgh Medical Center The Challenges of Providing Access and Quality

19 hospitals/ 200 primary care practices 90,000 patients with diabetes 90% diabetes care provided by PCPs Poor adherence to guidelines Lack of integrated technology Daily decisions made by patient Poor access for education and nutrition Undefined relationships to the community

Objective

By implementing a model for health care delivery we could:– Gain health system support– Demonstrate improvements in clinical

outcomes, A1C, BP and Lipids – Demonstrate reimbursement for services– Expand number of resources in communities

Health System

Prepared, Proactive Practice Team

Functional and Clinical Outcomes

Productive Interactions

CommunityResources and Policies

Health SystemOrganization of Healthcare

Self-Management

Support

Delivery System Design

Decision Support

Clinical Information

Systems

Informed, Activated

Patient

•UPMC board initiative•Presentations to leadership•Pittsburgh Regional Initiative for Diabetes Education (PRIDE)

Patient/Provider/Community

Community

Functional and Clinical Outcomes

•Resource Identification

•Focus groups with providers and patients

•Community leaders

•Local physicians

•Government

Decision Support

Functional and Clinical Outcomes

Evidence Based Guidelines

ADA Medical & Education Standards

Clinical Information Systems

•Paper Charts

•Excel spread sheets

•Laboratory feedback

•Electronic Medical Records

•Management systems

Clinical Information / Decision Support

Instituted ADA Guidelines Physician education

Regional programs System seminars Integrating CDEs into practices Office staff education

Clinical information Continuous feedback Comparative reports to peers

Community Medicine Inc. (CMI)

versus National Data

0%

20%

40%

60%

80%

100%

< 7% < 8% > 9%

A1C Levels

Community Practices National Data

DM Report Card for USA Annals Internal Medicine 2002;136 (8) 565-574DM Report Card for USA Annals Internal Medicine 2002;136 (8) 565-574

CMI vs National Data

0%

20%

40%

60%

80%

100%

<100 mg/dl <130 mg/dl

Lipid levels

Community Practices National Data

DM Report Card for USA Annals Internal Medicine 2002;136 (8) 565-574DM Report Card for USA Annals Internal Medicine 2002;136 (8) 565-574

UPMC Diabetes ManagementHbA1c Levels (2003-2006)

6.5

6.75

7

7.25

7.5

7.75

Base 2003 2004 2005 2006

CMI HbA1c Targeted HbA1c

Ave

rag

e H

bA

1c

Le

vels

Time

Proportion of Patients with HbA1c Levels < 8.0% & 7.0% (2003-2006)

0

20

40

60

80

100

Base 2003 2004 2005 2006

CMI HbA1c <= 8% CMI HbA1c <= 7%

Time

%

LDL Levels (2003-2006)

95

100

105

110

115

Base 2003 2004 2005 2006

CMI LDLc Targeted LDLc Level

Proportion of Patients with LDLc Levels < 130 mg/dL & 100 mg/dL (2003-2006)

0

20

40

60

80

100

Base 2003 2004 2005 2006

CMI LDLc <= 130 mg/dL CMI LDLc <= 100 mg/dL

Delivery System Design

Diabetes Educators in Primary CareDiabetes “Mini Clinics”

Is this where we are going????

Trends in Glycemic Control by Race Over Time

6

6.5

7

7.5

8

8.5

9

9.5

PreEducation

Start ofEducation

July 2003-Sept 2003

Oct 2003-Dec 2003

Jan 2004-March 2004

April 2004-June 2004

Me

an

A1

c

Caucasian Black

Proportion of People Educated at PCP Office Compared to

Hospital Based Outpatient DSME

15.810.4

0

20

40

60

80

100

Primary Care Hospital-based DSME

%

p<0.0001

n=686/4332 n=9,334/89,760

Nurse-directed protocols

Approved protocols for glycemic, hypertension and cholesterol management

Nurses used these protocols in management

Intervention in high-risk Hispanic community

Significant improvement in provider processes and patient outcomes

Davidson, M., et al Effect of nurse-directed diabetes care in minority populations: Diabetes Care, 2003.

Process measures

Measure ADA guidelines Nurse-directed care Usual care P

HbA1c Goal-yes, 1 per 6 months; Goal-no, 1 per 3 months 227/252 (90) 66/252 (26) <0.001

Lipid profile At least yearly 244/252 (97) 148/252 (59) <0.001

Eye exam At least yearly 240/252 (95) 200/252 (79) <0.001

Renal profile* Yearly 215/252 (85) 148/209 (71)

<0.001

If dipstick negative/trace, measure albumin-to-creatinine ratio 54/183 (30) 76/174 (44) <0.01

If dipstick negative/trace, or albumin-to-creatinine ratio >30 mg/g, ACE treatment 19/28 (68) 59/93 (63) NS

Foot exam At least biannually 245/252 (97) 202/252 (80) <0.001

2 visits

At least biannually 248/252 (98) 241/252 (96) NS

Diabetes education No frequency stated 239/252 (98) 122/252 (48) <0.001

Nutritional counseling No frequency stated 224/252 (89) 14/252 (6) <0.001

Davidson, M., et al Effect of nurse-directed diabetes care in minority populations: Diabetes Care, 2003.

HbA1c (% ± SD) outcome measure

Nurse-directed care Usual care P

All patients

 Percent of patients 249/252 (99) 201/252 (80) <0.001

 Initial 13.5 ± 3.7 12.1 ± 3.1 <0.001

2 tests

 Percent of patients 201/249 (81)* 145/201 (72) <0.05

 Initial 13.3 ± 3.5 12.3 ± 3.4 <0.02

 Final 10.3 ± 6.0 10.8 ± 3.2 NS

 Change -3.0 ± 6.6 -1.5 ± 2.9 <0.01

6 months

 Number of patients 120 145

 Initial 13.3 ± 3.4 12.3 ± 3.4 <0.02

 Final 9.8 ± 3.0 10.8 ± 3.2 <0.01

 Change -3.5 ± 3.8 -1.5 ± 2.9 <0.001

Data are n (%) or means ± SD. * Some of these patients were followed for <3 months.

Self-Management Support

Expanded Education sites

CDE in Primary Care

Traveling educator

AADE Outcomes System

System Measures Changes In…

Learning Behavior ClinicalIndicators

Health Status

AADE Outcome System (IMPACT)

Healthy eating

Being active

Monitoring

Taking medication

Problem-solving

Healthy coping

Reducing risks

AADE 7 Self-Care Behaviors

Add New Individual Session

Diabetes Prevention Program

150 minutes of exercise/week Healthy eating program 7% reduction in weight Results in:

Decreases in Blood pressure ( 130/85 mmHg) Decreases in Waist circumference

Men < 40 inches; Women < 35 inches Decreases in Triglyceride levels (< 150 mg/dL) Decreases in Glucose (< 100 mg/dL) Decreases in HDL cholesterol

Men > 40 mg/dL; Women > 50 mg/dL

Average Weight Loss Over Time

Diabetes Prevention Program-Braddock

218.2

202.2200.9

207.2

190

195

200

205

210

215

220

Baseline 3 MonthFollow-up

6 MonthFollow-up

12 MonthFollow-up

poun

ds

Lifestyle Modification Program 150 minutes of physical activity per week and a healthy eating program

Average Decrease in BMI Over Time

Diabetes Prevention Program-Braddock

36.6

34.334.7

33.7

3232.5

3333.5

3434.5

3535.5

3636.5

37

Baseline 3-Month Follow-Up

6 Month Follow-Up

12 Month Follow-up

Lifestyle Modification Program 150 minutes of physical activity per week

and a healthy eating program

Decreases in the Proportion of Subjects with Abdominal Obesity, Hypertension, and

Hypertriglyceridemia Over TimeDiabetes Prevention Program - Braddock

656558

50 50

65

3947 47

65

8995

0

20

40

60

80

100

Baseline 3 Month Follow-Up

6 Month Follow-Up

12-Month Follow-up

%

Conclusions The CCM provided a good framework for quality

improvements in primary prevention and treament Gained health system and community attention Increased number of resources Captured attention of state and federal policy makers Improved insurance coverage

Decision support – clinical improvements Clinical information systems afforded the opportunity for

tracking populations Self-management support – facilitated diabetes

education and behavior change System redesign

Improved access for education Physicians and patients reported increased

communication and satisfaction.

MICRO LEVEL•Informed•Motivated

MESO LEVEL•Organize & Equip•Coordinate•Community

MACRO LEVEL•Leadership& Advocacy•Integrate policies•Consistent financing•Human Resources•Legislative frameworks•Partnerships

Global Projects

Canada – Vancouver expanded CCM Mexico – Veracruz project Morocco – Nat’l. Government used ICCC Russian Federation – ICCC for secondary

prevention with 56 teams Rwanda – ICCC HIV/AIDS project United Kingdom – 10 yr. quality project

Key Messages Burden of chronic disease increasing Most health systems not equipped Patients do better with integrated system Evidence supports organized systems of care CCM has been successful in US ICCC depicts complimentary process CCM & ICCC need to be disseminated,

implemented & evaluated

Eppinger-Jordan, JE; Pruitt, SD, Bengoa, R., Wagner, E. Improving the quality of health care fore chronic conditions. Quality Safe Hl Care, 2004.

Special Acknowledgement Project team

– Janice Zgibor, RPh, PhD– Sharlene Emerson, CRNP, CDE– Gretchen Piatt, PhD, CHES– Janis McWilliams, MSN, CDE– Kristine Ruppert, DrPH– Francis Solano, MD

University of Pittsburgh Diabetes Institute University of Pittsburgh Division of Endocrinology and

Metabolism University of Pittsburgh Medical Center

“This research was partially sponsored by funding from the United States Air Force administered by the U.S. Army Medical Research Acquisition Activity, Fort Detrick, Maryland, Award Number W81XWH-04-2-0030."

WHO

JoAnne Eppinger-Jordan, PhD

Contact: K. Thompson thompsonk@who.int

When spider webs unite

they can tie a lion.

African Proverb