cvd risk factor reduction kelly moore, md, faap ihs division of diabetes treatment & prevention

CVD Risk Factor Reduction

Kelly Moore, MD, FAAPIHS Division of Diabetes Treatment &

Prevention

Overview• Standards of Care

• Current Quality of CVD Care

• Purpose of Competitive Grant Program

• Case Management Tools

Standards of Care IHS Standards of Care for Patients

with Type 2 Diabetes (August 2003) Includes recommendation for treatment of CVD

Risk Factors• Target BP < 130/80 mm Hg• LDL < 100 mg/dl• Antiplatelet Therapy• Tobacco cessation• Self-Management Education

Standards of Care IHS Best Practice Models

Cardiovascular Disease and Diabetes• Suggested practice models, levels of service and

components of care• Additional information on standards, target for

treatment

Impact of CVD

Number 1 cause of death in AI/ANs People with diabetes are 3-4 times

more likely to develop CVD Prevalence, mortality increasing Level of awareness of the link between

diabetes and CVD needs to be raised

Quality of Care - CVD Risk Reduction in AI/ANs with Diabetes

Evidence/DataIHS Diabetes Care and Outcomes Audit

Diabetes Care & Outcomes Diabetes Care & Outcomes AuditAudit

7

7.5

8

8.5

9

9.5

10

'94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04

Source: IHS National DiabetesProgram Statistics 1994-2004

A1C,

%

Mean A1C, 1994-2004

*p<0.0001 comparing mean HbA1 levels in FY94 and FY04

Diabetes Care & Outcomes Diabetes Care & Outcomes AuditAudit

7

7.5

8

8.5

9

9.5

10

'94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04

<55

55-64

65+

Source: IHS National DiabetesProgram Statistics 1994-2004

A1C,

%

Glycemic control, 1994-2004

*p<0.0001 comparing mean HbA1 levels in FY94 and FY04

0

20

40

60

80

'97 '98 '99 '00 '01 '02 '03 '04

LDL Tested

Diabetes Care & Outcomes Diabetes Care & Outcomes AuditAudit

Source: IHS National DiabetesProgram Statistics 1994-2004

Performance Measure: Dyslipidemia Assessment1998-2004

Per

cent

80

100

120

140

160

180

200

220

240

260

280

'94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04

Mean Chol

Mean TGs

Mean LDL

Diabetes Care & Outcomes Diabetes Care & Outcomes AuditAudit

Source: IHS National DiabetesProgram Statistics 1994-2004

Mean Lipid Values1994-2004

mg

/dl

0

20

40

60

80

100

'94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04

BP <140/<90

Diabetes Care & Outcomes Diabetes Care & Outcomes AuditAudit

Source: IHS National DiabetesProgram Statistics 1994-2004

Blood Pressure Control1994-2004

Per

cent

0

20

40

60

80

100

'94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04

BP <130/<80

Diabetes Care & Outcomes Diabetes Care & Outcomes AuditAudit

Source: IHS National DiabetesProgram Statistics 1994-2004

Blood Pressure Control1994-2004

Per

cent

10

20

30

40

'98 '99 '00 '01 '02 '03 '04

Tobacco Use

Use Undetermined

Diabetes Care & Outcomes Diabetes Care & Outcomes AuditAudit

Source: IHS National DiabetesProgram Statistics 1994-2004

Tobacco Use 1998-2004

Per

cent

0

20

40

60

80

100

'99 '00 '01 '02 '03 '04

On ASA

Diabetes Care & Outcomes Diabetes Care & Outcomes AuditAudit

Source: IHS National DiabetesProgram Statistics 1994-2004

Aspirin Therapy1999-2004

Per

cent

0

20

40

60

80

100

'94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04

Self Manag't Educ

Diabetes Care & Outcomes Diabetes Care & Outcomes AuditAudit

Source: IHS National DiabetesProgram Statistics 1994-2004

Self Management Education1999-2004

Per

cent

Diabetes Care & Outcomes Diabetes Care & Outcomes AuditAudit

Source: IHS National DiabetesProgram Statistics 1994-2004

Self Management Education1994-2004

Per

cent

20

40

60

80

'94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04

Diet Instr Exercise Other DM Educ

CGP CVD Risk Reduction Demonstration Project

Purpose: To implement an intensive, clinic based case

management approach to CVD Risk Reduction in individuals with Diabetes

Demonstration Project - Intensive treatment to target goals based on standards of care

Eligibility for Intensive Activities Adults with Diagnosis of Diabetes With or without CVD Exclusions (pregnant, ESRD, alcohol/substance abuse)

Core Elements: Case Management

Case Management Team

Case Management Strategy Individual case management Disease management Self-management education

Tools for Case Management Diabetes Registries Diabetes Management System/RPMS Integrated Case Management System

Role of Data Systems in Improving Patient Care in

Diabetes Individual Patient Level

Track one or many patients Identify specific clinical information Reminders/prompts

Population Level Calculate rates Measure performance Improve systems

Diabetes Management System

DMS Package in RPMS Several applications to view

individual patient data Screen access for direct data

entry “Integrated” e-mail, recall

Diabetes Management System

Diabetes Registry Data Items Maintained in the Diabetes

Registry - Patient Status - Type of Diabetes - Complications - Register Provider and Case Manager - Facility Where Patient is Routinely

Followed - Family Members - Last and Next Case Review Dates - Recall Date (Optional)

Diabetes Management System

Diabetes Registry Lists Patient Status

Active, Inactive, Transient, Lost to Followup, Unreviewed, Deceased, Non-IHS Care

Diagnosis Type 1, Type 2, Gestational, IGT

Complications CVA (Stroke), Myocardial Infarction, End Stage

Renal Disease, Hypertension, Retinopathy, Laser Treatment for Retinopathy, High Risk Foot, Minor Amputation, Major Amputation(s)

Diabetes Management System

Diabetes Patient Care Summary Used by provider to manage/update care

during clinical encounter “Electronic” flowsheet – to do lists for

recommended care A part of Adult Health Summary

Electronic Audits using DMS/RPMS Nationally defined audit elements

Integrated Case Management Package Documentation of care plans, in development

Capacity to Use DMS in CGP RPMS Survey – CGP CVD Grant Programs

Question Percent

Sites using RPMS 92

Sites with DMS Package installed 90

Sites using DMS 76

Sites conducting electronic audits 45

Next Steps

Treatment of CVD Risk Factors As a part of intensive case management strategy Grantee Panel discussion/questions

Core Elements: Case Management Draft protocol/required elements for discussion

Explore DMS as an option May need to schedule additional training Use of paper tracking until everyone using Need to consider those not on RPMS