creating models for health care delivery that address chronic disease linda siminerio, phd senior...
TRANSCRIPT
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."
When spider webs unite
they can tie a lion.
African Proverb