IMPROVING DIABETES CARE FOR ADULTS:

A Population-Based Approach

Patrick J. O’Connor, MD, MPH

Senior Clinical Investigator

HealthPartners Research Foundation

Today’s Objectives

– Leadership and Resources: The Burden of Diabetes and the Cost of Doing Nothing

– Population Health Impact and Cost of Competing Diabetes Improvement Priorities

– The “Enhanced Primary Care Model”

– Results and Future Challenges

CDC, 1998.

Burden of Diabetes in the US Morbidity and Mortality

– Mortality: #3 cause, with 182,000 deaths each year

– Prevalence doubling every 10-15 years

– The death rate in the diabetic population is slowly decreasing for men but increasing for women

– 70% of deaths in adults with DM are related to MI or CVA

– Clinical trials provide evidence that control of hyperglycemia, dyslipidemia, and hypertension and use of ASA lower the risk of macro and micro complications.

Primary Prevention of Type 2 Diabetes

– Physical Activity

– Weight Management

– Finnish Study 57% Reduction in Incidence

- mean age around 60 years with IGT

- dietary instruction 8 weekly sessions, then q 3 mo

- structured physical activity 3 x a week

- lost about 5 Kg.

Economic Burden of Diabetes in Adults

The Cost of Doing Nothing

3 Year Charges

$38,700 $40,200 $42,500$45,600

$49,700

$10,400$9,600$9,000$8,600$11,600

$0

$10,000

$20,000

$30,000

$40,000

$50,000

6% 7% 8% 9% > 10%

CHD & DM

DM only

HBA1c

Selecting Improvement Goals

All Goals Are Not Equal

Prioritizing Diabetes Treatment Goals Prioritizing Diabetes Treatment Goals

– Gap Analysis

– Consider Population Health Benefits--NNT, Events

– Consider Incremental Direct Costs to Payers

– Clinical Strategies:

Glycemic control

Lipid control

Blood pressure control

Aspirin use

Percent of Adult Diabetes Patients NOT at Goal

60%

60%

40%

60%

50%

70%

10%

10%

0% 20% 40% 60% 80%

LDL < 130 Non-CHD

LDL < 100 in CHD

HBA1c < 8

BP < 130/85

Aspirin Use

HBA1c < 7

Kidney Test - 1 Year

Eye Exam in 2 Years

Bar 1

Number Needed to Treat for 5 Years to Prevent Progression of One Microvascular Complication

0

10

20

30

40

50

60

70

80

BP Control Glycemic Control

2 8

7 2

NN

T

- 10/5 mm Hg - 1% HBA1c

Micro Events Averted

0

50

100

150

BP Control HBA1c Improved < 8% HBA1c Improved < 10%

1 0 7

5 6

1 4

Relative Impact of Various DM Improvement Strategies on Population Health OutcomesEvents Averted per 10,000 Adults with DM Over 5 Years Time

Number Needed to Treat for 5 Years to Prevent One Heart Attack or Stroke

0

10

20

30

40

50

60

LDL <100mg/dl in CHD

Patients

Lower BP10/5 mm Hg

Lower A1c1%

ASA LDL <130mg/dl in Non-CHD Patients

61 2

2 0

4 0

6 0

Macro Events Averted

050

100150200250300350400450500

LDL <100mg/dl inCHD

Patients

BP Control HBA1cImproved

<8%

Aspirin Use LDL <130mg/dl in

Non-CHDPatients

HBA1cImproved

<10%

5 0 0

2 5 0

2 0 0

1 1 15 8 5 0

Relative Impact of Various DM Improvement Strategies on Population Health OutcomesEvents Averted per 10,000 Adults with DM Over 5 Years Time

Direct Costs of DM Improvement Strategies

Literature Cost/Pt/YrLower BP 50% of Pts need

3+ drugs$630

Lower HBA1c IntensiveManagement

with Monitoring,Oral Agents,

insulin

$1600 - $3600

Use Aspirin 325 mg ec po QD $20Lower LDL Statins, Fibrates $700 - $1400

5-Year Net Cost to Health Plan for Every 10,000 Adults with Diabetes for Selected Diabetes Care Improvement Strategies

(Increased Treatment Costs - Savings from Averted Events)

COST (SAVINGS)

BP Control ($4,800,000)

Aspirin Use ($3,300,000)

Control HBA1c to < 10% $5,700,000

Control HBA1c to < 8% $64,800,000

LDL <100 mg/dl in CHD Patients $4,100,000

LDL <130 mg/dl in Non-CHD Patients $11,400,000

Diabetes Improvement GoalsDiabetes Improvement Goals

– Various evidence-based diabetes clinical care recommendations have very different costs and very different benefits, calculated on a population basis

– Aspirin use and blood pressure control have the most favorable ratio of benefits to costs

Diabetes Improvement GoalsDiabetes Improvement Goals

– Lipid control in heart patients gives more benefit at lower cost than lipid control in patients without heart disease.

– Glycemic control is an important element of diabetes care. Costs and benefits of glycemic control are sensitive to the HBA1c goal of care.

The Enhanced Primary Care Model

Better than Carve Out

Disease Management

Enhanced Primary Care Model--Advantages

- Invest in Care System

- -Extend Benefits to Multiple Clinical Domains

- Strengthen, not Weaken Continuity and Coordination of Care

- Seamless to Patients

- Better Population Penetration

Successful Chronic Disease Care: Messages to Docs

– Do This, or Die (Economic and Breadth of Practice Issues)

– Don’t Blame Patients---Solve Problems

– Doing things together is more important than doing things alone

- Partner with the Patient

- Team up with nurses, educators, other docs

Data and Information Systems Support

Road MapGuidelines

Effective Care Team

Activated Patient

The Enhanced Primary Care Model--Foundations

CQI

Registry

Prioritize

Monitor

Planned Care & Active Outreach

The Enhanced Primary Care Model--Operation

CQI

Active Registry or Risk List

– For each doc and each clinic, new every 3 months

– List of DM patients from highest to lowest HBA1c (later added CHD status and LDL-levels)

– Permits proactive, population-based management

– ID diabetes is 91% sensitive with 94% positive predictive value

– Generally positive response from docs

Monitor Clinical Status or Risk

– HBA1c, LDL, CHD status

– Want BP control, aspirin use, smoking status

– Key Decision: What clinical domain to emphasize

- Do what is easy? Or

- Do what is right?

Prioritize Patients Based on Risk

– Novel concept to many nurses and educators

– Use both clinical status and “readiness to change”

– Focus most energy on those ready to change (varies by specific issue--smoking, diet, activity, DM care in general)

– Those in worst shape most ready to change

– Do NOT ignore those who are doing well--if so, doomed to clinical success and financial disaster (pipeline effect)

Active Outreach -- Proactive Care

– Need more than just docs to do this

– Empower nurses and educators

– Respect patient’s constitutional rights and privacy

– Calls come directly from clinic, usually a nurse pt knows

– First check: Medication intensity

– Second check: Motivational and educational needs

Visit Planning

– A form of decision support

– Do the hard way, by hand--too expensive

– Do the easy way AMR/automated systems

– Flow sheets are the poor clinic’s solution to this problem

– Have not done yet, but results better than those who have made this a primary emphasis of improvement

– AMR clinic with DM GL is good, but not best clinic

Median HBA1c Cross-Section

7.26.9 6.8 6.9 6.7

6.3

8.37.9 7.8 7.7 7.5

7.1

9.69.1 8.9 8.9

8.68.2

6.0

7.0

8.0

9.0

10.0

1994 1995 1996 1997 1998 1999

Med

ian

HB

A1c

25th percentile Median HBA1c 75th percentile

N = 4782

85.2%

N = 6238

85.1%HBA1c Test Rate

Cross-Sectional Change in Mean HBA1c

8.55

8.168.02 8.03

7.82

7.45

7.07.27.47.67.88.08.28.48.68.89.0

1994 1995 1996 1997 1998 1999

Cohort LDL Changes

132129

124

118

113110

115

120

125

130

135

140

1995 1996 1997 1998 1999

Chronic Disease Care

– Identify Problems

– Prioritize Problems in Partnership with Patient

– Initiate Treatment

– Monitor Response

– Titrate to Goal

Summary

– 40% reduction in macrovascular risk

– 25% reduction in microvascular risk

– In well organized (enhanced) primary care clinics with a part time on-site DM nurse educator (not necessarily CDE)

– Patient Education NOT associated with significantly better A1c

– Improvement NOT due to: carve out disease management, endocrinology consults (<5% per year), less than 2% of patients use either TZD, alpha glucosidase, or meglitamides

Key Components

– Medical Group Physician Involvement and Leadership

– Resources--show ”cost of doing nothing”

– Intelligent use of information: identify patients with diabetes, monitor, prioritize, proactive outreach & visit planning

– Organize clinics to give proactive, population-based care

– Intensify Treatment--Titrate to Goal

– Consider Evidence AND Value when selecting improvement goals

Future Directions

– Variation Continues--Plenty of room for more improvement

– Ascertain most appropriate level for QI intervention

– Focus on blood pressure reduction

– Focus on “Patient Activation”

– Focus on Visit Planning

– Focus on Physician decision making process and methods to change physician behavior

– Development of “Patient Archetypes” to advance care