Monthly Diabetes Team Meeting

First Things First

Purpose

• Achieve DM quality goals using the Chronic Care Model– FMC, team, individual physician

• Demonstrate Residents’ Practice Based Learning & Improvement– Demonstrate leadership in care team – Use database to assess practice quality – Propose & complete PDSA cycle – Teach evidence based practice

Initial DM Quality Goals

• > 70% have Self management Goals • > 60% HgbA1c < 7%• > 40% BP < 130/70• > 70% LDL < 100• Eye exam, monofilament, microalbumin Q yr• Depression screen each visit• <12% current smoking• ACE/ARB

The Chronic Care Model

Expectations

• Every month before PGY2/3 core – If unable to schedule before PGY2/3 core,

then team decides on alternate

• Meeting lasts ≤ 30 min

• Work will occur outside meeting

• All faculty, PGY3, PGY2, RNs

• Representatives from ancillary staff

Agenda

• Preparation– Review team and personal DM quality

• FMC quality data report

• Team report on PDSA cycle

• Resident presentation related to PDSA

• Team meetings to suggest next PDSA

Chronic Care Portfolio

• Perform data base query

• Propose, complete, report PDSA cycle

• Update, present chronic care topic

• Case study difficult chronic care patient

• Self management goal setting

The Chronic Care Model

Self-Management

• Effective self-management is very different from telling patients what to do. Patients have a central role in determining their care, one that fosters a sense of responsibility for their own health.

Delivery System Design

• The delivery of patient care requires not only determining what care is needed, but clarifying roles and tasks to ensure the patient gets the care; making sure that all the clinicians who take care of a patient have centralized, up-to-date information about the patient’s status; and making follow-up a part of standard procedure.

Decision Support

• Treatment decisions need to be based on explicit, proven guidelines supported by at least one defining study. Health care organizations creatively integrate explicit, proven guidelines into the day-to-day practice of the primary care providers in an accessible and easy-to-use manner.

Clinical Information System

• A registry — an information system that can track individual patients as well as populations of patients — is a necessity when managing chronic illness or preventive care.

Organization of Health Care

• Health care systems can create an environment in which organized efforts to improve the care of people with chronic illness take hold and flourish.

Community

• To improve the health of the population, health care organizations reach out to form powerful alliances and partnerships with state programs, local agencies, schools, faith organizations, businesses, and clubs.

Predicted Benefits of Control (Archimedes Model)

HgbA1c < 7

Within 6 mos Within 24 mos

Proteinuria 52% 15%

ESRD 44% 16%

Eye surgery 73% 41%

Blindness 73% 47%

Bailey JInt J Clin Pract 2005;59:1309-1316

Joe Average Doc

• “Not satisified” with HgbA1c >7, but….– 68% reinforced diet and exercise– 27% augmented oral agents– 8% increased insulin

Glargine 2 for 20 Rule

• Start 10 units Daily (HS or AM)• Adjust weekly based on last 2 FPG

values• Titration schedule

– 2 units for each 20mg above 100mg• FPG 140 increase 4 units• FPG 200 Increase 10 units

• NO increase in dose if BG < 72 or documented severe hypoglycemia

BP Control Strategies

• ACE, then diuretic, then ARB

• If not a goal confirm – proper BP measurement– medication adherence– low sodium – Avoid EtOH > 2 oz /day, NSAID,

decongestants, high dose estrogen

Diabetic Nephropathy aka microalbuminura

Preserving Renal FunctionLevel I recommendations

• Systolic BP < 120mmHg

• Maximum recommended ACE dose

• Maximum recommended ARB dose

• ACE plus ARB

• Avoid dihydropyridine CCBs

• Use beta blockers (BB)– preferred over DHCCB

Preserving Renal FunctionLevel II recommendations

• Glycemic control (HgbA1c < 7)

• Stop smoking

• Statin to achieve LDL < 100, or <70

• Aspirin

• Limit sodium to 2-3 grams/day

• Chicken instead of red meat?

ACE worries

• OK if creatinine > 3 mg/dl

• Serum creatinine rises up to 50% OK if no further increase

Hebert LA Kidney Int 2001;59:1211-1226

Safety of ACE + ARB

• Only decrease BP 4.5/2.5 mmHg

• Small increase in K+

• Slight decrease in GFR

• Proteinuria improves