5/21/2018. Workshop Maximizing Heightened Attention and Learning at Diagnosis to Avoid Complacency. Background

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1 Workshop Maximizing Heightened Attention and Learning at Diagnosis to Avoid Complacency Rohan Mahabaleshwakar, PhD Center for Outcomes Research and Evaluation Andrea M DeSantis, DO Department of Family Medicine Background Nearly half of patients with Type 2 Diabetes (T2D) do not achieve recommended glycosylated hemoglobin (HbA1c) goal of < 7%. 1,2 and 40% do not reach an HbA1c of < 8% 3 Clinical inertia or the delay of treatment intensification is a major cause of inadequate glycemic control. 4 Though adherence factors play a large roll in clinical inertia, often providers do not escalate therapy for various reasons. 1.Casagrande SS, Fradkin JE, Saydah SH, Rust KF, Cowie CC. The prevalence of meeting HbA1c, blood pressure, and LDL goals among people with diabetes, Diabetes Care. 2013; 36(8): Phillips LS, Branch WT, Cook CB, et al. Clinical inertia. Ann Intern Med. 2001; 135(9): Centers for Disease Control and Prevention. A1c distribution among adults with Diagnosed Diabetes, Accessed February 12, Schmittdiel, PhD, Heisler, Mishele, MD, MPA et al. Why Don t patients Achieve Recommended Risk Factor Targets? Poor Adherence vs Lack of Treatment Intensification. Journal of General Internal Medicine. Jan 28, (5) Clinical Inertia of 49.8% for Goal HbA1C < 8 [VALUE] 50.2 Clinical Inertia Treatment Intensification 1

2 Clinical Inertia for 67.9% for Goal HbA1c < 7 [VALUE] 67.9 Clinical Inertia Treatment Intensification Clinical Inertia is Lethal and Costly Diabetes was the 7th leading cause of death in Estimated total cost in 2015 was $322 billion. Average annual expenditure is $13,700 per person. Adjusted for age and sex, the average cost was 2.3 times higher than those without diabetes.2 1. Centers for Disease Control, US Department of Health and Human Services May American Diabetes Association. Economic costs of diabetes in the U.S. in Common reasons for not achieving treatment goals Patient issues Access proximity and transportation, appointment availability, narrow networks, financial barriers to care Health Literacy and Cultural Barriers to care Psychosocial Issues (motivation, depression, addiction ) Financial barriers Provider issues Over estimation of care provided lack of medical education, barriers to accessing status reports Busy treating other more pressing health issues (pain, CAD/CHF, psychosocial etc..) Fear of costs and side effects for patient (pre-authorization) Lack of system support (practice or health care system) Financial barriers within the office 2

3 Impact of Timely Treatment Intensification on Glycemic Goal Achievement *denotes the probability of not achieving Clinical Inertia Does the timing of intensification matter? Rajpathak et al studied 5,870 patients EMR data at General Electric metformin monotherapy failure defined as a HbA1c > % vs 41.7% were able to achieve goal (HbA1c <7.0) when treatment intensification (oral add on therapy) occurred within the first 3 months vs months1 Pantalone et al looked at 5,239 patient EMR records of the Cleveland Clinic TI more loosely defined as a change in metformin dose, Rx for another diabetic medication or weight loss medication, or a referral to a diabetes educator Timely TI (before 6 month vs after 6 months or never) was seen for HbA1c >7=62%, 7.5=69%, and 8=72% with the period of time until A1c goal attainment measures was significantly shorter for all three Timely TI groups.2 1. Rajpathak SN, et al Journal of Diabetes Complications Pantalone KM, et al. Diabetes Care Crossing the Quality Chasm for Diabetes Management Journal of the American Board of Family Medicine 43 patients studied and treated over 24 months Monthly meetings using repeated and rapid cycle trials to make changes in the approach to 5 parameters of diabetes management (Tobacco, SBP, LDL, Aspirin use, and HbA1c) Team based included Physician, LPN, RN, Diabetes educator, and IT Flexible (gathered feedback and made adjustments in care plan and interventional efforts accordingly) Proportion of patients achieving targeted improvements by comparison increased from 5.7 to 42.9% for 4/5 measures (but not A1C) LI Solberg et al Crossing the Quality Chasm for Diabetes Care: The Power of One Physician, His Team and Systems Thinking Journal of the Board of Family Medicine May-June (3)

4 Taking Time for Diabetes Management Heightened attention at the time of diagnosis Heightened Attention After an Event This Photo by Unknown Author is licensed under CC BY SA 4

5 Take a Patient Centered Approach This Photo by Unknown Author is licensed under CC BY SA A Patient Centered Approach The Institute of Medicine, defines Patient-Centered Care as an approach that involves listening to, informing, and involving patients in their care. Providing care that is respectful of and responsive to the individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions. May 15, 2015 Picker s Eight Principles of Patient Centered Care The Picker Institute and Harvard Medical School, May 2015 Respect for Patient s Preferences Coordination and Integration of Care Information and Education Physical Comfort Emotional Support Involvement of Family and Friends Continuity and Transition Access to Care This Photo by Unknown Author is licensed under CC BY SA 5

6 Making Time for Diabetes Management Anticipate Success Set an Appointment Cadence Bring an intentional approach to management Build in Flexibility Take a Patient centered Approach Teamwork! Timely and Interactive Patient Centered Communication entails identifying... The Patient's perspective The psychosocial context Shared Understanding Sharing power and responsibility Evidence Based Recommendations for Practice M. Jawad Hasam, MD, Am Fam Physician 2017 Jan 1;95(1):

7 Anticipate Success and Communicate Treatment Goals Erlich, Slawson and Shaughnessy, Am Fam Physician 2014 Feb 15;89(4): Patient interaction video Patient Centered Approach video 7

8 Case Study #2 34 year old Caucasian female with a history of PCOS, seasonal allergies, low back pain and OSA Vitals: BP 142/90, HR 82, BMI of 41.5 Married, cleans houses full time, 3 kids and is uninsured Her initial A1c was 8.6 with a Cholesterol of 250, HDL 35, LDL 140 and Triglycerides of 275. She was started on Metformin monotherapy with instructions to taper to 2 grams daily, Lisinopril, Atorvastatin and referred to a nutritionist. Case #2 Follow up at 3 months Only taking 1000 mg daily of Metformin. She complains the pills are too big and worries about taking so much medication. Never started the statin due to fear of liver disease. She estimates missing 2-3 doses a month of all of her medications She met with the nutritionist and has made some good changes in the diet but is currently not exercising. Her repeat A1c is 8.1%. BP 132/78 She is referred to our clinical pharmacist to be evaluated for the addition of a GLP-1 agonist. Case #2 Follow up at 6 months She in now taking 2000 mg of Metformin, The A1c is 7.6%. Met with the clinical pharmacist but is not interested injection medication. She complains of increasing back pain and low mood. Her diet has reverted back to increased starches and sweet snacks. She informs you she cannot take off work to see the ophthalmologist. She want to change her diet but does not have a plan. 8

9 Managing multiple comorbidities What would you do for this patient? A) Dismiss her from the practice? She clearly is not interested in following directions and advise B) Engage a diabetes educator? C) Ask her to bring her most trusted family or friend to her next appointment? D) Administer the PHQ-9 depression assessment tool? E) Refer her for health coaching? F) Address her pain and schedule another appointment for diabetes management? The Disengaged Patient Unorganized with executing plan of care Trouble retaining information Missed appointments and referrals Appears to be uninterested Has an excuse or story 9

10 Addressing the Emotional and Social Aspects of Chronic Disease Management Untreated depression and anxiety Eating disorders and other untreated addictions Myths and fears Financial barriers Low health literacy Functional illiteracy The Stages of Change Continuum Adapted from DiClemente and Prochaska, 1997 World Health Organization Adherence to the Plan of care 10

11 Health Coaching? Health Coaching! Ideas for re-engaging and re-energizing Reaching out in person, phone, text, portal or Using a Team Group Visits Virtual visits Interactive Apps Reward Engagement 11

12 Anticipate Success by Communicating Treatment Goals Erlich, Slawson and Shaughnessy, Am Fam Physician 2014 Feb 15;89(4): Taking a Team Approach to Care Interactive Activity What does (or might) your team look like? 12