Standards of Care Topics

Transcription

1 Diabetes Boot Camp Class 2 Beverly Dyck Thomassian, RN, MPH, BC ADM, CDE President, Diabetes Education Services Standards of Care Standards of Care Topics Review the 15 Standards of Care with a focus on updated standards Keeping it Patient Centered National goals and getting to target Prevention and lifestyle interventions Poll Question 1 What is the preferred approach when providing diabetes education with patients? a. Provide patient centered selfmanagement support b. Instruct all patients to meet national standards c. Highlight risk of complications when goals aren t met d. Remind them that insulin treatment can be beneficial. Page 1

2 1. Promoting Health Reducing Disparities in Populations Start with patient centered communication. Incorporate pt preferences, literacy, life experiences Treatment decisions timely, based on evidence and tailored to individual pt. Align care with Chronic Care Model to ensure proactive practice and informed, activated patient. Provide team based care, community involvement, decision support tools. 1. Strategies for Improving Care Based on a recent report by the CDC, <7% of privately insured adults with newly diagnosed diabetes from 2009 to 2012 joined a selfmanagement education and training program. Consider Chronic Care Model 1. Optimize Provider and Team Behavior 2. Support Patient Behavior Change 3. Change the Care System Chronic Care Model CCM 6 core elements for optimal diabetes care Proactive (vs reactive) care delivery system. Planned visits coordinated through a team based approach Self Management support Decision support (basing care on evidence based guidelines) Clinical information systems (registries that provide patient specific and population based support to team) Community policies and resources to support healthy lifestyles Health systems that create a culture of quality Page 2

3 Health Disparities Tailor Treatment Consider individualized care and create environmental structures to support people with: Food insecurity Cognitive dysfunction Mental illness (2 3 x s higher rates of diabetes in schizophrenia, bipolar) HIV (meds can cause pancreatic dysfunction) Health disparities related to: Ethnicity, culture, sex, socioeconomic status Poll Question 2 According to ADA 2017 Standards, who should be screened for prediabetes/ diabetes? a. JR, has family history of diabetes, BMI 22, age 39 b. MS, age 47 c. LK, smokes, has HTN age 43 d. RA, Hispanic, low HDL, avg wt 2. Classification and DM Diagnosis Pre Diabetes & Type 2 Screening Guidelines Start screening at age 45 or for anyone who is overweight (BMI 25, Asians BMI 23 ) with one or > additional risk factor: First degree relative w/ diabetes Member of a high risk ethnic population Habitual physical inactivity PreDiabetes History of heart disease Page 3

4 Diabetes 2 Who is at Risk? (ADA Clinical Practice Guidelines) Risk factors cont d HTN BP > 140/90 HDL < 35 or triglycerides > 250 baby >9 lb History Gestational Diabetes Polycystic ovary syndrome (PCOS) Other conditions assoc w/ insulin resistance: Severe obesity, acanthosis nigricans (AN) Screening for Type 2 25% of all people with diabetes are undiagnosed 50% of all Asian and Hispanic Americans are undiagnosed Most people with prediabetes are undiagnosed. The duration of glycemic burden is a strong predictor of adverse outcomes. Use Validated Diabetes Risk Test (ADA) to identify those at risk and promote behavior change action for individuals and their communities. Dentists have an excellent opportunity to find patients with undetected diabetes, since up to 30% of patients over the age of 30 seen in general dental practices have dysglycemia. Page 4

5 Test Criteria T2 Kids & Adolescents Overweight plus any two: Family history type 2 in 1 st or 2 nd degree relative Race/ethnicity Signs of insulin resistance or conditions associated with insulin resistance Maternal history of diabetes or GDM Start testing at 10 yrs or onset of puberty Recheck every 3 years or if symptoms A1c preferred screening method 3. Comprehensive Medical Evaluation, Assessment of Comorbidities It is necessary to take into account all aspects of a patient s life circumstance A team approach is important to integrate medical eval, patient engagement and lifestyle changes. 3. Initial Eval and Diabetes Management Planning Medical Evaluation 1. Classify diabetes 2. Detect diabetes complications 3. Review previous treatment and risk factor control 4. Assist in formulating a management plan 5. Provide a basis for continuing care Page 5

6 3. Initial Eval Conditions to look for Type 1 Autoimmune diseases Other conditions that may appear Type 1 /2 Depression and anxiety Obstructive sleep apnea Fatty liver disease Cancer Fractures Cognitive impairment Low Testosterone in Men Periodontal disease Hearing Impairment 3. Keep it Patient Centered it is clear that optimal diabetes management requires an organized, systematic approach and the involvement of a coordinated team of dedicated health professionals, working in an environment where patient centered care is a high priority. Coordinate care as patients transition through different stages of life. Pt Centered Collaborative Care Use communication style that: Uses active listening Elicits patients preferences and beliefs Assess literacy, numeracy and barriers to care Optimize Patient health outcomes Health related quality of life Page 6

7 4. Lifestyle Management Education Setting Up Successful Diabetes Ed Program Level 2 Nutrition Physical Activity Smoking Cessation Psychosocial Care Immunization 4. Lifestyle Management Patients with prediabetes Refer to behavioral counseling /DSME program to: Focus on intensive diet and physical activity Weight loss target of 7% Increase physical activity to 150 minutes a week Follow up counseling critical for success Consider Metformin for type 2 prevention if A1c Especially with BMI >35 and hx of GDM Monitor annually and screen and mitigate modifiable CV risk factors Poll Question 3 What are the ADA current exercise recommendations? a. Walk daily for 30 minutes b. 30 minutes activity 5xs a week plus daily strengthening exercises c. 10 minutes of activity three times daily. d. 30 minutes activity 5xs a week plus strengthening exercises 2 3 times /wk Page 7

8 Physical Activity Children with diabetes 60 mins / day Adults 150 min/wk moderate intensity over 3 days a week. Don t miss > 2 consecutive days w/out exercise Get up every 30 mins Reduce sedentary time T1 and T2 resistance training 2 3 xs a week Flexibility and balance training 2 3 xs a week (Yoga and Tai Chi) 4. Goals of Medical Nutrition Therapy ADA Promote and support healthful eating patterns Emphasize eating a variety of nutrient dense foods in appropriate portions to: Attain individualized B/P, BG and lipid goals Attain and maintain body wt goals Delay and/or prevent complications Address individual nutrition needs based on personal and cultural preferences, access to food, willingness and barriers Maintain pleasure of eating by providing positive messages about food Limit food choices only when backed by science Provide practical tools for day to day planning 4. E Cigarettes Not supported as an alternative to smoking or to facilitate smoking cessation. Encourage all patients not to use cigarettes, other tobacco products, e cigs Provide counseling The uptake of e-cigarettes, which use battery-powered cartridges to produce a nicotine-laced vapor (and often contain other bad stuff) Page 8

9 4. Smoking Smoking and Diabetes and Diabetes Smoking increases risk of diabetes 30% Ask at every visit Assess Advise Assist with stop smoking Arrange for referrals Organize your clinic Vaccinations Immunizations Influenza vaccine every year starting at age 6 months Hepatitis B Vaccine For diabetes pts age (not previously vaccinated) Double risk of Hep B due to lancing devices/ glucose meter exposure Pneumonia Vaccinations Pneumonia polysaccharide PPSV23 vaccine to all patients starting at age 2 Adults 65 years of age, if not previously vaccinated, should receive pneumococcal conjugate vaccine 13 (PCV13), followed by PPSV months after initial vaccination. Adults 65 years of age, if previously vaccinated with PPSV23 should receive a follow up 12 months with PCV13. Page 9

10 Psychosocial Care Provide to all pts with diabetes Integrate with a collaborative, pt centered approach. Routinely screen for depression, diabetes distress, anxiety, disordered eating and cognitive capacities Evaluate adults over 65 years for cognitive impairment and depression 5. Prevention of Diabetes Medicare will start funding approved Diabetes Prevention Programs 2018 Poll Question 4 According to the Diabetes Prevention Trial, losing 5 7 % of body wt and accumulating 150 minutes activity a week can: a. Help prevent type 1 diabetes b. Lower risk of getting prediabetes c. Decrease risk of getting diabetes d. Prevent type 2 diabetes Page 10

11 Can we stop pre diabetes from progressing? 3, 234 people w/ Pre Diabetes randomized: Placebo Diet/Exercise or Metformin over a three year period Diabetes Prevention Program (DPP) 2001 CDC Diabetes Prevention Program Standard Group 29% developed DM Lifestyle Results 14% developed DM 58% (71% for 60yrs +) Risk reduction 30 mins daily activity 5 7% of body wt loss Metformin 850 BID 22% developed DM 31% risk reduction (less effective with elderly and thinner pt s) Have Pre Diabetes? Steps to Prevent Type 2 Lose 7% of body weight Healthy eating, high fiber, low fat, avoid sugar sweetened beverages, reduce total caloric intake Exercise 150 minutes a week Consider Metformin Therapy for Women with history of GDM Patients with BMI of 35 or greater Under the age of 60 Follow up and group education Annual monitoring and tx of CVD risk factors Page 11

12 DSM Education & Support All people with diabetes and pre diabetes should receive DSME at diagnosis and as needed Pt centered, respectful, responsive to individual pt preferences, needs, values Address psychosocial issues and emotional well being Effective self management results in cost savings, improved outcomes, health status and quality of life. Should be monitored as part of care 6. Glycemic Targets A1C Blood Pressure Cardiovascular risk reduction 6. Glycemic Targets Adult non pregnant A1c goals A1c < 7% a reasonable goal for adults. A1c < 6.5% may be appropriate for those without significant risk of hypoglycemia or other adverse effects of treatment. A1c < 8% may be appropriate for patients with history of hypoglycemia, limited life expectancy, or those with longstanding diabetes and vascular complications. Frequency: If pt meeting goal At least 2 times a year If pts not meeting goal Quarterly Page 12

13 6. A1c and Estimated Avg Glucose (eag) A1c (%) eag Order teaching tool kit free at diabetes.org eag = 28.7 x A1c 46.7 ~ 29 pts per 1% Translating the A1c Assay Into Estimated Average Glucose Values ADAG Study Diabetes Care: 31, #8, August A1c Test Measures glycation of RBC s over 2 3 months Weighted mean (50% preceding month) Each 1% ~ 29mg/dl Accuracy: affected by some anemias, hemoglobinopathies A measurement of glucose in fasting and postprandial states African Americans may have false lows 6. Pediatric Glycemic Targets A1c goal <7.5 % for all ages; however individualization is still encouraged. A lower goal, <7% if can be achieved w/out excessive hypoglycemia Blood glucose goals Before meals: Bedtime/overnight: Page 13

14 Poll Question 5 According to the American Association of Clinical Endo (AACE), what is the A1c goal? a. Less than 6.5 for all patients b. Pre meal blood glucose less than 110 c. A1c less than 7% d. A1c less than 6.5 for healthy patients American Association Clinical Endo (AACE) Fructosamine Test Just in case The level of fructosamine in the blood is a reflection of glucose levels over the previous 2 3 weeks Can be used to eval: Effects of rapid changes in diabetes treatment Diabetes control during pregnancy to help monitor and accommodate shifting glucose, insulin, or other medication requirements. Glucose control for pts with shortened RBC life span such as anemia or blood loss. In these situations, A1c result is falsely low. Abnormal forms of hemoglobin such as in sickle cell anemia. Page 14

15 Glucose Goals Individualize Targets ADA Pre Prandial BG hr post prandial < than 180 *for nonpregnant adults Poll Question 6 Which study demonstrated that keeping A1c less than 7% reduces complications for Type 1? a. Diabetes Prevention Trial b. Diabetes Control and Complications Trial c. United Kingdom Prospective Diabetes Study d. YOUTH Trial Diabetes Control and Complications Trial (DCCT) In June, 1993 the New England Journal of Medicine published the results of the landmark DCCT. The largest, most comprehensive diabetes study ever conducted. The 10 year study involved more than 1400 subjects with Type 1 DM. It compared the effects of two treatment regimens standard therapy and intensive control on the complications of diabetes. Page 15

16 DCCT Conclusions By maintaining A1C < 7%: Eye disease 76% reduced risk Kidney disease 50% reduced risk Nerve disease 60% reduced risk Management elements included: SMBG 4 or more times a day 4 daily insulin injections or insulin pump Greater risk of hypoglycemia UKPDS Results United kingdom Prospective Diabetes Study Conducted over 20 years involving over 5,100 patients with Type 2 diabetes 1% decrease in A 1 c reduces microvascular complications by 35% 1% decrease in A 1 c reduces diabetes related deaths by 25% B/P control (144/82) reduced risk of: Heart failure (56%) Stroke (44%) Death from diabetes (32%) Lancet 352: , 1998 Legacy Effect For participants of DCCT and UKPDS long lasting benefit of early intensive BG control prevents microvascular complications Macrovascular complications (15 55% decrease) Even though their BG levels increased over time Message Catch early and Treat aggressively Page 16

17 7. Obesity Treatment This section incorporates bariatric surgery, assessment of weight and the treatment of overweight and obesity through behavior and pharmacotherapy. Will cover in BootCamp 6 At each pt encounter, calculate BMI and document in medical record Poll Question 7 According to the ADA and AACE, which of the following diabetes med class is the first choice? a. Sulfonylureas b. GLP 1 Receptor Agonists c. SGLT 2 Inhibitors d. Biguanides Section 8 Pharmacologic Approaches to Glycemic Treatment Cover content in Boot Camp 5 Page 17

18 9. Cardiovascular Disease and Risk Management Cardiovascular disease is the leading cause of mortality and morbidity in diabetes Largest contributor to direct and indirect costs Controlling cardiovascular risk improves outcomes Large benefits are seen when multiple risk factors are addressed globally 9. BP Goal BP < 140 / 90 Some pts may benefit from B/P 130/80 (younger and achieved with undue tx burden) Studies indicate that the previous B/P target of 140/80 didn t improve outcomes enough to balance the risk of side effects such as orthostatic hypotension and polypharmacy. 9. Hypertension Guidelines Screening Check BP at each visit. If either systolic 140 or > diastolic 90 or > repeat on separate day. Hypertension = Repeat systolic or diastolic above or equal to these levels When taking B/P Pt sit still for 5 min s Feet on floor, Arm supported at heart level Right size cuff Page 18

19 9. BP Treatment ADA Standards Pts with B/P > 120/80 encourage lifestyle changes to reduce B/P B/P > 140/90 Lifestyle plus prompt initiation of B/P meds Lifestyle = Weight loss DASH Style diet (fresh fruit, veggies, whole grains, reducing sodium and increasing potassium intake) Moderation of alcohol intake Increased physical activity 9. Blood Pressure Treatment First Line B/P Drugs Any of the 4 classes of BP meds can be used to tx hypertension (without albuminuria). This includes ACE Inhibitors, ARBs, thiazide like diuretics or calcium channel blockers. Multiple Drug Therapy often required For best effect, administer at least one at bedtime 8. Dyslipidemia Screening Adults Screening lipid profile is recommended at time of diagnosis And/or at 40 years And periodically thereafter (every 1 2 years) Page 19

20 8. Dyslipidemia Management Start with lifestyle Reduce trans, saturated fat, cholesterol Increase intake of omega 3 fatty acids, viscous fiber, and plant stanols/sterols Contained in grains, vegetables, fruits, legumes, nuts, and seeds. Also added to margarine, OJ and other food products Lose weight (if indicated) Get Active 8. Dyslipidemia Management Intensify lifestyle therapy and optimize glucose control for patients with: Triglycerides 150 and/or HDL 40 (men) 50 (women) Most Pts Need a Statin Statin lowers cholesterol production in liver Ezetimibe (Zetia) blocks absorption of cholesterol in intestine Page 20

21 Statin Therapy High intensity statins (lowers LDL 50%): Lipitor (atorvastatin) 40 80mg Crestor (rosuvastatin) 20 40mg Moderate intensity (lowers LDL 30 50%) Lipitor (atorvastatin) 10 20mg Crestor (rosuvastatin) 5 10mg Zocor (Simvastatin) 20 40mg Pravachol (pravastatin) 40 80mg Mevacor (lovastatin) 40 mg Lescol (fluvastatin) XL 80mg Livalo (pitavastatin) 2 4mg Antiplatelet Agents Consider aspirin therapy ( mg/day) As a primary prevention strategy for T1 or T2 at increase CV risk (10 yr risk >10%) In pts who can t tolerate, use Plavix, (clopidogrel) Combo therapy of aspirin + clopidogrel is reasonable for a year after MI Includes most men or women w DM age 50 years, with at least 1 additional risk factor: Family history of premature ASCVD Hypertension Smoking Dylipidemia Albuminuria 8. Coronary Heart Disease In pts with known CVD, use: Aspirin Statin B/P Med Consider ACE Inhibitor to reduce risk of CV event In pts with prior MI, Beta Blockers should be continued at least 2 years after the event Don t use Actos or Avandia in pts with CHF In pts with stable CHF, Metformin can be used in renal function normal and stable Page 21

22 A 78 yr old man, smokes ppd A1c was 8.1% (down from 10.4%) B/P 136/76 AM BG 100, 2 hr pp 190 Chol TG 54, HDL 46, LDL 98 Meds: Insulin 16 units Lantus at HS Benazepril 20 mg Metoprolol 50mg Actos 15 mg Daily aspirin What class of meds is this patient on? Any special instructions? Any med missing? Poll Question 8 78 year old, A1c 8.1, LDL 98, smokes ppd. Based on ADA guidelines, what med is missing? a. Sulfonylurea b. Vitamin D c. SGLT2 Inhibitor d. Statin Diabetes Care Guidelines ADA Test / Exam Frequency A1c At least twice a year B/P Each diabetes visit Cholesterol (HDL, Tri) Yearly (less if normal) Weight each diabetes visit Microalbumin/GFR/Creat Yearly Eye exam Yearly Dental Care At least twice a year Comprehensive Foot Exam Yearly (more if high risk) Physical Activity Plan As needed to meet goals Preconception counseling As needed Page 22

23 ABCs of Diabetes A1c less than 7% (avg 3 month BG) Pre meal BG Post meal BG <180 Blood Pressure < 140/90 Cardiovascular risk reduction Eval if statin therapy indicated Mr. Jones What are Your Recommendations for Self Care? Patient Profile 62 yr old with newly dx type 2. History of previous MI. Meds: Lasix, synthroid Labs: A1c 9.3% HDL 37 mg/dl LDL 156 mg/dl Triglyceride 260mg/dl Proteinuria neg B/P 142/92 Self Care Skills Walks dog around block 3 x s a week Bowls every Friday Widowed, so usually eats out See Courses in Level 2 for following Topics for Standards Page 23

24 10. Microvascular Complications "Every time you see your doctor, take off your shoes and socks and show your feet!" For patients with loss of protective sensation, foot deformities, or a history of foot ulcers Comprehensive foot eval each year to identify risk & promote prevention 10. Microvascular Complications Nephropathy Diabetic Kidney Disease Optimize glucose and B/P Control to protect kidneys Screen for Albumin Creat ratio and GFR Type 2 at dx then yearly Type 1 with diabetes for 5 years, then yearly Treat hypertension with ACE or ARB and intensify as needed Consider referral to specialist when management is difficult and kidney disease is advanced Not recommended to limit dietary protein intake below 0.8 g/kg/day (doesn t improve outcomes) See Level 2 Course, Microvascular Complications 10. Microvascular Complications Eye Disease Optimize glucose and B/P Control to protect eyes Screen with initial dilated and comprehensive eye exam by ophthalmologist or optometrist Type 2 at diagnosis, then every one to 2 years Type 1 within 5 years of dx, then every 1 2 years Can use high quality fundus photography as screening tool Initial exam should be done in person Promptly refer pts with macular edema, severe non proliferative disease trained specialist Treatment includes laser therapy (retinopathy) and Antivascular and Endothelial Growth Factor for Macular Edema Page 24

25 10. Microvascular Complications Nerve Disease Tight glycemic control Medication recommendations updated Screen all patients for nerve disease using simple tests, such as a monofilament Type 2 at diagnosis, then annually Type 1 diabetes 5 years, then annually Assess and treat patients to reduce pain and symptoms to improve quality of life. 11. Older Adults 26% of people over 65 have diabetes (expected to rise) Asses the medical, functional, mental and social geriatric domains for diabetes. Provide individualized care Determine targets and therapeutic approaches Over age 65, high risk for depression Provide nursing home staff with education See Level 2 Course, Older Adults and Diabetes Older Adults ( 65 years) with diabetes Annual screening for early detection of mild cognitive impairment or dementia High priority population for depression screening and treatment Avoid hypoglycemia in this high risk group Prevent hypo by adjusting glycemic targets and adjusting pharmacologic interventions Page 25

26 12. Children and Adolescents Start preconception counseling at puberty for all girls of childbearing potential decreases risk of malformations associated with unplanned pregnancies and poor metabolic control, Type 1 or Type 2 Diabetes? Many children are overweight with new See Level 2 Course - Kids hyperglycemia. and Diabetes for full detail 6% of children with new type 2 present in DKA. Type 2 in kids is different than type 2 in adults, including more rapid decline in beta cell function and accelerated development of diabetes complications. Evaluate autoantibodies and do a careful history to determine the correct diagnosis and provide early and appropriate treatment. 13. Gestational DM ~ 7% of all Pregnancies GDM prevalence increased by % during the past 20 yrs Native Americans, Asians, Hispanics, African American women at highest risk Immediately after pregnancy, 5% to 10% of GDM diagnosed with type 2 diabetes Within 5 years, 50% chance of developing DM in next 5 years. 13. Meds used in Pregnancy Insulin is the preferred med to be used in pregnancy Glyburide and Metformin cross the placenta Long term studies needed Page 26

27 14. Diabetes Care in Hospital, Nursing Home and Skilled Nursing Facility Get A1c on all patient with DM/hyperglycemia Start discharge planning on admission Avoid sole use of sliding scale insulin during hospital stay Basal bolus preferred treatment Have hypoglycemia protocol Clearly identify type of diabetes on admission Inpatient glucose goals: Start insulin if BG >180 Goal BG (some pts may benefit from ) New Parenteral/Enteral Feeding Chart 15. Diabetes Advocacy People living with diabetes should not face discrimination We need to all be a part of advocating for the best care and the rights of people living with diabetes. Thank You us with any questions. View recorded webcasts and take post test and survey at Thank you! Page 27