Diabetes Care begins with Diabetes Prevention. Neha Sachdev, MD Janet Williams, MA

Transcription

1 Diabetes Care begins with Diabetes Prevention Neha Sachdev, MD Janet Williams, MA

2 Objectives Describe the clinical practice burden and trends in type 2 diabetes Review evidence for diabetes prevention Describe AMA s offerings and assistance to healthcare organizations in developing diabetes prevention strategies 2

3 Epidemiology and Clinical Burden of Prediabetes 3

4 Alex 2003 Prediabetes age 55 4

5 Alex 2003 Prediabetes age Type 2 Diabetes Glucometer Lancets Test Strips Diabetes Education Metformin Statin Aspirin? ACE-I? Referral Ophthalmology Referral Podiatry Office Visit q 3 months Labs and Urine 5

6 Alex 2003 Prediabetes age Type 2 Diabetes 2016 Retinopathy 6

7 Alex 2003 Prediabetes age Type 2 Diabetes 2016 Retinopathy 2020 CKD Referral Nephrology Prior authorizations Ongoing refills Ongoing labs Medical complications Anemia Osteoporosis Edema 7

8 Adults with Diagnosed Diabetes in the US, Age-Adjusted Percentage 30+ MILLION Americans have diabetes Source: Disclaimer: This is a user generated report. The findings and conclusions are those of the user and do not necessarily represent the views of the CDC. National Center for Chronic Disease Prevention and Health Promotion Division of Diabetes Translation

9 Adults with Diagnosed Diabetes in Tennessee, Age-Adjusted Percentage Source: Disclaimer: This is a user generated report. The findings and conclusions are those of the user and do not necessarily represent the views of the CDC. National Center for Chronic Disease Prevention and Health Promotion Division of Diabetes Translation

10 Health burden of diabetes Compared to people without diabetes, those with diabetes are: 100% more likely to develop hypertension 1 80% more likely to be hospitalized for heart attack 2 50% more likely to be hospitalized for a stroke 2 70% more likely to die from heart disease or stroke 2 10

11 Cost of diabetes American Diabetes Association. Economic Costs of Diabetes in the US in Diabetes Care. 2018; 41(5):

12 Total Medical Expenditure In The Years Leading to Diabetes Diagnosis Ongoing research at the American Medical Association $ prior to diabetes diagnosis ( ) Diabetes Diagnosis (2014) $ over same 5 year period ( ) No Diabetes Diagnosis (2014) 12

13 Current burden of prediabetes 84 MILLION ADULTS HAVE PREDIABETES 1 A reversible condition in which plasma glucose levels are higher than normal but not high enough to diagnose type 2 diabetes 9 OF10 DON'T KNOW THEY HAVE PREDIABETES 2 1 IN 3 ADULTS HAS PREDIABETES 1 1 IN 2 age

14 Prediabetes diagnosis

15 Progression from prediabetes to type 2 diabetes 15 15

16 Prevention: need to engage the rising risk Only 3% of our national health expenditure is spent on prevention 1 Move beyond keeping the healthy well to target those with identifiable risk factors to prevent progression = rising risk % of a Population Stratifying a population High cost/ utilization Rising Risk e.g., 15% to 30% chance of progressing from prediabetes to diabetes Risk factors Healthy / low risk 16

17 Evidence Base for Diabetes Prevention

18 One solution: National Diabetes Prevention Program Prediabetes is a reversible condition. The National DPP can help patients lower their risk of developing type 2 diabetes and reduce the likelihood of: ILLNESS MEDICATION EXPENSE 18

19 What is the National DPP? Examples of sessions: 1. Eat Well to Prevent T2 2. Get Active to Prevent T2 3. Shop and Cook to Prevent T2 4. Find Time for Fitness 5. Eat Well Away from Home 6. Stay Motivated to Prevent T2 7. Manage Stress 8. Have Healthy Food You Enjoy 19

20 Historical starting point: DPP randomized controlled trial DPP Research Study: People with prediabetes who took part in a structured lifestyle change program reduced their risk of developing type 2 diabetes (at average follow-up of 3 years) compared to placebo. And the lifestyle change program was nearly twice as effective as metformin. 58% risk reduction DPP Intensive Lifestyle Change Program (71% reduction for patients over age 60) 31% risk reduction METFORMIN Glucose Lowering Drug (Currently, there is no FDA approval for metformin for the indication of diabetes prevention) 20

21 National DPP Lifestyle Change Program Program goal MINIMUM BODY WEIGHT LOSS +6 5% IN 6 MONTHS MONTHS OF MAINTENANCE Emphasis on prevention, and empowerment Lifestyle coach motivates and supports individuals In person program Peer to peer camaraderie Face to face coaching Progress reports CDC recognized Online program Patient flexibility Complete modules on own schedule Web/mobile enabled dashboards CDC recognized 21

22 Benefits of the DPP DPP clinical impact: (over 3 years, after program completion per 100 high-risk adults) 15 FEWER NEW CASES OF DIABETES 1 8 FEWER PATIENTS USING ANTI-HYPERTENSIVE MEDICATION 2 4 FEWER PATIENTS USING ANTI-LIPID MEDICATION 2 1. Knowler et al. N Engl J Med 2002;346: The DPP Research Group. Impact of lifestyle and metformin therapy on cardiovascular disease risk factors in the diabetes prevention program. Diabetes Care 2005:28(4):

23 USPSTF abnormal glucose screening recommendation USPSTF standards suggest testing patients every 3 years. AGE & BMI Grade B recommendation age AND BMI 25 * The American Diabetes Association encourages screening for diabetes at a BMI of 23 for Asian Americans 23

24 USPSTF abnormal glucose screening recommendation Family history Family history of type 2 diabetes includes first-degree relatives (a person s parent, sibling or child) Medical history Gestational diabetes Polycystic ovary syndrome Racial and ethnic minorities African Americans American Indians or Alaskan Natives Asian Americans Hispanics or Latinos Native Hawaiians or Pacific Islanders 24

25 USPSTF abnormal glucose screening recommendation Grade B recommendation Screen for abnormal blood glucose with a fasting glucose, hemoglobin A1C or oral glucose tolerance test Refer patients with abnormal glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity 25

26 Diabetes Prevention Leads to Improved Health Adheres to evidencebased guidelines Provides patients with skills and counseling to make sustainable lifestyle changes Achieves the Quadruple Aim Better Care Better Outcomes Lowers incidence of diabetes Included in MIPS Aligns with PCMH or other value based arrangements Addresses rising risk population segment Reduces medical expenditures ~$2,650 savings per Medicare beneficiary and ~ $2,700 per commercial beneficiary Lower Cost Improved Provider Experience Helps patients achieve clinically significant outcomes Reduces clinical practice burden of diabetes 26

27 National Movement 27

28 Challenges Facing Clinical Team The current and growing volume of chronic disease Lack of time to effectively deliver the intensive counseling needed for lifestyle changes Social determinants of health often fall outside our scope of influence Lack of adequate information about community based resources for diabetes prevention 28

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31 AMA Efforts to Prevent Diabetes Goal: Galvanize efforts to increase screening for prediabetes and raise participation in evidence-based diabetes prevention programs Approach: Engage health systems across the U.S. in diabetes prevention Help link clinical practices to diabetes prevention programs Develop, test and disseminate relevant tools and resources Advocate for inclusion of lifestyle interventions in health benefits 31

32 Effecting clinical practice change in diabetes prevention 32

33 Core decisions and planning Assess Current State Patient Awareness and Messaging Identification of Eligible Patients DPP Offering Management and Referral Process Physician Engagement & Education Feedback Loop on Patient Progress Sustainability, Evaluation and Expansion 33

34 AMA diabetes prevention offerings The AMA offers a comprehensive program to guide implementation of clinical practice change in order to prevent type 2 diabetes. Personal Consulting Implementation Support Connections to Partners Clinical Practice Tools Resources (examples, not comprehensive) 34

35 Determine DPP offering Internal DPP Other treatment options Virtual DPP Partner with community organization 35

36 Patient Awareness and Messaging Identification of Eligible Patients Patient communication and awareness Management and Referral Process preventdiabetesstat.org and doihaveprediabetes.org 36

37 Patient Awareness and Messaging Identification of Eligible Patients Educate patients, discuss testing and treatments Management and Referral Process Prediabetes is common, but is treatable and often reversible Treatment options include the National DPP lifestyle change program, among others 37

38 Patient Identification of Awareness and Eligible Patients Messaging Management and Referral Process Identify patients eligible for screening 38

39 Patient Awareness and Messaging Identification of Eligible Patients Manage patients with prediabetes Management and Referral Process ICD 10 code R73.03 Prediabetes 39

40 Physician and care team engagement Grand rounds and webinar presentations Evidence and research information Online CME modules 40

41 STEPS Forward and PI CME

42 Referral Process and Feedback Loop Care team workflows EHR capabilities include order sets and registries Extension of Medical Care Bi-directional feedback between provider and program Provide enrollment, completion, outcomes information Arrange follow-up Provider visit, lab monitoring 42

43 Evaluation Process Patients Identified Patients Referred Outcomes BMI A1C/FPG Medications HTN Program Enrollment Sessions Attended Physical Activity Minutes Weight Loss 43

44 CLIENT JOURNEY MAP Create Snapshot of Potential Costs/ Benefits Secure Class Location/Time Identify and Train DPP Coaches Identify Eligible Patients Define Reporting Metrics Initiate Patient Communication & Messaging MONTH 1 MONTH 2 MONTH 3 MONTH 4 Launch DPP Secure Organizational Buy in Milestones Identify Physician Champion Develop Referral Process to DPP Develop Physician Engagement & Education Development Plan AMA Facilitate Webinar or Co Present to Physician Team Submit CDC Application Final Class Preparation Meeting/Phone Conference with the AMA *Visual example; not fully comprehensive of the process in its entirety 44

45 System-wide Diabetes Prevention Strategic Plan Purpose: Intermountain will develop and implement a systematic and comprehensive approach to identify individuals at-risk for diabetes and match them with evidence-based interventions in an effort to prevent type 2 diabetes. PROPRIETARY

46 Impact of Coverage: The Case Avoidance Equation Could Intermountain target a 2018 enrollment goal for our Medicare capitated insurance product? Target 1949 individuals for enrollment (total n=6495) Cumulative DM incidence at 1 yrs: DPP vs Controls (2.1% vs 5.0%) 3% reduction $6030 difference in healthcare costs for those with T2DM compared to those with prediabetes* By hitting our enrollment goal, avoid 58 cases of diabetes...indicating a $349,723 savings to the system *Internal analysis of Intermountain health plan claims

47 Shared Decision Making Tools The use of a decision aid (DA), defined as a tool that makes the clinical decision explicit, describes the options available, and helps people to understand these options as well as their possible benefits and harms, is one way to frame preference-sensitive decisions. This is particularly critical for patients with prediabetes, who are often confused about the short-term and longterm risks associated with their asymptomatic condition, are uncertain what else they can do to prevent diabetes, and feel left in mid-air to fend for themselves PROPRIETARY

48 Shared Decision Aid for Prediabetes Initial Preferences D E L I B E R A T I O N (45 to 60 minute clinical encounter with the pharmacist). Informed Preferences STAGE 1: Talk About Choice STAGE 2: Talk About Options STAGE 3: Talk About Decision Step back & describe problem Offer choice Justify choice (explain uncertainty, concept of personal preferences). Check patient reaction Check knowledge 1 List options (lifestyle, metformin) 1 Describe options, including harms and benefits 2 Provide decision support 2 Summarize Focus on preferences 3 Elicit a preference 3 Leaning toward decision 4 Offer review 5 Make decision 6 PROPRIETARY

49 Final Thoughts 49

50 Best Practice Treating Prediabetes Raise awareness amongst physicians, care teams and patients through Ad Council campaign, grand rounds, webinars and CME Approach as a process or quality improvement initiative Automate screening and referrals Retrospective query to identify those at risk Referral through EMR Build feedback loops so that physicians can discuss progress with their patients 50

51 51 Neha Sachdev assn.org Janet Williams assn.org

52 Questions 52