C2/D2: Diabetes Care at Kaiser Permanente Population-based Approach

Transcription

1 C2/D2: Diabetes Care at Kaiser Permanente Population-based Approach Alide Chase, Senior Vice President, Medicare Clinical Operations & Population Care and Executive Director, Care Management Institute

2 Objectives Review a large system s approach to population-based care with a focus on pre-diabetes and diabetes Appreciate the need to focus on the few treatments most impactful Appreciate the use of segmentation to customize approach to different people s care needs Review the importance of measurement and use of dashboards from a system level to individual level Share successful use of technology to increase compliance and self care 2

3 Today s Focus Tactics 1. Prevention 2. Treatment Intensification 3. Prevention of Complications 4. Segmentation 5. Technology 6. Metrics 7. Outcomes 3

4 Other Diseases Coronary Artery Disease Dyslipidemia Diabetes Evolution of Population Care Old Days New Approach 1997 Disease Management 2010 Complete Care Chronic Conditions Prevention Lifestyle/Behavior 4

5 5 NEW THINKING: Population Care Complete Care

6 Key themes People Patient centered care and focus Make the right thing easier to do Get the right person to do the right job Need for sponsorship at all levels Systems Focus on what needs to be improved Metrics Integration of members of the healthcare team Emphasis on process improvement techniques Technology Electronic Medical Record: Delivering the right information at the right time Registries Panel management tools Web and smart phone applications Interactive voice responses 6

7 7 Diabetes Basics and Facts

8 Diabetes Basics Most diabetes develops in people with inherent insulin resistance (high prevalence in the Middle Eastern population) Obesity adds to the risk due to excess food and lack of exercise This leads to: Cardiovascular disease (heart attacks & strokes) and Hyperglycemia (excessive blood sugar) which can lead to blindness, kidney failure, amputations, and coma 8

9 Middle East & North Africa Diabetes Facts IDF estimates suggest that one in five people in the Middle East are now living with diabetes, a number expected to increase to 1 in every 3 by 2030* Two out of every five respondents are at risk of developing diabetes,. However, almost 40% of those at risk have never had a blood glucose test**. Six out of the world s top ten countries for highest prevalence of diabetes are in the Middle East and North Africa Region Kuwait, Lebanon, Qatar, Saudi Arabia, Bahrain and the United Arab Emirates ranks #2 in the world at 19.5% prevalence ***. The region spends $5.5 billion annually treating diabetes**** *International Diabetes Federation s (IDF) World Diabetes Congress (WDC) ** Novo Nordisk s diabetes awareness survey in the MENA region November 2010 ***PLoS One. 2012; 7(8): e40948 **** International Diabetes Foundation 2012 fifth edition 9

10 Why Behavior Change Now? Kaiser Permanente diabetes burden to surge over time Pre-diabetes million 52% develop 29% develop diabetes over diabetes 10 years 2 over 3 years 2 New cases of diabetes by ,630 KP members with type 2 DM in ,383 = $3.48 B/year 4 New cases of diabetes by ,400 = $6.3 B/year 4 1 Preliminary data; CMI Analysis October Pre-diabetes defined according to ADA definition using lab values. 2 Diabetes Prevention Research Group; Diabetes Prevention Program 3 Preliminary data; CMI Analysis, as of March CORE KP HEDIS Diabetes cohort, minus expected % of Type 1 diabetes per CDC national prevalence 4 Based on average annual medical expenditure estimates, Vojta et al, Hlth Aff, Jan Effective Interventions for Stemming Diabetes and Pre-Diabetes 10

11 11 How does KP Apply a Population-based Approach to Diabetes Care?

12 Kaiser Permanente s Approach Prevention of both Pre-Diabetes and Diabetes (DM): Weight control & exercise Prevention and Treatment of DM complications: focus on the few most impactful treatments customize approach measurement (metrics) and dashboards from a system to individual level Use technology 12

13 Population View with Sub-Populations Obesity 8% KP 11-20% ME Pre-Diabetes Uncomplicated Diabetes Complicated 20% KP ME 40%, but ½ not tested l Total Population

14 To Prevent Pre-DM and DM Evidence: Decrease weight and increase exercise in obese and pre-diabetes individuals prevents diabetes The Diabetes Prevention Trial (DPT) showed that a combination of: 150 min of exercise and 7% weight loss will lead to 30% less progression of pre- diabetes in 10 yrs. as compared to Metformin, an oral glucose control medication that led to an 18% reduction in progression to diabetes. Diabetes may be reduced to pre-diabetes or normal state with weight loss Action: Using Diabetes Programs, educate people how to lose weight and exercise Approach: Public health messages on TV & radio; create walking paths, work with schools to remove sugared drinks from vending machines, healthy choices in cafeteria, and promote exercise Patient Engagement: interactive online education programs, education classes, individual counseling by health coaches and dietitians 14

15 Prevention of DM complications: focus on the few most impactful treatments We must know: What are the biggest causes of morbidity, mortality and cost of care of diabetes complications? it is not what most people think If treatments are used that decrease morbidity & mortality, then what is the cost of care? best to model the result with a program like Archimedes 15

16 In Millions $ Costs of Diabetes Complications BP & cholesterol treatments decrease CVD is the biggest cost of care in diabetes Unfortunately sugar control doesn t help Sugar control [A1C] prevents MI, Stroke Kidney Disease Coma Amputation Blindness Based on Northern Cal KP 1996 data 16

17 Full Adherence Full Adherence What Works: BP & Lipid Meds Prevent CVD ACE-I fixed dose 25% 20% 15% 10% 5% 0% 22% Heart Protection Study MRC/BHF Heart Protection Study of cholesterollowering therapy and of antioxidant vitamin supplementation in a wide range of patients at increased risk of coronary heart disease death: early safety and efficacy experience. Eur Heart J 1999;20: Decreased CVD HOPE Study Effects of an Angiotensin-Converting Enzyme Inhibitor, Ramipril, on Cardiovascular Events in High-Risk Patients.The Heart Outcomes Prevention Evaluation Study Investigators N Engl J Med 2000; 342:

18 Kaiser Permanente s ALL Approach Start all three drugs at fixed dose at once: Aspirin, Lisinopril or other ACE Inhibitor/ARB Lipid Lowering (statins) In member s with diabetes above age 55 (ASA optional ) and those with CAD Then repeat BP and Cholesterol test and if still elevated, Treat BP & Lipids until normal 18

19 Archimedes Model: Benefit of just starting a fixed dose of ALL Average annual risk of various events 0.04 Nothing HbA1c control 0.03 ALL % decline MI Stroke ESRD Blind Dying 19

20 Which Segment of the Population with Diabetes do you focus on? Which segment is easy to identify for treatment with ALL? People with diabetes who are over 55 have a 94% chance of having either high BP or cholesterol, * the criteria proven in HOPE to benefit from Lisinopril ** Therefore consider all people with DM over 55 for ALL & treat high BP and cholesterol at any age**** Which people are at highest risk for sugar sensitive complications like blindness amputations and kidney failure? The higher the A1C the more likely each of those complications are***. American Diabetes Association and NCQA both agree HgbA1c should be <9**** All patients should be below Hgb A1C 9, and all should be as near normal as possible without producing significant low blood sugars. 20 **** ADA glucose targets NCQA HEDIS targets * Selby ** Mircohope *** DCCT,

21 How do the Few Actions Fit into KP Diabetes: Step 1, consider ALL medications Uncomplicated Diabetes >55yo Use ALL Meds Complicated Diabetes 21

22 Kaiser Permanente Diabetes: Step 2 Focus on Treatment Intensification of the Other 3 Treatments : BP, LDL Cholesterol, & A1C Uncomplicated Diabetes Focus on the Few Complicated Diabetes ALL Meds Treat to Target Then BP, LDL, A1c Ctrl Not in control 22

23 Technology: Make the Right Thing Easier In-Reach: to patients during clinic visit Electronic Medical record organizes the opportunities Patient Panels: Panel Management Panel support Tool In Reach at time of visit: Maximizing use of the medical assistant Out reach: to patients at home Automated electronic contacts Medication adherence: automated letters & calls Automated lab results Patient contacts provider 23

24 Making the Right Thing Easier Physician Education Tools HEDIS Performance Panel Support Tool Physician Member Visit 24

25 South Bay Beta Blocker Adherence Program Clinical Strategic Goals Results In-Reach: Electronic Medical Record Data Organization CSG Results - Persistence of Beta Blocker Treatment post Heart Attack Intern started South Bay BB adherence program - June 2009 South Bay SC REGION period 1 - February 2009 period 2 - April 2009 period 3 - June 2009 period 4 - August 2009 period 5 - October 2009

26 26 Panel Support Tool

27 A Team Approach to Care Identify missing labs, screenings, kp.org status, etc. Provide member instructions Contact member and document encounter in HealthConnect Vital sign collection & documentation Identify and flag alerts for provider Prepare patient for exams Pre-encounter follow-up After visit summary, care instructions, follow-up appt, educational materials, access to kp.org Follow-up contact and appointments 27

28 Outreach: Medication adherence: Refill Call/Letter Reminder 19% 28

29 29 29 Automated Communication: Million Members Viewed Their Test Results in 1 year

30 Million Members ed their Doctor

31 And... Improved OUTCOMES Health Affairs. 2010;29:1370.

32 What Metrics Do We Need at Provider Level to Drive Improvement? Principle: metrics alone do not decrease diabetes or its complications Therefore those that lead to ACTIONS are most important: ACTIONABLE is the test of value of use of a metric at any given time Items to titrate: BP, LDL, Cholesterol, and A1C Medication dispensed and refilled that are on the ABC list : Adherence drops 50% in one year so adherence is a major issue Others that are helpful for other preventative measures annually: Fasting Blood Sugar: to diagnose DM, and following at home glucose testing if results will be ACTIONABLE Eye exams Kidney: urine microalbumin, Nerve: Foot exams What to display at each level to drive action towards improvement? 32

33 Metrics: All Start With a Registry A list of who is in your population that has diabetes Criteria: usually based on a diagnosis of diabetes or use of medications for sugar control Optimal to have just a few metrics: Best with results of BP, lipids, A1c, and their medications including last refill This registery & its metrics allow for assessing: If BP, lipid, A1C treatments initiation & adherence, and if contact patients by In-reach: reminders to providers to consider treatment or Out-reach: reminders to patients to get treatments advised Adherence: the percent on a medication over time. 33

34 For Comparisons with the Nation and Regions, Ambulatory Metrics are used Major Initiatives HED IS Nat ' l Percentiles 75t h N o n- PPOs 9 0 t h N o n- PPOs Pro g ramwid e Perf o rmance HED IS (PY 2011) HED IS A d min. '12 3rd Qtr N o rt hern C alif o rnia So ut hern C alif o rnia HED IS ( Perf o rmance Y ear ) Kaiser Permanete C olorado Georgia Hawaii M id - A t lant ic St at es N o rt hwest Ohio ( ) Most Effective Cardiovascular Care Cardiovascular Cholesterol Management for Patients With Cardiovascular Conditions LDL-C Screening 92.70% 94.91% 90th 75th 97.49% 96.51% 94.81% 96.70% 98.92% 95.82% 97.43% 95.23% LDL-C Level < % 72.51% 90th 90th 82.22% 82.26% 81.25% 78.95% 84.49% 78.11% 76.44% 75.18% Controlling High Blood Pressure 70.90% 75.55% 75th 90th 87.03% 89.47% 83.38% 81.08% 84.85% 85.81% 83.32% 78.43% Persistence of Beta-Blocker Treatment After a Heart 90.82% 94.25% 90.53% 94.39% 93.45% 84.91% 83.33% 84.67% 94.06% 87.50% Diabetes Comprehensive Diabetes Care HbA1c Testing 93.92% 95.62% 90th 75th 96.99% 97.49% 95.60% 95.14% 98.87% 95.51% 97.62% 94.60% HbA1c Control >9% (low rate better) 15.93% 11.68% 90th 75th 9.91% 8.74% 15.00% 13.83% 8.49% 10.78% 8.50% 12.60% HbA1c Control <8% 75.46% 79.51% 79.51% 81.75% 73.33% 74.09% 79.95% 78.59% 80.43% 73.67% Retinal Exam 74.70% 80.78% 90th 82.18% 85.40% 79.61% 48.38% 86.59% 78.43% 84.05% 70.45% LDL-C Screening 91.97% 94.38% 96.72% 96.23% 91.55% 95.08% 98.26% 95.29% 96.59% 95.44% LDL-C Level < % 66.43% 90th 90th 79.87% 77.16% 71.91% 69.35% 81.98% 73.98% 72.85% 74.01% Medical Attention for Nephropathy 92.09% 94.16% 90th 90th 96.82% 97.92% 94.55% 94.72% 95.01% 96.82% 97.38% 96.65% Blood Pressure Control <140/ % 63.02% 90th 90th 76.28% 81.34% 72.94% 70.07% 75.22% 76.78% 75.58% 72.37% Blood Pressure Control <140/ % 76.64% 90th 90th 86.04% 88.24% 85.87% 81.97% 84.99% 84.50% 83.90% 83.13% High Impact Measure - Prevention Adult BMI Assessment 80.31% 88.58% 90th 90th 99.00% 98.97% 96.00% 99.00% 95.99% 96.82% 98.27% 94.40% Breast Cancer Screening - Ages % 80.63% 90th 90th 87.93% 90.91% 88.49% 86.21% 81.36% 90.35% 88.06% 84.70% Colorectal Cancer Screening 68.93% 76.02% 90th 90th 87.90% 87.28% 85.26% 84.97% 82.26% 87.72% 87.29% 86.78% 34

35 Outcomes: What Did We Accomplish? Targeted medication utilization Intermediate outcomes: how did we do with BP lipid & A1C control compared to the nation? Targeted outcomes: Heart attacks & strokes In the Diabetic & CVD populations using ALL Total population in a large region 35

36 We Achieved >77% Medication Initiation & Adherence on Heart Attack & Stroke Prevention Meds On Statin Chart Title On ACE/ARB % DM Pts in Southern California 36

37 Achieved 75th-90 th Percentile in Testing and Treating for AC1C, BP, and Lipid control Ambulatory Strategic Subscale 2012 (Performance Year 2011) Compared to 2011 National Percentiles Medicare Ambulatory 2012 (Performance Year 2011) Major Initiatives 75t h N o n- PPOs 9 0 t h N o n- PPOs HED IS (PY 2010) HED IS (PY 2011) N o rt hern C alif o rnia At/above 75 th percentile At/above 90 th percentile So ut hern C alif o rnia C olorado Georgia Hawaii M id - A t lant ic St at es N o rt hwest Ohio ( ) 2 Most Effective Cardiovascular Care Cardiovascular Cholesterol Management for Patients With Cardiovascular Conditions LDL-C Screening 92.22% 94.40% 90th 90th 97.78% 97.67% 98.50% 96.39% 98.84% 95.74% 97.12% 95.86% LDL-C Level < % 72.15% 90th 90th 81.61% 82.57% 86.28% 79.34% 85.55% 78.36% 75.98% 80.54% Controlling High Blood Pressure 68.86% 74.42% 75th 90th 84.02% 86.37% 88.33% 75.08% 87.83% 85.97% 80.29% 88.81% Persistence of Beta-Blocker Treatment After a Heart 88.03% 91.58% 90.50% 91.81% 98.61% 70.97% 90.00% 85.54% 90.97% 98.51% Diabetes Comprehensive Diabetes Care HbA1c Testing 93.93% 95.95% 75th 75th 97.76% 97.61% 97.82% 97.32% 98.30% 95.79% 98.29% 96.59% HbA1c Control >9% (low rate better) 16.11% 11.31% 75th 90th 8.95% 8.66% 10.90% 9.49% 9.73% 11.15% 7.96% 10.71% HbA1c Control <8% 75.43% 80.18% 79.87% 81.04% 78.50% 76.89% 75.91% 79.85% 81.37% 75.43% Retinal Exam 73.66% 79.28% 90th 90th 82.43% 83.88% 87.23% 86.37% 85.40% 81.01% 82.97% 87.83% LDL-C Screening 91.48% 94.07% 75th 75th 98.40% 0.00% 97.91% 0.00% 91.90% 0.00% 97.08% 0.00% 97.57% 0.00% 95.43% 0.00% 96.96% 0.00% 95.62% 0.00% LDL-C Level < % 65.37% 90th 90th 84.03% 80.00% 79.44% 73.97% 81.27% 72.56% 73.99% 75.91% Medical Attention for Nephropathy 91.56% 93.92% 75th 90th 98.40% 97.91% 99.07% 96.84% 96.59% 96.58% 97.31% 94.65% Blood Pressure Control <140/80* N/A N/A N/A N/A 77.64% 78.66% 77.88% 82.97% 79.56% 72.29% 73.19% 71.78% Blood Pressure Control <140/ % 75.06% 75th 90th 90.10% 87.91% 92.21% 91.24% 88.56% 82.01% 81.79% 84.43% High Impact Measure - Prevention Adult BMI Assessment 65.69% 80.23% 90th 90th 99.00% 98.97% 96.00% 99.00% 95.99% 96.82% 98.27% 94.40% Breast Cancer Screening - Ages % 80.92% 75th 90th 88.55% 89.68% 85.75% 83.43% 89.02% 90.04% 88.78% 86.56% Colorectal Cancer Screening 68.71% 75.57% 90th 90th 91.30% 88.61% 84.02% 85.59% 78.61% 82.26% 85.65% 86.15% * First Year M easure HEDIS HED IS N at ' l Percent iles 1 Pro g ramwid e Perf o rmance 1 HEDIS 2011 National Percentiles. HEDIS 2012 benchmarks will be available in Aug. for Commercial, Oct. for M edicare. HED IS ( Perf o rmance Y ear ) Kaiser Permanete DUC _001 37

38 We Decreased Myocardial Infarcts in Northern California Kaiser Members 38 24% decline ~60% drop N Engl J Med. 2010;362:

39 Diabetes & CVD Patients Decreased MI s & Strokes over 60% with Use of ALL Decrese in MI & Strokes/1000 persons/yr low util High Util RR 60% decrease -26 Even 1 day of 5 utilization was significant, but taking it 2/3 of the time was much more beneficial

40 Summary Use a large systems approach to population care Focus on the few who will benefit most using segmentation to find those at highest risk of heart attacks & strokes, and use: Simplified, inexpensive Treat To Target protocols, Registry and dashboard of metrics of medication adherence, BP, cholesterol and A1C to a few targets and corrective action until achieved, and Technology, including a panel support tool, proactive office encounter, automatic call/letter reminders, communication, KP achieved >77% of the critical medication initiation/adherence, >75% ile A1C, lipid and bp control compared to the nation, and The major outcome of decreasing severe heart attacks & or strokes in >60% in both the diabetes and entire Northern California population 40

41 Ask Alide Questions? 41

42 Presenter Alide Chase Senior Vice President, Medicare Clinical Operations & Population Care Executive Director, CMI

43 43 APPENDIX

44 Treatment Algorithm: ABC's of DM Step 1 if >55yo or CVD start ALL ASA A: /d Step 2 After ALL, If still high, Add Then add Then add B:BP meds L: Lisinopril 20 if SBP>140 Prinzide 20/25 Add Amlodipine Add Atenolol C: Chol L: atorvastatin if LDL>100 atorvastatin 40 Atorva 80 S: Sugar Control Diet & Exercise pre meal Sugar>120 metformin skip or add glipizide add Insulin 44