Type 2 Diabetes Performance Improvement Initiative: Chart Reviews. Lara Zisblatt Boston University School of Medicine Boston, MA

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1 Type 2 Diabetes Performance Improvement Initiative: Chart Reviews Lara Zisblatt Boston University School of Medicine Boston, MA

2 Participants in the Program 487 people registered 217 people started the program 182 people started their initial chart review 35 people completed their initial chart review 22 people are working on their Action Plans 3 people completed the program 2

3 Examples of Action Plans Screening all medical records for patients with type 2 diabetes every 6 months and notifying them by phone if they need an A1C test Creating an exercise plan worksheet for patients to write out their exercise plans Providing patient education about the importance of self- monitoring blood glucose levels; training the medical assistant to check all meters to assure they are working properly and that patients know how to use them Enrolling all type 2 diabetes patients in an education class available at the practice Creating a registry of all patients with type 2 diabetes that would track all tests necessary for these patients Use the diabetes care form to keep good records of patients with type 2 diabetes and an excel form to track patients Routine prescription for exercise Diabetes flow sheets in all charts Will move educational materials to exam rooms 3

4 Action Plans Start simple Small changes can mean big improvements in patient care Chart review is the first step The tough part was getting started. Once I did the first chart review, every review after became easier and faster. The chart review was a great way for me to systematically look at my practice. I could see how I was actually doing and not just how I thought I was doing. 4

5 Type 2 Diabetes Program Make a commitment to yourself and to your patients to work toward improving care! Complete the chart review as soon as possible as your first step toward improvement For those of you who have completed chart reviews, please feel free to call us if you would like to discuss your plan for improvement If you have any questions, please us at mentorqi@bu.edu or call us at

6 Applying What We ve Learned: Patient Case Studies (Part 1) Elliot Sternthal, MD Clinical Director, Diabetes Services Boston Medical Center Boston, MA

7 Mr. D 69-yr yr-old male 11-yr history of type 2 DM Mild retinopathy, distal neuropathy, microalbuminuria,, obesity, coronary artery disease, hypertension, hypercholesterolemia, dyslipidemia,, erectile dysfunction Current medication regimen: Glipizide ER 10 mg qd, metformin 1000 mg BID, HCTZ 25 mg qd, valsartan 160 mg qd, cardizem CR 120 mg qd, ASA 325 mg qd, atorvastatin 20 mg qd Pertinent physical examination findings BMI 37, BP 114/58, rare retinal microaneurysms, vibratory perception

8 Mr. D (cont d) Self-care behaviors Self-monitoring of blood glucose (SMBG): erratic, usually premeal BG >200 mg/dl Dietary: limited adherence, likes starches, occasional binges Physical activity: walking at moderate pace Lab data A1C 8.8%; mean FBG ~180; mean 2-hr 2 PBG >240 8

9 What Are the Clinical Challenges With This Patient? 9

10 Clinical challenges: Improve pre- & postprandial BGs, promote weight loss, prevent recurrent CV events Desired treatment goals: Preprandial BG , 2-hr 2 pp BG , 140, A1C 7% (? 6.5%) BP 130/80 mm Hg LDL <70, HDL >40, TG <150 Urine microalbumin ratio <20 Weight loss of 20 lbs

11 What Treatment Options Are Available to Improve Mr. D s D Glycemic Control Before Adding Insulin? 11

12 Lifestyle Changes Continuation of walking program Stress test to determine if more vigorous exercise is appropriate Dietitian evaluation Nurse educator to review SMBG, diabetes self-management education (DSME) 12

13 Medication Addition: What Are The Pros and Cons? Add a thiazolidinedione (TZD)? Add an alpha-glucosidase inhibitor? Add a DPP-4 4 inhibitor? Add exenatide? 13

14 Exenatide Added Effect on overall glycemic control: A1C to 7.1% after 3 months Effect on postprandial glycemia: 70 mg/dl Weight effect: 8 lb

15 Ms. C Recently immigrated to US; speaks rudimentary English Lives with a cousin, works in housekeeping in a hotel Recently diagnosed type 2 DM at walk-in clinic: random BG

16 Ms. C (cont d) Pertinent physical examination findings» Wt 216, Ht 5 6, 5, BMI 35, BP 140/82 Marked acanthosis nigricans and facial acne No retinopathy or neuropathy Self-care behavior Little knowledge of diabetes or diet No SMBG No exercise: too tired; works 50 hrs per week 16

17 Ms. C (cont d) Lab Data A1C 9%; urine microalbumin ratio 10 Hypercholesterolemia: LDL 122, HDL 57, TG

18 What Are the Clinical Challenges With This Patient? 18

19 Clinical Challenges: Lack of diabetes education Goals: Nutrition counseling for hyperlipidemia,, weight loss Teaching SMBG, DSME Potential barriers to successful treatment: Language/medical literacy Cultural/social beliefs Economic concerns Comprehension of her illness and treatment Complex treatment program Medication side effects

20 Desired treatment goals: Preprandial BG , 2-hr 2 pp BG ; A1C 6.5%-7% BP 130/80 mm Hg LDL <100, HDL >50, TG <150 Weight loss of 20 lbs 20

21 What Pharmacologic Treatment Should Be Started? Monotherapy?? Combination Therapy? 21

22 Initial Plan Start combination glyburide 1.25 mg/metformin metformin 250 mg qam ASA 81 mg qd? 22

23 A1C 8.3% Follow-Up: 3 months Pre-breakfast BG Pre-dinner BG Occasional 2-hr 2 pc BG 170 No hypoglycemia or excessive hunger Forgets medication once or twice per week Weight 5 lbs LDL 88, HDL 49, TG

24 What Would You Do Next? Pros and Cons Increase glyburide/metformin combination? Add a TZD? Add a DPP-4 4 inhibitor? Add exenatide? 24

25 Increase Glyburide/ Metformin Glyburide/metformin increased incrementally to 5 mg/1000 mg twice per day over next 6 months A1C 7.7% 25

26 What Would You Do Next? Wait another 3 months? Add another medication? 26

27 Applying What We ve Learned: Patient Case Studies (Part 2) John R. White, PA-C, PharmD Professor of Pharmacotherapy Washington State University College of Pharmacy Spokane, WA

28 Mr. J 52-year year-old Caucasian male Type 2 DM X 12 years Also followed for obesity, hypertension, elevated lipids Meds: Metformin 1,000 mg bid (X 10 years) Glimepiride 4 mg qam (X 5 years) Insulin glargine 80 units qhs Enalapril/HCTZ /HCTZ- 10/25 qam Atorvastatin 10 mg daily 28

29 Mr. J (cont d) Working as a CPA for a tax firm Walks for about 30 minutes 3x weekly Admits to eating whatever he likes; has gained 4 lbs within last year SMBG values: only measures fasting; usually in the range BP 134/90 mm Hg Weight 230 lb; BMI 36 A1C value today is 8.2% 29

30 What Would Your Next Treatment Decision Be? Start a diet and exercise program? Add thiazolidinedione?? Alpha-glucose inhibitor? Exenatide? Sitagliptin? Start a rapid-acting acting insulin analog (RAIA)? Obtain more blood glucose data (fasting, preprandial,, postprandial)? 30

31 Mr. J: 3 Days of Intensive Monitoring Fast Pre- lunch Post- break Post- lunch Pre- dinner Post- dinner Low 130s

32 What Insulin Program Would You Initiate? Split glargine dose? Switch insulin to bid pre-mix (70/30)? Add 3 pre-prandial prandial RAIA injections? Add preprandial RAIA before the meal with the greatest glycemic excursion? 32

33 Mr. J: Follow-Up RAIA added to regimen pre-lunch (started with 4 units, eventually titrated to 8 units) Patient consistently measures fasting and continues to periodically monitor pre- and postprandial levels Patient was referred to a dietitian and has improved his diet A1C value 3 months later is 7.2% 33

34 Ms. L 62-year year-old female of Asian descent Type 2 DM X 16 years Meds: Metformin 1,000 mg bid (X 10 years) Glipizide 20 mg qam (X 15 years) 70/30 insulin-30 units qam and 20 units qpm 34

35 Ms. L (cont d) Currently teaches history in a middle school Eats a fairly consistent diet (low fat, moderate protein and carbohydrate) Participates in water aerobics twice weekly, walks at lunch Complains of hypoglycemic episodes before and after lunch (50-80s), fasting levels vary but are generally in the 150s A1C value 9% 35

36 What Next? D/C glipizide or metformin or both? Reduce the PM 70/30 dose? D/C 70/30 and start a long-acting analog? Reduce the AM 70/30 dose 36

37 Ms. L, Case continued Meds: Metformin 1,000 mg bid (X 10 years) Glipizide 20 mg qam (X 15 years) 70/30 insulin discontinued Detemir initiated at a dose of 40 units daily and provided with a titration schedule 37

38 Ms. L, Case continued Patient is in contact with clinic via telephone over the next few weeks and continues to titrate detemir (current dose 54 units) Returns to clinic in 3 months No complaints of hypoglycemia A1C 7.8 Fasting glucose levels s 140s 38

39 What Next? Increase the glipizide dose? Continue the detemir titration and obtain more blood glucose data? Start a RAIA with the largest meal? Start tid RAIA? 39

40 Performance Improvement Strategies: What and Why Elaine Fleck, MD Associate Clinical Professor of Medicine New York Presbyterian Hospital-Columbia University Medical Center New York, NY

41 Improving Care Need Need to shift from single intervention to change the behavior of individual (providers) and focus instead on the practice systems and organizations in which (providers) work. Solberg LI. Jt Comm J Qual Improv ; 26:

42 Improving Care What gaps do you see between care as it is and care as it could and should be for patients? Identify a set of goals that you would like to accomplish over a set time period Understand and implement improvement techniques that can change the nature of care delivery in your practice for type 2 diabetes Institute for Healthcare Improvement. Available at: Accessed February 23,

43 Improving Diabetes Care in Practice Findings from the TRANSLATE trial Objective: To determine whether implementation of a multicomponent organizational intervention can produce significant change in diabetes care and outcomes in community primary care practices R/Research: : Group randomized controlled clinical trial involving 24 practices, implementing a number of interventions using the ADA targets Conclusion: Introducing... interventions in the primary care setting significantly increases the percentage of type 2 diabetic patients achieving recommended outcomes. Peterson KA, et al. Diabetes Care ;31:

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45 Create Registry Hospital # Visit date Last A1C value Last A1C date Last LDL value Last LDL date Last microalbumin value Last microalbumin test date XXXXXX 3/30/ /10/ /10/ /30/2007 XXXXXX 3/29/ /13/ /13/ /29/2007 XXXXXXX 1/26/ /6/ /6/ /26/

46 Sample of Provider Reports Provider/ site total # of patients with visits in quarter # of patients with A1C one yr before visit # of patients with last A1C < 7 # of patients with last A1C 9 # of patients with A1C test # of patients with 2 or more A1C tests # of patients with LDL in one yr before visit # of patients With last LDL test result <100 # of patients with last LDL test result >130 # of patients with Microalbumin tested one yr before last visit ALTMAN % 47.4% 10.5% 15.8% 78.9% 94.7% 78.9% 15.8% 68.4% Smith % 32.4% 21.6% 18.9% 75.7% 91.9% 66.2% 9.5% 50.0% ASCHER % 38.9% 16.7% 14.8% 77.8% 94.4% 55.6% 16.7% 70.4% Jones % 33.3% 15.2% 9.1% 90.9% 93.9% 57.6% 12.1% 27.3% BASULTO % 40.4% 10.5% 40.4% 52.6% 78.9% 43.9% 15.8% 8.8% Franklin % 17.4% 8.7% 26.1% 60.9% 82.6% 56.5% 13.0% 4.3% BERMON % 24.2% 21.2% 9.1% 84.8% 90.9% 39.4% 24.2% 81.8% 46

47 Theme From Case Studies: Diabetes Is a Self-Care Disease Meal planning Physical activity Medication Blood glucose monitoring 47

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49 Patient Flow Sheet Date (xx/xx/xxxx) Diabetes Flow Sheet Management goals (every visit) Weight in pounds (every visit) BMI (calculated) A1C (2-4 times yearly) goal <7% BP (every visit) goal <130/80 LDL (yearly) goal <100 mg/dl Urine microalbumin (yearly) Ophthalmology exam (once yearly) Foot exam with monofilament Review of self-management goals (every visit) Glucose meter use and review of log (every visit) Nutrition visit (once yearly) 49

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51 Group Classes 51

52 Diabetes Self-care Educated Patient = Empowered Patient Use Materials to Promote Self-Management Provide written materials for reinforcement Distribute diabetes self-management tool Management/Self-Management_diabetes.aspManagement_diabetes.asp 52

53 Practice Improvement Group classes/diabetes Health Education Program Roblin DW, et al. J Ambul Care Manage ;30: Conversation mapping Nurse Case Management in Underinsured Philis-Tsimikas A, et al. Diabetes Care ;27: POC Testing Kennedy L, et al, Diabetes Care ;29:1-8 Self-Management Education Sone H, et al. Diabetes Care ;25: Nurse-Directed Diabetes Care Davidson MB. Diabetes Care ;26:

54 Performance Improvement 54

55 Q&A 55