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 Stages of Engagement 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, 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 2018 American Medical Association. All rights Division reserved. of Diabetes Translation

9 Adults Diagnosed with Diabetes in Ohio, 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 2018 American Medical Association. All rights Division reserved. 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 11

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 A reversible condition in which plasma glucose levels are higher than normal but not high enough to diagnose type 2 diabetes 84 MILLION ADULTS HAVE PREDIABETES 1 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 Group support 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 DPP Benefits Practicing Physicians & Health Systems Why prioritize diabetes prevention? Allows physicians to offer our patients the intensive lifestyle change counseling they need, but that we don t have the time/capacity to give Aligns to value based care trends Included as Improvement Activities under QPP (MIPS) Aligns with PCMH standards Medicare reimbursement scheduled to begin 2018 Achieves the IHI Triple (Quadruple) Aim Better care: Adheres to evidence-based guidelines for diabetes prevention Better outcomes: Lowers incidence of diabetes by 58 percent Lower cost: Medicare estimated savings at $2,650 per beneficiary Improving Care Giver Experiences: Reduce prevalence 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 Changing Clinical Practice 32

33 AMA diabetes prevention offerings The AMA offers a comprehensive program to guide implementation of clinical practice change in order to prevent type 2 diabetes. Services Engagement Consulting Implementation support (admin) Walk through core decisions Tools and solutions (examples, not comprehensive) 33

34 Determine DPP offering Internal DPP Something else Virtual DPP Partner with community organization 34

35 Physician and care team engagement Clinic awareness Grand rounds Online modules PI CME (Part IV MoC) 35

36 STEPS Forward and PI CME

37 Patient identification 37

38 Patient communications preventidiabetesstat.org and doihaveprediabetes.org 38

39 Referral process and feedback loop 39

40 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 40

41 Evaluation Identification DPP Referral DPP Enrollment DPP Participation Attendance and Retention Outcomes Cost Weight Loss Physical Activity HbA1c Blood Pressure Medications 41

42 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

43 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

44 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

45 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

46 Final Thoughts 46

47 Best practices for enabling physicians and care teams to refer 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 Criteria to identify those most at risk/likely to act/likely to be successful Referral through EMR Build feedback loops so that physicians can discuss progress with their patients

48 48 Neha Sachdev Kelly Sill Janet Williams

49 Questions 49