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Preventing and Managing Complications of Diabetes Webinar #2 - Diabetes Care Improvement Series Chris Cammisa, MD, Medical Consultant, California Quality.

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Presentation on theme: "Preventing and Managing Complications of Diabetes Webinar #2 - Diabetes Care Improvement Series Chris Cammisa, MD, Medical Consultant, California Quality."— Presentation transcript:

1 Preventing and Managing Complications of Diabetes Webinar #2 - Diabetes Care Improvement Series Chris Cammisa, MD, Medical Consultant, California Quality Collaborative (CQC) David Eibling, MD, Medical Director, Health Plan of San Joaquin (HPSJ) January 9, 2013

2 Todays Agenda Discuss the prevention and management of cardiovascular complications of diabetes Mention the other complications along with prevention and management Demonstrate the financial impact of complication reduction Discuss HPSJ incentives to improve diabetes care 1

3 Long Term Complications of Diabetes Heart attack Stroke Kidney disease/failure Vision problems –Retinopathy –Cataract –Glaucoma Damage to blood vessels Dental and gum disease Nerve damage (neuropathy) Sexual impotence Foot problems Persistent skin or gum infections Stomach paralysis (gastroparesis) Mental health issues 2

4 Key Messages Promote the ABCs – A1c, Blood Pressure and Cholesterol Promote a healthy lifestyle Explain the risks of diabetes and the benefits of good self management Discuss medication adherence Assess symptoms and provide the appropriate referrals 3

5 Reducing Cardiovascular Complications of Diabetes In addition to the ABCs a number of other measures are important Quit smoking Aspirin (81 to 100 mg per day) is recommended for anyone with diabetes who already has or is at increased risk of cardiovascular disease 4

6 Achieving Glycemic Control Strong predictor of complications. A1c closely represents the average glucose over the last 3 months The ADA recommends that patients have A1c done at least every 6 months if they are stable and at goal Every 3 months in patients who are not at goal or who are changing therapy The A1c goal for most adult patients with diabetes should be < 7.0%, in order to decrease the long term risk of complications Consider an A1c goal (such as < 6.5%) for some patients Less stringent A1C goals (such as <8%) may be appropriate for certain patients 5

7 General Principles of Pharmacotherapy Start with lifestyle/behavior modification, weight loss, physical activity promotion, and dietary control Most patients with type 2 diabetes will also need oral or insulin medications Diabetes progresses over time Multiple drugs may be necessary 6

8 The effectiveness of therapies is predicated not only on the intrinsic characteristics of the intervention (i.e.. the drug), but also on the baseline glycemia, duration of diabetes, previous therapy, and other factors A major factor in selecting a class of drugs, is the ambient level of glycemic control New recommendations from the ADA - The choice of glycemic goals and the medications must be individualized balancing the benefits and the risks In newly diagnosed type 2 diabetic patients with markedly symptomatic and/or elevated blood glucose levels or A1C, consider insulin therapy, with or without additional agents, from the outset Selecting Medications 7

9 Summary of Hyperglycemic Interventions 8 InterventionsExpected Decrease in A1c AdvantagesDisadvantages Lifestyle1-2Low cost, many benefits Fails for most in 1 st year Metformin1.5No hypoglycemia, weight neutral, inexpensive GI side effects, rare lactic acidosis InsulinunlimitedNo dose limit, inexpensive, improved lipid profile Injections, monitoring, hypoglycemia

10 Summary of Hyperglycemic Interventions 9 InterventionsExpected decrease in A1c AdvantagesDisadvantages Sulfonylureas1.5InexpensiveWeight gain, hypoglycemia TZDs.5-.8Improved or neutral effect on lipid profile Fluid retention, heart failure, weight gain, fracture risk, expensive DPP 4 Inhibitors*.6-.7Weight neutral, no hypoglycemia, and they are oral Relatively less experience, cost possible infections GLP 1 Receptor Agonists.5-1.0Weight lossInjections, frequent GI side effects, expensive

11 Algorithm for Hyperglycemic Control This has been a controversial area with several algorithms proposed over the last few years This example is the most recent developed in a joint effort by the ADA and the European Association for the Study of Diabetes: nStatementADA_EASD_2012.full.pdf nStatementADA_EASD_2012.full.pdf 10

12 Key Points Glycemic targets and glucose-lowering therapies must be individualized All treatment decisions, should be made in conjunction with the patient, focusing on his/her preferences, needs, and values Unless there are contraindications, metformin is the optimal first-line drug After metformin, there are limited data to guide us Ultimately, many patients will require insulin therapy alone or in combination Include cardiovascular risk reduction as a major focus of therapy 11

13 After Metformin Use a two drug combination Options include (order not meant to indicate a preference): –Sulfonylurea –Thiazoladinedione –DPP-4-Inhibitor –GLP-1 receptor agonist –Insulin (usually basal) Make decision based on efficacy, hypoglycemia, weight, major side effects and cost 12

14 Three Drug Combination and Beyond If needed to reach individualized A1c goal after 3 months proceed to a three drug combination To Su add TZD, DPP-4-I, GLP 1- RA, or Insulin To TZD, add SU, DPP-4-I, GLP-1-RA, or Insulin To DPP-4-I inhibitor add SU, TZD or Insulin To GLP-1-RA, add SU, TZD or Insulin To Basal Insulin add TZD, DPP-4-I, or GLP-1-RA If combination therapy that includes basal insulin has failed to achieve goal after 3-6 months, proceed to a more complex insulin strategy usually in combination with one or two non-insulin agents 13

15 Managing High Blood Pressure Employ a combination of lifestyle modifications and pharmacologic therapies to reach target blood pressure values The goal for blood pressure control has been revised to suggest that the systolic blood pressure goal for many people with diabetes and hypertension should be <140 mmHg Lower systolic targets (such as <130 mmHg) may be appropriate for certain individuals, such as younger patients, if it can be achieved without undue treatment burden Advise pts to self monitor at home and work 14

16 General Management of Hypertension in Diabetes Patients with confirmed blood pressure 140/80 mmHg should have titration of pharmacological therapy to achieve blood pressure goals Lifestyle therapy for elevated blood pressure consists of weight loss, if overweight Pharmacological therapy for patients with diabetes and hypertension should be with a regimen that includes either an ACE inhibitor or an ARB Multiple-drug therapy is generally required to achieve blood pressure targets Administer one or more antihypertensive medications at bedtime If ACE inhibitors, ARBs, or diuretics are used, serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored 15

17 Drug Classes – Hypertension 16 Drug Class/CategoryMechanism of ActionCommon Side Effects Thiazide diureticsInhibits sodium and chloride reabsorption Dizziness, lightheadedness, blurred vision Angiotensin Converting Enzyme Inhibitors Prevents the formation of angiotensin II Cough, elevated potassium levels, low blood pressure, dizziness, headache, drowsiness, weakness, abnormal taste, rash Calcium Channel Blockers, Non- Dihydropyridines Blocks calcium channels Constipation, nausea, headache, edema, drowsiness, dizziness, difficulty breathing

18 Drug Classes - Hypertension 17 Drug Class/CategoryMechanism of ActionCommon Side Effects Aldosterone receptor blockers Blocks the action of epinephrine and norepinephrine Cough, diarrhea, flu like symptoms Beta blockersBlocks the action of epinephrine and norepinephrine Dizziness, lightheadedness, drowsiness

19 Managing Dyslipidemia - Screening In most adult patients with diabetes, measure fasting lipid profile at least annually In adults with low-risk lipid values (LDL cholesterol 50 mg/dL, and triglycerides <150 mg/dL), lipid assessments may be repeated every 2 years 18

20 Managing Dyslipidemia - Treatment Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for high risk diabetic patients For lower-risk patients*, statin therapy should be considered in addition to lifestyle therapy if LDL cholesterol remains above 100 In individuals without overt CVD, the goal is LDL cholesterol <100 In individuals with overt CVD, a lower LDL cholesterol goal of <70 mg/dL using a high dose of a statin, is an option If drug-treated patients do not reach the above targets on maximal tolerated statin therapy, a reduction in LDL cholesterol of 30–40% from baseline is an alternative therapeutic goal Triglyceride levels 40 mg/dL in men and >50 mg/dL in women are desirable. However, LDL cholesterol–targeted statin therapy remains the preferred strategy Combination therapy has been shown not to provide additional cardiovascular benefit above statin therapy alone and is not generally recommended 19

21 Drug Classes - Lipid Management 20 Drug Class/CategoryMechanism of ActionPotential Side Effects StatinsInhibits HMG-CoA reductase, causing a slow down in the production of cholesterol Muscle pain, rhabdomyolysis, occasional headaches and nausea Cholesterol Absorption inhibitors Inhibits intestinal cholesterol absorption Diarrhea, abdominal pain

22 Drug Classes - Lipid Management 21 Drug Class/CategoryMechanism of ActionPotential Side Effects NiacinInhibits fatty acid release from adipose tissue and inhibits liver production of fatty acids and triglycerides Stomach upset, flushing, and increased uric acid Fibric acid derivativesDecrease Liver production of VLDL Nausea, stomach upset, diarrhea, liver inflammation Bile acid sequestrantsBinds with cholesterol containing bile acids in the intestines Constipation, abdominal pain, bloating

23 Tobacco as a Risk Factor for Diabetes Increases insulin resistance and chronic inflammation Affects the way the body is able to respond to insulin and affects the ability to control diabetes Increases the risk of CV disease 22

24 Tobacco Cessation Interventions All patients who smoke need to be advised to quit Stress that effective treatments exist Identify and offer treatment Combine counseling and medication –There are seven effective medications approved for treatment –The combination of counseling and meds is most effective Refer to quit line, or telephone-based counseling –This is effective with diverse populations and has broad reach – California Smokers Helpline (1-800-NO-BUTTS) 23

25 Aspirin Therapy Use aspirin therapy (75–162 mg/day) as a secondary prevention strategy in those with diabetes with a history of CVD Consider aspirin therapy (75–162 mg/day) as a primary prevention strategy in those with diabetes at increased cardiovascular risk (10-year risk >10%) Aspirin should not be recommended for CVD prevention for adults with diabetes at low CVD risk In patients in these age-groups with multiple other risk factors (e.g., 10-year risk 5–10%), clinical judgment is required 24

26 Coronary Heart Disease Screening and Treatment Screening - In asymptomatic patients, routine screening for coronary artery disease (CAD) is not recommended, as it does not improve outcomes as long as CVD risk factors are treated Treatment –In patients with known CVD, consider ACE inhibitor therapy and use aspirin and statin therapy (if not contraindicated) to reduce the risk of cardiovascular events –Avoid thiazolidinedione treatment in patients with symptomatic heart failure –Metformin may be used in patients with stable congestive heart failure if renal function is normal –It should be avoided in unstable or hospitalized patients with CHF 25

27 Foot Care For all patients with diabetes, perform an annual comprehensive foot examination Provide general foot self-care education to all patients with diabetes A multidisciplinary approach is recommended for individuals with foot ulcers and high-risk foot disease, especially those with a history of prior ulcer or amputation Refer high risk patients to foot care specialists for ongoing preventive care and lifelong surveillance Initial screening for peripheral arterial disease should include a history for claudication and an assessment of the pedal pulses. Refer as needed 26

28 Depression and Mental Health The overwhelming impact of diabetes can have a strong impact on mental health Persons with diabetes are 52% more likely to become depressed than persons without diabetes Conversely, persons who are depressed are more likely to develop diabetes Use the PHQ 2 and 9 to screen for depression 27

29 Eye Disease Over time, diabetes and hypertension can damage the retina and small blood vessels in the eyes To reduce the risk or slow the progression of retinopathy, optimize glycemic and blood pressure control Patients diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist shortly after the diagnosis of diabetes Subsequent examinations should be repeated annually by an ophthalmologist or optometrist Less frequent exams (every 2–3 years) may be considered following one or more normal eye exams High-quality fundus photographs can detect most clinically significant diabetic retinopathy. Interpretation of the images should be performed by a trained eye care provider While retinal photography may serve as a screening tool for retinopathy, it is not a substitute for a comprehensive eye exam 28

30 Renal Disease Diabetes can lead to chronic kidney disease (CKD) and kidney failure Perform an annual test to assess urine albumin excretion in diabetic patients Measure serum creatinine at least annually in all adults with diabetes regardless of the degree of urine albumin excretion In the treatment of patients with elevated urinary albumin excretion either ACE inhibitors or ARBs are recommended When ACE inhibitors, ARBs, or diuretics are used, monitor serum creatinine and potassium levels 29

31 Neuropathy Over time, people with diabetes can develop damage to the nervous system All patients should be screened annually for distal symmetric polyneuropathy using simple clinical tests Screening for signs and symptoms of cardiovascular autonomic neuropathy Special testing is rarely needed and may not affect management or outcomes Medications for the relief of specific symptoms related to painful DPN and autonomic neuropathy are recommended, as they improve the quality of life of the patient 30

32 The Financial Impact of Improvement 31

33 The Impact of Improvement DCCT and EDIC studies Prevalence of complications Expected reduction in complications from improvement in A1c control Number of pts with diabetes in HPSJ 32

34 DCCT and EDIC DCCT took 1,441 volunteers, ages 13 to 39, with type 1 diabetes and compared the effects of standard control of blood glucose versus intensive control on the complications of diabetes DCCT found Intensive blood glucose control reduces risk of eye disease by 76%, kidney disease by 50% and nerve disease by 60% The EDIC study is also examining the impact of intensive control versus standard control on quality of life for persons with Type 2 Diabetes EDIC found that Intensive blood glucose control reduces risk of any cardiovascular disease event by 42% and nonfatal heart attack, stroke, or death from cardiovascular causes by 57% 33

35 Financial Impact of Complication Reduction We know that the prevalence of diabetic complications ranges from 6.6% for CVA to 27.8% for CKD based on State of Diabetes Complication in America – National Health And Nutrition Examination Survey If we assume a 20% improvement equals about a 1/5 reduction in the incidence of complications And we know from published studies that the cost of complications range from $12,577 to $28,661 The estimated cost savings of a 20% improvement in control would be $ to $ pmpy in the first year alone Or for HPSJ with 4739 pts with diabetes the impact would be $3,435,817-3,913,877 per year Conclusion: Some assumptions were made and estimates may be imperfect but financial impact from improvement is huge 34

36 Next it is my pleasure to introduce Dr. David Eibling, Medical Director at HPSJ who will talk about what HPSJ has implemented to partner with their practices to align incentives for improvements in diabetes control 35

37 Health Plan of San Joaquin Primary Care Provider Shared Risk Incentive Program Incentive accounts for 15% of PCP income on average HEDIS scores comprise 35% of total incentive NCQA Medicaid Minimum Performance Level (MPL = 25 th percentile nationwide) qualifies Increasing reimbursement for th percentile, 75 th to 90 th percentile and > 90 th percentile (HPL) 36

38 DHCS NCQA Diabetic Measures MeasureMPLHPL HgA1C testing Hg A1C control (< 8.0%) LDL-C testing LDL-C Control (<100 mg/dl) Nephropathy screening or treatment Retinopathy screening Blood Pressure (<140/90)

39 Member Incentives Completion of testing Approved by DHCS Movie tickets or Gift Certificate (Value < $25) 38

40 Effectiveness of Incentive Programs 39

41 Future Webinars 40 From the Frontline of Care Improvement – How to do it Right Promoting Patient Self- Management and Medication Adherence Friday, January 18 th 12:15 - 1:15 pm Wednesday, January 23 rd 12:15 - 1:15 pm We will discuss lessons learned from rock-star improvement projects across California, with a guest speaker from San Joaquin General Hospital whose efforts resulted in NCQA recognition. Learn how to help your patients take charge of their health, with a guest speaker from the California Diabetes Program sharing lessons learned from 25 years of on-the-ground improvement work. Dial-in Info: , Passcode ; Webinar link: Dial-in Info: , Passcode ; Webinar link: Please RSVP at: entsID=895 entsID=895 Please RSVP at: entsID=896 entsID=896

42 Presentation Slides Can be found here: atientResouces.aspx atientResouces.aspx

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