1. Today’s 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

2. 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

3. Key Messages Promote the ABC’s – 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

4. 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

5. 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

6. 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

7. Selecting Medications
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 7

8. Summary of Hyperglycemic Interventions
Expected Decrease in A1c
Advantages
Disadvantages
Lifestyle
1-2
Low cost, many benefits
Fails for most in 1st year
Metformin
1.5
No hypoglycemia, weight neutral, inexpensive
GI side effects, rare lactic acidosis
Insulin
unlimited
No dose limit, inexpensive, improved lipid profile
Injections, monitoring, hypoglycemia 8

9. Summary of Hyperglycemic Interventions
Expected decrease in A1c
Advantages
Disadvantages
Sulfonylureas
1.5
Inexpensive
Weight gain, hypoglycemia
TZDs
.5-.8
Improved or neutral effect on lipid profile
Fluid retention, heart failure, weight gain, fracture risk, expensive
DPP 4 Inhibitors*
.6-.7
Weight neutral, no hypoglycemia, and they are oral
Relatively less experience, cost possible infections
GLP 1 Receptor Agonists
.5-1.0
Weight loss
Injections, frequent GI side effects, expensive 9

10. 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:

11. 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

12. 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

13. 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

14. 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

15. 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

16. Drug Classes – Hypertension
Drug Class/Category
Mechanism of Action
Common Side Effects
Thiazide diuretics
Inhibits 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 16

17. Drug Classes - Hypertension
Drug Class/Category
Mechanism of Action
Common Side Effects
Aldosterone receptor blockers
Blocks the action of epinephrine and norepinephrine
Cough, diarrhea, flu like symptoms
Beta blockers
Dizziness, lightheadedness, drowsiness

18. 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 <100 mg/dL, HDL cholesterol >50 mg/dL, and triglycerides <150 mg/dL), lipid assessments may be repeated every 2 years

19. 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 <150 mg/dL and HDL cholesterol >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

20. Drug Classes - Lipid Management
Drug Class/Category
Mechanism of Action
Potential Side Effects
Statins
Inhibits 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 20

21. Drug Classes - Lipid Management
Drug Class/Category
Mechanism of Action
Potential Side Effects
Niacin
Inhibits fatty acid release from adipose tissue and inhibits liver production of fatty acids and triglycerides
Stomach upset, flushing, and increased uric acid
Fibric acid derivatives
Decrease Liver production of VLDL
Nausea, stomach upset, diarrhea, liver inflammation
Bile acid sequestrants
Binds with cholesterol containing bile acids in the intestines
Constipation, abdominal pain, bloating 21

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. The Financial Impact of Improvement31

32. 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

33. 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

34. 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

35. Next it is my pleasure to introduce Dr
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

36. 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 = 25th percentile nationwide) qualifies
Increasing reimbursement for 50-75th percentile, 75th to 90th percentile and > 90th percentile (HPL) 36

37. DHCS NCQA Diabetic Measures
MPL
HPL
HgA1C testing
77.6
90.9
Hg A1C control (< 8.0%)
39.9
59.1
LDL-C testing
70.4
84.2
LDL-C Control (<100 mg/dl)
27.3
45.9
Nephropathy screening or treatment
73.9
86.9
Retinopathy screening
43.8
70.6
Blood Pressure (<140/90)
54.3
76.0 37

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

39. Effectiveness of Incentive Programs39

40. Promoting Patient Self-Management and Medication Adherence
Future Webinars
From the Frontline
of Care Improvement –
How to do it Right
Promoting Patient Self-Management and Medication Adherence
Friday, January 18th
12:15 - 1:15 pm
Wednesday, January 23rd
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: pbgh.adobeconnect.com/webinar3/
Dial-in Info: , Passcode ; Webinar link: pbgh.adobeconnect.com/webinar4/
Please RSVP at:
Please RSVP at: 40

41. Presentation Slides
Can be found here: