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Clinical Inertia and the CDE: How long does it take to go from

0-88? JenniferOkemahMSRDBCADMCDECSSD

SaluteNutrition,PLLCWADEConferenceApril26th,2019

Disclosures to Participants •  NoticeofRequirementsforSuccessfulCompletion:Forsuccessfulcompletion,participantsarerequiredtobeinattendanceinthe

fullactivityandcompletetheprogramevaluationattheconclusionoftheeducationalevent.•  PresenterConflictsofInterest/FinancialRelationshipsDisclosuresConsultant:Insulet,Medtronic,TandemSpeaker’sBureau:CompanionMedical

•  DisclosureofRelevantFinancialRelationshipsandMechanismtoIdentifyandResolveConflictsofInterest:NursePlannerfoundnoissuewithconflictofinterestorbias.Speakeragreestotheconstraintsofshowinganylogosorpreferencetoanyproductorcompany.Speakerstatesslideswillbefreeofanybias.

•  Non-EndorsementofProducts:AccreditedstatusdoesnotimplyendorsementbyAADE,ANCC,ACPEorCDRofanycommercial

productsdisplayedinconjunctionwiththiseducationalactivity.•  Off-labelUse:Participantswillbenotifiedbyspeakerstoanyproductusedforapurposeotherthanthatforwhichitwas

approvedbytheFoodandDrugAdministration.

Objectives

1.  DefinethetermClinicalInertia2.  Explorebarriersofpatientsupportwithinthemedicalteam3.  ReviewtheroleoftheCDEandscopesofpracticetosupport

initiationoftherapychanges4.  Listtechniques/approachesusedtohelpreduceCDEinertia5.  Createchange–decreaseclinicalinertia

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The back story…….

1. Clinical Inertia – What is it? The big picture:

Inthecontextofdiabetes,clinicalinertiaiswhenpatientsdonotbeginorintensifytreatmentdespitenotachievingtheirA1Cgoal

in·er·tia

/iˈnərSHə/ Noun 1. A tendency to do nothing or to remain unchanged. 2.PHYSICS a property of matter by which it continues in its existing state of rest or uniform motion in a straight line, unless that state is changed by an external force.

InthispresentationIwillprovideanoverviewofclinicalinertiaintermsoftheclinicalmanagementofdiabetes.IaimtoprovidesuggestionsforCertifiedDiabetesEducatorsinidentifyingandovercomingaspectsthatmayhaveanegativeimpactonourpatientsandourspecialty.

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The journey:

• Provider• Patient• Systems

OverviewofClinicalInertia

• Past• Present• Future

OurClinicalInertia

• Educationplan

• Agentofchange

Solutions

Theproblem:• Despitetheincreaseintheavailabilityofantihyperglycemicmedicationsandevidence-basedtreatmentguidelines,theproportionofpeoplewithdiabetes(T2)whofailtoachieveglycemicgoalscontinuestorise.Onemajorcontributorisadelayintreatmentintensificationdespitesuboptimalglycemiccontrol;referredtoasclinicalinertia.

•  ThepresenceofclinicalinertiaappearstohinderescalationoftreatmentfromOADstoinsulintherapy,withdelaysofapproximately6to8years.

•  Failuretointensifytreatmentmayalsooccurinpatientswhoareoptimizedonbasalinsulin,butstillfailtoreachA1Ctargetsdespiteachievingfastingplasmaglucose(FPG)withintargetranges.

Thestudies:•  Aretrospectivecohortstudyinvolving11,696patientswithT2DintheUKClinicalPracticeResearchData-linkdatabasereportedthatonly30.9%ofpatientswithA1Cofatleast7.5%(i.e.,eligiblefortreatmentintensification)hadtheirtreatmentregimenintensifiedwithbolusorpre-mixinsulinoraglucagon-likepeptide1receptoragonist(GLP-1RA),andthemediantimetointensificationwas3.7years

•  AstudyonalargecohortofpatientswithT2Dfollowedoveraperiodof22yearsshowedthata1-yeardelayintreatmentintensificationinpatients,oneitheroralanti-diabetesmedications(OADs)orinsulintherapywhoseA1Cpersistedabove7.0%,significantlyincreasedtheriskofmyocardialinfarction,heartfailure,stroke,andacompositeofcardiovascularevents

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2. Explore barriers of patient support within the medical team- •  ReportsfromsurveysdemonstrateadisconnectbetweenHCP-andpatient-perceivedbarriers.

•  HCPsidentifiedfearofhypoglycemiaandabsenceofsymptomsasbarrierstobasalinsulininitiationanddosetitration,whereaspatientsreportedthelengthoftimetakentoreachtargetasagreaterbarrierthanhypoglycemia.

•  Patientsoftengetfrustratedwhentheydonotachieveglycemictargets,afeelingthatincreasesinparallelwithtreatmentdurationandmayleadpatientstostopmedicationwithoutdiscussionwiththeirphysician.

•  Physiciansoftenoverestimatepatientresistancetoinsulininitiationbecauseoffearofinjection-inducedpain

• WhiletherehavebeennumerousstudiesonthebestapproachforeducatingpatientswithT2D,thereislessinformationavailableonhowtoeducateandsupportHCPs

• Clinicalinertiaresultsfromacomplexinteractionbetweenpatient,health-careproviders,andhealthcaresystembarriersthatneedtobeaddressed.

Providerrelated

Healthcaresystemrelated

Patientrelated

TimeconstraintsLackofsupportfromclinicalstaffConcernsofcostsoftreatmentReactivevsProactivecareUnderestimationofpatientneedsDifficultieswithnavigatingguidelines/algorithmsLackofinformationofnewtreatmentsLackofinformationonsideeffects,iefearofhypoglycemiaLackofclearguidanceonindividualizingtreatmentConcernsoverpatientsabilitytomanagemorecomplicatedtreatmentsConcernsoverpatientadherence

NoclinicalguidelinesNodiseaseregistryNovisitplanningNoactiveoutreachtopatientsNodecisionsupportNoteamapproachtocare–noreferralstoCDEPoorcommunicationbetweenproviderandstaff

DenialofdiseaseLackofawarenessofprogressivenatureofdiseaseLackofawarenessofimplicationsofpoorglycemiccontrolFearofsideeffectsConcernsoverabilitytomanagemorecomplicatedtreatmentregimensToomanymedicationsTreatmentcostsPoorcommunicationwithproviderLackofsupportLackoftrustinprovider

https://youtu.be/JhJGOYJo9mM

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What does this mean for CDE’s?

• Weareinthebestplaceevertodecreasepatientandproviderbarriers• Wehaveourownclinicalinertiathatwemustadmitandaddress• Wehaveworktodo!

https://youtu.be/K5pZ86G4y9w

Why should we care? Youareeitherpartofthesolutionorpartoftheproblem.–EldridgeCleaverRapidlychangingmedicalmarket–akathe‘Uber-izationofhealthcare’

ConsumermarketProjectVision–AADEBETHEAGENTOFCHANGEforpatients/providersCareersecuritynowandforthefutureCareersatisfaction–lovewhatyoudoandbeappreciatedforitStayrelevant!

The hard part……

Wehavetoadmitthatwemaybepartoftheproblem

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What does CDE clinical inertia look like? Youknowyouarestuckinneutralifyoufindyourselfdoingthefollowingthings:Yourecommendthe45gcarbsforeverywomanand60gforeverymanasandRDorasanon-RDw/oreferraltodietitianYourpatienthasanelevatedA1CandismaxedoutoncurrentmedsandyoudonoteducatethemonnextlinetherapyoptionsYouknowyourpatientneedsinsulinbutyoudon’trecommendittotheproviderIfasked,“whatisyourfavoriteCGMorpump”,youhaveaspecificproductanswerYouanswerYesorNotonutritionquestions,suchas“isDietCokebadforme”YoudonotreachouttocolleaguesforassistancefortopicsoutofyourcomfortzoneorscopeofpracticeYoudon’trecommendamedicationormedicationclassbecauseyouthinkitmightcosttoomuch.Youdonotthinkyoucanorareallowedtoinitiateormanagetechnology–pumps/cgmAnswersonbehalfofpatientbasedonassumptionsNegativebarrierlanguage:‘Can’t,Notmyjob,Won’t,We’vealwaysdoneitthisway,’Whatareothersyoucanthinkof?Askingforafriend…….

Lets take a step back

• CDEscopeofpractice

• CDEcompetencies

3. Review the role of the CDE and scopes of practice to help initiate therapy changes •  Overview:Alldiabeteseducators,nomattertheirdiscipline,provideallaspectsofDSME/T.Itisrecognizedthatmembersofthevarioushealthcaredisciplineswhopracticediabeteseducationbringtheirparticularfocustotheeducationalprocess.Thiswidensornarrowsthescopeofpracticeforindividualeducatorsasisappropriatewithintheboundariesofeachhealthprofession,whichmayberegulatedbynationalorstateagenciesoraccreditingbodies.Regardlessofdiscipline,thediabeteseducatormustbepreparedtoprovideclientswiththeknowledgeandskillstoeffectivelymanagetheirdiabetes.DiabeteseducatorsmustpossessabodyofknowledgethatspansacrossdisciplinestoprovidecomprehensiveDSME/T-AADETheScopeofPractice,StandardsofPractice,andStandardsofProfessionalPerformanceforDiabetesEducators

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Competencies

AADE2016CompetenciesfordiabeteseducatorsanddiabetesparaprofessionalsThepurposeofthepracticelevelsistoincreaseaccesstoDSMESandachievebetterpatientcareby:•  1.Delineatingtherolesandresponsibilitiesofthemultiplelevelsofdiabeteseducatorsanddiabetesparaprofessionals.

•  2.Suggestingacareerpathfordiabeteseducatorsanddiabetesparaprofessionals.Levelsofpracticearedesignedtohelpindividualsdeterminehisorherappropriateentrypointintothepracticeofdiabeteseducationandtoclarifythecompetenciesrequiredfortheadvancementtothenextlevel.

•  3.Clarifyingthecontributionthatcanbemadebyindividualswhohavetheknowledge,capability,diversity,andlanguageskillsneededtoaddressdiabetesself-managementeducationandsupportinavarietyofsettings.

Competencies – where are you and what should you know?

InitiallybasedonnumberofYearsinDirectDiabetesEducationand/orManagement•  LEVEL1:0–2yearsofdirectcareexperienceindiabetes(percentageoftimedevotedtodiabetesspecialtypractice).

•  LEVEL2:3–5yearspostachievementofCDE®/ormoreexperiencedindiabetesclinical/educationalcare.

•  LEVEL3:Morethan5yearsofdirectengagementinthediabetesasaspecialtypractice.

5 Competency domains – as we know them today Domain1:Pathophysiology,Epidemiology,andClinicalPracticeofPrediabetesandDiabetesCompetencyStatement:Demonstratesfamiliaritywithpathophysiology,epidemiology,andclinicalpracticeconsistentwithpracticelevel.Domain2:CulturalCompetencyAcrosstheLifespanCompetencyStatement:Providesdiabetessupportandcareinaculturally-competentmanneracrossthelifespan.Domain3:TeachingandLearningSkillsCompetencyStatement:Appliescurrentprinciplesofteachingandlearningand/orbehaviorchangetofacilitateself-managementskills.PursuesongoingprofessionaldevelopmentDomain4:Self-ManagementEducationCompetencyStatement:Workswithaninterdisciplinarydiabetescareteamtotailorinterventionstoindividualself-managementeducationneeds.Domain5:ProgramandBusinessManagementCompetencyStatement:Appliesprinciplesofprogramand/orbusinessmanagementtocreateaclimatethatsupportssuccessfulself-managementofdiabetes.

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Example of domain breakdown

DomainIexample:PATHOPHYSIOLOGYDiabetesEducator,Level1Describesnormalglucosemetabolism.Explainsthepathophysiologicmechanismsresponsibleforthedevelopmentofprediabetes,type1diabetes,type2diabetes,andgestationaldiabetes.Explainsthesignsandsymptomsofacutehyperglycemia,hyperosmolarhyperglycemicstate(HHS),anddiabeticketoacidosis(DKA).Identifiescausesofhypoglycemia.Identifiescommonriskfactorsforthedevelopmentoftheacuteandchroniccomplicationsofdiabetes.DiabetesEducator,Level2Outlinesthepathophysiologyofgestationaldiabetesanditsrelationshiptothedevelopmentoftype2diabetes.Describesthepathophysiologicbasisofhypoglycemia,HHS,andDKA.Identifiesriskfactorsforhypoglycemia,HHS,andDKA.DiabetesEducator,Level3Appliesknowledgeofdiabetespathophysiologytodirectdiabeteseducationand/ordiabetescare.

Domain breakdown example 2 DOMAIN4:SelfmanagementeducationTAKINGMEDICATIONS•  DiabetesEducator,Level1Identifiesandexplainsthedifferencesbetweenprescribedoralandinjectablemedicationsfordiabetesandco-morbidconditions.Discussessafeuseandcommonsideeffectsofprescribeddiabetesmedications.Teachesstaffandpatientsonsafepreparation,storage,administrationofinjectablemedicationsanddisposalofsyringesandlancets.Discussesuseofoverthecounter(OTC)medications,supplements,andcomplementaryalternativemedicine(CAM)andpossibleeffectsonglucoselevels.

•  DiabetesEducator,Level2Workswithpersonandhealthcareteamtoindividualizethediabetesmedicationregimen.Supportspersonastheyconsider,initiate,andlearnhowtouseaninsulinpump.Coordinatestheplanofcarebetweentheprescriber,insulinpumpmanufacturer,andinsulinpumptrainerduringpumpinitiationandongoingmanagement.Obtainscertificationtoprovidetrainingintheuseofeachspecificbrandandmodelofinsulinpumpwithwhichtheywork.

•  DiabetesEducator,Level3Workswithpersonanddiabetescareteamtosimplifymedicationregimensandfindlowermedicationcostopportunities,whenneedisidentified.Assessesforpotentialdrug/drugorfood/druginteractionsandreferstopharmacistorregistereddietitian/registereddietitiannutritionistasappropriate.Periodicallyassessesforchangesinperson’sclinicalcondition,motivation,abilities,andlifecircumstancesthatmaynecessitatetheneedtoreconsiderappropriatenessofinsulinpumptherapy.Makesmedicationchangesorfollowsmedicationadjustmentprotocols,ormakesnecessaryrecommendationtoprimarycareprovider.

Press pause:

Whereareyou?Whereareyougoing?Wheredoyouneedtobe?Wheredoyouwanttobe?Howdoyougetthere?---------------------------------------------------------IdentifyyourpersonalareasofclinicalinertiaCreateaplantoreducethemExpandyourvoiceandimprovediabetescare

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4.List techniques/approaches used to help reduce personal clinical inertia and help patients reach their goals • UseTheLanguageofDiabetes•  Findresourcesforyou,yourpatients,yourreferringproviders• Patientcentermodels• MIapproaches,CBTreferrals• Checklistsareguides;notroadmaps• RELATIONSHIPS!• RECOMMENDATIONS!Stickyourneckout

The value of the CDE to the team

•  Youknowthepatient•  Youknowthedisease•  Youknowthemeds•  Youknowthetechnology•  Youknowyourscopeofpractice• MAKETHERECOMMENDATIONS

5. Create change: make a therapeutic recommendation - • Whoareyoucommunicatingwith?

•  Theprescriber• Whatshouldyouknow?

•  Etiquette:Whenandhowtoapproach• Whatdoyouknow?

•  TheBRIEFsynopsisofthestoryandtheanswerstotheanticipatedquestions• Whatdoyounotknow?

•  Verbalizeuncertaintywithasolution• Whatareyoutryingtoaccomplish?

•  Changeintherapytoreduceclinicalinertiaofprovider/patient•  Howdoyousayit?

•  Withpractice.Onpaper.Verbal.Infrontofamirror.Withyourcolleagues.Toyourdog,orhedgehog

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How NOT to say it?

•  “Dr.X–PatientYneedstobeoninsulinrightaway”•  “Dr.X–PatientYhastakeahigherdoseofmedZ”•  “Dr.X–PatientYneedsadifferentmedication”•  “Dr.X–PatientYhastogoonapump”

https://youtu.be/nSlUoUuVktw

A good example/approach

• Dr.X–PatientYhasbeenexperiencingconsistenthyperglycemia>200afterbreakfast,throughouttheday.He/Shehasbeentakingmedicationsasprescribedandstickingtothemealplan.Ihaveeducatedhim/heronthenextlinetherapies.He/Sheisnotopposedtoinjectiontherapy.Icheckedwithhis/herinsuranceplanandthefollowingarecovered.Wealsohaveco-paycardstoassistoutofpocketcosts.Pleaseadviseifthissoundslikethedirectionyouwouldliketogo.

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George McFly needs a little help

https://youtu.be/cZ7XXrRhXgIhttps://youtu.be/JcBWGlYRhrc

•  ThepoweroftheCDE–whatpartsofclinicalinertiadowehaveanimpacton?

PROVIDERRELATED:ü  Timeconstraintsü  Lackofsupportfromclinicalstaffü  Concernsofcostsoftreatmentü  ReactivevsProactivecareü  Underestimationofpatientneedsü  Difficultieswithnavigating

guidelines/algorithmsü  Lackofinformationofnew

treatmentsü  Lackofinformationonsideeffects,

iefearofhypoglycemiaü  Lackofclearguidanceon

individualizingtreatmentü  Concernsoverpatientsabilityto

managemorecomplicatedtreatments

ü  Concernsoverpatientadherence

HEALTHSYSTEMS:?NoclinicalguidelinesNodiseaseregistry?NovisitplanningNoactiveoutreachtopatientsNodecisionsupportü  Noteamapproachtocare–noreferralsto

CDEPoorcommunicationbetweenproviderandstaff

PATIENTRELATED:ü  Denialofdiseaseü  Lackofawarenessof

progressivenatureofdisease

ü  Lackofawarenessofimplicationsofpoorglycemiccontrol

ü  Fearofsideeffectsü  Concernsoverabilityto

managemorecomplicatedtreatmentregimens

ü  Toomanymedicationsü  Treatmentcostsü  Poorcommunicationwith

providerü  Lackofsupportü  Lackoftrustinprovider

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Summary and challenge

•  Identifyyourindividualpointsofinertia• Createalearningplantobuildknowledgeandconfidence• Betheexpertwithinyourscope• Betheadvocate•  Speakup• Reductionofourclinicalinertiahasthepowertoreducesystemicinertia

References JOkemah,JPeng,MQuinonesAddressingClinicalInertiainType2DiabetesAdvancementsinTherapy,October2018KKhunti,DMillar-JonesClinicalinertiatoinsulininitiationandintensificationintheUK:afocusedliteraturereviewPrimCareDiabetes,2017SKPaul,KKlein,BLThorsted,MLWolden,KKhuntiDelayintreatmentintensificationincreasestherisksofcardiovasculareventsinpatientswithtype2diabetesCardiovascDiabetol,2015SARossBreakingdownpatientandphysicianbarrierstooptimizeglycemiccontrolintype2diabetesAmJMed,2013SARoss,HDTildesley,JAshkenasBarrierstoeffectiveinsulintreatment:thepersistenceofpoorglycemiccontrolintype2diabetesCurrMedResOpin,2011MPeyrot,RRRubin,TLauritzenResistancetoinsulintherapyamongpatientsandproviders:resultsofthecross-nationaldiabetesattitudes,wishes,andneeds(DAWN)studyDiabetesCare,2005SNakar,GYitzhaki,RRosenberg,SVinkerTransitiontoinsulinintype2diabetes:familyphysicians’misconceptionofpatients’fearscontributestoexistingbarriersJDiabetesComplications,2007YoshiokaN,IshiiH,TajimaN,IwamotoY,DAWNJapangroup.Differencesinphysicianandpatientperceptionsaboutinsulintherapyformanagementoftype2diabetes:theDAWNJapanstudy.CurrMedResOpin.2014;30(2):177–83WDStrain,MBlüher,PPaldániusClinicalinertiainindividualisingcarefordiabetes:istheretimetodomoreintype2diabetes?DiabetesTher,2014CAChrvala,DSherr,RDLipmanDiabetesself-managementeducationforadultswithtype2diabetesmellitus:asystematicreviewoftheeffectonglycemiccontrolPatientEducCouns,2016AZafar,MAStone,MJDavies,KKhuntiAcknowledgingandallocatingresponsibilityforclinicalinertiainthemanagementoftype2diabetesinprimarycare:aqualitativestudyDiabetMed,2015DHLaursen,KBChristensen,UChristensen,AFrølichAssessmentofshortandlong-termoutcomesofdiabetespatienteducationusingthehealtheducationimpactquestionnaire(HeiQ)BMCResNotes,2017