Clinical Inertia and the CDE Inertia and... · 2019-04-26 · Inertia •Past •Present •Future...
Transcript of Clinical Inertia and the CDE Inertia and... · 2019-04-26 · Inertia •Past •Present •Future...
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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