The Diabetes Registry: A Cost-The Diabetes Registry: A Cost-Effective Approach to Practicing Effective Approach to Practicing

Quality MedicineQuality Medicine

Edward Shahady, MD Edward Shahady, MD

Medical Director, Diabetes Clinician Program Medical Director, Diabetes Clinician Program Florida Academy of Family PhysiciansFlorida Academy of Family Physicians

““Diabetes is the Diabetes is the 6th leading cause of death, leading 6th leading cause of death, leading cause of blindness, chronic renal disease, cause of blindness, chronic renal disease, amputationsamputations and a major contributor to coronary and a major contributor to coronary artery disease and strokes. artery disease and strokes.

Florida with its aging population has a large number Florida with its aging population has a large number of diabetic and pre-diabetic patients that require of diabetic and pre-diabetic patients that require extensive medical attention. extensive medical attention.

The extent of this care demands time, knowledge, The extent of this care demands time, knowledge, compassion and commitment from all members of the compassion and commitment from all members of the clinician’s office, the patient, families and other care clinician’s office, the patient, families and other care giversgivers. Simply stated it takes a village to care for a . Simply stated it takes a village to care for a diabetic.” diabetic.”

More Diabetes FactsMore Diabetes Facts• 20% of Medicare population has diabetes20% of Medicare population has diabetes• 30% of the Medicare Budget is spent on diabetes30% of the Medicare Budget is spent on diabetes• Leading cause of blindness is diabetic retinopathy Leading cause of blindness is diabetic retinopathy

and it is 90% preventable - and it is 90% preventable - National Eye InstituteNational Eye Institute• Diabetic nephropathy is the leading cause of end Diabetic nephropathy is the leading cause of end

stage renal disease - most is preventable - stage renal disease - most is preventable - NIDDKDNIDDKD• Diabetes accounts for 60% of all non-traumatic Diabetes accounts for 60% of all non-traumatic

amputations - 85% preventable - amputations - 85% preventable - ADA CDCADA CDC

Epidemic of DiabetesEpidemic of Diabetes• Between 2009 and 2034, # with diagnosed and undiagnosed Between 2009 and 2034, # with diagnosed and undiagnosed

diabetes is anticipated to increase from 23.7 million to 44.1 million. diabetes is anticipated to increase from 23.7 million to 44.1 million. • During the same period, annual diabetes-related spending is During the same period, annual diabetes-related spending is

expected to increase from $113 billion to $336 billion (2007 dollars). expected to increase from $113 billion to $336 billion (2007 dollars).

• Medicare - the diabetes population is expected to rise from 8.2 Medicare - the diabetes population is expected to rise from 8.2 million in 2009 to 14.6 million in 2034million in 2009 to 14.6 million in 2034

““Excellent evidence documents Excellent evidence documents that when patients that when patients achieve control of their HbA1c, LDL and Blood achieve control of their HbA1c, LDL and Blood pressurepressure through life style changes and medication, through life style changes and medication, obtain recommended immunizations, eye exams, foot obtain recommended immunizations, eye exams, foot exams, urine microalbumin and take aspirin daily, exams, urine microalbumin and take aspirin daily, significant reduction in complications will be significant reduction in complications will be achievedachieved..

Practices that measure Practices that measure individual individual and and practice practice achievementachievement of these evidenced based activities and of these evidenced based activities and share that information with clinicians, staff and share that information with clinicians, staff and patients patients achieve better diabetes control and reduce achieve better diabetes control and reduce costs and complications.”costs and complications.”

Background InformationBackground Information

• DMCP Florida Academy of Family Physicians started in DMCP Florida Academy of Family Physicians started in November 2003November 2003

• Funded by grants Funded by grants • Now have 84 offices and over 250 clinicians and 450 Now have 84 offices and over 250 clinicians and 450

nurses; MA’s have received training and use the nurses; MA’s have received training and use the registryregistry

• Partnering with ADA, JADE, and Rural Health Networks Partnering with ADA, JADE, and Rural Health Networks - St John’s, Big Bend, and Heartlands - St John’s, Big Bend, and Heartlands

Background InformationBackground Information(Training)(Training)

• After all their diabetes data are entered into the registry the After all their diabetes data are entered into the registry the clinician and staff (MA/LPN) receive initial training of 4.0 clinician and staff (MA/LPN) receive initial training of 4.0 hours followed by two 2-hr sessions over one year. hours followed by two 2-hr sessions over one year.

• Follow-up training consists of visits to clinicians office and Follow-up training consists of visits to clinicians office and of emails sharing data and recent articles of emails sharing data and recent articles

• Training includes(evidenced based CME credit)Training includes(evidenced based CME credit)– Evidence Based standards of care Evidence Based standards of care – How to use patient reports from diabetes registryHow to use patient reports from diabetes registry– How to use population reports from the registryHow to use population reports from the registry– How to conduct group visitsHow to conduct group visits– Up-to-date knowledge about diabetes, lipids and hypertension Up-to-date knowledge about diabetes, lipids and hypertension – How to address clinician and patient barriers to standards How to address clinician and patient barriers to standards

adherence - clinical inertiaadherence - clinical inertia

Value of DMCPValue of DMCP• Increased quality of care for diabetics in your practice Increased quality of care for diabetics in your practice • Decreased complications and suffering for your patientsDecreased complications and suffering for your patients• Entry into the Medical Home conceptEntry into the Medical Home concept• Increased reimbursement for quality of careIncreased reimbursement for quality of care• Increased prestige through recognition and certificationIncreased prestige through recognition and certification

– Office recognized as a center of diabetes excellence Office recognized as a center of diabetes excellence – Clinicians certified as Diabetes Master CliniciansClinicians certified as Diabetes Master Clinicians– Staff certified as Diabetes Master Clinician AssociatesStaff certified as Diabetes Master Clinician Associates

DMCP Diabetes Registry DMCP Diabetes Registry

• Is Internet based - all data and reports on the Is Internet based - all data and reports on the webweb

• Research assistant places initial data for all Research assistant places initial data for all diabetic patients from a practice into the diabetic patients from a practice into the registry. registry.

• Staff then keeps up data entryStaff then keeps up data entry• Initial training begins once data from practice is Initial training begins once data from practice is

enteredentered

In addition to the registry, In addition to the registry, taught how to do group taught how to do group visits. visits.

Actual group visit - patients completing Actual group visit - patients completing first part of medical recordfirst part of medical record

Registry Reports (Tools) Registry Reports (Tools)

• Point of Care Reports for the clinician and the Point of Care Reports for the clinician and the Patient - Patient - report cardsreport cards

• Population-based Reports that identifyPopulation-based Reports that identify• Patients at increased risk because of Patients at increased risk because of

increased HbA1c, LDL, B/P, non-HDL, increased HbA1c, LDL, B/P, non-HDL, triglyceridestriglycerides• Patients who do not have documented Patients who do not have documented

annual recommendations or daily ASAannual recommendations or daily ASA

Barriers to Quality AchievementBarriers to Quality Achievement

• Most clinicians believe they are achieving better Most clinicians believe they are achieving better goal attainment than they aregoal attainment than they are

• Do not have a feel for the patients who are not Do not have a feel for the patients who are not being seenbeing seen

• Office staff not used to aiding quality Office staff not used to aiding quality achievement-push to the limit of their license achievement-push to the limit of their license

• Reimbursed for volume and ability to code - Reimbursed for volume and ability to code - not not qualityquality

Lets look at the evidenced-based goals for diabetes

care that are used in our registry.

What does reaching goals accomplish?What does reaching goals accomplish?

• A 1% decrease in HbA1C decreases the chances of blindness, amputations and renal disease by 35% (DCCT-UKPDS-Kumamoto) (Level A)

• Reduction of LDL (lousy cholesterol) less than 100 or 70, and systolic blood pressure less than 130 decreases risk of CVD 40-50% (CARDS, 4S, TNT, PROVE-IT) (Level A)

A1C goals?A1C goals?• For patients in general, is an A1C goal of 7% (B)

• For the individual patient, as close to normal (6%) as possible without hypoglycemia (E, A)

• Less stringent goals if patient has history of severe hypoglycemia, older, prior CV event, etc.

• Obtain A1C every 3 months (not controlled - every 6 months controlled)

– (2010) ADA Clinical Practice Recommendations Diabetes Care. Available at: www. diabetes.org

Lipid goals?Lipid goals?• Obtain lipid profile at least 1 time a year (E)

• The primary goal is an LDL <100 mg/dl (A) if high risk <70 (E) Recent suggestion is <70 if diabetes plus one risk factor (smoking, >BP, Fam Hx).

• For those >40 years old statin therapy to achieve an LDL reduction of 30-40% regardless of baseline LDL levels is recommended (A)

• Lower triglycerides to 150 mg/dl and raise HDL cholesterol to >40 mg/dl in men and >50 mg/dl in women

• (2010) ADA Clinical Practice Recommendations Diabetes Care. Available at: www. diabetes.org(2010) ADA Clinical Practice Recommendations Diabetes Care. Available at: www. diabetes.org

B/P goals?B/P goals?• Treat systolic BP<130 (B), treat diastolic BP to <80 (B)Treat systolic BP<130 (B), treat diastolic BP to <80 (B)

• Drug Rx as well as TLC (A)Drug Rx as well as TLC (A)

• More than 1 drug often needed (B) usually add a diuretic to More than 1 drug often needed (B) usually add a diuretic to ACE or ARBACE or ARB

• Measure B/P with feet on floor and arm supported at heart Measure B/P with feet on floor and arm supported at heart level: level: two measurements (JNC7) (E) (JNC7) (E)

• ADA goal 130/80ADA goal 130/80

– (2010) ADA Clinical Practice Recommendations Diabetes Care. Available at: www.diabetes.org , Chobanian AV et al. (2003) JAMA 289(19):2560-2572

Other goals?Other goals?• Yearly Yearly flu shotsflu shots (B) (B)• Pneumovax Pneumovax (1 shot): if first shot before 65, another 5-10 years (1 shot): if first shot before 65, another 5-10 years

after firstafter first• Dilated eye examDilated eye exam yearly in T2D, T1D 3-5 years after the onset , yearly in T2D, T1D 3-5 years after the onset ,

then yearly (B)then yearly (B)• Annual test for of micro-albuminuria Annual test for of micro-albuminuria even if on ACE or ARB (E)even if on ACE or ARB (E)• Annual test for sensation like Annual test for sensation like 10-g monofilament pressure 10-g monofilament pressure

sensation and vibration perception using a 128-Hz tuning fork sensation and vibration perception using a 128-Hz tuning fork excellent tools for detecting neuropathy -feet (B)excellent tools for detecting neuropathy -feet (B)

– (2010), ADA Clinical Practice Recommendations Diabetes Care. Available at: www. diabetes.org

Let’s look at some reports from the

registry.

Saves Saves Clinician 5 Clinician 5 MinutesMinutes

Patient Report Care

Also in Spanish

Report informs practice of goal achievement.

Report informs each clinician of goal achievement.

Report informs each clinician of goal achievement.

Reports identify patients at high risk - not at goal - all names fictitious.

Patients not at goal for LDL

How many patients with CKD are at LDL How many patients with CKD are at LDL goal? Don’t know without a registrygoal? Don’t know without a registry

• National Kidney foundation goal for LDL in CKD is National Kidney foundation goal for LDL in CKD is <100<100

• 4541 patients in Kaiser Colorado System - with GFR 4541 patients in Kaiser Colorado System - with GFR <60<60– 1384 - 30% no lipid profile in last 365 days– 3157 - 70% of those that had a lipid profile at LDL goal– 72% of those at goal on a statin (only drug with evidence of

↓ of CAD in patients with CKD and ↓ in progression of loss of renal function

• Stadler et al J. Clin Lipidology 2010;4;298-304

Diabetics at-risk smokers

Patients who have not had recommended quality measure for 5 items

Use this report to improve screening for CKD in diabetes

Office staff are the missing link to reaching quality goals.

Need to push them to limit of their licensure.

Impact of Medical Assistants Impact of Medical Assistants Over 8-month period for 140 patients Over 8-month period for 140 patients

1.1. MA gave MA gave patients and patients and physicians physicians report cardsreport cards

2.2. MA Ordered MA Ordered tests per tests per protocol and protocol and

3.3. MA did the MA did the monofilament monofilament examsexams

Sample of Best PracticesSample of Best Practices

ADA Quality Indicator

Yearly Cost Savings if indicator achieved

HBA1C ≤ 7 $279.00

LDL ≤ 100 $369.00

Syst BP ≤ 130 $474.00

Total yearly savings

$1122.00

Towers Perrin actuarial evaluation Towers Perrin actuarial evaluation 2006 Bridges to Excellence2006 Bridges to Excellence

http://www.bridgestoexcellence.orghttp://www.bridgestoexcellence.org

# Patients reaching goal for quality indicator above national average in 2002

Yearly Cost Savings if indicator achieved

HbA1c 1079 patients $301,041.00

LDL 3582 patients $1,321,758.00

BP 3938 patients $1,866,612.00

Total yearly savings $3,489,411.00

Yearly Cost Savings using Bridges to Yearly Cost Savings using Bridges to Excellence data as of June 2009Excellence data as of June 2009

www.bridgestoexcellence.orgwww.bridgestoexcellence.org

http://www.fafp.org/diabetes_mc.html

Other informationOther information

• Dr. Shahady can be contacted at Dr. Shahady can be contacted at eshahady@att.net..

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