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A-L-L: Care Team Approach to Diabetic Medication Management Aspirin Lisinopril and lipid lowering
Anna Cosyleon, MD * Physician Lead Diabetes Kaiser Permanent Colorado
Department Population and Prevention Services. *No Financial Disclosures
2 | © Kaiser Permanente 2010-2011. All Rights Reserved.May 27, 2014
Objectives: A-L-L use and Team approachin Diabetes Care
Defining the Problem
Foundation
Tools
Support Systems
?
3 | © Kaiser Permanente 2010-2011. All Rights Reserved.May 27, 2014
Overwhelming Burden for Millions
CDC Statistics– 25.8 million with diabetes – 18.8 Million Diagnosed– 7 million undiagnosed– Estimated 79 million with pre-
diabetes
Burden of Diabetes
Major cause blindness, renal failure, amputation and CVD Total cost in the US in 2013 = $245 billion 1 out of every 3 Medicare dollars spent on
diabetes Prevalence of 11.3% in US adults in 2011
CDC. National diabetes fact sheet, United States 2013ADA Diabetes Care 2003;26:917
– Leading cause kidney failure, blindness, amputation– Risk cardiovascular disease 2 to 4 fold– 7th leading Cause of Death– 30% of Diabetics over 40 y/o have impaired
sensation in their feet
Complications
6 | © Kaiser Permanente 2010-2011. All Rights Reserved.May 27, 2014
Aspirin, Lisinopril, and Lipid Lowering (statin)
A-L-L Therapy is our best option for mitigating the risks associated with having diabetes
How Can We Reduce this Burden?
What is ALL?
In all eligible DM patients, use: Aspirin
– Recommended dose of 81 mg qd Lisinopril
– Target dose of ≥ 20 mg qd Lipid-lowering agents
– Simvastatin 40 mg for risk <7.5% and Atorvastatin 40 for >7.5%
? 25%
22%MI
33%CVA
Cardiovascular Risk Reduction with A-L-L
Benefit of combined treatment
9 | © Kaiser Permanente 2010-2011. All Rights Reserved.May 27, 2014
Average Annual Risk per Event
0
0.005
0.01
0.015
0.02
0.025
0.03
0.035
0.04
0.045
MI Stroke ESRD Blind Dying
Nothing
A1c control
ALL
Based on Archimedes model
71% decline with ALL
11 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
May 27, 2014
Cholesterol Levels as a Trigger for Statin Rx
Cholesterol Levels as trigger for Statin are not relevant
If a patient falls within the four groups most likely to benefit from statin therapy, he/she should be prescribed a statin
Titration is no longer necessary
Monitoring LDL start levels religiously, is no longer necessary
Take Home Points: ALL Therapy
Combination lowers CV events Low risk Low cost Low monitoring
– Glycemic control– Blood pressure- Lisinopril (ACEI) or Losartan (ARB)– Statin Simvastatin or atorvastatin dose based on risk– Aspirin based on risk for cardiovascular disease– Nephropathy– Eye exam– Foot exam
How can the busy Primary Care provider address all the quality goals of this enlarging population?
Problem Defined: There are too many issues to be addressed for each diabetic patient to consistently expect them to be adequately covered at each visit one patient at a time
14 © Kaiser Permanente 2010-2011. All Rights Reserved.May 27, 2014
Team approach to increase both medication & guideline adherence
Foundation
Building a new strategy to care for all of the needs for a diabetic patient.
It takes a team
Foundation of Team Approach
Leadership with clear and measurable goals Whole team engagement Culture of Transparent Accountability Clear communication between teams Sharing of successful practices
Foundation Tools
Registry –Know who are our patients
Data analysis –how are our patients doing?
Actionable quality lists/alerts–Scheduled List monitoring and outreach
• Defining the Problem• Foundation
• Tools• Support Systems• Provider Incentive
Accurate list of patients–Define and track who has DM–Track medication prescriptions and lab
reports– Ideally automated administrative process
Registry
Two A1c ≥ 6.5% Two Fasting Blood Sugars ≥ 126Diagnosis DM On insulin or Oral Hypoglycemic medicationDiagnosis DM and on metformin
Registry: Criteria for inclusion
Ability to extract and arrange information from the patient record, lab, radiology, hospital and pharmacy Present in format that is actionable Needs to be current: “real time”
Data Systems
Diabetes Gap Report Other lists
– No visit in 12 month list– No Statin list– No A1c in 10 month list– Ace/ARB/Micro albumin list
Quality Lists/Care Gap Identification
Team Can Identify
individuals who could
benefit from ALL
Summary Tab in chart indicating testing/quality gaps– viewed by whole care team at each visit & phone call
Electronic prompts for whole care team – A1c, chemistry, urine tests or Retinal exam due– Automatic lab ordering
Blood Pressure alerts
Electronic Medical Record Alerts
1. Defining the Problem2. Foundation3. Tools
4. Support Systems5. Provider Incentive
A centralized team of RNs and support staff Analytic chart review Uses guidelines and tools Outreach patients who have care needs (gap) Focus on total patient care needs PCP works with care delivery team to deliver on
recommendations
Quality Support Team
50% have completed the recommended lab work or prevention screening within 90 days 75% who required an office visit have had an office visit
within 90 days 20% with A1c >8.0% will have an A1c < 8.0% within 12
months of chart review
Quality Support Team outreach success
12 FTE RN’s who specialize in diabetes care◦ Focus on insulin titration and self management
Phone/email based care◦ Patients with A1c ≥ 8.0% on insulin◦ Patients new to insulin or short acting meal time insulin◦ Patients on insulin with recurrent hypoglycemia◦ Consult support Whole Patient care address all care needs◦ address A-L-L
Diabetes Care Team
Clinical Pharmacy support Free walk in BP appointments Free scheduled RN BP appointments BP alert signaling staff to check second BP if BP
greater than goal
Blood Pressure Control
Clinical Pharmacy Specialists- outreach for A-L-L Registered dieticians DM Basics class DM insulin class Webinars Other on-line education support
Other Ancillary Support
1) Defining the Problem2) Foundation3) Tools4) Support Systems
5) Provider Incentive
Monthly regional and individual reports
Selected quality goals set by our Primary Care Quality Council
Quality Dashboards
Successful Adherence to ALL
Barriers ALL
Cost of medications Patient/provider does not understand value of ALL Fear of medication side effects Multiple drug therapies
Not takenas prescribed
Long-Term
Not FinishedNot Started
Not Filled
Take Home Points: ALL Therapy Registry Ability to collect and analyze data Tools identify quality gaps and provide an actionable list Team Approach to increase adherence Incentives to the PC team to continue to address quality
goals
Questions
40| © Kaiser Permanente 2010-
2011. All Rights Reserved.May 27, 2014