2/24/2015. Collaborative Care. Population Management. Population Management. Population Management

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Optimizing Collaboration between the Primary

Care Provider and the Specialist for Co-Managing

High Risk Patients

John Devlin, MD

Endocrinologist

Collaborative Care

Ciechanowski PS. American Diabetes Association Annual Conference, San Francisco 2014

A

team

with a shared

mission

using improved clinical

systems

to

deliver improved

care

to a patient

population

supported by

operational

and

financial systems.

Such care is

continuously evaluated

through

improvement

processes

and

effectiveness measurement.

Population Management

Community Hospital, Grand Junction, CO

Comprehensive Primary Care Initiative (CMS): IHI Triple Aim

• Decrease unnecessary ED visits and hospitalizations

• Improve transitions of care

At Risk clients

1. Stratification (Low, Medium, High) based on stages of current

(chronic) diseases

2. Implementation of a care management program to manage

condition(s)

Murray D. American Diabetes Association Annual Conference, San Francisco, 2014

Level A

Level B

Level C

Level D

• HbA1c ≥ 9 • DM plus 1 or more uncontr comorbid* • In NON-SELF Management • HbA1c 7-8.9 • DM plus 1-3 co-morbidities* • Independent SELF Management State • HbA1c < 7 • DM plus 1-3 stable co-morbidities* • Hospice or SNF • Receives services elsewhere

• Patient Opted Out

• Requires BOTH physician and RN assessment • RN Care Coordinator • Health Coach Assessment • Health Coach Assessment N/A

Requires DSMT DSMT applicable with Primary Educational Activities + DSM Plan DSMT applicable with Primary Educational Activities + DSM Plan N/A Tipping Point ≥ 4 out of 7 Tipping Point > 3 out of 7 Tipping Point ≤ 2 out of 7

Population Management:

Risk Stratification Behavior Change

*_{May include: CHF, CAD, HTN, open wounds, neuropathy, nephropathy, retinopathy, gastroparesis}

Population Management

Assessment

Care Coordination

Support

Wiegert K. ADA Annual Conference, San Francisco 2014

• Conduct Needs

Assessment • Assess Safety • Create Plan of Care

• Coordinate Services • Navigate Transitions of Care • Prevent Unnecessary Care • Provide Education and Guidance • Goal Setting • Encourage DSM techniques

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Population Management

“The focus of the population management process is to proactively

manage the health of each patient through a coordinated team effort”

Diabetes management:

• Improve quality outcomes

• Identify gaps in delivery of care

• Advance clinical processes using efficient utilization of resources

• Decrease avoidable episodic events with chronic conditions

• Improve access to health care services by providing PCMH and

collaborative medical visits

• Standardize care processes for disease specific conditions

Murray D. ADA Annual Conference, San Francisco 2014

Standardize Care Processes

Antihyperglycemic therapy in type 2 diabetes: general recommendations.

Inzucchi S E et al. Dia Care 2015;38:140-149

Mullan et al Arch Intern Med 2009

Video / Web

Victor Montori, Shared Decision-Making

Considerations in Medication Choice

• Efficacy

• β cell function

• Hypoglycemia Risk

• Weight

• Side effects

• Cardiovascular

• Cost

Glucose (mg/dL) 50 – 100 – 150 – 200 – 250 – 300 – 350 – 0 – 50 – 100 – 150 – 200 – 250 – -10 -5 0 5 10 15 20 25 30 Years of Diabetes

*IFG=impaired fasting glucose.

Burger HG, Loriaux DL, Marshall JC, Melmed S, Odell WD, Potts JT, Jr., Rubenstein AH. 2001. Diabetes Mellitus, Carbohydrate Metabolism, and Lipid Disorders. Chap. in Endocrinology. 4th ed. Edited by Leslie J. DeGroot and J. Larry Jameson. Vol. 1. Philadelphia: W.B. Saunders Co. Originally published in Type 2 Diabetes BASICS. (Minneapolis, International Diabetes Center, 2000).

Relative Function (%)

Fasting Glucose Postmeal Glucose

Obesity IFG* Diabetes Uncontrolled _{Hyperglycemia}

Insulin Resistance

-cell Failure

Can the Course of Type 2 Diabetes Be

Altered?

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B e ta -c e ll Fu nc ti on (% )* Postprandial Hyperglycemia IGT† Type 2 Diabetes Phase I Type 2 Diabetes Phase II Type 2 Diabetes Phase III

Years from Diagnosis

Patients Treated with Metformin and/or Sulfonylureas (SUs)‡

Can The Decline Be Altered?

UKPDS: Beta-cell Decline Over Time

25 – 100 – 75 – 0 – 50 – l -12 l -10 l -6 l -2 l 0 l 2 l 6 l 10 l 14

ADOPT: Treatment effect on primary

outcome

Kahn SE et al. N Engl J Med. 2006;355:2427-43. 40 30 20 10 0 Glyburide Metformin Rosiglitazone 0 1 2 3 4 5 Years Cumulative incidence of mono-therapy failure* (%)

Hazard ratio (95% CI)

Rosiglitazone vs metformin, 0.68 (0.55–0.85), P < 0.001 Rosiglitazone vs glyburide, 0.37 (0.30–0.45), P < 0.001

N = 4351

*Time to FPG >180mg/dL

ADOPT: Treatment effect on insulin

sensitivity and β-cell function

Kahn SE et al. N Engl J Med. 2006;355:2427-43.

*At 4 years

†Homeostasis model assessment (HOMA 2) Insulin sensitivity† (%) 50 60 40 30 0 Years 70 -Cell function† (%) 80 90 70 60 0 Years 100 5 4 3 2 1 0 Glyburide Metformin Rosiglitazone Treatment difference* (95% CI) Rosiglitazone vs metformin

12.6 (8.1 to 17.3), P < 0.001 Rosiglitazone vs glyburide

41.2 (35.2 to 47.4), P < 0.001

Treatment difference* (95% CI) Rosiglitazone vs metformin 5.8 (1.9 to 9.8), P = 0.003 Rosiglitazone vs glyburide -0.8 (-4.7 to 3.1), P = 0.67 5 4 3 2 1 0

UKPDS

• Newly diagnosed

type 2

diabetes; intensive

versus conventional

policy; primary report

published September

1998

• Follow-up observation

published October 2008

Holman RR, Paul SK, Bethel MA, Neil HA, Matthers DR. N Engl J Med. 2008;359:1565-1576.

Post-Trial Changes in A1C

UKPDS results presented

Mean (95%CI)

Holman RR, Paul SK, Bethel MA, Neil HA, Matthers DR. N Engl J Med. 2008;359:1565-1576.

MI Hazard Ratio

Fatal or Non-Fatal MI or Sudden Death

)

Intensive (Sulfonylurea/Insulin) Versus Conventional Glucose Control

HR (95%CI)

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Glycemia Reduction Approaches in Diabetes:

A Comparative Effectiveness Study (GRADE)

• Metformin 1000-2000 mg daily

• HbA1c 6.5-8.5%

• Duration < 10 years

• Randomize:

• Glimepiride (SU)

N = 1500

• Sitagliptin (DPP-4 inhibitor)

N = 1500

• Liraglutide

GLP-1 agonist

N = 1500

• Glargine

insulin

N = 1500

• Follow-up over 7 years

http://care.diabetesjournals.org/content/early/2012/04/19/dc12-0413.full.pdf+html

Figure 3

Getting to insulin

• Overcoming “psychological insulin resistance”

• Patient

• Provider

• Overcoming therapeutic inertia

• Insulin initiation

• Insulin titration

Basal Insulin

• Glargine vs. NPH

• Starting dose

• Combination with oral hypoglycemic drugs

• Titration

The Treat-to-Target Trial

Riddle MC, et al. Diabetes Care 2003;26:3080-86

Randomized addition of

or

human

insulin to oral therapy of

type 2 diabetic patients

Riddle MC, et al. The Treat-to-Target Trial

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Riddle MC, et al. The Treat-to-Target Trial

Diabetes Care

2003; 26: 3080-6

Riddle MC, et al. The Treat-to-Target Trial

Diabetes Care

2003; 26: 3080-6

Riddle MC, et al. The Treat-to-Target Trial

Diabetes Care 2003

Hypoglycemia: Events per patient per year

All Symptomatic Events Confirmed ≤ 72 mg/dL Confirmed ≤ 56 mg/dL

Glargine

13.9

9.2

3.0 NPH

17.7

12.9

5.1

http://care.diabetesjournals.org/content/early/2012/04/19/dc12-0413.full.pdf+html

Initiating insulin

• Typically begin at low dose

0.1-0.2 units/kg/day

• In more severely hyperglycemic

0.3-0.4 units/kg/day

Clinical Case

89 y.o. gentleman has had acceptable glycemic control until recently, on metformin 1000 mg BID and glipizide ER 5 mg daily.

• S. creatinine 1.12 (eGFR 58 ml/min/1.73m2₎

Lately, he has had higher glucose readings overnight, with bedtime BGs in 200-260 mg/dl range. He admits to having desserts at night.

• Nocturia every 2 hours

• S. creatinine increased to 1.3 (eGFR 48 ml/min/1.73m2₎

• His nephrologist tells him this is due to dehydration, and advises him to drink more water

Your advice?

• Stop eating dessert • Drink more fluids • Stop metformin • Start insulin

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Health Services Models

Ciechanowski PS. American Diabetes Association Annual Conference, San Francisco 2014

Team approaches have been shown to improve quality of

care and outcomes of patients with:

• Depression

• Diabetes

• Asthma

• Hypertension

• CHF

Medicare Patients

Ciechanowski PS. ADA Annual Conference, San Francisco 2014

Multiple morbidity

is the norm:

• 80% of those with CHF

• 71% of those with Depression

• 56% of the with Diabetes

have 4+ Chronic Conditions

Health Services Modes for Natural

Clusters of Illness

Diabetes

HTN

CAD

Depression

AHRQ Multiple Chronic Conditions (MCC) project

American Diabetes Assn. Annual Scientific Sessions, Chicago, June 22, 2013

48.9% of Cohort has a

Behavioral Health Disorder

MCC Behavioral Health

Group

Number Distinct

Members

No BH

32,272

SA Only

1,610

MH Only SMI

5163

MH Only non-SMI

12,002

Dual (MH and SA)

7,861

MR/DD/TBI

4,233

OVERALL TOTAL

63,141

AHRQ MCC project, presented at Am Diabetes Assn, June 2013

118% 91% 80% 80% 77% 52% 48% -8% -35% 4 or More Chronic Conditions Mental Illness and Substance Abuse Serious Mental

Illness Decline in MentalHealth Fragmented CareIncreased Mental IllnessNon-Serious Conditions3 Chronic

Factors predicting developing complications:

Persons with uncomplicated diabetes at baseline

Percent more likely…

Improved Continuity of Care Improved Mental Health

AHRQ MCC project, presented at American Diabetes Association, June 2013

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Clinical Vignettes

1.) Schizophrenic patient hearing voices that were telling him that starting insulin would cause cancer. CDE had to also provide education to the voices to correct misinformation so patient would feel comfortable starting insulin.

2.) Another patient with type 1 and thought disorder felt Novolog and Humalog caused his hair to smell like broccoli; CDE able to patiently work with him to restart analog insulin based on discussion that doing so would improve running/biking times (no ketones=faster times)— creativity at it’s best. Meet people where they are.

3.) When new patient referrals are triaged and it is determined that they will likely need to start insulin or transition to MDI, they are scheduled with CDE immediately following MD appointment to reduce barriers for doing so (strike while the iron is hot). Provider updates CDE on plan and off we go. F/U with CDE can be more frequent to ease transition, answer questions, make insulin adjustments prn.

4.) Otherwise, we accommodate pts as best we can at time of appointment when insulin or other injectable is unexpectedly needed rather than having them return (or cancel/no show) on a different day to do so.

To address lack of treatment intensification

Schmittdiel et al. J Gen Intern Med 2008;23(5):588-594

Study: 161,697 patients (Kaiser Permanente)

• HbA1c > 7%

• Systolic BP > 130

• LDL > 100

Adequate adherence Poor adherence

Clinical Inertia

30-47% lacked treatment intensification by healthcare team 20-23%

Literature Review

Ciechanowski PS. ADA, San Francisco 2014

Problems with patients:

• Poor collaboration

• Non-adherence

• Missed appointments

• Dissatisfaction with care

• Do-it-alone approach

• Poor self-care

• Stress, anxiety and depression

providers

Collaborative Care

Patient PCP Psychiatric and Medical Case Review Care Manager

Multi-Condition Collaborative Care

Ciechanowski PS. Am Diabetes Assn Annual Conference, San Francisco 2014

Program goals:

• Improve depression care

• Behavioral activation

• Antidepressants

• Improve medical disease control

• A

(A1c)

• B

(Blood Pressure)

• C

(LDL-Cholesterol)

• D

(Depression)

• Improve self-care

• Diet, exercise

• Smoking cessation

• Glucose monitoring

Multi-Condition Collaborative Care

Identify Goals

Support Self-care

Monitor

Progress Treat-to-Target

Systematic Case Review Care Coordination

Core Components

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Multi-Condition Collaborative Care

Nurse training:

• Motivational interviewing/enhancement

• Problem solving

• Behavioral activation

• Antidepressants

• Treat-to-Target

• HbA1c

• Blood Pressure

• LDL

Multi-Condition Collaborative Care

Treat-to-Target:

• Treatment titration

• Frequent and consistent

• Relentless, incremental increases/changes

• Always

• Increase/change to next step

• If not,

document why not!

• Treat-to-Target Algorithm

• Simplified and uniform approaches across

conditions to achieve targets

• Riddle, Diabetes Care 2003

• Kaiser Permanente, Care Management Institute

Approach to starting and adjusting insulin in type 2 diabetes.

Inzucchi S E et al. Dia Care 2015;38:140-149

Pre-mixed insulins

Target: FPG 100 mg/dL Subjects (n = 364) were randomized to:

Insulin glargine once daily + continued OADs Pre-mixed insulin 70/30 BID

Baseline Endpoint

Time (wk)

0 24

Treatment Regimen

*Sulfonylurea +metformin OAD=oral anti-diabetic drug

Janka HU et al. Presented at: American Diabetes Association 64th Scientific Sessions; June 4-8, 2004; Orlando, FL; Abstract 548-P; Study 4027

Insulin Glargine Plus OADs vs

Twice-Daily Pre-Mixed Insulin

OADs*

Change in A1C From Baseline to Study Endpoint

Janka HU, et al. Diabetes Care. 2005;28:254-259

8.85

8.83

7.15

7.49

5 6 7 8 9

Insulin Glargine + OAD

Pre-mixed

P<0.0005

A1c

Superior HbA1c Reduction With Glargine Plus

OADs vs Twice-Daily Pre-Mixed Insulin

Baseline 24 week

(9)

Documented Hypoglycemic Episodes Per Patient-Year

Less Hypoglycemia With Glargine Plus

OADs vs Twice-daily Premixed Insulin

Average dose = 28.2 IU with G + OAD vs 64.5 IU with premixed insulin Weight Gain: 1.4 ± 3.4 kg with G + OAD vs 2.1 ± 4.2 kg with pre mixed insulin Janka HU, et al. Diabetes Care. 2005;28:254-259.

4.1 9.9 0 2 4 6 8 10 # of Episodes Per Patient-Year P<0.0001

Insulin Glargine + OAD Premixed

Three-year efficacy of complex insulin regimens

in Type 2 Diabetes

Holman RR, et al.

N Engl J Med

2009;361:1736-47

Treating to Target in Type 2 Diabetes (“4-T”)

• Suboptimal HbA1c while taking metformin and

sulfonylurea

• Randomly assigned to receive biphasic insulin b.i.d.,

prandial aspart t.i.d., or basal detemir once daily (or

b.i.d. as needed)

• Target BG: ac 72-99 mg/dl, and 2-h pc 90-126 mg/dl

Holman RR, et al. Three-year efficacy of complex insulin regimens in type 2 diabetes.

N Engl J Med 2009; 361: 1736-47

Holman RR, et al. Three-year efficacy of complex insulin regimens in type 2 diabetes.