Clinical Inertia and the CDE - Washington Association of ...wadepage.org/files/2019Conf/Clinical...

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4/26/19 1 Clinical Inertia and the CDE: How long does it take to go from 0-88? Jennifer Okemah MS RD BCADM CDE CSSD Salute Nutrition, PLLC WADE Conference April 26 th , 2019 Disclosures to Participants Notice of Requirements for Successful Completion: For successful completion, participants are required to be in attendance in the full activity and complete the program evaluation at the conclusion of the educational event. Presenter Conflicts of Interest/Financial Relationships Disclosures Consultant: Insulet, Medtronic, Tandem Speaker’s Bureau: Companion Medical Disclosure of Relevant Financial Relationships and Mechanism to Identify and Resolve Conflicts of Interest: Nurse Planner found no issue with conflict of interest or bias. Speaker agrees to the constraints of showing any logos or preference to any product or company. Speaker states slides will be free of any bias. Non-Endorsement of Products: Accredited status does not imply endorsement by AADE, ANCC, ACPE or CDR of any commercial products displayed in conjunction with this educational activity. Off-label Use: Participants will be notified by speakers to any product used for a purpose other than that for which it was approved by the Food and Drug Administration. Objectives 1. Define the term Clinical Inertia 2. Explore barriers of patient support within the medical team 3. Review the role of the CDE and scopes of practice to support initiation of therapy changes 4. List techniques/approaches used to help reduce CDE inertia 5. Create change – decrease clinical inertia

Transcript of Clinical Inertia and the CDE - Washington Association of ...wadepage.org/files/2019Conf/Clinical...

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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