Preventing and Managing Complications of Diabetes

Webinar #2 - Diabetes Care Improvement Series

Chris Cammisa, MD, Medical Consultant, California Quality

Collaborative (CQC)

David Eibling, MD, Medical Director, Health Plan of San

Joaquin (HPSJ)

January 9, 2013

Today’s Agenda

• Discuss the prevention and management of cardiovascular complications of diabetes

• Mention the other complications along with prevention and management

• Demonstrate the financial impact of complication reduction

• Discuss HPSJ incentives to improve diabetes care

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Long Term Complications of Diabetes

• Heart attack • Stroke • Kidney disease/failure• Vision problems

– Retinopathy – Cataract – Glaucoma

• Damage to blood vessels • Dental and gum disease • Nerve damage

(neuropathy) • Sexual impotence• Foot problems • Persistent skin or gum

infections • Stomach paralysis

(gastroparesis) • Mental health issues

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Key Messages

• Promote the ABC’s – A1c, Blood Pressure and Cholesterol

• Promote a healthy lifestyle

• Explain the risks of diabetes and the benefits of good self management

• Discuss medication adherence

• Assess symptoms and provide the appropriate referrals

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Reducing Cardiovascular Complications of Diabetes

• In addition to the “ABCs” a number of other measures are important

• Quit smoking

• Aspirin (81 to 100 mg per day) is recommended for anyone with diabetes who already has or is at increased risk of cardiovascular disease

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Achieving Glycemic Control

• Strong predictor of complications. • A1c closely represents the average glucose over the last

3 months• The ADA recommends that patients have A1c done at

least every 6 months if they are stable and at goal• Every 3 months in patients who are not at goal or who

are changing therapy• The A1c goal for most adult patients with diabetes

should be < 7.0%, in order to decrease the long term risk of complications

• Consider an A1c goal (such as < 6.5%) for some patients

• Less stringent A1C goals (such as <8%) may be appropriate for certain patients 6

General Principles of Pharmacotherapy

• Start with lifestyle/behavior modification, weight loss, physical activity promotion, and dietary control

• Most patients with type 2 diabetes will also need oral or insulin medications

• Diabetes progresses over time

• Multiple drugs may be necessary

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• The effectiveness of therapies is predicated not only on the intrinsic characteristics of the intervention (i.e.. the drug) , but also on the baseline glycemia, duration of diabetes, previous therapy, and other factors

• A major factor in selecting a class of drugs, is the ambient level of glycemic control

• New recommendations from the ADA - The choice of glycemic goals and the medications must be individualized balancing the benefits and the risks

• In newly diagnosed type 2 diabetic patients with markedly symptomatic and/or elevated blood glucose levels or A1C, consider insulin therapy, with or without additional agents, from the outset

Selecting Medications

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Summary of Hyperglycemic Interventions

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Interventions Expected Decrease in A1c

Advantages Disadvantages

Lifestyle 1-2 Low cost, many benefits

Fails for most in 1st year

Metformin 1.5 No hypoglycemia, weight neutral, inexpensive

GI side effects, rare lactic acidosis

Insulin unlimited No dose limit, inexpensive, improved lipid profile

Injections, monitoring, hypoglycemia

Summary of Hyperglycemic Interventions

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Interventions Expected decrease in A1c

Advantages Disadvantages

Sulfonylureas 1.5 Inexpensive Weight gain, hypoglycemia

TZDs .5-.8 Improved or neutral effect on lipid profile

Fluid retention, heart failure, weight gain, fracture risk, expensive

DPP 4 Inhibitors* .6-.7 Weight neutral, no hypoglycemia, and they are oral

Relatively less experience, cost possible infections

GLP 1 Receptor Agonists

.5-1.0 Weight loss Injections, frequent GI side effects, expensive

Algorithm for Hyperglycemic Control

• This has been a controversial area with several algorithms proposed over the last few years

• This example is the most recent developed in a joint effort by the ADA and the European Association for the Study of Diabetes: http://professional.diabetes.org/admin/UserFiles/PositionStatementADA_EASD_2012.full.pdf

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Key Points

• Glycemic targets and glucose-lowering therapies must be individualized

• All treatment decisions, should be made in conjunction with the patient, focusing on his/her preferences, needs, and values

• Unless there are contraindications, metformin is the optimal first-line drug

• After metformin, there are limited data to guide us • Ultimately, many patients will require insulin therapy

alone or in combination• Include cardiovascular risk reduction as a major focus

of therapy

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After Metformin

• Use a two drug combination• Options include (order not meant to indicate a

preference):– Sulfonylurea– Thiazoladinedione– DPP-4-Inhibitor– GLP-1 receptor agonist– Insulin (usually basal)

• Make decision based on efficacy, hypoglycemia, weight, major side effects and cost

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Three Drug Combination and Beyond

• If needed to reach individualized A1c goal after 3 months proceed to a three drug combination

• To Su add TZD, DPP-4-I, GLP 1- RA, or Insulin• To TZD, add SU, DPP-4-I, GLP-1-RA, or Insulin• To DPP-4-I inhibitor add SU, TZD or Insulin• To GLP-1-RA, add SU, TZD or Insulin• To Basal Insulin add TZD, DPP-4-I, or GLP-1-RA• If combination therapy that includes basal insulin has

failed to achieve goal after 3-6 months, proceed to a more complex insulin strategy usually in combination with one or two non-insulin agents

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Managing High Blood Pressure

• Employ a combination of lifestyle modifications and pharmacologic therapies to reach target blood pressure values

• The goal for blood pressure control has been revised to suggest that the systolic blood pressure goal for many people with diabetes and hypertension should be <140 mmHg

• Lower systolic targets (such as <130 mmHg) may be appropriate for certain individuals, such as younger patients, if it can be achieved without undue treatment burden

• Advise pts to self monitor at home and work

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General Management of Hypertension in Diabetes• Patients with confirmed blood pressure ≥140/80 mmHg should

have titration of pharmacological therapy to achieve blood pressure goals

• Lifestyle therapy for elevated blood pressure consists of weight loss, if overweight

• Pharmacological therapy for patients with diabetes and hypertension should be with a regimen that includes either an ACE inhibitor or an ARB

• Multiple-drug therapy is generally required to achieve blood pressure targets

• Administer one or more antihypertensive medications at bedtime

• If ACE inhibitors, ARBs, or diuretics are used, serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored

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Drug Classes – Hypertension

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Drug Class/Category Mechanism of Action Common Side Effects

Thiazide diuretics Inhibits sodium and chloride reabsorption

Dizziness, lightheadedness, blurred vision

Angiotensin Converting Enzyme Inhibitors

Prevents the formation of angiotensin II

Cough, elevated potassium levels, low blood pressure, dizziness, headache, drowsiness, weakness, abnormal taste, rash

Calcium Channel Blockers, Non-Dihydropyridines

Blocks calcium channels

Constipation, nausea, headache, edema, drowsiness, dizziness, difficulty breathing

Drug Classes - Hypertension

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Drug Class/Category Mechanism of Action Common Side Effects

Aldosterone receptor blockers

Blocks the action of epinephrine and norepinephrine

Cough, diarrhea, flu like symptoms

Beta blockers Blocks the action of epinephrine and norepinephrine

Dizziness, lightheadedness, drowsiness

Managing Dyslipidemia - Screening

• In most adult patients with diabetes, measure fasting lipid profile at least annually

• In adults with low-risk lipid values (LDL cholesterol <100 mg/dL, HDL cholesterol >50 mg/dL, and triglycerides <150 mg/dL), lipid assessments may be repeated every 2 years

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Managing Dyslipidemia - Treatment

• Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for high risk diabetic patients

• For lower-risk patients*, statin therapy should be considered in addition to lifestyle therapy if LDL cholesterol remains above 100

• In individuals without overt CVD, the goal is LDL cholesterol <100• In individuals with overt CVD, a lower LDL cholesterol goal of

<70 mg/dL using a high dose of a statin, is an option• If drug-treated patients do not reach the above targets on maximal

tolerated statin therapy, a reduction in LDL cholesterol of 30–∼40% from baseline is an alternative therapeutic goal

• Triglyceride levels <150 mg/dL and HDL cholesterol >40 mg/dL in men and >50 mg/dL in women are desirable. However, LDL cholesterol–targeted statin therapy remains the preferred strategy

• Combination therapy has been shown not to provide additional cardiovascular benefit above statin therapy alone and is not generally recommended

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Drug Classes - Lipid Management

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Drug Class/Category Mechanism of Action Potential Side Effects

Statins Inhibits HMG-CoA reductase, causing a slow down in the production of cholesterol

Muscle pain, rhabdomyolysis, occasional headaches and nausea

CholesterolAbsorption inhibitors

Inhibits intestinal cholesterol absorption

Diarrhea, abdominal pain

Drug Classes - Lipid Management

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Drug Class/Category Mechanism of Action Potential Side Effects

Niacin Inhibits fatty acid release from adipose tissue and inhibits liver production of fatty acids and triglycerides

Stomach upset, flushing, and increased uric acid

Fibric acid derivatives Decrease Liver production of VLDL

Nausea, stomach upset, diarrhea, liver inflammation

Bile acid sequestrants Binds with cholesterol containing bile acids in the intestines

Constipation, abdominal pain, bloating

Tobacco as a Risk Factor for Diabetes

• Increases insulin resistance and chronic inflammation

• Affects the way the body is able to respond to insulin and affects the ability to control diabetes

• Increases the risk of CV disease

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Tobacco Cessation Interventions

• All patients who smoke need to be advised to quit• Stress that effective treatments exist• Identify and offer treatment• Combine counseling and medication

– There are seven effective medications approved for treatment

– The combination of counseling and meds is most effective

• Refer to quit line, or telephone-based counseling – This is effective with diverse populations and has

broad reach– California Smokers’ Helpline (1-800-NO-BUTTS)

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Aspirin Therapy

• Use aspirin therapy (75–162 mg/day) as a secondary prevention strategy in those with diabetes with a history of CVD

• Consider aspirin therapy (75–162 mg/day) as a primary prevention strategy in those with diabetes at increased cardiovascular risk (10-year risk >10%)

• Aspirin should not be recommended for CVD prevention for adults with diabetes at low CVD risk

• In patients in these age-groups with multiple other risk factors (e.g., 10-year risk 5–10%), clinical judgment is required

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Coronary Heart Disease Screening and Treatment

• Screening - In asymptomatic patients, routine screening for coronary artery disease (CAD) is not recommended, as it does not improve outcomes as long as CVD risk factors are treated

• Treatment– In patients with known CVD, consider ACE inhibitor therapy

and use aspirin and statin therapy (if not contraindicated) to reduce the risk of cardiovascular events

– Avoid thiazolidinedione treatment in patients with symptomatic heart failure

– Metformin may be used in patients with stable congestive heart failure if renal function is normal

– It should be avoided in unstable or hospitalized patients with CHF

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Foot Care

• For all patients with diabetes, perform an annual comprehensive foot examination

• Provide general foot self-care education to all patients with diabetes

• A multidisciplinary approach is recommended for individuals with foot ulcers and high-risk foot disease, especially those with a history of prior ulcer or amputation

• Refer high risk patients to foot care specialists for ongoing preventive care and lifelong surveillance

• Initial screening for peripheral arterial disease should include a history for claudication and an assessment of the pedal pulses. Refer as needed

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Depression and Mental Health

• The overwhelming impact of diabetes can have a strong impact on mental health

• Persons with diabetes are 52% more likely to become depressed than persons without diabetes

• Conversely, persons who are depressed are more likely to develop diabetes

• Use the PHQ 2 and 9 to screen for depression

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Eye Disease

• Over time, diabetes and hypertension can damage the retina and small blood vessels in the eyes

• To reduce the risk or slow the progression of retinopathy, optimize glycemic and blood pressure control

• Patients diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist shortly after the diagnosis of diabetes

• Subsequent examinations should be repeated annually by an ophthalmologist or optometrist

• Less frequent exams (every 2–3 years) may be considered following one or more normal eye exams

• High-quality fundus photographs can detect most clinically significant diabetic retinopathy. Interpretation of the images should be performed by a trained eye care provider

• While retinal photography may serve as a screening tool for retinopathy, it is not a substitute for a comprehensive eye exam

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Renal Disease

• Diabetes can lead to chronic kidney disease (CKD) and kidney failure

• Perform an annual test to assess urine albumin excretion in diabetic patients

• Measure serum creatinine at least annually in all adults with diabetes regardless of the degree of urine albumin excretion

• In the treatment of patients with elevated urinary albumin excretion either ACE inhibitors or ARBs are recommended

• When ACE inhibitors, ARBs, or diuretics are used, monitor serum creatinine and potassium levels

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Neuropathy

• Over time, people with diabetes can develop damage to the nervous system

• All patients should be screened annually for distal symmetric polyneuropathy using simple clinical tests

• Screening for signs and symptoms of cardiovascular autonomic neuropathy

• Special testing is rarely needed and may not affect management or outcomes

• Medications for the relief of specific symptoms related to painful DPN and autonomic neuropathy are recommended, as they improve the quality of life of the patient

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The Financial Impact of Improvement

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The Impact of Improvement

• DCCT and EDIC studies

• Prevalence of complications

• Expected reduction in complications from improvement in A1c control

• Number of pts with diabetes in HPSJ

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DCCT and EDIC

• DCCT took 1,441 volunteers, ages 13 to 39, with type 1 diabetes and compared the effects of standard control of blood glucose versus intensive control on the complications of diabetes

• DCCT found Intensive blood glucose control reduces risk of eye disease by 76%, kidney disease by 50% and nerve disease by 60%

• The EDIC study is also examining the impact of intensive control versus standard control on quality of life for persons with Type 2 Diabetes

• EDIC found that Intensive blood glucose control reduces risk of any cardiovascular disease event by 42% and nonfatal heart attack, stroke, or death from cardiovascular causes by 57%

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Financial Impact of Complication Reduction• We know that the prevalence of diabetic complications

ranges from 6.6% for CVA to 27.8% for CKD based on State of Diabetes Complication in America – National Health And Nutrition Examination Survey 1994-2004

• If we assume a 20% improvement equals about a 1/5 reduction in the incidence of complications

• And we know from published studies that the cost of complications range from $12,577 to $28,661

• The estimated cost savings of a 20% improvement in control would be $516.16 to $611.46 pmpy in the first year alone

• Or for HPSJ with 4739 pts with diabetes the impact would be $3,435,817-3,913,877 per year

• Conclusion: Some assumptions were made and estimates may be imperfect but financial impact from improvement is huge

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Next it is my pleasure to introduce Dr. David Eibling, Medical Director at HPSJ who will talk about what HPSJ has implemented to partner with their practices to align incentives for improvements in diabetes control

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Health Plan of San Joaquin Primary Care Provider Shared Risk Incentive Program

• Incentive accounts for 15% of PCP income on average

• HEDIS scores comprise 35% of total incentive

• NCQA Medicaid Minimum Performance Level (MPL = 25th percentile nationwide) qualifies

• Increasing reimbursement for 50-75th percentile, 75th to 90th percentile and > 90th percentile (HPL)

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DHCS NCQA Diabetic Measures

Measure MPL HPL

HgA1C testing 77.6 90.9

Hg A1C control (< 8.0%) 39.9 59.1

LDL-C testing 70.4 84.2

LDL-C Control (<100 mg/dl) 27.3 45.9

Nephropathy screening or treatment 73.9 86.9

Retinopathy screening 43.8 70.6

Blood Pressure (<140/90) 54.3 76.0

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Member Incentives

• Completion of testing

• Approved by DHCS

• Movie tickets or Gift Certificate (Value < $25)

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Effectiveness of Incentive Programs

46.72 51.82 55.96

0

20

40

60

80

2010 2011 2012

Hemoglobin A1c (<8.0%)(CDC-HC)

CDC-HC MPL 39.9 HPL 59.1

32.85 30.66 30.17 31.39

38.93

0

10

20

30

40

50

2008 2009 2010 2011 2012

Low Density Lipoprotein Control (<100 mg/dL)(CDC-LC)

CDC-LC MPL 27.3 HPL 45.9

72.26 72.2677.37

74.9476.16

80.29

40

50

60

70

80

90

2007 2008 2009 2010 2011 2012

Medical Attention for Nephropathy(CDC-N)

CDC-N MPL 73.9 HPL 86.9

46.72 51.82 55.96

0

20

40

60

80

2010 2011 2012

Hemoglobin A1c (<8.0%)(CDC-HC)

CDC-HC MPL 39.9 HPL 59.1

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Future Webinars

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From the Frontline of Care Improvement –

How to do it Right

Promoting Patient Self-Management and Medication

Adherence

Friday, January 18th 12:15 - 1:15 pm

Wednesday, January 23rd 12:15 - 1:15 pm

We will discuss lessons learned from rock-star improvement projects across California, with a guest speaker from San Joaquin General Hospital whose efforts resulted in NCQA recognition.

Learn how to help your patients take charge of their health, with a guest speaker from the California Diabetes Program sharing lessons learned from 25 years of on-the-ground improvement work.

Dial-in Info: 1-800-615-2820, Passcode 415-615-6376; Webinar link: pbgh.adobeconnect.com/webinar3/

Dial-in Info: 1-800-615-2820, Passcode 415-615-6376; Webinar link: pbgh.adobeconnect.com/webinar4/

Please RSVP at: www.caldiabetes.org/events_display.cfm?eventsID=895

Please RSVP at: www.caldiabetes.org/events_display.cfm?eventsID=896

Presentation Slides

• Can be found here: http://www.thecmafoundation.org/projects/APED/NewPatientResouces.aspx