Building a Diabetes Alliance: The Role of Provider Education

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Building a Diabetes AllianceThe Role of
Provider Education

• Robert E. Jones, MD, FACP, FACE
• Professor of Medicine
• University of Utah School of Medicine
• and Friend of the UDPCP

2
The Problem
3
Distribution of Glycemic Abnormalities in US
US Population 275 million in 2000
Undiagnosed diabetes 5.9 million
Diagnosed type 1 diabetes 1.0 million
Additional 16 million with prediabetes
Diagnosed type 2 diabetes 10 million
CDC. Available at http//www.cdc.gov/diabetes/pub
s/estimates.htm ADA. Facts and Figures. Available
at www.diabetes.org/main/application/commercewf?
origin.jspeventlink(B1)
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Coronary Artery Disease -3 to 6 fold increased
risk compared to non-diabetics -Major cause of
death in all people with diabetes -10 to 20
year reduction in life expectancy
Neuropathy -Types 1 and 2 gt50 lifetime risk
(approaches 100 with nerve conduction studies)
Retinopathy -Type 1 60 at 10 years and 100
at 20 years -Type 2 20 at diagnosis and
60-80 at 20 years
Peripheral Vascular Disease -Lifetime risk of
amputation is 8/1000
Nephropathy -Type 1 40-50 at 20 years -Type 2
5-10 at 20 years
Diabetes Complications
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Building a Coalition

• Diabetes and its complications are expensive and
  both the suffering and expense might be avoidable
  
• Stakeholders must be identified and all should
  benefit from participation
• Patients, providers, insurers and government
  agencies
• There is a common mistrust between all

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Diabetes Alliance

• Must involve a commitment of all those affected
  by diabetes
• Patients
• Providers
• Insurers
• Government agencies
• Do any of these groups benefit from a bad
  outcome?
• In the short term, they all do
• In the long term, they all suffer

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The Importance of Early, Aggressive Glucose
Control
8
DCCT Change in A1C Over Time
Conventional Group
A1C ()
Intensive Group
Years
DCCT. N Engl J Med. 1993329977
9
DCCT Diabetic ComplicationEvent Rates
76 Risk Reduction
60

• 55.0

50
59 Risk Reduction
40
39 Risk Reduction
Cumulative Incidence ()
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29.8
64 Risk Reduction

• 23.9

20
54 Risk Reduction
16.4

• 13.4

10
13.0
7.9

• 5.1

5.0
2.5
0
Retinopathy
Laser Rx1
Micro-
Albuminuria2
Clinical
Progression1
albuminuria2
Neuropathy3
1. DCCT Research Group. Ophthalmology.
1995102647 2. DCCT Research Group.Kidney Int.
1995471703 3. DCCT Research Group. Ann Intern
Med. 1995122561
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DCCT Lifetime Benefits of Intensive Therapy
Gain inComplications-Free Living
15.3
Gain in Length of Life
5.1
0
5
10
15
20
Years
Significant microvascular or neurologic
complication
DCCT. JAMA. 19962761409
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DCCT Average A1C 4 Years After Trial
Conventional Therapy
A1C ()
Intensive Therapy
EDIC Year
DCCT/EDIC Research Group. N Engl J Med.
2000342381
12
DCCT Progression of Retinopathy 4 Years After
Trial
Conventional Therapy
Cumulative Incidence ()
Intensive Therapy
EDIC Year
Reprinted with permission from DCCT/EDIC Research
Group. N Engl J Med. 2000342381
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EDIC Reduction in CV Disease
Events were reduced 57 (12-79 95 CI P0.02)
DCCT
EDIC
NEJM 20053532643-2654
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UK Prospective Diabetes Study Group A1C
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Conventional Group
Intensive Group
8
A1C ()
Subjects with A1C lt7 3 years 45
6 years 30 9
years 15
7
6
0
1
2
3
4
5
6
7
8
9
10
Years
Reprinted with permission from UKPDS. Lancet.
1998352837-853.
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Control Reduction In Complications
Complications DCCT1,2 Kumamoto3 UKPDS4 9
7 9 7 8 7 Retinopathy 63 69 17
21 Nephropathy 54 70 2433 Neuropathy 60
Macrovascular disease 41 16
Not statistically significant 1DCCT Research
Group. N Engl J Med. 1993329977 2DCCT Research
Group. Diabetes. 199544968 3Ohkubo Y et al.
Diabetes Res Clin Pract. 199528103 4UKPDS
Group. Lancet. 1998352837
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UKPDS 10 Year Poststudy Followup

• Following completion of UKPDS, therapy was left
  to the discretion of providers
• The difference in A1C disappeared (like EDIC)
• Results
• Microvascular Disease (RR0.76 p0.001)
• Diabetes Endpoint (RR0.91 p0.04)
• Death from Diabetes (RR0.83p0.01)
• All Cause Mortality (RR0.87p0.007)
• Myocardial Infarction (RR0.85p0.01)

Holman RR et al. NEJM 20083591577-1589
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Pre-Study Glyemic Exposure and Microvasular
Outcomes

Neuropathy




ADVANCE
UKPDS
VADT
Glycemic ExposureDuration of Diabetes x Study
Entry A1C
Statistically Significant
Jones RE, Wadweker D. In press, 2010.
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Utah Diabetes Prevention and Control
ProgramProvider Education
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First Attempt (1995)
Over 50 providers licensed in Utah were given the
primary literature (DCCT and UKPDS plus
derivative articles) and asked to establish
treatment goals for glucose, lipids and blood
pressure in people with diabetes
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First Attempt (1995)
7.2---Its Up to You! BP 140/90 mm Hg LDLc 130
mg/dl
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Introduction

• 1997 was a unique year
• DCCT was 4 years old and UKPDS was 2 years
  old
• The ADA had just defined goals for diabetes
  management
• Insulin lispro, metformin and troglitazone were
  recently approved by the FDA
• The Expert Committee redefined the diagnostic
  criteria for diabetes (FBS 126 vs 140 mg/dl)
• Utah Diabetes Control Program initiated a
  process for certification of Diabetes Self
  Management Programs

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The Perfect Storm
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Phase 1 (1999-2002)Defining Diabetes, Targets
and Complications

• CME events were by invitation of the local
  certified diabetes educators in order to
  highlight their skills
• Topics centered on the diagnosis of diabetes,
  setting targets, the management of diabetes and
  diabetes complications plus treatment of HTN and
  lipids
• Attendees were given copies of the Utah Diabetes
  Management Handbook (1999)

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Topics

• Diagnosis and natural history of diabetes (types
  1 and 2)
• Management of type 1 diabetes
• Management of type 2 diabetes
• Insulin resistance
• Cardiovascular complications of diabetes
• Microvascular complications of diabetes and
  management
• Acute complications of diabetes
• Designing insulin regimens
• Insulin pumps

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Phase 2 (2003-2006)The Utah Diabetes Practice
Recommendations

• Again, CME events were by invitation of the local
  providers or the diabetes educators
• Topics centered on the management of diabetes
  in a variety of settings (outpatient, inpatient
  and pregnacy)
• Providers were given a Chinese Menu for topics
• Attendees were given copies of the Utah Diabetes
  Management Handbook (2003) and applicable UDPRs

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Topics

• Utah Diabetes Practice Recommendations
• Management of diabetes in adults
• Glycemic management (types 1 and 2)
• Management of HTN and lipids
• Establishing and achieving targets for BP,
  lipids, feet and eyes
• Hyperglycemia in pregnancy
• Hyperglycemia in hospitalized patients
• Diabetes in children and adolescents
• http//health.utah.gov/diabetes/diabetespracticere
  commendations/udpr.htm
• Prior topics were also available

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ADA/EASD Consensus Statement (2008)
Tier 1 Well-validated core therapies
Step 2
Step 2
Step 3
Step 1
Tier 2 Less well-validated therapies
Step 2
Reinforce lifestyle interventions at every visit
and check A1C every 3 months until A1C is lt7 and
then at least every 6 months.
Adapted from Nathan DM et al. Diabetes Care.
2008311-11.
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ADA/EASD Consensus Statement (2008)
Tier 1 Well-validated core therapies
Step 2
Step 2
Step 3
Step 1
Tier 2 Less well-validated therapies
Step 2
Reinforce lifestyle interventions at every visit
and check A1C every 3 months until A1C is lt7 and
then at least every 6 months.
Adapted from Nathan DM et al. Diabetes Care.
2008311-11.
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Current Therapies

• The failure of clinicians and their patients with
  diabetes to implement currently available
  interventions aggressively and effectively isthe
  major barrier to good care. This problem will
  not be fixed by making more medications available.

Nathan D. NEJM 2007356437-440.
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UDPRs Glycemic Algorithm
Diagnosis initiate lifestyle modifications
(education) and start metformin
UDPRs, 2009
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Hypertension Algorithm
UDPRs, 2009
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Measurables

• UDPRs
• 38,500 downloads
• Interest and inquiries throughout the country
• Provider education
• Independent reviews, insurers and patient surveys
• The frequency of target measurement/documentation
  (lipids, BP, microalbumin, A1C, foot exam) has
  significantly increased
• Meeting established targets cannot be ascertained
  or has not changed

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Are We Having an Impact?
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Current State of Diabetes Management

• Targets
• A1C lt 7
• BP lt 130/80 mm Hg
• Total cholesterol lt 200 mg/dL or LDL lt 100 mg/dL

Study A1C Blood Pressure Cholesterol All 3 Met
NHANES1 37 35.8 51.8 7.3
BARI 2D2 33
1 Saydah et al. JAMA 2004291335-342 2 BARI 2D
Study Group. NEJM 20093602503-25-2515.
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