Building a Diabetes Alliance: The Role of Provider Education Robert E. Jones, MD, FACP, FACE Professor of Medicine University of Utah School of Medicine.

Building a Diabetes Alliance:The Role of Provider Education

Robert E. Jones, MD, FACP, FACE

Professor of Medicine

University of Utah School of Medicine

and Friend of the UDPCP

The Problem

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

Distribution of Glycemic Abnormalities in US

CDC. Available at: http://www.cdc.gov/diabetes/pubs/estimates.htm

ADA. Facts and Figures. Available at: www.diabetes.org/main/application/commercewf?origin=*.jsp&event=link(B1)

Diabetes Complications

Retinopathy:

-Type 1: 60% at 10 years and ~100% at 20 years -Type 2: 20% at diagnosis and 60-80% at 20 years

Neuropathy:

-Types 1 and 2: >50% lifetime risk (approaches 100% with nerve conduction studies)

Nephropathy:

-Type 1: 40-50% at 20 years -Type 2: 5-10% at 20 years

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

Peripheral Vascular Disease:

-Lifetime risk of amputation is 8/1000

Building a Coalition

• Diabetes and it’s 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

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

The Importance of Early, Aggressive Glucose Control

6

6.5

7

7.5

8

8.5

9

9.5

0 1 2 3 4 5 6 7 8 9

Years

A1C

(%

)

Intensive GroupIntensive Group

ConventionalConventional Group Group

DCCT: Change in A1C Over Time

DCCT. N Engl J Med. 1993;329:977

DCCT: Diabetic ComplicationEvent Rates

•55.0

29.8

•23.9

•5.1

•13.413.0

7.9

16.4

5.02.50

10

20

30

40

50

60

RetinopathyProgression1

Laser Rx1 Micro-albuminuria2

Albuminuria2 ClinicalNeuropathy3

Conventional

Intensive

76%76%Risk ReductionRisk Reduction





Cu

mu

lati

ve I

ncid

en

ce (

%)

1. DCCT Research Group. Ophthalmology. 1995;102:647; 2. DCCT Research Group.Kidney Int. 1995;47:1703; 3. DCCT Research Group. Ann Intern Med. 1995;122:561

DCCT: Lifetime Benefits of Intensive Therapy

5.1

15.3

0 5 10 15 20Years

DCCT. JAMA. 1996;276:1409

Gain inComplications-

Free Living*

Gain in Length

of Life

*Significant microvascular or neurologic complication

EDIC Year

6

6.5

7

7.5

8

8.5

9

9.5

0 1 2 3 4

A1

C (

%)

Intensive TherapyIntensive Therapy

Conventional TherapyConventional Therapy

DCCT: Average A1C 4 Years After Trial

DCCT/EDIC Research Group. N Engl J Med. 2000;342:381

0

4

8

12

16

20

0 1 2 3 4

DCCT: Progression of Retinopathy 4 Years After Trial

Conventional TherapyConventional Therapy

Intensive TherapyIntensive Therapy

Cum

ula

tive In

cidence

(%

)

EDIC Year

Reprinted with permission from DCCT/EDIC Research Group. N Engl J Med. 2000;342:381

EDIC Reduction in CV Disease

Events were reduced 57% (12-79% [95% CI]; P=0.02)

NEJM 2005;353:2643-2654

DCCT EDIC

UK Prospective Diabetes Study Group: A1C

Reprinted with permission from UKPDS. Lancet. 1998;352:837-853.

6

7

8

9

0 1 2 3 4 5 6 7 8 9 10

Years

A1

C (

%)

Intensive Group

Conventional GroupConventional Group

Subjects with A1C <7%: 3 years 45% 6 years 30% 9 years 15%

Complications DCCT1,2 Kumamoto3

UKPDS4

9% 7% 9% 7% 8% 7%

Retinopathy 63% 69% 17%–21%

Nephropathy 54% 70% 24%–33%

Neuropathy 60% – –

Macrovascular disease 41%* –16%*

Control: Reduction In Complications

*Not statistically significant

1DCCT Research Group. N Engl J Med. 1993;329:977; 2DCCT Research Group. Diabetes. 1995;44:968;3Ohkubo Y et al. Diabetes Res Clin Pract. 1995;28:103; 4UKPDS Group. Lancet. 1998;352:837

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 (RR=0.76; p=0.001)

– Diabetes Endpoint (RR=0.91; p=0.04)

– Death from Diabetes (RR=0.83;p=0.01)

– All Cause Mortality (RR=0.87;p=0.007)

– Myocardial Infarction (RR=0.85;p=0.01)

Holman RR et al. NEJM 2008;359:1577-1589

Pre-Study Glyemic Exposure and Microvasular Outcomes

10

20

30

40

7.1 57.6 108.1

Glycemic Exposure*

Com

plic

atio

n R

isk

Red

uctio

n (%

)

ADVANCE

*Glycemic Exposure=Duration of Diabetes x Study Entry A1C

NeuropathyNephropathy

Retinopathy

Jones RE, Wadweker D. In press, 2010.

UKPDS VADT

** Statistically Significant

**

**

**

**

**

Utah Diabetes Prevention and Control Program:

Provider Education

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

First Attempt (~1995)

7.2---It’s Up to You!BP 140/90 mm HgLDLc 130 mg/dl

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

The Perfect Storm

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)

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

ADA/EASD Consensus Statement (2008)

Tier 1: Well-validated core therapies

Tier 2: Less well-validated therapies

Adapted from Nathan DM et al. Diabetes Care. 2008:31;1-11.

Reinforce lifestyle interventions at every visit and check A1C every 3 months until A1C is <7% and then at least every 6 months.

Step 1Step 2

Step 3

At diagnosis:

Lifestyle+

Metformin

Lifestyle + Metformin+

Basal Insulin


Sulfonylurea


Intensive Insulin


Pioglitazone


GLP-1 agonist


Pioglitazone+

Sulfonylurea


Basal Insulin

Step 2

Step 2

ADA/EASD Consensus Statement (2008)

Tier 1: Well-validated core therapies

Tier 2: Less well-validated therapies

Adapted from Nathan DM et al. Diabetes Care. 2008:31;1-11.

Reinforce lifestyle interventions at every visit and check A1C every 3 months until A1C is <7% and then at least every 6 months.

Step 1Step 2

Step 3

At diagnosis:

Lifestyle+

Metformin


Basal Insulin


Sulfonylurea


Intensive Insulin


Pioglitazone


GLP-1 agonist


Pioglitazone+

Sulfonylurea


Basal Insulin

Step 2

Step 2

UDPRs Glycemic Algorithm

UDPRs, 2009

Possible weight increase, Greater A1C lowering (>1%), Principally

reduce FPG

Possible weight increase, Greater A1C lowering (>1%), Principally

reduce FPG

Basal insulin (most

effective)

Basal insulin (most

effective)

Sulfonylureas (least

expensive)

Sulfonylureas (least

expensive)

TZDs (no

hypoglycemia)

TZDs (no

hypoglycemia)

Incretomimetics (most weight

loss)

Incretomimetics (most weight

loss)

DPP-IV inhibitors

(least effective)

DPP-IV inhibitors

(least effective)

Possible weight loss (or neutral), Lesser A1C lowering (<1%),

Principally reduce PPG

Possible weight loss (or neutral), Lesser A1C lowering (<1%),

Principally reduce PPG

Not included: Amylomimetic

s; Meglitinides;

AGIs

Not included: Amylomimetic

s; Meglitinides;

AGIs

Diagnosis; initiate lifestyle modifications (education) and

start metformin

Diagnosis; initiate lifestyle modifications (education) and

start metformin

-Patient’s Goals -Fasting v Postprandial

Target (A1C) -Weight Effects -

Cost -Relative Efficacy -Age -Cardiac, Renal and

Hepatic Function

-Patient’s Goals -Fasting v Postprandial

Target (A1C) -Weight Effects -

Cost -Relative Efficacy -Age -Cardiac, Renal and

Hepatic Function

Individually Assess Patient Individually Assess Patient

Hypertension Algorithm

UDPRs, 2009

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

Are We Having an Impact?

Current State of Diabetes Management

• Targets– A1C < 7%

– BP < 130/80 mm Hg

– Total cholesterol < 200 mg/dL or LDL < 100 mg/dL

1 Saydah et al. JAMA 2004;291:335-342

2 BARI 2D Study Group. NEJM 2009;360:2503-25-2515.

Study A1C Blood Pressure

Cholesterol All 3 Met

NHANES1 37% 35.8% 51.8% 7.3%

BARI 2D2 33%

Building a Diabetes Alliance: The Role of Provider Education Robert E. Jones, MD, FACP, FACE Professor of Medicine University of Utah School of Medicine.

Documents

years dcct

dcctedic slide

years type

dcct research group

problem slide

udpcp slide

years a1c

diabetes alliance