The Big 3 UIM Resources. Learning objectives Highlight 3 changes to the treatment of Type 2 DM in the 2013 ADA Guidelines Name two pharmacy chains offering.

The Big 3UIM Resources

Learning objectives• Highlight 3 changes to the treatment of Type 2 DM in the 2013

ADA Guidelines • Name two pharmacy chains offering free oral medications for

diabetes• Outline the JNC-7 treatment algorithm for essential

hypertension• Identify 3 UIM resources to assist with the management of

diabetes, hypertension and obesity• Recognize that overweight and obesity are largely

undiagnosed in the US• Assign appropriate follow-up intervals for patients with

uncontrolled diabetes and hypertension

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8000 UIM Chronic Diseases

Systolic Blood Pressure LDL A1C Hydroxyurea

March 2013 SBP March 2013 LDL March 2013 A1C Mar-13

# of visits 2621 # of visits 1724 # of visits 1140 # patients on Hydroxyurea

57Mean SBP: 133.28 Mean LDL: 100.54 Mean A1C: 6.97

< 140 1758 67% < 130 1403 81% < 8% 906 79% % increase 6%

≥ 140 863 33% ≥ 130 321 19% ≥ 8% 234 21%

*65 visits missing SBP not included

February 2013 SBP February 2013 LDL February 2013 A1C Feb-13



< 140 1664 65% < 130 1322 81% < 8% 833 79% % increase 8%

≥ 140 905 35% ≥ 130 308 19% ≥ 8% 218 21%


January 2013 SBP January 2013 LDL January 2013 A1C Jan-13



< 140 1926 67% < 130 1544 81% < 8% 1034 81% % increase 19%

≥ 140 931 33% ≥ 130 352 19% ≥ 8% 250 19%


December 2012 SBP December 2012 LDL December 2012 A1C Dec-12



< 140 1482 64% < 130 1230 83% < 8% 783 79% % increase 14%

≥ 140 816 36% ≥ 130 251 17% ≥ 8% 207 21%


November 2012 SBP November 2012 LDL November 2012 A1C Nov-12



< 140 1689 67% < 130 1280 82% < 8% 836 80% % increase 6%

≥ 140 840 33% ≥ 130 288 18% ≥ 8% 208 20%


October 2012 SBP October 2012 LDL October 2012 A1C Oct-12



< 140 1776 68% < 130 1362 83% < 8% 859 77% % increase 13%

≥ 140 842 32% ≥ 130 279 17% ≥ 8% 262 23%


Quality Measures

Case study• 76 yo m with AODM x 20 years, HTN, dyslipidemia. He has

never smoked cigarettes, and there is no family history of early coronary disease. A1C 9.4% at last visit 4 months ago - Metformin increased from 500 mg bid to 1000mg bid. Two weeks ago he woke up with diaphoresis and weakness, ate a sandwich and felt much better.

• He is taking lisinopril and atorvastatin – BP 145/90; LDL 134, BMI is 28. States that he had been seeing a doctor in Walterboro for “years” and he does not think his diabetes has ever been under good control. He did not bring in pill bottles. States he has been out of the metformin for “about a week”.

Case studyWhat is this patient’s A1C goal?

1. <6%2. <7%3. <8%4. <10%

ADA Guidelines

Lowering A1C to below or around 7%has been shown to reduce microvascularcomplications of diabetes, andif implemented soon after the diagnosisof diabetes is associated withlong-term reduction in macrovasculardisease. Therefore, a reasonable A1Cgoal for many nonpregnant adults is7%.

ADA Guidelines

Providers might reasonably suggestmore stringent A1C goals (such as6.5%) for selected individual patients,if this can be achieved withoutsignificant hypoglycemia or other adverseeffects of treatment. Appropriatepatients might include those with shortduration of diabetes, long life expectancy,and no significant CVD.

ADA GuidelinesLess stringent A1C goals (such as8%) may be appropriate for patientswith a history of severe hypoglycemia,limited life expectancy, advanced microvascularor macrovascular complications,extensive comorbid conditions,and those with long-standing diabetesin whom the general goal is difficult toattain despite diabetes self-managementeducation (DSME), appropriate glucosemonitoring, and effective doses ofmultiple glucose-lowering agents includinginsulin.

Case Study, cont.You discuss the patient’s A1C goal, and stress the importance of taking his metformin every day. He states he is having trouble buying this and all of his testing supplies. Which of the following pharmacies has many free oral diabetes medications?

1. Walgreen’s2. Walmart3. Harris Teeter4. CVS

Free Oral Diabetes Med (metformin and XR, glipizide)• Harris-Teeter• Publix• Bi-Lo

Case Study, cont.According to the 2013 ADA guidelines, how often should he be checking fingerstick glucoses at home?

1. Every morning fasting2. 2-3 times per day

rotating times3. Only when symptomatic4. Every evening before

bed

ADA 2013 Guidelines

“When prescribed as part of a broadereducational context, SMBG results maybe helpful to guide treatment decisionsand/or patient self-management forpatients using less frequent insulin injectionsor noninsulin therapies. ”

What is this patient’s BP goal?

1. Systolic <1202. Systolic <1403. Diastolic <804. Diastolic <905. 1 and 36. 2 and 3

ADA BP GuidelinesPeople with diabetes and hypertensionshould be treated to a systolic bloodpressure goal of <140 mmHg. (B)

Lower systolic targets, such as < 130mmHg, may be appropriate for certainindividuals, such as younger patients, ifit can be achieved without unduetreatment burden. (C)

Patients with diabetes should be treatedto a diastolic blood pressure < 80mmHg. (B)

Lifestyle Modification and Hypertension• What diet recommended by JNC-7 has been shown to effect

reductions in blood pressure similar to single drug therapy?

1. Weight Watchers2. Atkin’s diet3. DASH diet4. Southbeach diet5. Jenny Craig

DASH diet• Dietary Approaches to Stop Hypertension eating plan• www.nhlbi.nih.gov• 64 pages of instruction• Vegetables, lean meat, lowfat dairy, nuts and seeds

http://www.nhlbi.nih.gov/

JNC-7 Treatment• In general, what should be the first choice of medication class

for most patients with Hypertension?1. ACE-I2. Beta blockers3. Calcium channel blockers4. Thiazide diuretics5. Spironolactone

JNC-7 Treatment• “Thiazide-type diuretics should be used as initial therapy for

most patients with hypertension, either alone or in combination with one of the other classes (ACEIs, ARBs, BBs, CCBs) demonstrated to be beneficial in randomized controlled outcome trials.”

Case StudyWhen would you bring the patient back to be seen?

1. 1 month2. 3 months3. 6 months4. PRN

JNC-7• “Once antihypertensive drug therapy is initiated, most

patients should return for follow-up and adjustment of medications at approximately monthly intervals until the BP goal is reached. More frequent visits will be necessary for patients with stage 2 hypertension or with complicating comorbid conditions.”

Adherence• In patients with chronic medical conditions, what percent is

non-adherent after 1 year of treatment?1. 10%2. 20%3. 30%4. 50%5. 70%

Patient Barriers to Adherence• Complexity: “There are so many pills, I can’t keep them straight!”• High cost: “I can’t afford my medicine so I will only take half a pill

today.”• Difficulty remembering schedules: “I forget to take them.”• Lack of understanding: “Why do I need them?”• Not feeling sick: “I feel fine. I don’t need them.”• Side effects: “The yellow pills make me feel sick and I heard the

blue pills give you liver problems.”• Embarrassment/Stigma: “I don’t want my friends to know that

I’m sick.”• Depression: “I don’t care…. What’s the point?”• Health literacy: “I can’t understand these instructions!”• Belief systems: “My sister took insulin, then had her leg

amputated.”

Perceptions of Overweight/Obese• According to NHANES data from 16,720 American patients,

what percentage of overweight women perceived themselves as having the right weight?

1. <5%2. 5-10%3. 10-20%4. 20-30%5. 30-40%

International Journal of Obesity (2011) 35, 1063–1070; published online 2 November 2010

NHANES Data• A large proportion of overweight individuals (23% women,

48% men) perceived themselves as having the right weight.


NHANES, cont.• What percentage of overweight patients had ever received a

diagnosis of being “overweight” from a health care professional?

1. 10%2. 20%3. 30%4. 50%5. 90%


Healthcare Advice Matters• Also, 74% of overweight and 29% of obese individuals never

had an HCP diagnosis of overweight/obesity.• Among overweight/obese adults, those with an health care

provider diagnosis of overweight/obesity were more likely to diet (74 versus 52%), exercise (44 versus 34%), or pursue both (41 versus 30%, all P<0.01) than those who remained undiagnosed.

• Conclusion: HCPs have unused opportunities to motivate their patients to control and possibly lose weight by correcting weight perceptions and offering counseling on healthy weight loss strategies.

• International Journal of Obesity (2011) 35, 1063–1070; published online 2 November 2010

Weight Loss Goals• What percent of the patient’s body weight does he need to

lose to reduce the severity of his hypertension and diabetes?1. 5%2. 10%3. 15%4. 20%5. 25%

Weight Loss Goals• “The rationale for the initial 10-percent goal is that a

moderate weight loss of this magnitude can significantly decrease the severity of obesity associated risk factors.”

Consistent Message• Cut out sugary beverages• Reduce the “white” on your plate• Walk every day • Eat more vegetables• Stop smoking• Take your medicines as they are prescribed

UIM Resources• Aging Q3 – Clinical Tools: ADA 2013 Guidelines• PharmD/CDE – adjust prescribed oral meds/insulin without

orders; start new meds/insulin with MD• RN and PharmD/CDE – can teach glucose testing, insulin,

complications, goals• RN Case Manager – phone follow-up of glucoses, lifestyle, etc.• Dietician – referral - Carb counting • MSW – help for medications and supplies, insurance,

counseling• Patient Assistance – next to RT pharmacy; medications for

uninsured /underinsured patients

Other Resources• MUSC Weight Management (free studies)• Quit for Keeps, SC Tobacco Quitline• Work Programs• Weight Watchers (meeting or online)• Overeaters Anonymous• YMCA• Recreation Departments• Lighten Up Charleston• Lowcountry Senior Centers• 211 United Way (Diabetes Education)• WIC Program can be used at Farmer’s Markets (Downtown,

MUSC, Mt Pleasant, Summerville)

The Big 3 UIM Resources. Learning objectives Highlight 3 changes to the treatment of Type 2 DM in the 2013 ADA Guidelines Name two pharmacy chains offering.

Documents

mean sbp

mean a1c

mean ldl

visits missing sbp

patients a1c goal

hypertension slide

uncontrolled diabetes

management of diabetes