1 Type 2 Diabetes Type 2 Diabetes Performance Performance Improvement Initiative: Improvement Initiative: Chart Reviews Chart Reviews Lara Zisblatt Lara Zisblatt Boston University School of Boston University School of Medicine Medicine Boston, MA Boston, MA 2 Participants in the Program Participants in the Program 487 people registered 487 people registered 217 people started the program 217 people started the program 182 people started their initial chart review 182 people started their initial chart review 35 people completed their initial chart 35 people completed their initial chart review review 22 people are working on their Action Plans 22 people are working on their Action Plans 3 people completed the program 3 people completed the program 3 Examples of Action Plans Examples of Action Plans – Screening all medical records for patients with type 2 diabetes Screening all medical records for patients with type 2 diabetes every 6 months and notifying them by phone if they need an A1C every 6 months and notifying them by phone if they need an A1C test test – Creating an exercise plan worksheet for patients to write out Creating an exercise plan worksheet for patients to write out their exercise plans their exercise plans – Providing patient education about the importance of self Providing patient education about the importance of self- monitoring blood glucose levels; training the medical assistant monitoring blood glucose levels; training the medical assistant to check all meters to assure they are working properly and that to check all meters to assure they are working properly and that patients know how to use them patients know how to use them – Enrolling all type 2 diabetes patients in an education class Enrolling all type 2 diabetes patients in an education class available at the practice available at the practice – Creating a registry of all patients with type 2 diabetes that wo Creating a registry of all patients with type 2 diabetes that would uld track all tests necessary for these patients track all tests necessary for these patients – Use the diabetes care form to keep good records of patients with Use the diabetes care form to keep good records of patients with type 2 diabetes and an excel form to track patients type 2 diabetes and an excel form to track patients – Routine prescription for exercise Routine prescription for exercise – Diabetes flow sheets in all charts Diabetes flow sheets in all charts – Will move educational materials to exam rooms Will move educational materials to exam rooms
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Type 2 Diabetes Type 2 Diabetes Performance Performance
Lara ZisblattLara ZisblattBoston University School of Boston University School of
MedicineMedicineBoston, MABoston, MA
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Participants in the ProgramParticipants in the Program
487 people registered487 people registered
217 people started the program217 people started the program
182 people started their initial chart review182 people started their initial chart review
35 people completed their initial chart 35 people completed their initial chart reviewreview
22 people are working on their Action Plans22 people are working on their Action Plans
3 people completed the program3 people completed the program
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Examples of Action PlansExamples of Action Plans
–– Screening all medical records for patients with type 2 diabetes Screening all medical records for patients with type 2 diabetes every 6 months and notifying them by phone if they need an A1C every 6 months and notifying them by phone if they need an A1C testtest
–– Creating an exercise plan worksheet for patients to write out Creating an exercise plan worksheet for patients to write out their exercise planstheir exercise plans
–– Providing patient education about the importance of selfProviding patient education about the importance of self--monitoring blood glucose levels; training the medical assistant monitoring blood glucose levels; training the medical assistant to check all meters to assure they are working properly and thatto check all meters to assure they are working properly and thatpatients know how to use thempatients know how to use them
–– Enrolling all type 2 diabetes patients in an education class Enrolling all type 2 diabetes patients in an education class available at the practiceavailable at the practice
–– Creating a registry of all patients with type 2 diabetes that woCreating a registry of all patients with type 2 diabetes that would uld track all tests necessary for these patientstrack all tests necessary for these patients
–– Use the diabetes care form to keep good records of patients withUse the diabetes care form to keep good records of patients withtype 2 diabetes and an excel form to track patientstype 2 diabetes and an excel form to track patients
–– Routine prescription for exerciseRoutine prescription for exercise–– Diabetes flow sheets in all charts Diabetes flow sheets in all charts –– Will move educational materials to exam roomsWill move educational materials to exam rooms
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Action PlansAction Plans
•• Start simpleStart simple
•• Small changes can mean big improvements in patient Small changes can mean big improvements in patient carecare
•• Chart review is the first stepChart review is the first step
•• ““The tough part was getting started. Once I did The tough part was getting started. Once I did the first chart review, every review after became the first chart review, every review after became easier and faster.easier and faster.””
•• ““The chart review was a great way for me to The chart review was a great way for me to systematically look at my practice. I could see systematically look at my practice. I could see how I was actually doing and not just how I how I was actually doing and not just how I thought I was doing.thought I was doing.””
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Type 2 Diabetes ProgramType 2 Diabetes Program
Make a commitment to yourself and to your Make a commitment to yourself and to your patients to work toward improving care!patients to work toward improving care!
Complete the chart review as soon as possible Complete the chart review as soon as possible as your first step toward improvementas your first step toward improvement
For those of you who have completed chart For those of you who have completed chart reviews, please feel free to call us if you would reviews, please feel free to call us if you would like to discuss your plan for improvementlike to discuss your plan for improvement
If you have any questions, please email us at If you have any questions, please email us at [email protected]@bu.edu or call us at or call us at 617.638.4605617.638.4605
Applying What WeApplying What We’’ve ve Learned:Learned:
Patient Case Studies Patient Case Studies (Part 1)(Part 1)
–– Marked Marked acanthosisacanthosis nigricansnigricans and facial acneand facial acne–– No retinopathy or neuropathyNo retinopathy or neuropathy
SelfSelf--care behaviorcare behavior–– Little knowledge of diabetes or dietLittle knowledge of diabetes or diet–– No SMBGNo SMBG–– No exercise: too tired; works 50 hrs per weekNo exercise: too tired; works 50 hrs per week
What Are the Clinical Challenges What Are the Clinical Challenges With This Patient?With This Patient?
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Clinical Challenges: Clinical Challenges: Lack of diabetes educationLack of diabetes education
Goals:Goals:Nutrition counseling for Nutrition counseling for hyperlipidemiahyperlipidemia, weight loss, weight lossTeaching SMBG, DSMETeaching SMBG, DSME
Potential barriers to successful treatment:Potential barriers to successful treatment:–– Language/medical literacyLanguage/medical literacy–– Cultural/social beliefsCultural/social beliefs–– Economic concernsEconomic concerns–– Comprehension of her illness and treatmentComprehension of her illness and treatment–– Complex treatment programComplex treatment program–– Medication side effectsMedication side effects
Glyburide/metforminGlyburide/metformin increased increased incrementally to 5 mg/1000 mg twice per incrementally to 5 mg/1000 mg twice per day over next 6 monthsday over next 6 months
A1C A1C 7.7%7.7%
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What Would You Do Next?What Would You Do Next?
Wait another 3 months?Wait another 3 months?
Add another medication?Add another medication?
Applying What WeApplying What We’’ve ve Learned:Learned:
Patient Case Studies Patient Case Studies (Part 2)(Part 2)
John R. White, PAJohn R. White, PA--C, C, PharmDPharmDProfessor of PharmacotherapyProfessor of PharmacotherapyWashington State UniversityWashington State University
College of PharmacyCollege of PharmacySpokane, WASpokane, WA
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Mr. JMr. J
5252--yearyear--old Caucasian maleold Caucasian maleType 2 DM X 12 years Type 2 DM X 12 years Also followed for obesity, hypertension, Also followed for obesity, hypertension, elevated lipidselevated lipidsMeds:Meds:–– MetforminMetformin 1,000 mg bid (X 10 years)1,000 mg bid (X 10 years)–– GlimepirideGlimepiride 4 mg 4 mg qamqam (X 5 years)(X 5 years)–– Insulin Insulin glargineglargine 80 units 80 units qhsqhs–– EnalaprilEnalapril/HCTZ/HCTZ-- 10/25 10/25 qamqam–– AtorvastatinAtorvastatin 10 mg daily10 mg daily
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Mr. J Mr. J (cont(cont’’d)d)
Working as a CPA for a tax firmWorking as a CPA for a tax firm
Walks for about 30 minutes 3x weeklyWalks for about 30 minutes 3x weekly
Admits to eating whatever he likes; has Admits to eating whatever he likes; has gained 4 lbs within last year gained 4 lbs within last year
SMBG values: only measures fasting; SMBG values: only measures fasting; usually in the 120usually in the 120--130 range130 range
BP 134/90 mm HgBP 134/90 mm Hg
Weight 230 lb; BMI 36Weight 230 lb; BMI 36
A1C value today is 8.2% A1C value today is 8.2%
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What Would Your Next What Would Your Next Treatment Decision Be?Treatment Decision Be?
•• Start a diet and exercise program? Start a diet and exercise program?
•• Add Add preprandialpreprandial RAIA before the meal RAIA before the meal with the greatest glycemic excursion?with the greatest glycemic excursion?
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Mr. J: FollowMr. J: Follow--UpUp
RAIA added to regimen preRAIA added to regimen pre--lunch (started lunch (started with 4 units, eventually titrated to 8 units)with 4 units, eventually titrated to 8 units)
Patient consistently measures fasting and Patient consistently measures fasting and continues to periodically monitor precontinues to periodically monitor pre-- and and postprandial levelspostprandial levels
Patient was referred to a dietitian and has Patient was referred to a dietitian and has improved his dietimproved his diet
A1C value 3 months later is 7.2% A1C value 3 months later is 7.2%
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Ms. LMs. L
6262--yearyear--old female of Asian descentold female of Asian descentType 2 DM X 16 years Type 2 DM X 16 years Meds:Meds:–– MetforminMetformin 1,000 mg bid (X 10 years)1,000 mg bid (X 10 years)–– GlipizideGlipizide 20 mg 20 mg qamqam (X 15 years)(X 15 years)–– 70/30 insulin70/30 insulin--30 units 30 units qamqam and 20 units and 20 units qpmqpm
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Ms. L Ms. L (cont(cont’’d)d)
Currently teaches history in a middle Currently teaches history in a middle school school Eats a fairly consistent diet (low fat, Eats a fairly consistent diet (low fat, moderate protein and carbohydrate)moderate protein and carbohydrate)Participates in water aerobics twice Participates in water aerobics twice weekly, walks at lunchweekly, walks at lunchComplains of hypoglycemic episodes Complains of hypoglycemic episodes before and after lunch (50before and after lunch (50--80s), fasting 80s), fasting levels vary but are generally in the 150slevels vary but are generally in the 150sA1C value 9%A1C value 9%
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What Next ?What Next ?
•• D/C D/C glipizideglipizide or or metforminmetformin or both?or both?
•• Reduce the PM 70/30 dose?Reduce the PM 70/30 dose?
•• D/C 70/30 and start a longD/C 70/30 and start a long--acting acting analog?analog?
•• Reduce the AM 70/30 doseReduce the AM 70/30 dose
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Ms. L, Case continuedMs. L, Case continued
Meds:Meds:–– MetforminMetformin 1,000 mg bid (X 10 years)1,000 mg bid (X 10 years)–– GlipizideGlipizide 20 mg 20 mg qamqam (X 15 years)(X 15 years)–– 70/30 insulin70/30 insulin——discontinueddiscontinued–– DetemirDetemir initiated at a dose of 40 units initiated at a dose of 40 units
daily and provided with a titration daily and provided with a titration scheduleschedule
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Ms. L, Case continuedMs. L, Case continued
–– Patient is in contact with clinic via Patient is in contact with clinic via telephone over the next few weeks telephone over the next few weeks and continues to titrate and continues to titrate detemirdetemir(current dose 54 units)(current dose 54 units)
–– Returns to clinic in 3 monthsReturns to clinic in 3 months•• No complaints of hypoglycemiaNo complaints of hypoglycemia•• A1C 7.8A1C 7.8•• Fasting glucose levelsFasting glucose levels-- 130130--140s140s
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What Next ?What Next ?
•• Increase the Increase the glipizideglipizide dose?dose?
•• Continue the Continue the detemirdetemir titration and titration and obtain more blood glucose data?obtain more blood glucose data?
•• Start a RAIA with the largest meal?Start a RAIA with the largest meal?
Professor of MedicineProfessor of MedicineNew York Presbyterian New York Presbyterian
HospitalHospital--Columbia Columbia University Medical CenterUniversity Medical Center
New York, NYNew York, NY
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Improving CareImproving Care
““Need to shift from single intervention Need to shift from single intervention to change the behavior of individual to change the behavior of individual (providers) and focus instead on the (providers) and focus instead on the practice systems and organizations in practice systems and organizations in which (providers) work.which (providers) work.””
What gaps do you see between care as it is What gaps do you see between care as it is and care as it could and should be for and care as it could and should be for patients?patients?Identify a set of goals that you would like to Identify a set of goals that you would like to accomplish over a set time periodaccomplish over a set time periodUnderstand and implement improvement Understand and implement improvement techniques that can change the nature of techniques that can change the nature of care delivery in your practice for type 2 care delivery in your practice for type 2 diabetesdiabetes
Institute for Healthcare Improvement. Available at: Institute for Healthcare Improvement. Available at: http://http://www.ihi.orgwww.ihi.org/IHI. Accessed /IHI. Accessed February 23, 2009.February 23, 2009.
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Improving Diabetes Care in PracticeImproving Diabetes Care in Practice
Findings from the TRANSLATE trialFindings from the TRANSLATE trialObjectiveObjective:: To determine whether implementation of a To determine whether implementation of a
multicomponentmulticomponent organizational intervention can produce organizational intervention can produce significant change in diabetes care and outcomes in significant change in diabetes care and outcomes in community primary care practicescommunity primary care practices
R/ResearchR/Research: Group randomized controlled clinical trial : Group randomized controlled clinical trial involving involving 24 practices, implementing a number of interventions 24 practices, implementing a number of interventions using the ADA targetsusing the ADA targets
ConclusionConclusion: : Introducing . . . interventions in the primary care Introducing . . . interventions in the primary care setting significantly increases the percentage of type 2 setting significantly increases the percentage of type 2 diabetic patients achieving recommended outcomes. diabetic patients achieving recommended outcomes.
Peterson KA, et al. Peterson KA, et al. Diabetes CareDiabetes Care. 2008;31: 2238. 2008;31: 2238--2243.2243.
Management goals (every visit)Weight in pounds (every visit) BMI (calculated)A1C (2-4 times yearly) goal <7%BP (every visit) goal <130/80
LDL (yearly) goal <100 mg/dl
Urine microalbumin (yearly)Ophthalmology exam (once yearly)Foot exam with monofilamentReview of self-managementgoals (every visit)Glucose meter use and review oflog (every visit)Nutrition visit (once yearly)