Diabetes Mellitus

Diabetes Outreach Program

Our philosophical orientation makes us vigilant about the value of health care – a relationship of the quality, cost-effectiveness and efficacy of both therapeutic intervention and prevention. One area of special interest in this regard is disease state management programs (DSMs).

Disease State Management Programs

DSMs are concentrated efforts to reach out to at-risk populations; they help organized health care delivery systems and their constituencies focus attention on clinical processes and outcomes. DSMs are becoming available for cardiovascular disease, congestive heart failure, diabetes, asthma, depression, arthritis, epigastric pain and peptic ulcer disease, stroke, AIDS, hemophilia, cancer, hypertension and otitis media.

DF: Disease State Management (DSM)

With a micro-focus on a specific disease state and individual patient’s needs, DSM programs identify, support and promulgate the best clinical processes across the entire spectrum of health care. Broad in scope, their macro objective is to improve the value of health care through prevention, treatment and outcomes management, continuously. DSMs help with case finding, case management (outreach), compliance and communication (feedback). Standards are also part of disease state management programs; they define what can and should be done for a particular disease state

Criteria for Choosing DSMs

1) Do-able -- there is enough of a consensus for an evidence-based approach

2) Opportunity -- serious money can be saved by managing the patient’s care needs, better

3) Customers’ Needs – outcomes are measured, compared, and reported

Caveats and Warnings About DSMs

- Beware DSMs (esp. those supported by the Pharmaceutical and Research industry) as being merely: value-added marketing efforts, ploys to get preferred status of their me-too formulation, foci on parts of a disease or diseases out of context, and self-serving research.

- Remember the balloon -- squeeze in one place; it inflates elsewhere. Also called the offset effect or tradeoffs in health care, be vigilant that cost reduction does not compromise quality or access, that unit cost reduction does not increase frequency, and that reducing the cost of a piece does not increase costs, overall.

- Although unlikely to be overt or even conscious, there is evidence of racism health care DSMs and other programs; this is evidenced by disparities in the rates of certain procedures.^[1] This is also a call for medical schools to come to terms with the need to enhance culturally sensitive training. That is, in a survey of 78 U.S. medical schools, only 13 offered courses designed to improve understanding of diverse ethnic groups; all but one of those courses were elective.^[2]

- Managed Care organizations cannot, shall not, do not practice medicine; this is a violation of the rule against the corporate practice of medicine.

- Savings should inure to the customer.

- Non-prescriptive, dynamic guidelines as living documents that require buy in and do not address cost issues to the exclusion of quality or customer (real or perceived) need.

Diabetes mellitus (DM) is a special DSM because of three reasons: 1) A recognized standard of care has emerged. 2) The disease state, DM is highly amenable to both treatment and prevention. 3) Data are available from the claims trail to help manage most disease states, however, these data require translation into useful clinical information. Survey data such as from patient satisfaction, clinical outcomes, quality of life and degree of function or productivity surveys can be used to supplement them.

Diabetes Mellitus

The purpose of any diabetes management program is to identify those at risk for the complications of diabetes mellitus (DM) and reduce morbidity and complications, if not death from its ravages. The techniques used to achieve these objectives include the identification of patients being treated, those at risk identified through screening techniques, and by reviewing ‘slippage’ -- patients seen in the emergency room, hospital or having complications of DM that could have been addressed in the ambulatory setting.

It is known from the Diabetes Control and Complications Trial (DCCT)^[1] that intense control (intervention) can reduce or delay diabetic complications and improve quality of life; correspondingly it can reduce the diabetic’s use of emergency departments, urgent care facilities and hospitalizations. The Diabetes Outreach Program is predicated on the findings of the DCCT, extending the capability and capacity of the practitioner in disease state management (DSM). _____ wants its affected members to receive the education and support necessary to comprehend the basic pathology of DM; it’s natural history, consequences, preventive measures and the coping skills necessary to work with the disease. This Program is intended to introduce risk-modifying behaviors for all afflicted or at-risk patients including diet, exercise, and cholesterol control, the proper use of oral and injectable medications. It reviews and encourages the self and medical monitoring of blood glucose levels in insulin-dependent and other diabetics in order to achieve homeostasis. Finally, the program is designed to improve the patient’s self-management skills and ability to navigate in a health care delivery system.

Intense control of diabetes warrants a multidisciplinary, team approach that may include the following health care practitioners: primary care physicians, certified diabetes educators (CDEs are usually RNs or registered dieticians), ophthalmologists or optometrists, diabetologists or endocrinologists, podiatrists, utilization or case management nursing staff, and social workers.

The Diabetes Outreach Program -- Description

Patients can self-refer or be referred by their PCP, a specialist or community outreach programs.

1. The Diabetes Outreach Program includes a comprehensive, two-hour review of the pathophysiology of diabetes mellitus; it reinforces education about primary treatments and prevention including: weight management, exercise, basic nutrition/meal planning, complications management, sick day management, medical interventions in identifying low and high blood sugar states, etc.

2. Member education will be focused on self-directed care, empowering the member to be successful with his or her PCP. These programs will be a joint effort of community resources and _____ PCPs and specialists physicians, particularly endocrinologists/diabetologists as mention earlier.

3. Diabetes Educators – Referral to a participating Heritage CDE. This referral will be generated upon Program registration and is valid for 45 days from the date of each authorization. PCPs are notified about members who do not schedule appointments within 45 days of receipt of referral.

4. Foot Care – _____ recognizes the American Diabetes Association’s (ADA’s) recommendation about routine and preventive foot examinations. Therefore, those members who are considered at risk, especially those with known peripheral vascular disease (PVD) and/or neuropathy, structural abnormalities, abnormal gait or a history of foot and lower extremity problems should be referred to a qualified, network podiatrist. Patients who smoke, have poor glucose control or who have experienced foot injury are especially at risk.

5. Eye Care – Referral to Optometrists/Ophthalmologists is medically important and should be consummated on a yearly basis. PCPs should be aware of this standard and help Heritage learn when this occurs as not every referral to specialists in this field generates a claim (i.e., sometimes patients choose to see a non-network provider for some of their care.) Should this care not be documented, Heritage will survey a sample of its at-risk members and give feedback about compliance with this standard to the physician-of-record.

6. Testing – Hemoglobin A-1-Cs are essential at baseline and quarterly thereafter.

7. On-Going Support – _____ members are encouraged to participate in programs conducted by local community resource groups such as the ADA.

8. Follow-up on all Diabetes Outreach Program Participants – All participants will receive follow-up phone calls at one month and at three-month intervals to gauge their reaction to this program and their rates of compliance.

Outcome Measurement

Outcomes can be measured subjectively by the SF-36 with modification or enhancement for diabetes mellitus. The member following their first diabetes education class and quarterly (to coincide with the HGB A-1-C measurement) can complete this questionnaire, thereafter.

Objective measurements include: Hgb A-1-C levels, initially and quarterly; dilated retinal examinations, yearly; body mass index (BMI = height in cm²/weight in Kg.); blood pressure; microalbuminuria; Cr.; peripheral pulse palpation; and complications of DM checked periodically but at least semi-annually.

Improving Compliance with DSMs

Improving compliance with difficult treatment regimes can be difficult. One technique that has had some success in this regard is establishing, as part of a diabetic DSM, a "contract" with the afflicted or at-risk patient. The technique is not a legal arrangement or obligation. Rather, it is designed to improve adherence to a diabetes management regime through improved understanding. The "contract" establishes a moral, not a financial obligation; it serves to help motivate the patient to enter into a special, more intense, clearly defined arrangement.

It's a compliance issue in the final analysis that establishes goals and parameters for both the health care organization in terms of service that should be provided and the informed patient in terms of their self-care responsibilities.

per·sua·sion (per-swa"zhun) n. 1. The act of persuading or the state of being

persuaded. 2. The ability or power to persuade. 3. A strongly held opinion; a

conviction. 4.a. A body of religious beliefs; a religion. b. A party, faction,

or group holding to a particular set of ideas or beliefs. 5. Informal. Kind;

sort.

un·der·stand·ing (un"der-st²n"d1ng) n. 1. The quality or condition of one who

understands; comprehension. 2. The faculty by which one understands;

intelligence. 3. Individual or specified judgment or outlook; opinion. 4.a. A

compact implicit between two or more people or groups. b. The matter implicit in

such a compact. 5. A reconciliation of differences; a state of agreement.

Outline of the Diabetes Mellitus DSM

Hypothesis: tighter control; healthier patient

1. Those who might benefit

1. Claims and/or pharmacy data bases are used to identify the at-risk population

(1) L

(1) Insulin

(1) Humulin (DNA)--shorter onset and briefer duration

(2) Purified pork (preferred in children--slower onset/more even duration

(3) Iletin (beef/pork), being phased out

(2) Oral sulfonureas (Heritage interested in pushing such patients to insulin (in keeping with the DCCT, notwithstanding items c-e, below

(3) Glipside (Glucotrol; Phizer)

(4) Glyburide (Micronase; Upjohn), Diabeta; Hoechst)

(5) Alpha-glucosidase (Upjohn)

(2) Know full well that about one-half the type II=s are not even diagnosed

(3) Define the population who may possibly benefit from the DSM

(1) E.g., gestational diabetes, not the comfortable 80 year old

2. Opportunity of _____ as an integrated health care system

1. Better communication, better care

2. Better access and the concept of the Ateachable moment

(1) Active patient participation

3. Better coordination, a multidisciplinary approach

4. Processes of care

(1) E.g., Maternal care elements

(1) glycosolated hemoglobins, thyroid, renal scan and lipid laboratory assessments

(2) Opthalmologic and ECG on selected patients

(2) E.g., Fetal diagnostic and care elements

(1) ultrasound (level three)

(2) serum a-fetoprotein, biophysical measurements (e.g., fetal movement records, fetal heart rate testing), lung maturation indices

5. Outcomes of care

(1) hyperbilirubinemia, hypoglycemia, Type I diabetes, respiratory distress, polycythemia, hypocalcemia

(2) birth defect rates

(3) congenital anomalies

(4) fetal death rates

(5) preeclampsia, preterm labor, chronic hypertension, pylonephritis, ketoacidosis, polyhydramnios

(6) macrosomia, C-section

6. Monitor outcomes, e.g., maternal and neonatal morbidity, cost-effectiveness, etc.

3. Infrastructure Issue: Build a database (DPS) to permit case finding and tracking;

1. Identification of patients through pharmaceutical and clinical data bases (DBs)

2. Prospectively pick-up patients

(1) Premorbid Conditions or states

(1) Hgb A1c rising trend or high absolute values

(1) lower HgbA1c associated with reduction in fetal malformation rate and prematurity

(2) Microalbinuria

(3) Early onset

(4) Emotional liability

(5) Mild hypertension

(2) Before conception?

(1) Population-based

3. Materials supplied by vendor who can be trusted to not be self-serving

(1) Patient Education materials

(1) Nutritional counseling, diets, monitoring

(2) Provider Educational materials, especially

(1) those that test changes in provider behavior (acceptance of a standard)

(3) Compliance programs

(4) Case Management, Outreach

(5) Outcomes Studies

(1) HgbA1c

(1) More practical than evaluating diary of blood glucose levels (Q.I.D, plus)

(2) Nutritional counseling

(3) Increased frequency of insulin dosing

(4) Handling complications

(1) Retinopathy

(2) Nephropathy; use of ACE inhibitors

(3) CAD; influence of medical v. surgical management

(4) Hypertension; impact of Rx, exercise

(5) Concomitant steroid uses a confound

(6) Vendors

(1) Diabetes Treatment Centers of America (relatively neutral)

(1) Network model

(2) Center of excellence model (preliminary discussion with Westchester)

(2) Phizer (very impressive patient ed. materials--Diabetes Control Network)

(3) Ely Lilly

(4) Bristol-Meyers Squibb

(5) Various academic centers

4. Goal--see hypothesis

5. Objectives of case and DSM--intervening and monitoring disease-state

1. Decrease acuity of illness (ER)

2. Decrease in morbidity associated with chronicity

3. Risk (cost of care); risk of under treatment

(1) Prevent high cost complications; compression of morbidity/mortality

4. Improve quality of life

5. Reduce voluntary disenrollments

6. Development of a Patient/Physician contract

1. (See Attachment #1 from the AAACE Guidelines for the Management of Diabetes Mellitus,@ Jacksonville Florida: May 1, 1994. Endocrine Practice 1(2):149-57, March/April 1995.)

7. Self-Responsibility/Self-Care--the primary component of diabetes care

(See Clinical Practice Guideline on Diabetes from Humana, attached)

1. Self-monitoring

2. Education (Knowledge)

3. Attention to all aspects of daily living

(1) Diet/Nutrition

(2) Exercise

(3) Skin Care

(4) Early warning signs

4. Doctoring (annual and periodic)

(1) Blood glucose monitoring

(2) Cardiovascular, renal and retinal attention

(3) Immunizations

5. Compliance-Rx

(1) Ability to avoid hypoglycemia, yet have tight control