NurseDirected Diabetes Care
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Slide 1 :
REDUCING HEALTH DISPARITIES WITH NURSE-DIRECTED DIABETES CARE: CARVE OUT VS CARVE IN MODELS Mayer B. Davidson, MD Professor of Medicine Charles Drew University David Geffen School of Medicine at UCLA
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EFFECT OF NURSE-DIRECTED DIABETES CARE IN MINORITY PATIENTS IN A PRIMARY CARE SETTING Mayer B. Davidson, MD Professor of Medicine Charles Drew University David Geffen School of Medicine at UCLA
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The Economist, February 17th -23rd, 2007 DIABETES: AN AMERICAN EPIDEMIC
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NEW PATIENTS WITH DIABETES New patient each 21 seconds = 3 per minute 1440 minutes per day x 3 = 4,320 patients per day 365 days per year x 4,320 = 1,576,800 new patients with diabetes per year
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IT IS ESTIMATED THAT ONE IN THREE CHILDREN BORN IN THE UNITED STATES TODAY WILL DEVELOP DIABETES IN THEIR LIFETIME !!!
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African-Americans – 1 in 2 Latinos - ???? (probably similar)
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Diabetes Complications 2 in 3 people with diabetes die of heart disease or stroke Diabetes is the #1 cause of adult blindness Diabetes is the #1 cause of kidney failure Diabetes causes more than 60% of non-traumatic lower-limb amputations each year NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2005.
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DIABETES IN MINORITIES Compared to Caucasians, both African-Americans and Latinos had more/higher: Retinopathy DKA Microalbuminuria A1C levels Clinical proteinuria Poor care End stage renal disease Mortality Lower extremity amputations
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DIABETES IN MINORITIES However, with the exception of a slight increase in renal disease, complications in African-Americans and Latinos were similar to Caucasians in a Kaiser or a Veterans Administration medical care system. Thus, there are little intrinsic racial/ethnic differences to account for these disparities. Karter et al: JAMA 287: 2519, 2002 Jha et al: JAMA 285:297, 2001
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American Diabetes Association Standards of Care Process Measures Number of tests/exams performed per period of time or whether specific treatment being given. Outcome Measures Actual results of the test or the effect of the treatment.
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Hb A1c every 6 months if <7% goal attained; every 3 months if greater LDL Cholesterol yearly or more often <100 mg/dl as necessary 3. Triglycerides yearly or more often <150mg/dl* as necessary *Once LDL cholesterol at goal, the NCEP suggests considering treatment for triglyceride concentrations >200 mg/dl if the non-HDL cholesterol is >130 mg/dl. Frequency Goal CURRENT AMERICAN DIABETES ASSOCIATION GUIDELINES
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4. Renal profile – yearly or more often as necessary a) Dipstick for proteinuria (1) if > 1+ positive, (and not due to an other identifiable cause, e.g., infection, bleeding) ACE inhibitor unless contraindicated; serum creatinine every 6 months: (2) if dipstick negative or trace; evaluation for microalbuminuria; if positive and confirmed, ACE inhibitor unless contraindicated.
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5. Blood pressure – minimum every 6 months (or more often as necessary) as long as target level of <130/80 mm Hg met. 6. Visits-minimum every 6 months as long as all goal levels met; otherwise a contact at least every 3 months. 7. Eye exam-yearly dilated funduscopic exam in all diabetic patients except type 1 patients within 5 years of diagnosis.
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8. Foot examinations- minimum every 6 months or more often as necessary. 9. Weight – minimum every 6 months. 10. Smoking assessment – yearly; if current smoker, counseling or referral for cessation. 11. Aspirin (75-325 mg/day) in patients >30 years of age with macrovascular disease or one or more cardiovascular risk factors (unless contraindicated).
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NURSE-DIRECTED DIABETES CARE IN A MINORITY POPULATION (CARVE OUT MODEL) Specially trained registered nurse followed detailed treatment algorithms Endocrinologist (MBD) available by phone Endocrinologist met with nurse once per week to sign charts and review any problems (mostly administrative) Clinics two evenings and Saturday mornings
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Patient Recruitment and Retention
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DEMOGRAPHICS Number of Patients – 367 Age – 51.2 ± 10.6 years Disease Duration – 6.9 ± 6.6 years Females – 71% Race/Ethnicity African-American - 80 (22%) Caucasian - 2 (0.5%) Latino - 283 (77%) Asian - 2 (0.5%) Type 1 diabetes – 2 (0.5%) Type 2 diabetes – 365 (99.5%)
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EDUCATION AND INCOME LEVELS Subset of Latino patients (107/283) queried Education (n=102) – 73% had 6th grade or less Household Income (n=63) – 95% <$25,000
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PROCESS MEASURES Overall, all ADA-recommended process measures were carried out significantly more (P<0.001) during nurse-directed diabetes care (98%) than during the year prior (54%).
Slide 21 :
OUTCOME MEASURES (Hb A1C - %) Usual Care* Nurse-Directed Care P Value (n=303) (n=364)+ Initial 9.3 ± 2.5 8.8 ± 2.5 <0.001 Final 8.7 ± 2.4 7.0 ± 1.3 <0.001 Change -0.6 ± 2.8 -1.8 ± 2.6‡ <0.001 P Value <0.001 <0.001 *Prior year +3 patients had hemoglobinopathies ‡ n= 361 (3 patients had only one test)
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A1C LEVELS 9.3 +2.6 8.8 +2.5 7.0 +1.3 8.8 8.4 P <0.001 for similarly marked comparisons, * and ** 6.7
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OUTCOME MEASURES(Hb A1C – Percent meeting goal of <7.0%) Usual Care* Nurse-Directed Care P Value (n=303) (n=361) Initial 17% 28% <0.001 Final 28% 60% <0.001 P value <0.001 <0.001 * Prior year
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OUTCOME MEASURES(LDL Cholesterol – Percent meeting goal*) Usual Care** Nurse-Directed Care P Value (n=244) (n=366) Initial 51% 50% NS Final 50% 82%† <0.001 P Value NS <0.001 *Goal <130 mg/dl in year 1 and <100 mg/dl in years 2 and 3 **Prior year †352 patients had at least 2 values
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TOTAL URGENT CARE AND EMERGENCY ROOM VISITS AND HOSPITALIZATIONS Year Prior Nurse-Directed Care Urgent Care 30 19 ER 49 25 Hospitalizations 16 8 Total 95 52 45% reduction (P <0.001)
Slide 26 :
PREVENTABLE DIABETES-RELATED URGENT CARE (UC) AND EMERGENCY ROOM (ER) VISITS AND HOSPITALIZATION Causes UC/ER Visits Hospitalizations Year Prior DMCP Year Prior DMCP Metabolic* 11 1 2 0 Infection** 4 4 4 1 Total 15 5 6 1 *Hyperglycemia, hypoglycemia, DKA **Foot ulcer, cellulitis, fungal
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TOTAL CHARGES FOR URGENT CARE AND EMERGENCY ROOM VISITS AND HOSPITALIZATIONS Year Prior DMCP $129,426 $24,630
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LIMITATIONS OF STUDY Patients may have used non-county centers (unlikely because only 15% had any kind of insurance) Differences between usual care and nurse-directed care may be greater in minorities (possibly true) Total charges do not reflect actual costs nor reimbursements (cost savings can not be determined)
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Effects of Quality Improvement Strategies for Type 2 Diabetes on Glycemic Control: A Meta-Regression Analysis (JAMA 296:424-440, 2006) Ineffective Slightly Effective Audit and Feedback Case Management Electronic Patient Registry Team Changes Clinician Education Clinician Reminders Patient Education Promotion of Self-Management Patient Reminder Systems Continuous Quality Improvement Facilitated Relay of Clinical Information to Clinicians
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CONCLUSION “Most QI strategies produced small to modest improvements in glycemic control. Team changes and case management showed more robust improvements, especially for interventions in which case managers could adjust medications without awaiting physician approval.”
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IMPORTANCE OF NURSES INDEPENDENTLY IMPLEMENTING TREATMENT Nurse? PCP a Nurse Alone b A1C (%) Control Intervention Control Intervention (n=103) (n=106) (n=29) (n=36) Baseline 9.2 9.3 10.2 10.1 Change -0.16 -0.02 -0.9c -2.1c a Am J Med 116: 732, 2004 b Am J Manag Care 11: 253, 2005 c P <0.03 } Same VA system
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PHARMACIST CASE MANAGEMENT Observed effect size on hemoglobin A1c (A1c) by country and pharmacist prescriptive authority Pharmacotherapy 28:421, 2008
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TWO BARRIERS TO GENERALIZABILITY OF CARVE OUT MODELS Fragmented patient care Many too few endocrinologists
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REMOVAL OF BARRIERS(?CARVE IN MODEL) Barrier Solution Fragmented patient care Nurse-directed diabetes care delivered in the primary care setting Too few endocrinologists Supervision by primary care physicians
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CARVE IN MODEL DEMOGRAPHICS Number of Patients – 114 Age – 54.5 ± 8.6 years Disease Duration – 10.4 ± 6.5 years Females – 61% Race/Ethnicity African-American – 19 (17%) Caucasian - 0 (0%) Latino - 93 (81%) Asian - 2 (2%) Type 1 diabetes – 1 (1%) Type 2 diabetes – 113 (99%)
Slide 37 :
CARVE IN MODEL RESULTS*(ABSOLUTE VALUES) Measure Baseline Final P Value † (Mean ± SD) (Mean ± SD) Hb A1c (%) 10.9 ± 2.6 8.7 ±1.9 <10-5 LDL Chol (mg/dl) 108 ± 45 84 ± 43 < 10-5 Triglyceride (mg/dl) 169 ± 155 130 ± 66 <10-3 Systolic BP (mm Hg) 130 ± 20 124 ± 14 <10-4 Diastolic BP (mm Hg) 73 ± 9 68 ± 8 <10-5 *mean duration – 5.8 months; †Wilcoxon signed-rank test
Slide 38 :
CARVE IN MODEL RESULTS*(PERCENT ACHIEVING TARGETS) Measure (Target) Baseline Final P Value † Hb A1c (<7.0%) 4% 13% <0.004 LDL Chol (<100 mg/dl) 41% 72% <10-5 Triglyceride (<150 mg/dl) 51% 70% <0.0002 Systolic BP (<130 mm Hg) 42% 63% <10-3 Diastolic BP (<80 mm Hg) 72% 90% <10-4 *mean duration – 5.8 months; †McNemar’s test
Slide 39 :
Characteristics of Models Carve Out Carve In Nurse following algorithms Yes Yes Supervision by Endocrinologist PCP Subjects Randomized Referred Computer tracking of broken Yes No visit and lab appointments Medical assistant Yes No Evening/Saturday clinics Yes No
Slide 40 :
KEY COMPONENTS FOR GOOD DIABETES CARE Knowledgeable provider Time to interact with patient Communication with patient Educated patient Patient’s ability to carry out treatment recommendations Nurses following protocols under appropriate supervision do it better!
Slide 41 :
CONCLUSION Policy makers seeking to improve diabetes care and conserve resources (especially in minority populations) should seriously consider adopting nurse-directed diabetes care.
Slide 42 :
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