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ASSESSMENT OF DIABETES MANAGEMENT IN FAMILY CARE CLINIC AT RCRMC FROM 2004-2007

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ASSESSMENT OF DIABETES MANAGEMENT IN FAMILY CARE CLINIC AT RCRMC FROM 2004-2007 Presented by Dr. Keyla Blandon & Dr. Sabeen Abdul-Sattar In most of the clinic ... – PowerPoint PPT presentation

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Title: ASSESSMENT OF DIABETES MANAGEMENT IN FAMILY CARE CLINIC AT RCRMC FROM 2004-2007


1
ASSESSMENT OF DIABETES MANAGEMENT IN FAMILY
CARE CLINIC AT RCRMC FROM 2004-2007 Presented
by Dr. Keyla Blandon Dr. Sabeen Abdul-Sattar
2
GENERAL OBJECTIVE TO DETERMINE TO WHAT EXTENT
HAVE DIABETIC PATIENTS MANAGED IN FAMILY CARE
CLINIC (RCRMC) REACHED THEIR DIABETIC GOALS, AND
WHAT ARE THE MAIN OBSTACLES TO AHIEVE THEM
3
SPECIFIC OBJECTIVES 1- To determine what
percentage of diabetic patients managed in family
care clinic have achieved the ABCs of diabetes
(AHA1clt7, Bblood pressure lt130/85, CLDLlt100
or lt70 if high risk for cardiovascular
events 2- To identify what treatment modalities
are used more frequently 3- To identify which
treatment modalities are more effective in
getting patients to achieve their diabetes
goals 4-To identify if exercise and nutrition
are part of the assessment/plan during
clinic visits for diabetes management 5-To
identify obstacles in the management and
treatment of diabetes patients
4

METODOLOGIC
DESIGN TYPE OF STUDY Retrospective chart
review SAMPLE 300 charts of diabetic patients
seen in family care clinic (RCRMC), were
reviewed Each clinic visit where diabetes was
assessed was included
5
INCLUSION CRITERIA 1-Diabetic patients seen in
FCC for at least six months 2-Age gt18 years
old 3-No visual or hear impairment that limits
their ability to follow the doctor
recommendations at home 4-No diagnosis of
dementia that compromise patients capacity to
follow doctors recommendations
6
EXCLUSION CRITERIA 1- To have been a diabetic
patient in FCC for less than six months 2-To
have another outside doctor that also manage
patient diabetes 3-Patients with dementia that
impairs patients abilities to follow up doctors
recommendations 4-Patients with visual or hear
impairment that limits their abilities to follow
doctors recommendations 5-Agelt 18 years old
7
  • VARIABLES
  • SOCIODEMOGRAPHIC VARIABLES
  • -Age
  • -Sex
  • Number of years being a patient in FCC
  • DIABETES VARIABLES
  • -HA1c
  • -LDL
  • -HDL
  • -Triglycerides
  • -Blood pressure
  • -Annual eye exam

8
EDUCATIONAL VARIABLES -Exercise as part of the
treatment plan -Education on nutrition -Number
of visits to Diabetes Class TREATMENT
VARIABLES -Sulfonilureas -Biguanides -Thiazolidin
ediones -Combination of oral therapy -Insulin
basal -Insulin mixed preparations -Combination
basal insulin with rapid acting
insulin -Combination insulin with oral therapy
9
BACKGROUND INFORMATION
10
EPIDEMIOLOGY Diabetes has reached epidemic
proportions, more then 20.8 million Americans are
affected by diabetes (7 of the population)
(3) Type 2 diabetes accounts for 90 to 95
of all diagnosed diabetes cases An alarming
situation is the fact that although still rare in
children and adolescents, diabetes now is being
diagnosed more frequently in these groups
particularly in American Indians, African
Americans, and Hispanic/Latino Americans (2)
11
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12
COMPLICATIONS OF DIABETES IN THE UNITED STATES
(2) Heart disease and stroke account for about
65 of deaths in people with diabetes About
73 of adults with diabetes have blood pressure
greater than or equal to 130/80 millimeters of
mercury (mmHg) or use prescription medications
for hypertension Diabetes is the leading cause
of new cases of blindness among adults aged 20-74
years Diabetes is the leading cause of kidney
failure, accounting for 44 of new cases in
2002 About 60-70 of people with diabetes have
mild to severe forms of nervous system damage
impaired sensation or pain in the feet or hands,
slowed digestion of food in the stomach, carpal
tunnel syndrome
13
More than 60 of nontraumatic lower-limb
amputations occur in people with diabetes
Almost one-third of people with diabetes have
severe periodontal disease with loss of
attachment of the gums to the teeth measuring 5
millimeters or more Poorly controlled diabetes
before conception and during the first trimester
of pregnancy can cause major birth defects in
5-10 of pregnancies and spontaneous abortions in
15 to 20 of pregnancies, while poorly
controlled diabetes during the second and third
trimesters of pregnancy can result in excessively
large babies, posing a risk to both mother and
child The risk of unfavorable outcomes is
particularly great for patients whose care has
not emphasized the importance of glycemic control
and risk factor intervention (5)
14
ESTIMATED DIABETES COSTS IN THE UNITED STATES
IN 2002 (2) Total (direct and indirect)
132 billion Direct medical costs 92
billion Indirect costs 40 billion
(disability, work loss, premature mortality)
15
PREVENTING DIABETES COMPLICATIONS
16
Type 2 diabetes is a progressive disease
requiring individualized strategy and a team
approach to achieve and maintain long-term, near
normal blood glucose and blood pressure levels
17
Several large trials, including the Diabetes
Control and Complications Trial (DCCT) and the
United Kingdom Prospective Diabetes Study (UKPDS)
have demonstrated the benefits of tight glucose
control in reducing risk for microvascular
complications Increasing body of evidence to
support the theory that normalizing blood glucose
decreases risk of macrovascular complications,
with A1C a good predictor of ischemic heart
disease. Recent study from the American
Diabetes Association noted that 50 of patients
are not treated to target even if there are
complications (3)
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19
GLUCOSE CONTROL Every percentage point
drop in A1C reduces the risk of microvascular
complications (eye, kidney and nerve diseases) by
22-35 Note that AIC is the sum of both
fasting and postprandial glucose
excursions(2) Recent studies point to the
effect postprandial glucose has on A1C compared
to the usual correlation of fasting glucose
levels. Postprandial state can be 16-18 hours per
day in the patient with type 2 diabetes, with as
much as a 70 variance in determining A1C versus
the fasting state (3)
20
BLOOD PRESSURE CONTROL -Blood
pressure control reduces the risk of
cardiovascular disease (heart disease or stroke)
among persons with diabetes by 33 to 50, and
the risk of microvascular complications by
approximately 33 -In general, for every 10mmHg
reduction in systolic blood pressure, the risk
for any complications related to diabetes is
reduced by 12 (2) CONTROL OF BLOOD LIPIDS
-Improved of cholesterol or blood lipids (HDL,
LDL and triglycerides) can reduce cardiovascular
complications by 20 to 50 (2)
21
PREVENTIVE CARE PRACTICES FOR EYES, KIDNEYS AND
FEET Detecting and treating diabetic eye
disease with laser therapy can reduce the
development of severe vision loss by an estimated
50 to 60 Comprehensive foot care programs
can reduce amputation rates by 45 to 85
Detecting and treating early diabetic kidney
disease by lowering blood pressure can reduce the
decline in kidney function by 30 to 70 (2)
22
TREATMENT GOALS IN DIABETES
23
To prevent all diabetes complications the
health team in charge of diabetic patients must
try to achieve what is called the ABCs of
diabetes control A? HgA1C lt7 by the American
Diabetes Association (ADA) or lowest possible
without unacceptable hypoglycemia, or below 6.5
by the American Association of Clinical
Endocrinologists (AACE) B? Blood pressure equal
or below 130/80mmHg or further lowering if
tolerated by patients C? Cholesterol lt 100 or
below 70 for high risk patients with diabetes and
CVD
24
OTHER IMPORTANT TREATMENT GOALS
Fasting/preprandial glucose level lt110 mg/dl by
the American College of Endocrinologists (ACE) ,
and between 90-130mg/dl by the AMERICAN
DIABETES ASSOCIATION (ADA) 2-hr postprandial
lt140 mg/dl by the ACE, and lt180 by the ADA
HDL gt 40mg/dl in men gt50 mg/dl in women
Triglycerides lt 150 mg/dl
25
The earlier we achieve these goals the better,
studies have shown that when current glycemic
goals are achieved early, beta cells are
preserved
The traditional management approach is to wait
until one treatment is failing before adding
another agent or intensifying therapy
The United Kingdom Diabetes Study (UKDS)
showed the gradual failure of therapy over time
correlating with a decline in insulin secretion
and an increase in plasma glucose concentration,
after 6 years of antihyperglycemic monotherapy,
approximately 55 of patients were able to attain
A1C levels below 7, but by 9 years only 24 were
able to do so
The American Association of Clinical
Endocrinologists (AACE) issued a comprehensive
report titled STATE OF DIABETES IN AMERICA, a
report on diabetes management in the United
States, the report was conducted during 2003 and
2004 in 39 states The results were compared with
the HA1c level goal set by the AACE of 6.5 or
less. It included more than 157,000 people with
type 2 diabetes. The result revealed that 67 or
two out of three people analyzed in the study
failed to meet the AACE target A1c goal
26
TREATING DIABETES
27
Diabetes is aprogressive disease that
requires the patient to be not a passive but an
active participant of the plan of care The
ideal health care team would have a nurse
practitioner and/or nutritionist plus the
physician to educate and follow patients and
intervene promptly when deficiencies are
found Diabetes self-management education
(DSME) gives the idea that patient participation
is key to achieve treatment goals in diabetes
patients who are involved in their treatment are
likely to have better outcomes Blood glucose
self-monitoring is an important tool for
self-management Having patients assess fasting
and postprandial glucose gives a more complete
picture of metabolic control and allows the
clinician to introduce basal and prandial insulin
when appropriate (3)
28
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29
-The addition of insulin to sulfonylurea therapy
improves glycemic control, as shown by a subset
analysis of the United Kingdom Prospective
Diabetes Sudy (UKPDS), without promoting weight
gain or increased risk of hypoglycemia -Addition
al benefits or early insulin therapy include
prevention of glucose toxicity, slowed
deterioration of existing beta-cell function, and
delayed vascular complications -An A1C greater
than 7 is the trigger for a change in therapy
according to the American Diabetes Association
Standards of Care. (3)
30
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31
TREATMENT OPTIONS
32
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34
  • Considerations in whether to add supplemental
    insulin to an existing oral regimen or to replace
    oral therapy with an all-insulin regimen include
    the likelihood of adverse effects, patient
    acceptance, and the cost of therapy
  • - Faced with a patient who is failing a maximal
    oral antihyperglycemic regimen, many experienced
    diabetologists would institute a simple basal
    insulin regimen in addition to continued oral
    therapy. Most often the regimen is a once-daily
    injection of an intermediate-acting or a
    long-acting insulin preparation, given at bedtime
    (currently the most popular option), or at
    breakfast (5)

35
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36
Most recently, the Treat-to-Target Trial (6)
addressed the impact of adding a once-daily basal
insulin injection to a failing oral regimen,
which included a combination of agents (eg,
sulfonylurea plus metformin, sulfonylurea plus
TZD) in two thirds of study subjects Using
bedtime NPH insulin or insulin glargine, HbA1c
levels fell from a mean of 8.6 to the target of
less than 7 in nearly 60 of participants. In
this study, the insulin dose was adjusted weekly
to attain target fasting glucose levels below
100mg/dl, and by studys completion the average
dose was 47 U/day for the insulin glargine group
and 42 U/day for the bedtime NPH insulin group.
Nighttime hypoglycemia was significantly less
frequent in the insulin glargine group
37
Daytime sulfonylurea plus bedtime NPH
insulin The addition of bedtime insulin at a
starting dose of 15 to 20 U (or 0.2 U/kg) has
been shown to reduce HbA1c levels by at least
0.8 to 1.3 when added to failing oral regimens
of glyburide or glipizide (7,8)
Sulfonylurea plus insulin glargine In an RCT,
Frische (10) compared the efficacy and
hypoglycemic frequency of treatment with
glimepiride plus insulin glargine to that of
treatment with glimepiride plus bedtime NPH
insulin. The glimepiride/insulin glargine
combination was further studied by comparing
morning versus bedtime insulin administration. In
this 28 week study, HbA1c, levels improved by
1.24 in the morning insulin glargine group, by
0.96 in the bedtime insulin glargine group, and
by 0.84 in the bedtime NHP insulin group.
Frequency of nocturnal hypoglycemia was
significantly less in the morning (17) and
bedtime (23) insulin glargine groups than in the
evening NPH insulin group (38)
38
Sulfonylurea plus suppertime 70/30
insulin Riddle et al (9) compared once-daily
(before breakfast) glyburide plus once-daily
(before supper) 70 NPH insulin/30 regular
insulin with insulin alone in a 16-week study
involving 21 obese patients who had failed
monotherapy with glyburide 20mg/day (average
baseline HbA1c, 11). Patients were randomized to
receive insulin before supper and placebo before
breakfast or insulin before supper and glyburide
10mg before breakfast. HbA1c levels decreased
1.3 in the combined therapy group compared with
0.8 in the insulin monotherapy group
39
Metformin plus insulin Several RCTs comparing
insulin monotherapy with insulin plus metformin
suggest a synergistic effect of combined therapy.
In a study by Yki-Jarvinen et al (11) patients
failing sulfolnyurea only therapy (mean baseline
HbA1c, 9.9) were randomized to bedtime NPH
insulin plus 1) glyburide, 2)metformin,
3)glyburide and metformin, or 4) a second
injection of NPH insulin in the morning. At
1-year follow-up, patients receiving metformin
plus bedtime NPH insulin had the lowest attained
mean HbA1c (7.2) as well as the least weight
gain and lowest incidence of hypoglycemia (both
at P lt0.05) TZD plus insulin Raskin et al
(12) conducted an 8-week trial comparing
twice-daily insulin plus placebo with twice-daily
insulin plus rosiglitazone in 319 patients (mean
baseline HbA1c, 8.9). In the insulin plus
rosiglitazone group, HbA1c dropped by 1.2
compared with no changes in the insulin plus
placebo group. Edema may be anticipated in 15 or
more of patients using the combination (13)
40
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43
BARRIERS TO SUCCESSFUL DIABETES
MANAGEMENT
44
CLINICIAN BARRIERS Excluding postprandial
blood glucose patterns Complexity of adding
more aggressive therapies Weak support for
self-management of diabetes Few incentives to
change practices and behavior (3)
PATIENTS BARRIERS Resistance to starting
insulin therapy - Misconceptions
about insulin - Anxiety about weight
and hypoglycemia Feelings of failure to
manage diabetes Feelings of loss of control
Doubt about managing an insulin regimen

45
OUR FINDINGS
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50
(49)
(48)
(68)
OF 300 PATIENTS 172 (57), WERE ON ASPIRIN
51
(42)
(38)
(67)
OF 300 PATIENTS 156 (52) HAD AN EKG DONE
52
Most patients with Systolic pressures of lt130
were in their 40s
53
Of the one year patients 33 positives, 8 (24)
were not on an ACE or ARB Of the two years
patients 41 positives, 5 (12) were not on an ACE
or ARB Of the three yearS patients 103
positives, 8 (8) were not on an ACE or ARB
54
One year (45) Two years (41) Three
years (42)
55
One year (63) Two years (64) Three
years (76)
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60
247 (82) of 300 patients were on an ACE or ARB
61
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62
212 (71) of 300 patients were on a statin
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65

IMPORTANT FINDINGS There were 25 patients in
whom hypoglycemic episodes were reported at least
one time, most of them were older than 55 years
old, and were on one of the following Maximum
doses of glucovance, or glyburide or combination
of oral agents (15) Combination of oral agents
and lantus (3) NPH BID (2) NPH BID and oral
agents (1) NPH BID and regular insulin (2) Lantus
and regular insulin (1) Lispro and lantus (1)
Most frequent intervention was to stop or
decrease the dose of glucovance or glyburide,
although in a few occasions, glucovance or
glyburide were continued and avandia and or
lantus were stopped
66
In most of the clinic visits a chemstick was
documented, although the number found didnt
impact the plan, unless there were more than
250s, when sometimes medications were increased
or there was a clear statement indicating need
for patient to bring diabetes log book in next
clinic visit There was a good proportion of
clinic visits were blood glucose levels at home
were documented although most of the time, was
written in the form of a range, instead of
fasting or postprandial values Patients that
were on insulin alone and/or in combination with
oral agents, there was a trend towards
documenting both fasting and postprandial blood
glucose levels with a clear improvement on HA1c
levels with time In some patients were
doctors were more aggressive in increasing
medications or starting insulin just by the
levels of chemstick in FCC and without a
documentation of glucose levels at home, there
was a trend towards lowering the HA1c levels
faster In several clinic visits there was
intention of initiating insulin use, but patients
refused
67
Since 2006 there has been a tendency towards
starting insulin earlier, most commonly lantus,
and also in documenting the postprandial glucose
values at home There is also documentation
were patients started on lantus were taught to
increase the dose by themselves at home based on
the fasting glucose values, although most of the
time on follow up visits the doctor ended up
increasing the dose him or herself Most of
the time lantus dose is increased by 2 or 3
points per visit In some cases the number of
visits correlated with glucose control (more
visits better control), but this was not a
consistent finding
68
On many occasions the HA1C, was high and
fasting blood sugars were between 120s to 200s
and the plan was to bring log book next visit
In some occasions the plan was to increase a
medication or to add on a new one that was
already increased in a previous visit
In a few occasions when patients were changed
from NPD BID to lantus, there was worsening of
control, and in some cases patients were put back
to NPH BID In some patients there were
compliance or insurance issues that aggravated
glycemic control Sometimes there was
documentation of fasting blood sugars in good
range, but HA1c of more than 7, in which the plan
was to continue with same management
69

CONCLUSIONS Diabetes is a
progressive disease that requires the active
participation of both the physician and the
patient to promptly achieve the goals of therapy
and prevent complications Postprandial glucose
levels need to be monitor by the patients to
help the physician in implementing the best
treatment strategies Patients need to know
their goals of therapy and the increments
in their health risks when these goals are not
achieved Insulin as a treatment option needs
to be mentioned to patients early, with emphasis
in the fact that diabetes is a progressive
disease in which most likely insulin will be
needed at some point, this need not to be seen by
patients as a failure in treatment Physicians
need to ask patients early their beliefs about
insulin to clarify any misconceptions with
time
70

REFERENCES 1-State of Diabetes in America ( a
comprehensive report issued by the American
Association\ Of Clinical Endocrinologists 2-Nati
onal Diabetes Fact Sheet Unites States, 2005, CDC
Division of Diabetes 3- Diabetes, Optimizing
Outcomes with insulin for patients with type 2
Diabetes a team Approach management 4-ACE/AACE
Diabetes Recommendations Implementation
Conference, Road Map for the Prevention and
treatment type 2 Diabetes 5- Summary of
Revisions for the 2007 Clinical Practice
Recommendations, ADA
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