# Presentation: 358230

## 164R Focused Disease Management through CPRS: Diabetes & Hyperlipidemia

- Rachel Chandra, PharmD
- Clinical Pharmacy Specialist
- Brian V. Burke, MD, FACP
- Chief, Metabolism & Diabetes
- Dayton VAMC

- Please write questions on a 3 X 5 card
- Give to assistants in the room
- Questions will be answered at the end of the presentation

## Objectives

- Describe the available tools to efficiently enter orders
- Identify electronic tools available in CPRS to aid in the management of patients with chronic diseases
- Evaluate local menus and orders for efficiency

## Hyperlipidemia Background

- Lipid performance measures not at goal
- High statin dollars
- VISN, National LDL goals consistently NOT met

## Analysis of report

- ~ 4,000 patients not at LDL goal
- ~ 550 patients – within 6% of LDL goal
- Formulary vs. Non-Formulary (NF)
- 1⁄3 on a NF agent
- 42% on a NF agent not at goal
- Just in time for conversions – lovastatin, ezetimibe/simvastatin & atorvastatin

## What should we do with this information?

- We can ignore this information
- Demonstrate an attempt to do *something*
- Provider problem not pharmacy
- Inform the providers and do nothing more
- Develop a hospital based strategic plan between medicine & pharmacy in efforts to obtain LDL goals

## Historical Challenges

## Historical Positives

## Current Hyperlipidemia Challenges 

- Inadequate staff
- Overworked staff
- NF approvals inconsistent
- Increasing patient load
- Decreasing provider availability
- Diverse treatment groups
- Lipid Clinic - Not a new phenomenon
- ?? FTE for clinic
- What should we do now?

## Patient  Mapping

## Hospital Based Treatment Pathways

## Objectives for Lipid Template

- Decrease CV risk
- Obtain VISN & National goals
- Distribute workload - *Not a provider problem*
- Simple process
- Flexibility in time

## Lipid Template Options

- Notes
- New notes
**Hyperlipidemia (HLP) assessment**
**HLP assessment telephone**
**Lipid medications**

## Lipid Template 

**for **
**Pharmacists & Nurses**

## Slide 15

## Slide 16

## Slide 17

## Click here

- Paste here

## Slide 19

## Slide 20

## Slide 21

## Slide 22

- Assessment template
- Provider Medication template

## Slide 24

## Provider: Lipid Pharmacy Medications

**Patients currently on a statin**
- Statin naive

## Patients currently on a statin

- Maximum tolerated dose of formulary statin
- Patient developed an ADR to formulary statin
**Additional LDL reduction needed**

## Slide 27

## Patients currently on a statin

**Maximum tolerated dose of formulary statin**
- Patient developed an ADR to formulary statin
- Additional LDL reduction needed

## Slide 29

## Patients currently on a statin

- Maximum tolerated dose of formulary statin
**Patient developed an ADR to formulary statin**
- Additional LDL reduction needed

## Slide 31

## Lipid Pharmacy Medications

- Patients currently on a statin
**Statin naive **

## Click here

**Click here**

## Slide 34

## Slide 35

## Paste here

**Paste here**

## Slide 37

## Upon Completion of template

- Click finish
- Labs are ordered
- Medications are ordered
- Nutrition consult are ordered
- One signature

## List of Websites

- https://vhav10share.v10.med.va.gov/sites/Dayton/CPRS/CPRS%20V26%20Demos/Calculators/LDL_REDUX_CALCii.mht
- http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof

## Inpatient Hyperglycemia and Chronic Disease Management

**What** is the connection?
**Why** bother?
**How** does the DAVA protocol work?
**Who** makes it work?
**Where** ‘s the interface with CPRS?
**When** will he stop using these pronouns?

## Inpatient Hyperglycemia and Chronic Disease Management

- 			**What is the connection?**
- Diabetes = Chronic Disease
- Over 50% of costs are Inpatient related ADA, 2008
- Decreased LOS Multiple
- 467% return on investment Newton,2006
- Missed opportunity cost: Diabetic Patients
- 30-50% risk of re-hospitalization in next12 months
- Poor Control: Average A1c% ~9% Umpierrez
- Behavior Change and Stress

**Notes:**
Newton CA, Financial implications of gly..., Endocr Pract. 2006 Jul-Aug;12 Suppl 3:43-8
Umpierrez, GE, Diabetes Care. 2007 Sep;30(9):2181-6. Epub 2007 May 18

## Inpatient Hyperglycemia and Chronic Disease Management

**Why Bother?**
- EBM and Expert Opinion
- ADA Inpatient Guidelines
- ACE/ADA Consensus Statement on Inpatient Diabetes and Glycemic Control
- Joint Commission
- Order sets may decrease insulin errors Magee, 2007
- Independent marker of in-hospital mortality Umpierrez, 2002
- Patient satisfaction? Opinion, 2008

**Notes:**
Magee MF, Am J Health Syst Pharm. 2007 May 15;64(10 Suppl 6):S15-20; quiz S21-3.
Umpierrez, GE, J Clin Endocrinol Metab. 2002 Mar;87(3):978-82

## Inpatient Hyperglycemia and Chronic Disease Management

**How does the DAVA SC protocol work?**
- Basal Insulin: Glargine
- Bolus & Correction Insulin: Aspart
- IV insulin: Regular
- Discharge insulin (s): based upon Inpatient Doses

## Inpatient Hyperglycemia and Chronic Disease Management

**How does the DAVA SC protocol work?**
- Nurse _Managed _& Championed
- Resident Initiated & Titrated
- Patient Health Education Collaboration
- Inpatient Diabetes Consult Service Back-up
- Laboratory Data Analysis
- Nutrition Sponsored
- Administration/CEB/Pharmacy endorsed

## Inpatient Hyperglycemia and Chronic Disease Management

**How does the DAVA SC protocol work?**
- CPRS Protocol
- Dose calculation/guide
- CPRS Hypoglycemic Protocol
- CPRS Discharge Guide

## Inpatient Hyperglycemia and Chronic Disease Management

**How does the DAVA SC protocol work?**
- Bedside Glucometers
- Uploaded multiple times/ day (CPRS)
- House officer titrated per protocol (CPRS)
- FSBG, Insulin and Meals
- Nursing protocol (unit)
- Hypoglycemia
- Nursing protocol (CPRS)

## Slide 47

## Slide 48

## Slide 49

## Slide 50

## Slide 51

## Slide 52

## Slide 53

## Slide 54

## Slide 55

## Slide 56

## Slide 57

## Slide 58

## Slide 59

## Slide 60

## Slide 61

## Slide 62

## Slide 63

## Slide 64

## Slide 65

## Slide 66

## Slide 67

## Slide 68

## Slide 69

## Slide 70

## Slide 71

## Slide 72

## Inpatient Hyperglycemia and Chronic Disease Management

- Summary:
**Dayton VA CPRS inpatient insulin protocols**
- improve the utilization and efficiency of complex medical management
- reduce errors
- reduces LOS in diabetic patients
- acts as a conduit for outpatient chronic disease management

## Presentation Summary

- Chronic Illness
- Creates additional demands
- Multi-disciplinary, -tasking,- faceted
- Complexity becomes routine
- CPRS
- Assimilates critical data
- Facilitates reaction & better care

## Contact Information

- rachel.chandra@va.gov
- brian.burke@va.gov
- mary.gochenour@va.gov