# Presentation: 389002

## Monthly Diabetes Team Meeting

- First Things First

## Purpose 	

- Achieve DM quality goals using the Chronic Care Model
- FMC, team, individual physician
- Demonstrate Residents’ Practice Based Learning & Improvement
- Demonstrate leadership in care team
- Use database to assess practice quality
- Propose & complete PDSA cycle
- Teach evidence based practice

## Initial DM Quality Goals

- > 70% have Self management Goals
**> 60% HgbA1c < 7%**
**> 40% BP < 130/70**
- > 70% LDL < 100
- Eye exam, monofilament, microalbumin Q yr
- Depression screen each visit
- <12% current smoking
- ACE/ARB

## The Chronic Care Model

## Expectations

- Every month before PGY2/3 core
- If unable to schedule before PGY2/3 core, then team decides on alternate
- Meeting lasts ≤ 30 min
- Work will occur outside meeting
- All faculty, PGY3, PGY2, RNs
- Representatives from ancillary staff

## Agenda 

- Preparation
- Review team and personal DM quality
- FMC quality data report
- Team report on PDSA cycle
- Resident presentation related to PDSA
- Team meetings to suggest next PDSA

## Chronic Care Portfolio

- Perform data base query
- Propose, complete, report PDSA cycle
- Update, present chronic care topic
- Case study difficult chronic care patient
- Self management goal setting

## The Chronic Care Model

## Self-Management 

- Effective self-management is very different from telling patients what to do. Patients have a central role in determining their care, one that fosters a sense of responsibility for their own health.

**Notes:**
Decision Support Treatment decisions need to be based on explicit, proven guidelines supported by at least one defining study. Health care organizations creatively integrate explicit, proven guidelines into the day-to-day practice of the primary care providers in an accessible and easy-to-use manner. Delivery System Design The delivery of patient care requires not only determining what care is needed, but clarifying roles and tasks to ensure the patient gets the care; making sure that all the clinicians who take care of a patient have centralized, up-to-date information about the patient’s status; and making follow-up a part of standard procedure. Clinical Information System A registry — an information system that can track individual patients as well as populations of patients — is a necessity when managing chronic illness or preventive care. Organization of Health Care Health care systems can create an environment in which organized efforts to improve the care of people with chronic illness take hold and flourish. Community To improve the health of the population, health care organizations reach out to form powerful alliances and partnerships with state programs, local agencies, schools, faith organizations, businesses, and clubs. 

## Delivery System Design 

- The delivery of patient care requires not only determining what care is needed, but clarifying roles and tasks to ensure the patient gets the care; making sure that all the clinicians who take care of a patient have centralized, up-to-date information about the patient’s status; and making follow-up a part of standard procedure.

**Notes:**
Decision Support Treatment decisions need to be based on explicit, proven guidelines supported by at least one defining study. Health care organizations creatively integrate explicit, proven guidelines into the day-to-day practice of the primary care providers in an accessible and easy-to-use manner. Clinical Information System A registry — an information system that can track individual patients as well as populations of patients — is a necessity when managing chronic illness or preventive care. Organization of Health Care Health care systems can create an environment in which organized efforts to improve the care of people with chronic illness take hold and flourish. Community To improve the health of the population, health care organizations reach out to form powerful alliances and partnerships with state programs, local agencies, schools, faith organizations, businesses, and clubs. 

## Decision Support 

- Treatment decisions need to be based on explicit, proven guidelines supported by at least one defining study. Health care organizations creatively integrate explicit, proven guidelines into the day-to-day practice of the primary care providers in an accessible and easy-to-use manner.

**Notes:**
Delivery System Design The delivery of patient care requires not only determining what care is needed, but clarifying roles and tasks to ensure the patient gets the care; making sure that all the clinicians who take care of a patient have centralized, up-to-date information about the patient’s status; and making follow-up a part of standard procedure. Clinical Information System A registry — an information system that can track individual patients as well as populations of patients — is a necessity when managing chronic illness or preventive care. Organization of Health Care Health care systems can create an environment in which organized efforts to improve the care of people with chronic illness take hold and flourish. Community To improve the health of the population, health care organizations reach out to form powerful alliances and partnerships with state programs, local agencies, schools, faith organizations, businesses, and clubs. 

## Clinical Information System 

- A registry — an information system that can track individual patients as well as populations of patients — is a necessity when managing chronic illness or preventive care.

**Notes:**
Decision Support Treatment decisions need to be based on explicit, proven guidelines supported by at least one defining study. Health care organizations creatively integrate explicit, proven guidelines into the day-to-day practice of the primary care providers in an accessible and easy-to-use manner. Delivery System Design The delivery of patient care requires not only determining what care is needed, but clarifying roles and tasks to ensure the patient gets the care; making sure that all the clinicians who take care of a patient have centralized, up-to-date information about the patient’s status; and making follow-up a part of standard procedure. A registry — an information system that can track individual patients as well as populations of patients — is a necessity when managing chronic illness or preventive care. Organization of Health Care Health care systems can create an environment in which organized efforts to improve the care of people with chronic illness take hold and flourish. Community To improve the health of the population, health care organizations reach out to form powerful alliances and partnerships with state programs, local agencies, schools, faith organizations, businesses, and clubs. 

## Organization of Health Care 

- Health care systems can create an environment in which organized efforts to improve the care of people with chronic illness take hold and flourish.

**Notes:**
Decision Support Treatment decisions need to be based on explicit, proven guidelines supported by at least one defining study. Health care organizations creatively integrate explicit, proven guidelines into the day-to-day practice of the primary care providers in an accessible and easy-to-use manner. Delivery System Design The delivery of patient care requires not only determining what care is needed, but clarifying roles and tasks to ensure the patient gets the care; making sure that all the clinicians who take care of a patient have centralized, up-to-date information about the patient’s status; and making follow-up a part of standard procedure. Clinical Information System Community To improve the health of the population, health care organizations reach out to form powerful alliances and partnerships with state programs, local agencies, schools, faith organizations, businesses, and clubs. 

## Community 

- To improve the health of the population, health care organizations reach out to form powerful alliances and partnerships with state programs, local agencies, schools, faith organizations, businesses, and clubs.

**Notes:**
Decision Support Treatment decisions need to be based on explicit, proven guidelines supported by at least one defining study. Health care organizations creatively integrate explicit, proven guidelines into the day-to-day practice of the primary care providers in an accessible and easy-to-use manner. Delivery System Design The delivery of patient care requires not only determining what care is needed, but clarifying roles and tasks to ensure the patient gets the care; making sure that all the clinicians who take care of a patient have centralized, up-to-date information about the patient’s status; and making follow-up a part of standard procedure. Clinical Information System Organization of Health Care Health care systems can create an environment in which organized efforts to improve the care of people with chronic illness take hold and flourish. 

## Predicted Benefits of Control (Archimedes Model)

|  | HgbA1c  < 7 |  |
| --- | --- | --- |
|  | Within 6 mos | Within 24 mos |
| Proteinuria |  52% |  15% |
| ESRD |  44% |  16% |
| Eye surgery |  73% |  41% |
| Blindness |  73% |  47% |

- Bailey JInt J Clin Pract 2005;59:1309-1316

## Joe Average Doc

- “Not satisified” with HgbA1c >7, but....
- 68% reinforced diet and exercise
- 27% augmented oral agents
- 8% increased insulin

**Notes:**
However, even when physicians are dissatisfied with their results, there may be a reluctance to change practices. For example, in the Diabetes in Canada Evaluation (DICE) study, although the majority of physicians were not satisfied with an HbA1c of > 7%, most favoured conservative approaches to achieving glycaemic targets. Of note, 68% opted to reinforce lifestyle therapy, 27% augmented the use of oral antidiabetic agents and only 8% increased the use of insulin therapy.[24] 

## Glargine  2 for 20 Rule 

- Start 10 units Daily (HS or AM)
- Adjust weekly based on last 2 FPG values
- Titration schedule
- 2 units for each 20mg above 100mg
-  FPG 140  increase 4 units
- FPG 200   Increase 10 units
- NO increase in dose if BG < 72 or documented severe hypoglycemia

**Notes:**
Clearer directions concerning insulin initiation and titration are becoming available from clinical trials. For example, the Treat-to- Target study provides guidelines for dosing of a once-daily basal insulin analog.[8] This study provided support for starting with a once-daily 10-U basal insulin dose and adjusting the dose weekly based on the results of 2 consecutive FPG levels. The titration schedule calls for 2-U increases for every 20-mg/dL increment of FPG above 100 mg/dL (so, for example, an FPG of 100–120 mg/dL calls for a 2-U increase, whereas an FPG of 120–140 mg/dL calls for a 4-U increase in the insulin dose, up to 8 U for >/= 180 mg/dL), with the caveat that there are no episodes of severe hypoglycemia or documented blood glucose </= 72 mg/dL. The recent 1-2-3 study supports the use of once-daily insulin aspart 70/30 to achieve HbA1c goals, with the flexibility to increase the number of doses in patients who require more insulin to achieve goals.[13] In this study, patients started taking 12 U of insulin aspart 70/30 at dinner; if HbA1c goals were not achieved, then 6 U were added at breakfast time. If further HbA1c reduction was required, patients then added 3 U at the midday meal. In this study, 41% of patients achieved the HbA1c goal of < 7% with once-daily administration, 71% did with once- or twice-daily administration, and a total of 77% of patients reached goal with once, twice, or three times daily use of a single product. 

Start 10 units Daily (HS or AM)
Adjust weekly based on last 2 FPG values
Titration schedule
2 units for each 20mg above 100mg
 FPG 140  increase 4 units
FPG 200   Increase 10 units
NO increase in dose if BG < 72 or documented severe hypoglycemia

## BP Control Strategies 

- ACE, then diuretic, then ARB
- If not a goal confirm
- proper BP measurement
- medication adherence
- low sodium
- Avoid EtOH > 2 oz /day, NSAID, decongestants, high dose estrogen

## Diabetic Nephropathy aka microalbuminura

**Notes:**
The diagram shows how kidney function reduces and the amount of protein in the urine increases in diabetic nephropathy.
1. It begins with a tiny amount of protein appearing in the urine - this is called microalbuminuria.  The kidney function may well be normal at this point.2. Over 10-15 years proteinuria increases, and nephrotic syndrome may develop3. With the development of proteinuria, the kidneys' ability to remove poisons from the blood deteriorates such that 5-10 years later the kidneys are almost completely unable to remove these poisons from the blood.4.This is called "end-stage renal disease" (ESRD), and, unless treated, the poisons can build up to fatal levels.

## Preserving Renal FunctionLevel I recommendations

- Systolic BP < 120mmHg
- Maximum recommended ACE dose
- Maximum recommended ARB dose
- ACE plus ARB
- Avoid dihydropyridine CCBs
- Use beta blockers (BB)
- preferred over DHCCB

**Notes:**
General recommendationsA-Level evidence
To reduce the risk and/or slow the progression of nephropathy, optimize glucose control. 
To reduce the risk and/or slow the progression of nephropathy, optimize blood pressure control. 
ScreeningExpert consesus
Perform an annual test for the presence of microalbuminia in 1) type 1 diabetic patients who have had diabetes >5 years and 2) all type 2 diabetic patients starting at diagnosis. 
TreatmentA-Level evidence
In the treatment of albuminuria/nephropathy both ACE inhibitors and ARBs can be used: 
In hypertensive and nonhypertensive type 1 diabetic patients with any degree of albuminuria, ACE inhibitors have been shown to delay the progression of nephropathy. 
In hypertensive type 2 diabetic patients with microalbuminuria, ACE inhibitors and ARBs have been shown to delay the progression to macroalbuminuria. 
In patients with type 2 diabetes, hypertension, macroalbuminuria, and renal insufficiency (serum creatinine >1.5 mg/dl), ARBs have been shown to delay the progression of nephropathy. 

If one class is not tolerated, the other should be substituted. 
B-Level evidence
With the onset of overt nephropathy, initiate protein restriction to  0.8 g · kg-1 body wt · day-1 ( 10% of daily calories), the current adult RDA for protein. Further restriction may be useful in slowing the decline of GFR in selected patients. 
Expert consensus
If ACE inhibitors or ARBs are used, monitor serum potassium levels for the development of hyperkalemia. 
Consider referral to a physician experienced in the care of diabetic renal disease when either the GFR has fallen to <60 ml · min-1 · 173 m-2 or difficulties have occurred in the management of hypertension or hyperkalemia. 
Consider the use of non-DCCBs or ß-blockers in patients unable to tolerate ACE inhibitors or ARBs. 

## Preserving Renal FunctionLevel II recommendations

- Glycemic control (HgbA1c < 7)
- Stop smoking
- Statin to achieve LDL < 100, or <70
- Aspirin
- Limit sodium to 2-3 grams/day
- Chicken instead of red meat?

## ACE worries

- OK if creatinine > 3 mg/dl
- Serum creatinine rises up to _**50%**_ OK if no further increase

- Hebert LA Kidney Int 2001;59:1211-1226

**Notes:**
Hebert LA Renoprotection: one or many therapies? Kidney International 2001;59:1211-1226

## Safety of ACE + ARB 

- Only decrease BP 4.5/2.5 mmHg
- Small increase in K+
- Slight decrease in GFR
- Proteinuria improves