Hypoglycemia Safety Initiative HSI October 2014 Susan Kirsh MD MPH Mark McConnell MD Storm Morgan RN MSN MBA October 2012 Bernie Good MD Donna Leslie PharmD Chartered May 2014 ID: 784202
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Choosing Wisely Task ForceHypoglycemia Safety Initiative (HSI)October 2014
Susan Kirsh, MD, MPH Mark McConnell, MDStorm Morgan, RN, MSN, MBA
October 2012
Bernie Good, MDDonna Leslie, PharmDChartered May, 2014
Under auspices of
Dr
Leonard Pogach (Specialty Care) and Dr. Gordon
Schectman
(Primary Care
Slide2Recommendation: “There is no evidence that using medications to achieve tight glycemic control in older adults (65 and older) with type 2 diabetes is beneficial.”1
Slide3Choosing Wisely:VA Hypoglycemia Safety Initiative (HSI)Ultimate Goal:To foster shared decision making between clinicians and Veterans that is informed by the best available evidence and reduce unnecessary care.
Slide4Objectives3Describe the HSI: VA voluntary effort to identify and reduce hypoglycemiaDescribe the tools available for useInvite any site or VISN to join!
Slide5Federal Alignment4September 29
th: The Federal Diabetes Mellitus Interagency Coordinating Committee (DMICC) has a one day meeting at NIH to present the HHS National Action Plan for Hypoglycemic Safety and elicit Federal Collaboration October 30th: Health and Human Services (Office of the Assistant Secretary) sponsoring a conference for representatives from about 100 Federal Agencies and Private Sector Organizations to kick off a
National Action Plan to decrease adverse drug events (opioids, anticoagulation, hypoglycemia)
Slide6How do WE help lower the risk?5
Be able to identify what causes hypoglycemia
Be aware of the symptoms
Be able to counsel on management (15-15 rule)Act!Be sure we have the right goalIdentify and intervene for patients at riskRecognize that WE created the riskEach PACT Teamlet the key!Outreach to Veterans and Familieshttp://diabetes.niddk.nih.gov
Slide76Individual goal setting is needed to find an appropriate, safe, A1c goalVA/DoD Diabetes Guideline 2010Individualized A1C goals based on patient preferences, complications, and co-morbiditiesBased on best available evidenceAvoids “one size fits all” approach
PACT: emphasis on shared decision making
Slide87Goal: 7-8-9(the evidence says it’s time for a new “sound-bite”
Major Comorbidity or
Physiologic Age Microvascular Complications
Absent or MildModerateAdvancedAbsent >10 years of life expectancy <7%<8%8-9%Present 5 to 10 years of life expectancy <8%<8%8-9%
Marked
<5 years of life
expectancy
8-9%
8-9%
8-9%
Slide9HSI-VISN 12 example8
Utilize VISN Data Warehouse (VDW)
Generate lists for each PC Team
A1c < 7 and on Insulin or Sulfonylurea who:Are age 75 or greaterOR cognitive impairment regardless of ageOR renal impairment (creatinine >2.0)Use CPRS shared template to gather dataApproach:Proactive: call patientsClinical reminder for face-to-face visitsEasily Measured! (by uniform health factors)
Slide10HSI-VISN 12 Cohort Identification9
DO YOU BELIEVE THIS PATIENT IS GETTING ANY BENEFIT FROM GLIPIZIDE?
WHAT ABOUT HARMS?
Slide11Patient Case #110
70 year old male with CKD (
SCr
3.7)Seen for routine care, at which time PCP noted his Clinical Reminder saying he was due for hypoglycemia screening. Taking NPH 10 units dailyA1c 6.1%Denies hypoglycemiaPCP stopped insulin A1c remains well below goal at 6.4% (8-9 per CPG)
Slide12Patient Case #211
81 year old frail man and his wife
On insulin NPH/REG 70/30 35 units twice daily and 2 units of
Aspart with each mealA1c = 6.7Hypoglycemic episodes about twice/weekPCP stopped Aspart & reduced 70/30 insulin to 30 units in AM/20 units in PM3 months later: A1c = 8.4“He feels SO much better”
Slide13Hypoglycemia Risk Change12
Age ≥ 75 or Dementia/CI or SCr > 1.7March 2012(N = 4,185)
March 2013(N = 4,266)March 2014(N = 4,475)
Aug 2014(N = 4,445)A1c < 7%35.7%31.7%29.3%28.1%A1c < 6.5%17.2%14.8%13.0%12.9%A1c < 6%5.5%5.0%4.0%3.9%
Slide14Choosing Wisely: VA HSI13
National
voluntary
opportunity, similar to VISN 12ListsHigh risk: A1c < 7 and on Insulin or SulfonylureaAre age 75 or greaterOR renal impairment (creatinine >2.0)Ultra high risk: A1c <7 and on Insulin or Sulfonylurea who are on Cholinesterase InhibitorAny VISN/site interested in participating can receive
Slide15Choosing Wisely: VA HSI Toolkit14
QSV Tool kit
(coming soon)Lists of patients at high riskHow to ImplementWho is involved?How to discuss with patientsClinician facing educationPatient facing education
Slide16Choosing Wisely-VA HSI“The List” (courtesy of PBM)15
Slide17Choosing Wisely: VA HSI: Implementation16
Pro-active assessment of these patients using “non face-to-face” care (telephone encounters)
The addition of a coversheet Clinical Reminder prompts face-to-face evaluation when these patients have a clinic visit.
Teams are encouraged to review their lists of patients and decide on a strategy for contacting them: Providers, Nurses (RN), Diabetes Educators (CDE), and Clinical Pharmacy Specialists (CPS)
Slide18Choosing Wisely: VA HSI:Teamlet Implementation17
The Team decides who will contact patients:
If a Provider or CPS with Scope of Practice: the entire process can be completed in one encounter
If an RN or CDE: a “huddle” will be needed after evaluation to determine actionPatient contact can be made using a phone encounterConsider a standardized templateUsing health factors in a standard ‘reminder dialog’ CPRS template would allow for data collection if desired
Slide19Summary18
Hypoglycemia is a severe and significant risk
Everyone at VA can help by being aware of causes/symptoms/management of hypoglycemia
We can easily identify a high-risk cohortWe have the ability to proactively reach out to these patients and potentially lower their risk
Slide20What Can YOU do?19
Encourage your leaders/site to join the effort!
Remember, it’s
voluntary: NOT a “Directive”So, Veterans NEED you to volunteer!Sign up for the “HSI Listserv”We will regularly update everyone on this email group about activities related to HSIContact us if you want lists of your site’s patient lists sent to you for actionmark.mcconnell@va.gov