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: 444273
Download Presentation The PPT/PDF document "Choosing Wisely Task Force" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
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 CareSlide2
Recommendation: “There is no evidence that using medications to achieve tight glycemic control in older adults (65 and older) with type 2 diabetes is beneficial.”1Slide3
Divider Page
“Changing long-held beliefs is never easy, even when the need for change is based on strong evidence.
Change is especially difficult when
prior beliefs are firmly embedded in culture, accepted as dogma, and codified in books, articles, guidelines, public service announcements, and performance measures.”Hayward and KrumholzCirc Cardiovasc Qual Outcomes, 2012;5:2-5Slide4
Choosing Wisely:VA Hypoglycemia Safety Initiative (HSI)3
Ultimate Goal:
To foster shared decision making
between clinicians and Veterans that is informed by the best available evidence and reduce unnecessary care. Slide5
Objectives4
Describe the HSI:
VA voluntary effort to identify and reduce hypoglycemia
Describe the tools available for useInvite any site or VISN to join!Slide6
5Background
Approximately 25.8 million Americans have diabetes — 8.3 percent of the U.S. population
Total health care and related costs for the treatment of diabetes run about $174 billion annually
Complications are costly and decrease quality of lifeTreatment largely focuses on lowering A1c
QUESTION
: Should we individualize A1c goals in order to reduce hypoglycemia in those at risk?
http://ndep.nih.gov
– Diabetes SnapshotSlide7
6Background
Reducing Hypoglycemia is part of the National Action Plan developed by multiple Federal Agencies
Sulfonylureas and insulin are 2 of the top 4 medications associated with ER visits or hospitalizations
In one VISN, 4400 of 54,000 (8%) patients with DM comprise a high risk cohort for serious hypoglycemia (VISN Data Warehouse)Nationally there are 4600 patients at VERY high risk of hypoglycemia: Age, A1c, on Cholinesterase Inhibitor (PBM Data)Budnitz DS, et al. NEJM 2011 Slide8
7Potential Overtreatment of Veterans on Sulfonylurea and/or Insulin Therapy Tseng et al, JAMA-IM, February 2014
Group
High risk patients
Increased number of patientsNumber of patients in denominator% of study population a (n=652,738)Overtreatment measures (in %). % with A1c
<6.0
%
<6.5%
<7.0%
7.0-7.4%
A
Age >75y;
creatinine
>=2mg/dl;
CI
b
/D
c
205,857
31.5
11.3
28.6
50.0
18.1
B
A+advanced
diabetes
complications
d
28,035
233,892
35.8
10.7
27.2
47.9
17.9
C
B+diminished
life
expectancy
e
37,972
271,864
41.7
10.9
27.3
47.7
17.7
D
C+major
neurological
disorders
f
8,075
279,939
42.9
10.9
27.2
47.5
17.6
E
D+cardiovascular
diseases
g
115,767
395,706
60.6
10.0
25.3
44.8
17.4
F
E+major
depression
17,268
412,974
63.3
10.0
25.1
44.4
17.3
G
F+alcohol
/drug abuse
17,204
430,178
65.9
10.1
25.2
44.3
17.1Slide9
8Slide10
Federal Alignment9
September 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)Slide11
How do WE help lower the risk?10
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 goal
Identify and intervene for patients at risk
Recognize that WE created the risk
Each PACT
Teamlet
the key!
Outreach to Veterans and Families
http://diabetes.niddk.nih.govSlide12
Individual goal setting is needed to find an appropriate, safe, A1c goal11
We need an appropriate A1c goal
VA/
DoD Diabetes Guideline 2010Individualized A1C goals based on patient preferences, complications, and co-morbiditiesBased on best available evidenceAvoids “one size fits all” approachPACT: emphasis on shared decision makingSlide13
Goal: 7-8-9(the evidence says it’s time for a new “sound-bite”)12
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%Slide14
The “7-8-9” Approach13
Using VA/
DoD
Diabetes Guidelines “The target range for glycemic control should be individualized, based on the provider’s appraisal of the risk-benefit ratio and discussion of the target with the individual patient. “ (Preventing A1c Craziness or Laziness)Slide15
14UKPDS
ACCORD, ADVANCE, VADTSlide16
Inappropriate Targets - Consequences15
Hassle (“the four P’s”)
Patients
ProvidersPharmacyPhonesTIMEDistraction (opportunity costs)And...hypoglycemia...Slide17
HSI – VISN 12 attempt to reduce risk 16
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)Slide18
HSI – VISN 12 Cohort Identification17
DO WE BELIEVE THIS PATIENT IS GETTING ANY BENEFIT FROM GLIPIZIDE?
WHAT ABOUT HARMS?Slide19
Patient Case #118
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)Slide20
Patient Case #219
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”Slide21
Does Shared Decision Making Impact A1c Goal?20Slide22
Does it work?21Patient GoalAge < 75
Age 75 and older<772%39%
<824%52%
<93%9%Slide23
Hypoglycemia Risk Change22
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%Slide24
Choosing Wisely: VA HSI23
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 receiveSlide25
Choosing Wisely: VA HSI Toolkit24
QSV Tool kit
(coming soon)Lists of patients at high riskHow to ImplementWho is involved?How to discuss with patientsClinician facing educationPatient facing educationSlide26
Choosing Wisely - VA HSI: “The List” (courtesy of PBM)25Slide27
Choosing Wisely: VA HSI: Implementation26
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)Slide28
Choosing Wisely: VA HSI: Teamlet Implementation27
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 desiredSlide29
Summary28
Hypoglycemia is a severe and significant risk
Everyone in 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 riskSlide30
What Can YOU do?29
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 HSI Contact us if you want lists of your patients sent to you for actionMark.Mcconnell@va.gov