American Diabetes Association. reports that approximately. 21 million Americans have outcomes for diabetes treatment. in the nation; yet, as a physician, …
For access to Fairviews provider portal, call 612-672-6805
Scope
a diabetes diagnosis meant a death sentence at any hospital in the country We had no ability to treat diabetes and little understanding of the disease process Most patients could expect to live only for a few years, if they were lucky It wasnt until about 1910 that we were able to measure blood glucose values by conducting chemical assays When insulin became available in 1922, we taught patients with type 1 diabetes how to use it and how to test their urine to monitor their blood glucose levels These simple measures remained our treatment tools until the 1960s, when oral hypoglycemics became available for patients with type 2 diabetes During the early 1980s, insulin, oral hypoglycemic medications and lifestyle changes represented our main methods of diabetes treatment Since then, our knowledge of the disease and our ability to treat it have grown exponentially We know a great deal more about the importance of glucose control and the impact of elevated lipids and blood pressure on long-term complications of diabetes We also have far more effective medications, such as statins and ACE inhibitors, to treat related
conditions that accelerate those complications And with home blood glucose monitors, carbohydrate counting and a wide array of more reliable and effective insulins, patients with diabetes can much more closely manage their blood glucose levels Ultimately, this results in fewer complications and improved long-term health for our patients
vol 11, iSSue 9 September 2006
Diabetes care, then and now
As we celebrate Fairviews centennial, we acknowledge our partnerships with community and academic physicians for the important advances in care our patients have enjoyed In this issue of Scope, we look at one key diagnosis– diabetes–and realize how far we have come, as well as how far we have yet to go
contents
Colleagues 2 JCAHO2007patientsafetygoals3 Fairviewearnsawardfor palliativecare6 Physicianleadershiptraining programregistrationopens 6 IntheNews 7 Formularycommitteereport 8 LabFocusinsert
Marking a century of care
By Loie Lenarz, MD, president and senior medical director, Fairview clinics, and medical director, Scope
O
ne in 10 Minnesotans has diabetes or a high risk of developing the disease, according to the Minnesota Department of Health Additionally, the American
Diabetes Association reports that approximately 21 million Americans have diabetes, and as of 2002, diabetes-related costs nationwide totaled 132 billion annually In 2005, 156 percent of inpatients and 44 percent of outpatients who visited a Fairview hospital had diabetes Currently, 8 percent of all adult patients who visit one of our primary care clinics has type 1 or type 2 diabetes We can anticipate that these numbers will increase during the next several years, due to our nations high level of obesity and our aging population
Moving the clinical excellence indicators
At the community level, clinicians–including physicians, nurses and dietitians–have worked to increase the percentage of adults with diabetes who meet specified clinical indicators In 2000, when we began measuring these indicators, 25 percent of patients with diabetes achieved optimal outcomes on all five measures As of second quarter 2006, 178 percent of our patients now achieve optimal outcomes, based on seven indicators, two of which were added in 2005 Minnesota has the best outcomes for diabetes treatment in the nation; yet, as a physician, I believe not one of us can say our diabetes care is good enough We
cannot be satisfied when only 18 percent of patients with diabetes receive optimal care
During the past 100 years, we have made enormous strides in our understanding of diabetes and our ability to help patients manage its impact Our next challenge will be to redesign how we deliver care to narrow the gap between the care we deliver today and the higher quality of care we know is possible –Loie Lenarz, MD
Diabetes continued on pages 4-5
Clinicalexcellence indicators
Fairviewaimstoimprovediabetes careforalladultpatientsusingthe followingindicators:
The patient is a non-smoker The patient takes an aspirin every day Hemoglobin A1c test completed every six months Hemoglobin A1c results below 7 mg/dl LDL test completed every 12 months LDL results below 100 mg/dl Blood pressure below 130/80 mm/hg
Looking back
When Fairview Hospital opened its doors in 1916,
SeeFairviewsdiabetes measuresandotherclinical excellencescoresintheGreen Book,intranetfairvieworg orportalfairvieworgboth sitesarepasswordprotected; call612-672-6805forportal access
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Diabetes continued from page 1
Enhancing processes of care
As the number of diabetes patients increases–especially those with type 2 diabetes– Fairview colleagues are working to provide the best possible treatment through process development, patient education and research One use of technology supports primary care providers by giving them access to graphs and charts that illustrate risks patients face For example, caregivers can use a patients lifestyle choices to extrapolate that patients chances of losing his or her vision or developing kidney failure The ability to graphically dissect patients A1c levels enables us to bring meaning to their treatment and explain how their behavior has helped minimize their risks for certain complications, says David Nelson, MD, family medicine, France Avenue Family Physicians You get much more buy-in from patients when you can explain why they are taking certain medications or why we are focusing on one area of their care plan France Avenue Family Physicians in Edina consistently has met clinical excellence indicators see sidebar Nelson attributes the high scores to personalizing care and tracking patients visits and
measures
Diabetes patient education, circa 1970
Newsubcutaneous insulinordersets
Inresponsetogrowingevidence thatimprovedglycemiccontrol inhospitalizedpatientsoffers improvedoutcomesandreduction ofinfection,Fairviewhasdeveloped astandardizedsubcutaneousinsulin managementordertheorderset willbeimplementedfullyinhospitalsacrossthesystembyOctober Allprevioussubcutaneousinsulin ordersetswillbepurgedfrom thesystem theordersetprovidesfor subcutaneousinsulintherapyas acombinationof: 1basalinsulinusingalong-acting orintermediate-actinginsulin preparation; 2prandialinsulinatmealtimes forpatientswhoareeating, usingarapid-actinginsulin preparation;and 3correctioninsulinusinga rapid-actinginsulingivenwith theprandialinsulindoseorat
specifiedtimeintervalsinpatients whoarenoteatingbasedonthe prevailingbloodsugar theordersetallowsmodification forindividualpatientcircumstances includingpatientswhoareNPOor oncontinuousparenteralorenteral nutrition,saysBruce redmon, md,endocrinology,universityof minnesotaPhysicians,andassociate professor,universityofminnesota medicalSchool thedocumentalsocontains o 
rdersfortransitioningfromcontinuousintravenousinsulintoperiodic subcutaneousinsulininjections,says
teresa Pearson, ms, rn,Fairviewsystemdirectorofdiabetescare andco-chairoftheworkgroup Includedwiththeordersetare guidelinesandsuggestionsfordetermininginitialsubcutaneousinsulin doses,patternedcloselyonordersets developedinmay2005bytheInstituteforClinicalSystemsImprovement Formoreinformationondiabetes ordersets,contactPearson,612-6721950,tpearso2@fairvieworg
1994
We take the time to individualize care for each patient, says Nelson You can look at any patient on paper, see his or her blood sugar readings and come up with a pretty good care plan But it makes a big difference when you approach patients as individuals and see what motivates them Another interactive tool, MyChart, allows patients to receive messages from their Fairview clinic providers and use secure Internet access to view an electronic version of their medical records Messages include such information as blood sugar results or a notice of overdue lab appointments, all of which patients can view at home at their convenience This interactive capability has allowed us to engage patients so they take greater responsibility for their care, says Barry Bershow, MD, Fairview medical director of quality and informatics Use of
an electronic health record also can enable clinicians to improve care through standing orders and testing reminders in patient records During a patients clinic visit, alerts remind physicians and clinic staff if the patients hemoglobin A1c test is overdue, LDL level is too high or he or she has missed an appointment, among other variables
2005
fairview named one of 10 Best Practices in Diabetes by the american medical Group association
1966
first pancreas transplant in the world performed by University of minnesota physicians
1979
first living-donor pancreas transplant in the world performed by University of minnesota physicians
2000
first simultaneous laparoscopic livingdonor pancreas and kidney transplant in the world performed at the University of minnesota medical Center, fairview
Diabetes institute for immunology and transplantation Diit created at the University of minnesota to perfect the use of pancreas and islet transplantation as a cure for diabetes
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Marking a century of care: diabetes, then and now
Expanding patient education and treatment
The average 50-year-old patient with diabetes spends only 02
percent of his or her time in the health care system, according to Teresa Pearson, MS, RN, Fairview system director of diabetes care Such limited exposure calls for more patient education to prepare patients better to manage the disease at home, she says During the past two years, all seven of our care systems have received endorsement by the American Diabetes Association So now we can offer–and receive reimbursement for– diabetes education classes that patients can afford, says Pearson These classes have boosted patients access to diabetes education by approximately 30 percent during the past two years, according to Pearson Along with offering classes, Fairview is moving toward a model of care that includes group diabetes visits and classes taught by patients The goal is for patients to collaborate on a plan of care to suit their lifestyles, says Pearson In addition to patient education, Fairviews weightloss surgery program has helped improve the lives of patients with type 2 diabetes Gastric bypass surgery is proving to greatly improve–and often cure–this type of diabetes, says Paul Benn, MD, medical director and surgeon, Fairview Southdale Weight Loss Surgery Patients often
need less diabetes medicine right after surgery, and many of them do not need insulin or diabetes pills at all a few months later
Research
In 1966, a University of Minnesota team performed the first pancreas transplant in the world Since then, University of Minnesota surgeons have performed more than 1,500 pancreas transplants more than 150 each year, making its program the oldest and largest in the world Clearly, we have a better understanding of what causes both type 1 and type 2 diabetes, which has helped in designing therapies, treatment and research, says Bruce Redmon, MD, endocrinology, University of Minnesota Physicians, and associate professor, University of Minnesota Medical School For example, Bernhard J Hering, MD, associate professor of surgery, University of Minnesota, leads an investigation into the use of pig islet cells as a potential cure for diabetes Thus far, his team has successfully reversed type 1 diabetes both in monkeys and humans In addition to local studies, Fairview and University of Minnesota Physicians also are involved in national clinical and laboratory research Two such studies seek the best way to minimize cardiovascular complications for patients
with type 2 diabetes Look AHEAD is the first research to examine longterm health effects of weight loss in patients who are overweight and have type 2 diabetes A second study, ACCORD, aims to determine whether intensive glycemic control, treatment to increase HDL-cholesterol levels and to decrease triglycerides, and
intensive blood pressure control reduce cardiovascular events in patients with type 2 diabetes According to Redmon, advancements that could have the most impact on diabetes care in the future include: Developing practical glucose sensors that could function as an artificial pancreas Finding a source for transplantation of animal islets Ongoing development of new medications for type 2 diabetes Stem cell transplant trials, which may become available in the future For more information on clinical studies, visit lookAHEADstudy org and accordtrialorg For more information about diabetes care, contact Pearson, 612-672-1950, tpearso2@fairvieworg
High-performingclinics
thefollowingclinicsconsistently metclinicalexcellenceindicator goalsfordiabetescareorachieved significantimprovementsthroughoutthepasttwoyears: Bloomington Lake Clinic Burnsville Family Physicians
Endocrinology Clinic of Minneapolis Fairview Crosstown Clinic Fairview Hiawatha Clinic Fairview Highland Park Clinic Fairview Oxboro Clinic Fairview Northeast Clinic Fairview Lakeville Clinic Farmington Clinic France Avenue Family Physicians Richfield Medical Group
David ER Sutherland, MD, PhD, director, Diabetes Institute for Immunology and Transplantation As a young resident in 1966, Sutherland witnessed the worlds first kidney-pancreas transplant in a patient with diabetes, performed by University of Minnesota physicians Richard Lillehei and William Kelley In 1974, Sutherland performed the worlds first transplant of insulin-producing islet cells from a deceased human donor to a living person He also performed the worlds first living-donor segmental pancreas transplant in 1979 For more information, visit diabetesinstituteorg
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Source:fairview.org
