To increase the residents understanding and knowledge of Diabetes Mellitus II with 1. Describe the prevalence of diabetes in the US and worldwide, and its overall …
This product was developed by the St Peter Family Medicine Residency Program in Olympia, WA Support for this product was provided by a grant from the Robert Wood Johnson Foundation in Princeton, New Jersey
Diabetes and IGT impaired glucose tolerance: Patient Self-Management Workshop Goals and Objectives Goals: To increase the residents understanding and knowledge of Diabetes Mellitus II with an emphasis on patient self-management Objectives: At the conclusion of this workshop the resident will be able to:
1 Describe the prevalence of diabetes in the US and worldwide, and its overall financial impact on society 2 Discuss the chronic care model of disease management 3 List the clinical criteria for diagnosis of diabetes and IGT 4 Describe the latest published literature on chronic disease and patient selfmanagement/self-efficacy, and apply it to practice 5 Demonstrate a practical approach to seeing a diabetic or IGT patient in the confines of a routine 15-minute encounter to include: Background Barriers to lifestyle modification Exploring a patients successes with lifestyle modification Asses a patients willingness to change Develop an action plan Reinforcement and how your
office and staff can help 6 Engage and support a patient in reaching a self-management goal as part of the diabetes care routine by demonstrating with role-playing
Diabetes IGT/IFG akaPre-Diabetes: Patient Self-Management
June 4, 2003 Devin Sawyer, MD
Chronic disease in your practice:
70 60 50 40 30 20 10 0 1990 2020 Injury Other disease Chronic disease
St Peter Family Practice visits
18 16 14 12 10 8 6 4 2 0 The Practice GME Pregnancy Depression URI Diabetes HTN Fib/Arth Lower Resp Addiction LBP Asthma
St Peter Family Practice with diagnosis
60 50 40 30 20 10 0 GME Pregnancy Depression URI Diabetes HTN Fib/Arth Lower Resp Addiction LBP Asthma The Practice
SPFP grads; what are they seeing?
Goodman VA in Las Vegas- Every
patient has diabetes Cates SeaMar- Frustrating and difficult, I need help from DE I feel under-prepared to educate my patients Group visits were great Satisfying when it works Sargent Indian Health Services- Open Access and max-pack the visit is how I survived Diabetes educators on site
SPFP grads; what are they seeing?
Taylor local private practice- Lifestyle
modification? A dismal failure Michaels Glass Shiprock ,NM- Diabetes educators on site in
the waiting room Kershisnik local private practice- It is so satisfying to hang in with a patient diabetic for 5 or more years and they finally make a breakthrough with lifestyle changes
Prevalence of Diabetes IGT:
An estimated 16 million people have
diabetes in the US 6 million of those dont know it yet Some estimate a 11-20 prevalence of impaired glucose tolerance IGT in the US between 20 and 39 million people
Prevalence of Diabetes IGT:
WHO estimates that those with DM
worldwide will double from 140 million to 300 million in the next 25 years WHO estimates that 40-45 of persons age 65 years of age or older have either type 2 diabetes or IGT
Cost of diabetes care:
Medical cost of diabetes in 2002 was an
estimated 92 Billion 44 Billion in 1997 Adding medical cost and lost productivity, diabetes cost an estimated 132 Billion in 2002 98 Billion in 1997
Diagnosis of diabetes IGT:
IGT is a 2 hr PP 75gm BS from 140 to
200 or the IHOP test IFG is a fasting BS from 110-125 Diabetes is a 2 hr PP 75gm BS over 200 and/or a fasting BS over 125 A repeat test should be done on a separate day to confirm diagnosis of diabetes
What is Self-Management?
Checking blood
sugars Taking meds pills and shots Eating right CDE, doctor, other diabetics Exercising 30 mins/day, 150 mins/week Checking feet Making appointments PCP, eye doc, CDE Compliance???
What is Self-Management?
The patients right and responsibility to make
decisions that make sense within the context of their lives Education and support refocused on helping patients achieve goals and outcomes that they themselves have selected Must acknowledge and support the patients role as the key decision maker in self-management Patient role? Provider role? Staff role? Others?
A new drug on the horizon:
lifestyle change is disease management
Ann Intern Med 2001;134:96-105 diabetic nurses N Engl J Med, 2001; 344,18:1343-1350 Finnish diabetes prevention study Diabetes Care, 1997; 20,4:537-544 China prevention study N Engl J Med, 2003; 348,5:383-459 Copenhagen CV event study N Engl J Med, 2002; 346: 393 Diabetes Prevention Program
Ann Intern Med 2001;134:96-105
Physical activity and risk for cardiovascular events in diabetic women, Harvard, Boston 5125 female nurses with DM were assessed on their level of physical activity number of hours per week and level of intensity, number of
flights of stairs, walking pace and asked to keep activity diaries
Ann Intern Med 2001;134:96-105
323 new cases of vascular disease stroke,
AMI- fatal and non fatal 104 cases/7918 person yrs 1hr/wk RR1 76/6385 with 1-19hr/wk 93 83/8091 with 2-39hr/wk 82 52/7650 with 4-69hr/wk 54 8/1389 with 7hr/wk 52 No change in RR when controlled for BMI and smoking
Ann Intern Med 2001;134:96-105
Relative Risk Reduction
1 09 08 07 06 05 04 03 02 01 0 1 1-19 2-39 4-69 7 Hours per week
NEnglJMed, 2001;344,18:1343-1350
Finnish Diabetes Prevention Study 522 overweight patients with IGT Mean age 55, BMI 31, followed up to 6 years Randomized into intervention and control
Interv- met with nutritionist 7x during 1st year and every 3 months thereafter, with these 5 goals: 1 to loose 5 wt, 2 fat intake 30, 3 sat fat 10, 4fiber 15gms/1000kcal 5 exercise 30 minutes per day
NEnglJMed, 2001;344,18:1343-1350 Percent of patients going on to DMII
40 35 30 25 20 15 10 5 0 0 goals 1 goal 2 goals 3 goals 4 goals 5 goals Control Intervention
NEnglJMed, 2001;344,18:1343-1350
Diabetes did not develop in any patient who
reached 4 or 5 of the goals Those who did not meet the weight goal but met the
exercise goal had an 80 reduction in risk of developing DMII Number needed to treat to prevent one case of DM was 5 patients for 5 years 91 of patients completed the study
Diabetes Care, 1997; 20,4:537-544
Diabetes prevention with IGT 110,660 patients in 33 clinics in China were screened for IGT and DMII 577 classified as IGT and randomized into
Control Diet only Exercise only Diet and exercise
Followed at 2 year intervals for 6 years
Diabetes Care, 1997; 20 
,4:537-544
Results: Those who developed DM in 6 years Control 677 Diet 438 Exercise 411 Both 460
N Engl J Med, 2003; 348,5:383-459
Steno-2 study in Copenhagen looked at 8
year cardiovascular event occurrences in DMII with microalbuminuria 160 pts randomized to 1 intensive treatment, and 2 usual care Intensive tx aggressive and strict treatment guidelines and protocols, and support for behavior modification
N Engl J Med, 2003; 348,5:383-459
44 events in 35 patients in the conventional group 33 events in 19 patients in the intensive treatment group Nephropathy macroprot 31 and 16 patients Retinopathy 51 and 38 patients
Number needed to treat 5 patients to
prevent one event
N Engl J Med, 2003;
348,5:383-459
The NPR news report: Experienced TEAM Motivated Enthusiastic Gung Ho
N Engl J Med, 2002; 346: 393
Diabetes Prevention Program 3234 with IFG and IGT followed for an average of 28 years Randomized to placebo, metformin 850mg BID, or lifestyle modification Primary outcome: DMII Study was terminated 1 year early
N Engl J Med, 2002; 346: 393
Lifestyle Modification: Goals: 7 weight reduction and 150 minutes of moderate physical activity a week 16 lesson curriculum on lifestyle modification looking at food choices and physical activity followed by monthly meetings 50 met weight loss goal 74 met exercise goal
N Engl J Med, 2002; 346: 393
40 35 30 25 20 15 10 5 0 1 year 2 years 3 years 4 years Placebo Metformin Lifestyle
N Engl J Med, 2002; 346: 393
58 reduction in progression to DMII with
Lifestyle modification whether they mets goals or not 31 reduction in metformin group Effects found across gender, ethnicity, ages, BMI, and baseline glucose levels Conclusion: Lifestyle modification could prevent up to 1 million cases of DMII/year in the US
N Engl J Med, 2002; 346: 393
The DPP is a landmark trial and is one of the most important studies in the recent
history of diabetes
Christopher D Saudek, MD President American Diabetes Association
What study is needed now?
A study showing that a group of providers working in a costeffective system of care designed to provide patient centered care and effective self-management support has patients with better controlled disease and improved outcomes
Practice At Large
1000 900 800 700 647 572 557 549 527 536 676 722
Percent of Patients with HbA1c 95
745
percent
600 500 400 300 200 100 00
Aug -0 2
Sep -0 2
Oct -0 2
No v-0 2
Dec-0 2
J an-0 3
Feb -0 3
M ar-0 3
Ap r-0 3
M y-0 3
J un-0 3
J ul-0 3
1000 900 800 700 600 500 400 300 200 100 00
Aug -0 2 Sep -0 2
Percent of Patients with Documented Self-Management Goals
percent
544 436 277 162 153 153 177 176 189
Oct-0 2
No v-0 2
Dec-0 2
J an-0 3
Feb -0 3
M ar-0 3
Ap r-0 3
M y-0 3
J un-0 3
J ul-0 3
TEAMWORK WORKS
Team A
1000 900 800 700
percent
Percent of Patients with Documented Self-Management Goals
600 500 400 300 200 100 00
Oct-0 2 No v-0 2 Dec-0 2 Jan-0 3 Feb -0 3 Mar-0 3 Ap r-0 3 My-0 3 Jun-0 3 Jul-0 3
365 182 172 172 171 222
427
Team B
1000 900 800 700
percent
Percent of Patients with Documented
Self-Management Goals
600 500 400 300 200 100 00
Oct-0 2 No v-0 2 Dec-0 2 Jan-0 3 Feb -0 3
657 567 495 361 365 345 326
Mar-0 3
Ap r-0 3
My-0 3
Jun-0 3
Jul-0 3
Team C
1000 900 800 700
percent
Percent of Patients with Documented Self-Management Goals
600 500 400 300 200 100 00
Oct-0 2 No v-0 2 Dec-0 2 Jan-0 3 Feb -0 3 Mar-0 3
589 455 308 145 188 203 302
Ap r-0 3
My-0 3
Jun-0 3
Jul-0 3
How do we do and teach this?
Big Bad Sugar WAR
The 15 minute encounter: A tool Big Bad Sugar WAR
Background Barriers Successes Willingness to change Action plan Reinforcement
The 15 minute visit:
How do you spend your time?
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Chart review, labs, referrals, meds, last notes etc Discussion with patient history Physical exam Make an assessment Plan med changes and additions, referrals, labs, immuniz, etc Self-management
Background
Who are they, where are they with their disease, are there other diseases, who is their support, where and with who do they live- get to know the patient well
Barriers
What hasnt worked well in past, what makes it difficult to make lifestyle changes around food choices and physical activity
Successes
Focus on what a
patient has done well and highlight it even if, deep down, you dont feel they were very successful
Willingness to change WTC
Characterize a patients readiness or willingness to change ie, pre-contemplation, contemplation, preparation, action, maintenance
A tool to assess WTC JABFP, 2002
Precontemplation- neg response to 4 statements ContemplationI am intending to make changes in my diabetes care in the next 6 months PreparationI am intending to make changes in my care in the next month ActionI have made changes in in the last 6 months MaintenanceMy diabetes is in good control for 6 months
JABFP, 2002; 15,4:266-271
University of Minnesota Looked at using a tool to assess readiness to
change asking patients to pick one or none of the statements listed that fit them Used it with 50 consecutive patients with HBA1C90 and followed usual care for 24 months
JABFP, 2002; 15,4:266-271
In 12 months: Precontemplation and Contemplation changed HBA1C from 105 to 103 Preparation changed HBA1C from 103 to 83 Action changed from 107 to 82
The 15 minute encounter: A tool Big Bad Sugar WAR
Background Barriers Successes Willingness to change Action plan Reinforcement
Action
Plan
Patient oriented, patient driven, and highly specific Write it down and give it to the patient
An Action Plan:
Something the patient WANTS to do Should be REASONABLE Behavior specific Should answer the questions:
What? How much? When? How often?
Confidence level likelihood-of-success 1-10
adapted from work by Kate Lorig, Stanford, California
An Action Plan:
Refrain from telling the patient
what you think they should do Incorporate an activity into their everyday life
VANITY
HEALTH
HOME
ACTIVITY
WORK
FUN
Reinforcement
Follow-up with encouragement and motivation MA or PCP phone call, next planned visit, group visit, other patients, family, friends- be creative and refine, redefine, or stretch the goal
SMG Cycle
Introduce concept to patient initial phone
call, provider visit, group visit Planned visit Provider visit Group visit F/U phone call and so on
Source:healthprep.com
