Transcript Cost-Effectiveness Strategies, Part 3 of 4

Cost-Effectiveness of
Treatment Strategies for
Comorbid Diabetes and Dyslipidemia
Part 3
Using SMAs to improve care and
Profitiability
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An SMA (group visit) is a periodic medical
appointment held by a clinician for 90 or more
minutes to provide routine or follow-up care to
groups of patients
The clinician is supported by other health
professionals in conducting the SMA
Private one-on-one time with the clinician is
available to patients who want/need it
Source: SMA Workshop, 2005; Noffsinger EB. Running Group Visits in Your Practice. 2009:4,9.
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Patients Suited to SMAs
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SMAs are well-suited to:
– Patients with chronic conditions
– High utilizers
– Those with extensive emotional, informational, or
psychosocial needs
– Patients having difficulty making behavioral/ lifestyle
changes—eg, smoking cessation, medication adherence
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Source: AAFP Web site. Group visits: introduction:1; Schmucker D. Group Medical Appointments. 2006:85.
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Types of SMAs
 Cooperative
Health Care Clinic
(CHCC)
 Drop-in
Group Medical Appointment
(DIGMA)
 SMA
for Physical Exams
(Physicals SMA)
Source: SMA Workshop, 2005; Noffsinger EB. Running Group Visits in Your Practice. 2009:122.
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Privacy Issues
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Anything patients say about themselves is not of
concern regarding HIPAA
–HIPAA requires written consent before providers
disclose patients’ personal information
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Patients sign privacy notice when entering
meeting or exam room
Oral privacy reminders are given at the
beginning of each SMA
Private time is available with the physician
Sources: Schmucker D. Group Medical Appointments. 2006:147-148; SMA Workshop, 2005; Noffsinger EB. Running Group Visits in Your Practice. 2009:9.
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SMA Benefits
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SMAs offer:
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More time and a more relaxed pace of care
Increased patient education
Peer support and encouragement
The opportunity to identify psychosocial issues or previously
unnoticed medical issues
Care delivered by a team
Opportunity for family/caregivers to participate
Better customer focus
Better Profitability
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Source: SMA Workshop, 2005; Noffsinger EB. Running Group Visits in Your Practice. 2009:9,12.
Strategic Use of Medications:
Treatment Goals
Patient with Diabetes and CVD
Glycemic Control
ADA Guidelinesa1
A1C
<7%
FPG
≤70-130 mg/dL
2-hour
PPG
<180 mg/dL
Lipid Management
LDL-C Goals
(NCEP ATP III,2,3 ADA,1 and AACE4)
LDL-C <100 mg/dL
<70 mg/dL (optional goal for
patients with diabetes and CVD)
30% to 40% reduction in those
uncontrolled on maximally
tolerated statin doses4
aFor
most nonpregnant adults with diabetes; individualized goals are endorsed, with less stringent control for those with more
advanced disease or history of severe hypoglycemia
ADA = American Diabetes Association; A1C=glycosylated hemoglobin; FPG = fasting plasma glucose: PPG=postprandial glucose
1. American Diabetes Association. Diabetes Care. 2009;32(suppl 1):S13-S61. 2. NCEP Expert Panel on the Detection, Evaluation,
and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Circulation. 2002;106(25):3143-3421. 3. Grundy SM,
et al. Circulation. 2004;110:227-239. 4. Rodbard HW, et al. Endocr Pract. 2007;13(suppl 1):1-68.
Road Map to Achieve Glycemic Goals:
Welchol® (colesevelam HCl) Is Indicated for
Patients With Diabetes
Current Therapy
6.5
to
8.5
*
**
a
b
c
d
e
f
Monotherapy :
Continue Lifestyle Modification
Curre
nt
A1C%
Glinides, SU, AGI,
metformin, TZD, DPP-4,
premixed insulin
preparationsa, prandialb or
basal insulinc
Combination
Therapy:
Intervention
Intensify Lifestyle Modification
Initiate Combination Therapy
• Metformin + SU or Glinide
• Metformin + TZDd,e or AGI
• TZD + SU
• DPP-4 + Metformin ± SU
• DPP-4 + TZD
• Colesevelam + met, SU or insulin
• Incretin mimetic* + metformin and/or
SU
Other approved combinations including
approved oral agents with insulinf
• Incretin mimetic
+ metformin
and/or TZD
• Basalc or premixed
insulin
preparationsa
• Amylin analog**
with prandial
insulinb
Intensify Lifestyle Modification
Maximize Combination Therapy
Maximize Insulin Therapy
• If elevated FPG, add or increase basal insulinc
• If elevated PPG, add or increase prandial insulinb
• If elevated FPG and PPG, add or intensify basalc +
prandialb or premixed insulin therapya
• Combine with approved oral agentsf
• Amylin analog** with prandial insulinb
Add incretin mimetic to patients on SU, TZD,
and/or metformin
Continuous
Titration of Rx
(2-3 months)
Monitor/adjust
Rx to maintain
ACE Glycemic
Goals†
Continuous
Titration of Rx
(2-3 months)
Glinides, SU, DPP-4, AGI,
metformin, TZD,
Monitor/adjust
colesevelam
colesevelam,
Rx to maintain
incretin mimetic*, premixed
a
ACE Glycemic
insulin preparations ,
prandial2 or basal insulinc
Goals†
Available as exenatide
Available as pramlintide
Analog preparations preferred
†ACE Glycemic Goals
Prandial insulin (rapid-acting insulin analogs available as lispro, aspart, glulisine, or regular insulin) can be added to any
≤ 6.5% A1C
therapeutic intervention at any time to address persistent postprandial hyperglycemia
<110 mg/dL FPG
Available as glargine and detemir
<110 mg/dL preprandial
A recent meta-analysis suggests a possible link of rosiglitazone to cardiovascular events; other studies do not confirm or
exclude this risk. TheFDA has stated “In their entirety, the available data on the risk of myocardial infarction are inconclusive.”
<140 mg/dL 2-hr PPG
Cannot be used in NYHA CHF Class 3 or 4
According to the FDA, rosiglitazone not recommended with insulin
ACE/AACE Diabetes Road Map Task Force. April 2008 Revision. http://www.aace.com/pub/roadmap/index.php.
Accessed March 23, 2009.
Summary
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Diabetes is a highly prevalent and costly disease in the US population
– Most patients with diabetes have elevated LDL-C
– Patients with diabetes have at least a twofold increase in risk of heart
disease compared with people without diabetes
– Cost increases with severity of CVD risk factors
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Patients with comorbid diabetes and dyslipidemia need
comprehensive care to lower their risk of CHD and complications
Potentially cost-effective strategies for managing comorbid diabetes
and dyslipidemia include
– Targeting high-risk patients for intervention
– Use of collaborative care programs using nurse and/or pharmacist case
managers to direct care
– Use of SMA’s to improve patient care and profitability
– Appropriate use of medications to achieve glycemic and lipid control