Optimal Blood Glucose Monitoring Diabetes Policy Summit: Exploring Policy Options for Better Diabetes Outcomes in Ontario Optimal Blood Glucose Monitoring Objectives 1.       Identify the challenges  that Ontarians with diabetes face in receiving optimal care in the three critical areas. 2.       Collectively explore strategies and policy solutions to overcome some of these challenges in Ontario   Invitation for you to speak about Blood Glucose Monitoring: ·         BG control & diabetes management (SMBG, A1C and CGM) ·         Gaps and challenges ·         Best practices ·         Policy solutions Gilian Booth, MD …. Susie Jin, RPh CDE CPT Endocrinologist Pharmacist, Certified Diabetes Educator St. Mike’s Hospital Pharmacy 101 November 4, 2014

Insert Gillian’s slides…

Optimal Blood Glucose Monitoring Diabetes Policy Summit: Exploring Policy Options for Better Diabetes Outcomes in Ontario Optimal Blood Glucose Monitoring Susie’s intro… “normal” vs. who is the “train-wreck” = health care system Gillian has provided a high-level overview. Susie to speak “from the clinician’s point of view” From my point of view… Gap exists… what we’re doing… what we should be doing… Gilian Booth, MD …. Susie Jin, RPh CDE CPT Endocrinologist Pharmacist, Certified Diabetes Educator St. Mike’s Hospital Pharmacy 101 November 4, 2014

What we’re doing What we should be doing From my point of view… Gap exists… what we’re doing… what we should be doing…

What we’re doing What we should be doing = What we should be doing Clearly a Gap exists… what we’re doing… what we should be doing…

Guideline Targets Achieved % of patients ABSTRACT Objective: To gain insight into the current management of patients with type 2 diabetes mellitus (T2DM) by Canadian primary care physicians. Methods: 479 primary care physicians from across Canada submitted data on 5123 T2DM patients whom they had seen on a single day on or around World Diabetes Day, November 14th, 2012. Results: Mean A1C was 7.4%, LDL-C 2.1 mmol/L and blood pressure 128/75 mmHg. A1C≤7.0% was met by 50%, LDL-C ≤2.0 mmol/L by 57%, BP <130/80 mmHg by 36% and the composite triple target by 13% of patients. Diet counselling had been offered to 38% of patients. Of the 87% prescribed antihyperglycemic agents, 18% were on 1 non-insulin antihyperglycemic agent (NIAHA) (85% of which was metformin), 15% 2 NIAHAs, 6% ≥3 NIAHAs, 19% insulin only and 42% insulin+≥1 NIAHA(s). Amongst the 81% prescribed lipid-lowering therapy, 88% were on monotherapy (97% of which was a statin). Amongst the 83% prescribed antihypertensive agents, 39%, 34% and 21% and 6% received 1, 2, 3 and >3 drugs, respectively, with 59% prescribed angiotensin-converting enzyme inhibitors and 35% angiotensin II receptor blockers. Conclusion: The DM-SCAN survey highlights the persistent treatment gap associated with the treatment of T2DM and the challenges faced by primary care physicians to gain glycemic control and global vascular protection in these patients. It also reveals a higher use of insulin therapy in primary care practices relative to previous surveys. Practical strategies aimed at more effectively managing T2DM patients are urgently needed. Leiter LA et al. Can J Diabetes 2013; in press

Blood Glucose Control & Diabetes Self-Management A1C Hemoglobin A1C SMBG Self-Monitoring of Blood Glucose CGMS Continuous Glucose Monitoring System

A1C How often? What to do with the numbers? Every 3 months… if not at target and/or if adjusting meds Every 6 months… if consistently at target What to do with the numbers? TAKE ACTION Refer to Blood Glucose Lowering on guidelines.diabetes.ca website Hyperlink on guidelines.diabetes.ca guidelines.diabetes.ca

SMBG How often? Hyperlink on guidelines.diabetes.ca

SMBG How often? What to do with the numbers? TAKE ACTION Refer to Blood Glucose Lowering on guidelines.diabetes.ca website Refer to Hyperlink on guidelines.diabetes.ca Hyperlink on smbg.diabetes.ca smbg.diabetes.ca guidelines.diabetes.ca

Monitoring with PURPOSE GAPs… Number of tests performed at the frequency indicated according to best-practice or evidence-based guidelines Too little Too many Acting on the results Monitoring with PURPOSE REASONS WHY TESTS NOT PERFORMED / ORDERED as often as indicated in CPGs PCP does not order the test (A1C) PwD does not go to the lab to have blood work done Wrt SMBG… tests performed not often enough… tests performed TOO often ACTING ON THE RESULTS PCP gets the results and tells the PwD… nothing… or “it’s fine” PwD does not act on the results of SMBG.

Diabetes is a Chronic Disease Refer to Organization of Care, chapter 6 Hyperlink on guidelines.diabetes.ca …What should we be doing? Diabetes care should be delivered using as many elements as possible of the chronic care model. Recommendations Diabetes care should be proactive, incorporate elements of the chronic care model (CCM), and be organized around the person living with diabetes who is supported in self-management by an interprofessional team with specific training in diabetes [Grade C, Level 3 (6,23)]. The following quality improvement strategies should be used, alone or in combination, to improve glycemic control [Grade A, Level 1 (12)]: a) Promotion of self-management b) Team changes c) Disease (case) management d) Patient education e) Facilitated relay of clinical information f) Electronic patient registries g) Patient reminders h) Audit and feedback i) Clinician education j) Clinician reminders (with or without decision support) Diabetes care management by an interprofessional team with specific training in diabetes and supported by specialist input should be integrated within diabetes care delivery models in the primary care [Grade A, Level 1A (12,21)] and specialist care [Grade D, Consensus] settings. The role of the diabetes case manager should be enhanced, in cooperation with the collaborating physician [Grade A, Level 1A (12,21)], including interventions led by a nurse [Grade A, Level 1A (29,30)], pharmacist [Grade B, Level 2 (34)] or dietitian [Grade B, Level 2 (70)], to improve coordination of care and facilitate timely diabetes management changes. As part of a collaborative, shared care approach within the CCM, an interprofessional team with specialized training in diabetes, and including a physician diabetes expert, should be used in the following groups: a) Children with diabetes [Grade D, Level 4 (71)] b) Type 1 diabetes [Grade C, Level 3 (46)] c) Women with diabetes who require preconception counselling [Grade C, Level 3 (72–74)] and women with diabetes in pregnancy [Grade D, Consensus] d) Individuals with complex (multiple diabetes-related complications) type 2 diabetes who are not reaching targets [Grade D, Consensus] 6.Telehealth technologies may be used as part of a disease management program to: a) Improve self-management in underserviced communities [Grade B, Level 2 (67)] b) Facilitate consultation with specialized teams as part of a shared-care model [Grade A, Level 1A (69)] Abbreviation: CCM, chronic care model. guidelines.diabetes.ca

The 5Rs of Organized Care Recognize:  Consider diabetes risk factors for all of your patients and screen appropriately for diabetes Register:  Develop a registry or a method of tracking all your patients with diabetes. Resource: Support self-management through the use of interprofessional teams which could include the primary care provider, diabetes educator, nurse, pharmacist, dietitian, and other specialists. Hyperlink on guidelines.diabetes.ca guidelines.diabetes.ca

The 5Rs of Organized Care (continued) Relay:  Facilitate information sharing between the person with diabetes and team members for coordinated care and timely management change Recall:  Develop a system to remind your patients and caregivers of timely review and reassessment of targets and risk of complications Hyperlink on guidelines.diabetes.ca guidelines.diabetes.ca

Consider all these resources… … refer.. … Communicate … Support role expansion Engage… the evidence guidelines.diabetes.ca guidelines.diabetes.ca