Diabetes, Dyslipidemia, and Continuous Quality Improvement Using the Chronic Care Model in the Treatment of Patients Class of 2011, Family and Community Medicine Clerkship Nichole J. Mirocha DO

Objectives   Understand the key principles of the Chronic Care Model and how it applies to the care of the patient with diabetes. Explain the findings needed to diagnose DM2. Identify the various goals for patients with diabetes (i.e. A1c, lipids, BP’s, etc.) Understand the known complications of diabetes, how to monitor for them, and how to lower risk of getting them. Explain how and when to use various medications for diabetes. Understand the proper use of statin therapy and how to monitor for side-effects and adverse reactions.

Chronic Care Model by Ed Wagner, MD, MPH

Self-Management Patients must take a role in determining their care – a sense of responsibility for their health

Decision Support Treatment decisions should be based on guidelines that are evidence-based

Delivery System Design Delivery of patient care is determining what care is needed and clarifying the roles and tasks of the providers so that the care is provided to the patient. Clinicians need centralized, up-to-date information about patient’s status. Follow-up is a part of the standard procedure.

Clinical Information System A registry – or tracking of individual patients as well as groups of patients and their progress – and the progress of the providers

Organization of Health Care An environment in which patient’s with chronic illness can receive care in an organized way that can help them to achieve their goals.

Organization of Health Care An environment in which patient’s with chronic illness can receive care in an organized way that can help them to achieve their goals.

Community Improvement of health of a population achieved through health care organizations working together – forming alliances with state programs, local agencies, schools, faith organizations, businesses, and clubs.

Question 1 Your patient, Jane Smith, is a 38 year old female who comes in to clinic today because she’s worried about possible diabetes. Her sister, mother, aunt, and grandfather all have diabetes. She has been feeling more tired lately, and they’ve all urged her to “come get checked out” because they’re worried about her weight and the possibility of diabetes. Other than fatigue, she denies any other symptoms. Her vitals are normal, BMI is 38. You perform a finger glucose test in clinic, which is 180. Pt is non-fasting.

Does this patient have diabetes? What other information would you need to help determine the presence of diabetes? What should this patient start working on in terms of lifestyle changes?

Question 2 Your patient returns the following week for fasting lab work, which showed a fasting glucose of 160. A repeat fasting glucose confirms the diagnosis of diabetes. Her hemoglobin A1C is 7.8%. Additional labs reveal normal CMP, cholesterol 220, triglycerides 183, HDL 27, LDL 156, cholesterol to HDL ratio 8.1. She returns to clinic to discuss lab work and reports feeling fine. BP is 139/90.

What is her goal A1C?   What is her goal BP?    How do you interpret her fasting lipid profile – good, bad, ugly? What if the patient had not been fasting – would any portion of the lipid profile be useful?  What are the next steps in management? What meds would you consider starting? What additional examinations/labs do you need to order to evaluate for possible diabetic complications?

Question 3 Your patient agrees to start metformin for her diabetes but would like to hold off on starting any cholesterol meds.

What specific lifestyle changes would your suggest to help improve her lipid profile? What % LDL reduction could we expect from maximal dietary therapy? Does Mrs. Smith have CHD risk equivalents? What conditions are considered CHD risk equivalents?  At what LDL would you strongly consider drug therapy?

Question 4 Your patient returns 6 months later and her A1C is now 7.3% despite maximum doses of metformin. She asks about Byetta because she saw an ad for it on TV.

How does Byetta work? What are the advantages and disadvantages of its use?  What are 3 other treatment options for diabetes you would consider using before Byetta? What are the advantages and disadvantages for these 3 drugs?

Question 5   You elect to continue your patient on metformin and start glipizide. She is now on lisinopril for HTN. She does not keep her next scheduled appointment, and finally returns to see you 1 year later. Her A1C is now 9.2%. She states she feels “fine”. BP is 129/78, weight is 70kg. She’s not checking her blood sugar. Monofilament exam reveals absent sensation on both feet. Given her elevated A1C you recommend starting insulin.

What interventions should be recommended given her absent monofilament sensation? How often should this patient be checking her blood sugars? What specific insulin regimen would you start her on? What side effects of insulin would you warn her about?

Question 6 Your patient returns 6 months later and a repeat FLP reveals cholesterol 210, triglycerides 175, HDL 27, LDL 160, cholesterol to HDL ratio 7.8.

What drug classes are available to offer to her What drug classes are available to offer to her? Describe the lipid effects of each class. Which cholesterol med could worsen her diabetes? You decide to prescribe lovastatin. What symptoms would you ask her to contact your office about?  When and how often would you plan to check her LFT’s?

Question 7 Jane Smith starts lovastatin 20mg daily. In 4 weeks, she experiences diffuse muscle aches and contacts your office. You ask her to hold the medication and come in for lab work including LFT’s and a CK level.

How much of a rise in liver enzymes or CK levels would necessitate stopping the lovastatin or lowering the dose?  What medications might you be concerned about taking while on a statin?   Which statins are associated with less muscle toxicity?  Your patient recently read an article about fish oil supplements and cholesterol. She wants to know your thoughts. What do you tell her?

Question 8 Mrs. Smith refers her husband, Joe Smith to you as well. He is a 46 year old male who is worried about having a heart attack since his father had his first MI at age 55. He has HTN and takes HCTZ. He smokes 1 ppd, but has been working on diet and exercise, and had his cholesterol checked at a career fair last week. He was told it was “a little high” and was instructed to follow-up with his PCP. On today’s exam, his BP is 126/73, height 6’1”, weight 130kg. You get a FLP that shows total cholesterol 260, HDL 35, LDL 190, triglycerides 380.

What other lab work would you consider ordering for Mr. Smith? What are his major risk factors that affect his risk of CAD and his goal LDL?  Using the Framingham scoring system, what is his 10 year risk of CAD? If he quits smoking, what is his new Framingham 10 year risk of CAD? W hat would his LDL goal be? How did you determine that goal? What would be your next step of action?

Question 9 You decide to prescribe Joe Smith simvastatin 20 mg daily. He does not keep his f/u appointment in 3 months but does return in 6 months. You obtain a repeat FLP that is actually higher than it was 6 months ago.

You suspect Mr. Smith of being non-adherent with his medications You suspect Mr. Smith of being non-adherent with his medications. What might be some reasons?   How might you help with medication adherence? If cost is an issue, which statins may be more affordable for him?

Question 10 Mr. Smith’s next FLP showed a modest decrease in LDL and triglycerides, so you continue to increase his statin. On the maximum statin dose (which he’s actually taking now), his triglycerides are still well over 300.

What factors could contribute to elevated triglycerides? What options are available to further lower his triglycerides? You decide to add an additional lipid lowering drug, but are concerned about increased side effects. What type of combinations might help minimize toxicity?

Reference: These questions were created by Amanda Allmon, MD and Sarah Swofford, MD How Sweet It Is: A Creative Approach to Teaching Diabetes, Dyslipidemia, and CQI.