Choosing Wisely Task Force Hypoglycemia Safety Initiative (HSI) October 2014 Susan Kirsh, MD, MPH Mark McConnell, MD Storm Morgan, RN, MSN, MBA October 2012 Bernie Good, MD Donna Leslie, PharmD Chartered May, 2014 Under auspices of Dr Leonard Pogach (Specialty Care) and Dr. Gordon Schectman (Primary Care

VETERANS HEALTH ADMINISTRATION Recommendation: “There is no evidence that using medications to achieve tight glycemic control in older adults (65 and older) with type 2 diabetes is beneficial.” 1

VETERANS HEALTH ADMINISTRATION Choosing Wisely: VA Hypoglycemia Safety Initiative (HSI) Ultimate Goal: To foster shared decision making between clinicians and Veterans that is informed by the best available evidence and reduce unnecessary care.

VETERANS HEALTH ADMINISTRATION Objectives 3 Describe the HSI: – VA voluntary effort to identify and reduce hypoglycemia Describe the tools available for use Invite any site or VISN to join!

VETERANS HEALTH ADMINISTRATION Federal Alignment 4 September 29 th : The Federal Diabetes Mellitus Interagency Coordinating Committee (DMICC) has a one day meeting at NIH to present the HHS National Action Plan for Hypoglycemic Safety and elicit Federal Collaboration October 30 th : Health and Human Services (Office of the Assistant Secretary) sponsoring a conference for representatives from about 100 Federal Agencies and Private Sector Organizations to kick off a National Action Plan to decrease adverse drug events (opioids, anticoagulation, hypoglycemia)

VETERANS HEALTH ADMINISTRATION How do WE help lower the risk? 5 1)Be able to identify what causes hypoglycemia 2)Be aware of the symptoms 3)Be able to counsel on management (15-15 rule) 4)Act! – Be sure we have the right goal – Identify and intervene for patients at risk 5)Recognize that WE created the risk 6)Each PACT Teamlet the key! 7)Outreach to Veterans and Families

VETERANS HEALTH ADMINISTRATION 6 Individual goal setting is needed to find an appropriate, safe, A1c goal VA/DoD Diabetes Guideline 2010 – Individualized A1C goals based on patient preferences, complications, and co- morbidities – Based on best available evidence – Avoids “one size fits all” approach PACT: emphasis on shared decision making

VETERANS HEALTH ADMINISTRATION 7 Goal: (the evidence says it’s time for a new “sound-bite” Major Comorbidity or Physiologic Age Microvascular Complications Absent or MildModerateAdvanced Absent >10 years of life expectancy <7%<8%8-9% Present 5 to 10 years of life expectancy <8% 8-9% Marked <5 years of life expectancy 8-9%

VETERANS HEALTH ADMINISTRATION HSI-VISN 12 example 8 Utilize VISN Data Warehouse (VDW) Generate lists for each PC Team – A1c < 7 and on Insulin or Sulfonylurea who: Are age 75 or greater OR cognitive impairment regardless of age OR renal impairment (creatinine >2.0) Use CPRS shared template to gather data Approach: 1.Proactive: call patients 2.Clinical reminder for face-to-face visits Easily Measured! (by uniform health factors)

VETERANS HEALTH ADMINISTRATION HSI-VISN 12 Cohort Identification 9 DO YOU BELIEVE THIS PATIENT IS GETTING ANY BENEFIT FROM GLIPIZIDE? WHAT ABOUT HARMS?

VETERANS HEALTH ADMINISTRATION Patient Case # year old male with CKD (SCr 3.7) Seen for routine care, at which time PCP noted his Clinical Reminder saying he was due for hypoglycemia screening. Taking NPH 10 units daily A1c 6.1% Denies hypoglycemia PCP stopped insulin – A1c remains well below goal at 6.4% (8-9 per CPG)

VETERANS HEALTH ADMINISTRATION Patient Case # year old frail man and his wife On insulin NPH/REG 70/30 35 units twice daily and 2 units of Aspart with each meal A1c = 6.7 Hypoglycemic episodes about twice/week PCP stopped Aspart & reduced 70/30 insulin to 30 units in AM/20 units in PM – 3 months later: A1c = 8.4 – “He feels SO much better”

VETERANS HEALTH ADMINISTRATION Hypoglycemia Risk Change 12 Age ≥ 75 or Dementia/CI or SCr > 1.7 March 2012 (N = 4,185) March 2013 (N = 4,266) March 2014 (N = 4,475) Aug 2014 (N = 4,445) A1c < 7%35.7%31.7%29.3%28.1% A1c < 6.5%17.2%14.8%13.0%12.9% A1c < 6%5.5%5.0%4.0%3.9%

VETERANS HEALTH ADMINISTRATION Choosing Wisely: VA HSI 13 National voluntary opportunity, similar to VISN 12 Lists – High risk: A1c < 7 and on Insulin or Sulfonylurea Are age 75 or greater OR renal impairment (creatinine >2.0) – Ultra high risk: A1c <7 and on Insulin or Sulfonylurea who are on Cholinesterase Inhibitor Any VISN/site interested in participating can receive

VETERANS HEALTH ADMINISTRATION Choosing Wisely: VA HSI Toolkit 14 QSV Tool kit (coming soon) – Lists of patients at high risk – How to Implement Who is involved? How to discuss with patients – Clinician facing education – Patient facing education

VETERANS HEALTH ADMINISTRATION Choosing Wisely-VA HSI “The List” (courtesy of PBM) 15

VETERANS HEALTH ADMINISTRATION Choosing Wisely: VA HSI: Implementation 16 Pro-active assessment of these patients using “non face-to-face” care (telephone encounters) The addition of a coversheet Clinical Reminder prompts face-to-face evaluation when these patients have a clinic visit. Teams are encouraged to review their lists of patients and decide on a strategy for contacting them: – Providers, Nurses (RN), Diabetes Educators (CDE), and Clinical Pharmacy Specialists (CPS)

VETERANS HEALTH ADMINISTRATION Choosing Wisely: VA HSI: Teamlet Implementation 17 The Team decides who will contact patients: – If a Provider or CPS with Scope of Practice: the entire process can be completed in one encounter – If an RN or CDE: a “huddle” will be needed after evaluation to determine action Patient contact can be made using a phone encounter – Consider a standardized template – Using health factors in a standard ‘reminder dialog’ CPRS template would allow for data collection if desired

VETERANS HEALTH ADMINISTRATION Summary 18 Hypoglycemia is a severe and significant risk Everyone at VA can help by being aware of causes/symptoms/management of hypoglycemia We can easily identify a high-risk cohort We have the ability to proactively reach out to these patients and potentially lower their risk

VETERANS HEALTH ADMINISTRATION What Can YOU do? 19 Encourage your leaders/site to join the effort! – Remember, it’s voluntary: NOT a “Directive” – So, Veterans NEED you to volunteer! Sign up for the “HSI Listserv” – We will regularly update everyone on this group about activities related to HSI Contact us if you want lists of your site’s patient lists sent to you for action