1. The Impact of Diabetes on Hospital Readmissions James Desemone, MD Director of Medical Staff Quality Ellis Medicine October 15, 2011 New York State Regional Family Medicine Conference

2. Dr. Desemone has no financial disclosures nor conflicts of interest to declare

3. The Impact of Diabetes on Hospital Readmissions With Special Thanks to: Nancy Landor Senior Director, Strategic Quality Initiatives, HANYS Amy Jones Manager, Quality Initiatives, HANYS Karen Pirigyi Assistant to the Director, Quality Services, Ellis Medicine

4. Impact of Diabetes on Hospital Readmissions By attending this conference, the participant should be able to: 1.Name 3 of the measures in the National Committee for Quality Assurance (NCQA) Diabetes Recognition Program 2.Explain how diabetes education reduces the cost of care 3.Name the percentage of patients with diabetes that physicians refer to diabetes education

5. Hospital Readmissions CHFCOPDPneumoniaAMI

6. What about Diabetes? Keeps a low profileKeeps a low profile Frequently a secondary diagnosisFrequently a secondary diagnosis

7. Estimated Adult Diabetes Prevalence in NYS, 2002-2008

8. Past and projected prevalence of overweight (BMI >25 kg/m²) Wang YC, et al. Lancet 378: 815–25 (2011)

9. New York State Emergency Department Utilization Diabetes Patients Admitted as Inpatient as a % of Total ED Visits Healthcare Association of New York State, July 2010 726,5537,146,817

10. Percentage of NYS Admissions with Diabetes as 1 o or 2 o Dx Healthcare Association of New York State, July 2010

11. NYS Readmission Rates, 2008 Healthcare Association of New York State, July 2010

12. Healthcare Association of New York Statewww.hanys.org Survey : NYS Systems/Hospitals n=70 Do you have discharge planning criteria for referring any type of diabetes patient to a Certified Diabetes Educator (CDE) or ADA/AADE Certified Education Program post-discharge? Criteria in Place No Criteria in Place

13. Healthcare Association of New York Statewww.hanys.org HANYS’ Study—NYS Data Identifying Routine Diabetes Care Room for Improvement There are 33,327 diabetes patients on the 5% SAF Carrier File or Medicare patients. Of those, 3,327 (10%) did not receive any preventive care. Only 12,969 (38.9%) received all of the recommended procedures in the year. Source: 2007 Medicare Limited Data Set Standard Analytic Files 5% version

14. Healthcare Association of New York Statewww.hanys.org National Committee for Quality Assurance Diabetes Recognition Program

15. Healthcare Association of New York State, July 2010

16. Reducing Readmissions Improved Diabetes Treatment by the Provider?Improved Diabetes Treatment by the Provider? Referral to a Diabetes Self- Management Training and Education (DSMT/E) Program?Referral to a Diabetes Self- Management Training and Education (DSMT/E) Program?

17. PhiladelphiaPhiladelphia January 1994 to December 2001January 1994 to December 2001 80,218 unique patients with diabetes80,218 unique patients with diabetes 224,818 hospital discharges to self-care224,818 hospital discharges to self-care

18. Robbins JM, et al. J Health Care for the Poor and Underserved 19:562-573 (2008) Odds ratio for Hospital Readmission within 30 days

19. Maybe… ….for patients who are discharged without a recorded diagnosis of diabetes Caveats:Caveats: –Administrative data are prone to error –Did not examine transition of care from inpatient to outpatient

20. What We Want Safe, Positive Clinical Quality Cost Savings

21. Hospital Costs Account for Majority of Total Costs of Diabetes Per Capita Health Care Expenditures (2002) DiabetesWithout Diabetes Hogan P, et al. Diabetes Care. 2003;26:917 – 932.

23. Duncan et al, The Diabetes Educator. 35:752-761 (2009) Assessing the Value of Diabetes Education 2005, 2006, 20072005, 2006, 2007 InsuranceInsurance –Commercial or Medicare Purpose:Purpose: –Evaluate the impact of Diabetes Self- Management Training and Education (DSMT/E) on the cost of care

24. Duncan et al, The Diabetes Educator. 35:752-761 (2009) Number of Patients with Diabetes Who Received Education 7.3% 3.8% Commercial 482,571 Medicare 152,074

27. Preliminary Conclusion The CARE with DSMT/E is better. Duncan et al, The Diabetes Educator. 35:752-761 (2009)

30. Assessing the Value of Diabetes Education, 2008 Tucker ME. Hospitalist News Digital Network, 2010-08-31

31. Duncan et al, The Diabetes Educator. 35:752-761 (2009) Assessing the Value of Diabetes Education, 2008 Tucker ME. Hospitalist News Digital Network, 2010-08-31

32. Duncan et al, The Diabetes Educator. 35:752-761 (2009) Assessing the Value of Diabetes Education, 2008 Tucker ME. Hospitalist News Digital Network, 2010-08-31

33. Duncan et al, The Diabetes Educator. 35:752-761 (2009) Assessing the Value of Diabetes Education, 2008 Tucker ME. Hospitalist News Digital Network, 2010-08-31

34. Duncan et al, The Diabetes Educator. 35:752-761 (2009) Assessing the Value of Diabetes Education, 2008 Tucker ME. Hospitalist News Digital Network, 2010-08-31

35. Duncan et al, The Diabetes Educator. 35:752-761 (2009) Assessing the Value of Diabetes Education, 2008 Tucker ME. Hospitalist News Digital Network, 2010-08-31

36. Duncan et al, The Diabetes Educator. 35:752-761 (2009) The Impact of Diabetes Education Conclusions 1.Reduction in cost of care was driven by reducing admissions –Two or more DSMT/E sessions per year is better than 0 or 1 sessions per year 2.DSMT/E –Physicians refer to DSMT/E infrequently –Patients of physicians who refer to DSMT/E receive better care

37. TREATMENT MODALITIES

38. Assessing the Value of Diabetes Education …in patients with significant diabetes complications

40. McMurray SD, et al. Am J Kid Dis. 40:566-575 (2002) Diabetes Education During Dialysis Hemodialysis PatientsHemodialysis Patients –Educators met with patient during each dialysis visit M-W-F: study groupM-W-F: study group T-R-S: control group (no education)T-R-S: control group (no education) Peritoneal Dialysis PatientsPeritoneal Dialysis Patients –Met with educator once a month

41. Diabetes Education During Dialysis Dialysis Type Control Group (n=38) Study Group (n=45) HD3337 PD58 Type 2 DM90%84% McMurray SD, et al. Am J Kid Dis. 40:566-575 (2002)

42. Diabetes Education During Dialysis McMurray SD, et al. Am J Kid Dis. 40:566-575 (2002)

43. Diabetes Education During Dialysis McMurray SD, et al. Am J Kid Dis. 40:566-575 (2002)

44. Diabetes Education During Dialysis McMurray SD, et al. Am J Kid Dis. 40:566-575 (2002) Control Group (n=38) Study Group (n=45) Amputations 2 pts toes 2 pts BKA 1 pt AKA 0 Admissions (PVD, infections, amputations) 101

45. Diabetes Education During Dialysis Conclusions McMurray SD, et al. Am J Kid Dis. 40:566-575 (2002) 1.Fewer Amputations 2.Fewer Hospitalizations 3.Better A 1c

46. Medicare Reimbursement Diabetes Self Management Training Medical Nutrition Therapy Diabetes Education Services, Reimbursement Tips for Primary Care Practice Am Assoc Diab Educators, Revised February 2009

47. Conclusions DSMT/E 1.is an underutilized treatment modality 2.improves Quality of Care 3.reduces the Cost of Care by reducing admissions

48. Impact of Diabetes on Hospital Readmissions By attending this conference, the participant should be able to: 1.Name 3 of the measures in the National Committee for Quality Assurance (NCQA) Diabetes Recognition Program 2.Explain how diabetes education reduces the cost of care 3.Name the percentage of patients with diabetes that physicians refer to diabetes education

49. Thank you James Desemone, MD Director, Medical Staff Quality Ellis Medicine James Desemone, MD Director, Medical Staff Quality Ellis Medicine