1. Cost-Effectiveness of Treatment Strategies for Comorbid Diabetes and Dyslipidemia Part 3

2. 2 Using SMAs to improve care and Profitiability  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.

3. 3 Patients Suited to SMAs  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  Source: AAFP Web site. Group visits: introduction:1; Schmucker D. Group Medical Appointments. 2006:85.

4. 4  Cooperative Health Care Clinic (CHCC)  Drop-in Group Medical Appointment (DIGMA)  SMA for Physical Exams (Physicals SMA) Types of SMAs Source: SMA Workshop, 2005; Noffsinger EB. Running Group Visits in Your Practice. 2009:122.

5. 5 Privacy Issues  Anything patients say about themselves is not of concern regarding HIPAA –HIPAA requires written consent before providers disclose patients’ personal information  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.

6. 6 SMA Benefits  SMAs offer: –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 Source: SMA Workshop, 2005; Noffsinger EB. Running Group Visits in Your Practice. 2009:9,12.

7. Strategic Use of Medications: Treatment Goals ADA Guidelines a1 A1C<7% FPG≤70-130 mg/dL 2-hour PPG <180 mg/dL Patient with Diabetes and CVD Glycemic Control Lipid Management 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. a For 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 LDL-C Goals (NCEP ATP III, 2,3 ADA, 1 and AACE 4) 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 doses 4

8. Current Therapy Intervention 6.5 to 8.5 Continue Lifestyle Modification Monitor/adjust Rx to maintain ACE Glycemic Goals † Monotherapy : Glinides, SU, AGI, metformin, TZD, DPP-4, premixed insulin preparations a, prandial b or basal insulin c Continuous Titration of Rx (2-3 months) Combination Therapy: Glinides, SU, DPP-4, AGI, metformin, TZD, colesevelam, incretin mimetic*, premixed insulin preparations a, prandial 2 or basal insulin c Intensify Lifestyle Modification Maximize Combination Therapy Maximize Insulin Therapy Monitor/adjust Rx to maintain ACE Glycemic Goals † Intensify Lifestyle Modification Initiate Combination Therapy Incretin mimetic + metformin and/or TZD Basal c or premixed insulin preparations a Amylin analog** with prandial insulin b Metformin + SU or Glinide Metformin + TZD d,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 insulin f If elevated FPG, add or increase basal insulin c If elevated PPG, add or increase prandial insulin b If elevated FPG and PPG, add or intensify basal c + prandial b or premixed insulin therapy a Combine with approved oral agents f Amylin analog** with prandial insulin b Add incretin mimetic to patients on SU, TZD, and/or metformin Continuous Titration of Rx (2-3 months) Road Map to Achieve Glycemic Goals: Welchol ® (colesevelam HCl) Is Indicated for Patients With Diabetes † ACE Glycemic Goals ≤ 6.5% A1C <110 mg/dL FPG <110 mg/dL preprandial <140 mg/dL 2-hr PPG *Available as exenatide **Available as pramlintide aAnalog preparations preferred bPrandial insulin (rapid-acting insulin analogs available as lispro, aspart, glulisine, or regular insulin) can be added to any therapeutic intervention at any time to address persistent postprandial hyperglycemia cAvailable as glargine and detemir dA 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.” eCannot be used in NYHA CHF Class 3 or 4 fAccording 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. Curre nt A1C% colesevelam

9. Summary  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  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