Cost-Effectiveness of Treatment Strategies for

Comorbid Diabetes and Dyslipidemia

Part 3

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

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

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

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

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.

Strategic Use of Medications: Treatment Goals

ADA Guidelinesa1

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.

aFor most nonpregnant adults with diabetes; individualized goals are endorsed, with less stringent control for those with moreadvanced disease or history of severe hypoglycemiaADA = American Diabetes Association; A1C=glycosylated hemoglobin; FPG = fasting plasma glucose: PPG=postprandial glucose

LDL-C Goals (NCEP ATP III,2,3 ADA,1 and AACE4)

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 doses4

Current Therapy Intervention

6.5

to

8.5

Continue Lifestyle M

odification

Monitor/adjust Rx to maintain ACE Glycemic

Goals†

Monotherapy :

Glinides, SU, AGI, metformin, TZD, DPP-4, premixed insulin preparationsa, prandialb orbasal insulinc

Continuous Titration of Rx (2-3 months)

Combination Therapy:

Glinides, SU, DPP-4, AGI,metformin, TZD, colesevelam,incretin mimetic*, premixedinsulin preparationsa,prandial2 or basal insulinc

Monitor/adjust Rx to maintain ACE Glycemic

Goals†

• Incretin mimetic+ metformin and/or TZD

• Basalc or premixed insulin preparationsa

• Amylin analog** with prandial insulinb

• Metformin + SU or Glinide• Metformin + TZDd,e or AGI• TZD + SU• DPP-4 + Metformin ± SU• DPP-4 + TZD• Colesevelam + met, SU or insulin• Incretin mimetic* + metformin and/or SUOther approved combinations including approved oral agents with insulinf

• If elevated FPG, add or increase basal insulinc

• If elevated PPG, add or increase prandial insulinb

• If elevated FPG and PPG, add or intensify basalc + prandialb or premixed insulin therapya

• Combine with approved oral agentsf

• Amylin analog** with prandial insulinb

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 pramlintidea Analog preparations preferredb Prandial 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 hyperglycemiac Available as glargine and detemird A 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.”e Cannot be used in NYHA CHF Class 3 or 4f According 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.

Current

A1C%

colesevelam

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