DIABETI I i O Improving O Th R l f th H The Role of the H C ESRD: O

Transcription

DIABETIC ESRD:
ESRD
I
Improving
i OOutcomes
t
–
Th Role
The
R l off th
the HHemodialysis
di l i Unit
U it
Mark E. Williams, MD,
M FACP, FASN
Associate Professor of Mediccine, Harvard Medical School
Co-Director of Dialysis, Beth Israel Deaconess
Medical Center
Senior Staff Physician,
Physician Joslin Diabetes Center
Progress
s Report
Diabetes,, Dialysis
Diabetes
1995
USRDS (2008)
¾ Incident Patients
27,364
¾ Deaths
17,445
¾ Cost per patient per year
$55,249
$55 249
¾ Hospital days per year
18.4
¾ Annual mortality rate/1000 patient-years
275
¾ AMR,
AMR wait
wait-listed
listed for transplant
144
¾ AMR, returned to dialysis
250
¾ AMR, never wait-listed
306
¾ Survival (1,2,3,5 years), per cent
• 74
• 52
• 37
• 19
2005
43,317
33,420
$75 058
$75,058
17.4
251
121
224
274
79
63
49
28
USRDS 2008: Adjus
sted ESRD incident
rates of ESRD
due to diabetes, by
b race/ethnicity
Figure hp.20
0 (Volume 2)
illi
illi
lla
lla
Incident ESRD patients; adjusted for age & gender. For Hispanic patients we present data beginning in 1996, the first full year after
the April 1995 introduction of the revised Medical Evidence form, which contains more specific questions on race & ethnicity.
Growing Burden off Diabetic ESRD in
the Elderly
(Sloan Arch Int Med 2008; 168: 192)
¾35% increase in US ad
dults >75 yrs with
diabetes
¾194% increase in diab
betic ESRD incidence
rate in p
patients >75 yyrs
s
USRDS 0
08
100
200
75
150
50
100
25
50
0
All
1
2
3
4
5
6
7
8
9
10
ESRD ne
etwork
11
12
13
14
15
16
17
18
0
Green: R
Rate Per Millio
on, 2006
Blue: Perce
ent change, 19
996 to 2006
Growth in Incident ES
SRD Populations,
by Primary Diagnosis & Network:
Diabetes, 1996-2006
1996 2006
Treatment modalities for prevalent
p
patients with
ESRD who received Medica
are benefits
benefits, according to
diabetic status in
n the year 2006
USRD
DS 08
ESRD Diabete
es Population
¾ Incident:

94% hemodialysis
6% peritoneal dialysis
¾ Prevalent:

94% hemodialysis
h
di l i
6% peritoneal dialysis
Epidemic of
o diabetes
NEJM 2008
Burden of Diabetes in the Dialysis Unit
¾ Diabetes mellitus represents 37
7% of all prevalent cases of
ESRD patients receiving dialyssis
¾ Incident 1995-1999 patients en
ntering dialysis, one-year survival,
Medical Evidence Form: 44% as
a primary cause of renal failure
¾ Secondary or complicating condition: 6.4%
¾ Claims for service (diabetes tessting supplies, glucose control
monitors hospitalizations): 10
monitors,
10.5
5
5% actually had DM not on
Medical Evidence Form
¾ TOTAL = 60.9%
USRDS 2008: Adjusted
d ESRD incident rates,
by primary diagn
nosis & diabetes
nosis,
in the genera
al population
Figure hp.4 (Volume 2)
Incident ESRD patients; rates adjusted for age, gender, & race. Data
D
on the prevalence of diabetes in the general population obtained
from the CDC’s Behavioral Risk Factor Surveillance System, at www.cdc.gov/brfss.
w
Crude and Age-Adjusted Incidence of ESRD Related
to Diabetes Mellitus (ESRD-DM) United States, 1980-2006
Prevalence of Diabetes in the General Population
500
Incideence (per 100,000 P
Population)
Med
dian Percent of Po
opulation
8
6
4
2
400
300
200
100
Crude
Age-Adjusted
0
0
95
96
97
98
99
00
01
02
03
04
05
06
80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06
Year
Norrmal Albuminuria
Renoprotective
e Effect of ARB
in type 2 diabetic CKD
¾ Lewis NEJM 345: 861 ’01

Irbesartan vs. Placebo
Risk reduction 20%
Proteinuria declined by 33%
¾ Brenner NEJM 345: 861 ’01

Losartan vs. Placebo
Risk reduction 16%
Proteinuria declined 35%
No cardiovascular benefit
USRDS 08: prevalence
e of RAS blockade use
incre
eased
Diabetic CKD patients
p
receiving
medical evaluattion & treatment,
by age & ra
ace/ethnicity
Figure hp.22 (Volume 2)
illi
illi
lla
lla
a
evaluation: general Medicare
patients diagnosed with CKD
& di
diabetes
b t iin each
h year, age 65
& older at the beginning of
each year, alive & continuously
enrolled in Medicare
inpatient/outpatient &
physician/supplier program
through the whole year.
Patients enrolled in an HMO
or diagnosed with ESRD are
excluded. Testing checked in
each year. “All three tests”
includes at least two HbA1c
tests, at least one lipid test, &
at least one diabetic eye
examination Treatment:
examination.
Medicare Current Beneficiary
Survey (MCBS) patients with
CKD & diabetes, age 65 &
older. ESRD patients excluded.
• For Hispanic patients we
present data beginning in 1996,
the first full year after the
introduction of the April, 1995,
revision of the Medical
Evidence form, which
introduced more specific
questions on race & ethnicity.
OUTCO
OMES
USRDS Annua
al Data Report
200
06:
Ho it lizations
Hospital
li
l tio
¾ Hospital admissions 26% high
her for diabetic hemodialysis patients
than nondiabetic
¾ Diabetic inpatient utilization higher for all causes (26%),
cardiovascular (27%), infectio
on (31%), and vascular access (13%)
admissions
USRD
DS 08
DS
Inpatient Utilization
U
USRDS
S 2006
% Increase in Diabetic
D
Patients
¾ All causes: +25%
79%
¾ Endocrine/Metabolic: +17
¾ Infectious Diseases: +30%
%
¾ Circulatory Diseases: +26
6%
¾ Vascular/dialysis
y
Accesss: +10%
Incident ESRD patients rec
ceiving a transplant within
three years,
years by age,
age gender,
nder race/ethnicity,
race/ethnicity &
primary diagnosis
d
Figure hp.17
7 (Volume 2)
illi
illi
lla
lla
Incident ESRD patients
younger than 70; patients
with a prior transplant are
excluded. Percents
estimated
ti t d using
i the
th
Kaplan-Meier
methodology. For
Hispanic patients we
present data beginning in
1996, the first full year
after the April 1995
introduction of the revised
Medical Evidence form,
which contains more
specific questions on race
& ethnicity.
Diabetic Transplaant Recipients:
Type of Diiabetes
Type 1
51%
Type 2
49%
%
Type 1
Type 2
Becker BN. Preemptive transplantation for patiennts with diabetes-related kidney disease. Arch
Intern Med. 2006 Jan 9;166(1):44-8.
Diabetic Transsplant
p
Recipients:
p
Type of Transplant
Deceased
d
donor
49%
Deceased
D
do
onor KP
22%
Deceased donor
KP
Living donor
Deceased donor
ving donor
Liv
29%
Becker BN. Preemptive transplantation for patiennts with diabetes-related
kidney disease. Arch Intern Med. 2006 Jan 9;1666(1):44-8.
Diabetic Transplan
nt Recipients:
Timing of Traansplant
Preempttive
11%
Preemptive
ESRD
ESRD
89%
Becker BN. Preemptive transplantation for patients
p
with diabetes-related kidney
disease. Arch Intern Med. 2006 Jan 9;166(1)):44-8.
45
40
35
30
25
20
15
10
5
0
19
83
19
86
19
89
19
92
19
95
19
98
20
01
Numberr DM Patiients 75+
Number of Diabetic, Ellderly kidney
t
transplant
l t recipients,
i i t , 1983-2003
1983 2003
Kidney
transplant
recipients
Kidney Transplantation in the
Elderly
Elde l Diab
betic Patient
¾ Growing number of elderly patients on kidney transplant
waiting lists
¾ For
F allll ages, % with
ith di
diabe
betes
t lower
l
th
than % with
ith di
diabetes
b t
who are on dialysis
¾ More likely to be considered for expanded donor list
¾ Limited data suggest lowe
er mortality if transplanted,
compared
p
to elderly
y diabe
etic p
patients on waiting
g list
Predictors of
o mortality
in Diabettic ESRD
¾
¾
¾
¾
¾
¾
¾
¾
Age at initiation
Not African American or Hispanic
Nutritional status
Dyslipidemia
Cardiovascular complicationss
Amputation
Poor functional status
? Glycemic control
ESRD Survival
S
First, second, fifth, and tenth yeear patient SURVIVAL estimates
for DM and non DM paatients receiving dialysis
Early ESRD Mo
ortality Rates
USRD
DS 08
Diabetic ESRD
D Mortality
y
SHOJI, T. et al. J Am Soc Nephrol
2001;12:2117-2124
Outcomes HD
H vs. PD
• PD survival advantage first two years except older
female diabetic patients
• No survival differences subbsequently
q
y
• May be due to unmeasured baseline case mix
differences or better residual renal
r
function
• Other data suggest higher PD
P mortality risk if overt
cardiac disease at evaluation
First, second, fifth, and 10th yearr unadjusted patient survival
estimates for non DM and DM recipients of cadaveric renal
TRANSPL
LANTS
Data collected during the years 19993, 1992, 1989, and 1984
Patient Cha
aracteristics
USRD
DS 08
ESRD Diabetes
D
¾ IIncident
id t L
Labs:
b
Creat 6.0 mg/dL vs 7.0m
mg/dL
Hematocrit 30.6% vs 30.6%
Serum albumin 3.1
3 1 g/dL vs
v 33.1
1 g/dL
eGFR 11.2 vs 10.6 ml/min
n
¾ Mean BMI 30.2 vs 28.5
¾ Medicaid 28.6% vs 24.7%
¾ Independence:
Walking disabilities 17 vs
s 15%
Assistance devices 32 vs 27%
Unable to ambulate 11.6 vs
v 9.8%
Characteristics of Diabetic
Hemodialysis Population
P
Fresenius Dataabase
Type 1 DM study patients ( 5.5%) weree significantly different from Type 2
DM (94.5%) patients: younger age (49.3 vs. 64.5 years, p<0.0001), different
racial distribution with 60.6% white racce vs. 52.6% (p<0.0001), longer
dialysis vintage at 1,172 vs. 1,044 days (p
(p<0.0016),
0.0016), slightly lower body
surface area (1.82 vs. 1.86 m², p<0.0001), and differential distribution of
dialysis vascular access (AV fistula 34.44% vs. 29.7%, p=0.003). Laboratory
evaluation
l ti indicated
i di t d that
th t Type
T
1 DM paatients
ti t had
h d slightly
li htl higher
hi h serum
phosphorus (5.89 vs 5.59 g/dL, p<0.00116), while eKt/V (1.4), hemoglobin
(11.7g/L), albumin (3.8 g/dL), and serum
m calcium (9.3 g/dL) were not
different between the diabetic groups.
ESRD Network of
o New England:
Prevalent Patien
nts with Diabetes
200
08--9
08
¾ 50% with diabetes codes (5,409 patients)
alcium, Phosphorus, Kt/V
¾ Hemoglobin, Albumin, Ca
similar to nondiabetic pattients
¾ Incident patients:

23% AVF; nondiabetic 20%
48% catheters; nondiabetic 600%
Elderly: 47% catheters; nonddiabetic 62%
Diabetic ESRD: ES
SRD Characteristics
Performance Measure
Status in Diabetic
Patients
Vascular access
Poorer
Anemia management
Worse earlier
Serum albumin
concentration
Lower
Parathyroid levels
No different
Diabetic ESRD Characteristics
Problem
Evalua
ation
Glycemic control
Hemog
globin A1c, home glucose monitoring
Angina, myocardial infarction
Visual impairment
Exercis
se tolerance test, P-thallium,
echoca
ardiogram catheterization
ardiogram,
Ophtha
almology evaluation
Foot ulcers
Podiatrry evaluation
Peripheral vascular disease, limb
amputation
Gastroparesis
er flow studies
Dopple
N
Neuropathic
hi problems
bl
El
Electro
omyography,
h neurologist
l i
Malnutrition
Serum albumin, dietary counseling, PE
Gastric
c emptying study
Consequences of Hyperglycemiia in Patients with Diabetes on
Hemod
dialysis
• Thirst, excessive fluid intake, weiight gains between
dialysis, hypertension
• Pulmonary edema, increased weigght gains
• Severe hyperkalemia
yp
• Diabetic ketoacidois
• Shifts in serum osmolality
• Anorexia, nausea, vomiting, weakkness
• Increased
I
d risk
i k off infection
i f i
• Gastroparesis
• Malnutrition
•Cardiovascular disease
Why glycemic control is difficult to achieve in
ESR
RD:
¾ Variations in dietary intakke
¾ Inconsistent food absorpttion
¾ Effects of uremia
¾ Confounding effects of dialysis therapy
ESRD Diabete
es Treatment
¾ Reduced insulin requirem
ments
¾ From insulin to oral hypog
glycemic agents
¾ Reduced oral hypoglycem
mic agents
¾ Off oral hypoglycemic age
ents
¾ Off insulin
Assessing Glycemic Control
in Diabettic ESRD
Blood Glucose
? Anemia
A
i
? EPO
Few min
Bl d
Blood
Glucose
1-2 wks
Gl
Glycated
t d
Albumin
2-3 wks
2
F ctosamine
Fruc
t
i
HyperH
glycemia
6-8 wks
HbA1
HbA1c
Hemoglo
obin A1c
¾ Center of clinical manageme
ent of hyperglycemia
¾ Measure of risk for developm
ment of diabetes
complications
¾ Indicates whether strategy iss working and metabolic
control has been maintained
d within target range
¾ Used by QA programs to assess quality of diabetes care
¾ Routine testing improves glyycemia
Hgb A1c in a Larg
ge Dialysis Chain
Q 4 2002 Averag e HG Ba1c Dis
strib u tion b y Diab etic Categ ory
53.37%
60%
A D ULT ONS E T D IA B E TE S
(N=26,127, Mean=6.74%, S D =1.68%)
0.46%
0.94%
0.08%
0.53%
0.23%
0.59%
0.08%
0.18%
0.06%
0.15%
0.00%
0.09%
8.55%
2.02%
8
1.14%
2.61%
0.00%
0.71%
7
1.68%
3.94%
%
0.27%
1.23%
6
13.40%
18.45%
11.29%
3.99%
%
5
3.91%
%
7.19%
0.57%
3.44%
%
4
5.81%
10.14%
1.07%
%
3.35%
3
11.02%
18.90%
10%
0%
3.36%
%
1.87%
9.44%
20%
0%
19.22%
30%
NON D IA B E TIC (N=2,629,
Mean=5.25%, S D =1.04%)
D IA B E TIC S TA TUS UNK NOW N
(N=1,134, Mean=6.14%, S D =1.71%)
19.24%
19.88%
%
40%
31.47%
23.08%
%
19.63%
26.72%
34.39%
JUV E NILE D IA B E TE S (N=2,032,
Mean 7 48% S D =1.95%)
Mean=7.48%,
1 95%)
0.03%
0.15%
0.04%
0.09%
Percent of Patients
50%
9
10
11
12
13
14
15
P atient A verage HG B a1c
a1c, R ounded to Nearest Integer (% )
Risk of Intensive Glucose
G
Lowering
in ESRD Patients
¾ Hypocaloric diet: malnutrition
n
¾ Exercise: cardiovascular eve
ents, foot injuries, hypoglycemic
episodes
¾ Metformin: lactic acidosis
mia
¾ Chlorpropamide: hypoglycem
¾ Glyburide:
y
hypoglycemia
yp g y
¾ Acarbose: contraindicated
¾ Insulin: hypoglycemia
¾ NOTE: ACCORD,
ACCORD ADVANCE
E studies 2008

INDIVIDUALIZE GLYCE MIC MANAGEMENT
M
CONSIDER AGE, LIFE EXPECT
TANCY, COMORBIDITIES
Glycemic Control and
d Intradialytic Weight
Gain in HD
D Patients
¾ Ifdu
Am J Kidney Dis 23:686
6, 1994
Glycemic
y
Control in Diabetic ESRD:
Conventio
onal Goals
¾
¾
¾
¾
Special consideration
Random blood glucose 100-180
Hemoglobin A1C <9%
Good enough control to prote
ection against metabolic disorders
and infections
¾ Protection against infections
¾ Lower risk of hypoglycemia with
w less intensive therapy
¾ Tzamaloukas, Int J Art Organs; 15:390, 1992
Glycemic Contro
ol and Mortality
Database Analysis,
is Retrospective
Glycosylated Hemoglobin and
Cardiovascularr Disease in DM
¾ Meta-analysis of observationa
al studies
¾ Type 1 (n=1688) and Type 2 (n=7435) patients
¾ Abstracted adjusted effect esttimates (odds ratios,
ratios relative risks)
to link CV risk and baseline or updated HbA1c levels
¾ Multiple cardiovascular diseasse endpoints
¾ For 1% increase in A1c, relatiive CV risk was 1.18 in type 2 and
1.15 for type 1 diabetes
Selvin Ann Internal Med 141: 421
421, 2004
Cardiovascular Comorbidity
C
in
Incident Dialy
ysis Patients
USRDS 2005 Annual Data Report, page 84
CV Morbidities
Elderly Diabetic ESRD
CAD risk factors
Traditional
Nontraditional
DM
CKD/ESRD
hypertension
hypertension
hypercholesterolemia
dyslipidemia
h
hypertriglyceridemia
i l
id i
l f ventricular
left
i l hypertrophy
h
h
vascular inflammation
anemia
endothelial dysfunction
disordered mineral metabolism
hyperglycemia
impaired platelet aggregation
hyperinsulinemia
elevated inflammation factors
impaired fibrinolysis
elevated prothrombotic factors
Type 2 diabetes patients classified according to CKD
Diabetic Foo
ot Syndrome
Type 1 (left) and
d Type 2 (right)
ESRD patients
p
Wolf, G. et al. Nephrol. Dial. Transplant. 2009 24:18961901; doi:10.1093/ndt/gfn724
Copyright restrictions ma
ay
apply.
Diabetic Foo
ot Syndrome
¾ Directly related to HgbA1c
¾ As kidney function decreases,
risk of diabetic foot syndrome
increases
¾ If ESRD, diabetic foot
complications double
¾ Risk of amputations
p
increased
up to 10X that of general
diabetic population
¾ Neuropathy + Ischemia +
Infection
¾ Frequently occur with onset of
renal replacement therapy
Foot Examination
¾ Inspect Skin and Na
ails
¾ Look for any bony a
abnormalities
¾ Check Peripheral Pu
ulses
¾ Inspect Capillary Re
efill
¾ Palpate for edema
¾ Monofilament Sensa
ation
¾ Vibratory Sensation
¾ Deep Tendon Reflex
xes
The Diab
betic
betic Foot
Access p
procedu
ures in p
prevalent
hemodialysis
h
di l i patien
i nts, by
b diabetic
di b i status
Figure hp.1
13 (Volume 2)
illi
illi
lla
lla
Period prevalent hemodialysis patients with or without simple fisttulas. Data from physician/supplier claims. Some patients may have
more than one access at a given point in time.
Economic
c Costs of
Diabeti
i b ic ESRD
¾ Over
O
80% off costs
t for
f diabe
di betes
t care is
i ffor complications
li ti
¾ Higher CKD costs:

DM without CKD: $7,248
DM with
i h CKD:
C
$26,036
$26 036

Cardiovascular disease
Poorlyy controlled hyperglycemia
yp g y
a/hypoglycemia
yp g y
Sepsis
Access failure
¾ In/Out ESRD Patient costs higher by 25%
g
inpatient
p
costs mainlyy account for the difference
¾ Higher
¾ More frequent hospitalizatio
ons:
Role of the Hemodialysis Unit
¾ Avoid glycemia-related hospiitalizations
¾
¾
¾
¾
¾
¾
¾
¾
• Hypoglycemia
• Diabetes out of control
Avoid CHF
nfections
Minimize foot and extremity in
Increase access to transplanttation
Identify
de t y the
t e team
tea involved
o ed in d
diabetes
abetes and
a d ot
other
e aspects o
of ca
care
e
outside of dialysis
Maximize quality indicators
Reach KDOQI targets
E l t benefits
Evaluate
b
fit off th
the expanded
d d chronic
h i care model
d l
r
of the dialysis
Confront limitations in future reimbursement
procedure: Pursue case
e-mix adjustment for diabetes
Minimum Role
R
of the
Dialysis Unit
U
Staff
¾ Know recommended glycemicc goals:
• Before meals 90-130 mg/dL
• After meals <180 mg/dL
¾ Know how to give supplemen
ntal insulin on an individualized basis
Role of the Staff: Recognize
R
and Treat
Hypogly
ycemia
¾ Negative
g
side of ledger
g
¾ More common than generallyy thought
¾ Insulin, OHA, poor nutrition, deficient
d
gluconeogenesis, poor
counterregulatory hormones
¾ Signs and symptoms of chan
nges in mental status or
neurologic condition
¾ Hypoglycemia may occur posst-dialysis
¾ Can result in serious morbidity or mortality
¾ Major limitation in achieving ttight glycemic control
Role of the Staff:
Know about Acute Se
evere Hyperglycemic
in Diabettic ESRD
¾ Extreme hyperglycemia oftten asymptomatic;
absence of glycosuria
gy
¾ Causes hyperkalemia
nary edema
¾ Thirst, weight gain, pulmon
¾ Diabetic ketoacidosis
Role of the Sttaff: Referral
for Hospittalization
¾ Diabetic ketoacidosis: pla
asma glucose >250 mg/dl,
serum bicarbonate <15 meq/l,
m
arterial pH <7.30
¾ Hyperglycemic
H
l
i h
hyperosm
molar
l state:
t t severe
hyperglycemia (>600mg/d
dl) and elevated serum
osmolality (<320mOsm/k
( 320mOsm/kg)
¾ Hypoglycemia (<50mg/dl) with altered sensorium,
behavior, coma, seizuress
Congestive Heart
H
Failure
¾ Gill CJASN 2008; 3L S29
2:1186
¾ CV disease event rates
¾ High rate of CHF in dialysis
-Banerjee CJASN 2007;
-HD survival after hospitalization for CV event
-Diabetes death increased
23%
ACCESS TO KIDN
NEY TRANSPLANT
by age
age, diabetic stattus,
tus and time period
Van Dijk, P. et al. Renal replacement therapy for diabbetic end-stage renal disease: Data
from 10 registries in Europe (1991-2000). Kidney Innternational 2005; 67: 1489-1499.
Quality Indicators: Diabetes
USRD
DS 08
Diabetic ESRD
D and Clinical
Performanc
ce Measures
¾ Rocco Ann Int Med 200
06; 145: 512
¾ Random sampling of long
g-term hemodialysis patients
¾ CMMS clinical performan
nce project
¾ Targets: hemoglobin, albumin, AVF, dialysis adequacy
g multiple
p clinical p
performance measures
¾ Meeting
associated with decrease
ed hospitalization and mortality
rates
¾ Patients with diabetes les
ss likely to meet clinical
performance measures
KDOQI Targets and Improved Survival:
Diab
betes
¾ Tentori JASN 2007; 18
8: 2377
¾ Retrospective analysis, DCI
D
¾ Incident patients 1998-20
1998 20
004
¾ Adequacy, hematocrit, albumin, calcium, phosphorus,
Pth
¾ Largest survival benefit was
w for albumin
¾ All six guidelines – 89% reduction
r
in mortality
¾ Guideline adherence (hem
matocrit Pth) less strongly
matocrit,
associated with improved
d survival in diabetes
Professional Team for
f Diabetes Disease
Manag
gement
¾
¾
¾
¾
¾
¾
¾
¾
Primary Care Physician
gist
Diabetologist or Endocrinolog
Nephrologist
p
g
Cardiologist
Podiatrist
Ophthalmologist
Pharmacist
Dentist
Diabetes Self
Self--Ma
anagement Study
¾ McMurray
AJKD 40: 56
66, 2002
Diabetes Ca
ase Manager
¾ Identifies physician primarily responsible for managing the
patient’s diabetes
¾ Reviews home glucose readiings monthly
¾ Reviews quarterly laboratoryy HbA1c
¾ Also reviews blood pressuress,
s lipid levels
levels, need for aspirin
therapy
¾ Informs physician (nephrolog
gist, pcp, internist, or
endocrinologist) of laboratoryy results
¾ Performs regular foot checkss on the patient
¾ Follows up
p on eye
y examinations
¾ Motivational coaching: emottional support, problem solving,
encouragement
Interventions in the Dialysis Unit
¾
¾
¾
¾
¾
¾
¾
¾
¾
Include A1c on rounding reports, monthly care plans
Provide monthly reports for the p
patient
Site for diabetes self-management education
Reinforce annual screening
g reco
ommendations
Recognize when urgent management or referral are warranted
Identify physician responsible forr diabetes management
E t bli h communications
Establish
i ti
with
ith other
oth care providers
id
List of providers with contact info
ormation
Assign case manager to integrate diabetes care
Type 2 Diabetes CQI:
Effects of Different Strategies
on Glycem
mic Control
Postintervention Differences in Serum HbA1c Values
V
After Adjustment
j
for Study
y Bias and
Baseline HbA
A1c Values
Shojania, K. G. et al. JAMA 2006;296:427-440.
Copyright restrictions may apply.
Di b
Diabetes
Case
C
M
Man
nagement Study
S d
¾ Intensive education and case management
¾ 83 patients followed for one yea
ar
¾ Self-management
S f
education, dia
abetes self-care
f
monitoring,
motivational coaching, foot checcks
¾ Improved HbA1c in treatment grroup
¾ Improved
I
d selflf managementt beh
b havior
h i
¾ Foot risk category stable, fewer foot amputations
(McMurray Am J Kidney Dis 40:
4 566, 2002
ESRD Med
dical Home
¾ McMurray Nephrology Newss and Issues 10/2009
Summ
mary
¾ Scope of diabetic ESRD problem; outcomes
¾ Unique aspects of diabetic ESRD patients
¾ Dialysis Unit
Unit-based
based qualitty improvement