the impact of diabetes on hospital readmissions

The Impact of Diabetes on The Impact of Diabetes on Hospital ReadmissionsHospital Readmissions

James Desemone, MDJames Desemone, MDDirector of Medical Staff QualityDirector of Medical Staff Quality

Ellis MedicineEllis Medicine

October 15, 2011October 15, 2011

New York State RegionalNew York State RegionalFamily Medicine Conference Family Medicine Conference

Dr. Desemone has no Dr. Desemone has no financial disclosures financial disclosures

nor conflicts of nor conflicts of interest to declareinterest to declare

The Impact of Diabetes on The Impact of Diabetes on Hospital ReadmissionsHospital Readmissions

With Special Thanks to:With Special Thanks to:

Nancy LandorNancy LandorSenior Director, Strategic Quality Initiatives, HANYSSenior Director, Strategic Quality Initiatives, HANYS

Amy JonesAmy JonesManager, Quality Initiatives, HANYSManager, Quality Initiatives, HANYS

Karen PirigyiKaren PirigyiAssistant to the Director, Quality Services, Ellis MedicineAssistant to the Director, Quality Services, Ellis Medicine

Impact of Diabetes on Impact of Diabetes on Hospital ReadmissionsHospital Readmissions

By attending this conference, the participant By attending this conference, the participant should be able to:should be able to:

1.1. Name 3 of the measures in the National Committee Name 3 of the measures in the National Committee for Quality Assurance (NCQA) Diabetes for Quality Assurance (NCQA) Diabetes Recognition ProgramRecognition Program

2.2. Explain how diabetes education reduces the cost Explain how diabetes education reduces the cost of careof care

3.3. Name the percentage of patients with diabetes that Name the percentage of patients with diabetes that physicians refer to diabetes educationphysicians refer to diabetes education

Hospital ReadmissionsHospital Readmissions

CHFCHF

COPDCOPD

PneumoniaPneumonia

AMIAMI

Hospital ReadmissionsHospital Readmissions

What about Diabetes?What about Diabetes?

• Keeps a low profileKeeps a low profile

• Frequently a secondary Frequently a secondary diagnosisdiagnosis

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

Past and projected prevalence Past and projected prevalence of overweight (BMI >25 kg/m²)of overweight (BMI >25 kg/m²)

Wang YC, et al. Lancet Wang YC, et al. Lancet 378: 815–25 (2011)378: 815–25 (2011)

New York StateNew York StateEmergency Department UtilizationEmergency Department Utilization

Diabetes Patients Admitted as Inpatient as a % of Total ED VisitsDiabetes Patients Admitted as Inpatient as a % of Total ED Visits

Healthcare Association of New York State, July 2010Healthcare Association of New York State, July 2010

726,553 7,146,817

Percentage of NYS Admissions Percentage of NYS Admissions with Diabetes as 1with Diabetes as 1oo or 2 or 2oo Dx Dx


NYS Readmission Rates, 2008NYS Readmission Rates, 2008


Healthcare Association of New York State www.hanys.org

Survey : NYS Systems/Hospitalsn=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 PlaceCriteria in Place No Criteria in PlaceNo Criteria in Place


HANYS’ Study—NYS DataIdentifying 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


National Committee for Quality Assurance Diabetes Recognition Program

National National Committee for Committee for

Quality Quality AssuranceAssurance

Diabetes Diabetes Recognition Recognition

ProgramProgram


Reducing ReadmissionsReducing Readmissions

• Improved Diabetes Treatment by Improved Diabetes Treatment by the Provider?the Provider?

• Referral to a Diabetes Self-Referral to a Diabetes Self-Management Training and Management Training and Education (DSMT/E) Program?Education (DSMT/E) Program?

• 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

Robbins JM, et al. J Health Care for the Poor and Underserved 19:562-573 (2008)Robbins JM, et al. J Health Care for the Poor and Underserved 19:562-573 (2008)

Odds ratio for Hospital Readmission Odds ratio for Hospital Readmission within 30 days within 30 days

Maybe…Maybe……….for patients who are discharged without a recorded diagnosis of .for patients who are discharged without a recorded diagnosis of

diabetesdiabetes

•Caveats:Caveats:– Administrative data are prone to errorAdministrative data are prone to error– Did not examine transition of care from inpatient to outpatient Did not examine transition of care from inpatient to outpatient

What We WantWhat We Want

Safe, Positive Clinical QualitySafe, Positive Clinical Quality

Cost SavingsCost Savings

Hospital Costs Account for Majority Hospital Costs Account for Majority of Total Costs of Diabetesof Total Costs of Diabetes

0

1000

2000

3000

4000

5000

6000

7000

Inpatient Nursing Home Physician’sOffice

OutpatientPrescription

Insulin andSupplies

Do

llar

s

Per Capita Health Care Expenditures (2002)

Diabetes Without Diabetes

Hogan P, et al. Diabetes Care. 2003;26:917–932.

Duncan et al, Duncan et al, The Diabetes Educator. The Diabetes Educator. 35:752-761 (2009)35:752-761 (2009)

Assessing the Value ofAssessing the Value ofDiabetes EducationDiabetes Education

• 2005, 2006, 20072005, 2006, 2007

• InsuranceInsurance– Commercial or MedicareCommercial or Medicare

• Purpose:Purpose:– Evaluate the impact of Diabetes Self-Evaluate the impact of Diabetes Self-

Management Training and Education Management Training and Education (DSMT/E) on the cost of care(DSMT/E) on the cost of care


Number of Patients with Number of Patients with Diabetes Who Received Diabetes Who Received

EducationEducation

7.3%7.3% 3.8%3.8%

Commercial

482,571Medicare

152,074

Preliminary ConclusionPreliminary Conclusion

The The CARECARE with with DSMT/E is better.DSMT/E is better.



Assessing the Value ofAssessing the Value ofDiabetes Education, 2008Diabetes Education, 2008

Tucker ME. Hospitalist News Digital Network, 2010-08-31Tucker ME. Hospitalist News Digital Network, 2010-08-31


The Impact of The Impact of Diabetes EducationDiabetes Education

ConclusionsConclusions

1.1. Reduction in cost of care was driven by Reduction in cost of care was driven by reducing admissionsreducing admissions

– Two or more DSMT/E sessions per year is better Two or more DSMT/E sessions per year is better than 0 or 1 sessions per yearthan 0 or 1 sessions per year

2.2. DSMT/E DSMT/E – Physicians refer to DSMT/E infrequentlyPhysicians refer to DSMT/E infrequently– Patients of physicians who refer to DSMT/E Patients of physicians who refer to DSMT/E

receive better carereceive better care

TREATMENT MODALITIESTREATMENT MODALITIESTREATMENT MODALITIESTREATMENT MODALITIES

DIET

EXERCISE INSULIN

DIET

EXERCISE INSULIN

Assessing the Value ofAssessing the Value ofDiabetes EducationDiabetes Education

……in patients with significant in patients with significant diabetes complicationsdiabetes complications

McMurray SD, et al. Am J Kid Dis. 40:566-575 (2002)McMurray SD, et al. Am J Kid Dis. 40:566-575 (2002)

Diabetes Education During DialysisDiabetes Education During Dialysis

• Hemodialysis PatientsHemodialysis Patients– Educators met with patient during each Educators met with patient during each

dialysis visitdialysis 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 monthMet with educator once a month


Dialysis TypeDialysis Type Control GroupControl Group(n=38)(n=38)

Study GroupStudy Group(n=45)(n=45)

HD 33 37

PD 5 8

Type 2 DM 90% 84%




Control GroupControl Group(n=38)(n=38)

Study GroupStudy Group(n=45)(n=45)

Amputations2 pts toes2 pts BKA1 pt AKA

0

Admissions(PVD, infections,

amputations)10 1

Diabetes Education During DialysisDiabetes Education During DialysisConclusionsConclusions


1.1. Fewer AmputationsFewer Amputations

2.2. Fewer HospitalizationsFewer Hospitalizations

3.3. Better ABetter A1c1c

Medicare ReimbursementMedicare ReimbursementDiabetes Self Management TrainingDiabetes Self Management Training

Medical Nutrition TherapyMedical Nutrition Therapy

Diabetes Education Services, Reimbursement Tips for Primary Care Practice Am Assoc Diab Educators, Revised February 2009

ConclusionsConclusions

DSMT/E DSMT/E 1.1. is an underutilized is an underutilized

treatment modalitytreatment modality

2.2. improves Quality of Careimproves Quality of Care

3.3. reduces the Cost of Carereduces the Cost of Care by reducing admissionsby reducing admissions

Impact of Diabetes on Impact of Diabetes on Hospital ReadmissionsHospital Readmissions

By attending this conference, the participant By attending this conference, the participant should be able to:should be able to:

1.1. Name 3 of the measures in the National Committee Name 3 of the measures in the National Committee for Quality Assurance (NCQA) Diabetes for Quality Assurance (NCQA) Diabetes Recognition ProgramRecognition Program

2.2. Explain how diabetes education reduces the cost Explain how diabetes education reduces the cost of careof care

3.3. Name the percentage of patients with diabetes that Name the percentage of patients with diabetes that physicians refer to diabetes educationphysicians refer to diabetes education

Thank Thank youyouThank Thank youyou

James Desemone, MDJames Desemone, MDDirector, Medical Staff QualityDirector, Medical Staff Quality


James Desemone, MDJames Desemone, MDDirector, Medical Staff QualityDirector, Medical Staff Quality


the impact of diabetes on hospital readmissions

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