Building a Diabetes Alliance:

The Role of Provider Education

Robert E. Jones, MD, FACP, FACE
Professor of Medicine
University of Utah School of Medicine
and Friend of the UDPCP
The Problem
US Population: 275 million in 2000
Undiagnosed
diabetes
5.9 million
Diagnosed
type 1 diabetes
~1.0 million
Additional
16 million with
prediabetes
Diagnosed
type 2 diabetes
10 million
Distribution of Glycemic
Abnormalities in US
CDC. Available at: http://www.cdc.gov/diabetes/pubs/estimates.htm
ADA. Facts and Figures. Available at:
www.diabetes.org/main/application/commercewf?origin=*.jsp&event=link(B1)



Diabetes Complications
Retinopathy:
-Type 1: 60% at 10 years and ~100% at 20 years
-Type 2: 20% at diagnosis and 60-80% at 20 years
Neuropathy:
-Types 1 and 2: >50% lifetime risk (approaches
100% with nerve conduction studies)
Nephropathy:
-Type 1: 40-50% at 20 years
-Type 2: 5-10% at 20 years
Coronary Artery Disease:
-3 to 6 fold increased risk compared to non-diabetics
-Major cause of death in all people with diabetes
-10 to 20 year reduction in life expectancy
Peripheral Vascular Disease:
-Lifetime risk of amputation is 8/1000
Building a Coalition
Diabetes and its complications are
expensive and both the suffering and
expense might be avoidable
Stakeholders must be identified and all
should benefit from participation
Patients, providers, insurers and government
agencies
There is a common mistrust between all

Diabetes Alliance
Must involve a commitment of all those affected
by diabetes:
Patients
Providers
Insurers
Government agencies
Do any of these groups benefit from a bad
outcome?
In the short term, they all do
In the long term, they all suffer
The Importance of Early,
Aggressive Glucose Control
6
6.5
7
7.5
8
8.5
9
9.5
0 1 2 3 4 5 6 7 8 9
Years
A
1
C

(
%
)

Intensive Group
Conventional Group
DCCT: Change in A
1C

Over Time

DCCT. N Engl J Med. 1993;329:977
DCCT: Diabetic Complication
Event Rates
55.0
29.8
23.9
5.1
13.4
13.0
7.9
16.4
5.0
2.5
0
10
20
30
40
50
60
Retinopathy
Progression
1
Laser Rx
1
Micro-
albuminuria
2
Albuminuria
2
Clinical
Neuropathy
3
Conventional
Intensive
76%
Risk Reduction
59%
Risk Reduction
39%
Risk Reduction
54%
Risk Reduction
64%
Risk Reduction
C
u
m
u
l
a
t
i
v
e

I
n
c
i
d
e
n
c
e

(
%
)

1. DCCT Research Group. Ophthalmology. 1995;102:647; 2. DCCT Research Group.
Kidney Int. 1995;47:1703; 3. DCCT Research Group. Ann Intern Med. 1995;122:561
DCCT: Lifetime Benefits of
Intensive Therapy
5.1
15.3
0 5 10 15 20
Years
DCCT. JAMA. 1996;276:1409
Gain in
Complications-
Free Living*
Gain in Length
of Life
*Significant microvascular or neurologic complication
EDIC Year
6
6.5
7
7.5
8
8.5
9
9.5
0 1 2 3 4
A
1
C

(
%
)

Intensive Therapy
Conventional Therapy
DCCT: Average A
1C
4 Years
After Trial
DCCT/EDIC Research Group. N Engl J Med. 2000;342:381
0
4
8
12
16
20
0 1 2 3 4
DCCT: Progression of
Retinopathy 4 Years After Trial
Conventional Therapy
Intensive Therapy
C
u
m
u
l
a
t
i
v
e

I
n
c
i
d
e
n
c
e

(
%
)

EDIC Year

Reprinted with permission from DCCT/EDIC Research Group. N Engl J Med. 2000;342:381
EDIC Reduction in CV
Disease
Events were reduced 57%
(12-79% [95% CI]; P=0.02)
NEJM 2005;353:2643-2654
DCCT EDIC
UK Prospective Diabetes
Study Group: A
1C
Reprinted with permission from UKPDS. Lancet. 1998;352:837-853.
6
7
8
9
0 1 2 3 4 5 6 7 8 9 10
Years
A
1
C

(
%
)

Intensive Group
Conventional Group
Subjects with A
1C
<7%:
3 years 45%
6 years 30%
9 years 15%
Complications DCCT
1,2
Kumamoto
3
UKPDS
4
9% 7% 9% 7% 8% 7%

Retinopathy 63% 69% 17%21%

Nephropathy 54% 70% 24%33%

Neuropathy 60%

Macrovascular
disease 41%* 16%*

Control: Reduction In
Complications


*Not statistically significant

1
DCCT Research Group. N Engl J Med. 1993;329:977;
2
DCCT Research Group. Diabetes. 1995;44:968;
3
Ohkubo Y et al. Diabetes Res Clin Pract. 1995;28:103;
4
UKPDS Group. Lancet. 1998;352:837
UKPDS 10 Year
Poststudy Followup
Following completion of UKPDS, therapy was left to the
discretion of providers
The difference in A1C disappeared (like EDIC)
Results:
Microvascular Disease (RR=0.76; p=0.001)
Diabetes Endpoint (RR=0.91; p=0.04)
Death from Diabetes (RR=0.83;p=0.01)
All Cause Mortality (RR=0.87;p=0.007)
Myocardial Infarction (RR=0.85;p=0.01)
Holman RR et al. NEJM 2008;359:1577-1589
Pre-Study Glyemic Exposure
and Microvasular Outcomes
10
20
30
40
7.1

57.6

108.1

Glycemic Exposure*
C
o
m
p
l
i
c
a
t
i
o
n

R
i
s
k

R
e
d
u
c
t
i
o
n

(
%
)

ADVANCE
*Glycemic Exposure=Duration of Diabetes x Study Entry A1C
Neuropathy
Nephropathy
Retinopathy
Jones RE, Wadweker D. In press, 2010.
UKPDS VADT
** Statistically Significant
**
**
**
**
**
Utah Diabetes Prevention and
Control Program:
Provider Education
First Attempt (~1995)
Over 50 providers licensed in Utah
were given the primary literature
(DCCT and UKPDS plus derivative
articles) and asked to establish
treatment goals for glucose, lipids
and blood pressure in people with
diabetes
First Attempt (~1995)
7.2---Its Up to You!
BP 140/90 mm Hg
LDLc 130 mg/dl
Introduction
1997 was a unique year:
DCCT was 4 years old and UKPDS was 2 years
old
The ADA had just defined goals for diabetes
management
Insulin lispro, metformin and troglitazone were recently
approved by the FDA
The Expert Committee redefined the diagnostic criteria
for diabetes (FBS 126 vs 140 mg/dl)
Utah Diabetes Control Program initiated a process for
certification of Diabetes Self Management Programs
The Perfect Storm
Phase 1 (1999-2002)
Defining Diabetes, Targets and Complications
CME events were by invitation of
the local certified diabetes
educators in order to highlight
their skills
Topics centered on the diagnosis
of diabetes, setting targets, the
management of diabetes and
diabetes complications plus
treatment of HTN and lipids
Attendees were given copies of
the Utah Diabetes Management
Handbook (1999)
Phase 2 (2003-2006)
The Utah Diabetes Practice Recommendations
Again, CME events were by
invitation of the local providers or
the diabetes educators
Topics centered on the
management of diabetes in a
variety of settings (outpatient,
inpatient and pregnacy)
Providers were given a Chinese
Menu for topics
Attendees were given copies of
the Utah Diabetes Management
Handbook (2003) and applicable
UDPRs
ADA/EASD Consensus
Statement (2008)

Tier 1: Well-validated core therapies
Tier 2: Less well-validated therapies
Adapted from Nathan DM et al. Diabetes Care. 2008:31;1-11.
Reinforce lifestyle
interventions at every visit
and check A1C every 3
months until A1C is <7%
and then at least every 6
months.
Step 1
Step 2
Step 3
At diagnosis:
Lifestyle
+
Metformin
Lifestyle + Metformin
+
Basal Insulin
Lifestyle + Metformin
+
Sulfonylurea
Lifestyle + Metformin
+
Intensive Insulin
Lifestyle + Metformin
+
Pioglitazone
Lifestyle + Metformin
+
GLP-1 agonist

Lifestyle + Metformin
+
Pioglitazone
+
Sulfonylurea
Lifestyle + Metformin
+
Basal Insulin
Step 2
Step 2
ADA/EASD Consensus
Statement (2008)

Tier 1: Well-validated core therapies
Tier 2: Less well-validated therapies
Adapted from Nathan DM et al. Diabetes Care. 2008:31;1-11.
Reinforce lifestyle
interventions at every visit
and check A1C every 3
months until A1C is <7%
and then at least every 6
months.
Step 1
Step 2
Step 3
At diagnosis:
Lifestyle
+
Metformin
Lifestyle + Metformin
+
Basal Insulin
Lifestyle + Metformin
+
Sulfonylurea
Lifestyle + Metformin
+
Intensive Insulin
Lifestyle + Metformin
+
Pioglitazone
Lifestyle + Metformin
+
GLP-1 agonist

Lifestyle + Metformin
+
Pioglitazone
+
Sulfonylurea
Lifestyle + Metformin
+
Basal Insulin
Step 2
Step 2
UDPRs Glycemic
Algorithm
UDPRs, 2009
Possible weight increase, Greater A1C
lowering (>1%), Principally reduce FPG
Basal insulin
(most effective)
Sulfonylureas
(least expensive)
TZDs
(no hypoglycemia)
Incretomimetics
(most weight loss)
DPP-IV inhibitors
(least effective)
Possible weight loss (or neutral), Lesser
A1C lowering (<1%), Principally reduce PPG
Not included:
Amylomimetics;
Meglitinides; AGIs
Diagnosis; initiate lifestyle modifications
(education) and start metformin
-Patients Goals
-Fasting v Postprandial Target (A1C)
-Weight Effects
-Cost
-Relative Efficacy
-Age
-Cardiac, Renal and Hepatic Function
Individually Assess Patient
Hypertension Algorithm
UDPRs, 2009
Measurables
UDPRs
38,500 downloads
Interest and inquiries throughout the country
Provider education
Independent reviews, insurers and patient surveys
The frequency of target
measurement/documentation (lipids, BP,
microalbumin, A1C, foot exam) has significantly
increased
Meeting established targets cannot be ascertained or
has not changed
Are We Having an Impact?
Current State of Diabetes
Management
Targets
A1C < 7%
BP < 130/80 mm Hg
Total cholesterol < 200 mg/dL or LDL < 100 mg/dL

1
Saydah et al. JAMA 2004;291:335-342
2
BARI 2D Study Group. NEJM 2009;360:2503-25-2515.
Study A1C Blood
Pressure
Cholesterol All 3 Met
NHANES
1
37% 35.8% 51.8% 7.3%
BARI 2D
2
33%