Type 2 Diabetes - GENERAL CME OVERVIEW

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Clinical Topic Overview

Type 2 Diabetes

Primary care physicians are on the front lines of a diabetes epidemic. Approximately 24 million people—8 percent of the U.S. population—have diabetes, and approximately one-quarter of these cases are undiagnosed. The costs of the disease, in both human and economic terms, are vast. In addition to being the seventh leading cause of death in the U.S., it is the leading cause of blindness and kidney failure and is associated with 60 percent of all amputations. Heart disease mortality and stroke risk are two to four times higher among those with diabetes than those without. In economic terms, diabetes accounts for $174 billion in direct and indirect expenditures, including lost work days and productivity in the U.S.1 As the prevalence in the U.S. and around the world continues to rise,2, 3 these costs will only continue to grow.

Primary care physicians most frequently see patients at risk for and with type 2 diabetes. As such, they are in the best position to improve diagnosis and management of patients with type 2 diabetes. However, a 2009 needs assessment of primary care physicians conducted by PennCME/BestPractice revealed the following gaps:  

  • Physicians often fail to screen patients at risk for diabetes to improve rates of early diagnosis and treatment.
  • Inadequate glucose control as measured by regular administration of A1C tests and eye and foot exams to avoid and better manage complications of disease in type 2 diabetes patients.
  • Inadequate lipid management, BP control, depression screening, smoking cessation, and weight management guidance to minimize CV and CKD risks and manage other comorbid conditions in type 2 diabetes patients.
  • Physicians need to improve knowledge and understanding of treatment options, such as when to initiate insulin therapy and how to match patient needs and characteristics to the most appropriate antidiabetic agent.
  • Physicians need to address systems issues in their practices in order to provide integrated delivery of care to patients with type 2 diabetes.
  • Poor communication between patients and health care providers contributes to patient non-adherence to medication regimes, lifestyle changes and self monitoring. 

References:

1Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2007. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2008. Accessed on May 23, 2010. Available at: http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf

2Wild S, Roglic G, Green A, et al. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care.2004;27:1047-53.

3Fox CS, Pencina MJ, Meigs JB, et al. Trends in the incidence of type 2 diabetes mellitus from the 1970s to the 1990s: the Framingham Heart Study. Circulation. 2006;113:2914-8.

 

Target Audiences

Physicians in primary care practice, physician assistants, nurse practitioners, and other health care providers and clinical practice teams.

Titles & Formats

ABCs: Clinical review of areas of basic competencies in primary care

  • Starting Insulin in Type 2 Diabetes: When? Why? How?
  • Noninsulin Antidiabetic Agents: When? Which? How?
  • Screening for Prediabetes and Diabetes – Yes? No? Why? Why Not?
  • Depression in Patients with Type 2 Diabetes
  • Eight Steps to Streamlining – and Improving – Management of Your Diabetic Patients

Hot Topics: Short articles on focused clinical and/or practice management issues.

  • Common Errors in T2D Management: Problems with Blood Glucose Self-Monitoring
  • Common Errors in T2D Management: Picking the Right Oral Medication
  • Common Errors in T2D Management: Misuse of Insulin Secretagogues
  • Common Errors in T2D Management: Failure to Distinguish Between T2DM and T1DM
  • Common Errors in T2D Management: Overuse of Premixed Insulins
  • Common Errors in T2D Management: Delaying the Start of Insulin
  • Common Errors in T2D Management: Metformin and Renal Failure
  • Common Errors in T2D Management: Pushing for Weight Loss—But Not Too Much

Interactive Minicases: Based on real-life interactions between primary care physicians, the health practice team, and patients with Type 2 Diabetes.

  • Initiating Treatment for a Patient with Type 2 Diabetes
  • Managing a Depressed Patient with Type 2 Diabetes
  • Practice Improvement Scenario
  • An Angry Patient with Type 2 Diabetes

Simulations: Place physicians in the active role of problem solvers, learning critical skills in a practical setting.

  • Two Patients Whose Type 2 Diabetes is Tangled with Co-Morbidities

Point of Care CME: Structured, self-directed online learning by physicians on topics relevant to their clinical practice. 

Performance Improvement CME: Provides physicians with tools to assess their practice using evidence-based performance measures; feedback that compares their performance to national benchmarks; interventions based on the performance measures; and revaluation of performance in practice including reflection and summarization of outcome changes resulting from the PI CME activity.

Clinical Resources and References: Bibliography of cited evidence-based references and links to resources featured in this section.

Patient Resources: Provides patients with practical information and tools about their health and medical conditions to promote patient-self management and patient-physician partnerships.

Educational Goals and Objectives:

After participating in this educational initiative, learners are generally expected to:

  1. Improve timely diagnosis of type 2 diabetes.
  2. Change practice patterns to reflect current guidelines and best practices.
  3. Minimize risk and improve management of comorbidities in patients with type 2 diabetes.
  4. Demonstrate improved knowledge and application of guidelines/best practices for treatment of patients with type 2 diabetes.
  5. Apply new knowledge to improve the organization of delivery of medical care in their practice setting.
  6. Better integrate with community resources provided to patients.
  7. Provide culturally competent care to improve patient’s risk recognition and motivation to engage in positive health self-management behaviors.

Medium or Combination of Media Used

This educational initiative was developed using the following media:

  • Interactive minicase studies
  • Simulations
  • Targeted search at the point of care using iSEEK search engine
  • Internet-based enduring materials
  • Evidence-based resources
  • References to physician staff and patient education links
  • Web-based registry for Performance Quality Reporting Initiative (PQRI)

Method of Learner Participation in the Learning Process

1. Areas of Basic Competence (ABC) in type 2 diabetes present critical areas of knowledge in the disease in a highly organized, coherent pathway, along with practical approaches to achieving best practices. The goal is to engage the physician in “actionable learning.” This section provides a foundation and reference base for other featured interventions.

2. Hot Topics in Type 2 Diabetes are short, focused articles in a specific area of clinical management in type 2 diabetes. These articles are designed to engage the participant in the topic area and lead them to content that provides the opportunity for more in-depth learning.

3. Interactive Minicases offer a valuable learning experience based on real-life interactions between primary care physicians, the health practice team, and patients with type 2 diabetes. This method of engagement allows participants to build their knowledge and competence as they simulate both the management of type 2 diabetes patients and clinical-based systems in their practices. 

4. Point of Care Search CME (PoC) includes structured, self-directed online learning by physicians on topics relevant to their clinical practice. Learning for this activity occurs through a reflective process in which physicians document the clinical question, cite the sources consulted, and identify the application of the learning to their practice.   

5. Simulations place physicians in the active role of problem solvers, learning critical skills in a practical setting. The Patient Simulator provides individually tailored learning, allowing physicians to Increase Competence by applying new knowledge to solving diagnostic and therapeutic challenges in a non-threatening clinical environment.

6.  Quality Circles supporting Performance Improvement (PI-QC) are clinical, topic-specific, faculty-led communities of learning, supported by web communication tools and focused on specific PI measures and the PI-CME process in one clinical area.

7. Registry-based Performance Quality Reporting Initiative (PQRI) guides physicians through PQRI using a series of questions related directly to evidence-based quality indicators in type 2 diabetes.   Physicians can compare their performance against national benchmarks and qualify for an incentive bonus from the Center for Medicare and Medicaid Services (CMS). 

8. Performance Improvement CME leads physicians through an integrated three-stage process of practice performance improvement comprised of assessment, intervention and revaluation.

Faculty, Authors, and Contributors:

Editor-in-Chief
Zalman S. Agus, MD

Associate Dean for CME
Emeritus Professor of Medicine
Perelman School of Medicine at the University of Pennsylvania
Philadelphia, Pennsylvania

Dr. Agus received his MD degree, magna cum laude, from the University of Maryland in 1965. He completed his residency in internal medicine at the University of Maryland Hospital and a fellowship in renal and electrolyte medicine at the Hospital of the University of Pennsylvania, and then joined the faculty at UPenn in 1973. He was named Chief of the Renal and Electrolyte Section and Director of the Renal Fellowship Training Program in 1979, became Emeritus Professor of Medicine in 1996, and joined UpToDate, Inc., as Coordinating Editor. He was appointed Associate Dean for CME at the Perelman School of Medicine at the University of Pennsylvania in 2002.

Dr. Agus has published more than 120 articles and textbook chapters and has edited several publications. His scholarly interests are focused on acid-base and electrolyte disorders and mineral metabolism, and he is recognized as an international expert in the physiology and pathophysiology of calcium, phosphate, and magnesium transport.

Dr. Agus has served the American Society of Nephrology as Vice-Chairman of the Program Committee, Chair of the Nephrology Training Program Directors Committee, and Chair of the Informatics Committee. He has served on the Executive Committee of the National Medical Advisory Board and the Board of Directors of the National Kidney Foundation. He is a past Chairman of the Council on the Kidney in Cardiovascular Disease of the American Heart Association, was elected to membership in the American Society for Clinical Investigation, and has been a fellow in the American College of Physicians. He is currently listed in “Who's Who in America” and “Who's Who in the World.”

 


David K. McCulloch, MD, FRCP
Clinical Professor of Medicine/Endocrinology
University of Washington, Seattle
Medical Director, Clinical Improvement
Group Health Cooperative
Seattle, Washington

David K. McCulloch, MD, FRCP, obtained his MD at Edinburgh University, Scotland, in 1977 with additional postgraduate training at the University of Nottingham, England, and was elected a Fellow of the Royal College of Physicians in 1991. He moved to the University of Washington, Seattle, in 1983, where he is now a Clinical Professor of Medicine.

Dr. McCulloch has worked in the field of clinical diabetes innovation for more than 30 years and has more than 80 publications on a wide variety of diabetes-related topics. He works as a diabetologist, leading clinical improvement efforts in diabetes with an energetic team at Group Health Cooperative of Puget Sound, a managed care organization in Washington State with more than half a million enrolled members. The comprehensive and integrated approach implemented at Group Health Cooperative has resulted in improved health outcomes, increased patient satisfaction, decreased utilization of services, and reduced costs.

Dr. McCulloch has chaired national and statewide diabetes and cardiovascular disease collaboratives with a wide variety of health care organizations. Since 1998, he has been the diabetes chair in several national efforts to improve diabetes care in association with the Institute for Healthcare Improvement, the Bureau of Primary Care, and the Robert Wood Johnson Foundation. He is a recipient of numerous awards and honors in the field; Seattle Magazine voted him one of Seattle’s best doctors. Since 1995, he has consistently been included in “The Best Doctors in America: Pacific Region.”

 


Mark H. Schutta, MD
Clinical Assistant Professor of Medicine
Division of Endocrinology, Diabetes & Metabolism
University of Pennsylvania School of Medicine
Director, Penn Rodebaugh Diabetes Center
Philadelphia, Pennsylvania

Mark H. Schutta received his MD at Jefferson Medical College, Philadelphia, and completed his residency training at Jefferson University Hospital and a fellowship at the Hospital of the University of Pennsylvania, in Philadelphia. He is a board-certified internist and has served as the Director of the Penn Rodebaugh Diabetes Center since 2003 and is also the Medical Director of the Penn Islet Cell Transplantation Program. His research is focused on, and he has published a number of articles relating to, islet cell transplantation, implementation of a comprehensive diabetes disease management program, patient errors in the use of insulin, the epidemiology of hypertension and diabetes, and insulin resistance.

 


Serena Cardillo, MD
Assistant Professor of Medicine
Clinician, Penn Rodebaugh Diabetes Center
Division of Endocrinology, Diabetes & Metabolism
University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

Serena Cardillo, MD, completed her undergraduate studies at Johns Hopkins University where she received a BA in Behavioral Biology. She received her MD from the University of Pennsylvania in 2001 and completed both a residency in Internal Medicine and a fellowship in Endocrinology at the Hospital of the University of Pennsylvania. She joined the faculty in the Division of Endocrinology, Diabetes, & Metabolism as an Assistant Professor of Medicine in 2006. She is board-certified in Internal Medicine and in Endocrinology, Diabetes & Metabolism, and is also the Director of the Graduate Diabetes Education and Director of Ambulatory Medicine, Internal Medicine Training Program, at the Hospital of the University of Pennsylvania.

Dr. Cardillo’s research has focused on the impact of dietary intervention on adipocyte-derived hormones in obesity and on the impact of specialized multidisciplinary care in T2D. Her clinical interests include diabetes management, transplant-associated diabetes, obesity, and metabolic syndrome. She recently participated in a program for the American Academy of Family Physicians that focused on the subtleties of using antihyperglycemic medications, challenges and considerations when introducing insulin, use of blood glucose monitoring to guide treatment, and the importance of CVD risk reduction. Her clinical practice is based at the Penn Rodebaugh Diabetes Center.

 


Medical Editor

Lewis Miller, MS, CCMEP
Principal, WentzMiller & Associates
Darien, Connecticut

Medical Writers

Amanda M. Justice
Medical Consultant and Writer
Brooklyn, New York

Caitlin Rothermel, MA, MPHc
Medical and Health Economics Writer
Seattle, Washington

Program Directors

Chief Learning Officer
Mila Kostic
Director of Continuing Medical Education
Perelman School of Medicine at the University of Pennsylvania
Philadelphia, Pennsylvania
 
Chief Technology Officer
Lauren Patrick, MS
President, NetHealth
Malvern, Pennsylvania
 
Editorial Director
Laura Traynor, MA

Editorial Board

Joseph E. Scherger, MD, MPH
Professor of Clinical Family and Preventive Medicine
Director, San Diego Center for Patient Safety
Medical Director, Quality Improvement Education
Director, Quality Improvement in Correctional Medicine
University of California, San Diego School of Medicine (USCD)
San Diego, California

Matthew H. Rusk, MD
Associate Professor of Clinical Medicine
Program Director, Primary Care Program
Staff Internist
Division of General Medicine
Hospital of the University of Pennsylvania
Philadelphia, Pennsylvania

Dennis F. Saver, MD
President and Staff Physician
Primary Care of the TreasureCoast
Clinical Assistant Professor of Family Medicine
Florida State University
Vero Beach, Florida

Peter J. Ziemkowski, MD
Assistant Professor: Department of Family Medicine
College of Human Medicine
Michigan State University
Clerkship Director and Physician/Faculty
Michigan State University-Kalamazoo Center for Medical Studies
Kalamazoo, Michigan

Instructions for Obtaining CME Credit

To obtain Credit Certificate for CME-certified activities follow these steps:

  • Review the topic- and activity-specific overview
  • Complete the brief case-based pre-activity assessment
  • Review the entire educational activity
  • Answer all case-based questions in the post-activity assessment
  • Complete the evaluation
  • Proceed to view or print your certificate stored in your Personal Learning Center

Accreditation: The Perelman School of Medicine at the University of Pennsylvania is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Designation of Credit
These activities have been approved for AMA PRA Category 1 Credit(s) TM.

Disclosure of Commercial Support
Supported, in part, by educational grants from Abbott Laboratories,  Daiichi Sankyo, Inc., Genentech, Inc., GlaxoSmithKline, Lilly USA LLC, and Takeda Pharmaceuticals North America, Inc.

Disclosures of Personal Financial Relationships
It is policy at the Perelman School of Medicine at the University of Pennsylvania for individuals who are in a position to control the content of an educational activity to disclose to the learners all relevant financial relationships that they have with any commercial interest that provides products or services that may be relevant to the content of these continuing medical education activities. For this purpose, we consider relationships of the person involved in the CME activity to include financial relationships of a spouse or partner.

The intent of this policy is not to prevent expert faculty with relevant relationship(s) with commercial interest(s) from involvement in CME, but rather to ensure that Penn CME-certified activities promote quality and safety, are effective in improving medical practice, are based on valid content, and are independent of control from commercial interests and free of commercial bias. Peer review of all content was conducted for all faculty presentations whose disclosure information provided to the Penn Office of CME was found to contain relationships that created a conflict of interest relative to the topic of their presentation. In addition, all faculty were instructed to provide balanced, scientifically rigorous, and evidence-based presentations.

The staff in the Office of CME at the University of Pennsylvania School of Medicine, Mila Kostic, and the peer reviewer, Zalman Agus, MD, have reported no relevant financial relationships with any commercial interests related to the content of these educational activities.

The following staff and consultants have reported no relevant financial relationships with any commercial interests related to the content of these educational activities:  

Amanda Justice, Medical Writer

Lauren Patrick, President, NetHealth

Laura Traynor, MA, Editorial Director

The following staff members and consultants have reported the listed relevant financial relationships with any commercial interests related to the content of these educational activities:

Lewis A. Miller, MS, is a consultant for Takeda Pharmaceuticals North America.

Caitlin Rothermel, MA, MPHc, Medical and Health Economics Writer, is a consultant for Covidien Pharmaceuticals.

The following faculty have disclosed that they have no relevant financial relationships with any commercial interests related to the content of these educational activities:  

Faculty Name

David K. McCulloch, MD

Matthew Rusk, MD

Joseph E Scherger, MD, MPH

Peter Ziemkowski, MD

The following faculty have reported the listed relevant financial relationships with commercial interests related to the content of these educational activities. 

Faculty Name                        Name of Commercial Interest                        Relationship

Serena Cardillo, MD               AstraZeneca and Bristol Myers Squibb            Research

Dennis Saver, MD                  Boehringer Ingelheim and Genzyme                Consultant

                                                  First Consult                                                            Board Member

Mark Schutta, MD                   Sanofi-aventis                                                        Speaker

                                                Princeton Technology Advisors                            Consultant

                                                Merck Pharmaceuticals                                       Spouse’s employer

Relevant Financial Relationships: Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (eg, stocks, stock options, or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received or expected.

Investigational and/or Off-Label Use of Commercial Products and Devices

The Perelman School of Medicine at the University of Pennsylvania requires all faculty to disclose any planned discussion of an investigational and/or off-label use of a pharmaceutical product or device within their presentation. Participants should note that the use of products outside FDA-approved labeling should be considered experimental and are advised to consult current prescribing information for approved indications.

The faculty reported that there will be no specific mentions of off-label and/or investigational use of products within their presentations.

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For CME-related questions, please contact the Office of CME at the Perelman School of Medicine at the University of Pennsylvania at penncme@mail.med.upenn.edu

Learning Objectives:  Upon completion of this educational activity, the participant should be able to:

  • Recognize the critical importance of ruling out type 1 diabetes in adult patients and type 2 diabetes in pediatric and adolescent patients.
  • Apply the criteria to make the differential diagnosis between type 1 and type 2 diabetes before initiating treatment.

Faculty: Serena Cardillo, MD, CCMEP and Mark H. Schutta, MD
Editor: Lewis Miller, MS, CCMEP

Original Date of Release: June 15, 2010
Last Review Date: July 1, 2011
Expiration Date: July 1, 2014

Estimated Time to Complete: 30  minutes

Amount of CME Credit: Maximum of 0.50 AMA PRA Category 1 Credits™

Accreditation: The Perelman School of Medicine at the University of Pennsylvania is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Designation of Credit: The Perelman School of Medicine at the University of Pennsylvania designates this enduring material for a maximum of 0.50 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Supported, in part, by educational grants from Abbott Laboratories,  Daiichi Sankyo, Inc., Genentech, Inc., GlaxoSmithKline, Lilly USA LLC, and Takeda Pharmaceuticals North America, Inc.

 

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