March 2016
Volume: 5  Issue: 3
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Practical Ways to Approach Type II DM
With Treatment Tips from NEPHO Endocrinologist
David Toth, MD
34% of BCBS AQC Quality Measures in the 2016 contract are focused on management of diabetes. In addition, diabetes-related measures are highly weighted for many other commercial plans (HPHC, Tufts, Fallon, Cigna) as well as the Medicare ACO contract. See the NEPHO All-payer Quality Grid for a summary of quality measures, many of which are the same for each health plan.
Given the importance of diabetes management for NEPHO patients, Dr.David Toth, M.D., Endocrinologist at Lahey Outpatient Center in Danvers, was invited to present at each of the prescriber POD meetings in March and April. His approach to initiating treatment and adding therapies is summarized in Practical ways to approach the management of Type II Diabetes Mellitus.  Dr. Toth addressed numerous questions for providers in attendance and provided his contact information as well.
A one-page chart of a Stepwise Approach to Treating Type II DM, highlighting cost and efficacy of medications was provided at the POD meetings to support Dr. Toth's presentation. A more detailed version, which includes advantages and dis-advantages of current medication treatment therapies is also available, Stepwise Approach to Treating Type II DM (detailed)Questions regarding the medication charts can be referred to Carol Freedman, NEPHO Clinical Pharmacist (978 236 1774) or [email protected].
The detailed medication charts are included for your reference in light of a recent study evaluating "clinical inertia" in over 80,000 patients with diabetes (1).  See the summary points below:
  • Substantial proportion of people remain in poor glycemic control for several years before intensification with an oral antidiabetes drug (OAD) or insulin.
  • Mean A1C at intensification with OADs or insulin for people taking 1, 2, or 3 OADs was 8.7%, 9.1%, and 9.7% respectively.
  • Patients taking 1, 2, or 3 OADs, median time from therapy initiation to intensification with an OAD or insulin exceeded the maximum follow-up time of 7.2 years
  • There were significant delays in treatment intensification despite suboptimal control.
Here are some additional ways the Quality Team is available to support you in meeting AQC 2016 Quality Goals for your patients with diabetes:
  • Refer NEPHO patients with diabetes who are having difficulty in meeting the diabetes to measures to Alison Gustafson, Population Health Nurse Practitioner (978 236 1709) [email protected].
  • Do you have diabetic patients who would benefit from health coaching?  Refer them to your PHO Health Coach, Lucia Kmiec ( 978-236-1719), [email protected].
  • Referrals to the Diabetes Care Center at Lahey Outpatient Danvers can be made through Epic by selecting REF222.  Individual services (e.g. insulin teaching) can be selected via this form.
Clinical Inertia in People With Type 2 Diabetes: A retrospective cohort study of more than 80,000 people KamleshKhunti, MD1Michael L. Wolden, MSC2,Brian Larsen Thorsted, MSC2Marc Andersen, PHD3 and Melanie J. Davies, MD1 Diabetes Care July 22, 2013
MA Opioid Bill & CDC Opioid Guidelines Recently Released

A summary of Massachusetts Compromise Prescription Bill  by the Massachusetts Hospital Association hits the key points of the recent bill signed by Governor Baker. Portions of the bill take effect as of March 14, 2016. Click on Chapter 52 of the Acts of 2016, An Act Relative to Substance Use, Treatment, Education and Prevention for a complete copy of the bill.

See sample copy of patient agreement on controlled substance therapy for chronic opioid management.

  Some Early-Release Recommendations:
  • For chronic pain, first choices of treatment should be nonpharmacologic or nonopioid. Opioids should be an option only if the expected pain and function benefits outweigh the potential risks.
  • Patients starting opioids should be prescribed immediate-release opioids at the lowest effective dose, not extended-release/long-acting opioids.
  • Individual benefits and risks should be reassessed when increasing the dosage to 50 morphine milligram equivalents (MME) or more per day. Dosages of 90 MME or more should be avoided, (see below for calculation of MME tool) or clinicians should "carefully justify a decision" to increase the dosage to that level.
  • For acute pain, an opioid prescription for 3 days or fewer will often be enough. > 1 week is rarely needed.
  • Clinicians should regularly evaluate risk factors for opioid-related harms (e.g., history of overdose or substance use disorder) and consider offering naloxone to high-risk patients.
  • Concurrent prescriptions of opioids & benzodiazepines should be avoided.
  • See quick references from CDC:
NEPHO Clinical Newsletter
Produced by Northeast Physician Hospital Organization
For more information contact: 
Carol Freedman, RPh, MAS, CGP 
Clinical Pharmacist NEPHO 
[email protected] 
Louis Di Lillo M.D., Northeast PHO Medical Director 
[email protected]
In This Issue
Pharmacy Corner
Metformin Costs
FYI: The recently released generic formulation of GLUMETZA (metformin ER 1,000 mg Ext. Release 24-HR tablet  - modified release) currently costs ~$324 per month; patients are paying Tier-2 co-pays ($25 - $30 per month).  In contrast, metformin 750 mg & 500 mg ER tablets (osmotic release) cost < $10 per month and in some cases are FREE. 
Consider using 2-metformin 500mg ER tablets instead of metformin 1,000 mg Ext. Release product until there is more competition and the price of the 1,000 mg tablet declines...we hope!
 Prescription Drug Monitoring Program Enrollment Information
Physicians, nurse practitioners, physician assistants, dentists, and podiatrists with a Massachusetts Controlled Substance Registration (MCSR) should actively use the free Massachusetts Online Prescription Monitoring Program (MA Online PMP). The MA Online PMP is a secure website that allows prescribers to see which, if any, Schedule II-V medications a patient has been prescribed in the last 12 months, using information reported by pharmacies. The program supports the state's efforts to prevent harm from duplicate drug therapy and combat the mounting opioid crisis by identifying behaviors suggestive of misuse of prescription medications, such as obtaining controlled substance prescriptions from multiple doctors without informing the physicians of their other prescriptions.
Because MA Online PMP contains data reported by pharmacies and may contain inconsistent information, it may be necessary to verify the accuracy of the information in the prescription history with other prescribers and/or dispensers listed, before taking clinical action.
The Massachusetts Department of Public Health Drug Control Program (DCP) automatically enrolls physicians, dentists, and podiatrists in the MA Online PMP when they obtain a new MCSR or have an existing one recalled (every three years). However, if you are not enrolled in the MA Online PMP and your MCSR is not due to be recalled soon, you can download the enrollment form for free on the website. In addition to enrollment guidance, you will also find a detailed program description and some useful resources.

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