Renal Disease in Patients with Heart Failure

Aug 26, 2023

Renal Disease in Patients with Heart Failure

On December 12th, 2020 Get With The Guidelines®-Heart Failure was updated to expand data collection and measurement of renal disease in patients with heart failure and diabetes. Join us to hear a comprehensive review of the science behind these latest updates and for a demonstration of the data elements and measures. This event featured distinguished speaker Dr. Robert H. Eckel, President, Medicine \u0026 Science, American Diabetes Association and Professor of Medicine Emeritus, Endocrinology/Metabolism/Diabetes/Cardiology, University of Colorado School of Medicine.

Content

6.74 -> - [Renee] On behalf of the American Heart Association,

9.56 -> I would like to welcome you to today's webinar,

12.3 -> Renal Disease in Patients with Heart Failure and Diabetes:

15.9 -> Treatment Guidelines and Updates

17.43 -> in Get With The Guidelines-Heart Failure.

20.02 -> My name is Renee Sednew

21.39 -> and I'm a manager in quality outcomes,

23.62 -> research and analytics with the American Heart Association.

27.75 -> To begin, I'd like to go over a few items

30.16 -> so you know how to participate in today's event.

33.12 -> If you would like a copy of today's presentation,

36.48 -> you can download a PDF in the handout section

39.22 -> of your attendee control panel.

41.65 -> If you experience technical difficulties,

43.94 -> most user issues can be resolved by refreshing your browser.

48.05 -> If that does not work,

49.1 -> please contact the GoToWebinar customer service team

52.59 -> found in your confirmation and reminder email.

55.78 -> At the conclusion of today's presentation,

57.87 -> you will receive a link to access today's recording

60.93 -> as well as an invitation to complete our feedback survey.

65.77 -> We welcome you to submit questions for our presenter

68.77 -> at any time in the questions pane at the control panel.

72.46 -> We will collect your responses and address them

74.52 -> during the Q&A session at the end of today's presentation.

79.26 -> It is my pleasure to now introduce our speakers for today.

83.83 -> Dr. Robert Eckel is a distinguished alumnus

86.78 -> of the University of Cincinnati College of Medicine,

90.11 -> professor of medicine

92.72 -> with appointments in the division of endocrinology,

96.47 -> metabolism and diabetes, and division of cardiology.

101.26 -> And former Endowed Chair in Atherosclerosis

105.89 -> at the University of Colorado School of Medicine,

109.06 -> Medical Campus.

110.82 -> He was also a member of the Scientific Advisory Council

114.05 -> of the National Institute of Diabetes,

116.63 -> Digestive and Kidney Diseases

118.61 -> at the National Institutes of Health.

121.66 -> In addition, he served as president

123.63 -> of the North American Association for the Study of Obesity,

127.33 -> and president of the American Heart Association.

131.87 -> Welcome Dr. Eckel.

134.04 -> - Good, thank you very much Renee.

136.52 -> It's good to have everyone with us here

138.8 -> this morning on this webinar.

140.1 -> This is an incredibly important and evolving topic,

143.3 -> that really is an outcome in part

146.14 -> of the Know Diabetes by Heart program,

148.3 -> which is a joint venture between the AHA and the ADA.

152.36 -> I've already been announced,

153.58 -> so we don't need to belabor information on this slide.

157.29 -> And my disclosures really relate to activities

160.08 -> that are mostly in biotech firms

163.78 -> that ultimately don't have products on the market.

166.26 -> Novo Nordisk is the only one that does,

168.48 -> and I can assure you that that advisory board role

171.86 -> that I play with them

172.693 -> has nothing to do with the content directly

174.82 -> that I'm gonna be presenting today.

176.68 -> We're talking about here updated guidelines

179.47 -> that relate to chronic renal disease and heart failure

183.09 -> in patients with type 2 diabetes.

186.3 -> Now, Know Diabetes by Heart was an initiative put forth

190.45 -> to ultimately accomplish the goal

192.84 -> of reducing cardiovascular disease, deaths, heart attacks,

196.95 -> congestive heart failure, and strokes,

199 -> in people living with type 2 diabetes.

202.75 -> This has been jointly sponsored

204.76 -> by a number of different pharmaceutical companies

206.99 -> including Boehringer Ingelheim,

209.25 -> Lilly and Novo Nordisk as founding sponsors

212.39 -> and Sanofi, AstraZeneca and Bayer as national sponsors.

216.75 -> Ultimately, this now has extended

219.18 -> from heart disease and diabetes to renal disease too

224.23 -> and heart failure,

225.063 -> which really are incredibly important outcomes

227.66 -> of patients living with type 2 diabetes

230 -> at risk for these outcomes to follow.

233.35 -> So ultimately the Know Diabetes by Heart program,

235.54 -> I thought we'd start here just briefly

237.35 -> to identify the various pillars of activity

240.58 -> that are part of Know Diabetes by Heart.

243.19 -> The first is in consumer activation,

246 -> which is increasing the awareness

247.9 -> and understanding of the connection

249.56 -> between type 2 diabetes and cardiovascular disease.

253.35 -> These are broad strokes reaching out to a wide variety

257.06 -> of both the population and healthcare professionals.

261.16 -> There's the patient resources and support pillar,

264.31 -> which is a comprehensive portfolio of patient education,

268.29 -> resources and self-management tools.

270.86 -> It's really incredibly important to get our patients

273.56 -> involved in their own evaluation and care going forward.

278.48 -> The third is the professional resources

280.64 -> and education pillar.

282.27 -> And that's to improve health care provider adherence

285.28 -> to diabetes standards of care

286.93 -> for management of cardiovascular disease

289.51 -> and related risk factors in patients with type 2 diabetes.

293.647 -> And the final is on quality and systems improvement.

296.83 -> Here's a big tent ultimately to be part of this program,

301.16 -> that's to implement programs and activities

303.14 -> to help healthcare systems apply and practice

306.73 -> the most up-to-date evidence-based treatment guidelines

310.5 -> for primary and secondary prevention

312.41 -> of cardiovascular disease and stroke events

315.19 -> in patients living with type 2 diabetes.

319.23 -> So let's look at some data here.

320.64 -> There's more than 30 million Americans

322.81 -> that live with type 2 diabetes.

324.38 -> In fact, I think most of these are type 2,

326.84 -> 90 to 95% of those with diabetes are living with type 2.

331.35 -> And I might say in a tangent kind of manner

336.17 -> that ultimately there are patients with type 1 diabetes

338.84 -> who share many of these same risk factors,

341.02 -> and these patients are living quite longer these days,

343.9 -> but the intent of Know Diabetes by Heart

346.03 -> clearly is directed to the large majority of people

348.57 -> living with diabetes.

350.34 -> Cardiovascular disease, as most of us know,

352.31 -> is the leading cause of death

354.38 -> for people who live with type 2 diabetes.

357.3 -> And people with type 2 diabetes

359.71 -> are now two times more likely to develop and die

362.74 -> from cardiovascular disease,

364.37 -> such as heart attacks, heart failure and strokes

367.49 -> than people who do not have diabetes.

370.2 -> And for adults above the age of 60,

372.87 -> having type 2 diabetes and cardiovascular disease

375.44 -> shortens the life expectancy by an average of 12 years,

378.88 -> that's an incredible impact being at age 60

381.74 -> and having your life be shortened by over a decade

384.8 -> because of the coexistence of type 2 diabetes,

388 -> cardiovascular disease risk and related outcomes.

391.53 -> Now, 2015, I shared part of a multi author publication

396.3 -> by the American Heart Association

398.06 -> and the American Diabetes Association

400.22 -> called the Update on Prevention of Cardiovascular Disease

403.71 -> in Adults With Type 2 Diabetes in Light of Recent Evidence.

407.197 -> And I must say in parenthesis

409.45 -> that the light of recent evidence

410.85 -> has changed substantially since 2015,

414.66 -> and we're looking at a whole platform

417.37 -> and ultimately via going forward

419.39 -> that modifies how we approach patients with diabetes.

423.49 -> Now this slide is currently the approach utilized by the ADA

426.96 -> and also shared by Know Diabetes by Heart

429.58 -> that looks at the beginning of decision cycle

432.31 -> for patient-centered glycemic management

435.12 -> in those living with type 2 diabetes.

437.77 -> First is to assess the key patient characteristics.

441.68 -> The second is to consider specific factors

444.14 -> that impact our choice of therapy.

446.8 -> The third is shared decision-making

448.86 -> to create a management plan.

450.78 -> Isn't that true of all health care these days?

453.75 -> The fourth is agreeing

454.91 -> on this management plan going forward.

457.91 -> The next is implement the managed plan

460.33 -> to make sure that patients understand what we're doing

463.05 -> and why we're doing it.

464.71 -> The next is digging or ongoing monitoring and support,

468.91 -> including emotional wellbeing

471.18 -> and the other items shared here

473.62 -> under this set of bullet points to follow.

476.85 -> And finally review and agreeing on the management plan

479.48 -> that really relates, I think, in monitoring going forward

482.77 -> in terms of the success of all the steps

485.01 -> that preceded the management plan that's put forth.

488.42 -> Ultimately the goals of this care

490.66 -> is to prevent complications from diabetes

493.79 -> and optimize the quality of life going forward.

498.49 -> Now first assessing the key patient characteristics.

501.09 -> We're not gonna review all these in detail,

503.09 -> but just to list these

504.24 -> because they're so critically important.

506.74 -> Current lifestyle is so critically important.

509.28 -> In terms of nutrition,

510.3 -> it's not only the quantity of the diet,

512.47 -> meaning how many calories are reading

514.62 -> to induce weight reduction,

516.65 -> but also the quality of the diet.

518.3 -> This is incredibly important

519.66 -> for people living with diabetes.

521.88 -> The assessment and management of co-morbidities,

526.26 -> including atherosclerotic cardiovascular disease,

529 -> chronic kidney disease,

530.41 -> both of which relate to heart failure to follow.

533.61 -> Clinical characteristics that affect the management plan,

536.62 -> including the age of the patient, the A1C and weight.

540.49 -> This is called the individualization

542.64 -> of goal setting behavior

544.16 -> that we carry out routinely

545.54 -> in patients with type 2 diabetes.

547.86 -> Issues that are patient-centric

549.55 -> includes motivation and diabetes distress or depression

553.63 -> that enter into the decision making process.

556.4 -> And finally, importantly and increasingly importantly,

559.53 -> our culture on socioeconomic issues

561.91 -> that relate to the management plan and its success.

565.98 -> Now complicated slide,

567.37 -> I'm gonna try to summarize this very quickly

569.48 -> by going from left to right at the top.

572.25 -> Indicators of high risk

573.86 -> atherosclerotic cardiovascular disease

576.03 -> in terms of a risk for an event

578.22 -> or people with established cardiovascular disease,

581.11 -> we're looking at a choice of agents going beyond lifestyle

584.01 -> that relate to mostly the SGLT2 inhibitors

587.68 -> or the GLP-1 receptor agonists.

590.67 -> If the A1C is above an individualized target

593.96 -> and we wanna proceed,

595.52 -> ultimately we're thinking about issues

597.47 -> that need to avoid hypoglycemia.

600.29 -> And those are drug choices as shown here,

602.637 -> the DPP-4 inhibitors, the GLP-1 receptor agonists,

606.67 -> the SGLT2 inhibitors, and the thiazolidinediones.

610.03 -> Those that need to minimize weight gain

612.45 -> or promote weight loss,

613.73 -> we're looking here at the GLP-1 receptor agonist

616.91 -> and the SGLT2s,

618.64 -> and those that relate to out-of-pocket costs

621.05 -> and those basically of the sulfonylureas and the TZDs

624.2 -> to a large extent.

625.84 -> Now back up here the issue is to whether metformin

629.18 -> should be present initiating a therapy in patients

633.45 -> who have had a recent event,

634.66 -> who have been diagnosed with type 2 diabetes

637.07 -> remains debated in terms of the view

639.1 -> of the American Diabetes Association

641.36 -> and that of the European Association

643.53 -> for the Study of Diabetes

644.87 -> and the European Society for Cardiology.

648.36 -> Anyway, the metformin issue

649.71 -> is not something to get bogged down on.

652.54 -> Most of our patients are on metformin already,

655.05 -> and the choice of a GLP-1 receptor agonists,

657.68 -> or an SGLT2 inhibitor

659.09 -> should relate to the clinical trial data

661.34 -> that we now have available.

664.24 -> Now Target: Type 2 Diabetes is a program that spotlight

668.01 -> on how type 2 diabetes relates to cardiovascular disease

671.45 -> and joins up with Get With The Guidelines that the AHA

674.027 -> has been part of now for nearly a decade.

676.97 -> Now, ultimately the goal of this program

678.77 -> to target type 2 diabetes

680.85 -> is ultimately to address healthcare professionals

684.48 -> and ability to manage patients with type 2 diabetes,

687.67 -> both out of the hospital

689.64 -> and once hospitalized with a cardiac related condition,

693.23 -> or even perhaps beyond that,

695.14 -> that relate to the prevention

697.04 -> of a cardiovascular disease event to follow.

700.65 -> Ultimately, this has a series of activities

703.16 -> including acknowledgement of the guidelines

705.73 -> that currently exist,

707.51 -> ultimately resources that one can link onto

710.64 -> to provide information

711.96 -> to affect the healthcare professionals assessment

714.85 -> and care of patients, a series like this one,

717.64 -> a podcast and webinars that ultimately can be accessed

721.42 -> readily at the AhA website,

723.98 -> or theknowdiabetesbyheart.org website,

727.11 -> and quality improvement,

728.98 -> learning about ultimately how to improve the quality of care

732.33 -> going forward with Give Your Type 2 A Take Two approach

736.97 -> to the public in general.

738.5 -> Learning to live with type 2 diabetes

741.17 -> and putting you at a lesser risk

742.66 -> for heart disease and stroke going forward.

746.41 -> Now let's look at simply some examples of series of webinars

749.92 -> and podcasts that are currently available.

752.46 -> And I presume this one's gonna be added to this list.

755.74 -> Some sample resources

757.29 -> in terms of Know Diabetes by Heart pocket guide,

760.49 -> shared decision-making guide,

762.73 -> clinical case review options,

765.31 -> a series of slide decks,

766.69 -> boy, these are incredibly valuable,

768.87 -> and I've had the privilege of sharing in some of these.

771.37 -> And then for patient resources, a series of programs

774.19 -> our patients can ultimately link to and be further informed.

779.5 -> And some of these programs are in Spanish too.

781.82 -> And this is important because we have a large percentage,

784.94 -> a significant minority of our populations

787.55 -> at high risk with type 2 diabetes,

789.64 -> who in fact are not English speaking.

791.41 -> So this is kind of the example of the sample resources

795.12 -> that you can access readily and apply to your assessment

799.21 -> and care of patients with type 2 diabetes.

803.07 -> Now, the program's entitled

805.39 -> Diabetes & Chronic Kidney Disease

807.34 -> and its Relationship to Congestive Heart Failure.

810.24 -> Let's proceed systematically going forward.

814.01 -> Here's an overview of causes of chronic kidney disease.

816.91 -> Now I'm gonna be an internist here first

819.19 -> and not a nephrologist and your could be a pediatrician

822.71 -> or a family practitioner,

824.07 -> these are the kinds of things to think of

825.85 -> in patients who in fact have chronic kidney disease.

829.47 -> Diabetes, a leading cause of progressive renal dysfunction.

833.33 -> Hypertension, often present

835.1 -> in patients with type 2 diabetes links to that relationship

838.63 -> between diabetes and chronic kidney disease.

840.75 -> However, hypertension in the absence of diabetes

843.85 -> can also be a cause of chronic kidney disease.

847.42 -> All forms of glomerulonephritis

849.91 -> often presenting with hematuria and proteinuria,

852.78 -> but always not both.

854.6 -> This is another cause that needs to be assessed

856.74 -> when we evaluate patients with chronic kidney disease.

859.6 -> Systemic vasculitis,

861.62 -> ultimately polycystic kidney disease

863.92 -> and drugs that impair renal function.

865.79 -> I may not have covered everything here,

867.54 -> but I suspect that's 95% of the causes we know about

872.91 -> and assess clinically

874.32 -> for patients with chronic kidney disease.

876.95 -> I thought I'd present a case

878.14 -> that's fairly typical of the type of patient

880.27 -> we're thinking about here today.

883.26 -> I'm sorry, going forward.

884.76 -> This is an individual

886.46 -> who has a high school graduation weight

889.92 -> of ultimately 162 pounds and a BMI of 23.2.

894.45 -> So this 47 year old guy weighed actually 162

898.45 -> at high school graduation.

899.41 -> I like the high school graduation weight

901.64 -> because a lot of people think back

903.3 -> as to what their weight was

904.92 -> at the time they graduated from high school.

907.73 -> Ultimately, sorry,

913.33 -> then he was active during college,

915.48 -> but then took a sedentary job and began eating excessively,

919.91 -> less active at times

921.57 -> and gained around 40 pounds over 15 years.

925.4 -> Type 2 diabetes was diagnosed at age 42

928.74 -> when his weight was 232,

930.25 -> a BMI then of 33.3 kilograms per meter squared.

935.65 -> Subsequently developed left arm pain

937.76 -> while bowling two years ago.

939.94 -> And he had a PCI with a drug eluting stent that was placed.

943.92 -> He's been hypertensive since college,

945.67 -> but untreated until his PCI.

949.68 -> Multiple self prescribed lifestyle attempts of weight loss

952.49 -> have failed and he's not sought additional help

955.14 -> to get him to lose weight.

957.21 -> His family history is positive for type 2 diabetes,

960.67 -> but only late onset atherosclerotic cardiovascular disease.

965.01 -> And over the past two to three weeks,

966.68 -> he's noted some dyspnea while walking his dog.

969.81 -> Lots of issues here in this 47 year old guy,

972.95 -> too young to have all these issues to deal with clinically.

977.84 -> Now he works a sedentary job as a computer analyst.

981.56 -> He has no tobacco history.

983.07 -> He drinks three beers on weekends.

985.82 -> This diet admits to two servings of fruits

988.76 -> and vegetables a day and one serving the whole grains daily,

991.76 -> very poor and complex carbohydrate.

994.39 -> Fish, once a week, he doesn't read food labels

997.4 -> and he watches his carbohydrate intake,

999.41 -> but not sodium intake.

1000.68 -> Now, by the way, these are important

1002.68 -> lifestyle related questions

1004.12 -> we should all be asking in our practices.

1007.38 -> His exercise is limited to dog walking

1010.1 -> around 15 minutes twice a day.

1012.66 -> His current medications are lisinopril 40 milligrams a day,

1016.42 -> aspirin 81 milligrams daily, atorvastatin 40,

1019.8 -> metformin 1700 in the morning and 850 in the evening,

1023.42 -> and he's on sitagliptin

1024.77 -> as his other glucose monitoring therapeutic,

1028.01 -> a 100 milligrams a day.

1031.08 -> Physical exam 225, BMI 32.3, waist circumference 44.

1035.41 -> In general when BMI's are above 30

1037.7 -> you don't have to worry so much

1038.84 -> about waist circumference particularly in men.

1040.86 -> That's where it is.

1042.27 -> Pulse was 86, blood pressure of 148 over 68.

1045.67 -> And by the way just about his blood pressure,

1047.64 -> he's systolic hypertension,

1049.19 -> but look at the pulse pressure.

1050.93 -> The difference between his systolic pressure

1053.13 -> and his diastolic pressure.

1054.64 -> By the way, probably more than systolic hypertension.

1058.01 -> The pulse pressure

1059.09 -> is probably one of the greatest predictors

1061.39 -> of bad outcomes to follow.

1063.55 -> His extremity fat has reduced,

1065.14 -> his legs and arms are fairly thin,

1067.18 -> but there's no buffalo hump or striae.

1069.26 -> So now as an endocrinologist,

1071.21 -> this patient probably doesn't need a workup

1073.037 -> for Cushing's syndrome or Cushing's disease,

1075.53 -> but that's something you should keep on the back burner.

1078.15 -> His trace peripheral edema and his monofilament

1081.54 -> and deep tendon reflexes are normal.

1083.3 -> So no apparent neuropathy by a crude examination.

1087.18 -> Here's labs, the same anyone 7.4% is totals, 174,

1091.9 -> triglycerides are above normal, 220,

1094.487 -> HDL-C low at 38, LDL-cholesterol, 89.

1097.97 -> It's under a 100,

1098.94 -> but this man now has atherosclerotic cardiovascular disease.

1101.96 -> You could argue that it would be under 70 ideally

1105.29 -> and maybe even under 55 .

1107.47 -> Liver transaminations both have bit elevated

1109.85 -> by terribly high,

1111.24 -> but suggest maybe the presence

1113.1 -> of non-alcoholic fatty liver disease.

1115.42 -> Urinary microalbumin and creatinine,

1116.57 -> somewhat elevated at 360 milligrams per gram.

1120.6 -> And as estimated, glomerular filtration rate

1123.33 -> is reduced at 43 milliliters per minute.

1127.04 -> So that's the case,

1128.63 -> has common kind of co-morbidities

1131.49 -> related with type 2 diabetes,

1133.34 -> including renal disease, cardiovascular disease,

1135.87 -> and potentially now a risk for heart failure.

1139.44 -> So let's look at diabetes, heart health and kidneys:

1142.06 -> a triangle of risk.

1143.43 -> Approximately 1/3 of people with diabetes

1145.92 -> develop chronic kidney disease.

1147.6 -> In my experience, I would say it's 2/3,

1150.08 -> but nevertheless it's 1/3 based on population data.

1154.06 -> Diabetes can damage the blood vessels in your kidney,

1156.64 -> which can eventually lead to chronic kidney disease,

1158.71 -> that's a fairly simplistic statement.

1160.565 -> (chuckling) That's something that we're all pretty aware of.

1163.83 -> And high blood pressure as we mentioned earlier,

1166.4 -> can certainly worsen kidney damage

1168.54 -> and contribute to diabetes related renal disease

1171.53 -> and ultimately heart attack and stroke to follow.

1175.27 -> As we look at the natural history

1176.676 -> of type 2 diabetes and kidney disease,

1179.5 -> here's the diagnosis of type 2 diabetes,

1182.37 -> and we're looking at cardiovascular disease death,

1184.56 -> which is a fairly hard outcome

1186.73 -> related to the onset of diabetes.

1188.67 -> Now I'm gonna make a point here

1190.87 -> and that many people with impaired fasting glucose

1194.06 -> or impaired glucose tolerance,

1195.43 -> who we call pre-diabetic, ultimately also have a risk

1198.8 -> for cardiovascular disease related outcomes.

1201.26 -> Now that is the outcome we wanna prevent.

1203.63 -> And here are the issues that lead up to that,

1206.16 -> functional changes in the tissues

1208.51 -> such as those that relate

1209.72 -> to the development of chronic kidney disease.

1212.3 -> Structural changes follow.

1214.4 -> But rising blood pressure and hypertension precede this

1217.54 -> in most patients who develop chronic kidney disease.

1220.53 -> Microalbuminuria is not kidney disease.

1223.24 -> It's a leaky basement membrane

1224.98 -> that may predict the progression

1226.73 -> to Microalbuminuria to the right,

1229.19 -> but microalbuminuria can be transient and reversible,

1232.32 -> it's not kidney disease.

1234.34 -> It's simply a basement membrane

1235.99 -> where if you look at the escape of proteins

1238.63 -> from the vasculature,

1240.39 -> you can find albumin leakage into the lower extremities.

1243.87 -> So this is the same kind of thing we're talking about

1246.27 -> with microalbuminuria,

1247.65 -> but once microalbuminuria develops

1250.43 -> and ultimately kidney disease progresses

1252.81 -> that relate more specifically

1254.29 -> now to diabetes and hypertension,

1256.36 -> we see ultimately a rising serum creatinine

1259.11 -> and finally end stage renal disease

1261.28 -> that must be managed by haemodialysis

1264.04 -> or renal transplantation.

1266.81 -> Now, the thing about kidney disease and diabetes

1269.13 -> that link up so importantly to heart disease,

1271.9 -> it's not only atherosclerotic cardiovascular disease,

1274.55 -> which we know clearly is a consequence

1276.76 -> of both diabetes and chronic kidney disease,

1279.71 -> we're linking this whole issue

1281.72 -> with the development of heart failure.

1284.48 -> Ultimately type 2 can lead directly to heart failure.

1287.67 -> Heart failure can worsen glycemia control.

1290.42 -> Type 2 diabetes, as we've already covered,

1292.61 -> can lead to chronic kidney disease.

1294.97 -> Ultimately chronic kidney disease

1296.51 -> can lead to heart failure and vice versa.

1298.85 -> Once heart failure develops,

1300.21 -> particularly with reduced ejection fractions,

1302.87 -> kidney disease can worsen

1304.18 -> that's a whole management of fluid and electrolyte balance.

1307.81 -> But then as we think of electrolytes,

1310.16 -> sodium retention occurs with kidney disease,

1312.67 -> and sodium retention can lead to heart failure

1315.31 -> and heart failure through mechanisms

1317.8 -> relate to renin, aldosterone and angiotensin

1320.85 -> can lead to more sodium retention

1323.14 -> and perhaps even more kidney disease to follow.

1325.5 -> So this is a vicious cycle

1327.98 -> in terms of the relationship of diabetes to kidney disease,

1331.49 -> to sodium retention and heart failure

1333.99 -> as the ultimate outcome of this relationship.

1337.25 -> Now, ultimately Diabetes Care

1339.93 -> annually in the issue of January

1341.711 -> comes up with what they call

1343.24 -> the Standards of Medical Care in Diabetes.

1345.45 -> We reviewed those therapeutic guidelines

1347.493 -> related to medications already,

1350 -> but ultimately the guidelines have now been updated for 2021

1354.3 -> and include renal disease and heart failure.

1356.78 -> And I should point out under the leadership of Will Cefalu

1359.53 -> when he was our chief science and medical officer

1362.73 -> and I co-served with Will as president elect

1365.78 -> and this recent year, Bob Gabbay,

1368.44 -> as our chief science and medical officer.

1370.77 -> These standards of medical care have been updated

1373.06 -> when significant clinical trial data

1375.85 -> had been made available sufficient to modify the guidelines.

1379.77 -> So we don't have to wait for a whole year

1382.69 -> for the January issue to come out,

1384.57 -> to be updated on important recent clinical trials

1388.06 -> then impact our assessment and care of patients

1390.93 -> who live with type 2,

1392.11 -> and by the way, type 1 in rarer forms of diabetes to follow.

1396.97 -> So these are abridged standards that are available

1399.27 -> for primary care physicians

1400.58 -> and make things a little simpler

1402.24 -> than having to read hundreds of pages of recommendations

1405.83 -> to follow that are part

1406.98 -> of the standards of medical care in diabetes.

1411.78 -> Now of importance in terms of the topic before us today,

1416.4 -> in October, a joint venture was put forth,

1419.32 -> again, between the ADA and the AHA

1421.91 -> on the Cardiorenal Protection

1424.1 -> With the Newer Antidiabetic agents

1426.48 -> in Patients With Diabetes and Chronic Kidney Disease.

1429.53 -> This is mostly a statement from the ADA,

1431.76 -> but certainly is underwritten

1433.68 -> by this Know Diabetes by Heart program,

1435.91 -> which has been shared by the two professional organizations.

1440.54 -> Let's look at these updated guidelines that relate,

1444.01 -> I should call the recommendations, but they're guidelines.

1446.47 -> I think we could argue a little bit

1448.05 -> about how guidelines do differ a little bit

1449.92 -> with recommendations, but both are evidence-based.

1452.58 -> I think guidelines are little bit more stringent

1454.86 -> in terms of the criteria that are utilized,

1457.11 -> but don't get hung about

1458.68 -> on this relatively unimportant difference.

1462.02 -> So as we look at the scientific basis for new measures

1465.46 -> and Get With The Guidelines-Heart Failure,

1467.38 -> these are now guidelines.

1468.64 -> This is Get With The Guidelines,

1470.37 -> not in fact the standards of medical care,

1473.09 -> but they overlap very much

1474.92 -> with the updated standards of care

1476.42 -> that the ADA puts out annually.

1479.49 -> Let's look at the SGLT2 inhibitors

1481.57 -> for type 2 diabetes and chronic kidney disease.

1485.32 -> The percentage of heart failure patients

1486.96 -> with type 2 diabetes and chronic kidney disease

1489.43 -> who are prescribed SGLT2 inhibitors at discharge.

1492.84 -> This is an important update to the Get With The Guidelines.

1496.71 -> Another thing is the use of ACE inhibitors

1498.91 -> and angiotensin receptor blockers or ARNIs

1502.06 -> for the treatment of albuminuria.

1503.6 -> And this is related to the percent

1506.05 -> of heart failure patients with diabetes

1508.43 -> who have albuminuria who are prescribed an ACE inhibitor,

1512.54 -> or an angiotensin receptor blocker or ARNI

1516.09 -> at the time of discharge.

1517.7 -> And I think this whole field has even been evolving

1520.59 -> since the information was provided

1522.62 -> for the update of the medical standards of care.

1525.07 -> But I think have been updated here

1527.16 -> in terms of Get With The Guidelines.

1530.09 -> So let's look at the standards of medical care

1534.25 -> published in the ADA Diabetes Care Journal for 2021.

1538.83 -> And this is the use of SGLT2 inhibitors

1541.49 -> for type 2 diabetes and chronic kidney disease.

1544.61 -> Guideline 11.3, and by the way,

1547.29 -> the medical standards of care have,

1549.57 -> I think 21 or 22 different sets of guidelines

1552.9 -> that relate the various aspects of diabetes.

1555.38 -> I may not have that number accurately remembered,

1558 -> but there are a series of steps.

1559.31 -> So the set of guidelines under section 11

1563.22 -> are those that I'm relating to here.

1565.81 -> And section 11.3A, for patients with type 2 diabetes

1570.49 -> and diabetic kidney disease

1572.35 -> consider the use of an SGLT2 inhibitor

1575.75 -> and patients with an estimated GFR

1578.03 -> greater than or equal to 30 mils per minute.

1580.75 -> And that's expressed per meter squared

1583.03 -> and the urinary albumin excretion,

1585.18 -> or in other words macroalbuminuria

1587.23 -> above 300 milligrams per gram of creatinine a day.

1592.22 -> And that's a level A evidence,

1593.92 -> now from the clinical trial data that has been accrued

1596.52 -> using a series of different SGLT2 inhibitors.

1601.42 -> In terms of 11.3, this states,

1605.68 -> this is B,

1606.84 -> in patients with type 2 diabetes and diabetic kidney disease

1610.57 -> consider use of a sodium glucose transport inhibitor,

1613.48 -> SGLT2 inhibitor

1615.15 -> additionally for cardiovascular disease risk reduction

1618.44 -> when the eGFR and urinary albumin creatinine ratio

1622.92 -> are greater than 30

1624.62 -> or greater than 300 milligrams per gram respectively.

1628.11 -> So here either one of these can relate

1630.38 -> to the use of an SGLT2 inhibitor

1632.92 -> to modify the natural history of chronic kidney disease

1636.64 -> and cardiovascular disease risk.

1638.88 -> And finally, under option C is

1641.54 -> in patients with chronic kidney disease

1644.24 -> who are at increased risk for cardiovascular disease events,

1647.43 -> the use of a glucagon-like peptide-1 receptor agonist

1651.48 -> reduces renal end points.

1653.58 -> Primarily albuminuria and progression of albuminuria

1657.52 -> and cardiovascular disease events to follow.

1659.47 -> Again, level A evidence, that means you should do it.

1664.5 -> The idea here is which one do you choose?

1666.72 -> Do you choose a GLP-1 receptor agonists or D2 inhibitor?

1670.96 -> I would think it would relate mostly to the patient

1673.31 -> who's more at risk for heart failure

1675.5 -> or ultimately the one that relates mostly

1678.63 -> to the modification

1679.65 -> of atherosclerotic cardiovascular disease risk.

1682.08 -> And that's reviewed in the treatment algorithm

1684.6 -> that the ADA puts forth each year or updated when needed

1689.1 -> in terms of the standards of medical care

1690.87 -> related to pharmaceutical choices

1692.97 -> for treatment of patients with type 2 diabetes.

1695.79 -> Now the flow trial,

1697.6 -> which is also using Semaglutide now

1699.82 -> may in fact be additional validation

1702.93 -> of the use of a GLP-1 receptor agonist.

1705.47 -> We'll just have to be patient for relating

1707.98 -> to how that influences the outcome

1709.88 -> specifically that relates to cardiovascular disease events

1713.81 -> and progression of renal disease to follow.

1719.06 -> Now, in terms of the ACE/ARB issue

1721.64 -> or the use of ARNIs for albuminuria

1724.41 -> in terms of the management of kidney disease

1726.45 -> more specifically.

1728.28 -> Here's stated an 11.7, in non-pregnant patients

1732.57 -> with diabetes and hypertension,

1734.2 -> and I presume we're talking there about type 2 diabetes

1737.23 -> for the most part, but type 1 could relate to,

1740.08 -> but the trial data are probably greater for type 2 for sure.

1744.12 -> And by the way, randomized controlled trials

1746.05 -> and type 1 really are not existing.

1748.31 -> We really can't turn to the kind

1749.98 -> of randomized control trial data type 1,

1751.96 -> we can in type 2.

1753.66 -> Either an ACE inhibitor or an angiotensin receptor blockers

1757.43 -> recommended for those with modestly elevated urinary albumin

1760.94 -> to creatinine ratio, that's 32 to 299,

1764.16 -> so-called microalbuminuria, that's level evidence B.

1768.31 -> And it's strongly recommended

1769.91 -> for those with urinary albumin to creatine ratios

1773.05 -> and the Microalbuminuria range

1775.37 -> and/or an eGFR less than 60.

1778.03 -> So we're really starting to talk about

1780.92 -> really early stage three chronic kidney disease.

1784.44 -> So ultimately now we have a modified guideline

1787.16 -> or recommendation going forward

1788.137 -> that relates to ARBs and ACEs

1791.47 -> in terms of the management of these patients.

1794.4 -> An ACE inhibitor, this is 11.9,

1797.24 -> or an angiotensin receptor blocker

1798.77 -> is not recommended for the primary prevention

1802.27 -> of chronic kidney disease

1803.27 -> in patients with diabetes who have a normal blood pressure,

1806.33 -> a normal urinary albumin to creatinine ratio under 30

1809.767 -> and a normal eGFR.

1811.47 -> This in fact is strongly evidence-based.

1814.15 -> So we don't need to use these

1816.31 -> in terms of a preventive strategy

1818.81 -> for modifying the natural history of chronic kidney disease

1821.287 -> and those with type 2 diabetes

1823.44 -> who do not have kidney disease

1825.41 -> as manifested by any of these criteria in 11.9.

1830.59 -> Then I should turn basically to a set of guidelines

1833.69 -> that includes about every organization.

1835.57 -> We get into either list here

1838.01 -> that was published in 2017,

1841.05 -> and this was for the prevention, detection, evaluation

1844.07 -> and management of high blood pressure in adults.

1847.41 -> This is a class two B recommendation.

1850.52 -> And ultimately in adults with diabetes and hypertension,

1853.92 -> ACE inhibitors and ARBs may be considered

1855.97 -> in the presence of albuminuria.

1857.82 -> The level of evidence is B

1860.06 -> and NR I think stands for not recommended,

1862.83 -> but nevertheless this clearly relates to the updated nature

1867.95 -> of the Get With The Guidelines program

1869.76 -> that has modified this based on substantial data

1873.1 -> to support this modification going forward.

1877.75 -> So I'm gonna now turn to Christina

1879.87 -> to further the conversation about updates

1882.47 -> to Get With The Guidelines,

1883.85 -> specifically those that relate to heart failure.

1886.67 -> Christina, thanks for being on board with us.

1890.53 -> - Thank you, Dr.Eckel. - Thank you.

1892.163 -> - [Renee] Thank you, Dr. Eckel,

1893.79 -> and Christina, thank you for joining us.

1896.44 -> As a reminder we welcome you to submit text questions

1900.67 -> in the questions pane at the control panel

1903.42 -> for the Q&A session at the end of today's webinar.

1906.47 -> And it's now my pleasure as Dr.Eckel mentioned

1909.32 -> to introduce Christina Sterzing to the presentation.

1913.88 -> Christina Sterzing is the healthcare data manager

1916.43 -> in quality and health IT at the American Heart Association.

1920.67 -> Christina, the floor is yours.

1923.42 -> - [Christina] Thank you, Renee,

1924.47 -> and again, thank you, Dr. Eckel,

1926.74 -> that was a great presentation

1929.24 -> about how patients with heart failure and diabetes

1932.82 -> can be impacted

1934.86 -> and how to work with those with renal disease.

1938.42 -> So what I'm going to cover today are some of the updates

1942.24 -> that took place in December of 2020

1946.76 -> that we incorporated

1948.32 -> into our Get With The Guidelines-Heart Failure

1951.04 -> Infosario registry platform tool

1953.18 -> for those of you who use the full form.

1960.42 -> Next slide, please, Renee, thank you.

1964.18 -> For those of you who are using the limited form,

1969.36 -> which is just a slightly shorter form,

1974.24 -> you did not receive these updates

1977.37 -> because these were in place for the full form users

1980.23 -> as there are not recognition programs tied

1982.99 -> to this at this time.

1985.3 -> Next slide.

1990.78 -> Back in December, we did send out an email

1993.81 -> and provided information to our users about the updates.

1998.17 -> And so I just wanted to reiterate

1999.76 -> kind of the summary of these updates on this slide.

2002.94 -> So there were a handful of data collection changes,

2006.76 -> which are reflected in three measures

2010.55 -> that we will review today.

2011.88 -> So on the admission tab,

2014.43 -> there is a new medical history option to indicate

2017.46 -> whether the patient has had a kidney transplant.

2021.13 -> Then on the discharge tab, we added in urinary creatine,

2025.66 -> urinary albumin, eGFR, UACR,

2030.3 -> each of those lab values or calculations

2033.44 -> support the measures that we will review here,

2036.107 -> the SGLT2 inhibitor for type 2 diabetes and CKD.

2041.97 -> And the ACE/ARB or ARNI for albuminuria

2046.62 -> and then the defect-free renal

2048.89 -> protective medication composite,

2050.69 -> which is a composite of the two aforementioned measures.

2055.37 -> Next slide please.

2058.03 -> So now we'll take a look at just very straightforward look

2062.03 -> at what those changes look like in the tool.

2065.62 -> So again, on the admission tab, under medical history,

2070.37 -> which is, you're all familiar

2072.9 -> with the medical history section,

2074.2 -> we've added a kidney transplant option.

2077.37 -> So the kidney transplant may exclude some patients

2081.91 -> from the measures that we added.

2085.55 -> So you will now be able to indicate that on the form.

2090.12 -> Next slide.

2092.56 -> Then on the discharge tab,

2096.449 -> or the two different screenshots here

2099.12 -> show the different labs that we have added to the tool.

2103.01 -> So eGFR, that calculation can be either captured

2108.42 -> in the medical record and manually inputed into the form

2111.4 -> or there's variety of calculating tools

2115.97 -> that you could use to input that into the form.

2119.75 -> And you will also have an opportunity

2122.3 -> to enter in the urinary albumin values at discharge,

2126.95 -> the urinary creatinine at discharge,

2129.24 -> and then the urinary albumin to creatinine ratio

2132.66 -> calculation as well.

2135.9 -> And those are found under the lab section

2138.43 -> on the discharge tab.

2141.77 -> Next slide please.

2145.63 -> So each of these are required labs

2149.44 -> as indicated by the errors under the my task section

2152.93 -> now in the form.

2153.763 -> So if you are leaving those fields blank,

2156.74 -> you will get an error,

2158.45 -> which means that you won't be able

2160.67 -> to save the form as complete.

2163.2 -> However, you will be able to save the form and exit.

2166.2 -> You will just have those open errors reminding you

2168.94 -> that we are collecting

2170.14 -> and requiring these fields going forward.

2174.42 -> Next slide please.

2177.32 -> So a couple of things to note

2178.45 -> for these discharge lab values.

2181.96 -> eGFR we recommend that you use a validated formula

2186.77 -> such as the Chronic Kidney Disease

2188.78 -> Epidemiology Collaboration equation.

2192.41 -> So make sure that as you are collecting that,

2196.26 -> and it's a calculation that's in your medical record,

2201.06 -> make sure that it probably is a validated formula,

2204.1 -> but just double check that before entering

2206.52 -> that manually into the tool.

2210.11 -> The UACR or urinary albumin creatinine ratio,

2215.99 -> just take note that if you don't have a inpatient

2220.27 -> or admission record of the urinary albumin

2222.98 -> or urinary creatinine, you may go to prior lab results

2227.37 -> if they're available in the medical record.

2232.49 -> You may not find that there,

2233.84 -> but if that's something that was not performed

2236.85 -> during that patient's admission,

2239.17 -> you may go back to prior lab results.

2244.3 -> And also one note, and this has come up a couple of times

2246.86 -> from users that I wanted to address.

2249.31 -> So urinary creatinine and serum creatinine

2252.85 -> are two different lab values.

2255.27 -> So you would just want to make sure

2258.83 -> that you're capturing the urinary creatinine.

2262.89 -> In that section we also collect serum creatinine levels,

2267.41 -> but they are two different labs.

2273.5 -> And under the additional medical exclusions

2277.95 -> for some of the medications,

2280.706 -> while they're not on the form in the coding instruction,

2283.97 -> you'll note that pregnancy and acute kidney injury

2289.385 -> are acceptable reasons

2290.87 -> for not prescribing an ACE or ARB at discharge.

2296.05 -> If a patient falls into either of those categories,

2299.66 -> you're still able to select none contraindicated

2302.32 -> or NC on the form.

2304.907 -> And patients with acute kidney injury

2307.36 -> or those who are undernourished,

2310.34 -> if that applies to a patient, that is an acceptable reason

2314.18 -> for not prescribing SGLT2 inhibitors at discharge.

2320.04 -> Next slide please.

2321.97 -> All right now let's talk about the new measures

2324.47 -> that were added so you can track your patients with,

2330.28 -> those who were prescribing an ACE/ARB or ARNI at discharge

2333.92 -> and those who were prescribed SGLT2 inhibitors

2336.66 -> at discharge.

2337.78 -> So on the operational report screen,

2339.76 -> you'll see a new section,

2340.85 -> that's a new bundle that's titled

2343.96 -> Know Diabetes By Heart CKD.

2345.85 -> And the two measures can be selected at the same time

2349.06 -> or individually to run and view your case lists

2352.25 -> and perform other analysis on those records.

2356.85 -> Next slide please.

2360.15 -> And then finally we do have

2361.52 -> the defect-free composite measure,

2363.13 -> which is listed here under the defect-free measure bundle

2368.41 -> entitled Defect-Free Renal Protective Medication Composite.

2371.93 -> So you will be able to run that,

2373.977 -> and that looks at the composite of the two measures

2378.67 -> we've talked about already SGLT2 inhibitor

2380.88 -> and the ACE/ARB or ARNI measure.

2382.93 -> So it will look for patients

2384.39 -> who had what we're calling defect-free care,

2387.5 -> meaning they were prescribed

2388.87 -> or excluded for both of those measures.

2395.18 -> Next slide, please.

2398.78 -> So a couple of things to make it a little bit easier

2401.92 -> to understand which patients are included

2404.83 -> or excluded for the measures that we added here.

2408.59 -> This is the SGLT2 inhibitor.

2411.01 -> So what we're looking at here

2412.17 -> is the percentage of the heart failure patients

2414.3 -> that have type 2 diabetes and chronic kidney disease,

2418.16 -> and if they were prescribed SGLT2 inhibitor.

2421.8 -> So of course, we'll look at the patients with heart failure,

2425.53 -> either a primary diagnosis with CAD or without CAD,

2430.33 -> patients with a history

2432.12 -> or a new diagnosis of type 2 diabetes,

2435.52 -> eGFR levels of 30 to 60 milliliters per minute,

2440.27 -> or eGFR of greater than 60 milliliters per minute,

2445.66 -> and a UACR value of greater than 300.

2450.64 -> But we are also excluding patients

2453.42 -> that have contraindications or medical reasons

2456.38 -> for not prescribing SGLT2 inhibitor.

2459.13 -> So that would be captured

2460.34 -> under antihyperglycemic medications currently.

2466.38 -> So it would exclude any of those patients

2468.42 -> with those contra-indications or medical reasons.

2471.39 -> It will also exclude patients

2472.68 -> with the GLP-1 receptor agonists,

2475.24 -> those patients on dialysis,

2477.49 -> those with the history of kidney transplant,

2480.5 -> patients on comfort measures only,

2483.26 -> and then those patients who were discharged to hospice,

2485.79 -> left against medical advice,

2487.16 -> or were discharged to another

2491.6 -> acute care facility, sorry.

2496.8 -> And now let's look at the ACE/ARB or ARNI,

2501.2 -> inclusion and exclusion criteria.

2504.1 -> If you could go to the next slide, please.

2508.14 -> Let's see, I think you need to go back actually one.

2510.67 -> There you go, thanks.

2512.37 -> So this one, we are looking at patients with heart failure

2517.01 -> and diabetes who have albuminuria,

2521.87 -> who were prescribed on ACE, ARBs, or ARNIs at discharge.

2527.67 -> So again, we're looking at the inclusion criteria

2531.5 -> for patients with heart failure with or without CAD,

2534.76 -> and those who have a history

2537.15 -> or new diagnosis of type 2 diabetes,

2540.5 -> and a UACR value of greater than 300,

2544.89 -> and then excluding any patients with contraindications

2549.3 -> for not prescribing ACE, ARBs, or ARNI,

2553.27 -> patients on dialysis, patients with comfort measures only,

2556.38 -> and patients that were discharged to hospice,

2558.57 -> left against medical advice, or another acute care facility.

2563.15 -> Next slide is looking at the defect-free renal

2566.26 -> protective medication composite.

2568.76 -> So percentage of patients

2571.72 -> who received either or both, I'm sorry.

2576.06 -> Let me say that again,

2576.893 -> patients who received both renal protective medications,

2581.8 -> SGLT2 inhibitor and ACE or ARB or ARNI,

2585.54 -> and it includes patients who met criteria for both measures,

2589.77 -> but excludes patients who were excluded from both measures.

2592.63 -> So that's a good composite measure to run

2596.52 -> if you would like to see that defect-free care

2600.03 -> for your patient population.

2604.22 -> Next slide please.

2607.39 -> And we've come to an end discussing the updates

2612.39 -> that took place in December,

2613.52 -> but I wanted to give a really brief update

2615.47 -> on some exciting changes that are coming later this year.

2619.62 -> And one of them is introducing SGLT2 inhibitor

2623.8 -> as a standalone medication class.

2626.08 -> So this goes back to some of what Dr. Eckel presented

2630.04 -> with the importance of SGLT2 inhibitors

2632.61 -> as not just a diabetic or antihyperglycemic medication,

2636.82 -> but also as an important heart failure medication

2640.66 -> for patients with or without diabetes.

2642.54 -> So as that became FDA approved last year,

2647.64 -> we are introducing SGLT2 inhibitors

2650.25 -> as a standalone medication class.

2653.62 -> It's currently under antihyperglycemic medication.

2656.44 -> So we're just kind of taking it out of that class

2661.68 -> and making its own.

2663.533 -> We already collect SGLT2 inhibitors.

2666.48 -> So really the changes

2667.95 -> just that we are making its own class.

2670.5 -> So it will located in a different section

2675.37 -> or a different placement on the form

2677.38 -> and has its own list of contraindications,

2679.9 -> and to reemphasize the importance of this new medication.

2686.39 -> We'll also be introducing a composite measure

2689.2 -> later this year that shows the four medications

2694.61 -> that provide optimal care for heart failure patients,

2697.64 -> SGLT2 inhibitor being one of them,

2701.54 -> aldosterone antagonists, beta blockers,

2703.43 -> evidence based beta-blockers, and ACE or ARNIs

2707.46 -> will be part of that composite measure.

2710.3 -> We are also asking users to begin entering

2716.37 -> their medications at admission as if it's a required field.

2721.34 -> These have been on the form since probably,

2725.5 -> given the guidelines heart failure was created,

2728.14 -> but it's always been an optional field for full form users.

2734.02 -> We are going to make this a required field soon.

2737 -> So you might want to start

2740.36 -> making sure you're entering that now

2742.49 -> once we require that on the form

2745.51 -> there will be errors triggered

2747.56 -> whenever those fields are skipped.

2750.14 -> So keep an eye out for information about that.

2754.405 -> We also will be updating the tool

2757.46 -> for the task force for performance measure updates

2761.65 -> that came out in November I believe.

2764.35 -> So there were some additional labs and other criteria

2770.12 -> that were recommended in the task force

2772.05 -> for performance measures updates

2774.48 -> and we will be reflecting that in probably early summer

2780.04 -> this year so keep an eye out for that.

2782.5 -> And also this list here was just a brief overview

2786.22 -> of some of the updates, but it's not all inclusive.

2789.82 -> We have more things coming to make the tool

2795.689 -> even easier to use and with new dashboard,

2800.79 -> highlights and other exciting changes.

2803.1 -> So stay tuned for communications

2805.43 -> about all of those update details.

2810.88 -> And I believe that was the last slide.

2813.14 -> So we're probably, yes, thank you.

2816.89 -> I'll hand it back to Renee, thanks everyone.

2819.45 -> - [Renee] Thank you, Christina, and thank you, Dr. Eckel.

2824.59 -> At this time we will now move into the Q&A session.

2827.51 -> As a reminder, you can still submit questions

2829.88 -> for our presenters through the questions pane

2831.83 -> and the attendee control panel.

2834.26 -> And I also wanted to let everyone know

2837.06 -> that you are able to download a copy,

2840.793 -> a PDF of today's presentation in the handout section

2844.62 -> of your control panel.

2846.07 -> If you're having any trouble downloading that presentation,

2849.14 -> we will be sending a follow-up email to all registrants

2853.48 -> with both the recording and the presentation.

2856.51 -> So you will see that coming to your inbox

2859.07 -> in about an hour or so after the event.

2862.56 -> So we have several questions that have come through,

2865.03 -> and I'm just gonna go ahead and read the first one here.

2869.51 -> Dr. Eckel, I think this one would be for you.

2871.9 -> So the question is,

2874.7 -> of course, we are addressing heart failure and diabetes,

2880.64 -> that these two diseases come with renal problems.

2883.35 -> I think we should include endocrinologists

2885.68 -> and nephrologists on our discussions.

2888.14 -> So Dr. Eckel, I know that's more of a comment,

2891.28 -> but do you have anything to add to that statement?

2901.45 -> And Dr. Eckel, if you're speaking,

2903.1 -> you're on mute at the moment.

2910.48 -> And I'll go ahead and ask another question.

2912.72 -> Dr. Eckel, if you're able to get off mute,

2915.07 -> just let me know, okay.

2918.42 -> So Christina,

2924.918 -> so the question is, is there a timeframe

2927.31 -> that we should stay within for looking

2929.53 -> through past lab values, within six months, within a year,

2933.73 -> or does that timeframe not matter?

2937.88 -> - [Christina] I would recommend

2940.8 -> that just based on our other coding instructions

2945.25 -> for lab values or other things where we can kind of peek

2948.44 -> into the past for information,

2950.72 -> if that information was used

2952.52 -> for that particular inpatient admission,

2957.76 -> then it would still be relevant.

2959.32 -> So

2963.053 -> if you're using a lab value

2964.7 -> for a urinary albumin or urinary creatinine,

2969.65 -> you are allowed as mentioned before

2972.81 -> to look at previous lab values,

2975.42 -> but it would need to be those lab values

2977.93 -> that are used to evaluate and provide care to the patient

2981.49 -> during that particular admission.

2983.67 -> So,

2987.38 -> I know that's a little bit of a vague answer,

2989.55 -> but I think that it's important to make sure

2992.44 -> that there's some sort of notation

2995.767 -> that that was the information to use for that patient's care

2999.39 -> during that admission.

3002.11 -> So going back six months may or may not be relevant

3005.42 -> if it's suspected or known that those values

3010.12 -> are no longer applicable to the patient.

3013.45 -> So hopefully (chuckling) that does help

3019.66 -> answer your question although I do know that is vague.

3022.5 -> So if you have more space, like as this comes up

3024.72 -> and you have specific scenarios,

3028.19 -> you can reach out to your local QI representative

3033.37 -> for more assistance with that,

3034.83 -> but that would be my recommendation at this time.

3039.48 -> - [Renee] Thank you, Christina,

3040.313 -> and Dr. Eckel, I see you've come off mute,

3044.765 -> are you able to hear us?

3046.27 -> - [Eckel] Yes, I can, can you hear me all right?

3048.5 -> - [Renee] Yes, we can hear you.

3050.14 -> - [Eckel] I heard the question Renee or the comment.

3052.75 -> So I was muted by the organizer, I couldn't get out.

3055.43 -> So (chuckling) anyway--

3056.429 -> - I'm sorry, doctor. - I'm off that,

3057.36 -> that's all that's important.

3058.51 -> So anyway, the idea of a nephrologist

3060.82 -> and endocrinologists working together,

3062.61 -> I guess the question comes up,

3063.82 -> who's taking care of most patients with type 2 diabetes,

3067.07 -> who have little cardiovascular disease risk?

3069.52 -> And I think that for the large extent,

3071.06 -> that's the primary care physician,

3072.69 -> either an internist or a family practitioner.

3075.34 -> But once I think the eGFR falls below 60,

3079.03 -> the question is teaming up an endocrinologist

3081.34 -> with a nephrologist, I think is important,

3083.86 -> but also ultimately what a cardiovascular disease events,

3087.88 -> the cardiologist is involved too.

3089.95 -> And that's why Mike Blaha,

3091.45 -> Johns Hopkins, a preventative cardiologist,

3094.01 -> myself, an endocrinologist,

3095.72 -> have teamed up to try to promote

3097.44 -> the development of a new training program

3099.21 -> called cardiometabolic medicine.

3101.2 -> That program would involve a nephrologist and a hepatologist

3104.85 -> because of the relationship of diabetes

3107.55 -> to non-alcoholic fatty liver disease.

3109.89 -> So ultimately I think we need a new training program

3113.06 -> that encompasses this Venn diagram of overlap

3116.47 -> between diabetes, chronic kidney disease, heart disease,

3119.91 -> and now to some extent chronic liver disease.

3122.58 -> So, anyway, that's my thought,

3124.19 -> but I think when to get a nephrologist involved

3127.02 -> with an endocrinologist assuming she or he

3129.68 -> is taking care of the patient is up to some discussion,

3132.71 -> but I think macroalbuminuria and falls in eGFR

3137.135 -> in advancing states three kidney disease.

3138.93 -> Yes, the nephrologist should be involved.

3141.01 -> That's a long answer, but that's my thoughts on the topic.

3147.46 -> - [Renee] Thank you, Dr. Eckel.

3149.963 -> (Renee murmuring)

3158.241 -> There are quite a few questions.

3162.5 -> So this could be-- - Yeah (indistinct).

3164.782 -> (Renee and Eckel chuckles)

3165.75 -> - [Renee] So for the eGFR lab value,

3170.45 -> if it is documented as greater than 60,

3173.4 -> what is the best way to document this in the IRP?

3176.32 -> Should it be documented as 60, 61?

3178.81 -> Christina, are you able to answer that question?

3181.73 -> - [Renee] Well, that's a good question.

3183.8 -> It's really a static value and not a range

3186.97 -> that we're collecting in the tool.

3189.81 -> But I do think for purposes of the measure inclusion,

3195.49 -> if it's, I believe the example you gave was over 60

3199.56 -> is the documentation, I think--

3201.263 -> - Yes. - And Dr. Eckel

3202.31 -> may have some thoughts on this as well,

3203.79 -> but I think because it's over 60 range,

3206.94 -> you would probably want to just put maybe 61

3209.87 -> to make sure that it's

3213.52 -> included in measures,

3215.38 -> but yeah, we're not really collecting it

3218.21 -> as a range currently in the tool.

3220.64 -> So that would be my recommendation at this point.

3223.4 -> Although we could look at a range,

3224.56 -> if that's the way things are commonly documented

3227.61 -> in the record, we could look at a future update

3230.02 -> kind of incorporating ranges,

3233.12 -> but for now I would probably recommend you put 61

3236.84 -> just to make sure that it's in our measures.

3241.41 -> - [Eckel] Right, I think the ICD-10 codes

3243.57 -> really relate to ranges

3244.83 -> and our definitions of chronic kidney disease

3246.84 -> relate to ranges.

3247.72 -> But I think the number itself

3249.45 -> works fine under these circumstances.

3251.716 -> - [Renee] Okay, thank you.

3256.76 -> Okay, here's another one

3257.8 -> for the timing of the lab results at discharge

3260.62 -> if they only have labs drawn on admission,

3264.973 -> do we collect them for discharge values?

3268.37 -> So again, the question is,

3269.203 -> for the time the lab results are discharged,

3270.91 -> if they only have labs drawn at admission,

3274.04 -> do we collect them for discharge values?

3276.06 -> And then a second question,

3277.99 -> also you stated we could collect values before admission,

3281.29 -> what is the timeframe for those values?

3285.46 -> - [Christina] So I'll answer the second question first,

3287.93 -> that kind of it's very similar

3289.73 -> to the previously asked question

3292.24 -> about how far back can you go?

3293.71 -> I think if those values

3300.31 -> were used for that patient's current

3303.69 -> inpatient admissions treatment plan,

3307.09 -> then those would still be relevant.

3309 -> And there's not really a timeframe that we provided,

3311.96 -> although, I suppose we could look at that,

3314.721 -> especially if there is something

3317.623 -> that can provide more clarity there, we'll look at that.

3321.29 -> And then the first question there was,

3325.827 -> well, it's already escaped to me,

3327.07 -> can you remind me

3328.81 -> when I read the first one? - Yes.

3331.907 -> Let me just find it here and I'm sorry.

3339.46 -> And I'm sorry, there's been several,

3341.62 -> okay, so for the timing,

3343.16 -> if you only have labs drawn at admission,

3346.54 -> do you code them for discharge values?

3348.37 -> Sorry about that.

3349.96 -> - [Christina] So,

3353.16 -> I don't believe we,

3354.64 -> what our coding instructions say

3357.89 -> is just closest to discharge.

3359.96 -> So I don't know if Dr. Eckel has opinions on this.

3363.4 -> He certainly is the expert in this and not me,

3365.98 -> but we can make sure coding instructions capture that

3370.59 -> a little more clearly,

3371.71 -> but I'll defer to him to see if he has any thoughts.

3376.06 -> - [Eckel] Well, the important thing there, Christina,

3377.62 -> is the fact that renal function

3379.26 -> meaning assessed by particularly eGFR calculations

3384.31 -> really can be impacted by the hospitalization.

3386.87 -> So I think this is an incredibly important question

3389.97 -> to get documented.

3391 -> In other words, let's say someone

3392.54 -> has an acute coronary event

3394.06 -> and goes into heart failure transiently

3396.81 -> for a couple of days after their event,

3398.48 -> let's say on day two or day three,

3400.38 -> ultimately their current need may bump, the eGFR may fall.

3404.76 -> And ultimately once the heart failure is managed adequately,

3408.01 -> we're hopeful that it's gonna recover the baseline.

3410.5 -> So I think this really

3412.03 -> is an important area to consider further.

3414.91 -> I would think that closest to discharge

3416.9 -> is the best way right now going forward,

3418.697 -> but that could be misinterpreted too

3421.01 -> in terms of its impacts on events to follow.

3423.69 -> So this is important to document.

3426.32 -> Hopefully most of our patients have a discharge eGFR

3429.22 -> that's not that different than admission.

3431.05 -> So if in fact you only have the admission value,

3433.12 -> you should turn to that.

3434.04 -> But the most recent one I think right now

3436.55 -> is the gold standard and that could be modified.

3440.8 -> - [Renee] And then I think we have time

3441.633 -> for a couple more questions.

3443.06 -> So here's one more,

3445.94 -> are there any data on the prevalence of type 2 diabetes

3450.09 -> and CHF in lower income populations

3453.17 -> and treatment strategies

3454.43 -> for those who have limited insurance or payer source?

3459.01 -> - [Eckel] Well, health disparities

3460.25 -> in the care of patients with type 2 diabetes and beyond

3462.7 -> is an important topic of our time.

3464.92 -> There may be data that relate to that specific question.

3467.71 -> There are lots of components of that question

3469.8 -> to kinda sort out, but nevertheless,

3472.62 -> I suspect that heart failure is a much more common

3476.57 -> and are socioeconomically deprived in diverse populations.

3480.93 -> We certainly know that there's more type 2 diabetes,

3483.45 -> there's more cardiovascular disease to follow

3485.33 -> and there's more renal disease.

3486.47 -> So I can't envision that all of those factors

3489.21 -> would not impact the question that's been addressed

3493.37 -> in terms of heart failure

3495.107 -> and ultimately outcomes related to heart failure.

3497.31 -> So those data may be there,

3499.62 -> I don't have the exact numbers for you today, I'm sorry.

3503.77 -> - [Renee] Thank you.

3507.303 -> So-- - And low cost, by the way,

3509.103 -> is that an important issue.

3510.58 -> And I think that's something

3512.09 -> that we're really working on to modify.

3514.82 -> The GLP-1 receptor agonists and the SGLT2 inhibitors

3517.44 -> both are very effective, but they remain costly right now.

3520.59 -> Hopefully that can change in the very near future.

3524.25 -> - [Renee] And thank you, Dr. Eckel,

3525.18 -> I agree that that's such an important topic

3527.14 -> and I appreciate you answering that one.

3529.89 -> Christina, I think you may have answered this,

3531.7 -> but just to clarify there's a question about

3533.45 -> what if you don't have the lab values,

3537.07 -> you don't have those data available

3538.6 -> in the labs for a patient,

3539.72 -> how does this affect the facility measures?

3543.948 -> - [Christina] So you will have to indicate not document

3548.56 -> or not available on the form,

3550.89 -> how that will impact the measures is that you will not,

3557.12 -> let's see, I need to look at this specific measure criteria,

3560.53 -> but I believe that you will show those patients

3564.97 -> as noncompliant.

3570.011 -> You can use these measures and reports

3574.66 -> to help you perform some QI efforts at your site.

3578.15 -> I think as Dr Eckel mentioned that eGFR value

3581.17 -> can change throughout hospitalization.

3583 -> And while that may not be something

3584.75 -> that's commonly ordered closer to discharge,

3587.85 -> now it could be something that your site

3590.33 -> and your healthcare facility provides some QI

3595.83 -> and begins to offer

3597.21 -> or take those values closer to discharge.

3599.58 -> And therefore you're-- - Yeah.

3600.42 -> - [Christina] Able to input those more frequently.

3605.69 -> So I believe they would just provide you

3610.79 -> with additional QI efforts,

3612.61 -> is if you're concerned about where

3616.02 -> or how this might impact any sort of achievement award

3618.87 -> or other award status,

3620.6 -> these are currently considered reporting measures

3623.88 -> and used

3626.832 -> for your QI efforts at your hospital,

3629.3 -> but not for achievement or other awards.

3635.54 -> - [Renee] Thank you, Christina,

3636.93 -> and we're at the top of the hour

3638.81 -> and I appreciate all of these wonderful questions coming in.

3641.9 -> So at this point, I'd like to,

3644.03 -> again, thank our presenters for leading today's webinar,

3647.92 -> a very engaging presentation, so much important information.

3651.46 -> And thank you all for your participation in today's event

3654.46 -> and for submitting those questions.

3657.07 -> Again, after the webinar today,

3658.79 -> you will receive a follow-up email with the recording

3662.02 -> and a copy of the slides

3664.47 -> along with a survey about the presentation,

3666.377 -> and we greatly appreciate your feedback.

3669.41 -> On behalf of the American Association and our presenters,

3672.81 -> thank you for joining us and have a wonderful day.

3675.73 -> This concludes today's presentation.

3679.26 -> - [Eckel] Thank you.

Source: https://www.youtube.com/watch?v=4IQELO7bmY8