On November 30th, we will have the inauguration of the Joslin Diabetes Center Affiliate at Southeast Texas Medical Associates at 10:30 in the morning.  Invitations will be mailed soon, but you are invited to join us. Dr. Martin Abrahamson, Chief Medical Officer and Executive Vice President of Joslin will give the key-note address.

Inflammation and Diabetes

On Sunday evening, October 24th, the first session of the 20th Annual Meeting of the Joslin Diabetes Clinic Affiliated Programs opened with dinner and a lecture entitled "Targeting Inflammation in Type 2 Diabetes (the NIH study is entitled, TINSAL-T2D),"  Steve Shoelson,  MD, PhD, Section head, Cellular and Molecular Physiology, Joslin Diabetes and Professor, Department of Medicine, Harvard Medical School discussed his work in the role of inflammation in the pathogenesis of diabetes mellitus type 2.   Based on two papers published over 100 years ago, Dr. Shoelson and his colleagues have initiated an NIH-funded study of the role of high dose salsalate (a nonacetylated prodrug of salicylate - aspirin) as the major treatment of elevated glucose levels in diabetes. 

The preliminary conclusion of their work is:

"...salsalate was well tolerated in patients with type 2 diabetes and it improved glycemic control over the 3-month trial.  The drug's long-term safety in this population, and particularly its effects on renal function, require further investigation.  Because of salsalate's anti-inflammatory effects, our results suggest that inflammation plays a role in the pathogenesis of type 2 diabetes and that anti-inflammatory therapy may therefore be useful for treating diabetes."

It is remarkable to think that the day may come that some patients with diabetes may be treated with what can be called "high-dose aspirin."

SETMA's Report to the Affiliated Joslin Centers:

On Monday, each of the Joslin affiliates was given five minutes to summarize their work, particularly addressing two issues:

• Things we are proud of
• Areas in which we need help

Because SETMA is new as a Joslin Affiliate, we used our time to address our history with Joslin and our achievements thus far:  The following is a virtual word-for-word summary of those five minutes.  (Remember, if you are given an hour to discuss a subject, name it and we can begin immediately; if you are given five minutes, you can say a lot, but it requires careful planning.).  SETMA's report:

"SETMA is proud to be a Joslin Affiliate.  We began using an electronic health record (EHR) in 1999 and had our first formal contact with Joslin in 2003 at which time a two-hour presentation of SETMA's Diabetes Disease Management Tool (see www.jameslhollymd.com Electronic Patient Management Tools, Diabetes, Pre-Diabetes and Diabetes Screening).   SETMA has an eleven-years history of consistent, uninterrupted annual improvement in hemoglobin A1C results.  Examining the data from those eleven years, SETMA has identified three "break points" at which we had significant and greater improvement in Hgb A1Cs:

• The first was in 2001 and it was associated with the deployment of our diabetes disease management tool.  In the year following that deployment we had a .299% improvement in A1Cs.
• The second was in 2004 and it was associated with the deployment of SETMA's ADA-certified DSME and MNT education program.  The year following that deployment, we had a .226% improvement in Hgb A1Cs.
• The third was in 2006, which was the year after our successfully recruiting an endocrinologist.  That year, we had a .226% improvement in Hgb A1Cs.

"In 2010, we have worked on redoubling our efforts with all three of these initiatives in order to create another breakpoint.  We will be interested to see if our data demonstrates another improvement.

"On our website, all of SETMA's electronic patient management tools are published and we also display our "public reporting" by provider name of over 200 quality metrics.

"SETMA's efforts at quality improvement and of practice transformation have resulted in the achievement of the following:

• NCQA Tier III Medical Home recognition for all three SETMA Clinics
• NCQA Diabetes Recognition Program for all three SETMA Clinics
• AAAHC (Accreditation Association For Ambulatory Health Care) certification for ambulatory care
• AAAHC certification for Medical Home

"To support SETMA's pursuit of excellence, the partners of SETMA formalized The SETMA Foundation as a not-for-profit Foundation.  The partners have contributed over $1,000,000 to the foundation in the past 15 months.  The Foundation allows SETMA to pay for some of the care of our patients who cannot afford it.  The Foundation is set up so that none of the money can benefit or profit SETMA.

"In addition, monthly, a four-hour training session is conducted for all SETMA providers and a separate session is conducted for all of SETMA's nursing staff.  The October training sessions have been on the improvement of the use of SETMA's Preventive Health Programs for diabetes prevention and diabetes screening.

"In keeping with SETMA's transformation into a medical home, we have instituted a Department of Care Coordination which assists our providers in organizing and integrating the care of all of SETMA's patients including the following up of all hospital admissions and ER visits with extended care transition phone calls to the patients and the following up of selected clinic visits with similar calls.

"Finally, SETMA's Model of Care (described on our website) includes the auditing and analysis of our care of all of our patients.  In relationship to diabetes these functions include the analysis of care by:

• Ethnicity
• Socio-economic conditions
• Payer class
• Gender
• Age
• Frequency of visits
• Frequency of testing
• Number of medicines given
• If patient not to goal, was a change in care made

"SETMA is delighted to be part of the Joslin family.  We look forward to the results of our collaboration which has already been a benefit to SETMA through the certification program designed by Joslin through which all SETMA providers can be designated as Certified Joslin Diabetes Primary Care Providers.  Thus far ALL of SETMA providers including all of our specialists have completed the 10 Joslin Diabetes Monographs and successfully completed the ten tests associated with those studies.  Also, to date 23 of SETMA's nurses have completed the testing.  Thank you."

Improvements we will make as a result of this meeting

The most significant improvement will be SETMA's becoming a part of the Joslin Vision Network (JVN) which will allow us to complete an eye examination by retinal photography on all of our patients with diabetes. This examination is superior to a dilated eye examination to detect diabetic retinopathy.
           
All of SETMA's providers will complete the Joslin Diabetes Primary Care certification, but we will also continue our own quality improvement which will go beyond those program.  A copy of the 1209 page, 14th Edition of the Joslin's Diabetes Mellitus textbook is being obtained for all of SETMA's providers.  Each provider will be challenged to complete the reading and study of this text over the next 12-24 months.   While other issues will be covered in our monthly provider education programs, we will continue to focus heavily upon diabetes.

In a session entitled, "Clinical Quandaries," Joslin endocrinologists, Drs. Rich Jackson and Ken Snow, held a dialogue with healthcare providers on questions which they are examining in regard to the targets and goals of diabetes treatment.   This was the same discussion which Drs. Jackson and Snow had had with Drs. Ahmed, Anwar, Murphy and Holly when we attended the orientation meeting earlier this year.  By November 7, SETMA expects to have a COGNOS auditing tool completed which will allow SETMA to provide Joslin will granular data with which they can begin answering some of the questions presented in the quandary discussion.    This discussion is one of the most valuable aspects of our relationship with Joslin, which is the opportunity to participate in the dialogues which address active improvement in the care of patients with diabetes.

Where SETMA is

No organization could treat SETMA with more respect and enthusiasm for a relationship than has Joslin.  Their endorsement of our work and affirmation of our vision, accomplishments and care of patient with diabetes reinforces our efforts and reinvigorates our commitment to excellence in all areas of medicine and particularly in diabetes care.  If there were ever any question about whether this relationship would be transformative for SETMA, they have all been dispelled.  The reality is that though SETMA has been an affiliate for less than four months, we have been the beneficiary of Joslin's vision and expertise since 2003 and before.  We have been a "child of Joslin" for at least that long as we have benefited from their work and guidance. 

We can all be proud of SETMA's accomplishments and now of SETMA's formal relationship with, "The world's preeminent diabetes research and clinical care organization."