Why It Takes a Village to Help Diabetes Patients Achieve Multiple Treatment Goals

New Orleans, LA—Fewer complications occur when patients with diabetes have simultaneous control of A1c values, blood pressure (BP), and low-density lipoprotein (LDL). According to a session at CRS, it is possible to achieve all 3 aims in a primary care setting with a team-based approach to care.

Ed Shahady, MD, FAAFP, ABCL, president and medical director, Diabetes Master Clinician Program, Inc., led the session on managing cardiometabolic comorbidities in patients with diabetes. Dr Shahady discussed the role A1c, BP, and LDL play in diabetes complications, how simultaneous goals can be achieved in the primary care setting, and the value of a “participatory village,” which is a system of care that promotes a team office approach to clinical management tasks.

For patients with diabetes, the risk of developing cardiometabolic complications are often influenced by patient demographics, lifestyle, and health complica- tions. For instance, insulin resistance, dyslipidemia, race, gender, obesity, and tobacco use are all considered elements of cardiometabolic risk.

According to Dr Shahady, the 2 easiest factors to modify are smoking and insulin resistance. “Insulin resistance isn’t as simple but with physical activity and a minimum change in weight, you can influence insulin resistance tremendously and, therefore, decrease the risk for a cardiometabolic event,” he said.

How to Reduce All 3 Complication Risks

Patients with diabetes are also at an increased risk for microvascular and macrovascular complications. Control of A1c can lead to better patient outcomes for microvascular complications, but Dr Shahady said studies have not found a consistent association between A1c control and better macrovascular complications. However, both BP and lipid control are associated with reducing the risk of cardiovascular disease. Complications from a lack of A1c, BP, and lipid control can also contribute to premature mortality, disability, and an increased economic burden on society.

To reduce the risk of all complications, Dr Shahady said control of all 3 measures needs to be achieved at the same time. The reality, however, is that achieving all 3 at once is not a regular occurrence in current practice. Estimates of achieving all 3 goals based on data in national databases range from 12% to 18%.

“If I have a patient at goal for 1, it’s good, but if they are not at goal for the other 2, I am not helping the patient as much as I could if I got him at goal for all 3 at the same time,” stated Dr Shahady.

One study of veterans receiving care for diabetes found that the percentage of patients who achieved all 3 goals at the same time could be significantly improved after strategies such as yearly clinical reminders, enhanced patient education, home-based telephone monitoring, and diabetes case management were used.

However, another study that looked at patients in Denver Health and Kaiser Permanente in Colorado found that although patients were able to achieve all 3 goals (16% and 30%, respectively), maintaining control of all 3 was not permanent for most. Loss of BP control was often the reason for failing to meet all 3 measures.

Dr Shahady mentioned providing a diabetes system of care can help improve patient outcomes. For instance one 3-year study of primary care practices that evaluated success in 9 different components of a diabetes bundle—which included A1c control, BP control, LDL control, receiving a flu shot, or being a nonsmoker—looked at the impact of a team-based model of care. They found that after using a model that included incentives if physi- cians achieved all measures, delegated accountability to office team members, and included patient report cards, that there was a significant reduction in myocardial infarction, stroke, and retinopathy.

Getting Medical Assistants Involved

Dr Shahady suggested a system of care where everyone is actively involved in the care process. He said using such a system can improve patient outcomes and empower patients to take a more active role in their care. Using the participatory village design, the office approaches patient care as a team reviewing patient data to identify high-risk patients. They develop team solutions to address gaps in care, and use patient report cards, which are regularly reviewed with patients by nurses and medical assistants (MAs).

The Diabetes Master Clinician Program at the Florida Academy of Family of Physicians, which was started by Dr Shahady, includes an Internet-based Diabetes Registry where office members can enter key information about a patient’s weight, LDL levels, A1c levels, lab test results, whether they have received pneumococcus vaccine, and other measures. That data is then used to produce individual patient report cards that help guide the office team and the patient themselves. “We are empowering you to see what your ideal goals are and where you are,” Dr Shahady stated.