As the prevalence of diabetes in the United States grows, and as people with diabetes live longer with the disease, there is a need for improved health services to better manage the disease as well as to control its associated costs. This effort primarily consists of improved education and support for diabetes self-management as well as greater standardization of diagnostic and treatment practices for diabetes. While these initiatives are currently being supported by programs and guidelines developed by leading diabetes associations, clinical pathways provide an opportunity to aid the implementation of evidence-based practices for patients with diabetes in order to improve control of the disease, reduce the incidence of complications, and contain health care costs.
Approximately 1.4 million Americans are diagnosed with diabetes every year, according to the Centers for Disease Control and Prevention (CDC).1 As of 2012, the prevalence of diabetes in the United States was estimated at more than 29 million, or 9.3% of the population. Diabetes is particularly common among aging Americans; more than one-quarter of those aged 65 years and older has diabetes. At the same time, prediabetes is becoming more common: from 2010 to 2012, the number of Americans age 20 and older with prediabetes grew from 79 million to 86 million. If current trends continue, the prevalence of diabetes is projected to double for all US adults by 2050.1
Type 2 diabetes is the most common form of diabetes, accounting for 90-95% of diagnoses cases in US adults.1 In addition to the core symptom of insulin resistance, diabetes can lead to health complications including heart disease, stroke, kidney disease, blindness, and amputation of the legs or feet. As the prevalence of diabetes grows, and as people with type 2 diabetes live longer with the disease, there is a need for improved health services to better manage the disease as well as to control its associated costs, which have been estimated as totaling $176 billion, constituting an enormous burden on the health care system.1
Do Clinical Pathways Have a Place in Diabetes Management?
Diabetes management has become a complex multi-faceted treatment process, with the common goal of controlling serum glucose levels and preventing secondary complications. Interventions consist of behavior modifications, patient engagement, and medications. Environmental and behavior risk factors play an important role in determining the most effective interventions. For example, medication treatment is far beyond simply just choosing a representative medication from a therapeutic class at random, but rather choosing the most appropriate medication based upon the patient’s risk factors. Clinical pathways firmly have a place in diabetes care by: (1) assisting to systemically evaluate the patient’s clinical presentation and risk factors; (2) choosing the most appropriate behavioral and medication interventions; and (3) providing a timeline for patient follow-up and monitoring. In short, clinical pathways will assist in the coordination of care and follow-up.
Successful Diabetes Management Programs
Diabetes management requires a multidisciplinary approach, which includes medication to reduce glucose levels—insulin, oral medication, or a combination of both—as well as healthful eating, regular physical activity, and management of cormorbid conditions.1 The American Diabetes Association (ADA) has published Standards of Medical Care in Diabetes in order to provide primary care providers with current, evidence-based recommendations for the diagnosis and treatment of patients with all forms of diabetes.2 Recommended initial care consists of Diabetes Self-Management Education and Support, medical nutrition therapy (MNT), physical activity education, smoking cessation counseling, guidance on routine immunizations, psychosocial care, patient self-monitoring of blood glucose, and regular A1C testing.
Due to the risks associated with hypoglycemia, medication adherence and glucose monitoring are essential components of diabetes management. As a result, there is a large focus on improving patients’ self-management of their disease. The ADA, in conjunction with the American Association of Diabetes Educators (AADE), have published National Standards for Diabetes Self-Management Education and Support, which are designed to define quality diabetes self-management education and support and to assist diabetes educators in providing evidence-based education and self-management support.3 The Standards are intended to emphasize that the person with diabetes is at the center of their care and are the ones who do the important work of managing their condition on a day-to-day basis.
One example of a diabetes management program recognized by the American Diabetes Association as a quality diabetes self-management education program that meets the National Standards for Diabetes Self-Management Education is that at University Medical Center of Princeton.4 The program consists of a multidisciplinary team of diabetes specialists, includes a staff of Certified Diabetes Educators, who work closely with patients, their primary care physicians, and other health care providers. Services include individual and group education sessions by registered nurses and dietitians, medication management, blood glucose monitoring instruction, insulin pump training, community outreach programs, diabetes care and management for pre-pregnancy/conception and during pregnancy, MNT/nutrition education and meal planning, weight management, stress management and wellness programs, and professionally facilitated monthly support groups.
When a patient is hospitalized at University Medical Center of Princeton, the Certified Diabetes Educators of the Diabetes Management Program collaborate with the admitting physician and inpatient health care team to ensure optimum diabetes care. Upon discharge, a patient is referred to the comprehensive outpatient Self-Management Education Program for additional instruction in achieving optimal diabetes outcomes. After initial services, health care providers from the program continue to follow up with the patient to inquire about their progress and any ongoing needs, encouraging patients to make annual follow-up visits to the program.
A growing arena in diabetes management is telemedicine services, which are designed to keep patients engaged in their own care. In the area of diabetes management, telemedicine interventions can range from simple reminder messaging to more comprehensive monitoring where patients can upload their glucose levels measured with a home meter, as well as other monitoring metrics medications, dietary habits, activity level and medical history. Providers can review the data and provide feedback regarding medication adjustments and lifestyle modifications. In a recent review of over 3600 citations of the use of telemedicine in diabetes care, it was concluded that telemedicine maybe be a useful supplement to the usual clinical care, using the HbA1c as the indicator of clinical impact.5 The authors also concluded that telemedicine interventions appeared to be most effective when they were able to engage the patients using a more interactive interface.
Guidelines for Diabetes Treatment
In addition to improvement self-management of diabetes, the fast-paces growth of available medication options for diabetes warrants improved guidance for physicians in their decisions regarding pharmacological therapy for type 2 diabetes. The 2016 ADA Standards of Medical Care in Diabetes provide a comprehensive list of available glucose-lowering agents to guide individualized treatment choices. Metformin is considered the preferred initial pharmacological agent for patients for whom it is tolerated and not contraindicated. Further treatment with a secondary agent—sulfonylurea, thiazolidinedione, DPP-4 inhibitor, SGLT2 inhibitor, GLP-1 receptor agonist, or insulin—is based on whether patients are symptomatic and whether they are able to achieve glycemic goals. The guidelines recommend taking a “patient-centered approach” to dual therapy selection based on considerations including efficacy, hypoglycemia risk, weight, potential side effects, and costs.2 An algorithm for treatment selection based on these considerations, as well as for selection of triple therapy or combined injectable therapy regimens, is also provided in the form of a flow chart.2
Another approach that has been taken to guiding treatment decisions for patients with type 2 diabetes has been developed by the American Association of Clinical Endocrinologists (AACE) together with the American College of Endocrinology (ACE). The AACE/ACE Diabetes Management Algorithm includes guidance on lifestyle therapy, management of complications, glycemic control, insulin dosing, consideration of risk factors, and potential adverse events associated with antidiabetic medications.6 Similar to the ADA guidelines, the AACE/ACE Diabetes Management Algorithm also includes recommendations for the selection of glucose-lowering agents. However, the Algorithm goes further to rank different types of agents for monotherapy, dual therapy and trip therapy on the basis of the evidence to support each type of drug. Thus, the AACE/ACE approach is more similar to clinical pathways than the ADA, which offers more straightforward clinical practice guidelines.
Another model for clinical pathways for diabetes is those developed by the National Institute for Health and Care Excellence (NICE).7 As in the US, diabetes is increasing in prevalence, with major changes noted since 2004 to the routine management. In response, NICE updated several diabetes management pathways 2016, recommending aggressive HbA1c targets through aggressive therapies.7 The guidance stresses a patient-centered approach, including behavior and medication interventions, specifically providing steps for evaluation, and the appropriate treatment decision based upon the finding. It is the intent of the guidance to reduce the impact of secondary complications.7
Conclusion
Do clinical pathways have a place in diabetes management? Yes, they do. As we start to consider the expanding role of clinical pathways beyond that of medication treatment options, representing a true multidisciplinary approach, the link of clinical pathways to diabetes management become clear. All facets of diabetes management can become integrated into the pathway, including clinical presentation and evaluation, treatment intervention and patient engagement, and finally monitoring and follow-up. The pathway not only becomes a vehicle to approach the patient, but also becomes tool to systematically approach and treat the patient so that processes become standardize and consistent. Through this standardization and consistency, we should be able to achieve better outcomes and control our care cost.
References
1. Centers for Disease Control and Prevention. 2014 National Diabetes Statistics Report. CDC website. cdc.gov/diabetes/data/statistics/2014statisticsreport.html. May 15, 2015. Accessed November 23, 2016.
2. American Diabetes Association Position Statement: Standard of Medicare Care in Diabetes—2016. Diabetes Care. 2016;39(suppl 1):S1-112.
3. Haas L, Maryniuk M, Beck J, et al. National Standards for Diabetes Self-Management Education and Support. Diabetes Care. 2014;37(suppl 1):S144-S153.
4. University Medical Center of Princeton. Diabetes Management Program. https://www.princetonhcs.org/phcs-home/what-we-do/university-medical-center-of-princeton-at-plainsboro/what-we-do/additional-clinical-care--services/diabetes-management-program.aspx. Accessed November 23, 2016.
5. Faruque LI, Wiebe N, Ehteshami-Afshar A, et al. Effect of telemedicine on glycated hemoglobin in diabetes: a systematic review and meta-analysis of randomized trials [published online October 31, 2016]. CMAJ. doi:10.1503/cmaj.150885.
6. Garber AJ, Abrahamson MJ, Barzilay JI, et al. Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm—2016. Executive Summary. Endocr Pract. 2016;22(1):84-113.
7. National Institute for Health and Care Excellence. NICE pathways—diabetes overview. https://pathways.nice.org.uk/pathways/diabetes. Updated November 22, 2016. Accessed November 23, 2016.
