Inspiring Clinicians to Take Action on Closing Diabetes Care Gaps

The American Journal of Accountable Care. 2023;11(4):53-57. https://doi.org/10.37765/ajac.2023.89477

With the exciting introduction of new drug classes with the potential to address the interplay of cardiovascular, renal, and metabolic health in patients with diabetes, the traditional paradigm of diabetes management has gained another pillar supporting the aim of reducing complications. But just because these drugs have been approved by the FDA and introduced on the market does not mean the prescriptions are making their way into the hands of patients, indicating the substantial room for improvement in diabetes care.

These unmet needs and ample opportunities were the subject of an Institute for Value-Based Medicine^® population health event in Durham, North Carolina, on September 13, 2023. The event, held by The American Journal of Managed Care^® in partnership with Duke Health, featured faculty from Duke University Medical Center and Duke University School of Medicine, who discussed the origins of these gaps and actionable strategies for addressing them.

Kicking off the discussion was event chair Jennifer Green, MD, a professor of medicine in the Division of Endocrinology, Metabolism, and Nutrition at Duke University School of Medicine and Duke Clinical Research Institute. She set the stage for what she called the “diverse array of perspectives on diabetes management” that the audience would soon hear by highlighting the current unmet needs and opportunities in diabetes care. Research has identified many modifiable risk factors that can reduce the risk of complications, but these strategies are still underutilized, Green said.

Even as the Parthenon of diabetes management has gained a fourth pillar with the introduction of antidiabetic agents with cardiovascular and kidney benefit¹—adding to the existing 3 pillars of glycemic management, blood pressure management, and lipid management—recent surveys reveal that diabetes is often still treated with metformin, sulfonylureas, and insulin.²

“Those are the same medicines that were available to me when I came to Duke as an endocrine fellow in 1996, so there’s been very little change overall,” Green emphasized. “We talk a good game, the guidelines have evolved, we know a lot more about how to keep people with diabetes healthy, but we’re not particularly good at making it happen.”

She expressed her hope that the speakers to follow would provide impactful examples and approaches from their work at Duke that the audience could then apply in their own practices, rather than reinventing the wheel.

“We need to know what each other is doing to improve the health of people with diabetes and not just be trying the same things in our own locations that didn’t work other places,” Green concluded.

One strategy for improving outcomes for patients with diabetes is the population health approach described by the next speaker, Susan Spratt, MD, an associate professor of medicine at Duke University School of Medicine and a senior medical director in the Duke Population Health Management Office. Prevention is the best way to avoid diabetes complications, so the office has implemented best practice alerts into the electronic health record to remind care providers to assess patients for a diagnosis of prediabetes or order a hemoglobin A_1c (HbA_1c) test. The first alert also offers the clinician the option of referring the patient to a diabetes prevention program offered by either the YMCA³ or the state of North Carolina,⁴ and the second alert automatically orders an HbA_1c test if accepted. Since April 2023, the second alert has been triggered for 7511 patients with prediabetes but no recent HbA_1c test, resulting in 4793 of those patients then receiving a test.

For patients who do have diabetes, the Population Health Management Office is working on several avenues to improve glycemic control, such as calling patients with missing HbA_1c tests or high HbA_1c levels to schedule a primary care appointment. Another exciting intervention Spratt highlighted is the use of multidisciplinary teams making “diabetes rounds” to identify patients with a compelling indication for a sodium-glucose cotransporter 2 (SGLT2) inhibitor and encourage clinicians to prescribe this class. Internal data presented by Spratt showed a significantly higher SGLT2 inhibitor prescribing rate 90 days after their rounds for those who received a visit than for those who did not (25.5% vs 7.6%, respectively; P < .001).

Spratt also highlighted the work of her colleague and mentee Jashalynn German, MD, an assistant professor of medicine at Duke University School of Medicine, on Duke Health’s Collaborative to Advance Clinical Health Equity, which aims to identify and eliminate racial disparities in health care. Concerningly, German and her colleagues found evidence of clinical inertia in antidiabetic medication prescribing, as Black patients had significantly lower prescription rates for glucagon-like peptide-1 (GLP-1) receptor agonists and SGLT2 inhibitors than White patients. Medicare patients also had a lower rate of receiving these medications compared with those who have private insurance.

To address these disparities, which can sometimes be fueled by adverse social determinants of health, the Duke Population Health Management Office is focusing on whole-person care by screening for health-related social needs and linking patients to programs in the community that can help. For instance, the Eat Well produce prescription program gives eligible participants money to buy fruits and vegetables each month. The randomized controlled trial examining this intervention is not yet complete, but Spratt mentioned that the initial response from patients so far has been enlightening.

“We have an email joint box that patients respond back to, and it’s been an incredible experience reading those emails, both positive and negative,” Spratt said.

A show of hands from the audience revealed that just a couple of attendees knew about all these ongoing efforts to improve public health, and Green emphasized their potential to inspire others. “This is information that I think we need to take back and communicate to others to make sure that everyone who can benefit from these projects and initiatives will,” she said.

Another area of knowledge that can be disseminated to other institutions is technology’s role in diabetes management, as discussed by Matthew J. Crowley, MD, MHS, an associate professor of medicine in the Division of Endocrinology, Metabolism, and Nutrition at Duke University School of Medicine. Crowley, who is also a core investigator at the Durham Veterans Affairs (VA) Center of Innovation to Accelerate Discovery and Practice Transformation, highlighted how the incredibly complex nature of diabetes management and the impossibility of caring for these patients only in the clinic necessitates at-home approaches including telehealth.

The COVID-19 pandemic has popularized telemedicine—the use of telecommunications to deliver medical services—but Crowley prefers to broaden the focus to telehealth, which encompasses not just care delivery but also patient health education, social support, medication adherence initiatives, and much more. He defined the keys to addressing persistently poorly controlled diabetes as frequent contact to support self-management, access to patient data to power delivery of the intervention, and ongoing management of medications.

“The trick is really thinking about how we can deliver comprehensive telehealth effectively, but not only effectively, also feasibly in real-world practice,” Crowley said. “And in my mind, that’s really the critical next step to get us from where we are now, which is essentially delivering clinic-like care by phone or video, to really unlocking the potential of telehealth.”

One successful example is the PRACTICE-DM study (NCT03520413), on which he is the principal investigator. This comprehensive intervention incorporated remote patient monitoring, scheduled phone calls, diet and activity support, and depression screening. Findings from this randomized controlled trial revealed improvements in diabetes distress levels, self-care, and self-efficacy ratings among veterans who received the intervention. The approach has now been implemented in more than 20 VA medical centers nationwide, and in the real world, patients receiving this approach have seen a mean HbA_1c level decrease of 1.62% in 6 months. Beyond these impressive results, Crowley also touted the program’s feasibility, which was made possible by its use of existing VA staffing, equipment, and infrastructure.

Most attendees don’t practice in the single-payer environment of the VA, Crowley acknowledged, so they will need examples conducted in delivery systems with different infrastructures and reimbursement streams. One example is the ongoing EXTEND trial (NCT05120544) led by Crowley and Ryan Jeffrey Shaw, PhD, an associate professor at Duke University School of Nursing. For Duke patients with poorly controlled diabetes and hypertension, the study will compare mobile monitoring–enabled self-management vs a nurse-delivered intervention incorporating mobile monitoring, self-management support, and medication management.

“Building the infrastructure for using comprehensive telehealth…within a system like Duke has been a huge undertaking—it was really challenging, lots of barriers—but it is a necessary step in order to be able to deliver programs like this, within the context of Duke,” Crowley said. “Recruiting the patients was quite challenging within the Duke system, but successful thanks to a great team.”

He closed his portion of the event by expressing his hope that the EXTEND study would yield valuable information on how to feasibly implement an intensive telehealth intervention for diabetes management at not only Duke but also at other fee-for-service health systems.

As Green had mentioned in the introduction, many patients are not reaping the benefits of novel agents that work to reduce cardiovascular risk in type 2 diabetes, signifying huge missed opportunities in care coordination and evidence-based treatment. Up next to talk about a program to address that unmet need was Neha Pagidipati, MD, MPH, an associate professor of medicine in the Division of Cardiology at Duke University School of Medicine and director of Duke Cardiometabolic Prevention Clinic.

Despite the interdisciplinary consensus and numerous guidelines endorsing the use of high-intensity statins, angiotensin-
converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), SGLT2 inhibitors, and GLP-1 receptor agonists, a recent analysis of commercially insured patients found that only approximately half were taking an ACE inhibitor or ARB and 9.9% were taking an SGLT2 inhibitor or GLP-1 receptor agonist.⁵ More than one-third, or 37.4%, were taking none of these, a statistic that Pagidipati called “truly horrifying.”

To address this gap, Pagidipati and colleagues conducted the COORDINATE-Diabetes trial (NCT03936660) to test the impact of a clinic-level intervention on prescription of these 3 groups of therapies (high-intensity statins; ACE inhibitors or ARBs; and SGLT2 inhibitors or GLP-1 receptor agonists). The multifaceted intervention incorporated assessment of each clinic’s specific barriers to prescribing, development of care pathways, care coordination tools, clinician education resources, and educational materials for participants, followed by audit and feedback of quality metrics.

The intervention focused on cardiology clinics, given data that there may be a lack of familiarity and comfort with prescribing these new agents among cardiologists. Compared with control practices, which just received guidelines, the intervention sites demonstrated a 23.4% absolute increase in the proportion of patients who were prescribed all 3 therapies (adjusted odds ratio, 4.38; 95% CI, 2.49-7.71; P < .001).

“One of the coolest things is that the sites really came up with their own solutions,” Pagidipati said. One example was a placemat given to patients that combined lifestyle suggestions with explanations and reminders to take the new medications.

Returning to the event’s theme of spreading actionable strategies across other practices, Pagidipati encouraged attendees to check out the freely available resources like videos and templates used in the COORDINATE-Diabetes trial. “Now the burden is on us to figure out how to implement it and disseminate it broadly because if we just stand here and we give talks about it, there’s absolutely no point,” she said.

Green noted that these findings reflect the importance of getting various specialist types involved in the mission to streamline and improve diabetes care, “but we can’t forget that diabetes is almost entirely a primary care–managed condition.” As such, Ranee Chatterjee, MD, MPH, an associate professor of medicine in the Division of General Internal Medicine at Duke University School of Medicine, next took the stage to talk about the primary care perspective on diabetes management.

Chatterjee discussed the role of primary care providers in a 4C model, which describes the 4 core functions of primary care: contact, comprehensiveness, coordination, and continuity. For instance, being the first point of contact for a patient with a chronic condition like diabetes is key, so providers will need to leverage telehealth visits or other non–face-to-face tools like online messaging “because not all concerns arise between 8 [AM] and 5 [PM].” Comprehensiveness could encompass thorough screening according to American Diabetes Association guidelines, referral to diabetes prevention programs, and suggestions for realistic lifestyle changes.

Primary care clinicians must stay on top of the array of tests and measurements required for patients with diabetes, from lipid levels to blood pressure to renal function markers and eye exams. They also need to be mindful of all the other comorbidities and risk factors that their patients have, so screening for mental health and encouraging adherence to recommended vaccinations cannot fall by the wayside while treating diabetes, Chatterjee said, with immunizations being especially important because individuals with diabetes are prone to infections.

The role of primary care providers in the coordination component is crucial, as they manage referrals to specialists and community resources, transitions of care, and the exchanging of information. Finally, what Chatterjee called “the best part of being a primary care provider” is continuity: “seeing my patients over time, sometimes seeing their family members, understanding a little bit what’s going to work with them, what’s not going to work with them, and building that trust to hopefully improve their care long term.”

Earlier speakers had mentioned the importance of ensuring access to medication and food in diabetes care interventions, but the next presenter, Bryan C. Batch, MD, MHS, associate professor of medicine in the Division of Endocrinology, Metabolism, and Nutrition at Duke University School of Medicine, focused specifically on access and equity at the local, systems, and global levels—including “how we work within our systems and how sometimes our systems work against our patients.” Her talk began with a review of the global burden of diabetes, then zoomed in to recap the known disparities in diabetes prevalence in the United States, with the disease more common in Black, Hispanic, and Asian/Pacific Islander individuals than in White individuals.

“This has been a standard bearer. We know this. That has not changed over the years,” Batch said. “Again, despite more medications, more interventions, telehealth and telemedicine, this has not changed.”

Even beyond biological factors like obesity, insulin resistance, and genetics, the nonmedical factors encompassing social determinants of health, such as education, environment, and economic stability, are key but underrecognized drivers of diabetes outcomes. Only recently have health systems started to think about these social drivers rather than just telling patients to improve their lifestyle and telling clinicians to improve their prescribing patterns. Structural inequity and social determinants combine to create the pathway leading to disparities, Batch said, seen in examples such as cost-related nonadherence or food insecurity driving poor diabetes outcomes.

Such a complex interplay of factors does not have a simple solution, but any successful intervention needs to take into account public awareness, sociocultural norms, and economic stability to build the capacity for change, Batch explained. Another key component of efforts to improve diabetes outcomes at the structural level will be public policy that supports equitable care, with Batch highlighting the components of the Inflation Reduction Act that will cap out-of-pocket insulin costs for Medicare beneficiaries, saving them many millions of dollars.⁶

“What we need to be able to do is change our ecosystem, to build capacity for patients, in order to build productive clinical relationships in clinical care,” Batch said. “We can’t do one or the other. We’ve been doing that for a long time, and it’s not working. We need to be systematic in our approach, and we need to be inclusive in our approach.”

“It is easy to get caught up in the excitement of all the new technologies and medications and other treatments for diabetes,” Green added, “but unless we’re really very intentional about ensuring that these are delivered in an equitable fashion, we’ll only worsen the disparities in care that already exist.”

Finally, all the speakers returned to the stage for a panel discussion. The first question came from 2 nurse practitioner students at Duke University who asked for advice as they prepare to step into the clinician role. Spratt emphasized that there are plenty of avenues for individuals to make a difference, whether it be through clinical research, quality improvement, patient education, or implementation science. The most important first step, the panelists all agreed, was to do what the students just did—attend events where they can build connections with others in the field and ask thoughtful questions.

Green then called on Larry Wu, MD, medical director at Blue Cross Blue Shield of North Carolina, to provide a payer perspective on the thoughts shared throughout the evening. Wu noted that diabetes is top of mind for payers grappling with the substantial costs of the disease—in fact, it’s more expensive than any single cancer type. His experience has convinced him that there is no one Holy Grail solution for diabetes care improvement and that each practice will need to determine which strategy or bunch of strategies will yield the most return on investment.

“At Blue Cross, we want to partner with all the players in the ecosystem—the members, the providers, and, to some extent, the health systems—to do the right thing to improve the health of our patients,” Wu said.

Although the task of trying to improve an issue as convoluted as diabetes control can seem daunting, the panelists agreed that there is always something to be done. “All it takes is one person at a clinic to say, ‘What we’re doing is unacceptable, and I’m going to fix it,’ ” said Pagidipati.

“It’s always nice to have more than one person, but often it just starts with that one individual,” Green agreed. “So it doesn’t take everybody being on board to improve the health of people with diabetes, wherever you happen to practice.”

Author Information: Ms Mattina is an employee of MJH Life Sciences^®, parent company of the publisher of The American Journal of Accountable Care.

REFERENCES

1. American Diabetes Association Professional Practice Committee. 10. cardiovascular disease and risk management: Standards of Medical Care in Diabetes—2022. Diabetes Care. 2022;45(suppl 1):S144-S174. doi:10.2337/dc22-S010

2. Fang M, Wang D, Coresh J, Selvin E. Trends in diabetes treatment and control in U.S. adults, 1999-2018. N Engl J Med. 2021;384(23):2219-2228. doi:10.1056/NEJMsa2032271

3. YMCA’s Diabetes Prevention Program. YMCA. Accessed October 25, 2023. https://bit.ly/3G6oYbD

4. Eat Smart, Move More NC is a statewide movement promoting opportunities for healthy eating and physical activity wherever people live, learn, earn, play, and pray. Eat Smart, Move More North Carolina. Accessed October 25, 2023. https://www.eatsmartmovemorenc.com/

5. Nelson AJ, Ardissino M, Haynes K, et al. Gaps in evidence-based therapy use in insured patients in the United States with type 2 diabetes mellitus and atherosclerotic cardiovascular disease. J Am Heart Assoc. 2021;10(2):e016835. doi:10.1161/JAHA.120.016835

6. Jeremias S. IRA insulin cap could have saved Medicare beneficiaries millions in 2020. The Center for Biosimilars. January 24, 2023. Accessed October 31, 2023. https://www.centerforbiosimilars.com/link/150