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Evidence-Based Diabetes Management
Optimal Health Requires More Than Medication
Chronic conditions, such as type 2 diabetes mellitus (T2DM) and heart disease, continue to increase in prevalence and cost. The American Diabetes Association estimates that 29.1 million Americans had diabetes in 2012.1 The healthcare cost of the 21.1 million who were actually diagnosed totalled $245 billion, which is more than 2 times higher than nondiabetics.2 The World Health Organization estimates that by 2030, 330 million people worldwide3 will have diabetes. These sobering statistics only begin to tell the human story. Diabetes is the major cause of both end-stage renal disease leading to dialysis or kidney transplant and noncongenital blindness. End-stage organ failure significantly reduces the quality of life of people with diabetes and takes a major emotional toll on patients and their families.
T2DM and many other chronic conditions can be prevented, controlled, even reversed with a combination of medical treatment and lifestyle changes. Unfortunately, many people are unable to start or maintain these needed steps. A better healthcare system that treats the whole person—not only the condition—can help.
THE CRITICAL ROLE OF MEDICATIONS IN TREATMENT
No doubt, medications play a critical role in the management of chronic disease and in preventing or delaying additional more serious conditions. For example, controlling blood glucose with and without insulin, is an important goal for diabetics and helps to prevent a number of vascular and neurologic complications and related disabilities. Effective adherence to medication regimens will improve both outcomes and quality of life for patients, and reduce both direct and indirect costs.
Reminder programs, timers, electronic pill boxes, and other devices can be great tools for helping patients who are forgetful or are on complex medication schedules. Additionally, plan designs, such as Aetna RX Healthy Outcomes, remove or lower the co-payment for targeted drugs to help address financial barriers. However, even a $0 co-pay does not always result in perfect adherence.
Most medication nonadherence stems from patients choosing not to take their medications based on beliefs about their treatment, diagnosis, and prognosis. They may choose not to fill their prescriptions, take the medication infrequently, or stop taking medication altogether due to side effects or other concerns. Studies that examine intentional and unintentional nonadherence show that 80% of medication nonadherence is deliberate. Further, despite much attention, health literacy accounts for only 20% of nonadherence.
ENGAGING MIND AND BODY
Patients are not pill-taking machines, and medication adherence alone is not the answer to improving health. Healthy diet and exercise can also deliver significant health benefits. Still, the disease is only one part of a person’s life. Medication, diet, and exercise must be incorporated into a person’s existing routine in a way that is both realistic and sustainable—and that requires motivation.
Health plans, both insured and employer-sponsored, often feature incentives and reward programs for healthy actions. These external motivators may include a reduction in premiums for completing an activity, such as answering a health risk—assessment questionnaire or reaching a health goal (target cholesterol levels, healthy weight, steps walked, etc).
Taken a step further, programs like Aetna’s Metabolic Syndrome Program assess a person’s current risk for metabolic syndrome. This group of 5 closely related conditions—increased blood pressure, elevated blood sugar, excess body fat around the waist, low HDL, and high triglyceride cholesterol levels—can increase a person’s risk of heart disease, stroke, and diabetes. The more conditions a person has at one time, the greater the risk. However, metabolic syndrome can be reversed by making changes to diet, losing weight, and exercising. Aetna’s program provides a detailed, personalized health report with suggested steps that help prompt the member to take action to better health. While both incentives and actionable information can provide a great start, continuing the journey to better health requires development beyond external motivators to internal motivation.
DEVELOPING THE INNER DRIVE
Suppose a person takes up jogging to lose weight and increases the amount of aerobic activity that he can log in his employer-sponsored health challenge, he may be rewarded for meeting a new health goal. But, over time, those rewards begin to matter less. To keep running, he needs to want to run. Running—not the external reward—becomes the goal. The satisfaction that he feels when he completes a run, logs miles for the week, or enjoys the camaraderie of being with like-minded individuals at a local 5K race are all rewards in themselves. The popularity of Team-In-Training and the high participation rates in marathons and races of all lengths demonstrate the power of internal motivation.
Recognizing the importance of internal motivation, Aetna’s care management programs have integrated motivational interviewing (MI) techniques to help people identify and develop internal motivators. Instead of telling people why they need to follow a treatment or just rewarding them for doing so, nurses and health coaches help each individual develop a unique set of internal motivators. MI focuses on mutual, personal guidance and has been proved in clinical studies to decrease resistance and enhance motivation to change. Building from this evidence, Aetna health coaches can better empower members in their care.
Practicing the principles of MI, Aetna’s disease management nurses have an enhanced ability to create a safe place for members to focus on their health. Nurses elicit, rather than impose, motivation to change. They help members explore and reinforce their own arguments for change, and then guide fully informed and autonomous choices. Creating a highly personalized member experience with real conversations, not scripted interactions, encourages members to take greater responsibility for their actions and health.
Studies also demonstrate that adherence improves in patients who report a good relationship with their physician, with effective communication being an important factor in those relationships. A patient-centered approach to care promotes a partnership in making decisions about medication, considers cultural beliefs and attitudes, and actively encourages input and feedback from the patient.
TECH SUPPORT FOR HEALTH
Mobile technology is transforming the world, and health care is no different. Patients have a growing selection of phone apps and Web-based tools to help inform, connect, motivate, and track their health goals. Several adherence apps are free and have companion websites that allow physicians to enter their patients’ prescriptions. Many have privacy-compliant cloud data storage that can be accessed from the doctor’s office, updated, and delivered to the patients’ mobile devices. Customized reminders also can be set up, and information on doses taken or missed can be exported to the doctor’s office for review. Still, technology alone has limited benefits. Many of the apps rightly have disclaimers advising that patients should not rely on an app alone to remember to take medications.
Addressing the problem of chronic disease management requires approaching people as an entire being, not as a machine fuelled by pills. Rather than focusing on medication adherence alone, patients need access to a combination of external and internal motivators that can help them start and maintain a routine that successfully integrates medication, healthy diet, and exercise. When health plans, plan sponsors, healthcare providers, and patients can work more closely to ensure all of the elements are considered and supported, better health outcomes will follow.
Ed Pezalla, MD, is vice president, national medical director for Aetna Pharmacy Policy and Strategy; Mark Friedlander, MD, is chief medical officer for Aetna Behavioral Health; and Mary Von, RN, is senior project manager, Aetna Behavioral Health.
References
1. National Diabetes Statistics Report. CDC website. http://www.cdc.gov/diabetes/library/reports/surveillance.html. Published June 10, 2014. Accessed December 30, 2014.
2. American Diabetes Association. Economic costs of diabetes in the United States in 2012.Diabetes Care. 2013;36:1033-1046.
3. Country and regional data on diabetes. World Health Organization website. http://www.who.int/diabetes/facts/world_figures/en/. Accessed December 30, 2014.
