Reducing Cardiovascular Mortality in Patients With Type 2 Diabetes Mellitus - Episode 1

Overview of the Diabetes Burden

Dennis P. Scanlon, PhD: Hello, welcome to this American Journal of Managed Care Peer Exchange, “Reducing Cardiovascular Mortality in Patients with Type 2 Diabetes Mellitus.” My name is Dr. Dennis Scanlon, and I’m professor of health policy and administration, and director for the Center for Healthcare Policy and Research in the College of Health and Human Development at the Pennsylvania State University.

In today’s video program, Drs. Zachary Bloomgarden, Robert Gabbay, Michael Gardner, and John Johnson will share insight on the relationship between cardiovascular events and type 2 diabetes, specifically its effect on treatment selection in the management of patients’ glycemic control. We will also review the latest data from key trials that has revealed new findings in cardiovascular outcomes in type 2 diabetes that affect various stakeholders in the field.

Before we begin, let me introduce each of our expert panelists:

Dr. Zachary Bloomgarden is a clinical professor in the Department of Medicine at the Icahn School of Medicine at Mount Sinai in New York, New York. He is also the Editor of the Journal of Diabetes.

Dr. Michael Gardner is a medical director for the Cosmopolitan International Diabetes and Endocrinology Centre at the University of Missouri in Columbia, Missouri.

Dr. John Johnson, senior medical director with WellCare Health Plans, Inc, in Atlanta, Georgia.

And Dr. Robert Gabbay, the chief medical officer and senior vice president of the Joslin Diabetes Center in Boston, Massachusetts.

So, thank you gentlemen for joining us. I wanted to start with an overview of the diabetes epidemic—both its incidence and prevalence, and how it’s affecting you all in practice.

The American Diabetes Association estimates that more than 29 million Americans have diabetes, and more than 95% of them have type 2 diabetes. The CDC also reports that the incidence, or new cases of diabetes, may have declined, although Zachary, I know you’re not quite sure that that evidence is so clear.

Zachary T. Bloomgarden, MD, MACE: Right. There’s been a tremendous growth in diabetes over the past 2 or 3 decades in the United States and worldwide—going from approximately 4% of the population to the current level of around 9% of the population in the United States, and essentially tracking with the growth in obesity in the US population.

Now, over the past year or two, the level may be flattening out—although it’s hard to tell, and certainly worldwide, it’s not flattening out. The latest information from the International Diabetes Federation shows an increase from about 380 million to 420 million people worldwide. So we can see that the factors that underlie the epidemic of this paradigm of noncommunicable diseases are still there. It’s a lack of physical activity, excess nutrition, and everything that is leading to a variety of other disorders—lipids, blood pressure, and so on.

Dennis P. Scanlon, PhD: We also talk about prediabetes, and it has been estimated that there are millions of patients in the population with prediabetes. Any thoughts on what we’re doing to address that population? And when we think of preventing people from getting diagnosed with 2 type diabetes, how have we been doing?

Michael Gardner, MD: I’d have to say we’re not doing very well, because as was just mentioned, the incidence continues to increase and the prevalence continues to increase. There have been some exciting things coming out with the DPP (Diabetes Prevention Program), and the actual implementation of that relatively old study. And funding for it through Medicare, now, I think is going to possibly help to turn this trend a little bit.

Robert Gabbay, MD, PhD, FACP: Yeah. I would also say, though, that for better or worse, I don’t think there’s been a public recognition of the seriousness of prediabetes and how it leads to diabetes. Even that term “prediabetes” is not uniformly known by everybody in the public. So I think we still have work to do from an awareness perspective. Then, I think as was mentioned, programs that we know can prevent the development of diabetes are available and we need to make them more widespread.

Dennis P. Scanlon, PhD: There are relatively few endocrinologists relative to primary care providers who are the bulk of the professionals treating this illness. What’s going on in terms of primary care in terms of addressing this? And are we making the strides we need to make? I know, John, you deal with a lot of clinicians in your role as a payer.

John A. Johnson, MD, MBA: What we’ve seen in the United States is that there’s approximately 5000 endocrinologists, and we’re seeing that diabetes is being managed more by the primary care community. So, as guidelines are being made available to the primary care providers, they’re expected to lean forward and assist with care of these patients.

Dennis P. Scanlon, PhD: Somebody mentioned the Medicare payment for the Diabetes Prevention Program. I’m hearing mixed thoughts on that in terms of both the reimbursement and the potential impact of the program. I’m wondering if any of you have some thoughts on how that’s playing out?

Zachary T. Bloomgarden, MD, MACE: The dilemma is that we’ve all known for decades that physical activity and a healthy diet will prevent the development of diabetes. The diabetes prevention program that Michael mentioned, the DPP, absolutely showed that it’s better than medication in preventing development of diabetes. But delivering that intervention is tremendously difficult and it requires a high level of interaction between healthcare providers not necessarily tremendously trained, but individuals who will encourage people to eat right and exercise right. Getting that daily exercise, walking the 10,000 steps, and limiting your diet is just very hard for many people to do.

Michael Gardner, MD: I think that’s very important, what Zach just said. The DPP, the successful intervention, was much more intensive than what many of us are able to do in our offices and in our clinics. That’s what I think is so exciting about the program that the YMCA has been bringing out across the country and now is being picked up by Medicare. They are bringing these more intensive interventions and the support network into the community level and having trained community volunteers reach out to their peers, their friends in the community, to achieve the 7% weight loss that was seen in the DPP.

John A. Johnson, MD, MBA: I think this is where the managed care community can step in and partner with the providers and community resources to create a social safety network for diabetics. For example, so much of diabetes education and awareness occurs outside of the presence of a provider, such that [through] nurses and social workers, who play a major part in nutrition, diet counseling, and carb counting. So there’s more that the managed care community, particularly at WellCare, are leaning forward to help our providers and help our members by providing a patient-centered approach to care.

Zachary T. Bloomgarden, MD, MACE: Even nonprofessionals can really play a role. Many years ago, I was visiting South Africa giving talks. And I went to a clinic where a group of volunteers, totally non-healthcare professionals, had set up essentially a gym and were teaching people how to eat properly. They had great interest in the community and they were very excited about it—and I’m sure they were doing a great job.

Robert Gabbay, MD, PhD, FACP: Sure. Fundamentally, because of the scope of pre-iabetes being more than 80 million people, it has to happen at the community level. The healthcare system alone can’t absorb that. And honestly, I don’t think the role of the physician is that great in all of this—other than endorsing the work and doing the warm handoff to the kinds of programs that are effective. Most of these programs are effective without physicians being involved. It’s community people who can be trained by organizations to deliver this kind of work.

Michael Gardner, MD: And to go where the people are.

Robert Gabbay, MD, PhD, FACP: Right. Exactly. Because it’s a weekly or bi-weekly program.

John A. Johnson, MD, MBA: But I think physicians, being in front of the patient and driving the care, can endorse those resources in a way that the patients will be more likely to engage it.

Robert Gabbay, MD, PhD, FACP: Absolutely.

John A. Johnson, MD, MBA: And I think what we’ve seen is the utilization of these care-management, disease-management resources [is] very limited because there’s still not an increased awareness about them.