The study found that certified diabetes educators were able to act quickly on intensifying therapy, resulting in improved A1C and cholesterol.
The effect of “clinical inertia” on patients with type 2 diabetes mellitus (T2DM) is well-known—patients stay on lower doses of therapy longer than they should, and they may not get the most personalized advice about diet, exercise, or self-care.
A study funded by the American Diabetes Association and presented as its 75th Scientific Sessions in Boston Sunday examined what would happen if certified diabetes educators (CDEs) were attached to primary care practices in a meaningful way—with access to the electronic health record (EHR), the ability to recommend prescriptions, and, most of all, easier access to patients themselves. Results showed justification for expanding the role of CDEs in primary care—assuming practices can find ways to pay for it.
Presented by Janice C. Zgibor, RPh, PhD, an associate professor of epidemiology at the University of Pittsburgh, the study was a randomized controlled trial that used CDEs in 2 different groups across 15 nonacademic practices. The practices would identify and refer patients who met eligibility criteria for a diabetes diagnosis (A1C at least 7%, or LDL cholesterol at least 100 mg/dL, or blood pressure at least 140/80 mm/Hg) to the CDE for either diabetes management protocols or usual care. Patients who met the criteria could also self-refer, and there were materials in the offices with instructions on that process.
· In the practices randomized for the diabetes management protocols, staff identified and referred 175 patients, who were eligible for intensified therapeutic management based on evidence-based guidelines. Access to the EHR was critical, as the CDEs often left recommended prescriptions for doctors, who could act on them within a day.
· In the usual care practices, staff identified and 65 patients, who were eligible to take part in a monthly visit from the CDE. Dr Zgibor speculated that the fact that the CDEs were only in these practices once a month may have led to the smaller number of referrals.
The average age of the patients in both groups was 61 years, evenly divided between men and women, and 83% were white. After 3 months, results showed that the patients in practices where CDEs were using diabetes management controls were experiencing more rapid improvement in health outcomes, as follows:
· A1C: For the patients receiving care under diabetes management protocols, it decreased from 8.8% to 7.8%; for the usual care group, it went up slightly, 8.2% to 8.3%.
· LDL cholesterol: For the diabetes management protocol group, it decreased from 104.9 mg/dL to 88.2 mg/dL; for usual care it went down 100.2 mg/dL to 89.6 mg/dL.
· Blood pressure differences were not significant.
Dr Zgibor observed that patients receiving care from the CDEs administering evidence-based protocols were more likely to have medication adjusted quickly; changes took longer to occur for the usual care group. This is the hallmark of “clinical inertia,” and patients can suffer health effects during the time it takes for primary care to catch up with where doses need to be.
Members of the audience asked about the challenge of billing for CDEs, and Dr Zgibor said this is her next area of research.
Zgibor JC, Maloney M, Tilves D, Solano FX. Redesigning primary care to overcome clinical inertia and improve outcomes. Diabetes. 2015; 64(suppl1) abstract 208-04.