Reducing Cardiovascular Mortality in Patients With Type 2 Diabetes Mellitus - Episode 7

Using Guidelines to Overcome Clinical Inertia

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Dennis P. Scanlon, PhD: We talked about guidelines earlier and how it’s difficult to keep them up-to-date; and often they aren’t. In these choices of therapies in treatment decisions [that are] customized to patients—if you look at the ADA (American Diabetes Association) or the AACE (American Association of Clinical Endocrinologists) guidelines—are they helpful? Bob mentioned earlier “decision support.” Are they (the guidelines) able to keep up with the advances and the availability of pharmaceutical therapies?

Zachary T. Bloomgarden, MD, MACE: I think that this is the real strength of professional societies—being able to look at all the available data as clinicians and educators who are tremendously knowledgeable about the field, and then making recommendations.

I’ve had the honor of serving on the AACE Diabetes Guidelines Committee for a number of years and we’ve worked very hard to try to [evaluate] the real evidence that’s out there and [determine] how to make recommendations of what to use and at what level of A1C (glycated hemoglobin), and [figure out] what caveat there should be for individualizing. The ADA has done a wonderful job also.

But, you mentioned something in the introduction which I think is so important. If one actually reads the text of the guidelines, the 30 pages or so, they’re all tremendously nuanced and fascinating. If you only limit yourself to the 1-page summary of summaries, it’ll be very specific—do this, do that.

Dennis P. Scanlon, PhD: People like the CliffsNotes—the 1-pager.

Michael Gardner, MD: In the newest guidelines, I think there actually has been a nice step forward in terms of the summary of summaries (as you put it). The AACE guidelines, in particular, are showing that these agents have these strengths—strength of effect and also risk of side effect—and give some ranking. [In contrast], the previous guidelines have sort of been about metformin and then anything else.

John A. Johnson, MD, MBA: The point is to be thought provoking—meaning that the clinician is at least thinking about moving the needle and pushing the diabetic toward a goal, and not to be in a place of what we call “medical inertia,” where there’s the resistance to push them to the other end or add a second or third agent.

Dennis P. Scanlon, PhD: Somebody mentioned earlier adherence and the patient perspective. We are at the American Journal of Managed Care Patient-Centered Diabetes Care conference, and imagine that we are thinking about the patient and involving the patient in treatment decisions.

I’m wondering where we think we are in practice with these decisions and engaging in shared decision making, and understanding or explaining to patients the trade-offs? It’s very difficult for clinicians to understand this, let alone to be able to communicate this to patients, I would imagine.

Michael Gardner, MD: This is very challenging. We are trained to put the cure, the treatment, and the eradication of disease first. Many of us in medical school were trained that way.

This is one thing that I think is becoming innovative in medical school now, at least at the University of Missouri where I teach. I help teach a course where we bring together nurses, pharmacists, and medical students. We all sit in one room and we talk and work as a team through the medical care process.

But the other thing (that I think the medical homes do very well), is to look at the patients and [understand] what their priorities are. I see a fair number of my referrals, so to speak, are [examples of], “Well, this patient won’t go on insulin. Please get him on insulin okay?”

Sometimes sitting down and talking with that patient [is important]. “Well, why aren’t you doing insulin?” “What are your concerns?” “What are your priorities?” “Is your priority to get your A1C down, or is your priority not to have these side effects and not to have hypoglycemia?” “Do you live alone?” “Do you have some cognitive challenges?” Trying to build a treatment program for them is really what patient-centered care is all about.

Zachary T. Bloomgarden, MD, MACE: Right. It’s so difficult to get over this adherence challenge. There are good studies of statins which show that, at best, you see maybe a 70% [rate] of treatment adherence among people with diabetes over the period of several years.

Insulin—as a diabetologist, I happen to know that if you’re supposed to take insulin in a certain way and you don’t take all of those shots, you’re not going to really click. This morning, somebody came to me—a lawyer, very intelligent. I’ve been working with him for years and I finally convinced him to actually take a multiple, daily insulin regimen. He came back and he said, “You know, I’m taking so much less insulin, but I’m actually taking those shots and my blood sugars are so much better.”

But, how do we get people to adhere to these regimens when there are so many things that they would rather not do?

Robert Gabbay, MD, PhD, FACP: It’s a big challenge. I think providers are not trained well in how to do that, and there are some best practices around doing that. You gave some great examples of using open-ended questions—not being directive to a patient and saying, “This is what you need to do,” but [instead], “Here are some choices.” “It seems like you have concerns.”

I don’t think we do a great job of asking about adherence in the right way, as opposed to saying, “Do you take your insulin?” Most people are going to answer, “Yes,” to their doctor.

If you ask, “Many people find it challenging to take insulin all the time. How’s it been going for you?” They’re much more likely to be honest, and now you can engage in a conversation about the barriers.

Michael Gardner, MD: Yeah, what are the barriers? That’s one of my favorite questions. “What’s the barrier to you?”

Robert Gabbay, MD, PhD, FACP: Right. “What are your concerns?” And then you can work with them to problem solve.

Zachary T. Bloomgarden, MD, MACE: [For example], “I happen to have noticed that your blood sugar today is 404 and your A1C was 13. Have you been having trouble taking your insulin?”

Robert Gabbay, MD, PhD, FACP: Right.