Primary Care Providers Can Take Today to Improve Care for Patients With Type 2 Diabetes
By Leonard E. Egede, M.D.; Kathie L. Hermayer, M.D., MS; Samuel Cykert, M.D.; M. Frampton Gwynette, M.D.; Carolyn Jenkins, Ph.D.; Pamela C. Arnold, MSN; Amanda Peterson, RDN, LD; and Kimberly McGhee
On completion of this article, readers should be able to:
- Describe the importance of testing all patients for prediabetes or type 2 diabetes at age 45 years, with earlier testing for patients with diabetes risk factors.
- Treat glycated hemoglobin (AIC), blood pressure, and cholesterol to target levels and facilitate adherence by tailoring medication regimens to address patient concerns.
- Optimize self-management skills through culturally sensitive diabetic education and nutritional counseling.
- Recognize the importance of treating depression, as it can lead to poor diabetes self-management.
- Define the chronic care model and give examples of how it could be implemented effectively in a primary care practice.
The biggest challenge facing the U.S. health care system is chronic disease, which, according to the Centers for Disease Control and Prevention, is responsible for seven of ten deaths each year and accounts for 86% of the nation’s health care costs.1
Type 2 diabetes mellitus (T2DM) is in many ways the poster child for chronic disease—it is associated with high rates of mortality and morbidity, places a heavy economic burden on the nation and on those it afflicts, and often remains undiagnosed until irreparable damage has been done.
Diabetes is the seventh leading cause of death in the U.S.; the leading cause of kidney failure, non-traumatic lower-limb amputations, and blindness; and a major cause of heart disease and stroke. Adults with diabetes are two to four times more likely to have heart disease or stroke than adults without diabetes.2
In 2012, diabetes-associated direct medical costs were $176 billion, two to eight times the amount spent on other chronic diseases. Patients with T2DM spend about $7,900 annually for diabetes-related medical care, much of it due to inpatient hospitalization and diabetes-related complications.3
Approximately one in ten (9.3%) people in the U.S. has diabetes, 95% of whom have type T2DM. One in three has prediabetes, defined as the presence of impaired glucose tolerance and/or impaired fasting glucose.4 More than a quarter (27.8%) of those with T2DM and nine out of ten of those with prediabetes remain undiagnosed.4
Primary care providers, who shoulder much of the burden of diagnosing and managing T2DM, can help reverse these alarming trends by taking the following ten steps.
1. Expand screening to all adults age 45 and over and to those under 45 with diabetes risk factors.
Both the U.S. Preventive Services Task Force (USPSTF; draft guidelines, 2014)5 and the American Diabetes Association (ADA)6 recommend screening all adults age 45 and older and those younger than 45 with risk factors for T2DM (any T2DM risk factors for the USPSTF; obesity plus one other T2DM risk factor for the ADA). The USPSTF, which previously recommended screening only hypertensive patients for T2DM, changed its position because studies have compellingly shown that metformin and lifestyle modification can cut the incidence of T2DM in patients with prediabetes by more than half.7-9
2. Support behavior change to prevent or minimize complications from T2DM.
Urge Smoking Cessation
The risk of developing T2DM is 30% to 40% higher for active smokers, and the risk is higher the more cigarettes they smoke. Patients with T2DM are already at a much higher risk of developing cardiovascular disease (CVD), and smoking further heightens that risk. Higher doses of insulin are needed in patients who smoke than those who do not, and research has shown that patients with T2DM who quit smoking achieve better glycemic control.10 Physicians can support patients in their quit attempts by providing medications and devices for smoking cessation (e-cigarettes are not considered a valid form of smoking cessation) and encouraging them to contact a quitline. The Tobacco Quitline offers regular follow-up with a smoking cessation coach to any resident of South Carolina free of charge.
Weight Loss and Exercise
A loss of 7% to 10% of body weight should be encouraged in T2DM patients and patients with prediabetes. In the U.S. Diabetes Prevention Program (DPP) study, overweight persons with prediabetes were asked to begin exercising at least 30 minutes five days a week; 58% of the patients who lost 7% of their body weight and 90% of those who lost 10% of their body weight did not develop T2DM.8 A follow-up study showed that prevention or delay of T2DM with lifestyle modification or metformin persisted for at least 10 years.9 Even patients who do not attain these goals will benefit as each kilogram (approximately 2.2 pounds) of mean weight loss is associated with a reduction of 16% in future diabetes incidence.8
Exercise need not require a gym membership, which could be prohibitively expensive for some patients. Walking briskly for 30 minutes a day (as part of an accumulated steps program with a goal of 10,000 steps five days a week for 12 weeks) has been shown to improve glucose metabolism and pancreatic cell function in T2DM as effectively as 30 minutes of daily aerobic exercise, with better adherence by patients.11
The primary care office should help patients find resources for lifestyle intervention, whether they be available at the community health department or provided by an insurer as part of a wellness or chronic disease management program. In 2015, Medicaid began offering reimbursement for intensive behavioral therapy for obesity (BMI >30 kg/m2). For more information, visit CMS.gov.
3. Ensure that patients receive diabetes self-management, education and nutritional counseling.
T2DM is a complicated disease, and effective self-management requires patients to test their glycemic levels regularly, know when and how to take medications, and choose a healthy and carbohydrate-controlled diet. Certified diabetes educators (CDEs), whose services are reimbursable by Medicare and other payors for T2DM patients, can help patients “learn the ropes” and do so in a way that is appropriate to the patient’s educational level. The National Certification Board for Diabetes Educators offers a tool to search for CDEs by zip code (available at http://www.ncbde.org/find-a-cde/).
Patients with T2DM who manage their diet appropriately are more likely to achieve good glycemic control with lower doses of medications.12 Registered dietitians can help teach patients about portion control, interpreting food labels, and planning carbohydrate-controlled meals and can help adapt patients’ favorite dishes or dishes favored by their culture to meet their dietary requirements. Physicians can find registered dietitians, whose services are covered for patients with T2DM by Medicare and other payors, in their area at http://www.eatright.org/find-an-expert.
For regions without a registered dietitian, telehealth may provide the answer. Nutritional counseling programs, such as that provided by Virtual Tele Consultation (VTC) at MUSC’s Center for Telehealth, enable T2DM patients at a primary care office, even in a remote area, to benefit from the services of a registered dietitian stationed elsewhere. Research has shown that telehealth-delivered nutritional counseling is as effective as that provided in person and can improve access to these services in underserved communities.13
Primary care offices should offer diabetes education and nutritional counseling to uninsured patients. Free patient education materials are available from the Academy of Nutrition and Dietetics (http://www.eatright.org/resources/food/nutrition), the South Carolina Academy of Nutrition and Dietetics (http://www.eatrightsc.org/), and the American Association of Diabetes Educators (https://www.diabeteseducator.org/patient-resources/aade7-self-care-behaviors).
4. Recognize that certain populations are at greater risk.
The burden of T2DM is especially heavy in the African American, Hispanic, and Native American populations, which report a 50% to 100% increased burden of illness and death associated with T2DM as compared to white Americans.14 Diabetes may also be harder to control in African American populations: racial/ethnic disparities in AIC levels and control were reported in a study of a national longitudinal cohort of veterans.15 Primary care offices can begin to combat racial disparities by recognizing and committing to reduce them and by designing, implementing, evaluating, and sustaining a quality improvement initiative that aims for equity.16
5. Address patients’ concerns when choosing medications.
Effective and inexpensive medications are available to treat the ABCs (AIC, blood pressure, cholesterol) of T2DM—metformin for glycemic control, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for hypertension, and statins for dyslipidemia, for example. Nonetheless, poor medication adherence continues to be a major challenge for diabetes management, with half of patients failing to take their medications as prescribed.17 A study by Egede et al18 showed that T2DM patients with poor medication adherence had 41% higher inpatient costs and estimated that reducing medication nonadherence would save the U.S. $661 million to $1.16 billion annually.
A recent meta-analysis19 showed that cost and depression were the two main causes of medication nonadherence in T2DM. (For more on depression, see Step 7.) Physicians should take the time to learn about their patients’ needs and, if cost is an issue, prescribe generic medications to treat the ABCs, taking care not to exceed about $50 per month.
6. Change or intensify medications if targets for ABCs, particularly blood pressure, are not met.
Control of the ABCs, especially blood pressure, is crucial in those diagnosed with T2DM to prevent CVD such as myocardial infarction and stroke and microvascular complications that can lead to blindness, end-stage renal failure, and amputation of lower extremities. The ADA’s 2015 Standards of Medical Care in Diabetes6 suggest the following targets: blood pressure less than 140/90 mm Hg, AIC less than 7%, and low-density lipoprotein cholesterol less than 100 mg/dL. However, stricter targets (e.g., blood pressure <130/80 mm Hg; AIC < 6.5%) may be appropriate for younger patients with little CVD to help stave off future complications, while less stringent AIC goals (<8%) may be appropriate for patients with limited life expectancy, advanced complications, a history of hypoglycemic episodes, or comorbid conditions.
Failure to meet targets, especially for blood pressure, should prompt physicians to increase the dose of the medication and/or consider a combination regimen. Although multiple-drug strategies can be complicated for patients and hurt adherence, the use of single-pill combinations, which combine two different categories of agents in a single pill, can be used to mitigate this problem.
7. Be vigilant in screening for and treating depression in T2DM patients as it can adversely affect medication adherence.
Patients with diabetes are twice as likely to develop depression,20 and diabetic patients with depression have poorer medication adherence and outcomes than those without diabetes.21, 22 Identifying depressive disorders (by documenting it ≥3 times in the medical record) can reduce the mortality rate in depressed patients with T2DM.21 Although primary care physicians can manage the care of many T2DM patients, those with treatment-resistant depression or with depression and another comorbid psychiatric condition should be referred to a psychiatrist, as depressed patients with diabetes may be candidates for aggressive treatment with serotonin reuptake inhibitors.23 Telehealth-based mental health counseling has a growing evidence base and has been shown to be noninferior to in-person counseling.24
8. Take full advantage of the electronic health record to monitor and follow up with your T2DM patients.
Primary care physicians who have undergone the sometimes painful transition from a paper-based to an electronic health record (EHR) can begin to reap some of the benefits the EHR offers for management of chronic diseases such as T2DM. Not all patients with T2DM understand the importance of glycemic and ABC control or the need for frequent follow-up. Therefore, primary care practices can query the EHR using a number of parameters, such as diagnosis codes for T2DM, AIC levels, or a missed appointment, every couple of months to identify patients who have lacked consistent follow-up and need to be engaged and educated about the importance of chronic disease management. Every practice can design such a system and bring these patients in for needed care and counsel. If possible, primary care offices should assign a licensed nurse to follow up with T2DM patients to track their values and make protocol-designated changes to their medication regimen. Comprehensive diabetes management algorithms are available from the American Association of Clinical Endocrinologists at http://dx.doi.org/10.4158/EP15693.CS.
9. Re-engage patients frequently.
Effective chronic care management does not happen overnight, but real improvement can be made over time. For T2DM patients with stable glucose levels, twice-a-year visits are recommended; for those who have not achieved stable control, quarterly visits are advised. A foot examination, in which a monofilament is used to test the sensation of a patient’s bare feet, should be performed at every visit. Patients should also be referred for an annual dilated eye examination. In addition to adjusting medication regimens to better meet targets, providers should ask about medication adherence while also assessing a patient’s self-management skills. Some patients with long-standing T2DM know surprisingly little about their disease and would benefit from diabetes self-management education and/or nutritional counseling.
10. Realize you don’t have to go it alone.
Primary care physicians cannot single-handedly provide the highly coordinated care and enhanced provider-patient communications that guidelines recommend. Moving from a traditional practice model, where the physician provides most of the care, to a team-based approach, where every care provider in the practice performs at the top of his/her training, will likely be necessary if the chronic care model, a patient-centered model advocated by 2015 ADA guidelines, is to be successfully implemented. Nurse practitioners and physician assistants are qualified to manage most cases of T2DM, with physician consultations limited to particularly complex cases. Pharmacists can also help educate patients about taking their medications appropriately, and registered nurses, licensed practical nurses, and community healthcare workers can engage in patient outreach and identify community resources. Front office staff can be directed to obtain additional history from T2DM patients, and the triage person, who typically checks blood pressure, pulse, and respiration, can be trained to perform foot examinations.
…And Some Models for the Future
As telehealth continues to expand, it will bring needed diabetes self-management education, nutritional counseling, and other services to rural areas. Smart phones will be used to text e-reminders about medication, diet, or exercise to patients between visits. New devices for remote monitoring will increasingly enable patients to regularly measure their blood pressure or glycemic level and transmit the data to the primary care office. Providers will be alerted when values exceed a certain threshold and require immediate attention, and blood pressure and glycemic levels can be plotted over time so that the provider can make more informed choices about medication during patient visits. The TIDES2 study at MUSC Health (PI, Leonard E. Egede, M.D.) is assessing whether outcomes improve in African American T2DM patients when they participate in regular telephonic sessions providing diabetes education and are equipped with these types of mHealth devices. If this strategy proves successful, it could be extended to other populations.
Primary Care Extension Centers
To fundamentally address chronic diseases such as T2DM and the health care disparities associated with them, changes in the infrastructure of primary care will likely be required. For example, some have advocated for the creation of primary care extension centers in rural or disadvantaged areas, modeled on the cooperative extension service. The primary care extension center serves as the hub for the primary care practices in the region, providing in-person and telehealth support to help them manage their patients with chronic disease. Such a center could provide personnel such as CDEs, registered dietitians, and community health workers to assist in patient outreach and help practices use the EHR to manage chronic care populations.
To learn more about redesigning primary care practices to deliver optimal diabetes care, sign up for this article’s CME-eligible sister telepresentation, Building Primary Care Teams to Support Great Diabetes Outcomes, at www.scahec.net/schools. The telepresentation is scheduled for October 29, 2015 from 1:00-2:00 pm and will be recorded and made available as enduring CME on the Progressnotes Available CME web page. Speakers are Leonard E. Egede, M.D., Professor of Medicine and Director of the Center for Health Disparities Research at the Medical University of South Carolina, and Samuel Cykert, M.D., Professor of Medicine at the University of North Carolina at Chapel Hill.
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