By Sara C. Miller, MS, Med-IQ, LLC; William A. Mencia, MS, Med-IQ, LLC; Dave Masom, PACK Health; Mazi Rasulnia, PhD, PACK Health
At a recent visit with his physician, ET, a patient with type 2 diabetes mellitus (T2DM), reported that he often ate fast food and large quantities of food. He also said his exercise routine was inconsistent. His HbA1C was 10.1 percent, and he weighed 228 pounds. His physician recommended personalized support in addition to medical treatment, which was connected to a clinician education program. ET agreed. Now at the conclusion of the program, ET lost 18 pounds and reduced his HbA1C to 6.6 percent. Perhaps most importantly, ET is proud of himself. What made the difference? The combination of clinician education and patient engagement.
In recent years, optimal glycemic targets, clinical practice guidelines and treatment algorithms for T2DM have evolved; general recommendations for broad patient populations have been largely replaced by individualized, patient-specific approaches.1 Currently, 10 classes of non-insulin medications are available for the management of hyperglycemia in T2DM. However, guideline recommendations regarding appropriate treatment initiation, intensification or modification and use of combination therapy vary significantly.1-5 Epidemiologic studies suggest trends of grossly mismanaged hyperglycemia, which are expected to continue for the foreseeable future without significant alterations in clinical practice.6-8
Overburdened primary care clinicians on the frontlines of diabetes care do not have sufficient time to parse through a substantial and growing body of clinical data when making complex treatment decisions, nor do these clinicians have the luxury of dedicating large amounts of time to the proper education and support of patients through the necessary lifestyle modifications. Primary care clinicians need practical resources and expert insight to help determine treatment approaches, personalize the care they deliver and optimize disease-related outcomes for their patients. To address this need, we developed a two-part initiative. Component one is a newscast-style webcast designed to help busy primary care clinicians sift through the growing body of clinical evidence to make optimal treatment decisions for their patients with T2DM who do not yet need insulin. Component two is a patient engagement solution designed to encourage and foster patient self-management through personalized coaching and tools.
This educational activity uses an engaging, point/counterpoint-approach webcast to arm primary care clinicians with practical strategies for intensifying non-insulin diabetes therapy and engaging patients as active partners in the management of their disease. During this Medical Insiders webcast, faculty members engage in a dynamic debate focused on a complex, real-world patient case. During the discussion, faculty experts share their specific challenges associated with complicated, multifaceted treatment decisions for T2DM management, discuss critical factors for individualizing therapy and highlight best practices for improving patient-clinician dialogue. Importantly, this Webcast model minimizes the use of slides and instead capitalizes on the dynamic interaction among three faculty experts. Visual reinforcement of key educational points is achieved with brief text on a lower banner at various points during the activity.
A critical barrier to the effective management of T2DM is the requirement of substantial patient self-management between visits with their clinicians. To address this gap, the Medical Insiders activity described above is supported by a personalized patient engagement strategy developed by Pack Health. The diabetes PACK program provides patients with access to a health advisor, as well as a disease-specific, evidence-based toolkit designed to improve patient involvement in their own care.
Clinicians participating in the Medical Insiders activity were able to request a “prescription pad” to prescribe the PACK to their patients with T2DM. Patients who filled their PACK prescriptions received kits containing self-care tools, including a pedometer, a nutrition guide and an exercise journal. Over the course of a 12-week period, these patients engaged with their health advisors to complete the structured program, which helps patients navigate the healthcare system, overcome barriers, and establish sustainable healthy behaviors.
This educational activity sought to ease the information burden on clinicians who must stay abreast of the ever-expanding dataset examining the safety and efficacy of non-insulin agents while also facing a growing caseload of individuals with T2DM.
More than 3,000 clinicians who care for more than 80,000 patients with T2DM participated in this initiative. Final data illustrate improvements in knowledge about the following:
- Importance of expected patient efforts in setting glycemic goals (32 percent increase in correct responses, P<0.001)
- Role of life expectancy in determining appropriate glycemic goals (36 percent increase in correct responses, P<0.001)
- Pharmacologic properties associated with various classes of therapies (34 to 36 percent increase in correct responses, P<0.001)
Our learning data also illustrate significant improvements in participant competence related to choosing optimal guideline-based non-insulin therapy for a patient with newly diagnosed T2DM (61 percent increase in correct responses, P<0.001).
Participants who used the PACK prescriptions found the program to be a useful tool to reinforce key information to their patients. As part of the patient engagement strategy, a combination of phone calls, text messages, emails, and direct mail were directed at patients, depending on their contact preferences. In total, health advisors had 7,894 touch points with patients (average of 70 per patient enrolled); health advisors invested an estimated 19,674 minutes in these touch points (almost three hours per patient).
The patient outcomes speak for themselves; data showed the following:
- An average reduction in HbA1C of 1.03 percent (n= 99), which was verified by a sample of test results obtained from the clinician’s office
- An average reduction in weight of 4.28 pounds (n = 88); • An 11 percent reduction in patient-reported emergency department/hospital visits
- A 23 percent increase in the proportion of patients who had completed a foot examination in the past year
- A 21 percent increase in the proportion of patients who had completed an eye examination in the past year
- A 54 percent increase in patients who reported eating healthy for seven or more meals per week
- A 42 percent increase in patients who reported engaging in physical activity two or more times per week
This innovative approach demonstrates the educational value and applicability of the Medical Insiders activity. A key component of the success of this program was the inclusion of practice pearls related to building successful patient-clinician teams, which are critical for improving disease control and mitigating comorbidities.
This approach was lauded by participating clinicians for its conversational tone and practical approach; comments include:
- “Great presentation with ‘real world’ problems and solutions!”
- “This was an excellent presentation. Very realistic and a great approach.”
- “I like the conversational format of this CME activity.”
- “The clinicians were clearly still seeing patients and presented realistic options.”
Additionally, the accompanying PACK program supports clinicians’ efforts to empower their patients to be active members of their healthcare teams, improve quality of life, have higher satisfaction with treatment, achieve better outcomes and have lower total medical costs without sacrificing valuable face-to-face time.
- American Diabetes Association. Standards of medical care in diabetes – 2016. Diabetes Care. 2016;39(Suppl 1):S1-S106.
- Inzucchi SE, Bergenstal RM, Buse JB, et al; American Diabetes Association; European Association for the Study of Diabetes. Management of hyperglycemia in type 2 diabetes: a patient-centered approach. Diabetes Care. 2012;35(6):1365-1379.
- Qaseem A, Humphrey LL, Sweet DE, Starkey M, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Oral pharmacologic treatment of type 2 diabetes mellitus: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2012;156(3):218-231.
- Garber AJ, Abrahamson MJ, Barzilay JI, et al; American Association of Clinical Endocrinologists. AACE comprehensive diabetes management algorithm 2016. Endocr Pract. 2016;22:84-112.
- Bailey T. Options for combination therapy in type 2 diabetes: comparison of the ADA/EASD position statement and AACE/ACE algorithm. Am J Med. 2013;126(9 Suppl 1):S10-S20.
- Cheung BMY, Ong KL, Cherny SS, et al. Diabetes prevalence and therapeutic target achievement in the United States, 1999 to 2006. Am J Med. 2009;122(5):443-453.
- Centers for Disease Control and Prevention. Diabetes Data & Trends. Accessed January 23, 2016. http://www.cdc.gov/diabetes/data/
- Sidorenkov G, Haaijer-Ruskamp FM, Zeeuw D, Denig P. A longitudinal study examining adherence to guidelines in diabetes care according to different definitions of adequacy and timeliness. PLoS ONE. 2011;6:e24278.