Working at the Intersection of Expertise to Improve Patient Care

December 11, 2019 – With eight-plus clinical areas under one roof, the DCRI enables faculty members of various specialties to work together to draw deeper insights in clinical research and find better treatments for patients.

Working at the Intersection of Expertise to Improve Patient Care

Traditionally, patient care has taken a somewhat siloed approach, with specialists treating patients for organ-specific complaints. However, advancements in medicine have resulted in the need for a new paradigm: one in which specialists in different areas of medicine come together to address issues at the intersection of their expertise.

“We now have tools that we know are effective in keeping our patients healthier and helping them to live longer,” said Jennifer Green, MD, an endocrinologist at the DCRI. “We all need to partner and be engaged in ensuring our patients’ care aligns with current evidence-based guidelines. This will require communication with other specialty areas, but it is very important to understand that optimization of care is a shared responsibility. We can no longer only focus on our areas of expertise; instead, we have to focus on collaborating to care for the whole patient.”

With 140 faculty members across nine therapeutic areas who often come together to work on clinical trials, the DCRI is particularly well poised to work in this space.

DCRI faculty from various specialty areas discuss ongoing projects and future opportunities for collaboration in the cardiometabolic and cardiorenal spaces.

New Medications, New Opportunity

As health care advances, patients live longer and develop more comorbidities, calling for a new era of health care in which providers must think about clinical areas outside the one in which they work. For instance, a cardiologist now needs to consider how medications he or she prescribes affect other conditions like diabetes or renal disease. Simultaneously, new evidence is emerging that show many therapies can be used for multiple indications.

Some of this evidence was presented at the American Heart Association Scientific Sessions 2019, such as results from DAPA-HF, which was led by John McMurray, MD, of the BHF Cardiovascular Research Centre in Glasgow, Scotland. The study results showed that dapagliflozin, an SGLT2 inhibitor traditionally used to treat diabetes, can also be used to safely and effectively treat heart failure with reduced ejection fraction both in patients with and without diabetes.

“It’s changed how we think of dapagliflozin; we now consider it a foundational therapy for reduced ejection fraction, and I think many of us eagerly await the preserved ejection fraction data, as well,” said Robert Mentz, MD, a heart failure specialist at the DCRI.

Although the DAPA-HF study was not powered to look at renal outcomes, nephrologists were also struck by the results, which Daniel Edmonston, MD, a nephrologist at the DCRI, called “profound.”

“Results like these are exciting for work moving forward from a cardio-renal-metabolic standpoint as we expand the use of these medications in growing indications outside of diabetes,” he said.

Green also looks forward to the opportunities provided by expanded uses for these medications. She is the principal investigator for a trial called EMPA-Kidney, which is examining the effects of empagliflozin, another SGLT2 inhibitor, in patients who have chronic kidney disease. Although empagliflozin, like dapagliflozin, was initially approved to reduce glucose levels in patients with type 2 diabetes, the leaders of EMPA-Kidney expect that it will also reduce cardiovascular and kidney complications in patients with and without diabetes.

“Although these drugs are traditionally viewed as diabetes medications, we need to start thinking of them as drugs with much broader benefits for our patients,” Green said.

Closing the Gap via Implementation Science

Although advancements like DAPA-HF have resulted in more options for treatment of previously difficult-to-treat conditions, implementation of these therapies into clinical practice remains challenging.

A DCRI-led study called COORDINATE-Diabetes is making an effort to tackle this problem by working with cardiology clinics to improve care for patients who have cardiovascular disease and diabetes. Through the intervention arm of the trial, teams from the DCRI are helping clinics identify their challenges and create solutions that would boost prescribing rates of efficacious therapies. The teams that visit the sites are diverse in their expertise—each team includes a cardiologist, an endocrinologist, and a quality improvement specialist—in an effort to help sites coordinate their patients’ care among cardiologists, endocrinologists, and primary care doctors.

DCRI co-chief fellow and cardiologist Adam Nelson, MBBS, PhD, who is working on COORDINATE-Diabetes along with Green and others from the DCRI, contributed to a poster presented at AHA 2019 that outlined data from patients similar to the COORDINATE study illustrating the depth of the problem. In a population of over 150,000 patients with both atherosclerotic cardiovascular disease and diabetes, fewer than 5 percent of all patients were being prescribed all three agents that have proven to be effective including high intensity statins, ACE inhibitors or ARBs, and SGLT2 inhibitors or GLP-1 receptor agonists.

Neha Pagidipati, MD, MPH, a cardiovascular prevention specialist and one of the faculty leads for COORDINATE-Diabetes, noted that there are multiple barriers to prescribing guideline-recommended therapies, both at the provider level and at the system level. Some cardiologists report hesitancy to infringe on the diabetes care providers’ space, while others share they are uncomfortable with some of the metabolic side effects that can accompany the newer medications proven to be effective for cardiovascular conditions. She said she hopes to see a shift as medications move from being defined as primarily diabetes treatments to now being seen as cardiovascular risk reduction medications.

“We have been thinking a lot at the DCRI about how to actually get therapies implemented because we know it takes approximately 17 years for guideline therapies to make it into clinical practice,” Pagidipati said. “When you have therapies that are this effective and populations that are at such high risk, this is not acceptable.”

The AHA 2019 analysis that Nelson contributed to provides further insight into this divide. In the cohort his team examined, less than 30 percent were seen by an endocrinologist, while 70 percent were seen by a cardiologist. Nelson said these findings show that an intervention targeted toward cardiologists has the greatest potential impact to increase prescriptions of guideline-recommended therapies. Through COORDINATE’s intervention, the study team will be looking for ways to empower cardiologists to take a more active role in their patients’ overall health and feel comfortable prescribing medications beyond traditional cardiovascular medications.

Looking Toward a Future of Integrated Care

Although it previously would have been unusual to see cardiologists working alongside a nephrologist to improve patient care, these days it is commonplace at the DCRI, Nelson said.

Edmonston agrees. “There is increasing overlap in the Venn diagram of subspecialty care for our patients,” he said. “It’s exciting to see opportunities where we will be able to work together across differing specialties to provide the best care.”

Because the DCRI contains eight different therapeutic areas under one roof, along with numerous subspecialties within these therapeutic areas, Nelson said the institute provides an ideal environment for a new way of working that lays the groundwork for the future of health care.

“The DCRI is a one-stop shop that has experts in every clinical area running trials and collaborating on research,” Nelson said. “A model in which we can see the common threads in our research helps us to aggregate data, opinions, and ideas to inform more well-rounded patient care.”