Education and interdisciplinary care are keys to overcoming barriers that prevent patients from receiving proven therapies
DURHAM, N.C. – Patients who have diabetes and heart disease do best when both conditions are treated according to established guidelines, but far too many are not prescribed the effective therapies.
A recent study — designed and led by the Duke Clinical Research Institute (DCRI) and an academic steering committee — found that a coordinated care approach between cardiologists and diabetes specialists resulted in more patients receiving the recommended therapies. The study was funded by Boehringer Ingelheim and Eli Lilly and Company.
The findings are being presented March 6 at the 2023 American College of Cardiology scientific meeting and simultaneously published in the Journal of the American Medical Association.
“There’s a clear gap between what we know we should be doing and what is actually occurring in clinical practice,” said lead author Neha Pagidipati, M.D., associate professor in the Division of Cardiology at Duke University School of Medicine and a member of the DCRI. “Our study demonstrates that coordinated, multi-disciplinary care can result in patients receiving the therapies that have been proven effective.”
Pagidipati and colleagues — including senior author Christopher Granger, M.D., professor of medicine in Duke’s cardiology division and DCRI member – partnered with 43 cardiology clinics across the U.S. as part of a clinical trial titled COORDINATE-Diabetes.
The clinics were randomly assigned to provide usual care or to implement a multi-faceted intervention. It was designed to remove barriers that keep cardiology clinicians from prescribing medications recommended for patients with diabetes and atherosclerotic cardiovascular disease, a narrowing of the arteries.
The recommended drug regimen includes high-intensity statins for cholesterol; angiotensin-converting enzyme inhibitors or angiotensin receptor blockers to lower blood pressure and protect heart and kidney health; and, for diabetes along with heart and kidney health, sodium-glucose cotransporter-2 inhibitors and/or glucagon-like peptide-1 receptor agonists.
The intervention required clinicians/clinics to:
- Assess barriers in the clinic that prevent or impede the patients from receiving the recommended prescriptions;
- Build interdisciplinary care teams to address barriers, including cardiologist, diabetes care specialists, pharmacists and others to address costs and access issues;
- Coordinate care between all participating clinicians and care teams;
- Provide clinician education through online learning modules and monthly calls to address questions and concerns;
- Provide feedback with real-time data, including comparative reports showing patient prescription numbers across all sites;
- Support patients with education tools about why the therapies are important and how they impact health markers.
More than 1,000 patients were enrolled and followed for up to 12 months. Among the clinics providing usual care, 14.5% patients were prescribed all the recommended therapies, while 37.9% of patients at the intervention sites received all three prescriptions.
“A 23-percent greater absolute use of three evidence-based therapies shows that coordinated efforts to implement effective therapies can result in markedly improved care,” Granger said. “Given the many treatments that are known to improve health, now the most important need is to generate high-level, randomized evidence to improve the use of these treatments. This is what we did in this trial.”
The study was not designed to measure the impact of the drug regimen on health risks, but an analysis showed that the intervention had a trend of risk reduction that would be expected with better use of the medications studied. Death or hospitalization for myocardial infarction, stroke, heart failure, or urgent revascularization occurred in 23 of the intervention participants (5%) compared to 40 of the usual care participants (6.8%).
“This was an evaluation of an intervention to see if it could improve prescribing behavior for three proven, recommended therapies,” Pagidipati said. “It not only is effective, it is also scalable to clinical use in real-world settings.”
In addition to Pagidipati and Granger, study authors include Adam J. Nelson, Lisa A. Kaltenbach, Monica Leyva, Darren K. McGuire, Rodica Pop-Busui, Matthew A. Cavender, Vanita R. Aroda, Melissa L. Magwire, Caroline R. Richardson, Ildiko Lingvay, Julienne K. Kirk, Hussein R. Al-Khalidi, Laura Webb, Tanya Gaynor, Jonathan Pak, Cagri Senyucel, Renato D. Lopes, and Jennifer B. Green.
Pagidipati and Granger receive institutional research support from funders Boehringer Ingelheim and Lilly; a full listing of author conflicts is provided in the study manuscript.
The study was initiated and led by an academic steering committee. The two pharmaceutical funders participated in the design and conduct of the study, interpretation of the data, and review and approval of the manuscript.