New diabetes treatment strategies for primary care to boost patient adherence

About 25.8 million U.S. children and adults  have diabetes. In 2013, diabetes accounted for $176 billion in direct medical costs. Part of the aim of the Affordable Care Act is to reduce these costs while improving the management of chronic conditions. Achieving these goals, however, requires primary care practices to update their strategies for keeping patients with diabetes healthy.

Perhaps the greatest challenge for primary care physicians (PCPs) practicing in the era of accountable care is meeting quality and outcomes targets that are dependent on patient behavior.

Of particular concern to many PCPs are the health issues faced by obese patients with diabetes, says Molly Cooke, MD, immediate past president of the American College of Physicians and a practicing internist. That’s because helping these patients-and meeting quality goals-usually requires the patient to make difficult behavioral changes such as losing weight and exercising more.

Like most PCPs, Cooke is always looking for creative ways to engage patients with diabetes. But patients’ feelings of frustration and denial about having a chronic condition often get in the way.  

“I wish we understood better how to get people fired up about their chronic illness,” she says. “The contrast for me comes from my early experience taking care of people with human immunodeficiency virus (HIV). They were [angry] that they had HIV and many of them fairly skeptical about their physicians. … I usually found that I could take that energy and really focus it on what the patient needed to do well.

“I began wondering why patients with diabetes often have an almost fatalistic attitude about their diabetes, and wishing I could transplant some of my HIV patients’ energy into my diabetic patients,” she adds. “I’m sure that there are ways to do that, but in general as doctors, we are not very good at it.”

Physicians have learned in recent years that some communication techniques are better for motivating healthy patient behavior than others. For example, motivational interviewing is becoming an increasingly popular technique for working collaboratively with patients to identify and overcome barriers to compliance. So instead of lecturing or arguing with patients about the need to improve their habits, Cooke recommends “really listening to the patient and exploring with him or her in a supportive way what the patient would need to do to accomplish the change.”

Leverage positive peer pressure

But while it’s important for physicians to recognize the flaws in medicine’s historically paternalistic approach, not all patient motivation has to come from the doctor. Wielding an often stronger influence over patients with diabetes are their peers. For that reason, shared medical appointments can be particularly beneficial for this population, says Cooke.

“Patients will often be a little firmer with each other than we’re sometimes comfortable being,” she says. “They’ll say, ‘We all have the same problems-we’re all taking care of our grandkids after school, we’re all busy, we’re all worried about taking walks in the neighborhoods we live in-but here are four different approaches to this issue that have been brought up in this group, so there are things you could try.’”

Daniel Spogen, MD, a member of the American Academy of Family Physicians’ board of directors and a practicing family physician in Reno, Nevada, has also used shared visits in his practice and touts their benefits. Not only can patients struggling with similar challenges give one another practical advice, he says, but their discussions can also be eye-opening for physicians. For example, he realized during a group visit that many of his patients didn’t understand the explanation he had been giving about what hemoglobin A1C levels meant, leading him to clarify the way he taught the concept.

Spogen does have a caveat about group visits, however. “There’s one kind of funny thing that happens. The people that are the best controlled really like to come to those group visits, though we’d really like to see more of the people with the worst control show up,” he says.

Nonetheless, group visits also help address physicians’ ever-increasing constraints on the amount of time they can spend with patients.

Team-based care can improve outcomes

Another efficiency booster for primary care practices is team-based care as part of the patient-centered medical home (PCMH) model.

Pediatrician Jeanne Marconi, MD, says her practice, the Center for Advanced Pediatrics in Norwalk, CT, has embraced PCMH ideals since before an official model existed. “We have a full complement here,” she says. “A newly-diagnosed diabetic patient, for example, will not only see the physician, but there’s also a nurse practitioner (NP) involved, as well as a social worker and nutritionist, so there’s really a team model. Everybody has a piece in the care.”

But to truly make the most of the model, strong communication and coordination among all team members is essential. While some of this communication is automated through electronic health records, Marconi’s practice deliberately carves out time for providers to meet face-to-face.

“In our practice we book out two hours every week we don’t see any patients, so groups can meet and work on recall or kids that need extra help,” she says. This time is uncompensated, Marconi notes, but it allows practitioners to talk about patients’ needs depending on their levels of disease control and compliance. “If it seems like the sugars really aren’t in control, they’ll spend more time with the NP and nutritionist adjusting the insulin levels.”

Spogen and Cooke agree that PCPs can realize substantial value by delegating much of the work that goes into keeping a diabetic patient engaged. “If you have a PCMH, you’re still managing the patient [as a physician], but you’re utilizing the skill sets of others around you,” Spogen says. “With my patients with diabetes, for example, I’m probably not the best person to talk with them about nutrition, but a nutritionist can sit with them one-on-one and get them to understand things better.”

Cooke adds that it’s a mistake for the physician to try and do everything for the patient. She recognizes, however, that not all physicians work in large academic centers, as she does, with ready access to nutritionists, psychologists, and diabetes educators.

For practices with more modest resources and staffing, she recommends referring patients to community or even online resources for extra support and motivation. The American Diabetes Association provides numerous online resources for patients, while wearable devices such as Fitbit allow patients to track their accomplishments and get reinforcement from a virtual community.

Keep quality targets in perspective

Physicians aren’t compensated directly for the time they spend managing and coordinating diabetic patients’ care, but their reimbursement increasingly depends on meeting certain quality and outcomes metrics.

In general, the arrival of clinical measures has changed healthcare for the better, says Spogen, though he notes some problems. “On one hand it’s good that things like Healthcare Effectiveness Data and Information Set measures are forcing us to look at certain things, but on the other hand, sometimes you kind of lose the forest for the trees because now you’re looking at all these individual measures and you’re forgetting about how the patient is doing.”

For example, one of Spogen’s patients with diabetes, who is in his late 70s, tends to have an A1C level in the mid-8s, which is higher than the recommended level. But every time the patient’s level drops lower, he runs low blood-sugar reactions and ends up in the hospital.

“So it’s really nice to know I’m not making my goal. But there’s a good medical reason we’re not making that goal, because we’d kill him if we did,” Spogen says. “The insurance company doesn’t care. … But in his case it’s healthier for him to run higher.”

Marconi voices similar frustrations with inflexible quality measures. “Health plans are just looking to see if the number is are just looking to see if the number is done, but they’re not always interested in what that number means for that child,” she says. For example, a pediatric patient’s numbers might show poor control during a growth spurt. “But for that child it might be a normal progression.”

In addition, Marconi says that she often finds herself in a catch-22 with insurers when it comes to meeting quality targets.

“Sometimes I’ll get a letter telling me a patient’s hemoglobin A1C is out of whack. Then I do my job by bringing the kid back a bunch of times, getting them to a nutritionist, and the payer tells me I have too many visits of a level four,” she says. “It’s like the right hand doesn’t really talk to the left, hand, and that’s where I think value-based and that’s where value-based care might cause a lot of trouble.”

Spogen also notes that payers’ targets often don’t keep up with changes in clinical guidelines, such as what constitutes a problematic A1C level for patients over age 75. “It’s recommended not to worry about their 0 unless it’s over 9, where most insurance companies are still sticking to trying to get them below 7,” he says. “When payers dictate care, there’s a problem.”

But at the end of the day, physicians must remember that they are in charge of patient care.

“As we jokingly say, these are guidelines,” Spogen says. “They’re not law. If you know where guidelines should be and you’re not reaching them for a reason, that should be okay. That’s good medicine.”