American Diabetes Association (ADA) 75th Scientific Sessions 2015:

Expanding the Role of Clinical Diabetes Educators Intensifies Diabetes Management

The redesign of primary care to improve outcomes in patients with type 2 diabetes was the subject of research performed by Janice C. Zgibor, PhD, RPh, Associate Professor of Epidemiology, Medicine, and Clinical Translational Science, University of Pittsburgh Graduate School of Public Health, Pennsylvania. Dr. Zgibor presented results of her group’s work at the American Diabetes Association’s 75th Scientific Sessions, in Boston, from June 5–9.

Treatment of Type 2 Diabetes Is Suboptimal
Adequate treatment of hyperglycemia, hypercholesterolemia, and hypertension can reduce morbidity and mortality in people with diabetes. Treatment, however, remains suboptimal. The majority of diabetes care is in the primary care setting where opportunities for timely interventions are often missed during office visits.

Redesign of Primary Care Approaches to Type 2 Diabetes
Evidence-based diabetes management protocols were used to deploy a systematic and effective redesign of diabetes treatment approaches in primary care. The cluster-randomized controlled trial employed certified diabetes educators to intensify therapeutic management. Fifteen nonacademic primary care practices were recruited and randomized to either the diabetes management protocol or usual care.

Eligibility criteria included type 2 diabetes diagnosis ≥1 year and a hemoglobin A1C ≥7% or low-density-lipoprotein cholesterol ≥100 mg/dL or blood pressure ≥140/80 mmHg. There were 240 participants enrolled (mean age: 61 years: range 29–87 years, 50% male, 83% Caucasian).

Treatment was intensified according to preapproved protocols, and diabetes education followed the American Diabetes Association standards.

Hemoglobin A1C Decreased with the New Protocol
Hemoglobin A1C decreased in patients receiving the diabetes management protocol (8.8%-7.8%, P<.0001), but not in those receiving usual care (8.2%-8.3%)

Low-Density-Lipoprotein Cholesterol Decreased with the New Protocol
Low-density-lipoprotein cholesterol decreased in both groups but significantly in the group receiving the diabetes management protocol (104.9-88.7 mg/dL, P<.05) vs the group receiving usual care (99.7-90.3 mg/dL).

Blood Pressures Did Not Differ Between Groups
Blood pressure differences were not significant, but the baseline average was130/77 mmHg.

Patients Receiving the New Treatment Protocol Experienced an Intensification of Antidiabetic and Lipid-Lowering Therapy
Preliminary results showed that in patients with hemoglobin A1C ≥8% at baseline, 65% began a new medication or had their therapy intensified at the first visit. Additionally, over the course of the study, 43% started new insulin, while 94% received a dose increase. If blood pressure was ≥140/80 mmHg, 65% had their medication intensified and 56% began a new medication while the remainder had a dosage increase.

If low-density-lipoprotein cholesterol was ≥100mg/dL, 63% had their lipid-lowering medication intensified. Of these, 50% began a new medication, 20% changed statins, and 34% had a dosage increase.

Conclusion
Results of this study provided evidence for expanded roles of certified diabetes educators. Using this model to deliver diabetes care may offer a more effective approach in diabetes management.

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