Swelling Diabetes Population Presents New Challenges

As the diabetic population continues to swell, diabetes care has shifted from being the purview of strictly endocrinologists to a focus for all health care providers.

The implementation of evidence-based interventions has done little to stem the tide of new diabetes cases and improve glycemic control ubiquitously.

The last time the journal Diabetes Care published a systematic review of primary care-based diabetes treatment evidence was in 2001, but governments and private insurance corporations are interested in updated information that separates worthwhile interventions from those that can be discarded.

Recently, a team of researchers conducted a systematic review of randomized controlled trials on the effectiveness of primary care and community-based diabetes interventions. This new study, which was published in the March 2016 issue of Diabetes Research and Clinical Practice, indicates that a few things have changed in the last 15 years.

The authors collected 30 studies examining how providers treating patients with type 1 and 2 diabetes in primary care and community settings handle their care. They excluded patient-only interventions and studies focusing on cardiovascular risk factors, in addition to HbA1C, systolic blood pressure, and total or low-density lipoprotein (LDL) cholesterol.

The researchers found some significant trends. For one, multifaceted interventions involving multiple members of the patient care team are much more effective than targeted interventions delivered by a single clinician. Diabetes care needs to be a team effort.

Professional education alone does not stimulate health care providers to prescribe treatments that produce clinically meaningful HbA1C, blood pressure, or LDL cholesterol reductions. Primary care providers indicated that diabetes management costs, insufficient time, patient refusal of insulin, and lack of financial incentives are barriers to effective care.

Financial incentives to providers do not work unless they were coupled with other interventions like clinical reminders and telemedicine. The researchers indicated that these interventions need to be used in concert, and that requires organizations to make large-scale changes.

So, what does work? Interventions are most effective when each and every provider applies his or her specific expertise, reinforcing messages at every visit. For pharmacists, those areas of expertise include counseling patients, providing medication updates to prescribers, and addressing adherence directly with (and providing support to) patients.

Highly effective interventions to improve diabetes care must involve multiple members of the care team in various ways to spur collaboration. Collaboration and organizational change are needed to improve glycemic control on a population-wide level.