Coordinated care can improve prescribing practices of recommended diabetes, CVD therapies
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Key takeaways:
- A coordinated intervention in cardiology clinics boosted prescriptions of guideline-recommended CVD and diabetes therapies.
- Researchers plan to scale this intervention across cardiology clinics.
NEW ORLEANS — Implementing a coordinated care intervention in U.S. cardiology clinics led to a fourfold increase in the prescription of three groups of guideline-recommended therapies in adults with type 2 diabetes and atherosclerotic CVD.
“High-intensity statins, ACE inhibitors and angiotensin receptor blockers, and SGLT2 inhibitors and GLP-1 receptor agonists are all proven to improve outcomes for patients with type 2 diabetes and ASCVD,” Neha J. Pagidipati, MD, MPH, associate professor in the division of cardiology at Duke University School of Medicine and member of the Duke Clinical Research Institute, said during a late-breaking clinical trial presentation at the American College of Cardiology Scientific Session. “Consequently, basically all of the guidelines and professional society recommendations endorse the use of these medications in this high-risk population.
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“So, the effectiveness of these therapies is not in question, and yet their use in routine clinical care is astonishingly low. In the U.S., among patients with type 2 diabetes and ASCVD, only 2.7% of patients are on all three of these groups of therapies and over one-third are on none.”
Coordinated, multifaceted intervention
The COORDINATE-Diabetes trial aimed to improve prescribing practices in this high-risk population by improving coordinated care among cardiologists, diabetes care specialists and primary care physicians.
Forty-three cardiology clinics in the U.S. were randomly assigned to provide usual care or implement the intervention, which was designed to remove barriers that prevent cardiologists from prescribing the recommended therapies for high-risk patients.
Pagidipati said the intervention was multifaceted because this is “a complex problem.” The intervention was based on three core principles: assessing barriers at the site level, developing strategies, and audit and feedback.
The six-part tailored intervention was focused on:
- clinic-specific assessment of barriers that prevent or impede prescribing the recommended therapies;
- development of interdisciplinary care pathways to address the barriers, involving cardiologists, diabetes care specialists, pharmacists and others to address access and cost issues;
- coordination of care between clinicians and care teams;
- clinician education via online learning modules and monthly calls;
- patient-oriented education materials; and
- audit and feedback of quality metrics showing real-time data and how their prescribing habits compared with those of other clinics.
Increased prescriptions
The trial enrolled 1,049 adults with type 2 diabetes and ASCVD across the cardiology clinics who were not already taking all three groups of guideline-recommended therapies. The median age of participants was 70 years, 32.2% were women, 16.5% were Black and 8.6% were Hispanic.
At the 12-month follow-up visit, about 37.9% of patients in clinics who received the intervention had been prescribed all three medication classes compared with 14.5% of patients in clinics that received usual care (difference, 23.4 percentage points; adjusted OR = 4.38; 95% CI, 2.49-7.71; P < .001), according to the results.
Patients in the intervention clinics were also more likely to be prescribed each of the three therapies at 12-month follow-up:
- high-intensity statins: change from 66.5% at baseline to 70.7% in intervention group vs. 58.2% to 56.8% in usual care group (aOR = 1.73; 95% CI, 1.06-2.83);
- ACE inhibitors or angiotensin receptor blockers: change from 75.1% to 81.4% in intervention group vs. 69.6% to 68.4% in usual care group (aOR = 1.82; 95% CI, 1.14-2.91); and
- SGLT2 inhibitors and/or GLP-1 receptor agonists: change from 12.3% to 60.4% in intervention group vs. 14.5% to 35.5% in usual care group (aOR = 3.11; 95% CI, 2.08-4.64).
The researchers said the difference between groups was primarily driven by the increase in prescriptions for SGLT2 inhibitors and GLP-1 receptor agonists. Prescriptions for SGLT2 inhibitors and GLP-1 receptor agonists increased in both groups, but prescriptions were more likely in clinics that received the intervention, according to Pagidipati and colleagues.
The secondary composite outcome of death or hospitalization for MI, stroke, HF or urgent revascularization occurred in 5% of the intervention group compared with 6.8% of the usual care group. Although the trial was not designed to assess clinical benefits, researchers said the increased adoption of guideline-recommended best practices may help patients better manage their chronic conditions over time, according to a press release.
Trial participants were recruited from July 2019 to May 2022. Pagidipati said the intervention was delivered remotely due to the COVID-19 pandemic and was, thus, less intensive than originally designed.
“Evidence-based therapies are underused in clinical practice and there is little high-quality data on how to improve this. This multifaceted intervention is effective in increasing the prescription of evidence-based therapies in adults with type 2 diabetes and ASCVD,” Pagidipati said. “The next step is to scale this intervention across cardiology practices that want to improve the quality of care being delivered.”
The researchers also plan to further analyze the data to assess trends in adherence, variation across clinics and the impacts of individual components of the intervention.
Find more information at www.coordinatediabetes.org.
Reference:
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Pagidipati NJ, et al. Joint American College of Cardiology/Journal of the American Medical Association Late-Breaking Clinical Trials. Presented at: American College of Cardiology Scientific Session; March 4-6, 2023; New Orleans (hybrid meeting).
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