Team-based telehealth approach improves medication use in high-risk patients with diabetes
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Key takeaways:
- A remote, team-based approach was effective at getting high-risk patients with diabetes to take medications.
- Initiating medications immediately was more effective than waiting until after an education period.
ATLANTA — A remote, team-based approach with immediate initiation of necessary medications improved guideline-directed medical therapy use at 6 months for patients with diabetes at high CV or renal risk, researchers reported.
For the DRIVE trial, presented at the American College of Cardiology Scientific Session and simultaneously published in Circulation, Alexander J. Blood, MD, MSc, FACC, associate director for the Accelerator for Clinical Transformation and attending physician in cardiovascular medicine and critical care at Brigham and Women’s Hospital and Newton-Wellesley Hospital, and colleagues randomly assigned 200 patients with type 2 diabetes and elevated risk in the form of presence of or elevated risk for atherosclerotic CVD, HF with reduced or preserved ejection fraction or chronic kidney disease (mean age, 67 years; 37% women; 12% Black) to one of two remote team-based approaches: education for 2 months followed by medication management or simultaneous education and medication management. In both cases, the team was led by a navigator, backed by a pharmacist and overseen by a physician.
Use of remote team
“What frequently happens in outpatient practices is if a patient wants to take some time to think about their medicine or understand their insurance coverage, we provide educational resources and guidance and schedule an appointment for down the line where we can address their questions and at that point prescribe therapy, and we wanted to see the effect of immediate prescription on that paradigm,” Blood told Healio. “We also wanted to see if using this remote team is an effective way to identify, educate, prescribe and get people taking therapies that we know improve outcomes in patients with type 2 diabetes and elevated cardiovascular or kidney risk.”
Patients already taking an SGLT2 inhibitor, a GLP-1 receptor agonist or short-acting insulin were excluded, as were those with a history of severe hypoglycemia or diabetic ketoacidosis.
Blood said during a presentation that the medication algorithm was as follows: Patients with chronic HF or chronic kidney disease got an SGLT2 inhibitor if estimated glomerular filtration rate (eGFR) was 25 mL/min/1.73 m2 or more (with increased monitoring if eGFR was 25-45 mL/min/1.73 m2) or a GLP-1 receptor agonist if eGFR was less than 25 mL/min/1.73 m2, whereas the same was true for patients with ASCVD or at high ASCVD risk except patients with eGFR 25 mL/min/1.73 m2 or more without a history of pancreatitis could get either drug class, with the decision based on their medical history.
The primary outcome of initiation of SGLT2 inhibitor or GLP-1 receptor agonist prescription at 6 months occurred in 70% of the simultaneous arm and 56% of the education-first arm (P < .001), Blood said.
The incidence of reporting taking an SGLT2 inhibitor or GLP-1 receptor agonist at 6 months was 59% in the simultaneous arm and 44% in the education-first arm (P < .001), he said.
At 2 months, 26% in the simultaneous arm and 4% in the education-first arm were taking an SGLT2 inhibitor and 17% in the simultaneous arm and 2% in the education-first arm were taking a GLP-1 receptor agonist, whereas at 180 days, 33% in the simultaneous arm and 25% in the education-first arm were taking an SGLT2 inhibitor and 19% in the simultaneous arm and 18% in the education-first arm were taking a GLP-1 receptor agonist, he said.
In the overall cohort, between baseline and 6 months, mean HbA1c declined from 7.3% to 6.9% (P < .001) and mean weight declined –3.4 kg (P < .001), with no differences between the groups, according to the researchers.
‘Strike while the iron is hot’
“Looking at the program window, we were effective” at getting patients to take guideline-directed therapies, Blood told Healio. “What we saw was a little bit different from what we were expecting at the start of the trial. We didn’t see as many patients [from the education-first group] accepting therapy or on therapy, either at 2 months or at 6 months. We expected that the simultaneous arm would be ahead at 2 months, but in the intervening 4 months, we thought there would be a catch-up or a crossing of the curves, where the patients who were getting more intensive coaching would be more comfortable with the medications. But we found the opposite: Strike while the iron is hot. These patients are activated and engaged with the education, so make sure you are not only providing them with the right resources, but also doing the medication management at the same time, which ends up getting more people on therapy, both in short order and over the course of 6 months.
“This is a scalable approach to chronic disease management,” Blood told Healio. “We have proven this out in hypertension, hyperlipidemia and heart failure. We are now expanding to additional disease states, and hope to expand to additional sites soon. Patients with type 2 diabetes with high cardiovascular or kidney risk are among those who can see benefit from a program like this. The strategy of waiting and following up is not as effective as managing medications off the bat.”
Editor’s note: This article was updated on April 12, 2024 to reflect changes requested by Dr. Blood, including updates to the data.
Reference:
For more information:
Alexander J. Blood, MD, MSc, FACC, can be reached at ablood@bwh.harvard.edu; X (Twitter): @ajbloodmd.
Perspective
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Edward T.A. Fry, MD, FACC, FSCAI
The take-home message is that if you do the simultaneous initiation of therapy instead of the step approach, you get quicker uptake of guideline-directed medical therapy. It appears that if follow-up was longer, the curves would probably have come together. It’s somewhat intuitive that if you don’t use up that lead-in time solely for education, you get to the results 2 months quicker.
This is another example of how team-based care is superior to the traditional model, and how you can initiate therapies quicker with it. I interpret this study as an endorsement of a novel operational approach more than anything else.
I would have liked to see cost data. It may be less expensive for the patient to implement things in this way because they do not have one or two office visits that they otherwise would.
Perspective
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Using a novel team-based approach of MD, pharmacists and patient navigators, this study was able to show success at prescribing diabetes medications known to reduce CV risk. The traditional care model has limitations because of long wait times to see doctors as well as short time allotments to meet with the doctor. The benefit of this approach is that it could allow for more patients to get prescribed medications that are known to reduce risk for CV events. The researchers had two study groups, one that received education first and a prescription later and a second that did both at the same time. They showed that doing both education and prescribing at the same time is more effective.
There are many novel approaches being considered to increase the ability to prescribe CV risk-reducing medications. This is one approach that integrates team-based care and allows for clinic spaces to better meet patient demands. Other considerations, including the integration of artificial intelligence, are underway.
A system like this would require a great deal of hiring of patient navigators. This could be a large resource, which would require a large amount of money to get underway. I see this as being feasible for larger health systems with some of these supports already in place. However, the care delivery would have to be guaranteed to work into current ways that patient care is reimbursed by insurance. I do not see any comment on this by the authors, but this is an important point.
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Blood AJ, et al. Featured clinical research II. Presented at: American College of Cardiology Scientific Session; April 6-8, 2024; Atlanta.
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