Q&A: Patient-centered focus should be core of diabetes management
Click Here to Manage Email Alerts
Key takeaways:
- A new position statement focuses on making patient experiences a key component of diabetes care.
- The statement includes recommendations on communication, telehealth, technology, therapies and more.
Making people with diabetes the center of all aspects of diabetes management is the focus of a new position statement published by the Endocrine Society.
On Feb. 21, the Endocrine Society released a position statement in The Journal of Clinical Endocrinology & Metabolism that discussed the importance of making patient experiences an integral part of diabetes management. The position statement was released following a series of diabetes consensus roundtables with representatives from major professional, governmental and patient advocacy organizations and social enterprises. According to the authors, the goals of the roundtables were to recognize existing gaps in diabetes management, build a consensus around a comprehensive approach to address those gaps, identify tools to empower providers and people with diabetes to address the challenges they face, and evaluate how technology can improve diabetes management for people with diabetes, their caregivers and providers.
The position statement focused on nine topics: patient-provider communication, psychosocial conditions in diabetes, diabetes self-management education and support, navigating therapeutic options, therapeutic inertia, risk reduction for cardiovascular disease and microvascular complications, hypoglycemia prevention and management, telehealth and technology integration.
“We designed the format of the statement by beginning [each section] with a patient scenario,” Rita R. Kalyani, MD, MHS, professor of medicine in the division of endocrinology, diabetes and metabolism at Johns Hopkins University School of Medicine and the chair of the position statement, told Healio. “The starting point for any discussion is the experience of the person living with diabetes, and then using that starting point for our clinical recommendations and our follow-up. It is important for us, as health care providers, to keep that in mind.”
Healio spoke with Kalyani about the importance of patient-centered diabetes management, better communication with people with diabetes, and practical tips for providers.
Healio: Why was it so important to release a position statement focused on patient-centered diabetes care?
Kalyani: The Endocrine Society assembled the writing group for this position statement recognizing that while we’ve had many developments in the treatments that we can offer to people with diabetes over the past decade, we continue to have gaps in our care between what our clinical guidelines recommend and what we’re able to implement in clinical practice. This is reflected by the fact that more than 500 million people live with diabetes around the world. We also know that as the number of people with diabetes grows and as people with diabetes live longer, the complications from diabetes will impose an additional personal and societal burden.
As clinicians, we are also well aware that, unfortunately, many people with diabetes don’t meet the metabolic goals that ideally would be needed to attain optimal health. This position statement was needed to address that gap, to better understand why, given the ever-changing landscape of increasing drugs and technologies and diabetes self-management programs available, we continue to observe this gap in what is recommended by our clinical guidelines and what is actually able to be implemented in practice. Acknowledging the patient experience and understanding the challenges they face on a day-to-day basis is important to ultimately attain the mutual goal of attaining optimal health outcomes for people with diabetes.
Healio: What are some ways providers can help foster two-way communication with patients?
Kalyani: There are multiple ways health care providers can foster effective communication with people who have diabetes. The first is through the use of patient-centered language. In the statement, we describe how patient-centered language focuses on the person with diabetes as opposed to their disease.
As an example, we don’t recommend use of the term “diabetic person,” which labels an individual by the disease they have. Instead, we say, “a person with diabetes” and/or “a person who has diabetes.” Another example might be using terms that might not be understandable for people who are not in the field, such as HbA1c, and instead describing what that is in a patient-centered manner, such as a reflection of blood glucose for the past 3 months.
The other aspect we highlight are different techniques health care providers can use to foster effective communication. The first, which I also use in my practice, is the teach-back technique. This simply asks the person with diabetes to repeat the information back that you have communicated to them in their own words, to ensure that they understand the clinical recommendations and can ask any questions they may have at that time.
Another common method is motivational interviewing. It’s a more guided-style of communication that focuses on the person’s desire to change, helping them plan step toward the change or focusing on a specific behavior, such as losing weight. There are resources out there, such as videos and interviewing scripts, that are available through many different organizations to help foster effective communication.
Healio: How does this position statement address telehealth? Are there certain people or situations where an in-person interaction may be better than a telehealth appointment?
Kalyani: With the COVID-19 pandemic, many of us realized that telehealth provided a modality by which health care providers could continue to see people with diabetes in follow-up and circumvent some of the concerns during the pandemic about in-person visits. It also allowed greater accessibility to people who might be living in more rural areas to see their health provider without necessarily having to deal with the transportation or the financial barriers. There are many benefits to telehealth that we all witnessed during the pandemic.
That being said, we know that not everyone with diabetes is able to benefit from telehealth. People who may not have reliable access to the internet or don’t have digital literacy were individuals that weren’t able to benefit from telemedicine. In some ways, telehealth further highlighted disparities in care. Some people have called digital literacy and internet connectivity an additional social determinant of health that needs to be addressed.
In addition, there are some people for whom telehealth may not be appropriate. We do highlight questions that a health care provider can consider before scheduling a telemedicine visit. A few straightforward questions are: Does the person have secure and reliable internet connectivity? Are they able to upload their diabetes technology data to the cloud? Is telemedicine affordable? Is this going to offer a new financial burden for the person if they have to get internet access or get a more reliable connection?
There are also circumstances where, even if those questions all are satisfactory, you might still not want to do telemedicine. For people who actually need to be examined because they have changes on their foot as we describe in the clinical scenario as an example, or some other physical finding, telemedicine may not be appropriate.
Healio: Why are some people not referred for diabetes self-management education and support?
Kalyani: It is well recognized that diabetes self-management education and support is important to help people with diabetes meet their health care goals, and there is an increasing availability of programs to support people with diabetes. Yet many people who could benefit from these services aren’t able to realize the benefits of those programs.
Many factors can contribute to that. One might simply be not having the awareness that the programs are out there. The first step is just knowing who the diabetes educators are in the area and where diabetes self-management education and support programs are available. If you’re in an academic institution and you have such programs available right on-site, that’s wonderful. But for the vast majority of health care providers, that may not be the case.
Another challenge is that people with diabetes may have an array of barriers themselves to accessing these services, such as a lack of financial resources or having to book another visit to another health care provider when time off work might already be limited. If programs are not near a person’s home, that can also prevent them from accessing these services. There are challenges both for the provider and people with diabetes in terms of accessing these services. We highlight several available resources to promote referrals to diabetes self-management education and support programs that can help, such as online directories of local programs and diabetes self-management education and support toolkits. Nonetheless, many of these are underutilized. Throughout the statement, we hope by highlighting the resources available to facilitate patient-centered care that we can increase their uptake.
Cultural factors are important to mention. There have been studies in the Hispanic and Latino community demonstrating that people with diabetes had difficulty implementing self-management behaviors due to language barriers. That, too, needs to be taken into consideration in the referral process and implementation of diabetes self-management education and support programs.
Healio: How can providers make sure that people who are using diabetes technology are comfortable with their device?
Kalyani: Diabetes technology and all of the therapeutic developments we’ve seen over recent years are exciting in terms of what can be done to improve quality of care and health outcomes for many people with diabetes.
That being said, technology is constantly changing. Even when a person with diabetes or caregiver might be comfortable with the current device, it requires a whole new learning process when there are updates or when there’s new device integrated into care. It behooves us as health care providers to ensure not only that we are familiar with the latest technological developments, but also that our patients feel comfortable using it, because they truly are the ones that will be monitoring and utilizing these devices in their day-to-day routines at home.
Some ways people with diabetes can feel more comfortable with their device is by ensuring they meet with a diabetes care and education specialist. We are part of a comprehensive team, and it’s important that the person with diabetes receives education on how to use their device from the beginning. They need to be aware of how to set the alarms on their [continuous glucose monitor] for highs and lows. They need to be aware of how to look at the trend arrows, to interpret whether their blood sugars are going high or low, and they need to be aware of what to do about those trend arrows, especially if the trend arrow is going low and into a range where it might be concerning for development of hypoglycemic symptoms.
Healio: What other areas of the position statement are important to highlight?
Kalyani: One area is hypoglycemia. We know that certain medications, such as insulin or sulfonylureas, can put people at higher risk for hypoglycemia. Hypoglycemia has been identified as one of the top three preventable serious adverse drug effects in the U.S. As health care providers, this is something we need to educate patients about, especially if they are on these medications that put them at higher risk. Also, we need to be identify and address hypoglycemia when we are reviewing blood glucose numbers, because it can be acute, rapidly progress and have serious consequences if not treated promptly
Another area is therapeutic inertia, which includes both provider inertia and patient inertia. When a person with diabetes doesn’t have follow-up, or you don’t see them more than once a year or twice a year, it can lead to gaps in our ability to attain metabolic targets. That’s also a common theme that, regardless of whatever regimen people are on, that therapeutic inertia needs to be addressed and minimized.
Lastly, we also highlight the challenges of navigating therapeutic options. We have so many newer therapies on the market that can protect or prevent the development of CVD, kidney disease or heart failure. These are exciting developments, but it can also be overwhelming for both providers and people with diabetes. Addressing how to best navigate the different therapeutic options, understanding what the person with diabetes’ daily routine is like and what side effects they might specifically be at risk for are all important to make them feel comfortable taking all their medications at home. Fortunately, many existing tools are available to help the busy health care providers and people with diabetes address these areas in clinical practice. However, in the ever-changing landscape of diabetes care, there is a need for continued adoption, dissemination and development of practical tools that can facilitate the delivery of patient-centered care to attain desired health outcomes for all people with diabetes in the future.
For more information:
Rita R. Kalyani, MD, MHS, can be reached at rrastogi@jhmi.edu.
Reference:
Kalyani RR, et al. J Clin Endocrinol Metab. 2024;doi:10.1210/clinem/dgad745.
Collapse
Healio Interviews
Click Here to Manage Email Alerts