University Hospitals Team Presents Innovative and Effective Diabetes Care Plan at National Meeting

UH Clinical Update | August 2023

A team from University Hospitals is piloting a new model of diabetes care that involves “big data,” extensive collaboration with primary care providers and referrals to a range of disease management programs addressing social and clinical determinants of health. Initial results, presented recently by the UH team at the annual meeting of the American Diabetes Association, show that every intervention tried led to statistically significant reductions in hemoglobin A1c among patients with diabetes.

This solution to better manage patients with diabetes is novel in the field – and critically needed, says senior study author Betul Hatipoglu, MD, Medical Director of the UH Diabetes & Metabolic Care Center and Mary B. Lee Chair in Adult Endocrinology.

“What we have done is very, very unique -- no one has ever done it, she says. “We are motivated by the fact that despite having new medications approved, new technology approved, so many of them in the last 15 years, the A1c levels in the United States have gone up rather than down,”

One factor behind these disappointing numbers is what’s known as therapeutic inertia -- the underuse of effective diabetes therapies, Dr. Hatipoglu says.

“In 2020, the American Diabetes Association released its three-year plan to address inertia,” she says. “Barriers such as time constraints, competing demands, lack of knowledge, confusion with current guidelines and lack of experience all contribute to therapeutic inertia, and it exists in both primary care and diabetes specialty services. Plus, diabetes is a team-based disease that needs the team to take care of patients, and not everybody has access to that team. Between 80 to 85 percent of people with diabetes, or even more in some areas in the United States, are taken care of by primary care physicians. To address this, we tackled the gap between a specialty provider and team care and how we can be a bridge to primary care.”

Study Details

For the study, Dr. Hatipoglu assembled a team of UH diabetes specialists, who conducted a chart review of members of the UH ACO or employee health plan whose A1c was over 8.5.

“We then sent the recommendation to their primary care provider, because primary care is still the main person who takes care of this patient, and we asked them if they would agree with our recommendation, and, if so, would they need any help to implement it,” she says. “It was a conversation, just simple messaging.”

Options for recommended care included:

• Multi-program: Referral to two or more diabetes services/pathways
• Primary care: Recommendations to the PCP with no additional programs suggested
• Navigator: Care coordinator offering scheduling and other services
• Endocrine: Referral to an endocrinologist or endocrine APP
• Milestones: Diabetes care and education program for UH employees
• Pharmacy: Phone call or telehealth visit with a pharmacist to cover medication issues and barriers
• CINEMA: Referral to the UH program geared toward people with type 2 diabetes who are high risk of cardiovascular events

Making an Impact

“To date, the collaborative program reached 666 people with diabetes in our ACO and overall results in a significant decrease in A1c,” Dr. Hatipoglu says. “All programs resulted in significantly lower A1c from pre- to post-. The program was well received and adopted by primary care. Our findings highlight the importance of integrating primary care and diabetes specialty care to address therapeutic inertia proactively. I was just beyond myself when I saw those results.”

Of the study participants, 18.6 percent were in the PCP pathway with no referral needed to a team-based diabetes pathway. The most common referral was Multi-program (21.3 percent), followed by Navigator (15.9 percent) and Endocrine (15.5 percent) to optimize medical therapy or diabetes technology that could not be communicated to the PCP.

Collaborating with Primary Care

For Dr. Hatipoglu, one of the best things about this project is generating even more evidence about the wisdom of clinical integration and specialists collaborating more closely with primary care.

“Primary care providers have a very special connection with their patients,” she says. “They are the gatekeepers. They know their patients the best. We can come and suggest to them what we feel is best. But at the end of the day, the primary care and the patient need to be the decision-makers.”

Next Steps

Dr. Hatipoglu and the study team plan next to develop a diabetes care “playbook” for primary care providers so they can continue to build knowledge and manage patients independently. She also envisions incorporating artificial intelligence as an element that can help guide treatment recommendations for patients. As she pursues this work, she looks to continue fruitful collaborations with primary care.

“Effective collaborations between primary and specialty care providers may be complex yet are key to delivering high-quality, patient-centered diabetes care,” she says. “Rather than support the status quo, it is time to innovate new models, evaluate what works and broadly implement those ideas.”