May 22, 2019 11:43 am Michael Devitt – Despite ample evidence that a collaborative, multidisciplinary team-based approach to managing type 2 diabetes that incorporates patient self-management leads to better outcomes than methods that rely largely on the expertise of a single clinician, research on how this model performs in the primary care setting -- particularly in rural communities -- has been limited.
Now, results of a recent study published in the Southern Medical Journal show just how effective such an approach can be in the hands of family physicians and other health care professionals working in a rural setting.
The study involved an intensive diabetes clinic set up in the Department of Family Medicine at West Virginia University School of Medicine in Morgantown that featured an interdisciplinary team consisting of an attending family physician, a family medicine resident, a pharmacist, a psychologist, a certified diabetes educator/dietitian, a case manager and nursing staff.
Study participants were referred to the clinic by their primary care physician with a new or established but poorly controlled diagnosis of diabetes or a hemoglobin A1c level of 9% or greater. Patients met individually with team members in succession, rather than as a group, and essential health information gathered was posted on a whiteboard to ensure completion of all necessary tasks.
A new study in the Southern Medical Journal highlights the effectiveness of a team-based approach to managing diabetes in a rural primary care setting.
This approach led to significant reductions in blood glucose levels, with results lasting as long as 18 months in many patients.
The study's lead author told AAFP News that under the right circumstances, the model could be used in a variety of settings.
Initially, a member of the nursing staff administered a survey to determine each patient's diabetes self-care knowledge and obtained basic health information. Next, the entire team huddled to determine the order in which to assign team members to see patients. Team members typically saw patients in pairs, with each member performing specific tasks and assessments.
After gathering that additional information, the team huddled a second time to discuss potential barriers to care and create a plan of action. The attending physician and resident then discussed the plan with the patient, answered any questions and scheduled two followup visits about a month apart. A case manager contacted the patient between visits to field additional questions or address other needs.
After the third visit, and if the patient's HbA1c level had decreased or no further interventions were planned, the patient "graduated" from the clinic and returned to usual care with his or her PCP.
Between June 2014 and October 2017, 94 patients with an HbA1c of 9% or higher attended an initial visit and at least one followup appointment within six months. Participants followed up with a third appointment about 18 months after their initial visit. Fifty-four percent of patients were female, and the mean age was 57.
The researchers found a significant reduction in median HbA1c levels at two points: from 10.25% at the initial visit to 8.7% at the first followup appointment, and from baseline to 8.4% at the most recent appointment any time between six and 18 months after the initial visit. Overall, 86% of patients showed a reduction in HbA1c levels at followup.
In addition, about one-third of patients completed self-care surveys both at baseline and followup. Two-thirds of these patients reported improvements in self-care knowledge, and the researchers found an association between HbA1c reductions and improvements in self-care scores.
The authors said their findings indicated that an interdisciplinary team-based approach to diabetes management not only demonstrated sustained reductions in HbA1c over a period of 18 months, but they also produced a lasting effect on patient self-care and knowledge and showed that the model could succeed in a rural primary care setting. Widespread use of the model, they speculated, "could have a dramatic impact on complication rates and subsequent health care costs" related to diabetes.
The authors also acknowledged the contributions of the pharmacist, care coordinator, dietitian and psychologist in patient self-care and knowledge of diabetes. Without their support, the researchers noted, it was "unlikely that the interdisciplinary team model can be duplicated in rural primary care."
Based on their findings, the authors called for additional research to evaluate the model and find the most efficient and effective ways of making the model more easily available.
AAFP News spoke with Dana King, M.D., M.S., chair of the Department of Family Medicine at WVU and the study's lead author, about his research. His comments are reflected in the following Q&A.
Q: What triggered the decision to pursue this area of research?
A: West Virginia has a high rate of diabetes; it is very prevalent in our patient population.
Q: What is the typical approach to managing diabetes?
A: Most of us learned to treat the patient at an individual visit every one to three months, focusing on brief counseling regarding lifestyle changes, referral of the patient to a dietitian and prescribing medications. Unfortunately, a good proportion of patients do not respond to these measures for varying reasons, including (not) understanding the lifestyle changes, poor adherence or understanding of the medications, not following a diet plan, or depression/anxiety interfering with being able to address diabetes adequately.
Q: What prompted the decision to use an interdisciplinary team model in this study?
A: We were aware of similar interdisciplinary models in specialty clinics for diabetes, COPD, cystic fibrosis and other conditions, but none of us had really seen the model applied to diabetes in a primary care office.
Q: What were the benefits and drawbacks of having health care professionals from different medical fields treat the same problem?
A: The benefits of the clinic were huge, including improved education of the patient and the often dramatically improved control of diabetes that occurred. Sometimes the improvement seemed to be the result of a big change in diet, sometimes a result of starting insulin or other medication, and sometimes behavioral change or reduced stress. In almost all cases, it was hearing the same message from different perspectives that seemed to connect with patients and trigger the change.
The drawback is that the visits take an hour of the patient's time and a committed afternoon clinic from several health professionals on our team. Also, often, the only person able to do billing is the physician because Medicare and other insurance frequently do not allow multiple bills from the same clinic on the same day for one patient.
Q: What, if any, effects did this approach to diabetes management have on team members?
A: The pharmacist, the dietitian, the psychologist, the care coordinator nurse, the physicians -- all of them give the clinic high marks as far as personal satisfaction.
There is a subjective camaraderie among the team members that goes well beyond that one afternoon a week. When I am away or out of town, team members literally welcome me back on that clinic afternoon and always mention I was missed.
Q: How and where do you see these results being replicated?
A: We tested this model in a rural academic clinic, but it could be replicated in rural federally qualified health centers or other larger rural clinics and could even be suitable for adaptation in non-rural academic primary care clinics.
If a dietitian, pharmacist, mental health provider, nurse and physician are available at a single site on the same day one day a week, then the model could be replicated many places. Regional or community clinics could work together to offer this type of service for patients with diabetes that is difficult to get under control.
The resources are there for this to be happening quickly in some places, and with more planning in other sites.
Q: Anything else you'd like to add?
A: The clinic has been a positive experience for the providers involved also. All the team members look forward to this clinic, they enjoy working together, and it has become a real antidote to professional burnout. It's been fun! It has been very gratifying to see so many patients do better.