Patients with diabetes and heart disease have better outcomes when both conditions are treated using established guidelines, according to a recent Duke study. But the authors concluded that too many patients are not prescribed the most effective therapies.
Designed and led by the Duke Clinical Research Institute (DCRI) and an academic steering committee , the study found that a coordinated care approach between cardiologists and diabetes specialists resulted in more patients receiving the recommended therapies. More than 1,000 patients were enrolled and followed for up to 12 months.
The findings were presented at the 2023 American College of Cardiology scientific meeting in March; the study was published simultaneously in the Journal of the American Medical Association.
“There’s a clear gap between what we know we should be doing and what is actually occurring in clinical practice,” says lead author Neha Pagidipati, MD, MPH, a cardiologist and member of the DCRI. “Our study demonstrates that coordinated, multi-disciplinary care can result in patients receiving the therapies that have been proven effective.”
Pagidipati and colleagues – including senior author Christopher Granger, MD, also a cardiologist and DCRI member – partnered with 43 cardiology clinics across the U.S. as part of a clinical trial titled COORDINATE-Diabetes.
Analysis designed to remove barriers that limit care
The clinics were randomly assigned to provide usual care or to implement a multi-faceted intervention. The analysis was designed to remove barriers that keep cardiology clinicians from prescribing medications recommended for patients with diabetes and atherosclerotic cardiovascular disease, a narrowing of the arteries.
The recommended drug regimen includes high-intensity statins for cholesterol; angiotensin-converting enzyme inhibitors or angiotensin receptor blockers to lower blood pressure and protect heart and kidney health; and, for diabetes along with heart and kidney health, sodium-glucose cotransporter-2 inhibitors and/or glucagon-like peptide-1 receptor agonists.
The intervention required clinicians/clinics to:
- Assess barriers in the clinic that prevent or impede the patients from receiving the recommended prescriptions
- Build interdisciplinary care teams to address barriers, including cardiologist, diabetes care specialists, pharmacists and others to address costs and access issues
- Coordinate care between all participating clinicians and care teams
- Provide clinician education through online learning modules and monthly calls to address questions and concerns
- Provide feedback with real-time data, including comparative reports showing patient prescription numbers across all sites
- Support patients with education tools about why the therapies are important and how they impact health markers.
Among the clinics providing usual care, 14.5% patients were prescribed all the recommended therapies, while 37.9% of patients at the intervention sites received all three prescriptions.
“A 23-percent greater absolute use of three evidence-based therapies shows that coordinated efforts to implement effective therapies can result in markedly improved care,” Granger says. “Given the many treatments that are known to improve health, now the most important need is to generate high-level, randomized evidence to improve the use of these treatments. This is what we did in this trial.”
The study was not designed to measure the impact of the drug regimen on health risks, but an analysis showed that the intervention had a trend of risk reduction that would be expected with better use of the medications studied. Death or hospitalization for myocardial infarction, stroke, heart failure, or urgent revascularization occurred in 23 of the intervention participants (5%) compared to 40 of the usual care participants (6.8%).
“This was an evaluation of an intervention to see if it could improve prescribing behavior for three proven, recommended therapies,” Pagidipati says. “It not only is effective, it is also scalable to clinical use in real-world settings.”
