Podcast 3: Collaborative Care to Improve Cardiovascular Outcomes in Type 2 Diabetes

00:00:00: You are listening to an ADIS journal podcast.

00:00:05: Hello, this is Nehaar Desai.

00:00:07: I'm an associate professor of medicine and vice chief for the section of cardiovascular medicine at The Yale University School Of Medicine in New Haven Connecticut.

00:00:16: Welcome to episode three of this podcast series exploring heart failure detection diagnosis management For endocrinologists primary care physicians And non cardiologist clinicians.

00:00:28: i'm joined again by dr Right and Dr.

00:00:31: Enzuki to discuss the collaborative care model, specifically how it can improve outcomes in patients with type two diabetes.

00:00:39: please introduce yourselves.

00:00:40: Hello again.

00:00:41: my name is Eugene Wright.

00:00:43: I'm a consulting associate at Duke University and serve as medical director for performance improvement here

00:00:56: And I'm Sylvia Onzuki, I am clinical chief of the section of endocrinology at Yale School of Medicine and medical director for the Yale Diabetes Center in Yale New Haven Hospital.

00:01:07: In previous episodes we discussed how heart failure is a common and sometimes underappreciated complication.

00:01:13: type two diabetes that patients with type II diabetes often have multiple comorbidities including chronic kidney disease or obesity are in fact all interconnected and can culminate in the so-called cardiovascular kidney metabolic syndrome.

00:01:32: This means that patients with type II diabetes, often engaging multiple healthcare professionals with different specialties And therefore effective health care collaboration may help improve patient care.

00:01:45: Eugene as an experienced primary care physician.

00:01:48: what is collaborative for patients with Type II Diabetes and Cardiovascular complications look like to you?

00:01:55: Thank you, Nihar.

00:01:56: In the majority of cases primary care physicians are likely to be the most common point-of contact for patients with type II diabetes and therefore they play a vital role in early detection of cardiovascular and kidney disease in these patients and well placed to coordinate collaborative person centered care.

00:02:17: The aim is for core multidisciplinary team including primary care cardiologists endocrinologists, nephrologists and others as necessary to provide holistic care for patients with multiple comorbidities rather than treating each disease separately.

00:02:35: And this is in line with the collaborative care approach recommended in Diabetes & Heart Failure guidelines.

00:02:42: As we discussed in a previous episode, patients with diabetes and heart failure usually have to make wholesale lifestyle changes such as losing weight increasing physical activity and smoking cessation, as well is potentially taking multiple medications.

00:02:59: Because of this collaborative care for these patients can also include dieticians pharmacists nurses advanced practice professionals And community support workers to support the patient's with barriers to self-care and To improve adherence to lifestyle modification and medication programs.

00:03:21: Yeah Eugene, I'm just going to build a little bit on that.

00:03:22: I think effective management of heart failure particularly in patients with diabetes really requires that comprehensive coordinated approach integrating multidisciplinary strategies to prevent progression of hard failure improve medication adherence and reduce hospitalizations.

00:03:39: Hospitalizations are common for patients with heart failure And there's a high risk of readmission following hospitalization.

00:03:49: There's a strong association between recurrent hospitalizations for heart failure and mortality.

00:03:55: And, For those with chronic heart failure, Mortality risk is greatest after discharge from a prior hospitalization for Heart Failure.

00:04:04: However studies have shown that most hospitalizations in patients With heart failure are not for heart Failure or cardiovascular causes.

00:04:13: This has also seen in clinical trials where a large proportion of hospitalizations in heart failure trials are not related to heart failure.

00:04:22: In patients with heart failure, A greater number of cardiometabolic comorbidities such as diabetes obesity and hypertension Are associated With an increased risk Of all-cause hospitalization.

00:04:34: This really highlights the clinical relevance of Hospitalizations As a marker of disease progression And reinforces The importance of prevention and heart failure-specific hospitalizations to improve outcomes for patients with diabetes.

00:04:50: In terms of strategies to reduce hospitalization, one part of that is medications.

00:04:56: however low medication adherence among patients with heart failure Is known To be a very common problem leading to worse outcomes.

00:05:06: in fact studies Of medication adherents in patients With hard failure have used interventions such as telemonitoring patient education and counseling, nurse-and pharmacist led counseling interviews.

00:05:19: And support medication adherence.

00:05:21: intervention can significantly reduce the risk of hospitalization in death in patients with heart failure.

00:05:28: several studies have also found that standalone and multidisciplinary intervention strategies such as medically tailored meals Heart Failure clinics telemonitoring were all effective In reducing all cause mortality and hospitalization for heart failure but had less clear benefit on all-cause hospitalization.

00:05:48: I think what this all demonstrates to me is the importance of a holistic approach to patient care, to treat the whole person and use interventions to reduce risk across the board.

00:06:01: You know it's also worth mentioning that this collaborative approach is achievable even for primary care physicians practicing in rural communities who may not have access large multidisciplinary health centers.

00:06:15: They can participate in virtual collaboration, as well as telehealth and digital health interventions which have been shown to improve outcomes for heart failure patients in underserved rural areas.

00:06:27: These approaches can also be used to spread information about proactive management of heart failure and raise social awareness of the risk of heart

00:06:35: failures.".

00:06:37: You know I might add that a really important part between physicians and other healthcare professionals.

00:06:47: So Eugene and I typically see patients with diabetes break risk for developing symptomatic heart failure, here's what a coordinated care approach

00:06:56: might look like

00:06:58: the primary care physician diagnosis type two diabetes in their patient.

00:07:01: initially they will work with the patient to implement lifestyle modifications.

00:07:13: The patient may then be referred to someone like me, an endocrinologist for a number of reasons.

00:07:17: It could the initial go at controlling blood glucose was just not successful despite combination therapy.

00:07:25: The PCP might want some advice on that next step.

00:07:30: Sometimes referrals stem from side effects from conventional medications.

00:07:36: We're often most helpful as endocrineologists and more complex patients particularly those in insulin especially if more than just basal insulin is required.

00:07:48: The endocrinologist then might develop a new treatment plan focusing on controlling blood sugar and perhaps extending to other cardiovascular risk factors.

00:07:59: This is often done in collaboration with the Certified Diabetes Care & Education Specialist or CDCES.

00:08:08: Those are formally referred to as CDEs, or certified diabetes educators.

00:08:14: So these individuals will work closely with the patient to provide personalized education and helping them to individualize the treatment plan to the needs of the patient.

00:08:26: This could also extend other comorbidities like obesity, hypertension, dyslipidemia And even CKD.

00:08:35: The focus is always on self-care.

00:08:41: Ideally, this would then be communicated back to the primary care physician with a plan for monitoring and follow-up either through the PCP alone or through co management.

00:08:51: With the endocrinologist now as we discussed in earlier episode of this podcast series patients with type two diabetes are at increased risk of developing heart failure.

00:09:04: In fact just having type II diabetes is already stage A heart failure.

00:09:09: so it's important PCPs and endocrinologists to recognize this, and identify risk factors for heart failure that might increase the chances of progression to later stages.

00:09:23: And also hospitalizations.

00:09:25: these include kidney disease as well as obesity.

00:09:30: I might also point out that even without heart failure people with diabetes particularly older ones are at higher risk particularly those with suboptimal self-management behaviors and those with poor functional status.

00:09:49: The primary care physician or the endocrinologist might then consult with a cardiologist for further evaluation of suspected heart failure, Or if there's any suspicion of significant coronary artery disease.

00:10:03: There should be ideally ongoing communication in collaboration to optimize patient outcomes and also to ensure adherence to guideline-directed medical therapy or GDMT.

00:10:16: Primary care physicians should consider coordinating the consultation of other specialties such as nephrologists, dietitians nurse practitioners clinical pharmacist and physician assistants as necessary to manage comorbidities.

00:10:32: Of course As I alluded earlier there may be difficulty assessing these for some clinicians.

00:10:39: However, in that case I would encourage the use of digital strategies to support management of comorbid conditions if possible.

00:10:47: Yeah Eugene with all this in mind and knowing having a hospitalization for heart failure is a big risk factor for subsequent hospitalizations If a heart failure event or heart failure hospitalization occurs.

00:11:01: This an opportunity implement targeted interventions across inpatient transitional and outpatient settings.

00:11:07: We should be asking the questions.

00:11:10: Are there problems with medication adherence or GDMT optimization?

00:11:14: Are their social factors that are contributing to poor self-care behavior, or low medication adherents?

00:11:20: does my patient have poor mental health?

00:11:23: Would my patient benefit from support in the community to adhere to lifestyle modifications?

00:11:28: Should we consider medically tailored meals or referral to a heart failure clinic where they can get support for specialized

00:11:34: nurses?".

00:11:35: Are there geriatric conditions that need to be addressed?

00:11:38: What are the gaps in my patient's knowledge about their disease or treatment plan, That we can all fill.

00:11:44: Patient education is a really important factor that can be coordinated by primary care physicians In collaboration with other healthcare professionals such as diabetes care and education specialists.

00:11:55: When patients are empowered To understand The link between Diabetes & Heart failure And to fully Understand Their Treatment Options they are able to contribute to informed and shared decision-making, and can effectively implement and continue with self care and guideline directed medical therapy.

00:12:13: Which then improve outcomes and reduce the risk of progression of heart failure.

00:12:18: in patients with diabetes There may be cost insurance coverage challenges for access diabetes care education specialist.

00:12:27: however Physicians can encourage their patients to engage with organizations such as No Diabetes by Heart, or local diabetes peer support groups where they can receive education and support.

00:12:41: Primary care physicians could also incorporate informed-and shared decision making into their interactions with patients—where they can take a patient-centered approach considering what matters most to my patient having discussions so that they are informed and coming to joint decisions on disease management.

00:13:03: And this is an approach that is recommended as best practice by both the American Diabetes Association, and The American Heart

00:13:10: Association.".

00:13:13: So just a summarize... Patients with cardioreno-metabolic conditions are often engaging with healthcare professionals at multiple different contact points—and that offers great opportunity for collaboration between health care professionals and between healthcare professionals, patients as well their caregivers which can really help improve risk reduction in patient care.

00:13:34: This includes coordinated care cross-specialties within the community to support patients with medication adherence lifestyle modifications and crucially education.

00:13:45: thank you both for this pragmatic discussion on how we collaborate better as physicians.

00:13:56: please check out the other podcast episodes in this series to hear more from me, Dr.

00:14:02: Nihar Desai, Dr Silvio Enzuki and Dr Eugene Wright about heart failure detection diagnosis For

00:14:17: a full list of declarations, including funding and author disclosure statements and copyright information please visit the article page on The Journal website.