Improving Patient Understanding of Type 2 Diabetes and Multidisciplinary Care

1. Improving Patient Understanding of Type 2 Diabetes and the Benefits of the Multidisciplinary Team Approach

2. Aims Provide practical guidance on improving diabetes care through highlighting the need for: increased patient understanding of type 2 diabetes and the importance of reaching glycemic goals shared responsibility/common philosophy for achieving glycemic goals a multidisciplinary team approach to treating type 2 diabetes

3. Majority of type 2 diabetes patients are not at HbA 1c goal Subjects (%) 0 20 40 60 80 100 6.5% > 6.5% HbA 1c Subjects (%) 0 20 40 60 80 100 < 7% 7% HbA 1c US 1 EU 2 31% 69% 36% 64% 1 Koro CE, et al. Diabetes Care 2004; 27:1720. 2 Liebl A. Diabetologia 2002; 45:S23S28.

4. Reaching glucose goals is important to reduce microvascular complications Retinopathy and nephropathy 1 4 present in ~1 in 5 patients at diagnosis leading causes of blindness and end-stage renal disease Neuropathy present in ~1 in 8 patients at diagnosis 1 affects ~70% of people with diabetes 5 a leading cause of non-traumatic lower extremity amputation 6 1 UK Prospective Diabetes Study Group. Diabetes Res 1990; 13:111. 2 Fong DS, et al. Diabetes Care 2003; 26 (Suppl. 1):S99S102. 3 The Hypertension in Diabetes Study Group. J Hypertens 1993; 11:309317. 4 Molitch ME, et al. Diabetes Care 2003; 26 (Suppl. 1):S94S98. 5 Kings Fund. Counting the cost. The real impact of non-insulin dependent diabetes. British Diabetic Association, 1996. 6 Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78S79.

5. Reaching glucose goals is important to reduce macrovascular complications Overall, 75% of people with type 2 diabetes die from cardiovascular disease 1,2 1 Gray RP & Yudkin JS. Cardiovascular disease in diabetes mellitus. In Textbook of Diabetes 2nd Edition, 1997. Blackwell Sciences. 2 Kannel WB, et al. Am Heart J 1990; 120:672676.

6. Barriers to achieving good glycemic control Need for shared understanding and mutual agreement regarding good glycemic control among members of the multidisciplinary team

7. Considering the patient perspective ? ? ? I have no symptoms so how can my condition be serious? ? I am afraid of the unknown I am anxious that my therapy will cause side effects What happens if I forget to take my medication on a regular basis? What if my therapy fails? I am afraid of needing insulin Why is lowering blood glucose so important? ? ? ? ?

8. Some misconceptions about diabetes I dont need to take my tablets I dont feel ill Complications only occur in patients who take insulin Only old people get diabetes

9. Challenges in improving patient understanding 35% recalled receiving advice about their medication 15% knew the mechanism of action of their therapy 10% taking sulfonylureas knew that they could cause hypoglycemia 20% taking metformin knew it could cause gastrointestinal side effects Patient knowledge of oral antidiabetic agents Browne DL, et al. Diabet Med 2000; 17:528531.

10. Challenges in increasing adherence Patient adherence to therapy 62% took tablets correctly in relation to food 20% regularly forgot to take their tablets 5% omitted tablets if their blood glucose was too high 2% omitted tablets if their blood glucose was too low Browne DL, et al. Diabet Med 2000; 17:528531.

11. Need for shared responsibility/ common philosophy for achieving glycemic goals

12. Establish a partnership between patient and healthcare professional Discuss importance of implementing change Build confidence that change is possible Establish rapport Agree mutual agenda Work together to: Reduce resistance to change Exchange information

13. The need to establish a good rapport My healthcare professional has helped me understand my blood glucose results and the importance of regular testing. I feel more in control of my diabetes I dont really monitor my blood glucose levels. It doesnt seem that important. The physician never asks me my numbers or measurements, so why am I doing it?

14. Motivating patients to achieve and maintain glycemic control This is great news. Continue with the good work and keep your blood sugar under control youll feel better for it! Ive reached my glucose target by eating properly, exercising more and taking my tablets Heisler M, et al. Diabetes Care 2005; 28:816 822.

15. Active Expresses views In control Decision maker Active listening Negotiation Provides information (when required) Use a patient-centered approach INFORMATION EXCHANGE Healthcare professional Patient Muhlhauser I, et al. Diabet Med 2000; 17:823829.

16. Initial consultation: where to start? What does type 2 diabetes mean: to you? to your family/friends? What are your fears/expectations? How will type 2 diabetes affect: your everyday life? your family? your job? your social life? What can we do about it together?

17. Subsequent consultations How are you? Have you been regularly monitoring sugar levels? You are not yet at goal how can I help? Discuss options and reach mutual decision Agree when and how to review options Apart from diabetes, what else is new?

18. Helping patients to accept their condition Diagnosis of type 2 diabetes = loss of patients accustomed state of health Patients willpower and ability to improve outcomes depend on degree of acceptance of the serious nature of their condition Relationship between healthcare professional and patient is critical in this process Lacroix A, et al. Schweiz Rundsch Med Prax 1993; 82:13701372.

19. Motivating and supporting patients to change their lifestyle Provide practical and realistic advice on implementing and sustaining lifestyle change Discuss steps that can be implemented now Where possible, involve other members of the diabetes care team, particularly family and friends

20. Role of the multidisciplinary team

21. The multidisciplinary team: core members Dietician Dietician Diabetes specialist nurse Diabetes specialist nurse Patient Patient Physician Physician Podiatrist Podiatrist National Diabetes Education Program. Team care: comprehensive lifetime management for diabetes . http://www.ndep.nih.gov/resources/health.htm.

22. The multidisciplinary team: additional members Pharmacist Diabetologist/ endocrinologist Other specialists Dietician Dietician Diabetes specialist nurse Diabetes specialist nurse Patient Patient Physician Physician Podiatrist Podiatrist National Diabetes Education Program. Team care: comprehensive lifetime management for diabetes . http://www.ndep.nih.gov/resources/health.htm.

23. Key function of the multidisciplinary team To provide: Continuous, accessible and consistent care focused on the needs of individuals with type 2 diabetes

24. Additional functions of a multidisciplinary team Provide input at diagnosis of condition and continually thereafter to: agree standards of care discuss rational therapeutic suggestions monitor guideline adherence and short-term outcomes avoid early complications or provide timely intervention to decrease diabetes-related complications Enable long-term patient self-management Codispoti C, et al. J Okla State Med Assoc 2004; 97:201204.

25. The multidisciplinary team requires Common goals Supportive/nurturing approach Commitment to principles of self care Good interpersonal skills of team members Clear definition of specific and shared responsibilities of team Tailoring of team members according to setting and resources

26. Pharmacist Diabetologist/ endocrinologist Other specialists Dietician Dietician Diabetes specialist nurse Diabetes specialist nurse Patient Patient Physician Physician Podiatrist Podiatrist The multidisciplinary team: shared responsibility for education EDUCATION EDUCATION

27. Impact of implementing an educational program via a multidisciplinary team *Significant improvement versus 0 months VARIABLE TIME PERIOD AFTER ATTENDING EDUCATION COURSES 0 MONTHS 12 MONTHS FPG (mmol/L) 10.2 8.7* HbA 1c (%) 8.9 7.8* Body weight (kg) 83.0 81.0* Systolic BP (mmHg) 154.0 143.0* Diastolic BP (mmHg) 95.0 87.0* Cholesterol (mmol/L) 6.2 5.4* Triglycerides (mmol/L) 2.8 2.1* Gagliardino JJ & Etchegoyen G. Diabetes Care 2001; 24:10011007.

28. Impact of a multidisciplinary team on glycemic control and hospital admissions Multidisciplinary team Control 30 25 20 15 10 5 0 Hospitalizations/1000 person-months Hospitalizations HbA 1c -1.4 -1.2 -1.0 -0.8 -0.6 -0.4 -0.2 0 Multidisciplinary team Control Change in HbA 1c from baseline (%) Sadur CN, et al. Diabetes Care 1999; 22:20112017.

29. A multidisciplinary team can reduce costs 0 20,000 40,000 60,000 80,000 100,000 120,000 0 months 12 months Cost of pharmacotherapy/year (US$) Annual cost of treatment -62% Gagliardino JJ & Etchegoyen G. Diabetes Care 2001; 24:10011007.

30. Other benefits of a multidisciplinary team approach to type 2 diabetes care Improved glycemic control 1,2 Improved quality of life 1 Increased patient follow-up 1 Higher patient satisfaction 1 Decreased healthcare costs 2 Lower risk of complications 2 1 Codispoti C, et al. J Okla State Med Assoc 2004; 97:201204. 2 Gagliardino JJ & Etchegoyen G. Diabetes Care 2001; 24:10011007.

31. How can expertise be best utilized in diabetes management? Implement a multi- and interdisciplinary team approach to diabetes management to encourage patient education and self-care and share responsibility for patients achieving glucose goals The Global Partnership recommends: Del Prato S, et al. Int J Clin Pract 2005; 59:13451355.