medwireNews: Day 3 of the 2017 American Diabetes Association 77th Scientific Sessions featured symposia on emerging therapeutic targets and their mechanism of action, exercise and diabetes complications, and pharmacologic strategies in diverse populations.
Shared decision-making: Improving patient–provider communication
Linda Siminerio (University of Pittsburgh, Pennsylvania, USA) opened The National Diabetes Education Program’s (NDEP) symposium on shared decision-making (SDM) by explaining that SDM involves three stages:
- Information sharing
- Deliberation
- Decision
She said that there is currently a gap between what patients want and what they get, and this can be overcome with SDM. But there are barriers to SDM that need to be addressed; healthcare professionals see SDM as a challenge to their autonomy, practices say they lack time to implement SDM, patients may have literacy issues, and there is a lack of decision aids for SDM.
However, there are strategies to overcome these barriers, which the other experts in the session discussed. Siminerio concluded by saying clinicians should keep the quote “no decision about me, without me” in mind when treating their patients.
Ann Albright (Centers for Disease Control and Prevention, Atlanta, Georgia, USA) added that clinicians need to think about where patients are on the “risk continuum” and how to have the most effective conversation to ensure they receive the most suitable intervention. This may include medication for patients at high risk for diabetes and promoting healthy lifestyle for those at low risk.
Race/ethnicity can also be a barrier to SDM, as highlighted by Monica Peek (The University of Chicago Medicine, Illinois, USA). She said that African Americans may want to participate in SDM but distrust and perceptions of discrimination can have a negative impact. However, Peek found that having a good narrative – she used a video of a patient unwilling to share information with her clinician – helps patient empowerment and improves SDM in these populations.
Another strategy that is helpful in SDM is the use of web-based decision aids, and Tim Wysocki (Nemours Children’s Health System) talked about his experience of developing a tool to help pediatric patients considering switching to an insulin pump or continuous glucose monitoring (CGM). He said that when developing this kind of tool it is essential to engage multiple stakeholders with diverse backgrounds and experiences to make sure the decision aids “really click” with users.
But how do you reach a decision when the evidence is ambiguous? John Buse (University of North Carolina School of Medicine, Chapel Hill, USA) said NDEP’s Guiding Principles for the Care of People With or at Risk for Diabetes are helpful but clinicians should also “embrace the fact that most of what the patient wants to know is unknown.” He added that working with the patient over a number of visits to find the best solution for them and then evaluating the impact is important.
Judith Frankin also spoke during the session, discussing the need for more behavioral research to improve management in type 1 diabetes.
Continuous glucose monitoring in type 2 diabetes?
After lunch, Jeremy Pettus (University of California, San Diego, USA) and William Polonsky (Behavioral Diabetes Institute, San Diego, California) debated whether CGM should be available to patients with type 2 diabetes on multiple daily insulin injections, basal insulin therapy, or no insulin at all.
Pettus opened with his arguments in favor of CGM for patients using multiple daily insulin injections. He cited published data to refute claims that patients with type 2 diabetes have less glucose variability, a lower risk for hypoglycemia, and are less “tech savvy” due to their age, than those with type 1 diabetes, and should therefore not be given CGM.
He added that the DiaMonD study provides evidence that CGM lowers glycated hemoglobin (HbA1c) in patients with type 2 diabetes, and this improvement comes from patient lifestyle changes rather than increased medication.
Responding to this, Polonsky said that Pettus had made some reasonable arguments, but the DiaMonD study showed that CGM had no impact on severe hypoglycemia – a possible benchmark for the cost-effectiveness – probably because the participants had no history of severe hypoglycemia. So the efficacy of CGM needs to be proved in this population.
In addition, DiaMonD patients had contact with healthcare providers seven times in 6 months, which does not reflect what happens in the real world and may be the reason for the reduction in HbA1c with CGM, rather than the use of CGM itself.
Polonsky also said that without the additional support, real-world patients may find CGM data confusing, overwhelming, and demotivating.
He concluded that the bottom line is that CGM may be beneficial in patients with type 2 diabetes on multiple daily insulin injections, but we need more evidence.
During the second debate, this time focusing on patients receiving basal insulin, Pettus said that CGM can detect unrecognized actionable hypoglycemia and help these patients maintain good blood glucose levels via patient motivation. Furthermore, it helps people to change their habits, with glycemic control persisting, even when CGM use stops. He concluded that CGM will eventually become the standard of care in this population.
Polonsky disagreed, again arguing that the benefits seen with CGM in basal insulin users may be due to the increased support given during the clinical trials. He suggested that guided support could work without CGM. Polonsky added that another trial showed greater patient satisfaction with standard blood glucose monitoring than CGM. He concluded that there is no solid evidence for CGM efficacy in patients with type 2 diabetes using basal insulin.
For the last debate, Pettus and Polonsky switched roles (and also jackets), with Polonsky arguing in favor of CGM in type 2 diabetes patients not using insulin. He said that, done right, it “could be terrific” for these patients as it will help them engage in their own care and allow them to feel more confident that they can be safe. It might also help them transition to injectable insulin when they need it. He concluded that although more evidence is needed, particularly surrounding who will benefit most, “this will change everything.”
Pettus said that since 2005 there have been 40 new therapies for type 2 diabetes, without any change in average HbA1c levels, and “a complex and time consuming therapy [like CGM] won’t help over overcome patient and physician inertia.”
Instead, time would be better spent helping patients adhere to their current medications and using additive therapy at the appropriate time, ie, early.
He concluded that therapies need to be “easy to prescribe and obtain, easy to take and use, and have a large and recognizable benefit, and currently CGM doesn’t fit this criteria.”
At the end of the debate, the audience members voted with Pettus in favor of CGM for patients using multiple daily insulin injections, but were more or less equally split when considering basal insulin and non-insulin users.
Using patient-reported outcomes to inform diabetes care
During a late afternoon session on patient-reported outcomes (PROs), Sarah Corathers (Cincinnati Children’s Hospital Medical Center, Ohio, USA), Paul Ciechanowski (University of Washington, Seattle, USA), and Jeffrey Gonzalez (Albert Einstein College of Medicine, New York, USA) talked about different aspects of psychosocial screening in patients with diabetes.
Corathers began by giving her experience of implementing the children’s depression inventory in adolescents with type 1 diabetes. She said that despite initial skepticism from healthcare providers, the overall response was positive.
However, she emphasized the need for training so that providers are able to acknowledge and interpret responses, respond to issues, and engage in psychosocial concerns, all of which will help improve their patient–provider relationship.
Corathers said that analyzing PRO data can drive changes in care practice and concluded: “PROs are clinically meaningful and can provide insight into patient experience beyond existing measures of glycemic control.”
Ciechanowski moved on to adult psychosocial screening and intervention and stressed the importance of determining how to deliver the best care. He used attachment styles as an example, saying that one study showed that patients with an interactive style, ie, easily able to get emotionally close to people, did not benefit from a diabetes care management program, contrary to those with an independent style, ie, a preference for being self-sufficient.
Ciechanowski said this demonstrates the power of psychosocial PROs in understanding how to connect with patients, and how they can help healthcare providers determine where to best place resources, which is particularly important in the era of value-based care.
Addressing the question “to screen, or not to screen,” Gonzalez said depressive symptoms are consistently related to poor outcomes in patients with diabetes, and based on that, it is reasonable to assume that if these patients can be identified, they can receive earlier intervention and improved outcomes.
But, experts disagree over the need for screening; US guidelines recommend that clinicians should consider screening, but Canadian and UK guidelines do not, and Gonzalez said that this is because there is no direct evidence to support routine screening. Instead, positive outcomes occur when screening is packaged with care enhancement. He also said that false positives can be a substantial problem because the screening tools have an average specificity of 68%.
Instead of screening, Gonzalez suggested that clinicians simply talk to their patients, regularly, about their mental wellbeing, and also think about context; symptoms of depression may be indicative of other problems such as diabetes distress.
Moving away from depression, Julie Wagner (University of Connecticut Health Center, Farmington, USA) used the Arabic proverb “he who doesn’t know the eagle will grill it, thinking it’s a chicken,” to illustrate the importance of addressing cultural disparities in diabetes care.
Wagner has extensive experience working with patients from a variety of backgrounds and said that healthcare providers need to “cultivate cultural humility” and learn about the patients’ demographics but avoid stereotyping, in order to build trust and eliminate health disparities among these groups.
She also stressed the importance of pilot testing – and retesting – tools to ensure they are suitable for the group of interest, adding that using an electronic spoken format can be extremely useful.
Taking a trauma-informed approach, ie, knowing that patients may have fled war, genocide, or famine, considering subethnicity, and using community health workers from the same cultural background as the target group are also helpful, Wagner said.
By Laura Cowen
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