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10-03-2023 | Primary care | News

COORDINATEd intervention boosts optimal prescribing in type 2 diabetes with ASCVD

Author: Eleanor McDermid


medwireNews: A multifaceted, clinic-level intervention results in a marked increase in the proportion of people with type 2 diabetes and atherosclerotic cardiovascular disease (ASCVD) receiving appropriate medications, shows the COORDINATE randomized trial.

The trial is published in JAMA and was presented at the ACC.23 conference in New Orleans, Louisiana, where investigator Neha Pagidipati (Duke Clinical Research Institute, Durham, North Carolina, USA) told attending press that the intervention “had multiple components, but it was low-tech, it was delivered in the context of a pandemic, and it was meant to be scaled.”

And she said that all the tools the team used are freely available on their website.

The aim of the intervention was to identify clinic-specific barriers to optimal prescribing; develop strategies to overcome them, such as education, revised care pathways, and improved coordination of care; and conduct regular auditing and feedback.

The goal was to increase the prescription of high-intensity statins; angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs); and glucose-lowering medications with cardiovascular benefits, namely glucagon-like peptide-1 receptor agonists or sodium-glucose cotransporter 2 inhibitors.

These medication groups are endorsed by multiple guidelines for people with type 2 diabetes and ASCVD, yet their use in clinical practice is “astonishingly low,” said Pagidipati.

After 6–12 months of follow-up, the proportion of people prescribed all three medication groups was 37.9% among 457 study participants treated at 20 clinics randomly assigned to receive the intervention.

By contrast, the prescription rate was just 14.5% among 588 participants treated at 23 control clinics, giving a 23.4% absolute difference that amounted to a significant adjusted odds ratio of 4.38 in favor of the intervention.

The corresponding prescription rates for the individual medication groups at follow-up were 70.7% versus 56.8% for statins, 81.4% versus 68.4% for ACE inhibitors or ARBs, and 60.4% versus 35.5% for glucose-lowering medications with cardiovascular benefits. The largest difference was for the diabetes medications, at an adjusted odds ratio of 3.11.

A key secondary outcome was the rate of major clinical events (mortality and hospitalization for myocardial infarction, stroke, heart failure, or urgent revascularization) and this occurred at a nonsignificantly lower rate in the intervention versus control groups (5.0 vs 6.8%).

Independent commentator Kristen Campbell (Duke University Hospital, Durham, North Carolina, USA) called the findings “truly valuable” and suggested that although the trial was not powered to assess the effect on clinical outcomes, “we can safely assume that patients will benefit based on the wealth of literature” supporting use of the medications.

“Of course, we still have a long way to go,” she said, stressing that the increased prescription rate is “notable” but still far from ideal.

Campbell also stressed that the trial findings “can be extrapolated to many other aspects of care, and really across multiple disease states, so that makes it very exciting from a much larger picture.”

medwireNews is an independent medical news service provided by Springer Healthcare Ltd. © 2023 Springer Healthcare Ltd, part of the Springer Nature Group

JAMA 2023; doi:10.1001/jama.2023.2854


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