My family was not a medical family and I have to say there were many things about medicine that were a big surprise to me. One of the biggest surprises? My professors did not teach me how to treat diabetes. They taught me about the science of diabetes. They taught me about the medications that are available to treat diabetes and the lifestyle measures available for diabetes, but they did not teach me the defined best practices to treat diabetes. Even at the time, that seemed strange to me. When I graduated from medical school it was up to me to develop a treatment plan with information that I remembered in my head for each individual patient that I saw. I only mentioned diabetes, but the model is the same for every chronic condition that a doctor treats. That is still the prevailing model, but now things are much more complcated. There are ten classes of medication available to treat type 2 diabetes and most of them have several members in the class. There are four different drugs in the same class as Jardiance, so there are dozens of choices. We should be teaching the best way to treat type 2 diabetes, and not leaving each provider to come up with her own priorities.
That is because there is a best way to treat diabetes and other chronic illnesses. In fact, the first step to the better management of chronic diseases is “evidence based care processes consistent with best practices.” Consider the patient with type 2 diabetes who has chronic kidney disease. The slide above lists the 12 steps that should happen for each patient every time unless there is an intolerance or contraindication that cannot be overcome.
These patients don’t die of a high sugar. They die of cardiovascular disease and half are gone by age sixty-eight. Every patient should have every test every year. The team can make certain of that. It does not require twenty years of education to assure these tests are done. These patients have a very high risk of death, heart attack and stroke and so the three risk factor goals should be more aggressive. Application of the six interventions should be equally consistent.
These patients should be on aspirin because of a very high risk of vascular events. Stopping smoking is very powerful. Patients who have the diagnosis of type 2 diabetes should be on metformin even if their sugar is now normal because of diet or exercise. That is because meformin blocks the effects of genes that were persistently switched on by the high sugar and continue to increase the risk of heart attack and stroke. Every person with a very increased risk of heart attack should be on a high intensity statin. Lisinopril or losartan and eplerenone or spironolactone are often needed to achieve a blood pressure of 130/80 consistently. Beyond that they are precision medicines that slow kidney and heart disease progression more than they lower the blood pressure. These six interventions protect all cells and organs in patients with diabetes and related conditions.
The advanced medical home team makes certain the steps are achieved. Nurse practitioners and pharmacists in a team with a primary care physician do the best job of making certain that all twelve steps are executed consistently. Nurse coaches and case managers teach patients self management and the lifestyle measures that are equally important. When these “evidence-based care processes consistent with best practices” come together, the next slide shows you the difference between those results and one provider trying to do it all based on what he can remember. If a patient can really cut back on carbs and sugar, and take metformin consistently, many of them will not progress to the more expensive brand name drugs and complications.
Very interesting piece; thank you.
Are the slides mentioned in it available?