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This article originally posted 13 January, 2012 and appeared in  PreventionIssue 608

Difficult Patients Benefit from Team Approach

A team-based approach helps improve control of diabetes, coronary heart disease, and depression in the primary care setting by modifying both patient and physician behaviors....

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According to Elizabeth Lin, MD, MPH, of Group Health Cooperative in Seattle, and colleagues, "Compared with usual care, a collaboration between a nurse care manager, physicians, and patients increased initiation of various types of medication, rates of treatment adjustment, and self-monitoring by patients.

The program -- called TEAMcare -- had previously been shown to improve A1c levels, LDL cholesterol levels, blood pressure, depression outcomes, quality of life, and disability compared with usual care in depressed patients with diabetes or coronary heart disease, the researchers reported.

Lin and colleagues concluded that, "Results of this trial suggest that improving specific patient and clinician behaviors (close monitoring of disease control parameters and timely treatment adjustments to achieve individualized goals) can improve disease control and quality of life among patients with multiple conditions and complex healthcare needs."

It is particularly difficult to maintain good disease control in patients with multiple chronic diseases because they often have multiple doctors, are on complex treatment regimens, and have a higher risk of harmful drug interactions. Depression exacerbates these challenges.

Lin and colleagues examined the aspects of the TEAMcare approach that might have resulted in the clinical benefits. In the program, a nurse care manager collaborated with physicians and patients to design individualized care plans. On a weekly basis, physician consults recommended treatment adjustments to achieve individualized targets.

The study included 214 patients from 14 primary care clinics in Washington state. All had depression and either poorly controlled diabetes (a glycated hemoglobin of 8.5% or higher) or coronary heart disease (blood pressure greater than 140/90 mm Hg or LDL cholesterol greater than 130 mg/dL).

During the year-long study, patients in the TEAMcare and usual care groups had similar numbers of outpatient visits (average 11.4 and 12.3, respectively) and telephone encounters (average 10.1 and 10.3, respectively).

Initiation of medication was higher in the TEAMcare group for antidepressants and lipid-lowering medications, but not for oral hypoglycemic drugs, insulin, or antihypertensives.

In the TEAMcare group, treatment adjustment -- an increase in the number of medication classes prescribed, changes in dosage, or a switch to a different drug -- occurred more frequently for all five classes of medication, generally within the first two months of the study (P<0.05 for all):

  • Antidepressants (RR 6.20)
  • Insulin (RR 2.97)
  • Antihypertensives (RR 1.86)
  • Oral hypoglycemic drugs (RR 1.80)
  • Lipid-lowering drugs (RR 1.56)

Medication adherence was not different between the two groups, which the authors attributed to high baseline adherence rates.
However, TEAMcare patients more frequently monitored blood pressure (average 3.6 versus 1.1 days/week; RR 3.20, P<0.001) and glucose (average 4.9 versus 3.8 days/week; RR 1.28, P=0.006).

Lin and colleagues noted that the generalizability of the study may be limited by the inclusion of complex patients with multiple uncontrolled chronic diseases, who comprise a small fraction of primary care patients.

"Even so," they added, "the principles of systematic chronic illness care, treat-to-target, and integration of treatment for mental and physical illnesses can be applied to most patients with chronic illnesses, regardless of whether they have depression or need intensive care management."

Elizabeth Bayliss, MD, MSPH, of the Kaiser Permanente Institute for Health Research in Denver, wrote in an accompanying editorial, that "current reimbursement structures do not encourage multidimensional care management and encourage measuring only disease-specific outcomes."

"This disease-specific perspective for reimbursement may change with increased attention to a more comprehensive assessment of the process and outcomes of patient-centered care," she continued. "With this shift, it may become not only medically correct but also financially feasible to implement effective integrated and multidimensional care management for persons with depression and other chronic medical conditions."

Practice Pearls:

  • In this study, the use of nurse care managers who worked with both patients and primary care physicians was associated with improved control of diabetes, depression, and heart disease.
  • Inadequate medication management is found in one-half to two-thirds of patients with uncontrolled diabetes and coronary heart disease and is even worse when patients have comorbid depression, which occurs in up to 20% of patients with diabetes.

Lin E, et al "Treatment adjustment and medication adherence for complex patients with diabetes, heart disease, and depression: a randomized controlled trial" Ann Fam Med 2012; 10: 6-14.

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This article originally posted 13 January, 2012 and appeared in  PreventionIssue 608

Past five issues: Issue 747 | Diabetes Clinical Mastery Series Issue 206 | SGLT-2 Inhibitors Special Edition September 2014 | Issue 746 | Diabetes Clinical Mastery Series Issue 205 |


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