By Richard S. Beaser, M.D., and Richard Jackson, MD
Do you know how to close the gap and meet your patients’ goals?
The successful treatment of diabetes, particularly type 2 diabetes, revolves around prevention of cardiovascular disease, and the approaches and choices for treating cardiovascular disease in patients with diabetes are nearly the same approaches and choices used to treat and prevent cardiovascular disease in patients without diabetes. There is nothing diabetes-specific about the macrovascular complications of diabetes, and the increasing recognition of metabolic syndrome as a common precursor to both cardiovascular disease and type 2 diabetes underscores this common ground. The approach must be multi-faceted, flexible, and, because of the life-long nature of cardiovascular risk, the approach must successfully include collaboration with the patient…..
Insulin resistance is the primary driver for metabolic syndrome, and a necessary component of type 2 diabetes. The most potent treatments for insulin resistance are lifestyle changes, increasing physical activity and making healthier food choices.
These remarkable reductions in cardiovascular events in type 2 diabetes are often overlooked, as the most common headlines about type 2 diabetes reflect the growing number of people with type 2 diabetes worldwide, and the growing impact of type 2 diabetes on our healthcare system. Lost in this epidemic of type 2 diabetes is the evidence of improving results. The ACCORD study is a good example of this lost message. This large, multi-center clinical trial tested, in one arm, the hypothesis that pushing treatment aggressively toward an A1C of under 6.0 would decrease cardiovascular events, compared to a control group with a standard A1C goal of 7.0. The patient population was higher risk than most, and the trial was stopped early because of an increase in cardiovascular mortality in the tight control arm, with 14 deaths per 1,000 patient years compared to 11 deaths per 1,000 patient years in the control group. A more impressive result of the study was not emphasized: the predicted cardiovascular event rate in this high risk group of patients with diabetes was 50 deaths per 1,000 patient years. Both control and treatment arms showed a much lower event rate than expected. This trend toward lower than expected cardiovascular event rates is showing up in all of the large clinical trials in type 2 diabetes. The SANDS study demonstrates this phenomenon well. The investigators showed that using more aggressive BP and LDL cholesterol goals (systolic BP <= 115, and LDL <= 70) decreased carotid intimal medial thickness and left ventricular mass, but stated that "Clinical events were lower than expected and did not differ significantly between groups. Further follow-up is needed to determine whether these improvements will result in lower long-term CVD event rates and costs and favorable risk-benefit outcomes." In their summary the authors state: "As the effectiveness of therapy improves and new treatment strategies are widely applied, it is becoming more difficult to conduct a trial in which adequate numbers of clinical end points are achievable in a reasonable length of time for individuals without CVD at baseline." In other words, patients with type 2 diabetes are living longer and are having fewer cardiovascular events, in large part due to the continuing improvement in cardiovascular event rates.
Closing the Gap in Meeting Targets
This improvement is occurring despite the fact that the majority of patients with cardiovascular risk are not meeting the currently recommended targets for glycemia, blood pressure, and lipids. This gap in meeting targets represents a wonderful opportunity to improve cardiovascular outcomes even further, with tools that are presently available, and whose efficacy is well-documented. However, there are clear barriers to meeting this goal. On the patient side there is concern about “compliance,” more recently replaced by the term “adherence.” On the provider side there is concern about “clinical inertia,” with documentation that even in the best practices there are frequent examples of undertreated patients. To overcome these barriers, physicians and patients need to work together collaboratively to align their goals, to choose appropriate treatment regimens, and to continually monitor the results and adjust the treatment regimen when needed.
Collaboration is Key to Adherence
The gap in meeting clinical targets is in large part due to the gap that presently exists between actual and optimal treatment goals and strategies for patients and physicians. Even when patients have an ongoing relationship with their primary physician, they often fall short of the recommended treatment goals due to gaps between actual and ideal treatment strategies. Collaboration is the key to closing this gap. Your patients are the most underused resource in your clinical practice. If you and your patients are able to jointly establish aligned goals, they will improve their health, and you will improve the efficiency of your practice and outcomes that you can achieve.
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