By Neeza Kamil, MD, MPH, Preventive Medicine Resident at ODPHP, Loma Linda University/Family Medicine Physician
Medications used to treat diabetes are among the most common causes of emergency hospitalizations due to adverse drug events. Diabetes agents are one of three medication classes that are the focus of the National Action Plan for Adverse Drug Event Prevention. The objectives of the action plan are to identify common, preventable, and measurable medication-induced harms and to align federal work to reduce adverse drug events nationally. The collective effort of all providers caring for patients with diabetes is essential in reaching national prevention goals for adverse drug events. The action plan has four main focus areas: surveillance, prevention tools, incentives and oversight, and research. Primary care physicians can contribute to each of these areas. Many tools and resources are available to primary care physicians to understand and implement the newest changes in diabetes care.
Shared Decision Making to Achieve Individualized Glycemic Goals
The goals of diabetes care are to reduce the risk of acute and chronic complications and minimize the harms and burden of treatment. Historically, an intensive glycemic control (hemoglobin A1c less than 7%) has been accepted as the standard of care for all individuals with diabetes. However, recent clinical guidelines and expert committees on the management of type 2 diabetes have recommended developing targets for blood sugar control that are individualized to each patient. These individualized glycemic targets require taking several factors into consideration, including an assessment of the patient’s risk for complications related to high blood sugar versus the risks of therapy within the context of the overall clinical setting. Presence of other health conditions and diabetic complications, duration of diabetes, risk of hypoglycemia (i.e. dangerously low blood sugar), psychological status and capacity for self-care, economic considerations, and family and social support systems are some of the key factors involved in individualized glycemic targets. Strategies to minimize the risk of hypoglycemia should include addressing the problem of hypoglycemia at each patient contact, patient education, and providing individualized glycemic goals.
Shared decision making — where clinicians and patients collaborate in making therapy decisions — can play a key role in individualizing glycemic targets. A position statement from the American Diabetes Association and the European Association for the Study of Diabetes, emphasized the need to adopt a patient-centric approach using shared decision making: “In a shared decision-making approach, clinician and patient act as partners, mutually exchanging information and deliberating on options, in order to reach a consensus on the therapeutic course of action.”
Resources on Individualized Glycemic Goals
As with any paradigm change, this change in diabetes care comes with new learning opportunities for physicians to provide quality care. Increasing our knowledge and understanding of the issue helps us get closer to the solutions that we seek. Physicians can use ODPHP’s e-learning course to learn about individualizing glycemic targets using health literacy strategies. A framework from ADA and the American Geriatrics Society on treatment goals for glycemic control in older adults with diabetes is a valuable resource in care for elderly. A more recent paper in JAMA proposed a framework to individualize glycemic treatment for older adults. AHRQ offers webinars, tools, and workshops about the SHARE Approach, a five-step process for shared decision making that explores and compares the benefits, harms, and risks of each option through meaningful dialogue.
Leveraging Health Information Technology and Sharing Evidence-Based Prevention Strategies
Many physicians and health care systems have developed prevention tools and decision aids to deliver patient-centered care and prevent adverse drug events. Sharing evidence-based prevention tools — such as the Diabetes Medication Choice, a decision aid developed by Mayo Clinic — reduces the burden of developing new tools and can help improve the reach of existing tools. Similarly, clinical decision support systems integrated with electronic health records are increasingly being used to stratify high risk patients for identification and intervention. Data shared through reporting systems improve public health surveillance and research. Finally, collaboration between physicians, health care systems, and federal agencies to advance research in diabetes medication safety is pivotal in our progress toward improving patient safety and quality of care.
Author’s note: I am privileged to have had the opportunity to complete a public health policy rotation at ODPHP. The very office whose mission is to keep our nation healthy! Thanks to Association for Prevention Teaching and Research for coordinating this opportunity for preventive medicine and primary care resident physicians.