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- [00:03]
A
Welcome to this special edition of Diabetes Core Update, where we will discuss a large topic that is near and dear to both clinicians and patients, and that is the changing face of primary care and the management of diabetes and cardiometabolic disease. This is important because how we organize things in primary care, from our approach to patients, the structure of the offices that the use of medicines and technology and collaborative care affects everything we do and all of the care that patients get. I AM your host, Dr. Neal Skolnick, professor of Family and Community Medicine at the Sidney Kimmel Medical College of Thomas Jefferson University. And joining us for today's episode are two master clinicians who have thought a lot about this topic. Dr. Asan Ebakanosian is the Chief Quality Officer for the American diabetes association, the ADA. In this role, he leads the ADA's effort to transform diabetes and obesity quality outcomes and improved access to evidence based practice. He is a recipient of a number of awards, including the 2024 James Reed NMA Outstanding Physician Award, the 2022 Eli Lilly Leonard Award in Diabe Research, the 2021 ISPAD International Pediatrics Diabetes Innovation Award, and the 2019 NAC CHO Model Practice Award, among others. He has co authored more than 100 manuscripts and is a frequent speaker at professional conferences both nationally and internationally.
- [01:53]
B
Kasagi welcome Neil, thank you for having me. And I'm excited to be here and look forward to the great conversation as always. Thank you.
- [02:01]
A
I am too. And also Joining us is Dr. Christopher Jones. Dr. Jones is the Medical Director for Internal Medicine, Intermountain Health in Murray, Utah. He is also chair of the American Diabetes Association's Primary Care Interest Group Leadership Team. Chris, welcome to our podcast.
- [02:22]
B
Thank you.
- [02:23]
C
I'm so happy to be here with two people I admire so much on a podcast that has such a profound impact on diabetes care today.
- [02:30]
A
Chris, I'm looking forward to your thoughts. Asaghi, let's start with you. Why did the ADA develop the role of Chief Quality Officer and what are your responsibilities in that position?
- [02:42]
B
It's a great question. So, you know, ADA has been known over the years for doing a lot of great things. You know, one of Verame's research, ADA has funded and has raised a lot of dollars for research and funding research. Millions every year go to funding, you know, very, very innovative research. ADA has been known for advocacy, being a voice for patients, being a voice for providers, been a voice for the diabetes community, spent a lot of time advocating on the hill, on the state legislature, on a lot of critical issues. And then education has been another Component where we've done an amazing job educating the providers, the patients on things related to diabetes and cardiometabolic health. But I think one thing sort of has remained elusive and been a little hard to sort of manage, which is despite a lot of these great efforts and a lot of the great leadership that's, that's been happening over the years, there are still gaps in care, there are still gaps in how our recommendations did recommendations gets to patients, gets to providers, how the providers implement and use those recommendations. And then the reality is that those recommendations are becoming a lot more complex and expanding right now. In our 2026 Standards of Care that was just released last month, In December of 2025, there are over 600 recommendations. So that is a burden in of itself. And ADA has sort of risen to the challenge of let's have a role that will be laser focused on helping to implement these recommendations in practice, that would be laser focused on taking these recommendations and working with providers, working with patients to ensure that those research that led to those recommendations, advocacy, pushing for large scale changes with those recommendations can be matched with on the ground implementation and transformation to improve quality. So that's the whole goal of the role. And I'm truly humbled to be in this role. I have an amazing team I work with and I also have amazing colleagues like you, like Chris, that are helping to support the same mission as well.
- [04:57]
A
So Asagi, let's talk a little bit about that, that gap and what quality assurance is and how it addresses that gap. Because as an educator I always like the idea of new information and I share it with enthusiasm and, and I kind of forget that the goal of education is actually behavioral change and that once some there's a gap between when I teach and what someone learns. In fact, one of my favorite sayings about education or stories is about these two boys talking to one another. And one says to the other says I taught my dog how to whistle. And the other boy says, I don't hear him whistling. And he says I taught him. I didn't say he learned right. And so there's this gap between teaching and learning. But then even when people learn something, there's this other gap between implementation, text, quality, assurance, address that gap between even when people know what to do or kind of know what to do, they don't always remember the 600 recommendations. How do you help us address that gap that leads to behavioral change and implementation?
- [06:08]
B
It's a great question. We sort of take a lens that, you know, there's a popular saying in the quality space, and that's the same lens we take that every system is designed to get the results it produces. So we feel and we know that the results we're seeing now in our healthcare system is as a result of how our system, our structures are designed. So what we're trying to do, in short, in quality and quality improvement and implementation sciences, how do we change the system? How do we make the system make the default, the easier piece to do. So I might have all this great information on medications and managing glycemia and all of the great things I need to do to help a patient, but if a patient comes in front of me and there are some missed opportunities early on in the process, so I don't have an A1C check or I don't have any of the device data uploads in my system, even with all the great knowledge and insight I have about what to do if the A1 is this and what to do if the random blood glucose is this, or you must see inflammations, all of those great things are great. But if my process or the system process and miss that opportunity to have that device upload in front of me at the time of seeing that patient, my knowledge doesn't matter anymore at that point because now I can't do anything to change course or correct course. So, you know, and that's a very simplified example. But what we're trying to do now is how do we help you, Neil, Dr. Chris, Dr. Neal, that before you get to that patient, we've designed a system or we've helped modify a system so that you have everything you need to do the right thing. So it's your medical assistant and the team have an easier process to upload the device data on you. Patient gets in front of you and there's an electronic medical record prompt reminding you of, oh, this patient. We've not had a modification of, we've not had a review of their glucose monitoring data or the CGM data or we haven't have this modification based on ADA standards of care. So we're reducing the burden of you having to know all these recommendations, reducing the burden of you thinking about what to do next and make it easier for you to do the right thing every single time. So all we're trying to do is change the system and the process to make it easier for us to do the right thing based on the standards of care.
- [08:45]
A
That's a really good point. The thing that comes readily to mind is uacr. You're an album of creatinine ratio, which we know needs to be done regularly. And I believe we nationally are only meeting, you know, the data better than I, but something like 50% of the time, Right?
- [09:01]
B
That's correct. That's correct. But that's a critical one, too. Right? Because. And I think most times, even when primary care, many primary care providers are thinking about kidney function, they're thinking of egfr. So even sort of helping them understand why we even need to do a uhcr, making the process easier to get that piece on board, understanding what to do with that results and what happens next, based on the results. I think those are all critical pieces that we can simplify the process. We can make it easier. We can make our systems and our policies and our processes and procedure help us align with that. Because when we have better systems and better processes, even when providers don't know all the nitty gritty of all the standards and the recommendations, they can still do the right thing because we've made it easier for them to get the right information. They need to do that right at that point in time. So. So it's a great example of the UCR, and you see a lot of that of the 600 recommendations. What my team and I are doing is we're going through these recommendations, we're looking at the data, we're looking at the evidence, we're seeing where those gaps are, and we're prioritizing. This is what we need to do next. This is what we need, and this is how we're going to do it. Myself and Chris working with a team of 40 other specialties in the primary care space now, for example, to look at diabetes technology in primary care. And what should Dr. Neal do? What should a primary care physician do? What should all of our colleagues do as it relates to cgm? Should they prescribe cgm? Should they prescribe aid when they prescribe cgm? How do we support them to make that process easier? But that's one example. That piece is also happening in the cardiometabolic space. It's also happening in all of the other sort of critical aspect of care, managing diabetes and cardiometabolic disease. So we have the urgency, we have the ambition of making life easier and improving outcomes, improving quality by redesigning systems to make it easier to get there.
- [11:11]
A
Yeah, the quality assurance is such an important piece. And we're talking before this podcast that this won't be the only time the three of us are on this podcast that we'll have other topics. And it strikes me that the topic one of the topics we ought to return to discuss is a deep dive on quality assurance, soggy important information. Let's move on now. What do you feel are some of the most important challenges as well as opportunities facing primary care today?
- [11:46]
B
Another great question, Neil. I see this on three different sort of layers or levels. On the individual level, an individual, I'm looking at both the patient and then on the primary care provider or doctor as an individual, I think there's the challenge of just how much primary care providers are tasked with doing right now in terms of the administrative burden, in terms of the volume, just the number of people primary care providers have to care for with cardiometabolic disease. So on that individual level, I think we're seeing that sort of big pressure on this increased prevalence and incidence of diabetes and cardiometabolic diseases. We have less number of primary care providers in this space and estimates, where they're estimated, of showing even more deficits in years to come for primary care, for the primary care workforce. So on the individual level, you're seeing that body. We just don't have enough people. And then you have a lot more people with cardiometabolic disease and you have less people to care for them. Then you go to sort of the institutional level, and this is where a lot of the policies and institutional procedures and processes comes in. I'm thinking of things like insurance, I'm thinking of things like prioritization. I'm thinking about some of the institutional policies or processes that are put in place that makes it even sort of the operation, the operations of electronic health records and some of the, you know, for lack of better terms, like handcuffs we have with it and what we can share, what we can share, how we can use it, how we can use it. So on the institutional level, there are those sort of challenges too, that makes it a big barrier on to get us there. And then broadly the system level, which is where I see the need for conversations like this, but more importantly the need for advocacy and policy. Because on the system level, we are having broad systemic challenges with reimbursement for primary care. We're having challenges with the complexity of managing diabetes and kind of metabolic diseases have increased over time. So like I said, when the standards of care started 36 years ago in 1985, in 1989, the standards of care were just four pages of this is what you need to do as a doctor caring for someone with diabetes. Right now there are over 350 pages of recommendations, insight, and that's expanding. So, yes, we're glad that science is evolving. Yes, we're glad that care is evolving, but as a system and the broader US Health system, in this case, how are we matching up to the evolution of care and how are we ensuring that our system is being designed and the systemic issues are being addressed to reduce some of those institutional and individual bodies which we sort of see? So I think it's a very complex issue. And on the individual, what each person needs to do and the system and then institution, it is one where we will need to address it across those different levels as well.
- [15:02]
A
Thanks so much for breaking it down in that organized plan. It really is when, as you. I listen to you describing it, its complexity becomes almost overwhelming. I just saw these standards of care in my mailbox, and where it used to be this thin, the paper version, now you have to lift it out, and it is overwhelming. Chris, your thoughts on opportunities and challenges to primary care?
- [15:30]
C
Nobody can highlight some of the challenges on a broad system level better than Usagi. And I appreciate those words. While echoing that sentiment, I also want to take from a little different perspective, which would be from an individual practitioner, an individual provider who's sitting at their desk wondering, how do I take care of my patients today? Or sitting with their patient or taking those phone calls, you know, what does it look like for that individual? Clearly, the interaction with their health system, with the system at large, is a critical piece, and we need to engage with that also on an individual basis. We have vast amounts of information that we need to internalize, figure out how we use our resources, be it AI or those standards of care, or all the other ways that we get information into, into our mind and into our practice, but also really want to highlight the understanding that as an individual or as a clinic or as a smaller team, we need to build teams, because we are never an individual, and we should never be sitting there thinking, I am in charge of my patients today, or I have the responsibility to make, you know, CGM data available for all of my patients today. We must consider ourselves part of a team, and we must create that team because we're the leader of that team. There are plenty of people listening to this podcast who are not the leaders necessarily of the team. They're not the physician or the app, but they're part of that team, and they're absolutely critical. And we need to all stand up together to. To then use all of the information, all of those resources most efficiently. And I think that's the biggest challenge that we have these days, is there is so much information, so much Interaction so much team based care. How do we use our time efficiently and use all of those resources efficiently to give the best care?
- [17:29]
A
Chris it's such an important point and it's a real challenge because often for us as clinicians, we are trained in pharmacology, we're trained in physiology, we're trained in clinical medicine, but we're not trained in organizational management. Any thoughts about how one goes about? And again, this is going to have to be the short version. As we're talking, I'm thinking of all these follow up episodes, but how do we go about even beginning to think about creating these systems?
- [18:04]
C
So beginning is a great word because you have to begin. Right. So we talk about clinical inertia with do we advance care in our patients? And I like to think of practice inertia. Is our practice just sitting there stable, being the same as it was yesterday and the same as it was a year ago or 10 years ago. Do we have practice inertia? We need to start and we need to move in a way to change our practice with the growing environment that we have. And that can be very simple and probably a common theme of what we hear today and what we hear often is identify where you are and then take the next step. Everybody's going to be in a little bit different place in their practice. Identify where you are. So for some, the next step is I feel isolated and alone. I need to just go talk to my nurse and my medical assistant and make sure that we're on the same team and have the same goals. For some, we already have a clinic built that has a vast array of practitioners and people who help us with medicine. And we look at that team and say, are we being efficient? Do we need to grow? Do we need to change the roles? Do we need to re identify what's not working in a quality improvement metric and make something work better with the team that we have. And I'd like to expand that as well to say, outside of our own clinics, how do we view that team? When we think about the endocrinology specialists, when we think about all the other specialists, behavioral health specialists. I was reading the standards of care, just this new one that came out and I love that in Table 1.1. Right, right at the very beginning, Table 1.1, it lists all of the potential people that are assisting in diabetes care. And I stopped counting at about 20 or something like that. Right. Our teams can really be vast. But what we need to do is make sure that we take the next step in making Something that's efficient in delivering good care for our patients.
- [20:03]
A
Chris, I love what you just said about that next step. And we're all at a different place and that that opportunity to take the next step requires assessment of where we are, where we need to be, and what's the next step in getting there. I know we've talked in the past you've had some thoughts about the changing relationship between patients, primary care clinicians and specialists. Do you want to share some of those thoughts?
- [20:31]
C
I'm very engaged in that because I see both sides of the coin in my own personal practice and within a larger health system. And there is some change that's happening and I would love to put a call out for more change to happen, more interaction between the primary care physician and specialist, particularly in this case endocrinology, but modeled out already that I think most people are aware of is the cardiometabolic kidney movement and how the we have a number of medications that overlap between these specialties, right kidney and cardiologists and primary care and diabetes. And we should all be titrating those medications and all be working collaboratively to get people to the goal. And so I love to think that we are beginning to and we need to advance more in how we collaborate between primary care and specialty care. For instance, if I may, I would love to see more interaction, not just a primary care sitting looking at the patient saying, you know what, this A1C is never getting to goal. I'm now going to hand this patient off to specialty care and say, good luck, here you go. Rather, I would love to see the primary care doctor identify the next step of good care, that that's a challenge for them. For instance, maybe I don't feel comfortable with CGMs. And so I know I have an endocrinology team that's good with CGMs and I'm going to, rather than just hand them off, say, hey, my, my good endocrinology colleagues, could you get this person started on a cgm, Teach them, train them, help them, see them a couple of times, make sure they understand and they're using it well, send them back to me and I'll continue to manage things like that, where we have a better communication and a better efficient use will mean that the endocrinologists are not getting bogged down with just the patients who are coming back over and over, but they really are at their maximum capacity of taking care of patients in the more difficult challenges. And the primary care clinic really feels empowered, engaged, because they get their patients and they're feeling that real true care for their patients as well as advancing in their ability to do so. I think those kinds of interactions and relationships between primary care and endocrinology are increasing across the country and should continue
- [23:00]
A
to increase as I'm listening, Chris, that makes so much sense because I know in our area, Philadelphia, where there is a lot of doctors, there's still a four to six month wait to get in to see an endocrinologist and a model where they take care of a specific thing and then send them back to me. Opens up those slots for patients who really need them. My patients like seeing me. They're used to me. There's a relationship and it allows me to also learn and grow and continue to give full care to my patients, which, frankly, is fun for me as a clinician. So I love that idea. Savi, let me turn back to you now with the next question, and that's one that you alluded to. There is an issue with the primary care workforce not being as large as it needs to be. And there are more and more patients with cardiometabolic disease. And it is no secret that many primary care physicians therefore are feeling overwhelmed. The rate of burnout is high. It's been talked about a lot. Of all the things we take care of, I think diabetes is probably the most complicated and I'll also say, at least for me, one of the most satisfying because there's a lot we can do in good care leads to better outcomes. When I get ready to walk into a room with a patient who has diabetes, I begin thinking about reviewing their blood sugar levels on their CGM, their A1C, a foot exam, tight control, blood pressure, cholesterol, vaccinations. And that's in addition to all the usual care that we give to people for their other illnesses, whether it's osteoarthritis, depression or preventive health. Mammograms, colonoscopy, on and on. That's a lot. Is this something that you try to accommodate for when you develop quality assurance approaches?
- [24:51]
B
Yes, you know, and I can answer that very definitively because it is something that ADA and our team have been been very intentional working towards. So there are two groups that's helping us to do this. And the first group is a group we call the Premier Council. And the Primary Care Council is a network now of 10 national associations that represent members of the care team. So AANP, the Association for Nurse Practitioners, AAPA, physician associates, ASHP, you know, for society, pharmacists, APHA, for community pharmacists, you know, AGCs, diabetes educators and diabetes education specialists. And you can find just the. And then also including physicians as well. AAFP is a part of this. ACP is a part of this. So what we did is we brought 10 national associations that represent over 800,000 professionals that are members of the Diabetes Care Team. We convene this group bimonthly every two months. We meet with them to have three broad conversations. First is what does your constituents need from the. From aapa, how can we help the physician associates better manage people with diabetes? Aanp, the same question, acp, the same question, diabetes educators, the pharmacist. So we're actually answering those questions, trying to get there. The second piece is shared learning and understanding of what are you doing differently? Apuc to equipment, your sort of constituents and people you represent. How can we learn from what the pharmacists are doing and take that to, you know, help with diabetes educators or take that to help with other groups as well. And then the third broad piece we're doing is how do we ensure that everyone is working at the top of their license, is working at the top of their credentials, is working at the top of their expertise? Chris talked about this earlier in his comment. How do we expand the role of the team? So as we're designing quality initiatives in the cardiometabolic space, it's not just ADA saying, we have the standards, we know what to do, let's do it. It is thinking about this is beyond. The Diabetes Care Team is inclusive of a lot of these roles. Like Chris talked About in Table 1.1, we want to bring organizations that represent these individuals in these roles to the table. Help us think through what's the best way to engage, what's the best way to empower, and what's the best way to ensure that they feel energized and activated to contribute in that care team. And so Eddie is thinking about this issue. We're solving it from 30,000ft view. I encourage and also add on to Chris sort of what to do next. I encourage each team to think about the members of your team in that role. Do you have a nurse practitioner, a PA or a pharmacist and have conversations with them on, are we working collectively, collaboratively, to the best of your license, to the best of your credential? Are there other things that you can be doing with standing order help to ensure that you can work to what your credential allows you? And then I can do my part two as well. Right. So we can tackle this from that 30,000 feed view. We can tackle this in your clinic tomorrow or as you're listening to this podcast. So that's one thing sort of broadly we're doing, and then the next is we are testing out workflow changes in clinics all across the country. So we have a group called the Primary Care alliance. And to anyone listening, you want to be a part of this, you can reach out to us. Qualityiabetes.org that's the email. Qualityiabetes.org that'S the email to reach out to our team. Someone will be on standby and respond to you if you want to be a part of the solution. You want to test things in your clinic, you want practical ideas on. Oh, I'm trying to do things around ckd. What does ADA recommend in the practical steps? We have those tools and we can direct you to that if you reach out to us. And a lot of it is also on our website as well, diabetes.org but my broader point with this is that we also know we need to test out a lot. So we're testing our things with AI. Chris talked about that. How do we use artificial intelligence solutions to simplify our standards? We're testing things with clinical decision support systems, with new workflows, new algorithms. So we know there's a lot to do. But we're rising up to the challenge where it's going to take all of us. It will take everyone listening, it will take everyone playing their role for us to sort of come together and think about what have I tried that has worked. And if you're willing, if you tried something that has worked, we want to hear about it as well. So if you're listening to this podcast and you're doing something really amazing, your primary care center around cardiometabolic health, please reach out to us. Qualityadiabetes.org we want to hear about that because we also want to promote what's working as we amplify and solve the solutions as well.
- [30:10]
A
So important, we're about out of time for today's podcast. I can tell we are going to be coming back for more discussions. For today, we're about out of time. Chris, do you have any final thoughts for our listeners?
- [30:23]
C
Neal the final thought I'd have is watch for further recommendations. The ADA is putting out some further recommendations for primary care, specifically on how they should be interacting in these particular roles and clarity clinics, also about technology and how we can improve our technology use in primary care. There's a lot of things happening. Watch for more information More Publications Stay connected to this podcast. It's powerful. There's so much to learn and so much to do and it's all enjoyable and fun. Thank you for having me today.
- [30:56]
A
Fantastic. Usagi, your final thoughts?
- [30:59]
B
No, thank you. I appreciate the opportunity to share and I appreciate the opportunity to collaborate with everyone too as well. Thank you.
- [31:07]
A
Dr. Asagi Evokinesian thank you so much for joining us. Dr. Chris Jones, thank you so much for joining us. And most of all, of course, thanks to our listeners. We covered a lot of ground today and as I'm reflecting on some of the things that we talked about, Asagi used the term intentional and our approach needs to be an intentional approach. As things get more complicated, we need to be intentional in our approach to things. And Chris, you used the term that I think we should use for a title of a future podcast, which is what to do next. Right? And that's always the way we move forward. We assess where we are, then we get to go to where we are going next. We have plenty of topics for future discussions. Quality assurance in more detail, team based care, AI. There's going to be a lot of good future conversations. Again, to our listeners, thanks for joining us for this special edition discussing primary care and the care of patients with diabetes and cardiometabolic disease. We thank you for listening. And for the American diabetes association, I'm Dr. Neal Stolnick. Until next time, stay safe and keep learning.