← Endocrine News Podcast
Loading summary
Transcript23 lines
- [00:00]
A
Hello, I'm Aaron Lohr, and this is the Endocrine News podcast. There's a lot to consider when treating diabetes, but there's one thing that's important that may not be getting the attention it deserves. Today we're talking about the importance of incorporating the patient experience into the management of diabetes. Joining me today is Dr. Rita Kalyani, professor of Medicine at Johns Hopkins University School of Medicine and President Elect of Medicine and Science at the American Diabetes Association. She and her colleagues recently published a position statement in the Journal of Clinical Endocrinology and Metabolism entitled Prioritizing Patient Experiences in the Management of Diabetes. And its an Endocrine Society position statement. Thank you for being with us today.
- [01:00]
B
Thanks for having me, Erin. I'm excited to be here.
- [01:03]
A
Now, we know that not everyone's journey with diabetes is going to be the same. Can you tell us a bit about common themes among challenges facing people with diabetes and their caregivers?
- [01:14]
B
We know that diabetes, while a very prevalent disease, we know that 90 to 95% of the diabetes in the world is type 2 diabetes and that currently more than 500 million people live with diabetes around the world, of which about 38 million people live here in the United States. There are differences between individuals in terms of how diabetes can present and the complications that people may eventually develop. So while we know that the experience of living with a chronic disease such as diabetes may be unique to the individual who has the condition, there are also common themes or or common challenges that arise throughout the journey of a lifetime of living with this disease and interacting with healthcare providers. In this position statement, we really wanted to highlight some common areas that people with diabetes might encounter at various stages throughout their lifetime of living with this disease, from diagnosis to screening and prevention of complications, to management of complications if they were to develop, and then also other aspects such as risk of hypoglycemia, the use of telemedicine for care appointments, and also incorporation of technology into patient visits.
- [02:32]
A
Now, the new position statement from the Endocrine Society points out that experiences of people with diabetes have not been fully considered in implementing recommended standards in diabetes care. So why not? And why is this so important?
- [02:46]
B
We often talk about patient centered care in our clinical practice guidelines. This is, I would say, a consistent theme among any clinical guidelines you read from major professional societies related to diabetes. Yet what do we really mean when we say patient centered care? I've been fortunate to be involved in the guideline process for both the Endocrine Society and the American Diabetes association and other societies as well as the guidelines that we develop are often based on the best evidence. We have to date the best trials, the largest trials, the most recent trials. But the challenge is when you do a research study, those parameters, that environment, that structured intervention, is very different than implementation into real world settings. And so when we talk about taking that evidence, translating it into guidelines, and then disseminating it into clinical practice, is that dissemination piece where we really don't have a lot of guidance. For instance, we present a clinical scenario where we know that there is great evidence for many of the newer glucose lowering medications, specific agents from the SGLT2 class and the GLP1 receptor agonist class for reducing cardiovascular and renal outcomes. However, how do you address affordability and accessibility in areas where people may not have ready access to those medications? We also talk about clinical and therapeutic inertia. There are health care providers who may not feel as familiar or comfortable providing these medications. So though we know that these medications have really great evidence, and our guidelines, almost all of them now universally recommend use of some of these agents for protection from cardiovascular disease and development of chronic kidney disease. How do we actually implement this in practice? How do we overcome therapeutic inertia practice? Those are the kinds of things that we sought to really address in this.
- [04:43]
A
Position statement and to help address how to do it. Are there, are there tools to help facilitate patient centered care? And if so, what are they and how might they help?
- [04:53]
B
There are many tools that are available. For instance, in one of the sections, which is a core section on the importance of patient provider communication, we talk about using patient centered language. For instance, instead of saying the diabetic person, we say the person with diabetes. We don't label individuals by their disease. Similarly, we give other more patient centered language examples that healthcare providers can use in practice. We don't favor as much anymore. Glycemic control, for instance, as a way to describe how patients management is going to the word control denotes that perhaps patients may not have full hold over their diabetes management, where in fact they may be doing everything they can. And really we need to be tweaking their medication regimen. And so instead we say management of blood glucose. So we give examples in that particular section of how language can become more patient centered. And we get very clear examples. For instance, another one is we try not to say non compliant with medications anymore. We don't like to say adherence or compliance. Again, that can be somewhat stigmatizing for the person who may have other challenges to taking their medications. Instead we say medication taking behavior or that they Take the medication, let's say 50% of the time. So those are some examples of some tools that are out there, some guidelines and language that might be more patient centered, not as stigmatizing, free of bias and more inclusive. Also, in regards to patient communication, there are ways to ensure that your patient understands what you're talking about. And one of them is called the teach back method. I do this in my practice as well, where I will, at the end of the conversation with the patient, ask them, can you repeat back to me what you understood? Do you have any other questions, anything that was unclear? There is also another kind of method called the motivational interviewing method, which is more a guided form of communication which helps elicit really what the main concerns are for the patient sitting in front of you. And for both of these methods, there are scripts readily available from different agencies. The Agency for Health Care Research and Quality has developed materials to educate patients on how to get the most out of their health care visits by having them have a checklist of questions that they can ask, for instance. So there are a variety of tools available. This was just one example for patient provider communication. But we provide other examples of existing tools that are out there. For instance, for screening for psychosocial conditions and diabetes, we know that this can have tremendous impacts on self management of diabetes. And most of the management for diabetes occurs at home. So making sure that the patient and their caregivers feel comfortable with management and also that psychosocial conditions such as depression, anxiety and diabetes distress or diabetes burnout, these are conditions that can make it more challenging to self management. You don't have the motivation to take care of your disease. So we also provide some questions that healthcare providers can ask to determine the need for additional psychosocial screening, such as, are you happy with your current treatment plan? Would you like to meet with a diabetes care educator specialist, a nutrition or a dietitian? Can we work together to set attainable goals? These are the kinds of tools that can help us deliver better patient centered care and practice.
- [08:25]
A
These tools sound very, very helpful. Now the position statement points out that many of these tools are underused. Why might that be? And how can we help to increase that usage?
- [08:35]
B
One of the challenges for any healthcare provider in practice is that they have many competing demands. Not only limited time with their patient, but also for our busy primary care provider, other conditions to address, not just diabetes during a clinical visit. So one of the challenges is that healthcare providers have a lot of demands on them and so the tools can't be burdensome to use in practice because they will just take away otherwise valuable time that the patient and provider have together. The second is just awareness of these rules, you know, getting the word out that they're there. For instance, there are online directories where the CDC and the ADA have a directory of where you can find diabetes educator programs or diabetes self management programs. And these are fantastic resources for areas in the country where there might not be large programs readily available. There's also online directories where you can find mental health specialists focused on diabetes or people who might need further counseling or further treatment. So those are the kinds of tools where getting the word out can really be helpful. And that's one of the things we also hoped that we provide direct links to these tools if they have websites in the position statement itself. The Endocrine Society also has a variety of patient focused resources in a patient engagement webpage that really getting the information out there to let patients know that this is an available free resource that they can use in between visits with their healthcare provider. So part of it is the awareness, part of it is the busy healthcare provider has a lot of demands on their time and these tools can't be burdensome. And part of it is that we need new tools to develop and evolve as we develop new guidance. One of the tools that we include in this position statement is a roadmap to improved outcomes and diabetes. And in this roadmap, we have a car going along a road with milestones along the way. And I really love this graphic because it demonstrates kind of the key milestones along the journey of having diabetes that patients should be aware of. And I use this all the time now in my practice. You know, at the beginning we talk about lifestyle changes, then we talk about how to modify cardiovascular risk factors, then we talk about screening for complications. And then down the road, if you develop complications, we talk about what drugs you can use to prevent cardiovascular disease or progression of cardiovascular disease. Then farther down, if you develop heart failure, drugs to prevent heart failure. And then one of the other milestones is if you develop kidney disease, drugs that you might preferentially use to prevent the progression of kidney disease. So I really love this idea of the roadmap because it shows where you are and where we're going. Another tool that we have in here, which I also really love, is the hypoglycemia graphic where we have a dashboard, a warning sign, dashboard of glucose levels on the left from 70 all the way below to 45. And then on the right hand side, we graphically show the Symptoms that can occur at a level of 70. We call these the neurogenic symptoms, the heart palpitations, the shakiness, the sweating and hunger. And then as you get lower to around 54, that's when the neuroglycopenic symptoms can occur. And we show graphics of someone looking tired or having a headache or irritability. And then if you get even lower than that, let's say to 45, we have a graphic of a coma or seizure. These kinds of tools that incorporate both interactive online tools and also graphics can further supplement the education for our patients with diabetes.
- [12:21]
A
So, as our listeners can tell, the position statement has a lot in it, A lot of time was devoted to it. Can you tell us a little bit more about the development of the statement, what brought it about and who was involved?
- [12:34]
B
The Endocrine Society had assembled the writing group for this position statement with the recognition that while we've had many developments in treatments and newer drug classes introduced over the recent years that can really help improve outcomes for people with diabetes, we continue to have substantial gaps in our care between what our clinical guidelines recommend and what we're actually able to implement in clinical practice. And so this position statement was designed to help fill that gap of what our guidelines recommend and what we're actually able to do in practice by highlighting tools that are currently available, including new tools that can be used, such as those graphical images that I shared, and then really discussing what current gaps we need new tools in still to be developed in the future. And so, as a result of wanting to fill in that gap, one of the best ways that we thought we could do that is by having all the important stakeholders at the table that really are involved in the comprehensive care of a person with diabetes. And. And so we were very fortunate, and it was so exciting for me to work with such an esteemed team that had so many representatives from so many different organizations. So we had representatives from professional societies. Those included not only the Endocrine Society, but also the American College of Cardiology, the American College of Physicians, the American Diabetes association, and the association of Diabetes Care and Education Specialists, and the Diabetes Technology Society. In addition, we had a representative from the Centers for Disease Control, our governmental organization, which is very involved especially with our DSMEs programs and DPP programs. We had several representatives from patient advocacy organizations, people who are on the front lines really advocating for patients with diabetes, diabetes sisters, close concerns in taking control of your diabetes. And then we also had a representative from social enterprises dedicated to people with diabetes, DQ and A. So we had Some phenomenal stakeholders at the table discussing these issues on how we can best take the evidence and the guidelines that we have and implement them in practice. With the patient front and center prioritizing their experiences to together attain best care they can and outcomes we can for people with diabetes.
- [14:59]
A
That's a real impressive group. And in the position statement, the output of this group is structured in a specific way with scenarios and discussions. Can you tell us more about what people will find when they read the statement and how it's laid out? It's really interesting.
- [15:14]
B
So we had two roundtables where we kind of discussed what we thought were the priorities to address. We had working groups for each of the nine sections that you'll see in the position statement. At the end of those two roundtables, we then put our findings together and compiled them in this position statement that we're discussing today. And so one of the things that came up as we were talking about how to format this position statement is that if we're prioritizing patient experiences, we should really start by talking about the patient experience and start with a very reflective patient scenario at the beginning of each section that many of us in clinical practice can relate to to highlight the challenges of really implementing the best care and practice. We know that the starting point for any discussion is with the patient, and so using that experience as a launch pad for further discussion. And so at the beginning of each of the nine sections, we have a scenario described that highlights some of the challenges. So, for instance, in the patient provider communication scenario, we have a scenario of one who has been trying to get in touch with his doctor's office. He's been having higher blood glucoses, and he's also been having symptoms of a cough and nasal congestion. He doesn't get any calls returned. He finally does reach someone and has a visit with a provider who's very busy, sees his numbers are in the three to four hundreds, and says that you need to increase your insulin dose. But the patient has a father who had a severe hypoglycemic reaction many years ago and has a fear hypoglycemia. So he doesn't increase the insulin, and he ends up being admitted to the hospital many days later with a fever, dehydration, and acute renal failure. And this highlights some of the challenges of communicating, of discussing the patient's concerns in really addressing some of the challenges of implementation. One of the other scenarios that I really love is in our telehealth section, and I think we can all relate to this one. Where during a telemedicine visit, it's just a routine care visit, the provider is talking with the patient and at the very end she says, well, oh, I also want to let you know that my foot is swollen. And the provider says, well, can you show me your foot on the call? And she says, no, I can't move from this spot, otherwise I'll lose my wireless Internet and the connection during the visit. And you know, it highlights what the challenges of incorporating telemedicine into diabetes care in some ways. And in the Endocrine Society had a statement out about this and the use of telemedicine and technology. In some ways, diabetes lends itself very well to telemedicine. We can look at glucose numbers remotely. People can download their CGM numbers to a platform that the healthcare provider can look at remotely. Many recommendations can be made with that data. But telemedicine is not for everyone. And so one of the other tools that we provide in this statement is questions that healthcare providers can use to consider telemedicine readiness and diabetes care. Questions such as how would telemedicine be beneficial to the patient? Is telemedicine affordable? Is the patient willing to incapable of uploading their diabetes technology data to the cloud? And how secure and private is the data being collected. And so these are some of the questions that really can help assess whether telemedicine is the best modality for a clinic visit and how best to really treat the patient and in what setting.
- [18:51]
A
If you're listening, you're probably eager to read the position statement to see all that we're talking about in there. And for those of you who are interested in that, we'll include a link to this position statement in the description of today's episode. I wanted to come back a little bit to the tools. We're talking about the tools that are available. And one thing you mentioned is we have tools, but there's also some places where maybe we don't have tools yet and we'd like to have tools. What challenges are we facing that we don't yet have great tools or strategies available?
- [19:21]
B
The priorities that we highlight in the statement, the things that we know today include that we need to continue to strive for effective communication during clinical interactions throughout the disease course. We need to address the emotional and psychological needs of people with diabetes and their caregivers. We need to ensure referrals to diabetes self management education programs are timely and accessible. Having tools to effectively navigate available therapeutic options together in explaining complex regimens are important to support medication taking. Behavior minimizing therapeutic and clinical inertia is clearly a priority. Discussing strategies ahead of time for hypoglycemia assessment and prevention, and then making sure that there's accessibility and affordability to some of these newer therapeutic options to improve cardiovascular renal outcomes. Using telehealth in the appropriate clinical setting, and then ensuring that technologies are integrated in a smooth and efficient way for both insulin pumps and CGM systems into routine diabetes management. So that's what we know in terms of what we have highlighted as the priorities in this statement. And we go through the tools that are available to help support those priorities. But we also know that in the ever changing landscape of diabetes and its management, that both healthcare providers and people with diabetes will continue to need new and evolving tools that respond to changing care delivery models, newer treatments and newer technologies. We know that technologies are being updated all the time. There's newer settings, there's newer devices. We also know that newer tools should include culturally or language specific interview scripts. As we are addressing and treating people from many different backgrounds, we need to be sensitive to that as well. And we don't currently have wide availability of those for anyone who's treated a person with diabetes in their clinic. Sometimes things are smoothly integrated and sometimes they're not. With technology into the electronic health record and so ensuring that there's smooth integration of patient data from diabetes devices into the electronic health record. I think many endocrine practices have really made this a focus, but primary care settings may be widely varying, well, depending on the resource availability. And this needs to be accessible to all patients, no matter where and who they're treated by. Also tools to support care coordination. Now that we know that there are all these newer medications available to treat people with diabetes, coordination with cardiologists, nephrologists, with the primary care provider, with the dietitian, with the educator, with the pharmacist, with the mental health provider. We need better systems and tools to support the efficient and coordination of care as well. Also, we need a way to better explicitly capture patients perspectives and healthcare priorities, not only in day to day management in our practices, but also in the development of clinical practice guidelines. And many guidelines are starting to include patient representatives on their writing team. It depends often on what the topic is and the society, but this is something that really should be incorporated either formally or as part of a stakeholder advisory group in terms of how the guidelines will eventually be received and incorporated into clinical practice.
- [22:44]
A
So we've covered a lot today and there's even so much more that we didn't get to so please check out the position statement. But to the healthcare provider or the person with diabetes or their caregiver, what would you say is the most important take home message from regarding the new position statement?
- [22:59]
B
I think that as endocrinologists we know that there is a lot of evidence, we know that there's a lot of research studies out there, we know that we have incredible tools to use to support management of diabetes. But I think the most important message is that we still have care gaps and we need to know why that is and we need to address those care gaps if we eventually want to attain optimal health outcomes for people with diabetes. So I think that the take home message is that it's not enough to look at the guidelines and follow the recommendations. We're all so busy. Health care providers are so busy. But when you're sitting in your clinical visit with the patient in front of you, with a caregiver in front of you, just ask them, what are you struggling with? What are your priorities here today? What would you like us to address? Simple questions can change the whole conversation and eventually help both the patient and the provider achieve the mutual goal of the best health outcomes possible for people with diabetes. And through this position statement, we really hope to help highlight the themes. We only focus on nine themes, but there are a lot more themes that we could have focused on. But we really want to focus some common themes that healthcare providers and patients may incorporate in practice as a starting point to really address those gaps and also to move forward with highlighting areas where we need to do better and where we can do better in order to support the person with diabetes throughout a lifetime of their disease.
- [24:32]
A
Before we go, one thing that is always fun for me is when the podcast guest has their own podcast and I believe you have your own. Can you tell us a little bit about your podcast and what you do?
- [24:44]
B
Thanks Erin. It's always fun to have the opportunity to do a podcast and as you mentioned, I do host a podcast and today it was great to be able to talk to you being on the other side of the coin. But yes, we do have a podcast series titled Diabetes Deconstructed. This is a podcast series that was launched on our website, the Johns Hopkins Patient Guide to Diabetes website. It's in partnership with an organization, the Franny foundation, that has been a great partner that I've had the privilege of working with over the past decade and we launched the website back in 2016 and the podcast series we launched Hard to Believe now three years ago and in this podcast series, which is designed for people with diabetes, I have the honor of talking with a variety of experts in a variety of specialties. Cardiology, ophthalmology, foot care, hearing loss, nutrition. We also interview people with diabetes and really highlighting the things that we think people with diabetes should know across all these areas so that they can really have the information they need to be empowered to take care of their disease at home and then also to work with their healthcare provider on challenging areas. I love the podcast format because you can listen to it anywhere. You can listen to it when you're. You're on the go, in the car, when you're doing other things. And so thanks so much for bringing it up. It's really been a treat to do that and to be here today on your podcast.
- [26:15]
A
Well, I think folks, listen to this one. If you like this one, check out that one. I bet you'll like that one as well. So that takes us to the end of our time today. Thank you so much for being with us.
- [26:24]
B
Dr. Kalyani, thanks so much, Aaron. It's been a pleasure.
- [26:28]
A
And that's all for this episode. I hope you enjoyed it. If you did, you may also enjoy a new learning activity from the Endocrine society entitled Patient POV Shared Decision Making in the Management of Type 2 Diabetes Mellitus with Comorbidities. In this activity, a clinician and patient advocate addressed the importance of shared decision making and its role in improving treatment adherence and helping patients reach their treatment goals. Learning objectives include applying Recent data regarding GLP1 receptor agonists and SGLT2 inhibitors to the manager Management of individual patients with type 2 diabetes mellitus and comorbid conditions. We'll include a link to that activity in today's episode. Description until next time, thanks for listening. Endocrine News Podcasts are a free service of the Endocrine Society. To learn more or to become a member, visit the society's website at www.endocrine.org.