6. Individualize HbA1c targets
Recent large clinical trials have indicated that no single A1c target is appropriate for all patients.19 Generally speaking, more aggressive, lower targets (eg, <7%) are appropriate for younger patients; recently diagnosed patients who do not have significant CV disease; and those who are highly motivated and have adequate resources and support.20
Higher targets (8% or even higher for some patients) may be appropriate for those who do not fit the above profile. The ADA suggests a fundamentally patient-centered approach to determine an individual’s A1c target, noting that “the desires and values of the patient should be considered, since the achievement of any degree of glucose control requires active participation and commitment.”21
7. Do more to engage patients
Achieving glycemic control and optimizing CV risk factors requires tremendous effort on the part of patients, and sometimes by their families, as well. Unilateral efforts by a physician, no matter how robust and determinedly implemented, nearly always fall short.
Given the complexities associated with managing diabetes, nearly all patients diagnosed with T2D will benefit from education. While some physicians and other health care team members have become very adept at this, there is almost always a role for certified diabetes educators. The ADA recommends that patients receive diabetes self-management education (DSME) according to national standards when their diabetes is diagnosed and as needed thereafter.7
While education is necessary, it is not sufficient. Success occurs only when the patient is educated, engaged, and activated—having the knowledge, skills, and confidence to play the key role in his or her own health care. A recent study with more than 5000 participants found that among those seeing the same physician, patients at higher levels of activation had better health care experiences than those who were less activated.22
Recommendations to patients with diabetes typically require that they carefully obtain, prepare, and consume a particular diet; exercise regularly; manage multiple medications; keep their health care appointments; and engage in regular monitoring of glucose levels and other parameters. Although the health care team may be the source of these recommendations, in every case, it is the patient who must carry them out.
For most patients, the greatest challenge lies in getting and staying motivated to implement all the recommended interventions. Motivational interviewing can be a powerful technique (http://www.motivationalinterview.org/ to learn more). But most patients require a multifaceted approach. Evidence-based principles for promoting and supporting optimal self-management in primary care—including the use of a collaborative, nonjudgmental approach and the support of diverse providers—were identified in a recent publication.23
Previsit labs: A simple but effective practice change
Many practices have adopted protocols that make it possible for patients with diabetes to have laboratory testing done prior to each visit—a change that benefits both patients and clinicians. office staff can be trained to do the work that this entails, which includes:
- following a protocol to determine which lab tests are indicated
- ensuring that patients have the appropriate lab order for testing before they leave
- contacting patients before their next appointment to ensure that the tests are done and the results available at the time of the visit.
In practices that have adopted such protocols, most visits conclude with the physician giving the patient the requisite lab order. Previsit lab results make an office visit more productive, as they allow for more targeted patient education and counseling, as well as any medication adjustment that is indicated.
This practice also increases efficiency, reducing the time and effort spent trying to communicate with patients after their visit regarding test results and new recommendations. more importantly, it makes it possible for physician and patient to negotiate and reach a consensus about any new interventions during a face-to-face encounter. even accounting for the extra effort of a separate visit for lab testing, we’ve found that most patients appreciate the added value of this approach and are happy to make the effort.
At our facility (UMass Memorial Health Care), primary care providers and diabetes specialists are working together to develop ways to more fully engage patients with diabetes. One such initiative, the Diabetes Scorecard, is delivered to each patient during check-in. Featuring patient-friendly language and simple graphics, the scorecard is automatically populated by data from our EHR, providing an at-a-glance summary that is useful to clinicians and patients alike.
To promote patient self-management and the ability of patients and clinicians to access and carefully review various parameters, several manufacturers of blood glucose meters have developed systems that allow patients to upload the data to a secure, Web-based database that both patients and providers can access and review. We have found, however, that only a few patients—and even fewer clinicians—consistently use them.