With real-world uptake of diabetes prevention remaining low, researchers at the David Geffen School of Medicine at the University of California, Los Angeles (UCLA) in 2015 launched a shared decision-making (SDM) program to improve patient awareness of prediabetes. Four months after the SDM visit, about 39% of patients with prediabetes had either participated in a National Diabetes Prevention Program or used metformin compared to 2% in the control group.
“The biggest thing for us was the outcome. At four months, people who did SDM lost an average of 4.9 pounds, compared to 0.7 in the control group—a difference of 4.3 pounds. This actually increased at 12 months where people who did SDM lost 5.3 pounds—control patients lost 0.2 pounds,” O. Kenrik Duru, MD, an internist and Professor of medicine at UCLA, said during an AMA Insight Network virtual meeting about partnering with patients to prevent type 2 diabetes.
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“These numbers may seem small, but we know—from the study—that losing around 5 pounds is actually clinically meaningful for diabetes risk reduction, particularly when you can keep it off for 12 months and, ideally, longer,” said Tannaz Moin, MD, an endocrinologist and Associate Professor of medicine at the David Geffen School of Medicine at UCLA, who also presented at the meeting. Since its launch, the shared decision-making effort has been implemented across UCLA as well as Intermountain Health in Utah, Nevada and Idaho.
The David Geffen School of Medicine at UCLA is part of the AMA GME Competency Education Program (GCEP), which is designed to help engage residents through interactive tutorials and track their progress during their competency training. GCEP is part of the AMA GME Resource Program, which gives the AMA more capacity to provide resources to help GME leaders more effectively meet accreditation requirements, enhance education delivery and improve well-being for their learners and faculty.
Here are some keys to their implementation of shared decision-making for diabetes prevention.
Embed pharmacists in the care team
“We didn’t want to implement an intervention that was going to work independently in a silo so that when the project ended, the intervention ended as well. We wanted to implement a program that was going to be sustainable over time,” Dr. Moin said. “So, at UCLA, in our primary care clinics … we have embedded pharmacists in primary care to help co-manage patients.”
“The idea was that our pharmacists had both the skills and the knowledge to be able to help us deliver shared decision-making,” she said.
Physicians are the public face
The primary care physicians need to “be the face the patient sees” without burdening the doctors, because “there are a lot of people with prediabetes,” said Dr. Duru. “If you did this for every patient each day, you’d get out at 9 p.m.”
To begin, each patient received a letter about diabetes prevention with the physician’s signature, followed by a call. This also included identification of high-risk patients in the EHR to engage them and bringing them in for the pharmacist to do the shared decision-making with physician approval, said Dr. Duru. After meeting with the patient, the pharmacist sends a note to update the physician.
Understand the time needed
With a team-based care model, shared decision-making takes about 37 minutes. This may be longer than the average time a physician has to interact with patients in routine clinic visits, but it does not add more work for the doctor.
“This is why we need all team members to be part of this process,” said Dr. Moin. At UCLA, “we have our embedded pharmacists, and we know now at Intermountain there are nurses and case managers who help co-manage patients in their system."
Sharing prediabetes “information at a pace and in a way that is easy for patients to understand and then actually assessing their understanding takes time,” she said. “We believe that that time is valuable, and we can lead to the results that we’re looking for in terms of impact.”
The AMA's Diabetes Prevention Guide supports physicians and health care organizations in defining and implementing evidence-based diabetes prevention strategies. This comprehensive and customized approach helps clinical practices and health care organizations identify patients with prediabetes and manage the risk of developing type 2 diabetes, including referring patients at risk to a National DPP lifestyle-change program based on their individual needs.
