New diabetes treatment strategies for primary care to boost patient adherence
About 25.8 million U.S. children and adults have diabetes. In 2013, diabetes accounted for $176 billion in direct medical costs. Part of the aim of the Affordable Care Act is to reduce these costs while improving the management of chronic conditions. Achieving these goals, however, requires primary care practices to update their strategies for keeping patients with diabetes healthy.
Perhaps the greatest challenge for primary care physicians (PCPs) practicing in the era of accountable care is meeting quality and outcomes targets that are dependent on patient behavior.
Of particular concern to many PCPs are the health issues faced by obese patients with diabetes, says Molly Cooke, MD, immediate past president of the American College of Physicians and a practicing internist. That’s because helping these patients—and meeting quality goals—usually requires the patient to make difficult behavioral changes such as losing weight and exercising more.
Like most PCPs, Cooke is always looking for creative ways to engage patients with diabetes. But patients’ feelings of frustration and denial about having a chronic condition often get in the way.
“I wish we understood better how to get people fired up about their chronic illness,” she says. “The contrast for me comes from my early experience taking care of people with human immunodeficiency virus (HIV). They were [angry] that they had HIV and many of them fairly skeptical about their physicians. … I usually found that I could take that energy and really focus it on what the patient needed to do well.
“I began wondering why patients with diabetes often have an almost fatalistic attitude about their diabetes, and wishing I could transplant some of my HIV patients’ energy into my diabetic patients,” she adds. “I’m sure that there are ways to do that, but in general as doctors, we are not very good at it.”
Physicians have learned in recent years that some communication techniques are better for motivating healthy patient behavior than others. For example, motivational interviewing is becoming an increasingly popular technique for working collaboratively with patients to identify and overcome barriers to compliance. So instead of lecturing or arguing with patients about the need to improve their habits, Cooke recommends “really listening to the patient and exploring with him or her in a supportive way what the patient would need to do to accomplish the change.”
Leverage positive peer pressure
But while it’s important for physicians to recognize the flaws in medicine’s historically paternalistic approach, not all patient motivation has to come from the doctor. Wielding an often stronger influence over patients with diabetes are their peers. For that reason, shared medical appointments can be particularly beneficial for this population, says Cooke.
“Patients will often be a little firmer with each other than we’re sometimes comfortable being,” she says. “They’ll say, ‘We all have the same problems—we’re all taking care of our grandkids after school, we’re all busy, we’re all worried about taking walks in the neighborhoods we live in—but here are four different approaches to this issue that have been brought up in this group, so there are things you could try.’”
Daniel Spogen, MD, a member of the American Academy of Family Physicians’ board of directors and a practicing family physician in Reno, Nevada, has also used shared visits in his practice and touts their benefits. Not only can patients struggling with similar challenges give one another practical advice, he says, but their discussions can also be eye-opening for physicians. For example, he realized during a group visit that many of his patients didn’t understand the explanation he had been giving about what hemoglobin A1C levels meant, leading him to clarify the way he taught the concept.
Spogen does have a caveat about group visits, however. “There’s one kind of funny thing that happens. The people that are the best controlled really like to come to those group visits, though we’d really like to see more of the people with the worst control show up,” he says.
Nonetheless, group visits also help address physicians’ ever-increasing constraints on the amount of time they can spend with patients.