DISCUSSION
One of the primary challenges in routine clinical settings is the implementation of protocolized interventions, as well as the adequate analysis/reporting of outcomes to continually refine them. At Lifedoc Health, patients having at least one cardiometabolic condition (OW/OB, Pre-DM/DM, elevated A1c, or HTN) should activate the MDT co-management, though this did not occur in 32% of the sample. Enabling patients to access best clinical practice in a health system depends on several factors related to the patient, the providers, and the health system itself.
This study further reinforces the notion that co-management with MDT improved CMRF profile compared to PCP-exclusive patients. MDT was associated with a greater reduction of weight (- 4.29 Kg), BMI (-1.43 Kg/m2), SBP (- 2.18 mmHg), and DBP (- 1.97 mmHg) as well as the number of CMRF. In addition, MDT patients having an A1c ≥ 6.5% saw and a sustained and significant improvement compared to baseline readings, though adequate comparisons could not be drawn due to limitations in A1c readings ≥ 6.5% in PCP group. Higher A1c was a consistent activator of MDT co-management in our clinical setting, with 97% of the patients with an A1c ≥ 6.5% being activated to the MDT protocol. However, in this sample composed largely of minority patients with overweight/obesity, increased risk for DBCD, and ≥1 CMRF, the presence of dysglycemia via A1c was evaluated in only 25% of the PCP patients. These findings suggest that early diagnosis of dysglycemia may not be as high a priority in the PCP setting, especially with the presence of competing for acute or chronic conditions at the time of the encounter. MDT co-management, on the other hand, may prove timelier and more effective in monitoring and screening the evolution of dysglycemia in at-risk patients. The notion that DM can be prevented or delayed if dysglycemia is identified in the pre-disease phase [12] should be emphasized and this type of standardized screening protocol should be considered as a strategic tool to overcome these obstacles.
Less weight loss has been reported with lifestyle intervention in AA women (-4.5%) compared to their C and H counterparts (-8.1% and -7.1%, respectively) in the DPP [13] as well as male and female AA patients with DM in the Look AHEAD trial [14]. In this study, no race disparities in weight loss were detected, suggesting a similar benefit among all races. A higher reduction in SBP (-2.49 mmHg) was found in H compared to AA, though this was likely not mediated by weight changes. Number of CMRFs negatively affected SBP and DBP changes and was associated with an increase of 1.66 and 1.04 mmHg, respectively, though the clinical significance of these findings was not supported by the binary model.
At the time of this one-year analysis, we found no between-group difference in mean length-of-care, with a total sample average of 61.8 months (Table 1). Those co-managed with MDT averaged twice as many visits in the same period compared to PCP-exclusive patients (12.3 vs. 6.6 visits/y, p<0.001). Our findings support the sustained benefit of a higher number of total visits integrating regular clinical care, care coordination, and lifestyle counseling as in the LDH model. This could explain lower patient attrition and higher levels of engagement, as it presents greater opportunity to reinforce lifestyle education and promote behavioral changes. While benefits of an MDT approach on cardiometabolic risk has been reported within controlled clinical trials, a specialist-based model for patients with severe obesity has been proposed, named Weight Assessment and Management Clinic (WAMC) [15]. High-intensity, lifestyle-based treatment program for obesity delivered in an underserved primary care population produced clinically significant weight loss at 2 years [16]. On the other hand, a review of treatment of obesity in primary care practices in US did not support the exclusive use of low-to-moderate intensity PCP counseling to achieve significant weight loss, though this can be achieved when used in combination with either pharmacotherapy or intensive counseling and meal replacements from dietician/nurse [17]. Implementation of MDT interventions in clinical settings does impose certain challenges. In this study, MDT provided the opportunity for more interaction with providers, intensive pharmacological management, CMRF screening tools and lifestyle counseling. At Lifedoc Health, patients in MDT group were co-managed by PCP and most visits were scheduled simultaneously as shared medical appointments (SMA) where possible to maximize the patient’s convenience. SMAs involved several care team members, including personnel trained in delivering patient education (lifestyle provider), facilitating patient interaction (medical assistant), and a prescribing provider (endocrinologist or endocrinologist-directed nurse practitioner), initiating and sustaining a comprehensive care plan [18]. SMAs have been shown to improve A1c and SBP in patients with DM [19], though there is less evidence of its efficacy in other chronic conditions [20].
The detection and management of cardiometabolic diseases in a real-world clinical setting is complex as involves multiple drivers, multi-morbidity, and genetic/environmental interactions [21]. Protocol activation promotes the patient’s access to the best health care within the health system and is subject to both patient-imposed and provider-imposed barriers. In this study, some factors may have limited a patient’s activation to MDT such as ethnocultural disparities in weight perception, as well as social determinants of health, including a lack of transportation or insurance, lower-income, low health literacy, or work-related constraints for appointments, each of which contributes to the proportion of no-shows. Understandably, both time constraints and multi-morbidity can impose barriers to better outcomes in PCP-driven interventions. This ultimately causes PCPs frustration in treating obesity, since limited time for simple lifestyle prescription does not lead to sustainable weight loss or improved management of comorbidities for the majority. Payer impact on patient outcomes should also be recognized, as their preferred fee-for-service reimbursement model contributes to the implementation of a volume-driven practices with more restricted visit durations making it extremely difficult to cover all aspects of a patient with multiple competing chronic conditions. In this study, patients undergoing MDT co-management were older and heavier suggesting that weight stigma could also contribute to a lack of provider’s activation of younger and overweight patients. Clinical inertia – failure of providers to initiate or intensify treatment when indicated – and diagnosis inertia – unawareness/failure to diagnose a condition when present [22] – can also foster lack of activation. However, contrary to the general idea that providers are chiefly responsible for inertia, all participants in the care delivery experience including patients, pharmacists, nurses, medical assistants, health authorities, payers and policy makers should be considered to play a role. [23]. Rather than an accusatory outlook towards reduced MDT activation or provider inertia, a clear understanding of its multiple causes and determinants should be captured, and development of specific, integrated strategies in clinical practice should be promoted to overcome these barriers.
Some limitations of this study deserve to be mentioned. Because this data is drawn from routine clinical practice, not all are obtained at the same intervals for which the average of measurements from Q1 and Q4 were used. Similarly, laboratory tests were not available for all participants in Q1 and Q4, so it was not possible to analyze the changes in blood glucose and lipid profile and only the A1c readings of those patients with baseline A1c ≥ 6.5% were included in DM range, as those tests are payer reimbursable. Patients referred to MDT by PCP were heavier, which may suggest a selection bias, though MDT remained more effective even after adjusting by baseline age and BMI. Outcomes of interventions carried out in routine clinical settings are infrequent [24]. This study has the strength to accurately depict of what occurs in daily clinical practice. Furthermore, a high proportion of patients were underserved, low-income minorities with multiple social barriers, which only further limits the effectiveness of the intervention.
In conclusion, there is a need to simplify the translation of evidence-based interventions into daily clinical practice and to ease healthcare accessibility. Lifedoc’s protocolized, integrated, outcome-based clinical model may positively impact the progression of overweight, obesity as well as evolution of blood pressure and A1c and reduced the overall numbers of CMRF in a low-income, minority cohort of adults compared to a PCP-exclusive approach. Results from this analysis can be easily applied to optimize clinical practice, more positively improve health outcomes, and ultimately reduce healthcare system inertia and cost of care in real-world settings. Significant improvement in outcomes of the MDT group suggests that other associated factors should be further investigated and identified to promote strategies for reducing the burden and epidemic progression of cardiometabolic conditions.