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.