TAKING CHARGE: Patient Engagement in Diabetes Care

Kevin Kobalter, MD, and Arpita Pitroda, MD

The concept of patient engagement has been much discussed of late, particularly in the context of government imperatives to streamline healthcare delivery and reduce costs. Patient engagement means different things to different people, but a definition from the Center for Advancing Health seems to capture the essence: “We define engagement as actions individuals must take to obtain the greatest benefit from the healthcare services available to them.”[1]

Achieving this goal requires emotional and intellectual involvement by patients in healthcare decisions and actions. They need to grasp the complexities of medical testing and the consequences of pharmacologic agents, and to possess the skills necessary for navigating digital medical records. They have to interact with providers not just in the office but also online, and to avail themselves of the considerable educational data linked to online medical care. All of this requires both computer hardware and computer literacy.

Diabetes care provides a particular set of challenges for patient engagement. The disease is disproportionally costly from a payor’s standpoint: most data suggest that while diabetics represent only 7-8% of the population, their healthcare costs consume nearly 30% of dollars spent. Providers and insurers therefore have a vested interested in leveraging those aspects of patient engagement with diabetes that maximize benefit while limiting costs. Patients face similar issues with respect to their unreimbursed costs, not to mention the very real impact of diabetic complications.

Most medical conditions require some type of therapy and a mechanism for monitoring the success of that therapy. For conditions like hypertension or hyperlipidemia, simple measurements are usually made to assess the adequacy of daily pharmacologic therapy. The patient must comply with medication regimens and periodically visit the doctor or laboratory; but on a daily basis the time and effort are modest.

In contrast, diabetes provides a more complex landscape. Virtually every aspect of life impacts both short- and long-term success of diabetes treatment. Diet, exercise and drug therapy for the disease all interact in complex patterns. Absent careful attention to all these factors, both medical failure and severe consequences associated with hypoglycemia can arise. The full palate of diabetic complications need not be recited, but most are closely tied to long-term levels of glucose as measured by HbA1c. Myocardial infarction and stroke arise at much higher rates among diabetic patients, and these are tied to glucose control as well. For the patient, diabetes tends to be an overwhelming and challenging condition. It arises suddenly from the patient standpoint and dramatically alters their sense of well-being.

To maximize patient engagement with diabetes, various psychological, educational, institutional and financial barriers must be overcome. In our practice model at Kaiser San Rafael, we address the disease at many different levels. These include patient-centered issues like education and decision making, interaction with a digital record, and online access to providers and informational links. Our multidisciplinary team of providers also pursues diagnostic screening and outreach based on data mining of electronic medical records. This mining allows for identification of all diabetics in our facility and use of population management strategies through registries.

Oversight is performed by members of our healthcare team, which includes physicians, pharmacists, nurse practitioners and clerical support staff. Protocols for optimizing glucose control and preventive therapy for coronary disease, peripheral vascular disease and renal insufficiency can be broadly applied. Compliance is reinforced by phone or email contact.

From an institutional standpoint, patients whose records are computerized, who have access to their records, lab, and medications, and who actively participate with online communication are more likely to be invested in their well-being. They will have a greater sense of control over their diabetes. The feedback and dialogue possible with online access to providers and medical records represent the best of the benefits offered by evolving healthcare data innovations. These innovations are necessary to realize the purported benefits of expensive digital records and online data.

At the level of the individual patient--the human being in our office--the problems are more complex. As noted above, the diabetic patient commonly faces a sudden diagnosis that confers both inconvenience as well as questions of longevity and health. The disease challenges the very foundations of most people’s lives. At this more granular level, our approach is focused on the individual rather than being population-based.

For physicians to administer optimal care, they must understand their patients and their lives. They must also accurately assess which interventions are possible and most likely to succeed. In some instances this assessment will involve choosing the right medication. More commonly, it will involve understanding the how and why of patients’ lives. The assessment also extends to age, comorbidities, intellectual capacity, long-term prognosis and many other complexities.

Connections on the individual level require time and thought. This extra effort is necessary because failure to provide such connections can result in suboptimal outcomes. For many years, the management paradigms for diabetes were extremely prescriptive. They ranged from specific therapies to frequency of testing and a rigid set of dietary recommendations. These recommendations were often bitterly debated among academics. The most frequent losers in those debates were patients who may have been provided with general dietary advice that was personally irrelevant or incorrect.

Thankfully, over the past two years, shifts in conventional thinking--and perhaps more importantly, organizational guidelines--have moved toward a more patient-centered care model. Specific therapies, diets and targets for glycemic control have given way to more broadly organized ideals with considerable room for individualization.[2] This shift represents a win for diabetic patients and their physicians, but it does encumber doctors with an obligation to educate and assess patients, and to make important therapeutic decisions that are not clearly defined in a simple guideline.

To ensure optimal outcomes, physicians not only need to grasp the intricacies of each individual patient, but also to assess whether the patient understands the disease and is adequately motivated. We find there are typically three types of people who suffer from diabetes. They live along a spectrum, and often our job is to move them from one part of the spectrum to another.

The first segment of the spectrum is best described as denial. These patients don’t feel bad, don’t acknowledge illness, and do little or nothing to address their diabetes. The second part of the spectrum consists of patients who understand they have an illness and that their illness has consequences. The sine qua non of this group is that they will tell you why they cannot: cannot exercise, cannot eat correctly, cannot reliably take their medication. Typically they attend visits but fail to achieve glycemic goals. The third portion of the spectrum is comprised of people who resemble those in the second, except instead of telling you why they cannot, they tell you how they will make the necessary changes to improve their diabetes. Often the most critical part of patient engagement lies here: investing the individual with responsibility for control of his or her disease.

The concept of patient engagement is varied and complex. It depends on whether one looks at the patient’s perspective, the healthcare organization’s perspective, or the payor’s perspective. While all have a vested interest in maximal engagement and best outcomes, the fundamental elements of healthcare have not changed. Although computers, digital medical records, web-based education and 24-hour email access offer considerable opportunity, optimal care outcomes are still primarily dependent upon the patient and providers who have the time, interest and knowledge to inform and motivate their patients to take charge.

Even if patients develop the skills needed to successfully navigate the healthcare system, they can never be fully successful without expert caring. The challenge going forward will be in providing this essential element to our patients with diabetes, not to mention a myriad of other conditions.

---

Dr. Kobalter and Dr. Pitroda are both endocrinologists at Kaiser San Rafael.

Emails: kevin.kobalter@kp.org, arpita.pitroda@kp.org

References

1. Center for Advancing Health, “A New Definition of Patient Engagement,” cfah.org (2010).

2. Inzucchi SE, et al, “Management of hyperglycemia in type 2 diabetes: A patient-centered approach,” Diabetes Care, 35:1364-79 (2012).