Team diabetes (American College of Physicians annual session)

When it comes to diabetes care, primary care physicians no longer are being asked to shoulder the burden alone.

In recognition of both the fact that the disease's incidence continues to increase and its management is becoming more complicated, the American College of Physicians launched a $10 million, three-year diabetes project. The initiative aims to improve care by advancing a team-approach model and providing educational tools for physicians, allied health care practitioners and patients.

"To tackle diabetes, we are looking beyond our 116,000 member internists to the health care team as a whole: the medical subspecialists, physician assistants, nurse educators and patients themselves," said ACP President Charles K. Francis, MD.

The project was launched last month at the organization's annual meeting in San Francisco, which also featured 16 educational sessions about various aspects of diabetes care. Practices that participate and demonstrate improvements will receive official ACP recognition. "That will be something they can hang in their practice or use as a measure in pay for performance," said Vincenza Snow, MD, ACP's clinical director for the initiative.

The project is the largest of its kind ever launched by the college and is funded by Novo Nordisk, a manufacturer of diabetes treatments. At the three-year point, ACP hopes to have data showing that the effort improved overall outcomes and generated new ideas for managing the condition.

Getting to the goal

Physicians praised this diabetes focus as offering help in an area that continues to perplex them in patient care.

"We've all been frustrated by the patient who doesn't get to the goal we've learned can make a difference," said Cheryl E. Weinstein, MD, general internist from Cleveland.

The educational sessions explored several relatively new strategies that, although well-supported by data, are making care for this patient group increasingly complex. For example, experts called for more emphasis on cardiovascular risk factors while keeping prevention of complications in mind.

"Our patients suffer from microvascular complications but they die of macrovascular complications. Treat aggressively. Try to get the hemoglobin A1c to less than seven within six months, but don't be gluco-centric. We really need to have a global approach to our patients and treat all the cardiovascular risk factors," said Edward S. Horton, MD, director of clinical research at the Joslin Diabetes Center in Boston during his presentation about outpatient management of diabetes.

Dr. Horton favors getting cholesterol low, keeping blood pressure under control and pushing patients to quit smoking. As for controlling blood sugar, he urges attention to the declining function of beta cells rather than the issue of insulin resistance.

"At the time we diagnose people with diabetes, they've already lost about 50% of beta cell function, and it only gets worse over time," he said.

Using combinations of drugs geared toward different aspects of the disease rather than higher doses of a single drug was another of his suggestions. Patients also should be put on insulin replacement more quickly.

"It's often a challenge to convince patients that they should start insulin. I think a lot of physicians don't like to take that step either because it means a lot more patient education, and there's a lot of concern about hypoglycemia," he said. "But the majority of patients will ultimately be on combination therapy with oral agency and/or insulin treatment."

Control issues

Other sessions concentrated on controlling postprandial as well as preprandial blood sugars because of a growing body of evidence suggesting that high post-meal blood sugars could be contributing to some of the disease's morbidity.

"If a normal person never gets [blood sugar] above 140 mg/dL, why should it be OK for diabetics to be 200 or 300 after every meal?" asked Steven Edelman, MD, professor of medicine in the division of endocrinology, metabolism and diabetes at the University of California, San Diego. He spoke on diabetic management dilemmas. "If you want to get the A1c to normal, you're going to have to attack postprandial glucose."

Sessions also addressed debates regarding unanswered questions about where improvements in care can be made. Many doctors quizzed speakers on what to do with patients with impaired glucose tolerance or pre-diabetes, a relatively new category of diabetes with no recommended pharmacology. Experts suggested starting with lifestyle changes, and audience members agreed that medication should be used with caution.

"It's all the more incentive for using lifestyle changes, which is my primary focus," said Timothy W. Allari, MD, general internist from Santa Cruz, Calif.

The only issue not a matter of debate was the fact that diabetes is becoming more common and more complicated to manage. The subject pervaded every session.

Physicians said that otherwise clear treatment situations can become murky when diabetes is in the picture. Almost regardless of the patient's complaint, whether a common cold or achy joints, most experts tend to be more aggressive with diabetics who had poor control of their disease but tended to treat their well-controlled diabetics much like any other patient. Should this be the case?

"We don't have good studies to really give us good answers," said Ralph Gonzales, MD, MSPH, associate professor of medicine, epidemiology and biostatistics at the University of California, San Francisco, during his session, "Conundrums in the Management of Upper Respiratory Tract Infections in the Era of Antibiotic Resistance."