Collaborative Diabetes Medication Management: Advanced Practice Clinicians Working with Patients

Advanced practice clinicians are in a unique position to facilitate a patient's engagement in his or her health care.

Busy advanced practice clinicians are duty-bound to provide their patients not only with the medicines to treat disease, but also the know-how to use them properly. This is particularly important in the management of diabetes. Diabetes, which afflicted over 29 million Americans in 2012 and was the seventh leading cause of death in 2010, is a chronic metabolic disease requiring continuous education and engagement by the clinician with the patient.¹

With the complexity of the disease, it is can be difficult for the advanced practice clinician to allocate time to adequately educate a patient, especially in the fast-pasted outpatient setting of the retail-based clinic. A noteworthy study by Rhoades et al published observational data from 60 routine primary care office visits that evaluated the length of time that resident physicians and patients spoke and the number of interruptions. Results showed that patients spoke without interruption for an average 12 seconds after the resident entered the room. One-fourth of the time, residents interrupted patients before they finished speaking. With the average time spent with the patient at 11 minutes, the patient spoke for a total of about 4 minutes. Not surprisingly, increased frequency of interruptions was associated with less favorable patient perceptions of the visit.²

The establishment of a trusting relationship between provider and patient is monumental in enhancing adherence. Advanced practice clinicians, such as physician assistants and nurse practitioners, are in an excellent position to provide stellar care and education to patients with diabetes, and often, midlevels have more time in the clinic to spend with the individual.

Assessing a patient’s knowledge and understanding of the disease is important. Furthermore, it is wise to assess the patient’s appreciation of the lifelong consequences of diabetes, particularly if uncontrolled. Health care providers are well aware of the morbidity of diabetes, but it is recommended that they talk with their patients to assess their understanding of potential future complications of the disease. Such an assessment not only provides insight into the patient’s thought process, knowledge, and level of education, but it allows the provider to begin a conversation that could ultimately yield a stronger patient— provider bond.

There are identifiable risk factors for poor follow-through and nonadherence. Elderly and adolescent patients tend to be less adherent with their care plans. In addition, a complex medication administration or dosing schedule significantly reduces the likelihood that a patient will follow directions. The presence of multiple chronic conditions can also impair follow-through. This is of substantial import, as patients rarely have just 1 condition; they often contend with several, as is the case in patients with metabolic syndrome, a cluster of diseases that can include diabetes, hypertension, and obesity. Other notable risk factors include a lack of financial and social resources, high medicine cost, low education level, a patient’s lack of understanding of the disease, and an inadequate relationship between patient and provider.

Warning signs of poor patient adherence specific to diabetes include uncontrolled blood glucose (BG), labile and erratic fluctuations in BG, multiple cancelled or missed appointments for office visits and testing, and lack of follow-through with self-monitoring of BG.³Long-term adherence to oral glucose- lowering agents has been reported to be 36% to 93%, and insulin adherence in type 2 diabetes ranges from 62% to 80%.^4,5Poor follow-through has been shown to correlate with worse glycemic and lipid control.^4,6

Despite these statistics, the best efforts of advanced practice clinicians are still fruitful when key points are made clear to the patient. Moreover, a multidisciplinary approach is paramount in inducing adherence. A collaborative team of physicians, advanced practice clinicians, pharmacists, nurses, certified diabetic educators, and dietitians is, without doubt, the key to improvement in clinical outcomes. The pharmacist on the health care team can play an important role in encouraging the use of tools that improve medication adherence. Aids such as pill boxes, medication reminders, and blister packaging are helpful. Many pharmacies provide delivery of medications and supplies and offer medication adherence services.

With regard to insulin, the advanced practice clinician needs to match the patient’s need to his or her lifestyle. The most physiologic insulin regimen is the basal-bolus schedule that carries the advantage of being able to adjust the dose of the rapid-acting according to meal timing and content. Pre-mixed insulin (neutral protamine hagedorn [NPH]/ regular) can be chosen if the person is unable to arbitrate dose calculations or prefers to inject fewer times per day. For example, the elderly patient experiencing hardship with carbohydrate counting may be best suited to a twice‑daily regimen such as the NPH/regular combination, whereas the college graduate requiring tight control will likely do best with multiple daily injections associated with carbohydrate counting and correction boluses. An insulin pump may not be suitable for a collegiate swimmer with diabetes, whereas the middle-aged, poorly-controlled patient with type 2 diabetes would find the pump befitting.

The clinician should educate the patient on how to properly administer insulin. The demonstration pens provided by pharmaceutical companies are very helpful. During an office visit, the clinician can use the saline pen to inject herself as a true demonstration, then have the patient make his or her own first injection during the same visit. This reduces anxiety when the patient has to do it at home and away from direct clinical support.

The health care clinician should explain the risk factors for hypoglycemia (eg, missed or irregular meals) and hyperglycemia (eg, missed insulin doses and infection). Premade handouts on what to do in these situations are a good start. Actively writing a list with the patient in the room of which foods constitute 15 g of glucose, however, may be more engaging than simply handing out a piece of paper. Having the patient jot these down may be even better.

Concerns that providers may not think about or may find trivial can often be monumental to the patient. The average patient will not know, for example, what to do with the syringe after it is used or how to dispose of it. He or she also needs to be educated on which areas of the body are acceptable injection sites. Simply framed tools that the patient can relate to, such as thinking of one’s abdomen as a clock and moving the needle around the clock to change injection locations, are beneficial. It is effective to anticipate patients’ needs and concerns when events arise, such as what to do when at a restaurant and how to manage diabetes when sick.

Assessing patient fears over insulin and diabetes management, as a whole, is critical. There are patients who associate insulin initiation with dialysis and blindness, and there are many who have a fear of needles. It is the job of the health care provider to address these fears by first listening to patients without interruption. Some of the needle fear may be mitigated with the use of newer injectable noninsulin type 2 diabetes medicines, such as liraglutide and exenatide, which are provided in prefilled disposable pens.

During the visit, clinicians should address possible adverse effects of medications and prepare patients for what to expect. A clinician may be thorough in explaining that metformin can cause diarrhea, but only skim over what the patient should do if her or she becomes acutely ill or is planned for a computed tomography scan with contrast.

It is the clinician’s job to not only educate, but encourage patients. Making it clear to patients that controlling blood sugar will extend life expectancy and delay or prevent comorbidity is essential. As serious as diabetes can be, clinicians need to express that there is treatment and there is hope. It is important to show the patient how the insulin is working to lower BG and to explain the proven clinical benefits of insulin therapy. Many pharmaceutical companies have insulin programs and support lines that are easily accessible to patients.

To further strengthen a patient’s engagement in their health care and enhance the patient—provider relationship, it must be clearly stated that he or she may contact the provider with further questions and concerns. A common send-off to patients as they walk out of the room is, “Give me a call with any questions.” The affirmation to the patient, however, lies in the support that is actually given. When the patient calls with a question, who returns the call: the medical assistant or the provider? Does the call back occur within the day or the week? The patient will feel secure when walked through their complex diabetes management by a trusted health care professional.

With volumes upon volumes of textbooks and journals about diabetes, it is impossible to adequately summarize all aspects of the disease in one 15-minute encounter. Thus, proper follow-up is paramount. Before scheduling follow- up, however, the importance of the follow-up must be relayed to the patient. Uncontrolled patients with diabetes need quarterly office visits. This does not include the recommended dilated eye and foot exams that are inherent to proper diabetes management.

The goal of self-management is to encourage adherence and appropriate follow-through with patients with diabetes. It is important to facilitate a patient’s engagement in his or her own health care, without which effective glucose control is unlikely. Advanced practice clinicians have a significant opportunity to encourage patients with diabetes along the path to improved clinical outcomes.

Michele Brannan, MPAS, PA-C, graduated magna cum laude with a bachelor’s degree in health science and graduated with distinction with her master of physician assistant studies degree, each from Gannon University. She started her career at St. Louis University, working in cardiology before joining Alton Internal Medicine, where she has practiced for 10 years.

References

1. Statistics about diabetes. American Diabetes Association website. www.diabetes.org/diabetes-basics/statistics/?referrer. Updated May 18, 2015. Accessed 4 July 2015.

2. Rhoades DR, McFarland KF, Finch WH, Johnson AO. Speaking and interruptions during primary care office visits. Fam Med. 2001;33(7):528-532.

3. Leichter SB. Making outpatient care of diabetes more efficient: analyzing noncompliance. Clin Diabetes. 2005;23(4):187-190.

4. Cramer JA. A systematic review of adherence with medications for diabetes. Diabetes Care. 2004;27(5):1218-1224.

5. Rubin RR. Adherence to phamacologic therapy in patients with type 2 diabetes mellitus. Am J Med. 2005;118(suppl 5A):27S-34S.

6. Lin EH, Katon W, Von Korff M, et al. Relationship of depression and diabetes self-care, medication adherence, and preventive care. Diabetes Care. 2004;27(9):2154-2160.