Individualized Decision Making and Care for Patients With Type 2 Diabetes
In this video, Kathryn Kreider, DNP, APRN, FAANP, FNP-BC, speaks about how clinicians can individualize care for their patients with type 2 diabetes, including strategies that can be used, what clinicians should consider when creating an individualized care plan, and what current barriers exist for patients with type 2 diabetes.
For more type 2 diabetes content, visit the Excellence Forum.
Kathryn Kreider, DNP, APRN, FAANP, FNP-BC, is a clinical professor of nursing and the director of the Endocrinology Specialty Training Program for nurse practitioners at Duke University School of Nursing (Durham, NC)
TRANSCRIPTION
Kathryn Kreider, DNP, APRN, FAANP, FNP-BC: Hi, everyone. My name is Kathryn Kreider. I am a clinical nursing professor at Duke University School of Nursing. I am also the director of the endocrinology specialty training program for nurse practitioners there at Duke. And I practice clinically in Duke's Division of Adult Endocrinology, Metabolism and Nutrition. And so I'm here today to talk a little bit about individualizing care in patients with type 2 diabetes.
Consultant360: What are some strategies that clinicians can utilize for individualizing care of patients with type 2 diabetes?
Dr Kreider: So there is definitely a push, in general in the clinical world, and I think leaders such as the American Diabetes Association (ADA) are leading this charge. And it's so important. And that is thinking about how we individualize and optimize care for each patient. And one of the reasons that this is the case is because now we have so many new medication options.
So it used to be like we had sulfonylureas and metformin and insulin, and that was pretty much it. And then [thiazolidinediones] TZDs, for example. But now we really do have more opportunities to think about what's in our toolbox and how we address each patient specifically.
And so if we're thinking about strategies, the first place to start would be thinking about what makes your patient unique. What are the individual characteristics of your patient that will impact their diabetes care? And so we can think about things like their personal goals, right? Maybe they don't believe that they should have an A1C less than seven because they're worried about hypoglycemia. So that's a discussion point for you all. Maybe they have a strong history of hypoglycemia. That's another area to explore. Maybe they are very high in weight, right? So there's all these things that make someone who they are that really could impact your decision making on their behalf and, really we want to call it shared decision making, and really help frame the way that you take care of this patient, okay? So strategies are first going to be trying to identify what the most important factors are about this person in front of you that need to be considered when you're designing a plan for their diabetes.
C360: What are the main considerations for clinicians who want to provide a more personalized approach?
Dr Kreider: The first thing that I think would be very beneficial to think about is what are some of the possible barriers to care, right? We think we can think about things like social determinants of health, for example. And I know that a lot of clinicians can shy away from that because that particular area feels so big and so hard for us to do anything about. But it's really critical for us to acknowledge because if we don't think about cost and access and even something like health literacy, for example, we're not going to be able to really devise a plan that works for this patient. Okay, so think about the barriers to optimizing their health.
The second thing I would recommend is thinking about what health comorbidities that they have in addition to diabetes. So do they have heart failure or are they at high risk for heart failure? Do they have chronic kidney disease (CKD) or they are at high risk for CKD? Do they have established or high risk for [atherosclerotic cardiovascular disease] ASCVD? If those are present, then that will guide us down the right medication selection pathway, right? And this is from the ADA in the latest standards of care. So if someone has established cardiovascular disease, they really need to be on an SGLT-2 inhibitor or a GLP-1 receptor agonist because both of those medicines are known to reduce their risk. And this discussion could go on and on.
But the point is, think about what their health comorbidities are. So CKD, heart failure, CVD, but also their risk for hypoglycemia, that's very important in medication selection, and their weight, very important in medication selection because now we have these medicines such as GLP-1 receptor agonists and GLP-GIP that are highly effective for weight reduction.
So that's a great place to start. So social determinants of health, barriers to care, health comorbidities. and then also have a discussion about what the patient's goals are, their goals, because if you can come together and meet in the middle, it's going to be a much more optimized and improved outcome.
C360: Are there any barriers that may affect personalized care for patients with type 2 diabetes?
Dr Kreider: For sure. So we think we can think about this from the patient side and also the health care provider side. Let's start with us as providers. We are so rushed, right? And I think many of us would really wish that we had more time with each patient, but we don't. And so us trying to think about how we can be individualized and talk to patients about their goals and all that sometimes feels like a pipe dream because it's hard in our clinical context. So what I would recommend there is maybe think about one thing. One thing that your patient is struggling with that will really impact their ability to get to optimal health outcomes. Maybe it's cost of medicines, maybe they need a patient assistance program, maybe they have housing instability. You don't have to solve the problem, but maybe you can connect them to the right resource. Okay, so our time is very challenging, but we can try to address one thing in each clinic visit, at least discuss it with the patient, see if we have any opportunities to connect them with the right resources.
From the patient side, there's a lot, right? And then we are not expected to solve that, but I think trying to understand their perspective. Long are the days gone, that we could go into a room and write a prescription and not get any input and expect someone to kind of follow your recommendations, right? That has not been shown to be effective diabetes management. So what are ways that we can work with the patient to address their concerns, their goals, and come together to develop shared decision making? From a barriers perspective, we have the tools that we need to start breaking down these barriers and to provide individualized care, but we really need to be intentional about how we go about that.
C360: What are the overall take-home messages from our conversation?
Dr Kreider: Individualized patient care in diabetes is critical and if you have patients in your practice and we all do, we all have these patients, that over and over and over again they're not meeting their treatment goals. Think about the things that are not working, right? And it might be because maybe you don't have the right medication for this patient that they need. Maybe they can really benefit from something else. Think about ways that you can start breaking down those barriers by getting a little bit more information about your patient and asking questions without taking up too much time about what their barriers are and what their goals are. And then think about their health comorbidities and make sure that you're optimizing their management based on the tools and resources that we have now that really help to reduce cardiovascular risk, reduce the risk of hypoglycemia, help patients lose weight, and then, something we haven't talked about yet, are even opportunities for using continuous glucose monitors, for example. That is an excellent way to start optimizing individualizing patient care because you can see exactly what someone's patterns are of glucose dysregulation and you can help add in medications that will specifically address those issues.
So that's another way with the new technology and the better medicines that we have to think about what will work best for this patient. Work together on making goals and I really believe that you'll start to see some great improvement in your diabetes outcomes.
Dr Kreider: Thank you so much for joining me today to talk a little bit about individualized decision-making and individualized patient care in diabetes. This is such a critical area that I'm really passionate about, and I feel that if you make some small steps to improving your ability to deliver individualized care in your clinical setting, you will truly see improved outcomes from a patient perspective. And so I encourage you to work on this. I know it's not easy, but it is worth it in the long run.