Coordinated care improves use of CVD-preventive therapies in T2D

A coordinated, multifaceted intervention of assessment, education, and feedback has resulted in an increase in the prescription of recommended, evidence-based therapies in adult patients with type 2 diabetes (T2D) and atherosclerotic cardiovascular disease (CVD), reveals a study presented at ACC 2023.

The therapies include high-intensity statins, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), and sodium-glucose cotransporter 2 (SGLT2) inhibitors and/or glucagon-like peptide 1 receptor agonists (GLP-1RAs).

“Evidence-based therapies to reduce atherosclerotic CVD risk in adults with T2D are underused in clinical practice,” according to the researchers led by Dr Neha J. Pagidipati from the Duke Clinical Research Institute in Durham, North Carolina, US. [ACC 2023, abstract 409-16]

Pagidipati and colleagues conducted a cluster randomized clinical trial of adults with T2D and atherosclerotic CVD who were not taking evidence-based therapies at 43 US cardiology clinics between July 2019 and May 2022. They followed the participants through December 2022.

A total of 1,049 patients (median age 70 years) were randomized to intervention (n=459) or usual care (n=590) clinics. Interventions included assessing local barriers, developing care pathways, coordinating care, educating clinicals, reporting data back to the clinics and providing tools for participants, while usual care was based on practice guidelines.

Of the participants, 338 (32.2 percent) were women, 173 (16.5 percent) were Black, and 90 (8.6 percent) were Hispanic. [N Engl J Med 2023;doi:10.1001/jama.2023.2854]

Patients in the intervention group had a higher likelihood of being prescribed all three recommended therapies compared to those in the usual care group (37.9 percent vs 14.5 percent) at follow-up (12 months for 97.3 percent of participants), with a difference of 23.4 percent (adjusted odds ratio [aOR], 4.38, 95 percent confidence interval [CI], 2.49‒7.71; p<0.001).

Likewise, the intervention cohort were more likely to be prescribed each of the three therapies (change from baseline in high-intensity statins: from 66.5 percent to 70.7 percent for intervention vs 58.2 percent to 56.8 percent for usual care; aOR, 1.73, 95 percent CI, 1.06‒2.83; ACEIs or ARBs: 75.1 percent to 81.4 percent for intervention vs 69.6 percent to 68.4 percent; aOR, 1.82, 95 percent CI, 1.14‒2.91; SGLT2 inhibitors and/or GLP-1RAs: 12.3 percent to 60.4 percent vs 14.5 percent to 35.5 percent; aOR, 3.11, 95 percent CI, 2.08‒4.64).

Notably, no significant association was observed between the intervention and changes in atherosclerotic CVD risk factors.

The composite outcomes of all-cause death or hospitalization for myocardial infarction, stroke, decompensated heart failure, or urgent revascularization occurred in 23 (5 percent) of 457 participants in the intervention group vs 40 (6.8 percent) of 588 in the usual care group (adjusted hazard ratio, 0.79, 95 percent CI, 0.46‒1.33).

Implications

These findings have important implications. Initially, “usual dissemination of clinical outcomes evidence alone results in slow uptake of therapies,” said the researchers.

An earlier study of commercially insured individuals with T2D and atherosclerotic CVD showed that only 24.7 percent were taking statins, 53.1 percent were taking ACEIs or ARBs, and only 2.7 percent were taking all three groups of medications. [J Am Heart Assoc 2021;10:e016835]

Secondly, “the trial shows that while clinician behaviour has historically proven difficult to change, an intervention with multiple synergistic components can have an effect on clinician prescribing patterns for evidence-based therapies,” the researchers said.

The intervention of the current study included six complementary components. Previous trials reported how multifaceted strategies were more effective than single-component strategies. [Lancet 2017;390(10104):1737-1746; Circulation 2017;135:e122-e137]

Finally, “even though many prior implementation strategies have been shown to be effective in single-system settings, the strategy evaluated in the current trial was successful across multiple clinic sites in the US,” the researchers said. [Circulation 2021;143:427-437; JAMA Cardiol 2023;8:12-21]

“This success may be related to the initial assessment of local barriers to delivering evidence-based care, an element that allowed tailoring of the intervention to the specific challenges faced at each clinic site,” they added.