Superior Diabetes Care with 1) Shared Decision Making, 2) a Diabetes Checklist and 3) Screenings

This video provides an in-depth exploration of three critical systems of care identified by University of Minnesota Medical School researchers that lead to superior diabetes outcomes. Dr. Eric Bricker, from AHealthcareZ, begins by establishing diabetes as a significant "bane of existence" for employee health plans and a major risk factor for severe complications like heart attack, stroke, kidney failure, blindness, neuropathy, and amputations. He emphasizes that given the profound suffering and disability caused by diabetes, any effective treatment strategies should be embraced. The presentation then systematically breaks down each of the three research-backed systems, highlighting their practical application and the pitfalls of neglecting them.

The first system discussed is "Shared Decision Making," which advocates for a collaborative dialogue between physician and patient rather than a passive acceptance of doctor's orders. Dr. Bricker stresses the importance of identifying "reasonable management options for the individual," acknowledging the unique circumstances of each patient, such as transportation issues, literacy levels, or access to pharmacies. He provides vivid examples of how pragmatic considerations, often overlooked in rushed seven-minute visits, are essential for effective diabetes management. Without this collaborative approach, he argues, treatment plans are destined to fail.

The second system is the implementation of a "Diabetes Care Checklist," drawing a parallel to Dr. Atul Gawande's famous surgery checklist. Dr. Bricker asserts that relying solely on a physician's memory for comprehensive diabetes care is a "horrible approach." He suggests that this checklist, whether written or integrated into an Electronic Medical Record (EMR), should prompt doctors to periodically check crucial metrics like Hemoglobin A1C, ensure annual retina exams by an ophthalmologist, screen urine for protein to detect nephropathy, and monitor kidney function via serum creatinine. He highlights that patients typically present for acute "sick visits," making it the doctor's responsibility, guided by a checklist, to proactively address silent chronic diseases like diabetes that ultimately lead to severe long-term complications.

Finally, the third system focuses on "Guideline-Based Screenings" for conditions outside of diabetes itself, which are nonetheless crucial for diabetic patients. Dr. Bricker explains that regular screenings recommended by the U.S. Preventive Services Task Force for conditions like hypertension and high cholesterol are vital because these are major risk factors for coronary artery disease, exacerbating the risks already posed by diabetes. He also underscores the importance of screening for depression, as it significantly hinders a patient's ability to self-manage their diabetes. Furthermore, screening for and addressing cigarette smoking and alcohol abuse are critical, as these habits cause immense damage to blood vessels, compounding the vascular issues inherent in diabetes. The video concludes by emphasizing that merely having a primary care physician is not a magical solution; these structured systems of care, including the potential for virtual visits, are essential for improving diabetes outcomes.

Key Takeaways:

• Diabetes as a Major Health Burden: Diabetes is a leading cause of heart attack, stroke, kidney failure, blindness, neuropathy, and amputations, necessitating effective and proactive management strategies to mitigate its severe impact on patient health and healthcare costs.
• Shared Decision Making is Crucial: Effective diabetes care requires a collaborative dialogue between the physician and patient to identify "reasonable management options" tailored to the individual's unique life circumstances, including social determinants of health like transportation, literacy, and access to resources.
• Individualized Care Over Generic Prescriptions: A one-size-fits-all approach to diabetes management is ineffective; care plans must be pragmatic and adaptable to the patient's specific challenges to ensure adherence and positive outcomes.
• The Power of a Diabetes Care Checklist: Implementing a structured checklist, similar to surgical checklists, significantly improves diabetes outcomes by ensuring that essential screenings and interventions are not overlooked, moving beyond reliance on physician memory.
• Essential Diabetes-Specific Screenings: The checklist should include periodic checks for Hemoglobin A1C (90-day blood sugar control), annual retina exams by an ophthalmologist, urine protein checks for nephropathy, and serum creatinine tests for kidney function.
• Proactive Management of Silent Chronic Diseases: Physicians must use checklists to proactively address chronic conditions like diabetes during acute "sick visits," as patients rarely initiate discussions about their chronic disease screenings.
• Broader Guideline-Based Screenings are Vital: Beyond diabetes-specific checks, regular screenings for co-morbidities like hypertension, high cholesterol, depression, cigarette smoking, and alcohol abuse are critical, as these conditions significantly worsen diabetes outcomes and increase overall health risks.
• Addressing Mental Health and Lifestyle Factors: Screening for and treating depression is paramount, as it severely impairs a diabetic patient's ability to manage their condition. Similarly, addressing smoking cessation and alcohol abuse is crucial due to their damaging effects on blood vessels.
• Structured Care is Not Optional: Simply having a primary care physician does not guarantee effective diabetes management; superior outcomes depend on the consistent application of structured systems involving shared decision-making, checklists, and comprehensive screenings.
• Virtual Visits Enhance Accessibility: Especially in contexts like a pandemic, virtual visits offer a highly effective means to implement these three systems of care, improving patient access and adherence to essential diabetes management protocols.

Key Concepts:

• Shared Decision Making: A collaborative process where patients and clinicians make healthcare decisions together, taking into account the best available evidence and the patient's values and preferences.
• Diabetes Care Checklist: A systematic tool used by healthcare providers to ensure all necessary screenings, tests, and interventions for diabetes management are consistently performed.
• Guideline-Based Screenings: Preventive health checks and diagnostic tests recommended by authoritative bodies (e.g., U.S. Preventive Services Task Force) for various health conditions, applied to diabetic patients to manage co-morbidities.
• Hemoglobin A1C: A blood test that measures a person's average blood sugar level over the past 2-3 months, used to monitor diabetes control.
• Nephropathy: Kidney disease, a common and severe complication of diabetes, often screened for by checking for protein in the urine.
• Serum Creatinine: A blood test used to measure kidney function.

Examples/Case Studies:

• Patient with no transportation: A patient who could only walk or use public transport, necessitating medication pick-up directly from the clinic rather than a pharmacy.
• Illiterate patient: A patient who could not read, requiring their spouse to accompany them to appointments to understand instructions.
• Atul Gawande's Surgery Checklist: Referenced as a successful model for how simple checklists can dramatically improve outcomes in complex medical procedures, applied here to diabetes care.