A coordinated multidisciplinary intervention can help to improve prescriptions of evidence-based drugs such as 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]) in patients with type 2 diabetes and atherosclerotic cardiovascular disease (ASCVD), according to the COORDINATE Diabetes trial, the results of which were presented at the ACC.23 conference in New Orleans, Louisiana and simultaneously published in JAMA.^1-3

This multicenter randomized trial recruited 1049 patients with type 2 diabetes and atherosclerotic cardiovascular disease. It was conducted in 43 cardiology clinics in the United States from July 2019 to May 2022 with an objective to evaluate if a coordinated, multifaceted intervention increase the prescription of ACEIs or ARBs, high-intensity statins, SGLT2 inhibitors and/or GLP-1 receptor agonists compared to the usual care. Twenty clinics were randomized to the intervention with the three groups of medicine, while 23 were assigned to the usual care as recommended by American College of Cardiology/American Heart Association (ACC/AHA) and American Diabetes Association (ADA) guidelines. The mean age of the study subjects was 70 years and majority were male with women comprising 32.2% of the study population. At study entry, one-third of the participants were being treated with one of the three groups of drugs and just over 50% were on two of these medications.

Doctors and other health personnel at the intervention clinics were trained by a coordinating team of 3 clinicians (an endocrinologist, a cardiologist and an implementation specialist) on the six components of the intervention: evaluation of local barriers to providing evidence-based care, developing local interdisciplinary care pathways, coordinating care amongst the physicians, education of the clinicians, audit of clinic data and providing tools in the form of educational material to the participants.

Analysis of data showed that at 12 months, patients from the intervention clinics were 4 times more likely to be prescribed all three medications under study compared to the patients receiving usual care (37.9% vs 14.5%, respectively) with adjusted odds ratio (aOR) of 4.38, which was also the primary outcome of interest in the trial. When the three individual drugs were examined, their prescription also showed an increase compared to baseline in the intervention group.

The prescription for high-intensity statins increased from 66.5% to 70.7% in the intervention group vs from 58.2% to 56.8% in the usual care group with aOR of 1.73. Similarly, the prescriptions for ACEIs/ARBs increased from 75.1% to 81.4% with intervention vs from 69.6% to 68.4% for usual care (aOR 1.82). SGLT2i and/or GLP-1RA prescriptions also increased in the intervention group compared to the usual care group; from 12.3% to 60.4% vs from 14.5% to 35.5%, respectively (aOR 3.11). No changes were observed in the risk factors for ASCVD, which was a secondary outcome of interest, in the intervention group. However, the authors noted that “the trial was not powered to show this nor was risk factor data mandated for collection”. Fewer participants in the intervention group experience the composite secondary outcome of all-cause death or hospitalization for myocardial infarction, stroke, decompensated heart failure, or urgent revascularization vs the usual care group; 5% vs 6.8%, respectively with aOR of 0.79.

Treatment of diabetes is not just limited to achieving the desired glycemic control. There is also a need to manage the various micro- and macrovascular complications that occur. Hence, a multidisciplinary approach to care with multiple treatment goals is required. Physicians treating diabetes patients do not work in isolation. Instead, it is a team of doctors from different specialties delivering optimal diabetes care, with the patients also as an integral part of the team, for better patient outcomes.

These findings of this randomized trial uphold the significance of coordinated multidisciplinary care in patients with diabetes. They elucidate that an intervention of “assessment, education and feedback” increases the prescription of high-intensity statins, ACEIs/ARBs including SGLT2i and/or GLP-1RA, which are backed by a large volume of quality evidence supporting their use in adult patients with type 2 diabetes and atherosclerotic cardiovascular disease to prevent CV events.

References

1. PagidipatiNJ, et al; COORDINATE–Diabetes Site Investigators. Coordinated care to optimize cardiovascular preventive therapies in type 2 diabetes: a randomized clinical trial. JAMA. 2023 Mar 6:e232854. doi: 10.1001/jama.2023.2854.
2. ACC News, March 06, 2023. Available at: https://www.acc.org/Latest-in-Cardiology/Articles/2023/03/01/22/45/mon-830am-coordinate-diabetes-acc-2023. Accessed on March 18, 2023.
3. TCTMD news, March 7, 2023. Available at: https://www.tctmd.com/news/multifaceted-approach-coordinate-diabetes-care-improves-gdmt. Accessed on March 18, 2023.