Preventive Cardiology: Rethinking Diabetes Care to Improve Heart Health
By Jimmy McDermott
How one clinic is integrating diabetes and heart health, focusing on comprehensive risk reduction, including medications that both lower blood glucose and protect the heart, and potentially creating a new business model
Update 7/13/20: The Saint Luke’s Cardio Metabolic Center of Excellence is expanding its model of care through the National Cardiometabolic Center Alliance. The goal is to establish more centers of care in the United States to reimagine treatment and improve the long-term health of people with type 2 diabetes. Learn more about this exciting news.
Adults with diabetes are two to four times more likely to have heart-related complications than those without diabetes. Although closely connected, diabetes and heart health are often not cared for in an integrated way. It is essential that people with diabetes and their healthcare providers know their options and have a treatment plan that focuses on comprehensive diabetes management, which should include not only glucose-related numbers (A1C levels, time-in-range, etc) but also the prevention of complications such as coronary artery disease, heart failure, and kidney disease.
The Saint Luke’s Michael and Marlys Haverty Cardio Metabolic Center of Excellence in Kansas City, Missouri is a new clinic designed with one key objective – to provide comprehensive risk reduction, by focusing on the prevention and treatment of heart complications in people with type 2 diabetes (and prediabetes). Dr. Mikhail Kosiborod, Co-Director of the Haverty Cardio Metabolic Center, has worked at the intersection of diabetes and heart disease for nearly 20 years. diaTribe visited Dr. Kosiborod to see the workings of the Cardio Metabolic Center and examine its care model that incorporates diabetes management and heart protection.
We were impressed by how this clinic integrates both diabetes and heart care into a single visit, emphasizes diabetes medications that also have heart health benefits, and focuses on optimal outcomes, not just the quantity of people seen. We hope these takeaways from the Cardio Metabolic Center will help spark important discussions between people with diabetes and their healthcare providers – please share this article with your own healthcare team!
From Fragmented to Integrated Care
People with diabetes often see multiple healthcare providers (e.g., a primary care clinician, a cardiologist, an endocrinologist), which can lead to “siloed”, fragmented care and may limit the integration of expertise on health matters that are closely linked: diabetes management as well as heart and kidney health.
To address this problem, healthcare professionals at the Cardio Metabolic Center ask questions that are generally asked by an endocrinologist or a cardiologist, but usually not assessed in a single appointment. The health assessment includes “cardio” (heart-related) questions (What is your heart health history? Have you had any heart-related complications and/or procedures?), “metabolic” (diabetes-related) questions (How long have you had diabetes? What diabetes-related complications do you have? What is your A1C?), questions to screen for kidney disease, and those related to other risk factor management (blood pressure, cholesterol and triglycerides, smoking, diet and exercise). According to Melissa Magwire RN,MSN, CDE, the Manager of the Center, this type of assessment makes a real impact since, “Approaching each individual person with diabetes in such a comprehensive manner is an aspect of care that is often missing in those with multiple heath conditions, as traditional healthcare settings are often focused on looking at just one issue during a visit.”
This assessment is reviewed by the preventive cardiologist, as well the team of nursing staff cross-trained in diabetes and heart disease, and a certified diabetes educator (CDE), who then have a detailed discussion with each person with diabetes and share treatment options to lower the risk of diabetes-related heart and kidney complications. This holistic assessment may reduce the burden of seeing multiple clinicians and ensure that diabetes care is patient-centered, individualized and focused on the prevention of these complications.
Diabetes + Heart Treatment Options
Generally, the majority of individuals with type 2 diabetes follow a glucose-lowering treatment plan that does not necessarily include heart protective therapies. Dr. Kosiborod described that both globally, and in the US, a common treatment process for people with type 2 diabetes is 1. metformin 2. sulfonylureas and/or DPP-4 inhibitors, and 3. insulin. Dr. Kosiborod noted that while these therapies lower blood glucose, none have been clearly proven to reduce the risk of heart-related complications.
Instead, healthcare professionals at the Cardio Metabolic Center emphasize drugs such as SGLT-2 inhibitors (e.g., Invokana, Farxiga, Jardiance) and GLP-1 agonists (e.g., Victoza, Trulicity, Ozempic), which have been shown to provide heart and kidney protective benefits in addition to glucose lowering. According to Dr. Kosiborod, these are the treatments that are being increasingly emphasized in people with type 2 diabetes with heart and/or kidney complications by the practice guidelines from both diabetes and cardiovascular professional organizations. In describing treatment options, the clinicians at the Cardio Metabolic Center emphasize education: not only what you can take but why that medication may be beneficial for you. If a person is prescribed an injectable medication, such as a GLP-1 agonist, the first injection will be right there in the Center, so that the healthcare team can help and educate.
Dr. Kosiborod offered advice to people with type 2 diabetes to “take initiative and learn about the treatment options that reduce the risk of heart and kidney complications. We live in a new world where treatment choices really matter.” Click on the links above to learn more about the heart-protective benefits of each medication!
Given the rising costs of healthcare, driven, in large part, by chronic conditions such as type 2 diabetes, a value-based care model – where improvement in outcomes, rather than number of visits or procedures, is prioritized - has been proposed as one possible solution to reduce costs and improve care. Most clinics are currently paid according to the total number of people they treat, as well as other services (e.g., procedures) they perform – often called “fee for service.” According to Dr. Kosiborod, chronic disease management programs, such as the Cardio Metabolic Center, may position healthcare systems well for the potential future transition to value-based care given the clinic’s care model that incentivizes delivering the best, personalized care for each person to improve diabetes management and prevent future costly complications.
According to Dr. Kosiborod, “This care model is feasible, replicable, scalable and can be implemented across various institutions in the US, and perhaps globally. It is a model that is a clear win for people with diabetes, health care systems, and healthcare providers. In short, it's a model that may fundamentally transform how type 2 diabetes care can and should be delivered. We have now proven that it can be built, and can be successful.”
To see disclosures for Dr. Kosiborod and Melissa Magwire RN,MSN,CDE, click here.