Dr. Janice Zgibor’s ‘remedy’ to improving diabetes care

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Primary care providers need help providing quality care to patients with diabetes, according to Dr. Janice Zgibor of the USF College of Public Health.

Zgibor, an associate professor in the Department of Epidemiology and Biostatistics with more than 20 years of experience in diabetes research, examined how certified diabetes educators (CDEs) improved patient outcomes.

Her research, “Effectiveness of certified diabetes educators following pre-approved protocols to redesign diabetes care delivery in primary care: Results of the REMEDIES 4D trial,” is shared in Contemporary Clinical Trials.

Janice Zgibor, RPh, PhD

“For years I’ve studied diabetes and I have seen that standards of care set forth from the American Diabetes Association are not being met,” she said. “It’s not that physicians can’t follow them, or don’t want to follow them, but there are a lot of competing demands on physicians. We implemented a diabetes care model that would be more supportive of primary care and integrate ancillary care providers into practices to improve outcomes of people with diabetes.”

The REMEDIES 4D trial, conducted in 15 community-based primary care practices treating 240 total patients with type 2 diabetes in suburban Pittsburgh, examined how patient outcomes differed when care included interaction and treatment intensification by a CDE.

The one-year intervention was conducted in the primary care office setting among patients with uncontrolled blood glucose, blood pressure or low density lipoprotein (LDL) cholesterol levels.

Findings suggested that CDEs following standardized protocols in primary care improved glycemic control.

“Diabetes educators can improve outcomes in people with diabetes and can support that management by supporting treatment intensification in the primary care setting,” Zgibor said.

The intervention population saw a decrease in glucose levels, whereas those who were not in the intervention group  experienced a slight increase, and those in the intervention group were more likely to have glucose-lowering medicine intensified.

“Primary care providers don’t have a lot of time to spend on the educational and behavioral aspects of diabetes care that are so critical to successful diabetes management,” Zgibor said. “That’s where CDEs come in; to deal with psychosocial issues in addition to the clinical issues. They are a huge source of support for the patient and provider in terms of caring for diabetes.”

According to Zgibor only about 6 percent of those with diabetes schedule appointments with educators or take classes to learn about managing their diabetes.

“A large portion of the population is not accessing the benefit of a diabetes educator, so the treatment of those with diabetes is not as it should be; the blood pressure, glucose and lipid management all need to improve,” she said.

(Photo courtesy of iStock)

Diabetes educators usually have backgrounds as nurses, dieticians, or pharmacists, according to Zgibor.

She said patient interaction with CDEs is low because most of them require a referral from a primary care provider and are only available at hospitals, something Zgibor said can be seen as a barrier to patients.

In the REMEDIES 4D trial, patients saw CDEs within their primary care office setting.

“The primary care provider is a known entity; they are comfortable there and the CDE is likely to see them on the spot,” Zgibor said.

She said she hopes to see CDEs become more integrated into the primary care setting and hopes this research adds to the evidence of benefits.

“I’m hoping the evidence is building that you can have a CDE in your practice,” she said.

Zgibor said that since the research was conducted, the health system that included the primary care offices involved in the study created pods where several practices now have access to share the services of a CDE, case manager, and behavioral specialist.

“The offices are sharing this person in terms of salary, and they go to the different practices to see patients,” she said. “A model like this may be more feasible from a cost perspective.”

She said her future research goals include conducting similar studies in Florida.

“We’re trying to support the physician by letting the CDE make treatment recommendations and doing a lot of the ground work for the visit,” she said. “Over the course of the study, the providers embraced having the CDE there, in terms of handing insulin starts and treatment recommendations, and patients loved it.”

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Zgibor, J., Maloney, M., Malmi Jr., M., Fabio, A., Kuo, S., Solano, F., Tilves, D., Lu, L., & Davidson, M. (2017). Effectiveness of certified diabetes educators following pre-approved protocols to redesign diabetes care delivery in primary care: Results of the REMEDIES 4D trial. Contemporary Clinical Trials, doi.org/10.1016/j.cct.2017.10.003

Story by Anna Mayor, USF College of Public Health