Perspectives on Diabetes Care

By Hope Warshaw, MMSc, RD, CDCES, BC-ADM, FAADE

Since 2015 the Endocrine Society has been laser focused on reducing the incidence of hypoglycemia in the U.S. with the Hypoglycemia Prevention Initiative (HypoPrevent).^1,2 This is a multiyear quality improvement project to design and test interventions to improve early identification and management of hypoglycemia in older adults (>65) with type 2 diabetes at high risk. The end goal is to determine best practices in primary care. The initiative is being conducted in collaboration with Avalere Health, a national healthcare advisory firm, based in Washington DC.

The Association of Diabetes Care & Education Specialists (ADCES) along with several diabetes care and education specialists (DCES) has been involved in various aspects of this initiative as detailed below. In these roles, DCES have and continue to draw attention to our specialty and our valuable roles in reducing hypoglycemia among older adults with type 2 diabetes.

This blog shares the chronology of the Endocrine Society’s HypoPrevent and the ADCES and DCES engagement along with references to key publications published to date for use by DCES. The blog then, in an interview format, offers details on the HypoPrevent study and shares insights from the first HypoPrevent study coordinator, a DCES.  

Chronology of the Endocrine Society’s Hypoglycemia Prevention Initiative with ADCES and DCES Engagement

	Effort	Engagement

Interview with Debra Zlomek, HypoPrevent Study Coordinator at Pottstown Medical Specialists

1. What is the HypoPrevent Study?

   DZ: The Hypoglycemia Prevention Study (HypoPrevent) aims to reduce hypoglycemia in older adults (>65) with type 2 diabetes who are at high risk. To lower the risks and incidences of hypoglycemia, providers will use shared decision making, individualized A1C goals and/or changes to glucose-lowering medications. The first study site, Pottstown Medical Specialists (PMSI), was chosen in early 2019. PMSI is a five-site physician-owned primary care practice in southeastern Pennsylvania where I’m employed as a DCES. I identified this study in an article in the e-newsletter circulated by ADCES for DSMES quality coordinators. I learned Endocrine Society was recruiting a primary care site for this study and I brought this opportunity to the attention of the PMSI providers. After a lengthy review process, PMSI was chosen and I was selected to serve as the study coordinator.

2. Describe your practice setting and how long you’ve been working at PMSI?

   DZ: PMSI is a physician-owned multi-specialty group practice with offices in Berks and Montgomery Counties in Southeastern Pennsylvania. We’re committed to delivering the highest quality medical healthcare through the coordination of properly planned, managed and utilized medical services. With respect, compassion and consideration, providers deliver appropriate healthcare to the people we care for. I have been working as a DCES at PMSI since September 2009.

3. What is your role at PMSI, how do you cover all 5 sites and how has your role evolved over the years?

   DZ: I have learned that barriers must be reduced to encourage people to come in for DSMES. For this reason, I try to make the services I provide easier for people to access by going to each office once a week. This allows people to come to the clinic where they see their provider and makes it easier for the providers to encourage people to meet with me. I have found that meeting with people regularly and in-person builds high quality working relationships and helps develop valuable trust. It also provides me with an opportunity to more quickly implement a treatment plan or reduce the time needed to make changes. Over the decade that I’ve been employed as a DCES at PMSI, I’ve demonstrated the value of my services. In fact, my department’s role has expanded to include an accredited/CDC-recognized Diabetes Prevention Program.

4. Describe how HypoPrevent is being implemented at PMSI?

   DZ: Due to the HypoPrevent initiative, providers have become more aware of the prevalence of hypoglycemia among older adults with type 2 diabetes who take insulin or other insulin secretagogues. This is true even in people they may have considered “well-managed.” As a result, they’re asking people if they’re encountering hypoglycemia and they are more fully explaining hypoglycemia symptoms. Additionally, they’re encouraged to ask people about how hypoglycemic events affect their daily activities. Lastly, they’ve increased their referrals to me to train people on the use of continuous glucose monitoring (CGM).

5. What are your roles in the Hypoglycemia Prevention Initiative at PMSI?

   DZ: By reviewing the medications, age, comorbidities, duration of diabetes and recent labs results, I’ve helped providers identify people in our practice who are at potential risk for hypoglycemia. I follow-up with people who have been identified as being in need of further DSMES and/or initiation and use of CGMs. Lastly, I consult with providers on treatment plan changes and provide education to people on changes in the treatment plan that providers have made.

6. What is the timeline to completion for this phase of the HypoPrevent Initiative?

   DZ: Enrollment in the study ended on December 20, 2019. The last follow-up will be six months from that date.

7. What actions would you encourage DCES to take in their practice settings to decrease the incidence of hypoglycemia based on what you’re learning?

   DZ: Don't assume that because a person has an A1C within their target range that they are well managed. Medicare and many commercial health plans cover DSMES services. Encourage providers to refer people to receive your services. DCES should make both providers and people with diabetes aware of their health plan benefits for DSMES. People with type 2 diabetes should be told their diabetes is progressive. As they age and develop comorbidities, it is important for them to seek ongoing DSMES to maintain optimal health and quality of life.

About the Author

Hope Warshaw, is a Registered Dietitian and Certified Diabetes Educator. She has spent her career involved in diabetes care and education and has a consulting practice based in Asheville, NC. She has been actively involved with promoting the role and value of peer support to people with diabetes, caregivers and healthcare providers for nearly a decade. She was President of the Association of Diabetes Care & Education Specialists (ADCES) in 2016 and currently serves on the Academy and Nutrition and Dietetics Foundation Board.  

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References:

1. US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2014) National Action Plan for Adverse Drug Event Prevention. Washington, DC.

2. Lash RW, Lucas DO, Illes J. Preventing hypoglycemia in type 2 diabetes.J Clin Endo & Metab. 2018;103(4):1265–1268.

3. Endocrine Society. Hypoglycemia quality collaborative strategic blueprint: Report and strategic recommendations. (2016) https://endocrinenews.endocrine.org/wp-content/uploads/HQC_Strategic_Blueprint_VIEW.pdf. Accessed January 15, 2020.

4. Agiostratidou G, Anhalt H, Ball D, et al. Standardizing clinically meaningful outcome measures beyond HbA1C for type 1 diabetes: a consensus report of the American Association of Clinical Endocrinologists, the American Association of Diabetes Educators, the American Diabetes Association, the Endocrine Society, JDRF International, The Leona M. and Harry B. Helmsley Charitable Trust, the Pediatric Endocrine Society, and the T1D Exchange. Diabetes Care. 2017;40:1622–1630.

5. American Diabetes Association. 6. Glycemic Targets: Standards of medical care in Diabetes – 2020. Diabetes Care. 2020;43(Supp 1):S66-S76.https://doi.org/10.2337/dc20-S006.

6. Warshaw HS, Zlomek D. Diabetes Educators Facilitate Primary Care Study To Decrease Hypoglycemia, Improve Safety In Type 2 Diabetes. American Association of Diabetes Educators Annual Meeting 2019, Abstract. https://www.endocrine.org/-/media/endocrine/files/hpi/hpi_poster_2019.pdf).

7. Rosenzweig JL, Conlin PR, Gonzalvo JD, et al. 2019 Endocrine Society measure set for older adults with type 2 diabetes at risk for hypoglycemia: Performance measures for eligible clinicians developed by the endocrine society. J. Clin Endo & Metab. (Accepted manuscript:https://doi.org/10.1210/clinem/dgz250. Final publication due out in the journal early 2020.)

ADCES Perspectives on Diabetes Care

The Association of Diabetes Care & Education Specialists Perspectives on Diabetes Care covers diabetes, prediabetes and other cardiometabolic conditions. Not all views expressed reflect the official position of the Association of Diabetes Care & Education Specialists.

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