Timely adjustment of treatment, improvements in patient self-monitoring associated with improved control of diabetes, heart disease, depression, study data suggest

Timely adjustment of drug therapy and greater self-monitoring by patients are associated with better control of diabetes, coronary heart disease (CHD) and depression, according to findings from a randomized controlled trial. The trial was conducted to evaluate the effects of a patient-centered, team-based intervention (TEAMcare) on outcomes in patients with diabetes (hemoglobin A1C level of 8.5 percent or greater) or CHD (blood pressure [BP] greater than 140/90 mm Hg or LDL cholesterol...

Timely adjustment of drug therapy and greater self-monitoring by patients are associated with better control of diabetes, coronary heart disease (CHD) and depression, according to findings from a randomized controlled trial.

The trial was conducted to evaluate the effects of a patient-centered, team-based intervention (TEAMcare) on outcomes in patients with diabetes (hemoglobin A1C level of 8.5 percent or greater) or CHD (blood pressure [BP] greater than 140/90 mm Hg or LDL cholesterol level greater than 130 mg/dL) and coexisting depression (score of 10 or higher on the nine-item Patient Health Questionnaire). It included a total of 214 participants who were members of Group Health Cooperative, an integrated health care system in Washington in which primary care services have been organized under a medical home model since 2006.

The participants were randomized to receive the TEAMcare intervention or usual care. In the TEAMcare group, a nurse care manager collaborated with primary care physicians (PCPs), patients and consultants to deliver a treat-to-target approach for multiple conditions, with a focus on medication initiation, medication adjustment, patient self-monitoring and medication adherence.

According to the authors of the current study, previously published data have shown that the TEAMcare intervention reduced A1C levels, LDL cholesterol levels, blood pressure (BP) and depression scores; improved quality of life; and reduced disability as compared with usual care. In the current analysis, they examined possible mechanisms underlying this improvement, including adjustment of treatment by physicians, patient self-monitoring and medication adherence.

Although physicians in both groups received periodic notifications of disease control measures, the physicians in the TEAMcare group made more timely and more frequent adjustments to pharmacotherapy.

For example, during the 12-month follow-up, medication adjustments (including initiation of therapy and subsequent treatment changes) occurred significantly more frequently in the TEAMcare group as compared with the usual care group for all five drug classes analyzed. Specifically, rates of adjustments for antidepressants, insulin, BP-lowering drugs, oral diabetes drugs and lipid-lowering drugs were 6.2 times higher, 2.97 times higher, 1.86 times higher, 1.8 times higher and 1.56 times higher in the TEAMcare group.

The authors also analyzed rates of medication adjustment for four drug classes (BP-lowering drugs, insulin, antidepressants and lipid-lowering drugs) during the first two months of follow-up. Rates of medication adjustment during the first two months were 10 times higher for antidepressants and more than twice as high for BP-lowering drugs and insulin in the TEAMcare group as compared with the usual care group.

The TEAMcare intervention also led to significant improvements in patient self-monitoring, with patients in this group monitoring their BP and blood glucose significantly more frequently than patients in the usual care group did. At 12 months, the average rate of BP self-monitoring was 3.6 days per week in the TEAMcare group compared with 1.1 days per week in the usual care group. The average rate of blood glucose monitoring by patients was 4.9 days per week in the TEAMcare group and 3.8 days per week in the usual care group.

During follow-up, medication adherence did not increase substantially in the TEAMcare group as compared with the control group, although the study authors noted that medication adherence was high in both groups at baseline.

On the basis of these trial results, the study authors suggested that improving patient and physician behaviors can lead to improvements in disease control and quality of life among patients with multiple health conditions.

They added, "In view of the current state of fragmented care of individual patients, a TEAMcare program, through which primary and specialty care services are integrated and coordinated to provide patient-centered services, offers a sorely needed framework and methods to improve outcomes of patients with chronic illness and coexisting mood disorders within the primary care medical home setting."

This research was published in the January/February issue of Annals of Family Medicine.