Study groups and interventions
Intervention groups were defined as: (1) PCP, including those patients
evaluated at least one time by PCP with ≤ 1 endocrinology visit and no
visits with any lifestyle intervention provider (nutrition, wellness, or
education) within the observation period or (2) MDT, including those
patients with ≥ 2 endocrinology visits and at least 1 visit with the
lifestyle provider in the same period. MDT included primarily
endocrinology-oriented visits coordinated by an endocrinologist and
provided by nurse practitioner, lifestyle counseling provided by an
exercise physiologist including physical activity and nutritional
counselling, and care coordination. Although cardiac function
evaluations and eye exams increased detection of risk
factors/complications, these were not considered as grouping variables.
The number of cardiometabolic risk factors (CMRF) for DM, HTN, and
obesity and time of exposure to LDH interventions were recorded. To
account for variability in time of exposure to the intervention,
patients were classified as (1) ‘established patients’, namely those
receiving care at LDH between January 01, 2008, and November 15, 2017,
and (2) ‘new patients’, describing attending the center only between
November 15, 2017, and March 31, 2018 (end of the first quarter).
Per LDH’s outcome-oriented approach (Figure 1), a patient is activated
to MDT when ≥ 1 cardiometabolic condition (OW/OB, Pre-DM/DM, or HTN, A1c> 5.6) is detected. The present analysis compares
the group of patients co-managed by MDT to a group of patients that
should have been activated but were not and continued only being cared
for by the PCP. Once MDT was activated, blood samples were collected
following a ≥ 8h overnight fast and 75g oral glucose tolerance test
(OGTT) with serum glucose and insulin samples at 0, 30, 60, 90, and 120
minutes was performed [12]. Patients underwent treatment based on a
protocolized drug curriculum. Those with OW/OB were treated with
topiramate (25 mg, BID) and a low dose of phentermine (18.5 mg, QD)
unless contraindicated or otherwise not tolerated. Those with insulin
resistance were treated with metformin (1500 mg initial dose and then up
titrated to 2000 mg). Patients with type 2 DM were treated with
anti-diabetic drugs clinically proven to promote weight loss, primarily
metformin and either glucagon-like peptide 1-based (GLP-1) therapies
such as GLP-1 receptor agonists and dipeptidyl-peptidase 4 (DPP-4)
inhibitors or sodium-glucose cotransporter-2 (SGLT-2) inhibitors.
Specific medication was decided according to individual clinical
conditions and insurance coverage. Lifestyle recommendations were
provided for nutrition, wellness or educational visits and included
nutritional counseling with caloric/carbohydrate restriction and
physical activity recommendations. In the MDT group, most visits were
coordinated and implemented and performed simultaneously between regular
medical care and lifestyle counseling. Patients’ individual needs were
considered in the implementation of follow-up and engagement protocols.