‘One-Stop Shop’ Clinics Treat Heart Disease, Diabetes in Tandem

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Source: BersDonald_14UCRegents1.jpg - BersDonald
From left, University of California, Davis Health System researchers Lianguo Wang, Crystal Ripplinger and Donald Bers, PhD, study biological pathways that link diabetes and heart disease.

With cardiovascular disease being the No. 1 killer of Americans and type 2 diabetes one of its most common comorbidities, a number of clinics see coordinated, comprehensive care as a way to treat both conditions. These “one-stop shops” offer a gamut of medical services, from clinical evaluations to nutrition and exercise counseling.

Consolidated care

On Wednesdays, endocrinologist Bindu Chamarthi, MD, of Brigham and Women’s Hospital in Boston, has a special clinic assignment. She treats patients at the Watkins Cardiovascular Clinic in the hospital’s Carl and Ruth Shapiro Cardiovascular Center who have both cardiovascular disease and type 2 diabetes.

The impetus behind Chamarthi’s Wednesday clinic, which started in 2009, is to offer patients with both conditions the care they need in a single location. “We felt it would be more of a patient-centered, multidisciplinary approach to managing these patients. These are complex patients,” Chamarthi says.

In addition to Chamarthi and a team of cardiologists, the clinic also has a nutritionist, a nurse and a nurse practitioner on staff. If patients are newly diagnosed diabetics, they will see Chamarthi and a nutritionist on the same day. On the next visit, patients may see the nurse practitioner for follow-up and detailed diabetes education. The nurse on staff also may provide some general diabetes education.

Patients may get referred to the clinic by their primary care physician or by their cardiologist. Chamarthi may also refer patients to a cardiologist or a vascular specialist if she sees the need. A nurse practitioner often sees patients during follow-up visits.

This type of collaboration is important because of the need to control risk factors in these patients, Chamarthi adds. “There is a huge connection between diabetes and heart disease,” she says. “People with diabetes have a four-fold higher risk of cardiovascular disease.”

Variation on a theme

Cardiologist Scott Chadderdon, MD, director of the Heart Disease and Diabetes Clinic at Oregon Health and Science University (OHSU) in Portland, also sees patients with both conditions. The staffing and setup are similar to the Watkins-Shapiro clinic, but Chadderdon says his clinic takes only patients who are pre-diabetic with or without established coronary artery disease or diabetic with or without established coronary artery disease.

Patients see both a cardiologist and an endocrinologist on the same day, then attend a 45-minute education session with a diabetes educator. During that session, both physicians discuss the patient’s needs and put together a treatment plan. Patients may need more management and return to the clinic after a visit with their primary care physician.

On follow-up, staff assess whether there are any barriers to education and assist with diet and exercise counseling. A cardiology specialist serves as a physician’s assistant and a PhD follows up with patients and assesses diet and exercise.

There is also a dedicated nurse and nurse manager. They play a major role during patient follow-up visits. The nurse manager helps determine whether a patient meets entrance criteria, reviews follow-up plans and also makes sure lab tests are done.

Costs & results

Both clinics are staffed with clinical staff and administrative staff. Nurses, medical assistants and the administrative team are all part of the clinics’ overhead costs.

Chamarthi says she bills for a standard office visit, and that visit includes the nurse practitioner’s diabetes education. The nutrition department, however, bills separately. At OHSU, the setup is similar. Chadderdon says new patients are billed as new consultations on the first day. The diabetes educator is provided through the hospital.

Both Chamarthi and Chadderdon say their programs have been successful. Chamarthi says she hasn’t yet formally determined outcomes, but patients and clinicians have offered positive feedback.

“I can say from a clinical perspective that the physicians are happier. The cardiologists are happy to have someone to work with and the patients seem to like it, too. All the care is in one place,” she says.

Chadderdon expects statistics in the early fall, but clinical data suggest his patients are improving. “At entrance, out of the patients we’ve seen, about a quarter were at goal for HgbA1C, cholesterol and systolic blood pressure. At follow-up, about 60 percent were achieving all three goals.”

He says the patient retention rate is about 65 percent, with the most motivated patients being the ones to return to the clinic and actively participate in treatment.

Tips for success

“These clinics can be incorporated into an existing clinic structure,” Chamarthi says.  The medical assistants and administrative staff from the existing clinic can be used, but there will be a need for additional staff, such as a nutritionist, diabetes educator and nurses.

It is helpful to have a diabetes nutritionist at the clinic rather than having to refer patients to a separate department, and there is definitely a need for a nurse educator, she says. This educator could be a Certified Diabetes Educator (CDE), a nurse with a CDE certification or some facilities utilize a pharmacologist with a CDE.

Chadderdon adds that it is also important to select the right patient population. The OHSU clinic excludes patients with end-stage heart failure or severe renal disease, for example.

“Their mortality is based off those issues as opposed to controlling their diabetes or blood pressure,” he explains. “We choose patients where risk can be modified the most, such as patients with pre-diabetes without coronary artery disease, patients with coronary artery disease without severe heart failure or valvular disease, or patients with diabetes with or without coronary artery disease.”

Future directions

Chadderdon says while the clinic has been a great success, he hopes for some future growth. There are plans for clinical trials that evaluate the effects of exercise on skeletal muscle flow and vasodilators as well as supplements that could benefit patients with early-onset diabetes along with medical therapy. They also plan to improve coordination of care with internal primary care providers and add additional cardiologists and endocrinologists.

Chamarthi says she also hopes for additional research collaboration. She would like to add an endocrinologist if patient volume allows for it and perhaps another clinic day. “These kinds of multidisciplinary approaches are the way to go to manage these patients to try and reduce their long-term risk,” she says.

Biological Link Uncovered

Recently, researchers uncovered what could be the biological reason behind that connection between diabetes and some cardiovascular diseases. Donald Bers, PhD, chair of pharmacology at the University of California, Davis and colleagues found that a high blood sugar level activates a biological pathway that ultimately leads to cardiac arrhythmias (Nature 2013; 502:372-376).

Through a series of experiments using both rat and human tissues and proteins, the researchers found that high blood sugar levels cause a sugar molecule called O-linked N-acetylglucosamine (O-GlcNAc) to bind to a site on calcium/calmodulin-dependent protein kinase (CaMKII), a protein that regulates calcium levels and cardiac activity. CaMKII then becomes activated.

“What’s been shown in heart failure and arrhythmia is that when CaMKII gets into an activated state, the enzyme is then chronically on,” he says.

He says future research could determine whether blocking this pathway would inhibit cardiac arrhythmias, and “if we or drug companies come up with a good CaMKII inhibitor, it could be a good drug for these patients.”