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.
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