1. Improving Patient Understanding of Type 2 Diabetes and the Benefits of the Multidisciplinary Team Approach

2. Aims Provide practical guidance on improving diabetes care
through highlighting the need for:
increased patient understanding of type 2 diabetes and the importance of reaching glycemic goals
shared responsibility/common philosophy for achieving glycemic goals
a multidisciplinary team approach to treating type 2 diabetes

3. Majority of type 2 diabetes patients are not at HbA1c goal
US1
EU2
100
100 80 80
69%
64% 60 60
Subjects (%)
Subjects (%)
36%
31% 40 40 20 20
Approximately two-thirds of patients with type 2 diabetes in the US and EU do not achieve glycemic goals.
The US National Health and Examination Survey (NHANES) III (1999–2000) revealed that only 35.8% of individuals with type 2 diabetes had HbA1c < 7%. Earlier figures from NHANES show that this figure had dropped from 44.5% in 1988–1994.1
The Cost of Diabetes in Europe – Type 2 (CODE-2) study, which evaluated the effect of glycemic control on complications in 7,000 individuals with type 2 diabetes, revealed that only 31% achieved good glycemic control (HbA1c  6.5%).2
1. Koro CE, et al. Diabetes Care 2004; 27:17–20.
2. Liebl A. Diabetologia 2002; 45:S23–S28.
< 7%
≥ 7%
 6.5%
> 6.5%
HbA1c
HbA1c
1Koro CE, et al. Diabetes Care 2004; 27:17–20.
2Liebl A. Diabetologia 2002; 45:S23–S28.

4. Reaching glucose goals is important to reduce microvascular complications
Retinopathy and nephropathy1–4
present in ~1 in 5 patients at diagnosis
leading causes of blindness and end-stage
renal disease
Neuropathy
present in ~1 in 8 patients at diagnosis1
affects ~70% of people with diabetes5
a leading cause of non-traumatic lower
extremity amputation6
Achieving and maintaining good glycemic control is important for the prevention of diabetes-related microvascular complications, which include retinopathy, nephropathy and neuropathy.
Diabetic retinopathy: present in 21% of people at time of diagnosis of type 2 diabetes1 and the leading cause of new blindness among adults aged 20–74 years.2
Diabetic nephropathy: present in 18% of people at diagnosis.3 Diabetes is a leading cause of end-stage renal disease.4
Diabetic neuropathy: present in 12% of people at diagnosis,1 affects approximately 70% of people with diabetes5 and is a leading cause of non-traumatic lower extremity amputations.6
1UK Prospective Diabetes Study Group. Diabetes Res 1990; 13:1–11.
2Fong DS, et al. Diabetes Care 2003; 26 (Suppl. 1):S99–S102.
3The Hypertension in Diabetes Study Group. J Hypertens 1993; 11:309–317.
4Molitch ME, et al. Diabetes Care 2003; 26 (Suppl. 1):S94–S98.
5King’s Fund. Counting the cost. The real impact of non-insulin dependent diabetes. British Diabetic Association, 1996.
6Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78–S79.
1UK Prospective Diabetes Study Group. Diabetes Res 1990; 13:1–11. 2Fong DS, et al. Diabetes Care 2003; 26 (Suppl. 1):S99–S102.
3The Hypertension in Diabetes Study Group. J Hypertens 1993; 11:309–317. 4Molitch ME, et al. Diabetes Care 2003; 26 (Suppl. 1):S94–S98.
5King’s Fund. Counting the cost. The real impact of non-insulin dependent diabetes. British Diabetic Association, 1996.
6Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78–S79.

5. Reaching glucose goals is important to reduce macrovascular complications
Overall, 75% of people with type 2 diabetes die
from cardiovascular disease1,2
Meeting and maintaining good glycemic control is also important for the prevention of diabetes-related macrovascular complications, which include cardiovascular disease and stroke.
Cardiovascular disease: 75% of individuals with type 2 diabetes die from cardiovascular causes.1
Stroke: diabetes is associated with a 2–4-fold increase in cardiovascular mortality and stroke.2
1Gray RP & Yudkin JS. Cardiovascular disease in diabetes mellitus. In Textbook of Diabetes 2nd Edition, Blackwell Sciences.
2Kannel WB, et al. Am Heart J 1990; 120:672–676.
1Gray RP & Yudkin JS. Cardiovascular disease in diabetes mellitus. In Textbook of Diabetes 2nd Edition, Blackwell Sciences.
2Kannel WB, et al. Am Heart J 1990; 120:672–676.

6. Barriers to achieving good glycemic control
Need for shared understanding and mutual agreement regarding good glycemic control among members of the multidisciplinary team
The Global Partnership acknowledges there are barriers that need to be addressed in order for individuals to achieve glycemic goals.
The Global Partnership has identified several key areas that will help the diabetes care team to increase the proportion of individuals achieving good glycemic control and thus decrease the risk of complications.
These include the need for shared understanding and mutual agreement between the team members and the individual with diabetes and between each of the team members.

7. Considering the patient perspective?
I am anxious that my therapy will cause side effects
What if my therapy fails? ? ?
Why is lowering blood glucose so important? ? ?
What happens if I forget to take my medication on a regular basis?
I am afraid of the unknown ? ?
For many individuals, being diagnosed with type 2 diabetes can be a very traumatic experience.
Fear of side effects, therapies being ineffective, the apparently inevitable requirement for insulin injections or even fear of the unknown can present a major barrier to achieving optimal glycemic control.
Some patients may not be aware of the full implications of their condition if they have no obvious symptoms, which may lead them to question the need for glycemic control, regular monitoring of glycemia and adherence to their treatment regimen. These factors can lead to suboptimal management of glycemia.
It is important that healthcare professionals involved in diabetes care have the time to discuss these anxieties with their patients. This includes helping to allay their fears concerning the likely course of their disease and how individuals can take control of their condition in order to improve their outcomes.
I have no symptoms so how can my condition be serious?
I am afraid of needing insulin ?

8. Some misconceptions about diabetes
“I don’t need to take my tablets
– I don’t feel ill”
“Only old people get diabetes”
Many patients have misconceptions about type 2 diabetes and its management, as illustrated by these quotations.
Common misconceptions include:
a belief that the condition only occurs in elderly people, is not serious and does not require any treatment because it can be asymptomatic
a lack of awareness or misconception regarding the importance of taking diabetes medications regularly
fear of progressing to insulin injections.
In fact, the average age of diagnosis of type 2 diabetes in the NHANES study (1999–2000) was 46 years, a reduction of six years from the NHANES III study (1988–1994),1 and the disease is becoming increasingly common in children and young adults.2 2.2% of the US population aged 20–39 years, and 9.7% of those aged 40–59, are diabetic.3
1Koopman RJ, et al. Ann Fam Med 2005; 3:60–63.
2Botero D & Wolfsdorf JI. Arch Med Res 2005; 36:281–290.
3http://diabetes.niddk.nih.gov/dm/pubs/statistics/.
“Complications only occur
in patients who take insulin”

9. Challenges in improving patient understanding
35% recalled receiving advice about their medication
15% knew the mechanism of action of their therapy
10% taking sulfonylureas knew that they could cause hypoglycemia
20% taking metformin knew it could cause gastrointestinal side effects
Patient knowledge of oral antidiabetic agents
Improving patients’ knowledge of their oral diabetes medication is a key challenge in type 2 diabetes management, as illustrated by data from a survey of 261 patients with type 2 diabetes.1
In the survey, patient knowledge of oral antidiabetic agents was found to be suboptimal, with only:
35% of patients recalling receiving advice about their medication
15% of patients knowing the correct mechanism of action of their medication
10% of those taking a sulfonylurea knowing it may cause hypoglycemia
20% of those taking metformin aware of its gastrointestinal side effects.
Suboptimal patient knowledge may represent a significant obstacle to achieving optimal control of glycemia. More appropriate advice and information from prescribers may help to improve patient understanding and thus compliance.
1Browne DL, et al. Diabet Med 2000; 17:528–531.
Browne DL, et al. Diabet Med 2000; 17:528–531.

10. Challenges in increasing adherence
62% took tablets correctly in relation to food
20% regularly forgot to take their tablets
5% omitted tablets if their blood glucose was too high
2% omitted tablets if their blood glucose was too low
Patient adherence to therapy
Improving patients’ adherence to their oral diabetes medications represents another key challenge in type 2 diabetes management, as illustrated by data from a survey of 261 patients with type 2 diabetes.1
In the survey, patient adherence to therapy was found to be suboptimal, with:
62% of patients taking tablets correctly in relation to food
20% of patients forgetting to take their tablets on at least one occasion per week
5% omitting tablets because of hyperglycemia
2% omitting tablets because of hypoglycemia.
Reduced patient adherence may represent a significant obstacle to achieving optimal control of glycemia.
1Browne DL, et al. Diabet Med 2000; 17:528–531.
Browne DL, et al. Diabet Med 2000; 17:528–531.

11. Need for shared responsibility/ common philosophy for achieving glycemic goals

12. Establish a partnership between patient and healthcare professional
Establish rapport
Agree mutual agenda
Reduce resistance to change
Exchange information
Work together to:
Establishing a good rapport between the patient and healthcare professional is a critical first step for developing effective communication channels that will ultimately help to improve patient outcomes.
It is important to involve the patient in the process at all stages by agreeing a mutual agenda, with the common goal of managing their condition effectively in order to maintain best possible health.
This involves working together to discuss how implementing behavioral changes – such as adopting lifestyle changes, taking medications regularly and monitoring glycemia frequently – will have an important impact on outcomes, as well as building confidence that these goals are achievable.
Two key factors include a mutual exchange of information between patient and healthcare professional coupled with a reduction in the resistance of the patient to change.
Discuss importance of implementing change
Build confidence that change is possible

13. The need to establish a good rapport
“My healthcare professional has helped me understand my blood glucose results and the importance of regular testing. I feel more in control of my diabetes”
“I don’t really monitor my blood
glucose levels. It doesn’t seem that important. The physician never asks me my numbers or measurements, so why am I doing it?”
These quotations illustrate the difference between establishing a good and bad rapport between healthcare professional and patient.
In the first example, the patient and healthcare professional have built a good relationship involving a two-way exchange of views leading to mutual respect and agreement regarding the optimal treatment for the patient’s lifestyle.
In the second example, the patient has no control over the discussion and his specialist offers advice without considering how this will fit into the patient’s lifestyle.

14. Motivating patients to achieve and maintain glycemic control
“I’ve reached my glucose target by eating properly,
exercising more and taking my tablets”
“This is great news.
Continue with the good work and keep your blood sugar under control – you’ll feel better for it!”
It is important that healthcare professionals not only help motivate patients to achieve glycemic targets, but also to maintain glycemic control once targets are met. Long-term glycemic control has clear benefits in preventing microvascular and macrovascular complications.
Healthcare professionals can help motivate patients by discussing HbA1c results, explaining what they mean and their importance in diabetes management.
Patients who know their HbA1c values have reported a more accurate assessment of their glycemic control and an increased understanding of diabetes care compared with patients who do not know their HbA1c values.1
1Heisler M, et al. Diabetes Care 2005; 28:816–822.
Heisler M, et al. Diabetes Care 2005; 28:816–822.

15. Use a patient-centered approach
Healthcare professional
Patient
Active listening
Negotiation
Provides information (when required)
Active
Expresses views
In control
Decision maker
INFORMATION EXCHANGE
Use of a patient-centered rather than a physician-centered approach – involving a free exchange of information between healthcare professional and patient – is likely to be more successful in motivating patients to assume a more active and independent role in monitoring and treating their disease. It is also more likely to result in improved patient outcomes.1
Traditionally, the major objective of diabetes education has been to increase patient compliance to physician-defined therapeutic goals and treatment strategies. This is known as the physician-centered approach.
To strengthen patient rights and autonomy, patients need to have the opportunity where possible to express their views and to become more involved in medical decision making. This is the patient-centered approach.
The relative benefits of various interventions need to be communicated to the patient in an unbiased manner, so that he/she can make an informed choice with regard to different therapeutic goals and strategies.
This approach leads to a shared responsibility for maintaining the health of the patient, including a common philosophy to enable patients to achieve their glycemic goals.
1Muhlhauser I, et al. Diabet Med 2000; 17:823–829.
Muhlhauser I, et al. Diabet Med 2000; 17:823–829.

16. Initial consultation: where to start?
What does type 2 diabetes mean:
to you?
to your family/friends?
What are your fears/expectations?
How will type 2 diabetes affect:
your everyday life?
your family?
your job?
your social life?
What can we do about it together?
Adopting an appropriate format and tone for the first consultation is very important in order to establish a patient-centered approach from the outset.
Ideally, it is important to ascertain during the first consultation how the patient feels about their type 2 diabetes, including their fears and aspirations.
This will help the healthcare professional to manage patient expectations about their disease, treatment and overall outlook.
Considering the impact of diabetes in the context of the patient’s home, work and social environment are also important factors. For example, it may be impractical for individuals to eat little and often to fit in with their dosing regimen if they have a very hectic work schedule.
Developing an action plan for the treatment of their condition together with the healthcare professional can be very motivational for the individual with type 2 diabetes.

17. Subsequent consultations
How are you?
Have you been regularly monitoring
sugar levels?
You are not yet at goal – how can I help?
Discuss options and reach mutual decision
Agree when and how to review options
Apart from diabetes, what else is new?
In order to make the most of subsequent consultations, it is important for both patient and healthcare professional to be prepared, and adopting a regular structure can help.
A sense of continuity is important for monitoring the progress of the patient’s condition and sustaining their motivation to strive for optimal diabetes management and glycemic goals.
By maintaining an open dialogue and making mutual decisions, healthcare professionals and patients can work together to achieve treatment goals, improving the patient’s sense of control of their health and wellbeing.
Consultations should include discussion of diabetes-related complications, interventions and potential side effects, as well as advice on long-term self-management, including regular self-monitoring of blood glucose.
Frequent monitoring of glycemia is an important part of the consultation – particularly in patients with newly diagnosed diabetes – to assess the efficacy of treatment and implement modifications, when necessary.

18. Helping patients to accept their condition
Diagnosis of type 2 diabetes = loss of patient’s accustomed state of health
Patient’s willpower and ability to improve outcomes depend on degree
of acceptance of the serious nature of their condition
Individuals with type 2 diabetes often have anxieties about their condition, linked with a fear of the unknown. This may manifest itself as a sense of grieving or loss.1
It is important that healthcare professionals support the patient in acknowledging their change in health status. This will help them to come to terms with their condition and prepare them to do whatever is required to best improve their outlook.
Structured patient education has been shown to improve patient understanding of their diabetes and increase awareness that lifestyle changes can affect outcomes.1,2
1Lacroix A, et al. Schweiz Rundsch Med Prax 1993; 82:1370–1372.
2Skinner TC, et al. Diabetic Med 2005; 22 (Suppl. 2):1–121.
Relationship between healthcare professional and patient is critical in this process
Lacroix A, et al. Schweiz Rundsch Med Prax 1993; 82:1370–1372.

19. Motivating and supporting patients to change their lifestyle
Provide practical and realistic advice on implementing and sustaining lifestyle change
Discuss steps that can be implemented now
Where possible, involve other members of the diabetes care team, particularly family and friends
Healthcare professionals should also provide practical advice on implementing realistic lifestyle changes, for example:
improving diet
increasing physical activity
reducing/stopping smoking and reducing alcohol consumption where necessary.
It is important to discuss steps that can be implemented with immediate effect, taking into consideration:
establishing positive and negative influences within the patient’s social setting
agreeing changes that suit the patient’s lifestyle
discussing how best to sustain them.
Individuals may require considerable assistance and support in adopting and maintaining lifestyle changes. It is important that individuals are aware of the benefits of these changes for controlling their blood glucose levels.

20. Role of the multidisciplinary team

21. The multidisciplinary team: core members
Physician
Diabetes specialist nurse
Patient
Dietician
Podiatrist
The individual with type 2 diabetes is the central team member, and thus patients need to know about their daily roles as care providers and decision-makers and how to work with their diabetes care team.1
In addition to the patient, a ‘core’ team usually includes three or four healthcare professionals with complementary skills who are committed to a common philosophy and goals, for example:
the patient (supported by their family/friends)
physician
diabetes specialist nurse
dietician
podiatrist.
Note that the structure, size and members of the multidisciplinary team will vary according to the local healthcare system and resources.1
1National Diabetes Education Program. Team care: comprehensive lifetime management for diabetes.
National Diabetes Education Program. Team care: comprehensive lifetime management for diabetes.

22. The multidisciplinary team: additional members
Other specialists
Physician
Diabetes specialist nurse
Patient
Diabetologist/ endocrinologist
Dietician
Podiatrist
In addition to core team members, additional members of the multidisciplinary diabetes care team include:1
diabetes specialists (diabetologists/endocrinologists)
other specialist support services (these vary, but may include cardiologists, dentists/hygienists, exercise physiologists, nephrologists, neurologists, nurse midwives, obstetricians, opthalmologists, optometrists, pediatricians, physical therapists, psychologists, social workers and vascular surgeons)
pharmacists.
1National Diabetes Education Program. Team care: comprehensive lifetime management for diabetes.
Pharmacist
National Diabetes Education Program. Team care: comprehensive lifetime management for diabetes.

23. Key function of the multidisciplinary team
To provide:
Continuous, accessible and consistent care focused on the needs of individuals with type 2 diabetes
The key function of a multidisciplinary team is to provide continuous, accessible and consistent care that is focused on the needs of individuals with type 2 diabetes:
continuous: given the chronic nature of type 2 diabetes and its complications, it is important that diabetes care is maintained throughout the course of the disease
accessible: it is important that healthcare professionals establish a rapport with patients so that they feel they can approach a member of the team whenever they need support
consistent: spreading the responsibility for patient care over the whole multidisciplinary team helps to maintain high standards of care to help patients achieve their treatment goals and to maintain them in the long term.

24. Additional functions of a multidisciplinary team
Provide input at diagnosis of condition and continually thereafter to:
agree standards of care
discuss rational therapeutic suggestions
monitor guideline adherence and short-term outcomes
avoid early complications or provide timely intervention to decrease diabetes-related complications
Enable long-term patient
self-management
If properly implemented, a multidisciplinary approach to diabetes care is cost-effective and improves quality of care compared with individual patient–physician care.1
In addition to ensuring that treatment goals are maintained, the team approach helps to implement:
patient satisfaction and self-management
the development of a community support network
team coordination and communication
patient follow-up and outcome evaluations.
1Codispoti C, et al. J Okla State Med Assoc 2004; 97:201–204.
Codispoti C, et al. J Okla State Med Assoc 2004; 97:201–204.

25. The multidisciplinary team requires
Common goals
Supportive/nurturing approach
Commitment to principles of self care
Good interpersonal skills of team members
Clear definition of specific and shared responsibilities of team
Tailoring of team members according to setting and resources
It is important that the multidisciplinary diabetes care team has the following attributes:
common goals
a supportive/nurturing approach
a commitment to principles of self-care
good interpersonal skills of team members
a clear definition of specific and shared responsibilities of team.
Team members should be tailored according to settings, for example:
primary versus secondary care
rural versus urban
special features, such as deprived areas.

26. The multidisciplinary team: shared responsibility for education
Other specialists
Physician
Diabetes specialist nurse
EDUCATION
Patient
Diabetologist/ endocrinologist
Dietician
Podiatrist
In addition to the traditional medical care that is provided to individuals with type 2 diabetes, a key role of the multidisciplinary team is to help educate and support the patient and their family by involving them in decision making and provision of care.
Physicians and other healthcare professionals should recognize their important role in enabling and empowering patients to take control of their condition by providing effective communication and support, including the use of positive language, and by encouraging patient self-management.
Patient education can have significant effects on the lives of individuals with diabetes. In addition to enabling a better understanding of diabetes, education can lead to an increase in exercise, improvements in health and reductions in hospital visits.1,2
1Lorig KR, et al. Eff Clin Prac 2001; 4:256–262.
2Skinner TC, et al. Diabet Med 2005; 22 (Suppl. 2):1–121.
Pharmacist

27. TIME PERIOD AFTER ATTENDING EDUCATION COURSES Triglycerides (mmol/L)
Impact of implementing an educational program via a multidisciplinary team
VARIABLE
TIME PERIOD AFTER ATTENDING EDUCATION COURSES
0 MONTHS
12 MONTHS
FPG (mmol/L)
10.2
8.7*
HbA 1c
(%)
8.9
7.8*
Body weight (kg)
83.0
81.0*
Systolic BP (mmHg)
154.0
143.0*
Diastolic BP (mmHg)
95.0
87.0*
Cholesterol (mmol/L)
6.2
5.4*
Triglycerides (mmol/L)
2.8
2.1*
This study indicates the benefits of implementing an educational program designed and adapted to local conditions by a multidisciplinary group of healthcare professionals.1
By 12 months after implementation of a structured educational program, all parameters had improved significantly (P < 0.001), including:
fasting plasma glucose
HbA1c
body weight
systolic blood pressure
diastolic blood pressure
cholesterol
triglycerides.
These findings reinforce the value of education as an essential component of diabetes care.
1Gagliardino JJ, et al. Diabetes Care 2001; 24:1001–1007.
*Significant improvement versus 0 months
Gagliardino JJ & Etchegoyen G. Diabetes Care 2001; 24:1001–1007.

28. Impact of a multidisciplinary team on glycemic control and hospital admissions
HbA1c
Hospitalizations 30
-0.2 25
-0.4 20
-0.6
Change in HbA1c from baseline (%)
Hospitalizations/1000 person-months 15
-0.8 10
-1.0
This study evaluated a multidisciplinary team approach (involving a diabetes specialist nurse, psychologist, nutritionist and pharmacist) compared with standard diabetes care provided by primary care physicians in a health maintenance organization (HMO) setting over a
6-month time period.1
Both HbA1c levels and hospital admissions decreased significantly with the multidisciplinary team approach.1
HbA1c levels decreased by 1.3% in the multidisciplinary group compared with 0.2% in control subjects (P < ) at 6 months post-randomization.
Hospitalizations were 80% more frequent in control subjects compared with the multidisciplinary group during the 17–18 months following randomization (P = 0.04).
1Sadur CN, et al. Diabetes Care 1999; 22:2011–2017. 5
-1.2
-1.4
Control
Multidisciplinary team
Control
Multidisciplinary team
Sadur CN, et al. Diabetes Care 1999; 22:2011–2017.

29. A multidisciplinary team can reduce costs
Annual cost of treatment
120,000
100,000
-62%
80,000
Cost of pharmacotherapy/year (US$)
60,000
40,000
This study indicates the benefits of implementing an educational program designed and adapted to local conditions by a multidisciplinary group of healthcare professionals.1
By 12 months after implementation of a structured educational program, the decrease in pharmacotherapy required for control of diabetes, hypertension and hyperlipidemia represented a 62% decrease in the annual cost of treatment (US$107,940 versus US$41,106).
After deducting the additional cost of urine glucose monitoring (US$30,604), there was still a 34% annual saving in treatment costs.
1Gagliardino JJ, et al. Diabetes Care 2001; 24:1001–1007.
20,000
0 months
12 months
Gagliardino JJ & Etchegoyen G. Diabetes Care 2001; 24:1001–1007.

30. Other benefits of a multidisciplinary team approach to type 2 diabetes care
Improved
glycemic control1,2
Improved quality of life1
Increased patient follow-up1
Higher patient satisfaction1
Several studies have investigated the impact of a multidisciplinary team approach to diabetes care and demonstrated the merits of this approach in providing effective management of diabetes.
Benefits of the multidisciplinary approach include:
improved glycemic control1,2 and quality of life1
increased patient follow-up1
higher patient satisfaction1
lower risk of complications2
decreased healthcare costs.2
1Codispoti C, et al. J Okla State Med Assoc 2004; 97:201–204.
2Gagliardino JJ & Etchegoyen G. Diabetes Care 2001; 24:1001–1007.
Lower risk of complications2
Decreased healthcare costs2
1Codispoti C, et al. J Okla State Med Assoc 2004; 97:201–204.
2Gagliardino JJ & Etchegoyen G. Diabetes Care 2001; 24:1001–1007.

31. How can expertise be best utilized in diabetes management?
The Global Partnership recommends:
Implement a multi- and interdisciplinary team approach to diabetes management to encourage patient education and self-care and share responsibility for patients achieving glucose goals
Del Prato S, et al. Int J Clin Pract 2005; 59:1345–1355.