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Positive results in COORDINATE-Diabetes show prescribing habits can be changed


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Christopher B. Granger, MD, FACC, FAHA
Christopher B. Granger, MD, FACC, FAHA

The Coordinated Care to Optimize Cardiovascular Preventive Therapies in Type 2 Diabetes (COORDINATE-Diabetes) trial showed it is possible to change clinical practice and prescribing patterns. Trial results revealed an absolute 23.4.% improvement in prescribing all three guideline-recommended medication classes for patients with both type 2 diabetes and atherosclerotic cardiovascular disease (ASCVD) versus usual care.

The American Diabetes Association® (ADA), American College of Cardiology, and other professional groups worldwide recommend high-intensity statin, angiotensin converting enzymes (ACEIs), angiotensin II receptor blockers (ARBs) and sodium-glucose cotransporter-2 (SGLT2) inhibitors or glucagon-like peptide-1 (GLP-1) receptor agonists for all patients with both type 2 diabetes and atherosclerotic disease.

“We thought a 10% improvement would be great, and we saw 23.4% with nearly a fourfold adjusted relative improvement,” said Principal Investigator Christopher B. Granger, MD, FACC, FAHA, the Donald F. Fortin, MD, Distinguished Professor of Medicine, Duke Clinical Research Institute, Duke University School of Medicine. “COORDINATE shows that it is possible to change prescribing behavior using a process that is not resource intensive.”

Jennifer B. Green, MD
Jennifer B. Green, MD

Dr. Granger described the findings in the symposium COORDINATE—Diabetes Results. The session can be viewed on-demand by registered meeting participants at If you haven’t registered for the 83rd Scientific Sessions, register today to access the valuable meeting content through August 28.

The trial compared coordinated care for cardiovascular preventive therapies in type 2 diabetes in 24 cardiac clinics around the U.S. to 20 clinics randomized to usual care. The trial was based on the recognition that while the rates of cardiovascular events have fallen in recent years, absolute patient numbers have not.

Ildiko LIngvay, MD, MPH, MSCS
Ildiko Lingvay, MD, MPH, MSCS

“Even when we have treated everyone to guideline, there is a residual risk in people with type 2 diabetes,” said Jennifer B. Green, MD, Professor of Endocrinology, Metabolism, and Nutrition, Duke University Medical Center. “Heart failure and other complications of diabetes were not well addressed by traditional approaches that focused on reducing glycemia, blood pressure, and hyperlipidemia.”

She cited a recent nationwide study of patients with commercial insurance that found only 2.7% of patients with type 2 diabetes and ASCVD were on all three guideline-recommended therapies, and 37.4% were on none of them.

“Why should we diabetes providers care about a cardiology study?” asked Ildiko Lingvay, MD, MPH, MSCS, Professor of Endocrinology, University of Texas (UT) Southwestern Medical Center. “Because we endocrinologists and primary care providers are no better at prescribing all recommended medication classes than our cardiology colleagues.”

Neha Pagidipati, MD, MPH
Neha Pagidipati,

A UT Southwestern survey found that while cardiology provided guideline-indicated prescribing for 20.3% of patients, primary care and endocrinology were similar at 20.1% and 24.8%, respectively.

“The intervention COORDINATE tested can be extrapolated to any specialty,” Dr. Lingvay said. “We need to change our prescribing practices as much as cardiology does.”

Adam J. Nelson, MBBS, MBA, MPH, PhD
Adam J. Nelson, MBBS, MBA, MPH, PhD

A total of 43 cardiovascular clinics nationwide were randomized to a multifaceted intervention (20) or to receiving treatment guidelines (23). The primary outcome was prescribing all three groups of recommended therapies. Secondary outcomes included the proportion of individuals receiving each group of therapies and those achieving a composite score of equal to or greater than 2, and a composite of all-cause death or hospitalization for myocardial infarction, stroke, decompensated heart failure, or urgent revascularization.

“We need to take up these therapies as risk-reduction strategies,” explained Neha Pagidipati, MD, MPH, Associate Professor of Medicine and Director, Duke Cardiometabolic Prevention Clinic, Duke University School of Medicine. “Cardiovascular patients with type 2 diabetes are at six- to eightfold risk for adverse cardiac events.”

Mikhail N. Kosiborod, MD
Mikhail N.
Kosiborod, MD

The intervention tested was a three-pronged approach intended to identify patient, provider, and system barriers at each of the 20 intervention clinics and develop, then implement, strategies to overcome barriers. The COORDINATE study team visited each site, primarily virtually due to COVID-19, to help local providers assess their own local practices and barriers and devise solutions.

“We were guides, but the real work of assessment and changing practice was at the sites and by the sites,” said Adam J. Nelson, MBBS, MBA, MPH, PhD, Associate Professor, University of Adelaide, Adelaide, Australia, and Associate, Duke Clinical Research Institute.

The entire COORDINATE-Diabetes toolkit is available for use online.

“We all have the same goals in the care of cardiometabolic disease: to prolong life, to prevent complications and keep patients out of the hospital and the emergency department, and to help them live better, fuller lives—not just longer ones,” said Mikhail N. Kosiborod, MD, Executive Director, Cardiometabolic Center Alliance and Professor of Medicine, University of Missouri-Kansas City.

“This trial shows that addressing systemic barriers works to change clinical practice. It’s not a silver bullet, but we’ve got to start somewhere,” he continued. “We all need to do better, and we all need additional solutions.”