While much is known about the science of diabetes, implementation remains a challenge.

“There are so many things that we know work, but they are inconsistently implemented, nationwide and globally,” said John B. Buse, MD, PhD, University of North Carolina School of Medicine Diabetes Center and Translational and Clinical Sciences Institute, adding that implementation science was identified as one of the most important topics affecting diabetes care.

Dr. Buse chaired the ADA Diabetes Care Symposium—The Final Frontier—Implementing the Learning from Implementation Science, on Saturday, June 22, in which a panel of experts discussed real-world lessons and ways to move forward. The symposium can be viewed on-demand by registered meeting participants on the virtual meeting platform. If you haven’t registered for the 84^th Scientific Sessions, register today to access the valuable meeting content through Aug. 26.

Brian Oldenburg, MPsychol, PhD, Baker Heart and Diabetes Institute in Australia, discussed diabetes prevention over the past 20 years. He acknowledged that global implementation to prevent and improve diabetes outcomes remains a challenge.

“The majority of people who are at risk for or already have diabetes still don’t perceive what is really recommended in the evidence-based guidelines,” Dr. Oldenburg said.

That challenge is the focus of a paper released the day of the symposium in the journal Diabetes Care^®, “The Final Frontier in Diabetes Care: Implementing Research in Real-World Practice.” 

Implementation science looks at the “how” that bridges the gap between knowing what to do and actually doing it, including adapting interventions and programs, understanding barriers and enablers both individually and systemwide, and developing strategies to address these. Context is everything, Dr. Oldenburg emphasized, and if it is ignored or misunderstood, adoption is likely to be poor.

“The key point about implementation science, I think, is the importance of context, and understanding that context: the populations, the services, the socio-cultural features of different populations, and adapting the programs to those different populations,” he said.

While real-world implementation science shows some good news in terms of efficacy, it also shows low numbers relative to the population. Dr. Oldenburg has been part of diabetes prevention research in southern India for the past 15 years in which the main implementation trial resulted in good attendance in prevention program activities. He studied how to scale up the model to serve a larger group and learned that peer leaders, partnerships with government and research institutions, and the involvement of the state departments were essential to the programs’ success.

Matthew J. Crowley, MD, MHS, Duke University Medical Center, discussed using telehealth to improve diabetes management. He focused on the limitations of in-person care for glycemic management, comprehensive telehealth as a means to improve that management, and how to approach barriers to the real-world use of telehealth.

Despite the existence of and engagement in effective treatments for type 2 diabetes, many people do not meet ADA-recommended glycemic targets. Additionally, intermittent in-person care may not be enough to help a patient who does not have the capacity to self-manage a disease as complex as diabetes. That’s where telehealth comes in, providing remote delivery of care more frequently than in-person care.

Dr. Crowley shared details about the Advanced Comprehensive Diabetes Care (ACDC) program in place in 30 Veterans Affairs (VA) medical centers across the U.S. It’s designed to balance the work of self-management with a patient’s capacity and combat therapeutic inertia using Home Telehealth (HT) nurses and standard VA equipment. HT nurses had 30-minute calls every two weeks with patients for six months. Effectiveness trials showed improved A1C, improvements in distress, and low hypoglycemia rates. ACDC is the subject of an implementation trial at 10 VA sites.

“In order to facilitate successful implementation, interventions have to be designed and delivered in a system-specific manner that emphasizes feasibility and leverages available [clinical] resources,” he said.

Jennifer B. Green, MD, Duke University Medical Center, presented details of COORDINATE-Diabetes implementation and multifactorial cardiovascular risk reduction. The study was a cluster-randomized trial to improve care of patients in cardiology clinics with type-2 diabetes and atherosclerotic cardiovascular disease (ASCVD).

The objective of the study was to test the impact of a clinic-level, multifaceted intervention on the prescription of three key groups of evidence-based therapies: high-intensity statin; angiotensin-converting enzyme (ACE) inhibitors or angiotensin 2 receptor blockers (ARBs); or sodium-glucose transport protein-2 (SGLT2) inhibitors or glucagon-like peptide 1 (GLP-1) receptor agonists. There were 43 enrolling sites with a median of 24 participants per site receiving multifaceted intervention versus usual care, which just received guidelines for therapies.

The primary outcome was based on patients being on all three therapies at final follow-up. The usual care group saw a 14.5 percent increase in delivery of care on all three therapies, and the intervention group saw a 37.9 percent increase.

“If you’re not used to looking at the results of implementation studies, this is actually considered to be a very highly significant difference,” Dr. Green said. “Many of these trials are conducted, and in fact there is no difference at all.”

Because of the COVID-19 pandemic, the intervention was delivered remotely and therefore was less intensive than originally designed, but ultimately the outcome was positive, she said.

“This coordinated, multifaceted intervention clearly increased the prescription of three groups of evidence-based therapies in adults with type-2 diabetes and ASCVD,” she concluded. “We really were effective on moving the needle on how care was delivered in a variety of aspects to this high-risk group.”

Nisa M. Maruthur, MD, MHS, Johns Hopkins School of Medicine provided context for clinicians and health system leaders.

Among her recommendations were that research and care should focus on improving multiple outcomes for diabetes, not just one outcome, and the patient-doctor encounter as the primary focus for improving diabetes outcomes has to change. Team-based care is important and should be tailored to the local setting, and leadership must be engaged in changes. It’s all about continuous quality improvement (CQI), she emphasized.

“[CQI] is never done,” Dr. Maruthur said. “We have to keep on doing it.”