Study groups and interventions
Intervention groups were defined as: (1) PCP, including those patients evaluated at least one time by PCP with ≤ 1 endocrinology visit and no visits with any lifestyle intervention provider (nutrition, wellness, or education) within the observation period or (2) MDT, including those patients with ≥ 2 endocrinology visits and at least 1 visit with the lifestyle provider in the same period. MDT included primarily endocrinology-oriented visits coordinated by an endocrinologist and provided by nurse practitioner, lifestyle counseling provided by an exercise physiologist including physical activity and nutritional counselling, and care coordination. Although cardiac function evaluations and eye exams increased detection of risk factors/complications, these were not considered as grouping variables. The number of cardiometabolic risk factors (CMRF) for DM, HTN, and obesity and time of exposure to LDH interventions were recorded. To account for variability in time of exposure to the intervention, patients were classified as (1) ‘established patients’, namely those receiving care at LDH between January 01, 2008, and November 15, 2017, and (2) ‘new patients’, describing attending the center only between November 15, 2017, and March 31, 2018 (end of the first quarter).
Per LDH’s outcome-oriented approach (Figure 1), a patient is activated to MDT when ≥ 1 cardiometabolic condition (OW/OB, Pre-DM/DM, or HTN, A1c> 5.6) is detected. The present analysis compares the group of patients co-managed by MDT to a group of patients that should have been activated but were not and continued only being cared for by the PCP. Once MDT was activated, blood samples were collected following a ≥ 8h overnight fast and 75g oral glucose tolerance test (OGTT) with serum glucose and insulin samples at 0, 30, 60, 90, and 120 minutes was performed [12]. Patients underwent treatment based on a protocolized drug curriculum. Those with OW/OB were treated with topiramate (25 mg, BID) and a low dose of phentermine (18.5 mg, QD) unless contraindicated or otherwise not tolerated. Those with insulin resistance were treated with metformin (1500 mg initial dose and then up titrated to 2000 mg). Patients with type 2 DM were treated with anti-diabetic drugs clinically proven to promote weight loss, primarily metformin and either glucagon-like peptide 1-based (GLP-1) therapies such as GLP-1 receptor agonists and dipeptidyl-peptidase 4 (DPP-4) inhibitors or sodium-glucose cotransporter-2 (SGLT-2) inhibitors. Specific medication was decided according to individual clinical conditions and insurance coverage. Lifestyle recommendations were provided for nutrition, wellness or educational visits and included nutritional counseling with caloric/carbohydrate restriction and physical activity recommendations. In the MDT group, most visits were coordinated and implemented and performed simultaneously between regular medical care and lifestyle counseling. Patients’ individual needs were considered in the implementation of follow-up and engagement protocols.