Betul A. Hatipoglu, MD, Editor
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Diabetes remission is an encouraging diagnosis for type 2 diabetes (T2D). Several articles in this issue of Endocrinology and Metabolism Clinics of North America examine interventions demonstrating some effectiveness for diabetes remission, such as bariatric surgery, low-calorie diets, and carbohydrate restriction, among others.Endocrinologists and others who clinically manage diabetes now have a diagnostic criterion for remission, and caregivers can offer hope when counseling some people living with T2D. Interventions may achieve glycemic control for some patients for a prolonged period. However, diabetes is currently a nationwide epidemic. The percentage of patients with an HbA1c >9% is increasing despite more than 40 new treatment options approved since 2005 and improved technologies. We need a fresh look at diabetes care programs to find what is working and what needs improvement.
At the root of the issue is the current care model for diabetes. Fewer than 6500 adult endocrinologists care for patients in the United States.
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This is an alarmingly small number given the estimated 34.1 million adults, 18 years or older, living with diabetes in 2018.3
Diabetes care by an endocrinologist is associated with lower morbidities and health care costs, and fewer readmissions.4
The approximate ratio is 46,000 patients per endocrinologist, which is an impossible need to meet with the expected further decline in full-time adult endocrinologists in the United States through 2025.5
It is time to rethink our care models.To meet the rising demand for endocrine care will require inclusive team-based care for diabetes management. Within the last year, we launched this team-based model at University Hospitals, Cleveland to organize diabetes care to be patient-centric, to better utilize resources, to support primary care, and to maximize value. This model employs a multidisciplinary team approach without the classic patient interaction by the entire team. The model seeks to increase capacity to see more patients more quickly by the most appropriate provider, and to improve diabetes management and care across the continuum. Our diabetes care team operates in the outpatient setting of our health system, connecting the experience and wisdom of the endocrinologist to disciplines more readily available to see patients with T2D. Team members include an endocrinologist, diabetes educator, nutrition services, advanced practice providers, and others as needed, such as a PharmD, social worker, nurse navigator, and when needed, consultations from psychiatry, nephrology, and cardiology interacting with primary care.
The diabetes care team engages primary care physicians through meetings, building a relationship as a diabetes resource and endocrinology referral service. Primary care providers discuss their difficult diabetes patients with the team, and the team recommends care interventions based on the patient’s needs, serving as a coach more than a consultant. Each patient referral is assigned to the appropriate team member who quickly implements the intervention.
As with any chronic disease, including diabetes, it takes a team approach to connect all the services to help the patient manage their disease. If we can catch T2D and intervene early in the disease course and encourage substantial weight loss and lifestyle changes, there is greater potential to restore β-cell function and achieve remission.
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Of course, sustainability of a coaching rather than a consulting team-based diabetes care model is only possible if billing and reimbursement in the United States recognize and value the work. This will require a paradigm shift from the classic physician reimbursement and specialist care to a team supported by endocrinology leadership, from caring for advanced and complications of the disease to prevention and remission. The future of our population health heavily depends on today’s vision.
References
- Consensus report: definition and interpretation of remission in type 2 diabetes.Diabetes Care. 2021; 44: 2438-2444
- Trends in the endocrinology fellowship recruitment: reasons for concern and possible interventions.J Clin Endocrinol Metab. 2020; 105: 1701-1706
- National Diabetes Statistics Report, 2020. Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services.(Available at:) (Accessed June 15, 2021)
- Endocrinology: growing need, but shrinking workforce.Medscape, 2017 (Available at:) (Accessed June 23, 2021)
- The clinical endocrinology workforce: current status and future projections of supply and demand.J Clin Endocrinol Metab. 2014; 99: 3112-3121
- Type 2 diabetes: the pathologic basis of reversible β-cell dysfunction.Diabetes Care. 2016; 39: 2080-2088
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© 2022 Published by Elsevier Inc.
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