Virtual care and medication optimization: A pathway to overcoming clinical inertia and gaps in care

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Virtual care programs with live and asynchronous communications between a provider and a patient can help create an efficient path for proper medication usage. Read this blog to learn more about our recent study around medication optimization.

Virtual care programs, which provide individuals with access to support and coaching in between provider visits, promise to help them in their self-care and condition management. Through the Onduo program, we’ve also shown that a virtual care program – with live and asynchronous communications between a provider and a patient – can help create an efficient path for physicians to help their patients get on the right medications to steer them towards their treatment goals.

The goal in managing type 2 diabetes is to help individuals achieve improvements in overall glycemic control, measured by glycosylated hemoglobin (HbA1c) and the amount of time spent within target blood glucose range.1 For some individuals, improving glycemic control may mean their physician will need to change the medications being used, and then evaluate the impact on the individual’s blood glucose. This change process takes time and effort for the patient and coordination with their physician.

Unfortunately, for some people not at treatment goals, clinical inertia becomes a factor when medication regimens are not adjusted or intensified despite poor glucose control. Other gaps in care and factors may come into play, including nonadherence or confusion about treatment plans.

With clinical inertia, people are living with poor glucose control over long time periods. This increases risks of cardiovascular disease, diabetic kidney, nerve, or eye disease, and other debilitating, costly complications, which come at the expense of both quality of life and healthcare spend.

According to the American Diabetes Association (ADA), treatment goals should be assessed often. If glycemic goals are not met, treatment intensification should not be delayed.1

The Onduo solution

We know optimizing medication in a timely way can lead to better glycemic control and better outcomes. This means taking one step toward curbing clinical inertia, so people reach their target HbA1c and experience fewer side effects. The real question is, how?

The Onduo virtual care program is one answer. Our comprehensive approach to type 2 diabetes care consists of a mobile app, remote health and lifestyle coaching, connected devices, such as blood glucose meters and a continuous glucose monitors (CGM) when clinically indicated, and need-based telemedicine visits with expert, board-certified endocrinologists and pharmacists.

Onduo’s whole-person diabetes care solution closes gaps in care by giving members easier access to personalized, one-on-one support from endocrinologists who can manage their medications remotely – according to the latest ADA Standards of Care1 and based partly on data from devices like CGM – in the moments between traditional healthcare.

What is a CGM? CGM devices continually monitor glucose in the blood, usually by taking readings every five minutes and showing the amount of time someone’s values are low, high, or in range, according to goals set by their endocrinologist or diabetes care team. [For comparison, HbA1c is a three-month average measured by a lab test and is the gold standard for measuring blood glucose control over time.] Recent research indicates that the longer time people spend in range, the less likely they are to have certain diabetes complications.2,3 And these values give providers details beyond HbA1c, like glucose dips or spikes, to help modify treatment plans for certain people.

The Onduo virtual care program, which leverages the data from an individual’s CGM to help guide individuals in making timely changes to their lifestyle, including meals and exercise. And through the Onduo program, including the use of CGM, our specialists can make timely, precision treatment and medication changes for better outcomes.

Research shows the Onduo program can help overcome clinical inertia

Our research demonstrates that our multifaceted virtual care model can help people with poorly controlled type 2 diabetes meet their treatment goals. In a published prospective study, we were able to demonstrate participants had a significant drop in HbA1c of 1.6% from baseline (8.9% to 7.3%; SD 1%; P<.001; 55 adult participants) after four months with intermittent “sprints” of CGM use; plus, weekly coaching visits and at least one telemedicine, medication-management visit with an endocrinologist.3

In this study, participants also experienced other significant clinical improvements, including an average weight loss of nine pounds* and an increase in time spent in their target glucose range, or time in range.4

Overcoming clinical inertia with timely medication optimization

This research also demonstrates how endocrinologists used CGM data along with other factors to remotely optimize medications according to the latest guidelines, including5:

  • Adjusting nearly 90% (48 out of 55) of participants’ medications – a dose change, addition, or discontinuation

  • Increasing glucagon-like peptide 1 (GLP-1) receptor agonist prescriptions by 31%. These medications are highly effective at controlling blood glucose, while offering cardiovascular and weight-loss benefits

  • Discontinuing less effective medications, or drugs with less favorable side effects and comorbidity profiles, including reducing prescriptions of sulfonylureas by 23% and dipeptidyl peptidase 4 (DDP-4) inhibitors by 11%.

Unlike in traditional practice, medication optimization may take place over a long-term period, even years, when individuals return to their provider’s office for a clinical visit. Within this study, the first medication change was made approximately one month (on average) after individuals enrolled.

“The results of this study demonstrate how we can make data-based medication changes in real-time through virtual care. Our patients derive clear benefits from these timely and precise interventions. This is an effective way to overcome clinical inertia and address existing gaps in care. Through this approach, we can help our patients improve their glycemic control and ultimately, live healthier – and happier – lives with type 2 diabetes while reducing burdens on healthcare.”
– Dr. David M. Erani, M.D., Board-certified Endocrinologist

A spotlight on one patient: A compelling case study

Although people are not case studies but individuals with real lives and real needs who are not defined by their conditions, one patient case review highlighted within our published study helps demonstrate the use of CGM for treatment interventions.

At the start of the study, the 66-year-old female patient weighed 174 pounds., had a baseline HbA1c of 12.0%, and was taking three anti-diabetic medications. She was experiencing high blood glucose levels, time in range below target and some low glucose readings.

Over four-months, four CGM data-guided medication changes were made remotely by her Onduo physician:

  • Day 27: Discontinued sulfonylurea per concurrent insulin use; plus, discontinued the DDP-4 inhibitor and exchanged with a GLP-1 receptor agonist to address high blood glucose

  • Day 47: Increased GLP-1 receptor agonist dose per continued periods of high blood glucose

  • Day 67: Reduced basal insulin dose to address a small increase in low blood glucose readings

  • Day 108: Reduced insulin dose again

At the end of the study, this patient lost 25 pounds, had a 6.3% HbA1c, and experienced less glycemic variability with fewer blood glucose spikes after eating – called postprandial hyperglycemia – when comparing the first and last 10-day CGM wear periods.

In the figure below, their time in range is shown in green. Graph A shows poor glycemic control and variability during the first sensor wear period, versus graph B, which shows good glycemic control with the participant meeting treatment targets for time in range with minimal time spent in high and low glucose range, during the last sensor wear period.

Glycemic Control Before and After CGM-Guided Medication Changes
Glycemic Control Before and After CGM-Guided Medication Changes

The pathway is clear

Onduo’s holistic virtual care program can support individuals with type 2 diabetes between traditional healthcare visits through greater access to specialized care and diabetes technology, like CGM, to improve HbA1c and other outcomes.

After evaluating medication optimization achieved through our solution, we see virtual care provides telling data for timely – and vital – medication management, helping clear a pathway to overcome clinical inertia and close gaps in care.

References

*No individual weight loss result should be seen as typical; they are not guaranteed results. Individual weight loss results, amount, and time duration will vary.

  1. American Diabetes Association. Standards of Medical Care in Diabetes—2022. Diabetes Care. 2022;45(Supplement 1).

  2. Raj R, Mishra R, Jha N, et al. Time in range, as measured by continuous glucose monitor, as a predictor of microvascular complications in type 2 diabetes: a systematic review. BMJ Open Diabetes Res Care. 2022 Jan;10(1):e002573. doi: 10.1136/bmjdrc-2021-002573.

  3. Lu J, Wang C, Shen Y, et al. Time in Range in Relation to All-Cause and Cardiovascular Mortality in Patients With Type 2 Diabetes: A Prospective Cohort Study. Diabetes Care. 2021 Feb;44(2):549-555. doi: 10.2337/dc20-1862. Epub 2020 Oct 23.

  4. Majithia AR, Kusiak CM, Armento Lee A, et al. Glycemic Outcomes in Adults With Type 2 Diabetes Participating in a Continuous Glucose Monitor–Driven Virtual Diabetes Clinic: Prospective Trial. J Med Internet Res. 2020;22(8):e21778. PMID: 32856597

  5. Majithia AR, Erani DM, Kusiak CM, et al, Medication Optimization Among People With Type 2 Diabetes Participating in a CGM-Driven Virtual Care Program: Prospective Trial. JMIR Form Res. 2022 Feb 7. doi: 10.2196/31629. Online ahead of print.