Intensive Diabetes Management Program Lowers A1C Levels in Complex Patients

The Setting Targets Achieving Results Diabetes Mellitus (STAR-DM) Program at Brigham and Women’s Hospital (BWH) is an intensive management program for high-risk diabetes patients who are struggling to meet clinical targets, such as achieving their A1C target or avoiding too-low blood glucose (hypoglycemia).

Despite receiving primary care and specialty care from an endocrinologist, a small population of diabetes patients are unable to reach clinical targets without additional personalized care and intensive monitoring. The STAR-DM Program helps these complex diabetes patients meet clinical targets by providing six months of monitoring, treatment interventions, and ongoing diabetes education.

“For patients with chronic high blood glucose, the primary objective of the STAR-DM is to lower A1C blood levels by at least 0.5 percent in three months, or one percent in six months. We start an individualized A1C goal, which is generally as close as possible to, or less than, seven percent without hypoglycemia. Our goal is to help patients get on the right track to achieve a feasible target to lower the risk of long-term complications involving the kidneys, eyes, nerves and heart and blood vessels,” says Marie E. McDonnell, MD, director of the Diabetes Management Program within the Division of Endocrinology, Diabetes and Hypertension at BWH.

A patient’s six-month A1C target is determined from their baseline levels. A patient who enters the program with an A1C of 10 percent may aim for a reduction of one percent, whereas a patient with an A1C of 8 percent might aim to lower their A1C by 0.5 percent. Each patient also receives an assessment to determine what barriers they may face in controlling their blood glucose.

Over the course of six months, physicians, nurse practitioners and nurses employ multiple interventions to meet clinical targets. Providers monitor blood sugar, make insulin adjustments, and provide education. The medical team communicates with patients mostly over the phone, or through virtual visits.

“Each patient undergoes simple tests to characterize, or phenotype, their diabetes. The results give us a more accurate diabetes diagnosis. We can often improve a patient’s quality of life dramatically by switching to a more appropriate medication for a patient’s specific type of diabetes,” says Dr. McDonnell.

Seventy-two percent of patients who entered the STAR-DM Program had an A1C greater than or equal to 9 percent. Of the 48 program graduates, 68 percent lowered their A1C by at least 0.5 percent. Importantly, all patients felt better about their condition at the end of the program.

“In response to a validated survey administered before and after participation, patients reported feeling better about their overall health after participating in the STAR-DM Program. They also felt less overwhelmed, more optimistic about their diabetes, and felt more capable of self-managing their condition, which is the overarching goal of the STAR-DM Program,” says Kayla Del Valle, NP-C, a nurse practitioner within STAR-DM Program. These data were presented at the 2017 American Diabetes Association conference.

To enroll in the STAR-DM Program at this time, patients must be an established patient with an endocrine provider. The program hopes to expand referral options to patients who have received a diagnosis in a primary care setting. Providers are tracking long-term outcomes among graduates and are applying for funding to conduct clinical trials using different treatment approaches for this population of patients.

“Some physicians who care for complex diabetes patients become frustrated because they are not seeing their patients improve even after prescribing an effective regimen. The STAR-DM Program makes me feel confident and excited that we can offer better care to our high-risk diabetes patients. It is also teaching us what elements are most important, and what might still be missing in standard comprehensive diabetes care” says Dr. McDonnell.

To refer a patient to the STAR-DM Program, please email STARDM@partners.org. Our nurse practitioner, Kayla Del Valle, will contact the patient to assess interest in the program.

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