Welcome, everybody. Thank you so much for joining us at our special program today, Overcoming Therapeutic Inertia in Type 2 Diabetes, Benefiting Patients, Clinicians, and Health Systems. This session is brought to you by the American Diabetes Association's Overcoming Therapeutic Inertia Initiative, and you'll hear more about that today, and is supported in part by Sanofi Diabetes and Novo Nordisk. I am Bob Gabay, the Chief Scientific and Medical Officer here at the American Diabetes Association, and I have the pleasure of moderating this session, and really excited to have two fantastic individuals that will be talking about this important subject, and really looking to identify the issues related to therapeutic inertia. First will be Christine Beebe. She is a consultant in diabetes care and education with probably a typo, but over 50 years of experience in diabetes research, teaching, hospital administration, pharmaceutical and nonprofit leadership, she was past president of the American Diabetes Association Health Care and Education, and she's co-authored National Guidelines, has been on the Professional Practice Committee for the ADA, and has really been this incredible volunteer over the years, and also chaired an initiative by the ADA and CMS, it was a task force on diabetes self-management education and support. We then also are very fortunate to have Dr. Nailin Eng. He's a primary care diabetologist at Mohawk Valley Health Systems in Central New York. He serves as the co-leader of the Glycemic Management Team, a sort of unique quality improvement-based team focused on hospitalized patients. He's been volunteering in the overcoming therapeutic inertia for the ADA literally since the inception of this program a number of years ago, and so we're really pleased to have both of these speakers. Here you can see their disclosures. And as far as our learning objectives today, we're going to start by identifying the impact of therapeutic inertia on diabetes outcomes, and you'll see a lot of information around that. Then recognizing the factors that contribute to therapeutic inertia in type 2 diabetes. And then what I think is really most important for us is literally what can we do about it, so discovering effective strategies, best practices to deal with therapeutic inertia. And so with that, I am really excited to start this program and turn things over to Chris. Thank you, Bob. I'm delighted on behalf of all of the people, all of my colleagues who've been working on this project since 2017-18 to bring it to fruition over the years. We all know the personal and the clinical burden of diabetes, and we know it's a serious urgent health issue. Nearly 39 million Americans have diabetes. This represents almost 12% of the population. We know that one in four primary care office visits is at least for diabetes. These individuals have a higher risk of blindness, kidney failure, heart disease, stroke, and loss of limb. Unfortunately, over one in three adults in the U.S. also have prediabetes and are likely to join this group. Not only is it a personal burden, but it poses an enormous economic burden to our society in that every five years, the economic burden of diabetes is calculated, and Bob was part of that group. The most recent analysis published last year showed that the total cost of diabetes is nearly $413 billion. The direct cost is about $306 billion. This represents about one in four healthcare dollars. When you look at that in inflation-adjusted data, dollars adjusted to 2022, you see that that represents a 7% increase over 2017 and a 35% increase over 2012. And then, of course, individuals with diabetes themselves bear the economic burden in that they are two and a half times more likely to spend more money on their healthcare than the person who does not have diabetes. What are the costs, the primary costs? Interestingly, the largest contributors to the direct cost of diabetes are the higher use of medications that are used for the complications of diabetes. This represented about $84.5 billion spent on medications that were meant to address neurological issues, cardiovascular issues, renal, and ophthalmic. The higher use of inpatient services as well is a primary driver representing about $96 billion. Interestingly enough, the direct costs of medications to control blood glucose levels is about 17% of the total cost, or about $51.3 billion. So, enormous burden on society and individuals and families, as we know. We have long known that achieving glycemic, lipid, and blood pressure goals reduces the patient personal and economic burden. Yet, again, recent data shows that only half of persons with diabetes in the U.S. achieve an A1C less than 7%, less than half have adequate blood pressure control, and again, only about half are controlling lipid levels. Alarmingly, only one in five are able to control all three risk factors. Why is this? Well, many do not attain their goals because they're not receiving adequate pharmacotherapy. This has been shown to be particularly problematic in populations such as minorities, underinsured, and I think, alarmingly, in younger people who will have the longest glycemic burden of any individuals if they do not control their risk factors early on. So, research shows that the variability in the quality of diabetes care across practice settings indicates that substantial system-level improvements are needed. Let me go back here. So, why, again, are we not achieving our goals? Well, it is estimated that most patients are not receiving timely and appropriate intensification of their medications, and this has been dubbed therapeutic inertia. Therapeutic inertia is the failure to initiate or intensify therapy when the health goals are not met, and this could be adding a medication, increasing a dose, or it could actually be de-intensifying as well. This is happening despite a clear definition of appropriate targets. We know that. Types of achieving targets are well-established, and effective therapies are available. There's over 40 medications to manage type 2 diabetes in particular, and there are evidence-based guidelines and algorithms that are widely disseminated by organizations. So, it has been realized that therapeutic inertia is a major contributor to the failure to meet glycemic goals, and this can occur at all stages of treatment intensification. The effect of this therapeutic inertia has long been known, and I say long been, since the 90s, when early studies, particularly the UK PDF study, illustrated that when you compared individuals that were intensively treated, which is signified by the blue line here to conventional treated patients, and these were individuals with type 2 diabetes, that at the end of the period, despite the fact that the A1C levels began to migrate together and there was not a whole lot of difference, individuals who were in the intensive arm still had a lower incidence of complications 10 years later. So, this was clearly, this early intensification and early diabetes management generated a positive legacy effect, or metabolic memory, with 24% reduction in vascular complications, MIs, and all-cause mortality. And it wasn't just this study that showed that. Several clinical major landmark trials did in subsequent years. Routine real-world data has recently emerged, and I would say in the last five years or so. This is a study of a cohort of over 34,000 people with newly diagnosed type 2 diabetes, who were in poor control and had a 10-year survival rate. They were evaluated for the impact of glycemia on various points. The results demonstrated that when compared to individuals who had an A1C less than 6.5%, those individuals who had an A1C above 7 for the first year, had a 20% increased risk of future mortality. Those who had an A1C above 8% in the first year, this then risk increased to 29% and 32% increase in all-cause mortality when the A1C was above 9%. So, that clearly suggested that a legacy effect was noted in even non-trial populations. Again, this was a large cohort study of, I believe, managed care patients. Then, another recent study also illustrated this point when it showed that early action reduces related costs. So, it was a retrospective claims analysis looking at 21,000 adults with type 2 diabetes who had an A1C over 7% and they were followed for over 18 months. What the study, the retrospective analysis showed was that when providers took action to intensify therapy in the first six months compared to those who did, who took no action in the first six months, that diabetes-related outpatient costs were 60% higher at 18 months in those where no action was taken. So, again, clearly illustrating that early glycemic control can have a positive legacy effect. So, achieving this control does more than just lower A1C and the glycemic burden early on. Studies have shown it also allows for better maintenance of A1C over time and better long-term health outcomes, whether it's quality of life, physical health outcomes, and we know lower risk of microvascular and macrovascular complications. In addition, we have demonstrated that this could have some very significant effects on economic costs. In fact, modeling studies have showed that you can save over $7 billion by not delaying therapy in individuals after diagnosis. So, the causes of therapeutic inertia in type 2 diabetes are multifactorial. It involves individuals themselves with diabetes, and we'll talk a little bit more about that in a second. Clinicians and healthcare providers, which Naylin will discuss, healthcare systems, payers, industry, there's all kinds of reasons from formulary decisions down to patients not understanding what their medications are for. So, if we look, I'm going to focus just on individuals with diabetes. If we look at the most frequently cited contributors, number one is often that patients don't have an understanding that type 2 diabetes is progressive. Type 2 diabetes patients present with varying levels of insulin secretion due to beta cell destruction, varying levels of insulin resistance. So, no two treatments are the same, but more importantly, most patients don't understand that insulin resistance and beta cell secretion can change over time. So, unlike many other forms of therapy, diabetes in type 2 diabetes will often require treatment changes over time, and helping patients understand that is crucial. Studies show that most patients don't understand that at all, and poor access and participation in diabetes self-management education and medical nutrition therapy has also been cited. Diabetes self-management education, or DSME, is a covered benefit by Medicare and many insurers, yet our data shows that fewer than 10 percent of individuals with type 2 diabetes attend, and this is problematic because, again, all the day-to-day decisions, 99 percent of care that a patient provides is done by their own decision making. So, if they don't have the knowledge and the skills, they will not be successful. Poor communication and trust between physicians and patients has been shown to enhance treatment adherence. Understanding what the goal is for treatment is something that physicians and patients need to communicate on regularly, and then I know everyone here is keenly aware how the social determinants of health can affect access to care, cost of medications, etc. So, if we look at the progressive nature of diabetes, what can we do? This most recent NHANES data illustrated that only 17 percent of patients with type 2 diabetes were controlling their disease with diet and exercise alone, and while that is the foundation for all diabetes treatment, it still may not be enough as the disease progresses. Most individuals are on at least one or two or more diabetes medications. So, querying patients on their beliefs around medications is really important and providing them information about the progressive nature. Many patients, we all know, view themselves as sicker the more drugs they take, so getting them to understand that it is not failure on their part if they have to go on insulin. Twenty-five percent of patients, for example, will not go on insulin because they view it as a failure of their own abilities to control it with diet and exercise. So, again, helping patients understand is crucial and the ADA has materials available to you on the website that can help do that. Then we also mentioned how one of the most important things is referring and providing access to DSMES to produce improvements in clinical outcomes. Again, you cannot make good optimal decisions in care as a family or a person with diabetes if you don't have the knowledge and skills, and ADA has a recognition program where they have standardized the education process, so you know that you can produce when you refer someone to an ADA or ADCES program that you're going to, the patient will get the education they need. This is some very good data that has recently come out of the 23 Education Recognition Program, identifying that 75% of participants decreased their A1C as much as 1.4%. 60% of participants had fewer ER visits and hospital admissions. That's big economically and personally. And over 65% of patients lost weight. So their outcome measures are being produced constantly. So referring and providing access to patients is crucial. Studies have shown that as many as half of patients with type 2 diabetes don't realize that they can go to a program because either their physician is unaware of it or the physician has not referred them or even talked of the value of it to them. The other thing that's really important is building an empowered team to manage and support the person with diabetes. And this is generally a multidisciplinary type of team. The ADA OTI group commissioned a meta-analysis of over 22,000 patients with diabetes in 36 studies. And what they saw was that a reduction in A1C was achieved compared to usual controls, especially if nurses or diabetes care and education specialists were involved, care management and patient education was involved. You can see the drop in A1C in both. Pharmacist-led initiatives were also successful. Not to be confused, the physician-based initiatives, although it didn't look as well, that was based on educating physicians, not necessarily looking at specifics, providing education on diabetes management. But the conclusion of this study was monumental in that it found that nurses, diabetes educators and pharmacists that were empowered to initiate and intensify therapy independently, that's a key word, independently, supported by guidelines and protocols had the greatest reductions in A1C. And this has been shown in plenty of other studies as well. Mayor Davidson has done some very nice work in the primary care setting. Empowering that team, therefore, to work at their highest scope and abilities is really important. And a multidisciplinary team can be extremely valuable. What the results of this study showed, in addition to allowing our teams to independently adjust medication, after all, we're teaching the patients to do so, results might have been less dependent on who did it, but rather on how, in that nearly all the management and patient education interventions that are associated with significant A1C results use technology to support the communication between the team members and the patients. We're talking about text messaging, problem solving methods, frequent communication and intervention that facilitated rapid modifications in care or in medication. You don't have to wait for three to six months for the next visit. And in fact, that has been exemplified, I think, beautifully in a paper that came out of Joslyn that looked at the frequency of communication as it increased, the time to achieve goals decreased. If you look at the data on the right here, you can see how quickly with intervention, telehealth, social media, using devices like CGM, etc., patients were able to achieve an A1C less than 7% when frequency of communication was one to two every one to two weeks versus seeing that patient every three to six months. You can see the difference, 25 months compared to four months. The paper also highlighted data that showed the same thing in LDL, cholesterol, and blood pressure. So increasing frequency of communication using the team and adjusting medication therapy is one of the top strategies for helping people, persons with diabetes achieve blood glucose control quickly. So number one, help patients recognize the nature of type 2 diabetes and that their therapy will change. And that happens by setting shared goals with the clinician and including things such as social determinants of health in the decision-making. Help them seek information and learn to be self-managers. Again, I can't say enough about promoting diabetes education services and medical nutrition therapy. It's the foundation. And using technology to evaluate glycemic profiles, making decisions with the patient, etc. This is state-of-the-art management. So the American Diabetes Association's OTI initiative has come up with several tools that can be helpful to do this. And you will find at the end of this presentation, a resource list that will help direct you to these. But please go to the website to find these helpful tools. Thank you. Thank you very much. Thank you for joining us. And thank you, Dr. Gabay, for the kind introduction. And Chris did a really good job in terms of telling us how important the OTI is and the patient perspective. So I am going to talk a little bit about from the clinician perspective and the health system-wise perspective. And then, however, most of the data might be the same, but we are looking from the different angles. What I'm going to do is I'll talk a little bit about what are the major contributors to the therapeutic inertia from the clinician side, and then what are the proposed solutions. But I know I won't go deep into each solution. What I'm going to do is that, as Chris said, there are many great resources on the OTI website. So what I'm going to do is that I will just introduce those resources to you. So you can go into the OTI website and get more information on those things. And I'll do the same for the system-related contributors and the solutions. So first of all, the clinical-related is, you know, as you all know, there is a great demand, high demand, to get a quality diabetes care for the people with diabetes, you know, in the United States and everywhere else in the world as well. And we don't have enough resources, though. In terms of clinician, if we look at it, you know, we don't have enough endocrinologists. We have now few diabetologists, but it's a drop in the ocean. So majority of the people with diabetes are getting care from the primary care provider, and they are really good at doing, you know, giving care to the people with diabetes. Again, they have a lot of challenges, too. They got 15 minutes to take care of the patient with multiple complaints. And then, you know, there are other conflicting, overwhelming requirements as well. And another thing is how to, you know, initiate and intensify the treatment. So where is the guidelines, how to help the provider, the clinicians to help better manage the people with diabetes without causing any harms? So hypoglycemia is one of the big challenges. So people with diabetes, as well as clinicians, are afraid of not to get into other sites, right? So we intensify a lot if the patient started having hypoglycemia is not a good thing. And if you, you know, remember what Chris said, you know, our OTI, the TI is not just intensification. We also have to look at the de-intensification when the patient has hypoglycemia or at risk of hypoglycemia. So this is a legit reason that people are a little bit hesitant, but with the newer medications with no risk for hypoglycemia, that is a good opportunity to hold on that. And another thing is underestimating the patient needs and ability to manage their own diabetes. They are the main person who will take care of their own diabetes and underestimating their importance in the care can be a great contributors to the therapeutic inertia in the people with diabetes. And what I want to add here is, you know, underestimating our ability to help the people with diabetes as well. So as a clinician, as an educator, as a nutritionist, we can help them a lot. And instead of, you know, surrendering and saying that this is non-compliance issue, there may be many other things we can do to help the people with diabetes to overcome the therapeutic inertia. And Chris has mentioned several times about the importance of medical nutrition therapy and DSMES services, which are the, you know, core to diabetes management. Still, it's not happening enough. So I'll show in the few slides. So in 2018, the ADA convened a conference for, you know, with all the stakeholders to see what we can do about the therapeutic inertia. So if you look at here, the time and the education are the two big words, right? So time constraint, you know, we don't have enough time to take care of the people with diabetes, like quality care, you know, take times, educate the patients and all these things. And another thing is education, which has a multiple layers though. The first of all is what is TI? How important is the TI and how dangerous is the TI and how we can take care of that? And the second thing is more like a personal relationship to the TI. How about my patients? How about our healthcare system in the clinic? So I'll talk about that a little bit more in the system related things. And the third thing is, okay, we know that TI exists. TI is important in my clinic, in my patient population. How can we overcome that? So those kinds of things, all of those are important in terms of knowledge sharing, knowledge and education part. And traditionally, our approach to the diabetes management is wait and see and treat to fail. You know, that's, we see it every day in our clinics, right? So we, let's say, I will, you know, tell a little bit of like exaggerated maybe scenario, you know, patient diagnosed with diabetes, we see them for the first time. A1c might be 6.6, 6.7, not too bad. So we tell, you know, two minutes education with a couple of booklets. We might fail to send the patient referral to the, you know, DS and then, you know, MNT. We'll talk about that in the next couple of slides about that too. And then, you know, the, you want the patient to come back and see us in six weeks. The patient did not show up until three months later or six months later, and then the A1c is high enough. So you decided to start the metformin and want to see the patient back in three months. Patient came back in three months, but patient has other issues. Patient has knee pain and within 15 minutes, you cannot take care of a lot of things. Patient focuses on knee pain. He doesn't want to talk about anything related to diabetes. So come back in three months again to talk about the diabetes. And at that time, patient told, I take two days of metformin and then I stop because my friends say that can damage my kidney, right? So you educate the patient, you know, diabetes can damage your kidney. Metformin does not start taking it, but it's already like one and a half years or two years from the diagnosis. And you started the metformin later. So that is, you know, you usually see it in the clinical practice, but Dr. Kunti and group did a really great job to look at that, you know, the process and then, you know, published in 2016, which showed that, you know, if you look at here, patient on the one hypoglycemic agents go to the second one, when the A1C is not controlled, takes about one and a half years to three years. And once the patient is on two different hypoglycemic agents and still A1C is not under controlled, it took about another seven years to add the third anti-diabetes medication, right? In the meantime, the patient might probably say, I want to try, I was drinking a lot of soda. I will cut down the physician or clinician is, you know, pushing for them. Maybe, you know, there may be a lot of things, right? And then, you know, another seven years to add on the insulin, but this one is from 2016. So we have updated recommendation about how to add the injectable insulin versus GLP-1 agonists and stuff. So you can have more information on the standard of care. But what I want to focus here is it takes time and it, there is a significant delay and we wait and see, and we wait until the patient has a higher A1C of, you know, develop complications before we intercept either therapy. So we all know that DSMES and MNT is a core treatment modalities for the people with diabetes. And, you know, if you look at the status, only 6.8% are privately insured and 5% of the Medicare participants receive the referral during the first year of the diagnosis. So you all may aware that, you know, there are four critical times the referral is recommended, but technically speaking, you know, the new diagnosis is the best opportunity, right? The patient just know that they have diabetes and this is the best opportunity to get the referral out and get the patient seen by DSMES and MNT. However, only maybe less than, you know, 5, 10% were actually got a referral and seen the DSMES and the MNT. So there is a significant issues in terms of contributors. How can we, you know, what are the proposed solutions, right? The first thing is set the clear glycemic goals and timelines. So again, there are two components here goals. And fortunately some people, you know, patients, clinicians, whoever it is, you know, still think they're less than 9%. For some reason, there are a lot of push for the A1C of 9%. So as long as less than 9%, we're good. But actually it's not, you know, Dr. Chris already mentioned some of the data. And, you know, we want it under control, not in 20 years time or not in 30 years time as well, right? So we want it within certain period of time. Chris already mentioned about the legacy effect, metabolic memory effect and stuff like that. So we don't want to wait until patient double out several multiple, you know, complications. Patient already had a end-stage neural disease on dialysis and two heart attack and stroke and get an A1C down to seven. It's not ideal. We want it to be at goal as quick as possible before having any complications. And another thing is building the teams. That's true that, you know, time is not enough. We have a lot of other, you know, the requirements, but use the team members to, you know, build the teams. We can delegate the, our, you know, the things among our team members and able our team members and the best team members are, yes, you know, CDC, right? So we can get a certified diabetes educators and then try to build the team and enable that. And again, technology is extremely important. You know, I will talk a little bit more about that in the next few slides. So first of all, it's diabetes care plan. So diabetes care plan means that what is the current status and where we want it to be and over what period of time, right? So we want an A1C below, whatever the personalized A1C goal is or blood glucose goal is, LDL goal is, blood pressure goal is, and then what is the timeline? We don't have indefinite time. We want it under control as quick as possible before having any complications. So on the way there will be a barriers. How can we overcome the barriers? So that is the complete diabetes care plan. We put the patient in the center because the patient is the one who's going to take medication, who's going to eat what they want and not eat what they should or shouldn't. So, you know, informed decision-making with the, you know, with the patient in center, with team approach, try to come up with the diabetes care plan. And then we try to, you know, do whatever we can. There are things that we can do. There's things we can't do, but within our ability, what we can do. Sometimes we underestimate ourselves a lot. We just say that, you know, I told the patients to do this and the patient doesn't do it, but have we go deep into what is the problem? What is the barrier? And then try to overcome, try to tackle that as much as possible. So we have a diabetes care plan downloadable, the documents in the OTI website. We also have a webinars, but I think it's a part of the certificate program, but you can go into the OTI and get more information about, you know, diabetes care plan that works for the patient, how to, how to double up the care plan. So another of the good resources is about education, how to intensify, how to initiate the medications. You know, ADA published a standard of care every year, and it has a very good algorithm for type two diabetes management, as well as there's a type one, you know, the guidelines too. So there is apps on the phone you can easily assess, you know, during the room with a patient or when you are writing the patient instructions. So you can get a quick reference, how to get your patient to be on the good regimen. And then, you know, in addition to the standard of care and diabetes care plan, there are many other, you know, the resources on the OTI, there's webinars, practice polls, like short videos, infographics on how to de-intensify the insulin and some other, you know, the information, good resources. So Chris already talked about the meta-analysis, but I just want to use this as a summary for the clinicians. That is, you know, and the transition to the system-wise. Chris is part of this, you know, meta-analysis, really good ones. So if you look at this, there's four different, you know, intervention use, look at the, you know, the four different groups in that 36 studies. So in the care management, if you look at here, you see a lot of tele, you know, the communication tools use, virtual coaching and tele-monitoring and stuff like that. And then in the physician-based, as Chris said, it's more like trying to influence the physician behavior. And then the nurse and CDCS-based is mostly with the, you know, using the algorithm and the protocol, the same with the pharmacist. So out of those, this meta-analysis, you know, I just want to mention three different things, which is, you know, pharmacist-based and nurse or CDCS-based use the protocol or algorithm to better, you know, control the blood glucose. And that works well. So, which means that, you know, following the guidelines, following the algorithm will help you. You know, that's why, you know, Chris always mentioned, you know, forget about who did it, but what they do, right? So either physician or the nurse or CDCS or pharmacist, if they follow the guidelines, they can get good outcomes, right? The second thing is, you know, using the communications tools, telehealth, you know, remote monitoring systems, that helps. And the third thing I want to focus is the team-based. So that will be a good transition to the system-wise because, you know, diabetes cannot be treated by solo. You know, we have to work with the team. So if we look at the system-related, I just want to focus on the healthcare system and the practice. There are many other things that AD is doing a great job working with the, you know, AHR companies, peers, a lot of advocacy works, which affect the national, you know, everyone like national, right? But I want to focus just on the, you know, how can we do as a clinicians, educators, nutritionists and healthcare administrators in our own practice. So the bolded one, the first one is not from the, actually the reference that mentioned down, in the down, you know, in the bottom, that is more from my side, but I think it's important because if you look at the, you know, healthcare administrators and the, you know, peers, they have a lot of conflicting priorities to look at. If the, you know, the importance of the OTI is not recognized or the dangers of the TI is not recognized, that will be in the back end, right? So the other conflicting priorities will be prioritized first. So that will be very important to, you know, promote the importance of the, you know, tackling the therapeutic inertia in people with diabetes. Another thing is, okay, we are going to do something, how to identify, is it, you know, we know that OTI, you know, TI exists, you know, if you tackle that, that you will get good outcomes, but our patient have a TI, do, you know, that our clinics, our healthcare system, how prevalent is the TI in our clinic and healthcare system? So without knowing that, there's no starting point, right? And another thing is building the team with DSMES, you know, service as in the center. And then some of the other things that things seem to be out of our control, you know, insurance coverage, you know, what will be in the formulary and stuff like that. But, you know, that are the things that we can help the patient. For example, you know, every January, every, you know, start of the year, you can have a list of the, you know, formulary, you know, covered medication from the three top insurance payer in your healthcare system and make it available to all the providers, right? So you can, you will easily know that if it is this insurance, it's difficult though, you know, a different plan has a different, you know, preference, but you can have at least a little bit helpful to the, you know, clinicians in terms of when they are starting the new medication and stuff. One thing I want to mention as advocacy, that Chris already mentioned that Dr. Gabbay led this program and then it was a 2022 cost analysis for the people with diabetes, but I just want to look at from the different perspective. Chris already mentioned that only 17% of the total cost is used for the diabetes medication and supplies, which is about 51 billions. And then if you add up office visits, another 33, so the real cost for treating diabetes is about 90 billions. But when the diabetes is not under control, and then when the patients double up complications, you are going to spend 180 billions dollars, right? And then on top of that, you know, those patients who double up complications, they might die prematurely, they might be on the, you know, disability or cannot, will be not, their productivity will go down and the indirect cost will be about $106 billion because they don't work anymore. So if you look at here 90 billion to take care of the diabetes, and if you fail to do that, you are going to have to spend about $300 billion. That is a national level looking at the whole United States, but you can look at the same value in the different levels, right? If you as a nationally is spending that amount of money, you are in your clinic, in your healthcare system, you are most probably spending that kind of amount too, right? And if you go to the patient level, the same thing, right? So are we going to spend $90 a month on the diabetes or in five to 10 years, are you going to spend $300 a month for the complications? At that time, you might already have a stroke, you might already have a, you know, the end stage of disease on dialysis now, right? So you are going to spend more money and on top of that, your quality of life's go down. Are we going to wait for that or are we going to act now? You know, if you use more medication, if you build up the team, if you hire more people, you're going to spend more money for sure. But over time, over, you know, over in the next few years, you may save a lot of money. So after that, and then people in your clinic or healthcare system is kind of, okay, that's something that we work and work on there, then we can start working on it, right? So I, for the sake of the time, I'll go a little bit quicker. So what are the proposed strategies in the system related, right? So the one thing is how to identify, how prevalent is the TI in our healthcare system, in our clinic, right? And then another thing is how to assemble the team and how to get a DSMES involvement in our team. And then as Chris mentioned, you know, social determinant of health, how can we help, you know, with the patients to set up with a food bank or maybe help with the transportation for them to come and, you know, see the patients or have a virtual service and stuff like that, which go into the technologies, right? So there are some resources available on the OTI website. So first of all, is the EHR practice guide, which can be found on the OTI website and there's a webinar as well. So that will tell us, you know, how to find out what is the prevalence and who are at risk for the TI in your clinic. So then, you know, you will be able to, you know, identify those patients and do something about it. It may be as easy as not having the A1C, you know, the patient has a A1C of 8% one year ago and no follow-up A1C. You just need to order A1C. And A1C of 9% and no follow-up visits. You just need to, you know, have, you know, office business schedule. As easy as this to more, a little bit more complicated, you know, intervention needed. And there's a very good webinar from the different disciplines talking about how to assemble the team. And then there is, you know, another practice for finding diabetes support resource in your community. I think on the ADA website that there is a CDC directory. So even if you don't have one in your clinic or healthcare system, there are many in the community. So you can team up with, you know, diabetes educator, nutritionist, and then you can delegate the jobs. And, you know, prior authorization co-pay can be a big problems for the clinician and healthcare system. However, there are ways we can do efficiently. And, you know, as I said, ADA has been working really hard to national level, but we can do it in the provider level as well as in the health system levels. So many more webinars, practice calls available on the OTI website. So technologies, you know, not just, you know, remote monitoring with the continuous Google's monitoring system, you know, telecommunication, virtual coaching are very, very good resources as well. I think one of the positive aspect of, you know, COVID-19 pandemic is, I think that is the one, right? So now a lot of people, personally my patients are, you know, getting benefits from the tele-education sections from the CDC, yes. So they can stay in the comfort of the home, but they can get education from home. So that is a very good thing. I'm glad the CDC has, you know, extended that, you know, I think. So this, the conclusions. So this can be found on the standard of care as well. So how are we going to make difference? How are we going to overcome the therapeutic inertia? So the first thing is, you know, empower the patients and make sure that they know we are their champion. We are not going to be judgmental. We are not going to credit, you know, criticize them. We are not going to say that, how come you don't follow my recommendation, but be a barrier busters, right? So if I say do this, and if you don't do this, why is that problem? What is the issue? What is the barrier? And second thing is optimize care and treatment and act now, do it right now, not wait for until the complication arise. Whatever in your control, don't underestimate yourself, you know, try to help. There are many things that we can help. And the third thing is utilize the tools, utilize the technologies and utilize the team. You know, create the team, make sure that all the team members are able to make a high quality treatment decision quickly and consistently using the algorithms and protocols that you come up or you adopt. So thank you very much for listening. I will get back to Dr. Gabay. Great, thank you so much. Thank you both, Chris and Eileen for your presentations and you've covered a lot of ground. The session is recorded. So if you missed anything, because they covered a lot of really good ground, you can review it and let your clinician friends know about it. Handout will be available. So you'll be able to review all of this. And if you get one thing out of this whole thing, it's go to therapeuticinertia.diabetes.org, surf around there. You heard them, you know, mention all sorts of resources that are there. So let me jump to some questions here and I'm gonna start with one that is really sort of practical and I'd like each of you to sort of take a crack at this. So this comes from a clinician and they say, okay, great, this is a lot of good information. So give me one or two things I can do next week. So Chris, why don't you start? Okay, I would say from experience is try to find a group of individuals within your organization that can be the ambassadors for this and then reach out to several clinicians or community groups, data shows, even community educators can really make a difference in adherence to medications and things like that. So increasing your net of people, we can't do it alone. And the patient deserves to have a team and they may be more comfortable with one person than another. So it is possible. They don't have to be in your system directly. You can go outside of the system. There are lots of ways to do this, but get started by pulling together a group of like-minded individuals, I think. Right, that's good advice. Nalin, one or two tips that they can just like literally start doing next week. So I would say that start with advocacy like Chris suggests. So you need, if you are convinced that OTI is something you should do for your patient after listening to this webinar today, talk to other people. And there is a PowerPoint available to download on the OTI website. I think there's two or three. And then this will be recorded. You can share with other people too. And then you can download the PowerPoint. You can do your own presentation to the decision maker in your institution and get them on board and then start working on it. Whatever you can, like start the team-based approach and then whatever you can low hanging fruits first and then go to the complicated one later. Great, and you know, this dovetails with one of the other questions and I think a theme of what you're both saying around team. You know, it's another key thing like you're not gonna do it yourself. Figure out who your team is gonna be, build the team. And this is a question maybe I'll answer is, you know, that systematic analysis said, yes, how do you overcome therapeutic inertia? It's involving more team members. And they ask, what is the ADA doing to help particularly about reimbursement for RDs, RNs and pharmacists, which are important members of the team. And I can tell you that we are doing quite a lot about that, both at the congressional level where sometimes statute changes are important. And then also with CMS, with Medicare because usually what they decide other payers sort of follow through. I'm gonna jump to another question that came up and maybe I'll ask you to nail in this one. So gave an example of a complex patient and how long it took to be able to sort of get them, you know, where they needed to be. How do you go about prioritizing, you know, our patients often have multiple issues at the same time and what's your thinking around how to do that? So if you are a primary care providers and having to take care of multiple, you know, the complaints, I think it's better to start with the scheduling the diabetes only visit. So you're prepared and the patients are prepared and patients know ahead of time that this is for the diabetes visit. We are going to talk about diabetes and then you can even prepare yourself by having, you know, half day a week or half day a month or whatever you want to do and just see diabetes at that time. Have all the resources available around you. And if the CDCES, community CDCES is available to come in and talk to the patient, you know, another thing is interdisciplinary, you know, the visits that has been more popular these days, right? So you and the educator can sit and talk to the patient in the same visits. So those kinds of, you know, the setting the rules, you know, making sure that you both, you and the patients are on the same page, that might be a better way to go, I think. Great, so scheduling that kind of special diabetes visit. Chris, this one for you. Someone asked about the diabetes distress scale and how that might be helpful in terms of identifying how to target therapeutic inertia. That's an excellent point. And in fact, on the OTI website, we actually refer to the diabetes distress scale and talk about the issues of coping and depression and other components that interfere with a patient being able to activate or make decision, day-to-day decision. So I think that's an excellent point and reinforces how broad and complex this issue is. And that's where maybe the primary care doc doesn't have time for that, but someone else on the team might. So again, identifying the patients is crucial through different ways, all kinds of ways. Well, right, absolutely. Screening them and addressing those other issues. Unfortunately, we're running out of time. So let me take a moment to really thank Chris Beebe and Dr. Nae Lynn Ong for their presentations. I want to encourage you. We're going to be sending a survey to you with a link. Please take the time to fill that out. It really helps us to make sure we deliver the kind of information that's most valuable to you. As I mentioned at the beginning, the Overcoming Therapeutic Inertia is supported in part by Sanofi Diabetes and Novo Nordisk. I really want to thank our audience for taking the time out of their busy day to learn more about this important topic and let us know how we can help. See you all next time. Thank you.

Overcoming Therapeutic Inertia

Type 2 Diabetes

American Diabetes Association

Bob Gabay

Christine Beebe

Dr. Nailin Eng

diabetes outcomes

team-based approaches

technology for communication