The Accelerating Excellence In Translational Science (AXIS)Charles Drew University of Medicine and Science

Dr. Mayer B. Davidson

For treatment of chronic conditions like diabetes, the healthcare system may be falling short. Dr. Mayer Davidson is seeking to change that.

Currently, diabetes treatment is a problem throughout the medical system. Primary care physicians are seeing patients for as little as 15 minutes. They are pressed to address the most acute conditions and illnesses. Diabetes, because it can have few symptoms until it reaches a critical stage, can remain untreated. Even for patients diagnosed with diabetes, months go by between visits and it can take far longer than necessary to adjust medication and treatment for individuals. This ‘clinical inertia’ plagues diabetes care.

While working at Cedar-Sinai Medical Center in Los Angeles, Dr. Davidson witnessed how the rise of HMOs changed health care and its costs. “At the time, in the mid-1980s, HIV was a big problem. The medical director recognized that the cost to send HIV patients to primary care physicians was too great. He started a program that sent them to an infectious disease specialist.”

Diabetes needed a similar cost-saving program. As Director of the Diabetes Program at Cedar-Sinai, Dr. Davidson began to improve the effectiveness of diabetes care.

The term ‘diabetes’ refers to the medical condition diabetes mellitus; a condition in which a person’s blood sugar level is too high. This may be a result of the body not producing enough insulin—a hormone that regulates sugar levels—or because the person’s cells are not responding to insulin that is produced. Without treatment, diabetes can result in serious complications such as blindness, stroke, kidney failure, and cardiovascular disease.

After Cedar-Sinai, Dr. Davidson continued to pursue diabetes with passion. He was President of the American Diabetes Association (1997-1998), served on the editorial boards of several journals dedicated to diabetes research, and was associate director of Clinical Diabetes at the City of Hope. As a professor at Charles Drew University, Dr. Davidson is now studying how to manage treatment for diabetes patients.

Dr. Davidson developed detailed algorithms intended to train nurses, physician’s assistants, and pharmacists. These techniques give them prescriptive authority and the ability to make patient care decisions. They become diabetes specialists, able to tailor care to individuals in a timely manner, which can help improve patient outcomes.

In Dr. Davidson’s first study, nurse-directed care was given to 367 patients randomly selected from a primary care clinic. Nurse Maria Blanco-Castellanos saw each patient and consulted with Dr. Davidson on treatment options when needed, mostly over the phone.

The results were promising. The American Diabetes Association (ADA) has set three goals for outcome measures in diabetes patients— target values for A1C, a measure of blood glucose levels, LDL cholesterol concentration, and blood pressure level. The nurse-directed care resulted in 60% of patients meeting the A1C goal, and 82% the LDL cholesterol goal. Blood pressure was not tracked in this first study.

In Dr. Davidson’s model, patients are treated with pills—sulfonylurea and metaformin primarily—or insulin injections, depending on the level of care required by the disease progression.

“With diabetes there is a gradation of treatment,” Dr. Davidson explained. “As patients become more tolerant of the glucose control pills, they move to nightly insulin injections, then twice daily injections.”

“The research up until this point was purely academic,” Dr. Davidson said. “It would not work in the real world for two big reasons; there are not enough endocrinologists to serve as consultants and the system fragments patient care.”

To address real world diabetes treatment options, Dr. Davidson devised an integrated model of nurse-directed care. In this model, the nurse remains in the clinic and is supervised by the primary care physician.

“As you can imagine, the physicians referred the more difficult cases, those that had been living with diabetes for a longer period of time,” Dr. Davidson said. “Before [the study], the average beginning A1C baseline was 8.9%. [After the study], our patients had an average of 11.1% A1C.”

The primary care physician had to sign off on prescriptions given by the nurse, but Dr. Davidson quickly found that the physician began to agree with everything the nurse decided. They even referred more patients to her.

“[Ms. Blanco-Castellanos] did a tremendous job,” Dr. Davidson said. “She is well above average in knowledge and skill.”

In the integrated model, 47% percent met the A1C, LDL cholesterol, and blood pressure goals set by the American Diabetes Association. When compared with the 2-13% of patients that reach those same goals in nine published studies, this result is encouraging. Additionally, in a sub-study, Dr. Davidson found that they were able to reduce emergency room visits, urgent care center visits, and hospitalizations –all for largely preventable, diabetes-related episodes—by 75% in their patients.

Dr. Davidson’s integrated model is more likely to be adapted on a wider scale than just referring all patients to specialists and is more cost effective. Still, the model faces the same political and institutional hurdles any new system would face.

“The greatest obstacle for adoption of the program is cost.” Dr. Davidson said. For clinics in poorer communities, even the salary of a nurse is difficult to cover. “Still, there is a great potential for cost savings with this program.” Dr. Davidson hopes that nurse-directed diabetes care becomes a reality for more communities, bringing efficient and individual care to those that need it most.