Michele D. Huie
TCOYD Newsletter, Vol. 26, 2008

“If I take pills, I’m sick. If I don’t, I’m not.” This is the mindset that Dr. Mayer Davidson and his team are succeeding in changing in patients at the Martin Luther King outpatient center in Los Angeles. The following story comes from an interview with TCOYD medical advisory board member Mayer B. Davidson, MD.

We need different methods than we use now to treat diabetes,” said Dr. Davidson, Professor of Medicine, UCLA School of Medicine; Past President of the American Diabetes Association; Director of the Center of Urban Research and Education in Diabetes and Metabolism (CUREDM) at Charles Drew University; and co-director of TCOYD’s conference in Long Beach, California. “Because people with diabetes frequently have very few symptoms, and they feel fine, diabetes gets pushed down on doctors’ priority lists. Only when complications occur does diabetes get attention.”

Dr. Davidson set out to leverage the impact he could have on patients by building a care model that works. In 1998, he started a nurse directed diabetes program in south central L.A. The community he serves is primarily Hispanic with an average household income of less than $25,000.

In this impoverished minority population, Dr. Davidson and his team are arriving at outcomes of 7 percent average A1c.

“Nurses are often better able to communicate with patients,” he said. Citing the myths, misconceptions, other stresses and constraints in the cultures and communities his patients come from, Dr. Davidson got to the heart of the success of the program. “Our nurses are working with patients from the community and educating them on the importance of taking their medications. They work very hard—seeing patients quite frequently, sometimes even delivering medications right to their doors.”

Dr. Davidson sees clinic patients twice a week, and the staff of 5 nurses at the two clinics see patients five days a week. They serve about 1,200 people with diabetes.

Dr. Davidson wrote treatment algorithms for the nurses to follow, and supervises their care decisions. A treatment algorithm is like a health care roadmap. It shows, for example, that when a person with type 2 diabetes develops a consistent pattern of higher blood sugars while using treatment X, then that person’s doctor should know to consider adding treatment Y.

Of course, the treatment algorithm must be written for the drugs available. A regular hurdle is that the L.A. County formulary includes very few medications because of cost considerations. Dr. Davidson and his team work mostly with sulfonylureas, metformin, pioglitazone (only if the combination of the first 2 drugs doesn’t do the job) and NPH and regular insulins. No fast-acting analogs (Apidra, Novolog, Humalog); no long-acting analogs (Lantus, Levemir); no exenatide (Byetta); no pramlintide (Symlin); no sitagliptin (Januvia). However, he points out that these older medications are quite effective if used correctly, and especially important, in a timely manner.

Clinical Inertia “The key is to be able to communicate with patients in whatever capacity you can, and to make timely clinical decisions.” A good treatment algorithm is only useful if you act promptly on the information you have. A study done at a major HMO caring for 450,000 patients, showed the average A1c was 9.2%, and the average time a person spent with an A1c over 8% before modifying therapy was 30 months. In the diabetes world, when it takes too long for a health care professional to take action to improve glucose control in a patient who is not at goal, we refer to it as clinical inertia. (See Dr. Edelman’s Corner, TCOYD Newsletter, Vol 24).

A frighteningly common example of clinical inertia is the massive barrier doctors face to start insulin therapy. “For a doctor and a patient to start insulin, it takes a tremendous amount of time and care,” he said. Nurses on Dr. Davidson’s team are in contact with patients who have just started insulin every two to three days initially.

The Bottom Line The A1c reduction in nursedirected diabetes programs across the country is three times greater than in traditional care models. Unfortunately, the nurse-directed program model has not caught on. “Doctors are so overwhelmed now; and sometimes their egos get in the way; and there is the financial barrier. Some HMOs might be able to absorb the cost, but doctors and systems continue to resist,” he summarized.

Other Interests An area he has written on recently involves this question, “Where do we draw the line for glucose to define diabetes?”.

A person may have a blood sugar over 200 on the glucose tolerance test, but feel great, have no symptoms, and have an A1c of 5.5%. “When we diagnose diabetes in people with a normal A1c, there is an impact. There are implications for insurance and possible employment. There may be social and psychological fallouts.” Dr. Davidson argues that people with some glucose metabolism impairment (prediabetes) should be identified and their doctors should intervene with recommendations to halt the development of diabetes and cardiovascular disease, such as through diet and exercise. However, since slight abnormalities in glucose metabolism do not cause the small vessel complications in the eyes and kidneys, then Dr. Davidson challenges the benefit and purpose of a diabetes diagnosis.

Dr. Davidson is also involved in a project examining the effect of treating depression on glucose control in those with diabetes. He gave one group an antidepressant, and one a placebo. Once a month everyone in both groups met individually with an empathetic research coordinator to take a survey about their depression, and once a month patients met in an educational support group with the same individual to discuss their health. “Regardless of the pills,” he said, “we saw a 2 percent drop in A1c. The next step is to train health workers to be empathetic so we can get the same results without exposing patients to anti-depressant medications.”

In 1970, Dr. Davidson started a free medical clinic in Venice, California with another physician. Today, Dr. Davidson continues to practice there and help direct the Venice Family Clinic which serves 22,000 patients a year. It is the largest free medical clinic in the country, with 500 physician volunteers, seven different sites inWest Los Angeles, and a training program for medical students and medical residents in the area.

“There are two things I enjoy most about my work. One, the intellectual stimulation that comes from being in research—always reading, thinking, and looking for something. And two, providing good care to patients in such great need, and then leveraging that care to a larger population.”

Dr. Davidson has excelled at this in South Central andWest Los Angeles. He has also made a difference in the lives of individual people in his life. Dr. Edelman met Dr. Davidson as a young man, refers to him as an important mentor, and received some of that one-on-one care. Dr. Davidson explained, “Steve came to work in my lab as an undergrad and he had diabetes. He was very poorly controlled. My fellow and I encouraged him to seek better care.

“He did. He also got really interested in diabetes and the rest is history!”

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