A multifaceted, clinic-based intervention shown to increase the use of evidence-based medications in patients with diabetes (T2D) and atherosclerotic cardiovascular disease (ASCVD) in the COORDINATE-Diabetes trial was found to provide an equitable improvement regardless of sex, race or ethnicity, according to a prespecified secondary analysis of the study published in Circulation.

The COORDINATE-Diabetes cluster trial randomized 43 cardiology clinics across the U.S. to either usual care or a coordinated, multifaceted intervention focused on educating clinicians about professional society recommendations, identifying local challenges, establishing locally appropriate delivery plans, and providing audit and feedback. The median age of the 1,045 participants was 70 years, 32% were women, 16% Black and 9% Hispanic.

The intervention was provided to clinic staff by a coordinating center trio of a cardiologist, endocrinologist and implementation specialist. Along with helping to identify local barriers, care pathways were developed collaboratively to address them, such as working with a clinical pharmacist to identify most affordable options for each patient and navigate prior authorization. Electronic health record template letters were used to coordinate care among clinicians; education delivered through slide decks, grand rounds and monthly conference calls; monthly reports and patient-level trackers used to visualize progress at three-month intervals; and patient education materials provided on medication adherence and healthy lifestyles.

The primary endpoint was the proportion of participants prescribed all three groups of evidence-based therapy: high-intensity statins, ACE inhibitor or ARBs, and SGLT2 inhibitors or GLP-1RAs. Of note, at baseline, 8% of participants were not taking any of these medications, 37% were taking one and 55% were taking two medications.

Results showed that at the time of the last trial assessment, either six or 12 months, there was an absolute increase in the proportion of participants in whom the primary endpoint was achieved with the intervention vs. usual care, respectively: in women, 36% vs. 15% (adjusted odds ratio [aOR], 3.37); in Black patients, 41% vs. 18% (aOR, 3.50); and in Hispanic patients, 46% vs. 18% (aOR 3.40).

Models were adjusted for urban vs. rural site location, age, sex, race, ethnicity, baseline composite score, Charlson Comorbidity Index, and baseline systolic and diastolic blood pressures. A consistent benefit was found across sex (men vs. women, pinteraction=0.44); race (Black vs. White, pinteraction=0.59); and ethnicity (Hispanic vs. Non-Hispanic, pinteraction=0.78).

"Few other randomized implementation trials have been designed to address the underuse of evidence-based therapy, particularly in minority communities," write Manasi Tannu, MD, et al. "The success of this trial can be attributed to its focus on local needs, flexible interventions, and enhanced coordination of care among clinicians. Widespread implementation of this intervention could lessen the stark disparities that exist in diabetes and cardiovascular care among racial and ethnic minorities."