Access, complexities in treatment, gaps in clinical knowledge, coordination of care and patient education are among the top barriers to managing cardiovascular risk in patients with diabetes, according to an ACC survey of cardiovascular innovators actively participating in the Diabetes Collaborative Registry. The survey was conducted as part of ACC’s “Practicing on the Edge of Innovation” initiative aimed at identifying innovations and best practices to best optimize cardiovascular risk reduction strategies in diabetic patients.

When it comes to access, cost was a leading concern. “These newer compounds are great,” said one respondent, “but if it’s not on formulary and it’s a $60 copay… You get patients who have to make decisions like, “Do I pay my utility bill or my copay?”

Similarly, other respondents highlighted issues with payers refusing to pay for generic drugs, or requiring time-intensive prior authorization processes. “The more difficult it is to get through, the less likely we are to use it,” said one cardiologist.

Complexities in treatment were also identified as barriers. “Patients have multiple disorders and each disorder requires multiple treatments,” said a survey participant. Additionally, other respondents highlighted the difficulty with implementing “easy to prescribe, but hard to follow” lifestyle changes, like diet modification, weight loss and regular exercise. The breadth of information — often conflicting — regarding diet, management of hypertension and cholesterol, doesn’t make managing risks any easier.

Also complex: coordinating care across different providers like endocrinologists and primary care physicians. Many of those surveyed noted an overlap in issues with primary care and a concern about stepping on toes. “As a cardiologist, our practice is kind of feeling our way on how we do this because it is important for us to get our patients well treated, but how do we do this without offending our primaries,” said a survey respondent.

Gaps in care and clinician and patient knowledge were also viewed as significant barriers. Several survey respondents ranked understanding of new data from recent clinical trials like EMPA-REG, SUSTAIN-6 and LEADER as one of the most critical gaps needing to be overcome by all providers involved in treating patients with diabetes. “Obviously, if you don’t know the data, then you don’t practice it,” said one cardiologist. The majority surveyed said outcomes from these trials could be particularly “impactful for the cardiologist population” and should increase cardiologist “buy-in” on newer therapies if more were aware of the data.

“I don’t think you see as many cardiologists at this current time comfortable with titrating diabetes medications or starting new classes of diabetes medications because of their inexperience with [them] and relative lack of education,” said one respondent.

On the patient front, many surveyed noted difficulty in spending enough time with patients to explain the increased cardiovascular risk associated with diabetes. “It takes time to explain to them,” said one respondent. “People, … as well as some practitioners… [still] don’t realize that most people with diabetes die of heart disease.”

Going forward, most of those surveyed said they would like a stronger collaboration between primary care and endocrinology. Some cardiovascular clinicians felt their role should be greater when managing the complexities of a diabetic patient with cardiometabolic disease.

“I think there’s a different level of complexity beyond the diabetes patient without cardiovascular disease,” said one respondent. “And I think that it is appropriate for the cardiologist to have a greater role in managing those risk factors because they are managing them within the context of a patient with diabetes and heart disease, which is different.”

Another survey respondent noted: “I think that the cardiologist can help work with the primary care team and endocrine to ensure there are appropriate diabetes therapies that have been shown to reduce risks or have more favorable cardiovascular risk profiles… Cardiologists can provide that perspective.”

They also suggested neutralizing clinical knowledge gaps through things like continuing medical education credit, case studies and interactive information sessions at meetings like ACC’s Annual Scientific Session. Respondents also advocated for translation of latest knowledge and best practices into treatment pathways through the development of guidelines, risk stratification/decision algorithms, quality/performance metrics, registry benchmarking and mobile tools.

Despite very real challenges, most surveyed felt there was increasing interest in the cardiovascular space for improved care coordination, patient education and limiting gaps in knowledge than previously. “I think cardiologists are willing to use anything that reduces cardiovascular outcomes,” said one. “Now that we start to have data that shows treating diabetes in a particular way might be able to reduce events by adding an add-on glucose-lowering therapy, I think you’re going to see a lot more cardiologists take notice.”

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