Challenges in implementing an interdisciplinary cardiometabolic risk reduction clinic

Purpose: To determine the effectiveness and feasibility of a comprehensive clinic care model that utilizes a dietician/clinical lipid specialist, a pharmacist/certified diabetes educator, and a physician in improving cardiovascular risk factors associated with the metabolic syndrome through intensive lifestyle intervention.

Methods: Patients with a diagnosis of metabolic syndrome, as outlined in the National Cholesterol Education Program (NCEP) guidelines, were referred to the program by their primary providers. After determination of “readiness for change”, participants were given in-house nutrition and behavior change education, medical nutrition therapy, diabetes education, pharmacotherapy, as well as community education classes.  Patients chose bi-monthly individual or shared medical appointments over a period of 12 weeks.  Blood pressure, weight, waist circumference, BMI, A1c, fasting blood glucose, fasting lipid panel, sub-maximal VO2 treadmill testing for fitness level, and actual behavioral change were evaluated.

Results: Forty-six participants were referred during a 12-month period, although only 13 completed the full program.  One-third of participants attended only the initial appointment.  Improvements were seen in most parameters in completers.  There was a low referral rate, despite staff efforts in patient identification and marketing.  Due to the high attrition rate, surveys were mailed to all enrolled.  Positive feedback received about educators and program content. Reasons for discontinuation included cost, difficulty with intensity of lifestyle modifications, motivation, time, and psychosocial issues.

Conclusion: Although much data exists regarding the benefits of lifestyle modification and interdisciplinary approaches to managing cardiovascular risk, the implementation of such programs remains difficult. Reimbursement for these services is inadequate and patients are many times not willing to pay out of pocket.  This population had a significant psychosocial component and as such, a behavioral counselor as a team member would be beneficial.  Lastly, a physician or primary provider champion is a vital component to an interdisciplinary clinic.