Improving Diabetes Care in Both the Inpatient and Outpatient Setting

Robert A. Gabbay, M.D., Ph.D. is Associate Professor of Medicine in the Division of Endocrinology, Diabetes and Metabolism and Co-Director of The Penn State Diabetes Center. Dr. Gabbay is a clinical researcher focused on developing mechanisms to improve diabetes care in both the inpatient and outpatient setting.

Large randomized controlled trials have already demonstrated that most complications of diabetes are preventable with adequate control of glucose, cholesterol and blood pressure levels and appropriate screening for complications. However despite this evidence, most patients with diabetes are not receiving this level of care. My research is focused on ?bridging the gap? between clinical findings and implementation of those findings in the primary care setting, where most patients with diabetes receive their care. Our approach focuses on using nurse case management (NCM) to assist primary care physicians in meeting these goals. In collaboration with Family and Community Medicine and Genral Internal Medicine Departments, we conducted a randomized controlled trial of NCM in two primary care clinics (Cherry Drive and Fishburn Road) that demonstrated significant improvements in clinical outcomes and health related quality of life. Our goal is to expand this study through a recently revised NIH grant to implement NCM in nine Hershey Medical Center (HMC) clinics within the Penn State Ambulatory Care Research Network and three clinics affiliated with Reading Hospital that provide care to an under served Hispanic community. This represents a large inter-campus collaborative team effort whereby nurse case management will incorporate motivational interviewing techniques to improve patient adherence, provide basic diabetes self-management skills, track patient outcomes through the Penn State Diabetes Registry, and follow evidence based algorithms to focus on treatment of blood pressure, glucose, lipids and depression. Drs. Cheryl Dellasega, Kathleen Fisher and Rosemary Polomano of the School of Nursing, and Dr. Alan Adelman, will assist in the development of nurse case management approach. Along with evaluating clinical outcomes, a cost effectiveness analysis will be undertaken by Drs. Chris Hollenbeak (HES) and Dennis Scanlon (University Park) along with an ethnographic study of implementation barriers by Dr. Eric Ford (UP). Biostatistical support will be by Dr. David Mauger (HES). Intervention focused on the Hispanic population includes collaboration with Dr. Carol Horowitz (Mt. Sinai School of Medicine), Dr. David George (Reading Hospital), and Dr. Robert Weech-Maldonado (UP).

Research focused on improvement of inpatient diabetes management has involved implementation of an insulin infusion protocol for use in the perioperative care of coronary artery bypass graft patients. We recently reported that, despite more frequent glucose monitoring and routine endocrinologic consultation, significant improvement in glycemic control could be acheived with no increase in costs. Trends towards improvement in patient outcomes were also noted. As the importance of glycemic control in the inpatient setting has become more widely recognized, we have shifted focus towards other surgical populations. In collaboration with Dr. Chris Hollenbeak (HES) and Dr. Edward Alfrey (Transplant Surgery) we demonstrated that patients that develop diabetes after renal transplantation have inferior outcomes when compared to patients with longstanding diabetes who undergo renal transplant. We hypothesize that glycemic control in patients with diabetes diagnosed after renal transplant may go unnoticed, and, therefore, be under treated leading to poor postoperative outcomes over the first six months post-transplantation. In collaboration with Dr. Robert Cherry (Transplant Surgery) and Dr. David Mauger (HES), we were the first to report that diabetes patients who present with trauma have significantly greater hospital complication compared to those without diabetes. Collaboration s are also underway with Dr. Patrick McNulty (cardiology) to study the importance of glycemic control during coronary angioplasty procedures.

Dr. Gabbay is also involved in clinical trials evaluating new therapies for diabetes. In particular, he has an interest in noninvasive glucose monitoring to minimize the discomfort of home glucose monitoring for patients with diabetes. He was the clinical investigator of the team that reported the feasibility of ultrasound extracted interstitial glucoses for noninvasive testing glucose in patients with diabetes reported in Nature Medicine. Dr. Gabbay continues to follow developments in this field, and, as a member of the editorial board of Diabetes Technology and Therapeutics, has written several review articles on the subject. Several pharmaceutical trials with the Clinical Trials Office have also focused on evaluating new drug therapies for diabetes and is currently initiating a study with Hershey Foods to evaluate the glycemic index of different snacks.

Dr. Gabbay, originally a native of New York City, completed his Bachelor?s Degree at McGill University and received his Ph.D. in Biochemistry from the University of Wisconsin where he studied insulin signaling mechanisms. After an Internal Medicine Residency at Cornell University - New York Hospital and Fellowship and subsequent junior faculty at Beth Israel Deaconess Medical Center, Harvard Medical School he joined the College of Medicine faculty in 1998 and is a tenured Associate Professor of Medicine. He maintains an active clinical practice and is responsible for supervision of the Hershey Medical Center diabetes team. As Co-Director of The Penn State Diabetes Center, he has worked with Drs. Jan Ulbrecht, Thomas Gardner, and Jim Jefferson to facilitate greater research ties between diabetes investigators at University Park and The College of Medicine. A bi-weekly seminar series available online and a patient registry containing information on over 8,000 patients cared for through Hershey Medical Center has been important tools towards this goal.