A One-stop Center of Excellence for Diabetes

Friday, September 8, 2017

University Health System’s Texas Diabetes Institute combines superb care, education, prevention and research to combat a deadly chronic disease.

It began with a calamity. The only hospital on San Antonio’s West Side, Lutheran General Hospital, closed its doors two decades ago after years of financial struggles, leaving surrounding neighborhoods of modest homes and equally modest incomes without nearby medical care.

That’s when University Health System stepped forward. With overwhelming support from the community, the Health System purchased the site and built the Texas Diabetes Institute (TDI) — today an internationally known center of excellence for diabetes care, education, prevention and research. It offers a comprehensive array of services devoted to the care of patients with diabetes — and those at high risk of developing the disease.

“The old Lutheran General Hospital had history with a lot of people in this community,” says Theresa De La Haya, Senior Vice President of Community Health and Clinical Service Line Programs at University Health System. “When it closed, the community really rose up and said, we want a service that will meet our healthcare needs. And given the fact that more than 60 percent of the discharges from our hospital were related to diabetes at the time, it made sense to build the Texas Diabetes Institute.”

But TDI’s patients come from far and wide — not only for the superb care, but also for access to the latest therapies developed by some of the nation’s leading diabetes researchers who are based there. Providers and researchers from centers around the world visit TDI hoping to reproduce the model at their own institutions.

Discovering the Next Generation of Diabetes Treatments

In recent years, a number of effective, new diabetes drugs have hit the market. That’s the good news. The problem for doctors is which ones to prescribe.

Guidelines say metformin should be the first medication used. Much of the research leading to metformin’s approval was led by Ralph DeFronzo, MD, Deputy Director of University Health System’s Texas Diabetes Institute (TDI) and Chief of the Diabetes Division at UT Health San Antonio.

However, metformin stops working for most patients after a few years, as the disease progresses. That leaves doctors with a range of medications to offer next — often in combination with metformin.

Eugenio Cersosimo, MD, Medical Director of Clinical Research at TDI and Associate Professor of Medicine at UT Health San Antonio, heads the local arm of GRADE, or Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study. It’s an attempt to learn which of those second medications is the best fit for patients.

“The best second drug is still a mystery,” Dr. Cersosimo says.

Dr. DeFronzo did the earliest research into a unique class of drugs called SGLT2 inhibitors. These medications block a normal process that can be harmful to those with diabetes, in which the kidneys capture sugar before it’s eliminated in urine and return it to blood. Three different SGLT2 inhibitors are now available.

TDI will be taking part in a new, federally funded study of a promising artificial pancreas device for patients with Type 1 diabetes.

Finally, among many other studies underway, TDI is studying whether medications given to people with prediabetes might prevent or delay the progression of prediabetes to full-blown diabetes.

Endocrinology

Not surprisingly, TDI, located at 701 S. Zarzamora St., is home to one of the largest endocrinology practices in the region. Kathy LaCivita, MD, Medical Director of the Adult Endocrinology Clinic and Primary Care Clinic, is one of eight endocrinologists with University Medicine Associates, the nonprofit physician practice of University Health System.

Her team includes Aruna Venkatesh, MD; Alberto Chavez-Velazquez, MD; Scheherezada Urban McCarthy, MD; Vidhya Illuri, MD; Jorge Velez Garza, MD; Sarimar Agosto Salgado, MD; and Paula Phillips, MD.

While most of the team practices at TDI, some of the endocrinologists spend part of their weeks at TDI satellite clinics: Dr. Phillips at University Family Health Center — North at 302 Rector St., near North Star Mall; Dr. Agosto Salgado at University Family Health Center — Northwest at 7726 Louis Pasteur Drive; and Dr. Illuri at the new Dominion Crossing location at 21727 Interstate 10 West.

“TDI is a big referral center for the community doctors,” Dr. LaCivita says.

All of the endocrinologists treat patients with diabetes, while some have particular expertise in other areas of endocrinology. Dr. Velez Garza is skilled in thyroid ultrasound, fine needle aspiration and treating thyroid disorders. Dr. Agosto Salgado specializes in endocrine tumors, including those of the thyroid, adrenal and pituitary glands. She is also skilled in ultrasound of thyroid and fine needle aspiration and provides these biopsies for North Side patients. She works closely with the cancer specialists at the UT Health San Antonio Cancer Center, newly affiliated with the UT MD Anderson Cancer Center in Houston.

Young patients who have diabetes are treated at the Children’s Center at TDI, a program overseen by UT Health San Antonio physicians and led by Jane Lynch, MD, pediatric endocrinologist and Medical Director of the Children’s Center. Dr. Lynch is Professor of Pediatrics at UT Health San Antonio.

TDI patients needing other specialists don’t have to go far. The institute has clinics for nephrology, wound care (with two hyperbaric chambers), ophthalmology, podiatry, neurology and family medicine. Labs, imaging and a pharmacy are on-site, along with a chapel and a cafeteria. There’s even a 28-station dialysis center located at TDI.

If patients require a hospital stay, they have access to the recently built, million-square-foot Sky Tower at University Hospital, repeatedly named the best hospital in the San Antonio area and sixth best in Texas by U.S. News & World Report.

Education and Prevention

Patients newly diagnosed with diabetes typically start with TDI’s comprehensive diabetes education program. Living Well With Diabetes is a 10-hour, five-day self-management program based on American Diabetes Association clinical guidelines. Graduates of the program are invited to attend yearly refresher classes.

Primary care physicians often refer patients to diabetes education classes there, Dr. LaCivita says.

“The primary care doctors probably use our diabetes education department even more than we do,” Dr. LaCivita says. “They’re trying to get to [patients] early, start them on a healthy diet, get them losing weight [and] checking their sugars with their meter. Prediabetes, or first-stage diabetes care, is where you can really make a big difference toward preventing the complications of this disease with starting them down the correct pathway early.”

Registered dieticians provide instruction to patients in the classroom, in one-on-one sessions and in a well-equipped demonstration kitchen, which also hosts regular, low-cost, healthy cooking classes for the community.

Special courses available at TDI focus on carbohydrate management, insulin instruction and insulin pumps. Patients can drop by without an appointment one afternoon each month for a glucose test, or just to ask a question about their condition.

Another popular service at TDI is its gymnasium, where very low-cost memberships are available not only to patients and staff but also to anyone from the surrounding neighborhoods who wants to exercise there. Working with the San Antonio Food Bank, TDI introduced a community garden project last year, and the Food Bank’s Mobile Mercado, a grocery store on wheels stocked with fresh produce and healthy food choices for sale, makes a regular appearance.

The Children’s Center at TDI works with the American Diabetes Association to hold Camp PowerUp, a summer camp for kids at high risk of developing diabetes.

Treating Diabetes Early

A host of new diabetes medications have become available in recent years — many of them having undergone clinical trials led by Ralph DeFronzo, MD, and his team of researchers at TDI (see “Discovering the Next Generation of Diabetes Treatments” on page 7). This gives physicians a number of treatment options they can tailor to individual patients. Better drugs, along with treatment algorithms that can guide care, have allowed more patients to keep their disease under control and avoid complications, Dr. LaCivita says. However, she adds, the cost of the newer medications is still a barrier for many low-income patients, even those with insurance.

Dr. DeFronzo, an internationally recognized diabetes researcher, Deputy Director of TDI and Chief of the Diabetes Division at UT Health San Antonio, has been one of the most outspoken advocates for doctors taking a more aggressive approach to treating prediabetes — which affects 86 million Americans or more, according to the Centers for Disease Control and Prevention.

People with prediabetes suffer from insulin resistance and have higher-than-normal blood sugar levels but not high enough to qualify as full-blown diabetes. Most of these individuals will go on to develop diabetes unless they develop a healthier lifestyle by losing weight, eating healthier and becoming more active. According to Dr. DeFronzo, many are also already suffering eye and kidney damage from high blood sugar. Studies underway are looking at the effectiveness of treatment in this population.

Countering Complications

One of the most devastating complications of diabetes is the risk of blindness due to retinopathy, and not all patients get the recommended yearly eye exam, according to Dr. LaCivita.

University Health System introduced a telemedicine service for diabetic eye screenings at several of their locations. Photos are taken of the eye and read remotely by ophthalmologists, who then contact the patient and his or her primary care provider if the results are abnormal.

While the primary care physician is the first line of defense in preventing diabetes and treating it at its earliest stages, Dr. LaCivita says it’s a good idea to bring in an endocrinologist as early as possible.

“Those are what the primary care physicians call the easy cases, so they don’t always refer these patients,” Dr. LaCivita says. “They don’t have bad eyes and feet and a bad heart yet, but if they’re not managed aggressively at the start and plugged into the ancillary services needed to monitor them, they’re more likely to fall off the pathway to success.”


For more information about TDI, call (210) 358-0800 or visit universityhealthsystem.com/services/diabetes.