Primary Care Provider Encounter Cadence and HbA1c Control in Older Patients With Diabetes

Optimizing the frequency of physician encounters in follow - up care for patients with type 2 diabetes mellitus: a systematic review

BACKGROUND

Decisions on the frequency of physician encounters for patients with type 2 diabetes mellitus (T2DM) have significant impacts on both patients' health outcomes and burden on health systems, whereas definitive intervals for physician encounters are still lacking in most clinical guidelines. This study systematically reviewed the existing evidence evaluating different frequencies of physician encounters among T2DM patients.

METHODS

Systematic search of studies evaluating different visit frequencies for follow - up care in T2DM patients was performed in MEDLINE Ovid, Embase Ovid, and Cochrane library from database inception to 25 March 2022. Studies on the follow - up encounters driven by non - physicians and those on the episodic visits in the acute care settings were excluded in the screening. Citation searching was conducted via Google Scholar on the identified papers after screening. The risk of bias was assessed using Cochrane RoB2 tool for randomized controlled trials and Newcastle - Ottawa Scale for cohort studies. Findings were summarized narratively.

RESULTS

Among 6363 records from the database search and 231 references from the citation search, 12 articles were eligible for in - depth review. The results showed that for patients who had not achieved cardiometabolic control, intensifying encounter frequency could enhance medication adherence, shorten the time to achieve the treatment target, and improve the patients' quality of life. However, for the patients who had already achieved the treatment targets, less frequent encounters were equivalent to intensive encounters in maintaining their cardiometabolic control, and could save considerable healthcare costs without substantially lowering the quality of care and patients' satisfaction.

CONCLUSION

Existing evidence suggested that the optimal frequency of physician encounters for patients with T2DM should be individualized, which can be stratified by patients' risk levels based on the cardiometabolic control to guide the differential scheduling of physician encounters in the follow - up. More research is needed to determine how to optimize the frequency of physician encounters for this large and heterogeneous population.

Routine health data describe adherence and persistence patterns for oral diabetes medication for a virtual cohort in the Khayelitsha sub-district of Cape Town, South Africa

Type 2 diabetes mellitus (T2DM) is managed with combined lifestyle modifications and antidiabetic drugs, but people on treatment often fail to reach glycaemic control. Adherence is important for achieving optimal glycaemic control, and management of diabetes with drugs is a lifelong process, so understanding adherence through analysis of longitudinal medications data is important. Using retrospective routine health data and metformin dispensing records as a proxy for medication use, we describe longitudinal persistence and adherence to oral diabetes medication in a virtual cohort of 10541 people with diabetes (PLWD) in Khayelitsha subdistrict, Cape Town. Adherence was measured in 120-day sliding windows over two years and used to estimate metformin adherence trajectories. Multinomial logistic regression identified factors influencing these trajectories. Analysis of pharmacy dispensing records showed varying medication refill patterns: while some PLWD refilled prescriptions consistently, others had treatment gaps with periods of non-persistence and multiple treatment episodes-from one to five per individual across two years. There was a general trend of decreasing adherence over time across all sliding windows in the two-year period, with only 25% of the study population achieved medication adherence (> = 80% adherence) after two years. Four adherence trajectories; 'low adherence gradual decline (A), 'high adherence rapid decline' (B), 'low adherence gradual increase (C) and 'adherent' (D) were identified. Only trajectory D represented participants who were adherent at treatment start and remained adherent after two years. Taking HIV antiretroviral treatment before or concurrently with diabetes treatment and taking metformin in combination with sulphonylurea and/or insulin were associated with the long-term adherence (trajectory D). Routine data shows real life medication implementation patterns which might not be seen under controlled study conditions. This study illustrates the utility of these data in describing longitudinal adherence patterns at both an individual and population level.

Utilisation of government-subsidised chronic disease management plans and cardiovascular care in Australian general practices

Background

Government-subsidised general practice management plans (GPMPs) facilitate chronic disease management; however, impact on cardiovascular disease (CVD) is unknown. We aimed to determine utilisation and impact of GPMPs for people with or at elevated risk of CVD.

Methods

Secondary analysis of baseline data from the CONNECT randomised controlled trial linked to Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) claims. Multivariate regression examining the association of GPMP receipt and review with: (1) ≥ 1 MBS-subsidised allied health visit in the previous 24 months; (2) adherence to dual cardioprotective medication (≥ 80% of days covered with a dispensed PBS prescription); and (3) meeting recommended LDL-cholesterol and blood pressure (BP) targets concurrently.

Results

Overall, 905 trial participants from 24 primary health care services consented to data linkage. Participants with a GPMP (46.6%, 422/905) were older (69.4 vs 66.0 years), had lower education (32.3% vs 24.7% high school or lower), lower household income (27.5% vs 17.0% in lowest bracket), and more comorbidities, particularly diabetes (42.2% vs 17.6%) compared to those without a GPMP. After adjustment, a GPMP was strongly associated with allied health visits (odds ratio (OR) 14.80, 95% CI: 9.08–24.11) but not higher medication adherence rates (OR 0.82, 95% CI: 0.52–1.29) nor meeting combined LDL and BP targets (OR 1.31, 95% CI: 0.72–2.38). Minor differences in significant covariates were noted in models using GPMP review versus GPMP initiation.

Conclusions

In people with or at elevated risk of CVD, GPMPs are under-utilised overall. They are targeting high-needs populations and facilitate allied health access, but are not associated with improved CVD risk management, which represents an opportunity for enhancing their value in supporting guideline-recommended care.

Effect of interventions for non-emergent medical transportation: a systematic review and meta-analysis

INTRODUCTION

Transportation is an important social determinant of health. We conducted a systematic review of the associations on health and health care utilization of interventions aimed at reducing barriers to non-emergency transportation and non-medical transportation.

METHODS

We searched three databases and the gray literature through mid-January 2022. Included studies needed to assess an intervention targeted at non-emergency or non-medical transportation barriers, report missed (or kept) visits, health care utilization, costs, or health outcomes. Data extraction was performed in duplicate and included information about study design, results, and risk of bias. Primary outcomes were frequency of missed appointments, health care utilization, costs, and health outcomes. Synthesis was both narrative and meta-analytic using a random effects model.

RESULTS

Twelve studies met inclusion criteria, three randomized trials, one controlled trial, and eight observational studies. All included studies had some element of risk of bias. Populations studied usually had chronic or serious health conditions or were poor. Interventions included van rides, bus or taxi vouchers, ride-sharing services, and others. Meta-analysis of seven studies (three trials, four observational studies) yielded a pooled estimate of missed appointments = 0.63 (95% confidence interval [CI] 0.48, 0.83) favoring interventions. Evidence on cost, utilization, and health outcomes were too sparse to support conclusions. Evidence on the effect of non-medical transportation is limited to a single study.

CONCLUSIONS AND RELEVANCE

Interventions aimed at non-emergency transportation barriers to access health care are associated with fewer missed appointments; the association with costs, utilization or health outcomes is insufficiently studied to reach conclusions. This review was registered in PROSPERO as ID CRD42020201875.

Adherence to and persistence with antidiabetic medications and associations with clinical and economic outcomes in people with type 2 diabetes mellitus: A systematic literature review

We designed a systematic literature review to identify available evidence on adherence to and persistence with antidiabetic medication in people with type 2 diabetes (T2D). Electronic screening and congress searches identified real-world noninterventional studies (published between 2010 and October 2020) reporting estimates of adherence to and persistence with antidiabetic medication in adults with T2D, and associations with glycaemic control, microvascular and/or macrovascular complications, hospitalizations and healthcare costs. Ninety-two relevant studies were identified, the majority of which were retrospective and reported US data. The proportions of patients considered adherent (median [range] 51.2% [9.4%-84.3%]) or persistent (median [range] 47.7% [16.9%-94.0%]) varied widely across studies. Multiple studies reported an association between greater adherence/persistence and greater reductions in glycated haemoglobin levels. Better adherence/persistence was associated with fewer microvascular and/or macrovascular outcomes, although there was little consistency across studies in terms of which outcomes were improved. More adherent and more persistent patients were typically less likely to be hospitalized or to have emergency department visits/admissions and spent fewer days in hospital annually than less adherent/persistent patients. Greater adherence and persistence were generally associated with lower hospitalization costs, higher pharmacy costs and lower or budget-neutral total healthcare costs compared with lower adherence/persistence. In conclusion, better adherence and persistence in people with T2D is associated with lower rates of microvascular and/or macrovascular outcomes and inpatient hospitalization, and lower or budget-neutral total healthcare expenditure. Education and treatment strategies to address suboptimal adherence and persistence are needed to improve clinical and economic outcomes.

Association between risk factors and retinal nerve fiber layer loss in early stages of diabetic retinopathy

AIM

To investigate the changes of retinal nerve fiber layer (RNFL) among normal individuals, diabetic patients without diabetic retinopathy (NDR) and non-proliferative diabetic retinopathy (NPDR), and explore the possible risk factors of early diabetic retinopathy (DR).

METHODS

In this cross-sectional study, 107 participants were divided in three groups. Totally 31 normal individuals (control group), 40 diabetic patients without DR (NDR group) and 36 patients with NPDR (NPDR group) were included. Optical coherence tomography (OCT) was used to detect RNFL thickness and other optic disc parameters among different groups. The potential association between RNFL loss and systemic risk factors were assessed for DR, including diabetes duration, body mass index (BMI), hemoglobin A1c (HbA1c), serum lipids, and blood pressure.

RESULTS

The average and each quadrant RNFL thickness were thinner in NPDR group compared to control group of the right (P=0.00, P=0.01, P=0.01, P=0.02, P=0.04) and left eyes (P=0.00, P=0.00, P=0.00, P=0.03, P=0.04). The average, superior and inferior RNFL thickness were thinner in NDR group compared to the NPDR group of the right (P=0.00, P=0.02, P=0.03) and left eyes (P=0.00, P=0.00, P=0.01). Diabetic duration was negatively correlated with the superior, inferior, and average RNFL thickness of the right (r=-0.385, P=0.001; r=-0.366, P=0.001; r=-0.503, P=0.000) and left eyes (r=-0.271, P=0.018; r=0.278, P=0.015; r=-0.260, P=0.023). HbA1c was negatively correlated with the superior, inferior, and average RNFL thickness of the right (r=-0.316 P=0.005; r=-0.414, P=0.000; r=-0.418, P=0.000) and left eyes (r=-0.367, P=0.001; r=-0.250, P=0.030; r=-0.393, P=0.000). Systolic pressure was negatively correlated with the inferior and average RNFL thickness of the right eye (r=-0.402, P=0.000; r=-0.371, P=0.001) and was negatively correlated with the superior and average RNFL thickness of the left eye (r=-0.264, P=0.021; r=-0.233, P=0.043).

CONCLUSION

RNFL loss, especially in the superior and inferior quadrants, may be the earliest structural change of the retina in diabetic patients, and is also associated with diabetic duration, HbA1c, and systolic pressure.

Glycemic Control and Risk of Cellulitis

OBJECTIVE

We know that diabetes predisposes to common infections, such as cellulitis and pneumonia. However, the correlation between the level of glycemic control and the rate of infection is unknown.

RESEARCH DESIGN AND METHODS

We examined the association between glycemic control in patients with diabetes and the incidence of infection in the entire population of patients with diabetes in a large HMO. During the study period, we first selected an HbA_1c test for each patient and then searched for an infection diagnosis in the 60 days that followed the test. A multivariate logistic regression analysis was performed to determine the independent effect of HbA_1c on the likelihood of being diagnosed with an infection. We were able to control for many confounders, such as other chronic illness, time since the diagnosis of diabetes, and use of steroids before the infection.

RESULTS

We identified 407 cases of cellulitis. Multivariate logistic regressions for cellulitis showed a 1.4-fold increased risk among patients with HbA_1c >7.5% (58 mmol/mol). Factors such as obesity, Parkinson's disease, peripheral vascular disease, and prior treatment with prednisone predisposed to cellulitis. There was an increase of 12% in the odds of cellulitis for every 1% (11 mmol/mol) elevation in HbA_1c (odds ratio [OR] 1.12; CI 1.05-1.19). A similar analysis showed a trend toward an increased risk of pneumonia in patients with HbA_1c >7.5% (58 mmol/mol) (OR 1.1; CI 0.9-1.4).

CONCLUSIONS

Poor glycemic control was associated in this study with the development of cellulitis. The study also suggests that exposure to oral prednisolone increases the risk of cellulitis, pneumonia, and upper respiratory infection.