Predictors of suboptimal glycaemic control in type 2 diabetes patients: the role of medication adherence and body mass index in the relationship between glycaemia and age

Comparison of adherence between fixed and unfixed topical combination glaucoma therapies using Japanese healthcare/pharmacy claims database: a retrospective non-interventional cohort study

Background

Adherence to chronic therapies is crucial to prevent the progression of disease, such as glaucoma. However, only a limited number of studies have investigated them using real-world data in Japan. This study aimed to evaluate Japanese patients’ adherence to fixed- and unfixed-combination eye drops as a second-line therapy for glaucoma in real-world practice.

Methods

This retrospective, non-interventional cohort study utilized a commercially available Japanese healthcare database (MinaCare database). Medical/pharmacy claims data were collected from 2011 to 2016. The primary endpoint was adherence to medications, assessed by proportion of days covered (PDC) with medication during a 12-month post-index period. Meanwhile, the secondary endpoints included the persistence rate.

Results

A total of 738 patients were included in this study: 309 and 329 in the fixed- and unfixed-combination cohorts, respectively. Prostaglandin analog (PG)/β-blocker (BB) was most commonly claimed in 241/309 (78.0%) patients in the fixed-combination cohort. In the unfixed-combination cohort, PG and BB were claimed in 130/329 (39.5%) patients, whereas PG and α2-agonist were claimed in 87/329 (26.4%) patients. Patients were more adherent to the fixed-combination than the unfixed-combinations (mean PDCs [SD], 79.1% [32.1] vs. 62.2% [38.0]; P < 0.0001). The proportion of patients with good adherence (PDC ≥ 80%) was also higher in the fixed-combination cohort (69.6%) than in the unfixed-combination cohort (48.6%) (P < 0.0001). During the 12-month post-index period, the persistence rate was higher in the fixed-combination cohort than in the unfixed-combination cohort (47.6% [95% confidence intervals (CI): 41.9–53.0] vs. 24.9% [95% CI: 20.4–29.7], P < 0.0001).

Conclusions

Japanese patients with glaucoma preferred the fixed-combination therapies over the unfixed-combination therapies. Hence, fixed-combination therapies would contribute to the improvement of adherence.

A statistical model to identify determinants of glycemic control in patients with type 2 diabetes with different pharmacotherapeutic profiles

AIM

To develop a statistical model to identify determinants of glycemic control.

MATERIALS AND METHODS

A database was extracted from patients' records with at least one glycated hemoglobin (HbA1c) analysis and with antidiabetic therapy established and stabilized. A logistic regression model was designed to identify the statistical significance of factors associated with glycemic control.

RESULTS

Higher probability of success (HbA1c ≤8% [64 mmol/mol]) was found for those who were older in age, those who were men, and those with higher education levels. Increased values for the following variables were associated with the poorest glycemic control: number of years of T2DM since diagnosis, number of antidiabetic medicines, body mass index, low-density lipoprotein cholesterol, triglycerides, systolic blood pressure and number of diabetes consultations in the last twelve months. The following pharmacotherapeutic treatments were associated with glycemic control (in decreasing order of the results): oral antidiabetic drugs; oral antidiabetic drugs and insulin; insulin. Patients using metformin and a dipeptidyl peptidase-4 inhibitors have a higher probability of success than do patients using metformin and a sulfonylurea, and patients using insulin and metformin have a higher probability of success than do patients using insulin alone.

CONCLUSIONS

Sociodemographic, clinical and therapeutic parameters can strongly affect glycemic control. Studies based on real-life patient data provide important information on the development of more effective glycemic control.

Treatment patterns, glycemic control and bodyweight with canagliflozin 300 mg versus GLP1RAs in Type II diabetes patients

Aim: Real-world effectiveness of canagliflozin 300 mg versus glucagon-like peptide-1 receptor agonists (GLP1RAs) was examined in patients with Type II diabetes. Patients & methods: Patients were selected from the Optum integrated database of administrative claims and electronic health record data (1 January 2013 to 31 March 2015). Results: Patients were less likely to discontinue (p < 0.0001) or switch (p = 0.0048), more likely to add-on treatment (p = 0.0314), and achieve HbA1c <8.0% (p = 0.0364) or weight loss ≥5% (p < 0.0001) with canagliflozin versus GLP1RAs over 9 months. Mean HbA1c was similar at 3-month intervals over 9 months with canagliflozin and GLP1RAs. Conclusion: Patients were less likely to discontinue or switch with canagliflozin than GLP1RA, and were more likely to add-on. Canagliflozin patients were more likely to achieve HbA1c <8.0% and weight loss ≥5% than GLP1RA patients.

Utilization patterns of glucagon-like peptide-1 receptor agonists in patients with type 2 diabetes mellitus in Germany: a retrospective cohort study

OBJECTIVE

This retrospective database analysis complements previous research to understand treatment patterns for German patients newly-initiating or switching to subsequent GLP-1 RAs.

METHODS

Adult patients (≥18 years) initiating GLP-1 RA (Cohort 1 [C1]) or switching from a previous GLP-1 RA (Cohort 2 [C2]) to exenatide twice-daily (exBID), exenatide once-weekly (exQW), dulaglutide (DULA), or liraglutide (LIRA) were included in this analysis using IQVIA LRx from January 1, 2014-March 31, 2017. Patients were required to have ≥1 oral anti-hyperglycemic prescription during the 6-month pre-index period and ≥12 months follow-up. Persistence and treatment modifications were assessed within and beyond 12 months follow-up. Average daily/weekly dosage (ADD/AWD) was calculated during persistence.

RESULTS

C1 included 13,417 patients, while C2 included 4,264 patients. Mean ± standard deviation (SD) age was similar (57.7 ± 11.1 years [C1], 58.9 ± 10.1 years [C2]). Most patients using DULA in C2 had switched from LIRA (56.6%). For C1, mean ADD for LIRA was 1.41 ± 0.10 mg, slightly higher in C2, and increased over time. ADD for exBID was 16.9 ± 1.0 mcg, slightly greater in C2. AWD was 2.00 ± 0.05 mg for exQW users and 1.42 ± 0.03 mg for DULA users in C1, similar to C2. For C1, 27.0% exBID, 35.3% exQW, 50.9% DULA, and 48.1% LIRA users remained persistent at 12 months. Patients using DULA had a higher probability of remaining persistent over time (Kaplan-Meier) for both cohorts.

CONCLUSIONS

Patients using DULA had the highest probability of remaining persistent over time, followed by LIRA. ADD/AWD for DULA, exQW, and exBID were aligned with the recommended combination therapy dose; LIRA ADD suggests some patients use the 1.8 mg dose.

The relationship between patients' perception of type 2 diabetes and medication adherence: a cross-sectional study in Japan

BACKGROUND

The self-management of type 2 diabetes mellitus (T2DM), which involves adherence to medical instructions on diet and nutritional advice, physical activity, medication regimen, and weight and stress management, is necessary for the treatment of T2DM.In this study, we investigated the relationship between patients' perceptions of their disease and their adherence to their medications. And we attempted to determine whether distinct subphenotypes of behavioral change of medication adherence can be discerned based on a patients' perceptions.

METHOD

A cross-sectional study using a questionnaire was conducted among 157 patients with T2DM from October 2015 to September 2017. Questionnaires were administered to assess the participants' demographic and clinical characteristics, medication adherence, diabetes knowledge, and perception of being diabetic. Principal component analysis (PCA) and cluster analyses were performed to classify medication adherence patterns in the total cohort. Multiple regression analyses were performed to identify the determinant factors of medication adherence.

RESULTS

PCA showed the interpretable medication adherence of patients with diabetes by using component 1 ("accessibility to medical treatment") and component 2 ("status of taking medicines"). We identified four groups that show significantly different medication adherence by using cluster analysis on the basis of the two components. Multiple regression analysis showed that body mass index (BMI), family history of diabetes, one factor of patient's perception (living an orderly life), and diabetes knowledge were found to be significant predictors of medication adherence in patients with T2DM.

CONCLUSIONS

In patients with T2DM, the patient's diabetes perception of "living an orderly life" is associated with medication adherence. A poor adherence group may be able to change their adherence to diabetes treatment by developing the perception of "living an orderly life."

Adherence to oral glucose lowering drugs, quality of life, treatment satisfaction and illness perception: A cross-sectional study in patients with type 2 diabetes

OBJECTIVE

To evaluate treatment adherence to oral glucose lowering drugs (OGLD) and health related quality of life in Lebanese diabetics. Secondary objectives were to examine associations between treatment adherence, quality of life (QOL), treatment satisfaction and illness perception.

METHODS

This cross-sectional study, conducted in all districts of Lebanon between August 2016 and April 2017, enrolled 207 adult patients, taking any OGLD.

RESULTS

The effectiveness score (Beta = 0.55), female gender (Beta = 7.04), and the quality of life score (Beta = 0.28) would significantly increase the adherence score respectively. On another hand, the body mass index (Beta = -1.216) would significantly decrease the adherence score. Adherence was negatively and significantly associated to IPQ score (r = -0.181), effectiveness score (r = -0.504), side effects (r = -0.583), convenience (r = -0.317), global satisfaction (r = -0.428), physical health (r = -0.477), psychological health (r = -0.521), social relationships (r = -0.405) and environment (r = -0.429).

CONCLUSION

Perceived effectiveness and patient's quality of life seem to be important parameters enhancing adherence. Based on this study, planning interventions to enhance treatment adherence and improve the quality of life is crucial for all diabetic patients. Additional efforts are suggested to be made by concerned authorities to set up awareness campaigns to increase alertness on the importance of adherence to medications in diabetics.

Psychosocial and Behavioral Correlates of A1C and Quality of Life Among Young Adults With Diabetes

PURPOSE

The purpose of this study was to evaluate relationships between behavioral and psychosocial constructs, A1C, and diabetes-dependent quality of life (DQoL) among low-socioeconomic status, ethnically diverse young adults with diabetes.

METHODS

Using baseline data of 81 participants in the Resilient, Empowered, Active Living (REAL) randomized controlled trial, behavioral, cognitive, affective, and experiential variables were correlated with A1C and DQoL while adjusting for demographic characteristics, and these relationships were examined for potential effect modification.

RESULTS

The data indicate that depressive symptoms and satisfaction with daily activities are associated with both A1C and DQoL, while diabetes knowledge and participation in daily activities are associated with neither A1C nor DQoL. Two constructs, diabetes distress and life satisfaction, were associated with DQoL and were unrelated to A1C, while 2 constructs, self-monitoring of blood glucose and medication adherence, were associated with A1C but unrelated to DQoL. These relationships were largely unchanged by adjusting for demographic characteristics, while numerous effect modifications were found.

CONCLUSION

The data suggest that when tailoring interventions, depressive symptoms and satisfaction with daily activities may be particularly fruitful intervention targets, as they represent modifiable risk factors that are associated with both A1C and DQoL.

Utilization Patterns of Glucagon-Like Peptide-1 Receptor Agonists in Patients with Type 2 Diabetes Mellitus in Italy: A Retrospective Cohort Study

INTRODUCTION

Real-world evidence on glucagon-like peptide-1 receptor agonist (GLP-1 RAs) usage is emerging in different European countries but is lacking in Italy. This retrospective cohort study aimed to describe the real-world drug utilization patterns in patients initiating GLP-1 RAs for treating T2DM in Italy.

METHODS

Adults aged ≥ 20 years and with ≥ 1 oral antidiabetic drug (alone or in combination with insulin) other than GLP-1 RAs in the 6 months prior to initiating exenatide twice daily (exBID), exenatide once weekly (exQW), dulaglutide once weekly (DULA), liraglutide once daily (LIRA) or lixisenatide once daily (LIXI) between March and July 2016 were retrospectively identified in the Italian IMS LifeLink™ longitudinal prescriptions database (retail pharmacy data). Patients with ≥ 6-month follow-up (defined as evidence of any prescription activity) were included. Proportions of patients who remained persistent (continued treatment until discontinuation/switch) in the first 6 months and of those who discontinued or switched to a different GLP-1 RA over the entire follow-up were recorded. For each treatment, the average daily/weekly dosage (ADD/AWD) while persistent during the available follow-up was calculated.

RESULTS

We identified 7319 patients: 92 exBID, 970 exQW, 3368 DULA, 2573 LIRA and 316 LIXI. Across treatments, 89% patients were ≥ 50 years old, 54% were males, and the median follow-up duration ranged between 8.1 and 8.7 months. At 6 months, 35% exBID, 47% exQW, 62% DULA, 50% LIRA and 40% LIXI patients remained persistent. Over the entire follow-up, median persistence days varied from 73 (exBID) to > 300 days (DULA). The mean ± SD ADD/AWD was exBID: 17.7 ± 2.1 µg/day; exQW: 2.1 ± 0.1 mg/week; DULA: 1.5 ± 0.2 mg/week; LIRA: 1.5 ± 0.2 mg/day; LIXI: 21.0 ± 5.5 µg/day.

CONCLUSIONS

This real-world analysis suggests differences exist in persistence between patients treated with various GLP-1 RAs. Among the investigated treatments, patients prescribed exBID recorded the lowest and those prescribed DULA the highest persistence with therapy.

FUNDING

Eli Lilly and Co., Indianapolis, IN, USA.

Trends in the management levels of metabolic risk factors in middle-aged and elderly patients with type 2 diabetes mellitus: The Korean National Health and Nutrition Examination Survey 1998-2014

The present study examined the temporal trends in the management of blood pressure, glucose, and lipid levels among middle-aged and elderly patients with type 2 diabetes using data from the Korean National Health and Nutrition Examination Survey (1998–2014). A total of 3,689 patients with diabetes were included and divided into middle-aged (30–64 years old) and elderly (≥65 years old) groups. Demographic and lifestyle data were obtained using a self-reported questionnaire, and trained medical staff obtained fasting blood samples and blood pressure data. Laboratory testing was performed to determine blood glucose, cholesterol, and triglyceride levels. In the multivariable adjusted models, significant decreasing trends in the prevalences of hyperglycemia and hypertension were observed in both age groups during 1998–2014, although no trends were observed for lipid levels. Based on the most recent survey, approximately 50% of patients with diabetes had hyperglycemia, and one-third of patients with diabetes and hypertension did not appropriately manage their blood pressure. In addition, 50% of the patients in both age groups did not manage their lipid profiles, and the management of lipid profiles did not improve in recent years. These results suggest that continuous follow-up is needed to effectively manage metabolic risk factors, especially lipid profiles, among patients with diabetes.

Adherence, persistence, and treatment discontinuation with sitagliptin compared with sulfonylureas as add-ons to metformin: A retrospective cohort database study

BACKGROUND

Data are limited regarding adherence to dipeptidyl peptidase-4 inhibitors.

METHODS

The present retrospective cohort study of a claims database involved adults with type 2 diabetes mellitus, continuous enrollment for 12 months before the first prescription of add-on sitagliptin (SITA) or a sulfonylurea (SU) to metformin (MET) monotherapy (index date), and ≥45 days of MET coverage ≤90 days before the index date. The SITA and SU users were matched on duration of follow-up and propensity score (PS). Logistic regression analysis incorporated age, gender, comorbidities, and concomitant medications as independent variables.

RESULTS

Approximately 99 % of SITA patients were PS matched, resulting in 14 807 well-balanced PS-matched SITA/SU pairs. Mean proportion of days covered (PDC) was significantly higher for SITA (vs SU) + MET after 1 year (P < 0.001). Adherence (PDC ≥80 %) to SITA (vs SU) + MET was 59.1 % (vs 55.9 %; P < 0.001) at 1 year and 52.6 % (vs 49.9 %; P = 0.007) at 2 years. Using logistic regression models including out-of-pocket expense (OPE) as a covariate, we found improved mean PDC and adherence for SITA (vs SU) + MET. Numbers of patients who continued to use SITA (vs SU) + MET were significantly higher after Years 1, 2, and 3 (all P < 0.05).

CONCLUSIONS

Users of SITA + MET had significantly higher mean PDC, adherence, and persistence than those on SU + MET. These trends were robust to model alterations and were more marked when accommodating OPEs.

Retrospective Study on the Impact of Adherence in Achieving Glycemic Goals in Type 2 Diabetes Mellitus Patients Receiving Canagliflozin

INTRODUCTION

Adherence is poor among patients taking antihyperglycemic agents (AHAs) for type 2 diabetes mellitus (T2DM). Inadequate adherence has been linked to decreased glycemic control and increased healthcare costs and hospitalizations. We examined the impact of real-world adherence on glycemic control in T2DM patients treated with canagliflozin.

METHODS

This retrospective study used US administrative claims data from commercial and Medicare Advantage healthcare enrollees. Study subjects were adult T2DM patients with baseline HbA1c ≥7.0% and a pharmacy claim for canagliflozin between April 01, 2013 and August 31, 2014. Outcomes included treatment patterns, HbA1c reductions and goal attainment, pharmacy costs, and patient characteristics. Adherence, measured by the proportion of days covered (PDC), was calculated as the number of days of canagliflozin availability divided by the length of the follow-up period. Results were analyzed overall and compared between patients who were highly adherent (HA) (PDC ≥0.8) versus less than highly adherent (LHA) (PDC <0.8).

RESULTS

The study population included 2261 patients. At the end of follow-up, patients had an overall mean reduction in HbA1c of 0.97%. Those HA had larger reductions in HbA1c than those LHA (1.17% versus 0.73%, respectively, p < 0.001); 24.6% and 59.4% of patients achieved HbA1c goals of <7.0% and <8.0%, respectively. Highly adherent patients were more likely to achieve goals than those LHA. Less than highly adherent patients increased insulin use by 5.4% in the follow-up period, while HA patients decreased the use of most oral AHAs and had no change in insulin use.

CONCLUSIONS

Patients had an HbA1c reduction of 0.97% in the 12 months following the first canagliflozin fill. Highly adherent patients achieved a greater reduction in HbA1c at the end of the follow-up period and were more likely to reach HbA1c goals. Highly adherent patients also had reductions in the use of most oral AHAs, while LHA patients saw a small increase in insulin use.

Cross-sectional study of patients with type 2 diabetes in OR Tambo district, South Africa

OBJECTIVES

South Africa has pledged to the sustainable development goal of promoting good health and well-being to all residents. While this is laudable, paucity of reliable epidemiological data for different regions on diabetes and treatment outcomes may further widen the inequalities of access and quality of healthcare services across the country. This study examines the sociodemographic and clinical determinants of uncontrolled type 2 diabetes mellitus (T2DM) in individuals attending primary healthcare in OR Tambo district, South Africa.

DESIGN

A cross-sectional analytical study.

SETTING

Primary healthcare setting in OR Tambo district, South Africa.

PARTICIPANTS

Patients treated for T2DM for 1 or more years (n=327).

PRIMARY OUTCOME MEASURE

Prevalence of uncontrolled T2DM.

SECONDARY OUTCOME MEASURE

Determinants of uncontrolled T2DM (glycosylated haemoglobin (HbA1c) ≥7%).

RESULTS

Out of the 327 participants, 274 had HbA1c≥7% (83.8%). Female sex (95% CI 1.3 to 4.2), overweight/obesity (95% CI 1.9 to 261.2), elevated low-density lipoprotein cholesterol (95% CI 4.4 to 23.8), sedentary habits (95% CI 7.2 to 61.3), lower monthly income (95% CI 1.3 to 6.5), longer duration of T2DM (95% CI 4.4 to 294.2) and diabetes information from non-health workers (95% CI 1.4 to 7.0) were the significant determinants of uncontrolled T2DM. There was a significant positive correlation of uncontrolled T2DM with increasing duration of T2DM, estimated glomerular filtration rate and body mass index. However, a significant negative correlation exists between monthly income and increasing HbA1c.

CONCLUSIONS

We found a significantly high prevalence (83.8%) of uncontrolled T2DM among the patients, possibly attributable to overweight/obesity, sedentary living, lower income and lack of information on diabetes. Addressing these determinants will require re-engineering of primary healthcare in the district.

Obesity and glycemic control in patients with diabetes mellitus: Analysis of physician electronic health records in the US from 2009-2011

AIMS

Examine the association between obesity and glycemic control among patients with type 1 (T1DM) or type 2 diabetes mellitus (T2DM).

METHODS

Data from US physician electronic health records (Humedica®) from 2009-2011 were utilized. Patients were defined as having above-target glycemic control if they had an HbA1c ≥7% at any time during the study period. Multinomial logistic regressions were conducted separately for T1DM and T2DM patients, and examined associations between BMI categories and probability of having above-target glycemic control (≥7% and <8%, ≥8% and <9%, or ≥9%) while controlling for patient demographics, general health, comorbid conditions, and antihyperglycemic medication use.

RESULTS

There were 14,028 T1DM and 248,567 T2DM patients; 47.8% of T1DM and 63.4% of T2DM were obese (BMI ≥30kg/m(2)). For T1DM, being overweight (BMI 25-<30), obese class I (30-<35), II (35-<40), or III (≥40) was associated with a significantly higher probability of having HbA1c≥8% and <9% or ≥9%, while being overweight was associated with a significantly higher probability of having HbA1c ≥7% and <8% compared to normal BMI (BMI≥18.5 and<25). For T2DM patients, being overweight, obese class I, II, or III was associated with a significantly higher probability of having HbA1c ≥7% and <8%, ≥8% and <9%, or ≥9%.

CONCLUSIONS

For both T1DM and T2DM patients, there were positive and statistically significant associations between being overweight or obese and having suboptimal glycemic control. These findings quantify the associations between obesity and glycemic control, and highlight the potential importance of individual characteristics on glycemic control.

Achievement of partial combined control of major diabetes targets in primary care correlates with development of chronic complications in T2DM patients--A real life data

AIMS

Strict long term glucose, cholesterol and blood pressure control is advocated in type 2 Diabetes Mellitus (T2DM) patients. It is not known whether combined partial goals' achievement affects development of chronic complications.

METHODS

We evaluated the relative ability or failure of 5369 T2DM ambulatory patients to achieve and maintain control of blood pressure, glycaemia and cholesterol for 3 consecutive years. Correlation between the extent of combined goal achievement, and development of chronic complications was determined.

RESULTS

Only 9 patients (0.17%) fully achieved and none completely failed to achieve all strict goals. Therefore, patients were characterized as either partial achievers (PA) (n=699) or partial non achievers (PNA) (n=322). As compared to PA patients, PNA patients were significantly younger, single, and demonstrated a higher female and Arab ethnicity dominance. PNA patients had higher BMI, received more insulin treatment and consumed more hospital services. The incidence of microvascular complications during 3 years was significantly increased in PNA patients.

CONCLUSIONS

A negligible number of primary care patients completely and persistently achieve or fail to achieve combined control of major diabetes targets. Partial achievement of these targets correlates with specific patients' characteristics and incidence of chronic micro-vascular complications.

Impact on glycated haemoglobin of a biological response-based measure of medication adherence

AIMS

The aim of this study was to examine the relationship between a specific glycated haemoglobin (HbA1c) measurement and a pharmaceutical dispensings-based measure of adherence calculated over the 90 days before each HbA1c measure among patients who have newly initiated metformin therapy.

METHODS

We identified 3109 people with type 2 diabetes who initiated metformin as their first-ever antihyperglycaemic drug, analysing all 9918 HbA1c measurements that were taken over the next 2 years. We used an adaptation of the 'proportion of days covered' method for assessing medication adherence that corresponded to an ∼90-day interval preceding an HbA1c measurement, terming the adaptation the 'biological response-based proportion of days covered' (BRB-PDC). To account for multiple observations per patient, we analysed the association between HbA1c and BRB-PDC within the generalized estimating equation framework. Analyses were stratified by HbA1c level before metformin initiation using a threshold of 8% (64 mmol/mol).

RESULTS

After multivariable adjustment using 0% adherence as the reference category, BRB-PDC in the range 50-79% was associated with HbA1c values lower by -0.113 [95% confidence interval (CI) -0.202, -0.025] among patients with pre-metformin HbA1c <8%, and by -0.247 (95% CI -0.390, -0.104) among those with HbA1c ≥8% at metformin initiation. Full adherence (≥80%) was associated with HbA1c values lower by -0.175% (95% CI -0.257, -0.093) and by -0.453% (95% CI -0.586, -0.320).

CONCLUSIONS

Using this novel short-interval approach that more closely associates adherence with the expected biological response, the association between better adherence and HbA1c levels was considerably stronger than has been previously reported; however, the strength of the impact was dependent upon the HbA1c level before initiating metformin.

Diabetic patients' perspectives on the challenges of glycaemic control

Introduction

The factors affecting the control of diabetes are complex and varied. However, little is documented in the literature on the overall knowledge of diabetic patients about glycaemic control. This study explored the patients’ perspectives on the challenges of glycaemic control.

Methods

In this qualitative study, semi-structured interviews were conducted with seventeen purposively selected diabetic patients with HBA1c ≥ 9% at Mthatha General Hospital, South Africa. The interviews were conducted in the isiXhosa language and were audiotaped. Two experienced qualitative researchers independently transcribed and translated the interviews. Thematic content analysis was conducted.

Results

Three main themes emerged: overall knowledge of diabetes and treatment targets, factors affecting the control of diabetes and how glycaemic control could be improved.

The majority of the participants demonstrated poor knowledge of treatment targets for diabetes. The majority of the participants reported that lack of money affected their control of diabetes. Some of the participants reported that the nearest clinics do not have doctors; hence, they are compelled to travel long distances to see doctors.

Conclusion

Poverty, lack of knowledge and access to doctors affect the control of diabetes in the rural communities of Mthatha, South Africa. The government should address recruitment and retention of doctors in primary health care.

Impact of medication adherence and persistence on clinical and economic outcomes in patients with type 2 diabetes treated with liraglutide: a retrospective cohort study

Introduction

Adherence to diabetes medication has been linked to improved glycemic levels and lower costs, but previous research on adherence has typically involved oral antidiabetic medication or insulin. This study examines how adherence and persistence to once-daily liraglutide impact glycemic control and economic outcomes in a real-world population of adult type 2 diabetes (T2D) patients.

Methods

A retrospective cohort study using administrative claims data from July 2009 through September 2013. Patients aged ≥18 years with T2D treated with liraglutide were identified (index date = first liraglutide prescription). Adherence was based on the proportion of days covered (PDC); with PDC ≥0.80 classified as adherent. Non-persistent patients were those with a gap in therapy of >90 days. Lab results for glycated hemoglobin (A1C) were used to identify whether patients achieved target levels of <7.0% and ≤ 6.5%, or experienced a reduction of ≥1.0% in A1C from pre-index (baseline) to post-index (follow-up). Logistic regression was used to estimate the likelihood of achieving the A1C goals, adjusted for baseline characteristics. Diabetes-related medical, pharmacy, and total costs were modeled and estimated for the adherence and persistence cohorts.

Results

A total of 1321 patients were identified. The mean PDC was 0.59 and 34% of patients were classified as adherent, while 60% were persistent over 12 months of follow-up. Adherent and persistent patients were more likely to achieve each of the A1C goals than their non-adherent and non-persistent counterparts after adjusting for patient characteristics. Adherence and persistence were associated with higher adjusted diabetes-related pharmacy and total healthcare costs during follow-up; whereas persistent patients had significantly lower diabetes-related medical costs than non-persistent patients.

Conclusions

Adherence and persistence to liraglutide are associated with improved A1C outcomes. Persistent patients showed significantly lower medical costs versus those discontinuing liraglutide. Total healthcare costs were higher for adherent and persistent cohorts driven by higher pharmacy costs.

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-015-0199-z) contains supplementary material, which is available to authorized users.

Determinants of glycaemic control in a practice setting: the role of weight loss and treatment adherence (The DELTA Study)

AIMS

Examine the association between weight loss and adherence with glycaemic goal attainment in patients with inadequately controlled T2DM.

MATERIALS AND METHODS

Patients ≥ 18 years with T2DM from a US integrated health system starting a new class of diabetes medication between 11/1/10 and 4/30/11 (index date) with baseline HbA1c ≥ 7.0% were included in this cohort study. Target HbA1c and weight change were defined at 6-months as HbA1c < 7.0% and ≥ 3% loss in body weight. Patient-reported medication adherence was assessed per the Medication Adherence Reporting Scale. Structural equation modelling was used to describe simultaneous associations between adherence, weight loss and HbA1c goal attainment.

RESULTS

Inclusion criteria were met by 477 patients; mean (SD) age 59.1 (11.6) years; 50.9% were female; 30.4% were treatment naïve; baseline HbA1c 8.6% (1.6); weight 102.0 kg (23.0). Most patients (67.9%) reported being adherent to the index diabetes medication. At 6 months mean weight change was -1.3 (5.1) kg (p = 0.39); 28.1% had weight loss of ≥ 3%. Mean HbA1c change was -1.2% (1.8) (p< 0.001); 42.8% attained HbA1c goal. Adherent patients (OR 1.70; p = 0.02) and diabetes therapies that lead to weight loss (metformin, GLP-1) were associated with weight loss ≥ 3% (OR 2.96; p< 0.001). Weight loss (OR 3.60; p < 0.001) and adherence (OR 1.59; p < 0.001) were associated with HbA1c goal attainment.

CONCLUSIONS

Weight loss ≥ 3% and medication adherence were associated with HbA1c goal attainment in T2DM; weight loss was a stronger predictor of goal attainment than medication adherence in this study population. It is important to consider weight-effect properties, in addition to patient-centric adherence counselling, when prescribing diabetes therapy.

Defining the role of medication adherence in poor glycemic control among a general adult population with diabetes

Aims

This study assesses the attributable impact of adherence to oral glucose medications as a risk factor for poor glycemic control in population subgroups of a large general population, using an objective medication adherence measure.

Methods

Using electronic health records data, adherence to diabetes medications over a two-year period was calculated by prescription-based Medication Possession Ratios for adults with diabetes diagnosed before January 1, 2010. Glycemic control was determined by the HbA1c test closest to the last drug prescription during 2010–2012. Poor control was defined as HbA1c>75 mmol/mol (9.0%). Medication adherence was categorized as “good” (>80%), “moderate” (50–80%), or “poor” (<50%). Logistic regression models assessed the role medication adherence plays in the association between disease duration, age, and poor glycemic control. We calculated the change in the attributable fraction of glucose control if the non-adherent diabetic medication population would become adherent by age-groups.

Results

Among 228,846 diabetes patients treated by oral antiglycemic medication, 46.4% had good, 28.8% had moderate, and 24.8% had poor adherence. Good adherence rates increased with increasing disease duration, while glycemic control became worse. There was a strong inverse association between adherence level and poor control (OR = 2.50; CI = 2.43–2.58), and adherence was a significant mediator between age and poor control.

Conclusions

A large portion of the diabetes population is reported to have poor adherence to oral diabetes medications, which is strongly associated with poor glycemic control in all disease durations. While poor adherence does not mediate the poorer glycemic control seen in patients with longer-standing disease, it is a significant mediator of poor glycemic control among younger diabetes patients. A greater fraction of poorly controlled younger patients, compared to older patients, could be prevented if at least 80% adherence to their medications was achieved. Therefore, our results suggest that interventions to improve adherence should focus on this younger sub-group.

Association of Weight Loss and Medication Adherence Among Adults With Type 2 Diabetes Mellitus: SHIELD (Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes)

BACKGROUND

Adherence to prescribed diabetes medications is suboptimal, which can lead to poor glycemic control and diabetic complications. Treatment-related weight gain is a side effect of some oral antidiabetic agents and insulin, which may negatively affect adherence to therapy.

OBJECTIVE

This study investigated whether adults with type 2 diabetes mellitus (T2DM) who lost weight had better medication adherence than those who gained weight.

METHODS

Weight change over 1 year (2007 to 2008) was assessed among respondents in the US Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes (SHIELD). Weight loss of >1.0%, ≥3%, and ≥5% of weight was compared with weight gain of ≥1.0%. Medication adherence was assessed using the Morisky 4-item questionnaire for medication-taking behavior, with lower scores representing better adherence.

RESULTS

There were 746 T2DM respondents who lost >1.0%, 483 who lost ≥3%, 310 who lost ≥5%, and 670 who gained ≥1.0% of weight. Each weight-loss group had significantly lower Morisky scores than the weight-gain group; mean scores of 0.389 versus 0.473 (P = 0.050) for the >1.0% weight-loss group, 0.365 versus 0.473 (P = 0.026) for the ≥3% weight-loss group, and 0.334 versus 0.473 (P = 0.014) for the ≥5% weight-loss group. Significantly fewer respondents who lost weight had received insulin, sulfonylurea, or thiazolidinedione therapy (57%) compared with respondents who gained weight (64%) (P = 0.002). Demographics, exercise habits, and dieting were similar between weight-loss and weight-gain groups.

CONCLUSIONS

T2DM respondents with weight loss had significantly better medication adherence and were less likely to be on treatment regimens that increase weight than T2DM respondents with weight gain. These findings suggest that strategies that lead to weight loss, including use of diabetes medications associated with weight loss, may improve medication adherence.

An evaluation of patients' adherence with hypoglycemic medications among Papua New Guineans with type 2 diabetes: influencing factors

PURPOSE

The aims of this study were to evaluate the extent of adherence to hypoglycemic medications, assess the relationship between adherence and glycemic control, and evaluate factors affecting adherence.

RESEARCH DESIGN AND METHODS

This was a cross-sectional study of patients with established type 2 diabetes attending the Port Moresby General Hospital Diabetes Clinic. Face-to-face interviews were conducted using a questionnaire designed for the study and data were collected concerning the 3 months prior to interview. The questionnaire covered demographic details, lifestyle, biochemical and physical measurements, and medication management. Glycemic control was investigated among patients adhering to their medications (not missing doses) to different degrees (100%, 95%, 90%, and 80%).

RESULTS

Of a total of 356 participants who were prescribed hypoglycemic medications, 59.6% omitted some of their doses. Age appeared to have a significant impact on adherence at some levels of adherence, with those aged >60 years being more likely to be adherent (logistic regression). Those who were 95%-99% and those who were <80% adherent had a statistically significant risk of a high glycated hemoglobin of >10% (85.5 mmol/mol). Multiple factors were identified as contributors to nonadherence, with patient-based issues (86.0%) and the health care system (21.7%) being the most common.

CONCLUSION

This study showed a significant level of nonadherence among patients with type 2 diabetes in Papua New Guinea. Nonadherence to medication appeared to be associated with poor glycemic control and was due to a variety of reasons. Future interventions aimed at improving adherence will need to take these into account.

Age ≥ 60 years was an independent risk factor for diabetes-related complications despite good control of cardiovascular risk factors in patients with type 2 diabetes mellitus

Providing effective medical care for older patients with type 2 diabetes mellitus (T2D) that may contribute to their active aging has always been challenging. We examined the independent effect of age ≥ 60 years on disease control and its relationship with diabetes-related complications in patients with T2D in Malaysia. This was a cross-sectional study using secondary data from the electronic diabetes registry database Adult Diabetes Control and Management (ADCM). A total of 303 centers participated and contributed a total of 70,889 patients from May 2008 to the end of 2009. Demographic data, details on diabetes, hypertension, dyslipidemia and their treatment modalities, various risk factors and complications were updated annually. Independent associated risk factors were identified using multivariate regression analyses. Fifty-nine percent were female. Malay comprised 61.9%, Chinese 19% and Indian 18%. There were more Chinese, men, longer duration of diabetes and subjects that were leaner or had lower BMI in the older age group. Patients aged ≥ 60 years achieved glycemic and lipid targets but not the desired blood pressure. After adjusting for duration of diabetes, gender, ethnicity, body mass index, disease control and treatment, a significantly higher proportion of patients ≥ 60 years suffered from reported diabetes-related complications. Age ≥ 60 years was an independent risk factor for diabetes-related complications despite good control of cardiovascular risk factors. Our findings caution against the currently recommended control of targets in older T2D patients with more longstanding diseases and complications.