Blood glucose levels and glycaemic burden in 76,341 patients attending primary care: Bittersweet findings from a 9-year cohort study

The diagnosis and management of diabetes in Australia: Does the "Rule of Halves" apply?

The Rule of Halves (ROH) is a theoretical framework which states that roughly half of all people with a condition are diagnosed; half of those diagnosed receive care; half of those who receive care achieve their treatment targets; and half of those who reach their targets achieve the desired treatment outcomes. This review examined the applicability of the ROH to diabetes in Australia. Five databases were searched for articles and government reports published between January 2000 and August 2019. Data was extracted for each level of the framework, and pooled sample proportions calculated for the total population and sub-group analysis by ethnicity and type of diabetes. The results showed that 72% of people with diabetes are diagnosed. Approximately 50% are receiving standard care, and 40-60% are meeting treatment targets for HbA1c, blood pressure and lipid levels. Overall, Australia is doing better than the ROH when it comes to achieving treatment outcomes; prevalence of microvascular complications was 20-30% and cardiovascular disease 62%. Indigenous people were less likely to meet treatment targets and more likely to experience adverse complications of diabetes. This review indicates the ROH does generally apply for diabetes care and management in Australia, highlighting the need for further improvement.

Improving Type 2 Diabetes Management in General Practice Using a Second-Generation Basal Insulin Analogue Insulin Glargine 300 U/mL: A Practical Guide

Type 2 diabetes management can be improved by the use of second-generation basal insulin analogues as the first choice on commencement of insulin, in this instance focussing on insulin glargine 300 U/mL (Gla-300). The clinical application of the use of Gla-300 include advantages such as less intra- and interpatient variability in glucose control resulting in rather less hypoglycaemia, longer duration of action and greater flexibility in the timing of administration thus suiting a wide range of patient presentations.Funding: Sanofi Australia.

Both glucocentric and cardiocentric approaches are necessary for a resilient disease such as diabetes

Diabetes mellitus (DM) is a complex disease that compromises almost all systems in the human organism. Independently of the intrinsic mechanisms, the source of all consequences of DM is hyperglycemia, a condition associated to intense metabolic changes that will lead to increased morbidity and mortality in the long term. Several different therapeutic hypoglycemic oral agents were developed and significantly facilitated the treatment of hyperglycemia acting at different sites, since patients could take more than one agent. This glucocentric approach was somehow criticized as those hypoglycemic drugs have shown weaker than expected benefits in terms of cardiovascular outcomes and there was a sub use of statins and antihypertensive agents in this population. On the other hand, the catastrophic cardiovascular consequences of hypoglycemia in older adults submitted to tight glycemic control and the results of recent clinical trials that showed impressive reduction in cardiovascular outcomes with less potent antidiabetic agents seem to pave the way to a cardiocentric approach including a lax treatment of DM. Interestingly, the results obtained in recent studies with SGLT2 inhibitors are being mostly attributed to mechanisms other than its hypoglycemic effect in spite of including patients at high cardiovascular risk already taking hypoglycemic agents. Considering the worldwide growing number of patients with diabetes, caregivers must follow a dialectical thinking and choose a synthesis approach where glycemic control is the first and foremost target to be achieved, followed by control of cardiovascular risk factors.

Impact of a Novel Insulin Management Service on Non-insulin Pharmaceutical Expenses

BACKGROUND

Studies have shown that improvements in glycemic control are associated with avoidance or delayed onset of diabetes complications, improvements in health-related quality of life, and reductions in diabetes-related health care costs. Clinical practice guidelines recommend maintaining a hemoglobin A1c (HbA1c) level less than 7%, but among type 2 diabetes patients using insulin, two-thirds have HbA1c above 7% and one-third have HbA1c above 9%.

OBJECTIVES

This study examined the use of insulin management services to enable patients to optimize insulin dosing to achieve HbA1c targets and subsequently reduce health care costs. Cost savings may be achieved through reduced complications and hospitalizations, as well as reduced outpatient, physician, and clinic costs. This study quantified the reduction in pharmaceutical expenses related to the use of an enhanced insulin management service to improve glycemic control.

METHODS

Two hundred seventeen insulin-reliant patients were enrolled in the d-Nav® Insulin Guidance Service through a participating insurance group. A prospective cost analysis was conducted using data from enrolled patients who completed the first 90 days of follow up.

RESULTS

Of the 192 patients who completed the 90-day study period, 54 (28.13%) were prescribed one or more expensive medications at baseline, but 45 (83.33%) of those patients were eligible for medication discontinuation after 90 days. At baseline, the annual cost of expensive medications per patient was $7564 (CI: $5191-$9938) and $1483 (CI: -$1463-$4429) at 90 days (p<0.001). Direct savings from medication elimination was estimated to be $145 per patient per month (PPPM) or $1736 per patient per year (PPPY) for all patients and $514 PPPM/$6172 PPPY for the target group. Patients that completed the 90-day period significantly reduced HbA1c levels from 9.37% (CI:7.72%-11.03%) at baseline to 7.71% (CI: 6.70%-8.73%) (p<0.001). A total of 170 (88.54%) patients had improved HbA1c at 90 days.

CONCLUSIONS

Use of the insulin guidance service achieved improved glycemic control by optimizing insulin dosing, which enabled most patients using the service to reduce or eliminate the use of expensive diabetes medications. Further study is needed to assess the impact of optimized insulin dosing on other diabetes-related health care costs in a usual practice setting.