Patient-centred care in type 2 diabetes mellitus - Key aspects of PDM-ProValue are reflected in the 2018 ADA/EASD consensus report

The effectiveness of telemonitoring and integrated personalized diabetes management in people with insulin-treated type 2 diabetes mellitus

OBJECTIVE

To evaluate the effectiveness of integrated personalized diabetes management (iPDM) through telemedicine (tele-iPDM) with regard to glycaemic control.

METHODS

A 6-month single-centre, open-label, prospective randomized controlled trial enrolled insulin-treated patients with type 2 diabetes, aged 18-65 years with glycated haemoglobin (HbA1c) levels of 7.5%-10.5%. The tele-iPDM group received insulin adjustment by investigators through a cloud-based telemonitoring platform for 6 months (blood glucose monitoring reviewed weekly from Weeks 0 to 12 and then monthly from Weeks 13 to 24). The control group performed self-monitoring and insulin adjustment. The primary outcome was the difference in HbA1c change from baseline between the two groups at 24 weeks. Secondary outcomes included changes in HbA1c at 12 weeks, fasting plasma glucose, body weight, body mass index (BMI), the percentage of individuals achieving HbA1c <7% at 24 weeks, the percentage of individuals with an HbA1c reduction of >0.5% at 24 weeks, and incidences of hypoglycaemic events.

RESULTS

A total of 151 participants were enrolled, with a mean age of 53.36 ± 8.08 years and a mean diabetes duration of 12.38 ± 8.47 years. The baseline HbA1c was 8.47 ± 0.76%. The mean HbA1c decreased from baseline to 12 and 24 weeks in both groups. At 12 weeks, HbA1c reduction from baseline was -1.2% (95%CI -1.42 to -0.98) in the tele-iPDM group and -0.57% (95%CI -0.79 to -0.36) in the control group. The mean difference in HbA1c between the tele-iPDM and usual care groups at 12 weeks was -0.63% (95%CI -0.94 to -0.32; p < 0.001). At 24 weeks, HbA1c reduction from baseline was -1.14% (95%CI -1.38 to -0.89) in the tele-iPDM group and - 0.49% (95%CI -0.73 to -0.25) in the control group. The mean difference in HbA1c between the tele-iPDM and usual care groups was -0.65% (95%CI -0.99 to -0.30; p < 0.001). There were no significant differences in body weight, BMI, or hypoglycaemic events between the two groups.

CONCLUSION

Telemonitoring can support the iPDM care model in individuals with insulin-treated type 2 diabetes. It improves the efficiency of diabetes care, enhances glycaemic control at 12 weeks, and sustains glycaemic control at 24 weeks.

Effect of patient-centered self-management intervention on glycemic control, self-efficacy, and self-care behaviors in South Asian adults with type 2 diabetes mellitus: A multicenter randomized controlled trial

BACKGROUND

This study aimed to test the efficacy of patient-centered self-management intervention (PACE-SMI) to improve HbA1c, self-efficacy, and self-care behaviors in adults with type 2 diabetes mellitus (T2DM).

METHODS

In this multicenter, parallel two-arm randomized controlled trial, 612 adults with T2DM and HbA1c ≥ 7% were enrolled and assigned to the control group (n = 310) and the intervention group (n = 302) using stratified permuted block randomization. The control group received usual care, whereas the intervention group received usual care plus nurse-led, theory-driven, culturally tailored PACE-SMI, comprising eight weekly sessions of individualized education, counseling, behavioral training, and home visit. Outcomes were assessed at baseline, postintervention, and 3 months follow-up.

RESULTS

Data at 3 months were provided by 583 participants (control: n = 295, intervention: n = 288). Per-protocol analysis showed that the intervention group had a lower mean HbA1c (8.49% [standard deviation (SD), 1.58]) than the control group (8.74% [SD, 1.62]), with small yet statistically significant mean difference of 0.25% (95% confidence interval [CI], -0.01 to 0.51; Cohen's d = 0.16; p = 0.03). Self-efficacy and self-care behaviors significantly improved in the intervention group (116.89 [SD, 25.50] and 70.01 [SD, 17.97]) compared to the control group (75.43 [SD, 18.99] and 51.54 [SD, 12.04]), with mean differences of 41.48 (95% CI, 37.83-45.13; Cohen's d = 1.84; p < 0.0001) and 18.56 (95% CI, 16.08-21.04; Cohen's d = 1.22; p < 0.0001), respectively. Linear regression analysis indicated the effect of PACE-SMI on HbA1c was significantly mediated by improvements in self-efficacy and self-care behaviors (R2 = 0.232, p < 0.001).

CONCLUSION

PACE-SMI led to modest but significant improvement in HbA1c and substantial enhancements in self-efficacy and self-care behaviors in adults with T2DM.

The power of the placebo effect in diabetes: A systematic review and meta-analysis

This review aims to identify the magnitude of the placebo effect in people with type 2 diabetes mellitus. Literature research was conducted Medline, Embase and Virtual Health Library for studies published between the date of inception and June 2021. The eligibility criteria included randomized controlled trials, showing comparison to placebo, having participants with type 2 diabetes mellitus, and having glycated hemoglobin (HbA1c) as the primary outcome. Meta-analysis was conducted with the effect of changing HbA1c in relation to the baseline. Exploration of heterogeneity was performed.The meta-analysis showed an increase in the average of HbA1c compared to the baseline of 0.14% (95% CI: 0.07-0.21). There was a significant difference between follow-up times (p = 0.03) and between administration routes (p = 0.01), with an increase in HbA1c in the oral route [0.15% (95% CI: 0.07-0.23)]. The meta-regression of the year of publication showed a significant downward trend (p = 0.01) of the increase in HbA1c compared to the baseline.In this study, the expected placebo effect of Hba1c reduction was not found; instead, higher Hba1c levels were observed in the control groups, although this effect was reduced over the years. Registration: PROSPERO ID CRD42020172797.

Utilization of glucagon-like peptide-1 receptor agonists and changes in clinical characteristics in patients with type 2 diabetes by chronic kidney disease stage in Japan: A descriptive observational study using a nationwide electronic medical records database

AIM

To describe the utilization of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and changes in clinical characteristics before and after GLP-1 RA initiation in patients with type 2 diabetes (T2D) by chronic kidney disease (CKD) stage.

MATERIALS AND METHODS

In this retrospective descriptive study using a nationwide electronic medical records database in Japan, we included patients with GLP-1 RA prescriptions from June 2010 to October 2019. Clinical characteristics at GLP-1 RA initiation, persistence proportion, and changes in clinical measurements after GLP-1 RA initiation were described for all patients and by CKD stage, defined by baseline estimated glomerular filtration rate (eGFR).

RESULTS

We included 8049 patients. During the study period, the proportion of patients with T2D initiating GLP-1 RAs increased from 1.5% in 2010 to 3.3% in 2019. Also, the mean (95% confidence interval) of baseline age and eGFR ranged from 58.6 (56.7-60.4) to 66.3 (65.5-67.2) years and from 72.9 (68.0-77.9) to 64.0 (62.2-65.8) mL/min/1.73m² , respectively. The persistence proportion at 12 months was 49.5% overall, 37.8% in T2D patients with CKD with a baseline eGFR of less than 30 mL/min/1.73m² , and 34.6% in those undergoing dialysis. The rate of deterioration in renal function reduced after GLP-1 RA initiation.

CONCLUSIONS

The utilization of GLP-1 RAs has been increasing over the past decade, and GLP-1 RAs have been used in patients with limited treatment options, such as the elderly or those with CKD. In T2D patients with CKD, the persistence proportion of GLP-1 RAs was not low, and the renal dysfunction may be moderated by GLP-1 RA initiation.

Association of personalised care plans with monitoring and control of clinical outcomes, prescription of medication and utilisation of primary care services in patients with type 2 diabetes: an observational real-world study

OBJECTIVE

To study the association of personalised care plans with monitoring and controlling clinical outcomes, prescription of cardiovascular and antihyperglycaemic medication and utilisation of primary care services in patients with type 2 diabetes (T2D).

PATIENTS

Primary care T2D outpatients from the Rovaniemi Health Centre.

SETTING

The municipal health centre, Rovaniemi, Finland.

DESIGN

A cross-sectional, observational, retrospective register-based study. The patients were divided into three groups: 'no care plan entries' (usual care); '1-2 care plan entries'; and '3 or more care plan entries'.

MAIN OUTCOME MEASURES

Monitoring of clinical and biochemical measures, achievement of treatment targets, prescription of cardiovascular and antihyperglycemic medication, and use of primary care services.

RESULTS

A total of 5104 patients with T2D (mean age 65.5 years (SD 12.4)), of which 67% had at least one care plan entry. Compared to usual care, the establishment of a care plan (either care plan group) was associated with better monitoring of glycosylated haemoglobin A1c, low-density-lipoprotein cholesterol, systolic blood pressure (sBP), and renal function, and there was more frequent prescription of all cardiovascular and antihyperglycemic medication. Patients in either care plan group were more likely to achieve sBP target (p < 0.05). Patients without a care plan had more unplanned primary care physician contacts compared to patients in care plan groups (p < 0.001).

CONCLUSION

Establishment of a care plan is associated with more intensive and focussed care of patients with T2D. The appropriate use of primary care resources is essential and personalised care plans may contribute to the treatment of patients with T2D.Key PointsCare planning aims to empower patients with type 2 diabetes. This study demonstrates that personalised care planning is associated withmore frequent monitoring for clinical outcomes,more frequent prescription of cardiovascular and antihyperglycemic medication andmore frequent utilisation of planned diabetes consultations when compared to usual care.

Barriers and facilitators to successful management of type 2 diabetes mellitus in Latin America and the Caribbean: A systematic review

BACKGROUND

Given that most evidence-based recommendations for managing type 2 diabetes mellitus (T2DM) are generated in high-income settings, significant challenges for their implementation exist in Latin America and the Caribbean region (LAC), where the rates of T2DM and related mortality are increasing. The aim of this study is to identify the facilitators and barriers to successful management of T2DM in LAC, from the perspectives of patients, their families or caregivers, healthcare professionals, and/or other stakeholders.

METHODS

We conducted a systematic review in MEDLINE, Web of Science, SciELO, and LILACS. We included studies of disease management, prevention of complications and risk factor management. We qualitatively synthesized the verbatim text referring to barriers and/or facilitators of diabetes management according to the Theoretical Domain Framework and described their relative frequencies.

FINDINGS

We included 60 studies from 1,595 records identified. 54 studies (90%) identified factors related to the environmental context and resources, highlighting the importance of questions related to health care access or lack of resources in the health system, and the environmental context and living conditions of the patients. Issues related to "social influences" (40 studies) and "social/professional role and identity" (37 studies) were also frequently addressed, indicating the negative impact of lack of support from family and friends and clinicians' paternalistic attitude. 25 studies identified patients beliefs as important barriers, identifying issues such as a lack of patients' trust in the effectiveness of the medication and/or the doctor's advice, or preferences for alternative therapies.

CONCLUSIONS

Successful diabetes management in LAC is highly dependent on factors that are beyond the control of the individual patients. Successful disease control will require emphasis on public policies to reinforce health care access and resources, the promotion of a patient-centred care approach, and health promoting infrastructures at environmental level.