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Duffy RA, Jeffreys AS, Coffman CJ, Alexopoulos AS, Tarkington PE, Bosworth H, Edelman D, Crowley MJ. Evaluating Therapeutic Inertia in Two Telehealth Interventions for Type 2 Diabetes: Secondary Analyses of a Randomized Trial. Telemed J E Health 2024; 30:e1790-e1797. [PMID: 38377570 DOI: 10.1089/tmj.2023.0453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024] Open
Abstract
Introduction: Although therapeutic inertia is a known driver of suboptimal type 2 diabetes control, little is known about how to combat this phenomenon. We analyzed randomized trial data to determine whether a comprehensive telehealth intervention was more effective than a less structured telehealth approach (telemonitoring and care coordination) at promoting treatment intensification in poorly controlled diabetes. Methods: Patients with poorly controlled type 2 diabetes were randomized 1:1 to telemonitoring/care coordination or a comprehensive telehealth intervention, which included an active, study provider-guided medication management component. Prospectively collected medication lists were used to determine whether treatment intensification occurred for each patient during 3-month intervals throughout the study period. To examine between-arm differences in treatment intensification over time, we fit a generalized estimation equation model. In each arm, hemoglobin A1c levels at the beginning and end of each 3-month interval were used to distinguish between therapeutic inertia and potentially appropriate nonintensification of treatment. Results: The mean, model-estimated likelihood of treatment intensification during 3-month intervals was 61.3% in the comprehensive telehealth group versus 48.6% for telemonitoring/care coordination (odds ratio 1.7, 95% confidence interval 1.2-2.2; p = 0.0007), with no evidence that treatment effect varied over time (p = 0.54). Treatment intervals with observed therapeutic inertia were more common in the telemonitoring/care coordination arm than the comprehensive telehealth arm (116/300, 39% vs. 57/275, 21%). Conclusions: A comprehensive telehealth approach that integrated protocol-guided medication management increased treatment intensification and reduced therapeutic inertia compared with a less structured telehealth approach. The studied approaches may serve as examples of how systems might use telehealth to combat therapeutic inertia. Clinical Trial Registration: ClinicalTrials.gov NCT03520413.
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Affiliation(s)
- Ryan A Duffy
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Amy S Jeffreys
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
| | - Cynthia J Coffman
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Phillip E Tarkington
- Central Virginia VA Health Care System, Department of Veterans Affairs, Richmond, Virginia, USA
| | - Hayden Bosworth
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - David Edelman
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
| | - Matthew J Crowley
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, USA
- Division of Endocrinology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina; USA
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Khunti K, Cheng AYY. Therapeutic inertia in type 2 diabetes mellitus: a fine line between advancing and de-intensifying. Nat Rev Endocrinol 2023:10.1038/s41574-023-00857-w. [PMID: 37258612 DOI: 10.1038/s41574-023-00857-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK.
| | - Alice Y Y Cheng
- Trillium Health Partners and Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
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Remission of type 2 diabetes depends on prompt comprehensive lifestyle changes upon diagnosis: How can this "Road to Damascus" experience be supported? JOURNAL OF INTEGRATIVE MEDICINE 2022; 20:288-291. [PMID: 35430168 DOI: 10.1016/j.joim.2022.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 03/01/2022] [Indexed: 12/30/2022]
Abstract
Theoretically, a new diagnosis of type 2 diabetes mellitus (T2DM) requires a dramatic change in an individual's way of life. Weight loss and physical activity can lead to remission of diabetes, which has been associated with a lower risk of developing complications. Today, the importance of a healthy lifestyle is further highlighted by data showing that obesity and diabetes increase the risk of severe complications from coronavirus disease 2019. However, remission rarely occurs in reality, probably due to the inability of people with T2DM to adhere to the intensive lifestyle interventions that are necessary. The complexity of contributing factors may explain why making these changes is so challenging and underscore the fact that there is no magical solution for T2DM. Instead, hard work from both patients and health care providers is needed for the conversion to be achieved. This article calls for more research on the underlying reasons why adhering to a healthy way of life is so difficult for people with diabetes and obesity. Clearly defining these barriers would facilitate the planning of effective policies to promote the adoption of appropriate lifestyle changes early in the course of the disease.
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Holmes-Truscott E, Holloway EE, Husin HM, Furler J, Hagger V, Skinner TC, Speight J. Web-based intervention to reduce psychological barriers to insulin therapy among adults with non-insulin-treated type 2 diabetes: study protocol for a two-armed randomised controlled trial of ' Is insulin right for me?'. BMJ Open 2022; 12:e051524. [PMID: 35190420 PMCID: PMC8862461 DOI: 10.1136/bmjopen-2021-051524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Psychological barriers to insulin therapy are associated with the delay of clinically indicated treatment intensification for people with type 2 diabetes (T2D), yet few evidence-based interventions exist to address these barriers. We describe the protocol for a randomised controlled trial (RCT) examining the efficacy of a novel, theoretically grounded, psychoeducational, web-based resource designed to reduce psychological barriers to insulin among adults with non-insulin treated T2D: 'Is insulin right for me?'. METHODS AND ANALYSIS Double-blind, parallel group RCT. A target sample of N=392 participants (n=196/arm) will be randomised (1:1) to 'Is insulin right for me?' (intervention) or widely available online resources (control). Eligible participants include adults (18-75 years), residing in Australia, currently taking oral hypoglycaemic agents to manage T2D. They will be primarily recruited via invitations and reminders from the national diabetes registry (from a purposefully selected sample of N≥12 000). EXCLUSION CRITERIA experience of self-administered injectable; previously enrolled in pilot RCT; 'very willing' to start insulin as baseline. Outcomes will be assessed via online survey at 2 weeks and 6 months. Primary outcome between-group: difference in mean negative Insulin Treatment Appraisal Scores (ITAS negative) at 2-week and 6-month follow-up. SECONDARY OUTCOMES between-group differences in mean positive insulin appraisals (ITAS positive) and percentage difference in intention to commence insulin at follow-up time points. All data analyses will be conducted according to the intention-to-treat principle. ETHICS AND DISSEMINATION Deakin University Human Research Ethics Committee (2020-073). Dissemination via peer-reviewed journals, conferences and a plain-language summary. TRIAL REGISTRATION NUMBER ACTRN12621000191897; Australian and New Zealand Clinical Trials Registry.
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Affiliation(s)
- Elizabeth Holmes-Truscott
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
| | - Edith E Holloway
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
| | - Hanafi M Husin
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
| | - John Furler
- Department of General Practice, University of Melbourne, Carlton, Victoria, Australia
| | - Virginia Hagger
- School of Nursing and Midwifery, Deakin University, Burwood, Victoria, Australia
| | - Timothy C Skinner
- Rural Health School, La Trobe University, Bendigo, Victoria, Australia
- Department of Psychology, University of Copenhagen, Kobenhavn, Denmark
| | - Jane Speight
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
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Williams NA, Brunton SA, Scott GA. CRS Diabetes: An Effective Model for Improving Family Medicine Resident Knowledge, Competence, and Performance in Diabetes Care. Clin Diabetes 2022; 40:62-69. [PMID: 35221473 PMCID: PMC8865790 DOI: 10.2337/cd21-0066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The Chief Residents Summit on Intensifying Diabetes Management, now in its 15th year, has resulted in real-world improvements in patient outcomes and has shown itself to be an effective model for teaching diabetes to family medicine residents. This article describes the program and the evidence supporting its effectiveness.
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A cross-sectional survey to assess reasons for therapeutic inertia in people with type 2 diabetes mellitus and preferred strategies to overcome it from the perspectives of persons with diabetes and general/family practitioners: Results from the MOTION study. Can J Diabetes 2021; 46:337-345.e2. [DOI: 10.1016/j.jcjd.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 10/22/2021] [Accepted: 11/09/2021] [Indexed: 11/21/2022]
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Lau D, Eurich DT, Simpson SH. Foregone opportunities? Time-to-treatment intensification among adults with type 2 diabetes and elevated HbA1c on metformin monotherapy, 2009-2018. Can J Diabetes 2021; 46:238-243.e4. [DOI: 10.1016/j.jcjd.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/12/2021] [Accepted: 09/14/2021] [Indexed: 10/20/2022]
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Wrzal PK, Mohseni AA, Fournier C, Goldenberg R, Hollahan D, Jin S, Pedersen SD, Vallis M, Bunko A, Myageri V, Kukaswadia A, Neish CS, Ivers NM. Persons With Diabetes and General/Family Practitioner Perspectives Related to Therapeutic Inertia in Type 2 Diabetes Mellitus Using Qualitative Focus Groups and the Theoretical Domains Framework: Results From the MOTION Study. Can J Diabetes 2021; 46:171-180. [DOI: 10.1016/j.jcjd.2021.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 11/28/2022]
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Gembillo G, Ingrasciotta Y, Crisafulli S, Luxi N, Siligato R, Santoro D, Trifirò G. Kidney Disease in Diabetic Patients: From Pathophysiology to Pharmacological Aspects with a Focus on Therapeutic Inertia. Int J Mol Sci 2021; 22:4824. [PMID: 34062938 PMCID: PMC8124790 DOI: 10.3390/ijms22094824] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 12/11/2022] Open
Abstract
Diabetes mellitus represents a growing concern, both for public economy and global health. In fact, it can lead to insidious macrovascular and microvascular complications, impacting negatively on patients' quality of life. Diabetic patients often present diabetic kidney disease (DKD), a burdensome complication that can be silent for years. The average time of onset of kidney impairment in diabetic patients is about 7-10 years. The clinical impact of DKD is dangerous not only for the risk of progression to end-stage renal disease and therefore to renal replacement therapies, but also because of the associated increase in cardiovascular events. An early recognition of risk factors for DKD progression can be decisive in decreasing morbidity and mortality. DKD presents patient-related, clinician-related, and system-related issues. All these problems are translated into therapeutic inertia, which is defined as the failure to initiate or intensify therapy on time according to evidence-based clinical guidelines. Therapeutic inertia can be resolved by a multidisciplinary pool of healthcare experts. The timing of intensification of treatment, the transition to the best therapy, and dietetic strategies must be provided by a multidisciplinary team, driving the patients to the glycemic target and delaying or overcoming DKD-related complications. A timely nephrological evaluation can also guarantee adequate information to choose the right renal replacement therapy at the right time in case of renal impairment progression.
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Affiliation(s)
- Guido Gembillo
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (G.G.); (R.S.)
- Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, 98125 Messina, Italy; (Y.I.); (S.C.)
| | - Ylenia Ingrasciotta
- Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, 98125 Messina, Italy; (Y.I.); (S.C.)
| | - Salvatore Crisafulli
- Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, University of Messina, 98125 Messina, Italy; (Y.I.); (S.C.)
| | - Nicoletta Luxi
- Department of Diagnostics and Public Health, University of Verona, 37100 Verona, Italy; (N.L.); (G.T.)
| | - Rossella Siligato
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (G.G.); (R.S.)
| | - Domenico Santoro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (G.G.); (R.S.)
| | - Gianluca Trifirò
- Department of Diagnostics and Public Health, University of Verona, 37100 Verona, Italy; (N.L.); (G.T.)
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