Inercia y cumplimiento terapéutico en pacientes con diabetes mellitus tipo 2 en atención primaria

Non-adherence to non-insulin glucose-lowering drugs: Prevalence, predictors and impact on glycemic control and insulin initiation. A longitudinal cohort study in a large primary care database in Spain

BACKGROUND

A better understanding of patient non-adherence to type 2 diabetes medication is needed to design effective interventions to address this issue.

OBJECTIVES

(1) To estimate the prevalence of non-adherence to diabetes medication; (2) to examine its impact on glycemic control and insulin initiation; (3) to develop and validate a prediction model of non-adherence.

METHODS

We conducted a longitudinal cohort study based on data from electronic health records. We included adult patients registered within the Health Service of the Balearic Islands (Spain) starting a new prescription of a non-insulin glucose-lowering drug between January 2016 and December 2018. We calculated non-adherence at 12 months follow-up, defined as medication possession ratio (MPR) ≤ 80%. We fitted multivariable regression models to examine the association between non-adherence and glycemic control and insulin initiation and identified predictors of non-adherence.

RESULTS

Of 18,119 patients identified, after 12 months follow-up, 5,740 (31.68%) were non-adherent. Compared with non-adherent, adherent patients presented lower HbA1c levels (mean difference = -0.32%; 95%CI = -0.38%; -0.27%) and were less likely to initiate insulin (aOR = 0.77; 95%CI = 0.63; 0.94). A predictive model explained 22.3% of the variation and presented a satisfactory performance (AUC = 0.721; Brier score = 0.177). The most important predictors of non-adherence were: non-Spanish nationality, currently working, low adherence to previous drugs, taking biguanides, smoker and absence of hypertension.

CONCLUSION

Around one-third of the patients do not adhere to their non-insulin glucose-lowering drugs. More research is needed to optimise the performance of the predicting model before considering its implementation in routine clinical practice.

Regional differences in the degree of glycaemic diabetes control in Spain and associated factors. IBERICAN study

BACKGROUND AND OBJECTIVE

The prevalence of type 2 diabetes (T2D) is high, it is increasing and its degree of control seems to be improvable with important social and health consequences. The objective of this study is to determine the regional differences in the degree of glycaemic control of T2D in Spain and its associated factors.

MATERIAL AND METHODS

Cross-sectional, multicentre, observational study in patients with T2D between 18 and 85 years of age selected by consecutive sampling between 2014 and 2018. The population was divided into four regions: north, centre, Mediterranean and south-east. The main variable was the value of glycated haemoglobin (HbA1c). Sociodemographic and clinical variables, presence or absence of other risk factors and treatment were recorded.

RESULTS

A total of 1587 patients with T2D were analysed, with a mean age of 65.93 years (standard deviation [SD] 10.14); 54.5% were men; the mean duration of T2D was 8.63 years (SD 6.64) and the mean HbA1c value was 7.05%. Of the total, 59.8% had an HbA1c value ≤ 7% (north 59.5%, centre 59.5%, Mediterranean 60.6% and south-east 59.8%; P=.99). The factors for poor control were: in the north, duration of T2D and being sedentary; in the centre, duration of T2D and having a low income; in the Mediterranean, duration of T2D; and in the south-east, duration of T2D and having a low level of education or income. Overall, 76.2% of the subjects had hypertension, 75.1% dyslipidaemia, and 51.7% obesity, with significant differences between regions only being observed in the case of dyslipidaemia (P<.001).

CONCLUSIONS

No differences were observed in the degree of diabetes control in the different regions, with the percentage of patients needing intensification in their control being high in all of them. The factors associated with poor control were the duration of the disease, a low level of education or income, and a sedentary lifestyle.

[Overcoming the barriers in the approach of the chronic patient]

At least one in three adults has multiple chronic conditions. The assistance of patients with chronic conditions is mandatory. This is one of the main tasks of the primary care physicians. The approach in these patients is challenging, as there are many barriers at different levels (sanitary system, healthcare professionals and patients). In addition, COVID-19 pandemic has worsened this situation even more. Therefore, it is necessary to take actions that try to improve this state. For this purpose, with the aim to find solutions/recommendations that may be helpful to attain a better diagnosis, treatment and follow-up of patients with chronic diseases, a group of experts of SEMERGEN have tried to identify the problems in the attention to these patients, searching for potential solutions and areas of improvement. The present document has specifically focused on four prevalent chronic conditions in primary care: dyslipidemia, arterial hypertension, chronic venous disease and depression.

Perspectives and Views of Primary Care Professionals Regarding DiabeText, a New mHealth Intervention to Support Adherence to Antidiabetic Medication in Spain: A Qualitative Study

Background: Antidiabetic medication is effective in preventing diabetes-related complications. However, 40% of type 2 diabetic patients do not adhere to their medication regimes adequately. Brief text messages represent a promising approach to support medication adherence. The aim of this study was to explore the perspectives of primary care professionals (PCPs) concerning the DiabeText intervention, a new text messaging intervention to be developed to support medication adherence in people with type 2 diabetes (T2D) in Mallorca, Spain. Methods: We conducted four focus groups (n = 28) and eight semi-structured interviews with doctors and nurses. Data collection and analysis were carried out by researchers independently following Braun and Clark’s methodology. Results: Three main themes were identified: (1) text messaging interventions have the potential to effectively support diabetes self-management; (2) involving PCPs in the intervention would facilitate its design and implementation; (3) obtaining evidence supporting the cost-effectiveness is a key prerequisite for large-scale implementation of the intervention. PCPs identified barriers and enablers of the design and implementation of the intervention and made suggestions about the content and format of the text messages. Conclusion: The DiabeText intervention is perceived as useful and acceptable by PCPs provided its cost-effectiveness.

Adherence, control of cardiometabolic factors and therapeutic inertia in patients with type 2 diabetes in the primary care setting

Introduction

Studies on treatment adherence to glucose‐lowering drugs among patients with type 2 diabetes (T2D) including concomitant treatment for other cardiovascular risk factors are scarce. We aimed to estimate the prevalence of good adherence to all medications used to control diabetes, hypertension and dyslipidemia and to analyse cardiometabolic control and its associated factors in T2D patients in the primary care (PC) setting.

Methods

Observational, retrospective study conducted in adult patients with T2D who were followed in the PC setting in Spain. Patients were classified as adherent in a particular category if the summary of the proportion of days covered (PDC) for a particular medication category was ≥80% and were considered globally adherent if the PDC was ≥80% for each of the 3 medication categories.

Results

A total of 457 evaluable patients were recruited, among which 321 patients (70.3%, 95% CI 65.8 to 74.4) were adherent to the three drug categories. The proportion of patients controlled for the 3 cardiometabolic risk factors was 31% according to the contemporary clinical practice guideline criteria, 58% according to investigator judgment and 36% when the objective for HbA1c was individualized. In a multivariate analysis, presenting comorbidities was associated with a lower likelihood of showing adequate control of dyslipidemia (odds ratio [OR] 0.25, 95% CI, 0.16–0.40) and the three cardiometabolic factors as a whole (OR 0.43, 95% CI 0.26–0.70). In a post hoc analysis, therapeutic inertia was found to be greater for dyslipidemia and hypertension than for T2D.

Conclusions

Despite a relatively high adherence to all medications for treating diabetes, hypertension and dyslipidemia in patients with T2D in the PC setting in Spain, the control of cardiometabolic risk factors as a whole is far from optimal. This could be related, at least in part, to the high frequency of comorbidity of these patients.

Patients' Views on the Design of DiabeText, a New mHealth Intervention to Improve Adherence to Oral Antidiabetes Medication in Spain: A Qualitative Study

Background: Type 2 Diabetes Mellitus (T2DM) is a long-term condition affecting around 10% of people worldwide. This study aimed to explore T2DM patients’ views on DiabeText, a new text messaging intervention to be developed to support adherence to diabetes medication. Methods: A total of four focus groups were conducted with a purposive sample of people with T2DM (n = 34). The data were analysed by multiple researchers independently, and coded using thematic analysis. Results: There were two main themes that emerged: (1) “patients’ perspectives on unmet needs for diabetes self-management”, and (2) “acceptability and perceived utility of DiabeText”. The patients identified a number of barriers for diabetes self-management, including lack of appropriate information and support with diet and physical activity. Support for medication-taking was not perceived as urgently needed, although several barriers were identified (eating outside, traveling, polymedication, dispensation at the pharmacy). The participants anticipated that the proposed intervention would present high levels of patient acceptability and perceived utility as long as its content addresses the barriers that were identified, and includes specific features (short and clear messages, and personalized information). Conclusion: The proposed intervention has the potential to be well accepted and perceived as useful by T2DM patients who require support not only in terms of medication-taking, but more prominently of lifestyle behaviour.

Patient Preferences for Pharmacological Diabetes Treatment Among People with Diabetes in Spain: A Discrete Choice Experiment

INTRODUCTION

The aim of the project was to describe the preferences related to the medication attributes of people with diabetes mellitus (DM) treated in Spain.

METHODS

The project was carried out in four different phases. In phase A, a Steering Committee defined and selected a total of 18 attributes for treating DM and grouped them into four categories: health outcomes, adverse events, treatment characteristics and cost of treatment. In phase B, a questionnaire according to a discrete choice experiment (DCE) methodology was developed. In phase C, the online DCE survey was sent to members of associations of people with DM from the Spanish Diabetes Federation (FEDE). Finally, in phase D, the results were discussed in a deliberative process.

RESULTS

Of the 238 participants who completed the questionnaire (May-September 2020), 231 were included (mean age, 58 years; males, 62%). The DCE results showed that the best-valued category was health outcomes (39.67%), followed by adverse events (26.85%), treatment characteristics (21.70%) and treatment costs (11.77%). Ten of 18 attributes had a significant effect on participants' choice (p < 0.05) and the highest relative importance value: blood pressure reduction (12.82%), hypoglycaemia (12.77%), HbA_1c level reduction (8.54%), cost of the medication (8.13%), needle/tablet size (7.20%), weight change (6.72%), risk of genitourinary infections (6.36%), gastrointestinal problems (5.82%), improved kidney function (5.53%) and administration route (5.41%).

CONCLUSIONS

People with DM prefer a treatment that generates benefits in measurable health effects (reducing blood pressure and HbA_1c level, while not risking hypoglycaemia) and a convenient route of administration. Considering the preferences of people with DM could generate better clinical results and therapeutic adherence, reducing morbidity, mortality and disease burden.

[Management of patient profiles with type2 diabetes mellitus in Primary Care in Spain: CONTROVERTI2 Program]

AIM

To identify existing controversies in the routine management of patients with T2D and to contrast them with the latest scientific evidence and clinical guidelines, in order to help optimize and homogenize the treatment of patients with T2D in Primary Care (PC) in Spain.

MATERIAL AND METHODS

240 family doctors responded to an online questionnaire about the management of 6 patient profiles with T2D of increasing complexity.

RESULTS

The main drivers for the antihyperglycemic treatment choice are an HbA1c>10% and the presence of cardiovascular disease (CVD), although in evolved patients, the estimated glomerular filtration rate and the risk of hypoglycemia become more relevant. In newly diagnosed patients with an HbA1c>9%, treatment is still initiated with monotherapy (24%). In patients not controlled with metformin, dipeptidyl peptidase 4 inhibitors (DPP4-I, 54%) or sodium-glucose cotransporter 2 inhibitors (SGLT2-I, 39%) are usually added. On the other hand, type1 glucagon-like peptide receptor agonists (GLP1-RA) are mainly associated with obese patients with T2D. In patients not controlled with metformin+sulfonylurea (SU), SU replacement is preferred to adding a third antihyperglycemic agent to background therapy (77% vs. 23%).

CONCLUSIONS

T2D treatment in PC is still focused on HbA1c reduction and treatment safety. Thus, DPP4-I are widely used. SGLT2-I are usually preferred for patients with T2D and CVD and GLP1-RA for patients with T2D and obesity, although their use in PC is low.

[Uncontrolled type 2 diabetes in primary care health center: Modifiable factors and target population]

Objetivos

Detectar factores modificables y poblaciones diana asociados al mal control de la diabetes tipo 2 (DM2) en atención primaria.

Diseño

Estudio descriptivo transversal restrospectivo.

Emplazamiento

Centro de salud de Barranco Grande, Tenerife.

Participantes

selección aleatoria de pacientes con DM2 atendidos por 12 médicos de familia y 12 enfermeras.

Mediciones principales

Además del control de la DM2, se obtuvieron datos sociodemográficos, clínicos, hábitos de vida y seguimiento de medidas preventivas y terapéuticas. Tras análisis bivariado, se ajustó un modelo multivariado multinivel tomando el cupo médico-enfermero como efecto mixto de segundo nivel y el resto como variables de primer nivel.

Resultados

Fueron reclutados 587 pacientes (46,5% mujeres), tratados con 1,9±1,1 fármacos antidiabéticos, con 4,1% de incumplimiento terapéutico, y padeciendo un 13,8% inercia terapéutica. El 23,7% mostraba mal control de DM2, siendo peor (p<0,05) en sexo masculino, edad <65 años, evolución DM2 ≥5 años, dieta inadecuada, síndrome metabólico, ratio triglicéridos/HDL≥3, complicaciones de la DM2, índice Charlson<5, visitas a enfermera<3/año, sin ECG en el último año y mayor número de fármacos prescritos para DM2. El cupo médico-enfermero se asoció al mal control con un coeficiente intraclase de 0,01.

Conclusiones

Los hombres menores de 65 años con larga evolución de DM2 son población diana para intensificar intervenciones. El incumplimiento terapéutico, dieta inadecuada, falta de adhesión a los protocolos de seguimiento y ratio triglicéridos/HDL>3 son factores sobre los que intervenir. La asociación del cupo médico-enfermero con el control de la DM2 es débil, probablemente por adecuado seguimiento de los programas preventivos.

Real-world clinical outcomes and costs in type 2 diabetes mellitus patients after initiation of insulin therapy: A German claims data analysis

BACKGROUND

This study describes real-world treatment-related outcomes and healthcare costs of German type 2 diabetes mellitus (T2D) patients who initiated insulin therapy.

METHODS

This retrospective analysis includes German claims data from 01/01/2012 until 31/12/2016. Identification of eligible patients took place between 01/01/2013 and 31/12/2015, allowing for at least 1 year of follow-up. Clinical outcomes, such as HbA1c values and body mass index, were observed in a subpopulation participating in a Disease Management Program. Healthcare expenditures were evaluated for the first year of therapy.

RESULTS

Overall, 27,340 insulin starters with T2D were observed (mean age: 72.2 years, female: 51.4%). Treatment-related outcomes were evaluated in a subsample of 12,034 patients. Patients who started insulin combined with other antidiabetic drugs (ADs) achieved their HbA1c goals more frequently than patients on insulin monotherapy (+10.7 percentage points [pp] vs. +21.1 pp for insulin plus metformin). All-cause costs were by far highest among patients with insulin monotherapy (€ 12,283 per patient-year) compared with patients receiving a combined AD regimen (€ 9,947-10,509 per patient-year).

CONCLUSIONS

Changes in HbA1c values were not in favor of insulin monotherapy, compared to regimens including other ADs. It was also associated with higher costs, suggesting that insulin alone is a suboptimal treatment.

Therapeutic inertia in patients with type 2 diabetes treated with non-insulin agents

AIMS

To analyze therapeutic inertia in type 2 diabetes (T2D) subjects with suboptimal glycemic control and treated with ≥2 non-insulin antidiabetic agents in a primary care setting.

METHODS

A retrospective study was conducted using electronic medical records from subjects with HbA1c ≥7.0% (≥53 mmol/mol). Therapeutic inertia was defined as the absence of treatment intensification despite suboptimal glycemic control where intensification should have been implemented (HbA1c ≥7.5% [≥58 mmol/mol]). Time to the first intensification with non-insulin antidiabetic agent or insulin and HbA1c values at the time of intensification were evaluated by competing risk analysis.

RESULTS

2652 adults with T2D and HbA1c ≥7.0% (≥53 mmol/mol) were included. During the 4-year follow-up, among 1628 individuals with HbA1c ≥7.5% [≥58 mmol/mol], therapeutic inertia was present in 42.9% of cases. Median time to intensification was 14.5 months (IQR_25-75, 4-24 months). In this subgroup, 72.7% of subjects initiated non-insulin agents whereas 27.3% initiated insulin. Mean HbA1c values at initiation of treatment intensification were 8.6% (70 mmol/mol) and 9.2% (77 mmol/mol), respectively.

CONCLUSIONS

Therapeutic inertia occurred in over 40% of subjects. Treatment intensification took longer and was performed at higher HbA1c than recommended in clinical guidelines. Reducing therapeutic inertia is a priority to achieve therapeutic goals and prevent chronic complications in T2D.

[Adherence to healthy lifestyle behaviours in patients with type 2 diabetes in Spain]

OBJECTIVES

The aim of this study was to report on the main lifestyle components and related factors in adults with diabetes type 2 treated in Primary Care clinics in Spain.

MATERIAL AND METHODS

A cross-sectional and multicentre study was performed on a consecutive sample of patients with type 2 diabetes attending 25 Primary Care clinics between April 2018 and April 2019. Data were collected by auditing the computerised medical records, and an interview. An analysis was carried out on adherence to 4 healthy lifestyle trends (Mediterranean diet, regular exercise, not smoking, and emotional well-being).

RESULTS

A total of 412 patients were included in the analysis (mean age 69 (SD 8.65) years; 50.2% men). Only a minority was highly adherent to the Mediterranean diet, 92 (22.3%). Regular physical activity was carried out by 189 (45.8%). A total of 361 (87.6%) were non-smoking, and 259 (62.8%) felt emotional well-being. A small number (9, 2.1%) of patients had not followed any of the healthy lifestyle recommendations, with 87 (21.1%) following one, 145 (35.1%) two, 128 (31%) three, and 43 (10.4%) all 4 healthy habits: diet, exercise, not smoking, and emotional well-being. Healthy lifestyle adherence was related to gender. Obesity is poorly associated with adherence to diet and physical activity. The results for age, time with the disease, socioeconomic status, and treatment regimen were not consistent.

CONCLUSIONS

This study suggest that adherence to a healthy lifestyle pattern in DM2 is low. Less than a quarter follow a healthy diet, and less than a half practice regular exercise. Gender is the variable that most influences a healthy lifestyle in DM2, but not age, time with the disease, or treatment regimen.

Improving management of glycaemic control in people with T2DM in primary care: estimation of the impact on the clinical complications and associated costs

BACKGROUND

To estimate the potential benefits in terms of avoided complications and cost reduction if the Spanish health system would encourage the intensification of treatment for better glycaemic control in adults with Type 2 diabetes from the current HbA1c target used in clinical practice of 68 mmol/mol to a target of 53 mmol/mol.

METHODS

The IQVIA Core Diabetes Model (version 9.0) was used to model the impact of these changes in respect of micro- and macrovascular complications and the associated costs. The modelling was based on data derived from the SIDIAP-Q population database from Catalonia, taking a random cohort of 10,000 people with type 2 diabetes and dividing it into sub-groups based on their baseline HbA1c.

RESULTS

The CDM modelling showed that the average cost reduction per person varies depending on baseline HbA1c. The model estimates that after 25 years, people with a baseline HbA1c between 48 and 58 mmol/mol and > 75 mmol/mol show an average cost reduction of €6027 and €11,966, respectively. Applying the per-person cost reduction to the cohorts of the prevalent population in Spain (1,910,374) the overall estimated cost reduction was €14.7 billion over 25 years. The improvements in outcomes resulted in an estimated reduction of more than 1.2 million complications cumulatively over 25 years, of which more than 550,000 relate to diabetic foot and more than 170,000 related to renal disease.

CONCLUSION

Over a 25 year period, Spain could considerably reduce costs and avoid major complications if, on a population level, more ambitious glycaemic control, according to Spanish or EU guidelines, could be achieved among people with type 2 diabetes by reducing the HbA1c threshold for treatment intensification. Although there is a slower trajectory for benefits in earlier years, there is a much more rapid benefit gain between years 5 and 15.

Yoga-based lifestyle treatment and composite treatment goals in Type 2 Diabetes in a rural South Indian setup- a retrospective study

This multicentre retrospective study examined the effects of adjunct yoga-treatment in achieving composite cardiovascular goals for type 2 diabetes (T2D), set forth by the American Diabetes Association (ADA) in rural Indian settings. Records were extracted for 146 T2D patients, aged ≥20–70 years, and treated under the “Apollo Total Health Programme” for rural diabetes management, for the period April 2016 to November 2016. The study cohort comprised of two treatment groups (n = 73 each); non-yoga group (standard of care) and yoga group (adjunct yoga-treatment). Propensity score matching was applied between the study groups to define the cohort. Composite cardiovascular scores were based on the combination of individual ADA goals; A1c < 7%, blood pressure (BP) < 140/90 mmHg, stringent BP (<130/80 mmHg) and lipid, LDL-C < 100 mg/dl [risk factor for atherosclerotic cardiovascular disease]. Logistic regression was used to compare between the two treatment groups. Compared to standard of care, adjunct yoga-treatment was found to significantly facilitate the attainment of ADA composite score by 8-fold; A1c, ~2-fold; LDL-C, ~2-fold; BP < 140/90 mmHg and <130/80 mmHg by ~8-and ~6-fold respectively. This study provides the first evidence for significant efficacy of adjunct yoga-treatment for the attainment of favourable treatment goals for T2D in rural Indian settings. Clinical Trial Registration Number: CTRI/2020/02/0232790

Clinical Inertia in Poorly Controlled Type 2 Diabetes Mellitus Patients with Obesity: An Observational Retrospective Study

INTRODUCTION

To evaluate clinical inertia in patients with type 2 diabetes mellitus (T2DM), obesity and poor glycaemic control in routine clinical practice.

METHODS

This was a retrospective, observational study based on the analysis of medical records from the BIG-PAC® database. Subjects who required medical care in 2013 with the following characteristics were enrolled in the study: age ≥ 30 years, diagnosis of T2DM, glycosylated haemoglobin (HbA1c) ≥ 8%, obesity (body mass index [BMI] ≥ 30 kg/m²) and treatment with ≥ 2 oral antidiabetic drugs (OADs). Inertia was evaluated by time (days) to the first intensification during the period while HbA1c levels were ≥ 8% and percentage of patients whose treatment was not intensified at 6 months, 1, 2 and 3 years and the end of follow-up. The minimum length of follow-up was 4 years. Descriptive analyses and Kaplan-Meier survival curves were performed.

RESULTS

A total of 13,824 patients with T2DM receiving ≥ 2 OADs were identified; of these 2709 (19.6%) had HbA1c ≥ 8% and BMI ≥ 30 kg/m², thus fulfilling the inclusion criteria. Of these 2709 patients, the mean age was 65.5 (standard deviation [SD] 12.0) years; 54.9% were male, mean HbA1c level was 9.2% (SD 1.3%); mean BMI was 32.1 (SD 0.9) kg/m²; and mean time from diagnosis was 8.2 (SD 3.0) years. HbA1c remained ≥ 8% for a median of 440 (95% confidence interval [CI] 421-459) days. The median time to first intensification was 456 (95% CI 429-483) days. No intensification had occurred in 77.8, 59.5, 41.5, 28.1 and 22.4% of patients at 6 months, 1, 2, 3 years and the end of follow-up, respectively.

CONCLUSIONS

The patients with T2DM analysed in this study had a mean HbA1c of 9.2% at baseline, and this remained at ≥ 8% for > 1 year. The time to the first treatment intensification was longer than that recommended by guidelines. Treatment was not intensified in a large percentage of patients, with almost 60% of patients not receiving intensification at 1 year of follow-up.

The prevalence and risk factors associated with dyslipidemia in type 2 diabetic patients in the autonomous Region of Cantabria

BACKGROUND AND OBJECTIVE

Dyslipidemia is one of the main risk factors in cardiovascular disease in patients with diabetes mellitus type 2 (DM2). The aim of this study is to evaluate the prevalence and risk factors associated with dyslipidemia in the population with diabetes mellitus type 2 in the region of Cantabria.

MATERIAL AND METHODS

This is a transversal study carried out at Cantabrian primary health care centres (n=680). A representative, random sample of the population with DM2, ranging from 18-85, was selected using a multistage procedure. The medical records were obtained, and by means of interviews the data of the risk factors to be studied was secured. The correlation with dyslipidemia was analysed by means of logistic regression.

RESULTS

There were 52.1% of males, the average age was 69.8, the evolution of diabetes was 9.99 years, 84.3% had arterial hypertension, 76.6% were overweight or obese and the average HbA1c was 6.96%. The prevalence of dyslipidemia was 85.3%, and in the bivariate analysis this is associated with a history of peripheral artery disease, controlled diabetes, antihypertensive treatment, glomerular filtration, HbA1c>7%, body fat estimated as being either overweight or obese, a history of cardiovascular disease, age and HbA1c. In the multivariate analysis the independent factors were being female and a history of cardiovascular disease.

CONCLUSION

The prevalence of dyslipidemia in our study was 85.3%, and is consistent with figures found in previous published studies. The independent associated risk factors were being female and a past medical history of cardiovascular disease.

INTEGRA study protocol: primary care intervention in type 2 diabetes patients with poor glycaemic control

BACKGROUND

The management of hyperglycaemia and associated cardiovascular risk factors in patients with type 2 diabetes mellitus (T2DM) may reduce diabetes-related complications. The strategy to broaden the knowledge base of primary care professionals to improve health care has mainly been prompted by the current reality of limited resources and access to specialized care. The main objective of this study is to assess the effectiveness of comprehensive interventions focused on treatment intensification, decrease clinical inertia and reduce possible barriers to treatment adherence in patients with poorly controlled diabetes in a primary care setting.

METHODS

This is a two-phase mixed method study, whose aims are the development of complex interventions and the assessment of their effectiveness. The main study outcome is a change in glycated haemoglobin (HbA1c) levels. The INTEGRA study is divided into two phases. Phase 1: A qualitative study with a phenomenological approach using semi-structured interviews with the objective of determining the factors related to the participants and health care professionals that influence the development and implementation of a specific intervention strategy aimed at patients with poor glycaemic control of T2DM in primary care. Phase 2: Exploratory intervention study to be conducted in Primary Health Care Centres in Catalonia (Spain), including 3 specific health care areas. The intervention study has two arms: Intervention Group 1 and 2. Each intervention group will recruit 216 participants (the same as in the control group) between the ages of 30 and 80 years with deficient glycaemic control (HbA1c > 9%). The control group will be established based on a randomized selection from the large SIDIAP (Sistema d'Informació per al desenvolupament de la Investigació en Atenció Primària) database of patients with comparable socio-demographic and clinical characteristics from the three provinces.

DISCUSSION

This study is a comprehensive, pragmatic intervention based on glycaemic treatment intensification and the control of other cardiovascular risk factors. It is also aimed at improving treatment adherence and reducing clinical inertia, which could lead to improved glycaemic control and could likewise be feasible for implementation in the actual clinical practice of primary care.

TRIAL REGISTRATION

Clinicaltrials.gov . registration number. NCT02663245; January 25, 2016.

Supporting general practitioner-based care for poorly controlled type 2 diabetes mellitus (the DECIDE study): feasibility study and protocol for a pilot cluster randomised controlled trial

BACKGROUND

Poorly controlled type 2 diabetes mellitus (T2DM) is associated with significant morbidity, mortality and healthcare costs. Control of T2DM can be challenging for healthcare professionals for a number of reasons, including poor concordance with medications, difficulties modifying lifestyle behaviour and also clinical inertia, which is defined as a reluctance among health professionals to intensify medications. A complex intervention, called ComputeriseD dECisIonal support for poorly controlleD typE 2 Diabetes mellitus in Irish General Practice (DECIDE), was developed, identifying T2DM patients with poor glycaemic and blood pressure control and aiming to target clinical inertia, by supporting therapeutic action, including GP-led medication intensification where appropriate. A small-scale, uncontrolled, non-randomised feasibility study highlighted the acceptability of the DECIDE intervention within Irish General Practice. This paper presents a protocol for a pilot cluster randomised controlled trial (RCT) of the DECIDE intervention.

METHODS/DESIGN

The pilot cluster RCT will involve 14 practices and 140 patients in Irish General Practice. Intervention GPs will participate in the DECIDE intervention, comprising (a) a training programme for the practices and (b) a web-based clinical decision support system supporting treatment escalation, tailored to specific patient information. Only patients who have poorly controlled T2DM (defined as HbA1c > 70 mmol/mol and/or BP > 150/95) will be included. The primary outcomes will include measures of feasibility such as recruitment and retention of practices and acceptability of the intervention and also HbA1c. Secondary outcomes will include medication intensification, blood pressure and lipids. Control GPs will continue to provide usual care. A process evaluation will be performed to determine whether the intervention is delivered as intended and treatment fidelity assessed to monitor and enhance the reliability and validity of interventions. An exploratory health economic analysis will examine the potential costs and cost effectiveness of the intervention relative to the control.

DISCUSSION

A pilot cluster RCT will establish the feasibility of a complex intervention which aims to support primary care for patients with poorly controlled T2DM in Irish General Practice.

TRIAL REGISTRATION

The protocol for the pilot cluster RCT is registered on the ISRCTN Registry at: ISRCTN69498919.

Effectiveness of standardized nursing care plans to achieve A1C, blood pressure, and LDL-C goals among people with poorly controlled type 2 diabetes mellitus at baseline: four-year follow-up study

Background

No studies that have measured the role of nursing care plans in patients with poorly controlled type 2 diabetes mellitus. Our objectives were firstly, to evaluate the effectiveness of implementing Standardized languages in Nursing Care Plans (SNCP) for improving A1C, blood pressure and low density lipoprotein cholesterol (ABC goals) in patients with poorly controlled type 2 diabetes mellitus at baseline (A1C ≥7%, blood pressure ≥ 130/80 mmHg, and low-density lipoprotein cholesterol≥100 mg/dl) compared with Usual Nursing Care (UNC). Secondly, to evaluate the factors associated with these goals.

Methods

A four-year prospective follow-up study among outpatients with type 2 diabetes mellitus: We analyzed outpatients of 31 primary health centers (Madrid, Spain), with at least two A1C values (at baseline and at the end of the study) who did not meet their ABC goals at baseline. A total of 1916 had A1C ≥7% (881 UNC versus 1035 SNCP). Two thousand four hundred seventy-one had systolic blood pressure ≥ 130 mmHg (1204 UNC versus 1267 SNCP). One thousand one hundred seventy had diastolic blood pressure ≥ 80 mmHg (618 UNC versus 552 SNCP); and 2473 had low-density lipoprotein cholesterol ≥100 mg/dl (1257 UNC versus 1216 SNCP). Data were collected from computerized clinical records; SNCP were identified using NANDA and NIC taxonomies.

Results

More patients cared for using SNCP achieved in blood pressure goals compared with patients who received UNC (systolic blood pressure: 29.4% versus 28.7%, p = 0.699; diastolic blood pressure: 58.3% versus 53.2%, p = 0.08), but the differences did not reach statistical significance. For A1C and low-density lipoprotein cholesterol goals, there were no significant differences between the groups. Coronary artery disease was a significant predictor of blood pressure and low-density lipoprotein cholesterol goals.

Conclusions

In patients with poorly controlled type 2 diabetes mellitus, there is not enough evidence to support the use of SNCP instead of with UNC with the aim of helping patients to achieve their ABC goals. However, the use of SNCP is associated with a clear trend of a achievement of diastolic blood pressure goals.

Therapeutic inertia in the treatment of hyperglycaemia in patients with type 2 diabetes: A systematic review

AIMS

Therapeutic inertia, defined as the failure to initiate or intensify therapy in a timely manner according to evidence-based clinical guidelines, is a key reason for uncontrolled hyperglycaemia in patients with type 2 diabetes. The aims of this systematic review were to identify how therapeutic inertia in the management of hyperglycaemia was measured and to assess its extent over the past decade.

MATERIALS AND METHODS

Systematic searches for articles published from January 1, 2004 to August 1, 2016 were conducted in MEDLINE and Embase. Two researchers independently screened all of the titles and abstracts, and the full texts of publications deemed relevant. Data were extracted by a single researcher using a standardized data extraction form.

RESULTS

The final selection for the review included 53 articles. Measurements used to assess therapeutic inertia varied across studies, making comparisons difficult. Data from low- to middle-income countries were scarce. In most studies, the median time to treatment intensification after a glycated haemoglobin (HbA1c) measurement above target was more than 1 year (range 0.3 to >7.2 years). Therapeutic inertia increased as the number of antidiabetic drugs rose and decreased with increasing HbA1c levels. Data were mainly available from Western countries. Diversity of inertia measures precluded meta-analysis.

CONCLUSIONS

Therapeutic inertia in the management of hyperglycaemia in patients with type 2 diabetes is a major concern. This is well documented in Western countries, but corresponding data are urgently needed in low- and middle-income countries, in view of their high prevalence of type 2 diabetes.

Homogenization of the lipid profile values

Analytical reports from the clinical laboratory are essential to guide clinicians about what lipid profile values should be considered altered and, therefore, require intervention. Unfortunately, there is a great heterogeneity in the lipid values reported as "normal, desirable, recommended or referenced" by clinical laboratories. This can difficult clinical decisions and be a barrier to achieve the therapeutic goals for cardiovascular prevention. A recent international recommendation has added a new heterogeneity factor for the interpretation of lipid profile, such as the possibility of measuring it without previous fasting. All this justifies the need to develop a document that adapts the existing knowledge to the clinical practice of our health system. In this regard, professionals from different scientific societies involved in the measurement and use of lipid profile data have developed this document to establish recommendations that facilitate their homogenization.

Therapeutic inertia in patients treated with two or more antidiabetics in primary care: Factors predicting intensification of treatment

AIMS

To determine the patterns and predictors of treatment intensification in patients with type 2 diabetes on ≥2 non-insulin antidiabetic drugs (NIADs) and inadequate glycaemic control in primary care in Catalonia, Spain.

MATERIAL AND METHODS

This was a retrospective analysis using electronic medical records from patients with HbA1c ≥ 7% and a first prescription for a new NIAD or insulin recorded from January 2010 to December 2014. Therapeutic inertia was defined as no intensification if HbA1c was ≥8% at baseline or during follow-up. Time to first intensification was evaluated by time-to-event analysis, and factors predicting intensification through a competing-risk regression model.

RESULTS

Among 23 678 patients with HbA1c ≥ 7%, 26.2% were censored without treatment intensification after a median follow up of 4.2 years. Among the 12 730 patients in the subgroup with HbA1c ≥ 8% at baseline or during follow-up, therapeutic inertia was present in 18.1% of cases. In the overall cohort, mean HbA1c at initiation of insulin and NIAD were 9.4% ± 1.5% and 8.7% ± 1.3%, respectively. Median time to first intensification was 17.1 months in patients with HbA1c 8.0% to 9.9%, and 10.1 months in those with HbA1c > 10%. Variables strongly associated with intensification were HbA1c values 8.0% to 9.9% (subhazard ratio [SHR], 1.7; 95% CI, 1.65-1.78) and >10% (SHR, 2.5; 95% CI, 2.37-2.68); diabetes duration ≥20 years (SHR, 1.25; 95% CI, 1.11-1.41) and, to a lesser extent, female gender, presence of comorbidities, chronic kidney disease and microvascular complications.

CONCLUSIONS

Intensification was not undertaken in 1 in 5 patients. Both HbA1c thresholds and time until therapy intensification exceeded current recommendations.

Development of a complex intervention to promote appropriate prescribing and medication intensification in poorly controlled type 2 diabetes mellitus in Irish general practice

BACKGROUND

Poorly controlled type 2 diabetes mellitus (T2DM) can be seen as failure to meet recommended targets for management of key risk factors including glycaemic control, blood pressure and lipids. Poor control of risk factors is associated with significant morbidity, mortality and healthcare costs. Failure to intensify medications for patients with poor control of T2DM when indicated is called clinical inertia and is one contributory factor to poor control of T2DM. We aimed to develop a theory and evidence-based complex intervention to improve appropriate prescribing and medication intensification in poorly controlled T2DM in Irish general practice.

METHODS

The first stage of the Medical Research Council Framework for developing and evaluating complex interventions was utilised. To identify current evidence, we performed a systematic review to examine the effectiveness of interventions targeting patients with poorly controlled T2DM in community settings. The Behaviour Change Wheel theoretical approach was used to identify suitable intervention functions. Workshops, simulation, collaborations with academic partners and observation of physicians were utilised to operationalise the intervention functions and design the elements of the complex intervention.

RESULTS

Our systematic review highlighted that professional-based interventions, potentially through clinical decision support systems, could address poorly controlled T2DM. Appropriate intensification of anti-glycaemic and cardiovascular medications, by general practitioners (GPs), for adults with poorly controlled T2DM was identified as the key behaviour to address clinical inertia. Psychological capability was the key driver of the behaviour, which needed to change, suggesting five key intervention functions (education, training, enablement, environmental restructuring and incentivisation) and nine key behaviour change techniques, which were operationalised into a complex intervention. The intervention has three components: (a) a training program/academic detailing of target GPs, (b) a remote finder tool to help GPs identify patients with poor control of T2DM in their practice and (c) A web-based clinical decision support system.

CONCLUSIONS

This paper describes a multifaceted process including an exploration of current evidence and a thorough theoretical understanding of the predictors of the behaviour resulting in the design of a complex intervention to promote the implementation of evidence-based guidelines, through appropriate prescribing and medication intensification in poorly controlled T2DM.

[Adaptation and validation of the SMP-T2D questionnaire in Spanish for evaluating self-management of high blood pressure and type 2 diabetes: PAG-DT2+HTA]

BACKGROUND

High blood pressure is one of the most common chronic conditions worldwide. It affects one in every 3 adults over 40, while one in 10 suffers from diabetes. For both diseases, adherence to pharmacological treatment is over 30%, and self-management, which takes into account diet and physical activity, is still unknown, as there is no tool available to measure self-management. Therefore, the object of this study was to adapt and validate the Spanish version of the self-management profile for type 2 diabetes (SMP-T2D) questionnaire in patients with type 2 diabetes and high blood pressure among users of first level care in the social security institution of Mexico.

METHODS

The SMP-T2D was adapted to Spanish by translation into Spanish, and being used only in patients with high blood pressure and type 2 diabetes-hypertension. A convergent and discriminatory validation was performed. Patients over 50 years old with high blood pressure were include. Those that did not complete the questionnaire or give informed consent were rejected.

RESULTS

The Spanish version of the SMP-T2D was called PAG-DT2+HTA, and was applied to 145 people with hypertension: 54.4% with hypertension only, and 43.6% with hypertension and type 2 diabetes. Mean age was 66.14 years (SD=10.78), with 34.7% women and 65.3% men. Internal consistency by α-Cronbach for the questionnaire was 0.561 (P=.000). The correlation between the PAG-DT2+HTA and Morisky-Green was significant. The ability to discriminate between people with and without education and with and without economic means was obtained.

CONCLUSION

The Spanish version of SMP-T2D (PAG-DT2+HTA) that measures self-management in type 2 diabetes, can be used to measure self-management in people with type 2 diabetes-hypertension.

[Dyslipidemia management in patients with high cardiovascular risk in Spain. ALMA study]

Objetivo

Evaluar la actitud de los médicos de atención primaria (MAP) y de atención especializada (MAE) ante el tratamiento de pacientes con dislipemia, especialmente en aquellos con factores de riesgo cardiovascular (RCV).

Diseño

Estudio observacional, descriptivo, multicéntrico, basado en una encuesta.

Emplazamiento

Diferentes áreas sanitarias de España.

Participantes

1.402 MAP y 596 MAE.

Mediciones principales

Perfil de los médicos, hábitos de tratamiento en pacientes con dislipemia.

Resultados

El 84,3% consideraban el RCV para establecer el tratamiento. El objetivo de concentración de cLDL en pacientes sin factores de RCV fue < 130 mg/dl y < 160 mg/dl para el 51,9 y el 29,0%, respectivamente. En pacientes con hipertensión, tabaquismo o diabetes el objetivo de cLDL fue < 100 mg/dl para el 49-55%, mientras que en pacientes con complicación cardiovascular, cardiopatía isquémica o ictus fue < 70 mg/dl para el 71-88%. El fármaco de elección en pacientes sin factores de RCV fue atorvastatina (66%), mientras que en pacientes con diabetes, enfermedad renal o síndrome metabólico fue pitavastatina (80-89%). Los MAE mostraron una mayor tendencia que los MAP a considerar un objetivo de cLDL < 70 mg/dl en pacientes con antecedentes de ictus (77,5% vs 66,8%) o enfermedad coronaria (92,1% vs 80,6%) (p < 0,0001), y una mayor preferencia por el tratamiento combinado al no alcanzar el objetivo de cLDL (58,1% vs 50,2%; p = 0,0013).

Conclusiones

Aunque el cálculo del RCV se acepta de forma general, existe disparidad en los objetivos del cLDL. Los MAE consideran unos objetivos más ambiciosos y la asociación de fármacos hipolipemiantes con más frecuencia que los MAP.

Medication adherence and persistence in type 2 diabetes mellitus: perspectives of patients, physicians and pharmacists on the Spanish health care system

OBJECTIVE

A good relationship between diabetes patients and their health care team is crucial to ensure patients' medication adherence and self-management. To this end, we aimed to identify and compare the views of type 2 diabetes mellitus (T2DM) patients, physicians and pharmacists concerning the factors and strategies that may be associated with, or could improve, medication adherence and persistence.

METHODS

An observational, cross-sectional study was conducted using an electronic self-administered questionnaire comprising 11 questions (5-point Likert scale) concerning factors and strategies related to medication adherence. The survey was designed for T2DM patients and Spanish National Health System professionals.

RESULTS

A total of 963 T2DM patients, 998 physicians and 419 pharmacists participated in the study. Overall, a lower proportion of pharmacists considered the proposed factors associated with medication adherence important as compared to patients and physicians. It should be noted that a higher percentage of physicians in comparison to pharmacists perceived that "complexity of medication" (97% vs 76.6%, respectively) and "adverse events" (97.5% vs 72.2%, respectively) were important medication-related factors affecting adherence. In addition, both patients (80.8%) and physicians (80.8%) agreed on the importance of "cost and co-payment" for adherence, whereas only 48.6% of pharmacists considered this factor important. It is also noteworthy that nearly half of patients (43%) agreed that "to adjust medication to activities of daily living" was the best strategy to reduce therapeutic complexity, whereas physicians believed that "reducing the frequency of administration" (47.9%) followed by "reducing the number of tablets" (28.5%) was the most effective strategy to improve patients' adherence.

CONCLUSION

Our results highlight the need for pharmacists to build a stronger relationship with physicians in order to improve patients monitoring and adherence rates. Additionally, these findings may help to incorporate greater patient-centeredness when developing management strategies, focusing on adjusting medication regimens to patients' daily lives.

Clinical characteristics of type 2 diabetic patients on basal insulin therapy with adequate fasting glucose control who do not achieve HbA1c targets

BACKGROUND

The aim of the present study was to determine the clinical characteristics of patients with type 2 diabetes mellitus (T2DM) treated with basal insulin who achieved an adequate fasting plasma glucose (FPG) level (<130 mg/dL), but were unable to achieve the HbA1c target (<7%; <53 mmol/mol).

METHODS

A cross-sectional study was performed on T2DM patients aged 31-90 years treated with basal insulin registered in the SIDIAP^Q primary healthcare electronic database during 2010.

RESULTS

In 2010, of a population of 126 811 T2DM subjects, 9899 were treated with basal insulin (neutral protamine Hagedorn [NPH], detemir, or glargine). Of these, 23.5% (n = 2322) achieved optimal FPG control levels (<130 mg/dL) but an inadequate HbA1c target (>7%). Mean HbA1c values in the contolled and uncontrolled groups were 8.15% (65.6 mmol/mol) and 6.31% (45.5 mmol/mol), respectively. Patients with controlled FPG but uncontrolled HbA1c had longer T2DM duration (11.6 vs 9.9 years), higher systolic blood pressure (138.2 vs 136.3 mmHg) and low-density lipoprotein cholesterol (104 vs 99 mg /dL), and a higher prevalence of retinopathy (24.8% vs 18.2%) than patients (17.8%) with optimal control of both glycemic targets (P < 0.05). Multivariate analysis showed that inadequate glycemic control was positively related only to younger age.

CONCLUSION

One-quarter of T2DM patients treated with basal insulin have difficulties attaining the recommended HbA1c goal despite adequate FPG levels. As some guidelines state, healthcare professionals should focus on PPG to identify and intensify treatment to control prandial glucose excursions in these patients.

Concordance between two methods in measuring treatment adherence in patients with type 2 diabetes

OBJECTIVE

We analyzed the concordance between two methods for measuring treatment adherence (TA) and studied the determinants of TA in patients with type 2 diabetes mellitus.

METHODS

We conducted a cross-sectional descriptive study in a primary care center, involving 320 diabetic patients. TA was measured using the Haynes-Sackett (H-S) adherence test during the patient interview and based on pharmacy refill data. TA was calculated globally and by drug groups (antihypertensive, lipid-lowering, and antidiabetic drugs).

RESULTS

Poor TA as measured by the H-S test was observed in 11.2% of the patients. Based on pharmacy refill data, there was a poor global TA rate of 30.3%, which was 33.3%, 26.6%, and 34.2% for oral antidiabetic, antihypertensive, and lipid-lowering drugs, respectively. Concordance between the two methods was poor. There was no relationship between the degree of disease control and TA as measured by the H-S test. Good TA measured based on pharmacy refill data for antidiabetic and antihypertensive drugs was associated with lower glycosylated hemoglobin and diastolic blood pressure values, respectively. Patients with good global TA showed lower glycosylated hemoglobin, diastolic blood pressure, and low-density lipoprotein cholesterol values. The multivariate analysis found good oral antidiabetic adherence to be associated to free pharmacy service; good antihypertensive drug adherence to the existence of comorbidities; and good lipid-lowering drug adherence to a history of ischemic heart disease, and a more experienced physician and/or female physician.

CONCLUSION

Concordance between the two methods in assessing TA was low. Approximately one-third of the patients with type 2 diabetes mellitus presented poor TA in relation to antihypertensive, lipid-lowering, and antidiabetic medication. An improved TA was associated with a better control of the studied parameters. Comorbidities, such as ischemic heart disease and access to free pharmacy service, were identified as determinants of good TA.

[Adherence of Type 2 Diabetes Mellitus approach: Current situation and possible solutions]

Objetivos

Definir el impacto y las causas de la falta de adherencia terapéutica en los pacientes con diabetes mellitus tipo 2 (DM2), las posibles intervenciones para mejorarla y el papel de las distintas partes implicadas.

Diseño

Valoración de cuestionario estructurado mediante método Delphi aplicado en 2 rondas.

Emplazamiento

Estudio realizado en el ámbito de atención primaria.

Participantes

Panel formado por profesionales médicos de reconocido prestigio y con amplia experiencia en diabetes.

Mediciones principales

Valoración a través de una escala Likert de 9 puntos del grado de acuerdo o desacuerdo de 131 ítems agrupados en 4 bloques: impacto; causas de incumplimiento; diagnóstico de la falta de adherencia y de sus posibles causas, y mejores intervenciones y papel de los distintos roles implicados en la mejora de la adherencia.

Resultados

Con una tasa de participación del 76,31%, los profesionales sanitarios de atención primaria consensuaron 110 de las 131 aseveraciones propuestas (84%), mostrando acuerdo en 102 ítems (77,9%) y desacuerdo en 8 (6,1%). No se logró consenso en 21 ítems.

Conclusiones

La falta de adherencia en los pacientes con DM2 dificulta lograr el control terapéutico. La formación específica y disponer de los recursos necesarios en la consulta son esenciales para minimizar el impacto de la falta de adherencia terapéutica.

Prevalence, Treatment, and Control of Hypercholesterolemia in High Cardiovascular Risk Patients: Evidences from a Systematic Literature Review in Spain

Introduction

Cardiovascular diseases (CVDs) represent a major Public Health burden. High serum cholesterol levels have been linked to major CV risk. The objectives of this study were to review the epidemiology of hypercholesterolemia in high risk CV patients from Spain, by assessing its prevalence, the proportion of diagnosed patients undergoing pharmacological treatment and the degree of attained lipid control.

Methods

A systematic literature review was carried out using Medline and two Spanish databases. Manuscripts containing information on hypercholesterolemia in several high CV risk groups [diabetes mellitus (DM), Systematic COronary Risk Evaluation (SCORE) risk >5, or documented CVD], published between January 2010 and October 2014, were included.

Results

Of the 1947 published references initially retrieved, a full-text review was done on 264 manuscripts and 120 were finally included. Prevalence of hypercholesterolemia ranged from 50 to 84% in diabetics, 30–60% in patients with DM or elevated SCORE risk, 64–74% with coronary heart disease, 40–70% in stroke patients, and 60–80% in those with peripheral artery disease. Despite the finding that most of them were on pharmacological treatment, acceptable control of serum lipids was very variable, ranging from 15% to 65%. Among those with heterozygous familial hypercholesterolemia, 95–100% received treatment but less than 50% achieved their therapeutic goals.

Conclusions

An elevated prevalence of hypercholesterolemia can be found in targeted groups at high CV risk. Although most patients are receiving pharmacological treatment, rates of lipid control continue to be low, both in primary and secondary prevention.

Electronic supplementary material

The online version of this article (doi:10.1007/s12325-015-0252-y) contains supplementary material, which is available to authorized users.

Glycemic control and use of A1c in primary care patients with type 2 diabetes mellitus

AIMS

To evaluate the degree of glycemic control and its relationship with disease characteristics and antidiabetic treatment in patients with type 2 diabetes mellitus (DM), as well as the frequency of A1c use.

METHODS

For this purpose, an observational, cross-sectorial, and multicenter study was performed. A total of 443 patients were monitored in 17 Spanish primary healthcare centers. Demographic and clinical variables were recorded from the clinical history of patients.

RESULTS

Mean age was 68.9±12.0 years. Time of evolution of DM was 9.2±6.4 years. Mean A1c was 7.38±1.34% and 45% of patients achieved A1c <7%. There was a no significant relationship between the degree of control and time of evolution of DM. In 16% of patients no A1c determination was performed in the previous twelve months. In those patients in whom A1c was determined, 95% received pharmacologic treatment, and 31% insulin therapy. 66% of patients on monotherapy attained A1C <7%, compared with 39% and 23% of those receiving double- and triple-oral therapy, respectively (p<0.001). Only 21% of patients on insulin therapy achieved A1c <7%. The worst-controlled patients were those receiving oral antidiabetic agents and insulin (24% had A1c levels ≥9%).

CONCLUSIONS

A large proportion of patients are poorly controlled. Poor control increases according to complexity of treatment. A1c is underdetermined in many patients, likely related to clinical inertia.

[Satisfaction of patients with type 2 diabetes mellitus after starting treatment with insulin]

OBJECTIVES

The objective of this study is to evaluate if overcoming the barrier of starting treatment with insulin can lead to better clinical control and a higher level of patient satisfaction with their treatment.

MATERIAL AND METHODS

This is an observational, multicentre study of patients diagnosed with DM2 who attended primary care centres with poor glycaemic control (A1c≥8%) under treatment with oral antidiabetic drugs (OADs), and who were given motivational treatment to overcome their fear of injections, and started treatment with insulin. The level of satisfaction with the treatment was evaluated using the Diabetes Treatment Satisfaction Questionnaire (DTSQ). The questionnaire was used before initiating the treatment with insulin and in the follow-up visit (3-4 months from the beginning of treatment with basal insulin).

RESULTS

A total of 573 patients with a mean age of 64±10 years were recruited. The overall mean score from the DTSQs satisfaction questionnaire was 18.3±6.3, and the change of treatment led to an improvement in patient satisfaction compared to the previous treatment (DTSQc mean score 8.8±5.9). A1c dropped from an initial value of 8.7% (SD 0.8) to 7.5% (SD 0.7) (P<.001). The frequency of hyperglycaemic episodes perceived by the patients was significantly lower after they overcame their fear of injections (35.6% compared to 11.5%; P<.001), but no statistically significant differences were found in the frequency of hypoglycaemic episodes (32% compared to 35%; P=.059).

CONCLUSION

In patients with DM2 poorly controlled with OADs, overcoming a fear of injections and starting treatment with insulin was associated with an overall improvement in satisfaction with the new treatment, and decreased the perception of hyperglycaemic episodes. Glycaemic control and the metabolic profile of the patients also improved to a statistically significant degree with the change of treatment.

[Prospective observational study of insulin detemir in patients with poorly controlled type 2 diabetes mellitus initiating insulin therapy for the first time (SOLVE Study)]

Objetivo

Describir la experiencia en atención primaria con insulina detemir en pacientes con diabetes mellitus tipo 2 mal controlados con antidiabéticos orales que necesitan incorporar una insulina a su terapia antidiabética.

Métodos

Estudio observacional prospectivo de 6 meses de seguimiento realizado en 10 países. En España participaron solo centros de atención primaria. Se reclutaron pacientes con diabetes mellitus tipo 2 mal controlados a cuyo tratamiento con antidiabéticos orales se había añadido insulina detemir (una vez al día) durante el mes previo a la inclusión en el estudio. Se analizaron los cambios de HbA1c y de peso al final del estudio, así como la incidencia de hipoglucemia y reacciones adversas. Se presentan los resultados obtenidos en la cohorte española.

Resultados

Se incluyeron 17.374 pacientes en total, 973 en España (media de edad 64,8 años [DE 12]; duración de la diabetes 9,4 años [DE 6,2]; Hb1Ac 8,9% [DE 1,4]). En la muestra para eficacia (n = 474), el cambio medio de Hb1Ac fue −1,6% (IC 95%: −1,75 a −1,42; p < 0,001; el cambio medio del peso fue −2,9 kg (IC 95%: −3,72 a −2.08; p < 0,001. Solo se registró un episodio de hipoglucemia grave, que fue también la única reacción adversa grave comunicada en el estudio. La tasa de incidencia de hipoglucemia no grave fue de 2,44 eventos/paciente-año.

Conclusiones

En esta cohorte de pacientes con diabetes mellitus tipo 2 recientemente insulinizados, la insulina detemir (una vez al día) mejoró el control glucémico, con baja incidencia de hipoglucemia y una reducción significativa del peso.

[Therapeutic inertia in the management of type 2 diabetic patients in Primary Health Care]

OBJECTIVE

To assess therapeutic inertia (TI) in the management of type 2 diabetic patients (DM2), as regards glycemic and lipid control.

MATERIALS AND METHODS

Two groups of patients were studied. Group 1: All the patients were older than 14 years, diagnosed with DM2 up to 28th February 2013, and their last determination of HbA1c was ≥ 8.5%. Group 2: All patients, under 60 years old, diagnosed with DM2 between the 1st January 2011 and the 31st December 2012, with no chronic complications and their last determination of HbA1c was ≥ 6.5%.

RESULTS

Group 1: 253 patients were included (13% of DM2 diagnosed). TI was 43% for DM2, 83% for LDL cholesterol, and 80% for triglycerides. TI was lower (P=.037) in patients with HbA1c ≥ 10%. There was no difference in TI as regards the management of lipid profile depending on the HbA1c levels. Group 2: All DM2 patients (n=53) who met inclusion criteria were assessed (2.7% of DM2 diagnosed). Percentage of visits of those patients that had TI: 55% for DM2, 63% for LDL cholesterol and 64% for triglycerides. A more intense therapy was observed in patients with HbA1c>7.5% in 3 of the 5 visits made.

CONCLUSIONS

TI in both groups was high and there is a lack of recording the reasons for this. It is important to improve the attitude of the professionals who care for the diabetic population.

[Patient's care and management of dyslipidemia in type 2 diabetic patients in the clinical practice in Spain: The LIPEDIA study]

INTRODUCTION

Treatment of atherogenic dyslipidemia (AD) in type 2 diabetes (DM2) should focus on the global control of dyslipidemia. The aim of this study was to determine how hospital (MSs) and primary care specialist (GPs) from Spain manage AD in DM2 during their daily practice.

METHODS

An observational, cross-sectional, multicentric study was conducted. Information about daily practice was obtained from 497 MSs and 872 GPs across Spain.

RESULTS

66% of MSs and 30.5% of GPs considered DM2 patients to be high-risk. Most consider the c-LDL targets based on European guidelines. The statins most widely used are atorvastatin and simvastatin. However both MSs and GPs considered rosuvastatin to be the most appropriate statin for these patients. 82% of MSs and 68% of GPs considered that >50% of their patients achieved the c-LDL target. The main reasons of not achieving this target were lack of treatment adherence and pressure from the administration. Seventy four percent of MSs reported that there are no common clinical protocols with GPs.

CONCLUSIONS

The differences in the perception of the real cardiovascular risk of the patient, low use of more appropriate statins, lack of adherence and poor perception of real c-LDL control may contribute to the failure in achieving lipid targets in DM2.

Breaking Therapeutic Inertia in Type 2 Diabetes: Active Detection of In-Patient Cases Allows Improvement of Metabolic Control at Midterm

Type 2 diabetes (T2D) exists in 25-40% of hospitalized patients. Therapeutic inertia is the delay in the intensification of a treatment and it is frequent in T2D. The objectives of this study were to detect patients admitted to surgical wards with hyperglycaemia (HH; fasting glycaemia > 140 mg/dL) as well as those with T2D and suboptimal chronic glycaemic control (SCGC) and to assess the midterm impact of treatment modifications indicated at discharge. A total of 412 HH patients were detected in a period of 18 months; 86.6% (357) had a diagnosed T2D. Their preadmittance HbA1c was 7.7 ± 1.5%; 47% (189) had HbA1c ≥ 7.4% (SCGC) and were moved to the upper step in the therapeutic algorithm at discharge. Another 15 subjects (3.6% of the cohort) had T2D according to their current HbA1c. Ninety-four of the 189 SCGC patients were evaluated 3-6 months later. Their HbA1c before in-hospital-intervention was 8.6 ± 1.2% and 7.5 ± 1.2% at follow-up (P < 0.004). Active detection of hyperglycaemia in patients admitted in conventional surgical beds permits the identification of T2D patients with SCGC as well as previously unknown cases. A shift to the upper step in the therapeutic algorithm at discharge improves this control. Hospitalization is an opportunity to break therapeutic inertia.

[Consensus document on the treatment of dyslipidemia in diabetes]

People with type 2 diabetes mellitus have a 2 to 4 times higher risk of developing cardiovascular diseases when compared to general population of similar age and sex. This risk remains after adjustment of other traditional cardiovascular risk factors. The dyslipidemia associated with type 2 diabetes mellitus is present in up to 60% of people with diabetes and contributes greatly to increased cardiovascular, morbidity and mortality risk in these patients. Diabetic dyslipidemia is a disorder of lipid metabolism characterized by an excess of triglycerides, a decrease in HDL-cholesterol and altered lipoprotein composition, consisting mainly in an excess of small, dense LDL particles. Multiple clinical trials have demonstrated the benefits of drug treatment of dyslipidemia (mainly statins) to prevent cardiovascular events and mortality in people with diabetes, both in primary and secondary prevention. This consensus document, developed by general practitioners, members of the Diabetes Group of the Spanish Society of Primary Care Physicians (SEMERGEN), aims to assist in the management of patients with diabetes and dyslipidemia in accordance with the most recent recommendations.

Glycemic control in patients with type 2 diabetes mellitus in Spain

OBJECTIVE

To evaluate the degree of glycemic control in patients with type 2 diabetes in Spain and identify factors associated with glycemic control.

PATIENTS AND METHODS

This was a cross-sectional, multicenter, epidemiological study that used consecutive sampling and was conducted in primary care practices in Spain. A total of 5591 patients with type 2 diabetes mellitus lasting more than 1 year and who were treated with hypoglycemic agents for more than 3 months were included in the study. At a single visit, HbA1c levels were measured (A1cNow+ system) and demographic and clinical variables related to diabetes and its treatment were recorded. During the visit, CV risk factors (CVRF), the presence of target-organ damage (TOD), the presence of hypoglycemia and body weight changes within the previous year were recorded.

RESULTS

We analyzed data from 5382 patients (mean age 66.7 [10.8] years, mean duration of the diabetes 8.8 [6.3] years). TOD was present in 43.6% of the patients and 59.1% were taking 2 or more drugs. The patients' mean HbA1c was 7.1 (1.1)%, and 48.6% had HbA1c levels <7.0%. The patients with HbA1c levels ≥7.0% had longer-standing diabetes, a higher prevalence of TOD and CVRF, used more complex therapies, experienced more hypoglycemic episodes in the previous year and had more weight gain. In the multivariate analysis, the absence of insulin treatment, the absence of abdominal obesity and atherogenic dyslipidemia, a duration of the diabetes <10 years and an age >70 years were associated with improved glycemic control.

CONCLUSIONS

Patients with poorly controlled type 2 diabetes mellitus are highly prevalent in Spain. Factors associated with poorer glycemic control include the complexity of both the disease and the hypoglycemic therapy, a history of hypoglycemia and weight gain.

Nonmydriatic fundus photography for teleophthalmology diabetic retinopathy screening in rural and urban clinics

PURPOSE

To evaluate the relative diagnostic value of nonmydriatic fundus photography (nFP) among patients screened for diabetic retinopathy in remote rural medical clinics and an urban academic medical center for nonadherence to recommended annual dilated eye examination.

SUBJECTS AND METHODS

A retrospective cross-sectional study was performed among diabetic patients seen in primary outpatient clinics between 2006 and 2011 who were screened for diabetic retinopathy with nFP for history of nonadherence to recommended annual dilated eye examination. A single nonstereoscopic, 45°, 10-megapixel digital image of the disc and macula of both eyes was obtained locally and transmitted electronically to a retinal specialist for remote review. The results from remote rural Native American Indian reservations were compared with those from an urban academic family practice clinic. The proportion of subjects diagnosed with diabetic retinopathy and the quality of fundus images were compared.

RESULTS

Among 872 patients (1,744 eyes) screened from rural sites and 517 subjects (1,034 eyes) screened from an urban site, images were of good quality for evaluation in 82.4% and 85.7% of subjects, respectively. Diabetic retinopathy was noted in 12.6% of rural subjects and 29.6% of urban subjects (p<0.001).

CONCLUSIONS

nFP can be a useful tool in both rural and urban settings to screen for diabetic retinopathy in patients who are nonadherent to the recommended dilated annual eye exam. In our study population, a surprisingly higher percentage of diabetic subjects screened from the urban clinic had retinopathy compared with subjects screened in rural clinics.

Clinical inertia in the treatment of hyperglycemia in type 2 diabetes patients in primary care

OBJECTIVE

To assess clinical inertia, defined as failure to intensify antidiabetic treatment of patients who have not achieved the HbA1c therapeutic goal (≤7%).

RESEARCH DESIGN AND METHODS

Multicenter cross-sectional study. Clinical inertia was assessed in a random sample of type 2 diabetes mellitus (T2DM) patients seen in primary care centers.

RESULTS

A total of 2783 patients (51.3% males; mean age: 68 [±11.5] years; diabetes duration: 7.1 [±5.6] years; mean HbA1c: 6.8 [±1.5]) were analyzed. Of those, 997 (35.8%) had HbA1c >7%. Treatment was intensified in 66.8% and consisted of: dose increase (40.5%); addition of oral antidiabetic (45.8%); or insulin treatment initiation (3.7%). Mean HbA1c values in patients for whom treatment was intensified vs. non-intensified were 8.4% (±1.2) vs. 8.2% (±1.2), p < 0.05. Clinical inertia was detected in 33.2% of patients and diminished along with treatment complexity: lifestyle changes only (38.8%), oral monotherapy (40.3%), combined oral antidiabetics (34.5%), insulin monotherapy (26.1%) and combination of insulin and oral antidiabetics (21.4%). Clinical inertia decreased as HbA1c increased: 37.3% for HbA1c values ranging between 7.1%-8%; 29.4% for the 8.1%-9% HbA1c range and 27.1% for HbA1c ≥9%. Multivariate analysis confirmed that diabetes duration, step of treatment and HbA1c were related to inertia. For each unit of HbA1c increase clinical inertia decreased 47% (OR: 0.53).

LIMITATIONS

The retrospective design of the study precluded an accurate investigation about reasons for lack of intensification that could actually be justified by some patient conditions, especially patients' lack of adherence.

CONCLUSIONS

Clinical inertia affected one third of T2DM patients with poor glycemic control and was greater in patients treated with only lifestyle changes or oral monotherapy. Treatment changes were performed when mean HbA1c values were 1.4 points above therapeutic goals.

Quality of life and satisfaction with treatment in subjects with type 2 diabetes: results in Spain of the PANORAMA study

OBJECTIVES

Few studies are available on quality of life and treatment satisfaction of patients with type 2 diabetes mellitus (T2DM). Both of them were the primary objectives of the PANORAMA (NCT00916513) study. Metabolic control, treatment patterns, and management by healthcare professionals were also evaluated.

MATERIAL AND METHODS

This multicenter, cross-sectional, observational study randomly recruited>40 year-old patients with T2DM from Spanish healthcare centers. HbA1c was measured using the same technique in all patients, who also completed quality of life (EQ-5D and ADDQoL) and treatment satisfaction (DTSQ) questionnaires and the Hypoglycemia Fear Survey (HFS-II).

RESULTS

Fifty-four investigators recruited 751 patients, 60.3% of whom had HbA1c levels <7%. Approximately 25% of patients on monotherapy had HbA1c values ≥ 7%, Patients with longer disease duration and more complex treatments, especially with insulin, showed the poorer control. Despite good overall treatment satisfaction (mean 29.3±6.1, 0 to 36-point scale), patients with a poorer metabolic control, previous hypoglycemia episodes, and more complex therapies had a worse QoL and a greater fear of suffering hypoglycemia.

CONCLUSIONS

Despite advances in metabolic control, there are still areas to improve. Early addition of safe drugs to monotherapy would help achieve control objectives without increasing the risk of hypoglycemia, and delaying the start of insulin therapy. This would also improve QoL and treatment satisfaction.