1
|
Senior P, Hahn J, Mau G, Manivong P, Shaw E. Basal Insulin Initiation in Adults With Type 2 Diabetes Mellitus: A Retrospective Cohort Study Using Administrative Health Data in Alberta, Canada. Can J Diabetes 2024:S1499-2671(24)00100-X. [PMID: 38692484 DOI: 10.1016/j.jcjd.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 03/05/2024] [Accepted: 04/22/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVES Pharmacologic treatment of type 2 diabetes mellitus (T2DM) follows a stepwise approach. Typically, metformin monotherapy is first-line treatment, followed by other noninsulin antihyperglycemic agents (NIAHAs) or progression to insulin if glycated hemoglobin (A1C) targets are not achieved. We aimed to describe real-world patterns of basal insulin initiation in people with T2DM, and A1C not at target despite treatment with at least 2 NIAHAs. METHODS A retrospective cohort study was conducted using administrative health data from Alberta, Canada, among adults with T2DM, indexed on the first test with 7.0% < A1C < 9.5% (April 1, 2011 to March 31, 2019), with at least 2 previous NIAHAs but no insulin. Kaplan-Meier (KM) methodology was used to analyze time to basal insulin initiation, with stratification by index A1C. Annual patient status was categorized into 5 groups: basal insulin initiation, death, NIAHA intensification, no change in therapy (subgroups of A1C <7.1% and A1C ≥7.1% [clinical inertia]), or discontinuance. RESULTS The cohort included 14,083 individuals. The KM cumulative probability of initiating basal insulin was 7.7% (95% confidence interval [CI] 7.3% to 8.2%) at 1 year, increasing to 43.1% (95% CI 42.1% to 44.1%) at 8 years of follow-up. Higher A1C levels were associated with greater proportions of basal insulin initiation. By year 8, proportions with NIAHA intensification and clinical inertia were 12.1% and 19.3%, respectively, relative to year 7. CONCLUSIONS Despite current clinical practice guidelines recommending achieving A1C targets within 6 months, less than half of the individuals with T2DM and clear indications for basal insulin initiated treatment within 8 years. Efforts to reduce delays in basal insulin initiation are needed.
Collapse
Affiliation(s)
- Peter Senior
- Alberta Diabetes Institute-Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada.
| | - Jina Hahn
- Novo Nordisk Canada, Inc, Mississauga, Ontario, Canada
| | - Godfrey Mau
- Novo Nordisk Canada, Inc, Mississauga, Ontario, Canada
| | | | - Eileen Shaw
- Medlior Health Outcomes Research, Ltd, Calgary, Alberta, Canada
| |
Collapse
|
2
|
Riordan F, McHugh SM, O'Donovan C, Mtshede MN, Kearney PM. The Role of Physician and Practice Characteristics in the Quality of Diabetes Management in Primary Care: Systematic Review and Meta-analysis. J Gen Intern Med 2020; 35:1836-1848. [PMID: 32016700 PMCID: PMC7280455 DOI: 10.1007/s11606-020-05676-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 12/03/2019] [Accepted: 01/19/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Despite evidence-based guidelines, high-quality diabetes care is not always achieved. Identifying factors associated with the quality of management in primary care may inform service improvements, facilitating the tailoring of quality improvement interventions to practice needs and resources. METHODS We searched MEDLINE, EMBASE, CINAHL and Web of Science from January 1990 to March 2019. Eligible studies were cohort studies, cross-sectional studies and randomised controlled trials (baseline data) conducted among adults with diabetes, which examined the relationship between any physician and/or practice factors and any objective measure(s) of quality. Studies which examined patient factors only were ineligible. Where possible, data were pooled using random-effects meta-analysis. RESULTS In total, 82 studies were included. The range of individual quality measures and the construction of composite measures varied considerably. Female physicians compared with males ((odds ratio (OR) = 1.07, 95% CI: 1.04, 1.10), 8 studies), physicians with higher diabetes volume compared with lower volume (OR = 1.24, 95% CI: 1.05-1.47, 4 studies) and practices with Electronic Health Records (EHR) versus practices without (OR = 1.43, 95% CI: 1.11-1.84, 4 studies) were associated with a higher quality of care. There was no association between physician experience, practice location and type of practice and quality. Based on the narrative synthesis, increasing physician age and higher practice socio-economic deprivation may be associated with lower quality of care. DISCUSSION Identification of physician- and practice-level factors associated with the quality of care (female gender, younger age, physician-level diabetes volume, practice deprivation and EHR use) may explain differences across practices and physicians, provide potential targets for quality improvement interventions and indicate which practices need specific supports to deliver improvements in diabetes care.
Collapse
Affiliation(s)
- F Riordan
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland.
| | - S M McHugh
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
| | | | - Mavis N Mtshede
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
| | - P M Kearney
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
| |
Collapse
|
3
|
Thakarakkattil Narayanan Nair A, Donnelly LA, Dawed AY, Gan S, Anjana RM, Viswanathan M, Palmer CNA, Pearson ER. The impact of phenotype, ethnicity and genotype on progression of type 2 diabetes mellitus. Endocrinol Diabetes Metab 2020; 3:e00108. [PMID: 32318630 PMCID: PMC7170456 DOI: 10.1002/edm2.108] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 12/07/2019] [Indexed: 12/12/2022] Open
Abstract
AIM To conduct a comprehensive review of studies of glycaemic deterioration in type 2 diabetes and identify the major factors influencing progression. METHODS We conducted a systematic literature search with terms linked to type 2 diabetes progression. All the included studies were summarized based upon the factors associated with diabetes progression and how the diabetes progression was defined. RESULTS Our search yielded 2785 articles; based on title, abstract and full-text review, we included 61 studies in the review. We identified seven criteria for diabetes progression: 'Initiation of insulin', 'Initiation of oral antidiabetic drug', 'treatment intensification', 'antidiabetic therapy failure', 'glycaemic deterioration', 'decline in beta-cell function' and 'change in insulin dose'. The determinants of diabetes progression were grouped into phenotypic, ethnicity and genotypic factors. Younger age, poorer glycaemia and higher body mass index at diabetes diagnosis were the main phenotypic factors associated with rapid progression. The effect of genotypic factors on progression was assessed using polygenic risk scores (PRS); a PRS constructed from the genetic variants linked to insulin resistance was associated with rapid glycaemic deterioration. The evidence of impact of ethnicity on progression was inconclusive due to the small number of multi-ethnic studies. CONCLUSION We have identified the major determinants of diabetes progression-younger age, higher BMI, higher HbA1c and genetic insulin resistance. The impact of ethnicity is uncertain; there is a clear need for more large-scale studies of diabetes progression in different ethnic groups.
Collapse
Affiliation(s)
| | - Louise A. Donnelly
- Population Health & GenomicsSchool of MedicineUniversity of DundeeDundeeUK
| | - Adem Y. Dawed
- Population Health & GenomicsSchool of MedicineUniversity of DundeeDundeeUK
| | - Sushrima Gan
- Population Health & GenomicsSchool of MedicineUniversity of DundeeDundeeUK
| | | | | | - Colin N. A. Palmer
- Population Health & GenomicsSchool of MedicineUniversity of DundeeDundeeUK
| | - Ewan R. Pearson
- Population Health & GenomicsSchool of MedicineUniversity of DundeeDundeeUK
| |
Collapse
|
4
|
Murphy ME, McSharry J, Byrne M, Boland F, Corrigan D, Gillespie P, Fahey T, Smith SM. Supporting care for suboptimally controlled type 2 diabetes mellitus in general practice with a clinical decision support system: a mixed methods pilot cluster randomised trial. BMJ Open 2020; 10:e032594. [PMID: 32051304 PMCID: PMC7045235 DOI: 10.1136/bmjopen-2019-032594] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES We developed a complex intervention called DECIDE (ComputeriseD dECisIonal support for suboptimally controlleD typE 2 Diabetes mellitus in Irish General Practice) which used a clinical decision support system to address clinical inertia and support general practitioner (GP) intensification of treatment for adults with suboptimally controlled type2 diabetes mellitus (T2DM). The current study explored the feasibility and potential impact of DECIDE. DESIGN A pilot cluster randomised controlled trial. SETTING Conducted in 14 practices in Irish General Practice. PARTICIPANTS The DECIDE intervention was targeted at GPs. They applied DECIDE to patients with suboptimally controlled T2DM, defined as a glycated haemoglobin (HbA1c) ≥70 mmol/mol and/or blood pressure ≥150/95 mmHg. INTERVENTION The intervention incorporated training and a web-based clinical decision support system which supported; (i) medication intensification actions; and (ii) non-pharmacological actions to support care. Control practices delivered usual care. PRIMARY AND SECONDARY OUTCOME MEASURES Feasibility and acceptability was determined using thematic analysis of semi-structured interviews with GPs, combined with data from the DECIDE website. Clinical outcomes included HbA1c, medication intensification, blood pressure and lipids. RESULTS We recruited 14 practices and 134 patients. At 4-month follow-up, all practices and 114 patients were followed up. GPs reported finding decision support helpful navigating increasingly complex medication algorithms. However, the majority of GPs believed that the target patient group had poor engagement with GP and hospital services for a range of reasons. At follow-up, there was no difference in glycaemic control (-3.6 mmol/mol (95% CI -11.2 to 4.0)) between intervention and control groups or in secondary outcomes including, blood pressure, total cholesterol, medication intensification or utilisation of services. Continuation criteria supported proceeding to a definitive randomised trial with some modifications. CONCLUSION The DECIDE study was feasible and acceptable to GPs but wider impacts on glycaemic and blood pressure control need to be considered for this patient population going forward. TRIAL REGISTRATION NUMBER ISRCTN69498919.
Collapse
Affiliation(s)
- Mark E Murphy
- Department of General Practice, HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
| | - Jenny McSharry
- Health Behaviour Change Research Group, School of Psycology, NUI Galway, Galway, Ireland
| | - Molly Byrne
- Health Behaviour Change Research Group, School of Psycology, NUI Galway, Galway, Ireland
| | - Fiona Boland
- Department of General Practice, HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
| | - Derek Corrigan
- Department of General Practice, HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
| | - Paddy Gillespie
- School of Business and Economics, National University of Ireland, Galway, Ireland
| | - Tom Fahey
- Department of General Practice, HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
| | - Susan M Smith
- Department of General Practice, HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
| |
Collapse
|
5
|
Dailey GE, Dex TA, Roberts M, Liu M, Meneilly GS. Efficacy and safety of lixisenatide as add-on therapy to basal insulin in older adults with type 2 diabetes in the GetGoal-O Study. J Diabetes 2019; 11:971-981. [PMID: 31094074 PMCID: PMC6899823 DOI: 10.1111/1753-0407.12952] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 05/09/2019] [Accepted: 05/13/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND This study compared the efficacy and safety of lixisenatide with placebo as add-on therapy to basal insulin (BI) in adults aged ≥70 years with type 2 diabetes (T2D), with or without moderate renal insufficiency. METHODS This post hoc analysis evaluated data from non-frail patients with T2D inadequately controlled on BI with or without oral antidiabetic drugs (n = 108), randomized to once-daily lixisenatide 20 μg or placebo for 24 weeks (GetGoal-O Study). The primary endpoint was the change in HbA1c from baseline to Week 24. Secondary endpoints included changes from baseline in fasting plasma glucose, 2-hour postprandial plasma glucose (PPG), average seven-point self-monitored plasma glucose (SMPG), area under the curve for SMPG, daily BI dose, body weight, proportion of patients achieving HbA1c > 0.5%, and composite endpoints. Safety outcomes included the incidence of documented symptomatic hypoglycemia (plasma glucose <60 mg/dL) and gastrointestinal treatment-emergent adverse events (TEAEs). Outcomes were also analyzed by the occurrence of moderate renal insufficiency. RESULTS Compared with placebo, lixisenatide-treated patients had significantly greater reductions in HbA1c, 2-hour PPG, average seven-point SMPG, and body weight. Documented symptomatic hypoglycemia was approximately two-fold higher in patients treated with placebo than lixisenatide (12.7% vs 5.7%). GI TEAEs occurred more frequently in the lixisenatide- than placebo-treated group (34% vs 9.1%). Moderate renal insufficiency (estimated glomerular filtration rate between ≥30 and <60 mL/min/1.73 m2 ) did not negatively affect lixisenatide efficacy or safety. A greater proportion of patients treated with lixisenatide than placebo achieved composite endpoints. CONCLUSIONS Add-on therapy with lixisenatide in non-frail patients aged ≥70 years with T2D uncontrolled with BI is effective, safe, and well tolerated and should be considered in this population.
Collapse
|
6
|
Al-Musawe L, Martins AP, Raposo JF, Torre C. The association between polypharmacy and adverse health consequences in elderly type 2 diabetes mellitus patients; a systematic review and meta-analysis. Diabetes Res Clin Pract 2019; 155:107804. [PMID: 31376400 DOI: 10.1016/j.diabres.2019.107804] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/22/2019] [Accepted: 07/29/2019] [Indexed: 02/08/2023]
Abstract
AIM To summarize the existing literature concerning the association between polypharmacy and adverse health consequences in elderly patients with type 2 diabetes mellitus. METHODS We searched four literature databases (PubMed/Medline, ScienceDirect and Web of Science) through April 2019. We included all studies that addressed the association between polypharmacy and all-cause of mortality, glycemic control, macrovacular complications, hospitalization, potentially inappropriate medicines, drug-drug interactions and fall. A statistical program OpenMeta [Analyst] was used. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated with a random effects model. I2 statistics was performed to assess heterogeneity. RESULTS Out of sixteen studies, three studies were used for meta-analysis. A statistically significant association was found between polypharmacy and all-cause mortality (OR = 1.622, 95% CI (1.606-1.637) P < 0.001), and myocardial infarction (OR = 1.962, 95% CI (1.942-1.982), P < 0.001. Non-statistically significant association with evidence of moderate heterogeneity was found between polypharmacy and stroke (OR = 1.335; 95% CI (0.532-3.346), P = 0.538, I2 = 45%), and hospitalization (OR = 1.723; 95% CI (0.983-3.021), P = 0.057, I2 = 57%). CONCLUSIONS Pooled risk estimates reveal that polypharmacy is associated with increased all-cause mortality, macrovacular complications and hospitalization using categorical definitions. These findings assert the need for interventions that optimize the balance of benefits and harms in medicines prescribing.
Collapse
Affiliation(s)
- Labib Al-Musawe
- Faculty of Pharmacy, University of Lisbon, Lisbon, Portugal.
| | | | - Joao Filipe Raposo
- Nova Medical School, New University of Lisbon, Lisbon, Portugal; Portuguese Diabetes Association (APDP), Lisbon, Portugal
| | - Carla Torre
- Faculty of Pharmacy, University of Lisbon, Lisbon, Portugal
| |
Collapse
|
7
|
Murphy ME, Byrne M, Boland F, Corrigan D, Gillespie P, Fahey T, Smith SM. 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. Pilot Feasibility Stud 2018; 4:159. [PMID: 30345068 PMCID: PMC6186054 DOI: 10.1186/s40814-018-0352-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 10/02/2018] [Indexed: 01/30/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Mark E Murphy
- HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
| | - Molly Byrne
- Health Behaviour Change Research Group, School of Psychology, National University of Ireland, Galway, Ireland
| | - Fiona Boland
- HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
| | - Derek Corrigan
- HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
| | - Paddy Gillespie
- Health Economics and Policy Analysis Centre (HEPAC), National University of Ireland, Galway, Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
| | - Susan M Smith
- HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
| |
Collapse
|
8
|
Arnold RJG, Yang S, Gold EJ, Farahbakhshian S, Sheehan JJ. Assessment of the relationship between diabetes treatment intensification and quality measure performance using electronic medical records. PLoS One 2018; 13:e0199011. [PMID: 29894495 PMCID: PMC5997332 DOI: 10.1371/journal.pone.0199011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 05/30/2018] [Indexed: 11/19/2022] Open
Abstract
AIMS Assess the relationship between timely treatment intensification and hemoglobin A1C (HbA1C) control quality-of-care performance measures, i.e., HbA1C levels, among patients with uncontrolled type 2 diabetes. MATERIALS AND METHODS Electronic medical records and diabetes registry data from a large, accountable care organization (ACO) were used to isolate a sample of adult patients with type 2 diabetes who received at least one oral antidiabetes agent and had at least one HbA1C level measurement ≥8.0% (64 mmol/mol; i.e., uncontrolled diabetes) between 7/1/2011 and 6/30/2015. Treatment intensification status was evaluated for each patient during a 120-day treatment intensification window following the index HbA1c measure. Two-level hierarchical generalized linear models, with patients aggregated at the physician level, were used to assess the association between treatment intensification and achieving HbA1C quality performance measures. RESULTS 547 patients met study selection criteria and 480 patients had at least one HbA1C test after the treatment intensification window and were used for the statistical analyses. About 40% of patients who had uncontrolled diabetes received treatment intensification during the 120-day window. Greater index HbA1C, greater patient body mass index, and fewer unique pre-index oral antidiabetes agents were significantly associated with greater likelihood of receiving timely treatment intensification. The odds of receiving treatment intensification were about 1.8 times higher (P = 0.0027) among patients with poor index HbA1C control (HbA1c level >9.0% [75 mmol/mol]) compared to other patients (index HbA1c 8.0% - 9.0%). Hispanic patients (compared to White patients) were significantly more likely to exhibit poor control after treatment intensification (odds ratio [OR] 2.91, P = 0.0304), underscoring the difficulty of controlling diabetes in this vulnerable group. In contrast, being male and being treated primarily by an internist (compared to primary treatment by a family medicine specialist) were both significantly associated with achieving superior control (HbA1c level <8.0%) after treatment intensification (OR 0.53 [P = 0.0165]; OR 0.41 [P = 0.0275], respectively). CONCLUSIONS Timely treatment intensification was significantly associated with greater likelihood of patients achieving superior HbA1C control (<8.0%) and better HbA1C control quality performance for the practice. Even in an ACO with resources dedicated to diabetes control, it is incumbent upon clinicians to readily identify and open dialogues with patients who may benefit from closely supervised, individualized attention.
Collapse
Affiliation(s)
- Renée J. G. Arnold
- Quorum Consulting, Inc., New York, New York, United States of America
- Icahn School of Medicine at Mount Sinai, New York City, New York, United States of America
| | - Shuo Yang
- Quorum Consulting, Inc., New York, New York, United States of America
| | - Edward J. Gold
- Old Hook Medical Associates, Emerson, New Jersey, United States of America
| | | | | |
Collapse
|
9
|
Roussel R, Fontaine P, Gouet D, Serusclat P, Martinez L, Detournay B, Martin-Kristensen M. Le traitement du diabète de type 2 en France est dynamique plutôt qu’inerte : analyse des prescriptions de 847 122 patients. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/s1957-2557(18)30096-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
10
|
Perceptions of insulin use in type 2 diabetes in primary care: a thematic synthesis. BMC FAMILY PRACTICE 2018; 19:70. [PMID: 29788908 PMCID: PMC5964885 DOI: 10.1186/s12875-018-0753-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 05/01/2018] [Indexed: 01/29/2023]
Abstract
Background Increasing numbers of patients with type 2 diabetes mellitus are progressing to insulin therapy, and despite its potency many such individuals still have suboptimal glycaemic control. Insulin initiation and intensification is now often conducted by Practice Nurses and General Practitioners in many parts of the UK. Therefore, gaining insight into perspectives of patients and primary care clinicians is important in determining self-management and engagement with insulin. A thematic synthesis of studies was conducted exploring the views and experiences of people with type 2 diabetes and of healthcare professionals on insulin use and management in the context of primary care. Methods Protocol based systematic searches of electronic databases (CINAHL, Cochrane Library, EMBASE, MEDLINE, PsycINFO, and Web of Science) were performed on 1 October 2014 and updated on 31 March 2015, to identify studies that identified the views and experiences of adults with type 2 diabetes or primary care clinicians on the use of insulin in the management of type 2 diabetes. Studies meeting the review inclusion criteria were critically appraised using the CASP qualitative research checklist or Barley’s checklist for survey designs. A thematic synthesis was then conducted of the collected studies. Results Thirty-four studies were selected. Of these, 12 used qualitative interviews (nine with patients and three with healthcare professionals) and 22 were survey based (14 with patients, three with healthcare professionals, and five with both). Twelve key themes were identified and formed three domains, patient perceptions, healthcare professional perceptions, and health professional-patient relationships. The patient-centred themes were: insulin-related beliefs, social influences, psychological factors, hypoglycaemia, and therapy barriers. The clinician-related themes were: insulin skills of general practitioners, healthcare integration, healthcare professional-perceived barriers, hypoglycaemia, and explanations for adherence. Healthcare professional-patient relationship themes were drawn from the perspectives of patients and from clinicians. Conclusions This review reveals multiple barriers to optimal insulin use in primary care at both the patient and healthcare professional levels. These barriers indicate the need for multimodal interventions to: improve the knowledge and competencies of primary care professionals in insulin use; provide more effective patient education and self-management support; and introduce integrated insulin support systems. Electronic supplementary material The online version of this article (10.1186/s12875-018-0753-2) contains supplementary material, which is available to authorized users.
Collapse
|
11
|
Khunti K, Gomes MB, Pocock S, Shestakova MV, Pintat S, Fenici P, Hammar N, Medina J. Therapeutic inertia in the treatment of hyperglycaemia in patients with type 2 diabetes: A systematic review. Diabetes Obes Metab 2018; 20:427-437. [PMID: 28834075 PMCID: PMC5813232 DOI: 10.1111/dom.13088] [Citation(s) in RCA: 215] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/08/2017] [Accepted: 08/15/2017] [Indexed: 12/28/2022]
Abstract
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.
Collapse
Affiliation(s)
| | | | - Stuart Pocock
- London School of Hygiene and Tropical MedicineLondonUK
| | - Marina V. Shestakova
- Endocrinology Research CenterMoscowRussian Federation
- I.M. Sechenov First Moscow State Medical UniversityMoscowRussian Federation
| | | | | | - Niklas Hammar
- AstraZenecaMölndalSweden
- Institute of Environmental Medicine, Karolinska InstituteStockholmSweden
| | | |
Collapse
|
12
|
Murphy ME, Byrne M, Zarabzadeh A, Corrigan D, Fahey T, Smith SM. Development of a complex intervention to promote appropriate prescribing and medication intensification in poorly controlled type 2 diabetes mellitus in Irish general practice. Implement Sci 2017; 12:115. [PMID: 28915897 PMCID: PMC5602930 DOI: 10.1186/s13012-017-0647-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 09/11/2017] [Indexed: 01/12/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Mark E. Murphy
- HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
| | - Molly Byrne
- Health Behaviour Change Research Group, School of Psychology, National University of Ireland, Galway, Ireland
| | - Atieh Zarabzadeh
- HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
| | - Derek Corrigan
- HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
- HRB Centre for Primary Care Clinical Trials Network, Dublin, Ireland
| | - Susan M. Smith
- HRB Centre for Primary Care Research, Royal College of Surgeons, Dublin, Ireland
- HRB Centre for Primary Care Clinical Trials Network, Dublin, Ireland
| |
Collapse
|
13
|
Reach G, Pechtner V, Gentilella R, Corcos A, Ceriello A. Clinical inertia and its impact on treatment intensification in people with type 2 diabetes mellitus. DIABETES & METABOLISM 2017; 43:501-511. [PMID: 28754263 DOI: 10.1016/j.diabet.2017.06.003] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 05/24/2017] [Accepted: 06/14/2017] [Indexed: 12/13/2022]
Abstract
Many people with type 2 diabetes mellitus (T2DM) fail to achieve glycaemic control promptly after diagnosis and do not receive timely treatment intensification. This may be in part due to 'clinical inertia', defined as the failure of healthcare providers to initiate or intensify therapy when indicated. Physician-, patient- and healthcare-system-related factors all contribute to clinical inertia. However, decisions that appear to be clinical inertia may, in fact, be only 'apparent' clinical inertia and may reflect good clinical practice on behalf of the physician for a specific patient. Delay in treatment intensification can happen at all stages of treatment for people with T2DM, including prescription of lifestyle changes after diagnosis, introduction of pharmacological therapy, use of combination therapy where needed and initiation of insulin. Clinical inertia may contribute to people with T2DM living with suboptimal glycaemic control for many years, with dramatic consequences for the patient in terms of quality of life, morbidity and mortality, and for public health because of the huge costs associated with uncontrolled T2DM. Because multiple factors can lead to clinical inertia, potential solutions most likely require a combination of approaches involving fundamental changes in medical care. These could include the adoption of a person-centred model of care to account for the complex considerations influencing treatment decisions by patients and physicians. Better patient education about the progressive nature of T2DM and the risks inherent in long-term poor glycaemic control may also reinforce the need for regular treatment reviews, with intensification when required.
Collapse
Affiliation(s)
- G Reach
- Department of Endocrinology, Diabetes and Metabolic Diseases, Avicenne Hospital APHP and EA 3412, CRNH-IdF, Paris 13 University, 93017 Bobigny, France.
| | - V Pechtner
- Lilly Diabetes, Eli Lilly & Company, 92521 Neuilly-sur-Seine, France
| | - R Gentilella
- Eli Lilly Italia, Sesto Fiorentino, 50019 Florence, Italy
| | - A Corcos
- Eli Lilly Italia, Sesto Fiorentino, 50019 Florence, Italy
| | - A Ceriello
- U.O. Diabetologia e Malattie Metaboliche, Multimedica IRCCS Sesto San Giovanni, 20099 Milan, Italy
| |
Collapse
|
14
|
Blonde L, Aschner P, Bailey C, Ji L, Leiter LA, Matthaei S. Gaps and barriers in the control of blood glucose in people with type 2 diabetes. Diab Vasc Dis Res 2017; 14:172-183. [PMID: 28467203 PMCID: PMC5418936 DOI: 10.1177/1479164116679775] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Glycaemic control is suboptimal in a large proportion of people with type 2 diabetes who are consequently at an increased and avoidable risk of potentially severe complications. We sought to explore attitudes and practices among healthcare professionals that may contribute to suboptimal glycaemic control through a review of recent relevant publications in the scientific literature. METHODS An electronic search of the PubMed database was performed to identify relevant publications from January 2011 to July 2015. The electronic search was complemented by a manual search of abstracts from key diabetes conferences in 2014/2015 available online. RESULTS Recently published data indicate that glycaemic control is suboptimal in a substantial proportion (typically 40%-60%) of people with diabetes. This is the case across geographic regions and in both low- and higher-income countries. Therapeutic inertia appears to be an important contributor to poor glycaemic control in up to half of people with type 2 diabetes. In particular, prescribers are often willing to tolerate extended periods of 'mild' hyperglycaemia as well as having low expectations for their patients. There are often delays of 3 years or longer in initiating or intensifying glucose-lowering therapy when needed. CONCLUSION Many people with type 2 diabetes are failed by current management, with approximately half not achieving or maintaining appropriate target blood glucose levels, leaving these patients at increased and avoidable risk of serious complications. Review criteria: The methodology of this review article is detailed in the 'Methods' section.
Collapse
Affiliation(s)
- Lawrence Blonde
- Department of Endocrinology, Ochsner Medical Center, New Orleans, LA, USA
- Lawrence Blonde, Department of Endocrinology, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
| | - Pablo Aschner
- Endocrinology Unit, Javeriana University School of Medicine, Bogotá, Colombia
| | - Clifford Bailey
- School of Life & Health Sciences, Aston University, Birmingham, UK
| | - Linong Ji
- Peking University People’s Hospital, Beijing, China
| | - Lawrence A Leiter
- Keenan Research Center in the Li Ka Shing Knowledge Institute, St. Michael’s Hospital and Division of Endocrinology & Metabolism, University of Toronto, Toronto, ON, Canada
| | - Stephan Matthaei
- Diabetes, Metabolism and Endocrinology Center, Quakenbrück Hospital, Quakenbrück, Germany
| | | |
Collapse
|
15
|
Balkau B, Halimi S, Blickle JF, Vergès B, Avignon A, Attali C, Chartier I, Amelineau E. Reasons for non-intensification of treatment in people with type 2 diabetes receiving oral monotherapy: Outcomes from the prospective DIAttitude study. ANNALES D'ENDOCRINOLOGIE 2016; 77:649-657. [PMID: 27646493 DOI: 10.1016/j.ando.2016.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 03/17/2016] [Accepted: 03/23/2016] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To describe the management of glucose-lowering agents in people with type 2 diabetes initially on oral monotherapy, cared for by French general practitioners, and to identify reasons underlying treatment non-intensification. METHODS People with type 2 diabetes on oral monotherapy were recruited by general practitioners and followed-up over 12 months. Patient characteristics, HbA1c, and glucose-lowering treatments were recorded electronically. Management objectives and reasons for treatment non-intensification were solicited from the general practitioners. RESULTS A total of 1212 patients were enrolled by 198 general practitioners; 937 patients (mean age 68 years) were treated with oral monotherapy, and 916 patients had at least two successive HbA1c values recorded. Of these, 390 patients (43%) had HbA1c≥6.5% on both occasions, and 164/390 (42%) had their treatment intensified. The 226 patients whose treatment was not intensified were older (69±11 years vs. 66±12 years, P=0.02) and had better glycaemic control at study inclusion (6.9%±0.6 vs. 7.3%±0.8, P<0.0001) than treatment intensified patients. Among uncontrolled patients, there were no differences in general practitioner treatment objectives at inclusion for treatment intensified and non-intensified patients; the main reason given by general practitioners for non-intensification was that the patient had an adequate HbA1c (66%). HbA1c did exceed the 6.5% target, but was less than 7.0% in 69% of cases. CONCLUSIONS General practitioners showed a patient-centred approach to treatment, but clinical inertia was apparent for 31% of the uncontrolled patients.
Collapse
Affiliation(s)
- Beverley Balkau
- Inserm U-1018, CESP, Team 5 (EpReC, Renal and Cardiovascular Epidemiology), UVSQ-UPS, 94807 Villejuif, France.
| | - Serge Halimi
- Université Grenoble Alpes (UJF), 38043 Grenoble, France
| | | | | | | | - Claude Attali
- Université Paris Est, Faculté de Médecine, 94010 Créteil, France
| | | | | |
Collapse
|
16
|
Felton AM, LaSalle J, McGill M. Treatment urgency: The importance of getting people with type 2 diabetes to target promptly. Diabetes Res Clin Pract 2016; 117:100-3. [PMID: 27329028 DOI: 10.1016/j.diabres.2016.04.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/04/2016] [Accepted: 04/16/2016] [Indexed: 11/21/2022]
Abstract
The burgeoning population of individuals with type 2 diabetes provides challenges for management in terms of risk of diabetes-related complications. Early, intensive glycemic control particularly in newly-diagnosed people with type 2 diabetes has been shown to be beneficial in terms of reducing diabetic complications, indeed various national and international guidelines now routinely recommend intensive blood glucose control as an essential element of type 2 diabetes management. However, despite this, current management of glycemia is suboptimal and not enough people achieve their glucose targets worldwide. The Global Partnership for Effective Diabetes Management believe that an improved understanding of these contributing factors should enable the development of practice and guidance that will promote a drive toward better quality clinical outcomes.
Collapse
Affiliation(s)
| | - James LaSalle
- Medical Arts Research Collaborative, Excelsior Springs, MO, USA
| | - Margaret McGill
- Diabetes Centre, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia.
| |
Collapse
|
17
|
Branchereau M, Reichardt F, Loubieres P, Marck P, Waget A, Azalbert V, Colom A, Padmanabhan R, Iacovoni JS, Giry A, Tercé F, Heymes C, Burcelin R, Serino M, Blasco-Baque V. Periodontal dysbiosis linked to periodontitis is associated with cardiometabolic adaptation to high-fat diet in mice. Am J Physiol Gastrointest Liver Physiol 2016; 310:G1091-101. [PMID: 27033119 DOI: 10.1152/ajpgi.00424.2015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 03/03/2016] [Indexed: 01/31/2023]
Abstract
Periodontitis and type 2 diabetes are connected pandemic diseases, and both are risk factors for cardiovascular complications. Nevertheless, the molecular factors relating these two chronic pathologies are poorly understood. We have shown that, in response to a long-term fat-enriched diet, mice present particular gut microbiota profiles related to three metabolic phenotypes: diabetic-resistant (DR), intermediate (Inter), and diabetic-sensitive (DS). Moreover, many studies suggest that a dysbiosis of periodontal microbiota could be associated with the incidence of metabolic and cardiac diseases. We investigated whether periodontitis together with the periodontal microbiota may also be associated with these different cardiometabolic phenotypes. We report that the severity of glucose intolerance is related to the severity of periodontitis and cardiac disorders. In detail, alveolar bone loss was more accentuated in DS than Inter, DR, and normal chow-fed mice. Molecular markers of periodontal inflammation, such as TNF-α and plasminogen activator inhibitor-1 mRNA levels, correlated positively with both alveolar bone loss and glycemic index. Furthermore, the periodontal microbiota of DR mice was dominated by the Streptococcaceae family of the phylum Firmicutes, whereas the periodontal microbiota of DS mice was characterized by increased Porphyromonadaceae and Prevotellaceae families. Moreover, in DS mice the periodontal microbiota was indicated by an abundance of the genera Prevotella and Tannerella, which are major periodontal pathogens. PICRUSt analysis of the periodontal microbiome highlighted that prenyltransferase pathways follow the cardiometabolic adaptation to a high-fat diet. Finally, DS mice displayed a worse cardiac phenotype, percentage of fractional shortening, heart rhythm, and left ventricle weight-to-tibia length ratio than Inter and DR mice. Together, our data show that periodontitis combined with particular periodontal microbiota and microbiome is associated with metabolic adaptation to a high-fat diet related to the severity of cardiometabolic alteration.
Collapse
Affiliation(s)
- Maxime Branchereau
- Institut National de la Santé et de la Recherche Médicale U1048 and Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier, Toulouse, France
| | - François Reichardt
- Institut National de la Santé et de la Recherche Médicale U1048 and Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier, Toulouse, France
| | - Pascale Loubieres
- Institut National de la Santé et de la Recherche Médicale U1048 and Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier, Toulouse, France; Faculté de Chirurgie-Dentaire de Toulouse, Toulouse, France; and
| | - Pauline Marck
- Institut National de la Santé et de la Recherche Médicale U1048 and Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier, Toulouse, France
| | - Aurélie Waget
- Institut National de la Santé et de la Recherche Médicale U1048 and Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier, Toulouse, France
| | - Vincent Azalbert
- Institut National de la Santé et de la Recherche Médicale U1048 and Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier, Toulouse, France
| | - André Colom
- Equipe Intéraction Mycobactériennes avec les Cellules Hôtes, Institute of Pharmacology and Structural Biology, Centre National de la Recherche Scientifique, Toulouse, France
| | - Roshan Padmanabhan
- Institut National de la Santé et de la Recherche Médicale U1048 and Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier, Toulouse, France
| | - Jason S Iacovoni
- Institut National de la Santé et de la Recherche Médicale U1048 and Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier, Toulouse, France
| | - Anaïs Giry
- Institut National de la Santé et de la Recherche Médicale U1048 and Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier, Toulouse, France
| | - François Tercé
- Institut National de la Santé et de la Recherche Médicale U1048 and Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier, Toulouse, France
| | - Christophe Heymes
- Institut National de la Santé et de la Recherche Médicale U1048 and Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier, Toulouse, France
| | - Remy Burcelin
- Institut National de la Santé et de la Recherche Médicale U1048 and Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier, Toulouse, France
| | - Matteo Serino
- Institut National de la Santé et de la Recherche Médicale U1048 and Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier, Toulouse, France
| | - Vincent Blasco-Baque
- Institut National de la Santé et de la Recherche Médicale U1048 and Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse, France; Université Paul Sabatier, Toulouse, France; Faculté de Chirurgie-Dentaire de Toulouse, Toulouse, France; and
| |
Collapse
|
18
|
Inzucchi SE, Tunceli K, Qiu Y, Rajpathak S, Brodovicz KG, Engel SS, Mavros P, Radican L, Brudi P, Li Z, Fan CPS, Hanna B, Tang J, Blonde L. Progression to insulin therapy among patients with type 2 diabetes treated with sitagliptin or sulphonylurea plus metformin dual therapy. Diabetes Obes Metab 2015; 17:956-64. [PMID: 25962401 PMCID: PMC5033027 DOI: 10.1111/dom.12489] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 05/04/2015] [Accepted: 05/07/2015] [Indexed: 01/29/2023]
Abstract
AIM To assess time to insulin initiation among patients with type 2 diabetes mellitus (T2DM) treated with sitagliptin versus sulphonylurea as add-on to metformin. METHODS This retrospective cohort study used GE Centricity electronic medical records and included patients aged ≥18 years with continuous medical records and an initial prescription of sitagliptin or sulphonylurea (index date) with metformin for ≥90 days during 2006-2013. Sitagliptin and sulphonylurea users were matched 1 : 1 using propensity score matching, and differences in insulin initiation were assessed using Kaplan-Meier curves and Cox regression. We used conditional logistic regression to examine the likelihood of insulin use 1-6 years after the index date for each year. RESULTS Propensity score matching produced 3864 matched pairs. Kaplan-Meier analysis showed that sitagliptin users had a lower risk of insulin initiation compared with sulphonylurea users (p = 0.003), with 26.6% of sitagliptin users initiating insulin versus 34.1% of sulphonylurea users over 6 years. This finding remained significant after adjusting for baseline characteristics (hazard ratio 0.76, 95% confidence interval 0.65-0.90). Conditional logistic regression analyses confirmed that sitagliptin users were less likely to initiate insulin compared with sulphonylurea users [odds ratios for years 1-6: 0.77, 0.79, 0.81, 0.57, 0.29 and 0.75, respectively (p < 0.05 for years 4 and 5)]. CONCLUSIONS In this real-world matched cohort study, patients with T2DM treated with sitagliptin had a significantly lower risk of insulin initiation compared with patients treated with sulphonylurea, both as add-on to metformin.
Collapse
Affiliation(s)
- S E Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, CT, USA
| | - K Tunceli
- Merck & Co., Inc., Kenilworth, NJ, USA
| | - Y Qiu
- Merck & Co., Inc., Kenilworth, NJ, USA
| | | | | | - S S Engel
- Merck & Co., Inc., Kenilworth, NJ, USA
| | - P Mavros
- Merck & Co., Inc., Kenilworth, NJ, USA
| | - L Radican
- Merck & Co., Inc., Kenilworth, NJ, USA
| | - P Brudi
- Merck & Co., Inc., Kenilworth, NJ, USA
| | - Z Li
- Asclepius Analytics LLC, New York, NY, USA
| | - C P S Fan
- Asclepius Analytics LLC, New York, NY, USA
| | - B Hanna
- Asclepius Analytics LLC, New York, NY, USA
| | - J Tang
- Asclepius Analytics LLC, New York, NY, USA
| | - L Blonde
- Ochsner Medical Center, New Orleans, LA, USA
| |
Collapse
|
19
|
Mouland G. [Diabetes in general practice--were treatment goals reached?]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2014; 134:168-72. [PMID: 24477150 DOI: 10.4045/tidsskr.13.0375] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND In Norway, most people with diabetes are treated by general practitioners. At our own general practice, we wanted to find out whether we were succeeding in following the Directorate of Health's 2009 clinical guidelines on treatment and management of diabetes. MATERIAL AND METHOD All patients with the diagnosis diabetes mellitus in our electronic archive between November 2009 and October 2010 were registered. Those patients on our general practice lists in October 2010 were identified. The patient records were manually reviewed and relevant data recorded. RESULTS In all, 271 patients with diabetes attended our surgery for check-ups in October 2010. 11% had type 1 diabetes and 88% had type 2 diabetes. HbA1c was measured in 99% of the diabetes patients, blood pressure in 98% and lipids in 93%. The measurements were taken at our surgery during the past year for 96% of the patients. The treatment goals for HbA1c, systolic blood pressure and LDL cholesterol were reached in, respectively, 55%, 55% and 49% of the patients. 13% reached all three treatment goals. 82% had a check-up with an ophthalmologist. Weight and smoking habits were documented in 85% and 90% respectively. 19% of the patients for whom we had documented data, smoked. Examinations of height, feet and microalbumin were documented in 57%, 35% and 28% of the patients respectively. INTERPRETATION The guidelines are being followed on most points to a high degree, and the proportion of patients reaching the stricter treatment goals is consistent with the results of earlier Norwegian surveys. There is the potential for further improvement of these results.
Collapse
|
20
|
Raebel MA, Ellis JL, Schroeder EB, Xu S, O'Connor PJ, Segal JB, Butler MG, Schmittdiel JA, Kirchner HL, Goodrich GK, Lawrence JM, Nichols GA, Newton KM, Pathak RD, Steiner JF. Intensification of antihyperglycemic therapy among patients with incident diabetes: a Surveillance Prevention and Management of Diabetes Mellitus (SUPREME-DM) study. Pharmacoepidemiol Drug Saf 2014; 23:699-710. [DOI: 10.1002/pds.3610] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 01/23/2014] [Accepted: 02/16/2014] [Indexed: 01/17/2023]
Affiliation(s)
- Marsha A. Raebel
- Kaiser Permanente Colorado Institute for Health Research; Denver CO USA
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences; Aurora CO USA
| | - Jennifer L. Ellis
- Kaiser Permanente Colorado Institute for Health Research; Denver CO USA
| | - Emily B. Schroeder
- Kaiser Permanente Colorado Institute for Health Research; Denver CO USA
- University of Colorado School of Medicine; Aurora CO USA
| | - Stanley Xu
- Kaiser Permanente Colorado Institute for Health Research; Denver CO USA
| | | | | | - Melissa G. Butler
- Center for Health Research Southeast; Kaiser Permanente Georgia; Atlanta GA USA
| | | | | | - Glenn K. Goodrich
- Kaiser Permanente Colorado Institute for Health Research; Denver CO USA
| | - Jean M. Lawrence
- Department of Research and Evaluation; Kaiser Permanente Southern California; Pasadena CA USA
| | | | | | - Ram D. Pathak
- Marshfield Clinic Research Foundation; Marshfield WI USA
| | - John F. Steiner
- Kaiser Permanente Colorado Institute for Health Research; Denver CO USA
| |
Collapse
|
21
|
Blackberry ID, Furler JS, Best JD, Chondros P, Vale M, Walker C, Dunning T, Segal L, Dunbar J, Audehm R, Liew D, Young D. Effectiveness of general practice based, practice nurse led telephone coaching on glycaemic control of type 2 diabetes: the Patient Engagement and Coaching for Health (PEACH) pragmatic cluster randomised controlled trial. BMJ 2013; 347:f5272. [PMID: 24048296 PMCID: PMC3776648 DOI: 10.1136/bmj.f5272] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of goal focused telephone coaching by practice nurses in improving glycaemic control in patients with type 2 diabetes in Australia. DESIGN Prospective, cluster randomised controlled trial, with general practices as the unit of randomisation. SETTING General practices in Victoria, Australia. PARTICIPANTS 59 of 69 general practices that agreed to participate recruited sufficient patients and were randomised. Of 829 patients with type 2 diabetes (glycated haemoglobin (HbA1c) >7.5% in the past 12 months) who were assessed for eligibility, 473 (236 from 30 intervention practices and 237 from 29 control practices) agreed to participate. INTERVENTION Practice nurses from intervention practices received two days of training in a telephone coaching programme, which aimed to deliver eight telephone and one face to face coaching episodes per patient. MAIN OUTCOME MEASURES The primary end point was mean absolute change in HbA1c between baseline and 18 months in the intervention group compared with the control group. RESULTS The intervention and control patients were similar at baseline. None of the practices dropped out over the study period; however, patient attrition rates were 5% in each group (11/236 and 11/237 in the intervention and control group, respectively). The median number of coaching sessions received by the 236 intervention patients was 3 (interquartile range 1-5), of which 25% (58/236) did not receive any coaching sessions. At 18 months' follow-up the effect on glycaemic control did not differ significantly (mean difference 0.02, 95% confidence interval -0.20 to 0.24, P=0.84) between the intervention and control groups, adjusted for HbA1c measured at baseline and the clustering. Other biochemical and clinical outcomes were similar in both groups. CONCLUSIONS A practice nurse led telephone coaching intervention implemented in the real world primary care setting produced comparable outcomes to usual primary care in Australia. The addition of a goal focused coaching role onto the ongoing generalist role of a practice nurse without prescribing rights was found to be ineffective. TRIAL REGISTRATION Current Controlled Trials ISRCTN50662837.
Collapse
Affiliation(s)
- Irene D Blackberry
- General Practice and Primary Health Care Academic Centre, University of Melbourne, 200 Berkeley St, Carlton, VIC 3053, Australia
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Reach G, Le Pautremat V, Gupta S. Determinants and consequences of insulin initiation for type 2 diabetes in France: analysis of the National Health and Wellness Survey. Patient Prefer Adherence 2013; 7:1007-23. [PMID: 24143079 PMCID: PMC3797252 DOI: 10.2147/ppa.s51299] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The aim of the study was to identify the intrinsic patient characteristics and extrinsic environmental factors predicting prescription and use and, more specifically, early initiation (up to 5 years of disease duration) of insulin for type 2 diabetes in France. A secondary objective was to evaluate the impact of insulin therapy on mental and physical quality of life and patient adherence. METHODS The data used in this study were derived from the 2008, 2010, and 2011 France National Health and Wellness Survey. This survey is an annual, cross-sectional, self-administered, Internet-based questionnaire among a nationwide representative sample of adults (aged 18 years or older). Of the total of 45,958 persons recruited in France, 1,933 respondents (deduped) were identified as diagnosed with type 2 diabetes. All unique respondents from the three waves, currently using insulin or oral bitherapy or tritherapy at the time of assessment, were included in this analysis. RESULTS Early (versus late) initiation of insulin therapy was 9.9 times more likely to be prescribed by an endocrinologist or diabetologist than by a primary care physician (P < 0.0001). Younger age at diagnosis and current smoking habits were significant predictors of early (versus late) insulin initiation (odds ratio [OR] 1.031, 95% confidence interval [CI] 1.005-1.059, P = 0.0196, and OR 2.537, 95% CI 1.165-5.524, P = 0.0191, respectively). Patients with a yearly income ≥€50,000 were less likely to be put on insulin early (P = 0.0399). A link between insulin prescription and complications was shown only in univariate analysis. Mental quality of life was lower in patients on early (versus late) insulin, but only in patients with diabetes-related complications. Insulin users (versus oral bitherapy or tritherapy users) had 3.0 times greater odds of being adherent than uncontrolled oral bitherapy or tritherapy users (OR 2.983, 95% CI 1.37-6.495, P = 0.0059). CONCLUSION This study confirms the role of specialists in early initiation of insulin, and the data presented herein reflect the fact that early initiation is more frequent in younger patients, patients with diabetes-related complications, and current smokers, and less frequent in patients with a higher income. Moreover, we observed that being treated with insulin was not associated with deterioration in quality of life, and insulin-treated patients were more often adherent than uncontrolled oral bitherapy or tritherapy users. These data suggest that doctors' concerns about patient adherence and detrimental effects on quality of life should not be a barrier to their decision regarding early initiation of insulin therapy. Due to the nature of this cross-sectional survey (eg, inability to assess treatment flow), further research is needed to confirm its findings.
Collapse
Affiliation(s)
- Gérard Reach
- Department of Endocrinology, Diabetes, and Metabolic Diseases, Avicenne Hospital APHP, and EA 3412, CRNH-IdF, Paris 13 University, Sorbonnne Paris Cité, Bobigny, France
- Correspondence: Gérard Reach Service d’Endocrinologie, Diabétologie, Maladies Métaboliques, Hôpital Avicenne APHP, 125 route de Stalingrad, 93000 Bobigny, France, Tel +331 4895 5158, Fax +331 4895 5560, Email
| | | | | |
Collapse
|
23
|
Halimi S, Balkau B, Attali C, Detournay B, Amelineau E, Blickle JF. Therapeutic management of orally treated type 2 diabetic patients, by French general practitioners in 2010: the DIAttitude Study. DIABETES & METABOLISM 2012; 38 Suppl 3:S36-46. [DOI: 10.1016/s1262-3636(12)71533-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
24
|
Halimi S, Balkau B. Better analyze the determinants of therapeutic inertia to overcome it. DIABETES & METABOLISM 2012; 38 Suppl 3:S27-8. [DOI: 10.1016/s1262-3636(12)71531-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|