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Hickman E, Almaqhawi A, Gillies C, Khunti K, Seidu S. Beliefs, practices, perceptions and motivations of healthcare professionals on medication deprescribing during end-of-life care: A systematic review. Prim Care Diabetes 2024; 18:249-256. [PMID: 38443294 DOI: 10.1016/j.pcd.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 02/24/2024] [Indexed: 03/07/2024]
Abstract
AIM Conduct a systematic review to investigate current beliefs, practices, perceptions, and motivations towards deprescribing practices from the healthcare professional perspective in older adults residing in long term care facilities with cardiometabolic conditions, using a narrative approach. METHODS Studies were identified using a literature search of MEDLINE, CINAHL and Web of Science from inception to June 2023 Two reviewers (EH and AA) independently extracted data from each selected study using a standardised self-developed data extraction proforma. Studies reviewed included cross-sectional and observational studies. Data was extracted on baseline characteristics, motivations and beliefs and was discussed using a narrative approach. RESULTS Eight studies were identified for inclusion. Deprescribing approaches included complete withdrawal, dose reduction, or switching to an alternative medication, for at least one preventive medication. Most healthcare professionals were willing to initiate deprescribing strategies and stated the importance of such interventions, however many felt inexperienced and lacked the required knowledge to feel comfortable doing so. CONCLUSION Deprescribing is a key strategy when managing older people with cardiometabolic and multiple long term conditions (MLTC). Overall, HCPs including specialists, were happy to explore deprescribing strategies if provided with the relevant training and development to do so. Barriers that still exist include communication and consultation skills, a lack of evidence-based guidance and trust based policies, and a lack of MDT communications and involvement. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022335106.
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Affiliation(s)
- Elizabeth Hickman
- Diabetes Research Centre, Leicester Diabetes Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK.
| | - Abdullah Almaqhawi
- Diabetes Research Centre, Leicester Diabetes Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK
| | - Clare Gillies
- Diabetes Research Centre, Leicester Diabetes Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, Leicester Diabetes Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK
| | - Samuel Seidu
- Diabetes Research Centre, Leicester Diabetes Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK
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Pilla SJ, Jalalzai R, Tang O, Schoenborn NL, Boyd CM, Bancks MP, Mathioudakis NN, Maruthur NM. A National Survey of Physicians' Views on the Importance and Implementation of Deintensifying Diabetes Medications. J Gen Intern Med 2024; 39:992-1001. [PMID: 37940754 DOI: 10.1007/s11606-023-08506-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/20/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Guidelines recommend deintensifying hypoglycemia-causing medications for older adults with diabetes whose hemoglobin A1c is below their individualized target, but this rarely occurs in practice. OBJECTIVE To understand physicians' decision-making around deintensifying diabetes treatment. DESIGN National physician survey. PARTICIPANTS US physicians in general medicine, geriatrics, or endocrinology providing outpatient diabetes care. MAIN MEASURES Physicians rated the importance of deintensifying diabetes medications for older adults with type 2 diabetes, and of switching medication classes, on 5-point Likert scales. They reported the frequency of these actions for their patients, and listed important barriers and facilitators. We evaluated the independent association between physicians' professional and practice characteristics and the importance of deintensifying and switching diabetes medications using multivariable ordered logistic regression models. KEY RESULTS There were 445 eligible respondents (response rate 37.5%). The majority of physicians viewed deintensifying (80%) and switching (92%) diabetes medications as important or very important to the care of older adults. Despite this, one-third of physicians reported deintensifying diabetes medications rarely or never. While most physicians recognized multiple reasons to deintensify, two-thirds of physicians reported barriers of short-term hyperglycemia and patient reluctance to change medications or allow higher glucose levels. In multivariable models, geriatricians rated deintensification as more important compared to other specialties (p=0.027), and endocrinologists rated switching as more important compared to other specialties (p<0.006). Physicians with fewer years in practice rated higher importance of deintensification (p<0.001) and switching (p=0.003). CONCLUSIONS While most US physicians viewed deintensifying and switching diabetes medications as important for the care of older adults, they deintensified infrequently. Physicians had ambivalence about the relative benefits and harms of deintensification and viewed it as a potential source of conflict with their patients. These factors likely contribute to clinical inertia, and studies focused on improving shared decision-making around deintensifying diabetes medications are needed.
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Affiliation(s)
- Scott J Pilla
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Rabia Jalalzai
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Olive Tang
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nancy L Schoenborn
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cynthia M Boyd
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael P Bancks
- Department of Epidemiology & Prevention, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Nestoras N Mathioudakis
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nisa M Maruthur
- Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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Chittem M, Sridharan SG, Pongener M, Maya S, Epton T. Experiences of barriers to self-monitoring and medication-management among Indian patients with type 2 diabetes, their primary family-members and physicians. Chronic Illn 2022; 18:677-690. [PMID: 34259058 DOI: 10.1177/17423953211032251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES This study explored the subjective accounts of the main barriers to self-monitoring of blood-glucose (SMBG) and medication-management among Indian patients with type 2 diabetes (T2DM), their primary family-members (PFMs) and physicians. METHODS Using convenience sampling, patients with T2DM, their PFMs, and physicians, residing in a South Indian capital city, were recruited for semi-structured, audio-recorded interviews. Thematic analysis was used to analyze the data. RESULTS Fifty patients (female = 14; mean age = 42.5 years) and their PFMs (female = 38; mean age = 39 years), and 25 physicians (female = 4; mean age = 49.8 years) were recruited. Three superordinate themes were identified: (i) complex medication-regimen: confusion, forgetting and reduced motivation, (ii) family recommendations of alternative therapies due to the social pressures of avoiding stigma, intrusiveness and being misrepresented for injecting insulin, and (iii) an expensive illness: choosing to spend money on only medication. DISCUSSION Implications of the findings highlight the need to (i) train physicians in communication and empathy skills, (ii) empower patients to communicate their barriers to physicians through triadic communication models and question-prompt lists, (iii) educate communities on the benefits of insulin for managing T2DM to reduce stigma, and (iv) equip communities with information about health insurance to address the financial toll of T2DM management.
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Affiliation(s)
- Mahati Chittem
- Department of Liberal Arts, Indian Institute of Technology Hyderabad, Kandi, India
| | | | | | - Sravannthi Maya
- Department of Liberal Arts, Indian Institute of Technology Hyderabad, Kandi, India
| | - Tracy Epton
- Manchester Centre for Health Psychology, Division of Psychology & Mental Health, University of Manchester, Manchester, UK
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Santos EE, Korah J, Subramanian S, Murugappan V, Huang ES, Laiteerapong N, Cinar A. Analyzing Medical Guideline Dissemination Behaviors Using Culturally Infused Agent Based Modeling Framework. IEEE J Biomed Health Inform 2021; 25:2137-2149. [PMID: 33465031 DOI: 10.1109/jbhi.2021.3052809] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Clinical practice guidelines are a critical medium for the standardization of practices within the overall medical community. However, several studies have shown that, in general, there is a significant delay in the adoption of recommendations in such guidelines. Surveys have identified multiple barriers, including clinical inertia, organizational culture/incentives, access to information and peer influence on guideline dissemination and adoption. Although modeling techniques, especially agent-based models, have shown promise, a rigorous computational model for guideline dissemination that incorporates the intricacies of medical decision making and interactions of healthcare workers, and can identify more effective dissemination strategies, is needed. Similar modeling and simulation issues are also prevalent in many other domains such as opinion diffusion, innovation, and technology adoption. In this paper, we introduce a novel overarching computational modeling and simulation framework called the Culturally Infused Agent Based Modeling (CI-ABM) Framework. CI-ABM is a generalizable framework that provides the capability to model a wide range of real-world complex scenarios. To validate the framework, we focus on modeling and analyzing the dissemination of a Type 2 diabetes guideline that recommends individualizing glycemic (A1C) goals. Using existing cross-sectional surveys from physicians across the US, we demonstrate how our methodology for incorporating various socio-cultural and other related factors in agent based models lead to better posterior probability-based analysis and prediction of guideline dissemination behaviors.
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Oktora MP, Kerr KP, Hak E, Denig P. Rates, determinants and success of implementing deprescribing in people with type 2 diabetes: A scoping review. Diabet Med 2021; 38:e14408. [PMID: 32969063 PMCID: PMC7891362 DOI: 10.1111/dme.14408] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/20/2020] [Accepted: 09/15/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Individualizing goals for people with type 2 diabetes may result in deintensification of medication, but a comprehensive picture of deprescribing practices is lacking. AIMS To conduct a scoping review in order to assess the rates, determinants and success of implementing deprescribing of glucose-, blood pressure- or lipid-lowering medications in people with diabetes. METHODS A systematic search on MEDLINE and Embase between January 2007 and January 2019 was carried out for deprescribing studies among people with diabetes. Outcomes were rates of deprescribing related to participant characteristics, the determinants and success of deprescribing, and its implementation. Critical appraisal was conducted using predefined tools. RESULTS Fourteen studies were included; eight reported on rates, nine on determinants and six on success and implementation. Bias was high for studies on success of deprescribing. Deprescribing rates ranged from 14% to 27% in older people with low HbA1c levels, and from 16% to 19% in older people with low systolic blood pressure. Rates were not much affected by age, gender, frailty or life expectancy. Rates were higher when a reminder system was used to identify people with hypoglycaemia, which led to less overtreatment and fewer hypoglycaemic events. Most healthcare professionals accepted the concept of deprescribing but differed on when to conduct it. Deprescribing glucose-lowering medications could be successfully conducted in 62% to 75% of participants with small rises in HbA1c . CONCLUSIONS Deprescribing of glucose-lowering medications seems feasible and acceptable, but was not widely implemented in the covered period. Support systems may enhance deprescribing. More studies on deprescribing blood pressure- and lipid-lowering medications in people with diabetes are needed.
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Affiliation(s)
- M. P. Oktora
- Department of Clinical Pharmacy and PharmacologyUniversity of GroningenUniversity Medical Centre GroningenGroningenThe Netherlands
| | - K. P. Kerr
- School of Biomedical Sciences and PharmacyFaculty of Health and MedicineUniversity of NewcastleNewcastleNSWAustralia
| | - E. Hak
- Unit of PharmacoTherapy, Epidemiology and EconomicsGroningen Research Institute of PharmacyUniversity of GroningenGroningenThe Netherlands
| | - P. Denig
- Department of Clinical Pharmacy and PharmacologyUniversity of GroningenUniversity Medical Centre GroningenGroningenThe Netherlands
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Naser AY, Alsairafi Z, Alwafi H, Mohammad Turkistani F, Saud Bokhari N, Alenazi B, Zmaily Dahmash E, Alyami HS. The perspectives of physicians regarding antidiabetic therapy de-intensification and factors affecting their treatment choices-A cross-sectional study. Int J Clin Pract 2021; 75:e13662. [PMID: 32770843 DOI: 10.1111/ijcp.13662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 08/06/2020] [Indexed: 02/06/2023] Open
Abstract
AIMS Comprehensive diabetes management may include treatment intensification or the administration of antidiabetic combination therapy. However, this may be associated with an increased risk of adverse events and death. The aim of this study was to understand physicians' perspectives regarding treatment de-intensification, HbA1c goals individualisation, and factors affecting their treatment choice for patients with type 2 diabetes mellitus (T2DM). METHODS A cross-sectional study was conducted in primary and secondary care units in Saudi Arabia using online questionnaire. Two previously validated questionnaires were used to understand physicians' awareness of, agreement with, and their practices of individualising HbA1c goals and antidiabetic treatment optimisation, and to assess factors affecting physicians' treatment choice when prescribing antidiabetic treatment for patients with type 2 diabetes mellitus. Study population were physicians who are treating patients with diabetes mellitus during the period between October 2017 and May 2018. RESULTS A total of 205 physicians have participated in the study. Approximately 50% of physicians had family medicine speciality (n = 98, 47.8%). The majority of physicians (n = 183, 89.3%) were familiar with the concept of HbA1c goals individualisation. However, only 66.3% of them (n = 136) reported that they apply it either always or most of the time. 58.5% (n = 120) of physicians reported that they would not initiate conversations about de-intensifying antidiabetic therapy even if their patients had a stable HbA1c values for one year. Physicians showed higher consideration to objective patient clinical data and their assessment of patient's health status, with minor consideration to patient-related factors. CONCLUSIONS Healthcare professionals should focus more on implementing contemporary practices and applying any necessary treatment de-intensification or dose adjustment. Subjective patient factors should be taken into account further, as these factors are associated with better disease management.
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Affiliation(s)
- Abdallah Y Naser
- Department of Applied Pharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, Isra University, Amman, Jordan
| | - Zahra Alsairafi
- Department of Pharmacy Practice, Kuwait University, Kuwait, Kuwait
| | - Hassan Alwafi
- Faculty of Medicine, Umm Alqura University, Mecca, Saudi Arabia
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | | | | | - Badi Alenazi
- Paediatric Department, Alyamamah hospital, Riyadh, Saudi Arabia
| | - Eman Zmaily Dahmash
- Department of Applied Pharmaceutics and Clinical Pharmacy, Faculty of Pharmacy, Isra University, Amman, Jordan
| | - Hamad S Alyami
- Department of Pharmaceutics, College of Pharmacy, Najran University, Najran, Saudi Arabia
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Brenner S, Oberaigner W, Stummer H. In guidelines physicians trust? Physician perspective on adherence to medical guidelines for type 2 diabetes mellitus. Heliyon 2020; 6:e04803. [PMID: 32939405 PMCID: PMC7477256 DOI: 10.1016/j.heliyon.2020.e04803] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 01/28/2020] [Accepted: 08/24/2020] [Indexed: 11/21/2022] Open
Abstract
AIMS Adherence to treatment guidelines and treatment success are low in Type 2 diabetes mellitus (T2DM). This study aims to capture the physician perspective on T2DM guideline adherence and identify levers for increasing adherence. METHODS A survey among German physicians captured the perceived value of 4 areas in the national treatment guideline (NVL), 13 possible barriers, and 9 possible enablers for guideline adherence. Perceived value was assessed by ranking 4 NVL areas by implementation difficulty and impact on treatment success. Barriers and enablers were assessed by rating their influence on guideline deviation and adherence. The consistency of results across subgroups was assessed using Fisher's exact test. RESULTS Responses from 46 physicians showed a strong consensus about the value of each NVL area. Physicians perceived patient inability and demotivation to be the strongest adherence barriers (93%, 78%). All queried enablers were approved by ≥ 50% of participants. Physicians considered cross-provider collaboration and electronic therapy decision support as strongest enablers (85%, 80%). Consistency was high between subgroups. CONCLUSION This study suggests that physicians consider patient-related factors to be stronger barriers for guideline adherence than physician-related factors. Finding opportunities to increase physician buy-in is important for better guideline adherence. In this study, physicians voiced appreciation for adherence enablers based on digital solutions to support the care process and to reduce the complexity of therapy decisions.
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Affiliation(s)
- Sophie Brenner
- UMIT - Private University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Willi Oberaigner
- UMIT - Private University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Harald Stummer
- UMIT - Private University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
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Fernandes G, Matos JE, Jaffe DH, Beyer G, Yang L, Iglay K, Gantz I, Rajpathak S. Factors associated with the discontinuation of dipeptidyl peptidase-4 inhibitors (DPP-4is) after initiation of insulin. Curr Med Res Opin 2020; 36:377-386. [PMID: 31771370 DOI: 10.1080/03007995.2019.1698416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: Type 2 diabetes (T2D) is a prevalent health problem. Oral agents, with the exception of metformin, are often discontinued with the initiation of insulin. The objective was to understand the proportion of patients discontinuing dipeptidyl peptidase-4 inhibitors (DPP-4is) and the reasons for the decision to discontinue.Methods: A retrospective study using a health claims database investigated discontinuation of DPP-4i in adult patients on a dual therapy of metformin and DPP-4i who initiated insulin (n = 3391). An online survey administered to 406 physicians in the US examined reasons for discontinuation. Physicians surveyed included endocrinologists (34.5%), general practitioners (32.5%), internal medicine specialists (30.5%), and diabetologists (2.5%), treating a monthly average of 154 patients.Results: Among patients treated with metformin and DPP-4is who were newly prescribed insulin, 33.3 and 57.3% discontinued DPP-4i therapy within 3 and 12 months, respectively. Patients who discontinued DPP-4i therapy had higher out-of-pocket costs and a greater proportion of renal and liver disease. Top 3 responses for discontinuation included adverse events/tolerability issues (58.9%), lack of efficacy/treatment goals not being met (55.4%) and additional cost of DPP-4i with insulin (48.5%). Top 3 responses for continuing DPP-4i included meeting treatment goals (70.7%), using a lower dose of insulin (65.3%) and good tolerability (48.0%). Physician characteristics, such as physician specialty, age, gender and location impacted to some extent the reasons for treatment decisions.Conclusions: A large proportion of patients discontinue DPP-4is in the real world when initiating insulin. The impact of physician characteristics in treatment decisions highlights the need for enhanced physician training and support as new clinical data emerges and therapy options are available.
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Affiliation(s)
| | | | | | | | | | | | - Ira Gantz
- Merck & Co., Inc., Kenilworth, NJ, USA
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Laiteerapong N, Ham SA, Nathan AG, Sargis RM, Quinn MT, Huang ES. National physician survey on glycemic goals and medical decision making for patients with type 2 diabetes. Medicine (Baltimore) 2019; 98:e18491. [PMID: 31861034 PMCID: PMC6940189 DOI: 10.1097/md.0000000000018491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 10/15/2019] [Accepted: 11/22/2019] [Indexed: 11/26/2022] Open
Abstract
To describe how patient characteristics influence physician decision-making about glycemic goals for Type 2 diabetes.2016 survey of 357 US physicians. The survey included two vignettes, representing a healthy patient and an unhealthy patient, adapted from a past survey of international experts and a factorial design vignette that varied age, heart disease history, and hypoglycemia history. Survey results were weighted to provide national estimates.Over half (57.6%) of physicians recommended a goal HbA1c <7.0% for most of their patients. For the healthy patient vignette, physicians recommended a goal similar to that of international experts (<6.66% (95% Confidence Interval (CI), 6.61-6.71%) vs <6.5% (Interquartile range (IQR), 6.5-6.8%)). For the unhealthy patient, physicians recommended a lower goal than international experts (<7.38% (CI, 7.30-7.46) vs <8.0% (IQR, 7.5-8.0%)). In the factorial vignette, physicians varied HbA1c goals by 0.35%, 0.06%, and 0.28% based on age, heart disease history, and hypoglycemia risk, respectively. The goal HbA1c range between the 55-year-old with no heart disease or hypoglycemic events and the 75-year-old with heart disease and hypoglycemic events was 0.65%.Despite guidelines that recommend HbA1c goals ranging from <6.5% to <8.5%, US physicians seem to be anchored on HbA1c goals around <7.0%.
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Affiliation(s)
| | - Sandra A. Ham
- Center for Health and Social Sciences, University of Chicago
| | - Aviva G. Nathan
- Section of General Internal Medicine, Department of Medicine
| | | | | | - Elbert S. Huang
- Section of General Internal Medicine, Department of Medicine
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Triantafylidis LK, Phillips SC, Hawley CE, Schwartz AW. Finding the Sweet Spot: An Interactive Workshop on Diabetes Management in Older Adults. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2019; 15:10845. [PMID: 31911936 PMCID: PMC6944249 DOI: 10.15766/mep_2374-8265.10845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 06/24/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Intensive glucose lowering in older adults with diabetes leads to increased risks with minimal benefits. Surveys indicate that clinician confidence for individualizing glycemic goals and regimens remains low. We created an interactive workshop and clinical tool kit to improve clinician knowledge of safe diabetes management in older adults. METHODS Finding the Sweet Spot was a 1-hour workshop taught by pharmacists to medical and pharmacy learners that introduced a five-step framework for diabetes management in older adults. The interactive presentation included cases and a clinical tool kit based on current recommendations from the American Diabetes Association and American Geriatrics Society. Pilot workshops were held for 6 months, allowing for real-time revisions based on feedback; final implementation occurred for 6 months thereafter. We evaluated learner self-efficacy (via a 5-point Likert scale) and knowledge (via multiple-choice questions) of diabetes management in older adults before and after the workshop. RESULTS Thirty learners participated in Finding the Sweet Spot (70% medicine, 30% pharmacy). The percentage of confident learners increased from 55% to 97% (p < .05) after the workshop. All learners demonstrated improvements in knowledge, with the mean score on the knowledge assessment increasing from 61% to 80% (p < .05). Via open-ended feedback, learners expressed satisfaction and found the clinical tool kit especially helpful. DISCUSSION Our Finding the Sweet Spot workshop demonstrated statistically significant changes in self-efficacy and knowledge among learners, indicating that this interactive workshop improves medical and pharmacy provider confidence and skills in caring for older adults with diabetes.
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Affiliation(s)
| | - Sarah C. Phillips
- Instructor, Department of Family Medicine, Boston University School of Medicine
- Physician, Upham's Corner Elder Service Plan
- Affiliated Fellow in Geriatrics, VA Boston Healthcare System and New England Geriatric Research Education and Clinical Center
| | - Chelsea E. Hawley
- Clinical Pharmacist, Pharmacy Department, VA Boston Healthcare System
- Advanced Fellow in Geriatrics, New England Geriatric Research Education and Clinical Center
| | - Andrea Wershof Schwartz
- Associate Fellowship Director of the Harvard Multicampus Geriatrics Fellowship, VA Boston Healthcare System and New England Geriatric Research Education and Clinical Center
- Assistant Professor of Medicine, Department of Medicine, Harvard Medical School
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Bunn F, Goodman C, Jones PR, Russell B, Trivedi D, Sinclair A, Bayer A, Rait G, Rycroft-Malone J, Burton C. Managing diabetes in people with dementia: a realist review. Health Technol Assess 2018; 21:1-140. [PMID: 29235986 DOI: 10.3310/hta21750] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Dementia and diabetes mellitus are common long-term conditions that coexist in a large number of older people. People living with dementia and diabetes may be at increased risk of complications such as hypoglycaemic episodes because they are less able to manage their diabetes. OBJECTIVES To identify the key features or mechanisms of programmes that aim to improve the management of diabetes in people with dementia and to identify areas needing further research. DESIGN Realist review, using an iterative, stakeholder-driven, four-stage approach. This involved scoping the literature and conducting stakeholder interviews to develop initial programme theories, systematic searches of the evidence to test and develop the theories, and the validation of programme theories with a purposive sample of stakeholders. PARTICIPANTS Twenty-six stakeholders (user/patient representatives, dementia care providers, clinicians specialising in dementia or diabetes and researchers) took part in interviews and 24 participated in a consensus conference. DATA SOURCES The following databases were searched from 1990 to March 2016: MEDLINE (PubMed), Cumulative Index to Nursing and Allied Health Literature, Scopus, The Cochrane Library (including the Cochrane Database of Systematic Reviews), Database of Abstracts of Reviews of Effects, the Health Technology Assessment (HTA) database, NHS Economic Evaluation Database, AgeInfo (Centre for Policy on Ageing - UK), Social Care Online, the National Institute for Health Research (NIHR) portfolio database, NHS Evidence, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (Google Inc., Mountain View, CA, USA). RESULTS We included 89 papers. Ten papers focused directly on people living with dementia and diabetes, and the rest related to people with dementia or diabetes or other long-term conditions. We identified six context-mechanism-outcome (CMO) configurations that provide an explanatory account of how interventions might work to improve the management of diabetes in people living with dementia. This includes embedding positive attitudes towards people living with dementia, person-centred approaches to care planning, developing skills to provide tailored and flexible care, regular contact, family engagement and usability of assistive devices. A general metamechanism that emerges concerns the synergy between an intervention strategy, the dementia trajectory and social and environmental factors, especially family involvement. A flexible service model for people with dementia and diabetes would enable this synergy in a way that would lead to the improved management of diabetes in people living with dementia. LIMITATIONS There is little evidence relating to the management of diabetes in people living with dementia, although including a wider literature provided opportunities for transferable learning. The outcomes in our CMOs are largely experiential rather than clinical. This reflects the evidence available. Outcomes such as increased engagement in self-management are potential surrogates for better clinical management of diabetes, but this is not proven. CONCLUSIONS This review suggests that there is a need to prioritise quality of life, independence and patient and carer priorities over a more biomedical, target-driven approach. Much current research, particularly that specific to people living with dementia and diabetes, identifies deficiencies in, and problems with, current systems. Although we have highlighted the need for personalised care, continuity and family-centred approaches, there is much evidence to suggest that this is not currently happening. Future research on the management of diabetes in older people with complex health needs, including those with dementia, needs to look at how organisational structures and workforce development can be better aligned to the needs of people living with dementia and diabetes. STUDY REGISTRATION This study is registered as PROSPERO CRD42015020625. FUNDING The NIHR HTA programme.
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Affiliation(s)
- Frances Bunn
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Claire Goodman
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | | | - Bridget Russell
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Daksha Trivedi
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Alan Sinclair
- Foundation for Diabetes Research in Older People, Diabetes Frail Ltd, Luton, UK
| | - Antony Bayer
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, UK
| | - Greta Rait
- Research Department of Primary Care and Population Health, University College London Medical School, London, UK
| | | | - Chris Burton
- School of Healthcare Sciences, Bangor University, Bangor, UK
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