Association between performance measures and glycemic control among patients with diabetes in a community-wide primary care cohort

Racial and Ethnic Disparities in Blood Pressure and Glycemic Control in the US Community Health Center Patient Population

OBJECTIVE

To describe blood pressure and glycemic control by racial/ethnic group in the US Community Health Center (CHC) patient population, and whether center characteristics, proxying for higher resource levels and better quality of care, were associated with greater rates of controlled cardiometabolic conditions.

METHODS

Data came from the Uniform Data System, representing aggregate patient clinical data for individual health centers in 2019. Descriptive analyses were conducted weighting by health center patient populations to produce race-specific national rates of blood pressure and glycemic control, and linear regression is used to test whether cardiometabolic control rates varied by center characteristics.

RESULTS

Hypertension was controlled for 67.2% of non-Hispanic White, 66.9% of Hispanic, and 56.7% of non-Hispanic Black patients. Diabetes was controlled for 70.7% of non-Hispanic White, 65.7% of Hispanic, and 66.1% of non-Hispanic Black patients. The rate of blood pressure control was 2.54 to 3.99 percentage points higher across racial/ethnic groups in health centers that adopted a patient-centered medical home (PCMH) model of care relative to non-PCMH centers, while glycemic control was 1.08 to 2.27 pp. higher as a function of PCMH certification. Results for other center characteristics did not show consistent patterns across racial groups or outcomes.

CONCLUSION

This study documented racial and ethnic health disparities in the CHC patient population after major expansion of the CHC program. CHCs with PCMH certification have improved clinical outcomes among patients with hypertension and diabetes across racial/ethnic groups relative to centers without this certification.

Factors associated with potential over- and undertreatment of hyperglycaemia and annual measurement of HbA1c in type 2 diabetes in norwegian general practice

AIMS

To identify individual and general practitioner (GP) characteristics associated with potential over- and undertreatment of hyperglycaemia in type 2 diabetes and with HbA1c not being measured.

METHODS

A cross-sectional study that included 10233 individuals with type 2 diabetes attending 282 GPs. Individuals with an HbA1c measurement during the last 15 months were categorized as potentially overtreated if they were prescribed a sulphonylurea and/or insulin when the HbA1c was less than 53 mmol/mol (7%) when aged over 75 years or less than 48 mmol/mol (6.5%) when aged between 65 and 75 years. Potential undertreatment was defined as age less than 60 years and HbA1c > 64 mmol/mol (8.0%) or HbA1c > 69 mmol/mol (8.5%) and treated with lifestyle modification and/or monotherapy. We used multilevel binary and multinominal logistic regression models to examine associations.

RESULTS

Overall, 4.1% were potentially overtreated, 7.8% were potentially undertreated and 11% did not have HbA1c measured. Characteristics associated with potential overtreatment were as follows: long diabetes duration, prescribed antihypertensive medication, cardiovascular disease and renal failure. Potential undertreatment was associated with male gender, non-western origin and low educational level. Characteristics associated with not having an HbA1c measurement performed were male gender, age < 50 years and cardiovascular diseases. GP specialist status and GPs' use of a Noklus diabetes application reduced the risk of not having an HbA1c measurement performed.

CONCLUSION

Potential overtreatment in elderly individuals with type 2 diabetes was relatively low. Nevertheless, appropriate de-intensification or intensification of treatment and regular HbA1c measurement in identified subgroups is warranted.

Association between self-care management practices and glycemic control of patients with type 2 diabetes mellitus in Saud Arabia: A cross -sectional study

OBJECTIVE

In this cross-sectional study, we aimed to determine the association of self-care management practices and glycemic control of type 2 diabetes mellitus in Saudi Arabia.

METHODS

A total of 352 type 2 diabetes mellitus (T2DM) patients from two public tertiary hospitals in Saudi Arabia participated in this study. All T2DM patients were recruited and interviewed by a researcher between January to April 2018 from the outpatient diabetes clinics. All respondents answered a four-part questionnaire which includes demographics data, Diabetes Self-Management Questionnaire (DSMQ). Linear Regression was performed to assess the significance of predictors and compute the coefficient of determination.

RESULTS

The mean age of the participants was 51.89 ± 10.94. Of the 352 participants, 52% were obese (BMI: ≥30 kgm2) and 77% of the participants had glycated haemoglobin (HbA1c) over 7%. The analysis showed that subscale of Glucose management was the strongest predictor of Hba1c levels of participants' followed by physical activity. Gender and marital status emerged as significant predictors for their self-care management practices. Female patients had more self-care management practices than male patients (B 0.20; 95CI 0.10- 0.96 (p = 0.015).

CONCLUSION

This study provides an evidence on the self-care management of T2DM patients in Saudi Arabia. The high self-care management found in the study highlights that the patients are aware of the severity of and possible complications associated with T2DM.

Association of health literacy and self-management practices and psychological factor among patients with type 2 diabetes mellitus in Saudi Arabia

Objectives:

To determine the association between sociodemographic, clinical, and health literacy and the presence of depressed mood and their relationships to diabetes self-management among type 2 diabetes mellitus (T2DM) patients in Saudi Arabia.

Methods:

A total of 352 T2DM patients from 2 public tertiary hospitals in Saudi Arabia participated in this descriptive cross-sectional study between December 2016 and February 2017. All respondents answered a 4-part questionnaire, which includes demographic data, Diabetes Self-Management Questionnaire (DSMQ), 36-item test based Short Test of Functional Health Literacy in Adults, and a 2-item Patient Health Questionnaire (PHQ-2). The Chi-square test and logistic regression analysis were conducted to determine the relationship and significant predictors for self-management among T2DM patients.

Results:

The analysis showed that majority of the participants had low to marginal functional health literacy. The overall DSM-16 score was good, indicating more effective self-care, while 20% of the participants had a score of 2 or more in the PHQ-2 indicating presence of depressed mood. No significant association was found between DSM and health literacy among the study participants while age, gender, educational level, employment status, and level of the depressive symptom were significantly associated with differences in the level of functional literacy of the participants.

Conclusion:

The study shows that nearly half of the T2DM patients that exhibited low level of functional health literacy had low diabetes self-management. Our findings also show that gender significantly affects diabetes self-management in which odds are a lot higher among females than males with diabetes self-management. This study underscores the importance of proper counselling and education about diabetes control on both patients and family members.

Lasso Regression for the Prediction of Intermediate Outcomes Related to Cardiovascular Disease Prevention Using the TRANSIT Quality Indicators

BACKGROUND

Cardiovascular disease morbidity and mortality are largely influenced by poor control of hypertension, dyslipidemia, and diabetes. Process indicators are essential to monitor the effectiveness of quality improvement strategies. However, process indicators should be validated by demonstrating their ability to predict desirable outcomes. The objective of this study is to identify an effective method for building prediction models and to assess the predictive validity of the TRANSIT indicators.

METHODS

On the basis of blood pressure readings and laboratory test results at baseline, the TRANSIT study population was divided into 3 overlapping subpopulations: uncontrolled hypertension, uncontrolled dyslipidemia, and uncontrolled diabetes. A classic statistical method, a sparse machine learning technique, and a hybrid method combining both were used to build prediction models for whether a patient reached therapeutic targets for hypertension, dyslipidemia, and diabetes. The final models' performance for predicting these intermediate outcomes was established using cross-validated area under the curves (cvAUC).

RESULTS

At baseline, 320, 247, and 303 patients were uncontrolled for hypertension, dyslipidemia, and diabetes, respectively. Among the 3 techniques used to predict reaching therapeutic targets, the hybrid method had a better discriminative capacity (cvAUCs=0.73 for hypertension, 0.64 for dyslipidemia, and 0.79 for diabetes) and succeeded in identifying indicators with a better capacity for predicting intermediate outcomes related to cardiovascular disease prevention.

CONCLUSIONS

Even though this study was conducted in a complex population of patients, a set of 5 process indicators were found to have good predictive validity based on the hybrid method.

Associations of Four Community Factors With Longitudinal Change in Hemoglobin A1c Levels in Patients With Type 2 Diabetes

OBJECTIVE

To evaluate associations of community factors with glycated hemoglobin (HbA1c).

RESEARCH DESIGN AND METHODS

We identified patients with type 2 diabetes who had an HbA1c ≥7.5% (58 mmol/mol) and subsequent HbA1c testing within 90-270 days. We used mixed-effect models to assess whether treatment intensification (TI) and community domains (community socioeconomic deprivation [CSD], food availability, fitness assets, and utilitarian physical activity favorability [quartiled]) were associated with HbA1c change over 6 and 24 months, controlling for demographics, HbA1c, BMI, and time with evidence of type 2 diabetes. We evaluated whether community domains modified associations of TI with HbA1c change using cross product terms.

RESULTS

There were 15,308 patients with 69,818 elevated HbA1c measures. The average reduction in HbA1c over 6 months was 0.07% less in townships with a high level of CSD (third quartile versus the first). Reductions were 0.10% greater for HbA1c in townships with the best food availability (versus worst). HbA1c reductions were 0.17-0.19% greater in census tracts in the second and third quartiles of utilitarian physical activity favorability versus the first. The association of TI with 6-month HbA1c change was weaker in townships and boroughs with the worst CSD (versus best) and in boroughs with the best fitness assets (versus worst). The association of TI with 24-month HbA1c change was weaker in census tracts with the worst CSD (versus third quartile) and strongest in census tracts most favorable for utilitarian physical activity (versus worst).

CONCLUSIONS

Community domains were associated with HbA1c change and blunted TI effectiveness.

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

AIMS

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Medication usage, treatment intensification, and medical cost in patients with type 2 diabetes: a retrospective database study

OBJECTIVE

The goal of this study was to describe medication usage patterns in patients with type 2 diabetes mellitus (T2DM) initiating treatment with non-insulin antidiabetic drugs (NIADs), basal insulin, or prandial/mixed insulin using real-world data.

RESEARCH DESIGN AND METHODS

A retrospective analysis using the Truven Health MarketScan Research Databases was conducted to identify adults (≥18 years) with T2DM from 2006 to 2012. Patients were categorized into four cohorts based on diabetes treatment. Cohort 1 (n=597 664) consisted of newly diagnosed patients who did not receive any treatment, cohort 2 (n=342 511) included NIAD initiators, cohort 3 (n=99 578) included basal insulin initiators, and cohort 4 (n=62 876) included prandial/mixed insulin initiators. Patients transitioned out of a cohort once they met the criteria for the next one.

RESULTS

Patients in cohort 2 were younger (56.2 years, SD±12.1) than patients in cohorts 1, 3, and 4 (58 years, SD±0.75). Metformin was the most commonly prescribed drug in cohort 2 patients. Basal insulin usage decreased from 71% in year 1 to 47% in year 4, in cohort 3 patients. Approximately one-third of these patients switched to prandial/mixed insulin each year. In cohort 4, the usage of prandial/mixed insulin decreased to 61% by year 4. Use of basal insulin and NIAD remained common in this group. Mean glycosylated hemoglobin (HbA1c) values decreased by ∼1% for each of the treatment cohorts following treatment initiation and remained stable during follow-up. All-cause and diabetes-related medical costs were highest for patients in cohorts 3 and 4.

CONCLUSIONS

Overall, our findings demonstrate that treatment intensification was low in all study cohorts despite elevated HbA1c levels during preindex and follow-up period.

Level of A1C control and its predictors among Lebanese type 2 diabetic patients

AIM

Lebanon is among the top 10 countries with the highest prevalence of diabetes in the Middle East region with estimates reaching as high as 16.6% in adults aged 20-79 years. The objective of this study was to assess the level of A1C control among a cohort of type 2 diabetic patients and factors associated with uncontrolled A1C.

METHODS

We carried out a retrospective observational study among type 2 diabetes mellitus patients attending an outpatient endocrinologist's clinic between June 2008 and July 2012 in Beirut, Lebanon. Two groups were compared, based on their diabetic control (A1C < 7% and A1C ≥ 7%).

RESULTS

A total of 551 patients were included in this study, where 31.8% attained A1C control. Crude analyses showed that some factors were significantly associated with uncontrolled A1C, and these were long-standing diabetes, diabetes-related complications, uncontrolled blood pressure, lipid profile, as well as the use of metformin, sulfonylurea, or insulin. When multivariate analysis was carried out, the chances of having uncontrolled A1C were significantly higher among patients who developed neuropathy (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.11-3.90), had uncontrolled triglycerides (OR 1.98, 95% CI 1.33-2.94), used insulin (OR 4.52, 95% CI 2.32-8.83), and sulfonylureas (OR 2.88, 95% CI 1.88-4.40).

CONCLUSION

Uncontrolled diabetes is more likely to exist in patients with neuropathy, uncontrolled triglycerides and those using insulin or sulfonylurea. Further research is needed to confirm the findings.

Potential overtreatment and undertreatment of diabetes in different patient age groups in primary care after the introduction of performance measures

OBJECTIVE

To assess whether after the introduction of diabetes performance measures decreases in undertreatment correspond with increases in overtreatment for blood pressure (BP) and glycemic control in different patient age groups.

RESEARCH DESIGN AND METHODS

We conducted a cohort study using data from the Groningen Initiative to Analyse Type 2 Diabetes Treatment (GIANTT) database. General practices were included when data were available from 1 year before to at least 1 year after the introduction of diabetes performance measures. Included patients had a confirmed diagnosis of type 2 diabetes. Potential overtreatment was defined as prescribing maximum treatment or a treatment intensification to patients with a sustained low-risk factor level. Potential undertreatment was defined as a lack of treatment intensification in patients with a sustained high-risk factor level. Percentages of over- and undertreated patients at baseline were compared with those in subsequent years, and stratified analyses were performed for different patient age groups.

RESULTS

For BP, undertreatment significantly decreased from 61 to 57% in the first year after the introduction of performance measures. In patients >75 years of age, undertreatment decreased from 65 to ∼61%. Overtreatment was relatively stable (∼16%). For glycemic control, undertreatment significantly increased from 49 to 53%, and overtreatment remained relatively stable (∼7%).

CONCLUSIONS

The improvement of BP undertreatment after introduction of the performance measures did not correspond with an increase in overtreatment. The performance measures appeared to have little impact on improving glucose-regulating treatment. The trends did not differ among patient age groups.

Do treatment quality indicators predict cardiovascular outcomes in patients with diabetes?

Background

Landmark clinical trials have led to optimal treatment recommendations for patients with diabetes. Whether optimal treatment is actually delivered in practice is even more important than the efficacy of the drugs tested in trials. To this end, treatment quality indicators have been developed and tested against intermediate outcomes. No studies have tested whether these treatment quality indicators also predict hard patient outcomes.

Methods

A cohort study was conducted using data collected from >10.000 diabetes patients in the Groningen Initiative to Analyze Type 2 Treatment (GIANTT) database and Dutch Hospital Data register. Included quality indicators measured glucose-, lipid-, blood pressure- and albuminuria-lowering treatment status and treatment intensification. Hard patient outcome was the composite of cardiovascular events and all-cause death. Associations were tested using Cox regression adjusting for confounding, reporting hazard ratios (HR) with 95% confidence intervals.

Results

Lipid and albuminuria treatment status, but not blood pressure lowering treatment status, were associated with the composite outcome (HR = 0.77, 0.67–0.88; HR = 0.75, 0.59–0.94). Glucose lowering treatment status was associated with the composite outcome only in patients with an elevated HbA1c level (HR = 0.72, 0.56–0.93). Treatment intensification with glucose-lowering but not with lipid-, blood pressure- and albuminuria-lowering drugs was associated with the outcome (HR = 0.73, 0.60–0.89).

Conclusion

Treatment quality indicators measuring lipid- and albuminuria-lowering treatment status are valid quality measures, since they predict a lower risk of cardiovascular events and mortality in patients with diabetes. The quality indicators for glucose-lowering treatment should only be used for restricted populations with elevated HbA1c levels. Intriguingly, the tested indicators for blood pressure-lowering treatment did not predict patient outcomes. These results question whether all treatment indicators are valid measures to judge quality of health care and its economics.

The Diabetes Self-Management Questionnaire (DSMQ): development and evaluation of an instrument to assess diabetes self-care activities associated with glycaemic control

Background

Though several questionnaires on self-care and regimen adherence have been introduced, the evaluations do not always report consistent and substantial correlations with measures of glycaemic control. Small ability to explain variance in HbA_1c constitutes a significant limitation of an instrument’s use for scientific purposes as well as clinical practice. In order to assess self-care activities which can predict glycaemic control, the Diabetes Self-Management Questionnaire (DSMQ) was designed.

Methods

A 16 item questionnaire to assess self-care activities associated with glycaemic control was developed, based on theoretical considerations and a process of empirical improvements. Four subscales, ‘Glucose Management’ (GM), ‘Dietary Control’ (DC), ‘Physical Activity’ (PA), and ‘Health-Care Use’ (HU), as well as a ‘Sum Scale’ (SS) as a global measure of self-care were derived. To evaluate its psychometric quality, 261 patients with type 1 or 2 diabetes were assessed with the DSMQ and an established analogous scale, the Summary of Diabetes Self-Care Activities Measure (SDSCA). The DSMQ’s item and scale characteristics as well as factorial and convergent validity were analysed, and its convergence with HbA_1c was compared to the SDSCA.

Results

The items showed appropriate characteristics (mean item-total-correlation: 0.46 ± 0.12; mean correlation with HbA_1c: -0.23 ± 0.09). Overall internal consistency (Cronbach’s alpha) was good (0.84), consistencies of the subscales were acceptable (GM: 0.77; DC: 0.77; PA: 0.76; HU: 0.60). Principal component analysis indicated a four factor structure and confirmed the designed scale structure. Confirmatory factor analysis indicated appropriate fit of the four factor model. The DSMQ scales showed significant convergent correlations with their parallel SDSCA scales (GM: 0.57; DC: 0.52; PA: 0.58; HU: n/a; SS: 0.57) and HbA_1c (GM: -0.39; DC: -0.30; PA: -0.15; HU: -0.22; SS: -0.40). All correlations with HbA_1c were significantly stronger than those obtained with the SDSCA.

Conclusions

This study provides preliminary evidence that the DSMQ is a reliable and valid instrument and enables an efficient assessment of self-care behaviours associated with glycaemic control. The questionnaire should be valuable for scientific analyses as well as clinical use in both type 1 and type 2 diabetes patients.