Improving quality of care in people with Type 2 diabetes through the Associazione Medici Diabetologi-annals initiative: a long-term cost-effectiveness analysis

Achieving Good Metabolic Control Without Weight Gain with the Systematic Use of GLP-1-RAs and SGLT-2 Inhibitors in Type 2 Diabetes: A Machine-learning Projection Using Data from Clinical Practice

PURPOSE

Recently, the 2022 American Diabetes Association and European Association for the Study of Diabetes (ADA-EASD) consensus report stressed the importance of weight control in the management of patients with type 2 diabetes; weight control should be a primary target of therapy. This retrospective analysis evaluated, through an artificial-intelligence (AI) projection of data from the AMD Annals database-a huge collection of most Italian diabetology medical records covering 15 years (2005-2019)-the potential effects of the extended use of sodium-glucose co-transporter 2 inhibitors (SGLT-2is) and of glucose-like peptide 1 receptor antagonists (GLP-1-RAs) on HbA1c and weight.

METHODS

Data from 4,927,548 visits in 558,097 patients were retrospectively extracted using these exclusion criteria: type 1 diabetes, pregnancy, age >75 years, dialysis, and lack of data on HbA1c or weight. The analysis revealed late prescribing of SGLT-2is and GLP-1-RAs (innovative drugs), and considering a time frame of 4 years (2014-2017), a paradoxic greater percentage of combined-goal (HbA1c <7% and weight gain <2%) achievement was found with older drugs than with innovative drugs, demonstrating aspects of therapeutic inertia. Through a machine-learning AI technique, a "what-if" analysis was performed, using query models of two outcomes: (1) achievement of the combined goal at the visit subsequent to a hypothetical initial prescribing of an SGLT-2i or a GLP-1-RA, with and without insulin, selected according to the 2018 ADA-EASD diabetes recommendations; and (2) persistence of the combined goal for 18 months. The precision values of the two models were, respectively, sensitivity, 71.1 % and 69.8%, and specificity, 67% and 76%.

FINDINGS

The first query of the AI analysis showed a great improvement in achievement of the combined goal: 38.8% with prescribing in clinical practice versus 66.5% with prescribing in the "what-if" simulation. Addressing persistence at 18 months after the initial achievement of the combined goal, the simulation showed a potential better performance of SGLT-2is and GLP-1-RAs with respect to each antidiabetic pharmacologic class or combination considered.

IMPLICATIONS

AI appears potentially useful in the analysis of a great amount of data, such as that derived from the AMD Annals. In the present study, an LLM analysis revealed a great potential improvement in achieving metabolic targets with SGLT-2i and GLP-1-RA utilization. These results underscore the importance of early, timely, and extended use of these new drugs.

The AMD ANNALS: A continuous initiative for the improvement of type 2 diabetes care

AIMS

Since 2006, the Italian AMD (Associations of Medical Diabetologists) Annals Initiative promoted a continuous monitoring of the quality of diabetes care, that was effective in improving process, treatment and outcome indicators through a periodic assessment of standardized measures. Here, we show the 2022 AMD Annals data on type 2 diabetes (T2D).

METHODS

A network involving ∼1/3 of diabetes centers in Italy periodically extracts anonymous data from electronic clinical records, by a standardized software. Process, treatment and outcome indicators, and a validated score of overall care, the Q-score, were evaluated.

RESULTS

295 centers provided the annual sample of 502,747 T2D patients. Overall, HbA1c value ≤7.0% was documented in 54.6% of patients, blood pressure <130/80 mmHg in 23.0%, and LDL-cholesterol levels <70 mg/dl in 34.3%, but only 5.2% were at- target for all the risk factors. As for innovative drugs, 29.0% of patients were on SGLT2-i, and 27.5% on GLP1-RAs. In particular, 59.7% were treated with either GLP1-RAs or SGLT2-i among those with established cardiovascular disease (CVD), 26.6% and 49.3% with SGLT2-i among those with impaired renal function and heart failure, respectively. Notably, only 3.2% of T2D patients showed a Q score <15, which correlates with a 80% higher risk of incident CVD events compared to scores >25.

CONCLUSIONS

The 2022 AMD Annals data show an improvement in the use of innovative drugs and in the overall quality of T2D care in everyday clinical practice. However, additional efforts are needed to reach the recommended targets for HbA1c and major CVD risk factors.

Clinical Inertia in the Management of Type 2 Diabetes Mellitus: A Systematic Review

This review seeks to establish, through the recent available literature, the prevalence of therapeutic intensification delay and its sequences in poorly controlled Type 2 Diabetes Mellitus (T2DM) patients. The strategy identified studies exploring the clinical inertia and its associated factors in the treatment of patients with T2DM. A total of 25 studies meeting the pre-established quality criteria were included in this review. These studies were conducted between 2004 and 2021 and represented 575,067 patients diagnosed with T2DM. Trusted electronic bibliographic databases, including Medline, Embase, and the Cochrane Central Register of Controlled Trials, were used to collect studies by utilizing a comprehensive set of search terms to identify Medical Subject Headings (MeSH) terms. Most o the studies included in this review showed clinical inertia rates over 50% of T2DM patients. In the USA, clinical inertia ranged from 35.4% to 85.8%. In the UK, clinical inertia ranged from 22.1% to 69.1%. In Spain, clinical inertia ranged from 18.1% to 60%. In Canada, Brazil, and Thailand, clinical inertia was reported as 65.8%, 68%, and 68.4%, respectively. The highest clinical inertia was reported in the USA (85.8%). A significant number of patients with T2DM suffered from poor glycemic control for quite a long time before treatment intensification with oral antidiabetic drugs (OADs) or insulin. Barriers to treatment intensification exist at the provider, patient, and system levels. There are deficiencies pointed out by this review at specialized centers in terms of clinical inertia in the management of T2DM including in developed countries. This review shows that the earlier intensification in the T2DM treatment is appropriate to address issues around therapeutic inertia.

Cost-effectiveness of Interventions to Manage Diabetes: Has the Evidence Changed Since 2008?

OBJECTIVE

To synthesize updated evidence on the cost-effectiveness (CE) of interventions to manage diabetes, its complications, and comorbidities.

RESEARCH DESIGN AND METHODS

We conducted a systematic literature review of studies from high-income countries evaluating the CE of diabetes management interventions recommended by the American Diabetes Association (ADA) and published in English between June 2008 and July 2017. We also incorporated studies from a previous CE review from the period 1985-2008. We classified the interventions based on their strength of evidence (strong, supportive, or uncertain) and levels of CE: cost-saving (more health benefit at a lower cost), very cost-effective (≤$25,000 per life year gained [LYG] or quality-adjusted life year [QALY]), cost-effective ($25,001-$50,000 per LYG or QALY), marginally cost-effective ($50,001-$100,000 per LYG or QALY), or not cost-effective (>$100,000 per LYG or QALY). Costs were measured in 2017 U.S. dollars.

RESULTS

Seventy-three new studies met our inclusion criteria. These were combined with 49 studies from the previous review to yield 122 studies over the period 1985-2017. A large majority of the ADA-recommended interventions remain cost-effective. Specifically, we found strong evidence that the following ADA-recommended interventions are cost-saving or very cost-effective: In the cost-saving category are 1) ACE inhibitor (ACEI)/angiotensin receptor blocker (ARB) therapy for intensive hypertension management compared with standard hypertension management, 2) ACEI/ARB therapy to prevent chronic kidney disease and/or end-stage renal disease in people with albuminuria compared with no ACEI/ARB therapy, 3) comprehensive foot care and patient education to prevent and treat foot ulcers among those at moderate/high risk of developing foot ulcers, 4) telemedicine for diabetic retinopathy screening compared with office screening, and 5) bariatric surgery compared with no surgery for individuals with type 2 diabetes (T2D) and obesity (BMI ≥30 kg/m²). In the very cost-effective category are 1) intensive glycemic management (targeting A1C <7%) compared with conventional glycemic management (targeting an A1C level of 8-10%) for individuals with newly diagnosed T2D, 2) multicomponent interventions (involving behavior change/education and pharmacological therapy targeting hyperglycemia, hypertension, dyslipidemia, microalbuminuria, nephropathy/retinopathy, secondary prevention of cardiovascular disease with aspirin) compared with usual care, 3) statin therapy compared with no statin therapy for individuals with T2D and history of cardiovascular disease, 4) diabetes self-management education and support compared with usual care, 5) T2D screening every 3 years starting at age 45 years compared with no screening, 6) integrated, patient-centered care compared with usual care, 7) smoking cessation compared with no smoking cessation, 8) daily aspirin use as primary prevention for cardiovascular complications compared with usual care, 9) self-monitoring of blood glucose three times per day compared with once per day among those using insulin, 10) intensive glycemic management compared with conventional insulin therapy for T2D among adults aged ≥50 years, and 11) collaborative care for depression compared with usual care.

CONCLUSIONS

Complementing professional treatment recommendations, our systematic review provides an updated understanding of the potential value of interventions to manage diabetes and its complications and can assist clinicians and payers in prioritizing interventions and health care resources.

Artificial Intelligence and Big Data in Diabetes Care: A Position Statement of the Italian Association of Medical Diabetologists

Since the last decade, most of our daily activities have become digital. Digital health takes into account the ever-increasing synergy between advanced medical technologies, innovation, and digital communication. Thanks to machine learning, we are not limited anymore to a descriptive analysis of the data, as we can obtain greater value by identifying and predicting patterns resulting from inductive reasoning. Machine learning software programs that disclose the reasoning behind a prediction allow for “what-if” models by which it is possible to understand if and how, by changing certain factors, one may improve the outcomes, thereby identifying the optimal behavior. Currently, diabetes care is facing several challenges: the decreasing number of diabetologists, the increasing number of patients, the reduced time allowed for medical visits, the growing complexity of the disease both from the standpoints of clinical and patient care, the difficulty of achieving the relevant clinical targets, the growing burden of disease management for both the health care professional and the patient, and the health care accessibility and sustainability. In this context, new digital technologies and the use of artificial intelligence are certainly a great opportunity. Herein, we report the results of a careful analysis of the current literature and represent the vision of the Italian Association of Medical Diabetologists (AMD) on this controversial topic that, if well used, may be the key for a great scientific innovation. AMD believes that the use of artificial intelligence will enable the conversion of data (descriptive) into knowledge of the factors that “affect” the behavior and correlations (predictive), thereby identifying the key aspects that may establish an improvement of the expected results (prescriptive). Artificial intelligence can therefore become a tool of great technical support to help diabetologists become fully responsible of the individual patient, thereby assuring customized and precise medicine. This, in turn, will allow for comprehensive therapies to be built in accordance with the evidence criteria that should always be the ground for any therapeutic choice.

Economic Evaluation of Quality Improvement Interventions Designed to Improve Glycemic Control in Diabetes: A Systematic Review and Weighted Regression Analysis

OBJECTIVE

Quality improvement (QI) interventions can improve glycemic control, but little is known about their value. We systematically reviewed economic evaluations of QI interventions for glycemic control among adults with type 1 or type 2 diabetes.

RESEARCH DESIGN AND METHODS

We used English-language studies from high-income countries that evaluated organizational changes and reported program and utilization-related costs, chosen from PubMed, EconLit, Centre for Reviews and Dissemination, New York Academy of Medicine's Grey Literature Report, and WorldCat (January 2004 to August 2016). We extracted data regarding intervention, study design, change in HbA1c, time horizon, perspective, incremental net cost (studies lasting ≤3 years), incremental cost-effectiveness ratio (ICER) (studies lasting ≥20 years), and study quality. Weighted least-squares regression analysis was used to estimate mean changes in HbA1c and incremental net cost.

RESULTS

Of 3,646 records, 46 unique studies were eligible. Across 19 randomized controlled trials (RCTs), HbA1c declined by 0.26% (95% CI 0.17-0.35) or 3 mmol/mol (2 to 4) relative to usual care. In 8 RCTs lasting ≤3 years, incremental net costs were $116 (95% CI -$612 to $843) per patient annually. Long-term ICERs were $100,000-$115,000/quality-adjusted life year (QALY) in 3 RCTs, $50,000-$99,999/QALY in 1 RCT, $0-$49,999/QALY in 4 RCTs, and dominant in 1 RCT. Results were more favorable in non-RCTs. Our limitations include the fact that the studies had diverse designs and involved moderate risk of bias.

CONCLUSIONS

Diverse multifaceted QI interventions that lower HbA1c appear to be a fair-to-good value relative to usual care, depending on society's willingness to pay for improvements in health.

Quality of Diabetes Care for Individuals with Comorbid Chronic Psychotic Illness: A Sex-Based Analysis

BACKGROUND

Diabetes is common among individuals with chronic psychotic illness, yet they receive lower quality of diabetes care than those without psychosis. Men usually receive higher quality diabetes care than women, but whether this holds true in chronic psychotic illness populations is unknown. We aimed to determine whether quality of diabetes care differs between men and women with chronic psychotic illness.

METHODS

This population-based cohort study used Ontario health administrative data to compare women and men with comorbid chronic psychotic illness and diabetes mellitus (2011-2013). The primary outcome was adherence to diabetes monitoring guidelines, defined as ≥1 retinal exam, ≥4 hemoglobin A1c (HbA1c) tests, and ≥1 dyslipidemia test during a 2-year period. Logistic regression models compared women to men to generate adjusted odds ratios (aOR) and confidence intervals (95% CI), adjusting for potential confounding variables.

RESULTS

Women with chronic psychotic illness (n = 13,972) were slightly more likely to receive guideline-adherent diabetes monitoring than men (n = 12,287) (25.2% vs. 23.0%; aOR 1.20, 95% CI 1.10-1.30), including a greater likelihood of receiving ≥1 retinal exam (aOR 1.13, 95% CI 1.08-1.19) and ≥4 HbA1c tests (aOR 1.06, 95% CI 1.01-1.12). There was no difference in receipt of ≥1 dyslipidemia test (aOR 1.04, 95% CI 0.99-1.11).

CONCLUSIONS

Quality of diabetes monitoring is similarly poor in women and men with chronic psychotic illness, with women receiving only marginally more optimal monitoring than men. This differs from patterns in the general population, and could have implications when designing and implementing interventions to improve diabetes care in women and men with chronic psychotic illness.

How Consistent is the Relationship between Improved Glucose Control and Modelled Health Outcomes for People with Type 2 Diabetes Mellitus? a Systematic Review

BACKGROUND

There are an increasing number of studies using simulation models to conduct cost-effectiveness analyses for type 2 diabetes mellitus.

OBJECTIVE

To evaluate the relationship between improvements in glycosylated haemoglobin (HbA_1c) and simulated health outcomes in type 2 diabetes cost-effectiveness studies.

METHODS

A systematic review was conducted on MEDLINE and EMBASE to collect cost-effectiveness studies using type 2 diabetes simulation models that reported modelled health outcomes of blood glucose-related interventions in terms of quality-adjusted life-years (QALYs) or life expectancy (LE). The data extracted included information used to characterise the study cohort, the intervention's treatment effects on risk factors and model outcomes. Linear regressions were used to test the relationship between the difference in HbA_1c (∆HbA_1c) and incremental QALYs (∆QALYs) or LE (∆LE) of intervention and control groups. The ratio between the ∆QALYs and ∆LE was calculated and a scatterplot between the ratio and ∆HbA_1c was used to explore the relationship between these two.

RESULTS

Seventy-six studies were included in this research, contributing to 124 pair of comparators. The pooled regressions indicated that the marginal effect of a 1% HbA_1c decrease in intervention resulted in an increase in life-time QALYs and LE of 0.371 (95% confidence interval 0.286-0.456) and 0.642 (95% CI 0.494-0.790), respectively. No evidence of heterogeneity between models was found. An inverse exponential relationship was found and fitted between the ratio (∆QALY/∆LE) and ∆HbA_1c.

CONCLUSION

There is a consistent relationship between ∆HbA_1c and ∆QALYs or ∆LE in cost-effectiveness analyses using type 2 diabetes simulation models. This relationship can be used as a diagnostic tool for decision makers.

The complex interplay between clinical and person-centered diabetes outcomes in the two genders

Background

New approaches to cope with clinical and psychosocial aspects of type 2 diabetes (T2DM) are needed; gender influences the complex interplay between clinical and non-clinical factors. We used data from the BENCH-D study to assess gender-differences in terms of clinical and person-centered measures in T2DM.

Methods

Clinical quality of care indicators relative to control of HbA1c, lipid profile, blood pressure, and BMI were derived from electronic medical records. Ten self-administered validated questionnaires (SF-12 Health Survey; WHO-5 well-being index; Problem Areas in Diabetes (PAID) 5, Health Care Climate Questionnaire, Patients Assessment of Chronic Illness Care, Diabetes Empowerment Scale, Diabetes Self-care Activities, Global Satisfaction for Diabetes Treatment, Barriers to Taking Medications, Perceived Social Support) were adopted as person-centered outcomes indicators.

Results

Overall, 26 diabetes clinics enrolled 2,335 people (men: 59.7%; women: 40.3%). Lower percentages of women reached HbA1c levels < =7.0% (23.2% vs. 27.8%; p = 0.03), LDL-cholesterol < 100 mg/dl (48.3 vs. 57.8%; p = 0.0005), and BMI <27 Kg/m2 (27.2 vs. 31.6%; p = 0.04) than men. Women had statistically significant poorer scores for physical functioning, psychological well-being, self-care activities dedicated to physical activities, empowerment, diabetes-related distress, satisfaction with treatment, barriers to medication taking, satisfaction with access to chronic care and healthcare communication, and perceived social support than men; 24.8% of women and 8.8% of men had WHO-5 < =28 (likely depression) (p < 0.0001); 67.7% of women and 55.1% of men had PAID-5 > 40 (high levels of diabetes-related distress) (p < 0.0001). At multivariate analysis, factors associated with an increased likelihood of having elevated HbA1c levels (≥8.0%) were different in men and women, e.g. having PAID-5 levels >40 was associated with a higher likelihood of HbA1c ≥8.0% in women (OR = 1.15; 95%CI 1.05–1.25) but not in men (OR = 1.00; 95%CI 0.93–1.08).

Conclusions

In T2DM, women show poorer clinical and person-centered outcomes indicators than men. Diabetes-related distress plays a role as a correlate of metabolic control in women but not in men. The study provides new information about the interplay between clinical and person-centered indicators in men and women which may guide further improvements in diabetes education and support programs.

Gender-Disparities in Adults with Type 1 Diabetes: More Than a Quality of Care Issue. A Cross-Sectional Observational Study from the AMD Annals Initiative

We evaluated gender-differences in quality of type 1 diabetes (T1DM) care. Starting from electronic medical records of 300 centers, 5 process indicators, 3 favorable and 6 unfavorable intermediate outcomes, 6 treatment intensity/appropriateness measures and an overall quality score were measured. The likelihood of women vs. men (reference class) to be monitored, to reach outcomes, or to be treated has been investigated through multilevel logistic regression analyses; results are expressed as Odd Ratios (ORs) and 95% confidence intervals (95%CIs). The inter-center variability in the achievement of the unfavorable outcomes was also investigated. Overall, 28,802 subjects were analyzed (45.5% women). Women and men had similar age (44.5±16.0 vs. 45.0±17.0 years) and diabetes duration (18.3±13.0 vs. 18.8±13.0 years). No between-gender differences were found in process indicators. As for intermediate outcomes, women showed 33% higher likelihood of having HbA1c ≥8.0% (OR = 1.33; 95%CI: 1.25–1.43), 29% lower risk of blood pressure ≥140/90 mmHg (OR = 0.71; 95%CI: 0.65–0.77) and 27% lower risk of micro/macroalbuminuria (OR = 0.73; 95%CI: 0.65–0.81) than men, while BMI, LDL-c and GFR did not significantly differ; treatment intensity/appropriateness was not systematically different between genders; overall quality score was similar in men and women. Consistently across centers a larger proportion of women than men had HbA1c ≥8.0%, while a smaller proportion had BP ≥140/90 mmHg. No gender-disparities were found in process measures and improvements are required in both genders. The systematic worse metabolic control in women and worse blood pressure in men suggest that pathophysiologic differences rather than the care provided might explain these differences.

Interplay among patient empowerment and clinical and person-centered outcomes in type 2 diabetes. The BENCH-D study

OBJECTIVE

We evaluated empowerment in T2DM and identified its correlates.

METHODS

A sample of individuals self-administered the Diabetes Empowerment Scale-Short Form (DES-SF) and other 9 validated instruments (person-centered outcomes). Correlates of DES-SF were identified through univariate and multivariate analyses. For person-centered outcomes, ORs express the likelihood of being in upper quartile of DES-SF (Q4) by 5 units of the scale.

RESULTS

Overall, 2390 individuals were involved. Individuals in Q4 were younger, more often males, had higher levels of school education, lower HbA1c levels and prevalence of complications as compared to individuals in the other quartiles. The likelihood of being in Q4 was directly associated with higher selfreported self-monitoring of blood glucose (SDSCA6-SMBG) (OR=1.09; 95% CI: 1.03-1.15), higher satisfaction with diabetes treatment (GSDT) (OR=1.15; 95% CI: 1.07-1.25), perceived quality of chronic illness care and patient support (PACIC-SF) (OR=1.23; 95% CI: 1.16-1.31), and better person-centered communication (HCC-SF) (OR=1.10; 95% CI: 1.01-1.19) and inversely associated with diabetes-related distress (PAID-5) (OR=0.95; 95% CI: 0.92-0.98). Adjusted DES-SF mean scores ranged between centers from 69.8 to 93.6 (intra-class correlation=0.10; p<0.0001).

CONCLUSIONS

Empowerment was associated with better glycemic control, psychosocial functioning and perceived access to person-centered chronic illness care. Practice of diabetes center plays a specific role.

PRACTICE IMPLICATIONS

DES-SF represents a process and outcome indicator in the practice of diabetes centers.

Trends over 8 years in quality of diabetes care: results of the AMD Annals continuous quality improvement initiative

OBJECTIVE

Quality of care monitoring is a key strategy for health policy. In Italy, the AMD Annals continuous monitoring and quality improvement initiative has been in place since 2006. Results after 8 years are now available.

RESEARCH DESIGN AND METHODS

Quality of diabetes care indicators during the years 2004-2011 were extracted from electronic medical records of 300 diabetes clinics. From 200,000 to 500,000 patients with type 2 diabetes were analyzed per year. Six process indicators, eight intermediate outcome indicators, seven indicators of treatment intensity/appropriateness, and a quality of care summary score (Q score) were evaluated. Previous studies documented that the risk of developing a new cardiovascular event was 80 % higher in patients with a Q score <15 and 20 % higher in those with a score between 15 and 25, as compared to those with a score >25.

RESULTS

The proportion of patients with HbA1c ≤7 %, LDL cholesterol <100 mg/dl, and blood pressure ≥140/90 mmHg increased by 4.8, 21.9, and 10.0 %, respectively. Process and treatment intensity/appropriateness indicators consistently improved. The proportion of patients with a Q score <15 decreased from 13.5 to 6.5 %, while those with a Q score >25 increased from 22.9 to 38.5 %.

CONCLUSIONS

AMD Annals document the progress in quality of diabetes care. Longitudinal improvements in Q score can translate into less cardiovascular events, with evident clinical and economic implications. AMD Annals represent a physician-led effort not requiring allocation of extra-economic resources, which is easy to implement and deeply rooted in routine clinical practice. They are a potential case model for other healthcare systems.