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Narain KDC, Tseng CH, Bell D, Do A, Follett R, Duru OK, Moreno G, Mangione C. An Effectiveness Study of a Primary Care-embedded Clinical Pharmacist-Led Intervention Among Patients With Diabetes and Medicaid Coverage. J Pharm Pract 2024; 37:66-73. [PMID: 36052841 PMCID: PMC10804690 DOI: 10.1177/08971900221125008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: Examine the impact of a primary care-embedded clinical pharmacist-led intervention (UCMyRx) on hemoglobin A1C and blood pressure control, relative to usual care, among patients with Type 2 diabetes (TD2) and Medicaid, in a large healthcare system. Methods: We used data extracted from the Electronic Health Records system and a Difference-In-Differences study design with a 2:1 propensity-matched comparison group to evaluate the impact of UCMyRx on HbA1c and systolic blood pressure among patients with TD2 and Medicaid, relative to usual care. Results: Having at least one UCMyRx clinical pharmacist visit was associated with a significant reduction in HbA1c; (-.27%, P-value= .03) but no impact on SBP. We do not find differential UCMyRx effects on HbA1c or SBP among the subpopulations with baseline HbA1C ≥9% or SBP ≥150 mmHg, respectively. In Charlson Comorbidity Index (CCI)-stratified analyses we found stronger UCMyRx effects on HbA1C (-.47%, P-value< .02) among the CCI tercile with the lowest comorbidity score (CC1 ≤ 5). Significant UCMyRx effects are only observed among the subpopulation of Medicaid beneficiaries without Medicare (-.35%, P-value= .02). Conclusions: The UCMyRx intervention is a useful strategy for improving HbA1c control among patients with TD2 and Medicaid.
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Affiliation(s)
- Kimberly Danae Cauley Narain
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles, CA, USA
- Center for Health Advancement, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles, CA, USA
| | - Douglas Bell
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles, CA, USA
- Clinical and Translational Science Institute, University of California, Los Angeles, CA, USA
| | - Amanda Do
- Clinical and Translational Science Institute, University of California, Los Angeles, CA, USA
| | - Rob Follett
- Clinical and Translational Science Institute, University of California, Los Angeles, CA, USA
| | - O. Kenrik Duru
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles, CA, USA
| | - Gerardo Moreno
- Department of Family Medicine, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Carol Mangione
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles, CA, USA
- Department of Health Policy and Management, Fielding School of Public Health, Los Angeles, CA, USA
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Narain KDC, Moreno G, Bell DS, Chen L, Tseng CH, Follett RW, Skootsky S, Mangione CM. Pharmacist-Led Diabetes Control Intervention and Health Outcomes in Hispanic Patients With Diabetes. JAMA Netw Open 2023; 6:e2335409. [PMID: 37768663 PMCID: PMC10539985 DOI: 10.1001/jamanetworkopen.2023.35409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/18/2023] [Indexed: 09/29/2023] Open
Abstract
Importance Among patients with type 2 diabetes (T2D), Hispanic individuals are more likely than non-Hispanic White individuals to develop diabetes-related complications. Objective To examine the association of a pharmacist-led intervention (UCMyRx) with hemoglobin A1c (HbA1c) and systolic blood pressure (SBP) among Hispanic patients with T2D. Design, Setting, and Participants This quality improvement study used electronic health record data and a difference-in-differences study design to evaluate the association of UCMyRx exposure with changes in HbA1c concentration and SBP among Hispanic patients with T2D, relative to usual care, at University of California, Los Angeles primary care clinics between February and April of 2023. The study population included patients with an International Classification of Diseases, Ninth Revision/International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis of T2D, self-reporting Hispanic ethnicity, age 18 years or older, with 1 or more visits with a UCMyRx pharmacist (treatment) or 2 or more visits, 2 or more years apart, during the study window (comparison). Additionally, patients had to have the following observations during the study window (March 2, 2013-December 31, 2018): (1) a HbA1c 8% or higher, anywhere between 365 days before and 14 days after the index date (date of the first UCMyRx visit or a randomly generated index date) and a follow-up HbA1c measure within 120 to 365 days after the index date (n = 396) and/or (2) a SBP 140 mm Hg or higher between 365 days before and 14 days after the index date, and a follow-up SBP measure within 120 to 450 days after the index date (n = 795). Exposure Pharmacists review laboratory results/vital signs, perform medication reconciliation, and develop personally tailored interventions to address adherence barriers and increase guideline-concordant care. Main Outcomes and Measures Pre- to post-index date changes in HbA1c and SBP. Results Of the 931 unique patients with T2D analyzed, the mean (SD) age was 64 (14.1) years, and 552 (59.3%) were female. In adjusted analyses, having 1 or more UCMyRx visits was associated with a reduction in HbA1c concentration (β = -0.46%; 95% CI, -0.84% to -0.07%) but no change in SBP (β = -1.71 mm Hg; 95% CI, -4.00 to 0.58 mm Hg). Conclusions and Relevance In this quality improvement study of UCMyRx among Hispanic patients with T2D, a negative association was observed between UCMyRx exposure and HbA1c concentration but not SBP. Pharmacist-led intervention may be a strategy for improving outcomes among Hispanic patients with T2D.
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Affiliation(s)
- Kimberly Danae Cauley Narain
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles
- Center for Health Advancement, Fielding School of Public Health, University of California, Los Angeles
| | - Gerardo Moreno
- Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Douglas S. Bell
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles
- Clinical and Translational Science Institute, University of California, Los Angeles
| | - Lillian Chen
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California, Los Angeles
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles
| | - Robert W. Follett
- Clinical and Translational Science Institute, University of California, Los Angeles
| | - Samuel Skootsky
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles
- Population Health, University of California Health, Oakland
| | - Carol M. Mangione
- Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles
- Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles
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Hoog M, Smith JL, Yu M, Peleshok J, Mody R, Grabner M. Association of Dulaglutide Initiation Timing With Treatment Patterns and Clinical Outcomes in Patients With Type 2 Diabetes Mellitus in the United States. Clin Ther 2022; 44:873-887. [PMID: 35618571 DOI: 10.1016/j.clinthera.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/01/2022] [Accepted: 04/11/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE To describe clinical characteristics and treatment outcomes for early or late initiation of dulaglutide therapy in patients with type 2 diabetes. METHODS This retrospective, claims-based analysis evaluated adults with type 2 diabetes, ≥1 claim for dulaglutide 0.75 mg or 1.5 mg once-weekly injection (between November 2014 and August 2019), and no prior use of glucagon-like peptide 1 receptor agonists or insulin. Cohorts were defined based on the number of oral antidiabetic drug (OAD) classes used within the 24-month baseline period before dulaglutide therapy initiation: 1 OAD, 2 OADs, or ≥3 OADs. The number of OAD classes used before dulaglutide therapy initiation served as a proxy for timing of initiation, with a higher number of OAD classes indicating a longer duration of T2D. Baseline demographic and clinical characteristics were compared across each cohort. Six-month follow-up outcomes, including change in glycosylated hemoglobin (HbA1c) and treatment patterns, were descriptively assessed within each cohort. FINDINGS The study population consisted of 18,121 patients across the 1 OAD (n = 4822), 2 OADs (n = 6293), and ≥3 OADs (n = 7006) cohorts. Mean age at baseline was 54.7 years. Males were more prevalent in the ≥3 OADs cohort. Most patients (67%-70%) initiated treatment with dulaglutide 0.75 mg. Dose escalation to 1.5 mg was uncommon (15%-20%) but trended higher in the ≥3 OAD cohort. Adherence to dulaglutide at 6-month follow-up (61%-67%) increased with higher baseline OAD use. The HbA1c assessment (n = 3178) included 761 patients in the 1 OAD cohort, 1088 patients in the 2 OADs cohort, and 1329 patients in the ≥3 OADs cohort. Baseline mean [SD] HbA1c level increased with number of OAD classes (1 OAD: 8.18% [1.80]; 2 OADs: 8.56% [1.66]; and ≥3 OADs: 8.73% [1.51]). Patients in the early dulaglutide therapy initiator group experienced larger reductions in HbA1c levels (1 OAD: -1.39%; 95% CI, -1.50 to -1.27; 2 OADs: -1.30%; 95% CI, -1.39 to -1.20; and ≥3 OADs: -1.01%; 95% CI, -1.09 to -0.93) versus the patients in the delayed initiator group. Patients in the early dulaglutide therapy initiator group also achieved HbA1c <7% at 6-month follow-up more frequently than those in the later initiator group (1 OAD: 68%; 2 OADs: 51%; and ≥3 OADs: 33%). IMPLICATIONS Cohorts of dulaglutide therapy initiators, defined by prior OAD use as a proxy of timing of initiation, differed in their baseline characteristics and short-term follow-up outcomes. Earlier dulaglutide therapy initiation was associated with lower mean HbA1c levels and increased probability of achievement of HbA1c <7% during the 6-month follow-up period.
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Affiliation(s)
| | | | - Maria Yu
- Eli Lilly and Company, Indianapolis, Indiana
| | | | - Reema Mody
- Eli Lilly and Company, Indianapolis, Indiana
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Snoek FJ, Fisher L, Polonsky WH, Stuckey H, Hessler D, Tang T, Hermanns N, Mundet X, Silva M, Sturt J, Okazaki K, Hadjiyianni I, Desai U, Perez-Nieves M. Overcoming psychological insulin resistance: A practical guide for healthcare professionals. Prim Care Diabetes 2021; 15:619-621. [PMID: 33785288 DOI: 10.1016/j.pcd.2021.03.001] [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: 10/19/2020] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 11/29/2022]
Abstract
Despite the demonstrated benefits of using insulin, nearly a third of the patients with type 2 diabetes (T2D) are initially reluctant to initiate insulin therapy when it is first recommended by their healthcare provider (HCP). Several studies have documented the reasons for this phenomenon known as psychological insulin resistance (PIR) and also identified actionable strategies for HCPs to assist people with T2D to overcome their PIR. However, most strategies are based on the experiences of HCPs, rather than of patients. Based on findings from a study exploring real-world patient experience around HCP actions for mitigating PIR, we suggest that HCPs use collaborative strategies throughout the course of T2D treatment to 1) explore reasons for PIR, 2) help patients overcome PIR, and 3) follow-up regarding experience with insulin.
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Affiliation(s)
- Frank J Snoek
- Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, The Netherlands
| | - Lawrence Fisher
- University of California, San Francisco, San Francisco, CA, USA
| | - William H Polonsky
- Behavioral Diabetes Institute, San Diego, CA, USA; University of California, San Diego, La Jolla, CA, USA
| | | | | | - Tricia Tang
- University of British Columbia, Vancouver, Canada
| | | | - Xavier Mundet
- Universitat Autonoma de Barcelona, Bellaterra, Spain
| | - Maria Silva
- Instituto Multidisciplinar de Medicina, Sao Paulo, Brazil
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An Effectiveness Evaluation of a Primary Care-Embedded Clinical Pharmacist-Led Intervention Among Blacks with Diabetes. J Gen Intern Med 2020; 35:2569-2575. [PMID: 32144694 PMCID: PMC7458955 DOI: 10.1007/s11606-020-05750-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 02/07/2020] [Accepted: 02/14/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Black individuals with type 2 diabetes suffer disproportionate morbidity and mortality relative to whites with type 2 diabetes, irrespective of health insurance coverage. OBJECTIVE Examine the impact of a primary care-embedded clinical pharmacist-led intervention (UCMyRx) on cardiovascular risk factor control among blacks with type 2 diabetes in a large healthcare system. DESIGN We used data extracted from the electronic health records (EHR) system and a difference-in-differences study design with a propensity-matched comparison group to evaluate the impact of UCMyRx on HbA1c and systolic blood pressure (SBP) among black patients with type 2 diabetes, relative to usual care. PARTICIPANTS Individuals with type 2 diabetes identified as either black or African American in the EHR that were ≥ 18 years of age that had the following observations during the study window (03/02/2013-12/31/18: (1) HbA1C ≥ 8%, at least once, anywhere between 365 days before and 14 days after the UCMyRx visit and a follow-up HbA1c measure within 120 to 365 days after the visit and/or (2) SBP ≥ 140 mmHg at least once between 365 days before and 14 days after the UCMyRx visit that had a follow-up SBP measure within 120 to 450 days after the visit. INTERVENTION UCMyRx pharmacists review labs and vital signs, perform medication reconciliation, use a standardized survey to assess barriers to medication adherence, and develop tailored interventions to improve medication adherence. MAIN MEASURES Change in HbA1c and change in SBP from before to after the first UCMyRx visit. KEY RESULTS Having at least one visit with a UCMyRx clinical pharmacist was associated with a significant reduction in HbA1c (- 0.4%, p value = .01); however, there was no significant impact on SBP (- .051 mmHg, p value = 0.74). CONCLUSIONS The UCMyRx intervention is a useful strategy for improving HbA1c control among blacks with type 2 diabetes.
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Boye KS, Mody R, Lage MJ, Malik RE. The Relationship Between Timing of Initiation on a Glucagon-like Peptide-1 Receptor Agonist and Glycosylated Hemoglobin Values Among Patients With Type 2 Diabetes. Clin Ther 2020; 42:1812-1817.e2. [PMID: 32741645 DOI: 10.1016/j.clinthera.2020.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/26/2020] [Accepted: 06/26/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE This study examines the relationship between timing of initiation on a glucagon-like peptide-1 receptor agonist (GLP-1 RA) and glycosylated hemoglobin (HbA1c) values. METHODS The IBM MarketScan databases were used to identify adults with type 2 diabetes mellitus (T2DM) who initiated GLP-1 RA therapy and had multiple recorded HbA1c results. Time to GLP-1 RA initiation was proxied by the number of classes of glucose-lowering agents prescribed in the 2 years before GLP-1 RA initiation, with fewer glucose-lowering agents indicating initiation of a GLP-1 RA earlier in disease progression. Paired t tests examined differences in HbA1c values from preperiod to 2-year postperiod. Multivariable analyses examined the relationship between time to GLP-1 RA initiation and postperiod HbA1c values. FINDINGS Initiation on a GLP-1 RA was associated with a 0.6% reduction in HbA1c values over 2 years (P < 0.0001). Earliest starts were associated with a 1.3% reduction in HbA1c levels (P < 0.0001) and the highest likelihood of achieving a postperiod HbA1c level <7% (odds ratio, 4.9; 95% CI, 3.0-8.1). IMPLICATIONS Results indicate that although initiation on a GLP-1 RA is generally associated with reduced HbA1c levels, there may be additional clinical benefits associated with earlier initiation of a GLP-1 RA.
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Affiliation(s)
| | - Reema Mody
- Eli Lilly and Company, Indianapolis, IN, USA
| | - Maureen J Lage
- HealthMetrics Outcomes Research, Bonita Springs, FL, USA.
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Mehta RR, Edwards AM, Rajpathak S, Sharma A, Snow KJ, Iglay K. Effects of conformance to type 2 diabetes guidelines on health care resource utilization, clinical outcomes, and cost: A retrospective claims analysis. J Clin Transl Endocrinol 2020; 19:100215. [PMID: 32095429 PMCID: PMC7033581 DOI: 10.1016/j.jcte.2020.100215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To determine if there is a difference in the outcomes of diabetes patients managed with high, intermediate, or low conformance to diabetes guidelines. STUDY DESIGN Retrospective database analysis. METHODS This was a retrospective database analysis of adults diagnosed with type 2 diabetes and with glycated hemoglobin (HbA1c) ≥7% (53 mmol/mol) who were commercially insured by, or receiving Medicare benefits through, Aetna. Subjects were classified as having high, intermediate, or low conformance to current guidelines. Six, 12, and 18 months later, health care resource utilization, clinical outcomes, and costs were assessed using multivariable regression analysis to determine whether differences existed between patients with high, intermediate, and low conformance. Regression models were adjusted using pre-index variables, and the results were expressed as incidence rate ratios (IRRs) with 95% confidence intervals (CIs). RESULTS A total of 21,171 individuals were included in the analysis. In analyses of patients with low versus high conformance, pharmacy costs were significantly lower over 18 months of outcome assessment (P < 0.001), but diabetes-related outpatient costs were significantly higher (P < 0.001). In analyses of patients with intermediate versus high conformance, diabetes-related outpatient costs were significantly greater at 12 and 18 months (P < 0.001 for both). CONCLUSIONS Reduced conformance to guidelines leads to higher diabetes-related costs.
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Affiliation(s)
| | | | - Swapnil Rajpathak
- Center for Observational and Real-World Evidence, Merck & Co., Inc., Kenilworth, NJ, USA
- Corresponding author at: Merck & Co., Inc., 351 N. Sumneytown Pike, North Wales, PA 19454, USA.
| | | | | | - Kristy Iglay
- Center for Observational and Real-World Evidence, Merck & Co., Inc., Kenilworth, NJ, USA
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Chen P, Ma X, Chen H, Wang K, Zhou L. Delays in Insulin Initiation among Patients with Type 2 Diabetes Mellitus in Southeast China: A Retrospective, Real-World Study. Diabetes Metab Syndr Obes 2020; 13:3059-3068. [PMID: 32922056 PMCID: PMC7457728 DOI: 10.2147/dmso.s256381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 07/10/2020] [Indexed: 04/20/2023] Open
Abstract
PURPOSE To describe the extent of delays in insulin initiation, analyze its impact on glycemic control, and explore factors influencing delayed insulin initiation among Chinese type 2 diabetes mellitus (T2DM) patients. METHODS A real-world, retrospective cohort study with regional electronic health records from Fuzhou, southeast China was conducted among T2DM patients. Adult patients uncontrolled with oral antidiabetic drugs (OADs; HbA1c ≥7%) and initiated on insulin treatment were included. Time to insulin initiation was described. After propensity-score matching, Wilcoxon rank-sum test and chi-square test were used to compare follow-up HbA1c (first HbA1c 3 months after insulin initiation) between timely (initiated insulin within 6 months after OAD failure) and delayed (initiated after 6 months) insulin-initiation groups. Sensitivity analysis was also performed by linear and logistic regression. Factors associated with delayed insulin initiation were explored using logistic regression. RESULTS A total of 940 patients were included, with mean±SD age 66.3±11.9 years. In sum, 328 had HbA1c recorded 3 months after insulin initiation. After propensity-score matching (1:1 matching), 184 patients were included for further analysis. Median follow-up HbA1c was lower in the timely-initiation group than the delayed-initiation group (7.25% vs 8.25%, P=0.009). Patients in the timely initiation group also had higher odds of achieving HbA1c <7% (OR=3.15, P=0.001). Results were confirmed by logistic regression. Hypertension, coronary artery disease, baseline HbA1c, and hospital level at insulin initiation were associated with delays in insulin initiation. CONCLUSION Timely insulin initiation after OAD failure is associated with better glycemic control.
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Affiliation(s)
- Pin Chen
- Department of Endocrinology, 900 Hospital of the Joint Logistics Team, Fuzhou Clinical Medical College of Fujian Medical University, Fuzhou, People’s Republic of China
| | - Xiao Ma
- Lilly Suzhou Pharmaceutical, Shanghai, People’s Republic of China
| | - Hong Chen
- Lilly Suzhou Pharmaceutical, Shanghai, People’s Republic of China
| | - Ke Wang
- Lilly Suzhou Pharmaceutical, Shanghai, People’s Republic of China
| | - Li Zhou
- Lilly Suzhou Pharmaceutical, Shanghai, People’s Republic of China
- Correspondence: Li Zhou Lilly Suzhou Pharmaceutical, Shanghai, People’s Republic of China Email
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Stuckey H, Fisher L, Polonsky WH, Hessler D, Snoek FJ, Tang TS, Hermanns N, Mundet-Tuduri X, da Silva MER, Sturt J, Okazaki K, Cao D, Hadjiyianni I, Ivanova JI, Desai U, Perez-Nieves M. Key factors for overcoming psychological insulin resistance: an examination of patient perspectives through content analysis. BMJ Open Diabetes Res Care 2019; 7:e000723. [PMID: 31908792 PMCID: PMC6936574 DOI: 10.1136/bmjdrc-2019-000723] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/17/2019] [Accepted: 10/01/2019] [Indexed: 11/04/2022] Open
Abstract
Objective To understand participant perceptions about insulin and identify key behaviors of healthcare professionals (HCPs) that motivated initially reluctant adults from seven countries (n=40) who had type 2 diabetes (T2D) to start insulin treatment. Research design and methods Telephone interviews were conducted with a subset of participants from an international investigation of adults with T2D who were reluctant to start insulin (EMOTION). Questions related to: (a) participants' thoughts about insulin before and after initiation; (b) reasons behind responses on the survey that were either 'not helpful at all' or 'helped a lot'; (c) actions their HCP may have taken to help start insulin treatment; and (d) advice they would give to others in a similar situation of starting insulin. Responses were coded by two independent reviewers (kappa 0.992). Results Starting insulin treatment was perceived as a negative experience that would be painful and would lead down a 'slippery slope' to complications. HCPs engaged in four primary behaviors that helped with insulin acceptance: (1) showed the insulin pen/needle and demonstrated the injection process; (2) explained how insulin could help with diabetes control and reduce risk of complications; (3) used collaborative communication style; and (4) offered support and willingness to answer questions so that participants would not be 'on their own'. Following initiation, most participants noted that insulin was not 'as bad as they thought' and recommended insulin to other adults with T2D. Conclusions Based on these themes, two actionable strategies are suggested for HCPs to help people with psychological insulin resistance: (1) demonstrate the injection process and discuss negative perceptions of insulin as well as potential benefits; (2) offer autonomy in a person-centred collaborative approach, but provide support and accessibility to address concerns. These findings help HCPs to better understand ways in which they can engage reluctant people with T2D with specific strategies.
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Affiliation(s)
| | - Lawrence Fisher
- University of California San Francisco, San Francisco, California, USA
| | - William H Polonsky
- Behavioral Diabetes Institute, University of California, San Diego, Del Mar, California, USA
| | - Danielle Hessler
- University of California San Francisco, San Francisco, California, USA
| | - Frank J Snoek
- Amsterdam University Medical Centre Vrije Universiteit, Amsterdam, The Netherlands
| | - Tricia S Tang
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | - Kentaro Okazaki
- Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Dachuang Cao
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | | | | | - Urvi Desai
- Analysis Group Inc Boston, Boston, Massachusetts, USA
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Kefale AT, Biru TT, Addo HA. Appropriateness of insulin commencement and adequacy of glycemic control among ambulatory patients with type 2 diabetes in Ethiopia. J Diabetes Metab Disord 2019; 18:461-469. [PMID: 31890672 DOI: 10.1007/s40200-019-00448-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 10/03/2019] [Indexed: 10/25/2022]
Abstract
Background Knowing when to start insulin is central to optimal management of Type 2 diabetes mellitus (T2DM) but a real clinical challenge. Poor glycemic control is critical for development of the deadly diabetic complications. Objective The aim of the study was to assess the appropriateness of insulin commencement, adequacy of glycemic control and associated factors among patients with T2DM. Settings The study was conducted at three public hospitals in Southwest Ethiopia. Methods Cross sectional study was conducted using structured questionnaire and data abstraction format. All patients with T2DM who were available during the data collection period and fulfilling study criteria were included. Main outcome measure Multivariable binary logistic regression analysis was done for identifying factors associated with poor glycemic control by taking statistical significance at p value ≤0.05. Results One hundred sixty nine patient data was considered for analysis. Insulin was initiated in 28 patients, but only 10(35.7%) insulin commencements were appropriate. More than two third (70.4%) of the studied population had poor glycemic control. Addition of second antidiabetic medication (Adjusted Odds Ratio (AOR) = 2.5, 95% CI = 1.3-6.2) and living in urban areas (AOR = 2.5, 95% CI = 1.1-5.7) were associated with poor glycemic control while having regular diabetic care follow up of every >1 month (AOR = 0.4, 95% CI = 0.2-0.9) was negatively associated with poor glycemic control. Conclusions About two third of insulin commencements were inappropriate and majority of patients could not stay on optimal glycemic control. Addition of second antidiabetic medication and living in urban areas were found to be associated with poor glycemic control. Impact of findings on practice statements • Initiation of insulin before optimization of oral agents increase cost of care.• Proper titration of the first oral agent is important prior to adding other antidiabetic agents.• Emphasis should be given to improve glycemic control, and hence halt subsequent complications.
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Li J, Ji J, Liu F, Wang L. Insulin Glargine and Acarbose in the treatment of elderly patients with diabetes. Pak J Med Sci 2019; 35:609-613. [PMID: 31258562 PMCID: PMC6572939 DOI: 10.12669/pjms.35.3.86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective: To investigate the clinical efficacy of insulin glargine combined with acarbose in the treatment of elderly patients with diabetes. Methods: One hundred and forty-four elderly patients with diabetes who received treatment between December 2016 and December 2017 in Binzhou People’s Hospital, China, were selected and divided into a control group and an observation group, 72 each, using random number table. The control group was treated with insulin glargine, while the observation group was treated with insulin glargine combined with acarbose. The therapeutic effect, improvement of quality of life and adverse reactions were compared between the two groups. Results: After treatment, fasting blood glucose (FBG), 2h postprandial blood glucose (PBG) and glycosylated hemoglobin (Hb Alc) of the two groups were lower than those before treatment, and the decrease degree of the observation group was significantly larger than that of the control group (P<0.05). The time needed for blood glucose reaching the standard level and daily insulin dosage of the observation group were significantly lower than that of the control group, and the differences were statistically significant (P<0.05). SF-36 scale score of the observation group was significantly better than the control group, and the difference was statistically significant (P<0.05). There was no significant difference in the incidence of adverse reactions between the two groups (P>0.05). Conclusion: The combination of insulin Glargine and Acarbose can significantly control the blood glucose level of elderly patients with diabetes, improve the biochemical indicators, and enhance the quality of life. It is worth promotion in clinical practice.
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Affiliation(s)
- Jing Li
- Jing Li General Medicine (I), Binzhou People's Hospital, Shandong, 256610, China
| | - Jinzhi Ji
- Jinzhi Ji Department of Health Management Center, Binzhou People's Hospital, Shandong, 256610, China
| | - Fuyan Liu
- Fuyan Liu Department of Operation Room, Binzhou People's Hospital, Shandong, 256610, China
| | - Lingling Wang
- Lingling Wang General Medicine (I), Binzhou People's Hospital, Shandong, 256610, China
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12
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Fritsche A, Anderten H, Pfohl M, Pscherer S, Borck A, Pegelow K, Bramlage P, Seufert J. HbA1c target achievement in the elderly: results of the Titration and Optimization trial for initiation of insulin glargine 100 U/mL in patients with type 2 diabetes poorly controlled on oral antidiabetic drugs. BMJ Open Diabetes Res Care 2019; 7:e000668. [PMID: 31423316 PMCID: PMC6688703 DOI: 10.1136/bmjdrc-2019-000668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 06/19/2019] [Accepted: 07/02/2019] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES To identify real-world, age-related trends in the use of insulin glargine 100 U/mL (Gla-100) as part of basal-supported oral therapy (BOT). RESEARCH DESIGN AND METHODS The prospective, observational Titration and Optimization registry enrolled patients with poorly controlled type 2 diabetes mellitus initiated on Gla-100 BOT. The primary outcome was the proportion of patients with capillary fasting blood glucose (FBG) ≤110 mg/dL on ≥2 occasions and/or who met their individual HbA1c target within 12 months. RESULTS 2462 patients were analyzed (<65 years: n=1122; 65-74 years: n=771; ≥75 years: n=569). Diabetes duration (6.8, 8.9, and 11.2 years, p<0.0001) and proportion of women (40.7%, 47.9%, and 55.7%, p<0.0001) increased with age. Baseline HbA1c was highest in <65-year-olds (8.6% vs 8.4% and 8.5%, p<0.0001). Gla-100 up-titration until 12 months was highest in <65-year-olds (+11.6 U/day), compared with 65-74 (+10.2 U/day) and ≥75 years (+8.8; p<0.0001) but similar by units per kilogram, as was the decrease in FBG (<65: -64.1 mg/dL; 65-74: -56.1 mg/dL; ≥75: -53.4 mg/dL) and HbA1c (<65: -1.47%; 65-74: -1.31%; ≥75: -1.22%, p<0.0001). At 12 months, 65.9% of participants met the primary endpoint, with no significant difference between age groups. The proportion achieving their individual HbA1c target was lower for <65-year-olds (46.0% vs 54.3% and 54.7%; p<0.02). Symptomatic hypoglycemia incidence was more common in the ≥75-year-old group (3.4% vs 1.4% and 1.4%; p=0.0126). CONCLUSIONS BOT with Gla-100 results in similar improvements of glycemic values with low risk of hypoglycemia across age groups. Given the link between HbA1c and long-term cardiovascular risk, ensuring appropriately stringent target-setting, intensification of basal insulin and making sure hypoglycemia is avoided is of paramount importance. TRIAL REGISTRATION NUMBER Database: https://awbdb.bfarm.de; Identifier: 1641; Date of registration: September 23, 2013.
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Affiliation(s)
| | - Helmut Anderten
- Gemeinschaftspraxis Anderten-Krok & Partner, Hildesheim, Germany
| | - Martin Pfohl
- Medizinische Klinik I, Evang. Krankenhaus Bethesda gGmbH, Duisburg, Germany
| | - Stefan Pscherer
- Klinik für Innere Medizin III, Sophien- undHufeland-Klinikum, Weimar, Germany
| | - Anja Borck
- Sanofi-Aventis Deutschland GmbH, Berlin, Germany
| | | | - Peter Bramlage
- Institut für Pharmakologie und Präventive Medizin, Cloppenburg, Germany
| | - J Seufert
- Abteilung Endokrinologie und Diabetologie, Klinik für Innere Medizin II, Medizinische Fakultät, Albert-Ludwig-Universität Freiburg, Freiburg, Germany
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13
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Heller SR, Pratley RE, Sinclair A, Festa A, Kiljański J, Brusko CS, Duan R, Heine RJ. Glycaemic outcomes of an Individualized treatMent aPproach for oldER vulnerable patIents: A randomized, controlled stUdy in type 2 diabetes Mellitus (IMPERIUM). Diabetes Obes Metab 2018; 20:148-156. [PMID: 28671753 PMCID: PMC5724506 DOI: 10.1111/dom.13051] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 06/21/2017] [Accepted: 06/25/2017] [Indexed: 12/20/2022]
Abstract
AIMS To compare the glycaemic outcomes of 2 glucose-lowering treatment strategies in vulnerable (moderately ill and/or frail) patients aged ≥65 years with type 2 diabetes whose individual HbA1c targets were not met with diet/exercise and/or oral anti-hyperglycaemic medications (OAMs). METHODS The primary endpoint of this study was a composite of achieving/maintaining individualized HbA1c targets without "clinically significant" hypoglycaemia (severe hypoglycaemia or repeated hypoglycaemia causing interruption of patients' activities or blood glucose <54 mg/dL). Strategy-A comprised glucose-dependent therapies (n = 99) with a non-sulphonylurea OAM and a glucagon-like peptide-1 receptor agonist as the first injectable. Strategy-B comprised non-glucose-dependent therapies (n = 93) with sulphonylurea as the preferred OAM and insulin glargine as the first injectable. RESULTS There was no significant difference between Strategy-A and Strategy-B in percentages of patients achieving the primary endpoint (64.5% vs 54.9%; P = .190). Mean incidences (A vs B) of total (10.2% vs 53.8%), documented symptomatic (5.1% vs 36.6%), and asymptomatic (8.2% vs 32.3%) hypoglycaemia were lower for Strategy-A (P < .001 each). Proportions of patients achieving/maintaining HbA1c target (A, 63.3% vs B, 55.9%) were similar. CONCLUSION Similar proportions of older, vulnerable aged ≥65 years patients with type 2 diabetes achieved/maintained glycaemic treatment goals without clinically significant hypoglycaemia with Strategies A or B. However, Strategy-A resulted in lower risk of total, documented symptomatic, and asymptomatic hypoglycaemia. These results identify an approach of potential clinical benefit in this age group and will inform future clinical research in older patients with type 2 diabetes.
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Affiliation(s)
| | - Richard E. Pratley
- Florida Hospital and Sanford Burnham Prebys Translational Research InstituteOrlandoFlorida
| | - Alan Sinclair
- Foundation for Diabetes Research in Older People, Diabetes Frail LimitedDroitwichUK
| | | | | | | | - Ran Duan
- Lilly USA, LLCIndianapolisIndiana
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14
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Mata-Cases M, Franch-Nadal J, Real J, Gratacòs M, López-Simarro F, Khunti K, Mauricio D. Therapeutic inertia in patients treated with two or more antidiabetics in primary care: Factors predicting intensification of treatment. Diabetes Obes Metab 2018; 20:103-112. [PMID: 28656746 DOI: 10.1111/dom.13045] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 06/21/2017] [Accepted: 06/23/2017] [Indexed: 01/28/2023]
Abstract
AIMS To determine the patterns and predictors of treatment intensification in patients with type 2 diabetes on ≥2 non-insulin antidiabetic drugs (NIADs) and inadequate glycaemic control in primary care in Catalonia, Spain. MATERIAL AND METHODS This was a retrospective analysis using electronic medical records from patients with HbA1c ≥ 7% and a first prescription for a new NIAD or insulin recorded from January 2010 to December 2014. Therapeutic inertia was defined as no intensification if HbA1c was ≥8% at baseline or during follow-up. Time to first intensification was evaluated by time-to-event analysis, and factors predicting intensification through a competing-risk regression model. RESULTS Among 23 678 patients with HbA1c ≥ 7%, 26.2% were censored without treatment intensification after a median follow up of 4.2 years. Among the 12 730 patients in the subgroup with HbA1c ≥ 8% at baseline or during follow-up, therapeutic inertia was present in 18.1% of cases. In the overall cohort, mean HbA1c at initiation of insulin and NIAD were 9.4% ± 1.5% and 8.7% ± 1.3%, respectively. Median time to first intensification was 17.1 months in patients with HbA1c 8.0% to 9.9%, and 10.1 months in those with HbA1c > 10%. Variables strongly associated with intensification were HbA1c values 8.0% to 9.9% (subhazard ratio [SHR], 1.7; 95% CI, 1.65-1.78) and >10% (SHR, 2.5; 95% CI, 2.37-2.68); diabetes duration ≥20 years (SHR, 1.25; 95% CI, 1.11-1.41) and, to a lesser extent, female gender, presence of comorbidities, chronic kidney disease and microvascular complications. CONCLUSIONS Intensification was not undertaken in 1 in 5 patients. Both HbA1c thresholds and time until therapy intensification exceeded current recommendations.
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Affiliation(s)
- Manel Mata-Cases
- DAP-Cat group. Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Primary Health Care Center La Mina, Gerència d'Àmbit d'Atenció Primària Barcelona Ciutat, Institut Català de la Salut, Sant Adrià de Besòs, Spain
| | - Josep Franch-Nadal
- DAP-Cat group. Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Primary Health Care Center Raval Sud, Gerència d'Atenció Primaria, Institut Català de la Salut, Barcelona, Spain
| | - Jordi Real
- DAP-Cat group. Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
- Universitat Internacional de Catalunya, Epidemiologia i Salut Pública, Sant Cugat, Spain
| | - Mònica Gratacòs
- DAP-Cat group. Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Flora López-Simarro
- Àrea Bàsica de Salut Martorell, Institut Català de la Salut, Martorell, Spain
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Dídac Mauricio
- DAP-Cat group. Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
- Department of Endocrinology and Nutrition, Health Sciences Research Institute and Hospital Universitari Germans Trias i Pujol, Badalona, Spain
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15
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Raccah D, Huet D, Dib A, Joseph F, Landers B, Escalada J, Schmitt H. Review of basal-plus insulin regimen options for simpler insulin intensification in people with Type 2 diabetes mellitus. Diabet Med 2017; 34:1193-1204. [PMID: 28574177 PMCID: PMC5599968 DOI: 10.1111/dme.13390] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2017] [Indexed: 12/26/2022]
Abstract
AIMS To identify simple insulin regimens for people with Type 2 diabetes mellitus that can be accepted and implemented earlier in primary and specialist care, taking into consideration each individual's needs and capabilities. METHODS Using randomized clinical trials identified by a search of the PubMed database, as well as systematic reviews, meta-analyses and proof-of-concept studies, this review addresses topics of interest related to the progressive intensification of a basal insulin regimen to a basal-plus regimen (one basal insulin injection plus stepwise addition of one to three preprandial short-acting insulin injections/day) vs a basal-bolus regimen (basal insulin plus three short-acting insulin injections per day) in people with Type 2 diabetes. The review explores approaches that can be used to define the meal for first prandial injection with basal-plus regimens, differences among insulin titration algorithms, and the importance of self-motivation and autonomy in achieving optimum glycaemic control. RESULTS A basal-plus regimen can provide glycaemic control equivalent to that obtained with a full basal-bolus regimen, with fewer injections of prandial insulin. The first critical step is to optimize basal insulin dosing to reach a fasting glucose concentration of ~6.7 mmol/l; this allows ~40% of patients with baseline HbA1c >75 mmol/mol (9%) to be controlled with only one basal insulin injection per day. CONCLUSIONS Compared with a basal-bolus regimen, a basal-plus insulin regimen is as effective but more practical, and has the best chance of acceptance and success in the real world.
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Affiliation(s)
- D. Raccah
- Department of DiabetesSainte Marguerite HospitalMarseille
| | - D. Huet
- Department of DiabetesSaint‐Joseph HospitalParis
| | - A. Dib
- Eli Lilly FranceNeuilly sur SeineFrance
| | - F. Joseph
- Countess of Chester HospitalChesterUK
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16
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Omori K, Kawamura T, Urata M, Matsuura M, Kusama M, Imamine R, Watarai A, Nakashima E, Umemura T, Hotta N. Effect of re-coaching on self-injection of insulin in older diabetic patients - Impact of cognitive impairment. Diabetes Res Clin Pract 2017; 130:34-42. [PMID: 28554141 DOI: 10.1016/j.diabres.2017.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 05/02/2017] [Accepted: 05/08/2017] [Indexed: 12/30/2022]
Abstract
AIMS We investigated the effect of re-coaching on self-injection of insulin and impact of cognitive function in 100 older diabetic patients. METHODS We examined patients on a variety of skills and knowledge regarding self-injection of insulin and evaluated the effect of re-coaching the patients after 3months and 4years. We also investigated the influence of cognitive impairment (CI) on coaching. RESULTS Skills scores for self-injection of insulin and HbA1c improved significantly 3months after re-coaching. In 51 patients followed-up for 4years, skills scores were maintained during the 4years, while knowledge scores improved after 3months but then returned to the baseline level. In the group of patients with CI as determined by the Mini-Mental Status Examination, skills scores were similar to those in the group without CI, while knowledge scores were significantly lower as compared with those in the group without CI at any time point. Skills scores were maintained during the 4years regardless of CI. CONCLUSION The present study showed that re-coaching in skills for self-injection of insulin was effective in improving and maintaining insulin treatment in older diabetic patients, even if patients had CI.
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Affiliation(s)
- Keiko Omori
- Diabetic Center, Chubu Rosai Hospital, Nagoya, Japan
| | - Takahiko Kawamura
- Center for Preventive Medicine, Chubu Rosai Hospital, Nagoya, Japan; Department of Diabetes and Endocrine Internal Medicine, Chubu Rosai Hospital, Nagoya, Japan.
| | - Misako Urata
- Diabetic Center, Chubu Rosai Hospital, Nagoya, Japan
| | | | - Minoru Kusama
- Department of Diabetes and Endocrine Internal Medicine, Chubu Rosai Hospital, Nagoya, Japan
| | - Rui Imamine
- Department of Diabetes and Endocrine Internal Medicine, Chubu Rosai Hospital, Nagoya, Japan
| | - Atsuko Watarai
- Center for Preventive Medicine, Chubu Rosai Hospital, Nagoya, Japan
| | - Eitaro Nakashima
- Department of Diabetes and Endocrine Internal Medicine, Chubu Rosai Hospital, Nagoya, Japan
| | | | - Nigishi Hotta
- Department of Diabetes and Endocrine Internal Medicine, Chubu Rosai Hospital, Nagoya, Japan
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17
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Mauricio D, Meneghini L, Seufert J, Liao L, Wang H, Tong L, Cali A, Stella P, Carita P, Khunti K. Glycaemic control and hypoglycaemia burden in patients with type 2 diabetes initiating basal insulin in Europe and the USA. Diabetes Obes Metab 2017; 19:1155-1164. [PMID: 28251792 PMCID: PMC5573947 DOI: 10.1111/dom.12927] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 02/15/2017] [Accepted: 02/27/2017] [Indexed: 12/17/2022]
Abstract
AIMS To evaluate short- and long-term glycaemic control and hypoglycaemia incidence in insulin-naïve patients ≥30 years of age with type 2 diabetes (T2DM) initiating basal insulin (BI) with or without oral anti-hyperglycaemic drugs (OADs). METHODS This was an observational, retrospective longitudinal analysis of electronic medical records from 5 European countries and the USA. A multivariable logistic regression model assessed baseline and short-term (0-3 months post BI initiation) factors associated with long-term (3-24 months) glycaemic control and hypoglycaemia. RESULTS Overall, 40 627 patients were included; 20.9% and 27.8% achieved the general HbA1c target of ≤7% at 3 and 24 months post BI initiation, respectively. Failure to achieve HbA1c ≤7% at 3 months was associated with increased risk of failing to achieve target at 24 months (odds ratio [OR], 3.70 [95% CI, 3.41-4.00]). Over 24 months, 8.9% of patients experienced a recorded hypoglycaemic event. Hypoglycaemia during the initial 3-month period was associated with longer-term risk of these events over the ensuing 3 to 24 months (OR, 5.71 [95% CI, 4.67-6.99]). CONCLUSIONS Initiating BI with or without OADs is associated with short- and long-term suboptimal glycaemic control; the majority of patients fail to achieve HbA1c target ≤7% in the first 3 months, or after 2 years of BI treatment. Treatment response and hypoglycaemia incidence by 3 months post BI initiation are associated with longer-term glycaemic control and hypoglycaemic risk, respectively. These results support the need for early anti-hyperglycaemic interventions that more effectively control blood glucose levels without increasing the risk of hypoglycaemia.
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Affiliation(s)
- Dídac Mauricio
- Department of Endocrinology & NutritionHospital Universitari Germans Trias i Pujol, CIBERDEMBadalonaSpain
| | - Luigi Meneghini
- Division of Endocrinology, University of Texas Southwestern Medical CenterDallasTexas
- Parkland Health and Hospital SystemDallasTexas
| | - Jochen Seufert
- Division of Endocrinology and Diabetology, Department of Medicine II, Faculty of MedicineMedical Center – University of FreiburgFreiburgGermany
| | | | | | | | | | | | | | - Kamlesh Khunti
- Diabetes Research Centre, University of LeicesterLeicesterUK
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Feng X, Tan X, Riley B, Zheng T, Bias T, Sambamoorthi U. Polypharmacy and Multimorbidity Among Medicaid Enrollees: A Multistate Analysis. Popul Health Manag 2017; 21:123-129. [PMID: 28683221 DOI: 10.1089/pop.2017.0065] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The purpose of this study is to explore the associations between polypharmacy and multimorbidity using conventional and novel measures of polypharmacy. In this cross-sectional study, data on fee-for-service (FFS) Medicaid enrollees with at least 1 chronic condition and aged 18-64 years (N = 38,329) were derived from the 2010 Medicaid Analytic eXtract (MAX) files of Maryland and West Virginia. Polypharmacy, by the authors' novel definition, was determined as simultaneous use of ≥5 drugs for a consecutive period of 60 days. Multimorbidity was defined as having ≥2 chronic conditions based on the US Department of Health and Human Services framework. The association between multimorbidity and polypharmacy was examined with chi-square tests and logistic regression. Polypharmacy prevalence was estimated at 50.9% using the novel definition, as compared to 16.7% and 64.9% for the 2 commonly used conventional measures, respectively. For all 3 definitions, individuals with multimorbidity were more likely to have polypharmacy than those without multimorbidity (P < 0.001). The authors also consistently found, using all definitions, that those who were older, female, white, and eligible for Medicaid because of cash assistance were more likely to have polypharmacy (all P < 0.001). Polypharmacy was highly prevalent and significantly associated with multimorbidity among Medicaid FFS enrollees irrespective of the definitions used. The new measure may provide a more comprehensive and accurate estimation of polypharmacy than the conventional measures. These findings suggest the need for a paradigm shift from disease-specific care to patient-centered collaborative care to manage patients with multimorbidity and polypharmacy.
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Affiliation(s)
- Xue Feng
- 1 Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University , Morgantown, West Virginia
| | - Xi Tan
- 1 Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University , Morgantown, West Virginia
| | - Brittany Riley
- 2 Department of Pharmacy Practice, Administration and Research, School of Pharmacy, Marshall University , Huntington, West Virginia
| | - Tianyu Zheng
- 1 Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University , Morgantown, West Virginia
| | - Thomas Bias
- 3 Department of Health Policy, Management, and Leadership, School of Public Health, West Virginia University , Morgantown, West Virginia
| | - Usha Sambamoorthi
- 1 Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University , Morgantown, West Virginia
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19
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Feng X, Tan X, Riley B, Zheng T, Bias TK, Becker JB, Sambamoorthi U. Prevalence and Geographic Variations of Polypharmacy Among West Virginia Medicaid Beneficiaries. Ann Pharmacother 2017. [PMID: 28635299 DOI: 10.1177/1060028017717017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND West Virginia (WV) residents are at high risk for polypharmacy given its considerable chronic disease burdens. OBJECTIVE To evaluate the prevalence, correlates, outcomes, and geographic variations of polypharmacy among WV Medicaid beneficiaries. METHODS In this cross-sectional study, we analyzed 2009-2010 WV Medicaid fee-for-service (FFS) claims data for adults aged 18-64 (N=37,570). We defined polypharmacy as simultaneous use of drugs from five or more different drug classes on a daily basis for at least 60 consecutive days in one year. Multilevel logistic regression was used to explore the individual- and county-level factors associated with polypharmacy. Its relationship with healthcare utilization was assessed using negative binomial regression and logistic regression. The univariate local indicators of spatial association method was applied to explore spatial patterns of polypharmacy in WV. RESULTS The prevalence of polypharmacy among WV Medicaid beneficiaries was 44.6%. High-high clusters of polypharmacy were identified in southern WV, indicating counties with above-average prevalence surrounded by counties with above-average prevalence. Polypharmacy was associated with being older, female, eligible for Medicaid due to cash assistance or medical eligibility, having any chronic conditions or more chronic conditions, and living in a county with lower levels of education. Polypharmacy was associated with more hospitalizations, emergency department visits, and outpatient visits, as well as higher non-drug medical expenditures. CONCLUSIONS Polypharmacy was prevalent among WV Medicaid beneficiaries and was associated with substantial healthcare utilization and expenditures. The clustering of high prevalence of polypharmacy in southern WV may suggest targeted strategies to reduce polypharmacy burden in these areas.
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Affiliation(s)
- Xue Feng
- 1 West Virginia University, Morgantown, WV, USA
| | - Xi Tan
- 1 West Virginia University, Morgantown, WV, USA
| | | | | | | | - James B Becker
- 2 Marshall University, Huntington, WV, USA.,3 West Virginia Department of Health and Human Resources, Charleston, WV, USA
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20
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Mbanya JC, Sandow J, Landgraf W, Owens DR. Recombinant Human Insulin in Global Diabetes Management - Focus on Clinical Efficacy. EUROPEAN ENDOCRINOLOGY 2017; 13:21-25. [PMID: 29632602 PMCID: PMC5813441 DOI: 10.17925/ee.2017.13.01.21] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 02/13/2017] [Indexed: 11/25/2022]
Abstract
Biosynthetic human insulin and insulin analogues are the mainstay of insulin therapy for both type 1 and type 2 diabetes although access to human insulin at affordable prices remains a global issue. The world is experiencing an exponential rise in the prevalence of diabetes presenting an urgent need to establish effective diabetes therapy in countries burdened by inadequate health care budgets, malnutrition and infectious diseases. Recombinant human insulin has replaced animal insulins and animal-based semisynthetic human insulin thereby available in sufficient quantities and at affordable prices able to provide global access to insulin therapy. In many patients, analog insulins can offer additional clinical benefit, although at a considerably higher price thus severely restricting availability in low income countries. The approval process for recombinant human insulins (i.e. biosimilars) and analogue insulins is highly variable in the developing countries in contrast to Europe and in North America, where it is well established within a strict regulatory framework. This review aims to discuss the future access to human insulin therapy in a global context with an ever increasing burden of diabetes and significant economic implications.
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Affiliation(s)
- Jean Claude Mbanya
- University of Yaoundé I, Cameroon and Endocrinology and Metabolic Diseases Unit at the Hospital Central in Yaoundé, Cameroon
| | - Juergen Sandow
- Centre of Pharmacology, Johann-Wolfgang-Goethe University, Frankfurt/Main, Germany
| | - Wolfgang Landgraf
- Medical Affairs Diabetes Division, Sanofi-Aventis Frankfurt, Germany
| | - David R Owens
- Diabetes Research Group, College of Medicine, University of Swansea, Wales, UK
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21
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Bramlage P, Bluhmki T, Fleischmann H, Kaltheuner M, Beyersmann J, Holl RW, Danne T. Determinants of weight change in patients on basal insulin treatment: an analysis of the DIVE registry. BMJ Open Diabetes Res Care 2017; 5:e000301. [PMID: 28176957 PMCID: PMC5278215 DOI: 10.1136/bmjdrc-2016-000301] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 12/29/2016] [Accepted: 01/05/2017] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE We aimed to describe patterns of weight change in insulin-naive patients with type 2 diabetes mellitus (T2DM) starting basal insulin (BI) treatment. RESEARCH DESIGN AND METHODS Diabetes Versorgungs-Evaluation (DIVE) is an observational, multicenter, prospective registry in patients with T2DM. Patients were divided into those initiating BI therapy for the first time (with optional oral antidiabetic drugs (OADs)) and those initiating OADs only (OADo). RESULTS 521 patients were included in the analysis, 113 in the BI arm and 408 in the OADo arm. Relative to baseline, the BI group gained an average of 0.98±7.1 kg at 1 year, compared with a loss of 1.52±11.8 kg in the OADo group (p<0.001). This difference remained statistically significant when expressed as a proportional change from baseline (+0.014±0.08 vs -0.015±0.12, respectively (p<0.001)). Baseline weight (regression coefficient (RC) 0.89; 95% CI 0.81 to 0.97; p<0.001) and diabetes duration (RC 2.52; 95% CI 0.53 to 4.52; p=0.01) were the only factors identified as significant predictors of weight gain between baseline and 1 year follow-up in BI patients. CONCLUSIONS Though BI therapy leads to modest weight gain over the subsequent year, this may be limited by BI initiation at an early stage of the disease. As such, delaying the start of insulin therapy based on fears of weight gain appears counter-productive, and should be reconsidered.
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Affiliation(s)
- Peter Bramlage
- Institut für Pharmakologie und Präventive Medizin, Mahlow, Germany
| | | | | | - Matthias Kaltheuner
- winDiab GmbH, Düsseldorf, Germany
- Gemeinschaftspraxis Kaltheuner—v. Boxberg, Leverkusen, Germany
| | | | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Neuherberg, Germany
| | - Thomas Danne
- Kinder- und Jugendkrankenhaus “AUF DER BULT”, Hannover, Germany
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Curtis BH, Curtis S, Murphy DR, Gahn JC, Perk S, Smolen HJ, Murray J, Numapau N, Bonner JS, Liu R, Johnson J, Glass LC. Evaluation of a patient self-directed mealtime insulin titration algorithm: a US payer perspective. J Med Econ 2016; 19:549-56. [PMID: 26756804 DOI: 10.3111/13696998.2016.1141098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Objective To model the potential economic impact of implementing the AUTONOMY once daily (Q1D) patient self-titration mealtime insulin dosing algorithm vs standard of care (SOC) among a population of patients with Type 2 diabetes living in the US. Methods Three validated models were used in this analysis: The Treatment Transitions Model (TTM) was used to generate the primary results, while both the Archimedes (AM) and IMS Core Diabetes Models (IMS) were used to test the veracity of the primary results produced by TTM. Models used data from a 'real world' representative sample of patients (2012 US National Health and Nutrition Examination Survey) that matched the characteristics of US patients enrolled in the randomized controlled trial 'AUTONOMY' cohort. The base-case time horizon was 10 years. Results The modeling results from TTM demonstrated that total costs in the base-case were reduced by $1732, with savings predicted to occur as early as year 1. Results from the three models were consistent, showing a reduction in total costs for all sensitivity analyses. Limitations Data from short-term clinical trials were used to develop long-term projections. The nature of such extrapolation leads to increased uncertainty. Conclusion The results from all three models indicate that the AUTONOMY Q1D algorithm has the potential to abate total costs as early as the first year.
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Affiliation(s)
| | - Sarah Curtis
- a Eli Lilly and Company , Indianapolis , IN , USA
| | | | - James C Gahn
- b Medical Decision Modeling Inc. , Indianapolis , IN , USA
| | - Sinem Perk
- b Medical Decision Modeling Inc. , Indianapolis , IN , USA
| | - Harry J Smolen
- b Medical Decision Modeling Inc. , Indianapolis , IN , USA
| | - James Murray
- a Eli Lilly and Company , Indianapolis , IN , USA
| | - Nana Numapau
- a Eli Lilly and Company , Indianapolis , IN , USA
| | | | - Rong Liu
- a Eli Lilly and Company , Indianapolis , IN , USA
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23
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Finucane TE. “Beneficial” Effects of Early Insulin? J Am Geriatr Soc 2016; 64:243-4. [DOI: 10.1111/jgs.13912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Levin P, Zhou S, Durden E, Farr AM, Gill J, Wei W. Clinical and Economic Outcomes Associated With the Timing of Initiation of Basal Insulin in Patients With Type 2 Diabetes Mellitus Previously Treated With Oral Antidiabetes Drugs. Clin Ther 2016; 38:110-21. [DOI: 10.1016/j.clinthera.2015.11.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 10/08/2015] [Accepted: 11/16/2015] [Indexed: 12/28/2022]
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