Use of a Glucose Algorithm to Direct Diabetes Therapy Improves A1C Outcomes and Defines an Approach to Assess Provider Behavior

Management of type 2 diabetes: the current situation and key opportunities to improve care in the UK

In common with global trends, the number of individuals with type 2 diabetes in the UK is rising, driven largely by obesity. The increasing prevalence of younger individuals with type 2 diabetes is of particular concern because of the accelerated course of diabetes-related complications that is observed in this population. The importance of good glycaemic control in the prevention of microvascular complications of diabetes is widely accepted, and there is a growing body of evidence to support a benefit in the reduction of cardiovascular events in the long term. Despite the importance of maintaining a healthy weight for the prevention of type 2 diabetes, the results from trials of lifestyle intervention strategies to reduce body weight have been disappointing. New glucose-lowering agents offer some promise in this regard, offering an opportunity to combat the dual burden of hyperglycaemia and obesity simultaneously. The timing and appropriate choice of glucose-lowering therapy has never been more complex as a result of rising prevalence of obesity in the young, concomitant obesity in some 90% of adults with type 2 diabetes and an ever-increasing range of therapeutic options. The present review evaluates performance measures specific to weight and glycaemic control in type 2 diabetes in the UK using data from the Quality and Outcomes Framework in England and Wales, and the Scottish Diabetes Survey. Potential barriers to improvement in standards of care for people with type 2 diabetes are considered, including patient factors, clinical inertia and the difficulties in translating therapeutic guidelines into everyday clinical practice.

The use of quality improvement and health information technology approaches to improve diabetes outcomes in African American and Hispanic patients

Differences in rates of diabetes-related lower extremity amputations represent one of the largest and most persistent health disparities found for African Americans and Hispanics compared with Whites in the United States. Since many minority patients receive care in underresourced settings, quality improvement (QI) initiatives in these settings may offer a targeted approach to improve diabetes outcomes in these patient populations. Health information technology (health IT) is widely viewed as an essential component of health care QI and may be useful in decreasing diabetes disparities in underresourced settings. This article reviews the effectiveness of health care interventions using health IT to improve diabetes process of care and intermediate diabetes outcomes in African American and Hispanic patients. Health IT interventions have addressed patient, provider, and system challenges in the provision of diabetes care but require further testing in minority patient populations to evaluate their effectiveness in improving diabetes outcomes and reducing diabetes-related complications.

Cost and policy implications from the increasing prevalence of obesity and diabetes mellitus

BACKGROUND

The increasing prevalence of obesity and type 2 diabetes mellitus (DM), among children and adults, has posed important policy and budgetary considerations to government, health insurance companies, employers, physicians, and health care delivery systems.

OBJECTIVE

This article examines issues that are common to obesity and DM, including cost, clinical research, and treatment barriers, and proposes health policies to address these issues.

METHOD

A manual review was performed of authoritative literature from peer-reviewed medical publications and recently published medical textbooks.

RESULTS

Obesity has been disproportionately prevalent among women and minorities, accompanied by an increased risk for DM. Women have experienced an increased risk for the metabolic syndrome, DM, and cardiovascular disease after onset of menopause. Obesity has been related to an increased risk for breast cancer among women, and may be a barrier that prevents women from being screened for colon and breast cancers. Maternal obesity has been a risk factor for gestational DM.

CONCLUSIONS

Obesity and DM represent crises for the health care system and the health of the public, incurring costs and disease burden for adults and children, with increasing costs and prevalence expected unless more coordinated efforts to address the causes of these conditions at the national level are implemented. An investment in infrastructure to promote increased physical activity and reward weight management may be budget neutral in the long term by reducing the costs of morbidity and mortality. About two thirds of the costs from DM complications could be averted with appropriate primary care.

Use of a uniform treatment algorithm abolishes racial disparities in glycemic control

PURPOSE

The purpose of this study is to compare glycemic control between blacks and whites in a setting where patient and provider behavior is assessed, and where a uniform treatment algorithm is used to guide care.

METHODS

This observational cohort study was conducted in 3542 patients (3324 blacks, 218 whites) with type 2 diabetes with first and 1-year follow-up visits to a municipal diabetes clinic; a subset had 2-year follow-up. Patient adherence and provider management were determined. The primary endpoint was A1c.

RESULTS

At presentation, A1c was higher in blacks than whites (8.9% vs 8.3%; P < .001), even after adjusting for demographic and clinical characteristics. During 1 year of follow-up, patient adherence to scheduled visits and medications was comparable in both groups, and providers intensified medications with comparable frequency and amount. After 1 year, A1c differences decreased but remained significant (7.7% vs 7.3%; P = .029), even in multivariable analysis (P = .003). However, after 2 years, A1c differences were no longer observed by univariate (7.6% vs 7.5%; P = .51) or multi-variable analysis (P = .18).

CONCLUSIONS

Blacks have higher A1c than whites at presentation, but differences narrow after 1 year and disappear after 2 years of care in a setting where patient and provider behavior are comparable and that emphasizes uniform intensification of therapy. Presumably, racial disparities at presentation reflected prior inequalities in management. Use of uniform care algorithms nationwide should help to reduce disparities in diabetes outcomes.

Relationship between patient medication adherence and subsequent clinical inertia in type 2 diabetes glycemic management

OBJECTIVE

Clinical inertia has been identified as a critical barrier to glycemic control in type 2 diabetes. We assessed the relationship between patients' initial medication adherence and subsequent regimen intensification among patients with persistently elevated A1C levels.

RESEARCH DESIGN AND METHODS

We analyzed an inception cohort of 2,065 insured patients with type 2 diabetes who were newly started on hypoglycemic therapy and were followed for at least 3 years between 1992 and 2001. Medication adherence was assessed by taking the ratio of medication days dispensed (from pharmacy records) to medication days prescribed (as documented in the medical record) for the first prescribed hypoglycemic drug. Adherence was measured for the period between medication initiation and the next elevated A1C result measured at least 3 months later; intensification was defined as a dose increase or the addition of a second hypoglycemic agent.

RESULTS

Patients were aged (mean +/- SD) 55.4 +/- 12.2 years; 53% were men, and 19% were black. Baseline medication adherence was 79.8 +/- 19.3%. Patients in the lowest quartile of adherence were significantly less likely to have their regimens increased within 12 months of their first elevated A1C compared with patients in the highest quartile (27 vs. 37%, respectively, with increased regimens if A1C is elevated, P < 0.001). In multivariate models adjusting for patient demographic and treatment factors, patients in the highest adherence quartile had 53% greater odds of medication intensification after an elevated A1C (95% CI 1.11-1.93, P = 0.01).

CONCLUSIONS

Among insured diabetic patients with elevated A1C, level of medication adherence predicted subsequent medication intensification. Poor patient self-management behavior increases therapeutic clinical inertia.