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Flory JH, Guelce D, Goytia C, Li J, Min JY, Mushlin A, Orloff J, Mayer V. Prescriber Uncertainty as Opportunity to Improve Care of Type 2 Diabetes with Chronic Kidney Disease: Mixed Methods Study. J Gen Intern Med 2023; 38:1476-1483. [PMID: 36316625 PMCID: PMC10160326 DOI: 10.1007/s11606-022-07838-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/05/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Over 5 million patients in the United States have type 2 diabetes mellitus (T2D) with chronic kidney disease (CKD); antidiabetic drug selection for this population is complex and has important implications for outcomes. OBJECTIVE To better understand how providers choose antidiabetic drugs in T2D with CKD DESIGN: Mixed methods. Interviews with providers underwent qualitative analysis using grounded theory to identify themes related to antidiabetic drug prescribing. A provider survey used vignettes and direct questions to quantitatively assess prescribers' knowledge and preferences. A retrospective cohort analysis of real-world prescribing data assessed the external validity of the interview and survey findings. PARTICIPANTS Primary care physicians, endocrinologists, nurse-practitioners, and physicians' assistants were eligible for interviews; primary care physicians and endocrinologists were eligible for the survey; prescribing data were derived from adult patients with serum creatinine data. MAIN MEASURES Interviews were qualitative; for the survey and retrospective cohort, proportion of patients receiving metformin was the primary outcome. KEY RESULTS Interviews with 9 providers identified a theme of uncertainty about guidelines for prescribing antidiabetic drugs in patients with T2D and CKD. The survey had 105 respondents: 74 primary care providers and 31 endocrinologists. Metformin was the most common choice for patients with T2D and CKD. Compared to primary care providers, endocrinologists were less likely to prescribe metformin at levels of kidney function at which it is contraindicated and more likely to correctly answer a question about metformin's contraindications (71% versus 41%) (p < .05). Real-world data were consistent with survey findings, and further showed low rates of use of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists (<10%) in patients with eGFR below 60 ml/min/1.73m2. CONCLUSIONS Providers are unsure how to treat T2D with CKD and incompletely informed as to existing guidelines. This suggests opportunities to improve care.
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Affiliation(s)
- James H Flory
- Endocrinology Service, Department of Subspecialty Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Dominique Guelce
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA
| | | | - Jing Li
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA
| | - Jea Young Min
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA
| | - Al Mushlin
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA
| | - Jeremy Orloff
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY, USA
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de Lusignan S, McGovern A, Hinton W, Whyte M, Munro N, Williams ED, Marcu A, Williams J, Ferreira F, Mount J, Tripathy M, Konstantara E, Field BCT, Feher M. Barriers and Facilitators to the Initiation of Injectable Therapies for Type 2 Diabetes Mellitus: A Mixed Methods Study. Diabetes Ther 2022; 13:1789-1809. [PMID: 36050586 PMCID: PMC9500132 DOI: 10.1007/s13300-022-01306-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/25/2022] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Initiation of injectable therapies in type 2 diabetes (T2D) is often delayed, however the reasons why are not fully understood. METHODS A mixed methods study performed in sequential phases. Phase 1: focus groups with people with T2D (injectable naïve [n = 12] and experienced [n = 5]) and healthcare professionals (HCPs; nurses [n = 5] and general practitioners (GPs) [n = 7]) to understand their perceptions of factors affecting initiation of injectables. Phase 2: video-captured GP consultations (n = 18) with actor-portrayed patient scenarios requiring T2D treatment escalation to observe the initiation in the clinical setting. Phase 3: HCP surveys (n = 87) to explore external validity of the themes identified in a larger sample. RESULTS Focus groups identified patients' barriers to initiation; fear, lack of knowledge and misconceptions about diabetes and treatment aims, concerns regarding lifestyle restrictions and social stigma, and feelings of failure. Facilitators included education, good communication, clinician support and competence. HCP barriers included concerns about weight gain and hypoglycaemia, and limited consultation time. In simulated consultations, GPs performed high-quality consultations and recognised the need for injectable initiation in 9/12 consultations where this was the expert recommended option but did not provide support for initiation themselves. Survey results demonstrated HCPs believe injectable initiation should be performed in primary care, although many practitioners reported inability to do so or difficulty in maintaining skills. CONCLUSION People with T2D have varied concerns and educational needs regarding injectables. GPs recognise the need to initiate injectables but lack practical skills and time to address patient concerns and provide education. Primary care nurses also report difficulties in maintaining these skills. Primary care HCPs initiating injectables require additional training to provide practical demonstrations, patient education and how to identify and address concerns. These skills should be concentrated in the hands of a small number of primary care providers to ensure they can maintain their skills.
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Affiliation(s)
- Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK.
- Royal College of General Practitioners, Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC), London, UK.
| | - Andrew McGovern
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
- The Institute of Clinical and Biological Sciences, University of Exeter, Exeter, UK
| | - William Hinton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Martin Whyte
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Neil Munro
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | | | - Afrodita Marcu
- School of Health Sciences, University of Surrey, Guildford, UK
| | - John Williams
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Filipa Ferreira
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Julie Mount
- Eli Lilly and Company, Basingstoke, Hampshire, UK
| | - Manasa Tripathy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | | | - Benjamin C T Field
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
- Department of Diabetes and Endocrinology, East Surrey Hospital, Surrey and Sussex Healthcare NHS Trust, Redhill, Surrey, UK
| | - Michael Feher
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Tamez-Pérez HE, Delgadillo-Esteban E, Tamez-Peña AL. Underutilization of insulin and better metabolic control. A NOVA clinic experience. ACTA ACUST UNITED AC 2020; 66:334-337. [PMID: 32520154 DOI: 10.1590/1806-9282.66.3.334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 07/28/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To present the results of metabolic control in patients with type 2 Diabetes Mellitus from a private clinic in Northern Mexico. METHODS This cross-sectional study used retrospective data obtained from electronic records from a private outpatient clinic at the end of 2018. Inclusion criteria were a diagnosis of T2DM and age ≥ 18 years. Baseline characteristics (age, gender, drug use) were reported. The achievement of glycated hemoglobin goals was established as <7%. RESULTS A total of 3820 patients were evaluated. Their mean age was 59.86 years (+/-15.01). Of the population, 46.72% were men, and 53.28% were women. Glycated hemoglobin goals were adequate in 1872 (54%) patients. There were 3247 patients (85%) treated with oral medications, of which 1948 (60%) reported glycated hemoglobin less than 7%. Insulin use was reported in 573 (15%) patients, with 115 (20%) reporting glycated hemoglobin less than 7%. The most frequently used basal insulin was glargine in 401 (70%) patients. CONCLUSIONS Our findings are clearly higher than the control rate reported by our national health surveys of 25% with glycated hemoglobin < 7%, but similar to that reported in other countries. The most commonly used therapeutic scheme was the combination of oral hypoglycemic agents. The percentage of cases that include insulin in their treatment was lower. Clinical inertia to insulin initiation and intensification has been defined as an important cause of this problem.
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Affiliation(s)
- Héctor Eloy Tamez-Pérez
- . Research Subdirector, Faculty of Medicine and University Hospital "Dr. José Eleuterio González", Autonomous University of Nuevo León, Monterrey, México.,. Clinical Hospital NOVA, San Nicolás de los Garza, N.L., México
| | - Enrique Delgadillo-Esteban
- . Research Subdirector, Faculty of Medicine and University Hospital "Dr. José Eleuterio González", Autonomous University of Nuevo León, Monterrey, México
| | - Alejandra Lorena Tamez-Peña
- . Research Subdirector, Faculty of Medicine and University Hospital "Dr. José Eleuterio González", Autonomous University of Nuevo León, Monterrey, México
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