Clinical Inertia and 2-Year Glycaemic Trajectories in Patients with Non-Newly Diagnosed Type 2 Diabetes Mellitus in Primary Care: A Retrospective Cohort Study

Mandatory monthly outpatient visits could improve therapeutic inertia in patients with poorly controlled type 2 diabetes

AIMS/INTRODUCTION

Delayed intensification of treatment, or therapeutic inertia, increases the risk of diabetic complications and death. The aim of this study was to determine the effect of mandatory monthly outpatient visits on therapeutic inertia in patients with suboptimal control of type 2 diabetes.

MATERIALS AND METHODS

This retrospective cohort study used data from the Chang Gung Research Database and defined two study periods: the baseline period and the intervention period. The intervention period began when the Kaohsiung branch initiated a mandatory monthly outpatient visits program. Type 2 diabetes patients with baseline glycated hemoglobin (HbA1c) >7% and a follow-up HbA1c measurement were enrolled in each period, and divided into a Kaohsiung branch (intervention) group and the other branches (control) group. Therapy intensification was evaluated by comparing prescriptions after the follow-up HbA1c measurement with the prescriptions after the baseline HbA1c measurement.

RESULTS

A total of 5,045 patients at the Kaohsiung branch and 13,400 participants at other branches were enrolled in the baseline period; and 5,573 and 15,603 patients, respectively, were enrolled in the intervention period. The adjusted odds ratio (AOR) for therapy intensification in patients with baseline HbA1c ≥9% was not significantly higher at 1.21 (95% CI, 1.00-1.47) in the intervention period at the Kaohsiung branch, but was significantly higher (AOR, 1.53; 95% CI, 1.02-2.30) in the subgroup with worsened HbA1c.

CONCLUSIONS

Mandatory monthly outpatient visits could improve therapeutic inertia in patients with poorly controlled type 2 diabetes, especially in those with worsened control. The trajectory of HbA1c could significantly influence the assessment of the prevalence of therapeutic inertia.

Time trajectories of key cardiometabolic parameters and of cardiovascular risk in subjects with diabetes in a real world setting

BACKGROUND AND AIMS

Diabetes is associated with increased cardiovascular risk. Glycated haemoglobin (HbA_1c), lipid parameters and blood pressure are known risk factors for adverse outcome. The aim of the study was to explore the time trajectories of these key parameters and of the associated cardiovascular risk.

METHODS

We linked the diabetes electronic health records to the laboratory information system so as to investigate the trajectories of key metabolic parameters from 3 years prior to the diagnosis of diabetes to 10 years after diagnosis. We calculated the cardiovascular risk at the different time points during this period using the United Kingdom Prospective Study (UKPDS) risk engine.

RESULTS

The study included 21,288 patients. The median age at diagnosis was 56 years and 55.3% were male. There was a sharp decrease in HbA_1c after diagnosis of diabetes, but there was a progressive rise thereafter. All lipid parameters after diagnosis also improved in the year of diagnosis, and these improvements persisted even up to 10 years post-diagnosis. There was no discernible trend in mean systolic or diastolic blood pressures following diagnosis of diabetes. There was a slight decrease in the UKPDS-estimated cardiovascular risk after diagnosis of diabetes followed by a progressive increase. Estimated glomerular filtration rate declined at an average rate of 1.33 ml/min/1.73 m²/year.

CONCLUSIONS

Our data suggest that lipid control should be tightened with increasing duration of diabetes since this is more readily achievable than HbA_1c lowering and since other factors such as age and duration of diabetes are unmodifiable.

Shared-care models are highly effective and cost-effective for managing chronic hepatitis B in China: reinterpreting the primary care and specialty divide

Background

We evaluate the impact and cost-effectiveness of shared primary-specialty chronic hepatitis B (CHB) care models in China.

Methods

We constructed a decision-tree Markov model to simulate hepatitis B virus (HBV) disease progression in a cohort of 100,000 CHB individuals aged ≥18 years over their lifetime (aged 80). We evaluated the population impacts and cost-effectiveness in three scenarios: (1) status quo; (2) shared-care model with HBV testing and routine CHB follow-ups in primary care and antiviral treatment initiation in specialty care; and (3) shared-care model with HBV testing, treatment initiation and routine CHB follow-up in primary care and treatment for predetermined conditions in specialty care. We evaluated from a healthcare provider's perspective with 3% discounting rate and a willingness-to-pay (WTP) threshold of 1-time China's GDP.

Findings

Compared with status quo, scenario 2 would result in an incremental cost of US$5.79-132.43m but a net gain of 328-16,993 quality-adjusted life years (QALYs) and prevention of 39-1935 HBV-related deaths over cohort's lifetime. Scenario 2 was not cost-effective with a WTP of 1-time GDP per capita, but became cost-effective when treatment initiation rate increased to 70%. In contrast, compared with status quo, secnario 3 would save US$144.59-192.93m in investment and achieve a net gain of 23,814-30,476 QALYs and prevention of 3074-3802 HBV-related deaths. Improving HBV antiviral treatment initiation among eligible CHB individuals substantially improved the cost-effectiveness of the shared-care models.

Interpretation

Shared-care models with HBV testing, follow up and referring of predetermined conditions to specialty care at an appropriate time, especially antiviral treatment initiation in primary care, are highly effective and cost-effective in China.

Funding

National Natural Science Foundation of China.

Predictors of Clinical Inertia and Type 2 Diabetes: Assessment of Primary Care Physicians and Their Patients

With the growing prevalence and complex pathophysiology of type 2 diabetes, many patients fail to achieve treatment goals despite guidelines and possibilities for treatment individualization. One of the identified root causes of this failure is clinical inertia. We explored this phenomenon, its possible predictors, and groups of patients affected the most, together with offering potential paths for intervention. Our research was a cross-sectional study conducted during 2021 involving 52 physicians and 543 patients of primary healthcare institutions in Belgrade, Serbia. The research instruments were questionnaires based on similar studies, used to collect information related to the factors that contribute to developing clinical inertia originating in both physicians and patients. In 224 patients (41.3%), clinical inertia was identified in patients with poor overall health condition, long diabetes duration, and comorbidities. Studying the changes made to the treatment, most patients (53%) had their treatment adjustment more than a year ago, with 19.3% of patients changing over the previous six months. Moreover, we found significant inertia in the treatment of patients using modern insulin analogues. Referral to secondary healthcare institutions reduced the emergence of inertia. This assessment of primary care physicians and their patients pointed to the high presence of clinical inertia, with an overall health condition, comorbidities, diabetes duration, current treatment, last treatment change, glycosylated hemoglobin and fasting glucose measuring frequency, BMI, patient referral, diet adjustment, and physician education being significant predictors.