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McDaniel CC, Lo-Ciganic WH, Chou C. Diabetes-related complications, glycemic levels, and healthcare utilization outcomes after therapeutic inertia in type 2 diabetes mellitus. Prim Care Diabetes 2024; 18:188-195. [PMID: 38185576 DOI: 10.1016/j.pcd.2023.12.004] [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: 06/19/2023] [Revised: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 01/09/2024]
Abstract
AIMS To assess diabetes-related complications, glycemic levels, and healthcare utilization 12 months after exposure to therapeutic inertia among patients with type 2 diabetes mellitus (T2D). METHODS This retrospective cohort study analyzed data from the OneFlorida Clinical Research Consortium (electronic health records from Florida practices/clinics). The cohort included adult patients (≥18 years old) with T2D who had an HbA1c≥7.0% (53 mmol/mol) recorded from January 1, 2014-September 30, 2019. Therapeutic inertia (exposed vs. not exposed) was evaluated during the six months following HbA1c≥7.0% (53 mmol/mol). The outcomes assessed during the 12-month follow-up period included diabetes-related complications (continuous Diabetes Complications and Severity Index (DCSI)), glycemic levels (continuous follow-up HbA1c lab), and healthcare utilization counts. We analyzed data using multivariable regression models, adjusting for covariates. RESULTS The cohort included 26,881 patients with T2D (58.94% White race, 49.72% female, and mean age of 58.82 (SD=13.09)). After adjusting for covariates, therapeutic inertia exposure was associated with lower DCSI (estimate=-0.14 (SE=0.03), p < 0.001), higher follow-up HbA1c (estimate=0.14 (SE=0.04), p < 0.001), and lower rates of ambulatory visits (rate ratio=0.79, 95% CI=0.75-0.82). CONCLUSIONS Findings communicate the clinical practice implications and public health implications for combating therapeutic inertia in diabetes care.
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Affiliation(s)
- Cassidi C McDaniel
- Department of Health Outcomes Research and Policy, Harrison College of Pharmacy, Auburn University, Auburn, AL, USA.
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes and Policy, University of Florida, College of Pharmacy, Gainesville, FL, USA; Division of General Internal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh, Pittsburgh, PA, USA; North Florida/South Georgia Veterans Health System, Geriatric Research Education and Clinical Center, Gainesville, FL, USA
| | - Chiahung Chou
- Department of Health Outcomes Research and Policy, Harrison College of Pharmacy, Auburn University, Auburn, AL, USA; Department of Medical Research, China Medical University Hospital, Taichung City, Taiwan
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Tsai Y, Kuo T, Lin M, Shen F, Lin Y. Mandatory monthly outpatient visits could improve therapeutic inertia in patients with poorly controlled type 2 diabetes. J Diabetes Investig 2024; 15:227-236. [PMID: 37882416 PMCID: PMC10804897 DOI: 10.1111/jdi.14102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/30/2023] [Accepted: 10/10/2023] [Indexed: 10/27/2023] Open
Abstract
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.
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Affiliation(s)
- Ying‐Ying Tsai
- Division of Traditional Chinese MedicineChang Gung Memorial Hospital Chiayi BranchChiayiTaiwan
| | - Ting‐Yu Kuo
- Health Information and Epidemiology LaboratoryChang Gung Memorial Hospital Chiayi BranchChiayiTaiwan
| | - Meng‐Hung Lin
- Health Information and Epidemiology LaboratoryChang Gung Memorial Hospital Chiayi BranchChiayiTaiwan
| | - Feng‐Chih Shen
- Division of Endocrinology and Metabolism, Department of Internal MedicineKaohsiung Chang Gung Memorial HospitalKaohsiungTaiwan
| | - Yung‐Hsiang Lin
- Division of Endocrinology and MetabolismChang Gung Memorial Hospital Chiayi BranchChiayiTaiwan
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Chou YH, Su YT, Lo FS, Chiu CF, Huang YC. Influencing factors for treatment escalation from metformin monotherapy in youth-onset type 2 diabetes in Northern Taiwan. Pediatr Neonatol 2024:S1875-9572(23)00248-6. [PMID: 38216419 DOI: 10.1016/j.pedneo.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/16/2023] [Accepted: 09/21/2023] [Indexed: 01/14/2024] Open
Abstract
With the increasing prevalence of obesity, childhood type 2 diabetes (T2D) is a growing concern in Taiwan. Unlike its adult counterpart, T2D in children exhibits a more aggressive nature and earlier onset of complications. Metformin represents the first line of drug, but if blood sugar levels do not improve, other drugs are used. This retrospective cohort study endeavors to scrutinize and assess the pattern of treatment modification and associate factors among 79 young people with T2D in Taiwan. The study categorized participants into three distinct groups based on their treatment trajectory and outcomes: (1) those maintaining metformin (n = 34); (2) cases achieving remission (n = 7); and (3) individuals experiencing escalation through oral drugs or insulin (n = 38). The average follow-up period spanned 3.48 years. Findings from univariate analysis using a Cox proportional hazards model and propensity score weighting revealed that HbA1c and weight gain correlated with elevated risk of treatment escalation. Conversely, factors such as hypertension, high weight or body mass index (BMI) SDS, leptin levels, c-peptide concentrations, peak c-peptide values during glucagon stimulation test and LDL-cholesterol levels were associated with reduced risk of escalation. However, in multivariate analyses employing stepwise selection, the sole predictive factor for treatment escalation emerged as weight gain one year post-therapy (HR: 1.06, p < 0.001). This study underscores the interconnectedness between weight management and the trajectory toward either treatment escalation or disease remission. Furthermore, it highlights the cost-effective potential of intervening in younger populations. Ultimately, these insights accentuate the considerable opportunity for enhancing health care management strategies concerning pediatric T2D in Taiwan.
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Affiliation(s)
- Yi-Hsuan Chou
- Department of Pediatrics, Chang Gung Memorial Hospital Keelung, Keelung, Taiwan; Division of Pediatric Endocrinology and Genetics, Department of Pediatrics, Chang Gung Memorial Hospital Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ya-Ting Su
- Division of Pediatric Endocrinology and Genetics, Department of Pediatrics, Chang Gung Memorial Hospital Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Fu-Sung Lo
- Division of Pediatric Endocrinology and Genetics, Department of Pediatrics, Chang Gung Memorial Hospital Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan.
| | - Chiao-Fan Chiu
- Division of Pediatric Endocrinology and Genetics, Department of Pediatrics, Chang Gung Memorial Hospital Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yen-Chun Huang
- Division of Pediatric Endocrinology and Genetics, Department of Pediatrics, Chang Gung Memorial Hospital Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
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Legese GL, Asres G, Alemu S, Yesuf T, Tesfaye YA, Amare T. Determinants of poor glycemic control among type 2 diabetes mellitus patients at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia: Unmatched case-control study. Front Endocrinol (Lausanne) 2023; 14:1087437. [PMID: 36843610 PMCID: PMC9947343 DOI: 10.3389/fendo.2023.1087437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Poor glycemic control is one of the most determinant factors for type 2 diabetes-related morbidity and mortality. The proportion of type 2 diabetes mellitus patients with poor glycemic control remains high. Yet evidence on factors contributing to poor glycemic control remains scarce. The aim of this study is to identify determinants of poor glycemic control among type 2 diabetes mellitus patients at a diabetes mellitus clinic in University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia Determinants of Poor Glycemic Control among Type 2 Diabetes mellitus Patients at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia: Unmatched Case-Control Study. METHODS A hospital-based case-control study was conducted from June to September 2020. Using convenience sampling techniques, a total of 90 cases and 90 controls with type 2 diabetes were recruited. The data were entered into Epidata version 4.6.0.2 and analyzed by Stata version 14. A multivariable logistic regression analysis was performed to assess the association between independent variables and glycemic control. Both 95% CI and p-value<0.05 were used to determine the level and significance, respectively. RESULTS The mean age ( ± standard deviations) for the cases and controls were 57.55± 10.42 and 61.03± 8.93% respectively. The determinants of poor glycemic control were age (Adjusted odd ratio (AOR)= 0.08; 95% CI= 0.02-0.33), inadequate physical exercise (AOR = 5.05; 95% CI = 1.99-11.98), presence of comorbidities (AOR = 5.50; 95% CI = 2.06-14.66), non-adherence to anti-diabetes medications (AOR= 2.76; 95% CI= 1.19-6.40), persistent proteinuria (AOR=4.95; 95% CI=1.83-13.36) and high-density lipoprotein less than 40 mg/dl (AOR=3.08; 95% CI= 1.30-7.31). CONCLUSIONS Age less than 65 years, inadequate physical exercise, presence of comorbidities, non-adherence to anti-diabetes medications, persistent proteinuria, and high-density lipoprotein less than 40 mg/dl were the determinants of poor glycemic control. Therefore, targeted educational and behavioral modification programs on adequate exercise and medication adherence should be routinely practiced. Furthermore, early guideline-based screening and treatment of comorbidities and complications is required to effectively manage diabetes mellitus.
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Affiliation(s)
- Gebrehiwot Lema Legese
- Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
- *Correspondence: Gebrehiwot Lema Legese,
| | - Getahun Asres
- Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Shitaye Alemu
- Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tesfaye Yesuf
- Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Yeabsira Aklilu Tesfaye
- Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tsegaw Amare
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Medication non-adherence and therapeutic inertia independently contribute to poor disease control for cardiometabolic diseases. Sci Rep 2022; 12:18936. [PMID: 36344613 PMCID: PMC9640683 DOI: 10.1038/s41598-022-21916-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 10/05/2022] [Indexed: 11/09/2022] Open
Abstract
Poorly controlled cardiometabolic biometric health gap measures [e.g.,uncontrolled blood pressure (BP), HbA1c, and low-density lipoprotein cholesterol (LDL-C)] are mediated by medication adherence and clinician-level therapeutic inertia (TI). The study of comparing relative contribution of these two factors to disease control is lacking. We conducted a retrospective cohort study using 7 years of longitudinal electronic health records (EHR) from primary care cardiometabolic patients who were 35 years or older. Cox-regression modeling was applied to estimate how baseline proportion of days covered (PDC) and TI were associated with cardiometabolic related health gap closure. 92,766 patients were included in the analysis, among which 89.9%, 85.8%, and 73.3% closed a BP, HbA1c, or LDL-C gap, respectively, with median days to gap closure ranging from 223 to 408 days. Patients who did not retrieve a medication were the least likely to achieve biometric control, particularly for LDL-C (HR = 0.58, 95% CI: 0.55-0.60). TI or uncertainty of TI was associated with a high risk of health gap persistence, particularly for LDL-C (HR ranges 0.46-0.48). Both poor medication adherence and TI are independently associated with persistent health gaps, and TI has a much higher impact on disease control compared to medication adherence, implying disease management strategies should prioritize reducing TI.
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Ma RCW, Xie F, Lim CKP, Lau ESH, Luk AOY, Ozaki R, Cheung GPY, Lee HM, Ng ACW, Li HW, Wong CKM, Wong SYS, So WY, Chan JCN. A randomized clinical trial of genetic testing and personalized risk counselling in patients with type 2 diabetes receiving integrated care -The genetic testing and patient empowerment (GEM) trial. Diabetes Res Clin Pract 2022; 189:109969. [PMID: 35728675 DOI: 10.1016/j.diabres.2022.109969] [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: 04/08/2022] [Revised: 06/05/2022] [Accepted: 06/15/2022] [Indexed: 11/29/2022]
Abstract
AIMS We evaluated the effect of personalized risk counseling incorporating clinical and genetic risk factors on patient empowerment and risk factor control in diabetes. METHODS Patients with type 2 diabetes (T2D) with suboptimal glycaemic control (HbA1c ≥ 7.5%) were randomized to a genetic counselling (GC) or control group. All patients underwent genetic testing for alleles at three loci associated with diabetic complications. The GC group received additional explanation of the joint associations of genetic and modifiable risk factors on risk of complications. All patients were reassessed at 12 months including validated questionnaires for patient reported outcomes. The primary outcome was proportion of patients reaching ≥ 3 of 5 predefined treatment targets (HbA1c < 7%, BP < 130/80 mmHg, LDL-C < 2.6 mmol/L, Triglyceride < 2.0 mmol/L, use of renin-angiotensin system inhibitors). Secondary outcomes included new-onset chronic kidney disease or microalbuminuria and patient reported outcome measures. RESULTS A total of 435 patients were randomized and 420 patients were included in the modified intention-to-treat analysis. At 12 months, the proportion of patients who attained ≥ 3 targets increased from 41.6% to 52.3% in the GC group (p = 0.007) versus 49.5% to 62.6% in the control group (p = 0.003), without between-group difference. Both groups had similar reduction in HbA1c, LDL-C and increased use of medications. In per protocol analysis, the GC group had higher diabetes empowerment, with reduced diabetes distress. In the GC group, the greatest improvement in positive attitude and self-care activities was observed in the intermediate to high genetic risk score (GRS) groups. CONCLUSIONS In patients with T2D receiving integrated care, additional counselling on genetic risk of complications did not further improve risk factor control, although the improvement in self-efficacy warrants long-term evaluation.
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Affiliation(s)
- Ronald Ching Wan Ma
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong, China; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China; Chinese University of Hong Kong-Shanghai Jiao Tong University Joint Research Centre in Diabetes Genomics and Precision Medicine, China.
| | - Fangying Xie
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China.
| | - Cadmon King Poo Lim
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China; Chinese University of Hong Kong-Shanghai Jiao Tong University Joint Research Centre in Diabetes Genomics and Precision Medicine, China.
| | - Eric Siu Him Lau
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong, China.
| | - Andrea On Yan Luk
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong, China; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China; Chinese University of Hong Kong-Shanghai Jiao Tong University Joint Research Centre in Diabetes Genomics and Precision Medicine, China.
| | - Risa Ozaki
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong, China; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China.
| | - Grace Pui Yiu Cheung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China.
| | - Heung Man Lee
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China.
| | - Alex Chi Wai Ng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China.
| | - Heung Wing Li
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China.
| | - Carmen Ka Man Wong
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China.
| | - Samuel Yeung Shan Wong
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China.
| | - Wing Yee So
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong, China; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China.
| | - Juliana Chung Ngor Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong, China; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, China; Chinese University of Hong Kong-Shanghai Jiao Tong University Joint Research Centre in Diabetes Genomics and Precision Medicine, China.
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Luo J, Gabriel N, Korytkowski M, Hernandez I, Gellad WF. Association of formulary restrictions and initiation of an SGLT2i or GLP1-RA among Medicare beneficiaries with type 2 diabetes. Diabetes Res Clin Pract 2022; 187:109855. [PMID: 35346753 PMCID: PMC10767977 DOI: 10.1016/j.diabres.2022.109855] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 02/18/2022] [Accepted: 03/23/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Use of SGLT2 inhibitors (SGLT2i) and GLP-1 receptor agonists (GLP1-RA) among older adults with type 2 diabetes (T2D) has been limited. OBJECTIVE To examine factors associated with initiation of an SGLT2i or GLP-1RA among Medicare beneficiaries with T2D in the early years after their market approval, with a particular focus on formulary restrictions (e.g. prior authorization, step therapy requirements, higher co-pays). METHODS A retrospective cohort study using data from a 5% random sample of Medicare beneficiaries with T2D followed from 1/1/2015-12/31/16. Formulary restrictiveness was defined as: (1) the number of target drugs (i.e. SGLT2is or GLP1-RAs) included in tiers 1-3 of a beneficiary's formulary (greater number of drugs in tiers 1-3 being less restrictive) and (2) the number of drugs without prior authorization or step therapy (requirement to try less expensive drugs prior to "stepping up" to more expensive therapies). We used multivariable logistic regression models to estimate the association between measures of formulary restrictiveness and initiation of a target drug, controlling for patient demographics, diabetes duration, clinical comorbidities, and provider specialty. RESULTS Among 112,985 beneficiaries with T2D, 5,619 (5%) initiated an SGLT2i or GLP1-RA. After adjusting for baseline characteristics, patients enrolled in formularies with ≥ 2 target drugs available in tiers 1-3 had 17% higher odds of initiating an SGLT2i or GLP1-RA (aOR 1.17, 95% CI 1.05-1.31) compared to patients enrolled in formularies with 0 drugs available in tiers 1-3. There was no significant association between the number of drugs without prior authorization or step therapy requirements and initiation of a target drug (aOR 0.96, 95% CI, 0.85-1.09). Age 75 years or older (vs < 65, aOR 0.23, 95% CI 0.21-0.26) and black race (vs white, aOR 0.65, 95% CI 0.59-0.71) were associated with lower odds of initiating a target drug. CONCLUSIONS Having a greater number of target drugs available on less expensive formulary tiers is associated with increased odds of initiating an SGLT2i or GLP-1RA among Medicare beneficiaries with T2D.
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Affiliation(s)
- Jing Luo
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, United States.
| | - Nico Gabriel
- University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, United States
| | - Mary Korytkowski
- Division of Endocrinology and Metabolism, University of Pittsburgh School of Medicine, United States
| | - Inmaculada Hernandez
- University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, United States
| | - Walid F Gellad
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, United States; Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, United States
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Vajravelu ME, Hitt TA, Amaral S, Levitt Katz LE, Lee JM, Kelly A. Real-world treatment escalation from metformin monotherapy in youth-onset Type 2 diabetes mellitus: A retrospective cohort study. Pediatr Diabetes 2021; 22:861-871. [PMID: 33978986 PMCID: PMC8373808 DOI: 10.1111/pedi.13232] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/22/2021] [Accepted: 04/26/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Due to high rates of comorbidities and rapid progression, youth with Type 2 diabetes may benefit from early and aggressive treatment. However, until 2019, the only approved medications for this population were metformin and insulin. OBJECTIVE To investigate patterns and predictors of treatment escalation within 5 years of metformin monotherapy initiation for youth with Type 2 diabetes in clinical practice. SUBJECTS Commercially-insured patients with incident youth-onset (10-18 years) Type 2 diabetes initially treated with metformin only. METHODS Retrospective cohort study using a patient-level medical claims database with data from 2000 to 2020. Frequency and order of treatment escalation to insulin and non-insulin antihyperglycemics were determined and categorized by age at diagnosis. Cox proportional hazards regression was used to evaluate potential predictors of treatment escalation, including age, sex, race/ethnicity, comorbidities, complications, and metformin adherence (medication possession ratio ≥ 0.8). RESULTS The cohort included 829 (66% female; median age at diagnosis 15 years; 19% Hispanic, 17% Black) patients, with median 2.9 year follow-up after metformin initiation. One-quarter underwent treatment escalation (n = 207; 88 to insulin, 164 to non-insulin antihyperglycemic). Younger patients were more likely to have insulin prescribed prior to other antihyperglycemics. Age at diagnosis (HR 1.14, 95% CI 1.07-1.21), medication adherence (HR 4.10, 95% CI 2.96-5.67), Hispanic ethnicity (HR 1.83, 95% CI 1.28-2.61), and diabetes-related complications (HR 1.78, 95% CI 1.15-2.74) were positively associated with treatment escalation. CONCLUSIONS In clinical practice, treatment escalation for pediatric Type 2 diabetes differs with age. Off-label use of non-insulin antihyperglycemics occurs, most commonly among older adolescents.
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Affiliation(s)
- Mary Ellen Vajravelu
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Talia A. Hitt
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sandra Amaral
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Division of Nephrology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lorraine E. Levitt Katz
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joyce M. Lee
- Susan B Meister Child Health Evaluation and Research Center, Division of Pediatric Endocrinology, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrea Kelly
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Gooptu A, Taitel M, Laiteerapong N, Press VG. Association between Medication Non-Adherence and Increases in Hypertension and Type 2 Diabetes Medications. Healthcare (Basel) 2021; 9:healthcare9080976. [PMID: 34442113 PMCID: PMC8394266 DOI: 10.3390/healthcare9080976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 07/25/2021] [Accepted: 07/27/2021] [Indexed: 11/16/2022] Open
Abstract
Importance: Medication non-adherence is highly costly and leads to worse disease control and outcomes. However, knowledge about medication adherence is often disconnected from prescribing decisions, and this disconnect may lead to inappropriate increases in medications and higher risks of adverse events. Objectives: To evaluate the association between medication non-adherence and the likelihood of increases in the intensity of medication regimens for two chronic conditions, hypertension and type 2 diabetes. Design: Cohort Study. Setting and Participants: This study used US national pharmacy claims data for Medicare Part D (ages ≥ 65) and commercial (ages 50-64) plans to evaluate medication adherence and its association with the likelihood of receiving an increase in medication intensity for patients with hypertension and/or oral diabetes medication fills. Patients had an index fill for hypertension (N = 2,536,638) and/or oral diabetes (N = 701,376) medications in January 2015. Medication fills in the follow-up period from August 2015 to December 2016 were assessed for increases in medication regimen intensity. Main Outcome(s) and Measure(s): The proportion of days covered (PDC) over 181 days was used as a measure for patient's medication adherence before a medication addition, medication increase, or dosage increase. Differences in the likelihood of experiencing an escalation in medication intensity was considered between patients with a PDC < 80% vs. PDC ≥ 80%. Results: Among Medicare Part D and commercial plan patients filling hypertension and/or oral diabetes medications, non-adherent patients were significantly more likely to experience an intensification of their medication regimens (p < 0.001). Conclusions and Relevance: This study found a significant association between non-adherence to medications and a higher likelihood of patients experiencing potentially inappropriate increases in treatment intensity. Sharing of objective patient refill data between retail pharmacies and prescribers can enable prescribers to have more targeted discussions with patients about their adherence and overall treatment plan. Additionally, it can increase safe medication prescribing and plausibly reduce adverse drug events and healthcare costs while improving patient health outcomes.
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Affiliation(s)
- Angshuman Gooptu
- IMPAQ International LLC, 10420 Little Patuxent Parkway, Suite 300, Columbia, MD 21044, USA
- Correspondence: ; Tel.: +1-312-515-3898
| | - Michael Taitel
- Walgreen Co., 102 Wilmot, 5th Floor MS#125D, Deerfield, IL 60015, USA;
| | - Neda Laiteerapong
- University of Chicago Medicine, University of Chicago, 5841 Maryland Avenue, Chicago, IL 60637, USA; (N.L.); (V.G.P.)
| | - Valerie G. Press
- University of Chicago Medicine, University of Chicago, 5841 Maryland Avenue, Chicago, IL 60637, USA; (N.L.); (V.G.P.)
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10
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Effect of constructing doctor-pharmacist joint pharmacy clinic for outpatients on the comprehensive management of type 2 diabetes mellitus: a pilot RCT. Int J Diabetes Dev Ctries 2021. [DOI: 10.1007/s13410-021-00967-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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11
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Maegawa H, Ishigaki Y, Langer J, Saotome‐Nakamura A, Andersen M. Clinical inertia in patients with type 2 diabetes treated with oral antidiabetic drugs: Results from a Japanese cohort study (JDDM53). J Diabetes Investig 2021; 12:374-381. [PMID: 32643314 PMCID: PMC7926254 DOI: 10.1111/jdi.13352] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/30/2020] [Accepted: 07/05/2020] [Indexed: 12/17/2022] Open
Abstract
AIMS/INTRODUCTION Treatment intensification is commonly delayed in people with type 2 diabetes, resulting in poor glycemic control for an unacceptable length of time and increased risk of complications. MATERIALS AND METHODS This retrospective study investigated clinical inertia in 33,320 Japanese adults with type 2 diabetes treated with oral antidiabetic drugs (OADs) between 2009 and 2018, using data from the Computerized Diabetes Care (CoDiC® ) database. RESULTS The median time from first reported glycated hemoglobin (HbA1c) ≥7.0% (≥53 mmol/mol) to treatment intensification was considerably longer and HbA1c levels were higher the more OADs the patient was exposed to. For patients receiving three OADs, the median times from HbA1c ≥7.0% (53 mmol/mol) to intensification with OAD, glucagon-like peptide-1 receptor agonist or insulin were 8.1, 9.1 and 6.7 months, with a mean HbA1c level at the time of intensification of 8.4%, 8.9% and 9.3%, respectively. The cumulative incidence for time since the first reported HbA1c ≥7.0% (≥53 mmol/mol) to intensification confirmed the existence of clinical inertia, identifying patients whose treatment was not intensified despite poor glycemic control. HbA1c levels ≥7.0% (≥53 mmol/mol) after ≥6 months on one, two or three OADs were observed in 42%, 51% and 58% of patients, respectively, showing that approximately 50% of patients are above HbA1c target regardless of how many OADs they take. CONCLUSIONS Real-world data here show clinical inertia in Japanese adults with type 2 diabetes from early diabetes stages when they are receiving OADs, and illustrate a need for earlier, more effective OADs or injectable treatment intensification and better communication around the existence of clinical inertia.
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Affiliation(s)
- Hiroshi Maegawa
- Department of MedicineShiga University of Medical ScienceOtsuJapan
| | - Yasushi Ishigaki
- Department of Internal MedicineIwate Medical UniversityMoriokaJapan
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12
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Ampudia-Blasco FJ, Palanca A, Trillo JL, Navarro J, Real JT. Therapeutic inertia in patients with type 2 diabetes treated with non-insulin agents. J Diabetes Complications 2021; 35:107828. [PMID: 33436143 DOI: 10.1016/j.jdiacomp.2020.107828] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/04/2020] [Accepted: 11/24/2020] [Indexed: 12/21/2022]
Abstract
AIMS To analyze therapeutic inertia in type 2 diabetes (T2D) subjects with suboptimal glycemic control and treated with ≥2 non-insulin antidiabetic agents in a primary care setting. METHODS A retrospective study was conducted using electronic medical records from subjects with HbA1c ≥7.0% (≥53 mmol/mol). Therapeutic inertia was defined as the absence of treatment intensification despite suboptimal glycemic control where intensification should have been implemented (HbA1c ≥7.5% [≥58 mmol/mol]). Time to the first intensification with non-insulin antidiabetic agent or insulin and HbA1c values at the time of intensification were evaluated by competing risk analysis. RESULTS 2652 adults with T2D and HbA1c ≥7.0% (≥53 mmol/mol) were included. During the 4-year follow-up, among 1628 individuals with HbA1c ≥7.5% [≥58 mmol/mol], therapeutic inertia was present in 42.9% of cases. Median time to intensification was 14.5 months (IQR25-75, 4-24 months). In this subgroup, 72.7% of subjects initiated non-insulin agents whereas 27.3% initiated insulin. Mean HbA1c values at initiation of treatment intensification were 8.6% (70 mmol/mol) and 9.2% (77 mmol/mol), respectively. CONCLUSIONS Therapeutic inertia occurred in over 40% of subjects. Treatment intensification took longer and was performed at higher HbA1c than recommended in clinical guidelines. Reducing therapeutic inertia is a priority to achieve therapeutic goals and prevent chronic complications in T2D.
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Affiliation(s)
- F Javier Ampudia-Blasco
- Department of Endocrinology & Nutrition, Clinic University Hospital and INCLIVA, Valencia, Spain; Department of Medicine, Medicine Faculty, University of Valencia (UV), Valencia, Spain; CIBERDEM, CIBER de Diabetes y Enfermedades Metabólicas asociadas, Madrid, Spain
| | - Ana Palanca
- Department of Endocrinology & Nutrition, Clinic University Hospital and INCLIVA, Valencia, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jose Luis Trillo
- Department Clinic-Malvarrosa, Clinic University Hospital and INCLIVA, Valencia, Spain
| | - Jorge Navarro
- Department Clinic-Malvarrosa, Clinic University Hospital and INCLIVA, Valencia, Spain.
| | - Jose T Real
- Department of Endocrinology & Nutrition, Clinic University Hospital and INCLIVA, Valencia, Spain; Department of Medicine, Medicine Faculty, University of Valencia (UV), Valencia, Spain; CIBERDEM, CIBER de Diabetes y Enfermedades Metabólicas asociadas, Madrid, Spain
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13
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Patient Activation as a Pathway to Shared Decision-making for Adults with Diabetes or Cardiovascular Disease. J Gen Intern Med 2020; 35:732-742. [PMID: 31646455 PMCID: PMC7080922 DOI: 10.1007/s11606-019-05351-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 09/11/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Shared decision-making (SDM) is widely recognized as a core strategy to improve patient-centered care. However, the implementation of SDM in routine care settings has been slow and its impact mixed. OBJECTIVE We examine the temporal association of patient activation and patients' experience with the SDM process to assess the dominant directionality of this relationship. DESIGN Patient activation, or a patients' knowledge, skills, and confidence in self-management, was assessed using the 13-item Patient Activation Measure (PAM). Patient-reported assessment of the SDM process was assessed using the 3-item CollaboRATE measure. Patients at 16 adult primary care practices were surveyed in 2015 and 2016 on PAM (α = 0.92), CollaboRATE (α = 0.90), and demographics. The relationship between PAM and CollaboRATE was estimated using a cross-lagged panel model with clustered robust standard errors and practice fixed effects, controlling for patient characteristics. PARTICIPANTS 1222 adult patients with diabetes and/or cardiovascular disease with survey responses at baseline (51% response rate) and a 1-year follow-up (73% response rate). RESULTS PAM (mean 3.27 vs 3.28 on a range of 1 to 4; p = 0.082) and CollaboRATE (mean 3.62 vs 3.63 on a range of 1 to 5; p = 0.14) did not change significantly over time. In adjusted analyses, the path from baseline PAM to follow-up CollaboRATE (β = 0.35; p < 0.0001) was stronger than the path from baseline CollaboRATE to follow-up PAM (β = 0.04; p = 0.001). CONCLUSIONS The relationship between patient activation and patients' experiences of the SDM process is bidirectional, but dominated by baseline patient activation. Rather than promoting the use of SDM for all patients, healthcare organizations should prioritize interventions to promote patient activation and engage patients with relatively high activation in SDM interventions.
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14
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Nogueira M, Otuyama LJ, Rocha PA, Pinto VB. Pharmaceutical care-based interventions in type 2 diabetes mellitus : a systematic review and meta-analysis of randomized clinical trials. EINSTEIN-SAO PAULO 2020; 18:eRW4686. [PMID: 32022107 PMCID: PMC6986882 DOI: 10.31744/einstein_journal/2020rw4686] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 09/02/2019] [Indexed: 12/20/2022] Open
Abstract
Objective To investigate the impact of pharmaceutical care-based interventions on type 2 diabetes mellitus . Methods PubMed®, Cochrane and Web of Science data bases were searched for randomized controlled clinical trials. Studies evaluating pharmaceutical care-based interventions in type 2 diabetes mellitus published between 2012 and 2017 were included. Glycated hemoglobin was defined as the primary endpoint; blood pressure, triglycerides and cholesterol as secondary endpoints. The random effects model was used in meta-analysis. Results Fifteen trials involving 2,325 participants were included. Meta-analysis revealed considerable heterogeneity (I2>97%; p<0.001), reduction in glycated hemoglobin (-1.07%; 95%CI: -1.32; -0.83; p<0.001), glucose (-29.91mg/dL; 95%CI: -43.2; -16.6; p<0.001), triglyceride (19.8mg/dL; 95%CI: -36.6; -3.04; p=0.021), systolic blood pressure (-4.65mmHg; 95%CI: -8.9; -0.4; p=0.032) levels, and increased HDL levels (4.43mg/dL; 95%CI: 0.16; 8.70; p=0.042). Conclusion Pharmaceutical care-based clincal and education interventions have significant impact on type 2 diabetes mellitus . The tools Summary of Diabetes Self-Care Activities and the Morisky Medication Adherence Scale may be useful to monitor patients.
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Affiliation(s)
- Marcel Nogueira
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Leonardo Jun Otuyama
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Priscilla Alves Rocha
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Vanusa Barbosa Pinto
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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15
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Andreozzi F, Candido R, Corrao S, Fornengo R, Giancaterini A, Ponzani P, Ponziani MC, Tuccinardi F, Mannino D. Clinical inertia is the enemy of therapeutic success in the management of diabetes and its complications: a narrative literature review. Diabetol Metab Syndr 2020; 12:52. [PMID: 32565924 PMCID: PMC7301473 DOI: 10.1186/s13098-020-00559-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/08/2020] [Indexed: 12/17/2022] Open
Abstract
Diabetes mellitus is a chronic disease characterized by high social, economic and health burden, mostly due to the high incidence and morbidity of diabetes complications. Numerous studies have shown that optimizing metabolic control may reduce the risk of micro and macrovascular complications related to the disease, and the algorithms suggest that an appropriate and timely step of care intensification should be proposed after 3 months from the failure to achieve metabolic goals. Nonetheless, many population studies show that glycemic control in diabetic patients is often inadequate. The phenomenon of clinical inertia in diabetology, defined as the failure to start a therapy or its intensification/de-intensification when appropriate, has been studied for almost 20 years, and it is not limited to diabetes care, but also affects other specialties. In the present manuscript, we have documented the issue of inertia in its complexity, assessing its dimensions, its epidemiological weight, and its burden over the effectiveness of care. Our main goal is the identification of the causes of clinical inertia in diabetology, and the quantification of its social and health-related consequences through the adoption of appropriate indicators, in an effort to advance possible solutions and proposals to fight and possibly overcome clinical inertia, thus improving health outcomes and quality of care.
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Affiliation(s)
- F. Andreozzi
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Viale Europa, 88100 Catanzaro, Italy
| | - R. Candido
- Diabetes Center District 3, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - S. Corrao
- Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - R. Fornengo
- SSD of Diabetology and Metabolic Diseases, Hospital of Chivasso, Turin, Italy
| | | | - P. Ponzani
- Operative Unit of Diabetology, “La Colletta” Hospital, Genoa, Italy
| | - M. C. Ponziani
- SSD of Diabetology-Azienda Sanitaria Locale Novara, Novara, Italy
| | - F. Tuccinardi
- Diabetology and Endocrinology Unit “Clinica del Sole” Formia, Formia, Italy
| | - D. Mannino
- Section of Endocrinology and Diabetes, Bianchi Melacrino Morelli Hospital, Reggio Calabria, Italy
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Berbudi A, Rahmadika N, Tjahjadi AI, Ruslami R. Performance of Point-of-Care Testing Compared with the Standard Laboratory Diagnostic Test in the Measurement of HbA1c in Indonesian Diabetic and Nondiabetic Subjects. J Diabetes Res 2020; 2020:2037565. [PMID: 32733964 PMCID: PMC7369652 DOI: 10.1155/2020/2037565] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/29/2020] [Accepted: 06/19/2020] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE This study is aimed at investigating if point-of-care testing for HbA1c (POCT-HbA1c) using the HemoCue® HbA1c 501 system could be an alternative method for diabetes screening and monitoring to replace the HbA1c measurement in a standard diagnostic laboratory. DESIGN This was a cross-sectional study to assess the agreement between POCT and a standard laboratory measurement method for determining the level of HbA1c. Setting and Participants. In total, 108 participants were recruited to participate in this study, consisting of 61 diabetics and 47 nondiabetics. The diabetic group comprised 37 females and 24 males, diagnosed with type 2 diabetes mellitus (DM) and undergoing diabetes treatment at several community health care centres in Bandung, West Java. The nondiabetic group consisted of 15 female and 32 male patients of several community health care centres and healthy volunteers. Sample Collection and Analysis. A venous blood sample was taken for routine HbA1c analysis by the diagnostic laboratory method. For the POCT-HbA1c, a blood sample was taken from the fingertip at the same time and analysed with the HemoCue® HbA1c 501 system. Outcome Measures. The HbA1c results of both methods were compared and analysed with a Bland-Altman agreement plot. The sensitivity and specificity of the POCT-HbA1c data were also compared with those of the standard diagnostic results. RESULTS Based on the Bland-Altman plot, the HbA1c level for 100 out of 108 (92.59%) subjects analysed by the POCT-HbA1c was within the range of the 95% limit of agreement. Compared with the standard diagnostic assay, the sensitivity of the POCT-HbA1c was 97.83% and its specificity was 77.42%. CONCLUSIONS The high sensitivity and accuracy of POCT-HbA1c indicate that it is a potential method for diabetes screening and monitoring to replace the routine diagnostic laboratory HbA1c measurement, especially when a rapid result is required.
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Affiliation(s)
- Afiat Berbudi
- Department of Biomedical Sciences, Parasitology Division, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
- Infectious Disease Research Centre, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Nofri Rahmadika
- Infectious Disease Research Centre, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Adi Imam Tjahjadi
- Infectious Disease Research Centre, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
- Department of Biomedical Sciences, Microbiology Division, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Rovina Ruslami
- Infectious Disease Research Centre, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
- Department of Biomedical Sciences, Pharmacology and Therapy Division, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
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Kartoun U, Iglay K, Shankar RR, Beam A, Radican L, Chatterjee A, Pai JK, Shaw S. Factors associated with clinical inertia in type 2 diabetes mellitus patients treated with metformin monotherapy. Curr Med Res Opin 2019; 35:2063-2070. [PMID: 31337263 DOI: 10.1080/03007995.2019.1648116] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Aims: To assess demographic and clinical characteristics associated with clinical inertia in a real-world cohort of type 2 diabetes mellitus patients not at hemoglobin A1c goal (<7%) on metformin monotherapy.Methods: Adult (≥18 years) type 2 diabetes mellitus patients who received care at Massachusetts General Hospital/Brigham and Women's Hospital and received a new metformin prescription between 1992 and 2010 were included in the analysis. Clinical inertia was defined as two consecutive hemoglobin A1c measures ≥7% ≥3 months apart while remaining on metformin monotherapy (i.e. without add-on therapy). The association between clinical inertia and demographic and clinical characteristics was examined via logistic regression.Results: Of 2848 eligible patients, 43% did not achieve a hemoglobin A1c goal of <7% 3 months after metformin monotherapy initiation. A sub-group of 1533 patients was included in the clinical inertia analysis, of which 36% experienced clinical inertia. Asian race was associated with an increased likelihood of clinical inertia (OR = 2.43; 95% CI = 1.48-3.96), while congestive heart failure had a decreased likelihood (OR = 0.58; 95% CI = 0.32-0.98). Chronic kidney disease and cardiovascular/cerebrovascular disease had weaker associations but were directionally similar to congestive heart failure.Conclusions: Asian patients were at an increased risk of clinical inertia, whereas patients with comorbidities appeared to have their treatment more appropriately intensified. A better understanding of these factors may inform efforts to decrease the likelihood for clinical inertia.
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Affiliation(s)
- Uri Kartoun
- Center for Systems Biology, Center for Assessment Technology & Continuous Health (CATCH), Massachusetts General Hospital, Boston, MA, USA
- Faculty of Medicine, Harvard Medical School, Boston, MA, USA
| | | | | | - Andrew Beam
- Faculty of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | | | | | | | - Stanley Shaw
- Center for Systems Biology, Center for Assessment Technology & Continuous Health (CATCH), Massachusetts General Hospital, Boston, MA, USA
- Faculty of Medicine, Harvard Medical School, Boston, MA, USA
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Leiter LA, Cheng AY, Ekoé JM, Goldenberg RM, Harris SB, Hramiak IM, Khunti K, Lin PJ, Richard JF, Senior PA, Yale JF, Goldin L, Tan MK, Langer A. Glycated Hemoglobin Level Goal Achievement in Adults With Type 2 Diabetes in Canada: Still Room for Improvement. Can J Diabetes 2019; 43:384-391. [DOI: 10.1016/j.jcjd.2018.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/13/2018] [Accepted: 10/15/2018] [Indexed: 12/21/2022]
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Molló À, Berenguera A, Rubinat E, Vlacho B, Mata M, Franch J, Bolíbar B, Mauricio D. INTEGRA study protocol: primary care intervention in type 2 diabetes patients with poor glycaemic control. BMC FAMILY PRACTICE 2019; 20:25. [PMID: 30732583 PMCID: PMC6367799 DOI: 10.1186/s12875-019-0916-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 01/29/2019] [Indexed: 11/13/2022]
Abstract
BACKGROUND The management of hyperglycaemia and associated cardiovascular risk factors in patients with type 2 diabetes mellitus (T2DM) may reduce diabetes-related complications. The strategy to broaden the knowledge base of primary care professionals to improve health care has mainly been prompted by the current reality of limited resources and access to specialized care. The main objective of this study is to assess the effectiveness of comprehensive interventions focused on treatment intensification, decrease clinical inertia and reduce possible barriers to treatment adherence in patients with poorly controlled diabetes in a primary care setting. METHODS This is a two-phase mixed method study, whose aims are the development of complex interventions and the assessment of their effectiveness. The main study outcome is a change in glycated haemoglobin (HbA1c) levels. The INTEGRA study is divided into two phases. Phase 1: A qualitative study with a phenomenological approach using semi-structured interviews with the objective of determining the factors related to the participants and health care professionals that influence the development and implementation of a specific intervention strategy aimed at patients with poor glycaemic control of T2DM in primary care. Phase 2: Exploratory intervention study to be conducted in Primary Health Care Centres in Catalonia (Spain), including 3 specific health care areas. The intervention study has two arms: Intervention Group 1 and 2. Each intervention group will recruit 216 participants (the same as in the control group) between the ages of 30 and 80 years with deficient glycaemic control (HbA1c > 9%). The control group will be established based on a randomized selection from the large SIDIAP (Sistema d'Informació per al desenvolupament de la Investigació en Atenció Primària) database of patients with comparable socio-demographic and clinical characteristics from the three provinces. DISCUSSION This study is a comprehensive, pragmatic intervention based on glycaemic treatment intensification and the control of other cardiovascular risk factors. It is also aimed at improving treatment adherence and reducing clinical inertia, which could lead to improved glycaemic control and could likewise be feasible for implementation in the actual clinical practice of primary care. TRIAL REGISTRATION Clinicaltrials.gov . registration number. NCT02663245; January 25, 2016.
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Affiliation(s)
- Àngels Molló
- Centre d’Atenció Primària de Cervera, Lleida, Spain
- Insitut Català de la Salut. Institut Universitari d’Investigació en Atenció Primària Jordi Gol, Grup DAP_CAT.), Barcelona, Spain
- Membre del Grup d’Estudi de la Diabetis en Atenció Primària (GEDAPS) de la Societat Catalana de Medicina Familiar i Comunitària (CAMFIC) i de la RedGDPS, Barcelona, Spain
| | - Anna Berenguera
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol, Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, Spain
| | - Esther Rubinat
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol, Barcelona, Spain
- Serra Húnter fellow - Facultad de Enfermería y Fisioterapia de la Universidad de Lleida, Lleida, Spain
- Grup de Recerca en Cures de la Salut (GRECS) – IRBLleida, Lleida, Spain
- Centro de Investigacion Biomedica en Red de Diabetes y Enfermedades Metabolicas Asociadas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Gran Via Corts Catalanes, 587, àtic, 08007 Barcelona, Spain
| | - Bogdan Vlacho
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol, Gran Via Corts Catalanes, 587, àtic, 08007 Barcelona, Spain
| | - Manel Mata
- Centre d’Atenció Primària La Mina, Barcelona, Spain
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Madrid, Spain
- Institut Català de la Salut, Cerdanyola del Vallès, Spain
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol, Barcelona, Spain
- Membre del Grup d’Estudi de la diabetis en Atenció Primària (GEDAPS) de la Societat Catalana de Medicina Familiar i Comunitària (CAMFIC) i de la RedGDPS, C. Mar, s/n 08930 Sant Adrià de Besòs, Barcelona, Spain
| | - Josep Franch
- Centre d’Atenció Primària Raval Sud, CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Institut Català de la Salut, Institut Universitari d’Investigacióen Atenció Primària Jordi Gol, Av. Drassanes, 17-21 08001 Barcelona, Spain
| | - Bonaventura Bolíbar
- Institut Universitari d’Investigacióen Atenció Primària Jordi Gol, Barcelona, Spain
- Universitat Autònoma de Barcelona, Campus de la UAB, Plaça Cívica, 08193 Bellaterra, Spain
| | - Dídac Mauricio
- Department of Endocrinology & Nutrition, CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Health Sciences Research Institute and University Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol, Gran Via de Les Corts Catalanes, 591 atico, 08007 Barcelona, Spain
- Department of Endocrinology & Nutrition, Hospital de la Santa Creu i Sant Pau, Sant Quinti, 89, 08041 Barcelona, Spain
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Simacek K, Curran C, Fenici P, Garcia-Sanchez R. Patient perceptions of their glycemic control and its influence on type 2 diabetes outcomes: an international survey of online communities. Patient Prefer Adherence 2019; 13:295-307. [PMID: 30863019 PMCID: PMC6388747 DOI: 10.2147/ppa.s186801] [Citation(s) in RCA: 5] [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] [Indexed: 01/15/2023] Open
Abstract
PURPOSE This study aimed to assess awareness of glycated hemoglobin (A1C) testing and targets, perceived level of glycemic control and risk of complications, attitudes toward medications and self-management, and regimen-related distress in an international sample of patients with type 2 diabetes (T2D). METHODS The descriptive study used a single time-point survey of adults in online health communities in the USA, Canada, the UK, Germany, Spain, and Mexico, who self-reported T2D diagnosed by a physician. RESULTS In total, 661 patients participated. Awareness of their A1C value at last test varied considerably between countries (42%-89%), as did awareness of having an A1C target (26%- 70%). Self-reported A1C values were similar across US, Canadian, and European respondents (mean, 6.8%-7.3%). Approximately two-thirds of respondents from these countries (66%-71%) reported that their T2D was very or fairly well controlled, and few (5%-15%) expected to experience serious complications within 1 year. However, many respondents expected to experience microvascular (rather than macrovascular) complications in this time frame (eg, nerve pain, 5%-47%). Self-reported adherence to oral medication was generally high, with most respondents (86%-98%) taking their pills or tablets as directed by their healthcare provider, although for insulin injections adherence was lower in the USA (71%) and Mexico (78%) than in the other countries (86%-95%). The majority of respondents across countries (71%-79%) reported that taking injectable medications was not at all or a little burdensome. Respondents across countries appeared to be reasonably confident that they could adequately manage their blood sugar levels; despite this, a sizeable minority (21%-35%) had clinically significant levels of regimen-related distress. CONCLUSION Limited patient awareness of their A1C value and the potential complications of poorly controlled T2D, particularly regarding cardiovascular complications, may be a widespread problem. Furthermore, greater patient support may be needed to improve self-management of T2D and to reduce regimen-related distress.
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García Díaz E, Ramírez Medina D, Morera Porras ÓM, Cabrera Mateos JL. Determinants of inertia with lipid-lowering treatment in patients with type 2 diabetes mellitus. ACTA ACUST UNITED AC 2018; 66:223-231. [PMID: 30541682 DOI: 10.1016/j.endinu.2018.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/26/2018] [Accepted: 08/29/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To assess the control of cLDL in diabetic patients, to measure the impact on such control of inertia with lipid-lowering agents and to explore factors that allow for predicting this inertia. METHODS Study of historical cohorts of diabetic patients. The proportion of patients who achieved the target cLDL levels was estimated. Therapeutic inertia was considered when the dose of the lipid-lowering agents was not adjusted, or a lipid-lowering agent was not changed or added in patients with initial cLDL outside the target. Change in cLDL from the first to the last visit and inertia with lipid-lowering drugs were analyzed according to comorbidities, cardiovascular risk factors and treatments used. RESULTS The study simple consisted of 639 patients (mean follow-up time 11.1±11.2 months), of whom 27.5% achieved target cLDL levels. Inertia occurred in 43,6% of patients with initial cLDL outside the target. Independent predictors of inertia were the initial cLDL (P<0.001), polyneuropathy (P=0.014), adjustment of antihypertensive agents (P=0.002), adequacy of lipid-lowering agents (P<0.001), use of ezetimibe (P=0.001) and adherence to lipid-lowering drugs (P=0.015). CONCLUSIONS Inertia with lipid-lowering agents in a diabetic patient is less frequent in the presence of higher cLDL values, in cases of polyneuropathy, when antihypertensive agents are adjusted or changed, and when non-adherence is detected. The adequate initial prescription of statins and the association with ezetimibe decrease the likelihood of committing inertia.
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Affiliation(s)
- Eduardo García Díaz
- Unidad de Endocrinología, Hospital Dr. José Molina Orosa, Lanzarote, España.
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Lanzinger S, Schmid SM, Welp R, Zimmermann A, Fasching P, Wagner S, Holl RW. Clinical inertia among patients with type 2 diabetes mellitus treated with DPP-4i and/or SGLT-2i. Diabetes Res Clin Pract 2018; 146:162-171. [PMID: 30367902 DOI: 10.1016/j.diabres.2018.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 10/05/2018] [Accepted: 10/19/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Failure to intensify treatment of patients with type 2 diabetes (T2D) in a timely manner is a common challenge. If newer oral anti-diabetic drugs (NOADs) such as dipeptidyl peptidase-4 inhibitors (DPP-4i) and sodium/glucose cotransporter 2 inhibitors (SGLT-2i) do not achieve metabolic control, injectable therapy like insulin or glucagon-like Peptide 1 (GLP-1) receptor agonists are required. We investigated the time in poor glycaemic control (PC, HbA1c > 7%, >7.5%, >8%) in adults with T2D treated with DPP-4i/SGLT-2i until treatment intensification with insulin/GLP-1 or until the most recent documented visit. METHODS T2D ≥ 18 years were identified from the diabetes patient follow-up registry (DPV), which captures data from diabetes specialist care. Patients with ≥2 documented visits with DPP-4i/SGLT-2i treatment and with the most recent treatment year ≥2015 were included. RESULTS The study population consisted of 4576 patients treated with DPP-4i/SGLT-2i. A subgroup of 1416 patients were intensified with an injectable therapy. Mean time in PC until intensification with insulin/GLP-1 was 16.7 months (HbA1c > 7%), 15.7 and 15.1 months (HbA1c > 7.5%, HbA1c > 8%) in this subgroup, respectively. Mean time in PC until most recent visit was 12.6, 9.9 and 8.4 months in the subgroup of patients without treatment intensification. CONCLUSIONS Even with NOADs, a substantial proportion of T2D do not achieve good metabolic control. These findings may be due to individualized target setting for HbA1c, or reluctance of patients and physicians towards injectable therapy. Effective diabetes management strategies are necessary to reduce the risk of adverse outcomes and to increase quality of life in T2D.
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Affiliation(s)
- S Lanzinger
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany; German Center for Diabetes Research (DZD), München-Neuherberg, Germany.
| | - S M Schmid
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany; Department of Internal Medicine 1, University of Lübeck, Germany
| | - R Welp
- Internal Medicine, Knappschafts-Krankenhaus, Bottrop, Germany
| | - A Zimmermann
- Specialized Diabetes Practice, Bad Aibling, Germany
| | - P Fasching
- 5th Medical Department, Wilhelminenspital, Vienna, Austria
| | - S Wagner
- Medical Clinic II, Donauisar Clinical Center Deggendorf, Germany
| | - R W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany; German Center for Diabetes Research (DZD), München-Neuherberg, Germany
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Jannoo Z, Mamode Khan N. Medication Adherence and Diabetes Self-Care Activities Among Patients With Type 2 Diabetes Mellitus. Value Health Reg Issues 2018; 18:30-35. [PMID: 30419448 DOI: 10.1016/j.vhri.2018.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 05/02/2018] [Accepted: 06/21/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND The prevalence of type 2 diabetes mellitus (T2DM) is increasing at an alarming rate in developing countries. The accompanying complications of T2DM can be reduced by maintaining a good adherence to medication and self-care activities. OBJECTIVES To evaluate medication adherence and self-care behaviors among patients with T2DM. METHODS A total of 497 subjects with T2DM were recruited from three hospitals and a government clinic in the state of Selangor, Malaysia. Previously validated scales were used to measure medication adherence (Morisky Medication Adherence Scale) and diabetes self-care activities (Summary of Diabetes Self-Care Activities). Pearson correlation coefficient was used to investigate the relationship between the risk factors and medication adherence. Pearson χ2 test of association was used to test significant association. RESULTS The mean age of the subjects was 55.5 years. The mean Morisky Medication Adherence Scale score was 5.65 ± 1.97, indicating a moderate adherence level to medication. Among the subjects who had low adherence level, 50.9% were Malays, followed by 34.2% Indians. The Pearson χ2 test of association indicated a significant association (P = 0.000) between ethnicity and medication adherence. The subjects had better self-care behaviors in their general diet (mean 5.04 ± 1.88) and poor self-care behaviors in blood sugar testing (mean 2.13 ± 2.34). CONCLUSIONS The Malaysians had a moderate medication adherence level, whereas they were nonadherent to blood glucose testing. Emphasis on self-care activities and medication adherence is relevant to improve outcomes in the management of T2DM.
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Affiliation(s)
- Zeinab Jannoo
- Department of Economics and Statistics, University of Mauritius, Réduit, Mauritius.
| | - Naushad Mamode Khan
- Department of Economics and Statistics, University of Mauritius, Réduit, Mauritius
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López-Simarro F, Moral I, Aguado-Jodar A, Cols-Sagarra C, Mancera-Romero J, Alonso-Fernández M, Miravet-Jiménez S, Brotons C. Impacto de la inercia terapéutica y del grado de adherencia al tratamiento en los objetivos de control en personas con diabetes. Semergen 2018; 44:579-585. [DOI: 10.1016/j.semerg.2017.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 10/10/2017] [Accepted: 10/18/2017] [Indexed: 11/27/2022]
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Alvarenga MA, Komatsu WR, de Sa JR, Chacra AR, Dib SA. Clinical inertia on insulin treatment intensification in type 2 diabetes mellitus patients of a tertiary public diabetes center with limited pharmacologic armamentarium from an upper-middle income country. Diabetol Metab Syndr 2018; 10:77. [PMID: 30386438 PMCID: PMC6206856 DOI: 10.1186/s13098-018-0382-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 10/25/2018] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Clinical inertia is related to the difficulty of achieving and maintaining optimal glycemic control. It has been extensively studied the delay of the period to insulin introduction in type 2 diabetes mellitus (T2DM) patients. This study aims to evaluate clinical inertia of insulin treatment intensification in a group of T2DM patients followed at a tertiary public Diabetes Center with limited pharmacologic armamentarium (Metformin, Sulphonylurea and Human Insulin). METHODS This is a real life retrospective record based study with T2DM patients. Demographic, clinical and laboratory characteristics were reviewed. Clinical inertia was considered when the patients did not achieve the individualized glycemic goals and there were no changes on insulin daily dose in the period. RESULTS We studied 323 T2DM patients on insulin therapy (plus Metformin and or Sulphonylurea) for a period of 2 years. The insulin daily dose did not change in the period and the glycated hemoglobin (A1c) ranged from 8.8 + 1.8% to 8.7 ± 1.7% (basal vs 1st year; ns) and to 8.5 ± 1.8% (basal vs 2nd year; p = 0.035). The clinical inertia prevalence was 65.8% (basal), 61.9% (after 1 year) and 58.2% (after 2 years; basal vs 1st year vs 2nd year; ns). In a subgroup of 100 patients, we also studied the first 2 years after insulin introduction. The insulin daily dose ranged from 0.22 ± 0.12 to 0.32 ± 0.24 IU/kg of body weight/day (basal vs 1st year; p < 0.001) and to 0.39 ± 0.26 IU/kg of body weight/day (basal vs 2nd year; p < 0.05). The A1c ranged from 9.6 + 2.1% to 8.6 + 2% (basal vs 1st year; p < 0.001) and to 8.7 + 1.7% (1st year vs 2nd year; ns). The clinical inertia prevalence was 78.5% (at the moment of insulin therapy introduction), 56.2% (after 1 year; p = 0.001) and 62.2% (after 2 years; ns). CONCLUSION Clinical inertia prevalence ranged from 56.2 to 78.5% at different moments of the insulin therapy (first 2 years and long term) of T2DM patients followed at a tertiary public Diabetes Center from an upper-middle income country with limited pharmacologic armamentarium.
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Affiliation(s)
- Marcelo Alves Alvarenga
- Department of Medicine, Endocrinology Division, Diabetes Center, UNIFESP (Federal University of São Paulo), Rua Estado de Israel, 639 Vila Clementino, São Paulo, SP CEP 04022-001 Brazil
| | - William Ricardo Komatsu
- Department of Medicine, Endocrinology Division, Diabetes Center, UNIFESP (Federal University of São Paulo), Rua Estado de Israel, 639 Vila Clementino, São Paulo, SP CEP 04022-001 Brazil
| | - Joao Roberto de Sa
- Department of Medicine, Endocrinology Division, Diabetes Center, UNIFESP (Federal University of São Paulo), Rua Estado de Israel, 639 Vila Clementino, São Paulo, SP CEP 04022-001 Brazil
| | - Antonio Roberto Chacra
- Department of Medicine, Endocrinology Division, Diabetes Center, UNIFESP (Federal University of São Paulo), Rua Estado de Israel, 639 Vila Clementino, São Paulo, SP CEP 04022-001 Brazil
| | - Sergio Atala Dib
- Department of Medicine, Endocrinology Division, Diabetes Center, UNIFESP (Federal University of São Paulo), Rua Estado de Israel, 639 Vila Clementino, São Paulo, SP CEP 04022-001 Brazil
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Desai U, Kirson NY, Kim J, Khunti K, King S, Trieschman E, Hellstern M, Hunt PR, Mukherjee J. Time to Treatment Intensification After Monotherapy Failure and Its Association With Subsequent Glycemic Control Among 93,515 Patients With Type 2 Diabetes. Diabetes Care 2018; 41:2096-2104. [PMID: 30131396 DOI: 10.2337/dc17-0662] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 07/13/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The goal of this study was to evaluate the association between the timing of treatment intensification and subsequent glycemic control among patients with type 2 diabetes in whom monotherapy fails. RESEARCH DESIGN AND METHODS This retrospective analysis of the U.K. Clinical Practice Research Datalink database focused on patients with type 2 diabetes and one or more HbA1c measurements ≥7% (≥53 mmol/mol) after ≥3 months of metformin or sulfonylurea monotherapy (first measurement meeting these criteria was taken as the study index date). Baseline (6 months before the index date) characteristics were stratified by time from the index date to intensification (early: <12 months; intermediate: 12 to <24 months; late: 24 to <36 months). Intensification was defined as initiating after the index date one or more noninsulin antidiabetes medication in addition to metformin or a sulfonylurea. Association between time to intensification and subsequent glycemic control (first HbA1c <7% [<53 mmol/mol] after intensification) was evaluated using Kaplan-Meier analyses and Cox proportional hazard models that accounted for baseline differences. RESULTS Of the 93,515 patients who met the study criteria (mean age 60 years; ∼59% male; 80% taking metformin), 23,761 (25%) intensified <12 months after the index date; 11,908 (13%) intensified after 12 to <24 months; and 7,146 (8%) intensified after 24 to <36 months. Patients who intensified treatment ≥36 months after the index date (n = 9,638 [10%]) and those with no evidence of treatment intensification during the observable follow-up period (n = 41,062 [44%]) were not included in further analyses. The median times from intensification to control were 20.0, 24.1, and 25.7 months, respectively, for the early, intermediate, and late intensification cohorts. After adjustment for baseline differences, the likelihood of attaining glycemic control was 22% and 28% lower for patients in the intermediate and late intensification groups, respectively, compared with those intensifying early (P < 0.0001). CONCLUSIONS Earlier treatment intensification is associated with shorter time to subsequent glycemic control, independent of whether patients initiate first-line treatment with metformin or a sulfonylurea.
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Affiliation(s)
| | | | | | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, U.K
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Nichols GA, Raebel MA, Dyer W, Schmittdiel JA. The Effect of Age and Comorbidities on the Association Between the Medicare STAR Oral Antihyperglycemic Adherence Metric and Glycemic Control. J Manag Care Spec Pharm 2018; 24:856-861. [PMID: 30156449 PMCID: PMC10398005 DOI: 10.18553/jmcp.2018.24.9.856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The Medicare STAR program for Medicare Advantage Plans that include drug benefits provides monetary incentives for health plans to achieve good adherence to oral antihyperglycemic (OAH) agents but does not account for differential case mix that could affect the ability of health plans to achieve the required quality metrics. OBJECTIVE To determine whether OAH adherence varies by age and comorbidities among patients aged 65 years or older and the extent to which adherence affects glycemic control across age and comorbidity strata. METHODS We studied 54,480 patients with diabetes aged > 65 years from the Colorado, Northwest, and Northern California regions of Kaiser Permanente who received OAH agents but not insulin in 2010. We calculated adherence using the proportion of days covered (PDC) method. Per the STAR program, hemoglobin A1c < 8% defined good glycemic control. We also defined poor control as A1c > 9%. We used modified Poisson regression to identify predictors of adherence and to determine its effects on A1c across age and comorbidity strata, adjusting for sociodemographics and medication-related variables. RESULTS The risk of being adherent to OAH declined moderately with an increasing number of comorbidities (risk ratio [RR] = 0.99, 95% CI = 0.98-1.00 for 1 comorbidity and RR = 0.90, 95% CI = 0.88-0.91 for 4 or more comorbidities). Adherence to OAH agents was associated with a 0%-3% increased risk of A1c < 8% across age and comorbidity categories, as well as a large decreased risk (RR = 0.55-0.73) of A1c > 9% for patients aged < 80 years or with < 3 comorbidities. CONCLUSIONS Among patients with diabetes aged > 65 years, having multiple comorbidities affects adherence. Adherence reduces the risk of poor A1c control among patients aged 65-79 years or with 2 or fewer comorbidities. Our results suggest that health plan case mix minimally influenced the Medicare STAR OAH adherence metric, but it may affect glycemic control quality measures, especially if a HEDIS-like measure of poor control were adopted. DISCLOSURES This study was supported by grant number 1R21DK103146-01A1 from the National Institute of Diabetes and Digestive and Kidney Disorders. Nichols currently receives grant funding from Boehringer-Ingelheim, Sanofi, Amarin Pharma, and Janssen Pharmaceuticals for other unrelated research projects. The other authors declare no conflicts of interest. This study was presented at the American Diabetes Association's 77th Scientific Sessions; June 9-13, 2017; San Diego, CA.
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Affiliation(s)
- Gregory A Nichols
- 1 Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Marsha A Raebel
- 2 Kaiser Permanente Colorado Institute for Health Research, Denver
| | - Wendy Dyer
- 3 Kaiser Permanente Northern California Division of Research, Oakland
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Gilstrap LG, Mehrotra A, Bai B, Rose S, Blair RA, Chernew ME. National Rates of Initiation and Intensification of Antidiabetic Therapy Among Patients With Commercial Insurance. Diabetes Care 2018; 41:1776-1782. [PMID: 29794151 PMCID: PMC8742144 DOI: 10.2337/dc17-2585] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 04/23/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Prompt initiation and intensification of antidiabetic therapy can delay or prevent complications from diabetes. We sought to understand the rates of and factors associated with the initiation and intensification of antidiabetic therapy among commercially insured patients in the U.S. RESEARCH DESIGN AND METHODS Using 2008-2015 commercial claims linked with laboratory and pharmacy data, we created an initiation cohort with no prior antidiabetic drug use and an HbA1c ≥8% (64 mmol/mol) and an intensification cohort of patients with an HbA1c ≥8% (64 mmol/mol) who were on a stable dose of one noninsulin diabetes drug. Using multivariable logistic regression, we determined the rates of and factors associated with initiation and intensification. In addition, we determined the percent of variation in treatment patterns explained by measurable patient factors. RESULTS In the initiation cohort (n = 9,799), 63% of patients received an antidiabetic drug within 6 months of the elevated HbA1c test. In the intensification cohort (n = 10,941), 82% had their existing antidiabetic therapy intensified within 6 months of the elevated HbA1c test. Higher HbA1c levels, lower generic drug copayments, and more frequent office visits were associated with higher rates of both initiation and intensification. Better patient adherence prior to the elevated HbA1c level, existing therapy with a second-generation antidiabetic drug, and lower doses of existing therapy were also associated with intensification. Patient factors explained 7.96% of the variation in initiation and 7.35% of the variation in intensification. CONCLUSIONS Approximately two-thirds of patients were newly initiated on antidiabetic therapy, and four-fifths of those already receiving antidiabetic therapy had it intensified within 6 months of an elevated HbA1c in a commercially insured population. Patient factors explain 7-8% of the variation in diabetes treatment patterns.
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Affiliation(s)
- Lauren G Gilstrap
- Department of Health Care Policy, Harvard Medical School, Boston, MA .,Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, MA.,Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Barbara Bai
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Sherri Rose
- Department of Health Care Policy, Harvard Medical School, Boston, MA
| | - Rachel A Blair
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, MA
| | - Michael E Chernew
- Department of Health Care Policy, Harvard Medical School, Boston, MA
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Arnold RJG, Yang S, Gold EJ, Farahbakhshian S, Sheehan JJ. Assessment of the relationship between diabetes treatment intensification and quality measure performance using electronic medical records. PLoS One 2018; 13:e0199011. [PMID: 29894495 PMCID: PMC5997332 DOI: 10.1371/journal.pone.0199011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 05/30/2018] [Indexed: 11/19/2022] Open
Abstract
AIMS Assess the relationship between timely treatment intensification and hemoglobin A1C (HbA1C) control quality-of-care performance measures, i.e., HbA1C levels, among patients with uncontrolled type 2 diabetes. MATERIALS AND METHODS Electronic medical records and diabetes registry data from a large, accountable care organization (ACO) were used to isolate a sample of adult patients with type 2 diabetes who received at least one oral antidiabetes agent and had at least one HbA1C level measurement ≥8.0% (64 mmol/mol; i.e., uncontrolled diabetes) between 7/1/2011 and 6/30/2015. Treatment intensification status was evaluated for each patient during a 120-day treatment intensification window following the index HbA1c measure. Two-level hierarchical generalized linear models, with patients aggregated at the physician level, were used to assess the association between treatment intensification and achieving HbA1C quality performance measures. RESULTS 547 patients met study selection criteria and 480 patients had at least one HbA1C test after the treatment intensification window and were used for the statistical analyses. About 40% of patients who had uncontrolled diabetes received treatment intensification during the 120-day window. Greater index HbA1C, greater patient body mass index, and fewer unique pre-index oral antidiabetes agents were significantly associated with greater likelihood of receiving timely treatment intensification. The odds of receiving treatment intensification were about 1.8 times higher (P = 0.0027) among patients with poor index HbA1C control (HbA1c level >9.0% [75 mmol/mol]) compared to other patients (index HbA1c 8.0% - 9.0%). Hispanic patients (compared to White patients) were significantly more likely to exhibit poor control after treatment intensification (odds ratio [OR] 2.91, P = 0.0304), underscoring the difficulty of controlling diabetes in this vulnerable group. In contrast, being male and being treated primarily by an internist (compared to primary treatment by a family medicine specialist) were both significantly associated with achieving superior control (HbA1c level <8.0%) after treatment intensification (OR 0.53 [P = 0.0165]; OR 0.41 [P = 0.0275], respectively). CONCLUSIONS Timely treatment intensification was significantly associated with greater likelihood of patients achieving superior HbA1C control (<8.0%) and better HbA1C control quality performance for the practice. Even in an ACO with resources dedicated to diabetes control, it is incumbent upon clinicians to readily identify and open dialogues with patients who may benefit from closely supervised, individualized attention.
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Affiliation(s)
- Renée J. G. Arnold
- Quorum Consulting, Inc., New York, New York, United States of America
- Icahn School of Medicine at Mount Sinai, New York City, New York, United States of America
| | - Shuo Yang
- Quorum Consulting, Inc., New York, New York, United States of America
| | - Edward J. Gold
- Old Hook Medical Associates, Emerson, New Jersey, United States of America
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Milman T, Joundi RA, Alotaibi NM, Saposnik G. Clinical inertia in the pharmacological management of hypertension: A systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e11121. [PMID: 29924011 PMCID: PMC6025046 DOI: 10.1097/md.0000000000011121] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Clinical Inertia is defined as "failure of health care providers to initiate or intensify therapy according to current guidelines". This phenomenon is gaining increasing attention as a major cause of clinicians' failure to adequately manage hypertension, thus leading to an increased incidence of cardiovascular events. We performed a systematic review and meta-analysis of randomized controlled trials to determine whether interventions aimed at reducing clinical inertia in the pharmacological treatment of hypertension improve blood pressure (BP) control. METHODS MEDLINE, Embase, and Cochrane Database of Systematic Reviews were searched from the start of their database until October 3, 2017 for the MESH terms "Hypertension" or "Blood Pressure", their subheadings, and the keywords "Therapeutic Inertia" or "Clinical Inertia". Studies were included if they addressed pharmacologic hypertension management, clinical inertia, were randomized controlled trials, reported an outcome describing prescriber behavior, and were available in English. Data for the included studies was extracted by two independent observers. Quality of studies was analyzed using the Cochrane Risk of Bias Assessment. Data was pooled for statistical analysis using both fixed- and random-effects models. The primary study outcome was the percentage of patients achieving blood pressure control as defined by the Joint National Committee guidelines or study authors. RESULTS Of 474 citations identified, ten met inclusion criteria comprising a total of 26,871 patients, and eight were selected for meta-analysis. Interventions included Physician Education, Physician Reminders, Patient Education, Patient Reminders, Ambulatory BP Monitoring, Digital Medication Offerings, Physician Peer Visits, and Pharmacist-led Counselling. Pooled event rates revealed more patients with controlled BP in the intervention group versus control (55%, 95% CI 46-63% versus 45%, 95% CI 37-53%) and interventions significantly improved the odds of BP control (OR = 1.19, 95% CI = 1.12-1.27, P < .001). Heterogeneity in the quantitative analysis was moderate. CONCLUSIONS & RELEVANCE Addressing clinical inertia through physician reminders, ambulatory BP monitoring, and educational interventions for primary care providers was associated with an improvement in blood pressure control. Our findings encourage further research to investigate strategies at reducing clinical inertia in the management of hypertension.
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Affiliation(s)
- Tal Milman
- Faculty of Medicine Division of Neurology, Department of Medicine Division of Neurosurgery, Department of Surgery St. Michael's Hospital Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada
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Germain N, Khalfallah Y, Estour B, Galusca B. Insulin tolerance test predicts non response vs. sustained efficacy of Liraglutide on glycemic control in type 2 diabetes patients: A prospective real-world setting study. Diabetes Res Clin Pract 2018; 137:20-27. [PMID: 29253625 DOI: 10.1016/j.diabres.2017.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 11/29/2017] [Accepted: 12/12/2017] [Indexed: 12/22/2022]
Abstract
AIMS Less than half of type 2 diabetes patients treated with Glucagon-Like Peptide 1 (GLP-1) analogs displays good glycemic control, according to real life studies. Predictive markers of inefficacy/efficacy are therefore needed. The effectiveness of Liraglutide in terms of glycemic control and weight loss was then evaluated according to putative predictive parameters. METHODS 80 type 2 diabetes patients treated with Liraglutide were included in this prospective study. An Insulin Tolerance test (ITT) was performed at baseline to calculate velocity of C-Peptide decrease (C-peptide T½). Several clinical and biological parameters including HbA1c and weight were assessed at baseline and after 12, 24, 52 and 104 weeks of treatment. RESULTS HbA1c decrease over the follow-up period was highly associated with C-peptide T½. A mean fall of 0.7% of HbA1c (7.7 mmol/mol) was predicted with 82% sensitivity and 80% specificity by C-peptide T½. In patients with rapid response during ITT (C-peptide T½ < 120 min), a HbA1c decrease of 1.5% (16.5 mmol/mol) was constantly found (p = .002) all over the follow-up. HbA1c remained unmodified for the rest of the patients (p = .34) compared to baseline. HbA1c evolution was not predicted by diabetes duration. Weight loss was predicted only by low baseline C-peptide plasma level. CONCLUSIONS This study suggests ITT as an efficient test to discriminate non-response from long-term efficacy before initiating Liraglutide. ITT could therefore help avoiding "try and see" prescription pattern by using a more precise and patient-centered strategy in order to reduce inertia in adapting treatment and so reduce subsequent complications.
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Affiliation(s)
- Natacha Germain
- Department of Endocrinology, Diabetes and Metabolism, University Hospital of Saint-Etienne, Saint-Etienne, France; EA 7423 TAPE Research Team, Jean Monnet University of Saint-Etienne, France.
| | - Yadh Khalfallah
- Department of Endocrinology, Diabetes and Metabolism, University Hospital of Saint-Etienne, Saint-Etienne, France
| | - Bruno Estour
- Department of Endocrinology, Diabetes and Metabolism, University Hospital of Saint-Etienne, Saint-Etienne, France; EA 7423 TAPE Research Team, Jean Monnet University of Saint-Etienne, France
| | - Bogdan Galusca
- Department of Endocrinology, Diabetes and Metabolism, University Hospital of Saint-Etienne, Saint-Etienne, France; EA 7423 TAPE Research Team, Jean Monnet University of Saint-Etienne, France
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Saad AMJ, Younes ZMH, Ahmed H, Brown JA, Al Owesie RM, Hassoun AAK. Self-efficacy, self-care and glycemic control in Saudi Arabian patients with type 2 diabetes mellitus: A cross-sectional survey. Diabetes Res Clin Pract 2018; 137:28-36. [PMID: 29278711 DOI: 10.1016/j.diabres.2017.12.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 11/20/2017] [Accepted: 12/18/2017] [Indexed: 10/18/2022]
Abstract
AIMS To determine the prevalence of diabetes self-care activities among type 2 diabetes patients and examine the association between socio-demographic and clinical parameters, diabetes self-care activities, and glycemic control among type 2 diabetes patients. METHODS A cross sectional study was conducted among patients with diabetes (n = 123) at the Sultan Bin Abdulaziz Humanitarian City (SBAHC). A regression model was used to examine the variables that predicted glycemic control. Moreover, a regression analysis examining the effect of each self-efficacy subscale on its respective diabetes self -management (DSM) behavior was carried out. RESULTS The most frequently reported DSM behaviors were foot care followed by medication taking self-management behavior. The least frequently reported DSM behaviors were exercise self-management behavior and blood sugar testing behavior. Self-efficacy was associated with higher levels of diet, exercise, blood sugar testing, and medication taking self-management behaviors. Diet self-management behaviors and oral hypoglycemic agents (OHA) use were significantly independent predictors of glycemic control HbA1c <7% (53 mmol/mol). CONCLUSIONS The findings can serve to help clinicians have a better understanding on the extent to which different self-efficacy parameters have an influence on self-management behaviors, which will in turn lead to better glycemic control and thus improved HbA1c levels.
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Affiliation(s)
- Ahmad M J Saad
- Dubai Diabetes Center, Dubai Health Authority, Block C, Al Hudaiba Awards Building, P.O. Box 215252, Dubai, United Arab Emirates.
| | - Zeina M H Younes
- Dubai Diabetes Center, Dubai Health Authority, Block C, Al Hudaiba Awards Building, P.O. Box 215252, Dubai, United Arab Emirates
| | - Hafez Ahmed
- Dubai Medical College, Al Muhaisanah 1, Al Mizhar, P.O. Box 20170, Dubai, United Arab Emirates
| | - Jason A Brown
- Sultan Bin AbdulAziz Humanitarian City, Bahban, Riyadh 13567, Saudi Arabia
| | - Rafat M Al Owesie
- Sultan Bin AbdulAziz Humanitarian City, Bahban, Riyadh 13567, Saudi Arabia
| | - Ahmed A K Hassoun
- Dubai Diabetes Center, Dubai Health Authority, Block C, Al Hudaiba Awards Building, P.O. Box 215252, Dubai, United Arab Emirates
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Seidu S, Than T, Kar D, Lamba A, Brown P, Zafar A, Hussain R, Amjad A, Capehorn M, Martin E, Fernando K, McMoran J, Millar-Jones D, Kahn S, Campbell N, Brice R, Mohan R, Mistry M, Kanumilli N, St John J, Quigley R, Kenny C, Khunti K. Therapeutic inertia amongst general practitioners with interest in diabetes. Prim Care Diabetes 2018; 12:87-91. [PMID: 28993141 DOI: 10.1016/j.pcd.2017.09.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 08/29/2017] [Accepted: 09/06/2017] [Indexed: 11/21/2022]
Abstract
INTRODUCTION As the therapeutic options in the management of type 2 diabetes increase, there is an increase confusion among health care professionals, thus leading to the phenomenon of therapeutic inertia. This is the failure to escalate or de-escalate treatment when the clinical need for this is required. It has been studied extensively in various settings, however, it has never been reported in any studies focusing solely on primary care physicians with an interest in diabetes. This group is increasingly becoming the focus of managing complex diabetes care in the community, albeit with the support from specialists. METHODS In this retrospective audit, we assessed the prevalence of the phenomenon of therapeutic inertia amongst primary care physicians with an interest in diabetes in UK. We also assessed the predictive abilities of various patient level characteristics on therapeutic inertia amongst this group of clinicians. RESULTS Out of the 240 patients reported on, therapeutic inertia was judged to have occurred in 53 (22.1%) of patients. The full model containing all the selected variables was not statistically significant, p=0.59. So the model was not able to distinguish between situations in which therapeutic inertia occurred and when it did not occur. None of the patient level characteristics on its own was predictive of therapeutic inertia. CONCLUSION Therapeutic inertia was present only in about a fifth of patient patients with diabetes being managed by primary care physicians with an interest in diabetes.
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Affiliation(s)
- Samuel Seidu
- Diabetes Research Centre, Gwendolen Road, Leicester General Hospital, Leicester LE5 4WP, United Kingdom.
| | - Tun Than
- Diabetes Research Centre, Gwendolen Road, Leicester General Hospital, Leicester LE5 4WP, United Kingdom
| | - Deb Kar
- Diabetes Research Centre, Gwendolen Road, Leicester General Hospital, Leicester LE5 4WP, United Kingdom
| | - Amrit Lamba
- Colindale Medical Centre, 61 Colindeep Lane, Colindale, London, NW9 6DJ, United Kingdom
| | - Pam Brown
- Kings Road Surgery, Mumbles, Swansea, United Kingdom
| | - Azhar Zafar
- Diabetes Research Centre, Gwendolen Road, Leicester General Hospital, Leicester LE5 4WP, United Kingdom
| | | | - Ahmed Amjad
- Cheetham Hill Primary Care Centre, 244 Cheetham Hill Road, Manchester, Greater Manchester, M8 8UP, United Kingdom
| | | | - Elizabeth Martin
- Diabetes Department, St. James Teaching Hospital, United Kingdom
| | - Kevin Fernando
- North Berwick Health Centre, North Berwick Group Practice, 54 St. Baldred's Road, North Berwick, EH39 4PU, United Kingdom
| | - Jim McMoran
- The Community Diabetes and Cardiovascular Risk Clinic service is based on the first floor Spires Suite of City of Coventry Health Centre, 2 Stoney Stanton Road, Coventry CV1 4FS, United Kingdom
| | | | - Shahzada Kahn
- Vicarage Lane Health Centre, 10 Vicarage Lane, Stratford, London, Greater London, E15 4ES, United Kingdom
| | - Nigel Campbell
- Lisburn Health Centre, Linenhall Street, Lisburn, BT28 1LU, United Kingdom
| | - Richard Brice
- Estuary View Medical Centre, Boorman Way, Whitstable, CT5 3SE, United Kingdom
| | - Rahul Mohan
- Church House Surgery, Shaw Street, NG11 6HF Ruddington, United Kingdom
| | - Mukesh Mistry
- The Community Diabetes and Cardiovascular Risk Clinic service is based on the first floor Spires Suite of City of Coventry Health Centre, 2 Stoney Stanton Road, Coventry CV1 4FS, United Kingdom
| | | | - Joan St John
- Law Medical Group Practice, Wembley and Willesden, United Kingdom
| | - Richard Quigley
- Thornliebank Health Centre, 20 Kennishead Road, Glasgow, G46 8NY, United Kingdom
| | | | - Kamlesh Khunti
- Diabetes Research Centre, Gwendolen Road, Leicester General Hospital, Leicester LE5 4WP, United Kingdom
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Khunti K, Gomes MB, Pocock S, Shestakova MV, Pintat S, Fenici P, Hammar N, Medina J. Therapeutic inertia in the treatment of hyperglycaemia in patients with type 2 diabetes: A systematic review. Diabetes Obes Metab 2018; 20:427-437. [PMID: 28834075 PMCID: PMC5813232 DOI: 10.1111/dom.13088] [Citation(s) in RCA: 215] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/08/2017] [Accepted: 08/15/2017] [Indexed: 12/28/2022]
Abstract
AIMS Therapeutic inertia, defined as the failure to initiate or intensify therapy in a timely manner according to evidence-based clinical guidelines, is a key reason for uncontrolled hyperglycaemia in patients with type 2 diabetes. The aims of this systematic review were to identify how therapeutic inertia in the management of hyperglycaemia was measured and to assess its extent over the past decade. MATERIALS AND METHODS Systematic searches for articles published from January 1, 2004 to August 1, 2016 were conducted in MEDLINE and Embase. Two researchers independently screened all of the titles and abstracts, and the full texts of publications deemed relevant. Data were extracted by a single researcher using a standardized data extraction form. RESULTS The final selection for the review included 53 articles. Measurements used to assess therapeutic inertia varied across studies, making comparisons difficult. Data from low- to middle-income countries were scarce. In most studies, the median time to treatment intensification after a glycated haemoglobin (HbA1c) measurement above target was more than 1 year (range 0.3 to >7.2 years). Therapeutic inertia increased as the number of antidiabetic drugs rose and decreased with increasing HbA1c levels. Data were mainly available from Western countries. Diversity of inertia measures precluded meta-analysis. CONCLUSIONS Therapeutic inertia in the management of hyperglycaemia in patients with type 2 diabetes is a major concern. This is well documented in Western countries, but corresponding data are urgently needed in low- and middle-income countries, in view of their high prevalence of type 2 diabetes.
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Affiliation(s)
| | | | - Stuart Pocock
- London School of Hygiene and Tropical MedicineLondonUK
| | - Marina V. Shestakova
- Endocrinology Research CenterMoscowRussian Federation
- I.M. Sechenov First Moscow State Medical UniversityMoscowRussian Federation
| | | | | | - Niklas Hammar
- AstraZenecaMölndalSweden
- Institute of Environmental Medicine, Karolinska InstituteStockholmSweden
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Abughosh S, Wang X, Serna O, Esse T, Mann A, Masilamani S, Holstad MM, Essien EJ, Fleming M. A Motivational Interviewing Intervention by Pharmacy Students to Improve Medication Adherence. J Manag Care Spec Pharm 2018; 23:549-560. [PMID: 28448784 PMCID: PMC10398180 DOI: 10.18553/jmcp.2017.23.5.549] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Diabetes mellitus (DM) patients with comorbid hypertension (HTN) are at a higher risk of developing microvascular and macrovascular DM complications. Through guideline-driven recommendations, angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are highly recommended for these patients. Unfortunately, medication adherence to these products, though crucial to achieving therapeutic benefit, is frequently suboptimal. Motivational interviewing (MI) is a patient-centered collaborative communication style that is used to strengthen internal motivation for change that may prove effective in enhancing adherence. OBJECTIVE To examine the effect of an MI telephone intervention conducted by pharmacy students in improving adherence to ACEIs/ARBs among Medicare Advantage Plan (MAP) patients with both DM and HTN. METHODS A prospective study was conducted among patients enrolled in a Texas MAP. Medical claims data were used to identify patients with DM and HTN, and pharmacy claims were observed to recognize those who filled either an ACEI or an ARB during June 2014. Patients with a 6-month proportion of days covered (PDC) < 0.80 in the previous 6 months were determined nonadherent, and 75% of those were randomly selected to serve as potential subjects for the intervention, while 25% were randomly selected to serve as potential subjects for the control group. The intervention was a telephone call by a pharmacy student on rotation at the health plan, and 5 monthly follow-up calls. Before implementing calls, participating students attended a 3-day MI training course, where their proficiency for MI skills was evaluated. Refill data during the 6-month postintervention were evaluated to examine the intervention effect measured on 3 outcomes: PDC; PDC ≥ 0.80 versus < 0.80; and discontinuation versus continuation. Multivariate linear and logistic regression models were constructed to adjust for any imbalances in baseline characteristics, including age, gender, number of other medications, regimen complexity, health low-income subsidy status, prescriber specialty, comorbidities, 6-month previous hospitalization, baseline 6-month PDC, and Centers for Medicare & Medicaid Services risk score. RESULTS A total of 11 students participated in the intervention implementation. Patients receiving calls were randomly selected from those potential subjects for the intervention arm until a target of 250 was reached; 500 controls were randomly selected from the potential subjects for the control arm. The final cohort included in multivariate models consisted of 743 patients. Patients completing the initial call and at least 2 follow-ups were less likely to discontinue (OR = 0.29; 95% CI = 0.15-0.54; P < 0.001) and more likely to be adherent in the linear regression model (β = 0.0604, P < 0.001) and the logistic regression model (OR = 1.53; 95% CI = 1.02-2.28; P = 0.009). Other factors significantly associated with better adherence included higher baseline PDC and number of medications. Depression status was significantly associated with lower adherence. CONCLUSIONS Patients receiving 2 or more calls had significantly better adherence and less discontinuation during the 6 months following initial calls compared with those who did not receive calls. This finding indicates that an MI-based telephone intervention by pharmacy students may be a promising intervention to improve adherence. Future research should examine the sustainability of the intervention effect for longer time periods and its influence on associated clinical outcomes. DISCLOSURES This project was supported by the Pharmaceutical Research and Manufacturers of America Foundation (PhRMA). The content is solely the responsibility of the authors and does not necessarily represent the official views of PhRMA. The funding agency was not involved in research design, analysis, or reporting results. Funding was obtained by Abughosh. Holstad provided a consultation regarding the MI guide and provided the MI training. Study concept and design were contributed by Abughosh and Fleming, along with Serna, Esse, and Holstad. Serna, Esse, Mann, Holstad, and Masilamani collected the data, and data interpretation was performed by Abughosh, Wong, and Esse. The manuscript was written by Abughosh, Wong, and Esse and revised by Masilamani and Holstad, along with the other authors.
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Affiliation(s)
- Susan Abughosh
- 1 Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, Texas
| | - Xin Wang
- 1 Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, Texas
| | | | - Tara Esse
- 2 Cigna-HealthSpring, Houston, Texas
| | | | - Santhi Masilamani
- 3 Nell Hodgson Woodruff School of Nursing and Clinical and Social Science Integration, Emory Center for AIDS Research, Emory University, Atlanta, Georgia
| | - Marcia McDonnell Holstad
- 3 Nell Hodgson Woodruff School of Nursing and Clinical and Social Science Integration, Emory Center for AIDS Research, Emory University, Atlanta, Georgia
| | - Ekere James Essien
- 1 Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, Texas
| | - Marc Fleming
- 1 Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, Texas
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Gordon J, McEwan P, Idris I, Evans M, Puelles J. Treatment choice, medication adherence and glycemic efficacy in people with type 2 diabetes: a UK clinical practice database study. BMJ Open Diabetes Res Care 2018; 6:e000512. [PMID: 29755756 PMCID: PMC5942418 DOI: 10.1136/bmjdrc-2018-000512] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 03/07/2018] [Accepted: 04/12/2018] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE Using primary care data obtained from the UK Clinical Practice Research Datalink, this retrospective cohort study examined the relationships between medication adherence and clinical outcomes in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS Data were extracted for patients treated between 2008 and 2016, and stratified by oral antihyperglycemic agent (OHA) line of therapy (mono, dual or triple therapy). Patients were monitored for up to 365 days; associations between medication possession ratio (MPR) and outcomes at 1 year (glycated hemoglobin A1c (HbA1c), weight and hypoglycemia incidence) were assessed using linear regression modeling and descriptive analyses. RESULTS In total, 33 849 patients were included in the study (n=23 925 OHA monotherapy; n=8406 OHA dual therapy; n=1518 OHA triple therapy). One-year change in HbA1c was greater among adherent (-0.90 to -1.14%; -9.8 to -12.5 mmol/mol) compared with non-adherent patients (-0.49 to -0.69%; -5.4 to -7.5 mmol/mol). On average, adherent patients had higher hypoglycemia event rates than non-adherent patients (rate ratios of 1.24, 1.10 and 2.06 for OHA mono, dual and triple therapy cohorts, respectively) and experienced greater weight change from baseline. A 10% improvement in MPR was associated with -0.09% (-1.0 mmol/mol), -0.09% (-1.0 mmol/mol) and -0.21% (-2.3 mmol/mol) changes in HbA1c for OHA mono, dual and triple therapy cohorts, respectively. CONCLUSIONS For patients with type 2 diabetes, increasing medication adherence can bring about meaningful improvements in HbA1c control as the requirement for treatment escalation increases. Regimens associated with weight loss and the avoidance of hypoglycemia were generally associated with better medication adherence and improved glycemic control.
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Affiliation(s)
- Jason Gordon
- Health Economics & Outcomes Research Ltd, Cardiff, UK
- School of Medicine, University of Nottingham, Nottingham, UK
- Department of Public Health, University of Adelaide, Adelaide, Australia
| | - Phil McEwan
- Health Economics & Outcomes Research Ltd, Cardiff, UK
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Iskandar Idris
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Marc Evans
- Diabetes Resource Centre, Llandough Hospital, Cardiff, UK
| | - Jorge Puelles
- Global Outcomes Research, Takeda Development Centre Europe Ltd, London, UK
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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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Ratner NL, Davis EB, Lhotka LL, Wille SM, Walls ML. Patient-Centered Care, Diabetes Empowerment, and Type 2 Diabetes Medication Adherence Among American Indian Patients. Clin Diabetes 2017; 35:281-285. [PMID: 29263570 PMCID: PMC5734175 DOI: 10.2337/cd17-0008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
IN BRIEF Type 2 diabetes has been labeled an epidemic in many American Indian communities. Thus, identifying factors that improve medication adherence for American Indian patients is crucial. We found significant and positive relationships among patient-centered care, medication adherence, and diabetes empowerment. In addition, diabetes empowerment partially mediated the relationship between patient-centered care and medication adherence.
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Santos LL, Lima FJCD, Sousa-Rodrigues CFD, Barbosa FT. Use of SGLT-2 inhibitors in the treatment of type 2 diabetes mellitus. Rev Assoc Med Bras (1992) 2017; 63:636-641. [PMID: 28977090 DOI: 10.1590/1806-9282.63.07.636] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 12/19/2016] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Diabetes mellitus is one of the most common chronic diseases in the world, with high morbidity and mortality rates, resulting in a greatly negative socioeconomic impact. Although there are several classes of oral antidiabetic agents, most of the patients are outside the therapeutic goal range. OBJECTIVE To review the use of SGLT-2 inhibitors in the treatment of type 2 diabetes mellitus, focusing on their favorable and unfavorable effects, as well as on cardiovascular profile. METHOD A literature search on Pubmed database was performed using the following keywords: "SGLT-2 inhibitors," "dapagliflozin," "empagliflozin," "canagliflozin." RESULTS SGLT-2 inhibitors are a class of oral antidiabetic drugs directed to the kidney. Their mechanism of action is to reduce blood glucose by inducing glycosuria. Extra-glycemic benefits have been described, such as weight loss, decline in blood pressure and levels of triglycerides and uric acid, and they can slow the progression of kidney disease. Genitourinary infections are the main side effects. There is a low risk of hypotension and hypoglycemia. Diabetic ketoacidosis is a serious adverse effect, although rare. Empagliflozin has already had its cardiovascular benefit demonstrated and studies with other drugs are currently being performed. CONCLUSION SGLT-2 inhibitors are a new treatment option for type 2 diabetes mellitus, acting independently of insulin. They have potential benefits other than the reduction of blood glucose, but also carry a risk for adverse effects.
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Affiliation(s)
- Leyna Leite Santos
- Full Professor of Propedeutics, Centro de Estudos Superiores de Maceió, Maceió, AL, Brazil
| | | | - Célio Fernando de Sousa-Rodrigues
- PhD in Science. Associate Professor IV of Anatomy, Ufal, and Adjunct Professor, Universidade Estadual de Ciências da Saúde de Alagoas (Uncisal), Maceió, AL, Brazil
| | - Fabiano Timbó Barbosa
- PhD in Health Sciences. Adjunct Professor of Basics of Surgical and Anesthetic Technique, Ufal, Maceió, AL, Brazil
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Reach G, Pechtner V, Gentilella R, Corcos A, Ceriello A. Clinical inertia and its impact on treatment intensification in people with type 2 diabetes mellitus. DIABETES & METABOLISM 2017; 43:501-511. [PMID: 28754263 DOI: 10.1016/j.diabet.2017.06.003] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 05/24/2017] [Accepted: 06/14/2017] [Indexed: 12/13/2022]
Abstract
Many people with type 2 diabetes mellitus (T2DM) fail to achieve glycaemic control promptly after diagnosis and do not receive timely treatment intensification. This may be in part due to 'clinical inertia', defined as the failure of healthcare providers to initiate or intensify therapy when indicated. Physician-, patient- and healthcare-system-related factors all contribute to clinical inertia. However, decisions that appear to be clinical inertia may, in fact, be only 'apparent' clinical inertia and may reflect good clinical practice on behalf of the physician for a specific patient. Delay in treatment intensification can happen at all stages of treatment for people with T2DM, including prescription of lifestyle changes after diagnosis, introduction of pharmacological therapy, use of combination therapy where needed and initiation of insulin. Clinical inertia may contribute to people with T2DM living with suboptimal glycaemic control for many years, with dramatic consequences for the patient in terms of quality of life, morbidity and mortality, and for public health because of the huge costs associated with uncontrolled T2DM. Because multiple factors can lead to clinical inertia, potential solutions most likely require a combination of approaches involving fundamental changes in medical care. These could include the adoption of a person-centred model of care to account for the complex considerations influencing treatment decisions by patients and physicians. Better patient education about the progressive nature of T2DM and the risks inherent in long-term poor glycaemic control may also reinforce the need for regular treatment reviews, with intensification when required.
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Affiliation(s)
- G Reach
- Department of Endocrinology, Diabetes and Metabolic Diseases, Avicenne Hospital APHP and EA 3412, CRNH-IdF, Paris 13 University, 93017 Bobigny, France.
| | - V Pechtner
- Lilly Diabetes, Eli Lilly & Company, 92521 Neuilly-sur-Seine, France
| | - R Gentilella
- Eli Lilly Italia, Sesto Fiorentino, 50019 Florence, Italy
| | - A Corcos
- Eli Lilly Italia, Sesto Fiorentino, 50019 Florence, Italy
| | - A Ceriello
- U.O. Diabetologia e Malattie Metaboliche, Multimedica IRCCS Sesto San Giovanni, 20099 Milan, Italy
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Patient and Provider Factors Affecting Clinical Inertia in Patients With Type 2 Diabetes on Metformin Monotherapy. Clin Ther 2017; 39:1658-1670.e6. [PMID: 28689692 DOI: 10.1016/j.clinthera.2017.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 06/13/2017] [Accepted: 06/19/2017] [Indexed: 11/21/2022]
Abstract
PURPOSE Our aim was to determine the extent of clinical inertia and the associated patient and provider factors in patients with type 2 diabetes on metformin monotherapy (MM) at a large integrated health care system in the United States. METHODS The study cohort included patients with type 2 diabetes aged 18 to 85 years, on MM between January 2009 and September 2013, who experienced MM failure (had an uncontrolled glycosylated hemoglobin [HbA1c] reading (≥8.0% [64 mmol/mol]) after at least 90 days of MM). Clinical inertia was defined as absence of treatment intensification with an add-on therapy within 180 days after the MM failure (index date). The impact of patient and provider factors on clinical inertia was determined using generalized estimating equations. FINDINGS The study cohort consisted of 996 patients; 58% were men and 59% were white, with a mean age of 53 (11.8) years. Of these, 49.8% experienced clinical inertia. Lower HbA1c at index date, absence of liver diseases, absence of renal diseases, and greater provider age were associated with clinical inertia. The clinical inertia rate in a secondary analysis considering HbA1c <7.0% (53 mmol/mol) as glycemic control was 67.9%. Greater patient age, lower HbA1c at index date, greater provider age, and being a primary care physician were associated with clinical inertia. IMPLICATIONS Considerable clinical inertia rates were observed in our real-world patient population, suggesting the need of interventions to reduce clinical inertia in clinical practice. Information about patient and provider factors affecting clinical inertia provided by this study could help healthcare policymakers plan and implement such interventions.
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Machado-Duque ME, Ramírez-Riveros AC, Machado-Alba JE. Effectiveness and clinical inertia in patients with antidiabetic therapy. Int J Clin Pract 2017; 71. [PMID: 28524340 DOI: 10.1111/ijcp.12954] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
AIMS To establish the effectiveness of antidiabetic therapy and the frequency of clinical inertia in the management of type 2 diabetes mellitus in Colombia. METHODS A cross-sectional study with follow-up of patients who had been treated for at least 1 year and were receiving medical consultation for antidiabetic treatment. Effectiveness was established when haemoglobin-A1c levels were <7% and when clinical inertia was reached, which was defined as no therapeutic modifications despite not achieving management controls. Sociodemographic, clinical and pharmacological variables were evaluated, and multivariate analyses were performed. RESULTS In total, 363 patients with type 2 diabetes mellitus were evaluated, with a mean age of 62.0±12.2 years. A total of 1,016 consultations were evaluated, and the therapy was effective at the end of the follow-up in 57.9% of cases. Clinical inertia was found in 56.8% of patients who did not have metabolic control. The most frequently prescribed medications were metformin (84.0%), glibenclamide (23.4%) and insulin glargine (20.7%). Moreover, 57.6% of the patients were treated with two or more antidiabetic medications. Having metabolic control in the first consult of the follow-up was a protective factor against clinical inertia in the subsequent consultations (OR: 0.08; 95%CI: 0.04-0.15; P<.001). CONCLUSIONS The effectiveness of treatment for patients with type 2 diabetes mellitus has increased in Colombia, and for the first time, clinical inertia was identifiable and quantifiable and found in similar proportions to other countries. Clinical inertia is a relevant condition given that it interferes with the possibility of controlling this pathology.
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Affiliation(s)
- Manuel Enrique Machado-Duque
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Facultad Ciencias de la Salud, Universidad Tecnológica de Pereira, Colombia
| | | | - Jorge Enrique Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia
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'Treatment-resistant' type 2 diabetes: Which definition for clinical practice? DIABETES & METABOLISM 2017; 43:295-297. [PMID: 28552491 DOI: 10.1016/j.diabet.2017.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 04/18/2017] [Indexed: 02/08/2023]
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Abstract
INTRODUCTION Despite type 2 diabetes (T2D) management offers a variety of pharmacological interventions targeting different defects, numerous patients remain with persistent hyperglycaemia responsible for severe complications. Unlike resistant hypertension, treatment resistant T2D is not a classical concept although it is a rather common observation in clinical practice. Areas covered: This article proposes a definition for 'treatment resistant diabetes', analyses the causes of poor glucose control despite standard therapy, briefly considers the alternative approaches to glucose-lowering pharmacotherapy and finally describes how to overcome poor glycaemic control, using innovative oral or injectable combination therapies. Expert opinion: Before considering intensifying the pharmacotherapy of a patient with poorly controlled T2D, it is important to verify treatment adherence, target obesity and consider various non pharmacological improvement quality interventions. If treatment resistant diabetes is defined as not achieving glycated haemoglobin target despite oral triple therapy with a third glucose-lowering agent added to metformin-sulfonylurea dual treatment, the combination of a dipeptidyl peptidase-4 (DPP-4) inhibitor and a sodium glucose cotransporter type 2 (SGLT2) inhibitor may offer new opportunities before considering injectable therapies. Insulin basal therapy (± metformin) may be optimized by the addition of a SGLT2 inhibitor or a glucagon-like peptide-1 (GLP-1) receptor agonist.
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Affiliation(s)
- André J Scheen
- a Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM) , University of Liège , Liège , Belgium.,b Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine , CHU Liège , Liège , Belgium
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Abu-Ashour W, Chibrikova L, Midodzi WK, Twells LK, Gamble JM. Factors associated with early insulin initiation in Type 2 diabetes: a Canadian cross-sectional study. Diabet Med 2017; 34:229-234. [PMID: 26802577 DOI: 10.1111/dme.13082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2016] [Indexed: 01/23/2023]
Abstract
AIM To examine the patient characteristics associated with early initiation of insulin after a diagnosis of Type 2 diabetes. METHODS We analysed cross-sectional data from the 2012 Canadian Community Health Survey conducted by Statistics Canada. Multivariable logistic regression was used to explore the association between patient sociodemographic and health status characteristics and initiating insulin within 1 year of a diagnosis of Type 2 diabetes (early insulin use). RESULTS Weighted estimates for the Canadian population showed that 32% of patients with Type 2 diabetes initiated insulin within 1 year of their diagnosis. Of the insulin initiators, 52% were female and 68% were aged ≥60 years. Factors strongly associated with early initiation of insulin were age (60-69 years: adjusted odds ratio 1.89, 95% CI 1.84-1.94; ≥ 70 years, odds ratio 2.08, 95% CI 2.01-2.15, both vs 40-49 years); smoking (smoker vs never: odds ratio 2.39, 95% CI 2.32-2.46); geography (Western Canada: odds ratio 2.75, 95% CI 2.69-2.81; Quebec: odds ratio 2.20, 95% CI 2.13-2.27, both vs Ontario); mental health (poor vs excellent: odds ratio 1.98, 95% CI 1.92-2.04); BMI (overweight vs normal/underweight: odds ratio 1.63, 95% CI 1.58-1.67); oral antidiabetic medication use (yes vs no: odds ratio 0.66, 95% CI 0.65-0.68); and alcohol use (regular vs non-drinker: odds ratio 0.66, 95% CI 0.65-0.68). CONCLUSION One-third of the study population with Type 2 diabetes initiated insulin within their first year of diagnosis. Age, smoking status, geographical location, mental health, BMI, education, oral antidiabetic medication use, employment, physical activity, language, doctor visits and alcohol consumption were associated with timing of insulin initiation.
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Affiliation(s)
- W Abu-Ashour
- School of Pharmacy, Memorial University of Newfoundland, St. John's, NL, Canada
| | - L Chibrikova
- School of Pharmacy, Memorial University of Newfoundland, St. John's, NL, Canada
| | - W K Midodzi
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - L K Twells
- School of Pharmacy, Memorial University of Newfoundland, St. John's, NL, Canada
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - J-M Gamble
- School of Pharmacy, Memorial University of Newfoundland, St. John's, NL, Canada
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Martono DP, Hak E, Lambers Heerspink H, Wilffert B, Denig P. Predictors of HbA1c levels in patients initiating metformin. Curr Med Res Opin 2016; 32:2021-2028. [PMID: 27552675 DOI: 10.1080/03007995.2016.1227774] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim was to assess demographic and clinical factors as predictors of short (6 months) and long term (18 months) HbA1c levels in diabetes patients initiating metformin treatment. RESEARCH DESIGN AND METHODS We conducted a cohort study including type 2 diabetes patients who received their first metformin prescription between 2007 and 2013 in the Groningen Initiative to Analyze Type 2 Diabetes Treatment (GIANTT) database. The primary outcome was HbA1c level at follow-up adjusted for baseline HbA1c; the secondary outcome was failing to achieve the target HbA1c level of 53 mmol/mol. Associations were analyzed by linear and logistic regression. Multiple imputation was used for missing data. Additional analyses stratified by dose and adherence level were conducted. RESULTS The cohort included 6050 patients initiating metformin. Baseline HbA1c at target consistently predicted better HbA1c outcomes. Longer diabetes duration and lower total cholesterol level at baseline were predictors for higher HbA1c levels at 6 months. At 18 months, cholesterol level was not a predictor. Longer diabetes duration was also associated with not achieving the target HbA1c at follow-up. The association for longer diabetes duration was especially seen in patients starting on low dose treatment. No consistent associations were found for comorbidity and comedication. CONCLUSIONS Diabetes duration was a relevant predictor of HbA1c levels after 6 and 18 months of follow-up in patients initiating metformin treatment. Given the study design, no causal inference can be made. Our study suggests that prompt treatment intensification may be needed in patients who have a longer diabetes duration at treatment initiation.
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Affiliation(s)
- Doti P Martono
- a Unit of Pharmacotherapy and Pharmaceutical Care, Department of Pharmacy , University of Groningen , Groningen , The Netherlands
- b School of Pharmacy , Institut Teknologi Bandung , Bandung , Indonesia
| | - Eelko Hak
- c Unit of Pharmacoepidemiology and Pharmacoeconomics, Department of Pharmacy , University of Groningen , Groningen , The Netherlands
| | - Hiddo Lambers Heerspink
- d Department of Clinical Pharmacy and Pharmacology , University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | - Bob Wilffert
- a Unit of Pharmacotherapy and Pharmaceutical Care, Department of Pharmacy , University of Groningen , Groningen , The Netherlands
- d Department of Clinical Pharmacy and Pharmacology , University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
| | - Petra Denig
- d Department of Clinical Pharmacy and Pharmacology , University of Groningen, University Medical Center Groningen , Groningen , The Netherlands
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Bain SC, Feher M, Russell-Jones D, Khunti K. Management of type 2 diabetes: the current situation and key opportunities to improve care in the UK. Diabetes Obes Metab 2016; 18:1157-1166. [PMID: 27491724 DOI: 10.1111/dom.12760] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 08/01/2016] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- S C Bain
- Institute of Life Sciences, University of Swansea, Swansea, UK
| | - M Feher
- Beta Cell Diabetes Centre, Chelsea and Westminster Hospital, London, UK
| | - D Russell-Jones
- Diabetes and Research, Centre for Endocrinology, Royal Surrey County Hospital, Guildford, UK
- Diabetes and Metabolic Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - K Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
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Educational Outreach with an Integrated Clinical Tool for Nurse-Led Non-communicable Chronic Disease Management in Primary Care in South Africa: A Pragmatic Cluster Randomised Controlled Trial. PLoS Med 2016; 13:e1002178. [PMID: 27875542 PMCID: PMC5119726 DOI: 10.1371/journal.pmed.1002178] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 10/19/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In many low-income countries, care for patients with non-communicable diseases (NCDs) and mental health conditions is provided by nurses. The benefits of nurse substitution and supplementation in NCD care in high-income settings are well recognised, but evidence from low- and middle-income countries is limited. Primary Care 101 (PC101) is a programme designed to support and expand nurses' role in NCD care, comprising educational outreach to nurses and a clinical management tool with enhanced prescribing provisions. We evaluated the effect of the programme on primary care nurses' capacity to manage NCDs. METHODS AND FINDINGS In a cluster randomised controlled trial design, 38 public sector primary care clinics in the Western Cape Province, South Africa, were randomised. Nurses in the intervention clinics were trained to use the PC101 management tool during educational outreach sessions delivered by health department trainers and were authorised to prescribe an expanded range of drugs for several NCDs. Control clinics continued use of the Practical Approach to Lung Health and HIV/AIDS in South Africa (PALSA PLUS) management tool and usual training. Patients attending these clinics with one or more of hypertension (3,227), diabetes (1,842), chronic respiratory disease (1,157) or who screened positive for depression (2,466), totalling 4,393 patients, were enrolled between 28 March 2011 and 10 November 2011. Primary outcomes were treatment intensification in the hypertension, diabetes, and chronic respiratory disease cohorts, defined as the proportion of patients in whom treatment was escalated during follow-up over 14 mo, and case detection in the depression cohort. Primary outcome data were analysed for 2,110 (97%) intervention and 2,170 (97%) control group patients. Treatment intensification rates in intervention clinics were not superior to those in the control clinics (hypertension: 44% in the intervention group versus 40% in the control group, risk ratio [RR] 1.08 [95% CI 0.94 to 1.24; p = 0.252]; diabetes: 57% versus 50%, RR 1.10 [0.97 to 1.24; p = 0.126]; chronic respiratory disease: 14% versus 12%, RR 1.08 [0.75 to 1.55; p = 0.674]), nor was case detection of depression (18% versus 24%, RR 0.76 [0.53 to 1.10; p = 0.142]). No adverse effects of the nurses' expanded scope of practice were observed. Limitations of the study include dependence on self-reported diagnoses for inclusion in the patient cohorts, limited data on uptake of PC101 by users, reliance on process outcomes, and insufficient resources to measure important health outcomes, such as HbA1c, at follow-up. CONCLUSIONS Educational outreach to primary care nurses to train them in the use of a management tool involving an expanded role in managing NCDs was feasible and safe but was not associated with treatment intensification or improved case detection for index diseases. This notwithstanding, the intervention, with adjustments to improve its effectiveness, has been adopted for implementation in primary care clinics throughout South Africa. TRIAL REGISTRATION The trial is registered with Current Controlled Trials (ISRCTN20283604).
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Brod M, Pfeiffer KM, Barnett AH, Berntorp K, Vilsbøll T, Weissenberger B. Perceptions of diabetes control among people with type 2 diabetes treated with basal insulin in Sweden, Switzerland, and the United Kingdom. Curr Med Res Opin 2016; 32:1653-1661. [PMID: 27263866 DOI: 10.1080/03007995.2016.1198311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To investigate perceptions of control among people with uncontrolled and well controlled type 2 diabetes (T2D) treated with basal insulin, as well as differences in perceptions and diabetes management practices between the two groups. RESEARCH DESIGN AND METHODS Web surveys of 1012 people with uncontrolled T2D (HbA1c >8.0% or 64 mmol/mol) on basal insulin in Sweden, Switzerland, and the UK and 295 people with well controlled T2D (HbA1c <7.5% or 58 mmol/mol) on basal insulin in the UK were conducted. RESULTS People with uncontrolled T2D perceived a wide range of factors as very/extremely important for deciding whether they are well controlled, including diet (80.7%), HbA1c value (78.9%), times per day insulin taken (78.8%), insulin units taken per day (77.6%), and energy levels (74.5%). Fifty-one percent of uncontrolled respondents considered the past week or more recently when thinking about control. Perceived major obstacles to control included stress (75.4%), other health issues (70.8%), medicine side effects (69.9%), food cravings (69.8%), doctor not understanding individual situation (67.6%), and life crises (66.9%). Many uncontrolled respondents reported that diabetes was very/extremely interfering with their lives, including energy level (71.0%), performance at work (70.0%), general health (69.9%), and doing what one wants (69.3%). Analyses showed significant differences between well controlled and uncontrolled UK respondents. Compared to the uncontrolled, people with well controlled T2D were significantly more likely to consider the last 24 hours/current time when thinking about control (50% vs. 21%, p < 0.001) and reported greater healthcare contact related to diabetes and more frequent glucose measurement. Study limits include potential selection bias of web surveys and possible recall bias in patient-reported data. CONCLUSIONS The results illuminate how people with T2D treated with basal insulin perceive control and show important differences between the well controlled and uncontrolled. Findings may have implications for improving patient and physician education and diabetes management.
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Affiliation(s)
- Meryl Brod
- a The Brod Group , Mill Valley , CA , USA
| | | | - Anthony H Barnett
- b Heart of England NHS Foundation Trust, University of Birmingham , Birmingham , UK
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Harris SB. The power of two: an update on fixed-dose combinations for type 2 diabetes. Expert Rev Clin Pharmacol 2016; 9:1453-1462. [DOI: 10.1080/17512433.2016.1221758] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Stewart B. Harris
- Department of Family Medicine, Centre for Studies in Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
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