Reduced testing frequency for glycated hemoglobin, HbA1c, is associated with deteriorating diabetes control

Does an electronic pathology ordering system change the volume and pattern of routine testing in hospital? An interrupted time series analysis

AIMS

Identifying and reducing low-value care is a vital issue in Australia, with pathology test ordering a common focus in this field. This study builds on previous research and aimed to quantify the impact of the implementation of an electronic ordering (e-ordering) system on the volume of pathology testing, compared with manual (paper based) ordering.

METHODS

An audit and analysis of pathology test data were conducted, using an interrupted time series design to investigate the impact of the e-ordering system on pathology ordering patterns. All medical and surgical adult inpatients at a tertiary referral hospital in Newcastle, Australia, were included over a 3-year period.

RESULTS

Overall, there were no statistically significant differences in the volume of orders due to the implementation of the e-ordering system. There was a slight increase in the aggregated volume (tests per admission and tests per bed day) of tests ordered across the entire study period, reflecting a secular trend.

CONCLUSIONS

Despite providing greater visibility and tracking of orders, we conclude that the implementation of an e-ordering system does not, in and of itself, reduce ordering volume. Efforts to identify and reduce low-value care will require intentional effort and specifically designed educational programmes or hard-wired algorithms.

Efficacy of Self-Review of Lifestyle Behaviors with Once-Weekly Glycated Albumin Measurement in People with Type 2 Diabetes: A Randomized Pilot Study

INTRODUCTION

Lifestyle management, including appropriate modifications of nutrition, exercise, and medication behaviors, is essential for optimal glycemic control. The absence of appropriate monitoring methods to validate the lifestyle change may hinder the modification and continuation of behaviors. In this study, we evaluated whether once-weekly glycated albumin (GA) measurement received via a smartphone application could improve glycemia management in patients with type 2 diabetes mellitus by supporting self-review and modification of lifestyle behaviors.

METHODS

This open-label, randomized controlled, single-center study in Japan with an 8-week intervention period was conducted in individuals with type 2 diabetes mellitus and HbA1c levels between 7.0 and 9.0% (53‒75 mmol/mol). The intervention was once-weekly home monitoring of GA with a daily self-review of lifestyle behaviors using a smartphone application, in addition to conventional treatment.

RESULTS

A total of 98 participants (72.0% males; age 63.2 ± 11.4 years; HbA1c 7.39 ± 0.39% [57.3 ± 4.3 mmol/mol]) were randomly assigned to the intervention or control group. Significant decreases of the GA and HbA1c levels from the baseline to the last observation day were observed in the intervention group (- 1.71 ± 1.37% [- 39.1 ± 31.3 mmol/mol] and - 0.32 ± 0.32% [- 3.5 ± 3.5 mmol/mol], respectively). Significant decreases of the body weight, waist circumference, and caloric expenditure (p < 0.0001 and p = 0.0003, p = 0.0346, respectively), but not of the caloric intake (p = 0.678), were also observed in the intervention group as compared with the control group.

CONCLUSIONS

Self-review of lifestyle behaviors in combination with once-weekly GA home testing received via a smartphone application might potentially benefit glycemic management in people with type 2 diabetes mellitus.

TRIAL REGISTRATION

jRCTs042220048.

Consistent service use before the COVID-19 pandemic predicted the continuity of face-to-face appointments during the lockdown among type 2 diabetes patients

INTRODUCTION

The COVID-19 pandemic affected diabetes care among type 2 diabetes (T2D) patients. However, it is not known whether the observed changes in care concern all T2D patients equally. We examined the changes in health service usage and treatment outcomes among T2D patients according to the pre-pandemic follow-up activity.

METHODS

We analysed electronic health records of 11 083 T2D patients in North Karelia, Finland (March 2017-March 2021), categorizing them by pre-pandemic T2D-related in-person contact frequency. We focused on HbA1c and LDL measurement activity and treatment targets as care indicators.

RESULTS

Overall, health service usage and recording rates for HbA1c and LDL decreased during the pandemic. They decreased most but stayed at the highest level among patients with the most consistent pre-pandemic face-to-face service use, characterised by the highest proportion of comorbidities and elevated HbA1c. Their treatment outcomes were not negatively affected. In contrast, service usage and measurement activities increased among those with no pre-pandemic contact.

CONCLUSION

Those with consistent pre-pandemic service use and greater service needs were more likely to seek face-to-face care despite the lockdown, and no negative effect on treatment outcomes was seen.

Diabetic Pneumopathy- A Novel Diabetes-associated Complication: Pathophysiology, the Underlying Mechanism and Combination Medication

BACKGROUND

The "diabetic lung" has been identified as a possible target organ in diabetes, with abnormalities in ventilation control, bronchomotor tone, lung volume, pulmonary diffusing capacity, and neuroadrenergic bronchial innervation.

OBJECTIVE

This review summarizes studies related to diabetic pneumopathy, pathophysiology and a number of pulmonary disorders including type 1 and type 2 diabetes.

METHODS

Electronic searches were conducted on databases such as Pub Med, Wiley Online Library (WOL), Scopus, Elsevier, ScienceDirect, and Google Scholar using standard keywords "diabetes," "diabetes Pneumopathy," "Pathophysiology," "Lung diseases," "lung infection" for review articles published between 1978 to 2023 very few previous review articles based their focus on diabetic pneumopathy and its pathophysiology.

RESULTS

Globally, the incidence of diabetes mellitus has been rising. It is a chronic, progressive metabolic disease. The "diabetic lung" may serve as a model of accelerated ageing since diabetics' rate of respiratory function deterioration is two to three-times higher than that of normal, non-smoking people.

CONCLUSION

Diabetes-induced pulmonary dysfunction has not gained the attention it deserves due to a lack of proven causality and changes in cellular properties. The mechanism underlying a particular lung illness can still only be partially activated by diabetes but there is evidence that hyperglycemia is linked to pulmonary fibrosis in diabetic people.

Diabetic control and compliance using glycated haemoglobin (HbA1C) testing guidelines in public healthcare facilities of Gauteng province, South Africa

OBJECTIVE

This study aimed at evaluating diabetic control and compliance with testing guidelines, across healthcare facilities of Gauteng Province, South Africa, as well as factors associated with time to achieve control. South Africa's estimated total unmet need for care for patients with type 2 diabetes mellitus is 80%.

RESEARCH DESIGN, METHODS AND FINDINGS

The data of 511 781 patients were longitudinally evaluated. Results were reported by year, age category, race, sex, facility and test types. HbA1C of ≤7% was reported as normal, >7 - ≤9% as poor control and >9% as very poor control. The chi-squared test was used to assess the association between a first-ever HbA1C status and variables listed above. The Kaplan-Meier analysis was used to assess probability of attaining control among those who started with out-of-control HbA1C. The extended Cox regression model assessed the association between time to attaining HbA1C control from date of treatment initiation and several covariates. We reported hazard ratios, 95% confidence intervals and p-values. Data is reported for 511 781 patients with 705 597 laboratory results. Poorly controlled patients constituted 51.5%, with 29.6% classified as very poor control. Most poorly controlled patients had only one test over the entire study period. Amongst those who started with poor control status and had at least two follow-up measurements, the likelihood of achieving good control was higher in males (adjusted Hazard Ratio (aHR) = 1.16; 95% CI:1.12-1.20; p<0.001) and in those attending care at hospitals (aHR = 1.99; 95% CI:1.92-2.06; p<0.001).

CONCLUSION

This study highlights poor adherence to guidelines for diabetes monitoring.

The Effect of the COVID-19 Pandemic on HbA1c Testing: Prioritization of High-Risk Cases and Impact of Social Deprivation

INTRODUCTION

Studies show that the COVID-19 pandemic disproportionately affected people with diabetes and those from disadvantaged backgrounds. During the first 6 months of the UK lockdown, > 6.6 M glycated haemoglobin (HbA1c) tests were missed. We now report variability in the recovery of HbA1c testing, and its association with diabetes control and demographic characteristics.

METHODS

In a service evaluation, we examined HbA1c testing across ten UK sites (representing 9.9% of England's population) from January 2019 to December 2021. We compared monthly requests from April 2020 to those in the equivalent 2019 months. We examined effects of (i) HbA1c level, (ii) between-practice variability, and (iii) practice demographics.

RESULTS

In April 2020, monthly requests dropped to 7.9-18.1% of 2019 volumes. By July 2020, testing had recovered to 61.7-86.9% of 2019 levels. During April-June 2020, we observed a 5.1-fold variation in the reduction of HbA1c testing between general practices (12.4-63.8% of 2019 levels). There was evidence of limited prioritization of testing for patients with HbA1c > 86 mmol/mol during April-June 2020 (4.6% of total tests vs. 2.6% during 2019). Testing in areas with the highest social disadvantage was lower during the first lockdown (April-June 2020; trend test p < 0.001) and two subsequent periods (July-September and October-December 2020; both p < 0.001). By February 2021, testing in the highest deprivation group had a cumulative fall in testing of 34.9% of 2019 levels versus 24.6% in those in the lowest group.

CONCLUSION

Our findings highlight that the pandemic response had a major impact on diabetes monitoring and screening. Despite limited test prioritization in the > 86 mmol/mol group, this failed to acknowledge that those in the 59-86 mmol/mol group require consistent monitoring to achieve the best outcomes. Our findings provide additional evidence that those from poorer backgrounds were disproportionately disadvantaged. Healthcare services should redress this health inequality.

Assessment of the effect of the COVID-19 pandemic on UK HbA1c testing: implications for diabetes management and diagnosis

AIMS

The COVID-19 pandemic, and the focus on mitigating its effects, has disrupted diabetes healthcare services worldwide. We aimed to quantify the effect of the pandemic on diabetes diagnosis/management, using glycated haemoglobin (HbA1c) as surrogate, across six UK centres.

METHODS

Using routinely collected laboratory data, we estimated the number of missed HbA1c tests for 'diagnostic'/'screening'/'management' purposes during the COVID-19 impact period (CIP; 23 March 2020 to 30 September 2020). We examined potential impact in terms of: (1) diabetes control in people with diabetes and (2) detection of new diabetes and prediabetes cases.

RESULTS

In April 2020, HbA1c test numbers fell by ~80%. Overall, across six centres, 369 871 tests were missed during the 6.28 months of the CIP, equivalent to >6.6 million tests nationwide. We identified 79 131 missed 'monitoring' tests in people with diabetes. In those 28 564 people with suboptimal control, this delayed monitoring was associated with a 2-3 mmol/mol HbA1c increase. Overall, 149 455 'screening' and 141 285 'diagnostic' tests were also missed. Across the UK, our findings equate to 1.41 million missed/delayed diabetes monitoring tests (including 0.51 million in people with suboptimal control), 2.67 million screening tests in high-risk groups (0.48 million within the prediabetes range) and 2.52 million tests for diagnosis (0.21 million in the pre-diabetes range; ~70 000 in the diabetes range).

CONCLUSIONS

Our findings illustrate the widespread collateral impact of implementing measures to mitigate the impact of COVID-19 in people with, or being investigated for, diabetes. For people with diabetes, missed tests will result in further deterioration in diabetes control, especially in those whose HbA1c levels are already high.

The diabetes health plan and medication adherence among individuals with low incomes

OBJECTIVE

To test the impact of the Diabetes Health Plan (DHP), a diabetes-specific insurance plan that lowers out-of-pocket costs for diabetes-related medications and clinical visits, on adherence to oral hypoglycemic medications among low-income adults with Type 2 Diabetes (T2DM).

DATA SOURCES AND STUDY SETTING

Cohort of adults (18-64) with T2DM, an annual household income

STUDY DESIGN

We employed a linear regression Difference-In-Differences (DID) approach with a matched comparison group. To assess for differential DHP effects across adherent versus non-adherent patients, we ran a Difference-in-Difference-in-Differences (DDD) analysis by including an interaction term that included indicators for DHP exposure status and time, and low versus high baseline medication adherence.

DATA COLLECTION

The analytic data set is limited to employer groups that purchased the DHP and standard benefit plans from UnitedHealthcare, had internal pharmacy contracts; complete pharmacy claims data, and sufficient medical claims and lab data to identify employees and their dependents with T2DM.

PRINCIPAL FINDINGS

Our DID analysis did not show improved medication adherence associated with employer DHP adoption. However, the DDD model suggested a difference between DHP-exposed and comparison beneficiaries when comparing the relative effect on individuals who were adherent versus non-adherent at baseline, as suggested by the significant three-way interaction term (10.2,p = 0.028). This effect was driven by the 8.2 percentage point increase in medication adherence for the DHP subsample that was non-adherent at baseline.

CONCLUSIONS

The DHP may benefit low-income patients with low baseline medication adherence. Value-based insurance design may be an important strategy for mitigating income disparities in T2DM outcomes.

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Key Words

• diabetes
• health disparities
• health equity
• low-income
• medication non-adherence
• value based insurance design

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MESH Headings

• Adult
• Humans
• Diabetes Mellitus, Type 2/drug therapy
• Hypoglycemic Agents/therapeutic use
• Medication Adherence
• Pharmaceutical Services
• Cohort Studies
• Retrospective Studies

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Grants

• P30 AG021684 NIA NIH HHS
• U58 DP002722 NCCDPHP CDC HHS
• K08 AG068372 NIA NIH HHS
• U18 DP006128 NCCDPHP CDC HHS
• Centers for Disease Control and Prevention
• National Institute on Aging

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Affiliation(s)

Kimberly Danae Cauley Narain Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of MedicineUniversity of CaliforniaLos AngelesCaliforniaUSA Center for Health AdvancementFielding School of Public Health, University of California Los AngelesLos AngelesCaliforniaUSA Center for the Study of RacismSocial Justice, and Health Los AngelesLos AngelesCaliforniaUSA
Norman Turk Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of MedicineUniversity of CaliforniaLos AngelesCaliforniaUSA
O. Kenrik Duru Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of MedicineUniversity of CaliforniaLos AngelesCaliforniaUSA
Tannaz Moin Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of MedicineUniversity of CaliforniaLos AngelesCaliforniaUSA HSR&D Center for the Study of Healthcare Innovation, Implementation & PolicyVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
Sam Ho UnitedHealthcareMinnetonkaMinnesotaUSA
Carol M. Mangione Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of MedicineUniversity of CaliforniaLos AngelesCaliforniaUSA Fielding School of Public HealthUniversity of CaliforniaLos AngelesCaliforniaUSA

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Anthropometric Measurements and Laboratory Investigations in Children and Youth With Type 1 Diabetes Before and During the COVID-19 Pandemic

OBJECTIVES

Our aim in this study was to compare rates of anthropometric, blood pressure (BP) and glycated hemoglobin (A1C) measurements and laboratory screening for hypothyroidism, nephropathy and dyslipidemia in children and youth with type 1 diabetes (T1D), 1 year before and after the onset of COVID-19.

METHODS

Clinical data were analyzed from a voluntary registry of children and youth with T1D followed at the BC Children's Hospital between March 2019 and 2021. Logistic and Poisson mixed-effect models were used.

RESULTS

Four hundred forty patients, with median (interquartile range) age and time since diagnosis 12.7 (9.5 to 15.4) and 4.7 (2.6 to 7.9) years, respectively, were included. Clinic visits were all in-person before March 2020, and 99% via telemedicine afterward. The number of visits per patient was 2 (2 to 3), with a 6% increase during the pandemic (relative risk [RR], 1.06; 95% confidence interval [CI], 1.01 to 1.10). There was a substantial decrease in height, weight and BP measurements (RR, 0.32; 95% CI, 0.28 to 0.36; RR, 0.34, 95% CI, 0.31 to 0.38; RR, 0.005, 95% CI, 0.002 to 0.014, respectively); only 49% of patients had anthropometric and 1% BP data during the pandemic year, compared with >97% before the pandemic. A1C measurements dropped from 3 (2 to 4) to 1 (1 to 2) per patient per year (RR, 0.53; 95% CI, 0.48 to 0.57). Rates of screening investigations were suboptimal before the pandemic, and these rates continued to decline.

CONCLUSIONS

Shifting to telemedicine allowed ongoing care during the pandemic, but the frequency of anthropometric, BP and A1C measurements decreased dramatically. A combined telemedicine/in-person model may be needed to ensure adequate care for this population.

Improving Diabetes Care: A Fijian Diabetes Service Improvement Study

Background. Achieving good outcomes in type 2 diabetes mellitus patients’ needs a decent integrated care service with access to resources. The Fiji Islands has one of the highest rates of diabetes disease burden and has available resources to alleviate the diabetic disease pandemic in its population, yet patient outcomes are getting worse. We hypothesize that a dysfunction in health-care delivery system may be accentuating the diabetic disease process; therefore, this service evaluation study was conducted to provide insight into the management of T2DM in a secondary care clinic setting. Methods. We conducted a retrospective chart review of patient records for the past three years (2015-2018). Random quota sampling was used to extract patient folders over a one-month period. A total of 113 patient charts were analyzed which met the inclusion criteria. Results. The overall glycemic levels were uncontrolled in every seven out of ten patients. Most of the patients were on combination drug therapy and at maximum dosing ranges. HbA1c tests, as a monitoring tool, were being inadequately used. Nonadherence to management was prominent in poor controlled patients, and physicians failed to provide appropriate interventions in this group. Nearly all the patients had not received eye assessments, foot risk assessment, and individualized dietetic counselling over three years. Macrovascular complications were more common than microvascular end organ damage. Conclusion. There is a high degree of uncontrolled glycemia and comorbidities in patients attending the service of study which is being perpetuated by poor integrated diabetes care. Strengthening educational initiatives, using validated strategic tools to streamline diabetic services and astute evidence-based resource allocation and management, is needed.

Novel use of menstrual blood for monitoring glycaemic control in patients with diabetes: a proof-of-concept study

BACKGROUND

Glycated haemoglobin (HbA1c) is the diagnostic and prognostic standard for clinical management of diabetes mellitus (DM). Unfortunately, patient adherence to guidelines for routine testing can be poor and there are significant gender-based disparities in DM management and outcomes. Recent evidence suggests that menstrual blood may be comparable to systemic blood for monitoring of common biomarkers. The objective of the present study was to assess the concordance of HbA1c levels between menstrual and systemic blood in healthy women and women with diabetes of reproductive age.

METHODS

In this prospective, observational cohort study, we enrolled healthy and diabetic (type 1 and type 2 DM) reproductive-age women (aged ≥18 and ≤45 years). Menstrual blood and venous systemic blood specimens were simultaneously obtained at time of menstruation, and analysed for HbA1c levels. Participants self-collected menstrual blood using a QPad, a novel, modified menstrual pad with an embedded dried blood spot strip.

RESULTS

Among 172 participants, 57.6% were healthy and 42.4% had a diagnosis of either type 1 or type 2 DM. There were no significant differences in mean HbA1c values in menstrual and systemic blood across the overall cohort or within the diabetic subgroup. Furthermore, HbA1c levels between blood sources were robustly correlated and demonstrated a significant linear relationship.

CONCLUSIONS

There is a strong concordance in HbA1c levels between menstrual and systemic blood. Empowered by self-collection technologies, these findings suggest that menstrual blood may serve as a reliable, non-invasive and potentially cost-effective alternative to serum for HbA1c monitoring among reproductive-age women with DM.

The experience of blood glucose monitoring in people with type 2 diabetes mellitus (T2DM)

BACKGROUND

Finger prick blood glucose (BG) monitoring remains a mainstay of management in people with type 2 diabetes (T2DM) who take sulphonylurea (SU) drugs or insulin. We recently examined patient experience of BG monitoring in people with type 1 diabetes (T1DM). There has not been any recent comprehensive assessment of the performance of BG monitoring strips or the patient experience of BG strips in people with T2DM in the UK.

METHODS

An online self-reported questionnaire containing 44 questions, prepared following consultation with clinicians and patients, was circulated to people with T2DM. 186 responders provided completed responses (25.5% return rate). Fixed responses were coded numerically (eg not confident = 0 fairly confident = 1).

RESULTS

Of responders, 84% were treated with insulin in addition to other agents. 75% reported having had an HbA1c check in the previous 6 months. For those with reported HbA1c ≥ 65 mmol/mol, a majority of people (70%) were concerned or really concerned about the shorter term consequences of running a high HbA1c This contrasted with those who did not know their recent HbA1c, of whom only 33% were concerned/really concerned and those with HbA1c <65 mmol/mol of whom 35% were concerned. Regarding BG monitoring/insulin adjustment, only 25% of responders reported having sufficient information with 13% believing that the accuracy and precision of their BG metre was being independently checked. Only 9% recalled discussing BG metre accuracy when their latest metre was provided and only 7% were aware of the International Standardisation Organisation (ISO) standards for BG metres. 77% did not recall discussing BG metre performance with a healthcare professional.

CONCLUSION

The group surveyed comprised engaged people with T2DM but even within this group there was significant variation in (a) awareness of shorter term risks, (b) confidence in their ability to implement appropriate insulin dosage (c) awareness of the limitations of BG monitoring technology. There is clearly an area where changes in education/support would benefit many.

Frequency of A1C tests undertaken by patients assisted by pharmaceutical care services in Brazil

BACKGROUND AND AIMS

The test of glycated hemoglobin is used to assess the glycemic control of patients with diabetes mellitus, however is essential that the monitoring is carried out with adequate frequency. In this context, the objective of study is evaluate the frequency of A1C tests undertaken by patients assisted by pharmaceutical care services.

METHODS

Descriptive study that included patients with DM treated at pharmaceutical care services in Brazil. This service is provided by pharmacists, for optimizing of patient's drug therapy to achieve outcomes that improve a patient's quality of life. Frequency of A1C tests was collected, with a minimum interval of three and a maximum of six months being considered adequate. Tests performed with a minimum interval of less than three or greater than six months frequency were considered inadequate. The comparison of the mean time between the A1C tests between the groups was investigated by the Student's t-test. The significance level adopted was p < 0.05. The study was conducted using data recorded from March 2018 to December 2019.

RESULTS

The study included 66 patients and 67% of these underwent A1C test with inadequate frequency. The mean time between A1C tests was significantly higher (p < 0.0001) in group with inadequate frequency.

CONCLUSION

Only one third of DM patients treated by pharmaceutical care services are monitored with adequate A1C frequency. It is necessary to identify the causes of this underutilization and to develop tools to optimize the monitoring.

Variability in Test Interval Is Linked to Glycated Haemoglobin (HbA1c) Trajectory over Time

AIMS

We previously showed that the glycated haemoglobin (HbA1c) testing frequency links to diabetes control. Here, we examine the effect of variability in test interval, adjusted for the frequency, on change in HbA1c (ΔHbA1c). Materials & Methods. HbA1c results were collected on 83,872 people with HbA1c results at baseline and 5 years (±3 months) later and ≥6 tests during this period. We calculated the standard deviation (SD) of test interval for each individual and examined the link between deciles of SD of the test interval and ΔHbA1c level, stratified by baseline HbA1c.

RESULTS

In general, less variability in testing frequency (more consistent monitoring) was associated with better diabetes control. This was most evident with moderately raised baseline HbA1c levels (7.0-9.0% (54-75 mmol/mol)). For example, in those with a starting HbA1c of 7.0-7.5% (54-58 mmol/mol), the lowest SD decile was associated with little change in HbA1c over 5 years, while for those with the highest decile, HbA1c rose by 0.4-0.6% (4-6 mmol/mol; p < 0.0001). Multivariate analysis showed that the association was independent of the age/sex/hospital site. Subanalysis suggested that the effect was most pronounced in those aged <65 years with baseline HbA1c of 7.0-7.5% (54-58 mmol/mol). We observed a 6.7-fold variation in the proportion of people in the top-three SD deciles across general practices.

CONCLUSIONS

These findings indicate that the consistency of testing interval, not the just number of tests/year, is important in maintaining diabetes control, especially in those with moderately raised HbA1c levels. Systems to improve regularity of HbA1c testing are therefore needed, especially given the impact of COVID-19 on diabetes monitoring.

Can we check serum lithium levels less often without compromising patient safety?

BACKGROUND

Lithium is viewed as the first-line long-term treatment for prevention of relapse in people with bipolar disorder.

AIMS

This study examined factors associated with the likelihood of maintaining serum lithium levels within the recommended range and explored whether the monitoring interval could be extended in some cases.

METHOD

We included 46 555 lithium rest requests in 3371 individuals over 7 years from three UK centres. Using lithium results in four categories (<0.4 mmol/L; 0.40-0.79 mmol/L; 0.80-0.99 mmol/L; ≥1.0 mmol/L), we determined the proportion of instances where lithium results remained stable or switched category on subsequent testing, considering the effects of age, duration of lithium therapy and testing history.

RESULTS

For tests within the recommended range (0.40-0.99 mmol/L categories), 84.5% of subsequent tests remained within this range. Overall, 3 monthly testing was associated with 90% of lithium results remaining within range, compared with 85% at 6 monthly intervals. In cases where the lithium level in the previous 12 months was on target (0.40-0.79 mmol/L; British National Formulary/National Institute for Health and Care Excellence criteria), 90% remained within the target range at 6 months. Neither age nor duration of lithium therapy had any significant effect on lithium level stability. Levels within the 0.80-0.99 mmol/L category were linked to a higher probability of moving to the ≥1.0 mmol/L category (10%) compared with those in the 0.4-0.79 mmol/L group (2%), irrespective of testing frequency.

CONCLUSION

We propose that for those who achieve 12 months of lithium tests within the 0.40-0.79 mmol/L range, the interval between tests could increase to 6 months, irrespective of age. Where lithium levels are 0.80-0.99 mmol/L, the test interval should remain at 3 months. This could reduce lithium test numbers by 15% and costs by ~$0.4 m p.a.

Hemoglobin A1C testing frequency among patients with type 2 diabetes within a US payer system: a retrospective observational study

OBJECTIVE

The American Diabetes Association (ADA) guidelines recommend A1C testing schedules for patients with type 2 diabetes; however, level of real-world guideline adherence remains unclear. The current study evaluated A1C testing frequency and its association with glycemic control and cardiovascular outcomes.

METHODS

A retrospective study was conducted utilizing Aetna's Enterprise Data Warehouse. Adult patients with a medical claim for type 2 diabetes in 2017 (index date) were included. Patients had continuous enrollment through December 2019 and ≥1 reported A1C measurement from 2017 to 2019. Follow-up was up to 36 months post-index date.

RESULTS

Of the 112,572 eligible patients, 50.0% were female and median age was 70 years; 32.9% of patients with controlled baseline A1C (<8%, 64 mmol/mol) received less than the 2 tests/year recommended by the ADA, while 60.6% of patients with uncontrolled baseline A1C received less than the quarterly testing recommended by the ADA. More frequent testing was associated with age (65-75 years), uncontrolled baseline A1C and presence of comorbidities. In separate multivariable models, 2-3 A1C tests/year were associated with greater likelihood of A1C < 8% (64 mmol/mol) vs. <2 tests/year (OR = 1.07, 95% confidence interval [CI] 1.02-1.12), while >3 tests/year was associated with a modestly increased risk of cardiovascular events vs. <2 tests/year (OR = 1.08, 95% CI 1.01-1.15).

CONCLUSIONS

A large proportion of type 2 diabetes patients were not tested per guideline recommendations. The relationship between A1C testing frequency and glycemic control was inconsistent, though there was a significant association between more frequent testing and experiencing a CV event.

A comparative analysis and review of how national guidelines for chronic disease monitoring are made in low- and middle-income compared to high-income countries

BACKGROUND

Understanding how clinical practice guidelines and recommendations are adopted in high-income and low-income settings will help contextualise the value and validity of recommendations in different settings. We investigate how major guidelines and recommendations are developed for management and monitoring of post-diagnosis treatment for three important chronic diseases: HIV, hypertension and type 2 diabetes mellitus (T2DM).

METHODS

Eligible guidelines were searched for using PubMed, Google, and health ministry websites for all three conditions. Only guidelines published from 2010 to 2020 were included. The source of the guidelines, year of most recent guideline, and basis of the guidelines were assessed. Additionally, recommendations, the strength of the recommendation and the quality of the evidence for treatment goals of non-pregnant adults and the frequency of monitoring were also extracted and assessed.

RESULTS

Of the 42 countries searched 90%, 71% and 60% had T2DM, hypertension and HIV guidelines outlining targets for long-term management, respectively. Most T2DM guidelines recommend an HbA1c target of ≤7.0% (68%) or ≤6.5% (24%) as the ideal glycaemic target for most non-pregnant adults, while hypertension guidelines recommend blood pressure (systolic blood pressure/diastolic blood pressure) targets of <140/90 mm Hg (94%) and <130/80 mm Hg (6%). Of the identified HIV guidelines, 67% define virological failure as a viral load >1000 copies/mL, with 26%, mostly HICs, defining virological failure as a viral load >200 copies/mL. Recommendations for the frequency of monitoring for any diagnosed patients were available in 18 (55%) of the hypertension guidelines, 25 (93%) of HIV guidelines, and 27 (73%) of the T2DM guidelines. Only a few of the guidelines provide the strength of the recommendation and the quality of the evidence.

CONCLUSIONS

Most guidelines from LMICs are adopted or adapted from existing HIC guidelines or international and regional organisation guidelines with little consideration for resource availability, contextual factors, logistical issues and general feasibility.

Disparities in Hemoglobin A1c Testing During the Transition to Adulthood and Association With Diabetes Outcomes in Youth-Onset Type 1 and Type 2 Diabetes: The SEARCH for Diabetes in Youth Study

OBJECTIVE

To identify correlates of hemoglobin A1c (HbA1c) testing frequency and associations with HbA1c levels and microvascular complications in youth-onset diabetes.

RESEARCH DESIGN AND METHODS

The SEARCH for Diabetes in Youth study collected data from individuals diagnosed with diabetes before age 20 at 8 years (n=1,885 type 1, n=230 type 2) and 13 years (n=649 type 1, n = 84 type 2) diabetes duration. We identified correlates of reporting ≥3 HbA1c tests/year using logistic regression. We examined associations of HbA1c testing with HbA1c levels and microvascular complications (retinopathy, neuropathy, or nephropathy) using sequentially adjusted linear and logistic regression.

RESULTS

For type 1 diabetes, odds of reporting ≥3 HbA1c tests/year at 8 and 13 years diabetes duration decreased with older age at diagnosis (odds ratio [OR] 0.91 [95% CI 0.88-0.95]), longer duration of diabetes (OR 0.90 [0.82-0.99]), not having a personal doctor (OR 0.44 [0.30-0.65]), and lapses in health insurance (OR 0.51 [0.27-0.96]). HbA1c testing ≥3 times/year over time was associated with lower HbA1c levels (OR -0.36% [-0.65 to -0.06]) and lower odds of microvascular complications (OR 0.64 [0.43-0.97]) at 13 years duration, but associations were attenuated after adjustment for HbA1c testing correlates (OR -0.17 [-0.46 to 0.13] and 0.70 [0.46-1.07], respectively). For type 2 diabetes, not seeing an endocrinologist decreased the odds of reporting ≥3 HbA1c tests/year over time (OR 0.19 [0.06-0.63]), but HbA1c testing frequency was not associated with HbA1c levels or microvascular complications.

CONCLUSIONS

We observed disparities in HbA1c testing frequency predominately by health care-related factors, which were associated with diabetes outcomes in type 1 diabetes.

The effect of the Covid-19 shutdown on glycemic testing and control

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic caused a halt to in-person ambulatory care. We evaluated how the reduction in access to care affected HbA1c testing and patient HbA1c levels.

METHODS

HbA1c data from 11 institutions were extracted to compare testing volume and the percentage of abnormal results between a pre-pandemic period (January-June 2019, period 1) and a portion of the COVID-19 pandemic period (Jan-June 2020, period 2). HbA1c results greater than 6.4% were categorized as abnormal.

RESULTS

HbA1C testing volumes decreased in March, April and May by 23, 61 and 40% relative to the corresponding months in 2019. The percentage of abnormal results increased in April, May and June (25, 23, 9%). On average, we found that the frequency of abnormal results increased by 0.31% for every 1% decrease in testing volume (p < 0.0005).

CONCLUSION

HbA1c testing volume for outpatients decreased by up to 70% during the early months of the pandemic. The decrease in testing was associated with an increase in abnormal HbA1c results.

Effects of Patient-Initiated Visits on Patient Satisfaction and Clinical Outcomes in a Type 1 Diabetes Outpatient Clinic: A 2-Year Randomized Controlled Study

OBJECTIVE

We investigated the effects of replacing regular outpatient follow-up through prescheduled visits with patient-initiated visits on patient satisfaction and clinical variables of type 1 diabetes (T1D).

RESEARCH DESIGN AND METHODS

A 24-month randomized controlled trial in which adults with T1D were allocated to either patient-initiated unlimited access to outpatient visits or usual care through regular prescheduled visits. The primary outcome was seven patient-reported experience measures of patient satisfaction focused on benefit of consultation and accessibility of the outpatient clinic. Secondary outcomes included clinical variables of diabetes and use of staff resources.

RESULTS

We enrolled 357 outpatients (intervention, n = 178; control, n = 179). After 24 months, participants in the intervention group experienced more benefit from consultations compared with baseline within groups (P < 0.05) and fewer unnecessary visits compared with control subjects (P < 0.05). Patient needs covered and satisfaction with the outpatient clinic were high and unchanged in both groups, and accessibility was increased (three questions, all P < 0.05). A calculated seven-item patient satisfaction sum score favored the intervention group over control subjects (P < 0.001). There were no significant changes in glycated hemoglobin (HbA1c), LDL, blood pressure, and complication status. The mean number of outpatient visits over 24 months (± SD) was lower in the intervention group compared with control subjects (4.4 ± 2.8 vs. 6.3 ± 2.7; P < 0.001), while the number of telephone contacts was higher (3.1 ±3.4 vs. 2.5 ± 3.2; P < 0.001).

CONCLUSIONS

Patient satisfaction remained high or improved with patient-initiated on-demand use of the diabetes outpatient clinic, with no decline in the quality of diabetes care, and a reduction in the use of staff resources.

Assessing the Clinical Utility of Point of Care HbA1c in the Ophthalmology Outpatient Setting

Background/Aims

Effective management of diabetic retinopathy requires multidisciplinary input. We aimed to evaluate the impact of point of care (POC) HbA1c testing as a tool to identify patients most in need of specialist diabetologist input and assess the accuracy and determinants of patients’ insight into their glycaemic and blood pressure control.

Methods

Forty-nine patients with diabetic retinopathy were recruited from the eye clinic at Great Western Hospital. Patients completed a questionnaire and POC HbA1c and blood pressure values were measured. Statistical analysis was completed with SPSS v23.

Results

Mean age was 64.4 years, median interval since the last formal HbA1c reading was 10.2 months and the mean POC HbA1c was 64.1 mmol/mol. HbA1c significantly correlated with the degree of retinopathy. Of the patients, 81.6% had POC readings above the levels recommended by the National Institute for Health and Care Excellence, with only 16.3% having insight into this. Insight to HbA1c levels was predicted by age but not by duration of disease. Fourteen patients (33.3%) identified with high HbA1c readings were referred to secondary diabetic services and 88.8% of patients felt that the test was useful and likely to improve their diabetic control.

Conclusion

The majority of patients had poor insight into their diabetes control, with sub-optimal treatment and follow-up. Poor insight is high in younger patients, suggesting that POC HbA1c testing is particularly important in educating younger patients who may be Type 1 diabetics with more severe disease. POC HbA1c represents a cost-effective, reproducible and clinically significant tool for the management of diabetes in an outpatient ophthalmology setting, allowing the rapid recognition of high-risk patients and appropriate referral to secondary diabetic services.

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Improving Diabetes Control Using Lean Six Sigma Quality Improvement in an Endocrine Clinic in a Large Accountable Care Organization

This article describes a quality improvement project to reduce the number of patients with diabetes who have poor glycemic control in a large tertiary care endocrinology clinic. The project used the Lean Six Sigma Define-Measure-Analyze-Improve-Control process improvement methodology to develop clinic workflow processes for obtaining A1C measurements in a timely manner to facilitate interventions to improve glycemic control. The percentage of patients with poorly controlled diabetes (A1C >9.0% or missing value in the past 12 months) significantly improved from 26.4% at baseline to 16% (P <0.001), and the proportion of patients with an A1C test within 3-6 months of an appointment improved from 76 to 92%.

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

OBJECTIVE

To analyse diabetes treatment, treatment change and self-management behaviours in association with 2-year glycaemic trajectories in patients with non-newly diagnosed type 2 diabetes mellitus in Chinese primary care.

METHODS

This was an observational, multi-centre, longitudinal, retrospective cohort study. Clinical data of 4690 subjects were extracted from electronic medical records, including serial glycated haemoglobin A_1c (HbA_1c) measurements, antidiabetic medication records and compliance to exercise, diet, medications and self-monitoring of blood glucose (SMBG). Patterns of longitudinal HbA1c trajectories were identified using the percentage of HbA_1c measurements <7.5% from the second available HbA_1c measurement. Clinical relevance of the clusters was assessed through multivariable analysis.

RESULTS

Approximately half of the participants demonstrated good glycaemic control; of these, 34.5% demonstrated stable, good control, and 13.7% demonstrated relatively good control. About 16.2% demonstrated moderate control, and 35.6% demonstrated poor control. From the good to poor control groups, the percentage of subjects treated with insulin at baseline and during the follow-up period increased gradually, while the percentage of subjects adhering to exercise, diet, medications and SMBG decreased gradually. Compared with baseline, the adherence to exercise, diet, medications and SMBG improved significantly. Approximately 50% and 26% of subjects in the two poorest control groups, respectively, experienced treatment changes. After multivariable adjustments, baseline HbA_1c ≥7.5%, HbA_1c change ≥-0.5% from baseline to visit 1, insulin treatment, treatment change, poor adherence to diet, exercise, SMBG during the follow-up period and HbA_1c measurements <3 per year were significantly associated with poorer glycaemic control.

CONCLUSION

We identified four longitudinal HbA_1c trajectories in patients with non-newly diagnosed type 2 diabetes. Even if baseline HbA_1c is suboptimal, aggressive treatment changes, good adherence during the follow-up period, ≥3 HbA_1c measurements per year and reducing HbA_1c levels to a certain extent by the first follow-up visit were important for good, stable, long-term glycaemic control.

Screening for thyroid disease in patients with type 2 diabetes mellitus: An evaluation of current practice

BACKGROUND

United Kingdom national guidelines do not recommend routine testing for thyroid disease in people with type 2 diabetes mellitus (T2DM). However, some studies suggest an increased risk of thyroid dysfunction in T2DM. The aim of this study was to evaluate the current practice of screening for thyroid disease in patients with T2DM.

METHODS

Patients with pre-existing T2DM (n = 339) were selected from records for routine glycated haemoglobin testing performed in December 2008. Using routinely collected primary/secondary care data from 2009 to 2017, we examined longitudinal thyroid-stimulating hormone and free thyroxine requests to determine the overall proportion of patients screened for thyroid dysfunction and the time interval between thyroid tests requested.

RESULTS

Thirty-three patients (9.7%) had pre-existing thyroid disease. Of the remaining 306 patients, 96.4% had at least one thyroid test during the follow-up period. When the time interval between tests was evaluated in these patients, there was a discrete peak in thyroid function test requests at 12 months, consistent with routine annual testing. Most requests (77%) originated from a general practice setting.

CONCLUSIONS

Contrary to current guidelines, we have provided evidence suggestive of regular screening for thyroid dysfunction in patients with T2DM, particularly in general practice. The appropriateness of this practice remains unclear, but may warrant further examination to assess the clinical benefits of screening, balanced against cost.

Diabetes INSIDE: Improving Population HbA1c Testing and Targets in Primary Care With a Quality Initiative

OBJECTIVE

To improve outcomes of patients with adult type 2 diabetes by decreasing HbA_1c undertesting, reducing the proportion of patients with poor glycemic control, and lowering mean HbA_1c levels using a quality improvement (QI) program.

RESEARCH DESIGN AND METHODS

Six years of outpatient electronic health record (EHR) data were analyzed for care gaps before and 2 years after implementing a QI initiative in an urban academic medical center. QI strategies included 1) individual provider and departmental outcome reports, 2) patient outreach programs to address timely follow-up care, 3) a patient awareness campaign to improve understanding of achieving clinical goals, 4) improving EHR data capture to improve population monitoring, and 5) professional education.

RESULTS

Analysis (January 2010 to May 2018) of 7,798 patients from Tulane Medical Center (mean age 61 years, 57% female, 62% black, 97% insured) with 136,004 visits showed target improvements. A Cox proportional hazards model controlling for age, sex, race, and HbA_1c level showed a statistically significant reduction in HbA_1c undertesting >6 months (hazard ratio 1.20 ± 0.07). Statistical process control charts showed 15.5% relative improvement in the patient proportion with HbA_1c >9% (75 mmol/mol) from 13% to 11% (P < 10^-6) following QI interventions and a 2.1% improvement of population mean HbA_1c from 7.4% (57 mmol/mol) to 7.2% (55 mmol/mol) (P < 10^-6).

CONCLUSIONS

Multidisciplinary QI teams using EHR data to design interventions for providers and patients produced statistically significant improvements in both care process and clinical outcome goals.

The frequency of testing for glycated haemoglobin, HbA1c, is linked to the probability of achieving target levels in patients with suboptimally controlled diabetes mellitus

Background We previously showed, in patients with diabetes, that >50% of monitoring tests for glycated haemoglobin (HbA1c) are outside recommended intervals and that this is linked to diabetes control. Here, we examined the effect of tests/year on achievement of commonly utilised HbA1c targets and on HbA1c changes over time. Methods Data on 20,690 adults with diabetes with a baseline HbA1c of >53 mmol/mol (7%) were extracted from Clinical Biochemistry Laboratory records at three UK hospitals. We examined the effect of HbA1c tests/year on (i) the probability of achieving targets of ≤53 mmol/mol (7%) and ≤48 mmol/mol (6.5%) in a year using multi-state modelling and (ii) the changes in mean HbA1c using a linear mixed-effects model. Results The probabilities of achieving ≤53 mmol/mol (7%) and ≤48 mmol/mol (6.5%) targets within 1 year were 0.20 (95% confidence interval: 0.19-0.21) and 0.10 (0.09-0.10), respectively. Compared with four tests/year, having one test or more than four tests/year were associated with lower likelihoods of achieving either target; two to three tests/year gave similar likelihoods to four tests/year. Mean HbA1c levels were higher in patients who had one test/year compared to those with four tests/year (mean difference: 2.64 mmol/mol [0.24%], p<0.001). Conclusions We showed that ≥80% of patients with suboptimal control are not achieving commonly recommended HbA1c targets within 1 year, highlighting the major challenge facing healthcare services. We also demonstrated that, although appropriate monitoring frequency is important, testing every 6 months is as effective as quarterly testing, supporting international recommendations. We suggest that the importance HbA1c monitoring frequency is being insufficiently recognised in diabetes management.

Prevalence of diabetes and frequency of glycated haemoglobin monitoring in Extremadura (Spain) during 2012, 2013 and 2014: An observational study

AIMS

To analyze the prevalence of diabetes and the frequency of haemoglobin A_1C (HbA_1C) monitoring in the population with diabetes in Extremadura (Spain).

METHODS

Observational, longitudinal retrospective study in the population attended in the Extremadura Health System in 2012-2014. A total of 403,644 glycated haemoglobin determinations in 189,466 subjects (52.4% female) were studied. All patients with a prescription of antidiabetic drugs and those who, despite not having treatment, had any determination of HbA_1C ≥6.5% were considered as people with diabetes. All patients without treatment but with HbA_1C ≥5.7% and <6.5% were considered prediabetes patients.

RESULTS

The prevalence rate of diabetes was 8.3% and the frequency of HbA_1C monitoring was 0.9/patient/year in the diabetic population. 48.2% of the patients with monitoring of HbA_1C had diabetes, 21.2% had prediabetes, and 30.6% did not meet the criteria for diabetes or prediabetes. 12.7% of people with diabetes did not have determinations of HbA_1C and only 11.8% have had ≥6 determinations in the period analyzed.

CONCLUSIONS

The frequency of HbA_1C monitoring in the diabetic population is lower than that usually recommended. Moreover, there is an inadequate use of HbA_1C determinations, since one out of every 3 patients does not meet the criteria for diabetes or prediabetes.

Timings for HbA1c testing in people with diabetes are associated with incentive payments: an analysis of UK primary care data

AIMS

Guidelines recommend testing HbA1c every 3-6 months in people with diabetes. In the United Kingdom (UK), primary care clinics are financially incentivized to monitor HbA1c at least annually and report proportions of patients meeting targets on 31 March. We explored the hypothesis that this reporting deadline may be associated with over-frequent or delayed HbA1c testing.

METHODS

This analysis used HbA1c results from 100 000 people with diabetes during 2005-2014 in the Clinical Practice Research Datalink UK primary care database. Logistic regression was used to explore whether the four months prior to the deadline for quality reporting (December to March) or individual's previous HbA1c were aligned with retesting HbA1c within 60 days or > 1 year from the previous test, and identify other factors associated with the timing of HbA1c testing.

RESULTS

Retesting HbA1c within 60 days or > 1 year was more common in December to March compared with other months of the year (odds ratio 1.06, 95% confidence interval 1.04-1.08 for retesting within 60 days). Those with higher HbA1c were more likely to have a repeat test within 60 days and less likely to have a repeat test > 1 year from the previous test.

CONCLUSIONS

We have found that retesting HbA1c within 60 days and > 1 year from the previous test was more common in December to March compared with the other months of the year. This work suggests that both practice-centred administrative factors and patient-centred considerations may be influencing diabetes care in the UK.

Differences in HbA1C% screening among U.S. adults diagnosed with diabetes: Findings from the National Health and Nutrition Examination Survey (NHANES)

AIMS

To assess differences in HbA1C% screening by health care providers (HCP's) in U.S. adults with previously diagnosed diabetes using nationally representative survey data collected during the National Health and Nutrition Examination Survey (NHANES).

METHODS

Cross-sectional analysis of 1725 adults from the 2011-2016 NHANES. Logistic regression was used to calculate the adjusted odds ratios for having received HbA1C% screening from a health care provider in the past year for the entire population, as well as separately based on an individual's self-reported health insurance status.

RESULTS

Individuals with health insurance, a history of hypertension, a history of high cholesterol, a higher frequency of visits to a health care provider, and those surveyed during the 2015-2016 NHANES were all significantly more likely to have been screened for HbA1C% in the past year. When compared to Non-Hispanic Whites however, both Hispanic Americans (aOR 0.38 (95% CI, 0.25-0.60) and African Americans (aOR 0.53 (95% CI, 0.32-0.87) with health insurance were significantly less likely to have been screened for HbA1C% in the past year.

CONCLUSION

Our results indicate that despite having health insurance, people of color who have diabetes are significantly less likely to have their HbA1C% monitored by a health care provider.

Low annual frequency of HbA1c testing in people with Type 2 diabetes in primary care practices in Germany

AIMS

To analyse the annual frequency of HbA_1c testing, as well as the factors associated with higher or lower testing frequency, in people with Type 2 diabetes mellitus in general practices and specialist diabetes practices in Germany.

METHODS

A total of 43 509 people diagnosed with Type 2 diabetes between January 2016 and December 2016 in 557 medical practices (51% of all practices) were included in this study. The primary outcome was the annual recorded frequency of HbA_1c testing in 2016. Multivariable logistic regression analyses were performed to identify variables associated with the odds of HbA_1c concentration being tested at least twice in 2016, using predefined demographic and clinical variables.

RESULTS

The mean (sd) number of reported HbA_1c tests was 2.7 (1.6) in 2016. Overall, 74% of individuals had at least two annual HbA_1c measurements. The likelihood of receiving ≥2 HbA_1c tests was inversely associated with stroke (odds ratio 0.81, 95% CI 0.74-0.89), shorter diabetes duration (≤1 year: odds ratio 0.77, 95% CI 0.70-0.84) and higher mean HbA_1c concentration (≥8.5%: odds ratio 0.85, 95% CI 0.76-0.94) and was positively associated with specialist diabetes care (odds ratio 1.24, 95% CI 1.14-1.36), hypertension (odds ratio 1.10, 95% CI 1.04-1.17), hyperlipidaemia (odds ratio 1.48, 95% CI 1.41 to 1.55), renal complications (odds ratio 1.41, 95% CI 1.32 to 1.50), neuropathy (odds ratio 1.27, CI 1.20 to 1.35) and retinopathy (odds ratio 1.38, 95% CI 1.25 to 1.52).

CONCLUSIONS

Only three out of four individuals with Type 2 diabetes underwent at least two HbA_1c tests in Germany in 2016, which means that 25% of individuals underwent fewer tests than required by German guidelines.

Improving type 2 diabetes mellitus glycaemic outcomes is possible without spending more on medication: Lessons from the UK National Diabetes Audit

AIMS

To determine the factors at general practice level that relate to glycaemic control outcomes in people with type 2 diabetes (T2DM).

METHODS

Data were accessed from 4050 general practices (50% of total) covering 1.6 million patients with T2DM in the UK National Diabetes Audit 2013 to 2014 and 2014 to 2015. This audit reported characteristics, services and outcomes in the T2DM population, including percentage of patients who had total glycaemic control (TGC), defined as glycated haemoglobin (HbA1c) ≤7.5% (58 mmol/mol), and the percentage who were at higher glycaemic risk (HGR), defined as HbA1c >10% (86 mmol/mol); the respective figures were 67.2% and 6.2%. The medication data were examined in terms of annual defined daily doses (DDDs). Multivariate linear regression analysis was used to identify associations between DDD and patient and practice characteristics.

RESULTS

Over the period 2012/2013 to 2015/2016, patient numbers grew 4% annually and annual medication expenditure by 8%, but glycaemic control outcomes did not improve. The main findings were that practices with better outcomes: had a higher percentage of patients aged >65 years; provided more effective diabetes services (including case identification, care checks, patient education, percentage of patients with blood pressure and cholesterol under control and more patients with type 1 diabetes achieving target HbA1c levels); spent less overall on prescribing per patient with T2DM; and on average, prescribed fewer sulphonylureas, less insulin (for patients with T2DM), fewer glucagon-like peptide-1 agonists, more metformin, more dipeptidyl peptidase-4 inhibitors, and more blood glucose monitoring strips. Ethnicity and social disadvantage and levels of thiazolidinedione (glitazone) prescribing had no significant impact on outcomes. Sodium-glucose co-transporter-2 inhibitor use was too low for an effect to be observed in the period examined.

CONCLUSIONS

If all practices brought their service and medication to the level of the top decile practices, they could achieve 74.7% compared with the median of 67.3% of patients achieving TGC, showing an increase of 213 000 in patients achieving TGC, while reducing the number at HGR to 3.8% compared with 6.1%, benefiting 62 000 patients. This could have a major impact on the overall consequent healthcare costs of managing diabetes complications with their attendant mortality risks.

Targeted Adherence Intervention to Reach Glycemic Control with Insulin Therapy for patients with Diabetes (TARGIT-Diabetes): rationale and design of a pragmatic randomised clinical trial

INTRODUCTION

Adherence to and persistence of medications for chronic diseases remains poor and many interventions to improve medication use have only been modestly effective. Targeting interventions to patients who are most likely to benefit should improve their efficiency and clinical impact. This study aims to test the impact of three cost-equivalent pharmacist-led interventions on insulin persistence and glycaemic control among patients with diabetes.

METHODS AND ANALYSIS

TARGIT-Diabetes (Targeted Adherence Intervention to Reach Glycemic Control with Insulin Therapy for patients with Diabetes) is a randomised controlled trial that will evaluate three different multifaceted pharmacist-outreach strategies for improving long-term insulin use among individuals with diabetes. We will randomise 6000 patients in a large insurer to one of three arms. The arms are designed to deliver an increasingly intensive intervention to a progressively targeted population, identified using predictive analytics. The central component of the intervention in all arms is a tailored telephone consultation with a pharmacist which varies across arms based on the: (A) proportion of patients offered the intervention and (B) intervention intensity, including follow-up frequency and cointerventions such as text reminders and interactions with patients' providers. The primary outcome is insulin persistence, assessed using pharmacy claims data, and the secondary outcomes are glycaemic control as measured by glycosylated haemoglobin values, healthcare utilisation and healthcare spending.

ETHICS AND DISSEMINATION

This protocol has been approved by the Institutional Review Board of Brigham and Women's Hospital and the Privacy Board of Horizon Blue Cross Blue Shield of New Jersey. We plan to present the results of this trial at national meetings and in manuscripts submitted to peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT 02846779.

Characterizing Active Ingredients of eHealth Interventions Targeting Persons With Poorly Controlled Type 2 Diabetes Mellitus Using the Behavior Change Techniques Taxonomy: Scoping Review

BACKGROUND

The behavior change technique taxonomy v1 (BCTTv1; Michie and colleagues, 2013) is a comprehensive tool to characterize active ingredients of interventions and includes 93 labels that are hierarchically clustered into 16 hierarchical clusters.

OBJECTIVE

The aim of this study was to identify the active ingredients in electronic health (eHealth) interventions targeting patients with poorly controlled type 2 diabetes mellitus (T2DM) and relevant outcomes.

METHODS

We conducted a scoping review using the BCTTv1. Randomized controlled trials (RCTs), studies with or pre-post-test designs, and quasi-experimental studies examining efficacy and effectiveness of eHealth interventions for disease management or the promotion of relevant health behaviors were identified by searching PubMed, Web of Science, and PsycINFO. Reviewers independently screened titles and abstracts for eligibility using predetermined eligibility criteria. Data were extracted following a data extraction sheet. The BCTTv1 was used to characterize active ingredients of the interventions reported in the included studies.

RESULTS

Of the 1404 unique records screened, 32 studies fulfilled the inclusion criteria and reported results on the efficacy and or or effectiveness of interventions. Of the included 32 studies, 18 (56%) were Web-based interventions delivered via personal digital assistant (PDA), tablet, computer, and/or mobile phones; 7 (22%) were telehealth interventions delivered via landline; 6 (19%) made use of text messaging (short service message, SMS); and 1 employed videoconferencing (3%). Of the 16 hierarchical clusters of the BCTTv1, 11 were identified in interventions included in this review. Of the 93 individual behavior change techniques (BCTs), 31 were identified as active ingredients of the interventions. The most common BCTs identified were instruction on how to perform behavior, adding objects to the environment, information about health consequences, self-monitoring of the outcomes and/or and prefers to be explicit to avoid ambiguity. Response: Checked and avoided of a certain behavior Author: Please note that the journal discourages the use of parenthesis to denote either and/or and prefers to be explicit to avoid ambiguity. Response: Checked and avoided "and/or" and prefers to be explicit to avoid ambiguity. Response: Checked and avoided, and feedback on outcomes of behavior.

CONCLUSIONS

Our results suggest that the majority of BCTs employed in interventions targeting persons with T2DM revolve around the promotion of self-regulatory behavior to manage the disease or to assist patients in performing health behaviors necessary to prevent further complications of the disease. Detailed reporting of the BCTs included in interventions targeting this population may facilitate the replication and further investigation of such interventions.

Both the frequency of HbA1c testing and the frequency of self-monitoring of blood glucose predict metabolic control: A multicentre analysis of 15 199 adult type 1 diabetes patients from Germany and Austria

BACKGROUND

The objective of this study was to examine the association between metabolic control and frequency of haemoglobin A_1c (HbA_1c ) measurements and of self-monitoring of blood glucose, as well as the interaction of both.

METHODS

Data of 15 199 adult type 1 diabetes patients registered in a standardized electronic health record (DPV) were included. To model the association between metabolic control and frequency of HbA_1c testing or of self-monitoring of blood glucose, multiple hierarchic regression models with adjustment for confounders were fitted. Tukey-Kramer test was used to adjust P values for multiple comparisons. Vuong test was used to compare non-nested models.

RESULTS

The baseline variables of the study population were median age 19.9 [Q1; Q3: 18.4; 32.2] years and diabetes duration 10.4 [6.8; 15.7] years. Haemoglobin A_1c was 60.4 [51.5; 72.5] mmol/mol. Frequency of HbA_1c testing was 8.0 [5.0; 9.0] within 2 years, and daily self-monitoring of blood glucose frequency was 5.0 [4.0; 6.0]. After adjustment, a U-shaped association between metabolic control and frequency of HbA_1c testing was observed with lowest HbA_1c levels in the 3-monthly HbA_1c testing group. There was an inverse relationship between self-monitoring of blood glucose and HbA_1c with lower HbA_1c associated with highest frequency of testing (>6 daily measurements). Quarterly HbA_1c testing and frequent self-monitoring of blood glucose were associated with best metabolic control. The adjusted Vuong Z statistic suggests that metabolic control might be better explained by HbA_1c testing compared to self-monitoring of blood glucose (P < .0001).

CONCLUSION

This research reveals the importance of quarterly clinical HbA_1c monitoring together with frequent self-monitoring of blood glucose in diabetes management to reach and maintain target HbA_1c .

Regional variations in frequency of glycosylated hemoglobin (HbA1c) monitoring in Korea: A multilevel analysis of nationwide data

PURPOSE

Suboptimal frequency of glycosylated hemoglobin (HbA1c) monitoring is associated with poor diabetes control. We aimed to analyze compliance to HbA1c testing guidelines and explore associated individual and area-level determinants, focusing on regional variation.

METHODS

This cross-sectional study between the period of 2012-2013 was conducted by using the Korean National Health Insurance Research Database, and included 45,634 patients diagnosed with diabetes mellitus, who were prescribed any anti-diabetic medications, including insulin. We calculated the proportion of each HbA1c testing frequency (≥1, ≥2, or ≥4 times per year) stratified by 17 administrative regions. Multilevel and multivariate logistic analyses were performed with regional (proportion of farmer population) and individual characteristics (age, sex, income level, duration of diabetes, and most visited medical institution).

RESULTS

Overall, 67.3% of the patients received≥1 HbA1c test per year; 37.8% and 6.1% received ≥2 and ≥4 tests per year, respectively. Those managed in secondary-level hospitals or clinics and those living in rural areas were less likely to receive HbA1c testing. Even after adjusting for individual and regional level characteristics, significant area level variation was observed (variance participant coefficients were 7.91%, 9.58%, and 14.43% for testing frequencies of ≥1, ≥2, and ≥4 times a year, respectively).

CONCLUSIONS

The frequency of HbA1c monitoring is suboptimal in Korea, especially in rural areas. Moreover, significant regional variation was observed, implying a contextual effect. This suggests the need for developing policy actions to improve HbA1c monitoring. In particular, access to HbA1c testing in rural primary care clinics must be improved.

The Australasian Diabetes Data Network: first national audit of children and adolescents with type 1 diabetes

OBJECTIVES

To assess glycaemic control, anthropometry and insulin regimens in a national sample of Australian children and adolescents with type 1 diabetes.

DESIGN

Cross-sectional analysis of de-identified, prospectively collected data from the Australasian Diabetes Data Network (ADDN) registry.

SETTING

Five paediatric diabetes centres in New South Wales, Queensland, South Australia, Victoria and Western Australia.

PARTICIPANTS

Children and adolescents (aged 18 years or under) with type 1 diabetes of at least 12 months' duration for whom data were added to the ADDN registry during 2015.

MAIN OUTCOME MEASURES

Glycaemic control was assessed by measuring haemoglobin A1c (HbA1c) levels. Body mass index standard deviation scores (BMI-SDS) were calculated according to the CDC-2000 reference; overweight and obesity were defined by International Obesity Task Force guidelines. Insulin regimens were classified as twice-daily injections (BD), multiple daily injections (MDI; at least three injection times per day), or continuous subcutaneous insulin infusion (CSII).

RESULTS

The mean age of the 3279 participants was 12.8 years (SD, 3.7), mean diabetes duration was 5.7 years (SD, 3.7), and mean HbA1c level 67 mmol/mol (SD, 15); only 27% achieved the national HbA1c target of less than 58 mmol/mol. The mean HbA1c level was lower in children under 6 (63 mmol/mol) than in adolescents (14-18 years; 69 mmol/mol). Mean BMI-SDS for all participants was 0.6 (SD, 0.9); 33% of the participants were overweight or obese. 44% were treated with CSII, 38% with MDI, 18% with BD.

CONCLUSIONS

Most Australian children and adolescents with type 1 diabetes are not meeting the recognised HbA1c target. The prevalence of overweight and obesity is high. There is an urgent need to identify barriers to achieving optimal glycaemic control in this population.

Are Ethnic Disparities in HbA1c Levels Explained by Mental Wellbeing? Analysis of Population-Based Data from the Health Survey for England

Aims

It is unclear how ethnic differences in HbA_1c levels are affected by individual variations in mental wellbeing. Thus, the aim of this study was to assess the extent to which HbA_1c disparities between Caucasian and South Asian adults are mediated by various aspects of positive psychological functioning.

Methods

Data from the 2014 Health Survey for England was analysed using bootstrapping methods. A total of 3894 UK residents with HbA_1c data were eligible to participate. Mental wellbeing was assessed using the Warwick-Edinburgh Mental Well-being Scale. To reduce bias BMI, blood pressure, diabetes status, and other factors were treated as covariates.

Results

Ethnicity directly predicted blood sugar control (unadjusted coefficient −2.15; 95% CI −3.64, −0.67), with Caucasians generating lower average HbA_1c levels (37.68 mmol/mol (5.6%)) compared to South Asians (39.87 mmol/mol (5.8%)). This association was mediated by positive mental wellbeing, specifically concerning perceived vigour (unadjusted effect 0.30; 95% CI 0.13, 0.58): South Asians felt more energetic than Caucasians (unadjusted coefficient −0.32; 95% CI −0.49, −0.16), and greater perceived energy predicted lower HbA_1c levels (unadjusted coefficient −0.92; 95% CI −1.29, −0.55). This mediator effect accounted for just over 14% of the HbA_1c variance and was negated after adjusting for BMI.

Conclusions

Caucasian experience better HbA_1c levels compared with their South Asian counterparts. However, this association is partly confounded by individual differences in perceived energy levels, which is implicated in better glycaemic control, and appears to serve a protective function in South Asians.

Evaluation of a Behavioral Intervention With Multiple Components Among Low-Income and Uninsured Adults With Obesity and Diabetes

Purpose:

To examine the effects of a community-based behavioral intervention with multiple components on health outcomes among low-income and uninsured adults who were obese and had diabetes and treated in a “real-world” setting.

Design:

A longitudinal design with a retrospective comparison group was used to examine the ability of a health promotion program to improve body mass index (BMI) and hemoglobin A1c (HbA1c) among 87 treatment group and 62 comparison group participants.

Setting:

Urban/metropolitan city in the United States.

Intervention:

A community-based behavioral intervention with 3 components including health-coach visits, registered dietitian visits, and exercise consultations delivered over 12 months.

Measures:

Biometric measurements were collected at baseline, 3, 6, 9, 12, and 18 months, whereas self-reported measurements were collected at baseline, 6 months, and 12 months.

Analysis:

Linear mixed models with participant-level random intercepts were fitted for BMI and HbA1c.

Results:

The treatment group demonstrated reductions in BMI (percentage change = −2.1%, P < .001) and HbA1c (−0.6%, P < .001) as well as improvement in diabetes knowledge (+5.4%, P = .025), whereas the comparison group did not show any improvements in biometric measures. Dietitian visits were the most effective treatment component to reduce HbA1c (coefficient = −0.08, P = .025).

Conclusion:

Multiple component behavioral intervention in community settings, particularly when delivered by registered dietitians, shows promise to combat the dual epidemic of obesity and diabetes among low-income and uninsured patients.

Resource use associated with type 2 diabetes in Africa, the Middle East, South Asia, Eurasia and Turkey: results from the International Diabetes Management Practice Study (IDMPS)

OBJECTIVE

Type 2 diabetes (T2D) and its complications form a global healthcare burden but the exact impact in some geographical regions is still not well documented. We describe the healthcare resource usage (HRU) associated with T2D in Africa, the Middle East, South Asia, Eurasia and Turkey.

RESEARCH DESIGN AND METHODS

In the fifth wave of the International Diabetes Management Practices Study (IDMPS; 2011-2012), we collected self-reported and physician-reported cross-sectional data from 8156 patients from 18 countries across 5 regions, including different types of HRU in the previous 3-6 months. Negative binomial regression was used to identify parameters associated with HRU, using incidence rate ratios (IRRs) to express associations.

RESULTS

Patients in Africa (n=2220), the Middle East (n=2065), Eurasia (n=1843), South Asia (n=1195) and Turkey (n=842) experienced an annual hospitalization rate (mean±SD) of 0.6±1.9, 0.3±1.2, 1.7±4.1, 0.4±1.5 and 1.3±2.7, respectively. The annual number of diabetes-related inpatient days (mean±SD) was 4.7±22.7, 1.1±6.1, 16.0±30.0, 1.5±6.8 and 10.8±34.3, respectively. Despite some inter-regional heterogeneity, macrovascular complications (IRRs varying between 1.4 and 8.9), microvascular complications (IRRs varying between 3.4 and 4.3) and, to a large extent, inadequate glycemic control (IRRs varying between 1.89 and 10.1), were independent parameters associated with hospitalization in these respective regions.

CONCLUSIONS

In non-Western countries, macrovascular/microvascular complications and inadequate glycemic control were common and important parameters associated with increased HRU.

Membership in a diabetes-care network and adherence to clinical practice guidelines for treating type 2 diabetes among general practitioners: A four-year follow-up

OBJECTIVES

To assess whether private general practitioners (GPs) belonging to a diabetes-care network adhered more closely to clinical practice guidelines for diabetes care than GPs not in such a network, for all their patients with type 2 diabetes treated with medication (patients with diabetes), regardless of whether they received care through a network (that is, whether a halo effect occurred).

RESEARCH DESIGN AND MEASURES

The study, based on health insurance reimbursement databases in southeastern France, included 468 GPs in two networks and 468 non-network GPs in the same geographical area, matched one-to-one by propensity scores. We followed up their patients with diabetes (n=22,808) from 2008 through 2011, conducting multivariate time-to-event analyses (Cox models) that took the matching design into account to evaluate time from inclusion until performance of the given number of each of six recommended examinations/tests.

RESULTS

GPs belonging to a diabetes-care network adhered more closely to clinical practice guidelines but our result were slightly pronounced. Hazard ratios (HR) were significantly higher for patients of network GPs for the implementation of 3 HbA1C assays (HRa=1.13; [95%CI=1.10-1.16]), or 1 microalbuminuria assay (1.4 [1.35-1.45]); they were lower for LDL-cholesterol assays (1.04 [1.01-1.07]) and ophthalmological checkups (1.07 [1.04-1.10]), and not significant for creatinemia or cardiac monitoring.

CONCLUSIONS

Network GPs had better diabetes monitoring practices for all their patients with diabetes than the other GPs, especially for the most diabetes-specific tests. Further research is needed in other settings to confirm the existence of this halo effect.

The Glucose Measurement Industry and Hemoglobin A1c: An Opportunity for Creative Destruction

The MyStar Extra self-monitoring blood glucose (SMBG) system provides moving estimates of the patient's hemoglobin A1c (HbA1c). There is a treasure trove of highly accurate glucose data available from highly accurate SMBG, CGM and FGM along with highly accurate HPLC HbA1c. If Nathan's criteria are used to select subjects whose glucoses can be correlated to the HbA1c, then algorithms can be developed for robustly transforming glucose into HbA1c. These algorithms can then be implemented in any SMBG or with the CGM and FGM software. This calculated HbA1c would even be accurate with Nathan's excluded population thus reducing the use of fructosamine and glycated protein. Finally, the developer of these new algorithms is advised to use a specific approach for testing her algorithm.