Overview of Therapeutic Inertia in Diabetes: Prevalence, Causes, and Consequences

Use of Antihyperglycemic Medications Among US People with Limited English Proficiency

BACKGROUND

Language barriers can impact pharmaceutical disease management leading to potential health disparities among limited English proficiency (LEP) people with diabetes mellitus (DM) in the United States (US).

OBJECTIVE

To assess the use of antihyperglycemic medications and estimate their impact on glycemic control by LEP status.

DESIGN

Cross-sectional design. We compared the classes of prescribed antihyperglycemic medications and their impact on glycemic control between English-speaking and LEP participants (i.e., Spanish-speaking or needing interpretation services) with DM applying generalized linear models and adjusting for sociodemographic variables.

PARTICIPANTS

Data from the US National Health and Nutrition Examination Survey (NHANES 2003-2018).

MAIN MEASURES

Selected language for interview or interpreter request (main exposure). Outcomes include prescribed antihyperglycemic medications and glycemic control (HBA1c).

KEY RESULTS

Data for 4666 participants with DM were analyzed. Antihyperglycemic medications were similarly used by LEP and English-speaking people with DM, except for insulin, which was less frequently used by LEP people. Despite similar medications, LEP people using biguanides and TZDs were less likely to reach glycemic target levels (adjusted odds ratios ranging 1.7 to 3.3) compared to English-speaking people with DM.

CONCLUSIONS

Our findings indicate that the differences in DM outcomes among LEP people are likely attributed to factors other than medication prescription. These might include cultural beliefs, dietary adjustments, and communication barriers in healthcare. Enhanced patient education, acknowledgment of cultural practices, and improved language services could potentially mitigate these disparities.

Overcoming therapeutic inertia in newly diagnosed type 2 diabetes: Protocol of a randomized, quality improvement trial

Therapeutic inertia, the delay in the appropriate initiation and intensification of recommended therapies, is a major contributor to the lack of improvement in type 2 diabetes outcomes over the past decade. Therapeutic inertia during the period following diagnosis, when improvements in glycemic control can have lasting benefits, is often overlooked. Technology and team-based care approaches can effectively address therapeutic inertia. Here, we describe the protocol for a randomized, quality improvement trial targeting metformin-related therapeutic inertia among adults with recently diagnosed type 2 diabetes and a hemoglobin A1c <8 %. Service areas within an integrated healthcare delivery system were randomized to 1) usual care, 2) physician education on therapeutic inertia, and 3) physician education on therapeutic inertia paired with proactive outreach by a clinical pharmacist. The physician education sessions were offered to primary care providers working in the service areas randomized to Arm 2 and Arm 3, and proactive outreach by a clinical pharmacist was performed for patients of the providers in service areas randomized to Arm 3. Outcomes will be abstracted from the EHR at 6, 12, and 18 months following the physician education sessions. The primary outcome will be the proportion of patients with an HbA1c <7 % at each of the follow-up time points. Outcome abstraction and analyses will occur in late 2024. This trial seeks to rigorously evaluate care strategies that can shift stagnant type 2 diabetes outcomes. Our protocol, along with the pending results, may offer examples to other healthcare systems working to improve type 2 diabetes care.

Cardiologists vs Endocrinologists in Glycemic Control for Coronary Artery Disease Patients with Type 2 Diabetes: A Cross-Sectional Study

Background

The comorbidity of coronary artery disease (CAD) and type 2 diabetes mellitus (T2DM) presents significant challenges in clinical management, particularly regarding glycemic control. The clinical management of CAD complicated by T2DM requires coordinated glycemic control, as poor management can exacerbate cardiovascular risks and increase morbidity and mortality. While endocrinologists traditionally manage diabetes, cardiologists are increasingly involved due to the cardiovascular risks associated with poor glycemic control. This study explores the current practices of glycemic management by cardiologists and endocrinologists in patients with CAD and T2DM, focusing on treatment intensification in a Chinese hospital setting.

Methods

This cross-sectional study included 1,074 hospitalized patients with both CAD and T2DM, admitted to the Cardiology Department of Ruijin Hospital between January 2021 and December 2023. Data were retrospectively collected from electronic medical records, including demographic information, clinical characteristics, and treatment interventions. Patients were stratified by year, and differences in treatment strategies between cardiologists and endocrinologists were analyzed. Glycemic control was assessed using HbA1c levels, with treatment intensification defined by any adjustment in antidiabetic therapy and consideration for comprehensive cardiovascular risk factors.

Results

Endocrinologists were significantly more likely to initiate treatment intensification, especially in cases of severe hyperglycemia (HbA1c ≥9.0%), while cardiologists' role in glycemic management was limited, with a preference for outpatient endocrinology referrals over in-hospital adjustments. Despite improvements in glycemic control, the percentage of patients achieving comprehensive cardiovascular risk management targets remained low.

Conclusion

This study underscored the distinct yet complementary roles of cardiologists and endocrinologists in managing glycemic control among patients with CAD and T2DM, noting endocrinologists' more active involvement in treatment intensification. Future integrated care models should harness the unique expertise of both specialties to optimize patient outcomes, better address glycemic control needs, and enhance overall cardiovascular risk management in this high-risk patient population.

Clinical Outcomes of Rural Patients with Diabetes Treated by ECHO-Trained Providers Versus an Academic Medical Center

BACKGROUND

Despite clinical practice guidelines prioritizing cardiorenal risk reduction, national trends in diabetes outcomes, particularly in rural communities, do not mirror the benefits seen in clinical trials with emerging therapeutics and technologies.

OBJECTIVE

Project ECHO supports implementation of guidelines in under-resourced areas through virtual communities of practice, sharing of best practices, and case-based learning. We hypothesized that diabetes outcomes of patients treated by ECHO-trained primary care providers (PCPs) would be similar to those of patients treated by specialists at an academic medical center.

DESIGN

Specialists from the University of New Mexico (UNM) launched a weekly diabetes ECHO program to mentor dyads consisting of a PCP and community health worker at ten rural clinics.

PARTICIPANTS

We compared cardiorenal risk factor changes in patients with diabetes treated by ECHO-trained dyads to patients treated by specialists at the UNM Diabetes Comprehensive Care Center (DCCC). Eligible participants included adults with type 1 diabetes, type 2 diabetes on insulin, or diabetes of either type with A1c > 9%.

MAIN MEASURES

The primary outcome was change from baseline in A1c in the ECHO and DCCC cohorts. Secondary outcomes included changes in body mass index (BMI), blood pressure, cholesterol, and urine albumin to creatinine ratio (UACR).

KEY RESULTS

Compared to the DCCC cohort (n = 151), patients in the ECHO cohort (n = 856) experienced greater A1c reduction (-1.2% vs -0.6%; p = 0.02 for difference in difference). BMI decreased in the Endo ECHO cohort and increased in the DCCC cohort (-0.2 vs. +1.3 kg/m2; p = 0.003 for difference in difference). Diastolic blood pressure declined in the Endo ECHO cohort only. Improvements of similar magnitude were observed in low-density lipoprotein cholesterol in both groups. UACR remained stable in both groups.

CONCLUSIONS

ECHO may be a suitable intervention for improving diabetes outcomes in rural, under-resourced communities with limited access to a specialist.

The effect of oral supplementation of ginger on glycemic control of patients with type 2 diabetes mellitus - A systematic review and meta-analysis

BACKGROUND

Ginger, a root originating in Southeast Asia, has several therapeutic benefits to human health, including antioxidant activity. Currently, there are discussions regarding the hypoglycemic properties of dietary supplements derived from its phenolic compounds in the management of chronic diseases. Diabetes mellitus is a chronic and complex disease that requires continuous treatment, with glycemic control being decisive in the management of hyperglycemia.

AIM

This systematic review and meta-analysis aimed to identify the effects of oral supplementation of ginger in the treatment of type 2 diabetes mellitus (T2DM) in patients undergoing randomized clinical trial studies.

METHODS

Across the PubMed, Scopus, and Web of Science databases, randomized controlled trials that examined the role of ginger in T2DM until January 2022 were systematically researched. The parameters used to assess T2DM treatment control were Fasting Blood Glucose (FBS) and glycated hemoglobin (HbA1c). Bias risk assessment of the studies was performed using the RoB 2.0 tool. Meta-analysis was performed considering data compatibility.

RESULTS

Five studies were included in the analysis. Capsules containing Zingiber officinale powder were supplemented twice a day. The dose ranged from 1.2 to 2g/day, and the intervention period ranged from 4 to 12 weeks. Meta-analysis results indicated no significant effect of ginger supplementation on FBS or HbA1c. However, individual studies reported mixed results, with two studies showing a significant reduction in FBS. This suggests that while ginger may have potential as an adjuvant therapy, its overall impact on glycemic control in T2DM is not statistically significant when results are pooled.

CONCLUSION

Currently published articles are still limited, requiring further studies of high methodological quality to verify the effectiveness of ginger supplementation on T2DM parameters control.

A transparent machine learning algorithm uncovers HbA1c patterns associated with therapeutic inertia in patients with type 2 diabetes and failure of metformin monotherapy

AIMS

This study aimed to identify and categorize the determinants influencing the intensification of therapy in Type 2 Diabetes (T2D) patients with suboptimal blood glucose control despite metformin monotherapy.

METHODS

Employing the Logic Learning Machine (LLM), an advanced artificial intelligence system, we scrutinized electronic health records of 1.5 million patients treated in 271 diabetes clinics affiliated with the Italian Association of Medical Diabetologists from 2005 to 2019. Inclusion criteria comprised patients on metformin monotherapy with two consecutive mean HbA1c levels exceeding 7.0%. The cohort was divided into "inertia-NO" (20,067 patients with prompt intensification) and "inertia-YES" (13,029 patients without timely intensification).

RESULTS

The LLM model demonstrated robust discriminatory ability among the two groups (ROC-AUC = 0.81, accuracy = 0.71, precision = 0.80, recall = 0.71, F1 score = 0.75). The main novelty of our results is indeed the identification of two main distinct subtypes of therapeutic inertia. The first exhibited a gradual but steady HbA1c increase, while the second featured a moderate, non-uniform rise with substantial fluctuations.

CONCLUSIONS

Our analysis sheds light on the significant impact of HbA1c levels over time on therapeutic inertia in patients with T2D, emphasizing the importance of early intervention in the presence of specific HbA1c patterns.

Expert Opinion on Optimising Type 2 Diabetes Treatment Using Fixed-Ratio Combination of Basal Insulin and GLP-1 RA for Treatment Intensification and Simplification

The management of type 2 diabetes (T2D) often necessitates treatment intensification, and sometimes simplification to achieve glycaemic targets and mitigate complications. This expert opinion paper evaluates the use and positioning of the fixed-ratio combinations (FRCs) of basal insulin (BI) and glucagon-like peptide 1 receptor agonists (GLP-1 RAs) in optimising T2D management. On the basis of the evidence presented and discussions, these FRCs offer a promising approach for both treatment intensification and simplification in people with suboptimal glucose control despite receiving various therapies. In treatment intensification, FRCs provide a synergistic effect by addressing multiple pathophysiological defects contributing to hyperglycaemia. These FRCs effectively control both fasting and postprandial glucose (PPG) excursions, offering significantly improved glycaemic control with a lower hypoglycaemia risk and weight neutrality compared to traditional or complex insulin regimens. Moreover, the reduced injection frequency (once daily) and flexibility in the dosing schedule (with any major meal of the day) help mitigate patient resistance to insulin initiation or titration. This further reduces treatment burden, facilitating treatment adherence and enhancing patient convenience. These key benefits of FRCs over complex insulin regimens play a crucial role in long-term glycaemic management and overall treatment outcomes. Hence, the timely use of FRCs in the treatment algorithm for people with T2D represents a valuable strategy for optimising glycaemic control, addressing treatment barriers and enhancing patient-reported outcomes.

Characterizing Myasthenia Gravis Symptoms, Exacerbations, and Crises From Neurologist's Clinical Notes Using Natural Language Processing

Background Myasthenia gravis (MG) is a rare, autoantibody neuromuscular disorder characterized by fatigable weakness. Real-world evidence based on administrative and structured datasets regarding MG may miss important details related to the clinical encounter. Examination of free-text clinical progress notes has the potential to illuminate aspects of MG care. Objective The primary objective was to examine and characterize neurologist progress notes in the care of individuals with MG regarding the prevalence of documentation of clinical subtypes, antibody status, symptomatology, and MG deteriorations, including exacerbations and crises. The secondary objectives were to categorize MG deteriorations into practical, objective states as well as examine potential sources of clinical inertia in MG care. Methods We performed a retrospective, cross-sectional analysis of de-identified neurologist clinical notes from 2017 to 2022. A qualitative analysis of physician descriptions of MG deteriorations and a discussion of risks in MG care (risk for adverse effects, risk for clinical decompensation, etc.) was performed. Results Of the 3,085 individuals with MG, clinical subtypes and antibody status identified included gMG (n = 400; 13.0%), ocular MG (n = 253; 8.2%), MG unspecified (2,432; 78.8%), seropositivity for acetylcholine receptor antibody (n = 441; 14.3%), and MuSK antibody (n = 29; 0.9%). The most common gMG manifestations were dysphagia (n = 712; 23.0%), dyspnea (n = 626; 20.3%), and dysarthria (n = 514; 16.7%). In MG crisis patients, documentation of difficulties with MG standard therapies was common (n = 62; 45.2%). The qualitative analysis of MG deterioration types includes symptom fluctuation, symptom worsening with treatment intensification, MG deterioration with rescue therapy, and MG crisis. Qualitative analysis of MG-related risks included the toxicity of new therapies and concern for worsening MG because of changing therapies. Conclusions This study of neurologist progress notes demonstrates the potential for real-world evidence generation in the care of individuals with MG. MG patients suffer fluctuating symptomatology and a spectrum of clinical deteriorations. Adverse effects of MG therapies are common, highlighting the need for effective, less toxic treatments.

Prevalencia de neuropatía periférica dolorosa y asintomática de un programa de tamizaje para riesgo de pie diabético en un hospital público peruano

Objetivo: determinar la prevalencia de la neuropatía periférica (NP) dolorosa y asintomática en personas con diabetes mellitus tipo 2 (DM2) y sus características asociadas. Materiales y métodos: estudio transversal-descriptivo de pacientes del programa de pie en riesgo del Servicio de Endocrinología del Hospital Nacional María Auxiliadora (HMA). Se incluye a pacientes con DM2 atendidos entre el 2015 y el 2020. La definición de NP fue según el Consenso de Toronto, que considera la evaluación de tres componentes: síntomas, signos y reflejo aquíleo, calificando la certeza como posible y probable, según su combinación. Para la evaluación de síntomas se aplicó el puntaje total de síntomas (TTS, del inglés Total Symptom Score); para los signos se usó la prueba de monofilamento y se evaluó la sensibilidad vibratoria con diapasón de 128 Hz. La prevalencia de NP se calculó según sintomatología y la certeza del diagnóstico. Además, se describieron las características clínicas entre los grupos. Resultados: se incluyó a 1006 personas con una edad media de 60,5 años, de las cuales el 69,3% correspondió a mujeres. En aquellos que tenían al menos un criterio de Toronto (neuropatía posible y probable), un 60,5% presentó NP dolorosa y un 21,8% NP asintomática. Utilizando una mayor certeza diagnóstica, es decir, dos de tres criterios positivos (solo neuropatía probable), la prevalencia de NP dolorosa fue del 42,2% y la NP asintomática, 6,5%. Se establecieron cuatro grupos que presentaron distribuciones diferentes respecto a sexo, tiempo de diabetes, antecedente de úlcera, enfermedad arterial periférica y control glicémico. Conclusión: en pacientes del Servicio de Endocrinología del HMA, el 42,2 y el 6,5% presentaron una mayor certeza de presentar NP probable dolorosa y asintomática respectivamente. Se requiere estudios que confirmen la utilidad de estos criterios para estimar correctamente la carga de enfermedad.

Assessing the use of sodium-glucose cotransporter 2 inhibitor in patients with type 2 diabetes mellitus and chronic kidney disease in tertiary care: a SwissDiab Study

INTRODUCTION

The overall aim of this study was to evaluate the implementation of sodium-glucose cotransporter 2 inhibitors (SGLT2i) among patients in tertiary care with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD).

RESEARCH DESIGN AND METHODS

The cross-sectional analysis was based on outpatients in tertiary diabetes care enrolled in the Swiss Diabetes Registry with T2DM and a study visit January 1, 2020-March 31, 2021. Prevalence of CKD was ascertained as an estimated glomerular filtration rate <60 mL/min/1.73 m2 and/or persistent albuminuria as defined by Kidney Disease Improving Global Outcomes, and the proportion of patients prescribed SGLT2i was determined. Documented reasons for non-treatment with SGLT2i were extracted by a retrospective review of the medical records.

RESULTS

Of 368 patients with T2DM, 1.1% (n=4) were excluded due to missing data. Of the remaining 364 patients, 47.3% (n=172) had CKD of which 32.6% (n=56) were prescribed SGLT2i. The majority (75%) of these patients were on treatment already in 2018, before the renoprotective effects of SGLT2i were established. Among the 116 patients without SGLT2i, 19.0% had known contraindications, 9.5% stopped treatment due to adverse events, 5.2% had other reasons, and no underlying reason for non-treatment could be identified for 66.4%.

CONCLUSIONS

A divergence between recommended standard of care and implementation in daily clinical practice was observed. Although treatment should always consider patient-specific circumstances, the results highlight the need to reinforce current treatment recommendations to ensure patients benefit from the best available care.

Redesigning Diabetes Care for Treatment Inertia: A Population Health Model

In the past 2 decades, health care has witnessed technological and pharmacological advancements leading to innovations in diabetes management. Despite these advances, published guidelines, and treatment algorithms, most people with diabetes remain above glycemic targets. Thus, the authors designed a novel care model aimed at improving several causative factors, including therapeutic inertia, limited access to endocrinology and cardiovascular specialists, time constraints, and complexity in incorporating clinical practice guidelines. The model involves collaboration between the diabetes specialty team and primary care providers (PCPs). The intervention reviewed uncontrolled diabetes data and the patient's electronic medical record (EMR) and sent personalized, evidence-based recommendations to the provider using the task function in the EMR. Other services (eg, diabetes education) were utilized to optimize patient care to achieve optimal glycemic targets and address cardiometabolic risk. The overall mean hemoglobin A1c (HbA1c) decreased pre-post intervention by almost 1%, and 52.1% (347 of 666) of the cohort had ≥-0.5% change in HbA1c post-intervention. All pathways exhibited a decrease in HbA1c. Team-based approaches to managing diabetes patient care were the most effective. The interventions effectively utilized the resources across the health system without placing additional load or burden on primary care or diabetes specialty care teams. In the future, the authors hope to address the limitations of the current gap caused by increasing diabetes numbers, decreasing availability of PCPs and endocrinologists, and fee-for-service models using the innovative specialty consultant-primary care connection and knowledge exchange offered by this novel model, which can only be sustained with payer's support.

The Use of Rescue Insulin in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE)

OBJECTIVE

To describe rescue insulin use and associated factors in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE).

RESEARCH DESIGN AND METHODS

GRADE participants (type 2 diabetes duration <10 years, baseline A1C 6.8%-8.5% on metformin monotherapy, N = 5,047) were randomly assigned to insulin glargine U-100, glimepiride, liraglutide, or sitagliptin and followed quarterly for a mean of 5 years. Rescue insulin (glargine or aspart) was to be started within 6 weeks of A1C >7.5%, confirmed. Reasons for delaying rescue insulin were reported by staff-completed survey.

RESULTS

Nearly one-half of GRADE participants (N = 2,387 [47.3%]) met the threshold for rescue insulin. Among participants assigned to glimepiride, liraglutide, or sitagliptin, rescue glargine was added by 69% (39% within 6 weeks). Rescue aspart was added by 44% of glargine-assigned participants (19% within 6 weeks) and by 30% of non-glargine-assigned participants (14% within 6 weeks). Higher A1C values were associated with adding rescue insulin. Intention to change health behaviors (diet/lifestyle, adherence to current treatment) and not wanting to take insulin were among the most common reasons reported for not adding rescue insulin within 6 weeks.

CONCLUSIONS

Proportionately, rescue glargine, when required, was more often used than rescue aspart, and higher A1C values were associated with greater rescue insulin use. Wanting to use noninsulin strategies to improve glycemia was commonly reported, although multiple factors likely contributed to not using rescue insulin. These findings highlight the persistent challenge of intensifying type 2 diabetes treatment with insulin, even in a clinical trial.

Therapeutic Inertia in the Management of Type 2 Diabetes: A Narrative Review

Adequate glycemic control is key to prevent morbi-mortality from type 2 diabetes (T2D). Despite the increasing availability of novel, effective, and safe medications for the treatment of T2D, and periodically updated guidelines on its management, the overall rate of glycemic goal attainment remains low (around 50%) and has not improved in the past decade. Therapeutic inertia (TI), defined as the failure to advance or de-intensify medical therapy when appropriate to do so, has been identified as a central contributor to the lack of progress in the rates of HbA1c goal attainment. The time to treatment intensification in patients not meeting glycemic goals has been estimated to be between 1 and 7 years from the time HbA1c exceeded 7%, and often, even when an intervention is carried out, it proves insufficient to achieve glycemic goals, which led to the concept of intensification inertia. Therefore, finding strategies to overcome all forms of TI in the management of T2D is a fundamental initiative, likely to have an enormous impact in health outcomes for people with T2D. There are several factors that have been described in the literature leading to TI, including clinician-related, patient-related, and healthcare system-related factors, which are discussed in this review. Likewise, several interventions addressing TI had been tested, most of them proving limited efficacy. Within the most effective interventions, there appear to be two common factors. First, they involve a team-based effort, including nurses, pharmacists, and diabetes educators. Second, they were built upon a framework based on results of qualitative studies conducted in the same context where they were later implemented, as will be discussed in this article. Given the complex nature of TI, it is crucial to use a research method that allows for an in-depth understanding of the phenomenon. Most of the literature on TI is focused on quantitatively describing its consequences; unfortunately, however, not many study groups have undertaken qualitative studies to deeply investigate the drivers of TI in their diverse contexts. This is particularly true in the United States, where there is an abundance of publications exploring the effects of different strategies to overcome TI in type 2 diabetes, but a severe shortage of qualitative studies aiming to truly understand the phenomenon.

A Hybrid Model of In-Person and Telemedicine Diabetes Education and Care for Management of Patients with Uncontrolled Type 2 Diabetes Mellitus: Findings and Implications from a Multicenter Prospective Study

Background

Patients with uncontrolled type 2 diabetes mellitus (T2DM) require close follow-up, support, and education to achieve glycemic control, especially during the initiation or intensification of insulin therapy and self-care management. This study aimed to describe and evaluate the impact of implementing a hybrid model of in-person and telemedicine care and education on glycemic control for patients with uncontrolled T2DM (hemoglobin A1c [HbA1c] ≥9%) during the coronavirus disease pandemic.

Methods

This prospective multicenter-cohort pre-/post-intervention study was conducted on patients with uncontrolled T2DM. This study included three chronic illness centers affiliated with the Family and Community Medicine Department at Prince Sultan Military Medical City in Riyadh, Saudi Arabia. A hybrid model of in-person (onsite) and telemedicine care and education was developed. This involved implementing initial in-person care at the physicians' clinic and initial in-person education at the diabetes education clinic, followed by telemedicine services of tele-follow-ups, support, and education for an average 4-month follow-up period.

Results

Of the enrolled 181 patients, more than half of the participants were women (n = 103, 56.9%). The mean age of participants (standard deviation) was 58.64 ± 11.23 years and the mean duration of diabetes mellitus was 13.80 ± 8.55 years. The majority of the patients (n = 144; 79.6%) were on insulin therapy. Overall, in all three centers, the hybrid model had significantly reduced HbA1c from 10.47 ± 1.23% to 7.87 ± 1.59% (mean difference of reduction 2.59% [95% confidence interval (CI) = 2.34-2.85%], p < 0.001). At the level of each center, HbA1c was reduced significantly with mean differences of 3.17% (95% CI = 2.81-3.53%), 2.49% (95% CI = 1.92-3.06%), and 2.16% (95% CI = 1.76-2.57%) at centers A, B, and C, respectively (all p < 0.001).

Conclusion

The findings showed that the hybrid model of in-person and telemedicine care and education effectively managed uncontrolled T2DM. Consequently, the role of telemedicine in diabetes management could be further expanded as part of routine diabetes care in primary settings to achieve better glycemic control and minimize nonessential in-person visits when appropriate.

Identifying Barriers and Facilitators for Increasing Uptake of Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitors in British Columbia, Canada, using the Consolidated Framework for Implementation Research

Background

Care gaps remain in modern health care despite the availability of robust, evidence-based medications. Although sodium-glucose cotransporter-2 (SGLT2) inhibitors have demonstrated profound benefits in improving both cardiovascular and kidney outcomes in patients, the uptake of these medications remain suboptimal, and the causes have not been systematically explored.

Objective

The purpose of this study was to use the Consolidated Framework for Implementation Research (CFIR) to describe the barriers and facilitators faced by clinicians in British Columbia, Canada, when prescribing an SGLT2 inhibitor. To achieve this, we conducted semistructured interviews using the CFIR with practicing family physicians, nephrologists, endocrinologists, and cardiologists in British Columbia.

Design

Semistructured interviews.

Setting

British Columbia, Canada.

Participants

Actively practicing family physicians, nephrologists, endocrinologists, and cardiologists in British Columbia.

Methods

Twenty-one clinicians were interviewed using questions derived from the CFIR. The audio recordings were transcribed verbatim, and each transcription was individually analyzed in duplicate using thematic analysis. The analysis focused on identifying barriers and facilitators to using SGLT2 inhibitors in clinical practice and coded using the CFIR constructs. Once the transcriptions were coded, overarching themes were created.

Results

Five overarching themes were identified to the barriers and facilitators to using SGLT2 inhibitors: current perceptions and beliefs, clinician factors, patient factors, medication factors, and health care system factors. The current perceptions and beliefs were that SGLT2 inhibitors are efficacious and have distinct advantages over other agents but are underutilized in British Columbia. Clinician factors included varying levels of knowledge of and comfort in prescribing SGLT2 inhibitors, and patient factors included intolerable adverse events and additional pill burden, but many were enthusiastic about potential benefits. Multiple SGLT2 inhibitor related adverse events like mycotic infections and euglycemic diabetic ketoacidosis and the difficulty in obtaining reimbursement for these medications were also identified as a barrier to prescribing these medications. Facilitators for the use of SGLT2 inhibitors included consensus among colleagues, influential leaders, and peers in support of their use, and endorsement by national guidelines.

Limitations

The experience from the clinicians regarding costs and the reimbursement process is limited to British Columbia as each province has its own procedures. There may be responder bias as clinicians were approached through purposive sampling.

Conclusion

This study highlights different themes to the barriers and facilitators of using SGLT2 inhibitors in British Columbia. The identification of these barriers provides a specific target for improvement, and the facilitators can be leveraged for the increased use of SGLT2 inhibitors. Efforts to address and optimize these barriers and facilitators in a systematic approach may lead to an increase in the use of these efficacious medications.

Use of Voice-Based Conversational Artificial Intelligence for Basal Insulin Prescription Management Among Patients With Type 2 Diabetes: A Randomized Clinical Trial

Importance

Optimizing insulin therapy for patients with type 2 diabetes can be challenging given the need for frequent dose adjustments. Most patients receive suboptimal doses and do not achieve glycemic control.

Objective

To examine whether a voice-based conversational artificial intelligence (AI) application can help patients with type 2 diabetes titrate basal insulin at home to achieve rapid glycemic control.

Design, Setting, and Participants

In this randomized clinical trial conducted at 4 primary care clinics at an academic medical center from March 1, 2021, to December 31, 2022, 32 adults with type 2 diabetes requiring initiation or adjustment of once-daily basal insulin were followed up for 8 weeks. Statistical analysis was performed from January to February 2023.

Interventions

Participants were randomized in a 1:1 ratio to receive basal insulin management with a voice-based conversational AI application or standard of care.

Main Outcomes and Measures

Primary outcomes were time to optimal insulin dose (number of days needed to achieve glycemic control), insulin adherence, and change in composite survey scores measuring diabetes-related emotional distress and attitudes toward health technology and medication adherence. Secondary outcomes were glycemic control and glycemic improvement. Analysis was performed on an intent-to-treat basis.

Results

The study population included 32 patients (mean [SD] age, 55.1 [12.7] years; 19 women [59.4%]). Participants in the voice-based conversational AI group more quickly achieved optimal insulin dosing compared with the standard of care group (median, 15 days [IQR, 6-27 days] vs >56 days [IQR, >29.5 to >56 days]; a significant difference in time-to-event curves; P = .006) and had better insulin adherence (mean [SD], 82.9% [20.6%] vs 50.2% [43.0%]; difference, 32.7% [95% CI, 8.0%-57.4%]; P = .01). Participants in the voice-based conversational AI group were also more likely than those in the standard of care group to achieve glycemic control (13 of 16 [81.3%; 95% CI, 53.7%-95.0%] vs 4 of 16 [25.0%; 95% CI, 8.3%-52.6%]; difference, 56.3% [95% CI, 21.4%-91.1%]; P = .005) and glycemic improvement, as measured by change in mean (SD) fasting blood glucose level (-45.9 [45.9] mg/dL [95% CI, -70.4 to -21.5 mg/dL] vs 23.0 [54.7] mg/dL [95% CI, -8.6 to 54.6 mg/dL]; difference, -68.9 mg/dL [95% CI, -107.1 to -30.7 mg/dL]; P = .001). There was a significant difference between the voice-based conversational AI group and the standard of care group in change in composite survey scores measuring diabetes-related emotional distress (-1.9 points vs 1.7 points; difference, -3.6 points [95% CI, -6.8 to -0.4 points]; P = .03).

Conclusions and Relevance

In this randomized clinical trial of a voice-based conversational AI application that provided autonomous basal insulin management for adults with type 2 diabetes, participants in the AI group had significantly improved time to optimal insulin dose, insulin adherence, glycemic control, and diabetes-related emotional distress compared with those in the standard of care group. These findings suggest that voice-based digital health solutions can be useful for medication titration.

Trial Registration

ClinicalTrials.gov Identifier: NCT05081011.

LIVE INDIA: Effectiveness of Gla-100 in a Post hoc Pooled Analysis of FINE ASIA and GOAL Registries

INTRODUCTION

Real-world evidence on insulin glargine 100 U/ml (Gla-100) initiation in Indian type 2 diabetes mellitus (T2DM) individuals is limited. The present study aimed to evaluate the effectiveness of Gla-100 in insulin-naïve T2DM participants from India.

METHODS

This post hoc analysis includes real-world data of insulin-naïve Indian participants with T2DM who started Gla-100 treatment in two Asian registries: FINE ASIA and GOAL. Changes in glycated hemoglobin (HbA1c), fasting plasma glucose (FPG), body weight, insulin dose, and incidence of hypoglycemia from baseline to 6 months were assessed.

RESULTS

A total of 955 participants with T2DM were identified and analyzed. The mean [standard deviation (SD)] age and duration of diabetes were 54.7 (9.8) years and 9.8 (6.3) years, respectively. Mean HbA1c and FPG were significantly reduced after 6 months of Gla-100 treatment [- 2.07 (1.4) %; - 94.4 (65.2) mg/dl, respectively]. HbA1c targets of < 7.0% and < 7.5% were achieved by 292 (30.6%) and 589 (61.7%) study participants, respectively. The overall incidence of hypoglycemia was low (n = 52; 5.4%); only two participants (0.2%) reported severe hypoglycemia. Insulin was titrated with a mean (SD) increment of 2.5 (5.6) U/day after 6 months, leading to a mean Gla-100 dose of 18.2 (8.9) U/day. Mean body weight remained unchanged from baseline to 6 months (- 0.1 kg).

CONCLUSION

In routine clinical practice, Gla-100 significantly improved glycemic parameters after 6 months of treatment with a low risk of hypoglycemia and no weight change in participants with T2DM.

Trajectory of glycated haemoglobin over time, using real-world data, in type 2 diabetes patients with obesity on a U-100 basal-bolus insulin regimen

AIMS

To identify patient clusters with poor glucose control among type 2 diabetes mellitus (T2DM) patients with obesity who are receiving basal-bolus insulin and to identify the potential therapeutic inertia factors associated with poor control.

METHODS

Glycated haemoglobin (HbA1c) trajectories across a 3-year period were structured at 6-month intervals for a retrospective cohort of T2DM patients with obesity on basal-bolus insulin from the Veterans' Health Administration database. Based on each patient's longitudinal HbA1c features, an unsupervised clustering procedure was used to determine the numbers of clusters and associated trajectory patterns. Multinomial logistic regression was used to examine the association between HbA1c trajectory clusters and patient characteristics/treatment patterns.

RESULTS

A total of 51 273 patients were included, of whom 11.2% were in a subgroup with persistent missingness of HbA1c values. For those with sufficient HbA1c observations, cluster analysis indicated six distinct HbA1c trajectories: stable low (35.8%); stable high (20.8%); descending low (10.5%); ascending low (10.2%); descending high (5.7%); and ascending high (5.7%). Being of Black ethnicity, not initiating noninsulin antihyperglycaemic agents (sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists or thiazolidinediones) or concentrated insulin, low adherence (measured by proportion of days covered), and reduced insulin prescription refills were factors associated with poorer HbA1c clusters; similar factors were associated with persistent HbA1c missingness.

CONCLUSION

The present study found the potential for therapeutic inertia among a significant proportion of T2DM patients with obesity on basal-bolus insulin. Subgrouping T2DM patients based on HbA1c missingness and HbA1c trajectories can inform disease management strategies.

Overcoming Therapeutic Inertia as the Achilles' Heel for Improving Suboptimal Diabetes Care: An Integrative Review

The ultimate purpose of diabetes care is achieving the outcomes that patients regard as important throughout the life course. Despite advances in pharmaceuticals, nutraceuticals, psychoeducational programs, information technologies, and digital health, the levels of treatment target achievement in people with diabetes mellitus (DM) have remained suboptimal. This clinical care of people with DM is highly challenging, complex, costly, and confounded for patients, physicians, and healthcare systems. One key underlying problem is clinical inertia in general and therapeutic inertia (TI) in particular. TI refers to healthcare providers' failure to modify therapy appropriately when treatment goals are not met. TI therefore relates to the prescribing decisions made by healthcare professionals, such as doctors, nurses, and pharmacists. The known causes of TI include factors at the level of the physician (50%), patient (30%), and health system (20%). Although TI is often multifactorial, the literature suggests that 28% of strategies are targeted at multiple levels of causes, 38% at the patient level, 26% at the healthcare professional level, and only 8% at the healthcare system level. The most effective interventions against TI are shorter intervals until revisit appointments and empowering nurses, diabetes educators, and pharmacists to review treatments and modify prescriptions.

Practical Guidance for Healthcare Providers on Collaborating with People with Type 2 Diabetes: Advancing Treatment and Initiating Injectable Therapy

Type 2 diabetes (T2D) progresses over time, and to achieve and maintain adequate glucose control, many people eventually require injectable therapies such as insulin. However, there can be significant barriers to the initiation of these medications, both from people living with T2D and from healthcare practitioners (HCPs). Misconceptions and misinformation relating to the potential risks and benefits of injectable therapies are common and can contribute to negative perceptions regarding their use. Additionally, HCPs are often unaware of the emotional burden associated with T2D. In particular, diabetes distress is a key contributory factor that needs to be addressed to alleviate fears before diabetes education can be successful. The onus is often on the HCP to initiate effective, individualized communication with each patient and make that person feel an active and equal participant in the management of their T2D. Shared decision-making has been demonstrated to improve understanding of the pathophysiology and treatment options, to increase risk awareness, adherence, and persistence, and to improve self-management behaviors (e.g., exercise, self-care) and patient satisfaction. While therapeutic inertia can result from both patient and HCP, HCPs need to bear the responsibility for escalating therapy when necessary. A proactive approach by the HCP, combined with shared decision-making and a patient-centric approach, are important for optimal T2D management; therefore, an open and effective relationship between the HCP and the person living with T2D is essential. This article is written by a person with T2D, a nurse practitioner/Certified Diabetes Care and Education Specialist, and a clinical endocrinologist, with the goal of providing a holistic view of the management experience, exploring patient needs and expectations, recognizing and avoiding HCP and patient barriers, and providing practical advice to HCPs to empower patients who would benefit from injectable therapy.Infographic and video abstract available for this article.

Evolution of Clinical Complexity, Treatment Burden, Health Care Use, and Diabetes-Related Outcomes Among Commercial and Medicare Advantage Plan Beneficiaries With Diabetes in the U.S., 2006-2018

OBJECTIVE

To characterize trends in clinical complexity, treatment burden, health care use, and diabetes-related outcomes among adults with diabetes.

RESEARCH DESIGN AND METHODS

We used a nationwide claims database to identify enrollees in commercial and Medicare Advantage plans who met claims criteria for diabetes between 1 January 2006 and 31 March 2019 and to quantify annual trends in clinical complexity (e.g., active health conditions), treatment burden (e.g., medications), health care use (e.g., ambulatory, emergency department [ED], and hospital visits), and diabetes-related outcomes (e.g., hemoglobin A1c [HbA1c] levels) between 2006 and 2018.

RESULTS

Among 1,470,799 commercially insured patients, the proportion with ≥10 active health conditions increased from 33.3% (95% CI 33.1-33.4) in 2006 to 38.9% (38.8-39.1) in 2018 (P = 0.001) and the proportion taking three or more glucose-lowering medications increased from 11.6% (11.5-11.7) to 23.1% (22.9-23.2) (P = 0.007). The proportion with HbA1c ≥8.0% (≥64 mmol/mol) increased from 28.0% (27.7-28.3) in 2006 to 30.5% (30.2-30.7) in 2015, decreasing to 27.8% (27.5-28.0) in 2018 (overall trend P = 0.04). Number of ambulatory visits per patient per year decreased from 6.86 (6.84-6.88) to 6.19 (6.17-6.21), (P = 0.001) while ED visits increased from 0.26 (0.257-0.263) to 0.29 (0.287-0.293) (P = 0.001). Among 1,311,903 Medicare Advantage enrollees, the proportion with ≥10 active conditions increased from 51.6% (51.2-52.0) to 65.1% (65.0-65.2) (P < 0.001); the proportion taking three or more glucose-lowering medications was stable at 16.6% (16.3-16.9) and 18.1% (18.0-18.2) (P = 0.98), and the proportion with HbA1c ≥8.0% increased from 17.4% (16.7-18.1) to 18.6% (18.4-18.7) (P = 0.008). Ambulatory visits per patient per year remained stable at 8.01 (7.96-8.06) and 8.17 (8.16-8.19) (P = 0.23), but ED visits increased from 0.41 (0.40-0.42) to 0.66 (0.66-0.66) (P < 0.001).

CONCLUSIONS

Among patients with diabetes, clinical complexity and treatment burden have increased over time. ED utilization has also increased, and patients may be using ED services for low-acuity conditions.

Addressing Therapeutic Inertia: Development and Implementation of an Electronic Health Record-Based Diabetes Intensification Tool

Objective

To assess whether an electronic health record (EHR)-based diabetes intensification tool can improve the rate of A1C goal attainment among patients with type 2 diabetes and an A1C ≥8%.

Methods

An EHR-based tool was developed and sequentially implemented in a large, integrated health system using a four-phase, stepped-wedge design (single pilot site [phase 1] and then three practice site clusters [phases 2-4]; 3 months/phase), with full implementation during phase 4. A1C outcomes, tool usage, and treatment intensification metrics were compared retrospectively at implementation (IMP) sites versus nonimplementation (non-IMP) sites with sites matched on patient population characteristics using overlap propensity score weighting.

Results

Overall, tool utilization was low among patient encounters at IMP sites (1,122 of 11,549 [9.7%]). During phases 1-3, the proportions of patients achieving the A1C goal (<8%) were not significantly improved between IMP and non-IMP sites at 6 months (range 42.9-46.5%) or 12 months (range 46.5-53.1%). In phase 3, fewer patients at IMP sites versus non-IMP sites achieved the goal at 12 months (46.7 vs. 52.3%, P = 0.02). In phases 1-3, mean changes in A1C from baseline to 6 and 12 months (range -0.88 to -1.08%) were not significantly different between IMP and non-IMP sites. Times to intensification were similar between IMP and non-IMP sites.

Conclusion

Utilization of a diabetes intensification tool was low and did not influence rates of A1C goal attainment or time to treatment intensification. The low level of tool adoption is itself an important finding highlighting the problem of therapeutic inertia in clinical practice. Testing additional strategies to better incorporate, increase acceptance of, and improve proficiency with EHR-based intensification tools is warranted.

Addressing Clinical and Therapeutic Inertia Through Comprehensive Medication Review

Avoiding clinical and therapeutic inertia, through pharmacist-led medication therapy management, can lead to avoidance of inappropriate medication use and adverse medication events. Clinical and therapeutic inertia are terms that have been used indistinctly. One definition is inertia that appears when clinicians do not initiate or intensify therapy appropriately when therapeutic goals are not reached. Another definition is failure to advance or deintensify treatment, and in a broader sense beyond escalation or deintensification of therapy; definitions include failure to screen, make appropriate referrals, manage risk factors, and complications. Failure of clinicians to address clinical and therapeutic inertia in office or hospital visits can contribute to patients using inappropriate medications, and lead to avoidable serious adverse events. Addressing therapeutic inertia may also be a means to minimize prescription costs and improve quality of life. This case illustrates the importance of identifying and addressing the therapeutic appropriateness of medications for an older person who has been prescribed numerous medications over a long period but now has complaints of dizziness as well as the inability to afford all medications.

How use of continuous glucose monitoring can address therapeutic inertia in primary care

A significant proportion of individuals with diabetes have suboptimal glycemic management. Studies have shown that persistent hyperglycemia significantly increases the risks for both acute and long-term microvascular and macrovascular complications of diabetes. A key contributor to suboptimal glycemic management is therapeutic inertia in which clinicians delay intensifying therapy when patients are not meeting their glycemic goals. During the past five years, an increasing number of individuals with type 1 diabetes (T1D) and insulin-treated type 2 diabetes (T2D) have adopted use of continuous glucose monitoring (CGM) for daily measurement of glucose levels. As demonstrated in numerous clinical trials and real-world observational studies, use of CGM improves glycated hemoglobin (HbA1c) and reduces the occurrence and severity of hypoglycemia. However, for primary care clinicians who are unfamiliar with using CGM, integrating this technology into clinical practice can be daunting. In this article, we discuss the benefits and rationale for using CGM compared with traditional blood glucose monitoring (BGM), review the evidence supporting the clinical value of CGM in patients with T1D and T2D, and describe how use of CGM in primary care can facilitate appropriate and more timely therapy adjustments.

CRS Diabetes: An Effective Model for Improving Family Medicine Resident Knowledge, Competence, and Performance in Diabetes Care

The Chief Residents Summit on Intensifying Diabetes Management, now in its 15th year, has resulted in real-world improvements in patient outcomes and has shown itself to be an effective model for teaching diabetes to family medicine residents. This article describes the program and the evidence supporting its effectiveness.

Therapeutic inertia in the management of dyslipidaemia and hypertension in incident type 2 diabetes and the resulting risk factor burden: Real-world evidence from primary care

OBJECTIVE

To investigate trends in the prevalence of hypertension and dyslipidaemia in incident type 2 diabetes (T2DM), time to antihypertensive (AHT) and lipid-lowering therapy (LLT), and the association with systolic blood pressure (SBP) and lipid control.

RESEARCH DESIGN AND METHODS

Using The Health Improvement Network UK primary care database, 254 925 people with incident T2DM and existing dyslipidaemia or hypertension were identified. Among those without atherosclerotic cardiovascular disease (ASCVD) history and not on AHT or LLT at diagnosis, the adjusted median months to initiating an AHT or an LLT, and the probabilities of high SBP or lipid levels over 2 years in people initiating therapy within or after 1 year were evaluated according to high and low ASCVD risk status.

RESULTS

At diabetes diagnosis, 66% and 66% had dyslipidaemia and hypertension, respectively. During 2005 to 2016, dyslipidaemia prevalence increased by 10% in people aged <60 years, while hypertension prevalence remained stable in all age groups. Among those with high ASCVD risk status in the age groups 18 to 39, 40 to 49, and 50 to 59 years, the median number of months to initiation of therapy were 20.4 (95% confidence interval [CI] 20.3-20.5), 10.9 (95% CI 10.8-11.0), and 9.5 (95% CI 9.4-9.6) in the dyslipidaemia subcohort, and 28.1 (95% CI 28.0-28.2), 19.2 (95% CI 19.1-19.3), and 19.9 (95% CI 19.8-20.0) in the hypertension subcohort. Among people with high and low ASCVD risk status, respectively, compared to early LLT initiators, those who initiated LLT after 1 year had a 65.3% to 85.3% and a 65.0% to 85.3% significantly higher probability of failing lipid control at 2 years of follow-up, while late AHT initiators had a 46.5% to 57.9% and a 40.0% to 58.7% significantly higher probability of failing SBP control.

CONCLUSIONS

Significant delay in initiating cardioprotective therapies was observed, and time to first prescription was similar in the primary prevention setting, irrespective of ASCVD risk status across all T2DM diagnosis age groups, resulting in poor risk factor control at 2 years of follow-up.

Measurement of Pharmacist-Physician Collaborative Care on Therapeutic Inertia in Patients With Type 2 Diabetes

BACKGROUND

Team-based care practice models have been shown to improve diabetes-related therapeutic inertia, yet the method and type of antidiabetic treatment intensification (TI) leading to improvements in glycemic control are not well understood.

OBJECTIVE

To evaluate time to TI in a pharmacist-physician practice model (PPM) as compared with usual medical care (UMC), explore the method and type of antidiabetic TI, and evaluate achievement of hemoglobin A_1C (A1C) goal among each cohort.

METHODS

This was a retrospective cohort study conducted between January 1, 2017, and December 31, 2018. Median time to TI was calculated and compared between patients in the PPM and UMC groups using the log rank test. Descriptive statistics were used to evaluate the method and type of TI and A1C goal achievement.

RESULTS

A total of 56 patients were included. The median (interquartile range) time to antidiabetic TI among the PPM cohort was 37.5 days (8, 216.5), as compared with 142 days (16, 465) in the UMC cohort (P = 0.19). At 1 year post-index date, 25% of patients in the PPM cohort reached their A1C goal compared with 18.8% of patients in the UMC cohort. This effect was maintained in the subgroup (n = 49) of patients receiving TI (23.1% vs 17.8%).

CONCLUSION AND RELEVANCE

A shorter time to TI and improvement in A1C goal achievement was observed with pharmacist-physician care compared with UMC. These findings suggest that pharmacist-physician care may be one of several interventions necessary to overcome therapeutic inertia in diabetes care.

Quality of Diabetes Care in the USA

PURPOSE OF REVIEW

The purpose of this review is to provide an overview of the current quality of diabetes care in the USA, discuss barriers to guideline-recommended treatment adherence, and outline strategies for the improvement in care.

RECENT FINDINGS

Current treatment guidelines highlight the importance of glycemic control, use of novel medications with proven cardiovascular efficacy, and multifactorial cardiovascular risk factor intervention for the treatment of diabetes and associated complications. Albeit proven evidence for these guidelines, the vast majority of patients with diabetes remain insufficiently treated. Interventions to improve outcomes require focus on care delivery systems, physician behavior, and patient-centered approaches. De-fragmenting care systems to form collaborative, multi-specialty teams, use of standardized and comprehensive treatment algorithms, development of quality assessment tools, avoiding physician therapeutic inertia, and addressing patient barriers, including lack of perceived benefit, insufficient diabetes education and access to care, and medication costs, represent key objectives to improve diabetes care and outcomes. Clinical research in standardized trials has proven the feasibility to reduce morbidity and mortality associated with diabetes. Implementing models of care to disseminate these encouraging research findings to the wider population and to overcome barriers to achieving guideline-recommended treatment goals should be the objective to improve our current quality of diabetes care in the USA.

The effectiveness and safety of recombinant human growth hormone combined with alginate dressing in the treatment of diabetic foot ulcer: A protocol for systematic review and meta-analysis

BACKGROUND

Diabetic foot ulcer (DFU) is one of the serious complications of diabetes. It is the result of a joint effect of lower extremities vascular lesions, neuropathy, and infection, which require amputation and even threaten the life of the patient. At present, the conventional treatment for DFU includes infection control, wound care, wound reduction, reduction of foot pressure, use of dressings that are beneficial to wound surface healing, etc, but the effectiveness is not satisfactory. Recombinant human growth hormone and alginate dressing have been used in clinical, but there is lack of the relevant evidence of its effectiveness and safety, so this study evaluates the clinical effectiveness and safety of recombinant human growth hormone combined with alginate dressing in the treatment of DFU by systematic evaluation, the purpose is to provide a theoretical basis for the treatment of diabetic foot ulcer.

METHODS

This study mainly retrieves the randomized controlled trial of recombinant human growth hormone combined alginate dressing in the treatment of DFU in 7 electronic databases, such as PubMed, EMbase, Cochrane Library, SinoMed, CNKI, WANGFANG database, and VIP database. All the retrieval dates of database are from the establishment of the database until May 31, 2020. At the same time, searching the related degree papers, conference papers, and other gray literature by manual. The original literature data are independently screened and extracted by 2 researchers on the basis of inclusion and exclusion criteria and literature information sheets, and cross-checked and resolved through group discussions and consultations when there are differences of the opinion. Assessing the methodological quality of inclusion in the study based on the "Bias Risk Assessment Form" of the Cochrane Collaboration Network. Using the software of RevMan 5.3.3 and STATA 13.0 for statistical analysis.

RESULTS

This study compares the main and secondary outcome indicators by systematic evaluation and it will provide strong evidence of recombinant human growth hormone combined alginate dressing in the treatment of DFU.

ETHICS AND DISSEMINATION

All data in this study are obtained through the web database and do not involve humans, so ethical approval is not suitable for this study.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/W6P24.

CONCLUSION

This study will give positive conclusions about the effectiveness and safety of recombinant human growth hormone combined alginate dressing in the treatment of DFU.

Factors Associated with Adherence to Clinical Practice Guidelines for Patients with Type 2 Diabetes Mellitus: Results of a Spanish Delphi Consensus

OBJECTIVE

To assess factors associated with adherence to clinical practice guidelines (CPGs) for type 2 diabetes mellitus (T2DM).

METHODS

A cross-sectional multicenter study based on a two-round Delphi survey was designed. A total of 98 endocrinologists (mean age 45 years) involved in the care of T2DM patients completed a 43-item questionnaire assessing different aspects of adherence related to CPGs.

RESULTS

Most participants worked in tertiary care public hospitals. All participants used CPGs, with ADA/EASD as the most common (99%). The lack of time, establishment of an individualized management of patients, insufficient human resources, and therapeutic inertia were scored as the main reasons for not following CPGs recommendations. Participants agreed that insufficient material resources and limitations established by the healthcare system prevent adherence to CPGs. The risk of hypoglycemia was considered to be limiting factor for the patients' integral control. Also, there was consensus on the need to have the support of nursing personnel with specific training in diabetes as well as dietitians and podiatrists. There was disagreement regarding the influence on adherence to CPGs of patient's characteristics not matching those of CPGs, patient's preferences, tolerability of the action recommended, concomitant comorbidities, or pluripathological conditions. Differences according to the participant's age (≤40 years vs. >40 years) were not found. Therapeutic inertia and lack of time did not show a significant correlation.

CONCLUSIONS

Nonadherence to CPGs on T2DM is a multifactorial problem but the existence multiple CPGs, the lack of time, the therapeutic inertia, and insufficient human resources have been identified as factors limiting adherence. Hypoglycemia continues to be a barrier for achievement of targets recommended by CPGs.

Taurine with combined aerobic and resistance exercise training alleviates myocardium apoptosis in STZ-induced diabetes rats via Akt signaling pathway

AIM

The aim of this study was considering the effects of taurine supplementation with combined aerobic and resistance training (CARE) on myocardial apoptosis and Protein Kinase B (akt) level changes in diabetic rat.

MAIN METHODS

Forty male Wistar rats were randomly divided in to 5 groups of 8 animals in each: 1) control, 2) Diabetes Mellitus (DM), 3) DM with taurine supplementation (DM/T), 4) DM with CARE (DM/CARE), and 5) DM with combination of taurine and CARE (DM/T/CARE). DM was induced by injection of streptozotocin (STZ) and nicotine amid (NA) for 2, 3, 4 and 5 groups. Supplement groups received taurine in gavage, 100 mg/kg of body weight, 6 day per weeks, 8 weeks. CARE was performed at maximal speed and 1RM (40-60% of maximum for both).

KEY FINDINGS

The results of this study showed that DM significantly increased blood glucose and caspase 3, caspase 9 expressions and apoptosis cells in heart tissue and reduced Akt expression (p < 0.001). However, taurine and CARE interventions significantly decreased apoptosis markers (caspase 3 and caspase 9) and significantly increased Akt in heart of diabetic rats compare to DM groups (p < 0.05). The highest improvement observed in DM/T/CARE group (p < 0.05).

SIGNIFICANCE

Based on these results, it seems that the use of taurine with combined aerobic and exercise training minimize the cardiac damage caused by diabetes (especially apoptosis) trough increasing protein kinase Akt expression. This could improve cardiac remodeling after diabetes. However, more research is needed, especially on the human samples.