Meeting targets in type 2 diabetes care contributing to good glycaemic control. A cross-sectional study from a primary care setting in Estonia

High prevalence of cardiovascular disease and risk factors among type 2 diabetes patients followed in a hospital setting in Portugal: The PICT2RE observational study

INTRODUCTION AND OBJECTIVES

Portugal is a country with a high prevalence of type 2 diabetes (T2D) and cardiovascular disease (CVD). The prevalence of CVD and cardiovascular (CV) risk factors among T2D patients followed in hospitals in Portugal is not known. The primary objective of this study was to assess the prevalence of CVD and CV risk factors among T2D patients in a hospital setting in Portugal. The clinical management of CVD in the hospital setting was also assessed.

METHODS

We performed a non-interventional, multicenter, cross-sectional study with a retrospective phase. T2D patients were consecutively invited to participate. Data were collected retrospectively.

RESULTS

A total of 715 patients were included in the study. Mean age and diabetes duration were 66.6 and 17.4 years, respectively. Of these, 286 patients (40.0%) had been diagnosed with CVD, mostly ischemic heart disease (50.4%). All patients had at least one CV risk factor. CVD was significantly associated with hypertension, hypercholesterolemia, low high-density lipoprotein cholesterol, hypertriglyceridemia and smoking. During the three years prior to study inclusion, the incidence of hyperglycemic episodes and T2D complications increased among patients with established CVD, but the numbers of hospitalization episodes and specialist appointments remained stable. An improvement was observed in key cardiometabolic risk factors.

CONCLUSIONS

Our study revealed a high prevalence of CVD and CV risk factors among a sample of T2D patients in a hospital setting. Patients with established CVD seem to be adequately managed but further efforts are needed at the prevention stage for better control of risk factors and morbidity.

Mortality and potential years of life lost attributable to non-optimal glycaemic control in men and women with diabetes in the United Arab Emirates: a population-based retrospective cohort study

OBJECTIVES

Numerous studies reported that achieving near-normal glycated haemoglobin (HbA1c) levels in patients with diabetes may delay or even prevent vascular complications. However, information regarding the impact of non-optimal HbA1c control on adverse health outcomes in an Arab population is unknown. The aim of this study was to estimate the fraction of deaths and potential years of life lost (PYLL) attributable to non-optimal HbA1c control among Emirati men and women with diabetes in the United Arab Emirates (UAE).

DESIGN

A retrospective cohort study.

SETTING

This study was conducted in outpatient clinics at a tertiary care centre in Al Ain, UAE, between April 2008 and September 2018.

PARTICIPANTS

The sample comprised of 583 adult UAE nationals, aged≥18 years, with diabetes. Overall, 57% (n=332) of the study participants were men and 43% (n=251) were women.

EXPOSURE

Non-optimal HbA1c control, defined as HbA1c≥6.5%.

PRIMARY OUTCOME MEASURE

All-cause mortality, defined as death from any cause.

RESULTS

At the end of the 9-year follow-up period, 86 (14.8%) participants died. Overall, up to 33% (95% CI 2% to 63%) of deaths were attributable to non-optimal HbA1c control among patients with diabetes mellitus (DM). Stratified by sex, the adjusted fraction of avoidable mortality was 17% (95% CI -23% to 57%) for men and 50% (95% CI 3% to 98%) for women. Both deaths and PYLL attributable to non-optimal HbA1c control were higher in women compared with men.

CONCLUSIONS

Up to one-third of all deaths in adult UAE nationals with DM could be attributed to non-optimal HbA1c control. Effective sex-specific interventions and healthcare quality-improvement programmes should urgently be implemented.

Once-Weekly Semaglutide Versus Once-Daily Liraglutide for the Treatment of Type 2 Diabetes: A Long-Term Cost-Effectiveness Analysis in Estonia

INTRODUCTION

Once-weekly semaglutide is a novel glucagon-like peptide-1 (GLP-1) analogue for the treatment of type 2 diabetes that was associated with greater reductions in glycated hemoglobin (HbA1c) and body mass index (BMI) versus once-daily GLP-1 analogue liraglutide in a recent network meta-analysis (NMA). The aim of the present study was to assess the long-term cost-effectiveness of once-weekly semaglutide 1 mg versus liraglutide 1.2 mg in Estonia.

METHODS

Outcomes were projected over patient lifetimes using the IQVIA CORE Diabetes Model (version 9.0), with baseline cohort characteristics sourced from SUSTAIN 3 and changes in HbA1c, systolic blood pressure (SBP), and BMI associated with once-weekly semaglutide and liraglutide derived from the NMA. Patients were assumed to receive once-weekly semaglutide or liraglutide for 5 years before intensifying to basal insulin. Treatment effects were applied for the first 5 years, after which HbA1c increased to 7.0%, SBP followed a natural progression, and BMI reverted to baseline for the remainder of the analysis. Costs were expressed in euros (EUR) and estimated from a healthcare payer perspective. Utilities associated with diabetes and diabetes-related complications were taken from published sources.

RESULTS

Once-weekly semaglutide 1 mg was associated with improvements in quality-adjusted life expectancy of 0.13 quality-adjusted life years (QALYs) versus liraglutide 1.2 mg. Direct costs were EUR 67 higher with once-weekly semaglutide, due to the increased acquisition cost, but this was mostly offset by cost savings due to avoidance of diabetes-related complications. Once-weekly semaglutide 1 mg was therefore associated with an incremental cost-effectiveness ratio of EUR 523 per QALY gained versus liraglutide 1.2 mg, which falls well below a willingness-to-pay threshold of EUR 52,390 per QALY gained (three times the Estonian GDP per capita).

CONCLUSION

Once-weekly semaglutide was considered highly cost-effective versus liraglutide 1.2 mg for the treatment of patients with type 2 diabetes in Estonia.

FUNDING

Novo Nordisk A/S. Plain language summary available for this article.

Effectiveness and clinical inertia in patients with antidiabetic therapy

AIMS

To establish the effectiveness of antidiabetic therapy and the frequency of clinical inertia in the management of type 2 diabetes mellitus in Colombia.

METHODS

A cross-sectional study with follow-up of patients who had been treated for at least 1 year and were receiving medical consultation for antidiabetic treatment. Effectiveness was established when haemoglobin-A1c levels were <7% and when clinical inertia was reached, which was defined as no therapeutic modifications despite not achieving management controls. Sociodemographic, clinical and pharmacological variables were evaluated, and multivariate analyses were performed.

RESULTS

In total, 363 patients with type 2 diabetes mellitus were evaluated, with a mean age of 62.0±12.2 years. A total of 1,016 consultations were evaluated, and the therapy was effective at the end of the follow-up in 57.9% of cases. Clinical inertia was found in 56.8% of patients who did not have metabolic control. The most frequently prescribed medications were metformin (84.0%), glibenclamide (23.4%) and insulin glargine (20.7%). Moreover, 57.6% of the patients were treated with two or more antidiabetic medications. Having metabolic control in the first consult of the follow-up was a protective factor against clinical inertia in the subsequent consultations (OR: 0.08; 95%CI: 0.04-0.15; P<.001).

CONCLUSIONS

The effectiveness of treatment for patients with type 2 diabetes mellitus has increased in Colombia, and for the first time, clinical inertia was identifiable and quantifiable and found in similar proportions to other countries. Clinical inertia is a relevant condition given that it interferes with the possibility of controlling this pathology.

Factors influencing insulin usage among type 2 diabetes mellitus patients: A study in Turkish primary care

BACKGROUND

DM (diabetes mellitus) patients with poorly regulated blood glucose levels are at risk of increased morbidity and mortality. There are different factors that cause resistance to the initiation of insulin therapy such as beliefs and perceptions concerning diabetes and its treatment and the nature and consequences of insulin therapy.

OBJECTIVES

We aimed to explore the reasons for this reluctance and how these obstacles could be overcome so that DM patients who require insulin could initiate therapy.

METHODS

This was a cross-sectional, descriptive study of diabetic patients with glycated haemoglobin A_1c (HbA_1C) levels above 7.0%, who were followed-up at a primary care and endocrinology outpatient clinic.

RESULTS

Ninety-four patients (57.4% females, 42.6% males) were recruited for this study. Most patients (57.4%) considered that insulin was a drug of last resort. Among all patients, 34.1% thought that insulin lowered blood glucose levels to an extreme degree and 14.9% disagreed. The patients thought that self-injection was hard (27.6%), required someone else to administer the injection (27.6%), insulin injection was painful (33.0%). 59.6% of all patients believed that their religion did not restrict the use of insulin, 52.1% stated that their family physicians had sufficiently informed them.

CONCLUSION

Our most significant finding is that a lack of adequate information relating to insulin appears to be the major factor behind DM patients' refusal of insulin treatment. The fact that patients consider insulin treatment as a final solution to DM could be related to resistance to the initiation of insulin therapy. [Box: see text].

Level of A1C control and its predictors among Lebanese type 2 diabetic patients

AIM

Lebanon is among the top 10 countries with the highest prevalence of diabetes in the Middle East region with estimates reaching as high as 16.6% in adults aged 20-79 years. The objective of this study was to assess the level of A1C control among a cohort of type 2 diabetic patients and factors associated with uncontrolled A1C.

METHODS

We carried out a retrospective observational study among type 2 diabetes mellitus patients attending an outpatient endocrinologist's clinic between June 2008 and July 2012 in Beirut, Lebanon. Two groups were compared, based on their diabetic control (A1C < 7% and A1C ≥ 7%).

RESULTS

A total of 551 patients were included in this study, where 31.8% attained A1C control. Crude analyses showed that some factors were significantly associated with uncontrolled A1C, and these were long-standing diabetes, diabetes-related complications, uncontrolled blood pressure, lipid profile, as well as the use of metformin, sulfonylurea, or insulin. When multivariate analysis was carried out, the chances of having uncontrolled A1C were significantly higher among patients who developed neuropathy (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.11-3.90), had uncontrolled triglycerides (OR 1.98, 95% CI 1.33-2.94), used insulin (OR 4.52, 95% CI 2.32-8.83), and sulfonylureas (OR 2.88, 95% CI 1.88-4.40).

CONCLUSION

Uncontrolled diabetes is more likely to exist in patients with neuropathy, uncontrolled triglycerides and those using insulin or sulfonylurea. Further research is needed to confirm the findings.

Treatment targets in patients with type 2 diabetes set by primary care physicians from Central and Eastern Europe

BACKGROUND

Primary care physicians have an important role in the care of patients with Type 2 diabetes but little is known about this issue in Central and Eastern European countries.

OBJECTIVES

To investigate the treatment goals of patients with type 2 diabetes mellitus (type 2 DM) set by primary care physicians in Central and Eastern European countries and illustrate inter-country variation.

METHODS

A cross-sectional survey of primary care physicians randomly chosen in nine countries. A validated questionnaire was used. Physicians reported treatment goals for patients with type 2 DM.

RESULTS

A total of 44.1% of physicians, reported the acceptance of HbA1c < 6.5% (48 mmol/mol) as a treatment goal, whilst 40% chose lower levels (< 6.1%; 43 mmol/mol). In all countries, 62% of physicians set FPG at a level of < 6.0 mmol/l. Most respondents set low BP levels as a goal of therapy (47% of physicians in all countries: BP < 130/80 mmHg and 48% < 120/80 mmHg). A TC level < 4.5 mmol/l and a LDL-C level < 2.5 mmol/l were reported as the targets for patients with diabetes by 51% and 69% of all respondents, respectively. The overall differences between all the countries were statistically significant (P < 0.01).

CONCLUSION

For patients with diabetes approximately half of physicians set treatment goals at levels that were recommended within the international guidelines. Most of them set treatment goals for HbA1c and BP at very low levels. Educational efforts to raise awareness about new treatment goals are needed.

Using the Common Sense Model of Self-Regulation to Review the Effects of Self-Monitoring of Blood Glucose on Glycemic Control for Non–Insulin-Treated Adults With Type 2 Diabetes

Purpose

This systematic review examined the relationship between self-monitoring of blood glucose (SMBG) and glycemic control in patients with type 2 diabetes. The Common Sense Model of Self-Regulation (CSM) served as a theoretical framework for examining how, when (mediators), and for whom (moderators) SMBG improved glycemic control.

Data Sources

Five databases were searched: Medline, PsychInfo, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing & Allied Health Literature.

Study Selection

Included studies had cross-sectional, longitudinal, or randomized controlled trial designs; were published between 2007 and 2011; and included patients with type 2 diabetes at least some of whom were not taking insulin; 1318 studies were screened, 119 were reviewed in detail, and 26 were included.

Data Extraction

Data were collected on the relationship between SMBG and glycemic control, study design, mediators, moderators, participant characteristics, the CSM, and limitations.

Data Synthesis

Twenty-six studies met criteria for inclusion: 11 cross-sectional, 4 longitudinal, and 11 randomized controlled trials. The results of the cross-sectional studies were inconclusive. Results from the longitudinal studies and randomized control trials suggested that SMBG may improve glycemic control. The few studies investigating mediators or moderators reported mixed results. Few studies effectively measured the CSM.

Conclusion

Data suggested that SMBG may help improve glycemic control. Future trials must be designed to test hypotheses and improve our understanding of when, how, and for whom SMBG can enhance glycemic control. Rigorously controlled repetitions of current 2-arm trials will yield little new knowledge of theoretical or practical value.

Care for patients with type 2 diabetes in a random sample of community family practices in ontario, Canada

Objective. Diabetes care is an important part of family practice. Previous work indicates that diabetes management is variable. This study aimed to examine diabetes care according to best practices in one part of Ontario. Design and Participants. A retrospective chart audit of 96 charts from 18 physicians was conducted to examine charts regarding diabetes care during a one-year period. Setting. Grimsby, Ontario. Main Outcome Measures. Glycemic screening, control and management strategies, documentation and counselling for lifestyle habits, prevalence of comorbidities, screening for hypertension, hyperlipidemia, and use of appropriate recommended preventive medications in the charts were examined. Results. Mean A1c was within target (less than or equal to 7.00) in 76% of patients (ICC = -0.02), at least 4 readings per annum were taken in 75% of patients (ICC = 0.006). Nearly 2/3 of patients had been counselled about diet, more than 1/2 on exercise, and nearly all (90%) were on medication. Nearly all patients had a documented blood pressure reading and lipid profile. Over half (60%) had a record of their weight and/or BMI. Conclusion. Although room for improvement exists, diabetes targets were mainly reached according to recognized best practices, in keeping with international data on attainment of diabetes targets.

Prevalent obstacles and predictors for people living with type 2 diabetes

Background. Type 2 diabetes (T2DM) is a chronic, progressive disease with serious micro- and macrovascular complications. A person affected by T2DM should learn to accept the new restricted lifestyle. Aims. The aim of the study was to identify the prevalence of obstacles in coping with daily life for people with T2DM and the magnitude of the relationships of the obstacles with various patient characteristics. Methods. Participants were recruited from randomly selected GPs' lists in Estonia. Respondents completed the Estonian version of the Diabetes Obstacles Questionnaire (DOQ). The statements were assessed on a 5-point scale. Biomedical and clinical variables were measured. The central tendency statistics and skewness and kurtosis for all statements were computed to find out those that reflect obstacles. Then obstacles of the DOQ were stratified. Multinomial logistic regression (MLR) was computed to estimate the influences of descriptive variables on the statements. Results and Conclusions. Altogether, 138 diabetic patients were enrolled in the study. Fourteen statements were identified as obstacles. Variables such as age, type of diabetes treatment, and BMI had significant effects on five of them. Younger age, BMI, and insulin nonuse were revealed as the strongest predictive characteristics for perceiving obstacles more often in coping with daily life.

Fixed-dose combination antidiabetic therapy: real-world factors associated with prescribing choices and relationship with patient satisfaction and compliance

INTRODUCTION

Compliance with antidiabetic therapy has the potential to impact on the risk for complications by an effect on glycemic control. Fixed-dose combinations (FDCs) offer a simplified dosing regimen that may improve patient compliance. We undertook a retrospective database analysis to understand the real-world association between FDCs, treatment practices, glycated hemoglobin (HbA(1c)) levels, and patient perspectives in type 2 diabetes.

METHODS

Data were drawn from the Adelphi Diabetes Disease Specific Programme (DSP), a multicenter, patient recordbased market research study of primary care physicians and diabetologists/endocrinologists in Europe. The study is based on physician interviews, completion of detailed patient record forms by physicians, and a self-completion questionnaire by patients. Regression analyses were used to identify factors associated with (1) physician-reported dipeptidyl peptidase-4 inhibitor (DPP-4)/metformin FDC prescribing in dual or triple therapy regimens; (2) HbA1c of patients prescribed a DPP-4 FDC alone versus free-form DPP-4 plus metformin dual therapy regimens; and (3) differences between patients prescribed any oral antidiabetic therapy (OAD) FDC therapy (alone or in combination with one other OAD) versus those prescribed dual or triple OAD free-form combination therapy.

RESULTS

Physician-reported data were available for 5891 patients (mean age 61.5 years, 43% female, mean duration since diagnosis 5.7 years). Factors associated with DPP-4 FDC usage included physicians' reason for choice being "improves patient compliance." The relative mean % HbA(1c) level associated with being on a DPP-4 FDC rather than free-form independent of the physician perception of patient compliance was 0.25 lower (CI -0.40 to -0.09). When physician-perceived patient compliance was described as "fairly compliant" rather than "poorly compliant" or "not at all compliant," the relative mean % HbA1c level was 0.42 lower (CI -0.67 to -0.18). Similarly, being perceived as "fully compliant" rather than "fairly compliant" was associated with a relative mean % HbA(1c) level that was 0.17 lower (CI -0.31 to -0.02). A significant predictor for the current regimen being any FDC (alone or in combination with one other OAD) regimen was patients' satisfaction with treatment (odds ratio 1.32; 95% CI 1.10 to 1.58; P=0.003).

CONCLUSIONS

These results suggest that DPP-4 FDC prescribing is considered to be a positive prescribing choice to improve compliance and that choice is associated with improved glycemic control. From the patient's perspective, the decision to prescribe an FDC is associated with improved satisfaction with treatment.