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Le P, Ayers G, Misra-Hebert AD, Herzig SJ, Herman WH, Shaker VA, Rothberg MB. Adherence to the American Diabetes Association's Glycemic Goals in the Treatment of Diabetes Among Older Americans, 2001-2018. Diabetes Care 2022; 45:1107-1115. [PMID: 35076695 DOI: 10.2337/dc21-1507] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 01/01/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess trends in HbA1c and appropriateness of diabetes medication use by patient health status. RESEARCH DESIGN AND METHODS We conducted cross-sectional analysis of 2001-2018 National Health and Nutrition Examination Survey (NHANES). We included older adults age ≥65 years who had ever been told they had diabetes, had HbA1c >6.4%, or had fasting plasma glucose >125 mg/dL. Health status was categorized as good, intermediate, or poor. Being below goal was defined as taking medication despite having HbA1c ≥1% below the glycemic goals of the American Diabetes Association (ADA), which varied by patient health status and time period. Drugs associated with hypoglycemia included sulfonylureas, insulin, and meglitinides. RESULTS We included 3,539 patients. Mean HbA1c increased over time and did not differ by health status. Medication use increased from 59% to 74% with metformin being the most common drug in patients with good or intermediate health and sulfonylureas and insulin most often prescribed to patients with poor health. Among patients taking medications, prevalence of patients below goal increased while prevalence of those above goal decreased from 2001 to 2018. One-half of patients with poor health and taking medications had below-goal HbA1c; two-thirds received drugs associated with hypoglycemia. Patients with poor health who were below goal had 4.9 (95% CI 2.3-10.4) times the adjusted odds of receiving drugs associated with hypoglycemia than healthy patients. CONCLUSIONS In accordance with ADA's newer Standards of Medical Care in Diabetes, HbA1c goals were relaxed but did not differ by health status. Below-goal HbA1c was common among patients with poor health; many were prescribed medications associated with a higher risk of hypoglycemia.
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Affiliation(s)
- Phuc Le
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH
| | - Gina Ayers
- Department of Pharmacy and Center for Geriatric Medicine, Cleveland Clinic, Cleveland, OH
| | - Anita D Misra-Hebert
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH.,Healthcare Delivery and Implementation Science Center, Cleveland Clinic, Cleveland, OH
| | - Shoshana J Herzig
- Division of General Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - William H Herman
- University of Michigan School of Public Health, Ann Arbor, MI.,University of Michigan Medical School, Ann Arbor, MI
| | - Victoria A Shaker
- Center for Value-Based Care Research, Cleveland Clinic, Cleveland, OH
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Libiseller A, Kopanz J, Lichtenegger KM, Mader JK, Truskaller T, Lackner B, Aberer F, Pandis M, Reinisch-Gratzer J, Ambrosch GC, Sinner F, Pieber TR, Donsa K. Study protocol for assessing the user acceptance, safety and efficacy of a tablet-based workflow and decision support system with incorporated basal insulin algorithm for glycaemic management in participants with type 2 diabetes receiving home health care: A single-centre, open-label, uncontrolled proof-of-concept study. Contemp Clin Trials Commun 2020; 19:100620. [PMID: 32775762 PMCID: PMC7399114 DOI: 10.1016/j.conctc.2020.100620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 06/22/2020] [Accepted: 07/12/2020] [Indexed: 01/03/2023] Open
Abstract
Introduction Diabetes management can be especially complex for older adults who receive health care at home. Thus, international guidelines recommend basal-insulin regimens due to simpler handling and low hypoglycaemia risk. A basal-insulin algorithm (including basal-plus) was developed to also include participant's health status and subsequently implemented into a tablet-based workflow and decision support system, GlucoTab@MobileCare. This study protocol describes a proof-of-concept study to investigate user acceptance, safety and efficacy of the GlucoTab@MobileCare system in participants receiving home health care. Methods The open-label, single-centre, uncontrolled study will recruit a maximum of ten participants with insulin treated type-2-diabetes (age ≥18 years) who receive home health care. During a three month study period participants will receive basal- or basal-plus-insulin therapy once daily as suggested by the GlucoTab@MobileCare system. Statistical analysis will be conducted on an intention-to-treat basis. The primary endpoint is the percentage of tasks (BG measurements, insulin dose calculations, insulin injections) that were performed according to GlucoTab@MobileCare suggestions relative to the total of suggested tasks. Secondary endpoints include user acceptance, safety and efficacy parameters. The study was approved by the ethics committee and regulatory authorities. Before obtaining written informed consent, all participants will receive oral and written information about all aspects of the study. Results will be published in a peer-reviewed journal and at diabetes and geriatric conferences. Discussion Potential implications may be improved quality and safety of basal-insulin therapy in older adults as well as support for health-care-providers in daily routine including evidence-based knowledge. Trial registration German Clinical Trials Register (DRKS00015059);
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Affiliation(s)
- Angela Libiseller
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Austria
| | - Julia Kopanz
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Austria
| | - Katharina M Lichtenegger
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Austria
| | - Julia K Mader
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Austria
| | - Thomas Truskaller
- JOANNEUM RESEARCH Forschungsgesellschaft mbH, HEALTH, Institute for Biomedicine and Health Sciences, Graz, Austria
| | - Bettina Lackner
- JOANNEUM RESEARCH Forschungsgesellschaft mbH, HEALTH, Institute for Biomedicine and Health Sciences, Graz, Austria
| | - Felix Aberer
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Austria
| | - Marlene Pandis
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Austria
| | | | | | - Frank Sinner
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Austria.,JOANNEUM RESEARCH Forschungsgesellschaft mbH, HEALTH, Institute for Biomedicine and Health Sciences, Graz, Austria
| | - Thomas R Pieber
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Austria.,JOANNEUM RESEARCH Forschungsgesellschaft mbH, HEALTH, Institute for Biomedicine and Health Sciences, Graz, Austria
| | - Klaus Donsa
- JOANNEUM RESEARCH Forschungsgesellschaft mbH, HEALTH, Institute for Biomedicine and Health Sciences, Graz, Austria
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Triantafylidis LK, Phillips SC, Hawley CE, Schwartz AW. Finding the Sweet Spot: An Interactive Workshop on Diabetes Management in Older Adults. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2019; 15:10845. [PMID: 31911936 PMCID: PMC6944249 DOI: 10.15766/mep_2374-8265.10845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 06/24/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Intensive glucose lowering in older adults with diabetes leads to increased risks with minimal benefits. Surveys indicate that clinician confidence for individualizing glycemic goals and regimens remains low. We created an interactive workshop and clinical tool kit to improve clinician knowledge of safe diabetes management in older adults. METHODS Finding the Sweet Spot was a 1-hour workshop taught by pharmacists to medical and pharmacy learners that introduced a five-step framework for diabetes management in older adults. The interactive presentation included cases and a clinical tool kit based on current recommendations from the American Diabetes Association and American Geriatrics Society. Pilot workshops were held for 6 months, allowing for real-time revisions based on feedback; final implementation occurred for 6 months thereafter. We evaluated learner self-efficacy (via a 5-point Likert scale) and knowledge (via multiple-choice questions) of diabetes management in older adults before and after the workshop. RESULTS Thirty learners participated in Finding the Sweet Spot (70% medicine, 30% pharmacy). The percentage of confident learners increased from 55% to 97% (p < .05) after the workshop. All learners demonstrated improvements in knowledge, with the mean score on the knowledge assessment increasing from 61% to 80% (p < .05). Via open-ended feedback, learners expressed satisfaction and found the clinical tool kit especially helpful. DISCUSSION Our Finding the Sweet Spot workshop demonstrated statistically significant changes in self-efficacy and knowledge among learners, indicating that this interactive workshop improves medical and pharmacy provider confidence and skills in caring for older adults with diabetes.
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Affiliation(s)
| | - Sarah C. Phillips
- Instructor, Department of Family Medicine, Boston University School of Medicine
- Physician, Upham's Corner Elder Service Plan
- Affiliated Fellow in Geriatrics, VA Boston Healthcare System and New England Geriatric Research Education and Clinical Center
| | - Chelsea E. Hawley
- Clinical Pharmacist, Pharmacy Department, VA Boston Healthcare System
- Advanced Fellow in Geriatrics, New England Geriatric Research Education and Clinical Center
| | - Andrea Wershof Schwartz
- Associate Fellowship Director of the Harvard Multicampus Geriatrics Fellowship, VA Boston Healthcare System and New England Geriatric Research Education and Clinical Center
- Assistant Professor of Medicine, Department of Medicine, Harvard Medical School
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Montanier N, Bernard L, Lambert C, Pereira B, Desbiez F, Terral D, Abergel A, Bohatier J, Rosset E, Schmidt J, Sautou V, Hadjadj S, Batisse-Lignier M, Tauveron I, Maqdasy S, Roche B. Prospective evaluation of a dynamic insulin infusion algorithm for non critically-ill diabetic patients: A before-after study. PLoS One 2019; 14:e0211425. [PMID: 30689675 PMCID: PMC6349328 DOI: 10.1371/journal.pone.0211425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 01/14/2019] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Insulin infusion is recommended during management of diabetic patients in critical care units to rapidly achieve glycaemic stability and reduce the mortality. The application of an easy-to-use standardized protocol, compatible with the workload is preferred. Glycaemic target must quickly be reached, therefore static algorithms should be replaced by dynamic ones. The dynamic algorithm seems closer to the physiological situation and appreciates insulin sensitivity. However, the protocol must meet both safety and efficiency requirements. Indeed, apprehension from hypoglycaemia is the main deadlock with the dynamic algorithms, thus their application remains limited. In contrary to the critical care units, to date, no prospective study evaluated a dynamic algorithm of insulin infusion in non-critically ill patients. AIM This study primarily aimed to evaluate the efficacy of a dynamic algorithm of intravenous insulin therapy in non-critically-ill patients, and addressed its safety and feasibility in different departments of our university hospital. METHODS A "before-after" study was conducted in five hospital departments (endocrinology and four "non-expert" units) comparing a dynamic algorithm (during the "after" period-P2) to the static protocol (the "before" period-P1). Static protocol is based on determining insulin infusion according to an instant blood glycaemia (BG) level at a given time. In the dynamic algorithm, insulin infusion rate is determined according to the rate of change of the BG (the previous and actual BG under a specific insulin infusion rate). Additionally, two distinct glycaemic targets were defined according to the patients' profile: 100-180 mg/dl (5.5-10 mmol/l) for vigorous patients and 140-220 mg/dl (7.8-12.2 mmol/l) for frail ones. Different BG measurements for each patient were collected and recorded in a specific database (e-CRF) in order to analyse the rates of hypo- and hyperglycaemia. A satisfaction survey was also performed. A study approval was obtained from the institutional revision board before starting the study. RESULTS Over 8 months, 72 and 66 patients during P1 and P2 were respectively included. The dynamic algorithm was more efficient, with reduced time to control hyperglycaemia (P1 vs P2:8.3 vs 5.3 hours; HR: 2.02 [1.27; 3.21]; p<0.01), increased the number of in-target BG measurements (P1 vs P2: 37.0% vs 41.8%; p<0.05), and reduced the glycaemic variability related to each patient (P1 vs P2, %CV: 40.9 vs 38.2;p<0.05, Index Correlation Class:0.30 vs 0.14; p<0.05). In patients after the first event of hypoglycemia after having started the infusion, new events were lower (P1 vs P2: 19.4 vs 11.4; p<0.001) thanks to an earlier reaction to hypoglycaemia (8.3% during P1 vs 44.3% during P2; p = 0.004). With the dynamic algorithm, the percentage of recurrence of mild hypoglycaemia was significantly lower in frail patients (20.5% vs 10.2%; p<0.001), and in patients managed in the non-expert units (18 vs 7.1%, p<0.001). The %CV was significantly improved in frail patients (36.9%). Mean BG measurements for each patient/day were 5.5±1.1 during P1 and 6.0±1.6 during P2 (p = 0.6). The threat from hypoglycaemia and the difficulty in using dynamic algorithm are barriers for nurses' adherence. CONCLUSIONS This dynamic algorithm for non-critically-ill patients is more efficient and safe than the static protocol, and adapted for frail patients and non-expert units.
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Affiliation(s)
- Nathanaëlle Montanier
- CHU Clermont-Ferrand, Service d’endocrinologie, diabétologie et maladies métaboliques, Clermont-Ferrand, France
| | - Lise Bernard
- Pôle Pharmacie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Céline Lambert
- Délégation à la Recherche Clinique et à l'Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Bruno Pereira
- Délégation à la Recherche Clinique et à l'Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Françoise Desbiez
- CHU Clermont-Ferrand, Service d’endocrinologie, diabétologie et maladies métaboliques, Clermont-Ferrand, France
| | - Daniel Terral
- CHU Clermont-Ferrand, Service de Pédiatrie Générale, Clermont-Ferrand, France
| | - Armand Abergel
- CHU Clermont-Ferrand, Service de Médecine Digestive, Clermont-Ferrand, France
| | - Jérôme Bohatier
- CHU Clermont-Ferrand, Service de Court séjour Gériatrique, Riom, France
| | - Eugenio Rosset
- CHU Clermont-Ferrand, Service de Chirurgie vasculaire, Clermont-Ferrand, France
| | - Jeannot Schmidt
- CHU Clermont-Ferrand, Pôle Urgences, Clermont-Ferrand, France
| | - Valérie Sautou
- Pôle Pharmacie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Samy Hadjadj
- CHU Poitiers, Service de Médecine interne, endocrinologie et maladies métaboliques, Poitiers, France
| | - Marie Batisse-Lignier
- CHU Clermont-Ferrand, Service d’endocrinologie, diabétologie et maladies métaboliques, Clermont-Ferrand, France
- Laboratoire GReD: UMR Université Clermont Auvergne-CNRS 6293, INSERM U1103, Clermont-Ferrand, France
| | - Igor Tauveron
- CHU Clermont-Ferrand, Service d’endocrinologie, diabétologie et maladies métaboliques, Clermont-Ferrand, France
- Laboratoire GReD: UMR Université Clermont Auvergne-CNRS 6293, INSERM U1103, Clermont-Ferrand, France
| | - Salwan Maqdasy
- CHU Clermont-Ferrand, Service d’endocrinologie, diabétologie et maladies métaboliques, Clermont-Ferrand, France
- Laboratoire GReD: UMR Université Clermont Auvergne-CNRS 6293, INSERM U1103, Clermont-Ferrand, France
- * E-mail:
| | - Béatrice Roche
- CHU Clermont-Ferrand, Service d’endocrinologie, diabétologie et maladies métaboliques, Clermont-Ferrand, France
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