The increasing role of primary care physicians in caring for patients with type 2 diabetes mellitus

The Michigan Collaborative for Type 2 Diabetes (MCT2D): Development and implementation of a statewide collaborative quality initiative

BACKGROUND

Type 2 diabetes (T2D) is one of the most prevalent chronic diseases worldwide and a leading cause of cardiorenal disease and mortality. Only one-third of individuals with T2D receive care as recommended by the American Diabetes Association's clinical practice guidelines. Effective strategies are needed to accelerate the implementation of guideline concordant T2D care.

METHODS

The Michigan Collaborative for Type 2 Diabetes (MCT2D) is a statewide population health collaborative quality initiative (CQI) developed to improve the care of all people with T2D in Michigan. MCT2D has developed a learning health system with physician organizations and their constituent practices to support quality improvement initiatives focused on (1) improving use of guideline-directed pharmacotherapy to improve cardiorenal outcomes, (2) increasing evidence-based use of continuous glucose monitoring, and (3) supporting use of lower carbohydrate eating patterns.

RESULTS

Between 2021 and 2022, MCT2D recruited 28 of the 40 Michigan-based physician organizations participating in Blue Cross' Physician Group Incentive Program with 336 constituent practices and 1357 physicians in primary care (304), endocrinology (21) and nephrology (11). In January 2022, baseline data included a sample of 96,140 unique individuals with T2D. The baseline HbA1c was ≤ 7.0% for 66.3% of patients (n = 32,787), while 14.9% of patients had a most recent HbA1c ≥ 8.0% (n = 7,393). The most recent body mass index (BMI) was ≥ 30.0 for 64.8% of patients (n = 38,516).

DISCUSSION

MCT2D has organized a statewide collaborative to recruit and engage a diverse and large set of physician organizations and their constituent practices. This is a promising opportunity to accelerate adoption of guideline-concordant care for people with T2D and may be a model for other state or regional collaboratives. Future directions include specific evidence-based interventions targeted at reducing diabetes-linked comorbidities and associated healthcare costs as well as strategies focused on T2D prevention among at-risk populations.

The Dexcom Community Glucose Monitoring Project: 6-Month Results Using Continuous Glucose Monitoring in Type 2 Diabetes

The Dexcom Community Glucose Monitoring Project is a collaborative, ongoing, primary care-driven public health initiative designed to provide continuous glucose monitoring (CGM) systems to adults with type 2 diabetes who lack health insurance coverage for CGM. After 6 months of program participation, mean A1C decreased by 2.4 ± 1.9% from baseline to 6-month follow-up (from 9.4 ± 1.7 to 7.1 ± 1.2%, P <0.001). There was a clinically meaningful and statistically significant improvement in CGM metrics as well. Greater CGM use in the primary care setting among people with type 2 diabetes may help patients successfully manage their diabetes.

Artificial intelligence for diabetes care: current and future prospects

Artificial intelligence (AI) use in diabetes care is increasingly being explored to personalise care for people with diabetes and adapt treatments for complex presentations. However, the rapid advancement of AI also introduces challenges such as potential biases, ethical considerations, and implementation challenges in ensuring that its deployment is equitable. Ensuring inclusive and ethical developments of AI technology can empower both health-care providers and people with diabetes in managing the condition. In this Review, we explore and summarise the current and future prospects of AI across the diabetes care continuum, from enhancing screening and diagnosis to optimising treatment and predicting and managing complications.

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.

Can telehealth expansion boost health care utilization specifically for patients with substance use disorders relative to patients with other types of chronic disease?

OBJECTIVE

Patients with substance use disorders (SUDs) exhibit low healthcare utilization despite high risk of poor outcomes. Telehealth expansion may boost utilization, but it is unclear whether telehealth can increase utilization for patients with SUDs beyond that expected for other chronic diseases amenable to remote treatment, like type 2 diabetes. This information is needed by health systems striving to improve SUD outcomes, specifically. This study compared the impact of telehealth expansion during the COVID-19 public health emergency (PHE) on utilization for patients with SUDs and diabetes.

METHODS

Using Wisconsin Medicaid administrative, enrollment and claims data 12/1/2018-12/31/2020, this cohort study included nonpregnant, nondisabled adults 19-64 years with SUDs (N = 17,336) or diabetes (N = 8,499). Outcomes included having a primary care visit in the week (any, and telehealth) for any diagnosis, or a SUD or diabetes diagnosis; and the weekly fraction of visits completed by telehealth. Logistic and fractional regression examined outcomes pre- and post-PHE. Covariates included age, sex, race, ethnicity, income, geography, and comorbid medical and psychotic disorders.

RESULTS

Post-PHE, patients with SUDs exhibited greater likelihood of telehealth utilization (percentage point difference (PPD) per person-week: 0.2; 95% CI: 0.001-0.003; p<0.001) and greater fractional telehealth use (PPD: 1.8; 95%CI: 0.002-0.033; p = 0.025) than patients with diabetes despite a larger overall drop in visits (PPD: -0.5; 95%CI: -0.007- -0.003; p<0.001).

CONCLUSIONS

Following telehealth expansion, patients with SUDs exhibited greater likelihood of telehealth utilization than patients with diabetes. This advantage lessened the substantial PHE-induced healthcare disruption experienced by patients with SUDs. Telehealth may boost utilization for patients with SUDs.

Deintensification of potentially inappropriate medications amongst older frail people with type 2 diabetes: Protocol for a cluster randomised controlled trial (D-MED study)

AIMS

Amongst elderly people with type 2 diabetes (T2D) over prescribing can result in emergency ambulance call-outs, falls and fractures and increased mortality, particularly in frail patients. Current clinical guidelines, however, remain focused on medication intensification rather than deintensification where appropriate. This study aims to evaluate the effectiveness of an electronic decision-support system and training for the deintensification of potentially inappropriate medications amongst older frail people with T2D, when compared to 'usual' care at 12-months.

METHODS

This study is an open-label, multi-site, two-armed pragmatic cluster-randomised trial. GP practices randomised to the 'enhanced care' group have an electronic decision support system installed and receive training on the tool and de-intensification of diabetes medications. The system flags eligible patients for possible deintensification of diabetes medications, linking the health care professional to a clinical algorithm. The primary outcome will be the number of patients at 12-months who have had potentially inappropriate diabetes medications de-intensified.

RESULTS

Study recruitment commenced in June 2022. Data collection commenced in January 2023. Baseline data have been extracted from 40 practices (3145 patients).

CONCLUSIONS

Digital technology, involving computer decision systems, may have the potential to reduce inappropriate medications and aid the process of de-intensification.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number: ISRCTN53221378. Available at: https://www.isrctn.com/ISRCTN53221378.

Opportunities to overcome underutilization of enhanced insulin delivery technologies in people with type 2 diabetes: a narrative review

Use of innovative technologies such as continuous glucose monitoring (CGM) and insulin delivery systems have been shown to be safe and effective in helping patients with diabetes achieve significantly improved glycemic outcomes compared to their previous therapies. However, these technologies are underutilized in many primary care practices. This narrative review discusses some of the clinical and economic benefits of tubeless insulin delivery devices and discusses how this technology can overcome the main obstacles inherent to use of conventional insulin delivery devices.

Beneficial Effect of Remote Glucose Monitoring and Computerized Insulin Dose Adjustment Algorithms Independent of Insulin Dose Increases in Sizeable Minorities of Patients

This article describes a program through which interactions every 2-3 weeks between patients and primary care clinicians (PCCs), with recommendations based on analysis of remote glucose monitoring by computerized insulin dose adjustment algorithms, significantly improved diabetes control. Insulin doses increased by 30% in the majority of patients. A sizeable minority (36%) had a decrease or no increase in insulin doses, but still showed an improvement in diabetes control. Frequent interactions allowed PCCs the opportunity to recognize and address medication nonadherence.

Use of primary health care services and mortality in older patients with type 2 diabetes with or without comorbidities

OBJECTIVE

This study aimed to examine primary health care (PHC) service utilization and mortality in older patients with type 2 diabetes (T2D) with or without comorbidities.

DESIGN AND SETTING

A cohort study in PHC in the city of Vantaa, Finland. Follow-up period was set between the years 2011 and 2018.

SUBJECTS

PHC patients aged 60 years or more with a T2D were included.

MAIN OUTCOME MEASURES

Service utilization was defined as the number of face-to-face appointments and telephone contacts between a patient and general practitioner (GP) or nurse. The presence of comorbidities was defined using the Charlson Comorbidity Index (CCI). Mortality was assessed using hazard ratio (HR) and standardized mortality ratio (SMR).

RESULTS

In total, 11,020 patients were included and followed for 71,596 person years. Mean age of the women and men in the beginning of follow-up were 71 and 69 years, respectively. The patients in the study cohort had a mean of eight appointments per person year to the GPs or nurses. Patients with T2D with comorbidities had more appointments than patients with T2D without comorbidities (incidence rate ratio (IRR) 1.44 [95% CI 1.39-1.49]). Increase in the number of all appointments reduced mortality in patients with T2D with and without comorbidities. Between patients with T2D with comorbidities and patients with T2D without comorbidities, the age and sex adjusted HR for death was 1.50 (95% CI 1.39-1.62). The SMR was higher in patients with T2D with comorbidities (1.83 [95% CI 1.74-1.92]) than in patients with T2D without comorbidities (0.91 [95% CI 0.86-0.96]).

CONCLUSIONS

In older patients with T2D, the presence of comorbidities was associated with increased use of PHC services and increased mortality. Increase in the number of appointments was associated with reduced mortality in patients with T2D with or without comorbidities.Key PointsIn older patients with T2D, it has not been studied whether and to what extend multimorbidity affects use of PHC services and mortality.The presence of comorbidities according to the Charlson Comorbidity Index (CCI) was associated with increased use of PHC services.The number of appointments to GPs or nurses was associated with reduced mortality in patients with T2D with or without comorbidities according to the CCI.

Glucagon prescribing and prevention of hospitalization for hypoglycemia in a large health system

AIMS

To examine glucagon prescribing trends among patients at high risk of severe hypoglycemia and assess if a glucagon prescription is associated with lower rates of severe hypoglycemia requiring hospital care.

METHODS

Retrospective analysis of electronic health records from a large integrated healthcare system between May 2019 and August 2021. We included adults (≥18 years) with type 1 diabetes or with type 2 diabetes treated with short-acting insulin and/or recent history of hypoglycemia-related emergency department visit or hospitalization. We calculated rates of glucagon prescribing overall and by patient characteristics. We then matched 1:1 those who were and were not prescribed glucagon and assessed subsequent hypoglycemia-related hospitalization.

RESULTS

Of 9,200 high risk adults, 2063 (22.4%) were prescribed glucagon. Among patients more likely to be prescribed glucagon were those younger, female, White, living in urban areas, with prior severe hypoglycemia, and with a recent endocrinology specialist visit. In the matched cohort (N = 1707 per arm), 62 prescribed glucagon and 33 not prescribed glucagon were hospitalized for hypoglycemia (adjusted incidence rate ratio 1.71, 95% CI 1.10-2.66; P = 0.018).

CONCLUSION

Glucagon prescribing was infrequent with significant racial and rural disparities. Patients with glucagon prescriptions did not have lower rates of hospitalization for hypoglycemia.

Interventions to address global inequity in diabetes: international progress

Diabetes is a serious chronic disease with high associated burden and disproportionate costs to communities based on socioeconomic, gender, racial, and ethnic status. Addressing the complex challenges of global inequity in diabetes will require intentional efforts to focus on broader social contexts and systems that supersede individual-level interventions. We codify and highlight best practice approaches to achieve equity in diabetes care and outcomes on a global scale. We outline action plans to target diabetes equity on the basis of the recommendations established by The Lancet Commission on Diabetes, organising interventions by their effect on changing the ecosystem, building capacity, or improving the clinical practice environment. We present international examples of how to address diabetes inequity in the real world to show that approaches addressing the individual within a larger social context, in addition to addressing structural inequity, hold the greatest promise for creating sustainable and equitable change that curbs the global diabetes crisis.

Telementoring With Project ECHO: A New Era in Diabetes-Related Continuing Education for Primary Care to Address Health Disparities

Project ECHO® is a telementoring workforce development model that targets under-resourced communities lacking access to specialty care. The model builds virtual communities of practice, including specialists and community primary care professionals (PCPs) to combat clinical inertia and health disparities. While the ECHO model has gained global recognition, implementation of the model related to diabetes is lagging compared to other specialty conditions. This review highlights diabetes-endocrine (ENDO)-focused ECHOs using data reported in the ECHO Institute's centralized data repository (iECHO) and the learning collaborative for diabetes ECHOs. It also describes the implementation of diabetes ECHOs and their evaluation. Learner and patient-centered outcomes related to diabetes ECHOs are reviewed. Program implementation and evaluations have demonstrated utility of the ECHO model for diabetes programs to (1) address unmet needs of diabetes care in the primary care setting, (2) improve knowledge and confidence in managing complex diabetes and change provider prescribing habits, (3) improve patient outcomes, and (4) address diabetes quality improvement practices in primary care. More studies with broader collaboration among sites are needed to evaluate the model related to diabetes, especially applied to addressing therapeutic inertia, adoption of diabetes technology, and reducing health disparities.

Diabetes mellitus research in Saudi Arabia: A bibliometric study (2010-2021)

Diabetes Mellitus (DM) causes global exhaustion, consumes economic resources, and has several risk factors. The bibliometric studies re-evaluate the research efforts on this illness using mathematical and statistical tools to indicate current research and future trends. This study examines KSA's DM research during 2010-2021. Data were acquired from Scopus and analyzed using VOSviewer and MS Excel. Several characteristics were examined to measure the quantity and quality of KSA-related DM articles. In total, 1,919 journal and conference papers were published. DM research included researchers from multidisciplinary sectors. Thirty-seven percent of them have ten or more scientific publications. Al-Daghri, N.M. (King Saud University) leads the pack. In total, 757 (39.44%) research projects got funding from 159 sources within and outside KSA. Memish, Z.A. is the most cited author. The Saudi Medical Journal has the most citations (1214). Al-Daghri, N.M. (KSU) collaborates the most. One hundred forty-one nations aided KSA's diabetes research. Egypt's High Institute of Public Health has the most scientific collaboration with KSA. Authors' and all Keywords analyses indicated a rich knowledge structure. Diabetes Care Journal has the most cocitations with 2,220 and a total link strength of 19,283, followed by The New England Journal of Medicine. The study results will be helpful to stakeholders to understand better the trends and performance of diabetes-related regional research, which will be beneficial.

A primary care delivered, technology supported lifestyle program for Type 2 Diabetes Management: An evaluation of changes in metabolic health, feasibility, and acceptability - A pilot interventional study protocol

Background

Type 2 Diabetes (T2D) is associated with significant health complications and socioeconomic costs. Previous research conducted through an outpatient research facility demonstrated use of a low carbohydrate (LC) diet and exercise plan delivered in the format of an education book combined with use of real-time continuous glucose monitoring (RT-CGM) is an effective self-management intervention to improve weight and blood glucose management in patients with T2D. Primary health care remains the central access point for patient management of T2D, but General Practitioners (GPs) lack access to effective evidenced-based, self-management programs that can be prescribed to improve patient outcomes.

Methods

A single-arm, within-participant pilot intervention study will be conducted to evaluate the changes in metabolic health, acceptability and feasibility of a prescriptive LC diet and lifestyle program combined with RT-CGM (LC-RTC) delivered via GP practices. Forty adults with T2D will be recruited from GP practices and prescribed the LC-RTC intervention for 12 weeks. Outcomes will be assessed at baseline and 12-weeks post intervention. Changes in metabolic health will be assessed by changes in glycosylated hemoglobin (primary outcome), body weight, blood pressure, blood lipids, and medication usage. Post-intervention, participants will complete questionnaires and participate in focus groups to explore their experience of the LC-RTC program including acceptance, perceived benefits/barriers, limitations, financial feasibility, intervention drop-out rates, participant and GP engagement with the program (clinic attendance and contacts made to clinic for program support) and RT-CGM use and wear time acceptance. GPs and clinical staff involved will participate focus groups to evaluate the perceived value and feasibility of the LC-RTC program.

Discussion

This trial will provide a powered evaluation of the changes in metabolic health, acceptability, and feasibility of the LC-RTC program for patients with T2D delivered via GP practices.

Trial registration

ANZCTR: 12622000635763 (Website Link to full registration: ANZCTR - Registration). Registered 29^th April 2022. Overall trial status: Commenced; Recruitment Status: Commenced 1^st May 2022, with 40 participants recruited as of 2^nd May 2023 using a rolling recruitment approach.

Increasing Use of Diabetes Devices: What Do Health Care Professionals Need?

Despite evidence of improved diabetes outcomes with diabetes technology such as continuous glucose monitoring (CGM) systems, insulin pumps, and hybrid closed-loop (HCL) insulin delivery systems, these devices are underutilized in clinical practice for the management of insulin-requiring diabetes. This low uptake may be the result of health care providers' (HCPs') lack of confidence or time to prescribe and manage devices for people with diabetes. We administered a survey to HCPs in primary care, pediatric endocrinology, and adult endocrinology practices in the United States. Responding HCPs expressed a need for device-related insurance coverage tools and online data platforms with integration to electronic health record systems to improve diabetes technology uptake in these practice settings across the United States.

Achievement of treatment targets among patients with type 2 diabetes in 2015 and 2020 in Canadian primary care

BACKGROUND

An update on the degree to which patients with type 2 diabetes in Canada achieve treatment targets is needed to document progress and identify subgroups that need attention. We sought to estimate the frequency with which patients managed in primary care met treatment targets (i.e., HbA_1c ≤ 7.0%, blood pressure < 130/80 mm Hg and low-density lipoprotein cholesterol [LDL-C] < 2.00 mmol/L), guideline-based use of statins and of angiotensin-convertingenzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), and the effects of patient age and sex.

METHODS

We conducted a cross-sectional study of 32 503 and 44 930 adults with diabetes in Canada on June 30, 2015, and 2020, respectively, using electronic medical record data from primary care practices across 5 provinces. We grouped achievement of diabetes targets by age and sex, and compared between groups using logistic regression with adjustment for cardiovascular comorbidities.

RESULTS

In 2020, target HbA_1c levels were achieved for 63.8% of women and 58.9% of men. Blood pressure and LDL-C targets were achieved for 45.6% and 45.8% of women, and for 43.1% and 59.4% of men, respectively. All 3 treatment targets were achieved for 13.3% of women and 16.5% of men. Overall, 45.3% and 54.0% of women and men, respectively, used statins; 46.5% of women used ACE inhibitors or ARBs, compared with 51.9% of men. With the exception of blood pressure and HbA_1c levels among women, target achievement was lower among younger patients. Achievement of the LDL-C target, statin use and ACE inhibitor or ARB use were lower among women at any age. From 2015 to 2020, target achievement increased for HbA_1c, remained consistent for LDL-C and declined for blood pressure; use of statins and of ACE inhibitors or ARBs also declined.

INTERPRETATION

Target achievement for blood pressure and use of statins and of ACE inhibitors and ARBs declined between 2015 and 2020, and was suboptimal in all patient groups. Widespread quality improvement is needed to increase evidence-based therapy for people with diabetes.

Quality of Care for US Adults With Medicaid Insurance and Type 2 Diabetes in Federally Qualified Health Centers Compared With Other Primary Care Settings

OBJECTIVE

The objective of this study was to evaluate indicators of diabetes quality of care for US nonelderly, adult Medicaid enrollees with type 2 diabetes and compare federally qualified health centers (FQHCs) versus non-FQHCs.

RESEARCH DESIGN AND METHODS

We analyzed diabetes process measures and acute health services utilization with 2012 US fee-for-service and managed care Medicaid claims in all 50 states and DC. We compared FQHC (N=121,977) to non-FQHC patients (N=700,401) using propensity scores to balance covariates and generalized estimating equation models.

RESULTS

Overall, laboratory-based process measures occurred more frequently (range, 65.7%-76.6%) than measures requiring specialty referrals (retinal examinations, 33.3%; diabetes education, 3.4%). Compared with non-FQHC patients, FQHC patients had about 3 percentage point lower rates of each process measure, except for higher rates of diabetes education [relative risk=1.09, 95% confidence interval (CI): 1.03-1.16]. FQHC patients had fewer overall [incident rate ratio (IRR)=0.87, 95% CI: 0.86-0.88] and diabetes-related hospitalizations (IRR=0.79, 95% CI: 0.77-0.81), but more overall (IRR=1.06, 95% CI: 1.05-1.07) and diabetes-related emergency department visits (IRR=1.10, 95% CI: 1.08-1.13).

CONCLUSIONS

This national analysis identified opportunities to improve diabetes management among Medicaid enrollees with type 2 diabetes, especially for retinal examinations or diabetes education. Overall, we found slightly lower rates of most diabetes care process measures for FQHC patients versus non-FQHC patients. Despite having higher rates of emergency department visits, FQHC patients were significantly less likely to be hospitalized than non-FQHC patients. These findings emphasize the need to identify innovative, effective approaches to improve diabetes care for Medicaid enrollees, especially in FQHC settings.

Association between telemedicine use and diabetes risk factor assessment and control in a primary care network

PURPOSE

Our study examined whether telemedicine use in primary care is associated with risk factor assessment and control for patients with diabetes mellitus.

METHODS

This was a retrospective, 1:1 propensity score matched cohort study conducted in a primary care network between February 2020 and December 2020. Participants included patients with diabetes mellitus, ages 18 to 75. Exposure of interest was any telemedicine visit. We determined whether hemoglobin A1c (HbA1c), blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) were assessed for each patient. For each risk factor, we also determined whether the risk factor was controlled when they were assessed (i.e., last HbA1c < 8.0%, BP < 130/80 mmHg, LDL-C < 100 mg/dL).

RESULTS

After 1:1 propensity score matching, we identified 1,824 patients with diabetes during the study period. Telemedicine use was associated with a lower proportion of patients with all three risk factors assessed (162/912 [18%], versus 408/912 [45%], p < 0.001). However, when individual risk factors were assessed, telemedicine use did not impact risk factor control. When compared with patients with in-person visit only, the odds ratio (OR) for HbA1c < 8% was 1.04 (95% CI 0.74 to 1.46, p = 0.23) for patients with any telemedicine visit. Similarly, the OR for BP < 130/80 mmHg was 1.08 (95% CI 0.85-1.36 p = 0.53), and the OR for LDL-C < 100 mg/dL was 1.14 (95% CI 0.76-1.72, p = 0.52).

CONCLUSIONS

Telemedicine use was associated with gaps in risk factor assessment for patients with diabetes during the COVID-19 pandemic, but had limited impact on whether risk factors were controlled.

What helps and what hinders primary care treatment for women with type 2 diabetes and binge eating disorder? A qualitative study

AIM

Although binge-eating disorder (BED) is a common comorbidity of type 2 diabetes, little is known about the treatment experiences for persons with both conditions. Our aim was to explore perceptions of Primary Care Providers' (PCPs') treatment among adult women with both diagnoses.

METHODS

In this qualitative descriptive study, we conducted semi-structured interviews with a sample of 21 women (90% non-Hispanic white; mean age 49 ± 14.8 years, mean body mass index [BMI] 43.8 ± 8.4; 48% had type 2 diabetes, mean HbA_1c 68 mmol/mol, 8.4%) who had previously participated in a secondary care specialized eating disorder treatment programme. Interviews were audio-recorded, transcribed and analysed using thematic analysis and NVivo 12.

RESULTS

Participants described PCPs' helpful and unhelpful attitudes and behaviours during type 2 diabetes and BED treatment experiences. Helpful treatment was experienced when PCPs demonstrated a person-centred approach by providing adequate diabetes education, individualized care and non-judgmental attitudes from which participants reported increased understanding of diabetes and BED, improved diabetes self-care and fewer negative self-perceptions. Unhelpful treatment occurred when PCPs did not provide sufficient diabetes education and manifested deficient understanding of BED characterized by simplistic advice or judgmental attitudes, from which participants reported having limited knowledge and understanding of diabetes and BED, low self-efficacy, diminished trust and feelings of guilt, shame and failure.

CONCLUSIONS

We propose a preliminary pathways treatment model derived from our findings, which utilizes integrated type 2 diabetes and BED education and person-centred collaboration. This preliminary model needs to be tested in quantitative research with a larger sample.

Impact of a Provider Tele-mentoring Learning Model on the Care of Medicaid-enrolled Patients With Diabetes

BACKGROUND

Project ECHO (Extension for Community Healthcare Outcomes), a tele-mentoring program for health care providers, has been shown to improve provider-reported outcomes, but there is insufficient research on patient-level outcomes.

OBJECTIVES

To evaluate the impact of primary care provider (PCP) participation in Project ECHO on the care of Medicaid enrollees with diabetes.

RESEARCH DESIGN

New Jersey Medicaid claims and encounter data and difference-in-differences models were used to compare utilization and spending between Medicaid patients seen by PCPs participating in a Project ECHO program to those of matched nonparticipating PCPs.

SUBJECTS

A total of 1776 adult Medicaid beneficiaries (318 with diabetes), attributed to 25 participating PCPs; and 9126 total (1454 diabetic) beneficiaries attributed to 119 nonparticipating PCPs.

MEASURES

Utilization and spending for total inpatient, diabetes-related inpatient, emergency department, primary care, and endocrinologist services; utilization of hemoglobin A1c tests, eye exams, and diabetes prescription medications among diabetics, and total Medicaid spending.

RESULTS

Participation in Project ECHO was associated with decreases of 44.3% in inpatient admissions (P=0.001) and 61.9% in inpatient spending (P=0.021) among treatment relative to comparison patients. Signs of most other outcome estimates were consistent with hypothesized program effects but without statistical significance. Sensitivity analyses largely confirmed these findings.

CONCLUSIONS

We find evidence that Project ECHO participation was associated with large and statistically significant reductions of inpatient hospitalization and spending. The study was observational and limited by a small sample of participating PCPs. This study demonstrates the feasibility and potential value of quasi-experimental evaluation of Project ECHO patient outcomes using claims data.

Correlation of serum uric acid with lipid profile in patients with type 2 diabetes mellitus with normal creatinine level: Report from a tertiary care hospital in India

Background

Increased serum uric acid (SUA) level is considered a risk factor for kidney diseases in type 2 diabetes mellitus (T2DM) patients. Deranged lipid profile in T2DM is an overall risk factor for cardiovascular complications.

Aim

This study aimed to find the correlation between SUA and serum lipid profile in T2DM patients who had serum creatinine levels within normal limits.

Materials and Methods

This cross-sectional observational study was conducted in a tertiary care hospital in eastern India. Serum creatinine level was measured first. Then, patients with serum creatinine levels within normal limits were recruited as the final sample. Anthropometric measurements were conducted by an experienced clinician. A 12-h fasting venous blood sample was used to measure serum urea, lipids, sugar, and glycated hemoglobin.

Results

A total of 176 (male = 104 [59.1%], female = 72 [40.9%]) T2DM patients with a median age of 46 (Q1-Q3 = 40-55) years participated in the study. There was no gender difference in fasting blood sugar (FBS) (P = 0.57), SUA (P = 0.42), and high-density lipoprotein-cholesterol (HDL-C) (P = 0.17). Females showed higher total cholesterol (TC) (P < 0.0001), triglyceride (TG) (P = 0.002), low-density lipoprotein-cholesterol (LDL-C) (P = 0.0002), and very-low-density lipoprotein-cholesterol (VLDL-C) (P = 0.01). SUA showed significant positive correlation with TG (rs = 0.65, P < 0.0001) and VLDL-C (rs = 0.63, P < 0.0001) and significant negative correlation with HDL-C (rs = -0.35, P < 0.0001) and FBS (rs = -0.45, P < 0.0001).

Conclusions

A higher level of SUA, an indicator for kidney disease in T2DM patients, may be associated with a higher TG and VLDL-C and lower FBS and HDL-C. Thus, SUA should be monitored along with lipid profile for early detection of the risk of kidney diseases.

Family Physician Clinical Inertia in Managing Hypoglycemia

AIMS

Clinical inertia behaviour affects family physicians managing chronic disease such as diabetes. Literature addressing clinical inertia in the management of hypoglycemia is scarce. The objectives of this study were to create a measurement for physician clinical inertia in managing hypoglycemia (ClinInert_InHypoDM), and to determine physicians' characteristics associated with clinical inertia.

METHODS

The study was a secondary analysis of data provided by family physicians from the InHypo-DM Study, applying exploratory factor analysis. Principal axis factoring with an Oblimin rotation was employed to detect underlying factors associated with physician behaviors. Multiple linear regression was used to determine association between the ClinInert_InHypoDM scores and physician characteristics.

RESULTS

Factor analysis identified a statistically sound 12-item one-factor scale for clinical inertia behavior. No statistically significant differences in clinical inertia score for the studied independent variables were found.

CONCLUSIONS

This study provides a scale for assessing clinical inertia in the management of hypoglycemia. Further testing this scale in other family physician populations will provide deeper understanding about the characteristics and factors that influence clinical inertia. The knowledge derived from better understanding clinical inertia in primary care has potential to improve outcomes for patients with diabetes.

HbA1c-Triggered Endocrinology Electronic Consultation for Type 2 Diabetes Management

BACKGROUND

Electronic consultation (eConsultation) offers a potential mechanism to increase access to specialty care, address knowledge gaps, and overcome therapeutic inertia in patients with type 2 diabetes (T2DM) being managed by primary care physicians (PCPs).

OBJECTIVE

To develop and implement a system to provide unsolicited endocrinology eConsult for T2DM patients with HbA1c 8.5-10.5% managed by PCPs.

DESIGN

Cluster-randomized matched cohort study with implementation evaluation.

PARTICIPANTS

PCPs affiliated with Massachusetts General Hospital (MGH).

INTERVENTIONS

Unsolicited endocrinology eConsultation.

MAIN MEASURES

The primary clinical outcome was mean change in HbA1c at 6 months. Secondary process outcomes included referral completion rate, prescription rates of glucose-lowering medications, differences in rate of other management recommendations, change in all glucose-lowering medications, and number of face-to-face endocrinology visits.

KEY RESULTS

161 PCPs were randomly assigned to intervention (n=81) and control (n=80) arms. eConsultations were triggered on 130 patients from intervention arm PCPs. Intervention arm patients had a 0.89 (SD 1.45) decrease in HbA1c compared to 0.69 (SD 1.32) decrease in the control arm (p=0.28). There were significant differences in prescribing of glucose-lowering medications between arms. There was a 19.3% increase in patients prescribed GLP-1 RA or SGLT2i in the intervention arm compared to a 6.9% increase in control (p=0.003). There were also significant increases in prescription rates of metformin (3.1% vs -3.1%, p=0.03) and sulfonylureas (1.5% vs -6.9%, p=0.03). At 6-month follow-up, the intervention arm had 13 in-person endocrinology visits compared to 29 (p=0.012) in the control arm. PCPs were more likely to accept recommendations regarding adherence to or dose adjustment of current medications than initiation of new medications.

CONCLUSIONS

The implementation of an unsolicited endocrinology eConsult system for patients with poorly controlled T2DM is feasible. Unsolicited eConsultation was associated with increased prescribing of glucose-lowering medications without significant difference in HbA1c.

TRIAL REGISTRATION

Clinicaltrials.gov registration: NCT03542084.

GLP-1 receptor agonists and cardiovascular outcomes in patients with type 2 diabetes: Clinical evidence and best practice

ABSTRACT

Cardiovascular disease (CVD) is a major cause of death and disability among people with type 2 diabetes (T2D), presenting a significant impact on longevity, patient quality of life, and health care costs. In the United States, attainment of recommended glycemic targets is low and T2D-related cardiovascular complications remain a significant burden. Many glucose-lowering treatment options are available, but glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 (SGLT-2) inhibitors are recommended in recent guidelines as the preferred add-on therapy to metformin to improve glycemic control. This is particularly the case for patients with T2D and established atherosclerotic CVD, at high risk of atherosclerotic CVD, and/or with chronic kidney disease. Recommendations were based on GLP-1RA and SGLT-2 inhibitor cardiovascular outcomes trials (CVOTs), which consistently showed that these agents pose no additional cardiovascular risk compared with placebo. Three GLP-1RAs (liraglutide, dulaglutide, and subcutaneous semaglutide) demonstrated significantly lower major adverse cardiovascular events versus placebo and are now approved for this indication. However, to realize improvement in outcomes in the clinical setting, organized, systematic, and coordinated approaches to patient management are also needed. For example, nurse-led diabetes self-management education and support programs have been shown to be effective. This article explores T2D management with emphasis on cardiovascular risk and CVOTs performed to date and reviews the clinical experience with GLP-1RAs for managing hyperglycemia and their impact on cardiovascular risk. In addition, practical guidance is given for key health care providers involved in the care of patients with T2D with cardiovascular risk outside of diabetes clinics/endocrinology centers.

The Benefits of Utilizing Continuous Glucose Monitoring of Diabetes Mellitus in Primary Care: A Systematic Review

BACKGROUND

Continuous glucose monitoring (CGM) and intermittently scanned CGM (is-CGM) have shown to effectively manage diabetes in the specialty setting, but their efficacy in the primary care setting remains unknown. Does CGM/is-CGM improve glycemic control, decrease rates of hypoglycemia, and improve staff/physician satisfaction in primary care? If so, what subgroups of patients with diabetes are most likely to benefit?

METHODS

A comprehensive search in seven databases was performed in June 2021 for primary studies examining any continuous glucose monitoring system in primary care. We excluded studies with fewer than 20 participants, specialty care only, or hospitalized participants. The National Heart, Lung and Blood Institute and Grading of Recommendations Assessment, Development and Evaluation were used for the quality assessment. The weighted mean difference (WMD) of HbA1c between CGM/is-CGM and usual care with 95% confidence interval was calculated. A narrative synthesis was conducted for change of time in, above, or below range (TIR, TAR, and TBR) hypoglycemic events and staff/patient satisfaction.

RESULTS

From ten studies and 4006 participants reviewed, CGM was more effective at reducing HbA1c compared with usual care (WMD -0.43%). There is low certainty of evidence that CGM/is-CGM improves TIR, TAR, or TBR over usual care. The CGM can reduce hypoglycemic events and staff/patient satisfaction is high. Patients with intensive insulin therapy may benefit more from CGM/is-CGM.

CONCLUSIONS

Compared with usual care, CGM/is-CGM can reduce HbA1c, but most studies had notable biases, were short duration, unmasked, and were sponsored by industry. Further research needs to confirm the long-term benefits of CGM/is-CGM in primary care.

Maintenance of glycaemic control with liraglutide versus oral antidiabetic drugs as add-on therapies in patients with type 2 diabetes uncontrolled with metformin alone: A randomized clinical trial in primary care (LIRA-PRIME)

AIM

To compare (in the LIRA-PRIME [NCT02730377], a randomized open-label trial), the efficacy of liraglutide in controlling glycaemia versus an oral antidiabetic drug (OAD) in patients with uncontrolled type 2 diabetes (T2D), despite metformin use in a primary care setting (n = 219 sites, n = 9 countries).

MATERIALS AND METHODS

Adults (n = 1991) with T2D (HbA1c 7.5%-9.0%) receiving metformin were randomized 1:1 to liraglutide (≤1.8 mg/d) or one OAD, selected by the investigator, added to metformin, for up to 104 weeks. Primary endpoint: time to inadequate glycaemic control (HbA1c > 7.0%) at two scheduled consecutive visits after week 26. Outcomes were assessed for liraglutide versus a pooled OAD group, and (post hoc) liraglutide versus sodium-glucose co-transporter-2 inhibitors, dipeptidyl peptidase-4 inhibitors, and sulphonylureas individually.

RESULTS

Among randomized patients (liraglutide, n = 996; OAD, n = 995), 47.6% were female, mean age was 57.4 years and mean HbA1c was 8.2%. Median time to inadequate glycaemic control was 44 weeks longer with liraglutide versus OAD (109 weeks [25% percentile, 38; 75% percentile, not available] vs. 65 weeks [25% percentile, 35; 75% percentile, 107], P < .0001). Changes in HbA1c and body weight at week 104 or at premature treatment discontinuation significantly favoured liraglutide over OAD. Hypoglycaemia rates were comparable between groups and few patients discontinued because of adverse events (liraglutide, 7.9% [n = 79]; OAD, 4.1% [n = 41]). Similar results were observed in the post hoc analysis for liraglutide versus individual OAD classes.

CONCLUSIONS

Glycaemic control was better maintained with liraglutide versus OAD, supporting liraglutide use when intensifying therapy in primary care patients with T2D.

Utilizing point-of-care A1c to impact outcomes - can we make it happen in primary care?

PURPOSE OF REVIEW

Hemoglobin A1c testing provides a marker of glycemic control and is the standard for diabetes risk assessment. According to the Centers for Disease Control (CDC), only 67.3-71.4% of diabetic patients between 2011 and 2016 had at least two A1c levels tested per year. Moreover, 27.8% had uncontrolled diabetes with an A1c of ≥8.0%, increasing the risk of microvascular complications. Lack of monitoring presents a significant barrier, and improving ease of testing could improve glycemic control.

RECENT FINDINGS

Point-of-care (POC) A1c testing, obtained via capillary blood with results provided in 5-6 min, is available and used frequently in endocrine clinics. However, POC A1c testing is not standard in primary care, where 90% of type 2 diabetes patients are treated. Barriers include access and costs of POC A1c machines and standardization of testing in the primary care setting. Review of literature, however, suggests that POC A1c testing in primary care may lead to A1c reduction whereas being potentially cost-effective and strengths the patient-physician relationship.

SUMMARY

POC A1c testing in primary care, if widely available and integrated into workflow, has the potential to positively impact diabetes care. Real-time feedback may change patient and physician behaviors, allowing earlier therapeutic intensification.

Primary care service utilisation and outcomes in type 2 diabetes: a longitudinal cohort analysis

OBJECTIVES

To describe primary care utilisation patterns among adults with type 2 diabetes and to quantify the association between utilisation and long-term health outcomes.

DESIGN

Retrospective cohort study.

SETTING

168 primary care practices in Southern England within the Electronic Care and Health Information Analytics database between 2013 and 2020.

PARTICIPANTS

110 240 adults with Quality and Outcomes Framework read code of type 2 diabetes diagnosis; age greater than 18 years; linked and continuous records available from April 2013 until April 2020 (or death). PRIMARY AND SECONDARY OUTCOME MEASURES: (1) Rates of service utilisation (total number of primary care contacts per quarter) across the study period; (2) participant characteristics associated with higher and lower rates of service utilisation; and (3) associations between service utilisation and (A) cardiovascular disease (CVD events) and (B) all-cause mortality.

RESULTS

Mean (SD) number of primary care attendances per quarter in the cohort of 110 240 went from 2.49 (2.01) in 2013 to 2.78 (2.06) in 2020. Patients in the highest usage tertile were more likely to be female, older, more frail, white, from the least deprived quintile and to have five or more comorbidities. In adjusted models, higher rates of service utilisation (per consultation) were associated with higher rates of CVD events (OR 1.0058; 95% CI 1.0053 to 1.0062; p<0.001) and mortality (OR 1.0057; 95% CI 1.0051 to 1.0064; p<0.001).

CONCLUSIONS

People with type 2 diabetes are using primary care services more frequently, but increased volume of clinical care does not correlate with better outcomes, although this finding may be driven by more unwell patients contacting services more frequently. Further research on the nature and content of contacts is required to understand how to tailor services to deliver effective care to those at greatest risk of complications.

A Conversation on an Effective, Straightforward, Quantitative Approach to the Outpatient Use of Insulin

For primary care providers, using insulin can present challenges that can be met by a straightforward approach using the following principles. Depending on when it is injected, each component of the insulin regimen has a maximal effect on a specific period of the 24-hour cycle (e.g., overnight, morning, afternoon, or evening). The glucose pattern in that period determines whether the dose of that component of the insulin regimen requires adjusting. Regarding which insulin types and insulin regimens to use, human insulin (NPH and regular) is as effective as analog insulins, and a two-injection intensified insulin regimen is as effective as a four-injection regimen.

Differences in Breast Cancer Screening Practices by Diabetes Status and Race/Ethnicity in the United States

Introduction: Socioeconomic and health-related factors, including comorbid illness, may affect mammography screening rates and subsequently contribute to breast cancer outcomes. We explored the association between diabetes and mammography screening, and whether this association varied between racial, ethnic, and geographic groups. Methods: Cross-sectional data from the 2012, 2014, 2016, and 2018 Behavioral Risk Factor Surveillance System were used to fit logistic regression models assessing the association between diabetes and up-to-date mammography screening in 497,600 women, aged 50-74 years. Participants were considered exposed if they responded "yes" to "(Ever told) you have diabetes?" and up to date on screening if they responded "yes" to having a mammogram within the past 2 years. Models were adjusted for age, health status, socioeconomic, and access variables. Results: The majority of participants were White (79.6%), non-Hispanic (88.9%), and up to date on screening (78.8%). Overall, 16.8% reported having diabetes. In fully adjusted models, White women with diabetes were 12% more likely to be up to date on screening (odds ratio [OR]: 1.12, 95% confidence interval [CI]: 1.06-1.19) than those without diabetes. Black/African American women and those of Hispanic ethnicity with diabetes were more likely to report being up to date with mammography (OR_Black: 1.28, 95% CI: 1.12-1.45; OR_Hispanic: 1.19, 95% CI: 1.13-1.24) than those without. Patterns were similar across geographic regions. Conclusions: Women of ages 50-74 years with diabetes were more likely to be up to date on screening than women without diabetes. Chronic disease management may represent an opportunity to address cancer screening.

Practical guidance on the initiation, titration, and switching of basal insulins: a narrative review for primary care

Many patients with type 2 diabetes will ultimately require the inclusion of basal insulin in their treatment regimen. Since most people with type 2 diabetes are managed in the community, it is important that primary care providers understand and correctly manage the initiation and titration of basal insulins, and help patients to self-manage insulin injections. Newer, long-acting basal insulins provide greater stability and flexibility than older preparations and improved delivery systems. Basal insulin is usually initiated at a conservative dose of 10 units/day or 0.1-0.2 units/kg/day, then titrated thereafter over several weeks or months, based on patients' self-measured fasting plasma glucose, to achieve an individualized target (usually 80-130 mg/dL). Through a shared decision-making process, confirmation of appropriate goals and titration methods should be established, including provisions for events that might alter scheduled titration (e.g. travel, dietary change, illness, hospitalization, etc.). Although switching between basal insulins is usually easily accomplished, pharmacokinetic and pharmacodynamic differences between formulations require clinicians to provide explicit guidance to patients. Basal insulin is effective long-term, but overbasalization (continuing to escalate dose without a meaningful reduction in fasting plasma glucose) should be avoided.Key messagesPrimary care providers often initiate basal insulin for people with type 2 diabetes.Basal insulin is recommended to be initiated at 10 units/day or 0.1-0.2 units/kg/day, and doses must be titrated to agreed fasting plasma glucose goals, usually 80-130 mg/dL. A simple rule is to gradually increase the initial dose by 1 unit per day (NPH, insulin detemir, and glargine 100 units/mL) or 2-4 units once or twice per week (NPH, insulin detemir, glargine 100 and 300 units/mL, and degludec) until FPG levels remain consistently within the target range. If warranted, switching between basal insulins can be done using simple regimens.The dose of basal insulin should be increased as required up to approximately 0.5-1.0 units/kg/day in some cases. Overbasalization (continuing to escalate dose without a meaningful reduction in fasting plasma glucose) is not recommended; rather re-evaluation of individual therapy, including consideration of more concentrated basal insulin preparations and/or short-acting prandial insulin as well as other glucose-lowering therapies, is suggested.

Implications of remote monitoring Technology in Optimizing Traditional Self-Monitoring of blood glucose in adults with T2DM in primary care

BACKGROUND

Self-monitoring of blood glucose (SMBG) has been shown to reduce hemoglobin A1C (HbA1C). Accordingly, guidelines recommend SMBG up to 4-10 times daily for adults with type 2 diabetes (T2DM) on insulin. For persons not on insulin, recommendations are equivocal. Newer technology-enabled blood glucose monitoring (BGM) devices can facilitate remote monitoring of glycemic data. New evidence generated by remote BGM may help to guide best practices for frequency and timing of finger-stick blood glucose (FSBG) monitoring in uncontrolled T2DM patients managed in primary care settings. This study aims to evaluate the impact of SMBG utility and frequency on glycemic outcomes using a novel BGM system which auto-transfers near real-time FSBG data to a cloud-based dashboard using cellular networks.

METHODS

Secondary analysis of the intervention arm of a comparative non-randomized trial with propensity-matched chart controls. Adults with T2DM and HbA1C > 9% receiving care in five primary care practices in a healthcare system participated in a 3-month diabetes boot camp (DBC) using telemedicine and a novel BGM to support comprehensive diabetes care management. The primary independent variable was frequency of FSBG. Secondary outcomes included frequency of FSBG by insulin status, distribution of FSBG checks by time of day, and hypoglycemia rates.

RESULTS

48,111 FSBGs were transmitted by 359 DBC completers. Participants performed 1.5 FSBG checks/day; with 1.6 checks/day for those on basal/bolus insulin. Higher FSBG frequency was associated with greater improvement in HbA1C independent of insulin treatment status (p = 0.0003). FSBG frequency was higher in patients treated with insulin (p = 0.003). FSBG checks were most common pre-breakfast and post-dinner. Hypoglycemia was rare (1.2% < 70 mg/dL).

CONCLUSIONS

Adults with uncontrolled T2DM achieved significant HbA1C improvement performing just 1.5 FSBGs daily during a technology-enabled diabetes care intervention. Among the 40% taking insulin, this improvement was achieved with a lower FSBG frequency than guidelines recommend. For those not on insulin, despite a lower frequency of FSBG, they achieved a greater reduction in A1C compared to patients on insulin. Low frequency FSBG monitoring pre-breakfast and post-dinner can potentially support optimization of glycemic control regardless of insulin status in the primary care setting.

TRIAL REGISTRATION

Trial registration number: NCT02925312 (10/19/2016).

A historical cohort study of glycemic control in patients with concurrent type 2 diabetes and substance use disorder treated in a primary care setting

BACKGROUND

Substance use disorder (SUD) is a known barrier to patient-self-management, which can hinder efforts to achieve treatment goals in type 2 diabetes (T2D) when the conditions coexist.

OBJECTIVE

Identify the association between SUD and glycemic control in patients with T2D treated in a primary care setting.

METHODS

This retrospective cohort study included patients with T2D treated by providers at family medicine clinics at an academic medical center and its affiliated regional sites from January 2014 to October 2019. Study index date was the first A1c recorded when T2D and SUD diagnoses had both been documented in the medical record. Glycemic control, measured by hemoglobin A1c (A1c), was identified at baseline and over a 12-month follow-up period and was compared between SUD and non-SUD patients.

RESULTS

Of 9568 included patients with T2D, 468 (4.9%) had a SUD diagnosis. In 237 SUD and 4334 non-SUD patients with A1c data, mean (SD) baseline A1c was 8.2% (2.5) and 7.9% (2.1), respectively (P = 0.043). A1c reduction was statistically greater in SUD patients than non-SUD patients (-0.31% versus -0.06%, respectively; P = 0.015), although the clinical significance is modest. In a multivariable linear regression analysis, follow-up A1c was lower in the SUD versus non-SUD patients (coefficient -0.184, 95% CI -0.358, -0.010; P = 0.038).

CONCLUSIONS

Patients with T2D and SUD had higher baseline A1c but this difference was minimized over a 12-month follow-up period. Additional research is warranted to determine long-term glycemic control and barriers to attaining and maintaining glycemic control in patients with T2D and SUD.

Clinically significant depressive symptoms and high diabetes distress in adults with type 1 and type 2 diabetes in Appalachian Ohio

CONTEXT

In rural southeastern Ohio, the prevalence of diabetes is 19.9%, nearly double the national average of 10.5%. Despite the high rate of diabetes, its impact on the region is understudied; one such understudied topic is psychosocial difficulties. People with diabetes experience disproportionately higher rates of major depressive disorder (MDD), clinically significant depressive symptoms, and diabetes distress. Diabetes distress refers to the negative emotional experience of living with diabetes. It reflects an individual's worries, concerns, and fears about living a chronic and progressive disease.

OBJECTIVES

To assess the prevalence of diabetes distress as well as comorbid, clinically significant depressive symptoms and diabetes distress among patients in southeastern Ohio; and to assess impact of depressive symptoms and diabetes distress on A_1C levels, diabetes self care behaviors, and diabetes quality of life (DQOL).

METHODS

In this cross sectional survey study, individuals aged 18 years and older, diagnosed with type 1 (T1D) or type 2 (T2D) diabetes, who were able to read and speak English, and living in southeastern Ohio were invited to participate. Participants completed the Diabetes Distress Scale for T2D or T1D, the Patient Health Questionnaire-9, the Self Care Inventory-Revised, and the DQOL Scale as part of the study survey. Participants completed the survey via an online questionnaire service or mailed packets. Chi square tests determined the comorbidity of clinically significant depressive symptoms and high diabetes distress levels by type of diabetes. Multiple regression models examined the relationships among clinically significant depressive symptoms, diabetes distress scores, A_1C levels, self care behaviors, and DQOL scores. Statistical significance was defined as a p<0.05.

RESULTS

A total of 325 adults participated (mean ± standard deviation [SD] age, 41.6 ± 19.2 years; 131 (40.7%) with T1D; 194 (59.7%) with T2D; mean ± SD A_1C, 7.5 ± 1.6%; mean ± SD duration, 12.4 ± 9.6 years). Of the 325 participants, 70 (21.5%) indicated clinically significant depressive symptoms, with 29 (22.3%) T1D participants and 41 (21.0%) T2D participants reporting clinically significant depressive symptoms. A total of 92 (28.3%) participants reported high diabetes distress (39 (30.5%) T1D participants and 53 (27.5%) T2D participants). Forty-eight participants (15.0%) screened positive for both clinically significant depressive symptoms and high diabetes distress. Regression models showed that higher diabetes distress scores were associated with fewer self care behaviors (T1D, b=-0.268, p=0.030; T2D, b=-0.312, p<0.001) and lower DQOL (T1D, b=0.726, p<0.001; T2D, b=0.501, p<0.001). Further, more depressive symptoms were associated with lower DQOL in participants with T2D (b=0.363, p<0.001). Higher diabetes distress scores were not associated with higher A_1C levels in participants with T1D or T2D; however, increased depressive symptoms were associated with higher A_1C levels in participants with T2D (b=0.390, p<0.001).

CONCLUSIONS

Findings showed that adults in southeastern Ohio experienced high levels of diabetes distress and co-occurring clinically significant depressive symptoms that were within range of data from previous studies. These findings highlight the importance of routine screening for both clinically significant depressive symptoms and diabetes distress. Future longitudinal research is needed to confirm these findings and examine the evolution of these relationships over time.

Evaluation of Clinical Outcomes With the V-Go Wearable Insulin Delivery Device in Patients With Type 2 Diabetes

Uncontrolled type 2 diabetes can lead to a multitude of health complications. Insulin therapy is recommended when patients are unable to reach their A1C goal with oral or noninsulin injectable diabetes medications. This study evaluated the clinical benefits of switching from multiple daily insulin injections to a wearable insulin delivery device (V-Go). A retrospective chart review was conducted on 44 patients who received prescriptions for the V-Go at two family medicine offices. Investigators found a significant reduction in A1C and daily insulin requirements with no impact on weight or BMI.

Effect of Diabetes-Trained Nurse Practitioners on Glycemic Outcomes: Their Suggested Use in Busy Primary Care Practices

A Federally Qualified Health Center received ongoing external support for half-time salaries for two nurse practitioners to treat people with poorly controlled diabetes (A1C >9.0%) in the clinic's diabetes program using approved detailed treatment protocols. Patients were treated for 1 year and graduated from this program if their A1C fell to <7.5%. Ninety-one percent graduated, and treatment was deemed to have failed in 9% who did not achieve an A1C <7.5% by the end of the year of treatment. The suggestion is made to assign a specially trained diabetes nurse or physician assistant to serve many primary care providers at important clinical junctures to improve diabetes outcomes throughout busy primary care practices.

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.

Application of 2021 American Diabetes Association Glycemic Treatment Clinical Practice Recommendations in Primary Care

OBJECTIVE

We aimed to identify the proportion of primary care patients meeting criteria for sodium-glucose cotransporter 2 inhibitors (SGLT2is) and glucagon-like peptide 1 receptor agonists (GLP-1 RAs) for cardiorenal comorbidities per 2021 American Diabetes Association (ADA) Standards of Care recommendations using readily available electronic health record (EHR) characteristics.

RESEARCH DESIGN AND METHODS

We applied 2021 ADA recommendations to a primary care cohort of 13,350 adults with type 2 diabetes (T2D).

RESULTS

We found that 33% of patients with diabetes would be eligible for an SGLT2i or GLP-1 RA based on cardiorenal comorbidities, 13% of patients met criteria for an SGLT2i based on heart failure or albuminuric chronic kidney disease (CKD), and 18% of patients met criteria for either agent based on atherosclerotic cardiovascular disease or CKD with an albumin-to-creatinine ratio of ≤300 mg/g.

CONCLUSIONS

This EHR algorithm identified one-third of primary care patients with T2D as meeting criteria for SGLT2i and GLP-1 RA based on strict comorbidity definitions according to 2021 ADA recommendations.

Influence of patient immigrant status on physician trainee diabetes treatment decisions: a virtual patient experimental study

To determine the effect of patient immigrant status on physician trainees' diabetes treatment decisions. Participants were 140 physician trainees ('providers'). Providers viewed videos and vignettes of virtual patients differing in immigrant status (born in Mexico or U.S.; other characteristics held constant). Analyses were completed at the group and individual levels. Providers were less likely to refer foreign-born (vs. U.S.-born) patients to endocrinology. Individual-level results showed an almost even split between treatment ratings for foreign-born vs. U.S.-born patients for three decisions (take no action, add oral hypoglycemic agent, add/switch to insulin), explaining why group-level differences for these ratings did not emerge (i.e., they were cancelled out). Physician trainees are less likely to refer foreign-born patients to endocrinology. Half of individual-level decisions were influenced by patient immigrant status, but group-level analyses mask these differences. Systematic treatment differences based on non-relevant factors could lead to adverse outcomes for immigrants.

Spousal Influence on Diabetes Self-care: Moderating Effects of Distress and Relationship Quality on Glycemic Control

BACKGROUND

Spouses often attempt to influence patients' diabetes self-care. Spousal influence has been linked to beneficial health outcomes in some studies, but to negative outcomes in others.

PURPOSE

We aimed to clarify the conditions under which spousal influence impedes glycemic control in patients with type 2 diabetes. Spousal influence was hypothesized to associate with poorer glycemic control among patients with high diabetes distress and low relationship quality.

METHODS

Patients with type 2 diabetes and their spouses (N = 63 couples) completed self-report measures before patients initiated a 7-day period of continuous glucose monitoring. Mean glucose level and coefficient of variation (CV) were regressed on spousal influence, diabetes distress, relationship quality, and their two- and three-way interactions.

RESULTS

The three-way interaction significantly predicted glucose variability, but not mean level. Results revealed a cross-over interaction between spousal influence and diabetes distress at high (but not low) levels of relationship quality, such that spousal influence was associated with less variability among patients with low distress, but more among those with high distress. Among patients with high distress and low relationship quality, a 1 SD increase in spousal influence predicted a difference roughly equivalent to the difference between the sample mean CV and a CV in the unstable glycemia range.

CONCLUSIONS

This was the first study to examine moderators of the link between spousal influence and glycemic control in diabetes. A large effect was found for glucose variability, but not mean levels. These novel results highlight the importance of intimate relationships in diabetes management.

Using Virtual Reality to Improve Health Care Providers' Cultural Self-Efficacy and Diabetes Attitudes: Pilot Questionnaire Study

Background

In southeastern Appalachian Ohio, the prevalence of diabetes is 19.9%, nearly double that of the national average of 10.5%. Here, people with diabetes are more likely to have a delayed diagnosis, limited access to health care, and lower health literacy. Despite the high rates of diabetes in the region, the availability of endocrinologists and certified diabetes care and education specialists is limited. Therefore, innovative strategies to address the growing diabetes care demands are needed. One approach is to train the primary care workforce in new and emerging therapies for type 2 diabetes to meet the increasing demands and complexity of diabetes care.

Objective

The aim of this study was to assess the effectiveness of a virtual reality training program designed to improve cultural self-efficacy and diabetes attitudes.

Methods

Health care providers and administrators were recruited from large health care systems, private practices, university-owned hospitals or clinics, Federally Qualified Health Centers, local health departments, and AmeriCorps. Providers and administrators participated in a 3-hour virtual reality training program consisting of 360-degree videos produced in a professional, cinematic manner; this technique is called virtual reality cinema (cine-VR). Questionnaires measuring cultural self-efficacy, diabetes attitudes, and presence in cine-VR were administered to providers and administrators before and after the program.

Results

A total of 69 participants completed the study. The mean age of the sample was 42.2 years (SD 13.7), 86% (59/69) identified as female, 83% (57/69) identified as White, 86% (59/69) identified as providers, and 25% (17/69) identified as nurses. Following the training program, we observed positive improvements in all three of the cultural self-efficacy subscales: Cognitive (mean change –1.29; t₆₅=–9.309; P<.001), Practical (mean change –1.85; t₆₅=–9.319; P<.001), and Affective (mean change –0.75; t₆₅=–7.067; P<.001). We observed the largest magnitude of change with the subscale, with a Cohen d of 1.16 indicating a very large effect. In addition, we observed positive improvements in all five of the diabetes attitude subscales: Need for special training (mean change –0.21; t₆₇=–6.154; P<.001), Seriousness of type 2 diabetes (mean change –0.34; t₆₇=–8.114; P<.001), Value of tight glucose control (mean change –0.13; t₆₇=–3.029; P=.001), Psychosocial impact of diabetes (mean change –0.33; t₆₇=–6.610; P<.001), and Attitude toward patient autonomy (mean change –0.17; t₆₇=–3.889; P<.001). We observed the largest magnitude of change with the Psychosocial impact of diabetes subscale, with a Cohen d of 0.87 indicating a large effect. We observed only one significant correlation between presence in cine-VR (ie, Interface Quality) and a positive change score (ie, Affective self-efficacy) (r=.285; P=.03).

Conclusions

Our findings support the notion that cine-VR education is an innovative approach to improve cultural self-efficacy and diabetes attitudes among health care providers and administrators. The long-term impact of cine-VR education on cultural self-efficacy and diabetes attitudes needs to be determined.

Effective use of computerized insulin dose adjustment algorithms on continuous glucose monitoring results by a clinical pharmacist - Proof-of-concept

Highlights A clinical pharmacist using recommendations of Food and Drug Administration-cleared computerized insulin dose adjustment algorithms based on analyses of glucose readings from continuous glucose monitoring (Abbot Free Style Pro) in 13 poorly controlled insulin-requiring diabetic patients increased time in target range of 3.9 to 10.0 mmol/L from 29% to 51% and decreased time in range of >13.9 mmol/L from 43% to 23% (both P = 0.01) after 3 months. Glycated hemoglobin (HbA1c) levels (±SD) fell from 102 (±15) to 67 (±10) mmol/mol (P < 10-6 ).

Predictors of health facility readiness for diabetes service delivery in low- and middle-income countries: The case of Bangladesh

AIMS

We aimed to evaluate the readiness and predictors of diabetes service capability at the level of primary care in Bangladesh as an illustrative instance of readiness for diabetes care in low- and middle-income countries (LMICs).

METHODS

We used data from the 2014 Bangladesh Health Facility Survey (BHFS), a cross-sectional, nationally representative survey (n = 1596 health facilities). We constructed a diabetes-specific readiness index to assess diabetes service readiness in facilities with outpatient capability and used multivariable regression analysis to evaluate contextual predictors of diabetes service readiness.

RESULTS

Three-hundred and forty-five facilities with outpatient and diabetes service capability were included. Mean readiness for diabetes service capability on a scale of 0-100 was 24.9 (95%CI: 20.8-28.9) and was lowest in rural settings, districts with high social deprivation, and public facilities, where diabetes diagnostic equipment and medications were largely unavailable. Facility type was the strongest, independent predictor of diabetes service readiness.

CONCLUSIONS

Diabetes service readiness in outpatient facilities in Bangladesh was low, particularly in public facilities, rural settings, and districts with high social deprivation. .These findings could inform policies aimed at improving diabetes care in areas of high unmet need and may serve as a model to assess diabetes service readiness in other LMICs.

Evaluation of the Finnish Diabetes Risk Score (FINDRISC) for diabetes screening in Kayseri, Turkey

AIM

Diabetes is a major health problem worldwide, as its prevalence is increasing dramatically. Lifestyle modification can delay or prevent the onset of type 2 diabetes. Therefore, screening for prediabetes and type 2 diabetes risk through an assessment of risk factors is important. The objective of the study was to investigate the risk for type 2 diabetes using the Finnish Diabetes Risk Score (FINDRISC) in Kayseri.

METHODS

In total, 1500 adults aged 18 years or older were interviewed using the FINDRISC as Diabetes Risk Questionnaire and fasting serum glucose levels. The findings of FINDRISC were grouped according to gender and a score of 15 and above was accepted as a high risk in terms of Type 2 diabetes.

RESULTS

13.5% of the participants were in the high- risk group. There was a statistically significant relationship between total FINDRISC score and gender (p < 0.001). While 15.2% of the women were in the high -risk group, 12.4% of the men were in the high- risk group. The percentage of women in the low-risk group (35.9%) is less than the men with low- risk of diabetes (38.5%). As the BMI increased, the individuals were found to have a high risk evaluated with the use of FINDRISC. 14.3% of women with waist circumference >88 and 6.7% of men with waist circumference >102 were in the high- risk group. (p < 0.001) CONCLUSIONS: Risk of diabetes was found to be higher with the FINDRISC score as the BMI and waist circumference increased. FINDRISC can be used in the primary care for this purpose; fast and easy to be applied.

Impact of Participation in a Virtual Diabetes Clinic on Diabetes-Related Distress in Individuals With Type 2 Diabetes

The Onduo Virtual Diabetes Clinic is a telehealth program for people with type 2 diabetes that combines mobile app technology, remote personalized lifestyle coaching, connected blood glucose meters, real-time continuous glucose monitoring (rtCGM) devices, and clinical support from board-certified endocrinologists. This analysis evaluated change in diabetes distress among 228 program participants who reported moderate distress (score 2.0-2.9) or high distress (score ≥3.0) on the 17-item Diabetes Distress Scale (DDS17) at enrollment. Participants reported significant reductions in overall distress from 3.0 ± 0.8 at baseline to 2.5 ± 0.9 (P <0.001) at an average of 6 months of follow-up. Significant reductions in all DDS17 subscale scores were observed; most notable were reductions in the regimen-related and emotional distress subscales (-0.9 and -0.4, respectively; both P <0.001). Significantly greater reductions in overall distress (P = 0.012) and regimen-related distress (P <0.001) were reported by participants who were prescribed and used intermittent rtCGM (n = 77) versus nonusers (n = 151). Although the generalizability of these findings may be limited by the study's small sample size and potential for self-selection bias, these results do suggest that telemedicine programs such as the Onduo VDC could be a valuable tool for addressing the problem of diabetes-related distress.