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Paterno MV, Fitzgerald GK. Booster visits in the management of the acute musculoskeletal injuries: Transforming care to improve outcomes-A perspective review. J Orthop Res 2024; 42:1151-1158. [PMID: 38597734 DOI: 10.1002/jor.25852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 02/22/2024] [Accepted: 03/30/2024] [Indexed: 04/11/2024]
Abstract
The current healthcare delivery system for patients with acute musculoskeletal injury is failing. Current rehabilitation management of acute musculoskeletal injury typically includes physical therapy, focused on management of impairments, with an eventual transition to functional activities and release to prior level of function. At that point, formal physical therapy is often discontinued, despite the knowledge that a high percentage of patients fail to maintain preinjury level of activity and often reduce participation in regular physical activity. Further, for those who attempt to return to prior levels of pivoting and cutting activities, there is a high second injury rate. The long-term human experience is compromised by the current model of care which terminates at the point of transition to activity. This model of care fails to meet the continued needs of these patients and may result in long term deficits and potential disability. Extended care models include intermittent follow up visits after discharge from an acute episode of care and have been efficacious and cost effective in some patient populations with musculoskeletal conditions. Specifically, a type of extended care model, labeled "booster sessions," represents an opportunity to provide structured, intermittent care to assist in a smooth transition back to function, following an acute episode of care and promote a healthier life outcome. This perspective review will discuss the opportunity to transform acute musculoskeletal care to booster visit care model in an attempt to develop a more efficacious and cost-effective system of care which could be generalizable to all musculoskeletal conditions.
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Affiliation(s)
- Mark V Paterno
- Division of Occupational Therapy and Physical Therapy, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
- Division of Sports Medicine, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - G Kelley Fitzgerald
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Aroda VR, Nielsen N, Mangla KK, Multani J, Divino V, Namvar T, Rajpura J. Greater persistence and adherence to basal insulin therapy is associated with lower healthcare utilization and medical costs in patients with type 2 diabetes: a retrospective database analysis. BMJ Open Diabetes Res Care 2024; 12:e003825. [PMID: 38442988 PMCID: PMC11146418 DOI: 10.1136/bmjdrc-2023-003825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 02/04/2024] [Indexed: 03/07/2024] Open
Abstract
INTRODUCTION We aimed to assess persistence and adherence to basal insulin therapy, their association with all-cause healthcare resource utilization (HCRU) and direct medical costs, and predictors of persistence and adherence in adults with type 2 diabetes. RESEARCH DESIGN AND METHODS A retrospective cohort study was conducted with US adults with type 2 diabetes initiating basal insulin therapy between January 1, 2016, and December 31, 2018, using IQVIA PharMetrics Plus claims data. Persistence and adherence were assessed during 1 year post-initiation per previous definitions. Demographic/clinical characteristics were assessed during the 1 year pre-initiation. Inverse probability of treatment weighting (IPTW) was used to adjust for confounding variables. Post-IPTW, all-cause HCRU and direct medical costs were assessed during the first-year and second-year post-initiation by persistence and adherence status. Multivariable logistic regression was used to identify predictors of persistence and adherence. RESULTS The final sample comprised 64,953 patients; 56.8% demonstrated persistence and 41.9% demonstrated adherence. Patients demonstrating persistence and adherence were significantly less likely to have a hospitalization than patients demonstrating non-persistence or non-adherence, respectively. In the second-year post-initiation, total mean all-cause direct medical costs per patient were lower for patients demonstrating persistence and significantly lower for patients demonstrating adherence. Prior use of both oral and injectable antidiabetic medication predicted persistence and adherence compared with patients with only prior oral antidiabetic medication use (persistence OR, 1.50 (95% CI, 1.44 to 1.57); adherence OR, 1.48 (95% CI, 1.42 to 1.55)). CONCLUSIONS Persistence and adherence to basal insulin was associated with fewer hospitalizations and lower direct medical costs.
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Affiliation(s)
- Vanita R Aroda
- Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Snoswell CL, Vitangcol KJ, Haydon HM, Gray LC, Leedie F, Smith AC, Caffery LJ. Cost-effectiveness of remote patient monitoring for First Nations peoples living with diabetes in regional Australia. J Telemed Telecare 2023; 29:3S-7S. [PMID: 38007695 DOI: 10.1177/1357633x231214019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Abstract
The aim of this study was to determine the cost-effectiveness of remote patient monitoring (RPM) with First Nations peoples living with diabetes. This study was set at the Goondir Health Service (GHS), an Aboriginal and Torres Strait Islander Community-Controlled Health in South-West Queensland. Electronic medical records and RPM data were provided by the GHS. Clinical effectiveness was determined by comparing mean HbA1c before and after enrolment in the RPM service. Our analysis found no statistically significant effect between the mean HbA1c before and after enrolment, so this analysis focused on net-benefit and return on investment for costs from the perspective of the GHS. The 6-month RPM service for 84 clients cost AUD $67,841 to cover RPM equipment, ongoing technology costs, and a dedicated Virtual Care Manager, equating to $808 per client. There were 199 additional client-clinician interactions in the period after enrolment resulting in an additional $4797 revenue for the GHS. Therefore, the program cost the GHS $63,044 to deliver, representing a return on investment of around 7 cents for every dollar they spent. Whilst the diabetes RPM service was equally effective as usual care and resulted in increased interactions with clients, the cost for the service was substantially more than the additional revenue generated from increased interactions. This evidence highlights the need for alternative funding models for RPM services and demonstrates the need to focus future research on long-term clinical effects and the extra-clinical benefits resulting from services of this type.
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Affiliation(s)
- Centaine L Snoswell
- Centre for Online Health, The University of Queensland, Brisbane, Australia
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Kathryn J Vitangcol
- Centre for Online Health, The University of Queensland, Brisbane, Australia
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Helen M Haydon
- Centre for Online Health, The University of Queensland, Brisbane, Australia
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | - Leonard C Gray
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
| | | | - Anthony C Smith
- Centre for Online Health, The University of Queensland, Brisbane, Australia
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
- Centre for Innovative Medical Technology, University of Southern Denmark, Odense, Denmark
| | - Liam J Caffery
- Centre for Online Health, The University of Queensland, Brisbane, Australia
- Centre for Health Services Research, The University of Queensland, Brisbane, Australia
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Nosrati M, Ahmadi Fariman S, Saiyarsarai P, Nikfar S. Pharmacoeconomic evaluation of insulin aspart and glargine in type 1 and 2 diabetes mellitus in Iran. J Diabetes Metab Disord 2023; 22:817-825. [PMID: 37255793 PMCID: PMC10225402 DOI: 10.1007/s40200-023-01209-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 03/05/2023] [Indexed: 06/01/2023]
Abstract
Purpose The higher costs of insulin analogs including short-acting insulin aspart (IAsp) and long-acting insulin glargine (IGla) have restricted their widespread uptake despite having improved pharmacokinetic and pharmacodynamic properties and patient convenience. This study aims to evaluate the cost-effectiveness of IAsp versus Regular Insulin (RI) and IGla versus NPH Insulin in type 1 and 2 diabetes from the perspective of the Iranian healthcare system. Methods Clinical data including HbA1c levels, hypoglycemia, weight gain, and health-related quality of life were derived from the included systematic review and meta-analysis studies. Different methods of pharmacoeconomic evaluation were used for an annual time horizon. Utility decrements for diabetes-related complications were extracted from the literature. Direct medical costs were calculated in 2022 prices. A one-way sensitivity analysis was also performed. Results In type 1 diabetes, IAsp was associated with more costs and effects in terms of reducing HbA1c compared with RI. An incremental cost of $83 was estimated to obtain an additional 1% reduction in HbA1c per patient per year. Similarly, an incremental cost of $16 was estimated for IGla compared with NPH. In type 2 diabetes, IAsp and RI were associated with equal efficacy and safety. For IGla versus NPH, the incremental cost-effectiveness ratio was calculated at $1975 per quality-adjusted life-year. The robustness of the result was confirmed through sensitivity analysis. Conclusion Insulin analogs, IAsp and IGla, are cost-effective for type 1 diabetes versus human insulins, RI and NPH. For type 2 diabetes, IAsp is not cost-effective when compared with RI. For IGla versus NPH, however, the incremental cost-effectiveness ratio seems to be within the accepted thresholds.
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Affiliation(s)
- Marzieh Nosrati
- Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy, Tehran University of Medical Sciences, 16 Azar St., Enghelab-E Islami Sq, Tehran, Iran
| | - Soroush Ahmadi Fariman
- Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy, Tehran University of Medical Sciences, 16 Azar St., Enghelab-E Islami Sq, Tehran, Iran
| | - Parisa Saiyarsarai
- Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy, Tehran University of Medical Sciences, 16 Azar St., Enghelab-E Islami Sq, Tehran, Iran
| | - Shekoufeh Nikfar
- Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy, Tehran University of Medical Sciences, 16 Azar St., Enghelab-E Islami Sq, Tehran, Iran
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Ong-Artborirak P, Seangpraw K, Boonyathee S, Auttama N, Winaiprasert P. Health literacy, self-efficacy, self-care behaviors, and glycemic control among older adults with type 2 diabetes mellitus: a cross-sectional study in Thai communities. BMC Geriatr 2023; 23:297. [PMID: 37193967 DOI: 10.1186/s12877-023-04010-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 04/28/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Properly understanding the health information of people with type 2 diabetes mellitus (T2DM) is the basis for better risk factor management, which also positively affects their quality of life. The aim of this study was to investigate diabetes health literacy (HL), self-efficacy, and self-care behaviors associated with glycemic control among older adults with T2DM in northern Thai communities. METHODS A cross-sectional study was conducted among 414 older adults over the age of 60 diagnosed with T2DM. The study was conducted in Phayao Province from January to May 2022. Simple random sampling of the patient list for the Java Health Center Information System program was used. Questionnaires were used to collect data on diabetes HL, self-efficacy, and self-care behaviors. Blood samples were tested for estimated glomerular filtration rate (eGFR) and glycemic controls, such as fasting blood sugar (FBS) and glycated hemoglobin (HbA1c). RESULTS The mean age of participants was 67.1 years. FBS (mean ± SD = 108.5 ± 29.5 mg/dL) and HbA1c (mean ± SD = 6.6 ± 1.2%) levels were found to be abnormal in 50.5% (≥ 126 mg/dL) and 17.4% (≥ 6.5%) of the subjects, respectively. There was a strong correlation between HL and self-efficacy (r = 0.78), HL and self-care behaviors (r = 0.76), and self-efficacy and self-care behaviors (r = 0.84). The eGFR was significantly correlated with diabetes HL (r = 0.23), self-efficacy (r = 0.14), self-care behaviors (r = 0.16), and HbA1c (r = -0.16) scores. Linear regression after adjusting for sex, age, education, DM duration, smoking, and drinking alcohol showed that FBS level was inversely associated with diabetes HL (Beta = -0.21, R2 = 11.0%), self-efficacy (Beta = -0.43, R2 = 22.2%), and self-care behavior (Beta = -0.35, R2 = 17.8%), whereas HbA1C level was negatively associated with diabetes HL (Beta = -0.52, R2 = 23.8%), self-efficacy (Beta = -0.39, R2 = 19.1%), and self-care behavior (Beta = -0.42, R2 = 20.7%). CONCLUSION Diabetes HL was related to self-efficacy and self-care behaviors in elderly T2DM patients and was shown to influence their health, including glycemic control. These findings suggest that implementing HL programs to build competence in self-efficacy expectations is important for contributing to improvements in diabetes preventive care behaviors and HbA1c control.
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Affiliation(s)
| | | | | | - Nisarat Auttama
- School of Public Health, University of Phayao, Phayao, Thailand
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Hurteau LB, Hogue NJ. Pharmacy benefit considerations for continuous glucose monitoring acquisition: Vermont Medicaid experience. J Manag Care Spec Pharm 2023; 29:550-556. [PMID: 37121247 PMCID: PMC10387980 DOI: 10.18553/jmcp.2023.29.5.550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Many individuals with diabetes are not achieving their glycemic goals. Use of continuous glucose monitoring (CGM) improves diabetes management. Access to CGM is often hindered when individuals must acquire their supplies through the traditional durable medical device channel. Vermont Medicaid transitioned CGM coverage from a medical/durable medical equipment benefit to a pharmacy benefit. This improved access and lessened the burden on prescribing health care providers. We describe the process the Vermont Medicaid program implemented to make this transition. DISCLOSURES: Funding for editorial assistance in the development of this manuscript was provided by Abbott Diabetes Care. The funder had no input in the manuscript content. The authors received no compensation.
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Zhang X, McAdam Marx C. Short-term cost-effectiveness analysis of tirzepatide for the treatment of type 2 diabetes in the United States. J Manag Care Spec Pharm 2023; 29:276-284. [PMID: 36840958 PMCID: PMC10388019 DOI: 10.18553/jmcp.2023.29.3.276] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND: Tirzepatide is a novel once-a-week dual glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 receptor agonist that is used as an addition to diet and exercise to improve blood glucose in adults with type 2 diabetes. It is the first dual glucagon-like peptide-1 and glucose-dependent insulinotropic polypeptide receptor agonist that has been approved by the US Food and Drug Administration. The SURPASS-2 clinical trial demonstrated superiority of tirzepatide 10 mg and 15 mg over semaglutide 1 mg in glycated hemoglobin A1c reduction and weight loss from baseline to week 40. Economic analyses to support coverage and access decision-making for tirzepatide are limited. OBJECTIVES: To evaluate the cost-effectiveness of tirzepatide 10 mg vs semaglutide 1 mg injection over 52 weeks of treatment regarding A1c reduction and weight loss from the perspective of the US health care payer. METHODS: A decision tree model over a 52-week time horizon was developed to identify incremental treatment-related costs of once-weekly tirzepatide 10 mg vs semaglutide 1 mg injection. Costs were divided by mean reduction in A1c and change in body weight from baseline to week 52 observed in the SURPASS-2 clinical trial. In addition to efficacy, probabilities of adverse events, discontinuation, and need for rescue therapy were derived from the SURPASS-2 study. Drug costs in 2022 US dollars were based on wholesale acquisition cost. Costs associated with adverse events were sourced from the published literature. One-way sensitivity analyses were conducted. RESULTS: Treatment with once-weekly tirzepatide 10 mg injection was associated with a higher cost and larger reduction in A1c and body weight after 52 weeks, compared with once-weekly semaglutide 1 mg injection. The incremental cost-effectiveness ratio for tirzepatide vs semaglutide was $2,247 per 1% reduction in A1c and $237 per 1 kg weight loss. One-way sensitivity analysis suggested that incremental cost-effectiveness ratios were most sensitive to the drug costs and treatment effect on A1c and weight. CONCLUSIONS: Once-weekly tirzepatide 10 mg was associated with higher cost and greater reduction in A1c and weight vs semaglutide. Tirzepatide 10 mg is cost-effective compared with semaglutide 1 mg if payers' willingness-to-pay threshold exceeds $2,247 for 1% reduction in A1c level and $237 for 1 kg weight loss.
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Affiliation(s)
- Xiaotong Zhang
- University of Nebraska Medical Center, Department of Pharmacy Practice and Science, College of Pharmacy, Omaha
| | - Carrie McAdam Marx
- University of Nebraska Medical Center, Department of Pharmacy Practice and Science, College of Pharmacy, Omaha
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Gonzalvo JD, Meredith AH, Pastakia SD, Peters M, Eberle M, Schmelz AN, Pence L, Triboletti JS, Walroth TA. Changes in clinical markers observed from pharmacist-managed cardiovascular risk reduction clinics in federally qualified health centers: A retrospective cohort study. PLoS One 2023; 18:e0282940. [PMID: 36920963 PMCID: PMC10016666 DOI: 10.1371/journal.pone.0282940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 02/21/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Reductions in hemoglobin A1c (HbA1C) have been associated with improved cardiovascular outcomes and savings in medical expenditures. One public health approach has involved pharmacists within primary care settings. The objective was to assess change in HbA1C from baseline after 3-5 months of follow up in pharmacist-managed cardiovascular risk reduction (CVRR) clinics. METHODS This retrospective cohort chart review occurred in eight pharmacist-managed CVRR federally qualified health clinics (FQHC) in Indiana, United States. Data were collected from patients seen by a CVRR pharmacist within the timeframe of January 1, 2015 through February 28, 2020. Data collected include: demographic characteristics and clinical markers between baseline and follow-up. HbA1C from baseline after 3 to 5 months was assessed with pared t-tests analysis. Other clinical variables were assessed and additional analysis were performed at 6-8 months. Additional results are reported between 9 months and 36 months of follow up. RESULTS The primary outcome evaluation included 445 patients. Over 36 months of evaluation, 3,803 encounters were described. Compared to baseline, HbA1C was reduced by 1.6% (95%CI -1.8, -1.4, p<0.01) after 3-5 months of CVRR care. Reductions in HbA1C persisted at 6-8 months with a reduction of 1.8% ([95%CI -2.0, -1.5] p<0.01). The follow-up losses were 29.5% at 3-5 months and 93.2% at 33-36 months. CONCLUSIONS Our study augments the existing literature by demonstrating the health improvement of pharmacist-managed CVRR clinics. The great proportion of loss to follow-up is a limitation of this study to be considered. Additional studies exploring the expansion of similar models may amplify the public health impact of pharmacist-managed CVRR services in primary care sites.
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Affiliation(s)
- Jasmine D. Gonzalvo
- Purdue University College of Pharmacy, Indianapolis, Indiana, United States of America
- * E-mail:
| | - Ashley H. Meredith
- Purdue University College of Pharmacy, Indianapolis, Indiana, United States of America
| | - Sonak D. Pastakia
- Purdue University College of Pharmacy, Indianapolis, Indiana, United States of America
| | - Michael Peters
- Eskenazi Health, Indianapolis, Indiana, United States of America
| | - Madilyn Eberle
- Purdue University College of Pharmacy, Indianapolis, Indiana, United States of America
| | - Andrew N. Schmelz
- Butler University College of Pharmacy and Health Sciences, Indianapolis, Indiana, United States of America
| | - Lauren Pence
- Eskenazi Health, Indianapolis, Indiana, United States of America
| | - Jessica S. Triboletti
- Butler University College of Pharmacy and Health Sciences, Indianapolis, Indiana, United States of America
| | - Todd A. Walroth
- Eskenazi Health, Indianapolis, Indiana, United States of America
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Mendonça TS, Oliveira WN, Belo VS, Silva ES, Pereira ML, Obreli-Neto PR, Baldoni AO. Clinical and humanistic impact of pharmacotherapeutic follow-up in patients with type 1 diabetes mellitus treated judicially. Diabetol Metab Syndr 2022; 14:61. [PMID: 35501843 PMCID: PMC9061226 DOI: 10.1186/s13098-022-00835-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/13/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There is a lack of studies that assess the effectiveness of pharmacotherapeutic follow-up in the context of the judicialization of insulin analogues. AIMS To evaluate the clinical and humanistic impact of pharmacotherapeutic follow-up in patients with type 1 diabetes mellitus who receive insulin analogues by judicial decision in a Brazilian municipality. METHODS A quasi-experimental study of the before-and-after type was carried out through pharmacotherapeutic follow-up. Patients who accepted to participate in the study underwent laboratory tests of glycemic and lipid profile before and after the intervention, and underwent five pharmaceutical consultations. In addition, quality of life and health, knowledge, and skills related to insulin application techniques were analyzed. RESULTS 28 patients participated in all stages. Of these, most were female (53.6%), with a mean age of 32.8 ± 11.6 years. After the intervention, there was a reduction in blood glucose levels, blood pressure, and increased body mass index. In addition, there was greater knowledge and skills regarding insulin application techniques, improved quality of life, health, greater number of medications used, reduction of pharmacotherapeutic problems, and improvement in eating habits. CONCLUSION The pharmacotherapeutic follow-up promoted clinical and humanistic benefits, with improvement in quality of life and health.
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Affiliation(s)
- Thays S. Mendonça
- Programa de Pós-Graduação em Ciências da Saúde, Federal University of São João Del-Rei (UFSJ)–Campus Centro-Oeste Dona Lindu (CCO), Rua Sebastião Gonçalves Coelho, 400–Bairro Chanadour, Divinópolis, MG CEP:35501-296 Brazil
| | - William N. Oliveira
- Programa de Pós-Graduação em Ciências da Saúde, Federal University of São João Del-Rei (UFSJ)–Campus Centro-Oeste Dona Lindu (CCO), Rua Sebastião Gonçalves Coelho, 400–Bairro Chanadour, Divinópolis, MG CEP:35501-296 Brazil
| | - Vinícius S. Belo
- Programa de Pós-Graduação em Ciências da Saúde, Federal University of São João Del-Rei (UFSJ)–Campus Centro-Oeste Dona Lindu (CCO), Rua Sebastião Gonçalves Coelho, 400–Bairro Chanadour, Divinópolis, MG CEP:35501-296 Brazil
| | - Eduardo S. Silva
- Programa de Pós-Graduação em Ciências da Saúde, Federal University of São João Del-Rei (UFSJ)–Campus Centro-Oeste Dona Lindu (CCO), Rua Sebastião Gonçalves Coelho, 400–Bairro Chanadour, Divinópolis, MG CEP:35501-296 Brazil
| | - Mariana L. Pereira
- Programa de Pós-Graduação em Ciências da Saúde, Federal University of São João Del-Rei (UFSJ)–Campus Centro-Oeste Dona Lindu (CCO), Rua Sebastião Gonçalves Coelho, 400–Bairro Chanadour, Divinópolis, MG CEP:35501-296 Brazil
| | - Paulo R. Obreli-Neto
- Departamento de Farmácia, Centro Universitário das Faculdades Integradas de Ourinhos (UniFIO), Rodovia BR-153, Km 338 S/N Água do Cateto, Ourinhos, SP 19909-100 Brazil
| | - André O. Baldoni
- Núcleo de Ensino e Pesquisa em Farmácia Clínica (NEPeFaC), Federal University of São João Del-Rei (UFSJ), Rua Sebastião Gonçalves Coelho, 400 – Bairro Chanadour, Divinópolis, MG CEP:35501-296 Brazil
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Zou S, Jiao X, Liu J, Qi D, Pei X, Lu D, Huang S, Li Z. High-Fat Nutritional Challenge Reshapes Circadian Signatures in Murine Extraorbital Lacrimal Glands. Invest Ophthalmol Vis Sci 2022; 63:23. [PMID: 35588356 PMCID: PMC9123521 DOI: 10.1167/iovs.63.5.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose A high-fat diet (HFD) increases the risk of developing many systemic diseases; however, the effects of high fat intake on lacrimal gland functions and the molecular mechanisms underlying these effects are unknown. We explored the effects of an HFD on the circadian rhythms of the extraorbital lacrimal glands (ELGs). Methods Male C57BL/6J mice maintained on a 12/12-hour light/dark cycle were fed an ad libitum HFD or normal chow (NC) for 2 weeks. The ELGs were collected from euthanized animals every 3 hours throughout the circadian cycle (24 hours). Using high-throughput RNA-sequencing (RNA-Seq), we studied the circadian transcriptomic profile of the ELGs. Circadian oscillations in cell size, secretion response, lipid deposition, and immune cell trafficking of the ELGs were also analyzed. Results An HFD modulated the circadian transcriptomic profile of the ELGs, including the composition, phase, and amplitude of cyclical transcript oscillations, and affected the associated signaling pathways at spatiotemporal levels. HFD feeding significantly altered the normal rhythmic oscillations of ELG cell size, immune cell trafficking, secretion response, and lipid deposition. After dietary reversal in HFD-fed animals, the activity, core temperature, and lipid accumulation in lacrimal glands recovered partially to the level of NC-fed animals. However, the average cell size of the ELGs, the recruitment of immune cells, and the rhythm of lacrimal secretion did not return to the levels of the NC-fed group. Conclusions HFD perturbation interferes with the cyclical transcriptomic profile, cell size, immune cell trafficking, and secretion function of the ELGs with a strikingly high sensitivity.
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Affiliation(s)
- Sen Zou
- Henan Eye Institute, Henan Eye Hospital and Henan Key Laboratory of Ophthalmology and Visual Science, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou City, China
| | - Xinwei Jiao
- Henan Eye Institute, Henan Eye Hospital and Henan Key Laboratory of Ophthalmology and Visual Science, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou City, China
| | - Jiangman Liu
- Henan Eye Institute, Henan Eye Hospital and Henan Key Laboratory of Ophthalmology and Visual Science, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou City, China
| | - Di Qi
- Henan Eye Institute, Henan Eye Hospital and Henan Key Laboratory of Ophthalmology and Visual Science, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou City, China
| | - Xiaoting Pei
- Henan Eye Institute, Henan Eye Hospital and Henan Key Laboratory of Ophthalmology and Visual Science, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou City, China
| | - Dingli Lu
- Henan Eye Institute, Henan Eye Hospital and Henan Key Laboratory of Ophthalmology and Visual Science, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou City, China
| | - Shenzhen Huang
- Henan Eye Institute, Henan Eye Hospital and Henan Key Laboratory of Ophthalmology and Visual Science, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou City, China
| | - Zhijie Li
- Henan Eye Institute, Henan Eye Hospital and Henan Key Laboratory of Ophthalmology and Visual Science, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, People's Hospital of Henan University, Zhengzhou City, China
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Pastakia SD, Clark A, Lewis K, Taugher D, Patel R, Ali L, Wu C, Butler R, Bateman MT, McCarthy C, Vargas J, Poulsom C. The impact of clinical pharmacist led comprehensive medication management on diabetes care at Federally Qualified Health Centers within the
BD
Helping Build Healthy Communities
program. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022. [DOI: 10.1002/jac5.1586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Sonak D. Pastakia
- Purdue University Center for Health Equity and Innovation Indianapolis Indiana USA
| | | | | | | | - Rajal Patel
- Mountain Park Health Center Phoenix Arizona USA
| | - Liz Ali
- North County Health Project Inc., d.b.a. TrueCare San Marcos California USA
| | - Cecilia Wu
- Queenscare Health Centers Los Angeles California USA
| | | | | | | | | | - Carrie Poulsom
- Family Health Centers of Southwest Florida, Inc Fort Myers Florida USA
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Orabone AW, Do V, Cohen E. Pharmacist-Managed Diabetes Programs: Improving Treatment Adherence and Patient Outcomes. Diabetes Metab Syndr Obes 2022; 15:1911-1923. [PMID: 35757195 PMCID: PMC9231415 DOI: 10.2147/dmso.s342936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/07/2022] [Indexed: 11/23/2022] Open
Abstract
The health and economic burden of diabetes mellitus across the United States and the world is such that effective care is crucial to improving outcomes, including macro and microvascular complications, and lowering health care costs. Pharmacists are well placed within communities to provide the critical care necessary for patients with diabetes and have a unique skillset that has demonstrated clear benefits in clinical and non-clinical outcomes. Here, we will provide a narrative review of the literature including the role of the pharmacist in different care models, outcomes associated with pharmacist care, and future directions and opportunities for pharmacist-managed diabetes.
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Affiliation(s)
| | - Vincent Do
- Department of Pharmacy, Yale New Haven Health System, New Haven, CT, USA
| | - Elizabeth Cohen
- Department of Transplant Services, Yale New Haven Hospital, New Haven, CT, USA
- Correspondence: Elizabeth Cohen, Department of Transplant Services, Yale New Haven Hospital, 800 Howard Ave, 4th Floor, New Haven, CT, USA, Tel +1 203-200-5478, Email
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13
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Khaing Oo WW, Riewpaiboon A, Youngkong S, Ko K. How Economic Analysis Increases the Awareness of Clinical Services: A Case of Diabetes Mellitus at a Teaching Hospital in Myanmar. Value Health Reg Issues 2021; 29:21-27. [PMID: 34800825 DOI: 10.1016/j.vhri.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/29/2021] [Accepted: 09/06/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Myanmar faces a growing epidemic of type 2 diabetes mellitus, which has significant impact on the individual health and health service system; nevertheless, reliable cost estimate for treating diabetes is still unknown. Therefore, this study aimed to explore the treatment cost of hospitalization by type 2 diabetes mellitus and the association of complications and comorbidities with the treatment cost. METHODS The retrospective incidence-based cost of illness analysis was performed at the diabetes ward of 800-bed teaching hospital in Yangon, Myanmar. The data were retrieved from hospital financial reports and patient's medical records for the fiscal year 2017 to 2018. Data was analyzed by using descriptive statistics and multivariate statistics. One-way sensitivity analysis was used to assess the uncertainty of input parameters. RESULTS This study involved 87 inpatients with type 2 diabetes mellitus with an average length of stay of 16.1 ± 12.6 days. Of the study sample, 67% had complications whereas 74% had comorbidities. The average treatment cost per admission was $718.7 (equal to 58% of gross domestic product - GDP per capita) at 2018 prices. Based on the multiple regression analysis, cost savings per admission were $276.5, $307.3, and $319.5 from preventing foot ulcer, nephropathy, and retinopathy, respectively. CONCLUSIONS This study found that the treatment of diabetes is costly because of its preventable health consequences. Better disease management to prevent complications results in considerable cost savings. This quantitative evidence would increase awareness in health service system.
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Affiliation(s)
- Wah Wah Khaing Oo
- Master of Science Program in Social, Economic and Administrative Pharmacy, Mahidol University, Bangkok, Thailand
| | - Arthorn Riewpaiboon
- Division of Social and Administrative Pharmacy, Department of Pharmacy, Mahidol University, Bangkok, Thailand.
| | - Sitaporn Youngkong
- Division of Social and Administrative Pharmacy, Department of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Ko Ko
- Diabetes and Endocrinology Department, University of Medicine 2, Yangon, Myanmar
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14
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Samal L, Fu HN, Camara DS, Wang J, Bierman AS, Dorr DA. Health information technology to improve care for people with multiple chronic conditions. Health Serv Res 2021; 56 Suppl 1:1006-1036. [PMID: 34363220 PMCID: PMC8515226 DOI: 10.1111/1475-6773.13860] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 07/15/2021] [Accepted: 07/19/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To review evidence regarding the use of Health Information Technology (health IT) interventions aimed at improving care for people living with multiple chronic conditions (PLWMCC) in order to identify critical knowledge gaps. DATA SOURCES We searched MEDLINE, CINAHL, PsycINFO, EMBASE, Compendex, and IEEE Xplore databases for studies published in English between 2010 and 2020. STUDY DESIGN We identified studies of health IT interventions for PLWMCC across three domains as follows: self-management support, care coordination, and algorithms to support clinical decision making. DATA COLLECTION/EXTRACTION METHODS Structured search queries were created and validated. Abstracts were reviewed iteratively to refine inclusion and exclusion criteria. The search was supplemented by manually searching the bibliographic sections of the included studies. The search included a forward citation search of studies nested within a clinical trial to identify the clinical trial protocol and published clinical trial results. Data were extracted independently by two reviewers. PRINCIPAL FINDINGS The search yielded 1907 articles; 44 were included. Nine randomized controlled trials (RCTs) and 35 other studies including quasi-experimental, usability, feasibility, qualitative studies, or development/validation studies of analytic models were included. Five RCTs had positive results, and the remaining four RCTs showed that the interventions had no effect. The studies address individual patient engagement and assess patient-centered outcomes such as quality of life. Few RCTs assess outcomes such as disability and none assess mortality. CONCLUSIONS Despite a growing body of literature on health IT interventions or multicomponent interventions including a health IT component for chronic disease management, current evidence for applying health IT solutions to improve care for PLWMCC is limited. The body of literature included in this review provides critical information on the state of the science as well as the many gaps that need to be filled for digital health to fulfill its promise in supporting care delivery that meets the needs of PLWMCC.
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Affiliation(s)
- Lipika Samal
- Brigham and Women's HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Helen N. Fu
- Indiana University Richard M. Fairbanks School of Public HealthIndianapolisINUSA
- Regenstrief InstituteCenter for Biomedical InformaticsIndianapolisINUSA
| | - Djibril S. Camara
- Center for Disease Control and Prevention, Center for Surveillance, Epidemiology, and Laboratory Services (CSELS) Division of Scientific Education and Professional Development, Public Health Informatics Fellowship ProgramAtlantaGeorgiaUSA
- Center for Evidence and Practice Improvement, Agency for Healthcare Research and QualityRockvilleMDUSA
| | - Jing Wang
- Center for Evidence and Practice Improvement, Agency for Healthcare Research and QualityRockvilleMDUSA
- Florida State University College of NursingTallahasseeFloridaUSA
- Health and Aging Policy Fellows Program at Columbia UniversityNew YorkNYUSA
| | - Arlene S. Bierman
- Center for Evidence and Practice Improvement, Agency for Healthcare Research and QualityRockvilleMDUSA
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15
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Frank JR, Blissett D, Hellmund R, Virdi N. Budget Impact of the Flash Continuous Glucose Monitoring System in Medicaid Diabetes Beneficiaries Treated with Intensive Insulin Therapy. Diabetes Technol Ther 2021; 23:S36-S44. [PMID: 34546079 DOI: 10.1089/dia.2021.0263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objective: We assessed the economic impact of using the newest flash continuous glucose monitoring (CGM) among Medicaid beneficiaries with diabetes treated with intensive insulin therapy (IIT). Research Design and Methods: A budget impact analysis was created to assess the impact of increasing the proportion of Medicaid beneficiaries with diabetes on IIT, who use flash CGM by 10%. The analysis included glucose monitoring device costs, cost savings due to reductions in glycated hemoglobin, severe hypoglycemia events, and hyperglycemic emergencies such as diabetic ketoacidosis. The net change in costs per person to adopt flash CGM for three populations treated with IIT (adults with type 1 diabetes [T1D] or type 2 diabetes [T2D], and children and adolescents with T1D or T2D) was calculated; these costs were used to estimate the impact of increasing flash CGM use by 10% to the U.S. Medicaid budget over 1-3 years. Results: The analysis found that flash CGM demonstrated cost savings in all populations on a per patient basis. Increasing use of flash CGM by 10% was associated with a $19.4 million overall decrease in costs over the year and continued to reduce costs by $25.3 million in years 2 and 3. Conclusions: Our results suggest that the new flash CGM system can offer cost savings compared to blood glucose monitoring in Medicaid beneficiaries treated with IIT, especially T1D adults, and children and adolescents. These findings support expanding access to CGM by Medicaid plans.
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16
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Suzuki R, Saita S, Nishigaki N, Kisanuki K, Shimasaki Y, Mineyama T, Odawara M. Factors Associated With Treatment Adherence and Satisfaction in Type 2 Diabetes Management in Japan: Results From a Web-Based Questionnaire Survey. Diabetes Ther 2021; 12:2343-2358. [PMID: 34283372 PMCID: PMC8384993 DOI: 10.1007/s13300-021-01100-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 06/10/2021] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION To identify factors associated with treatment adherence and satisfaction in patients with type 2 diabetes (T2DM) in Japan. METHODS A web-based questionnaire survey was conducted from 6 to 17 March 2019 in patients with T2DM aged ≥ 20 years receiving diabetes treatment. Treatment adherence and satisfaction were self-assessed/reported by the patients. A multiple logistic regression model and the chi-square test were used to assess associated factors. RESULTS Responders (N = 1000) were aged 63.8 (standard deviation 11.9) years, and 739 (73.9%) were male. Adherence to treatment was reported in 941 (94.1%) patients and was significantly associated with higher household income (odds ratio [OR] 2.07, 95% confidence interval [CI] 1.11-3.86), age (OR 1.04, 95% CI 1.02-1.07), employment (OR 0.30, 95% CI 0.15-0.60) and having ≥ 1 impaired basic activity of daily living (BADL) (OR 0.33, 95% CI 0.13-0.82). Satisfaction with treatment was reported by 575 (57.5%) and was significantly associated with receiving/understanding guidance on how pharmacologic therapies are tailored (OR 1.73, 95% CI 1.19-2.51), male sex (OR 1.55, 95% CI 1.10-2.19), higher household income (OR 1.45, 95% CI 1.09-1.94) and age (OR 1.02, 95% CI 1.00-1.03). Treatment adherence was negatively associated with lower household income and having ≥ 1 impaired BADL in patients aged < 65 years, but not in those aged ≥ 65 years. Treatment satisfaction was positively associated with higher household income and receiving/understanding guidance on exercise therapy and the importance of achieving target haemoglobin A1c levels in patients aged ≥ 65 years, but with receiving/understanding guidance on the tailoring of pharmacologic therapies in patients aged < 65 years. CONCLUSION Lower age, lower household income, employment and impaired BADL may negatively impact treatment adherence in patients with T2DM. Appropriate physician guidance may promote treatment satisfaction. Differences in perspectives between patients aged < 65 and those aged ≥ 65 years should be considered. TRIAL REGISTRATION Japan Pharmaceutical Information Center, JapicCTI-194636.
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Affiliation(s)
- Ryo Suzuki
- Department of Diabetes Endocrinology and Metabolism, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan
| | - Shun Saita
- Japan Medical Office, Japan Pharma Business Unit, Takeda Pharmaceutical Company Limited, 2-1-1 Nihonbashi-Honcho, Chuo-ku, Tokyo, 103-8668, Japan.
| | - Nobuhiro Nishigaki
- Japan Medical Office, Japan Pharma Business Unit, Takeda Pharmaceutical Company Limited, 2-1-1 Nihonbashi-Honcho, Chuo-ku, Tokyo, 103-8668, Japan
| | - Koichi Kisanuki
- Japan Medical Office, Japan Pharma Business Unit, Takeda Pharmaceutical Company Limited, 2-1-1 Nihonbashi-Honcho, Chuo-ku, Tokyo, 103-8668, Japan
| | - Yukio Shimasaki
- Japan Medical Office, Japan Pharma Business Unit, Takeda Pharmaceutical Company Limited, 2-1-1 Nihonbashi-Honcho, Chuo-ku, Tokyo, 103-8668, Japan
| | - Tomoka Mineyama
- Japan Medical Office, Japan Pharma Business Unit, Takeda Pharmaceutical Company Limited, 2-1-1 Nihonbashi-Honcho, Chuo-ku, Tokyo, 103-8668, Japan
| | - Masato Odawara
- Department of Diabetes Endocrinology and Metabolism, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan
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17
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Egede LE, Dismuke CE, Walker RJ, Williams JS, Eiler C. Cost-Effectiveness of Technology-Assisted Case Management in Low-Income, Rural Adults with Type 2 Diabetes. Health Equity 2021; 5:503-511. [PMID: 34327293 PMCID: PMC8317594 DOI: 10.1089/heq.2020.0134] [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] [Accepted: 06/15/2021] [Indexed: 01/22/2023] Open
Abstract
Objective: The objective of this study was to examine whether delivering technology-assisted case management (TACM) with medication titration by nurses under physician supervision is cost effective compared with usual care (standard office procedures) in low-income rural adults with type 2 diabetes. Methods: One hundred and thirteen low-income, rural adults with type 2 diabetes and hemoglobin A1c (HbA1c) ≥8%, were randomized to a TACM intervention or usual care. Effectiveness was measured as differences in HbA1c between the TACM and usual care groups at 6 months. Total cost per patient included intervention or usual care cost, medical care cost, and income loss associated with lost workdays. The total cost per patient and HbA1c were used to estimate a joint distribution of incremental cost and incremental effect of TACM compared with usual care. Incremental cost-effectiveness ratios (ICERs) were estimated to summarize the cost-effectiveness of the TACM intervention relative to usual care to decrease HbA1c by 1%. Results: Costs due to intervention, primary care, other health care, emergency room visits, and workdays missed showed statistically significant differences between the groups (usual care $1,360.49 vs. TACM $5,379.60, p=0.004), with an absolute cost difference of $4,019.11. Based on the intervention cost per patient and the change in HbA1c, the median bootstrapped ICERs was estimated to be $6,299.04 (standard error=731.71) per 1% decrease in HbA1c. Conclusion: Based on these results, a 1% decrease in HbA1c can be obtained with the TACM intervention at an approximate cost of $6,300; therefore, it is a cost-effective option for treating vulnerable populations of adults with type 2 diabetes.
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Affiliation(s)
- Leonard E Egede
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Center for Advancing Population Science, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Clara E Dismuke
- Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Rebekah J Walker
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Center for Advancing Population Science, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Joni S Williams
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Center for Advancing Population Science, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Christian Eiler
- Center for Advancing Population Science, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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18
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Egede LE, Dismuke CE, Eiler C, Williams JS, Walker RJ. Cost-effectiveness of Telephone-Delivered Education and Behavioral Skills Intervention for African American Adults with Diabetes. Ethn Dis 2021; 31:217-226. [PMID: 33883862 DOI: 10.18865/ed.31.2.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Purpose Evaluate cost-effectiveness of a telephone-delivered education and behavioral skills intervention in reducing glycemic control (HbA1c) and decreasing risk of complications. Methods Data from a randomized controlled trial, conducted from August 1, 2008 - June 30, 2010 and using a 2x2 factorial design delivered to 255 African American adults not meeting glycemic targets for diabetes were used. Though the primary aim found no significant differences in HbA1c between groups, there was an overall drop in HbA1c across arms and differential cost. Primary clinical outcome was HbA1c measured at 12-months. Costs were estimated based on self-reported utilization of primary care, emergency, and other health care. Costs due to lost wages were calculated based on self-reported days of work missed due to illness. The Michigan Model for Diabetes was used to estimate 10-year probability of developing congestive heart failure, cardiovascular disease, end stage renal disease, stroke, myocardial infarction, all cause death, and CVD death. Total cost per patient and clinical outcomes were used to estimate an incremental cost effectiveness ratio (ICER) using non-parametric bootstrapping. Results ICERs indicated combined education and skills intervention was $3,630 less expensive than usual care to achieve a 0.6% decrease in HbA1c and was between $34,000 and $95,000 less expensive than usual care to reduce risk of complications. The knowledge only intervention was $661 less expensive than usual care and the behavioral skills only intervention did not indicate cost effectiveness. Conclusion The combined intervention ICER for HbA1c is comparable to other education programs and the ICER to reduce the probability of complications falls below previously recommended long-term cut-off of $100,000, suggesting cost-effectiveness in an African American population.
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Affiliation(s)
- Leonard E Egede
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI.,Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI
| | - Clara E Dismuke
- Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Palo Alto, CA
| | - Christian Eiler
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Joni S Williams
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI.,Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI
| | - Rebekah J Walker
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI.,Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI
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19
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Rawal L, Sahle BW, Smith BJ, Kanda K, Owusu-Addo E, Renzaho AMN. Lifestyle interventions for type 2 diabetes management among migrants and ethnic minorities living in industrialized countries: a systematic review and meta-analyses. BMJ Open Diabetes Res Care 2021; 9:e001924. [PMID: 33879514 PMCID: PMC8061857 DOI: 10.1136/bmjdrc-2020-001924] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 02/06/2021] [Accepted: 03/08/2021] [Indexed: 12/17/2022] Open
Abstract
The objective of this systematic review was to determine the effectiveness of lifestyle interventions to improve the management of type 2 diabetes mellitus (T2DM) among migrants and ethnic minorities. Major searched databases included MEDLINE (via PubMed), EMBASE (via Ovid) and CINAHL. The selection of studies and data extraction followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. In the meta-analysis, significant heterogeneity was detected among the studies (I2 >50%), and hence a random effects model was used. Subgroup analyses were performed to compare the effect of lifestyle interventions according to intervention approaches (peer-led vs community health workers (CHWs)-led). A total of 17 studies were included in this review which used interventions delivered by CHWs or peer supporters or combination of both. The majority of the studies assessed effectiveness of key primary (hemoglobin (HbA1c), lipids, fasting plasma glucose) and secondary outcomes (weight, body mass index, blood pressure, physical activity, alcohol consumption, tobacco smoking, food habits and healthcare utilization). Meta-analyses showed lifestyle interventions were associated with a small but statistically significant reduction in HbA1c level (-0.18%; 95% CI -0.32% to -0.04%, p=0.031). In subgroup analyses, the peer-led interventions showed relatively better HbA1c improvement than CHW-led interventions, but the difference was not statistically significant (p=0.379). Seven studies presented intervention costs, which ranged from US$131 to US$461 per participant per year. We conclude that lifestyle interventions using either CHWs or peer supporters or a combination of both have shown modest effectiveness for T2DM management among migrants of different background and origin and ethnic minorities. The evidence base is promising in terms of developing culturally appropriate, clinically sound and cost-effective intervention approaches to respond to the growing and diverse migrants and ethnic minorities affected by diabetes worldwide.
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Affiliation(s)
- Lal Rawal
- School of Health Medical and Applied Sciences, Collage of Science and Sustainability, Central Queensland University-Sydney Campus, Sydney, New South Wales, Australia
- Physical Activity Research Group, Appleton Institute, Central Queensland University, Adelaide, South Australia, Australia
- Translational Health Research Institute (THRI), Western Sydney University, Sydney, New South Wales, Australia
- School of Social Sciences, Western Sydney University, Sydney, New South Wales, Australia
| | - Berhe W Sahle
- Centre for Mental Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
- Centre for Quality and Patient Safety Research (QPS), Alfred Health Partnership, Melbourne, Victoria, Australia
| | - Ben J Smith
- Prevention and Health Promotion, The University of Sydney School of Public Health, Sydney, New South Wales, Australia
| | - Kie Kanda
- School of Nursing and Midwifery, Western Sydney University, Liverpool, New South Wales, Australia
| | - Ebenezer Owusu-Addo
- Bureau of Integrated Rural Development, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Andre M N Renzaho
- Translational Health Research Institute (THRI), Western Sydney University, Sydney, New South Wales, Australia
- School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
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20
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Egede LE, Walker RJ, Dismuke-Greer CE, Pyzyk S, Dawson AZ, Williams JS, Campbell JA. Cost-effectiveness of financial incentives to improve glycemic control in adults with diabetes: A pilot randomized controlled trial. PLoS One 2021; 16:e0248762. [PMID: 33735275 PMCID: PMC7971847 DOI: 10.1371/journal.pone.0248762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 03/02/2021] [Indexed: 01/22/2023] Open
Abstract
Purpose Determine the cost-effectiveness of three financial incentive structures in obtaining a 1% within group drop in HbA1c among adults with diabetes. Methods 60 African Americans with type 2 diabetes were randomized to one of three financial incentive structures and followed for 3-months. Group 1 (low frequency) received a single incentive for absolute HbA1c reduction, Group 2 (moderate frequency) received a two-part incentive for home testing of glucose and absolute HbA1c reduction and Group 3 (high frequency) received a multiple component incentive for home testing, attendance of weekly telephone education classes and absolute HbA1c reduction. The primary clinical outcome was HbA1c reduction within each arm at 3-months. Cost for each arm was calculated based on the cost of the intervention, cost of health care visits during the 3-month time frame, and cost of workdays missed from illness. Incremental cost effectiveness ratios (ICER) were calculated based on achieving a 1% within group drop in HbA1c and were bootstrapped with 1,000 replications. Results The ICER to decrease HbA1c by 1% was $1,100 for all three arms, however, bootstrapped standard errors differed with Group 1 having twice the variation around the ICER coefficient as Groups 2 and 3. ICERs were statistically significant for Groups 2 and 3 (p<0.001) indicating they are cost effective interventions. Conclusions Given ICERs of prior diabetes interventions range from $1,000-$4,000, a cost of $1,100 per 1% within group decrease in HbA1c is a promising intervention. Multi-component incentive structures seem to have the least variation in cost-effectiveness.
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Affiliation(s)
- Leonard E. Egede
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
- * E-mail:
| | - Rebekah J. Walker
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Clara E. Dismuke-Greer
- Health Economics Resource Center (HERC), Palo Alto VA Health Care System, Palo Alto, California, United States of America
| | - Sarah Pyzyk
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Aprill Z. Dawson
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Joni S. Williams
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Jennifer A. Campbell
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
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21
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Huckfeldt PJ, Frenier C, Pajewski NM, Espeland M, Peters A, Casanova R, Pi-Sunyer X, Cheskin L, Goldman DP. Associations of Intensive Lifestyle Intervention in Type 2 Diabetes With Health Care Use, Spending, and Disability: An Ancillary Study of the Look AHEAD Study. JAMA Netw Open 2020; 3:e2025488. [PMID: 33231638 PMCID: PMC7686866 DOI: 10.1001/jamanetworkopen.2020.25488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
IMPORTANCE Intensive lifestyle interventions focused on diet and exercise can reduce weight and improve diabetes management. However, the long-term effects on health care use and spending are unclear, especially for public payers. OBJECTIVE To estimate the association of effective intensive lifestyle intervention for weight loss with long-term health care use and Medicare spending. DESIGN, SETTING, AND PARTICIPANTS This ancillary study used data from the Look AHEAD randomized clinical trial, which randomized participants with type 2 diabetes to an intensive lifestyle intervention or control group (ie, diabetes support and education), provided ongoing intervention from 2001 to 2012, and demonstrated improved diabetes management and reduced health care costs during the intervention. This study compared Medicare data between study arms from 2012 to 2015 to determine whether the intervention was associated with persistent reductions in health care spending. EXPOSURE Starting in 2001, Look AHEAD's intervention group participated in sessions with lifestyle counselors, dieticians, exercise specialists, and behavioral therapists with the goal of reducing weight 7% in the first year. Sessions occurred weekly in the first 6 months of the intervention and decreased over the intervention period. The controls participated in periodic group education sessions that occurred 3 times per year in the first year and decreased to 1 time per year later in the trial. MAIN OUTCOMES AND MEASURES Outcomes included total Medicare spending, Part D prescription drug costs, Part A and Part B Medicare spending, hospital admissions, emergency department visits, and disability-related Medicare eligibility. RESULTS This study matched Medicare administrative records for 2796 Look AHEAD study participants (54% of 5145 participants initially randomized and 86% of 3246 participants consenting to linkages). Linked intervention and control participants were of a similar age (mean [SD] age, 59.6 [5.4] years vs 59.6 [5.5] years at randomization) and sex (818 [58.1%] women vs 822 [59.3%] women). There was no statistically significant difference in total Medicare spending between groups (difference, -$133 [95% CI, -$1946 to $1681]; P = .89). In the intervention group, compared with the control group, there was statistically significantly higher Part B spending (difference, $513 [95% CI, $70 to $955]; P = .02) but lower prescription drug costs (difference, -$803 [95% CI, -$1522 to -$83]; P = .03). CONCLUSIONS AND RELEVANCE This ancillary study of a randomized clinical trial found that reductions in health care use and spending associated with an intensive lifestyle intervention for type 2 diabetes diminished as participants aged. Intensive lifestyle interventions may need to be sustained to reduce long-term health care spending. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03952728.
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Affiliation(s)
- Peter J. Huckfeldt
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Chris Frenier
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Nicholas M. Pajewski
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Mark Espeland
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Anne Peters
- Keck School of Medicine of the University of Southern California, Los Angeles
| | - Ramon Casanova
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | | | - Dana P. Goldman
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
- School of Pharmacy, University of Southern California, Los Angeles
- Price School of Public Policy, University of Southern California, Los Angeles
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Simeone JC, Shah S, Ganz ML, Sullivan S, Koralova A, LeGrand J, Bushman J. Healthcare resource utilization and cost among patients with type 1 diabetes in the United States. J Manag Care Spec Pharm 2020; 26:1399-1410. [PMID: 33119443 PMCID: PMC10390920 DOI: 10.18553/jmcp.2020.26.11.1399] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND: Approximately 5%-10% of patients with diabetes are diagnosed with type 1 diabetes mellitus (T1DM), the incidence and prevalence of which is projected to increase through 2050. Despite this, T1DM-related health care resource utilization (HCRU) and economic burden in the United States have not been adequately assessed, since previous studies used various cost definitions and underlying methods to examine these outcomes. OBJECTIVE: To assess HCRU and costs incurred by patients with T1DM in the United States. METHODS: This retrospective cohort study used IBM Watson MarketScan data from 2011 to 2015 and Optum's electronic medical record (EMR) and integrated data (i.e., linked EMR and administrative claims data) from 2011 to 2016. Included patients had ≥ 1 T1DM diagnosis (the earliest diagnosis date was designated as the index date), were continuously enrolled for ≥ 6 months during their pre-index baseline periods, and had ≥ 1 pharmacy claim for insulin or an insulin pump within ± 90 days of the index date. Baseline demographic and clinical characteristics were summarized descriptively. Average monthly HCRU and costs per patient per month (PPPM) paid by the health plan and patient were assessed. Costs were adjusted for inflation to 2018 U.S. dollars. RESULTS: We identified 181,423 patients with T1DM who met the selection criteria in MarketScan, 84,759 in the Optum EMR, and 8,948 in the Optum integrated databases. Most patients were male (range across databases: 52.6%-53.1%), relatively young (medians: 33-35 years, overall range: 0-100 years), and had a Charlson Comorbidity Index score of 1 (69.2%-73.0%) across all databases. Total all-cause and diabetes-related costs ranged from $1,482 to $1,522 and $733 to $780 PPPM, respectively, during the follow-up period. Pharmacy costs contributed most to the total cost of care, accounting for 55.3% ($431) to 61.1% ($448) of total diabetes-related costs. On an annualized basis, patients had an average of 0.2-0.9 all-cause hospitalizations and 0.1-0.3 diabetes-related hospitalizations during follow-up. The median costs per diabetes-related hospitalization ranged from $6,548 to $8,439, accounting for 4%-7% of total monthly diabetes-related costs. Patients had an average of 0.4-0.5 all-cause and 0.1-0.2 diabetes-related emergency department (ED) visits annually; the median costs of ED visits were $972-$1,499, contributing about 2% of monthly diabetes-related costs during follow-up. CONCLUSIONS: In this large, retrospective, observational study of pediatric and adult patients with T1DM, diabetes-related costs totaled nearly $800 per month. Pharmacy costs contributed to over half of diabetes-related costs, indicating the substantial economic burden associated with the treatment of T1DM. Additional research is needed to determine risk factors associated with costly events (e.g., hospitalizations and ED visits) and indirect costs associated with T1DM. DISCLOSURES: JDRF International provided funding for this project and manuscript. JDRF International also contracted with Evidera, a research and consulting firm for the biopharma industry, for its participation in the project and in the development of this manuscript. The Leona M. and Harry B. Helmsley Charitable Trust provided JDRF International with funding. Simeone, Shah, and Ganz are employed by Evidera and do not receive any payment or honoraria directly from Evidera's clients. LeGrand is an employee of JDRF International. Bushman was employed by JDRF International during the conduct of the study and development of this manuscript. Sullivan and Koralova are employees of The Leona M. and Harry B. Helmsley Charitable Trust.
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Affiliation(s)
| | | | | | - Sean Sullivan
- The Leona M. and Harry B. Helmsley Charitable Trust, New York, NY
| | - Anne Koralova
- The Leona M. and Harry B. Helmsley Charitable Trust, New York, NY
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Alvarez C, Saint-Pierre C, Herskovic V, Sepúlveda M, Prieto F. Analysis of the relationship between treatment networks and the evolution of patients with Type 2 Diabetes Mellitus. J Biomed Inform 2020; 108:103497. [PMID: 32621884 DOI: 10.1016/j.jbi.2020.103497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 04/21/2020] [Accepted: 06/24/2020] [Indexed: 11/28/2022]
Abstract
Type 2 Diabetes Mellitus (T2DM) is a chronic disease that has been increasing in prevalence in recent years and that can cause severe complications. To ensure patient care is administered correctly, it is necessary for medical treatment teams to be both multidisciplinary and cohesive. The analysis of health processes is a constant challenge due to their high variability and complexity. This paper proposes a method based on the analysis of social networks to detect treatment networks, and to identify a relationship between these networks and patient evolution, as measured by glycated hemoglobin (HbA1c) levels. The networks were segmented based on patient adherence to their medical appointments and their mean time of delay. We applied this method on a sample of 1574 patients diagnosed with T2DM. Results show that participatory treatment -in which a patient sees a particular group of professionals on a recurrent basis - together with high levels of adherence are associated to those patients who improve their HbA1c levels in the case of high levels of adherence, while those who continually experience referrals to different professionals, remain unstable and, in some cases, get worse. On the other hand, in order to maintain a patient as stable, continuous control of the patient is enough, regardless of the recurrence to the same professionals.
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Affiliation(s)
- Camilo Alvarez
- Computer Science Department, School of Engineering, Pontificia Universidad Católica de Chile, Vicuña Mackenna 4860, Macul, Santiago, Chile.
| | - Cecilia Saint-Pierre
- Computer Science Department, School of Engineering, Pontificia Universidad Católica de Chile, Vicuña Mackenna 4860, Macul, Santiago, Chile.
| | - Valeria Herskovic
- Computer Science Department, School of Engineering, Pontificia Universidad Católica de Chile, Vicuña Mackenna 4860, Macul, Santiago, Chile.
| | - Marcos Sepúlveda
- Computer Science Department, School of Engineering, Pontificia Universidad Católica de Chile, Vicuña Mackenna 4860, Macul, Santiago, Chile.
| | - Florencia Prieto
- Family Medicine Department, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
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Bussière C, Sirven N, Rapp T, Sevilla-Dedieu C. Adherence to medical follow-up recommendations reduces hospital admissions: Evidence from diabetic patients in France. HEALTH ECONOMICS 2020; 29:508-522. [PMID: 31965683 DOI: 10.1002/hec.3999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 12/05/2019] [Accepted: 12/25/2019] [Indexed: 06/10/2023]
Abstract
The aim of this study was to document the extent to which diabetic patients who adhered to required medical follow-ups in France experienced reduced hospital admissions over time. The main assumption was that enhanced monitoring and follow-up of diabetic patients in the primary care setting could be a substitute for hospital use. Using longitudinal claim data of diabetic patients between 2010 and 2015 from MGEN, a leading mutuelle insurance company in France, we estimated a dynamic logit model with lagged measures of the quality of adherence to eight medical follow-up recommendations. This model allowed us to disentangle follow-up care in hospitals from other forms of inpatient care that could occur simultaneously. We found that a higher adherence to medical guidance is associated with a lower probability of hospitalization and that the take-up of each of the eight recommendations may help reduce the rates of hospital admission. The reasons for the variation in patient adherence and implications for health policy are discussed.
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Affiliation(s)
- Clémence Bussière
- LEDi (EA7467), Université de Bourgogne, France
- MGEN Foundation for Public Health, University of Bourgogne, Dijon, France, Paris, France
| | - Nicolas Sirven
- LIRAES (EA4470), Université de Paris Descartes, France
- IRDES, Paris, France
| | - Thomas Rapp
- LIRAES (EA4470), Université de Paris Descartes, France
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Meraya AM, Alwhaibi M. Health related quality of life and healthcare utilization among adults with diabetes and kidney and eye complications in the United States. Health Qual Life Outcomes 2020; 18:85. [PMID: 32228619 PMCID: PMC7106887 DOI: 10.1186/s12955-020-01336-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 03/19/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND One-third of adults with diabetes in the United States have chronic kidney disease (CKD), and 19% of them have eye complications (ECs). However, little is known about the Health-related Quality of Life (HRQoL) of adults with both of these diabetes-related complications. Therefore, the purpose of this study is to examine differences in the HRQoL, mental health, and healthcare utilization of adults with diabetes who have CKD, ECs, both or neither. METHODS A cross-sectional study design was implemented using data from multiple panels (2009-2015) of the Medical Expenditure Panel Survey. HRQoL was measured using the SF-12 Physical and Mental Component Summary (PCS & MCS) scores. The HRQoL, mental health, and healthcare utilization of four mutually exclusive groups: 1) diabetes with both CKD and ECs; 2) diabetes with CKD only; 3) diabetes with ECs only, and 4) diabetes with neither CKD nor ECs were compared. In all analyses, adults with neither CKD nor ECs were the reference group. RESULTS There were 8415 adults with diabetes who met the inclusion criteria. Approximately, 75% of the study sample had neither CKD nor ECs, 13.3% had ECs only, 5.7% had CKD only, and 5.5% had both CKD and ECs. In the adjusted analyses, adults with both CKD and/or ECs complications exhibited significantly lower HRQoL compared to those with neither CKD nor ECs. Mental illness and psychological distress were higher among adults with both CKD and ECs compared to those with neither CKD nor ECs. Furthermore, adults with CKD and/or ECs had higher polypharmacy, inpatient and emergency services use compared to those with neither CKD nor ECs. CONCLUSIONS The results indicate that the presence of both CKD and/or ECs was negatively associated with poor HRQoL, poor mental health, higher psychological distress and healthcare utilization in adults with diabetes. The findings emphasize the need for routine assessment and treatment for diabetes-related CKD and/or ECs complications to improve the quality of care for individuals with diabetes.
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Affiliation(s)
- Abdulkarim M Meraya
- Department of Clinical Pharmacy, College of Pharmacy, Jazan University, P.O Box 114-45124, Jazan, Saudi Arabia. .,Pharmacy Practice Research Unit, College of Pharmacy, Jazan University, Jazan, Saudi Arabia.
| | - Monira Alwhaibi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.,Medication Safety Research Chair, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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26
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Gucciardi E, Xu C, Vitale M, Lou W, Horodezny S, Dorado L, Sidani S, Shah BR. Evaluating the impact of onsite diabetes education teams in primary care on clinical outcomes. BMC FAMILY PRACTICE 2020; 21:48. [PMID: 32126965 PMCID: PMC7055112 DOI: 10.1186/s12875-020-01111-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 02/13/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND To evaluate the impact of integrating diabetes education teams in primary care on glycemic control, lipid, and blood-pressure management in type 2 diabetes patients. METHODS A historical cohort design was used to assess the integration of teams comprising nurse and dietitian educators in 11 Ontario primary-care sites, which delivered individualized self-management education. Of the 771 adult patients with A1C ≥ 7% recruited, 487 patients attended appointments with the diabetes teams, while the remaining 284 patients did not. The intervention's primary goal was to increase the proportion of patients with A1C ≤7%. Secondary goals were to reduce mean A1C, low-density lipoprotein, total cholesterol-high density lipoprotein, and diastolic and systolic blood pressure, as recommended by clinical-practice guidelines. RESULTS After 12 months, a higher proportion of intervention-group patients reached the target for A1C, compared with the control group. Mean A1C levels fell significantly among all patients, but the mean reduction was larger for the intervention group than the control group. Although more intervention-group patients reached targets for all clinical outcomes, the between-group differences were not statistically significant, except for A1C. CONCLUSIONS Nurse and dietitian diabetes-education teams can have a clinically meaningful impact on patients' ability to meet recommended A1C targets. Given the study's historical cohort design, results are generalizable and applicable to day-to-day primary-care practice. Longer follow-up studies are needed to investigate whether the positive outcomes of the intervention are sustainable.
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Affiliation(s)
- Enza Gucciardi
- grid.68312.3e0000 0004 1936 9422School of Nutrition, Ryerson University, Toronto, ON Canada
| | - Changchang Xu
- grid.17063.330000 0001 2157 2938Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- grid.250674.20000 0004 0626 6184Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
- Modellicity Inc, Toronto, Canada
| | - Michele Vitale
- grid.68312.3e0000 0004 1936 9422Postdoctoral Research Fellow, School of Nutrition, Ryerson University, Toronto, Canada
| | - Wendy Lou
- grid.17063.330000 0001 2157 2938Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Stacey Horodezny
- grid.417293.a0000 0004 0459 7334Adult Diabetes Programs, Trillium Health Partners, Mississauga, Canada
| | - Linda Dorado
- grid.68312.3e0000 0004 1936 9422Ryerson University, Toronto, Canada
| | - Souraya Sidani
- grid.68312.3e0000 0004 1936 9422Daphnee Cockwell School of Nursing, Ryerson University, Toronto, Canada
| | - Baiju R. Shah
- grid.17063.330000 0001 2157 2938Department of Medicine, University of Toronto, Toronto, Canada
- grid.413104.30000 0000 9743 1587Division of Endocrinology, Sunnybrook Health Sciences Centre, Toronto, Canada
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Dobson R, Whittaker R, Jiang Y, McNamara C, Shepherd M, Maddison R, Cutfield R, Khanolkar M, Murphy R. Long-term follow-up of a randomized controlled trial of a text-message diabetes self-management support programme, SMS4BG. Diabet Med 2020; 37:311-318. [PMID: 31722130 PMCID: PMC7004024 DOI: 10.1111/dme.14182] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2019] [Indexed: 01/03/2023]
Abstract
AIMS To determine the long-term effectiveness of an individually tailored text-message diabetes self-management support programme, SMS4BG, on glycaemic control at 2 years in adults with diabetes with an HbA1c concentration > 64 mmol/mol (8%). METHODS We conducted a 2-year follow-up of a two-arm, parallel, randomized controlled trial across health services in New Zealand. Participants were English-speaking adults with type 1 or 2 diabetes and with an HbA1c >64 mmol/mol (8%). In the main trial participants randomized to the intervention group (N=183) received up to 9 months of an automated tailored text-message programme in addition to usual care. Participants in the control group (N=183) received usual care for 9 months. In this follow-up study, 293 (80%) of 366 randomized participants in the main trial were included. The primary outcome measure was change in glycaemic control (HbA1c ) from baseline to 2 years. Mixed-effect models were used to compare the group differences at 3, 6, 9 and 24 months, adjusted for baseline HbA1c and stratification factors (health district category, diabetes type and ethnicity). RESULTS The decrease in HbA1c at 2 years was significantly greater in the intervention group [mean (sd) -10 (18) mmol/mol or -0.9 (1.6)%] compared with the control group [mean (sd) -1 (20) mmol/mol or -0.1 (1.8)%], with an adjusted mean difference of -9 mmol/mol (95% CI -14, -5) or -0.8% (95% CI -1.2, -0.4; P<0.0001). CONCLUSIONS Improvements in glycaemic control resulting from a text-message diabetes self-management support programme were sustained at 2 years after randomization. These findings support the implementation of SMS4BG in current practice.
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Affiliation(s)
- R. Dobson
- National Institute for Health InnovationSchool of Population HealthUniversity of AucklandAucklandNew Zealand
| | - R. Whittaker
- National Institute for Health InnovationSchool of Population HealthUniversity of AucklandAucklandNew Zealand
- Waitematā District Health BoardAucklandNew Zealand
| | - Y. Jiang
- National Institute for Health InnovationSchool of Population HealthUniversity of AucklandAucklandNew Zealand
| | - C. McNamara
- Waitematā District Health BoardAucklandNew Zealand
| | - M. Shepherd
- School of PsychologyMassey UniversityAucklandNew Zealand
| | - R. Maddison
- Institute for Physical Activity and NutritionDeakin UniversityBurwoodVic.Australia
| | - R. Cutfield
- Waitematā District Health BoardAucklandNew Zealand
| | - M. Khanolkar
- Auckland District Health BoardAucklandNew Zealand
| | - R. Murphy
- Auckland District Health BoardAucklandNew Zealand
- School of MedicineFaculty of Medical and Health SciencesUniversity of AucklandAucklandNew Zealand
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Gil J, Li Donni P, Zucchelli E. Uncontrolled diabetes and health care utilisation: A bivariate latent Markov model approach. HEALTH ECONOMICS 2019; 28:1262-1276. [PMID: 31502351 DOI: 10.1002/hec.3939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 05/03/2019] [Accepted: 07/08/2019] [Indexed: 06/10/2023]
Abstract
Although uncontrolled diabetes (UD) or poor glycaemic control is a widespread condition with potentially life-threatening consequences, there is sparse evidence of its effects on health care utilisation. We jointly model the propensities to consume health care and UD by employing an innovative bivariate latent Markov model that allows for dynamic unobserved heterogeneity, movements between latent states and the endogeneity of UD. We estimate the effects of UD on primary and secondary health care consumption using a panel dataset of rich administrative records from Spain and measure UD using a biomarker. We find that, conditional on time-varying unobservables, UD does not have a statistically significant direct effect on health care use. Furthermore, individuals appear to move across latent classes and increase their propensities to poor glycaemic control and health care use over time. Our results suggest that by ignoring time-varying unobserved heterogeneity and the endogeneity of UD, the effects of UD on health care utilisation might be overestimated and this could lead to biased findings. Our approach reveals heterogeneity in behaviour beyond standard groupings of frequent versus infrequent users of health care services. We argue that this dynamic latent Markov approach could be used more widely to model the determinants of health care use.
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Affiliation(s)
- Joan Gil
- Department of Economics, University of Barcelona, Barcelona, Spain
| | - Paolo Li Donni
- Department of Economics, Business and Statistics, University of Palermo, Palermo, Italy
| | - Eugenio Zucchelli
- Division of Health Research (DHR), Lancaster University, Lancaster, UK
- Madrid Institute for Advanced Study (MIAS) and Department of Economic Analysis, Universidad Autónoma de Madrid (UAM), Madrid, Spain
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King DE, Petrone AB, Alcantara FM, Elavsky MM, Prestoza MO, Siebart J, Castelli G. Outcomes in an Interdisciplinary Diabetes Clinic in Rural Primary Care. South Med J 2019; 112:205-209. [PMID: 30943537 DOI: 10.14423/smj.0000000000000960] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the effectiveness of an interdisciplinary diabetes team model of care in assisting patients to achieve improved glucose control in a primary care rural setting. METHODS A family medicine clinic at a rural university medical center developed an interdisciplinary diabetes team clinic composed of a certified diabetes educator/dietitian, a case manager, a pharmacist, nursing staff, a family medicine resident, a psychologist, and a board-certified family medicine attending physician. Patients were referred if their hemoglobin A1c (HbA1c) was ≥9% (75 mmol/mol); patients were seen for an initial consultation and for additional visits as needed. RESULTS A total of 94 patients attended an initial visit and at least 1 follow-up within 6 months. Mean age was 57 ± 13 years, and 54% were female. Median time from the initial intensive diabetes clinic visit to a follow-up visit was 2.8 months. There was a significant reduction in median HbA1c percentage from 10.25% (88.5 mmol/mol) ± 1.4% (range 73-104 mmol/mol) at the initial intensive diabetes clinic visit to 8.7% (72 mmol/mol) ± 1.8% (range 52-92 mmol/mol) at a 1- to 6-month follow-up (z = -7.161, P < 0.001) and a significant difference between baseline HbA1c (10.25% [88.5 mmol/mol] ± 1.4% [range 73-104 mmol/mol]) and latest HBA1c (1-18 months later) 8.4% (68 mmol/mol) ± 2.2% (range 44-92 mmol/mol; z = -7.022, P < 0.001). Overall, 86% of patients had a lower HbA1c at follow-up, and 33% had an HbA1c <8% (64 mmol/mol). There were no differences in patients' blood pressure, immunization rates, or lipid values between baseline and follow-up visits (P > 0.05). CONCLUSIONS An interdisciplinary team approach to glycemic control can achieve significant reductions in HbA1c in the rural primary care setting.
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Affiliation(s)
- Dana E King
- From the Department of Family Medicine, West Virginia University, Morgantown, West Virginia, and University of Pittsburgh Medical Center (UPMC), St. Margaret, Pittsburgh, Pennsylvania
| | - Ashley B Petrone
- From the Department of Family Medicine, West Virginia University, Morgantown, West Virginia, and University of Pittsburgh Medical Center (UPMC), St. Margaret, Pittsburgh, Pennsylvania
| | - Frederick M Alcantara
- From the Department of Family Medicine, West Virginia University, Morgantown, West Virginia, and University of Pittsburgh Medical Center (UPMC), St. Margaret, Pittsburgh, Pennsylvania
| | - Megan M Elavsky
- From the Department of Family Medicine, West Virginia University, Morgantown, West Virginia, and University of Pittsburgh Medical Center (UPMC), St. Margaret, Pittsburgh, Pennsylvania
| | - Michelle O Prestoza
- From the Department of Family Medicine, West Virginia University, Morgantown, West Virginia, and University of Pittsburgh Medical Center (UPMC), St. Margaret, Pittsburgh, Pennsylvania
| | - Judy Siebart
- From the Department of Family Medicine, West Virginia University, Morgantown, West Virginia, and University of Pittsburgh Medical Center (UPMC), St. Margaret, Pittsburgh, Pennsylvania
| | - Greg Castelli
- From the Department of Family Medicine, West Virginia University, Morgantown, West Virginia, and University of Pittsburgh Medical Center (UPMC), St. Margaret, Pittsburgh, Pennsylvania
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Real-world impact on monthly glucose-lowering medication cost, HbA 1c, weight, and polytherapy after initiating a GLP-1 receptor agonist. J Am Pharm Assoc (2003) 2019; 60:31-38.e1. [PMID: 31611005 DOI: 10.1016/j.japh.2019.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 08/28/2019] [Accepted: 09/03/2019] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Glucagon-like peptide-1 (GLP-1) receptor agonists are preferred injectable therapies for type 2 diabetes, but their high cost is an area of concern. This study evaluated monthly glucose-lowering medication cost and clinical impact after initiating a GLP-1 receptor agonist. DESIGN A retrospective, pre-post cohort study evaluated monthly glucose-lowering medication cost, glycated hemoglobin (HbA1c), weight, and polytherapy impact (name, dose, and number of daily doses or injections) when a GLP-1 receptor agonist was initiated (baseline) and after 6-12 months (follow-up). The population was analyzed overall and as subgroups, based on baseline medication regimen and demographics. SETTING AND PARTICIPANTS The study was performed at 8 ambulatory care sites (7 federally qualified health centers and a Program of All-Inclusive Care for the Elderly) in the greater Boston, MA, area. Patients were included in the analyses (n = 120) if they had a documented diagnosis of type 2 diabetes, were 18 years of age or older, had an HbA1c ≥ 7.5% measured within 3 months prior to the initiation of a GLP-1 receptor agonist, and an HbA1c measured 6 to 12 months following the initiation of a GLP-1 receptor agonist. OUTCOME MEASURES Primary outomes were changes in glucose-lowering medication cost, HbA1c, and weight. Secondary outcome analyses included the impact to the glucose-lowering medication regimen in terms of dose, number of medications, and number of daily doses or injections. RESULTS The study population was largely female, aged 55.8 ± 11.7 years, obese, 76% non-Caucasian, equally English and non-English speaking, had a high tablet and injection burden, and had an average baseline HbA1c of 10%. After the addition of a GLP-1 receptor agonist, monthly glucose-lowering medication cost increased $586.86 (overall), $741.69 (oral only baseline regimen), and $530.55 (insulin ± oral baseline regimen) (all P < 0.001). Mean decrease in HbA1c was 1.7% (18 mmol/mol) (P < 0.001) and was similar across all subgroups. Weight decreased overall (-1.8 kg, P < 0.001), and there was a significant shift toward taking fewer oral agents and insulin and fewer daily injections. No statistically significant differences in the primary outcomes were noted in terms of age, gender, English-speaking status, or race. CONCLUSION Although a positive impact was observed in glycemic control, weight, and reduced polytherapy 6-12 months after initiating a GLP-1 receptor agonist, the increase in monthly glucose-lowering medication cost was significant and may serve as a barrier to treatment.
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Prasad SS, Potter M, Keely S, Talley NJ, Walker MM, Kairuz T. Roles of healthcare professionals in the management of chronic gastrointestinal diseases with a focus on primary care: A systematic review. JGH OPEN 2019; 4:221-229. [PMID: 32280768 PMCID: PMC7144774 DOI: 10.1002/jgh3.12235] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/18/2019] [Accepted: 06/30/2019] [Indexed: 02/06/2023]
Abstract
Background and aim Inflammatory bowel disease (IBD) refers to a group of complex and chronic conditions that requires long‐term care delivered by a group of healthcare professionals through a multidisciplinary care model. We conducted a systematic review to examine and understand the role of healthcare professionals in the primary care management of IBD, and identify the gaps in IBD management that could be filled by primary care providers such as general practitioners (GPs) and pharmacists. Methods The search strategy retrieved published studies from five databases, and eligible articles were assessed for quality. A gray literature search of the websites of organizations was also undertaken. Results Twenty‐one studies were included, of which 19 were peer‐reviewed research articles and two reports were from organizational bodies. Although studies have shown the roles of GPs, pharmacists, dietitians, and psychologists in IBD management, nurses and gastroenterologists were the key drivers delivering specialized care to IBD patients. Many key services are accessible only for hospital inpatients (tertiary care) or through outpatient clinics (secondary care) with an absence of a multidisciplinary approach including GPs and pharmacists. Conclusion Gastroenterologists and nurses have an important role in the delivery of care to patients with chronic gastrointestinal diseases including IBD, coeliac disease, irritable bowel syndrome, and functional dyspepsia. The role of nurses includes provision of specialized care to IBD patients, as well as supportive care such as education, monitoring of therapy, and ongoing assistance. The available evidence shows many opportunities for primary care providers to play a more active role in the management of IBD patients.
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Affiliation(s)
- Sharmila S Prasad
- Faculty of Health and Medicine, School of Biomedical Science and Pharmacy University of Newcastle Callaghan New South Wales Australia.,Priority Research Centre, Digestive Health and Neurogastroenterology University of Newcastle New Lambton Heights New South Wales Australia
| | - Michael Potter
- Priority Research Centre, Digestive Health and Neurogastroenterology University of Newcastle New Lambton Heights New South Wales Australia.,Faculty of Health and Medicine, School of Medicine and Public Health University of Newcastle New Lambton Heights New South Wales Australia
| | - Simon Keely
- Faculty of Health and Medicine, School of Biomedical Science and Pharmacy University of Newcastle Callaghan New South Wales Australia.,Priority Research Centre, Digestive Health and Neurogastroenterology University of Newcastle New Lambton Heights New South Wales Australia
| | - Nicholas J Talley
- Priority Research Centre, Digestive Health and Neurogastroenterology University of Newcastle New Lambton Heights New South Wales Australia.,Faculty of Health and Medicine, School of Medicine and Public Health University of Newcastle New Lambton Heights New South Wales Australia
| | - Marjorie M Walker
- Priority Research Centre, Digestive Health and Neurogastroenterology University of Newcastle New Lambton Heights New South Wales Australia.,Faculty of Health and Medicine, School of Medicine and Public Health University of Newcastle New Lambton Heights New South Wales Australia
| | - Therése Kairuz
- Faculty of Health and Medicine, School of Biomedical Science and Pharmacy University of Newcastle Callaghan New South Wales Australia
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Ferrer RL, Neira LM, De Leon Garcia GL, Cuellar K, Rodriguez J. Primary Care and Food Bank Collaboration to Address Food Insecurity: A Pilot Randomized Trial. Nutr Metab Insights 2019; 12:1178638819866434. [PMID: 31384130 PMCID: PMC6664622 DOI: 10.1177/1178638819866434] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 07/06/2019] [Indexed: 11/16/2022] Open
Abstract
Food insecurity is common in the United States and linked to poor control of conditions influenced by diet. We conducted a pilot randomized trial to test whether a novel partnership between a primary care practice and a municipal food bank would improve control of type 2 diabetes among patients with food insecurity. Participants received food bank produce delivered twice monthly to the practice site, brief teaching from a food bank dietitian, and home-based education from a community health worker. After 6 months, glycosylated hemoglobin decreased (absolute change) by 3.1% in the intervention group vs 1.7% in the control group (P = .012). Scores on Starting the Conversation-Diet, a brief dietary measure, improved in the intervention group by 2.47 on a 14-point scale (P < .001). Body mass indexes (BMIs) were unchanged. In this early-stage study, onsite collaboration between primary care and a regional food bank generated clinically meaningful reductions in HbA1c and improvements in diet.
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Affiliation(s)
- Robert L Ferrer
- Department of Family and Community Medicine, UT Health San Antonio, San Antonio, TX, USA
| | | | | | | | - Jasmine Rodriguez
- Department of Family and Community Medicine, UT Health San Antonio, San Antonio, TX, USA
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Randomized Trial of a Lifestyle Intervention for Urban Low-Income African Americans with Type 2 Diabetes. J Gen Intern Med 2019; 34:1174-1183. [PMID: 30963440 PMCID: PMC6614233 DOI: 10.1007/s11606-019-04894-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 10/12/2018] [Accepted: 01/22/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND African Americans suffer more than non-Hispanic whites from type 2 diabetes, but diabetes self-management education (DSME) has been less effective at improving glycemic control for African Americans. Our objective was to determine whether a novel, culturally tailored DSME intervention would result in sustained improvements in glycemic control in low-income African-American patients of public hospital clinics. RESEARCH DESIGN AND METHODS This randomized controlled trial (n = 211) compared changes in hemoglobin A1c (A1c) at 6, 12, and 18 months between two arms: (1) Lifestyle Improvement through Food and Exercise (LIFE), a culturally tailored, 28-session community-based intervention, focused on diet and physical activity, and (2) a standard of care comparison group receiving two group DSME classes. Cluster-adjusted ANCOVA modeling was used to assess A1c changes from baseline to 6, 12, and 18 months, respectively, between arms. RESULTS At 6 months, A1c decreased significantly more in the intervention group than the control group (- 0.76 vs - 0.21%, p = 0.03). However, by 12 and 18 months, the difference was no longer significant (12 months - 0.63 intervention vs - 0.45 control, p = 0.52). There was a decrease in A1c over 18 months in both the intervention (β = - 0.026, p = 0.003) and the comparison arm (β = - 0.018, p = 0.048) but no difference in trend (p = 0.472) between arms. The intervention group had greater improvements in nutrition knowledge (11.1 vs 6.0 point change, p = 0.002) and diet quality (4.0 vs - 0.5 point change, p = 0.018) while the comparison group had more participants with improved medication adherence (24% vs 10%, p < 0.05) at 12 months. CONCLUSIONS The LIFE intervention resulted in improved nutrition knowledge and diet quality and the comparison intervention resulted in improved medication adherence. LIFE participants showed greater A1c reduction than standard of care at 6 months but the difference between groups was no longer significant at 12 and 18 months. NIH TRIAL REGISTRY NUMBER NCT01901952.
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Elgart JF, Silvestrini C, Prestes M, Gonzalez L, Rucci E, Gagliardino JJ. Drug treatment of type 2 diabetes: Its cost is significantly associated with HbA1c levels. Int J Clin Pract 2019; 73:e13336. [PMID: 30811770 DOI: 10.1111/ijcp.13336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 02/06/2019] [Accepted: 02/24/2019] [Indexed: 12/15/2022] Open
Abstract
AIMS To examine the relationship between costs of hyperglycaemia drug treatment and glycemic control amongst people with type 2 diabetes (T2D). METHODS This observational study utilised data from the QUALIDIAB database on 3,452 T2D patients seen in Diabetes Centers in Argentina. Patients were classified according to their HbA1c value into two groups: on target (OT; HbA1c ≤ 7%), and not on target (NOT; HbA1c > 7%); within each category we considered clinical and metabolic indicators, as well as type of hyperglycaemia treatment. Monthly expenditure on drugs was estimated by micro-costing. Multivariable regression analysis was used to evaluate the association between cost of hyperglycaemia treatment and HbA1c values. RESULTS In total, 48.9% of the participants have HbA1c OT values. Overall monthly per capita costs of this treatment increased significantly (134%) in the NOT group. Multivariable regression analysis showed that expenditure for hyperglycaemia drugs treatment was significant associated with glycemic control (OR: 0.705), diabetes duration (OR: 1.017), systolic blood pressure (OR: 1.006) and treatment of T2D (OR: 2.622). CONCLUSIONS HbA1c NOT significantly increases drugs monthly cost of hyperglycaemia treatment in people with T2D in a country with an emerging market economy.
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Affiliation(s)
- Jorge F Elgart
- CENEXA. Center of Experimental and Applied Endocrinology (UNLP-CONICET), School of Medicine, National University of La Plata, La Plata, Argentina
| | - Constanza Silvestrini
- CENEXA. Center of Experimental and Applied Endocrinology (UNLP-CONICET), School of Medicine, National University of La Plata, La Plata, Argentina
| | - Mariana Prestes
- CENEXA. Center of Experimental and Applied Endocrinology (UNLP-CONICET), School of Medicine, National University of La Plata, La Plata, Argentina
| | - Lorena Gonzalez
- CENEXA. Center of Experimental and Applied Endocrinology (UNLP-CONICET), School of Medicine, National University of La Plata, La Plata, Argentina
- School of Health Economics and Management of Healthcare Organizations, Faculty of Economic Sciences, National University of La Plata, La Plata, Argentina
| | - Enzo Rucci
- CENEXA. Center of Experimental and Applied Endocrinology (UNLP-CONICET), School of Medicine, National University of La Plata, La Plata, Argentina
- III-LIDI, Faculty of Informatics, National University of La Plata, La Plata, Argentina
| | - Juan J Gagliardino
- CENEXA. Center of Experimental and Applied Endocrinology (UNLP-CONICET), School of Medicine, National University of La Plata, La Plata, Argentina
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Simmons M, Bishu KG, Williams JS, Walker RJ, Dawson AZ, Egede LE. Racial and Ethnic Differences in Out-of-Pocket Expenses among Adults with Diabetes. J Natl Med Assoc 2019; 111:28-36. [PMID: 30129486 PMCID: PMC7995684 DOI: 10.1016/j.jnma.2018.04.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 04/17/2018] [Accepted: 04/25/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Racial and ethnic minority groups have a higher prevalence of diabetes, increased risk for adverse complications, and worse health outcomes compared to Non-Hispanic Whites. Evidence suggests they also have higher healthcare expenses associated with diabetes care. Therefore, the objective of this study was to assess racial and ethnic differences in out-of-pocket (OOP) costs among a nationally representative sample of adults with diabetes. METHODS Cross-sectional study of 17,702 adults (aged ≥18 years) with diabetes from years 2002-2011 in the Medical Expenditure Panel Survey Household Component. The outcome was OOP expenditures, and the primary predictor was race/ethnicity. Descriptive statistics summarized the sample population. Unadjusted mean values were computed to compare OOP expenses over time. A two-part model was used to estimate adjusted incremental OOP expenses. RESULTS For the overall sample, OOP expenditures decreased significantly over time. In addition, compared to NHWs, racial and ethnic minority groups had significantly lower OOP costs per year when adjusted for sociodemographic characteristics, comorbid conditions, and time. NHBs paid $481 less than NHWs; Hispanics paid $591 less than NHWs; and individuals in the 'Other' racial/ethnic category paid nearly $645 less compared to NHWs (p < 0.001). CONCLUSIONS Racial/ethnic minority patients with diabetes had significantly less OOP expenses compared to NHWs, possibly due to differences in healthcare utilization. OOP expenses decreased significantly over time for all racial and ethnic groups. Additional research is needed to understand the factors associated with differences in OOP expenditures among racial groups.
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Affiliation(s)
- Makiera Simmons
- Center for Health Disparities Research, Department of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Kinfe G Bishu
- Center for Health Disparities Research, Department of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA; Department of Medicine, Division of General Internal Medicine and Geriatrics, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Joni S Williams
- Department of Medicine, Division of General Internal Medicine, Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI 53226, USA; Center for Patient Care and Outcomes Research, Medical College of Wisconsin, 8701 Watertown Plank Road, Room H3165, Milwaukee, WI 53226, USA
| | - Rebekah J Walker
- Department of Medicine, Division of General Internal Medicine, Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI 53226, USA; Center for Patient Care and Outcomes Research, Medical College of Wisconsin, 8701 Watertown Plank Road, Room H3165, Milwaukee, WI 53226, USA
| | - Aprill Z Dawson
- Department of Medicine, Division of General Internal Medicine, Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI 53226, USA; Center for Patient Care and Outcomes Research, Medical College of Wisconsin, 8701 Watertown Plank Road, Room H3165, Milwaukee, WI 53226, USA
| | - Leonard E Egede
- Department of Medicine, Division of General Internal Medicine, Medical College of Wisconsin, 9200 W. Wisconsin Ave, Milwaukee, WI 53226, USA; Center for Patient Care and Outcomes Research, Medical College of Wisconsin, 8701 Watertown Plank Road, Room H3165, Milwaukee, WI 53226, USA.
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Factors Promoting Clinical Inertia in Caring for Patients with Dyslipidemia: A Consensual Study Among Clinicians who Provide Healthcare to Patients with Dyslipidemia. J Natl Med Assoc 2019; 111:18-27. [DOI: 10.1016/j.jnma.2018.04.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 03/30/2018] [Accepted: 04/08/2018] [Indexed: 11/23/2022]
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Wysham CH, Lefebvre P, Pilon D, Lafeuille MH, Emond B, Kamstra R, Pfeifer M, Duh MS, Ingham M. An investigation into the durability of glycemic control in patients with type II diabetes initiated on canagliflozin or sitagliptin: A real-world analysis of electronic medical records. J Diabetes Complications 2019; 33:140-147. [PMID: 30554838 DOI: 10.1016/j.jdiacomp.2018.10.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 10/24/2018] [Accepted: 10/25/2018] [Indexed: 12/01/2022]
Abstract
AIMS The aims of this study were to assess glycemic control, weight loss, and durability of glycemic control in patients initiated on canagliflozin (CANA) versus sitagliptin (SITA). METHODS Adults with type II diabetes mellitus initiated on CANA or SITA (index date) were identified from IQVIA™ Real-World Data Electronic Medical Records - US database (03/29/2012-04/30/2016). Inverse probability of treatment weighting accounted for baseline differences between cohorts. Outcomes were compared using weighted Cox regression and Kaplan-Meier curves and included time to reaching HbA1c thresholds (<7%[53 mmol/mol], <8%[64 mmol/mol], <9%[75 mmol/mol]), weight loss ≥5%, failure to maintain HbA1c below threshold, new antihyperglycemic (AHA) prescription, and failure to maintain HbA1c/new AHA prescription. RESULTS Weighted cohorts were well balanced (NCANA = 14,542; NSITA = 15,151). CANA patients were 12-15% more likely to reach the HbA1c thresholds, 47% more likely to lose ≥5% of body weight, 31% less likely to have a new AHA prescription, 10-15% less likely to fail to maintain HbA1c, and 13-26% less likely to fail to maintain HbA1c or have a new AHA, versus SITA patients. CONCLUSIONS CANA patients were more likely to reach HbA1c and weight loss thresholds and maintain HbA1c below threshold versus SITA patients, while being less likely to have a prescription for a new AHA, suggesting more durable glycemic control with CANA.
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Affiliation(s)
- Carol H Wysham
- Multicare Rockwood Clinic, 400 E 5th Ave, Suite 4 West, Spokane, WA 99202, USA.
| | - Patrick Lefebvre
- Analysis Group, Inc., 1000 De La Gauchetière West, Suite 1200, Montréal, Québec H3B 4W5, Canada.
| | - Dominic Pilon
- Analysis Group, Inc., 1000 De La Gauchetière West, Suite 1200, Montréal, Québec H3B 4W5, Canada.
| | - Marie-Hélène Lafeuille
- Analysis Group, Inc., 1000 De La Gauchetière West, Suite 1200, Montréal, Québec H3B 4W5, Canada.
| | - Bruno Emond
- Analysis Group, Inc., 1000 De La Gauchetière West, Suite 1200, Montréal, Québec H3B 4W5, Canada.
| | - Rhiannon Kamstra
- Analysis Group, Inc., 1000 De La Gauchetière West, Suite 1200, Montréal, Québec H3B 4W5, Canada
| | - Michael Pfeifer
- Janssen Scientific Affairs, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ 08560, USA.
| | - Mei Sheng Duh
- Analysis Group, Inc., 111 Huntington Avenue, 14th Floor, Boston, MA 02199-7668, USA.
| | - Mike Ingham
- Janssen Scientific Affairs, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ 08560, USA.
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Lee SM, Song I, Suh D, Chang C, Suh DC. Treatment Costs and Factors Associated with Glycemic Control among Patients with Diabetes in the United Arab Emirates. J Obes Metab Syndr 2018; 27:238-247. [PMID: 31089569 PMCID: PMC6513308 DOI: 10.7570/jomes.2018.27.4.238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 08/31/2018] [Accepted: 10/25/2018] [Indexed: 11/12/2022] Open
Abstract
Background We aimed to estimate the proportion of patients with diabetes who achieved target glycemic control, to estimate diabetes-related costs attributable to poor control, and to identify factors associated with them in the United Arab Emirates. Methods This retrospective cohort study used administrative claims data handled by Abu Dhabi Health Authority (January 2010 to June 2012) to determine glycemic control and diabetes-related treatment costs. A total of 4,058 patients were matched using propensity scores to eliminate selection bias between patients with glycosylated hemoglobin (HbA1c) <7% and HbA1c ≥7%. Diabetes-related costs attributable to poor control were estimated using a recycled prediction method. Factors associated with glycemic control were investigated using logistic regression and factors associated with these costs were identified using a generalized linear model. Results During the 1-year follow-up period, 46.6% of the patients achieved HbA1c <7%. Older age, female sex, better insurance coverage, non-use of insulin in the index diagnosis month, and non-use of antidiabetic medications during the follow-up period were significantly associated with improved glycemic control. The mean diabetes-related annual costs were $2,282 and $2,667 for patients with and without glycemic control, respectively, and the cost attributable to poor glycemic control was $172 (95% confidence interval [CI], $164–180). The diabetes-related costs were lower with mean HbA1c levels <7% (cost ratio, 0.94; 95% CI, 0.88–0.99). The costs were significantly higher in patients aged ≥65 years than those aged ≤44 years (cost ratio, 1.45; 95% CI, 1.25–1.70). Conclusion More than 50% of patients with diabetes had poorly controlled HbA1c. Poor glycemic control may increase diabetes-related costs.
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Affiliation(s)
- Seung-Mi Lee
- College of Pharmacy, Chung-Ang University, Seoul, Korea
| | - Inmyung Song
- College of Pharmacy, Chung-Ang University, Seoul, Korea
| | - David Suh
- School of Public Health, Columbia University, New York, NY, USA
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Henk HJ, Lopez JMS, Bookhart BK. Novel Type 2 Diabetes Medication Access and Effect of Patient Cost Sharing. J Manag Care Spec Pharm 2018; 24:847-855. [PMID: 30156451 PMCID: PMC10397984 DOI: 10.18553/jmcp.2018.24.9.847] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Although drug formulary restrictions may reduce use of prescription medication and pharmacy costs, the effect of patient cost sharing on medication adherence and health care utilization and cost is unclear. OBJECTIVE To evaluate the relationship between patient cost sharing for novel type 2 diabetes mellitus (T2DM) medications and medication adherence, persistence, and health care utilization and cost. METHODS This retrospective study used medical and pharmacy claims linked to pharmacy benefit plan design data. Patients with T2DM were identified via ICD-9-CM codes (medical claims), outpatient prescription fills (pharmacy claims), and pharmacy benefit design information. Patients with T2DM treated with novel T2DM medications (DPP4 or GLP-1) were enrolled in plans with fixed or coinsurance medication copayment structures and followed for 12-48 months. Endpoints included medication persistence and adherence and total all-cause health care cost. Multivariable regression analysis estimated the effect of benefit design parameters, adjusting for baseline patient characteristics. RESULTS The integrated database included 36,475 patients with T2DM. The majority (83.1%) had fixed copayment plans, and 3-tier plans were common (93.1%). Higher third-tier copayment was associated with poorer medication adherence and persistence but not total health care cost during follow-up. A $10 higher third-tier copayment was associated with 11% greater risk of novel T2DM medication discontinuation and 3% lower adherence. A comparison of patients with fixed versus coinsurance plans found that fixed plans were associated with higher adjusted persistence and total all-cause health care costs. CONCLUSIONS Higher medication copayment amounts were associated with lower patient medication adherence and persistence in T2DM but not total health care costs, as health plan costs decreased while patient out-of-pocket costs increased. We observed higher total all-cause health care costs among T2DM patients with a fixed copay (vs. coinsurance) pharmacy benefit. Additional research incorporating plan design information is needed to further examine this finding. DISCLOSURES This study was funded by Janssen Scientific Affairs, which was involved in study design, interpretation of data, editing manuscript content, and had final approval of the manuscript before submission. Lopez and Bookhart are employed by Janssen Scientific Affairs. At the time of this study, Henk was employed by Optum HEOR, which was contracted by Janssen to conduct this study. Portions of this study were presented at the 21st Annual International Meeting, ISPOR; May 21-25, 2016; in Washington, DC.
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Bansal M, Shah M, Reilly B, Willman S, Gill M, Kaufman FR. Impact of Reducing Glycated Hemoglobin on Healthcare Costs Among a Population with Uncontrolled Diabetes. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2018; 16:675-684. [PMID: 29936685 DOI: 10.1007/s40258-018-0398-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Glycated hemoglobin (A1C) is considered a "gold standard" measure of glycemic control in patients with diabetes and is correlated with a lower risk of diabetes complications and cost savings. This retrospective claims-analysis assessed the impact of A1C reduction on healthcare costs in patients with uncontrolled Type 1 and Type 2 diabetes. METHODS Using a large repository of US health plan administrative data linked to A1C values, patients with a diabetes diagnosis and at least two A1C values between 1 January 2009 and 31 December 2014 were selected to identify changes in A1C and associated changes in healthcare expenditure. We used all medical and pharmacy claims to calculate direct healthcare costs from 1 year prior to the index A1C to 2 years after the index A1C. A propensity score method was used to match patients with decreased A1C to patients whose A1C did not decrease, based on potentially confounding variables. Then, a generalized linear model regression was used to estimate the difference-in-difference (DD) effect on costs between the two groups. RESULTS Of the 3,197 patients who had a first A1C ≥ 9%, 2,273 patients (71%) had a decrease in A1C (Decreasers) and 924 patients (27%) had an increase in A1C (Non-decreasers). After matching, we compared 912 Decreasers to 912 Non-decreasers. Patients in the former group had average annual healthcare costs that were 24% lower during the first year of follow-up and 17% lower during the second year of follow-up, compared to patients whose A1C did not decrease. This reflected a savings of US$2503 and US$1690, respectively. For both time periods, the outpatient category was the largest contributor to cost savings. DISCUSSION In our analysis, A1C reduction among patients with T1DM and T2DM was associated with slower growth in healthcare costs within 1-2 years. These findings suggest that programs aimed at reducing A1C over a short timeframe may lead to substantial savings and may be worth pursuing by health plans and other payers.
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Affiliation(s)
- Megha Bansal
- Medtronic, 18000 Devonshire Street, Northridge, CA, 91325, USA.
| | - Mona Shah
- Medtronic, 18000 Devonshire Street, Northridge, CA, 91325, USA
| | - Brian Reilly
- Medtronic, 18302 Talavera Ridge, San Antonio, TX, 78257, USA
| | - Susan Willman
- Medtronic, 3033 Campus Drive, Plymouth, MN, 55441, USA
| | - Max Gill
- Medtronic, 18000 Devonshire Street, Northridge, CA, 91325, USA
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Ourth H, Nelson J, Spoutz P, Morreale AP. Development of a Pharmacoeconomic Model to Demonstrate the Effect of Clinical Pharmacist Involvement in Diabetes Management. J Manag Care Spec Pharm 2018; 24:449-457. [PMID: 29694293 PMCID: PMC10398278 DOI: 10.18553/jmcp.2018.24.5.449] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND A data collection tool was developed and nationally deployed to clinical pharmacists (CPs) working in advanced practice provider roles within the Department of Veterans Affairs to document interventions and associated clinical outcomes. Intervention and short-term clinical outcome data derived from the tool were used to populate a validated clinical outcomes modeling program to predict long-term clinical and economic effects. OBJECTIVE To predict the long-term effect of CP-provided pharmacotherapy management on outcomes and costs for patients with type 2 diabetes. METHODS Baseline patient demographics and biomarkers were extracted for type 2 diabetic patients having > 1 encounter with a CP using the tool between January 5, 2013, and November 20, 2014. Treatment biomarker values were extracted 12 months after the patient's initial visit with the CP. The number of visits with the CP was extracted from the electronic medical record, and duration of visit time was quantified by Current Procedural Terminology codes. Simulation modeling was performed on 3 patient cohorts-those with a baseline hemoglobin A1c of 8% to < 9%, 9% to < 10%, and ≥ 10%-to estimate long-term cost and clinical outcomes using modeling based on pivotal trial data (the Archimedes Model). A sensitivity analysis was conducted to assess the extent to which our results were dependent on assumptions related to program effectiveness and costs. RESULTS A total of 7,310 patients were included in the analysis. Analysis of costs and events on 2-, 3-, 5-, and 10-year time horizons demonstrated significant reductions in major adverse cardiovascular events (MACEs), myocardial infarctions (MIs), episodes of acute heart failure, foot ulcers, and foot amputations in comparison with a control group receiving usual guideline-directed medical care. In the cohort with a baseline A1c of ≥ 10%, the absolute risk reduction was 1.82% for MACE, 1.73% for MI, 2.43% for acute heart failure, 5.38% for foot ulcers, and 2.03% for foot amputations. The incremental cost-effectiveness ratios for cost per quality-adjusted life-year during the 2-, 3-, 5-, and 10-year time horizons were cost-effective for the cohorts of patients with a baseline A1c of 9% to < 10% and ≥ 10%. CONCLUSIONS CPs acting as advanced practice providers reduced A1c from baseline for veterans with type 2 diabetes compared with modeled usual care. Archimedes modeling of the A1c reductions projects a decreased incidence of diabetes complications and overall health care spending when compared with modeled usual care. DISCLOSURES There was no outside funding source or sponsor for this project. None of the authors report any conflicts of interest. The views expressed in this article are those of the authors and do not necessarily reflect the views or policies of the U.S. Department of Veterans Affairs. Preliminary data from this project were previously presented in abstract form at the Academy of Managed Care Pharmacy 27th Annual Meeting and Expo; April 8-10, 2015; in San Diego, California.
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Affiliation(s)
- Heather Ourth
- 1 Pharmacy Benefit Management Services, Department of Veterans Affairs, Washington, DC
| | - Jordan Nelson
- 2 Pharmacoeconomics, Clinical Informatics and Geriatrics, South Texas Veterans Health Care System, San Antonio, Texas
| | | | - Anthony P Morreale
- 1 Pharmacy Benefit Management Services, Department of Veterans Affairs, Washington, DC
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Alvarez C, Saint-Pierre C, Herskovic V, Sepúlveda M. Analysis of the Relationship between the Referral and Evolution of Patients with Type 2 Diabetes Mellitus. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E1534. [PMID: 30036937 PMCID: PMC6068730 DOI: 10.3390/ijerph15071534] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/10/2018] [Accepted: 07/13/2018] [Indexed: 12/30/2022]
Abstract
Type 2 Diabetes Mellitus (T2DM) is a chronic disease that has risen in prominence in recent years and can cause serious complications. Several studies show that the level of adherence to different types of treatment has a direct correlation with the positive evolution of chronic diseases. While such studies relate to patient adherence to medication, those that concern adherence to medical appointments do not distinguish between the different disciplines that attend to or refer patients. This study analyses the relationship between adherence to referrals made by three distinct disciplines (doctors, nurses, and nutritionists) and the results of HbA1c tests from a sample of 2290 patients with T2DM. The aim is to determine whether a relationship exists between patient improvement and the frequency with which they attend scheduled appointments in a timely manner, having been previously referred from or to a particular discipline. Results showed that patients tended to be more adherent when their next appointment is with a doctor, and less adherent when it is with a nurse or nutritionist. Furthermore, patients that remained stable had higher rates of adherence, whereas those with lower adherence tended to be more decompensated. The results can enable healthcare professionals to monitor patients and place particular emphasis on those who do not attend their scheduled appointments in a timely manner.
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Affiliation(s)
- Camilo Alvarez
- Department of Computer Science, Pontificia Universidad Católica de Chile, Santiago 7820436, Chile.
| | - Cecilia Saint-Pierre
- Department of Computer Science, Pontificia Universidad Católica de Chile, Santiago 7820436, Chile.
| | - Valeria Herskovic
- Department of Computer Science, Pontificia Universidad Católica de Chile, Santiago 7820436, Chile.
| | - Marcos Sepúlveda
- Department of Computer Science, Pontificia Universidad Católica de Chile, Santiago 7820436, Chile.
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Gil J, Sicras-Mainar A, Zucchelli E. Uncontrolled diabetes and health care utilisation: panel data evidence from Spain. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2018; 19:785-795. [PMID: 28799036 DOI: 10.1007/s10198-017-0920-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 07/25/2017] [Indexed: 05/24/2023]
Abstract
Despite size and relevance of uncontrolled diabetes, robust evidence on its effects on health care utilisation is very limited, especially among European countries. We employed longitudinal administrative data from Spain (2004-2010) to explore the relationship between uncontrolled type 2 diabetes and health care utilisation. We used a biomarker (glycated haemoglobin, HbA1c) to detect the presence of uncontrolled diabetes and explore its effects on both primary and secondary health care. We estimated a range of panel count data models, including negative binomials with random effects, dynamic and hurdle specifications to account for unobserved heterogeneity, previous utilisation and selection. We found uncontrolled diabetes in between 27 and 30% of patients of both genders. Our estimates suggested that although women appeared to systematically consume more health care compared to men, their consumption levels did not seem to be influenced by uncontrolled diabetes. Conversely, among men uncontrolled diabetes increased the average number of GP visits per year by between 3 and 3.4%, specialist visits by 5.3-6.1%, depending on specifications, and also extended annual hospital length of stay by 15%. We also found some evidence of heterogeneity in utilisation based on the level of uncontrolled diabetes among male individuals. Overall, our results suggested the need for different diabetes management plans depending on gender and levels of glycaemic control.
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Affiliation(s)
- Joan Gil
- Department of Economics and BEAT, University of Barcelona (UB), 696 Diagonal Ave, 08034, Barcelona, Spain.
| | | | - Eugenio Zucchelli
- Division of Health Research (DHR), Lancaster University, Lancaster, UK
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O'Brien MJ, Bullard KM, Zhang Y, Gregg EW, Carnethon MR, Kandula NR, Ackermann RT. Performance of the 2015 US Preventive Services Task Force Screening Criteria for Prediabetes and Undiagnosed Diabetes. J Gen Intern Med 2018; 33:1100-1108. [PMID: 29651678 PMCID: PMC6025671 DOI: 10.1007/s11606-018-4436-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 01/29/2018] [Accepted: 03/28/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND In 2015, The US Preventive Services Task Force (USPSTF) recommended screening for prediabetes and undiagnosed diabetes (collectively called dysglycemia) among adults aged 40-70 years with overweight or obesity. The recommendation suggests that clinicians consider screening earlier in people who have other diabetes risk factors. OBJECTIVE To compare the performance of limited and expanded screening criteria recommended by the USPSTF for detecting dysglycemia among US adults. DESIGN Cross-sectional analysis of survey and laboratory data collected from nationally representative samples of the civilian, noninstitutionalized US adult population. PARTICIPANTS A total of 3643 adults without diagnosed diabetes who underwent measurement of hemoglobin A1c (A1c), fasting plasma glucose (FPG), and 2-h plasma glucose (2-h PG). MAIN MEASURES Screening eligibility according to the limited criteria was based on age 40 to 70 years old and overweight/obesity. Screening eligibility according to the expanded criteria was determined by meeting the limited criteria or having ≥ 1 of the following risk factors: family history of diabetes, history of gestational diabetes or polycystic ovarian syndrome, and non-white race/ethnicity. Dysglycemia was defined by A1c ≥ 5.7%, FPG ≥ 100 mg/dL, and/or 2-h PG ≥ 140 mg/dL. KEY RESULTS Among the US adult population without diagnosed diabetes, 49.7% had dysglycemia. Screening based on the limited criteria demonstrated a sensitivity of 47.3% (95% CI, 44.7-50.0%) and specificity of 71.4% (95% CI, 67.3-75.2%). The expanded criteria yielded higher sensitivity [76.8% (95% CI, 73.5-79.8%)] and lower specificity [33.8% (95% CI, 30.1-37.7%)]. Point estimates for the sensitivity of the limited criteria were lower in all minority groups and significantly different for Asians compared to non-Hispanic whites [29.9% (95% CI, 23.4-37.2%) vs. 49.8% (95% CI, 45.9-53.7%); P < .001]. CONCLUSIONS Diabetes screening that follows the limited USPSTF criteria will identify approximately half of US adults with dysglycemia. Screening other high-risk subgroups defined in the USPSTF recommendation would improve detection of dysglycemia and may reduce associated racial/ethnic disparities.
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Affiliation(s)
- Matthew J O'Brien
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. .,Center for Community Health, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. .,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Kai McKeever Bullard
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Yan Zhang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Edward W Gregg
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Mercedes R Carnethon
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Namratha R Kandula
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Center for Community Health, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ronald T Ackermann
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Center for Community Health, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Blonde L, Raccah D, Lew E, Meyers J, Nikonova E, Ajmera M, Davis KL, Bertolini M, Guerci B. Treatment Intensification in Type 2 Diabetes: A Real-World Study of 2-OAD Regimens, GLP-1 RAs, or Basal Insulin. Diabetes Ther 2018; 9:1169-1184. [PMID: 29675797 PMCID: PMC5984932 DOI: 10.1007/s13300-018-0429-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Treatment guidelines recommend a stepwise approach to glycemia management in patients with type 2 diabetes (T2D), but this may result in uncontrolled glycated hemoglobin A1c (HbA1c) between steps. This retrospective analysis compared clinical and economic outcomes among patients with uncontrolled T2D initiating two oral antidiabetes drugs (OADs), glucagon-like peptide-1 receptor agonists (GLP-1 RAs), or basal insulin in a real-world setting. METHODS Adults with T2D on OAD monotherapy were identified in the MarketScan claims database (2007-2014). Those initiating two OADs (simultaneously or sequentially), GLP-1 RAs, or basal insulin were selected (date of initiation was termed the 'index date'); patients were required to have HbA1c > 7.0% in the 6 months pre-index date. HbA1c was compared from 6 months pre- to 1-year post-index. Annual all-cause healthcare utilization and costs were reported over the 1-year follow-up period. RESULTS Data for 6054 patients were analyzed (2-OAD, n = 4442; GLP-1 RA, n = 361; basal insulin, n = 1251). Baseline HbA1c was high in all cohorts, but highest in the basal-insulin cohort. Treatment initiation resulted in reductions in HbA1c in all cohorts, which was generally maintained throughout the follow-up period. Average HbA1c reductions from the 6 months pre- to 1 year post-index date were -1.2% for GLP-1 RA, -1.6% for OADs, and -1.8% for basal insulin. HbA1c < 7.0% at 1 year occurred in 32.6%, 47.5%, and 41.1% of patients, respectively. Annual healthcare costs (mean [SD]) were lowest for OAD (US$10,074 [$22,276]) followed by GLP-1 RA (US$14,052 [$23,829]) and basal insulin (US$18,813 [$37,332]). CONCLUSION Despite robust HbA1c lowering following treatment initiation, many patients did not achieve HbA1c < 7.0%. Basal insulin, generally prescribed for patients with high baseline HbA1c, was associated with a large reduction in HbA1c and with higher costs. Therapy intensification at an appropriate time could lead to clinical and economic benefits and should be investigated further. FUNDING Sanofi U.S., Inc.
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Affiliation(s)
- Lawrence Blonde
- Department of Endocrinology, Ochsner Medical Center, New Orleans, LA, USA.
| | - Denis Raccah
- University Hospital Sainte Marguerite, Marseille, France
| | | | - Juliana Meyers
- RTI Health Solutions, Research Triangle Park, Durham, NC, USA
| | | | - Mayank Ajmera
- RTI Health Solutions, Research Triangle Park, Durham, NC, USA
| | - Keith L Davis
- RTI Health Solutions, Research Triangle Park, Durham, NC, USA
| | | | - Bruno Guerci
- Diabetology Department, University of Lorraine, Vandoeuvre-Lès-Nancy, France
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Nejim B, Beaulieu RJ, Alshaikh H, Hamouda M, Canner J, Malas MB. A Unique All-Payer Rate-Setting System Controls the Cost but Not the Racial Disparity in Lower Extremity Revascularization Procedures. Ann Vasc Surg 2018; 52:116-125. [PMID: 29783031 DOI: 10.1016/j.avsg.2018.03.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 10/11/2017] [Accepted: 03/10/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with peripheral arterial disease often have high comorbidity burden that may complicate post-interventional course and drive increased health-care expenditures. Racial disparity had been observed in lower extremity revascularization (LER) patterns and outcomes. In 2014, Maryland adopted an all-payer rate-setting system to limit the rising hospitalization costs. This resulted in an aggregate payment system in which hospital compensation takes place as an overall per capita expenditure for hospital services. We sought to examine racial differences and other patient-level factors that might lead to discrepancies in LER hospital costs in the State of Maryland. METHODS We used International Classification of Diseases, Ninth Revision codes to identify patients who underwent infrainguinal open bypass (open) and endovascular repair (endo) in the Maryland Health Services Cost Review Commission database (2009-2015). Multivariable generalized linear model regression analysis was conducted to report cost differences adjusting for patient-specific demographics, comorbidities, and insurance status. Logistic regression analysis was used to assess quality metrics: intensive care unit (ICU) admission, 30-day readmission, protracted length of stay (pLOS) (endo: pLOS >9, open: pLOS > 10 days) and in-hospital mortality. RESULTS Among patients undergoing open, costs were higher for nonwhite patients (African-American [AA]: $6,092 [4,682-7,501], other: $3,324 [437-6,212]; both P ≤ 0.024), diabetics ($2,058 [837-3,279]; P < 0.001), and patients with Medicaid had an increased cost over Medicare patients by $4,325 (1,441-7,209). Critical limb ischemia (CLI) was associated with $5,254 (4,014-6,495) risk-adjusted cost increment. In addition, AA patients demonstrated higher risk-adjusted odds of ICU admission (adjusted odds ratio [aOR] [95% confidence interval {CI}]:1.65 [1.46-1.86]; P < 0.001) and pLOS (aOR [95% CI]: 1.56 [1.37-1.79]; P < 0.001) than their white counterparts. For patients undergoing endo, costs were higher for nonwhite patients (AA: $2,642 [1,574-3,711], other: $4,124 [2,091-6,157]; both P < 0.001). Patients with CLI and heart failure had increased costs after endo. AA patients were more likely to be readmitted or stayed longer after endo (1.16 [1.03-1.29], 1.34 [1.21-1.49]; both P < 0.010, respectively). The overall cost trend was rapidly increasing before all-payer rate policy implementation but it dramatically plateaued after 2014. CONCLUSIONS This study showed that the all-payer rate-setting system has curbed the LER rising costs, but these costs remained disproportionally higher for disadvantaged populations such as AA and Medicaid communities. This underpins the existing racial disparity in LER. AA patients had higher LER costs, most likely driven by extended hospitalization and ICU admission. Efforts could be directed to evaluate the contributing socioeconomic factors, invest in primary prevention of comorbid conditions that had shown to be associated with prohibitive costs, and identify mechanisms to overcome the existing racial disparity in LER within the promising cost-saving payment system at the State of Maryland.
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Affiliation(s)
- Besma Nejim
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD
| | - Robert J Beaulieu
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD
| | - Husain Alshaikh
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD
| | - Mohammed Hamouda
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD
| | - Joseph Canner
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD
| | - Mahmoud B Malas
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD.
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Dobson R, Whittaker R, Jiang Y, Maddison R, Shepherd M, McNamara C, Cutfield R, Khanolkar M, Murphy R. Effectiveness of text message based, diabetes self management support programme (SMS4BG): two arm, parallel randomised controlled trial. BMJ 2018; 361:k1959. [PMID: 29773539 PMCID: PMC5957049 DOI: 10.1136/bmj.k1959] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To determine the effectiveness of a theoretically based and individually tailored, text message based, diabetes self management support intervention (SMS4BG) in adults with poorly controlled diabetes. DESIGN Nine month, two arm, parallel randomised controlled trial. SETTING Primary and secondary healthcare services in New Zealand. PARTICIPANTS 366 participants aged 16 years and over with poorly controlled type 1 or type 2 diabetes (HbA1c ≥65 mmol/mol or 8%) randomised between June 2015 and November 2016 (n=183 intervention, n=183 control). INTERVENTIONS The intervention group received a tailored package of text messages for up to nine months in addition to usual care. Text messages provided information, support, motivation, and reminders related to diabetes self management and lifestyle behaviours. The control group received usual care. Messages were delivered by a specifically designed automated content management system. MAIN OUTCOME MEASURES Primary outcome measure was change in glycaemic control (HbA1c) from baseline to nine months. Secondary outcomes included change in HbA1c at three and six months, and self efficacy, diabetes self care behaviours, diabetes distress, perceptions and beliefs about diabetes, health related quality of life, perceived support for diabetes management, and intervention engagement and satisfaction at nine months. Regression models adjusted for baseline outcome, health district category, diabetes type, and ethnicity. RESULTS The reduction in HbA1c at nine months was significantly greater in the intervention group (mean -8.85 mmol/mol (standard deviation 14.84)) than in the control group (-3.96 mmol/mol (17.02); adjusted mean difference -4.23 (95% confidence interval -7.30 to -1.15), P=0.007). Of 21 secondary outcomes, only four showed statistically significant improvements in favour of the intervention group at nine months. Significant improvements were seen for foot care behaviour (adjusted mean difference 0.85 (95% confidence interval 0.40 to 1.29), P<0.001), overall diabetes support (0.26 (0.03 to 0.50), P=0.03), health status on the EQ-5D visual analogue scale (4.38 (0.44 to 8.33), P=0.03), and perceptions of illness identity (-0.54 (-1.04 to -0.03), P=0.04). High levels of satisfaction with SMS4BG were found, with 161 (95%) of 169 participants reporting it to be useful, and 164 (97%) willing to recommend the programme to other people with diabetes. CONCLUSION A tailored, text message based, self management support programme resulted in modest improvements in glycaemic control in adults with poorly controlled diabetes. Although the clinical significance of these results is unclear, the findings support further investigation into the use of SMS4BG and other text message based support for this patient population. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12614001232628.
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Affiliation(s)
- Rosie Dobson
- National Institute for Health Innovation, School of Population Health, University of Auckland, Auckland 1142, New Zealand
| | - Robyn Whittaker
- National Institute for Health Innovation, School of Population Health, University of Auckland, Auckland 1142, New Zealand
- Institute for Innovation and Improvement, Waitemata District Health Board, Auckland, New Zealand
| | - Yannan Jiang
- National Institute for Health Innovation, School of Population Health, University of Auckland, Auckland 1142, New Zealand
| | - Ralph Maddison
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Burwood VIC, Australia
| | - Matthew Shepherd
- School of Counselling, Human Services and Social Work, University of Auckland, Auckland, New Zealand
| | | | - Richard Cutfield
- Diabetes Service, North Shore Hospital, Takapuna, Auckland, New Zealand
| | - Manish Khanolkar
- Auckland Diabetes Centre, Greenlane Clinical Centre, Auckland, New Zealand
| | - Rinki Murphy
- Auckland Diabetes Centre, Greenlane Clinical Centre, Auckland, New Zealand
- School of Medicine, University of Auckland, Auckland, New Zealand
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Nuckols TK, Keeler E, Anderson LJ, Green J, Morton SC, Doyle BJ, Shetty K, Arifkhanova A, Booth M, Shanman R, Shekelle P. Economic Evaluation of Quality Improvement Interventions Designed to Improve Glycemic Control in Diabetes: A Systematic Review and Weighted Regression Analysis. Diabetes Care 2018; 41:985-993. [PMID: 29678865 PMCID: PMC5911791 DOI: 10.2337/dc17-1495] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 11/13/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Quality improvement (QI) interventions can improve glycemic control, but little is known about their value. We systematically reviewed economic evaluations of QI interventions for glycemic control among adults with type 1 or type 2 diabetes. RESEARCH DESIGN AND METHODS We used English-language studies from high-income countries that evaluated organizational changes and reported program and utilization-related costs, chosen from PubMed, EconLit, Centre for Reviews and Dissemination, New York Academy of Medicine's Grey Literature Report, and WorldCat (January 2004 to August 2016). We extracted data regarding intervention, study design, change in HbA1c, time horizon, perspective, incremental net cost (studies lasting ≤3 years), incremental cost-effectiveness ratio (ICER) (studies lasting ≥20 years), and study quality. Weighted least-squares regression analysis was used to estimate mean changes in HbA1c and incremental net cost. RESULTS Of 3,646 records, 46 unique studies were eligible. Across 19 randomized controlled trials (RCTs), HbA1c declined by 0.26% (95% CI 0.17-0.35) or 3 mmol/mol (2 to 4) relative to usual care. In 8 RCTs lasting ≤3 years, incremental net costs were $116 (95% CI -$612 to $843) per patient annually. Long-term ICERs were $100,000-$115,000/quality-adjusted life year (QALY) in 3 RCTs, $50,000-$99,999/QALY in 1 RCT, $0-$49,999/QALY in 4 RCTs, and dominant in 1 RCT. Results were more favorable in non-RCTs. Our limitations include the fact that the studies had diverse designs and involved moderate risk of bias. CONCLUSIONS Diverse multifaceted QI interventions that lower HbA1c appear to be a fair-to-good value relative to usual care, depending on society's willingness to pay for improvements in health.
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Affiliation(s)
- Teryl K Nuckols
- Cedars-Sinai Medical Center, Los Angeles, CA
- RAND Corp., Santa Monica, CA
| | | | - Laura J Anderson
- Cedars-Sinai Medical Center, Los Angeles, CA
- Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA
| | - Jonas Green
- Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Brian J Doyle
- VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | | | | | | | | | - Paul Shekelle
- RAND Corp., Santa Monica, CA
- VA Greater Los Angeles Healthcare System, Los Angeles, CA
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Kaholokula JK, Ing CT, Look MA, Delafield R, Sinclair K. Culturally responsive approaches to health promotion for Native Hawaiians and Pacific Islanders. Ann Hum Biol 2018; 45:249-263. [PMID: 29843522 PMCID: PMC6002761 DOI: 10.1080/03014460.2018.1465593] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
CONTEXT Obesity, diabetes and cardiovascular disease (CVD) have reached epidemic proportions among Native Hawaiians/Pacific Islanders (NHPI). Culturally responsive interventions that account for their interpersonal, sociocultural and socioeconomic realities are a public health priority. OBJECTIVE To describe cultural adaptation and culturally grounded approaches to developing health interventions for NHPI and to review the culturally responsive approaches used by, and outcomes from, two long-standing community-based participatory research projects (CBPR) in Hawai'i: PILI 'Ohana and KāHOLO Projects. METHODS A literature review of 14 studies from these two projects was done to exemplify the methods applied to culturally adapting existing evidence-based interventions and to developing novel interventions from the 'ground up' to address health disparities in NHPI. Of the 14 studies reviewed, 11 were studies of the clinical and behavioural outcomes of both types of interventions. RESULTS Both culturally adapted and culturally grounded approaches using community-based assets and NHPI cultural values/practices led to establishing sustainable and scalable interventions that significantly improved clinical measures of obesity, diabetes and hypertension. CONCLUSION Several recommendations are provided based on the lessons learned from the PILI 'Ohana and KāHOLO Projects. Multidisciplinary and transdisciplinary research using CBPR approaches are needed to elucidate how human biology is impacted by societal, environmental and psychological factors that increase the risk for cardiometabolic diseases among NHPI to develop more effective health promotion interventions and public health policies.
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Affiliation(s)
| | - Claire Townsend Ing
- Department of Native Hawaiian Health, John A. Burns School of Medicine, University of Hawai‘i at Mānoa
| | - Mele A. Look
- Department of Native Hawaiian Health, John A. Burns School of Medicine, University of Hawai‘i at Mānoa
| | - Rebecca Delafield
- Department of Native Hawaiian Health, John A. Burns School of Medicine, University of Hawai‘i at Mānoa
| | - Ka‘imi Sinclair
- Initiative for Research and Education to Advance Community Health (IREACH), Washington State University
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Siaw MYL, Malone DC, Ko Y, Lee JYC. Cost-effectiveness of multidisciplinary collaborative care versus usual care in the management of high-risk patients with diabetes in Singapore: Short-term results from a randomized controlled trial. J Clin Pharm Ther 2018; 43:775-783. [DOI: 10.1111/jcpt.12700] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 03/28/2018] [Indexed: 01/21/2023]
Affiliation(s)
- M. Y. L. Siaw
- Department of Pharmacy; Faculty of Science; National University of Singapore; Singapore Singapore
| | - D. C. Malone
- College of Pharmacy; University of Arizona; Tucson AZ USA
| | - Y. Ko
- Department of Pharmacy; College of Pharmacy; Taipei Medical University; Taipei Taiwan
- Research Center of Pharmacoeconomics; College of Pharmacy; Taipei Medical University; Taipei Taiwan
| | - J. Y.-C. Lee
- Department of Pharmacy; Faculty of Science; National University of Singapore; Singapore Singapore
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