High adherence to recommended diabetes follow-up procedures by general practitioners is associated with lower estimated cardiovascular risk

Effects of a national checklist on recommended procedures among patients with type 2 diabetes

BACKGROUND

Type 2 diabetes (T2D) is a common, potentially disabling, and costly chronic condition that requires consistent management. In 2008, Norway introduced a national checklist outlining services to include in an annual T2D exam, along with a reimbursement code for general practitioners (GPs) to bill upon completing it. This study investigates whether GP adoption of the checklist improves adherence to recommended services for T2D patients.

METHODS

To investigate the impact of GP checklist adoption, we use Norwegian registry data from 2006 to 2021 and apply two difference-in-differences (DID) methods that account for staggered adoption timing: the two-way fixed effects (TWFE) estimator and Callaway and Sant'Anna's DID method for variation in exposure timing (CSDID) (Callaway B. et al., J Econom 225:200-30, 2021).

RESULTS

We find that installing the electronic form has modest effects on the use of some recommended procedures.

CONCLUSIONS

Our study suggests that using the electronic form can have a positive effect on recommended services. However, the modest impact indicates that installing the form does not necessarily translate into its active regular use.

Development of explicit definitions of potentially inappropriate prescriptions for antidiabetic drugs in patients with type 2 diabetes: A multidisciplinary qualitative study

PURPOSE

The management of type 2 diabetes mellitus patients has changed over the past decade, and a large number of antidiabetic drug treatment options are now available. This complexity poses challenges for healthcare professionals and may result in potentially inappropriate prescriptions of antidiabetic drugs in patients with type 2 diabetes mellitus which can be limited using screening tools. The effectiveness of explicit tools such as lists of potentially inappropriate prescriptions has been widely demonstrated. The aim was to set up nominal groups of healthcare professionals from several disciplines and develop a list of explicit definition of potentially inappropriate prescriptions of antidiabetic drugs.

METHODS

In a qualitative, nominal-groups approach, 30 diabetologists, general practitioners, and pharmacists in France developed explicit definitions of potentially inappropriate prescriptions of antidiabetic drugs in patients with type 2 diabetes mellitus. A nominal group technique is a structured method that encourages all the participants to contribute and makes it easier to reach an agreement quickly. Each meeting lasted for two hours.

RESULTS

The three nominal groups comprised 14 pharmacists, 10 diabetologists, and 6 general practitioners and generated 89 explicit definitions. These definitions were subsequently merged and validated by the steering committee and nominal group participants, resulting in 38 validated explicit definitions of potentially inappropriate prescriptions of antidiabetic drugs. The definitions encompassed four contexts: (i) the temporary discontinuation of a medication during acute illness (n = 9; 24%), (ii) dose level adjustments (n = 23; 60%), (iii) inappropriate treatment initiation (n = 3; 8%), and (iv) the need for further monitoring in the management of type 2 diabetes mellitus (n = 3; 8%).

CONCLUSION

The results of our qualitative study show that it is possible to develop a specific list of explicit definitions of potentially inappropriate prescriptions of antidiabetic drugs in patients with type 2 diabetes mellitus by gathering the opinions of healthcare professionals caring for these patients. This list of 38 explicit definitions necessitates additional confirmation by expert consensus before use in clinical practice.

Factors Associated with Diabetic Complication Index among Type 2 Diabetes Patients: Focusing on Regular Outpatient Follow-up and HbA1c Variability

PURPOSE

Preventing diabetic complications involves regular outpatient follow-up and maintaining low variability in hemoglobin A1c (HbA1c) levels. This study investigated the factors associated with diabetic complications, with a specific focus on the impact of regular outpatient follow-up and HbA1c variability, among patients with type 2 diabetes.

METHODS

The study design was secondary data analysis of electronic medical records from a university hospital in Korea. It included patients aged 40-79 with type 2 diabetes who were prescribed diabetes medication within three months of their first HbA1c test by an endocrinologist and were followed up for at least five years. Follow-up regularity, adjusted standard deviation of HbA1c levels, and diabetic complication indices were collected. Data were analyzed using the Chi-square test, independent t-test, repeated measures analysis of variance, and multiple regression analysis.

RESULTS

The study included 1566 patients. Lower follow-up regularity was observed in patients of older age, with comorbidities, diabetic complications, insulin treatment, a history of hospitalization, lower baseline estimated glomerular filtration rate (eGFR) and total cholesterol (TC), and higher HbA1c variability. Higher HbA1c variability was observed in younger patients without comorbidity but with insulin treatment, a history of hospitalization, higher baseline blood glucose (BG), HbA1c, TC, and triglyceride levels. HbA1c variability had the strongest influence on BG and HbA1c levels at the five-year follow-up. Baseline eGFR and TC were the most influential factors for their respective levels at the five-year follow-up. Follow-up regularity significantly affected BG, HbA1c, eGFR, and TC at five-year follow-up.

CONCLUSIONS

It has been shown that several variables besides regular follow-up and HbA1c variability have an influence. However, these are the two that can be corrected through nursing intervention and are important, so intervention on these is important.

Social Networks and Cardiovascular Disease Events in the Jackson Heart Study

BACKGROUND

Cardiovascular disease (CVD) disproportionately affects Black adults. Greater social networks (SNs), or social connectedness, may lower the risk of CVD events. This study determined the association of SNs and incident CVD and tested mediation by depressive symptoms, hypertension control, and diabetes control.

METHODS AND RESULTS

We used the Social Network Index at exam 1 (2000-2004) to develop a continuous standardized SN score and binary categories (high versus low) among participants in the Jackson Heart Study (n=4686; mean age, 54.8 years). Surveillance of coronary heart disease, stroke, and heart failure events occurred after exam 1 (2005 for HF) until 2016. Using Cox proportional hazards regression, we estimated the association of SNs and CVD events by sex and tested the mediation of depressive symptoms, hypertension control, and diabetes control. Models adjusted for age, education, health behaviors, CVD comorbidities, and depressive symptoms. Among women, the SN score was associated with a lower hazard of stroke, coronary heart disease, and heart failure after full adjustment (hazard ratio [HR], 0.78 [95% CI, 0.64-0.95]; HR, 0.79 [95% CI, 0.71-0.88]; and HR, 0.78 [95% CI, 0.66-0.92], respectively). SN scores were also associated with a lower hazard of coronary heart disease in men (HR, 0.84 [95% CI, 0.75-0.94]) after full adjustment. High versus low SNs were associated with a lower hazard of coronary heart disease and heart failure among women after full adjustment. There was no evidence of mediation by depressive symptoms, diabetes control, and hypertension control.

CONCLUSIONS

Higher SNs may lower the risk of CVD events, especially in women.

Frequency of Follow-Up Attendance and Blood Glucose Monitoring in Type 2 Diabetic Patients at Moderate to High Cardiovascular Risk: A Cross-Sectional Study in Primary Care

Regular follow-up attendance in primary care and routine blood glucose monitoring are essential in diabetes management, particularly for patients at higher cardiovascular (CV) risk. We sought to examine the regularity of follow-up attendance and blood glucose monitoring in a primary care sample of type 2 diabetic patients at moderate-to-high CV risk, and to explore factors associated with poor engagement. Cross-sectional data were collected from 2130 patients enrolled in a diabetic retinopathy screening programme in Guangdong province, China. Approximately one-third of patients (35.9%) attended clinical follow-up <4 times in the past year. Over half of patients (56.9%) failed to have blood glucose monitored at least once per month. Multivariable logistic regression analysis showed that rural residents (adjusted odds ratio [aOR] = 0.420, 95% confidence interval [CI] = 0.338-0.522, p < 0.001, for follow-up attendance; aOR = 0.580, 95%CI: 0.472-0.712, p < 0.001, for blood glucose monitoring) and subjects with poor awareness of adverse consequences of diabetes complications (aOR = 0.648, 95%CI = 0.527-0.796, p < 0.001, for follow-up attendance; aOR = 0.770, 95%CI = 0.633-0.937, p = 0.009, for blood glucose monitoring) were both less likely to achieve active engagement. Our results revealed an urban-rural divide in patients' engagement in follow-up attendance and blood glucose monitoring, which suggested the need for different educational approaches tailored to the local context to enhance diabetes care.

Technology adoption by primary care physicians

We study primary care physicians' prevention and monitoring technology adoption. Physicians' adoption decisions are based on benefits and costs, which depend on payment incentives, educational assistance, and market characteristics. The empirical study uses national Norwegian register and physician claims data between 2009 and 2014. In 2006, a new annual comprehensive checkup for Type 2 diabetic patients was introduced. A physician collects a fee for each checkup. In 2013, an education assistance program was introduced in two Norwegian counties. We estimate adoption decisions by fixed-effect regressions, and two-part and hazard models. We use a difference-in-difference model to estimate the education program impact. Fixed-effect estimations and separate analyses of physicians who have moved between municipalities support a peer effect. The education program has a strongly positive effect, which is positively associated with a physician's number of diabetic patients, and the fraction of physician-adopters in the same market.