Barriers associated with poor control in Spanish diabetic patients. A consensus study

Treatment adherence and the contemporary approach to treating type 2 diabetes mellitus

The rising burden of type 2 diabetes mellitus (T2D) poses a significant healthcare challenge on a global scale. The economic impact is also substantial and continually increasing. In Serbia, even though the prevalence is officially around 12 percent, nearly 40 percent of the adult population is estimated to be living with undiagnosed diabetes and more than half the population is obese or overweight. This review comprehensively addresses the present approach to treating T2D, emphasizing the critical role of treatment adherence. We review the various components of T2D treatment, underlining the significance of lifestyle modifications. The pros and cons of medications used in treatment are discussed and factors influencing adherence are analysed. A healthy lifestyle remains the foundation of the treatment, and if not sufficient, early pharmacotherapy is initiated. Medications have been developed to lower blood sugar levels with cardiorenal protection, however, due to their still high cost, metformin remains the drug of first choice for most patients. Adherence to the treatment regimen is often poor. Factors associated with this are diverse and often multiple in a particular patient. Poor adherence is associated with poor glycaemic control, increased risk of disease complications, higher cardiovascular risk, increased mortality, hospitalizations, and healthcare costs. In addition to reducing the complexity of drug therapy and better informing the patient, improved education and motivation could lead to greater adherence. Enhanced communication between the patient and the physician and reduced treatment costs could also have a positive impact. The review concludes that addressing factors affecting adherence can significantly improve T2D outcomes and reduce costs. Further research is needed to identify region-specific risk factors for poor adherence.

Efficacy of Insulin Titration Driven by SMS in Improving Glycemic Control in People with Type 2 Diabetes

AIM

To evaluate the efficacy of the self-management of insulin titration based on information received by the Short Message Service (SMS).

METHODS

A case-control study including 59 subjects in each arm with 16 weeks of follow-up was performed. The inclusion criteria were: (1) Subjects with type 2 diabetes (T2D) under basal insulin treatment; (2) Suboptimal glycemic control: HbA1c ≥ 7.5% and fasting capillary blood glucose (FCBG) > 140 mg/dL (>3 times per week). Subjects were invited to use an insulin titration service based on SMS feedback aimed at optimizing glycemic control depending on fasting blood glucose levels. Psychological aspects were evaluated in the interventional group by means of validated questionnaires (DDS, HADS and SF-12).

RESULTS

The intervention group achieved a lower mean FCBG (126 mg/dL ± 34 vs. 149 mg/dL ± 46, p = 0.001) and lower HbA1c (7.5% ± 1.3 vs. 7.9% ± 0.9, p = 0.021) than the control group. In addition, the intervention group showed a significant improvement in psychological aspects related to Emotional Burden (p = 0.031), Regimen Distress (p < 0.001), Depression (p = 0.049) and Mental Health (p < 0.01).

CONCLUSIONS

The SMS-guided titration was effective in terms of improving glucometric parameters in comparison with the standard of care and improved significant psychological aspects-mainly, the stress associated with insulin treatment.

[Cardiovascular preventive recommendations. PAPPS 2022 thematic updates. Working groups of the PAPPS]

The recommendations of the semFYC's Program for Preventive Activities and Health Promotion (PAPPS) for the prevention of cardiovascular diseases (CVD) are presented. The following sections are included: epidemiological review, where the current morbidity and mortality of CVD in Spain and its evolution as well as the main risk factors are described; cardiovascular (CV) risk and recommendations for the calculation of CV risk; main risk factors such as arterial hypertension, dyslipidemia and diabetes mellitus, describing the method for their diagnosis, therapeutic objectives and recommendations for lifestyle measures and pharmacological treatment; indications for antiplatelet therapy, and recommendations for screening of atrial fibrillation, and recommendations for management of chronic conditions. The quality of testing and the strength of the recommendation are included in the main recommendations.

Barriers and Solutions to Improve Therapeutic Adherence from the Perspective of Primary Care and Hospital-Based Physicians

PURPOSE

To identify the barriers affecting treatment adherence in patients with chronic disease and to determine solutions through the physician's opinion of primary care and hospital settings.

METHODS

An observational study using the nominal group technique was performed to reach a consensus from experts. A structured face-to-face group discussion was carried out with physicians with more than 10 years of experience in the subject of treatment adherence/compliance in either the primary care setting or the hospital setting. The experts individually rated a list of questions using the Likert scale and prioritized the top 10 questions to identify barriers and seek solutions afterward. The top 10 questions that obtained the maximum score for both groups of experts were prioritized. During the final discussion group, participating experts analyzed the prioritized items and debated on each problem to reach consensual solutions for improvement.

RESULTS

A total of 17 professionals experts participated in the study, nine of them were from a primary care setting. In the expert group from the primary care setting, the proposed solution for the barrier identified as the highest priority was to simplify treatments, measure adherence and review medication. In the expert group from the hospital setting, the proposed solution for the barrier identified as the highest priority was training on motivational clinical interviews for healthcare workers undergraduate and postgraduate education. Finally, the expert participants proposed implementing an improvement plan with eight key ideas.

CONCLUSION

A consensual improvement plan to facilitate the control of therapeutic adherence in patients with chronic disease was developed, taking into account expert physicians' opinions from primary care and hospital settings about barriers and solutions to address therapeutic adherence in patients with chronic disease.

Patient Preferences for Pharmacological Diabetes Treatment Among People with Diabetes in Spain: A Discrete Choice Experiment

INTRODUCTION

The aim of the project was to describe the preferences related to the medication attributes of people with diabetes mellitus (DM) treated in Spain.

METHODS

The project was carried out in four different phases. In phase A, a Steering Committee defined and selected a total of 18 attributes for treating DM and grouped them into four categories: health outcomes, adverse events, treatment characteristics and cost of treatment. In phase B, a questionnaire according to a discrete choice experiment (DCE) methodology was developed. In phase C, the online DCE survey was sent to members of associations of people with DM from the Spanish Diabetes Federation (FEDE). Finally, in phase D, the results were discussed in a deliberative process.

RESULTS

Of the 238 participants who completed the questionnaire (May-September 2020), 231 were included (mean age, 58 years; males, 62%). The DCE results showed that the best-valued category was health outcomes (39.67%), followed by adverse events (26.85%), treatment characteristics (21.70%) and treatment costs (11.77%). Ten of 18 attributes had a significant effect on participants' choice (p < 0.05) and the highest relative importance value: blood pressure reduction (12.82%), hypoglycaemia (12.77%), HbA_1c level reduction (8.54%), cost of the medication (8.13%), needle/tablet size (7.20%), weight change (6.72%), risk of genitourinary infections (6.36%), gastrointestinal problems (5.82%), improved kidney function (5.53%) and administration route (5.41%).

CONCLUSIONS

People with DM prefer a treatment that generates benefits in measurable health effects (reducing blood pressure and HbA_1c level, while not risking hypoglycaemia) and a convenient route of administration. Considering the preferences of people with DM could generate better clinical results and therapeutic adherence, reducing morbidity, mortality and disease burden.

[Cardiovascular preventive recommendations. PAPPS 2020 update]

The recommendations of the semFYC's Program for Preventive Activities and Health Promotion (PAPPS) for the prevention of cardiovascular diseases (CVD) are presented. The following sections are included: Epidemiological review, where the current morbidity and mortality of CVD in Spain and its evolution as well as the main risk factors are described; Cardiovascular (CV) risk tables and recommendations for the calculation of CV risk; Main risk factors such as arterial hypertension, dyslipidemia and diabetes mellitus, describing the method for their diagnosis, therapeutic objectives and recommendations for lifestyle measures and pharmacological treatment; Indications for antiplatelet therapy, and recommendations for screening of atrial fibrillation. The quality of testing and the strength of the recommendation are included in the main recommendations.

Identification of Type 2 Diabetes Management Mobile App Features and Engagement Strategies: Modified Delphi Approach

BACKGROUND

Diabetes is a significant public health issue. Saudi Arabia has the highest prevalence of type 2 diabetes mellitus (T2DM) in the Arab world. Currently, it affects 31.6% of the general population, and the prevalence of T2DM is predicted to rise to 45.36% by 2030. Mobile health (mHealth) offers improved and cost-effective care to people with T2DM. However, the efficiency of engagement strategies and features of this technology need to be reviewed and standardized according to stakeholder and expert perspectives.

OBJECTIVE

The main objective of this study was to identify the most agreed-upon features for T2DM self-management mobile apps; the secondary objective was to identify the most agreed-upon strategies that prompt users to use these apps.

METHODS

In this study, a 4-round modified Delphi method was applied by experts in the domain of diabetes care.

RESULTS

In total, 11 experts with a mean age of 47.09 years (SD 11.70) consented to participate in the study. Overall, 36 app features were generated. The group of experts displayed weak agreement in their ranking of intervention components (Kendall W=0.275; P<.001). The top 5 features included insulin dose adjustment according to carbohydrate counting and blood glucose readings (5.36), alerting a caregiver of abnormal or critical readings (6.09), nutrition education (12.45), contacts for guidance if required (12.64), and offering patient-specific education tailored to the user's goals, needs, and blood glucose readings (12.90). In total, 21 engagement strategies were generated. Overall, the experts showed a moderate degree of consensus in their strategy rankings (Kendall W=0.454; P<.001). The top 5 engagement strategies included a user-friendly design (educational and age-appropriate design; 2.82), a free app (3.73), allowing the user to communicate or send information/data to a health care provider (HCP; 5.36), HCPs prescribing the mobile app in the clinic and asking about patients' app use compliance during clinical visits (6.91), and flexibility and customization (7.91).

CONCLUSIONS

This is the first study in the region consisting of a local panel of experts from the diabetes field gathering together. We used an iterative process to combine the experts' opinions into a group consensus. The results of this study could thus be useful for health app developers and HCPs and inform future decision making on the topic.

What are the development priorities for management of type 2 diabetes by general practitioners in Ningbo, China: a qualitative study of patients' and practitioners' perspectives

OBJECTIVES

To explore patients' and general practitioners' (GPs') perspectives on primary care management of patients with type 2 diabetes mellitus (T2DM) in Ningbo, China. We aimed to understand the current benefits and challenges and to identify development priorities.

DESIGN

Exploratory qualitative descriptive study using face-to-face interviews and analysed by thematic, inductive analysis.

SETTING

11 primary care facilities spread across the city of Ningbo, China.

PARTICIPANTS

23 patients with T2DM and 20 GPs involved in caring for patients with T2DM.

RESULTS

GPs were considered the first point of contact and providers of information. However, the care varied, and many GPs lacked confidence and felt overworked. The medication was a particularly weak area. The diagnostic screening commenced late, leading to crisis presentations. Patients were variably informed about their condition, contributing to poor adherence.

CONCLUSIONS

Future developments of primary care for T2DM in Ningbo should centre around improving GP confidence and workload and patient education and adherence.

Primary care physician perspectives on barriers and facilitators to self-management of type 2 diabetes

Objectives

To assess physician perspectives on perceived barriers and facilitators to type 2 diabetes self-management (DSM) in a primary care setting.

Methods

The study utilized survey methodology to measure perspectives of primary care physicians on DSM and the challenges they face in managing patients with poor glycaemic stability. Demographic and practice site-related information of the physicians were also collected.

Key findings

Of the 21 physicians who responded (53.8% response rate), 71.2% were aged 50 years or older, 54.2% had ≥25 years of clinical experience, and 50% practiced in an urban setting. The physicians examined 5–60 patients with type 2 diabetes per week (mean = 20), and over 75% of them spent &lt;20 min on face-to-face visits. Approximately, 95% of physicians considered self-care activities such as regular moderate exercise, following a recommended diet, regular blood glucose testing, proper insulin administration and adherence to oral medication as extremely important. Practice-related aspects such as patient–physician communication, patient health literacy and patient follow-up were unanimously considered extremely important, and performance on these measures was rated positively. Interestingly, 66% of physicians felt responsible to some extent for their patient's failure to reach type 2 DSM goals. Physician perceived barriers that contributed to clinical inertia included cost of medications, lack of patient motivation and knowledge, non-compliance with diet and medications, polypharmacy and lack of time and social support.

Conclusions

The study results underscore the importance of DSM in the overall management of type 2 diabetes. Addressing the challenges faced by physicians may result in better self-management and improved clinical outcomes in type 2 diabetes population.

Clinical inertia on insulin treatment intensification in type 2 diabetes mellitus patients of a tertiary public diabetes center with limited pharmacologic armamentarium from an upper-middle income country

BACKGROUND

Clinical inertia is related to the difficulty of achieving and maintaining optimal glycemic control. It has been extensively studied the delay of the period to insulin introduction in type 2 diabetes mellitus (T2DM) patients. This study aims to evaluate clinical inertia of insulin treatment intensification in a group of T2DM patients followed at a tertiary public Diabetes Center with limited pharmacologic armamentarium (Metformin, Sulphonylurea and Human Insulin).

METHODS

This is a real life retrospective record based study with T2DM patients. Demographic, clinical and laboratory characteristics were reviewed. Clinical inertia was considered when the patients did not achieve the individualized glycemic goals and there were no changes on insulin daily dose in the period.

RESULTS

We studied 323 T2DM patients on insulin therapy (plus Metformin and or Sulphonylurea) for a period of 2 years. The insulin daily dose did not change in the period and the glycated hemoglobin (A1c) ranged from 8.8 + 1.8% to 8.7 ± 1.7% (basal vs 1st year; ns) and to 8.5 ± 1.8% (basal vs 2nd year; p = 0.035). The clinical inertia prevalence was 65.8% (basal), 61.9% (after 1 year) and 58.2% (after 2 years; basal vs 1st year vs 2nd year; ns). In a subgroup of 100 patients, we also studied the first 2 years after insulin introduction. The insulin daily dose ranged from 0.22 ± 0.12 to 0.32 ± 0.24 IU/kg of body weight/day (basal vs 1st year; p < 0.001) and to 0.39 ± 0.26 IU/kg of body weight/day (basal vs 2nd year; p < 0.05). The A1c ranged from 9.6 + 2.1% to 8.6 + 2% (basal vs 1st year; p < 0.001) and to 8.7 + 1.7% (1st year vs 2nd year; ns). The clinical inertia prevalence was 78.5% (at the moment of insulin therapy introduction), 56.2% (after 1 year; p = 0.001) and 62.2% (after 2 years; ns).

CONCLUSION

Clinical inertia prevalence ranged from 56.2 to 78.5% at different moments of the insulin therapy (first 2 years and long term) of T2DM patients followed at a tertiary public Diabetes Center from an upper-middle income country with limited pharmacologic armamentarium.

Clinical inertia and its impact on treatment intensification in people with type 2 diabetes mellitus

Many people with type 2 diabetes mellitus (T2DM) fail to achieve glycaemic control promptly after diagnosis and do not receive timely treatment intensification. This may be in part due to 'clinical inertia', defined as the failure of healthcare providers to initiate or intensify therapy when indicated. Physician-, patient- and healthcare-system-related factors all contribute to clinical inertia. However, decisions that appear to be clinical inertia may, in fact, be only 'apparent' clinical inertia and may reflect good clinical practice on behalf of the physician for a specific patient. Delay in treatment intensification can happen at all stages of treatment for people with T2DM, including prescription of lifestyle changes after diagnosis, introduction of pharmacological therapy, use of combination therapy where needed and initiation of insulin. Clinical inertia may contribute to people with T2DM living with suboptimal glycaemic control for many years, with dramatic consequences for the patient in terms of quality of life, morbidity and mortality, and for public health because of the huge costs associated with uncontrolled T2DM. Because multiple factors can lead to clinical inertia, potential solutions most likely require a combination of approaches involving fundamental changes in medical care. These could include the adoption of a person-centred model of care to account for the complex considerations influencing treatment decisions by patients and physicians. Better patient education about the progressive nature of T2DM and the risks inherent in long-term poor glycaemic control may also reinforce the need for regular treatment reviews, with intensification when required.

Pharmacotherapy of 'treatment resistant' type 2 diabetes

INTRODUCTION

Despite type 2 diabetes (T2D) management offers a variety of pharmacological interventions targeting different defects, numerous patients remain with persistent hyperglycaemia responsible for severe complications. Unlike resistant hypertension, treatment resistant T2D is not a classical concept although it is a rather common observation in clinical practice. Areas covered: This article proposes a definition for 'treatment resistant diabetes', analyses the causes of poor glucose control despite standard therapy, briefly considers the alternative approaches to glucose-lowering pharmacotherapy and finally describes how to overcome poor glycaemic control, using innovative oral or injectable combination therapies. Expert opinion: Before considering intensifying the pharmacotherapy of a patient with poorly controlled T2D, it is important to verify treatment adherence, target obesity and consider various non pharmacological improvement quality interventions. If treatment resistant diabetes is defined as not achieving glycated haemoglobin target despite oral triple therapy with a third glucose-lowering agent added to metformin-sulfonylurea dual treatment, the combination of a dipeptidyl peptidase-4 (DPP-4) inhibitor and a sodium glucose cotransporter type 2 (SGLT2) inhibitor may offer new opportunities before considering injectable therapies. Insulin basal therapy (± metformin) may be optimized by the addition of a SGLT2 inhibitor or a glucagon-like peptide-1 (GLP-1) receptor agonist.

Basal insulin initiation in primary vs. specialist care: similar glycaemic control in two different patient populations

OBJECTIVE

To investigate the effect of healthcare provider (HCP) type (primary vs. specialist) on glycaemic control and other treatment parameters.

RESEARCH DESIGN AND METHODS

Study of Once-Daily Levemir (SOLVE(™) ) is an international, 24-week, observational study of insulin initiation in people with type 2 diabetes.

RESULTS

A total of 17,374 subjects were included, comprising 4144 (23.9%) primary care subjects. Glycaemic control improved in both HCP groups from baseline to final visit [glycated haemoglobin (HbA1c) -1.2 ± 1.4% (-13.1 ± 15.3 mmol/mol) and -1.3 ± 1.6% (-14.2 ± 17.5 mmol/mol), respectively]. After adjustment for known confounders, there was no statistically significant effect of HCP group on final HbA1c [-0.04%, 95% confidence interval (CI) -0.09 to -0.01 (-0.4 mmol/mol, 95% CI -1.0-0.1 mmol/mol), p = 0.1590]. However, insulin doses at the final visit were higher in primary care patients (+0.06, 95% CI 0.06-0.07 U/kg, p < 0.0001). Logistic regression demonstrated a significant effect of HCP type (primary vs. specialist care) on hypoglycaemia risk [odds ratio (OR) 0.75, 95% CI 0.64-0.87, p = 0.0002]. Primary care physicians took more time to train patients and had more frequent contact with patients than specialists (both p < 0.0001).

CONCLUSIONS

Primary care physicians and specialists achieved comparable improvements in glycaemic control following insulin initiation.

[Adherence of Type 2 Diabetes Mellitus approach: Current situation and possible solutions]

Objetivos

Definir el impacto y las causas de la falta de adherencia terapéutica en los pacientes con diabetes mellitus tipo 2 (DM2), las posibles intervenciones para mejorarla y el papel de las distintas partes implicadas.

Diseño

Valoración de cuestionario estructurado mediante método Delphi aplicado en 2 rondas.

Emplazamiento

Estudio realizado en el ámbito de atención primaria.

Participantes

Panel formado por profesionales médicos de reconocido prestigio y con amplia experiencia en diabetes.

Mediciones principales

Valoración a través de una escala Likert de 9 puntos del grado de acuerdo o desacuerdo de 131 ítems agrupados en 4 bloques: impacto; causas de incumplimiento; diagnóstico de la falta de adherencia y de sus posibles causas, y mejores intervenciones y papel de los distintos roles implicados en la mejora de la adherencia.

Resultados

Con una tasa de participación del 76,31%, los profesionales sanitarios de atención primaria consensuaron 110 de las 131 aseveraciones propuestas (84%), mostrando acuerdo en 102 ítems (77,9%) y desacuerdo en 8 (6,1%). No se logró consenso en 21 ítems.

Conclusiones

La falta de adherencia en los pacientes con DM2 dificulta lograr el control terapéutico. La formación específica y disponer de los recursos necesarios en la consulta son esenciales para minimizar el impacto de la falta de adherencia terapéutica.

Gender, diabetes education, and psychosocial factors are associated with persistent poor glycemic control in patients with type 2 diabetes in the Joint Asia Diabetes Evaluation (JADE) program

BACKGROUND

Factors associated with persistent poor glycemic control were explored in patients with type 2 diabetes under the Joint Asia Diabetes Evaluation (JADE) program.

METHODS

Chinese adults enrolled in JADE with HbA1c ≥8% at initial comprehensive assessment (CA1) and repeat assessment were analyzed. The improved group was defined as those with a ≥1% absolute reduction in HbA1c, and the unimproved group was those with <1% reduction at the repeat CA (CA2).

RESULTS

Of 4458 enrolled patients with HbA1c ≥8% at baseline, 1450 underwent repeat CA. After a median interval of 1.7 years (interquartile range[IQR] 1.1-2.2) between CA1 and CA2, the unimproved group (n = 677) had a mean 0.4% (95% confidence interval [CI] 0.3%, 0.5%) increase in HbA1c compared with a mean 2.8% reduction (95% CI -2.9, -2.6%) in the improved group (n = 773). The unimproved group had a female preponderance with lower education level, and was more likely to be insulin treated. Patients in the improved group received more diabetes education between CAs with improved self-care behaviors, whereas the unimproved group had worsening of health-related quality of life at CA2. Apart from female gender, long disease duration, low educational level, obesity, retinopathy, history of hypoglycemia, and insulin use, lack of education from diabetes nurses between CAs had the strongest association for persistent poor glycemic control.

CONCLUSIONS

These results highlight the multidimensional nature of glycemic control, and the importance of diabetes education and optimizing diabetes care by considering psychosocial factors.

[Prospective observational study of insulin detemir in patients with poorly controlled type 2 diabetes mellitus initiating insulin therapy for the first time (SOLVE Study)]

Objetivo

Describir la experiencia en atención primaria con insulina detemir en pacientes con diabetes mellitus tipo 2 mal controlados con antidiabéticos orales que necesitan incorporar una insulina a su terapia antidiabética.

Métodos

Estudio observacional prospectivo de 6 meses de seguimiento realizado en 10 países. En España participaron solo centros de atención primaria. Se reclutaron pacientes con diabetes mellitus tipo 2 mal controlados a cuyo tratamiento con antidiabéticos orales se había añadido insulina detemir (una vez al día) durante el mes previo a la inclusión en el estudio. Se analizaron los cambios de HbA1c y de peso al final del estudio, así como la incidencia de hipoglucemia y reacciones adversas. Se presentan los resultados obtenidos en la cohorte española.

Resultados

Se incluyeron 17.374 pacientes en total, 973 en España (media de edad 64,8 años [DE 12]; duración de la diabetes 9,4 años [DE 6,2]; Hb1Ac 8,9% [DE 1,4]). En la muestra para eficacia (n = 474), el cambio medio de Hb1Ac fue −1,6% (IC 95%: −1,75 a −1,42; p < 0,001; el cambio medio del peso fue −2,9 kg (IC 95%: −3,72 a −2.08; p < 0,001. Solo se registró un episodio de hipoglucemia grave, que fue también la única reacción adversa grave comunicada en el estudio. La tasa de incidencia de hipoglucemia no grave fue de 2,44 eventos/paciente-año.

Conclusiones

En esta cohorte de pacientes con diabetes mellitus tipo 2 recientemente insulinizados, la insulina detemir (una vez al día) mejoró el control glucémico, con baja incidencia de hipoglucemia y una reducción significativa del peso.

Family physician clinical inertia in glycemic control among patients with type 2 diabetes

Background

Many patients with diabetes do not achieve target values. One of the reasons for this is clinical inertia. The correct explanation of clinical inertia requires a conjunction of patient with physician and health care system factors. Our aim was to determine the rate of clinical inertia in treating diabetes in primary care and association of patient, physician, and health care setting factors with clinical inertia.

Material/Methods

This was a national, multicenter, observational, cross-sectional study in primary care in Croatia. Each family physician (FP) provided professional data and collected clinical data on 15–25 type 2 diabetes (T2DM) patients. Clinical inertia was defined as a consultation in which treatment change based on glycated hemoglobin (HbA1c) levels was indicated but did not occur.

Results

A total of 449 FPs (response rate 89.8%) collected data on 10275 patients. Mean clinical inertia per FP was 55.6% (SD ±26.17) of consultations. All of the FPs were clinically inert with some patients, and 9% of the FPs were clinically inert with all patients. The main factors associated with clinical inertia were: higher percentage of HbA1c, oral anti-diabetic drug initiated by diabetologist, increased postprandial glycemia and total cholesterol, physical inactivity of patient, and administration of drugs other than oral antidiabetics.

Conclusions

Clinical inertia in treating patients with T2DM is a serious problem. Patients with worse glycemic control and those whose therapy was initiated by a diabetologist experience more clinical inertia. More research on causes of clinical inertia in treating patients with T2DM should be conducted to help achieve more effective diabetes control.

Quality improvement of metabolic control for patients with type 2 diabetes treated at a general hospital: a quantitative open cohort study

RATIONALE, AIMS AND OBJECTIVES

Most patients with type 2 diabetes have metabolic risk factors above recommend goals. The present intervention aimed to escalate medical treatment to improve metabolic control. The study was carried out at a Norwegian general hospital as a quantitative open cohort study.

METHODS

The audit evaluated 191 patients treated from 2007 to 2012. To improve metabolic control, a medical intervention used stepped care and goals for the metabolic risk factors. A database was used to overview the intervention. Multiple regression analyses assessed whether baseline characteristics and components of the intervention were associated with change of metabolic risk factors.

RESULTS

The intervention increased number of antihypertensive drugs and dose of metformin and insulin. The intensification lowered mean systolic blood pressure from 142 to 132 mmHg, low-density lipoprotein cholesterol from 2.6 to 2.1 mmol L(-1) and glycated haemoglobin, HbA1c, from 8.5 to 7.6% (64-57 mmol mol(-1) , P < 0.001, t-tests). At end of the study, 25 (13%) patients fulfilled targets for the three metabolic risk factors. Multiple linear regression analyses showed that changes of the three metabolic risk factors were significantly associated with levels at start of the study and number of visits or length of follow-up.

CONCLUSIONS

Stepped care was an effective treatment for type 2 diabetes at a general hospital. The database supported the intervention. It improved metabolic control over 4 years.

Therapeutic inertia in hypercholesterolaemia is associated with ischaemic events in primary care patients. A case-control study

BACKGROUND

The frequency of therapeutic inertia (TI) is very high in the management of vascular risk factors, although its impact on the incidence of ischaemic events is not well-established. Our aim was to investigate the relationship between TI in the treatment of hypercholesterolaemia and the appearance of ischaemic events.

METHODS

An observational, multicentre, case-control study was conducted in 70 primary care centres in Spain. Case subjects (n = 235) were high-risk hypercholesterolaemic patients (both genders, ≥ 18 years) who had had a first event in the 12 months prior to recruitment. They were matched with 235 controls (by vascular risk, age and gender). The observation period was 18 months prior to the onset of a first event (cases) or to date of recruitment (control subjects).

RESULTS

The TI in the basal visit (an average of 7.8 months before the event) was slightly higher in cases than in controls (39.7% vs. 34.8%, NS). However, the accumulated TI was similar in both groups (70.7% for cases and 73.95% for controls, NS). The multivariate analysis, taking ischaemic events as the dependent variable, showed that the TI at baseline visit was significantly associated with the development of the event [OR 2.18 (95% CI 1.04-4.51), p < 0.05]. Other variables also associated with the ischaemic event were a family history of premature vascular disease [OR 3.38 (95% CI 1.35-8.49), p < 0.05] and uncontrolled hypertension [OR 2.35 (95% CI 1.02-5.43), p < 0.05].

CONCLUSION

The TI in high-risk hypercholesterolaemic patients in primary prevention in Spanish primary care centres doubled the risk of an ischaemic event in the short term.

Adherence to therapies in patients with type 2 diabetes

Adherence to therapy is defined as the extent to which a person's behavior in taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a healthcare provider. Patients presenting with type 2 diabetes mellitus are initially encouraged to maintain a healthy diet and exercise regimen, followed by early medication that generally includes one or more oral hypoglycemic agents and later may include an injectable treatment. To prevent the complications associated with type 2 diabetes, therapy frequently also includes medications for control of blood pressure, dyslipidemia and other disorders, since patients often have more than three or four chronic conditions. Despite the benefits of therapy, studies have indicated that recommended glycemic goals are achieved by less than 50% of patients, which may be associated with decreased adherence to therapies. As a result, hyperglycemia and long-term complications increase morbidity and premature mortality, and lead to increased costs to health services. Reasons for nonadherence are multifactorial and difficult to identify. They include age, information, perception and duration of disease, complexity of dosing regimen, polytherapy, psychological factors, safety, tolerability and cost. Various measures to increase patient satisfaction and increase adherence in type 2 diabetes have been investigated. These include reducing the complexity of therapy by fixed-dose combination pills and less frequent dosing regimens, using medications that are associated with fewer adverse events (hypoglycemia or weight gain), educational initiatives with improved patient-healthcare provider communication, reminder systems and social support to help reduce costs. In the current narrative review, factors that influence adherence to different therapies for type 2 diabetes are discussed, along with outcomes of poor adherence, the economic impact of nonadherence, and strategies aimed at improving adherence.