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Shabnam S, Abner S, Gillies CL, Davies MJ, Dex T, Khunti K, Webb DR, Zaccardi F, Seidu S. Effect of delay in treatment intensification in people with type 2 diabetes and suboptimal glycaemia after basal insulin initiation: A real-world observational study. Diabetes Obes Metab 2024; 26:512-523. [PMID: 37857573 DOI: 10.1111/dom.15337] [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: 08/16/2023] [Revised: 09/25/2023] [Accepted: 10/03/2023] [Indexed: 10/21/2023]
Abstract
AIM Despite global recommendations for type 2 diabetes mellitus treatment to maintain optimal glycaemic targets, a significant proportion of people remain in suboptimal glycaemic control. Our objective was to investigate the impact of intensification delay after basal insulin (BI) initiation on long-term complications in people with suboptimal glycaemia. MATERIALS AND METHODS We conducted a retrospective cohort study in individuals with type 2 diabetes mellitus initiated on BI. Those with suboptimal glycaemia (glycated haemoglobin ≥7% or ≥53 mmol/mol) within 12 months of BI initiation were divided into early (treatment intensified within 5 years), or late (≥5 years) intensification groups. We estimated the age-stratified risks of micro- and macrovascular complications among these groups compared with those with optimal glycaemia (glycated haemoglobin <7%). RESULTS Of the 13 916 people with suboptimal glycaemia, 52.5% (n = 7304) did not receive any treatment intensification. In those aged <65 years, compared with the optimal glycaemia group late intensification was associated with a 56% higher risk of macrovascular complications (adjusted hazard ratio 1.56; 95% confidence intervals 1.08, 2.26). In elderly people (≥65 years), late intensification was associated with a higher risk of cardiovascular-related death (1.62; 1.03, 2.54) and a lower risk of microvascular complications (0.26; 0.08, 0.83). CONCLUSIONS Those who had late intensification were at an increased risk of cardiovascular death if they were ≥65 years and an increased risk of macrovascular complications if they were <65 years. These findings highlight the critical need for earlier intensification of treatment and adopting personalized treatment strategies to improve patient outcomes.
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Affiliation(s)
- Sharmin Shabnam
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, UK
| | - Sophia Abner
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
- IQVIA, London, UK
| | - Clare L Gillies
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, UK
| | - Melanie J Davies
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, UK
| | - Terry Dex
- Department of Medical Affairs, Sanofi, Bridgewater, New Jersey, USA
| | - Kamlesh Khunti
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, UK
| | - David R Webb
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, UK
| | - Francesco Zaccardi
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, UK
| | - Samuel Seidu
- Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, UK
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
- NIHR Leicester Biomedical Research Centre, Leicester General Hospital, Leicester, UK
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Kanatsuka A, Sato Y, Higashi Y, Goto Y, Kawai K, Maegawa H. Combination of disease duration-to-age at diagnosis and hemoglobin A1c-to-serum C-peptide reactivity ratios predicts patient response to glucose-lowering medication in type 2 diabetes: A retrospective cohort study across Japan (JDDM59). J Diabetes Investig 2021; 12:1967-1977. [PMID: 33837666 PMCID: PMC8565405 DOI: 10.1111/jdi.13558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 02/17/2021] [Accepted: 04/04/2021] [Indexed: 01/22/2023] Open
Abstract
AIMS/INTRODUCTION Knowing the collective clinical factors that determine patient response to glucose-lowering medication would be beneficial in the treatment of type 2 diabetes. We carried out a retrospective cohort study to explore the combination of clinical factors involved in its therapeutic efficacy. MATERIALS AND METHODS The results of cohort studies retrieved using the CoDiC® database across Japan from January 2005 to July 2018 were analyzed based on criterion that using insulin therapy indicates severe type 2 diabetes. RESULTS A logistic regression analysis showed that age at diagnosis, disease duration, hemoglobin A1c (HbA1c) and serum C-peptide reactivity (CPR) at medication commencement were associated with the probability of insulin treatment. Receiver operating characteristic curve showed that these clinical factors predicted insulin treatment positivity with an area under the curve of >0.600. The area under the curve increased to 0.674 and 0.720 for the disease duration-to-age at diagnosis ratio and HbA1c-to-CPR ratio, respectively. Furthermore, area under the curve increased to 0.727 and 0.750 in the indices (duration-to-age ratio at diagnosis × 43 + HbA1c) and (duration-to-age ration at diagnosis × 21 + HbA1c-to-CPR ratio), respectively. After stratification to three groups according to the indices, monthly HbA1c levels during 6 months of treatment were higher in the upper one-third than in the lower one-third of patients, and many patients did not achieve the target HbA1c level (53 mmol/mol) in the upper one-third, although greater than fourfold more patients were administered insulin in the upper one-third. CONCLUSIONS The combination of disease duration-to-age at diagnosis and HbA1c-to-CPR ratios is a collective risk factor that predicts response to the medications.
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Affiliation(s)
| | - Yasunori Sato
- Department of Preventive Medicine and Public HealthKeio University School of Medicine Graduate School of MedicineTokyoJapan
| | | | | | | | - Hiroshi Maegawa
- Department of MedicineDivision of Diabetology, Endocrinology, and NephrologyShiga University of Medical ScienceOtsuJapan
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Liu Wei Di Huang Wan and the Delay of Insulin Use in Patients with Type 2 Diabetes in Taiwan: A Nationwide Study. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:1298487. [PMID: 34457016 PMCID: PMC8390129 DOI: 10.1155/2021/1298487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 07/12/2021] [Accepted: 08/07/2021] [Indexed: 11/18/2022]
Abstract
Introduction Patients with type 2 diabetes are widely prescribed metformin for controlling blood glucose levels to avoid related comorbidities. In Taiwan, traditional Chinese medicine (TCM) is also commonly used, especially Liu Wei Di Huang Wan (LWDHW), which has been reported to delay the occurrence of kidney failure. However, the effect of combinational therapy of TCM and oral antidiabetic drugs is still unclear. This study aims to estimate their efficacy in delaying insulin use. Materials and Methods This case-control study was conducted using one million randomized samples from the National Health Insurance Research Database in Taiwan. The effects of TCM and LWDHW were estimated using the Cox proportional hazards model. Results In this study, 70,036 diabetic patients were enrolled; of them, 17,451 (24.9%) used insulin, while the rest (52,585, 75.1%) did not. TCM users had a lower risk for insulin use (HR: 0.58, 95% CI: 0.56–0.60). LWDHW users had a lower risk compared with patients who used other TCM (HR: 0.86, 95% CI: 0.82–0.90) and presented a dose-dependent effect. Conclusion The use of LWDHW and oral antidiabetic drugs is highly associated with the delay in the use of insulin. Clinical practitioners may take them into consideration when treating patients with type 2 diabetes.
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Cowart K, Emechebe N, Pathak R, Abbruzese L, Hann J, Lloyd A, Roetzheim R, Zgibor J, Updike WH. Measurement of Pharmacist-Physician Collaborative Care on Therapeutic Inertia in Patients With Type 2 Diabetes. Ann Pharmacother 2021; 56:155-161. [PMID: 34105397 DOI: 10.1177/10600280211023492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Team-based care practice models have been shown to improve diabetes-related therapeutic inertia, yet the method and type of antidiabetic treatment intensification (TI) leading to improvements in glycemic control are not well understood. OBJECTIVE To evaluate time to TI in a pharmacist-physician practice model (PPM) as compared with usual medical care (UMC), explore the method and type of antidiabetic TI, and evaluate achievement of hemoglobin A1C (A1C) goal among each cohort. METHODS This was a retrospective cohort study conducted between January 1, 2017, and December 31, 2018. Median time to TI was calculated and compared between patients in the PPM and UMC groups using the log rank test. Descriptive statistics were used to evaluate the method and type of TI and A1C goal achievement. RESULTS A total of 56 patients were included. The median (interquartile range) time to antidiabetic TI among the PPM cohort was 37.5 days (8, 216.5), as compared with 142 days (16, 465) in the UMC cohort (P = 0.19). At 1 year post-index date, 25% of patients in the PPM cohort reached their A1C goal compared with 18.8% of patients in the UMC cohort. This effect was maintained in the subgroup (n = 49) of patients receiving TI (23.1% vs 17.8%). CONCLUSION AND RELEVANCE A shorter time to TI and improvement in A1C goal achievement was observed with pharmacist-physician care compared with UMC. These findings suggest that pharmacist-physician care may be one of several interventions necessary to overcome therapeutic inertia in diabetes care.
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Affiliation(s)
| | | | - Rashmi Pathak
- University of Oklahoma Health Science Center, Oklahoma City, OK, USA
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5
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Meredith AH, Buatois EM, Krenz JR, Walroth T, Shenk M, Triboletti JS, Pence L, Gonzalvo JD. Assessment of clinical inertia in people with diabetes within primary care. J Eval Clin Pract 2021; 27:365-370. [PMID: 32548871 DOI: 10.1111/jep.13429] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/10/2020] [Accepted: 05/18/2020] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Clinical inertia, defined as a delay in treatment intensification, is prevalent in people with diabetes. Treatment intensification rates are as low as 37.1% in people with haemoglobin A1c (HbA1c) values >7%. Intensification by addition of medication therapy may take 1.6 to more than 7 years. Clinical inertia increases the risk of cardiovascular events. The primary objective was to evaluate rates of clinical inertia in people whose diabetes is managed by both pharmacists and primary care providers (PCPs). Secondary objectives included characterizing types of treatment intensification, HbA1c reduction, and time between treatment intensifications. METHOD Retrospective chart review of persons with diabetes managed by pharmacists at an academic, safety-net institution. Eligible subjects were referred to a pharmacist-managed cardiovascular risk reduction clinic while continuing to see their PCP between October 1, 2016 and June 30, 2018. All progress notes were evaluated for treatment intensification, HbA1c value, and type of medication intensification. RESULTS Three hundred sixty-three eligible patients were identified; baseline HbA1c 9.6% (7.9, 11.6) (median interquartile range [IQR]). One thousand one hundred ninety-two pharmacist and 1739 PCP visits were included in data analysis. Therapy was intensified at 60.5% (n = 721) pharmacist visits and 39.3% (n = 684) PCP visits (P < .001). The median (IQR) time between interventions was 49 (28, 92) days for pharmacists and 105 (38, 182) days for PCPs (P < .001). Pharmacists more frequently intensified treatment with glucagon-like peptide-1 agonists and sodium glucose cotransporter-2 inhibitors. CONCLUSION Pharmacist involvement in diabetes management may reduce the clinical inertia patients may otherwise experience in the primary care setting.
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Affiliation(s)
- Ashley H Meredith
- Department of Pharmacy Practice, Purdue University College of Pharmacy, 575 W Stadium Ave, West Lafayette, IN, 47907, USA.,Department of Pharmacy, Eskenazi Health, 620 Eskenazi Ave, Indianapolis, IN, 46202, USA
| | - Emily M Buatois
- Department of Pharmacy Practice, Purdue University College of Pharmacy, 575 W Stadium Ave, West Lafayette, IN, 47907, USA.,Department of Pharmacy, Texas Tech University Health Sciences Center, 5220 80th Street, Lubbock, TX, 79424, USA
| | - James R Krenz
- Department of Pharmacy Practice, Purdue University College of Pharmacy, 575 W Stadium Ave, West Lafayette, IN, 47907, USA.,Department of Pharmacy, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Todd Walroth
- Department of Pharmacy, Eskenazi Health, 620 Eskenazi Ave, Indianapolis, IN, 46202, USA
| | - McKenzie Shenk
- Department of Pharmacy, Eskenazi Health, 620 Eskenazi Ave, Indianapolis, IN, 46202, USA.,Department of Pharmacy Practice, Cedarville University School of Pharmacy, 251 N Main St, Cedarville, OH, 45341, USA
| | - Jessica S Triboletti
- Department of Pharmacy, Eskenazi Health, 620 Eskenazi Ave, Indianapolis, IN, 46202, USA.,Department of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, 4600 Sunset Ave, Indianapolis, IN, 46208, USA
| | - Lauren Pence
- Department of Pharmacy, Eskenazi Health, 620 Eskenazi Ave, Indianapolis, IN, 46202, USA
| | - Jasmine D Gonzalvo
- Department of Pharmacy Practice, Purdue University College of Pharmacy, 575 W Stadium Ave, West Lafayette, IN, 47907, USA.,Department of Pharmacy, Eskenazi Health, 620 Eskenazi Ave, Indianapolis, IN, 46202, USA
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6
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Lingow SE, Guyton JE. Clinical inertia among health care providers in a public health safety-net clinic in the management of type 2 diabetes. J Am Pharm Assoc (2003) 2020; 60:734-739. [PMID: 32280024 DOI: 10.1016/j.japh.2020.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 01/27/2020] [Accepted: 02/24/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Clinical inertia is defined as the lack of treatment intensification in patients who are not at evidence-based goals of therapy; it may be related to provider, patient, and health system-wide factors. Patient factors, including nonadherence and tablet burden, are further compounded by health and social disparities present in safety-net clinics. Clinical pharmacist-based interventions may impact provider or health system factors to reduce inertia in patients with poorly controlled diabetes. OBJECTIVES To evaluate the rate of clinical inertia between health care providers in a safety-net clinic. METHODS A single-center, cross-sectional, retrospective study compared 2 cohorts of adult patients with type 2 diabetes and glycosylated hemoglobin (A1C) greater than 8% in 2016. Diabetes care was provided by clinical pharmacists in the intervention group and by primary care providers in the control group. The primary outcome was the difference in clinical inertia, measured by pharmacologic treatment intensification between groups within 4 months following the first A1C greater than 8% of the study period. RESULTS Of 276 eligible patients, 72 were in the intervention group and 204 in the control group. There was no statistical difference between baseline A1C between groups, with an average A1C of 10.01% for the study population. In the pharmacist group versus provider group, the rate of overall treatment, noninsulin, and insulin intensification was 79% versus 49% (P < 0.001), 40% versus 32% (P = 0.19), and 54% versus 19% (P < 0.001), respectively. Patients were contacted an average of 4 times during the follow-up period in the pharmacist group as compared to 1 time in the provider group (P < 0.001). CONCLUSION In this safety-net clinic, pharmacist-based interventions reduced clinical inertia in patients with poorly controlled diabetes. Future studies evaluating inertia long term and the impact on glycemic goals are needed.
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Cowart K, Updike W, Emechebe N, Zgibor J. Using an Advanced Practice Pharmacist in a Team-Based Care Model to Decrease Time to Hemoglobin A 1c Goal Among Patients With Type 2 Diabetes, Florida, 2017-2019. Prev Chronic Dis 2020; 17:E40. [PMID: 32498760 PMCID: PMC7279065 DOI: 10.5888/pcd17.190377] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Collaborative practice models that use an advanced practice pharmacist (APP) have been shown to improve outcomes for patients with chronic diseases. Few studies have evaluated the effects of team-based practice models involving an APP for time needed to attain glycated hemoglobin A1c (HbA1c) goals in patients with diabetes mellitus (type 2 diabetes). Ours is a retrospective cohort study, involving patients with type 2 diabetes who worked with a pharmacist in an academic family medicine clinic. These patients experienced a shorter time to achieve an HbA1c of less than 7%, as compared with patients who did not work with a pharmacist. Future studies should evaluate the length of time patients can sustain an HbA1c of less than 7% with team-based care involving an APP and the influence of such care on diabetes-related complications.
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Affiliation(s)
- Kevin Cowart
- Department of Pharmacotherapeutics & Clinical Research, Taneja College of Pharmacy, Morsani College of Medicine, University of South Florida, 12901 Bruce B Downs Blvd, MDC 30, Tampa, FL 33612. .,Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Wendy Updike
- Department of Pharmacotherapeutics & Clinical Research, Taneja College of Pharmacy, Morsani College of Medicine, University of South Florida, Tampa, Florida.,Department of Family Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Nnadozie Emechebe
- Department of Epidemiology, College of Public Health, University of South Florida, Tampa, Florida
| | - Janice Zgibor
- Department of Pharmacotherapeutics & Clinical Research, Taneja College of Pharmacy, Morsani College of Medicine, University of South Florida, Tampa, Florida.,Department of Epidemiology, College of Public Health, University of South Florida, Tampa, Florida
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Abstract
Factors contributing to therapeutic inertia related to patients' medication experiences include concerns about side effects and out-of-pocket costs, stigmatization for having diabetes, confusion about frequent changes in evidence-based guidelines, low health literacy, and social determinants of health. A variety of solutions to this multifactorial problem may be necessary, including integrating pharmacists into interprofessional care teams, using medication refill synchronization programs, maximizing time with patients to discuss fears and concerns, being cognizant of language used to discuss diabetes-related topics, and avoiding stigmatizing patients. Managing diabetes successfully is a team effort, and the full commitment of all team members (including patients) is required to achieve desired outcomes through an individualized approach.
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Affiliation(s)
| | - John E Begert
- School of Pharmacy, Pacific University Oregon, Hillsboro, OR
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Andreozzi F, Candido R, Corrao S, Fornengo R, Giancaterini A, Ponzani P, Ponziani MC, Tuccinardi F, Mannino D. Clinical inertia is the enemy of therapeutic success in the management of diabetes and its complications: a narrative literature review. Diabetol Metab Syndr 2020; 12:52. [PMID: 32565924 PMCID: PMC7301473 DOI: 10.1186/s13098-020-00559-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/08/2020] [Indexed: 12/17/2022] Open
Abstract
Diabetes mellitus is a chronic disease characterized by high social, economic and health burden, mostly due to the high incidence and morbidity of diabetes complications. Numerous studies have shown that optimizing metabolic control may reduce the risk of micro and macrovascular complications related to the disease, and the algorithms suggest that an appropriate and timely step of care intensification should be proposed after 3 months from the failure to achieve metabolic goals. Nonetheless, many population studies show that glycemic control in diabetic patients is often inadequate. The phenomenon of clinical inertia in diabetology, defined as the failure to start a therapy or its intensification/de-intensification when appropriate, has been studied for almost 20 years, and it is not limited to diabetes care, but also affects other specialties. In the present manuscript, we have documented the issue of inertia in its complexity, assessing its dimensions, its epidemiological weight, and its burden over the effectiveness of care. Our main goal is the identification of the causes of clinical inertia in diabetology, and the quantification of its social and health-related consequences through the adoption of appropriate indicators, in an effort to advance possible solutions and proposals to fight and possibly overcome clinical inertia, thus improving health outcomes and quality of care.
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Affiliation(s)
- F. Andreozzi
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Viale Europa, 88100 Catanzaro, Italy
| | - R. Candido
- Diabetes Center District 3, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - S. Corrao
- Department of Internal Medicine, University of Palermo, Palermo, Italy
| | - R. Fornengo
- SSD of Diabetology and Metabolic Diseases, Hospital of Chivasso, Turin, Italy
| | | | - P. Ponzani
- Operative Unit of Diabetology, “La Colletta” Hospital, Genoa, Italy
| | - M. C. Ponziani
- SSD of Diabetology-Azienda Sanitaria Locale Novara, Novara, Italy
| | - F. Tuccinardi
- Diabetology and Endocrinology Unit “Clinica del Sole” Formia, Formia, Italy
| | - D. Mannino
- Section of Endocrinology and Diabetes, Bianchi Melacrino Morelli Hospital, Reggio Calabria, Italy
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Abstract
INTRODUCTION Eighty-four million patients in the United States have prediabetes yet evidence-based interventions to prevent diabetes are infrequently used. The concept of prediabetes is contentious, although preventive interventions are guideline supported. Team-based care models incorporating pharmacists for prediabetes have been proposed; however, pharmacist perception regarding prediabetes has not been assessed. This study's objective was to assess ambulatory care pharmacists' perception of recommendations for prediabetes. METHODS An anonymous survey was electronically distributed through the American College of Clinical Pharmacy Ambulatory Care Practice and Research Network. The primary outcome was the proportion of respondents who reported supporting 3 main recommendations related to prediabetes (ie, screening, evidence-based lifestyle-intervention, metformin). The study was approved by the University of South Florida Institutional Review Board. Data collection and analysis occurred in 2017. RESULTS The survey was distributed to approximately 2209 potential participants. One hundred thirty-three surveys were completed. The American Diabetes Association guideline was the most common primarily supported guideline related to prediabetes (89%). Of the respondents, 87% supported all 3 main recommendations regarding prediabetes. Qualitative feedback demonstrated the full range of opinions; programs for prediabetes, limited intervention for prediabetes, and against prediabetes as a concept. CONCLUSIONS The majority of ambulatory care pharmacists responding supported all main recommendations related to prediabetes and therefore may be practicable for disseminating diabetes prevention interventions. However, barriers to implementation should be expected.
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Affiliation(s)
- Nicholas W Carris
- Department of Pharmacotherapeutics and Clinical Research, College of Pharmacy, 466516University of South Florida, Tampa, FL, USA.,Department of Family Medicine, Morsani College of Medicine, 466516University of South Florida, Tampa, FL, USA
| | - Kevin M Cowart
- Department of Pharmacotherapeutics and Clinical Research, College of Pharmacy, 466516University of South Florida, Tampa, FL, USA.,Department of Internal Medicine, Morsani College of Medicine, 466516University of South Florida, Tampa, FL, USA
| | - Angela S Garcia
- Department of Pharmacotherapeutics and Clinical Research, College of Pharmacy, 466516University of South Florida, Tampa, FL, USA
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Khunti K, Seidu S. Therapeutic Inertia and the Legacy of Dysglycemia on the Microvascular and Macrovascular Complications of Diabetes. Diabetes Care 2019; 42:349-351. [PMID: 30787057 DOI: 10.2337/dci18-0030] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, U.K.
| | - Samuel Seidu
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, U.K
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12
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Satoh J, Andersen M, Bekker Hansen B, Larsen Thorsted B, Tutkunkardas D, Zacho M, Maegawa H. Clinical inertia in basal insulin-treated patients with type 2 diabetes - Results from a retrospective database study in Japan (JDDM 43). PLoS One 2018; 13:e0198160. [PMID: 30226870 PMCID: PMC6143196 DOI: 10.1371/journal.pone.0198160] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 05/15/2018] [Indexed: 12/17/2022] Open
Abstract
Aims This retrospective cohort study investigated whether clinical inertia, the failure to intensify treatment when required, exists in Japanese clinical practice, using the CoDiC® database. How and when patients with type 2 diabetes treated with basal insulin received treatment intensification was also described. Materials and methods Patients with type 2 diabetes who initiated basal insulin between 2004 and 2011 were eligible for inclusion. Patients with an HbA1c ≥7.0% (≥53.0 mmol/mol) after 180 days of basal insulin titration were eligible for intensification, and their treatment was followed for up to 1.5 years. Endpoints were time to intensification, changes in HbA1c, and insulin dose. Results Overall, 2351 patients initiated basal insulin treatment (mean HbA1c 9.4% [79.2 mmol/mol]), and 1279 patients were eligible for treatment intensification (HbA1c ≥7.0% [≥53.0 mmol/mol]) after the 180-day titration period. During the 1.5-year follow-up period (beyond the 180-day titration period), 270 (21%) of these patients received treatment intensification. In patients receiving treatment intensification, mean HbA1c decreased from 8.6 to 8.2% (70.5 to 66.1 mmol/mol) at end of follow-up. Treatment was intensified using bolus insulin in 126 (47%) patients and with premixed insulin in 144 (53%) patients. The estimated probability of intensifying treatment during the 12 months after recording HbA1c ≥7.0% (≥53.0 mmol/mol) was 22.8%, and 27.5% after 17 months. Mean end-of-follow-up daily insulin dose was 35.11 units for basal–bolus compared with 20.70 units for premix therapy. Conclusions This study suggests clinical inertia exists in basal insulin-treated patients with type 2 diabetes in Japan. Strategies are needed to increase the number of patients undergoing therapy intensification and to reduce the delay in intensification in Japan.
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Affiliation(s)
- Jo Satoh
- Tohoku Medical and Pharmaceutical University Wakabayashi Hospital, Sendai, Japan
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13
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Cowart K, Sando K. Pharmacist Impact on Treatment Intensification and Hemoglobin A1C in Patients With Type 2 Diabetes Mellitus at an Academic Health Center. J Pharm Pract 2018; 32:648-654. [DOI: 10.1177/0897190018776178] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Achievement of treatment goals for patients with type 2 diabetes mellitus (T2DM) is suboptimal. This is in part driven by a lack of treatment intensification when warranted, termed “clinical inertia.” Objectives: To investigate time to treatment intensification and changes in A1C among pharmacist–physician managed (PPM) patients compared to usual medical care (UMC) in patients with T2DM. Methods: Retrospective matched cohort study at 2 academic family medicine clinics. Patients in each cohort were matched 1:1 based on age (±5 years), primary care provider, gender, and race. Results: A total of 50 patients met inclusion criteria. Mean time to treatment intensification was longer in the UMC cohort as compared with the PPM cohort (325 (66) days vs 200 (62) days [ P = .50]). A higher percentage of patients in the PPM cohort achieved ≥0.5% reduction in A1C in comparison to the UMC cohort (60% vs 44%, respectively [ P = .41]). Patients in the PPM cohort experienced a greater mean decrease in A1C from baseline when compared to patients in the UMC cohort (−1% (1.8%) vs −0.4% (2.2%) [ P = .24]). Conclusion: Patients exposed to a pharmacist in this retrospective matched cohort study experienced shorter time to treatment intensification and a greater reduction in A1C than those managed solely by a medical provider, although results were not statistically significant. Additional research is needed to evaluate the role of the pharmacist in improving clinical inertia in the management of T2DM.
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Affiliation(s)
- Kevin Cowart
- Department of Pharmacotherapeutics & Clinical Research, University of South Florida College of Pharmacy, Tampa, FL, USA
| | - Karen Sando
- Department of Pharmacy Practice, Nova Southeastern University College of Pharmacy, Davie, FL, USA
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Owens DR, Monnier L, Barnett AH. Future challenges and therapeutic opportunities in type 2 diabetes: Changing the paradigm of current therapy. Diabetes Obes Metab 2017; 19:1339-1352. [PMID: 28432748 PMCID: PMC5637910 DOI: 10.1111/dom.12977] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 04/05/2017] [Accepted: 04/13/2017] [Indexed: 02/06/2023]
Abstract
Most algorithms for type 2 diabetes mellitus (T2DM) do not recommend treatment escalation until glycated haemoglobin (HbA1c) fails to reach the recommended target of 7% (53 mmol/mol) within approximately 3 months on any treatment regimen ("treat to failure"). Clinical inertia and/or poor adherence to therapy contribute to patients not reaching glycaemic targets when managed according to this paradigm. Clinical inertia exists across the entire spectrum of anti-diabetes therapies, although it is most pronounced when initiating and optimizing insulin therapy. Possible reasons include needle aversion, fear of hypoglycaemia, excessive weight gain and/or the need for increased self-monitoring of blood glucose. Studies have suggested, however, that early intensive insulin therapy in newly diagnosed, symptomatic patients with T2DM with HbA1c >9% (75 mmol/mol) can preserve beta-cell function, thereby modulating the disease process. Furthermore, postprandial plasma glucose is a key component of residual dysglycaemia, evident especially when HbA1c remains above target despite fasting normoglycaemia. Therefore, to achieve near normoglycaemia, additional treatment with prandial insulin or a glucagon-like peptide-1 receptor agonist (GLP-1 RA) is often required. Long- or short-acting GLP-1 RAs offer effective alternatives to basal or prandial insulin in patients inadequately controlled with other therapies or basal insulin alone, respectively. This review highlights the limitations of current algorithms, and proposes an alternative based on the early introduction of insulin therapy and the rationale for the sequential or fixed combination of GLP-1 RAs with insulin ("treat-to-success" paradigm).
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Affiliation(s)
- David R. Owens
- Diabetes Research Unit, Institute of Life Sciences, College of MedicineSwansea UniversitySwanseaUK
| | - Louis Monnier
- Laboratory of Human Nutrition and Atherosclerosis, Institute of Clinical ResearchUniversity of MontpellierMontpellierFrance
| | - Anthony H. Barnett
- Diabetes and Endocrine CentreHeart of England NHS Foundation Trust, Birmingham Heartlands HospitalBirminghamUK
- University of BirminghamBirminghamUK
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Jain RK. Empagliflozin/linagliptin single-pill combination therapy for patients with type 2 diabetes mellitus. Expert Opin Pharmacother 2017; 18:545-549. [DOI: 10.1080/14656566.2017.1299712] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Rajeev Kumar Jain
- Aurora Health Center, Aurora Advanced Healthcare, Inc., Milwaukee, WI, USA
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Khunti K, Nikolajsen A, Thorsted BL, Andersen M, Davies MJ, Paul SK. Clinical inertia with regard to intensifying therapy in people with type 2 diabetes treated with basal insulin. Diabetes Obes Metab 2016; 18:401-9. [PMID: 26743666 PMCID: PMC5067688 DOI: 10.1111/dom.12626] [Citation(s) in RCA: 188] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 11/30/2015] [Accepted: 12/29/2015] [Indexed: 12/13/2022]
Abstract
AIM To investigate whether clinical inertia, the failure to intensify treatment regimens when required, exists in people with type 2 diabetes treated with basal insulin. METHODS This was a retrospective cohort study involving patients with type 2 diabetes in the UK Clinical Practice Research Datalink database between January 2004 and December 2011, with follow-up until December 2013. RESULTS A total of 11 696 patients were included in the analysis. Among all patients, 36.5% had their treatment intensified during the study period; of these, the treatment of 50.0, 42.5 and 7.4% was intensified with bolus or premix insulin or glucagon-like peptide-1 receptor agonists, respectively. The median time from initiation of basal insulin to treatment intensification was 4.3 years [95% confidence interval (CI) 4.1, 4.6]. Among patients clinically eligible for treatment intensification [glycated haemoglobin (HbA1c) ≥7.5% (58 mmol/mol)], 30.9% had their treatment regimen intensified. The median time to intensification in this group was 3.7 years (95% CI 3.4, 4.0). Increasing age, duration of diabetes, oral antihyperglycaemic agent usage and Charlson comorbidity index score were associated with a significant delay in the time to intensification (p < 0.05). Among patients with HbA1c ≥7.5% (58 mmol/mol), 32.1% stopped basal insulin therapy. CONCLUSIONS Strategies should be developed to increase the number of patients undergoing therapy intensification and to reduce the delay in intensifying therapy for suitable patients on basal insulin. Initiatives to support patients continuing on insulin are also required.
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Affiliation(s)
- K. Khunti
- Diabetes Research CentreUniversity of LeicesterLeicesterUK
| | | | | | | | - M. J. Davies
- Diabetes Research CentreUniversity of LeicesterLeicesterUK
| | - S. K. Paul
- Clinical Trials & Biostatistics UnitQIMR Berghofer Medical Research InstituteBrisbaneAustralia
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Yam FK, Lew T, Eraly SA, Lin HW, Hirsch JD, Devor M. Changes in medication regimen complexity and the risk for 90-day hospital readmission and/or emergency department visits in U.S. Veterans with heart failure. Res Social Adm Pharm 2015; 12:713-21. [PMID: 26621388 DOI: 10.1016/j.sapharm.2015.10.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 10/16/2015] [Accepted: 10/16/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Heart failure (HF) hospitalization is associated with multiple medication modifications. These modifications often increase medication regimen complexity and may increase the risk of readmission and/or emergency department (ED) visit. OBJECTIVES To determine the association between changes in medication regimen complexity (MRC) during hospitalization of patients with heart failure and the risk of readmission or ED visit at 90 days. Secondary objectives include examining the association between changes in MRC and time to readmission as well as the relationship between number of medications and MRC. METHODS This was a retrospective cohort study that included U.S. Veterans hospitalized with heart failure. MRC was quantified using the medication regimen complexity index (MRCI). The change in MRCI was the difference between admission MRCI and discharge MRCI recorded during the index hospitalization. Demographic and clinical data were collected to characterize the study population. Patient data for up to one year after discharge was recorded to identify hospital readmissions and ED visits. RESULTS A total of 174 patients were included in the analysis. Sixty-two patients (36%) were readmitted or had an ED visit at 90 days from the index hospitalization. The mean change (SD) in MRCI during the index hospitalization among the cohort was 4.7 (8.3). After multivariate logistic regression analysis, each unit increase in MRCI score was associated with a 4% lower odds of readmission or ED visit at 90 days but this finding was not statistically significant (OR 0.955; 95% CI 0.911-1.001). In the cox proportional hazard model, the median time to hospital readmission or ED visit was 214 days. Each unit increase in MRCI score was associated with a modest but non-significant increase in probability of survival from readmission or ED visit (HR 0.978; 95% CI 0.955, 1.001). CONCLUSION Changes in medication regimen complexity that occur during hospitalization may also be associated with optimization of medical therapy and do not necessarily portend worse outcomes in patients with HF.
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Affiliation(s)
- Felix K Yam
- UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, 9500 Gilman Drive, MC 0764, La Jolla, CA 92093, USA; VA San Diego Healthcare System, 3350 La Jolla Village Dr., San Diego, CA, USA.
| | - Tiffany Lew
- San Francisco VA Medical Center, 4150 Clement Street (119), San Francisco, CA 94121, USA
| | - Satish A Eraly
- VA San Diego Healthcare System, 3350 La Jolla Village Dr., San Diego, CA, USA; UC San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Hsiang-Wen Lin
- China Medical University, College of Pharmacy, No. 91 Hsueh-Shih Road, Taichung 40402, Taiwan, ROC
| | - Jan D Hirsch
- VA San Diego Healthcare System, 3350 La Jolla Village Dr., San Diego, CA, USA; UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, 9500 Gilman Drive, MC 0714, La Jolla, CA 92093, USA
| | - Michelle Devor
- VA San Diego Healthcare System, 3350 La Jolla Village Dr., San Diego, CA, USA; UC San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA 92093, USA
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Paul SK, Klein K, Thorsted BL, Wolden ML, Khunti K. Delay in treatment intensification increases the risks of cardiovascular events in patients with type 2 diabetes. Cardiovasc Diabetol 2015; 14:100. [PMID: 26249018 PMCID: PMC4528846 DOI: 10.1186/s12933-015-0260-x] [Citation(s) in RCA: 181] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 07/18/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The aim of the study was to evaluate the effect of delay in treatment intensification (IT; clinical inertia) in conjunction with glycaemic burden on the risk of macrovascular events (CVE) in type 2 diabetes (T2DM) patients. METHODS A retrospective cohort study was carried out using United Kingdom Clinical Practice Research Datalink, including T2DM patients diagnosed from 1990 with follow-up data available until 2012. RESULTS In the cohort of 105,477 patients mean HbA1c was 8.1% (65 mmol/mol) at diagnosis, 11% had a history of cardiovascular disease, and 7.1% experienced at least one CVE during 5.3 years of median follow-up. In patients with HbA1c consistently above 7/7.5% (53/58 mmol/mol, n = 23,101/11,281) during 2 years post diagnosis, 26/22% never received any IT. Compared to patients with HbA1c <7% (<53 mmol/mol), in patients with HbA1c ≥7% (≥53 mmol/mol), a 1 year delay in receiving IT was associated with significantly increased risk of MI, stroke, HF and composite CVE by 67% (HR CI: 1.39, 2.01), 51% (HR CI: 1.25, 1.83), 64% (HR CI: 1.40, 1.91) and 62% (HR CI: 1.46, 1.80) respectively. One year delay in IT in interaction with HbA1c above 7.5% (58 mmol/mol) was also associated with similar increased risk of CVE. CONCLUSIONS Among patients with newly diagnosed T2DM, 22% remained under poor glycaemic control over 2 years, and 26% never received IT. Delay in IT by 1 year in conjunction with poor glycaemic control significantly increased the risk of MI, HF, stroke and composite CVE.
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Affiliation(s)
- Sanjoy K Paul
- Clinical Trials and Biostatistics Unit, QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, Brisbane, QLD, 4006, Australia.
| | - Kerenaftali Klein
- Clinical Trials and Biostatistics Unit, QIMR Berghofer Medical Research Institute, 300 Herston Road, Herston, Brisbane, QLD, 4006, Australia.
| | | | | | - Kamlesh Khunti
- Leicester Diabetes Centre, University of Leicester, Leicester, UK.
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Singh DK, Tari V. Structured diabetes care (Freedom 365*) provides better glycemic control than routine medical care in type 2 diabetes: proof of concept observational study. Int J Diabetes Dev Ctries 2015. [DOI: 10.1007/s13410-014-0267-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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