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Davison NJ, Guthrie NL, Medland S, Lupinacci P, Nordyke RJ, Berman MA. Cost-Effectiveness Analysis of a Prescription Digital Therapeutic in Type 2 Diabetes. Adv Ther 2024; 41:806-825. [PMID: 38170435 PMCID: PMC10838832 DOI: 10.1007/s12325-023-02752-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/24/2023] [Indexed: 01/05/2024]
Abstract
INTRODUCTION BT-001 (AspyreRx™) prescription digital therapy, a form of personalized cognitive behavioral therapy, has demonstrated clinically meaningful and durable hemoglobin A1c reductions in patients with type 2 diabetes (T2D). The current study examined the cost-effectiveness of BT-001 plus standard of care (SoC) versus SoC alone in T2D over a lifetime horizon from a healthcare payer perspective. METHODS We modeled the T2D pathway using an individual patient-level simulation; clinical data were sourced from the intention-to-treat subset of the BT-001 randomized clinical trial (RCT). SoC across both arms included the composition of oral and injectable treatments for T2D. Events were simulated using the United Kingdom Prospective Diabetes Study Outcomes Model 2 risk equation. A 3-month model cycle length was used in the first year, then annual model cycles were used in line with the original risk engine specifications. Patient characteristics informed event equations and Monte Carlo random sampling was used to assess the occurrence of events within each model cycle. Incidence of hypoglycemic events, drug discontinuation, costs, and health utilities and disutility values were sourced from the literature. RESULTS From a payer perspective, BT-001 plus SoC versus SoC alone was dominant with a gain in quality-adjusted life years (QALYs) of 0.101 and cost savings of $7343 per patient over the lifetime horizon (i.e., more effective and less costly). BT-001 plus SoC was cost-effective at a willingness-to-pay of $100,000 per QALY (incremental net monetary benefit was $17,443). Savings with BT-001 were primarily driven by a reduction in drug acquisition costs. The reduction in hemoglobin A1c with BT-001 was associated with fewer T2D complications. CONCLUSIONS BT-001 plus SoC was estimated to dominate SoC alone over the lifetime horizon from a payer perspective, suggesting that using BT-001 can empower patients to better manage their diabetes with the potential for lifelong advantages.
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Affiliation(s)
| | - Nicole L Guthrie
- Better Therapeutics, 548 Market St, San Francisco, CA, 49404, USA
| | | | - Paul Lupinacci
- Villanova University, 800 Lancaster Ave, Villanova, PA, USA
| | | | - Mark A Berman
- Better Therapeutics, 548 Market St, San Francisco, CA, 49404, USA
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Antoniou M, Mateus C, Hollingsworth B, Titman A. A Systematic Review of Methodologies Used in Models of the Treatment of Diabetes Mellitus. PharmacoEconomics 2024; 42:19-40. [PMID: 37737454 DOI: 10.1007/s40273-023-01312-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Diabetes mellitus is a chronic and complex disease, increasing in prevalence and consequent health expenditure. Cost-effectiveness models with long time horizons are commonly used to perform economic evaluations of diabetes' treatments. As such, prediction accuracy and structural uncertainty are important features in cost-effectiveness models of chronic conditions. OBJECTIVES The aim of this systematic review is to identify and review published cost-effectiveness models of diabetes treatments developed between 2011 and 2022 regarding their methodological characteristics. Further, it also appraises the quality of the methods used, and discusses opportunities for further methodological research. METHODS A systematic literature review was conducted in MEDLINE and Embase to identify peer-reviewed papers reporting cost-effectiveness models of diabetes treatments, with time horizons of more than 5 years, published in English between 1 January 2011 and 31 of December 2022. Screening, full-text inclusion, data extraction, quality assessment and data synthesis using narrative synthesis were performed. The Philips checklist was used for quality assessment of the included studies. The study was registered in PROSPERO (CRD42021248999). RESULTS The literature search identified 30 studies presenting 29 unique cost-effectiveness models of type 1 and/or type 2 diabetes treatments. The review identified 26 type 2 diabetes mellitus (T2DM) models, 3 type 1 DM (T1DM) models and one model for both types of diabetes. Fifteen models were patient-level models, whereas 14 were at cohort level. Parameter uncertainty was assessed thoroughly in most of the models, whereas structural uncertainty was seldom addressed. All the models where validation was conducted performed well. The methodological quality of the models with respect to structure was high, whereas with respect to data modelling it was moderate. CONCLUSIONS Models developed in the past 12 years for health economic evaluations of diabetes treatments are of high-quality and make use of advanced methods. However, further developments are needed to improve the statistical modelling component of cost-effectiveness models and to provide better assessment of structural uncertainty.
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Affiliation(s)
- Marina Antoniou
- Division of Health Research, Lancaster University, Bailrigg, Lancaster, UK.
| | - Céu Mateus
- Division of Health Research, Lancaster University, Bailrigg, Lancaster, UK
| | | | - Andrew Titman
- Department of Mathematics and Statistics, Lancaster University, Bailrigg, Lancaster, UK
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Presley CA, Khodneva Y, Juarez LD, Howell CR, Agne AA, Riggs KR, Huang L, Pisu M, Levitan EB, Cherrington AL. Trends and Predictors of Glycemic Control Among Adults With Type 2 Diabetes Covered by Alabama Medicaid, 2011-2019. Prev Chronic Dis 2023; 20:E81. [PMID: 37708338 PMCID: PMC10516203 DOI: 10.5888/pcd20.220332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023] Open
Abstract
INTRODUCTION Despite advances in diabetes management, only one-quarter of people with diabetes in the US achieve optimal targets for glycated hemoglobin A1c (HbA1c), blood pressure, and cholesterol. We sought to evaluate temporal trends and predictors of achieving glycemic control among adults with type 2 diabetes covered by Alabama Medicaid from 2011 through 2019. METHODS We completed a retrospective analysis of Medicaid claims and laboratory data, using person-years as the unit of analysis. Inclusion criteria were being aged 19 to 64 years, having a diabetes diagnosis, being continuously enrolled in Medicaid for a calendar year and preceding 12 months, and having at least 1 HbA1c result during the study year. Primary outcomes were HbA1c thresholds of <7% and <8%. Primary exposure was study year. We conducted separate multivariable-adjusted logistic regressions to evaluate relationships between study year and HbA1c thresholds. RESULTS We included 43,997 person-year observations. Mean (SD) age was 51.0 (9.9) years; 69.4% were women; 48.1% were Black, 42.9% White, and 0.4% Hispanic. Overall, 49.1% had an HbA1c level of <7% and 64.6% <8%. Later study years and poverty-based eligibility were associated with lower probability of reaching target HbA1c levels of <7% or <8%. Sex, race, ethnicity, and geography were not associated with likelihood of reaching HbA1c <7% or <8% in any model. CONCLUSION Later study years were associated with lower likelihood of meeting target HbA1c levels compared with 2011, after adjusting for covariates. With approximately 35% not meeting an HbA1c target of <8%, more work is needed to improve outcomes of low-income adults with type 2 diabetes.
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Affiliation(s)
- Caroline A Presley
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
- Division of Preventive Medicine, University of Alabama at Birmingham, 1717 11th Ave South, MT-616, Birmingham, AL 35205
| | - Yulia Khodneva
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
| | - Lucia D Juarez
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
| | - Carrie R Howell
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
| | - April A Agne
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
| | - Kevin R Riggs
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
| | - Lei Huang
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham
| | - Maria Pisu
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
| | - Emily B Levitan
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham
| | - Andrea L Cherrington
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham Heersink School of Medicine
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Mayberry LS, Guy C, Hendrickson CD, McCoy AB, Elasy T. Rates and Correlates of Uptake of Continuous Glucose Monitors Among Adults with Type 2 Diabetes in Primary Care and Endocrinology Settings. J Gen Intern Med 2023; 38:2546-2552. [PMID: 37254011 PMCID: PMC10228889 DOI: 10.1007/s11606-023-08222-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 04/28/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Clinical trials indicate continuous glucose monitor (CGM) use may benefit adults with type 2 diabetes, but CGM rates and correlates in real-world care settings are unknown. OBJECTIVE We sought to ascertain prevalence and correlates of CGM use and to examine rates of new CGM prescriptions across clinic types and medication regimens. DESIGN Retrospective cohort using electronic health records in a large academic medical center in the Southeastern US. PARTICIPANTS Adults with type 2 diabetes and a primary care or endocrinology visit during 2021. MAIN MEASURES Age, gender, race, ethnicity, insurance, clinic type, insulin regimen, hemoglobin A1c values, CGM prescriptions, and prescribing clinic type. KEY RESULTS Among 30,585 adults with type 2 diabetes, 13% had used a CGM. CGM users were younger and more had private health insurance (p < .05) as compared to non-users; 72% of CGM users had an intensive insulin regimen, but 12% were not taking insulin. CGM users had higher hemoglobin A1c values (both most recent and most proximal to the first CGM prescription) than non-users. CGM users were more likely to receive endocrinology care than non-users, but 23% had only primary care visits in 2021. For each month in 2021, a mean of 90.5 (SD 12.5) people started using CGM. From 2020 to 2021, monthly rates of CGM prescriptions to new users grew 36% overall, but 125% in primary care. Most starting CGM in endocrinology had an intensive insulin regimen (82% vs. 49% starting in primary care), whereas 28% starting CGM in primary care were not using insulin (vs. 5% in endocrinology). CONCLUSION CGM uptake for type 2 diabetes is increasing rapidly, with most growth in primary care. These trends present opportunities for healthcare system adaptations to support CGM use and related workflows in primary care to support growth in uptake.
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Affiliation(s)
- Lindsay S Mayberry
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA.
- Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Charmin Guy
- School of Medicine, University of Mississippi, Jackson, MS, USA
| | - Chase D Hendrickson
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Allison B McCoy
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Tom Elasy
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Health Behavior and Health Education, Vanderbilt University Medical Center, Nashville, TN, USA
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Sadeghi A, Bayazidi Y, Davari M, Kebriaeezadeh A, Assarian A, Esteghamati A, Yousefi S. Individualized Glycemic Control in Type 2 Diabetic Patients in Iran: A Multi-Center Data Analysis. Iran J Med Sci 2023; 48:286-291. [PMID: 37791332 PMCID: PMC10542933 DOI: 10.30476/ijms.2022.92805.2409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 04/15/2022] [Accepted: 06/10/2022] [Indexed: 10/05/2023]
Abstract
Background Clinical guidelines and expert committees have recently suggested that the hemoglobin A1C (HbA1c) should be individualized based on various criteria. Data regarding the achievement of individualized glycemic targets in type 2 diabetes mellitus (T2DM) patients is scant in Iran. We intended to provide information found on real-world outcomes from the perspective of an individualized recommendation. Methods A cross-sectional analysis was conducted in 15 diabetes centers in Iran between 2013-2017. Two steps cluster sampling selection was used to recruit 1591 patients with T2DM. Considering Ismail-Beigi's individualized strategy, the study population was categorized into five treatment intensities of HbA1c: most intensive (≤6.5%), intensive (6.5-7.0%), less intensive (~7.0%), not intensive (7.0-8.0%), and moderated (~8.0%). The percentage of patients who met their group individualized glycemic targets was estimated as the degree of achievement of each treatment intensity. Results The cumulative incidence rate of early microvascular, advanced microvascular, and macrovascular complications was 53%, 25%, and 34%, respectively. Besides, [78% 77.6-79%] of patients did not achieve individualized glycemic targets. Conclusion The outcome showed poor individualized glycemic control and a high incidence of diabetes complications. Considering individualized HbA1c targets for Iranian patients with T2DM is an urgent need.
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Affiliation(s)
- Abolfazl Sadeghi
- Department of Pharmacoeconomics and Pharmaceutical Administration, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Yahya Bayazidi
- Department of Pharmacoeconomics and Pharmaceutical Administration, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Majid Davari
- Department of Pharmacoeconomics and Pharmaceutical Administration, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Abbas Kebriaeezadeh
- Department of Pharmacoeconomics and Pharmaceutical Administration, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Amin Assarian
- Department of Pharmacoeconomics and Pharmaceutical Administration, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Esteghamati
- Endocrinology and Metabolism Research Center, Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Sepideh Yousefi
- School of Pharmacy and Pharmaceutical Science, Islamic Azad University, Tehran, Iran
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Catharina de Beer J, Snyman J, Ker J, Miller-Janson H, Stander M. Budget Impact Analysis of Empagliflozin in the Treatment of Patients With Type 2 Diabetes With Established Cardiovascular Disease in South Africa. Value Health Reg Issues 2023; 33:91-98. [PMID: 36327769 DOI: 10.1016/j.vhri.2022.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 07/08/2022] [Accepted: 08/30/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES This study aimed to estimate the budget impact and affordability of empagliflozin added to usual care compared with usual care alone, in a diabetic population with established cardiovascular disease, from a private healthcare payer perspective in South Africa. METHODS A budget impact model was adapted and localized. Epidemiological data were obtained from the South African Council for Medical Schemes. Clinical event rates were sourced from the EMPA-REG OUTCOME trial and drug costs from list prices. Clinical event costs were derived from a claims data analysis of the South African private healthcare sector and microcosting. Scenario analyses were performed on select inputs. The modeled outcomes included annual budget impact of empagliflozin, the incremental cost per life per month, cardiovascular deaths averted, and incremental cost per life saved, over 3 years. RESULTS A total of 9 503 patients were eligible for empagliflozin (year 1), 12 670 (year 2), and 16 947 (year 3). The incremental cost was $1 272 297, $1 764 705, and $2 455 235, for years 1 to 3, respectively. The incremental cost per beneficiary per month was calculated as $0.012 (year 1), $0.016 (year 2), and $0.023 (year 3). The model estimated a 38.6% reduction in cardiovascular deaths, 305 lives saved, and an incremental cost per life saved of $17 999. CONCLUSIONS Adding empagliflozin to usual care has a marginal budget implication and is highly affordable for private healthcare payers, with an acceptable incremental cost based on clinical outcomes.
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Affiliation(s)
| | | | - James Ker
- University of Pretoria, South Africa
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Choi JG, Winn AN, Skandari MR, Franco MI, Staab EM, Alexander J, Wan W, Zhu M, Huang ES, Philipson L, Laiteerapong N. First-Line Therapy for Type 2 Diabetes With Sodium-Glucose Cotransporter-2 Inhibitors and Glucagon-Like Peptide-1 Receptor Agonists : A Cost-Effectiveness Study. Ann Intern Med 2022; 175:1392-1400. [PMID: 36191315 PMCID: PMC10155215 DOI: 10.7326/m21-2941] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Guidelines recommend sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP1) receptor agonists as second-line therapy for patients with type 2 diabetes. Expanding their use as first-line therapy has been proposed but the clinical benefits may not outweigh their costs. OBJECTIVE To evaluate the lifetime cost-effectiveness of a strategy of first-line SGLT2 inhibitors or GLP1 receptor agonists. DESIGN Individual-level Monte Carlo-based Markov model. DATA SOURCES Randomized trials, Centers for Disease Control and Prevention databases, RED BOOK, and the National Health and Nutrition Examination Survey. TARGET POPULATION Drug-naive U.S. patients with type 2 diabetes. TIME HORIZON Lifetime. PERSPECTIVE Health care sector. INTERVENTION First-line SGLT2 inhibitors or GLP1 receptor agonists. OUTCOME MEASURES Life expectancy, lifetime costs, incremental cost-effectiveness ratios (ICERs). RESULTS OF BASE-CASE ANALYSIS First-line SGLT2 inhibitors and GLP1 receptor agonists had lower lifetime rates of congestive heart failure, ischemic heart disease, myocardial infarction, and stroke compared with metformin. First-line SGLT2 inhibitors cost $43 000 more and added 1.8 quality-adjusted months versus first-line metformin ($478 000 per quality-adjusted life-year [QALY]). First-line injectable GLP1 receptor agonists cost more and reduced QALYs compared with metformin. RESULTS OF SENSITIVITY ANALYSIS By removing injection disutility, first-line GLP1 receptor agonists were no longer dominated (ICER, $327 000 per QALY). Oral GLP1 receptor agonists were not cost-effective (ICER, $823 000 per QALY). To be cost-effective at under $150 000 per QALY, costs for SGLT2 inhibitors would need to be under $5 per day and under $6 per day for oral GLP1 receptor agonists. LIMITATION U.S. population and costs not generalizable internationally. CONCLUSION As first-line agents, SGLT2 inhibitors and GLP1 receptor agonists would improve type 2 diabetes outcomes, but their costs would need to fall by at least 70% to be cost-effective. PRIMARY FUNDING SOURCE American Diabetes Association.
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Affiliation(s)
- Jin G Choi
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois (J.G.C., M.I.F., E.M.S., J.A., M.Z.)
| | - Aaron N Winn
- Medical College of Wisconsin, Milwaukee, Wisconsin (A.N.W.)
| | - M Reza Skandari
- Centre for Health Economics & Policy Innovation, Imperial College Business School, Imperial College London, London, United Kingdom (M.R.S.)
| | - Melissa I Franco
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois (J.G.C., M.I.F., E.M.S., J.A., M.Z.)
| | - Erin M Staab
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois (J.G.C., M.I.F., E.M.S., J.A., M.Z.)
| | - Jason Alexander
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois (J.G.C., M.I.F., E.M.S., J.A., M.Z.)
| | - Wen Wan
- Section of General Internal Medicine and Center for Chronic Disease Research and Policy, Department of Medicine, University of Chicago, Chicago, Illinois (W.W., E.S.H., N.L.)
| | - Mengqi Zhu
- Section of General Internal Medicine, Department of Medicine, University of Chicago, Chicago, Illinois (J.G.C., M.I.F., E.M.S., J.A., M.Z.)
| | - Elbert S Huang
- Section of General Internal Medicine and Center for Chronic Disease Research and Policy, Department of Medicine, University of Chicago, Chicago, Illinois (W.W., E.S.H., N.L.)
| | - Louis Philipson
- Sections of Adult and Pediatric Endocrinology, Diabetes & Metabolism, Department of Medicine, University of Chicago, Chicago, Illinois (L.P.)
| | - Neda Laiteerapong
- Section of General Internal Medicine and Center for Chronic Disease Research and Policy, Department of Medicine, University of Chicago, Chicago, Illinois (W.W., E.S.H., N.L.)
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Westall SJ, Narayanan RP, Watmough S, Irving G, Furlong N, McNulty S, Bujawansa S, Hardy K. The individualisation of glycaemic targets in response to patient characteristics in type 2 diabetes: a scoping review. Clin Med (Lond) 2022; 22:257-265. [PMID: 38589086 DOI: 10.7861/clinmed.2021-0764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Evidence and guidelines increasingly support an individualised approach to care for people with type 2 diabetes and individualisation of glycaemic targets in response to patient factors. METHODS We undertook a scoping review of the literature for evidence of factors impacting upon glycated haemoglobin target individualisation in adults with type 2 diabetes. Data were analysed thematically with the themes inductively derived from article review. FINDINGS Evidence suggests that presence of cardiovascular disease, hypoglycaemia unawareness, severe hypoglycaemia, limited life expectancy, advanced age, long diabetes duration, frailty, cognitive impairment, disability, extensive comorbidity, diabetes distress and patient preference should inform the setting of glycaemic targets. CONCLUSION The management of people with diabetes is complex. In clinical practice, many patients will have a variety of factors that should be considered when personalising their care. Approaches to personalised care and glycaemic treatment targets should be undertaken as part of a shared decision-making process between physician and patient. Use of electronic records might enable greater efficiency and more widespread use of personalised care plans for people with diabetes.
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Affiliation(s)
- Samuel J Westall
- St Helens and Knowsley Teaching Hospitals NHS Trust, St Helens, UK and Edge Hill University, Ormskirk, UK.
| | | | | | | | - Niall Furlong
- St Helens and Knowsley Teaching Hospitals NHS Trust, St Helens, UK
| | - Sid McNulty
- St Helens and Knowsley Teaching Hospitals NHS Trust, St Helens, UK
| | - Sumudu Bujawansa
- St Helens and Knowsley Teaching Hospitals NHS Trust, St Helens, UK
| | - Kevin Hardy
- St Helens and Knowsley Teaching Hospitals NHS Trust, St Helens, UK
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Park JY, Hwang JH, Kang MJ, Sim HE, Kim JS, Ko KS. EFFECTS OF GLYCEMIC VARIABILITY ON THE PROGRESSION OF DIABETIC RETINOPATHY AMONG PATIENTS WITH TYPE 2 DIABETES. Retina 2021; 41:1487-95. [PMID: 33252581 DOI: 10.1097/IAE.0000000000003049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE To evaluate the effects of glycemic variability on the progression of diabetic retinopathy (DR) among individuals with Type 2 diabetes and to test the hypothesis that consistent glycemic control delays the progression of DR. METHODS This retrospective study included 1,125 participants with a follow-up period of more than 5 years and more than 20 glucose laboratory test results. The hazard ratio of ≥3 steps of progression on the Early Treatment Diabetic Retinopathy Study person scale and progression to proliferative DR were assessed. RESULTS An increase in the HbA1c SD was associated with a higher risk of ≥3 step progression (P < 0.001) and progression to proliferative DR (P < 0.001). Not only mean HbA1c, but also HbA1c SD was associated with a lower risk of ≥3 steps of progression (P < 0.001), and progression to proliferative DR (P < 0.001). CONCLUSION Achievable and consistent glycemic control may contribute to the delay in DR progression. CLINICAL TRIAL REGISTRATION NUMBER Institutional review board of Inje University (No. 202003014).
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Guzauskas GF, Rind DM, Fazioli K, Chapman RH, Pearson SD, Hansen RN. Cost-effectiveness of oral semaglutide added to current antihyperglycemic treatment for type 2 diabetes. J Manag Care Spec Pharm 2021. [DOI: 10.18553/jmcp.2021.27.4.455] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Gregory F Guzauskas
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle
| | - David M Rind
- Institute for Clinical and Economic Review (ICER), Boston, MA
| | | | | | | | - Ryan N Hansen
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle
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Shao H, Laxy M, Gregg EW, Albright A, Zhang P. Cost-Effectiveness of the New 2018 American College of Physicians Glycemic Control Guidance Statements Among US Adults With Type 2 Diabetes. Value Health 2021; 24:227-235. [PMID: 33518029 DOI: 10.1016/j.jval.2020.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 07/27/2020] [Accepted: 09/20/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES This study aims to estimate the national impact and cost-effectiveness of the 2018 American College of Physicians (ACP) guidance statements compared to the status quo. METHODS Survey data from the 2011-2016 National Health and Nutrition Examination were used to generate a national representative sample of individuals with diagnosed type 2 diabetes in the United States. Individuals with A1c <6.5% on antidiabetic medications are recommended to deintensify their A1c level to 7.0% to 8.0% (group 1); individuals with A1c 6.5% to 8.0% and a life expectancy of <10 years are recommended to deintensify their A1c level >8.0% (group 2); and individuals with A1c >8.0% and a life expectancy of >10 years are recommended to intensify their A1c level to 7.0% to 8.0% (group 3). We used a Markov-based simulation model to evaluate the lifetime cost-effectiveness of following the ACP recommended A1c level. RESULTS 14.41 million (58.1%) persons with diagnosed type 2 diabetes would be affected by the new guidance statements. Treatment deintensification would lead to a saving of $363 600 per quality-adjusted life-year (QALY) lost for group 1 and a saving of $118 300 per QALY lost for group 2. Intensifying treatment for group 3 would lead to an additional cost of $44 600 per QALY gain. Nationally, the implementation of the guidance would add 3.2 million life-years and 1.1 million QALYs and reduce healthcare costs by $47.7 billion compared to the status quo. CONCLUSIONS Implementing the new ACP guidance statements would affect a large number of persons with type 2 diabetes nationally. The new guidance is cost-effective.
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Affiliation(s)
- Hui Shao
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA; Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA.
| | - Michael Laxy
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA; Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Munich, Germany
| | - Edward W Gregg
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA; Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
| | - Ann Albright
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ping Zhang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Rosa LDS, Mistro S, Oliveira MG, Kochergin CN, Cortes ML, de Medeiros DS, Soares DA, Louzado JA, Silva KO, Bezerra VM, Amorim WW, Barone M, Passos LC. Cost-Effectiveness of Point-of-Care A1C Tests in a Primary Care Setting. Front Pharmacol 2021; 11:588309. [PMID: 33542687 PMCID: PMC7851089 DOI: 10.3389/fphar.2020.588309] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/23/2020] [Indexed: 12/18/2022] Open
Abstract
Objective: We evaluated the cost-effectiveness of the point-of-care A1c (POC-A1c) test device vs. the traditional laboratory dosage in a primary care setting for people living with type 2 diabetes. Materials and Methods: The Markov model with a 10-year time horizon was based on data from the HealthRise project, in which a group of interventions was implemented to improve diabetes and hypertension control in the primary care network of the urban area of a Brazilian municipality. A POC-A1c device was provided to be used directly in a primary care unit, and for a period of 18 months, 288 patients were included in the point-of-care group, and 1,102 were included in the comparison group. Sensitivity analysis was performed via Monte Carlo simulation and tornado diagram. Results: The results indicated that the POC-A1c device used in the primary care unit was a cost-effective alternative, which improved access to A1c tests and resulted in an increased rate of early control of blood glucose. In the 10-year period, POC-A1c group presented a mean cost of US$10,503.48 per patient and an effectiveness of 0.35 vs. US$9,992.35 and 0.09 for the traditional laboratory test, respectively. The incremental cost was US$511.13 and the incremental effectiveness was 0.26, resulting in an incremental cost-effectiveness ratio of 1,947.10. In Monte Carlo simulation, costs and effectiveness ranged between $9,663.20-$10,683.53 and 0.33-0.37 for POC-A1c test group, and $9,288.28-$10,413.99 and 0.08-0.10 for traditional laboratory test group, at 2.5 and 97.5 percentiles. The costs for nephropathy, retinopathy, and cardiovascular disease and the probability of being hospitalized due to diabetes presented the greatest impact on the model's result. Conclusion: This study showed that using POC-A1c devices in primary care settings is a cost-effective alternative for monitoring glycated hemoglobin A1c as a marker of blood glucose control in people living with type 2 diabetes. According to our model, the use of POC-A1c device in a healthcare unit increased the early control of type 2 diabetes and, consequently, reduced the costs of diabetes-related outcomes, in comparison with a centralized laboratory test.
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Affiliation(s)
- Lorena de Sousa Rosa
- Program of Post-Graduation in Medicine and Health, Federal University of Bahia, Salvador, Brazil
| | - Sóstenes Mistro
- Program of Post-Graduation in Collective Health, Multidisciplinary Institute of Health, Federal University of Bahia, Vitória da Conquista, Brazil
| | - Marcio Galvão Oliveira
- Program of Post-Graduation in Collective Health, Multidisciplinary Institute of Health, Federal University of Bahia, Vitória da Conquista, Brazil
| | | | - Mateus Lopes Cortes
- Multidisciplinary Institute of Health, Federal University of Bahia, Vitória da Conquista, Brazil
| | - Danielle Souto de Medeiros
- Program of Post-Graduation in Collective Health, Multidisciplinary Institute of Health, Federal University of Bahia, Vitória da Conquista, Brazil
| | - Daniela Arruda Soares
- Program of Post-Graduation in Collective Health, Multidisciplinary Institute of Health, Federal University of Bahia, Vitória da Conquista, Brazil
| | - José Andrade Louzado
- Multidisciplinary Institute of Health, Federal University of Bahia, Vitória da Conquista, Brazil
| | - Kelle Oliveira Silva
- Multidisciplinary Institute of Health, Federal University of Bahia, Vitória da Conquista, Brazil
| | - Vanessa Moraes Bezerra
- Program of Post-Graduation in Collective Health, Multidisciplinary Institute of Health, Federal University of Bahia, Vitória da Conquista, Brazil
| | - Welma Wildes Amorim
- Departament of Natural Sciences, State University of Southwest Bahia, Vitória da Conquista, Brazil
| | - Mark Barone
- Intersectoral Forum to Fight NCDs in Brazil, São Paulo, Brazil
| | - Luiz Carlos Passos
- Program of Post-Graduation in Medicine and Health, Federal University of Bahia, Salvador, Brazil
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13
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Abstract
The United States is one of the few high-income countries not to apply economic evaluation routinely to health care decision making on a national level, yet it excels at spending least efficiently on health care. In the interest of continuing to develop new solutions to curb spending on health care and reduce waste in the United States, perhaps now is an important moment to reconsider the benefits of economic evaluation and the barriers that must be overcome to have it emerge as a solution for health care institutions and the patients they serve. This article offers several distinct considerations to make economic evaluation methods (such as cost-effectiveness analysis) an effective component of value-based decision making in the United States. These considerations include overcoming the barriers presented by opportunity costs, spending on health care services versus biomedical technologies, phasing out low-value care, using value of information to prioritize resources, and determining what to do with the quality-adjusted life-year. These issues need to be addressed to achieve a collective purpose for economic evaluation at state and national levels.
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Affiliation(s)
- William V Padula
- University of Southern California, Los Angeles, California, and University of York, York, United Kingdom (W.V.P.)
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14
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Theodoropoulou KT, Dimitriadis GD, Tentolouris N, Darviri C, Chrousos GP. Diabetes distress is associated with individualized glycemic control in adults with type 2 diabetes mellitus. Hormones (Athens) 2020; 19:515-521. [PMID: 32844383 DOI: 10.1007/s42000-020-00237-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 08/04/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE It has been proposed that the negative emotional state of diabetes distress (DD) may exert a detrimental effect on glycemic outcomes of individuals struggling with diabetes-related challenges. Thus far, no study has investigated this association by utilizing individualized treatment targets of patients' glycemic control. Therefore, we sought to identify the potential role of DD in the achievement of individualized glycemic targets (AIGTs) among persons with type 2 diabetes mellitus (T2D). METHODS This cross-sectional study included a well-characterized outpatient group of T2D adults cared for in an academic medical center. DD was evaluated with the Diabetes Distress Scale. The AIGTs was defined according to the American Diabetes Association guidelines. Logistic regression analyses were utilized to identify independent correlates of the AIGTs. RESULTS A total of 123 individuals (mean [standard deviation] age: 58.0 [6.2] years, 55.3% females) were included in the final analysis. AIGTs was observed in 43.9% of the patients. Experiencing greater DD was associated with a lower likelihood of AIGTs (unadjusted odds ratio [OR]: 0.17, 95% confidence interval [CI]: 0.08-0.34, P value < 0.001), even after accounting for additional individual-level covariates (adjusted OR: 0.18, 95% CI: 0.08-0.42, P value < 0.001). Medication adherence was also a determinant of participants' AIGTs (adjusted OR: 1.91, 95% CI: 1.13-3.23, P value = 0.015). CONCLUSION Our findings provide novel evidence that DD likely undermines glycemic status in adult outpatients with T2D, even in the context of individually tailored diabetes care, and this should be taken into account when necessary.
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Affiliation(s)
- Konstantina Th Theodoropoulou
- Postgraduate Course "Science of Stress and Health Promotion", School of Medicine, National and Kapodistrian University of Athens, Soranou Ephessiou Str. 4, GR-115 27, Athens, Greece.
| | - George D Dimitriadis
- Second Department of Internal Medicine, Research Institute and Diabetes Center, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Rimini Str. 1, GR-124 62, Athens, Greece
| | - Nikolaos Tentolouris
- First Department of Propaedeutic Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, Laiko University Hospital, Ag. Thoma Str. 17, GR-115 27, Athens, Greece
| | - Christina Darviri
- Postgraduate Course "Science of Stress and Health Promotion", School of Medicine, National and Kapodistrian University of Athens, Soranou Ephessiou Str. 4, GR-115 27, Athens, Greece
| | - George P Chrousos
- Postgraduate Course "Science of Stress and Health Promotion", School of Medicine, National and Kapodistrian University of Athens, Soranou Ephessiou Str. 4, GR-115 27, Athens, Greece
- Division of Endocrinology, Diabetes and Metabolism, First Department of Pediatrics, School of Medicine, National and Kapodistrian University of Athens, "Aghia Sophia" Children's Hospital, Thivon & Papadiamantopoulou Str., GR-115 27, Athens, Greece
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15
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Dadwani RS, Skandari MR, GoodSmith MS, Phillips LS, Rhee MK, Laiteerapong N. Alternative type 2 diabetes screening tests may reduce the number of U.S. adults with undiagnosed diabetes. Diabet Med 2020; 37:1935-1943. [PMID: 32449198 PMCID: PMC7572743 DOI: 10.1111/dme.14330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2020] [Indexed: 12/12/2022]
Abstract
AIM To evaluate the U.S. population-level impact of two alternatives for initial type 2 diabetes screening [opportunistic random plasma glucose (RPG) > 6.7 mmol/l and a 1-h 50-g glucose challenge test (GCT) > 8.9 mmol/l] compared with American Diabetes Association (ADA)-recommended tests. METHODS Using a sample (n = 1471) from the National Health and Nutrition Examination Survey (NHANES) 2013-2014 that represented 145 million U.S. adults at high risk for developing type 2 diabetes, we simulated a two-test screening process. We compared ADA-recommended screening tests [fasting plasma glucose (FPG), 2-h 75-g oral glucose tolerance test (OGTT), HbA1c ] vs. initial screening with opportunistic RPG or GCT (followed by FPG, OGTT or HbA1c ). After simulation, participants were entered into an individual-level Monte Carlo-based Markov lifetime outcomes model. Primary outcomes were representative number of U.S. adults correctly identified with type 2 diabetes, societal lifetime costs and quality-adjusted life years (QALYs). RESULTS In NHANES 2013-2014, 100 individuals had undiagnosed diabetes [weighted estimate: 8.4 million, standard error (se): 1.1 million]. Among ADA-recommended screening tests, FPG followed by OGTT (FPG-OGTT) was most sensitive, identifying 35 individuals with undiagnosed diabetes (weighted estimate: 3.2 million, se: 0.9 million). Four alternative screening strategies performed superior to FPG-OGTT, with RPG followed by OGTT being the most sensitive overall, identifying 72 individuals with undiagnosed diabetes (weighted estimate: 6.1 million, se: 1.0 million). There was no increase in average lifetime costs and comparable QALYs. CONCLUSIONS Initial screening using opportunistic RPG or a GCT may identify more U.S. adults with type 2 diabetes without increasing societal costs.
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Affiliation(s)
- R S Dadwani
- Pritzker School of Medicine, Chicago, IL, USA
| | - M R Skandari
- Imperial College Business School, Imperial College London, London, UK
| | | | - L S Phillips
- Division of Endocrinology and Metabolism, Department of Medicine, Emory School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - M K Rhee
- Division of Endocrinology and Metabolism, Department of Medicine, Emory School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - N Laiteerapong
- Section of General Internal Medicine, University of Chicago, Chicago, IL, USA
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16
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Fazioli KT, Rind DM, Guzauskas GF, Hansen RN, Pearson SD. The Effectiveness and Value of Oral Semaglutide for Type 2 Diabetes Mellitus. J Manag Care Spec Pharm 2020; 26:1072-1076. [PMID: 32857658 PMCID: PMC10391231 DOI: 10.18553/jmcp.2020.26.9.1072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
DISCLOSURES Funding for this summary was contributed by Arnold Ventures, California Health Care Foundation, Harvard Pilgrim Health Care, and Kaiser Foundation Health Plan to the Institute for Clinical and Economic Review (ICER), an independent organization that evaluates the evidence on the value of health care interventions. ICER's annual policy summit is supported by dues from Aetna, America's Health Insurance Plans, Anthem, Allergan, Alnylam, AstraZeneca, Biogen, Blue Shield of CA, Boehringer-Ingelheim, Cambia Health Services, CVS, Editas, Express Scripts, Genentech/Roche, GlaxoSmithKline, Harvard Pilgrim, Health Care Service Corporation, HealthFirst, Health Partners, Johnson & Johnson (Janssen), Kaiser Permanente, LEO Pharma, Mallinckrodt, Merck, Novartis, National Pharmaceutical Council, Pfizer, Premera, Prime Therapeutics, Regeneron, Sanofi, Spark Therapeutics, and United Healthcare. Fazioli, Rind, and Pearson are employed by ICER. Gazauskas and Hansen have nothing to disclose.
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Affiliation(s)
| | - David M. Rind
- Institute for Clinical and Economic Review, Boston, Massachusetts
| | - Gregory F. Guzauskas
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle
| | - Ryan N. Hansen
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle
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Abstract
CONTEXT It is well recognized that some hypothyroid patients on levothyroxine (LT4) remain symptomatic, but why patients are susceptible to this condition, why symptoms persist, and what is the role of combination therapy with LT4 and liothyronine (LT3), are questions that remain unclear. Here we explore evidence of abnormal thyroid hormone (TH) metabolism in LT4-treated patients, and offer a rationale for why some patients perceive LT4 therapy as a failure. EVIDENCE ACQUISITION This review is based on a collection of primary and review literature gathered from a PubMed search of "hypothyroidism," "levothyroxine," "liothyronine," and "desiccated thyroid extract," among other keywords. PubMed searches were supplemented by Google Scholar and the authors' prior knowledge of the subject. EVIDENCE SYNTHESIS In most LT4-treated patients, normalization of serum thyrotropin levels results in decreased serum T3/T4 ratio, with relatively lower serum T3 levels; in at least 15% of the cases, serum T3 levels are below normal. These changes can lead to a reduction in TH action, which would explain the slower rate of metabolism and elevated serum cholesterol levels. A small percentage of patients might also experience persistent symptoms of hypothyroidism, with impaired cognition and tiredness. We propose that such patients carry a key clinical factor, for example, specific genetic and/or immunologic makeup, that is well compensated while the thyroid function is normal but might become apparent when compounded with relatively lower serum T3 levels. CONCLUSIONS After excluding other explanations, physicians should openly discuss and consider therapy with LT4 and LT3 with those hypothyroid patients who have persistent symptoms or metabolic abnormalities despite normalization of serum thyrotropin level. New clinical trials focused on symptomatic patients, genetic makeup, and comorbidities, with the statistical power to identify differences between monotherapy and combination therapy, are needed.
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Affiliation(s)
- Matthew D Ettleson
- Section of Adult and Pediatric Endocrinology and Metabolism, University of Chicago, Chicago, Illinois, USA
| | - Antonio C Bianco
- Section of Adult and Pediatric Endocrinology and Metabolism, University of Chicago, Chicago, Illinois, USA
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18
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Peabody J, Paculdo D, Acelajado MC, Burgon T, Dahlen JR. Finding the clinical utility of 1,5-anhydroglucitol among primary care practitioners. J Clin Transl Endocrinol 2020; 20:100224. [PMID: 32368501 PMCID: PMC7184171 DOI: 10.1016/j.jcte.2020.100224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 04/02/2020] [Accepted: 04/04/2020] [Indexed: 11/07/2022] Open
Abstract
Background HbA1c is widely used as the standard measure to track glycemic control in patients with diabetes and pre-diabetes but measures average levels of glycated hemoglobin over two to three months, with limited utility in the presence of recent and/or short-term fluctuations in glycemic control, which are correlated with worse patient outcomes. Methods We examined the clinical utility of 1-5-anhydroglucitol (1,5-AG) in six different, but common, case types of diabetes patients with short-term glycemic variability. We conducted a randomized controlled trial of simulated patients to examine the clinical practice patterns of primary care physicians before and after introducing 1,5-AG. The 145 participants were randomly assigned into standard care or standard care + 1,5-AG arms. Provider care was reviewed against explicit evidence-based care standards. Results At baseline, we saw no difference between the two study arms in clinical quality of care provided (p = 0.997). After introduction of 1,5-AG, standard care + 1,5-AG providers performed 3.2% better than controls (p = 0.025. In diagnosis and treatment, there was a slight, but nonsignificant trend toward better care (+1.1%, p = 0.507) for intervention providers. Upon disaggregation by case, almost all the improvement occurred in the medication-induced hyperglycemia patients (+8.1%, p = 0.047). Conclusions A nationally representative sample of primary care physicians demonstrated that of six different cases used in this study, 1,5-AG was found to be most effective increasing awareness of poor glucose control in medication-induced hyperglycemia. If 1,5-AG is used in this particular circumstance, the overall savings to the healthcare system is estimated to be $28 million.
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19
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Mata-Cases M, Rodríguez-Sánchez B, Mauricio D, Real J, Vlacho B, Franch-Nadal J, Oliva J. The Association Between Poor Glycemic Control and Health Care Costs in People With Diabetes: A Population-Based Study. Diabetes Care 2020; 43:751-758. [PMID: 32029636 DOI: 10.2337/dc19-0573] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 01/13/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To analyze the differences in health care costs according to glycemic control in people with type 2 diabetes. RESEARCH DESIGN AND METHODS Data on health care resource utilization from 100,391 people with type 2 diabetes were extracted from the electronic database used at the Catalan Health Institute. Multivariate regression models were carried out to test the impact of glycemic control (HbA1c) on total health care, hospital admission, and medication costs; model 1 adjusted for a variety of covariates, and model 2 also included micro- and macrovascular complications. Glycemic control was classified as good for HbA1c <7%, fair for ≥7% to <8%, poor for ≥8% to <10%, and very poor for ≥10%. RESULTS Mean per patient annual direct medical costs were €3,039 ± SD €6,581. Worse glycemic control was associated with higher total health care costs: compared with good glycemic control, health care costs increased by 18% (€509.82) and 23% (€661.35) in patients with very poor and poor glycemic control, respectively, when unadjusted and by €428.3 and €395.1, respectively, in model 2. Medication costs increased by 12% in patients with fair control and by 28% in those with very poor control (model 2). Patients with poor control had a higher probability of hospitalization than those with good control (5% in model 2) and a greater average cost when hospitalization occurred (€811). CONCLUSIONS Poor glycemic control was directly related to higher total health care, hospitalization, and medication costs. Preventive strategies and good glycemic control in people with type 2 diabetes could reduce the economic impact associated with this disease.
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Affiliation(s)
- Manel Mata-Cases
- Centre d'Atenció Primària La Mina, Gerència Territorial de Barcelona, Institut Català de la Salut, Barcelona, Spain.,DAP-Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, Barcelona, Spain.,CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Barcelona, Spain
| | - Beatriz Rodríguez-Sánchez
- Department of Economic Analysis and Finance, Faculty of Law and Social Sciences, University of Castilla-La Mancha, Toledo, Spain
| | - Dídac Mauricio
- DAP-Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, Barcelona, Spain .,CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Barcelona, Spain.,Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Jordi Real
- DAP-Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, Barcelona, Spain.,CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Barcelona, Spain
| | - Bogdan Vlacho
- DAP-Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, Barcelona, Spain
| | - Josep Franch-Nadal
- DAP-Cat Group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, Barcelona, Spain .,CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Barcelona, Spain.,Centre d'Atenció Primària Raval Sud, Gerència Territorial de Barcelona, Institut Català de la Salut, Barcelona, Spain
| | - Juan Oliva
- Department of Economic Analysis and Finance, Faculty of Law and Social Sciences, University of Castilla-La Mancha, Toledo, Spain
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20
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GoodSmith MS, Skandari MR, Huang ES, Naylor RN. The Impact of Biomarker Screening and Cascade Genetic Testing on the Cost-Effectiveness of MODY Genetic Testing. Diabetes Care 2019; 42:2247-2255. [PMID: 31558549 PMCID: PMC6868460 DOI: 10.2337/dc19-0486] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 09/10/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE In the U.S., genetic testing for maturity-onset diabetes of the young (MODY) is frequently delayed because of difficulty with insurance coverage. Understanding the economic implications of clinical genetic testing is imperative to advance precision medicine for diabetes. The objective of this article is to assess the cost-effectiveness of genetic testing, preceded by biomarker screening and followed by cascade genetic testing of first-degree relatives, for subtypes of MODY in U.S. pediatric patients with diabetes. RESEARCH DESIGN AND METHODS We used simulation models of distinct forms of diabetes to forecast the clinical and economic consequences of a systematic genetic testing strategy compared with usual care over a 30-year time horizon. In the genetic testing arm, patients with MODY received treatment changes (sulfonylureas for HNF1A- and HNF4A-MODY associated with a 1.0% reduction in HbA1c; no treatment for GCK-MODY). Study outcomes included costs, life expectancy (LE), and quality-adjusted life years (QALY). RESULTS The strategy of biomarker screening and genetic testing was cost-saving as it increased average quality of life (+0.0052 QALY) and decreased costs (-$191) per simulated patient relative to the control arm. Adding cascade genetic testing increased quality-of-life benefits (+0.0081 QALY) and lowered costs further (-$735). CONCLUSIONS A combined strategy of biomarker screening and genetic testing for MODY in the U.S. pediatric diabetes population is cost-saving compared with usual care, and the addition of cascade genetic testing accentuates the strategy's benefits. Widespread implementation of this strategy could improve the lives of patients with MODY while saving the health system money, illustrating the potential population health benefits of personalized medicine.
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Affiliation(s)
| | - M Reza Skandari
- Imperial College Business School, Imperial College London, London, U.K
| | - Elbert S Huang
- Section of General Internal Medicine, University of Chicago, Chicago, IL
| | - Rochelle N Naylor
- Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL
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21
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Abstract
To describe how patient characteristics influence physician decision-making about glycemic goals for Type 2 diabetes.2016 survey of 357 US physicians. The survey included two vignettes, representing a healthy patient and an unhealthy patient, adapted from a past survey of international experts and a factorial design vignette that varied age, heart disease history, and hypoglycemia history. Survey results were weighted to provide national estimates.Over half (57.6%) of physicians recommended a goal HbA1c <7.0% for most of their patients. For the healthy patient vignette, physicians recommended a goal similar to that of international experts (<6.66% (95% Confidence Interval (CI), 6.61-6.71%) vs <6.5% (Interquartile range (IQR), 6.5-6.8%)). For the unhealthy patient, physicians recommended a lower goal than international experts (<7.38% (CI, 7.30-7.46) vs <8.0% (IQR, 7.5-8.0%)). In the factorial vignette, physicians varied HbA1c goals by 0.35%, 0.06%, and 0.28% based on age, heart disease history, and hypoglycemia risk, respectively. The goal HbA1c range between the 55-year-old with no heart disease or hypoglycemic events and the 75-year-old with heart disease and hypoglycemic events was 0.65%.Despite guidelines that recommend HbA1c goals ranging from <6.5% to <8.5%, US physicians seem to be anchored on HbA1c goals around <7.0%.
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Affiliation(s)
| | - Sandra A. Ham
- Center for Health and Social Sciences, University of Chicago
| | - Aviva G. Nathan
- Section of General Internal Medicine, Department of Medicine
| | | | | | - Elbert S. Huang
- Section of General Internal Medicine, Department of Medicine
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22
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Yan ST, Jia JH, Lv XF, Shao YH, Yin SN, Zhang XG, Li CL, Jin MM, Miao XY, Tian H. Glycemic control and comprehensive metabolic risk factors control in older adults with type 2 diabetes. Exp Gerontol 2019; 127:110713. [PMID: 31472256 DOI: 10.1016/j.exger.2019.110713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 07/12/2019] [Accepted: 08/26/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Older adults with type 2 diabetes are prone to multiple metabolic abnormalities. However, data from these patients on comprehensive metabolic risk factors control are limited. METHODS The present study included 2736 older adults aged 60 to 90 years with type 2 diabetes from 114 hospitals across 22 provinces in China. Metabolic abnormalities, including hypertension, dyslipidemia, hyperuricemia, and obesity, were recorded. Comprehensive metabolic risk factors control included the control of hemoglobin A1c (HbA1c) level, blood pressure, serum lipids level, serum uric acid level, and body mass index. The target glycemic control was defined as HbA1c <7%. RESULTS The proportion of older adults who achieved the HbA1c target was 23.0%. The glycemic control rate increased with the number of metabolic abnormalities increased. The patients who had all four metabolic abnormalities had 4.05 times (95% confidence interval: 2.16, 7.61) the odd to meet glycemic target than those with none of metabolic abnormalities. However, only 4.6% of patients met the targets for all 5 metabolic risk factors. The comprehensive rate of all 5 factors in control decreased from 13.4% to 0% with the number of metabolic abnormalities increased. CONCLUSION The glycemic control rate and the comprehensive metabolic risk factors control rate were 23.0% and 4.6%, respectively. As the number of metabolic abnormalities increased, the number of risk factor targets achieved decreased. Our findings suggest that a strategy for comprehensive control is urgently needed in older adults with type 2 diabetes, especially in those with co-existing metabolic abnormalities.
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Affiliation(s)
- Shuang-Tong Yan
- Department of Endocrinology, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Jun-Hong Jia
- Department of Endocrinology, the Fourth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiao-Feng Lv
- Department of Endocrinology, Army General Hospital of Chinese PLA, Beijing, China
| | - Ying-Hong Shao
- Outpatient Department, Chinese PLA General Hospital, Beijing, China
| | - Shi-Nan Yin
- Department of Endocrinology, the Fourth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xing-Guang Zhang
- Department of Endocrinology, Army General Hospital of Chinese PLA, Beijing, China
| | - Chun-Lin Li
- Department of Endocrinology, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Meng-Meng Jin
- Department of Endocrinology, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Xin-Yu Miao
- Department of Endocrinology, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Hui Tian
- Department of Endocrinology, the Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China.
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Taksler GB, Beth Mercer M, Fagerlin A, Rothberg MB. Assessing Patient Interest in Individualized Preventive Care Recommendations. MDM Policy Pract 2019; 4:2381468319850803. [PMID: 31192307 PMCID: PMC6540511 DOI: 10.1177/2381468319850803] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 04/12/2019] [Indexed: 12/31/2022] Open
Abstract
Background. Few Americans obtain all 41 guideline-recommended preventive services for nonpregnant adults. We assessed patient interest in prioritizing their preventive care needs. Methods. We conducted a mixed-methods study, with 4 focus groups (N = 28) at a single institution and a nationwide survey (N = 2,103). Participants were middle-aged and older adults with preventive care needs. We obtained reactions to written materials describing the magnitude of benefit from major preventive services, including both absolute and relative benefits. Recommendations were individualized for patient risk factors (“individualized preventive care recommendations”). Focus groups assessed patient interest, how patients would want to discuss individualized recommendations with their providers, and potential for individualized recommendations to influence patient decision making. Survey content was based on focus groups and analyzed with logistic regression. Results. Patients expressed strong interest in individualized recommendations. Among survey respondents, an adjusted 88.2% (95% confidence interval [CI] = 86.7% to 89.7%) found individualized recommendations very easy to understand, 77.2% (95% CI = 75.3% to 79.1%) considered them very useful, and 64.9% (95% CI = 62.8% to 67.0%) highly trustworthy (each ≥6/7 on Likert scale). Three quarters of participants wanted to receive their own individualized recommendations in upcoming primary care visits (adjusted proportion = 77.5%, 95% CI = 75.6% to 79.4%). Both focus group and survey participants supported shared decision making and reported that individualized recommendations would improve motivation to obtain preventive care. Half of survey respondents reported that they would be much more likely to visit their doctor if they knew individualized recommendations would be discussed, compared with 4.2% who would not be more likely to visit their doctor. Survey respondents already prioritized preventive services, stating they were most likely to choose quick/easy preventive services and least likely to choose expensive preventive services (adjusted proportions, 63.8% and 8.5%, respectively). Results were consistent in sensitivity analyses. Conclusions. Individualized preventive care recommendations are likely to be well received in primary care and might motivate patients to improve adherence to evidence-based care.
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Affiliation(s)
- Glen B Taksler
- Medicine Institute, Division of Clinical Epidemiology, Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | | | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
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24
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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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25
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Choi SE, Berkowitz SA, Yudkin JS, Naci H, Basu S. Personalizing Second-Line Type 2 Diabetes Treatment Selection: Combining Network Meta-analysis, Individualized Risk, and Patient Preferences for Unified Decision Support. Med Decis Making 2019; 39:239-252. [PMID: 30767632 DOI: 10.1177/0272989x19829735] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Personalizing medical treatment often requires practitioners to compare multiple treatment options, assess a patient's unique risk and benefit from each option, and elicit a patient's preferences around treatment. We integrated these 3 considerations into a decision-modeling framework for the selection of second-line glycemic therapy for type 2 diabetes. METHODS Based on multicriteria decision analysis, we developed a unified treatment decision support tool accounting for 3 factors: patient preferences, disease outcomes, and medication efficacy and safety profiles. By standardizing and multiplying these 3 factors, we calculated the ranking score for each medication. This approach was applied to determining second-line glycemic therapy by integrating 1) treatment efficacy and side-effect data from a network meta-analysis of 301 randomized trials ( N = 219,277), 2) validated risk equations for type 2 diabetes complications, and 3) patient preferences around treatment (e.g., to avoid daily glucose testing). Data from participants with type 2 diabetes in the U.S. National Health and Nutrition Examination Survey (NHANES 2003-2014, N = 1107) were used to explore variations in treatment recommendations and associated quality-adjusted life-years given different patient features. RESULTS Patients at the highest microvascular disease risk had glucagon-like peptide 1 agonists or basal insulin recommended as top choices, whereas those wanting to avoid an injected medication or daily glucose testing had sodium-glucose linked transporter 2 or dipeptidyl peptidase 4 inhibitors commonly recommended, and those with major cost concerns had sulfonylureas commonly recommended. By converting from the most common sulfonylurea treatment to the model-recommended treatment, NHANES participants were expected to save an average of 0.036 quality-adjusted life-years per person (about a half month) from 10 years of treatment. CONCLUSIONS Models can help integrate meta-analytic treatment effect estimates with individualized risk calculations and preferences, to aid personalized treatment selection.
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Affiliation(s)
- Sung Eun Choi
- Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, MA, USA
| | - Seth A Berkowitz
- Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | | | | | - Sanjay Basu
- Center for Primary Care and Outcomes Research and Center for Population Health Sciences, Departments of Medicine and of Health Research and Policy, Stanford University, Stanford, CA, USA.,Center for Primary Care, Harvard Medical School, Boston, MA, USA.,School of Public Health, Imperial College, London, UK
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26
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Abstract
Approaches to personalized therapy based on practical work of physicians are discussed. Personalized treatment considers patient’s interests and position, mechanisms of symptoms, somatic and mental comorbidities, chrono medicine, environment, genetics, and prognosis. Personalized treatment may be more effective, safe and inexpensive in compare with of traditional standardized care based on randomized controlled trials and clinical practice guidelines. Limitations and weaknesses of medical guidelines of authoritative professional societies are also discussed. Recommendations of clinical guidelines are based on randomized controlled trials with strict selection of patients without severe comorbid diseases. Accordingly, trials and guidelines conclusions cannot be applied for patients with heavy comorbidity. This justifies the need for organizational solutions and computer programs for support personalized treatment of patients. It is important to develop institute of primary care physicians and to train specialists in field of comorbid somatic diseases and mental disorders.
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McAlister FA, Lethebe BC, Lambe C, Williamson T, Lowerison M. Control of glycemia and blood pressure in British adults with diabetes mellitus and subsequent therapy choices: a comparison across health states. Cardiovasc Diabetol 2018; 17:27. [PMID: 29433515 PMCID: PMC5808447 DOI: 10.1186/s12933-018-0673-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 02/07/2018] [Indexed: 12/21/2022] Open
Abstract
Background To examine the intensity of glycemic and blood pressure control in British adults with diabetes mellitus and whether control levels or treatment deintensification rates differ across health states. Methods Retrospective cohort study using primary care electronic medical records (the United Kingdom Health Improvement Network Database) for adults with diabetes diagnosed at least 6 months before the index HbA1C and systolic blood pressure (SBP) measurements (to give their primary care physicians time to achieve treatment goals). We used prescribing records for 6 months pre/post the index measurements to determine who had therapy subsequently deintensified (based on “glycemic therapy score” and “antihypertensive therapy score” derived from number and dosage of medications). Results Of 292,170 individuals with diabetes, HbA1C < 6% or SBP < 120 mmHg after at least 6 months of management was less common in otherwise fit patients (15.0 and 12.7%) than in those who were mildly frail (16.6 and 13.2%) or moderately–severely frail (20.2 and 17.0%, both p < 0.0001). In the next 6 months, only 44.7% of those with HbA1C < 6% had glycemic therapy reduced (44.4% of fit, 47.1% of mildly frail, and 41.5% of moderate-severely frail patients) and 39.8% of those with SBP < 120 had their antihypertensives decreased (39.3% of fit, 43.0% of mildly frail, and 46.7% of moderate-severely frail patients). On the other hand, more individuals exhibited higher than recommended levels for HbA1C or SBP after the first 6 months of therapy (37.3, 33.4, and 31.3% of fit, mildly frail, and moderately–severely frail patients had HbA1C > 7.5% and 46.6, 51.4, and 48.5% had SBP > 140 mmHg). The proportions of patients with HbA1C or SBP out of recommended treatment ranges changed little 6 months later despite frequent (median 14 per year) primary care visits. Conclusions Glycemic and hypertensive control exhibited statistically significant but small magnitude differences across frailty states. Medication deintensification was uncommon, even in frail patients below SBP and HbA1C targets. SBP levels were more likely to be outside recommended treatment ranges than glycemic levels. Trial registration As this study is a retrospective secondary analysis of electronic medical record data and not a health care intervention trial it was not registered Electronic supplementary material The online version of this article (10.1186/s12933-018-0673-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Finlay A McAlister
- Division of General Internal Medicine, 5-134C Clinical Sciences Building, University of Alberta, 11350 83 Avenue, Edmonton, AB, T6G 2G3, Canada. .,Patient Health Outcomes Research and Clinical Effectiveness Unit, 5-134C Clinical Sciences Building, University of Alberta, 11350 83 Avenue, Edmonton, AB, T6G 2G3, Canada.
| | - Brendan Cord Lethebe
- Clinical Research Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Caitlin Lambe
- Clinical Research Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Tyler Williamson
- Clinical Research Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Mark Lowerison
- Clinical Research Unit, Cumming School of Medicine, University of Calgary, Calgary, Canada
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