Long-term Effects of a Collaborative Care Model on Metabolic Outcomes and Depressive Symptoms: 36-Month Outcomes from the INDEPENDENT Intervention

BACKGROUND

Collaborative care (CC) is a multicomponent team-based approach to providing mental health care with systematic integration into outpatient medical settings. The 12-month INDEPENDENT CC intervention improved joint disease control measures in patients with both depression and diabetes at 12 and 24 months following randomization.

OBJECTIVE

This study investigated the durability of intervention effects on patient outcomes at 36 months following randomization.

PARTICIPANTS

Adult patients with poorly controlled T2D and depression in India randomized to CC or usual care.

DESIGN

Post hoc analyses of between-group differences in patient outcomes at 36 months post-randomization (N = 331) and maintenance of outcomes from 12 to 36 months (N = 314).

MAIN MEASURES

We evaluated combined risk factor improvement since baseline, defined as ≥ 50.0% reduction in Symptom Checklist Depression Scale (SCL-20) scores along with reduction of at least 0.5 percentage point hemoglobin A1C, 5 mmHg systolic blood pressure, or 10 mg/dL low-density lipoprotein cholesterol. Improvements in single risk factors were also examined.

KEY RESULTS

There were no between-group differences in improvements since baseline in multiple or single risk factors at 36 months. Patients in the CC group with improved outcomes at 12 months were more likely to maintain a ≥ 50.0% reduction since baseline in SCL-20 scores (CC [54.9%] vs. UC [40.9%]; RR: 1.27 [95% CI: 1.04, 1.56]) and 0.5 percentage point reduction since baseline in hemoglobin A1C (CC [31.9%] vs. UC [19.5%]; RR: 1.64 [95% CI: 1.11, 2.41]) at 36 months.

CONCLUSIONS

While improvements since baseline in patient outcomes did not differ between the collaborative care and usual care groups at 36 months, patients who received CC were more likely to maintain improvements in depressive symptoms and glucose levels at 36 months if they had achieved these improvements at the end of active intervention.

TRIAL REGISTRATION NUMBER

NCT02022111.

Steroid use during COVID-19 infection and hyperglycemia - What a physician should know

BACKGROUND AND AIMS

The COVID-19 pandemic continues to challenge us. Despite several strides in management, steroids remain the mainstay for treating moderate to severe disease and with it arises challenges such as hyperglycemia. The review aims to enhance awareness amongst physicians on steroid use and hyperglycemia.

METHODS

An advisory document describing various strategies for hyperglycemia management was prepared in the public interest by DiabetesIndia.

RESULTS

The review provides awareness on steroids and hyperglycemia, adverse outcomes of elevated blood glucose levels and, advice at the time of discharge.

CONCLUSIONS

The article emphasizes enhancing awareness on effective management of hyperglycemia during COVID-19.

Medios- An offline, smartphone-based artificial intelligence algorithm for the diagnosis of diabetic retinopathy

Purpose:

An observational study to assess the sensitivity and specificity of the Medios smartphone-based offline deep learning artificial intelligence (AI) software to detect diabetic retinopathy (DR) compared with the image diagnosis of ophthalmologists.

Methods:

Patients attending the outpatient services of a tertiary center for diabetes care underwent 3-field dilated retinal imaging using the Remidio NM FOP 10. Two fellowship-trained vitreoretinal specialists separately graded anonymized images and a patient-level diagnosis was reached based on grading of the worse eye. The images were subjected to offline grading using the Medios integrated AI-based software on the same smartphone used to acquire images. The sensitivity and specificity of the AI in detecting referable DR (moderate non-proliferative DR (NPDR) or worse disease) was compared to the gold standard diagnosis of the retina specialists.

Results:

Results include analysis of images from 297 patients of which 176 (59.2%) had no DR, 35 (11.7%) had mild NPDR, 41 (13.8%) had moderate NPDR, and 33 (11.1%) had severe NPDR. In addition, 12 (4%) patients had PDR and 36 (20.4%) had macular edema. Sensitivity and specificity of the AI in detecting referable DR was 98.84% (95% confidence interval [CI], 97.62–100%) and 86.73% (95% CI, 82.87–90.59%), respectively. The area under the curve was 0.92. The sensitivity for vision-threatening DR (VTDR) was 100%.

Conclusion:

The AI-based software had high sensitivity and specificity in detecting referable DR. Integration with the smartphone-based fundus camera with offline image grading has the potential for widespread applications in resource-poor settings.

Effect of a Collaborative Care Model on Depressive Symptoms and Glycated Hemoglobin, Blood Pressure, and Serum Cholesterol Among Patients With Depression and Diabetes in India: The INDEPENDENT Randomized Clinical Trial

IMPORTANCE

Mental health comorbidities are increasing worldwide and worsen outcomes for people with diabetes, especially when care is fragmented.

OBJECTIVE

To assess whether collaborative care vs usual care lowers depressive symptoms and improves cardiometabolic indices among adults with diabetes and depression.

DESIGN, SETTING, AND PARTICIPANTS

Parallel, open-label, pragmatic randomized clinical trial conducted at 4 socioeconomically diverse clinics in India that recruited patients with type 2 diabetes; a Patient Health Questionnaire-9 score of at least 10 (range, 0-27); and hemoglobin A1c (HbA1c) of at least 8%, systolic blood pressure (SBP) of at least 140 mm Hg, or low-density lipoprotein (LDL) cholesterol of at least 130 mg/dL. The first patient was enrolled on March 9, 2015, and the last was enrolled on May 31, 2016; the final follow-up visit was July 14, 2018.

INTERVENTIONS

Patients randomized to the intervention group (n = 196) received 12 months of self-management support from nonphysician care coordinators, decision support electronic health records facilitating physician treatment adjustments, and specialist case reviews; they were followed up for an additional 12 months without intervention. Patients in the control group (n = 208) received usual care over 24 months.

MAIN OUTCOMES AND MEASURES

The primary outcome was the between-group difference in the percentage of patients at 24 months who had at least a 50% reduction in Symptom Checklist Depression Scale (SCL-20) scores (range, 0-4; higher scores indicate worse symptoms) and a reduction of at least 0.5 percentage points in HbA1c, 5 mm Hg in SBP, or 10 mg/dL in LDL cholesterol. Prespecified secondary outcomes were percentage of patients at 12 and 24 months who met treatment targets (HbA1c <7.0%, SBP <130 mm Hg, LDL cholesterol <100 mg/dL [<70 mg/dL if prior cardiovascular disease]) or had improvements in individual outcomes (≥50% reduction in SCL-20 score, ≥0.5-percentage point reduction in HbA1c, ≥5-mm Hg reduction in SBP, ≥10-mg/dL reduction in LDL cholesterol); percentage of patients who met all HbA1c, SBP, and LDL cholesterol targets; and mean reductions in SCL-20 score, Patient Health Questionnaire-9 score, HbA1c, SBP, and LDL cholesterol.

RESULTS

Among 404 patients randomized (mean [SD] age, 53 [8.6] years; 165 [40.8%] men), 378 (93.5%) completed the trial. A significantly greater percentage of patients in the intervention group vs the usual care group met the primary outcome (71.6% vs 57.4%; risk difference, 16.9% [95% CI, 8.5%-25.2%]). Of 16 prespecified secondary outcomes, there were no statistically significant between-group differences in improvements in 10 outcomes at 12 months and in 13 outcomes at 24 months. Serious adverse events in the intervention and usual care groups included cardiovascular events or hospitalizations (4 [2.0%] vs 7 [3.4%]), stroke (0 vs 3 [1.4%]), death (2 [1.0%] vs 7 [3.4%]), and severe hypoglycemia (8 [4.1%] vs 0).

CONCLUSIONS AND RELEVANCE

Among patients with diabetes and depression in India, a 12-month collaborative care intervention, compared with usual care, resulted in statistically significant improvements in a composite measure of depressive symptoms and cardiometabolic indices at 24 months. Further research is needed to understand the generalizability of the findings to other low- and middle-income health care settings.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02022111.

Simple, Mobile-based Artificial Intelligence Algoithm in the detection of Diabetic Retinopathy (SMART) study

INTRODUCTION

The aim of this study is to evaluate the performance of the offline smart phone-based Medios artificial intelligence (AI) algorithm in the diagnosis of diabetic retinopathy (DR) using non-mydriatic (NM) retinal images.

METHODS

This cross-sectional study prospectively enrolled 922 individuals with diabetes mellitus. NM retinal images (disc and macula centered) from each eye were captured using the Remidio NM fundus-on-phone (FOP) camera. The images were run offline and the diagnosis of the AI was recorded (DR present or absent). The diagnosis of the AI was compared with the image diagnosis of five retina specialists (majority diagnosis considered as ground truth).

RESULTS

Analysis included images from 900 individuals (252 had DR). For any DR, the sensitivity and specificity of the AI algorithm was found to be 83.3% (95% CI 80.9% to 85.7%) and 95.5% (95% CI 94.1% to 96.8%). The sensitivity and specificity of the AI algorithm in detecting referable DR (RDR) was 93% (95% CI 91.3% to 94.7%) and 92.5% (95% CI 90.8% to 94.2%).

CONCLUSION

The Medios AI has a high sensitivity and specificity in the detection of RDR using NM retinal images.

The INtegrating DEPrEssioN and Diabetes treatmENT (INDEPENDENT) study: Design and methods to address mental healthcare gaps in India

INTRODUCTION

Depression and diabetes are highly prevalent worldwide and often co-exist, worsening outcomes for each condition. Barriers to diagnosis and treatment are exacerbated in low and middle-income countries with limited health infrastructure and access to mental health treatment. The INtegrating DEPrEssioN and Diabetes treatmENT (INDEPENDENT) study tests the sustained effectiveness and cost-effectiveness of a multi-component care model for individuals with poorly-controlled diabetes and depression in diabetes clinics in India.

MATERIALS AND METHODS

Adults with diabetes, depressive symptoms (Patient Health Questionnaire-9 score≥10), and ≥1 poorly-controlled cardiometabolic indicator (either HbA1c≥8.0%, SBP≥140mmHg, and/or LDL≥130mg/dl) were enrolled and randomized to the intervention or usual care. The intervention combined collaborative care, decision-support, and population health management. The primary outcome is the between-arm difference in the proportion of participants achieving combined depression response (≥50% reduction in Symptom Checklist score from baseline) AND one or more of: ≥0.5% reduction in HbA1c, ≥5mmHg reduction in SBP, or ≥10mg/dl reduction in LDL-c at 24months (12-month intervention; 12-month observational follow-up). Other outcomes include control of individual parameters, patient-centered measures (i.e. treatment satisfaction), and cost-effectiveness.

RESULTS

The study trained seven care coordinators. Participant recruitment is complete - 940 adults were screened, with 483 eligible, and 404 randomized (196 to intervention; 208 to usual care). Randomization was balanced across clinic sites.

CONCLUSIONS

The INDEPENDENT model aims to increase access to mental health care and improve depression and cardiometabolic disease outcomes among complex patients with diabetes by leveraging the care provided in diabetes clinics in India (clinicaltrials.gov number: NCT02022111).

Consensus recommendations on exploring effective solutions for the rising cost of diabetes

Diabetes remains asymptomatic for a long period of time and its real burden gets noticed only once the complications set in. The number of individuals affected with the disease is also on the rise and more so in the low income countries. This scenario calls for urgent precautionary measures that need to be undertaken to equip ourselves to fight against this chronic disease. Individuals with financial constraints cannot afford to access even the basic treatment facilities and thus stands the most burdened. The International Diabetes Federation calls for 'Eyes on Diabetes' for the society to focus on early screening and early intervention. The rising cost of diabetes results from delayed and denied treatment. The panel discussion organized as a part of 4th Annual global diabetes convention of Jothydev's Professional Education Forum (JPEF, 2016) facilitated a platform to address diabetes as a serious health concern that needs to be given immediate priority by the policymakers as well as public and also to discuss about the feasible measures that will help achieve cost effective and affordable diabetes treatment. This was followed by in-depth literature search and finally a set of recommendations have been arrived at by the key opinion leaders to realize the dream of affordable diabetes care to all deserving individuals.

Clinical Effectiveness and Impact on Insulin Therapy Cost After Addition of Dapagliflozin to Patients with Uncontrolled Type 2 Diabetes

INTRODUCTION

Dapagliflozin, a sodium glucose co-transporter 2 (SGLT2) inhibitor, is a promising drug approved for the treatment of type 2 diabetes mellitus (T2DM). However, its cost is an obstacle for use in developing countries like India. Thus, we aimed to analyse the impact on the cost of insulin therapy after adding dapagliflozin for patients using insulin in real-world clinical practice.

METHODS

This retrospective chart review study included patients with uncontrolled T2DM previously on maximum doses of OADs and insulin therapy, initiated on dapagliflozin. Parameters measured were: HbA1c, changes in weight and insulin dosage, frequency and cost, at baseline and after 3 months of adding dapagliflozin 10 mg. Hospital records of patients attending the diabetes outpatient departments at the study centres were scrutinised to identify eligible patients. A treat-to-target approach was used to make changes in the insulin dosages and regimen. The cost of insulin was calculated based on the total daily dose, cost per unit based on the formulation and insulin delivery device. Statistical analysis included descriptive and inferential methods.

RESULTS

Overall, 70 patients meeting the inclusion criteria were included in the study. The mean age of patients and duration of T2DM were 52.6 ± 10 and 12 ± 5 years respectively. The mean reduction in HbA1c and weight was 2.1 ± 1% (p < 0.01) and 2.4 ± 1 kg (p < 0.01) respectively. Genital mycotic infections were reported in two (2.8%) patients. The mean reduction in the total daily dose of insulin was 9.5 ± 6 units. A significant reduction in the daily insulin requirement (19.87%, p < 0.01) was observed. The cost of insulin decreased by 22.3% or 17.8 ± 15 INR per day ($0.27 ± 0.22 per day) and the frequency of insulin shots administered per day decreased significantly (p < 0.01). In 12.8% and 2.8% of patients the frequency of administration of insulin decreased by one and two injections per day respectively.

CONCLUSIONS

Reduction in HbA1c and body weight along with minimal side effects was observed. Addition of dapagliflozin reduced the insulin daily dose requirement and cost of insulin therapy in these patients.

FUNDING

Diacon Hospital, Bangalore, India.

A Prospective Analysis of the Efficacy and Safety of Sodium Glucose Cotransporter 2 Inhibitors: Real World Evidence from Clinical Practice in India

BACKGROUND AND AIM

The number of patients with type 2 diabetes (T2DM) is increasing. Most patients with T2DM are uncontrolled and fail to achieve their target Hba1c. In recent years, newer agents such as SGLT2 inhibitors (SGLT2i) have been approved for clinical use. Though data from clinical trials and sub set analysis of Indian patients in global studies are promising, real world evidence from standard clinical practice in India is lacking. The aim of this study was to analyze the metabolic parameters in patients with T2DM on SGLT2i in real world clinical practice.

MATERIAL AND METHODS

This was a prospective, longitudinal study of 100 patients with uncontrolled T2DM attending the outpatient of a specialized diabetes hospital. Their metabolic parameters were evaluated at baseline and after 3 months of follow up. They were categorized based on their baseline anti diabetic medications into four groups (25 in each).The groups were as follows: metformin plus sulfonylurea, metformin plus DPP4 inhibitor, triple drug regimen with metformin plus DPP4 inhibitor plus sulfonylurea, and patients on insulin and on triple drug therapy with metformin plus sulfonylurea plus DPP4 inhibitor. Patients in each group were initiated with an SGLT2i. Descriptive statistical analysis was carried out using Microsoft excel. T test was used to calculate the p value at 5 % level of significance.

RESULTS

The mean age of the subjects in the study population was 53.20±12.1 years and the duration of diabetes was 13.1±7.26 years. The mean Hba1c reduction and weight reduction observed was 1.02±0.24% and 2.64±1.27 kg respectively. Genital pruritis was reported in 4% of the patients. There was a 16.6% reduction in the daily insulin requirement at follow up when compared to baseline. No other side effects were observed. The reductions in Hba1c and weight were statistically significant (p<0.05) across all groups.

CONCLUSIONS

This study demonstrates that when SGLT2i are added at any stage of the disease spectrum with any of the preexisting therapeutic agents for patients with uncontrolled T2DM, there is an improvement in glycemic control and body weight, with minimal side effects. The real world study data on Indian patients appears to be promising.

Cardiovascular risk factors, micro and macrovascular complications at diagnosis in patients with young onset type 2 diabetes in India: CINDI 2

CONTEXT

Type 2 diabetes mellitus (T2DM) in young adults is increasing in India. Data on the prevalence of cardiovascular (CV) risk factors and complications associated with young-onset T2DM (YOD) at the time of diagnosis of diabetes are limited. This data can aid in aggressive diabetes management, CV risk reduction, and prevention of complications.

AIM

To determine the prevalence of CV risk factors, micro and macrovascular complications in patients with newly diagnosed YOD. To assess the percentage of patients who require statin therapy based on current American Diabetes Association (ADA) guidelines.

SETTINGS AND DESIGN

This was a retrospective cross-sectional study of 1500 patients with newly detected YOD across seven centers from 2013 to 2015.

DESIGNS AND METHODS

Patients were evaluated for complications of diabetes and CV risk factors such as body mass index (BMI), hypertension, dyslipidemia, and smoking.

STATISTICAL ANALYSIS

Measurements have been presented as mean ± standard deviation; results on categorical measurements have been presented in percentages.

RESULTS

The mean age, glycated hemoglobin and BMI were 34.7 ± 4.2 years, 9.9 ± 2.4%, and 26.8 ± 4.7 kg/m(2). Hypertension, dyslipidemia, BMI >23 kg/m(2), and smoking were presented in 27.6%, 62.4%, 84.2%, and 24%. Diabetic retinopathy, neuropathy, and nephropathy were seen in 5.1%, 13.2%, and 0.9%. Ischemic heart disease, peripheral vascular disease, and stroke were presented in 0.7%, 2%, and 0.1%. As per current guidelines, 95.33% needed statin therapy.

CONCLUSION

This study demonstrates that patients with YOD have micro and macrovascular complications at diagnosis. Nearly, every patient required a statin to reduce CV risk. This highlights the importance of screening patients with YOD for CV risk factors and complications of diabetes at the time of diagnosis.

Saroglitazar for the treatment of hypertrig-lyceridemia in patients with type 2 diabetes: current evidence

Diabetes mellitus (DM) is one of the most dreaded metabolic disorders in the world today. It is the leading cause of morbidity and mortality, and plays a cardinal role in quality of life and health economics. DM is associated with a high prevalence of microvascular and macrovascular complications. DM is a very important cardiovascular (CV) risk factor. Cardiovascular disease (CVD) has been implicated as the prime cause of mortality and morbidity in patients with DM. Hence, treatment of DM goes beyond glycemic control, and demands a multidisciplinary approach that comprehensively targets risk factors inherent in CV events. Lipid abnormalities are undoubtedly common in patients with DM, and they contribute to an increased risk of CVD. A high-risk lipid profile, termed atherogenic dyslipidemia of diabetes (ADD), is known to occur in patients with DM. The use of lipid-lowering agents, a quintessential part of the multifactorial risk factor approach, is a crucial intervention to minimize diabetes-related complications. In this article, we discuss the role of peroxisome proliferator activator receptor (PPAR) alpha/gamma (α/γ) agonist, saroglitazar, in the management of ADD. While statins are irrefutably the first line of drugs for dyslipidemia management in patients with residual CV risk while on a statin, PPAR α/γ agonists have been found to be of substantial benefit. Data from the PRESS I-VI clinical trials testify to the fact that saroglitazar and fibrates have similar efficacy in reducing triglycerides and improving high-density lipoprotein. The ancillary benefit of improved glycemic control, without the weight gain of PPAR γ agonists, is an added advantage. Reduction in ADD, improved glycemic control, efficacy at par with fibrates, and an acceptable safety profile form the grounds on which this group of PPAR α/γ agonists, with their novel mechanism, holds a promising future in the management of diabetic dyslipidemia.