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Items: 7

1.
Diabet Med. 2017 Sep;34(9):1183-1184. doi: 10.1111/dme.13434.

Overtreatment of diabetes in older people.

Author information

1
University of Southampton.
PMID:
28815773
DOI:
10.1111/dme.13434
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3.
Diabetes Care. 2017 Oct;40(10):1394-1400. doi: 10.2337/dc17-0681. Epub 2017 Aug 15.

Prognosis and Its Predictors After Incident Stroke in Patients With Type 1 Diabetes.

Author information

1
Folkhälsan Institute of Genetics, Folkhälsan Research Center, Biomedicum Helsinki, Helsinki, Finland.
2
Abdominal Center Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
3
Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland.
4
Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland.
5
Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.
6
Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.
7
Folkhälsan Institute of Genetics, Folkhälsan Research Center, Biomedicum Helsinki, Helsinki, Finland per-henrik.groop@helsinki.fi.
8
Department of Diabetes, Central Clinical School, Monash University, Melbourne, Victoria, Australia.

Abstract

OBJECTIVE:

Although patients with type 1 diabetes have a poor prognosis after a stroke, predictors of survival after an incident stroke in these patients are poorly studied.

RESEARCH DESIGN AND METHODS:

In this observational study, a total of 144 patients of 4,083 with type 1 diabetes from the Finnish Diabetic Nephropathy (FinnDiane) Study suffered an incident stroke in 1997-2010, and were followed for a mean 3.4 ± 3.1 years after the stroke. Information was recorded on hard cardiovascular events and death as a result of cardiovascular or diabetes-related cause, collectively referred to as vascular composite end point. Information was collected from medical records, death certificates, and the National Care Register of Health Care. Predictors at the time of the incident stroke were studied for the end points.

RESULTS:

During follow-up, 104 (72%) patients suffered a vascular composite end point. Of these, 33 (32%) had a recurrent stroke, 33 (32%) a hard cardiovascular event, and 76 (53%) died of cardiovascular or diabetes-related causes, with an overall 1-year survival of 76% and 5-year survival of 58%. The predictors of a vascular composite end point were hemorrhagic stroke subtype (hazard ratio 2.03 [95% CI 1.29-3.19]), as well as chronic kidney disease stage 2 (2.48 [1.17-5.24]), stage 3 (3.04 [1.54-6.04]), stage 4 (3.95 [1.72-9.04]), and stage 5 (6.71 [3.14-14.34]). All-cause mortality increased with deteriorating kidney function.

CONCLUSIONS:

Patients with type 1 diabetes with an incident stroke have a poor cardiovascular prognosis and a high risk of all-cause mortality. In particular, hemorrhagic stroke subtype and progression of diabetic kidney disease conveys worse outcome.

PMID:
28811283
DOI:
10.2337/dc17-0681
[Indexed for MEDLINE]
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4.
Diabetes Care. 2017 Oct;40(10):1342-1348. doi: 10.2337/dc17-0140. Epub 2017 Aug 14.

Can Secure Patient-Provider Messaging Improve Diabetes Care?

Author information

1
Palo Alto Medical Foundation Research Institute, Palo Alto, CA chungs@pamfri.org.
2
Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA.
3
Department of Medicine, Stanford University School of Medicine, Stanford, CA.

Abstract

OBJECTIVE:

Internet-based secure messaging between patients and providers through a patient portal is now common in the practice of modern medicine. There is limited evidence on how messaging is associated with use and clinical quality measures among patients with type 2 diabetes. We examine whether messaging with physicians for medical advice is associated with fewer face-to-face visits and better diabetes management.

RESEARCH DESIGN AND METHODS:

Patients with diabetes who were enrolled in an online portal of an outpatient health care organization in 2011-2014 were studied (N = 37,762 patient-years). Messages from/to primary care physicians or diabetes-related specialists for medical advice were considered. We estimated the association of messaging with diabetes quality measures, adjusting for patient and provider characteristics and patient-level clustering.

RESULTS:

Most patients (72%) used messaging, and those who made frequent visits were also more likely to message. Given visit frequency, no (vs. any) messaging was negatively associated with the likelihood of meeting an HbA1c target of <8% (64 mmol/mol) (odds ratio [OR] 0.83 [95% CI 0.77, 0.90]). Among message users, additional messages (vs. 1) were associated with better outcome (two more messages: OR 1.17 [95% CI 1.06, 1.28]; three more messages: 1.38 [1.25, 1.53]; four more messages: 1.55 [1.43, 1.69]). The relationship was stronger for noninsulin users. Message frequency was also positively associated, but to a smaller extent, with process measures (e.g., eye examination). Physician-initiated messages had effects similar to those for patient-initiated messages.

CONCLUSIONS:

Patients with diabetes frequently used secure messaging for medical advice in addition to routine visits to care providers. Messaging was positively associated with better diabetes management in a large community outpatient practice.

PMID:
28807977
DOI:
10.2337/dc17-0140
[Indexed for MEDLINE]
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5.
Diabetes Care. 2017 Nov;40(11):1469-1478. doi: 10.2337/dc16-2725. Epub 2017 Aug 11.

Understanding the Gap Between Efficacy in Randomized Controlled Trials and Effectiveness in Real-World Use of GLP-1 RA and DPP-4 Therapies in Patients With Type 2 Diabetes.

Author information

1
Analysis Group, Menlo Park, CA.
2
Analysis Group, Menlo Park, CA ruo-ding.tan@analysisgroup.com.
3
Intarcia Therapeutics, Boston, MA.
4
Division of Endocrinology and Metabolism, School of Medicine, University of California, San Diego, San Diego, CA.
5
Taking Control of Your Diabetes, Del Mar, CA.
6
Veterans Affairs Medical Center, San Diego, CA.
7
Department of Psychiatry, University of California, San Diego, San Diego, CA.
8
Behavioral Diabetes Institute, San Diego, CA.

Abstract

OBJECTIVE:

The objective of this study was to estimate and explain the gap between clinical efficacy and real-world (RW) effectiveness of type 2 diabetes medications.

RESEARCH DESIGN AND METHODS:

This mixed-methods quasi-experimental study used retrospective claims (Optum/Humedica) to compare the change in HbA1c of RW patients with type 2 diabetes 12 months after starting a glucagon-like peptide 1 receptor agonist (GLP-1 RA) or dipeptidyl peptidase 4 (DPP-4) inhibitor with published findings from randomized controlled trials (RCTs) evaluating these drugs. Selected RW patients were similar to RCT patients, and regression analysis was used in the RW data to adjust for differences between poorly adherent and adherent patients to explain why RCT and RW findings may differ.

RESULTS:

RW patients initiating a GLP-1 RA (n = 221) or a DPP-4 (n = 652) experienced smaller reductions in HbA1c (GLP-1 RA: -0.52% [-6 mmol/mol], DPP-4: -0.51% [-6 mmol/mol])than reported in RCTs (-1.30% [-14 mmol/mol] from seven GLP-1 RA RCTs, n = 2,600; -0.68% [-8 mmol/mol] from four DPP-4 RCTs, n = 1,889). Baseline HbA1c, additional medications, and adherence were significant explanatory factors in the RW HbA1c change. Modeled estimates of RCT efficacy (-1.04% GLP-1 RA [-12 mmol/mol], -0.69% DPP-4 [-8 mmol/mol]) were within the RCTs' reported range (GLP-1 RA: -0.84% to -1.60% [-9 to -18 mmol/mol], DPP-4: -0.47% to -0.90% [-5 to -10 mmol/mol]). Poor medication adherence accounted for approximately three-fourths of the gap between RW and expected RCT results (gap = 0.51% [6 mmol/mol] GLP-1 RA; 0.18% [3 mmol/mol] DPP-4).

CONCLUSIONS:

Poor medication adherence is primarily why RW effectiveness is significantly less than RCT efficacy, suggesting an urgent need to effectively address adherence among patients with type 2 diabetes.

PMID:
28801475
DOI:
10.2337/dc16-2725
[Indexed for MEDLINE]
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6.
Diabetes Care. 2017 Nov;40(11):1588-1596. doi: 10.2337/dc16-1925. Epub 2017 Aug 11.

Association Between Adherence to Pharmacotherapy and Outcomes in Type 2 Diabetes: A Meta-analysis.

Author information

1
Leicester Diabetes Centre, Leicester General Hospital, Leicester, U.K. kk22@leicester.ac.uk.
2
Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, U.K.
3
Leicester Diabetes Centre, Leicester General Hospital, Leicester, U.K.
4
School of Clinical Sciences, University of Bristol, Southmead Hospital, Southmead, U.K.

Abstract

OBJECTIVE:

A previous study suggests an association between poor medication adherence and excess mortality in chronic disease. The purpose of this study was to assess the association between medication adherence and risk of cardiovascular disease (CVD), all-cause mortality, and hospitalization in type 2 diabetes.

RESEARCH DESIGN AND METHODS:

We conducted an electronic search on many electronic databases from inception to 27 April 2016. We selected randomized controlled trials and case-control and cohort studies reporting on CVD, all-cause mortality, or hospitalization outcomes by adherence in adults with type 2 diabetes. Two reviewers independently screened for eligible studies and extracted outcome data. Pooled relative risks (RRs) were calculated using a random-effects meta-analysis; risk of bias in each of the included studies was assessed using the GRADE approach.

RESULTS:

Eight observational studies were included (n = 318,125). The mean rate of poor adherence was 37.8% (95% CI 37.6-38.0). Adjusted estimates were provided by five studies only. The RRs of good (≥80%) versus poor adherence to medication were 0.72 (95% CI 0.62-0.82, I2 = 0%, three studies) for all-cause mortality and 0.90 (0.87-0.94, I2 = 63%, seven studies) for hospitalization. No evidence of small study bias was observed. Only one study reported CVD outcomes by adherence.

CONCLUSIONS:

We identified no trials reporting on outcomes by adherence, suggesting a systematic failure to include this information. Pooled estimates from available observational studies suggest that good medication adherence is associated with reduced risk of all-cause mortality and hospitalization in people with type 2 diabetes, although bias cannot be excluded as an explanation for these findings.

PMID:
28801474
DOI:
10.2337/dc16-1925
[Indexed for MEDLINE]
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7.
Diabetes Care. 2017 Nov;40(11):1425-1432. doi: 10.2337/dc16-1974. Epub 2017 Aug 11.

Type 2 Diabetes in the Real World: The Elusive Nature of Glycemic Control.

Author information

1
Division of Endocrinology and Metabolism, School of Medicine, University of California, San Diego, San Diego, CA svedelman@vapop.ucsd.edu.
2
Veterans Affairs Medical Center, San Diego, CA.
3
Taking Control of Your Diabetes, Del Mar, CA.
4
Department of Psychiatry, University of California, San Diego, San Diego, CA.
5
Behavioral Diabetes Institute, San Diego, CA.

Abstract

Despite U.S. Food and Drug Administration (FDA) approval of over 40 new treatment options for type 2 diabetes since 2005, the latest data from the National Health and Nutrition Examination Survey show that the proportion of patients achieving glycated hemoglobin (HbA1c) <7.0% (<53 mmol/mol) remains around 50%, with a negligible decline between the periods 2003-2006 and 2011-2014. The Healthcare Effectiveness Data and Information Set reports even more alarming rates, with only about 40% and 30% of patients achieving HbA1c <7.0% (<53 mmol/mol) in the commercially insured (HMO) and Medicaid populations, respectively, again with virtually no change over the past decade. A recent retrospective cohort study using a large U.S. claims database explored why clinical outcomes are not keeping pace with the availability of new treatment options. The study found that HbA1c reductions fell far short of those reported in randomized clinical trials (RCTs), with poor medication adherence emerging as the key driver behind the disconnect. In this Perspective, we examine the implications of these findings in conjunction with other data to highlight the discrepancy between RCT findings and the real world, all pointing toward the underrealized promise of FDA-approved therapies and the critical importance of medication adherence. While poor medication adherence is not a new issue, it has yet to be effectively addressed in clinical practice-often, we suspect, because it goes unrecognized. To support the busy health care professional, innovative approaches are sorely needed.

PMID:
28801473
DOI:
10.2337/dc16-1974
[Indexed for MEDLINE]
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