UPDATES DIABETES
Overcoming
Insulin
Fears
Diabetes &
Vaccines Treatment
Trends Type 2
For
Brought to you in conjunction with the:
Diabetes December 2014
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Table of Contents Treatment Trends for Type 2 Diabetes – G. Caleb Alexander, MD, FACP 4
Keeping Up With Vaccinations for People With Diabetes 8
A Message From the Editor At Physician’s Weekly, we are proud to present this monograph featuring several features that are applicable to those managing patients with diabetes. Created with the assistance of key opinion leaders and experts from the American Diabetes Association, these articles discuss important aspects of diabetes care and strategies to improve current practices. In the upcoming months, Physician’s Weekly will continue to feature topics on diabetes and its complications. Your feedback and opinions are welcome; email keith.doria@physweekly.com. Thanks for reading!
– Cecilia C. Low Wang, MD, FACP
Sincerely,
Initiating Insulin: Strategies to Overcome Patient Fears 12
Keith D’Oria
Editorial Director, Physician’s Weekly
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Achieving A1C Goals: Back to the Basics – Etie Moghissi, MD, FACP, FACE 23
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The Value of Inpatient Diabetes Education – Kathleen M. Dungan, MD, MPH 24
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Treatment Trend for Type 2 Diabete Treatments for type 2 diabetes have grown in complexity, while older therapies continue to be replaced or supplemented by newer ones. Monitoring these patterns is critical as emerging research compares safety and effectiveness of newer therapies versus older treatments.
T
he burden of diabetes is expected to increase over the next few decades in the United States, with about one in three American adults projected to be at risk for developing the disease by
G. Caleb Alexander, MD, FACP Associate Professor, Departments of Epidemiology and Medicine Co-Director, Center for Drug Safety and Effectiveness Johns Hopkins Bloomberg School of Public Health
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2050. Diabetes has also been linked to a considerable economic burden, with annual direct medical expenditures for treating and managing the disease totaling nearly $250 billion in 2012. Most of the medical expenditures for diabetes are attributable to hospitalizations and physician services, but the costs of prescription therapies are also significant. With the high prevalence and burden of diabetes, the disease has become a ripe target for pharmaceutical development. “During the past decade, several important changes in the diabetes marketplace have
s
This Physician’s Weekly feature on treatment trends for type 2 diabetes was completed in cooperation with the experts at the American Diabetes Association.
s
occurred,� explains G. Caleb Alexander, MD, FACP. For example, in the early 2000s, glitazones were rapidly adopted for use, but subsequent evidence suggested that these agents were associated with cardiovascular risks. In turn, this led to substantial declines in the use of glitazones during the latter half of the decade. In addition, new long-acting insulins and several new classes of therapies have emerged to treat type 2 diabetes, including injectable incretin mimetics such as glucagonlike peptide 1 (GLP-1) agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors, and sodium glucose cotransporter
2 (SGLT-2) inhibitors. The costs of these medications can be high, but clinicians appear to be interested in using them because of their novel mechanisms of action and potential promise in helping to improve glycemic control among those with type 2 diabetes.
Examining Recent Patterns Over the past 2 decades, clinical investigations have examined changes in the treatment of diabetes. These analyses identified several important trends, but much of this research was conducted before data
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It’s critical to monitor these patterns as additional evidence emerges. — G. Caleb Alexander, MD, FACP Using data from the IMS Health National Disease and Therapeutic Index, Dr. Alexander and colleagues focused on ambulatory visits for diabetes among patients aged 35 and older. The study showed that the number of ambulatory visits for diabetes treatment increased from 23 million in 1997 to 35 million in 2007 but declined to 31 million by 2012. “Over the past 15 years, the use of glitazones and sulfonylureas decreased,” says Dr. Alexander (Figure 1). The research also showed a plateauing of biguanide use after steady increases until 2010. Insulin use was stable but increasingly dominated by the use of long-acting insulin glargine.
emerged on risks from using some drug classes—glitazones, in particular—and before GLP-1 agonists, DPP-4 inhibitors, and SGLT-2 inhibitors reached the market. “A variety of factors, including clinical innovation, emerging evidence on safety and efficacy, and changes in payment and regulatory policy, have impacted the treatment landscape for type 2 diabetes,” Dr. Alexander says. Dr. Alexander and colleagues had a study published in Diabetes Care that examined treatment patterns for type 2 diabetes between 1997 and 2012 among office-based physicians in the U.S. In addition, the study paid close attention to the adoption of DPP-4 inhibitors and GLP-1 agonists and how changes in the use of long-acting insulins may have impacted the use of oral therapies. The analysis also examined treatment patterns with specific drug combinations, treatment complexity, and the aggregate cost of different classes of agents.
Figure 1
Embracing New Therapies Since 2005, the use of DPP-4 inhibitors increased steadily, representing 21% of treatment visits by 2012. GLP-1 agonists accounted for 4% of treatment visits in 2012. From 1997 to 2012, visits in which two or
Ambulatory Treatment Trends
The figure below depicts national trends in the ambulatory treatment of type 2 diabetes from 1997 to 2012: 70
Biguanides Glucagon-like peptide-1 (GLP-1) agonist Glitazones (thiazolidinediones)
60
Dipeptidyl peptidase-4 (DPP-4) inhibitors Insulins Sulfonylureas
Treatment visits, %
50 40 30 20 10 0
6
97
98
99
00
01
02
03
04
Year
05
06
07
08
09
10
11
12
Source: Adapted from: Turner LW, et al. Diabetes Care. 2014;37:985-992.
A Rapid Evolution According to Dr. Alexander, findings from the study are important because of the economic and clinical burden posed by type 2 diabetes and because of the rapidly evolving clinical marketplace. “There are many factors to consider when looking at the ways patients with diabetes are being treated,” he says. “We have many drugs and drug classes to choose from and there is increasing use of dual therapies and combination products. In addition, new medications with novel pathways are emerging. It’s critical to monitor these patterns as additional evidence emerges. We also need
Figure 2
Pharmacy Expenditure Trends
The figure below depicts national trends in pharmacy expenditures on diabetes drugs from 2008 to 2012. These data were adjusted for inflation using 2008 dollars: Sulfonylureas Glitazones Glucagon-like peptide-1 (GLP-1) agonist
Insulins Biguanides Dipeptidyl peptidase-4 (DPP-4) inhibitors
$12,000 $10,000 Total sales, millions
more drug compounds were used increased by nearly 40%. Between 2008 and 2012, drug expenditures increased by 61% to almost $22 billion, driven primarily by use of insulin glargine and DPP-4 inhibitors (Figure 2). “These data suggests that physicians are embracing the use of newer therapies that are being brought to market,” Dr. Alexander says. “It also shows that the treatment and management of these patients have grown in complexity and cost, while older treatments are continuing to be replaced or supplemented by newer therapies.”
$8,000 $6,000 $4,000 $2,000 $
2008
2009
2010 Year
2011
2012
Source: Adapted from: Turner LW, et al. Diabetes Care. 2014;37:985-992.
to conduct comparative effectiveness trials and to assess the potential risks of newer therapies so that every effort is being made to optimize patient outcomes.”
For more information on this article, including the contributor’s financial disclosure information, go to www.physweekly.com/diabetes-trends.
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Victor M. Montori, MD, MSc, explains how treatment administration and monitoring often go unaddressed patients with diabetes in our related article, Addressing Treatment Burden in Diabetes.
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Readings & Resources Turner LW, Nartey D, Stafford RS, Singh S, Alexander GC. Ambulatory treatment of type 2 diabetes in the U.S., 1997–2012. Diabetes Care. 2014;37:985-992. Available at: http://care.diabetesjournals.org/content/37/4/985.full. American Diabetes Association. Standards of Medical Care in Diabetes—2014. Diabetes Care. 2014;37:S14-S80. Ratner RE. Diabetes management in the age of national health reform. Diabetes Care. 2011;34:1054–1057. Sinha A, Rajan M, Hoerger T, Pogach L. Costs and consequences associated with newer medications for glycemic control in type 2 diabetes. Diabetes Care. 2010;33:695–700. American Diabetes Association. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 2013;36:1033–1046. Alexander GC, Tseng CW. Six strategies to identify and assist patients burdened by out-of-pocket prescription costs. Cleve Clin J Med. 2004;71:433–437. Cohen A, Rabbani A, Shah N, Alexander GC. Changes in glitazone use among office-based physicians in the U.S., 2003-2009. Diabetes Care. 2010;33:823–825. Drucker DJ, Sherman SI, Bergenstal RM, Buse JB. The safety of incretin-based therapies: review of the scientific evidence. J Clin Endocrinol Metab. 2011;96:2027–2031.
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Keeping Up With
Vaccinations for People With Diabetes Safe and effective vaccines are available to help patients with diabetes greatly reduce their risk of serious complications from several infectious diseases. Clinicians should be vigilant about ensuring that these vaccinations are given as required.
Cecilia C. Low Wang, MD, FACP Associate Professor of Medicine Associate Director, Fellowship/Education Division of Endocrinology, Metabolism and Diabetes Department of Medicine University of Colorado Anschutz Medical Campus/School of Medicine
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This Physician’s Weekly feature on keeping up with vaccinations in diabetes was completed in cooperation with the experts at the American Diabetes Association.
R
esearch has shown that patients with diabetes are more prone to getting various types of infections, which in turn can increase their risk for hospitalizations. According to Cecilia C. Low Wang, MD, FACP, it can be challenging for clinicians to ensure that their patients with diabetes are up to date with vaccinations against common infections. “Oftentimes, clinicians are busy focusing on the management of diabetes and diseaserelated complications,” she says. “Prevention efforts like immunizations can sometimes take a backseat to other diabetes care issues.”
Influenza & Pneumonia The American Diabetes Association, the CDC, and other groups have developed recommendations to guide clinicians on the vaccinations that should be administered to patients with diabetes. Influenza and pneumococcal vaccines are recommended for all individuals with diabetes (Table 1). The flu is among the most
common infections in diabetics and has been linked to high morbidity and mortality as well as an increase in hospitalizations. Published data have shown that the influenza vaccine helps reduce diabetes-related hospital admissions by nearly 80% during flu epidemics. Studies have also shown that people with diabetes appear to be at higher risk for pneumococcal infection and nosocomial bacteremia, which has a mortality rate that has been reportedly as high as 50%. “The flu and pneumonia are preventable infectious diseases,” says Dr. Low Wang. “Safe and effective vaccines are available and can greatly reduce the risk of serious complications from these infections.” The American Diabetes Association notes in its annual
Table 1
Key Recommendations Level of Evidence
Recommendation Annually provide an influenza vaccine to all diabetic patients who are 6 months of age or older.
C
Administer pneumococcal polysaccharide vaccine to all diabetic patients who are 2 years of age or older. A one-time revaccination is recommended for individuals older than 64 who were previously immunized when they were younger than 65 if the vaccine was administered more than 5 years ago. Other indications for repeat vaccination include nephrotic syndrome, chronic renal disease, and other immunocompromised states, such as after transplantation.
C
Administer hepatitis B vaccination to unvaccinated adults with diabetes who are between the ages of 19 and 59. Consider administering hepatitis B vaccination to unvaccinated adults with diabetes aged 60 and older.
C
Source: Adapted from: American Diabetes Association. Diabetes Care. 2013;36:S1-S110.
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Prevention efforts like immunizations can sometimes take a backseat to other diabetes care issues. —Cecilia C. Low Wang, MD, FACP Standards of Medical Care in Diabetes that there is sufficient evidence to support that people with diabetes have appropriate serological and clinical responses to the influenza and pneumococcal vaccines. Most individuals with diabetes should receive the pneumococcal polysaccharide (PPSV23) form of the pneumococcal vaccine, but this is contraindicated during pregnancy. A second dose of PPSV23 is required if the first dose was administered prior to the age of 65 and at least 5 years since the first dose.
Hepatitis B Late in 2012, the Advisory Committee on Immu nization Practices of the CDC recommended that all previously unvaccinated adults with diabetes between the ages of 19 and 59 be vaccinated against hepatitis B virus (HBV) as soon as possible after they are diagnosed with diabetes. The CDC also recommends that HBV vaccination be considered for those older than 60 after assessing risk and the likelihood of an adequate immune response. The age differentiation stems from CDC economic models. These models suggested that vaccinating adults with diabetes between the ages of 19 and 59 would cost an estimated $75,000 per quality-adjusted life-year saved. Cost per qualityadjusted life-year saved increased significantly at older ages. Also, the immune response to the HBV vaccine declines with age, and there are competing causes of mortality in older adults to consider (Table 2).
According to the CDC, at least 29 outbreaks of HBV have been reported in long-term care facilities and hospitals, with the majority of cases involving adults with diabetes who received assisted blood glucose monitoring. In these cases, this monitoring was done by a healthcare professional with responsibility for more than one patient. Studies show that the risk of acute HBV infection is about twice as high among adults with diabetes aged 23 and older when compared with adults who do not have diabetes. This finding occurred despite the exclusion of people with HBV-related risk behaviors. Furthermore, there is some evidence that diabetes imparts a higher HBV case fatality rate. Table 2
Hepatitis B Vaccination & Diabetes
The CDC has recommended that unvaccinated adults with diabetes aged 19 to 59 should receive the hepatitis B vaccine. ACIP also recommended that, at the discretion of clinicians, the hepatitis B vaccine be administered to unvaccinated adults with diabetes aged 60 and older. The table below demonstrates recent evidence on how the hepatitis B vaccine series was associated with the rates of protective response: Age of patients with diabetes Protective response rates from and no comorbid conditions hepatitis B vaccine series Aged 40 and younger
≥90%
Aged 41-59
80%
Aged 60-69
65%
Aged 70 and older
<40%
Abbreviation: ACIP, Advisory Committee on Immunization Practices of the CDC. Source: Adapted from: CDC. MMWR Morb Mortal Wkly Rep. 2011;60:1709-1711.
Additional Resources Online! View or download Standards of Medical Care in Diabetes—2014, which comprises all of the current and key clinical practice recommendations of the American Diabetes Association.
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Table 3
Other Vaccines to Consider
The Immunization Action Coalition has issued information on other vaccinations that can be helpful for adults with diabetes: Vaccines
Considerations
Hepatitis A
Patients should receive this vaccine if they have specific risk factors for hepatitis A virus infection or if they wish to be protected from it. The vaccine is usually given in two doses 6 months apart.
Human papillomavirus (HPV)
Women aged 26 or younger or men age 21 or younger should receive the HPV vaccine. Men aged 22 to 26 with a risk condition also need vaccination. Men aged 22 to 26 who wish to be protected from HPV may receive it. The vaccine is given in three doses over 6 months.
Measles, mumps, & rubella (MMR)
Patients need at least one dose of MMR if they were born in 1957 or later. They may also need a second dose.
Meningococcal disease (MCV4, MPSV4)
Patients need this vaccine if they have one of several health conditions or if they are aged 19 to 21 and a firstyear college student living in a residence hall and have never been vaccinated for it or were vaccinated before the age of 16.
Tetanus, diphtheria, and whooping cough (pertussis, Tdap, Td)
All adults with diabetes need to get Tdap vaccine. Women need to get a Tdap dose during each pregnancy. After Tdap is given, a Td booster dose is needed every 10 years. Patients should have at least three tetanus- and diphtheria-containing shots at some point in life or if they have deep or dirty wounds.
Varicella (Chickenpox)
Adults born in the United States in 1980 or later who have never had chickenpox or the vaccine should be vaccinated with this two-dose series.
Zoster (shingles)
A one-time dose of this vaccine should be given to patients who are 60 or older. Source: Adapted from: Immunization Action Coalition. Available at: www.immunize.org/catg.d/p4043.pdf.
“HBV is highly transmissible and stable for long periods of time on surfaces like lancing devices and blood glucose meters, even when no blood is visible,” says Dr. Low Wang. “Insulin pens are another potential source for HBV infection. As a result, patients should be instructed not to share these devices with other individuals.” Beyond HBV infection, Dr. Low Wang says other vaccinations that are recommended for the general population should also be provided to patients with diabetes. These include common vaccinations, such as measles, mumps, and rubella; meningococcal disease; tetanus, diphtheria, and whooping cough; varicella; zoster; hepatitis A; and HPV (Table 3).
Vigilance Required “Clinicians need to be vigilant about vaccinations when treating patients with diabetes,” Dr. Low Wang says. “Protocols should be in place to ensure that recommended vaccinations are accounted for in a checklist for comprehensive diabetes care,” she says. “Records should be updated on what vaccinations patients have completed as well as the ones that need to be administered. Clinicians should also refer back to vaccine recommendations from the American Diabetes Association and the CDC in case changes are made. The key is to keep immunizations in mind when treating patients with diabetes. This is an important part of care that should not be overlooked.”
For more information on this article, including the contributor’s financial disclosure information, go to www.physweekly.com/vaccinations.
Readings & Resources American Diabetes Association. Standards of Medical Care in Diabetes—2014. Diabetes Care. 2014;37:S14-S80. Centers for Disease Control and Prevention. Use of hepatitis B vaccination for adults with diabetes mellitus: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2012;60:1709-1711. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm6050a4.htm. Immunization Action Coalition. Vaccinations for Adults with Diabetes. Available at: www.immunize.org/catg.d/p4043.pdf. Smith SA, Poland GA. Use of influenza and pneumococcal vaccines in people with diabetes. Diabetes Care. 2000;23:95-108. Colquhoun AJ, Nicholson KG, Botha JL, Raymond NT. Effectiveness of influenza vaccine in reducing hospital admissions in people with diabetes. Epidemiol Infect. 1997;119:335-341. Bridges CB, Fukuda K, Uyeki TM, Cox NJ, Singleton JA; Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices. Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2002;51(RR-3):1-31.
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Initiating Insulin Strategies to Overcome Patient Fear Patients with diabetes often express fear when starting insulin, but physicians can help them overcome these problems by taking simple measures and talking about concerns early in the disease course.
M
any patients with type 2 diabetes eventually require insulin therapy and benefit from it. Timely initiation of insulin is critical to managing diabetes and helping patients avoid disease-related complications. “Insulin is an effective treatment for diabetes, but patients and physicians alike often consider this therapy a last resort. This can lead to long delays in patients starting insulin, which in turn lead to longer periods of elevated blood sugars that place these individuals at higher risk for complications,” says Jeremy Pettus, MD. “The reasons why patients are hesitant to take insulin are multifactorial. Providers need to understand the barriers to insulin initiation and reduce any negative perceptions that patients may have about taking this important medication.”
Jeremy Pettus, MD Endocrinology Fellow University of California, San Diego
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Considering Patient Barriers Many patients have misconceptions on what it means to be prescribed insulin, according to Dr. Pettus. Some patients see insulin as potentially leading to more health problems down the road. Others perceive it as a punishment if they fail to do what is necessary to properly manage their diabetes. Clinicians should get an understanding of patients’ views on insulin before they initiate it. “We should inform patients about the progressive nature of the disease that commonly results in requiring insulin and objectively explain to them why insulin is required,” Dr. Pettus says. “These conversations should happen early after a diabetes diagnosis and be framed in a way that leaves open the possibility that insulin may be necessary later in the course of the disease. In this way, insulin therapy is not a punishment, but a potential future therapeutic option.” Taking time to identify the reasons behind patient concerns can help physicians develop a strategy to initiating insulin. Determining the level of concern and asking open-ended questions about patient
in: s
This Physician’s Weekly feature on initiating insulin and strategies to overcome patient fears was completed in cooperation with the experts at the American Diabetes Association.
perceptions on insulin can help (Table 1). “We need to listen to patient responses to help us better understand why patients are apprehensive and then address the issues early,” adds Dr. Pettus.
Patient Education Matters Several strategies have been effective when addressing patient barriers to starting insulin. “Throughout the course of care, it’s important to educate patients about their treatment options and the medications they’re taking,” says Dr. Pettus. “They should also understand that insulin will be required when non-insulin treatment options are no longer effective.” He recommends informing patients early that insulin may be needed to prepare them well in advance of this potential need.
Stress the Positives Patients with diabetes should be informed that insulin is a hormone that is normally made by their own pancreas. Framing insulin therapy in this way as a natural therapy can often help reduce patient apprehension. Offering education about how insulin initiation can be a good thing may ease patient apprehension, Dr. Pettus says. “We should stress
the positive attributes that insulin can provide for patients. Insulin can help them continue to enjoy flexibility in their lives, perhaps with more energy to do activities they like doing” To address fears about painful injections, Dr. Pettus suggests that clinicians focus on telling patients about the advances that have been made with insulin needles. “The needles we use for insulin injections today are smaller and thinner than ever before,” he says (Table 2). “Taking some extra time to show patients that injections are painless can go a long way
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Table 1
Common Barriers & Solutions
Listed below are several barriers to insulin initiation and strategies that providers can use to break down these barriers: “If I need insulin, it is a personal failure.”
“Insulin is not effective.”
Explain diabetes as a progressive disease of insulin resistance and β-cell failure from the onset.
Point out to patients studies demonstrate the efficacy of insulin when used properly.
Point out that patients have not failed, but other treatment options have failed them.
Do not use insulin as a “threat” to promote meal planning and exercise behaviors; instead, describe insulin as a logical step in the continuum of treatment.
“If I use insulin, I may get hypoglycemia.”
“Insulin injections are painful.” Point out that insulin needles are smaller and thinner than ever before. Healthcare providers can consider giving a dry injection to themselves in front of patients or ask patients to give a dry injection to themselves in the office visit, regardless of whether insulin is indicated.
Tell patients that most insulin users find taking insulin less painful than testing their blood glucose levels. Discuss availability of insulin pens to quash concerns about the pain of injections. For patients with true needle phobias, offer psychological counseling.
“Insulin causes weight gain.” Be honest with patients about the potential for weight gain. Offer to arrange a meeting with a dietitian before initiating insulin to identify strategies to prevent weight gain.
to alleviating fears.” Some reports suggest that most patients find insulin injections to be less painful than testing their blood sugar. Some patients with diabetes have heard about negative experiences with insulin through relatives or friends. As a result, they may believe that insulin actually causes complications or death. “We may need to do more than simply present the facts on insulin to overcome patients’ fears,” Dr. Pettus says. He recommends that clinicians think about providing anecdotal information from their own experiences with managing patients who were fearful of starting insulin.
Involve DSMEs When initiating insulin, diabetes self-management educators (DSMEs) can be a great asset, especially in busy office settings. “DSMEs can help with
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Discuss how the insulins today are similar to what the body naturally makes.
Frame messages about insulin to match concerns and goals of patients beyond glucose control (eg, insulin may give patients more energy to enjoy life more).
Assess what patients have observed in others who required insulin and the outcome of the hypoglycemic event.
Tell patients that very few people with diabetes actually have severe hypoglycemia.
Reassure patients that they can Point out that hypoglycemia is be taught strategies to prevent, less likely to occur with newer recognize, and treat hypoglycerapid-acting and long-acting mia and avoid severe events. insulins. “Insulin causes complications or death.” Recognize that previous experiences may lead patients to false beliefs about insulin. Rather than use facts alone, acknowledge patient fears and offer information about the healthcare provider’s experiences in managing patients with insulin. Source: Adapted from: Funnell MM. Clin Diabetes. 2007;25:36-38.
Table 2
Other Helpful Strategies
A common concern among patients with diabetes is that once insulin is initiated, it will adversely affect their independence. Listed below are strategies that may be beneficial when managing patients who disclose fears about how starting insulin will impact their lifestyle: Provide information about insulin pens or other devices to increase accuracy and ease of administration. Teach patients to correctly identify symptoms of hypoglycemia and strategies to facilitate insulin use. Give information about insulin regimens that offer maximum flexibility and strategies for traveling with insulin. Describe how insulin pens can be helpful for overcoming concerns about requiring insulin in public places or at work. Remind patients that the Americans with Disabilities Act requires employers to make reasonable accommodations for patients with diabetes, including those who take insulin. Source: Adapted from: Funnell MM. Clin Diabetes. 2007;25:36-38.
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both initiating and titrating insulin,” says Dr. Pettus. “They can offer education about insulin and support efforts to ensure that patients continue using insulin as directed. DSMEs can also support and reinforce other important self-management strategies to diabetes care, particularly during early phases of the disease. Ultimately, the way to overcome fears of starting insulin will be to establish a proactive, collaborative relationship with patients. Taking time to teach patients about insulin and address their concerns early and often— and throughout treatment—will ensure that these messages are supportive and specific for each person with diabetes.” For more information on this article, including the contributor’s financial disclosure information, go to www.physweekly.com/insulin.
Additional Resources Online! To view the full study referenced in this article on overcoming barriers to the initiation of insulin therapy, visit us online! Visit physweekly.com/insulin or scan the QR code.
Readings & Resources American Diabetes Association. Standards of Medical Care in Diabetes—2014. Diabetes Care. 2014;37:S14-S80. Funnell MM. Overcoming barriers to the initiation of insulin therapy. Clin Diabetes. 2007;25: 36-38. Available at: http://clinical.diabetesjournals.org/content/25/1/36.full.pdf+html. Peyrot M, Rubin RR, Lauritzen T, et al, the International DAWN Advisory Panel. Resistance to insulin therapy among patients and provides: results of the cross-national Diabetes Attitudes, Wishes and Needs study. Diabetes Care. 2005;28:2673-2679. Nathan DM, Buse JB, Davidson MB, et al. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2009;32:193-203. Kabadi UM. Starting insulin in type 2 diabetes: overcoming barriers to insulin therapy. Int J Diabetes Dev Ctries. 2008;28:65-68. Hunt LM, Valenzuela MA, Pugh JA. NIDDM patients’ fears and hopes about insulin therapy: the basis of patient reluctance. Diabetes Care. 1997;20:292-298.
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Achieving A1C Goals: Back to the Basics
The resources fall under three overarching missions:
Etie Moghissi, MD, FACP, FACE Associate Clinical Professor of Medicine UCLA David Geffen School of Medicine Consultant, Endocrinology and Diabetes Marina Diabetes and Endocrinology Center
A
mong the nearly 26 million Americans with diabetes, approximately half have not achieved an American Association of Clinical Endocrinologists (AACE)-recommended A1C goal of 6.5% or less. To address this issue, AACE and the American College of Endocrinology developed the Blood Sugar Basics: Get to Your Goals program. The program consists of an array of customizable tools and resources—available online and as hard copy materials—to encourage and empower patients with type 2 diabetes to know the importance of their A1C and work with their healthcare providers to set and achieve individualized blood sugar goals.
A Helpful Resource Diabetes and its management can seem complex and overwhelming to patients, particularly for the newly diagnosed. “Patients need to understand that diabetes is a serious disease,” says Etie Moghissi, MD, FACP, FACE, the physician advisor for the Blood Sugar Basics program. “However, it’s important that they know that diabetes can be managed effectively when they’re engaged in their care.” To that end, the program—through its online home at www.blood sugarbasics.com—provides downloadable checklists, tips for everyday management, videos, questions for patients to ask their providers, a quiz to test patients’ A1C knowledge, and more. In-depth information is provided on the importance of diet, exercise, medication (if prescribed), and monitoring and preventing symptoms. The resource also informs patients on hypoglycemia and how to avoid it.
1
Gather intelligence. “The program provides recom mendations for controlling A1C and setting specific goals so that patients can have informed discussions with their providers,” explains Dr. Moghissi.
2
Finalize a strategy. “Patients should know how to achieve their A1C goals with lifestyle changes and by taking medications as prescribed,” Dr. Moghissi adds.
3
Regroup. Diabetes is a progressive disease that requires periodic reassessment to ensure that patients stay on track, says Dr. Moghissi. “If patients have not achieved their goals, it’s important to find out the reasons why,” she says. “In addition, patients should understand that not meeting their goal doesn’t mean they didn’t try hard enough. Patients can be empowered if they’re educated that medication adjustments are commonly needed to achieve long-term glycemic control.”
Collaboration Is Key Dr. Moghissi stresses the importance of patients and providers working as a team to assess and achieve blood sugar goals and notes that the resources available through the Blood Sugar Basics website can help. “There are many reputable websites with diabetes information, but there is also a lot of misinformation,” she notes. “This program was produced by reputable organizations, including AACE—the world’s largest medical society dedicated to clinical endocrinology—and provides accurate, reliable information that can be trusted.” For more information on this article, including the contributor’s financial disclosure information, go to www.physweekly.com/a1c.
Read Our Related Article! A recent study assesses patient knowledge of the “ABCs” of diabetes in our related article, Enhancing Patients’ Diabetes Knowledge.
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The Value of
Inpatient
Diabetes Education
Research suggests that inpatient diabetes education may help reduce hospital readmission rates for patients with the disease who have poor glycemic control. Efforts are needed to provide diabetes education through multiple outlets and sources.
H
ospital readmissions are important contributors to total medical expenditures in the United States and are an emerging indicator of quality of care. “CMS has started to reduce reimbursement for patients who are rehospitalized early for several
Kathleen M. Dungan, MD, MPH Associate Professor of Medicine Division of Endocrinology, Diabetes, and Metabolism The Ohio State University Wexner Medical Center
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conditions, but diabetes currently isn’t one of those diseases,” says Kathleen M. Dungan, MD, MPH. “However, it’s known that diabetes is associated with a higher risk for hospital readmission, and while it may not be the primary reason for admission, it is a frequent comorbidity.” Studies suggest that 20% of patients with diabetes are rehospitalized within 30 days of discharge, and 30% of these individuals are hospitalized more than once a year. There were 7.7 million hospital stays for patients with diabetes in the U.S. in 2008, accounting for 20% of hospitalizations and $83 billion in costs.
This Physician’s Weekly feature on the value of inpatient diabetes education was completed in cooperation with the experts at the American Diabetes Association.
Research has shown that rehospitalizations occur disproportionately among socioeconomically disadvantaged groups, including Hispanics and African Americans, those living in lower income areas, and those without private insurance. Other risk factors include previous hospitalizations, extremes of age, and socioeconomic barriers. Failing to acknowledge diabetes at discharge raises the risk of early hospital readmissions, says Dr. Dungan.
Examining the Literature Some studies have suggested that involving diabetes specialist teams may reduce readmission rates, but
results can vary depending on the individual components of the program and attention to discharge needs. Typically, inpatient diabetes management teams incorporate some component of diabetes education, but Dr. Dungan says many hospitals have inadequate funding or resources to optimize this treatment strategy. “Patient education for diabetes is often thought of as being most effective when delivered in the outpatient setting,” she says. “However, barriers to outpatient education—such as access, coverage, and competing medical priorities—are common, and it’s possible that diabetes education in the inpatient setting can further reduce hospital readmissions.”
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Benefits Seen With IDE A study published recently in Diabetes Care by Dr. Dungan and colleagues sought to determine whether inpatient diabetes education (IDE) improved the
Initial & Final Model for Readmission Within 30 & 180 Days
Table 1
180 days 30 days Odds Ratio Odds Ratio Unadjusted OR 0.62
0.74
Physician consult
1.04
0.86
Education consult
0.68
0.83
Male
0.87
0.91
African American
1.06
1.42
Married
0.87
0.99
HMO or PPO
1.35
1.09
Medicaid
1.48
1.57
Medicare
1.48
1.42
Other
Education consult Initial model
Insurance (vs self-pay)
0.89
0.81
Admit to ICU
1.40
0.89
Age
1.00
1.00
Log (length of stay)
1.41
1.40
Log (A1C)
0.41
0.47
Log (AGI)
0.75
0.83
Hyperglycemic emergency
0.77
Infectious disease
1.16
Year 2009 vs 2008
0.89
0.90
2010 vs 2008
0.85
1.06
0.66
0.80
HMO or PPO
1.24
1.08
Medicaid
1.53
1.60
Medicare
1.40
1.42
Other
0.84
0.78
1.41
1.38
Log (A1C)
-
0.46
African American
-
1.45
Final model Diabetes education Insurance (vs self-pay)
Log (length of stay)
Abbreviations: CI, confidence interval; HMO, health maintenance organization; PPO, preferred provider organization; AGI, average adjusted gross income (in 2009). Source: Adapted from: Healy SJ, et al. Diabetes Care. 2013;36: 2960-2967.
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frequency of readmissions in patients with poorly controlled diabetes, which was defined as having an A1C of 9% or higher. The retrospective analysis was done using patient records pulled from the Information Warehouse at Ohio State University. Patients were assessed for readmission within 30 and 180 days after discharge. All patients who received education had an IDE consult order from their physician. IDE was provided by certified diabetes educators and ranged from survival skills focusing on basic diabetes management to more comprehensive education that was individualized following patient assessment. “Even after we controlled for other variables, we found that formal IDE for those with poorly controlled diabetes led to fewer all-cause readmissions,” Dr. Dungan says. IDE was associated with 34% lower odds of all-cause readmissions by 30 days and 20% reduced odds of readmissions by 180 days (Table 1). The study also analyzed data according to race and showed that African Americans were equally likely to be readmitted within 30 days as other races but had a higher readmission frequency within 180 days (Table 2). However, there was a significant reduction in hospital readmissions within 30 days among all races receiving IDE. “Considering the magnitude of our findings, detailed IDE should be considered as a potentially effective patient management strategy that can be conducted in the hospital,” says Dr. Dungan. “IDE is one of several key drivers of effective hospital discharges among patients with poor glycemic control. Multiple approaches—such as follow-up appointments, medication reconciliation, and patient education—will be necessary to providing the most effective care and to reducing hospital readmission rates for this patient population.” She adds that patients with poor glycemic control stand to benefit the most from IDE.
More Confirmation Needed Further prospective randomized controlled studies are needed to determine whether actual individualized IDE improves readmission rates and to assess if this approach is cost-effective, according to Dr. Dungan. “Reducing readmissions can reduce healthcare costs and improve quality of care, but we need more data
to determine which patient characteristics predict the most benefit from IDE,” she says. More research is also needed to determine the most appropriate content and methodology of such education. The research by Dr. Dungan and colleagues is one of the largest studies to date to examine the effect of formal IDE on hospital readmissions. “Our finding that patients receiving IDE had significantly lower readmission rates is important when taken in the context of the overall increasing attention that’s being paid to hospital readmissions,” Dr. Dungan says. “If our data are confirmed in future analyses, it’s clear that we’ll need to focus more resources on implementing IDE as an important component of diabetes care.”
Additional Resources Online!
Characteristics of Patients Readmitted Within 30 or 180 Days By Race
Table 2
African American
Non-African American
Education consult
50%
38%
Physician consult
49%
43%
Age
50 years ± 15
51 years ± 14
Male
51%
54%
Married
21%
43%
AGI
$31,787
$38,205
Length of stay
4 days
4 days
Hyperglycemic emergency
9%
6%
Nonsurgical
90%
82%
Congestive heart failure
12%
14%
Infectious disease
11%
14%
Pneumonia
5%
4%
11.3%
10.7%
HMO or PPO
18%
27%
Discharge diagnosis
View or download Standards of Medical Care in Diabetes—2014, which comprises all of the current and key clinical practice recommendations of the American Diabetes Association.
Median A1C
Medicaid
30%
26%
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Medicare
22%
25%
Other
11%
8%
Self-pay
18%
14%
Any insurance
82%
86%
Admit to ICU
6%
5%
Readmission, 30 days
14%
14%
Readmission, 180 days
35%
29%
Insurance
Abbreviations: CI, confidence interval; HMO, health maintenance organization; PPO, preferred provider organization; AGI, average adjusted gross income (in 2009). Source: Adapted from: Healy SJ, et al. Diabetes Care. 2013;36: 2960-2967.
For more information on this article, including the contributor’s financial disclosure information, go to www.physweekly.com/education.
Readings & Resources Healy SJ, Black D, Harris C, Lorenz A, Dungan KM. Inpatient diabetes education is associated with less frequent hospital readmission among patients with poor glycemic control. Diabetes Care. 2013;36: 2960-2967. Available at: http://care.diabetesjournals.org/content/early/2013/07/01/dc13-0108.full.pdf+html. Moghissi ES, Korytkowski MT, DiNardo M, et al; American Association of Clinical Endocrinologists, American Diabetes Association. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care. 2009;32:1119–1131. Dungan KM, Osei K, Nagaraja HN, Schuster DP, Binkley P. Relationship between glycemic control and readmission rates in patients hospitalized with congestive heart failure during implementation of hospital-wide initiatives. Endocr Pract. 2010;16:945–951. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetologia. 2012;55:1577–1596. Koproski J, Pretto Z, Poretsky L. Effects of an intervention by a diabetes team in hospitalized patients with diabetes. Diabetes Care. 1997;20:1553–1555.
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