Budget impact analysis of darolutamide for treatment of nonmetastatic castration-resistant prostate cancer.

BACKGROUND: Darolutamide, a structurally distinct androgen receptor inhibitor approved for the treatment of men with nonmetastatic castration-resistant prostate cancer (nmCRPC), has been shown to increase metastasis-free survival among men with nmCRPC compared with placebo. This treatment has a novel chemical structure that may also have safety, tolerability, and efficacy advantages for men with nmCRPC. OBJECTIVE: To estimate the projected budget impact of including darolutamide on a U.S. payer formulary as a treatment option for men with nmCRPC. METHODS: A budget impact model was developed to evaluate darolutamide for nmCRPC for a hypothetical 1-million-member plan over a 5-year period. Costs (drug acquisition, drug administration, and treatment-related adverse events [AEs]) were estimated for 2 scenarios: with and without darolutamide treatment for nmCRPC. The budget impact of darolutamide was calculated as the difference in costs for these 2 scenarios. An analysis for high-risk nmCRPC also was conducted. The model included treatments recommended by the National Comprehensive Cancer Network (e.g., apalutamide and enzalutamide) and potential comparators that are used but are not specifically indicated for nmCRPC. All treatments were assumed to be administered in combination with a weighted average androgen deprivation therapy comparator (consisting of luteinizing hormone-releasing hormone [LHRH] agonists, LHRH antagonists, and first-generation antiandrogens). Market share estimates were derived from interviews with physicians treating men with nmCRPC. The model includes grade 3-4 AEs, and the rates were obtained from clinical trial data. Costs were taken from publicly available sources and varied in a one-way sensitivity analysis. RESULTS: For a plan with 1 million lives, there were approximately 90 incident cases of nmCRPC (46 high risk) each year, with 332 (109 high risk) treatment-eligible cases by year 5. Darolutamide's market share increased from 3.6% in year 1 to 18% in year 5. Given the utilization of other agents, introducing darolutamide along with other targeted therapies was predicted to increase the total budget by $158,640 ($0.0132 per member per month [PMPM]) in year 1, which decreased over time to a cost savings of $149,240 ($0.0124 PMPM) by year 5. The scenario with darolutamide showed reduced AE costs each year. Similar results were observed for the high-risk nmCRPC population. CONCLUSIONS: Adding darolutamide to a U.S. payer formulary for the treatment of nmCRPC can result in a manageable increase in the budget that is partly offset by AE costs in the first 4 years, followed by a cost savings by year 5. DISCLOSURES: This study was conducted by RTI Health Solutions under the direction of Bayer U.S. and was funded by Bayer U.S., which was involved in the design of the study; collection, analysis, and interpretation of the data; writing of the report; and the decision to submit the report for publication. Miles and Purser (and/or their institutions) are employees of RTI Health Solutions and received research funding from Bayer U.S. to develop the budget impact model. Appukkuttan and Farej are employees of Bayer U.S. Wen was an employee of Bayer U.S. at the time of the study. This study was presented as a poster at the AMCP Virtual Learning Event, April 20-24, 2020.

A Retrospective Claims Analysis of Advanced Prostate Cancer Costs and Resource Use.

BACKGROUND: Castration-resistant prostate cancer (CRPC) is associated with high costs and healthcare resource utilization (HCRU). OBJECTIVE: This study followed patients with CRPC through their continuum of care and analyzed claims data regarding treatments, total HCRU, and costs, both before and after metastasis diagnosis. METHODS: A retrospective cohort of patients with newly diagnosed metastatic CRPC (mCRPC) in the USA was identified from the Truven Health MarketScan database from January 2009 to March 2015. The mCRPC algorithm employed International Classification of Diseases, Ninth Revision codes for prostate cancer (pre-index) and secondary metastatic disease (index date) and a subsequent claim for a US FDA-approved treatment for mCRPC. Patient inclusion required evidence of surgical or pharmacological castration and no evidence of bone-targeted treatments during the baseline period while evaluating continuous enrollment 25 months pre-index and 6 months post-index. Treatment patterns were assessed during pre- and post-index periods; HCRU and costs were annualized for comparison purposes regarding both pre- and post-index timeframes. RESULTS: Among 261 patients with mCRPC (mean age 72 years), the most common treatments during the pre-index period were bicalutamide (90.04%), leuprolide (81.99%), abiraterone (22.22%), docetaxel (20.69%), and ketoconazole (18.01%). Mean per-patient-per-year (PPPY) all-cause annualized healthcare costs significantly increased from $US35,102.55 in the pre-index nonmetastatic CRPC (nmCRPC) period to $US156,499.89 after metastasis diagnosis (mCRPC). Mean PPPY inpatient admissions and emergency department visits increased from 0.20 to 1.36 and from 0.63 to 1.56, respectively. CONCLUSIONS: Average yearly costs and HCRU were four times higher following mCRPC diagnosis, indicating a need for appropriate management strategies to optimize the potential delay of disease progression among patients with nmCRPC.

Real-World Treatment Patterns in Patients with Castrate-Resistant Prostate Cancer and Bone Metastases.

BACKGROUND: Prostate cancer is the most frequently diagnosed cancer in men in the United States. There is scant real-world evidence characterizing the care utilization and clinical outcomes associated with the use of therapies currently approved by the US Food and Drug Administration (FDA) for patients with metastatic castrate-resistant prostate cancer (CRPC). OBJECTIVE: To describe the real-world treatment patterns, healthcare costs, and survival rates of patients with metastatic CRPC and bone metastases who have commercial or Medicare coverage. METHODS: This retrospective observational study was conducted using medical and pharmacy claims from the Humana research database for male patients who had Medicare or commercial coverage and were aged 55 to 89 years at the initiation of treatment for metastatic CRPC. Three inclusion criteria were used to identify appropriate patients for the 2 cohorts, including (1) a diagnosis of prostate cancer (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 185.x); (2) a diagnosis of bone metastasis (ICD-9-CM code 198.5) between 2013 and 2014; and (3) a healthcare insurance claim indicating a prescription for an FDA-approved first-line treatment for metastatic CRPC. Subsequent lines of treatment were also identified through the healthcare claims data. The 2-year survival rate was calculated and controlled for demographic and clinical characteristics, and the total costs (medical plus pharmacy) were calculated for the 6 months postindex. RESULTS: A total of 1855 patients met the study inclusion criteria. Of these patients, 660 (35.6%) received at least 1 medication. The patient count by line of treatment was 660 (100%) who received first-line therapy, 380 (57.6%) who received second-line treatment, 204 (30.9%) who received third-line therapy, and 107 (16.2%) who received fourth-line therapy. The medication distribution by line of treatment (using first-, second-, third-, or fourth-line therapy for each drug) was abiraterone acetate (50.5%, 61.3%, 68.6%, 75.7%); enzalutamide (15.6%, 39.2%, 54.4%, 71.0%); sipuleucel-T (9.2%, 13.9%, 20.1%, 20.6%); radium-223 dichloride (1.7%, 2.6%, 7.4%, 13.1%); cabazitaxel (2.3%, 5.5%, 16.2%, 19.6%); and docetaxel (22.1%, 32.1%, 42.6%, 48.6%). The total monthly unadjusted healthcare costs for patients who received an FDA-approved treatment was much higher ($9435) than for patients with metastatic prostate cancer who did not receive an FDA-approved treatment ($5055), and the 2-year survival rate for patients who received an FDA-approved treatment was 57.1% (25th percentile, 250 days; 50th percentile, 541 days). CONCLUSIONS: The most common first-line treatment for patients with commercial or Medicare coverage who had metastatic CRPC was abiraterone or enzalutamide. Hormone therapies used as monotherapy were the most frequently used treatment, and their concomitant administration with other treatments was the second most common treatment pattern. Additional clinical studies are needed to further elucidate the treatment sequencing for patients with metastatic CRPC.

Evaluation of Treatment Patterns and Costs in Patients with Prostate Cancer and Bone Metastases.

BACKGROUND: There are a lack of guideline recommendations for patients with metastatic castration-resistant prostate cancer (mCRPC) undergoing treatment progression and sequencing. Understanding treatment patterns and associated utilization and costs may help inform stakeholders and guide decision making. OBJECTIVE: To describe treatment patterns and health care costs in prostate cancer (PC) patients with bone metastases treated with agents approved by the FDA for mCRPC. METHODS: 2 large integrated claims databases (MarketScan and PharMetrics) were used to identify males aged ≥ 18 years who were diagnosed and treated for PC (ICD-9-CM code 185.xx or 233.4) with bone metastases (ICD-9-CM code 198.5) from June 2013 to September 2014. Patients were required to be continuously enrolled for ≥ 6 months before and after initiation of treatment with abiraterone, cabazitaxel, docetaxel, enzalutamide, mitoxantrone, radium-223, sipuleucel-T, or other chemotherapy. Study endpoints included lines of therapy, health care resource utilization per patient per month (PPPM), PPPM costs, and mortality rate. Descriptive analysis was completed for the study sample, and survival function was calculated via Kaplan-Meier estimates. RESULTS: There were 953 patients meeting all inclusion criteria in the MarketScan database and 565 patients in the PharMetrics database. The median follow-up time was 18 months (interquartile range [IQR] = 14-23) for MarketScan and 14 months (IQR = 11-18) for PharMetrics. Mean age (SD) was 71 (± 10.7) and 66 (± 9.3) years, respectively. Before mCRPC treatment initiation, patients received palliative radiation therapy and bone antiresorptive therapy. For MarketScan and PharMetrics, respectively, 14.0% and 18.2% of patients received radiation therapy, 36.1% and 40.0% received denosumab; 16.5% and 16.8% received zoledronic acid; and 0.2% and 0.8% received pamidronate. Across both databases, abiraterone was the most commonly received bone metastasis treatment agent across all lines of therapy, except fourth line. Radium-223, cabazitaxel, and mitoxantrone were the least utilized therapies. The median cost PPPM during the post-index period was $10,916 (IQR=$5,334-$13,457) in MarketScan and $10,292 (IQR = $7,245-$14,699) in PharMetrics. The cost PPPM during the 6-month pre-index period was $2,643 (IQR = $850-$4,357) in MarketScan and $2,742 (IQR = $1,484-$4,730) in PharMetrics. CONCLUSIONS: Patients were treated mainly with abiraterone across most lines of care, with radium-223, cabazitaxel, and mitoxantrone as the least utilized therapies. Median costs PPPM increased by approximately $8,900 after initiation of FDA-approved agents for mCRPC, with the largest increase in cost stemming from oral medications. DISCLOSURES: Funding for this study was provided by Bayer HealthCare Pharmaceuticals. All authors were employees at Bayer HealthCare Pharmaceuticals at the time this study was conducted. This study was presented as a poster at the 2017 American Society of Clinical Oncology (ASCO) Genitourinary Cancers Symposium; February 16-18, 2017; Orlando, FL.

Improving quality of care in oncology through healthcare payment reform.

OBJECTIVES: To provide an overview of alternative payment models (APMs) and describe how leading national organizations involved with oncology care and payment are linking quality improvement initiatives and payment reform. STUDY DESIGN: Literature review. METHODS: For this review, we summarized the literature on APMs and their goals of improving healthcare quality while jointly controlling the cost of care. We described the types of APMs that have been examined in the real-world setting, specifically in the area of oncology, and how they have affected the quality of oncology care. RESULTS: Currently, the following types of APMs are actively being explored by public- and private-sector insurers, specifically in oncology: accountable care organizations, bundled payments, clinical pathways, and patient-centered medical homes. To a great extent, the driving force behind implementing APMs tied to quality can be attributed to the initiatives of several leading national organizations, including the National Academy of Medicine, the American Society of Clinical Oncology, the National Committee for Quality Assurance, HHS, and CMS. Real-world evidence of APMs shows that progress is being made toward improving the quality of oncology care in the United States while simultaneously reducing costs. CONCLUSIONS: The effective pairing of quality initiatives with healthcare reimbursement structures will likely be key to the long-term success of such APMs.

Two-year continuation of intrauterine devices and contraceptive implants in a mixed-payer setting: a retrospective review.

BACKGROUND: As the popularity of long-acting reversible contraception increases, so does the need for accurate data on method continuation in diverse clinical settings. We determined 2-year continuation rates for the levonorgestrel 52-mg intrauterine device, the copper T380A intrauterine device, and the 68-mg etonogestrel contraceptive implant in an academic healthcare system with mixed-payer reimbursement. OBJECTIVE: The purpose of this study was to examine the proportion and characteristics of women who continue intrauterine device and implant use to 2 years and to relate continuation to device type when controlling for patient characteristics. STUDY DESIGN: This retrospective chart review assessed University of Utah Healthcare System patients who had an intrauterine device or contraceptive implant inserted between January 1, 2004, and December 31, 2012. We identified users and dates of insertions and removals by querying billing, medication, and procedural data in the Electronic Data Warehouse. Multivariable Poisson regression was conducted to estimate incidence risk ratios and to relate the probability of 2-year continuous use to device type. RESULTS: Data on 8603 device insertions were obtained with the following distribution: levonorgestrel 52-mg intrauterine devices (6459; 75.1%), copper T380A intrauterine devices (1136; 13.2%), and 68-mg etonogestrel implant (1008; 11.7%). Two-year continuation rates were 77.8%, 73.1%, and 75.9%, respectively. There was no statistical difference in 2-year continuation between levonorgestrel 52-mg intrauterine device users (adjusted risk ratio, 1.1; 95% confidence interval, 1.0-1.1) and 68-mg etonogestrel implant users (adjusted risk ratio, 1.1; 95% confidence interval, 1.0-1.1) compared with copper device users, after we controlled for age, Hispanic ethnicity, payer type, and year of insertion. Older-age, self-pay, or public payer insurance (reference commercial payer) and Hispanic ethnicity were associated with 2-year continuation. CONCLUSION: Three-quarters of women with an intrauterine device or implant continue using it for 2 years. In this cohort, the 2-year continuation rates were 77.8%, 73.1%, and 75.9% for the levonorgestrel 52-mg intrauterine device, copper T380A intrauterine device, and 68-mg etonogestrel implant, respectively.

Opioid Use Among Metastatic Prostate Cancer Patients With Skeletal-related Events.

PURPOSE: The development of skeletal-related events (SREs) (pathologic fracture, need for surgery and/or radiation to bone, spinal cord compression, and hypercalcemia of malignancy) in metastatic prostate cancer (MPC) is associated with worsened pain and compromised quality of life. Opioids are frequently used throughout the course of SRE treatment. This study describes the treatment patterns and incremental use of opioids in MPC patients diagnosed with SREs. METHODS: PC patients with bone metastases newly diagnosed with an SRE between January 1, 2005, and September 30, 2014, were identified using MarketScan Commercial and Medicare databases. Included patients were aged ≥40 years, had medical/pharmacy benefits for ≥12 months before (preindex) and ≥6 months after (postindex) diagnosis, and were without evidence of other primary cancers. Patients were categorized as nonusers of opioids (<10 days), short-term users (≥10 and <60 days), or long-term users (≥60 days) and further by SRE type. Opioid type, proportion of time on opioids, morphine-equivalent dose, adjuvant medications, and radiation use before and after SRE diagnosis were evaluated. FINDINGS: A total of 1071 eligible patients were identified (mean age, 71 years; 10.8% had chronic pain at baseline). The most common SRE types present were radiation (60.2%), radiation and bone surgery (15.0%), pathologic fracture (7.2%), and bone surgery (6.5%). Opioid use increased from 49.9% preindex to 53.3% postindex (P < 0.0001). The proportion of time on opioids doubled after SRE (pre, 0.3 vs post, 0.6; P < 0.0001). A greater percentage of patients used only opioids after an SRE (pre, 11.0%; post, 46.1% [P < 0.0001]), while a lesser percentage of patients used only radiation after an SRE (pre, 36.0%; post, 4.7% [P < 0.0001]). An increase was observed in patients using neither radiation nor opioids (pre, 14.5%; post, 42.0% [P < 0.0001]). An increase of ~50% was noted in long-term opioid users (from 22.1% to 32.1%). The use of monotherapy with a short-acting opioid decreased (pre, 35.1%; post, 32.5% [P < 0.0001]), while use of mixed opioids increased (pre, 13.7%; post, 19.1% [P < 0.0001]). Mean morphine-equivalent dose increased from pre- to post-SRE (9.1 vs 13.1 mg). Bisphosphonate and NSAID users decreased from before to after an SRE diagnosis (bisphosphonates, 40.2% vs 8.6%; NSAIDs, 26.7% vs 17.5% [both, P < 0.0001]). IMPLICATIONS: Long-term opioid use and dose were significantly increased after SRE development in MPC. The high percentage of patients not treated with an opioid or radiation potentially supports the need for additional treatment options for controlling pain if medically necessary and/or to prevent SREs.

Comprehensive diagnostic program for medically underserved women with abnormal breast screening evaluations in an urban population.

OBJECTIVE: To institute a patient navigator program for underinsured women to eliminate delays in diagnostic resolution of abnormal screening mammograms, provide services for abnormalities noted during breast cancer screening, describe demographic and clinical characteristics of enrollees, and assess postscreening follow-up care. PATIENTS AND METHODS: Coordinators from area health departments worked with a navigator nurse at Mayo Clinic Cancer Center in Jacksonville, FL, to refer patients for additional diagnostic services, including diagnostic mammography, ultrasonography, ultrasonography-guided biopsy, stereotactic biopsy, breast magnetic resonance imaging, and biopsy guided by magnetic resonance imaging. Women with abnormal screening mammograms (Breast Imaging Reporting and Data System [BI-RADS] category 4 or 5) or palpable suspect breast masses were eligible. Data were extracted from clinical service records. Timeliness of postscreening follow-up was assessed. RESULTS: The study enrolled 447 women from June 30, 2000, to December 29, 2006. Data on the time from screening to diagnosis were available for 399 women, and median time from detection of screening abnormality to diagnosis was 37 days. Time between screening and diagnosis was 60 days or less for 325 (81%) of the 399 women for whom data were available and for 60 (82%) of the 73 women with BI-RADS category 4 or 5 assessments. Both of these percentages exceeded the Centers for Disease Control and Prevention quality benchmark of 75%. Mean time from study enrollment to diagnosis was 2 days for women with BI-RADS category 3 or 4 assessments and 7 days for women with BI-RADS category 5 assessments. CONCLUSION: This program demonstrated a successful collaboration between an academic medical center and community health centers. Most women with BI-RADS category 4 or 5 assessments received a diagnosis within 60 days of screening.

Number needed to treat: a descriptor for weighing therapeutic options.

PURPOSE: The utility and limitations of the number needed to treat (NNT) are described and compared with those of alternative descriptors of therapeutic yield. SUMMARY: Pharmacists, physicians, and patients are more likely to launch interventions based on relative measures of therapeutic yield. The NNT is a simple way to express the absolute therapeutic yield of an intervention. It is essential to take baseline risk and length of follow-up into account when calculating and interpreting absolute or relative measures of therapeutic yield. Patients may have difficulty understanding what the NNT tells them about the benefits and harms associated with an intervention, and confidence intervals for the NNT can be difficult to interpret. Relative measures of benefits are advantageous for comparing benefits across populations with different risks. The use of absolute measures to describe therapeutic options leads to more conservative decision-making and is potentially more useful. Among the absolute measures, the absolute risk reduction may be easier to understand than the NNT. These measures are most helpful when the best options are not clear or when patient input is needed. Personal digital assistants and Web-based tools can assist with calculations. CONCLUSION: The NNT is a useful measure but is influenced by numerous variables and may not be easily understood by patients.

Communicating about medications during primary care outpatient visits: the role of electronic medical records.

OBJECTIVES: To assess the role of electronic medical records (EMR) in facilitating the content and process of patient-provider exchanges about medications during outpatient primary care visits. METHODS: Fifty encounters with six physicians using the EMR were videotaped, transcribed and content-analysed by applying conversation analysis and ethnomethodology techniques. The analysis focused on three aspects of medication communication: (1) process of care: practices by patients and physicians to implement medication decisions; (2) themes: medication topics that consistently emerge; and (3) names: ways patients and physicians refer to medications. In-depth analysis of 20 encounters examined the extent to which either or both parties initiated, expanded and concluded medication discussions. RESULTS: On average 21.2 (range: 8-35; SD=7.4) distinct exchanges per encounter were observed. Of those, 33% were related to medication. Of the 350 medication-related exchanges throughout the encounters, 56% were categorised as routine medication discussion such as ordering and/or refilling medications. Mailing issues were the next most common medication-related exchanges (10.6%), followed by partial adherence (8.9%), self-regulation (7.4%), alternative therapy/over-the-counter medication (6.6%), side effects (6%) and formulary issues (4.6%). Patients and providers used three ways to name medications: generic/scientific name (42%); physical description (39.7%) and brand name (18.3%). Forty-one percent of exchanges included initiation by one or both parties but no further discussion of the issue; 42% included initiation and expansion by both parties but not conclusion; only 17% of exchanges contained complete medication exchanges (initiation, expansion and conclusion) by both parties. CONCLUSIONS: EMR facilitated content and process of communication regarding medications during outpatient encounters, especially among patients taking multiple medications and patients who used physical descriptions to identify their medications. EMR use stimulated medication exchanges, leading to further expansion about the topic. However, fewer than one-fifth of exchanges ended with clear conclusions by both parties regarding prescribed medication regimens.

Association between self-monitoring of blood glucose and glycemic control in patients with type 2 diabetes mellitus.

PURPOSE: The relationship between the self-monitoring of blood glucose (SMBG) and glycemic control in patients with type 2 diabetes mellitus in a Veterans Affairs (VA) medical center was studied. METHODS: Laboratory, inpatient, outpatient, and demographic data for patients with type 2 diabetes mellitus who were seen for three years continuously or receiving their care regularly from a single Texas VA facility between October 1, 1999, and September 30, 2002, were obtained. Local pharmacy data were used to identify patients who received blood-glucosemonitoring strips. Patients were assigned to one of four mutually exclusive groups: those who did not receive monitoring strips at all, those who received strips in fiscal year (FY) 2002 only, those who received strips in FYs 2001 and 2002, and those who received strips during all three years (FYs 2000, 2001, and 2002). Frequency of monitoring and case-mix scores were measured. Nonparametric statistics were used to compare the demographic and clinical characteristics of the four groups. Robust regression was used to analyze the relationships between SMBG and glycemic control in FY 2002. RESULTS: Of the 1185 patients who received oral hypoglycemic medications during all three fiscal years, 976 patients met the criteria for inclusion in one of the four groups. There were no significant differences among the four groups in baseline hemoglobin A1c (HbA1c) values, body mass index, or case-mix scores. The Kruskal-Wallis test found no significant difference among the four groups in the number of laboratory blood glucose tests conducted, but there were significant differences in the number of HbA1c tests conducted among the groups. CONCLUSION: SMBG was not associated with glycemic control in VA patients with type 2 diabetes mellitus managed on oral hypoglycemic medications.

Family support and diet barriers among older Hispanic adults with type 2 diabetes.

BACKGROUND AND OBJECTIVES: Diet plays an important role in the management of diabetes, and a suboptimal diet is a commonly identified problem. Family support may be important in overcoming barriers to good diet. We conducted this study to examine the role of the family in overcoming barriers to diet self-care among older Hispanic patients with diabetes. METHODS: We performed a cross-sectional survey of 138 older Hispanic adults seeking care at an outpatient university clinic. Patients reported on their perception of family functioning, family support for diet, and barriers to diet self-care. RESULTS: Level of family functioning was related to family support for diet self-care, and family support for diet was related to perceived barriers to diet self-care. Scores for family support were higher for those who perceived their family as functional compared to those who perceived their family as mildly dysfunctional or dysfunctional. As family support for diet increased, perceived barriers to diet self-care decreased. CONCLUSIONS: To fully understand difficulties encountered by older Hispanic adults with adherence to a diabetic diet, primary care physicians should explore the role of family support and family functioning. For those with poorly functioning families or low levels of family support, family-level interventions may need to be considered.

Family support, diet, and exercise among older Mexican Americans with type 2 diabetes.

PURPOSE: The purpose of this study was to examine the relationship between diabetes-specific family support and other psychosocial factors with regard to diet and exercise self-care behavior among older Mexican Americans with type 2 diabetes. METHODS: Adults aged 55 years and older who presented for care in a primary care clinic for type 2 diabetes (N=138) completed a survey to assess family support specific to diabetes, barriers to self-management, self-efficacy, and diabetes self-care activities. Multivariate regression analyses were conducted to evaluate the relationship between family support and self-care activities for diet and exercise. RESULTS: Higher levels of perceived family support and greater self-efficacy were associated with higher reported levels of diet and exercise self-care. As the barriers to exercise increased, the levels of exercise self-care decreased. Living with family members (more than just a spouse or significant other) was associated with higher levels of diet self-care, as was older age. CONCLUSIONS: Family behavior is associated with diet and exercise self-care. Diabetes educators and healthcare providers should consider involving the entire family in the management of older patients with type 2 diabetes. Interventions designed to improve diabetes self-management should address family support specific to diabetes, self-efficacy, and barriers to self-care.