Contemporary use of cardiovascular risk reduction strategies in type 2 diabetes. Insights from the diabetes collaborative registry.

BACKGROUND: Cardiovascular disease remains the primary source of morbidity and mortality in type 2 diabetes (T2D). We characterized the change over time in the use of evidence-based therapies to reduce cardiovascular risk in US patients with T2D. METHODS: Data from a longitudinal outpatient diabetes registry were used to calculate the prescription of SGLT2i or GLP-1RA over time and among those with high-risk comorbidities (atherosclerotic cardiovascular disease [ASCVD], heart failure [HF], chronic kidney disease [CKD]) and a diabetes cardiovascular composite score (DCCS; calculated as: #eligible medications prescribed/#eligible medications x 100 for SGLT2i, GLP-1RA, statin, antiplatelet/anticoagulant therapy, ACEi/ARB/ARNI). Scores ranged from 0% to 100% (higher=more optimal care). RESULTS: Among 1,001,542 outpatients from 391 US sites, 51.7% patients had ASVCD, 17.7% HF, and 23.0% CKD. The percentage of patients prescribed an SGLT2i or GLP-1RA increased over time (7.3% in 2013 to 28.8% in 2019), and 18.3% of patients with ASCVD, HF, or CKD were on at least one of these medications at last follow-up vs 25.5% of patients without any of these comorbidities. Mean DCCS was 54±36%; 54±25% in patients with ASCVD, HF, or CKD vs 52±50% in patients without any of these comorbidities (P<0.001 for both). In a hierarchical linear model, male sex, and a diagnosis of CKD were independently associated with higher DCCS whereas a diagnosis of HF or ASCVD was associated with a lower DCCS. CONCLUSIONS: In a large, contemporary cohort of patients with T2D, we found improvement in the use of SGLT2i and GLP-1RA but unexpectedly lower use in patients with ASCVD, heart failure, and CKD, highlighting a treatment-risk paradox. Further education is needed to shift the understanding of these medications as tools for glucose-lowering to cardiovascular risk reduction and to improve their implementation in clinical practice.

Understanding the role of psychiatrists in the diagnosis and management of mild cognitive impairment and mild Alzheimer's disease dementia: a cross-sectional survey.

BACKGROUND: Alzheimer's disease (AD) is a progressive neurological disorder and the most common cause of dementia. The clinical continuum of AD ranges from asymptomatic disease to mild cognitive impairment (MCI), followed by AD dementia, categorized as mild, moderate, or severe. Almost one-third of patients suspected of having MCI or mild AD dementia are referred to specialists including psychiatrists. We sought to better understand the role that psychiatrists play in the diagnosis, treatment, and management of patients with all-cause MCI or mild AD dementia. METHODS: We conducted an anonymous, online survey among physicians in the United States between February 4, 2021, and March 1, 2021. We surveyed psychiatrists, primary care physicians (PCPs), geriatricians, and neurologists who treat patients with all-cause MCI or mild AD dementia. RESULTS: A total of 301 physicians participated in the survey, 50 of whom were psychiatrists. Of their patients with all-cause MCI or mild AD dementia, psychiatrists reported personally diagnosing two-thirds (67%). Psychiatrists used various methods to diagnose MCI or mild AD dementia including mental status testing (94%), review of patient medical history (86%), and neurological exams (61%). Upon diagnosis, psychiatrists reported most commonly discussing treatments (86%), management strategies (80%), disease progression (72%), and etiology of MCI or mild AD dementia (72%) with their patients. Most psychiatrists surveyed (82%) reported receiving advanced formal training in MCI and AD dementia care, primarily via residency training (38%), continuing medical education (22%) or fellowship (18%). Additionally, almost all psychiatrists (92%) reported receiving referrals for ongoing management of patients with MCI or mild AD dementia, primarily from PCPs or neurologists. However, only 46% of psychiatrists viewed themselves as the coordinator of care for their patients with MCI or mild AD dementia. CONCLUSIONS: Many psychiatrists indicated that they were well-informed about MCI and AD dementia and have a strong interest in providing care for these patients. They can provide timely and accurate diagnosis of clinical MCI and mild AD dementia and develop optimal treatment plans for patients. Although many psychiatrists consider other physicians to be the care coordinators for patients with MCI and mild AD dementia, psychiatrists can play a key role in diagnosing and managing patients with MCI and mild AD dementia.

Alzheimer's disease (AD) is the most common cause of dementia. Symptoms of AD include a decline in memory, language, problem-solving, and other thinking abilities that affect daily life. AD may first appear as mild cognitive impairment (MCI) but eventually progresses to AD dementia which is categorized as mild, moderate, or severe based on how much symptoms interfere with patients' everyday activities. We wanted to better understand the roles of different types of doctors in the diagnosis and management of MCI and mild AD dementia. A total of 301 doctors in the United States took an online survey in 2021. Of these, 50 were psychiatrists who specialize in mental health. Psychiatrists used several methods to diagnose patients with MCI or mild AD dementia, including mental status and memory testing. At diagnosis, psychiatrists discussed various topics with their patients who have MCI or mild AD dementia, including treatment options, ways to manage the disease, cause of the disease, and its progression. After diagnosis, most psychiatrists saw their patients with MCI or mild AD dementia at least four times a year. Most psychiatrists reported having advanced training in MCI and AD dementia care. Almost all psychiatrists said other doctors refer patients to them for ongoing management. However, less than half of psychiatrists consider themselves to be the coordinator of care for their patients with MCI or mild AD dementia. As physicians with training in MCI and AD dementia care, psychiatrists can play an important role in the timely diagnosis, treatment, and management of MCI and mild AD dementia.

Quality of life in patients with type 2 diabetes after switching to insulin degludec: results from a cross-sectional survey.

PURPOSE: Five quality of life (QoL) domains are particularly important to patients with type 2 diabetes (T2D) using basal insulin-sense of physical well-being, sense of safety regarding hypoglycemia, sense of diabetes as burdensome, feelings of freedom and flexibility, and sleep quality. METHODS: An online survey assessed these QoL domains in adult patients with T2D in the USA who had switched from a previous basal insulin to insulin degludec (IDeg): modified versions of the World Health Organization (Five) Well-Being Index (WHO-5), Hypoglycemia Attitudes and Behavior Scale (HABS; confidence and anxiety subscales only), and Diabetes Distress Scale (DDS; emotional burden and regimen-related distress subscales only); three items assessing feelings of freedom and flexibility; and one item assessing sleep quality (hours of restful sleep). Patients rated each item for their previous basal insulin and currently while using IDeg. Correlations between sleep quality and the other QoL scales were also assessed. RESULTS: In total, 152 patients completed the survey and were included in the study sample. Patients reported significantly improved scores while using IDeg on all WHO-5, DDS, HABS, feelings of freedom and flexibility item scores, and total raw/mean subscale scores (P < 0.0001). Patients also reported a significantly greater number of hours of restful sleep [mean (SD) 6.6 (2.0) vs. 5.5 (1.8); P < 0.0001]. Better sleep quality statistically significantly correlated with improved QoL in all other domains assessed. CONCLUSIONS: Treatment with IDeg after switching from a previous basal insulin was associated with statistically significant improvements in all QoL domains assessed.

Exploring Why People With Type 2 Diabetes Do or Do Not Persist With Glucagon-Like Peptide-1 Receptor Agonist Therapy: A Qualitative Study.

OBJECTIVE: Despite the demonstrated benefits of glucagon-like peptide 1 (GLP-1) receptor agonist therapy, adherence and persistence with this therapy is often challenging. The purpose of this study was to expand current understanding of patients' experiences, motivations, and challenges relevant to their persistence with GLP-1 receptor agonist therapy. DESIGN AND METHODS: This noninterventional, cross-sectional, qualitative study used face-to-face interviews with 36 adults with type 2 diabetes who had been treated with at least one GLP-1 receptor agonist medication. Inclusion criteria were: ≥18 years of age, diagnosed with type 2 diabetes, and currently treated with a GLP-1 receptor agonist for ≥1 month at the time of screening ("continuers") or discontinued use of a GLP-1 receptor agonist ≤1 year of screening but with a total ≥1 month of treatment ("discontinuers"). Interviews were conducted using a semi-structured qualitative interview guide that included open-ended questions and probes to obtain both spontaneous and prompted input from participants about their current and past treatment experiences with GLP-1 receptor agonist therapy. RESULTS: Among continuers (n = 16), the most commonly identified facilitators supporting the decision to continue were the observations of improved glucose control (50%) and weight loss (55%). Among discontinuers (n = 20), the most commonly identified challenges leading to treatment discontinuation were side effects (55%) and high cost (50%). Continuers were more likely than discontinuers to receive clinically relevant information from their health care team, including facts about GLP-1 receptor agonist medications, likely treatment benefits, the importance of gradual dose titration, and the need to adjust diet after initiation. CONCLUSION: Although cost is a major obstacle to treatment continuation, it can only be resolved through changes in ongoing reimbursement coverage and policies. However, many other obstacles could potentially be addressed (e.g., reducing side effects with gradual dosage titration and setting appropriate expectations regarding efficacy) through more collaborative patient-clinician interactions before initiating therapy.

Methods, rationale, and design for a remote pharmacist and navigator-driven disease management program to improve guideline-directed medical therapy in patients with type 2 diabetes at elevated cardiovascular and/or kidney risk.

AIM: Describe the rationale for and design of Diabetes Remote Intervention to improVe use of Evidence-based medications (DRIVE), a remote medication management program designed to initiate and titrate guideline-directed medical therapy (GDMT) in patients with type 2 diabetes (T2D) at elevated cardiovascular (CV) and/or kidney risk by leveraging non-physician providers. METHODS: An electronic health record based algorithm is used to identify patients with T2D and either established atherosclerotic CV disease (ASCVD), high risk for ASCVD, chronic kidney disease, and/or heart failure within our health system. Patients are invited to participate and randomly assigned to either simultaneous education and medication management, or a period of education prior to medication management. Patient navigators (trained, non-licensed staff) are the primary points of contact while a pharmacist or nurse practitioner reviews and authorizes each medication initiation and titration under an institution-approved collaborative drug therapy management protocol with supervision from a cardiologist and/or endocrinologist. Patient engagement is managed through software to support communication, automation, workflow, and standardization. CONCLUSION: We are testing a remote, navigator-driven, pharmacist-led, and physician-overseen management strategy to optimize GDMT for T2D as a population-level strategy to close the gap between guidelines and clinical practice for patients with T2D at elevated CV and/or kidney risk.

Perspectives of patients, care partners, and primary care physicians on management of mild cognitive impairment and mild Alzheimer's disease dementia.

OBJECTIVES: Early diagnosis of mild cognitive impairment (MCI) and mild Alzheimer's disease (AD) dementia is crucial for effective disease management and optimizing patient outcomes. We sought to better understand the MCI and mild AD dementia medical journey from the perspective of patients, care partners, and physicians. METHODS: We conducted online surveys in the United States among patients/care partners and physicians in 2021. RESULTS: 103 patients with all-cause MCI or mild AD dementia aged 46-90 years, 150 care partners for someone with all-cause MCI or mild AD dementia, and 301 physicians (101 of which were primary care physicians, [PCPs]) completed surveys. Most patient/care partners reported that experiencing forgetfulness (71%) and short-term memory loss (68%) occurred before talking to a healthcare professional. Most patients (73%) followed a common medical journey, in which the initial discussion with a PCP took place 15 months after symptom onset. However, only 33% and 39% were diagnosed and treated by a PCP, respectively. Most (74%) PCPs viewed themselves as coordinators of care for their patients with MCI and mild AD dementia. Over one-third (37%) of patients/care partners viewed PCPs as the care coordinator. CONCLUSIONS: PCPs play a vital role in the timely diagnosis and treatment of MCI and mild AD dementia but often are not considered the care coordinator. For the majority of patients, the initial discussion with a PCP took place 15 months after symptom onset; therefore, it is important to educate patients/care partners and PCPs on MCI and AD risk factors, early symptom recognition, and the need for early diagnosis and treatment. PCPs could improve patient care and outcomes by building their understanding of the need for early AD diagnosis and treatment and improving the efficiency of the patient medical journey by serving as coordinators of care.

Alzheimer's disease (AD) is not a normal part of aging, but many people develop AD as they age, and it is the seventh leading cause of death in the US. AD is a neurological condition that begins as mild cognitive impairment (MCI) or mild AD dementia. To understand the medical journey of patients with MCI or mild AD dementia, we surveyed 103 patients with MCI or mild AD dementia, 150 care partners, and 301 doctors. Patients had several symptoms before talking to a doctor, including forgetfulness and short-term memory loss; most patients (64%) first discussed these symptoms with a primary care physician (PCP) on average 15 months later. However, most patients were not diagnosed or treated by a PCP for MCI or mild AD dementia. We asked patients/care partners who they believe is the coordinator of their care for MCI and mild AD dementia. Thirty-seven percent felt the PCP was the coordinator of care. Most surveyed PCPs (74%) considered themselves to be the coordinator of care for their patients with MCI or mild AD dementia. In conclusion, PCPs play a key role in the care of patients with MCI and mild AD dementia. It is important for patients and care partners to understand the symptoms of MCI and mild AD dementia, and the need to get a diagnosis and treatment soon after symptoms appear. PCPs can play an important role in early diagnosis and treatment and serve as coordinators of care for their patients with MCI and mild AD dementia.[Figure: see text].

Successful Implementation of an All-or-None Diabetes Measure in 10 US Health Systems.

Type 2 diabetes mellitus (T2DM) affects 31.5 million adults in the United States and is commonly treated in primary care settings. One promising approach to comprehensive care is to focus on an all-or-none diabetes bundle measure, which ensures each patient meets a set of guideline-recommended measures. This requires a practice-level coordinated strategy. The purpose of this initiative was to help health care organizations (HCOs) improve the care and outcomes of patients with T2DM using an all-or-none bundle measure. This observational study was carried out in the context of a national best practices learning Collaborative that implemented targeted interventions in primary care settings and measured success using an all-or-none bundle measure. Ten AMGA member-HCOs, across 8 states, treating nearly 300,000 adult patients with T2DM in primary care participated. The primary measure, the Together 2 Goal® Core Bundle, included hemoglobin A1c (A1c) control (<8%), blood pressure (BP) control (<140/90 mmHg), lipid management (prescribed a statin), and medical attention for nephropathy. All 10 HCOs improved the Core Bundle measure during the 12-month Collaborative. The rate for the Core Bundle improved from 40.2% to 42.8%, an absolute increase of 2.6% (P < 0.001). In addition, 9 HCOs improved BP control, 8 improved lipid management, 6 improved attention to nephropathy, and 4 improved A1c control. Implementing interventions in primary care settings was successful in achieving comprehensive care for an estimated additional 7700 people living with T2DM who met all 4 components of the bundle measure during the 12-month intervention period.

Cardiovascular Disease in Patients With Type 2 Diabetes: A Qualitative Analysis of Knowledge, Attitudes, and Beliefs of Health Care Professionals.

Guidelines for the management of patients with type 2 diabetes mellitus (T2DM) recommend SGLT-2 (sodium-glucose cotransporter 2) inhibitors and GLP-1 RAs (glucagon-like peptide 1 receptor agonists) as second-line agents for patients with, or at risk for, cardiovascular disease. A better understanding of guideline implementation will further the provision of evidence-based health care to patients. Interviews and surveys of clinicians were conducted to understand providers' knowledge, attitudes, and beliefs related to the 2019 American Diabetes Association Standards of Care for T2DM. There was a lack of widespread knowledge of the guidelines and comfort with their use. Clinicians require additional training and education on the efficacy of the new medications and accompanying clinical guidelines.

Assessing Prevalence of Hypoglycemia in a Medical Transcription Database.

PURPOSE: The prevalence of hypoglycemia in patients with diabetes mellitus is likely underreported, particularly with regard to non-severe episodes, and representative estimates require more detailed data than claims or typical electronic health record (EHR) databases provide. This study examines the prevalence of hypoglycemia as identified in a medical transcription database. PATIENTS AND METHODS: The Amplity Insights database contains medical content dictated by providers detailing patient encounters with health care professionals (HCPs) from across the United States. Natural language processing (NLP) was used to identify episodes of hypoglycemia using both symptom-based and non-symptom-based definitions of hypoglycemic events. This study examined records of 41,688 patients with type 1 diabetes mellitus and 317,399 patients with type 2 diabetes mellitus between January 1, 2016, and April 30, 2018. RESULTS: Using a non-symptom-based definition, the prevalence of hypoglycemia was 18% among patients with T1DM and 8% among patients with T2DM. These estimates show the prevalence of hypoglycemia to be 2- to 9-fold higher than the 1% to 4% prevalence estimates suggested by claims database analyses. CONCLUSION: In this exploration of a medical transcription database, the prevalence of hypoglycemia was considerably higher than what has been reported via retrospective analyses from claims and EHR databases. This analysis suggests that data sources other than claims and EHR may provide a more in-depth look into discrepancies between the mention of hypoglycemia events during a health care visit and documentation of hypoglycemia in patient records.

Injectable Antihyperglycemics: A Systematic Review and Critical Analysis of the Literature on Adherence, Persistence, and Health Outcomes.

INTRODUCTION: Improving real-world medication adherence to injectable antihyperglycemics in type 2 diabetes mellitus (T2DM) is a clinical challenge. Quantification of the level of adherence required to achieve a minimal clinically important difference (MCID) in glycemic control would assist in meeting this goal. The study objective was to review the literature regarding the relationships of medication adherence and persistence with health outcomes in adult T2DM patients using injectable antihyperglycemics. METHODS: Systematic searches were conducted using electronic databases to identify publications over the last decade. Publications were screened against established eligibility criteria. Study data were extracted, evaluated, and used to identify strengths, limitations, and gaps in current evidence. RESULTS: Eligibility criteria were met by 38 studies, and this report analyzed 34 studies related to glycemic control (n = 25), healthcare resource use (n = 9), and healthcare costs (n = 14). Eight of these studies examined adherence to glucagon-like peptide-1 receptor agonists (GLP-1 RA), including 1 study regarding adherence to GLP-1 RA or to insulin, and 1 study investigating a GLP-1 RA/insulin combination; the remaining studies involved insulin. Studies used a broad range of measures to classify adherence and persistence, and most measures were unable to reliably evaluate the complexities of patient behavior over time. Better adherence to injectable antihyperglycemic medications was generally found to be associated with improved glycemic control, although no studies attempted to identify a MCID. Although higher diabetes-related pharmacy and total healthcare costs were reported for adherent or persistent patients, these patients tended to have lower diabetes-related and all-cause medical costs. CONCLUSION: Results of this review confirmed the effectiveness of injectable antihyperglycemic medications for glycemic control, suggesting that there are clinical and financial consequences to nonadherence. Although attempts were made to quantify the effects of nonadherence, the interpretation of study results was limited by the lack of a MCID and inadequate study design. FUNDING: Novo Nordisk, Inc., Plainsboro Township, NJ, USA. Plain language summary available for this article.