Prescriber Uncertainty as Opportunity to Improve Care of Type 2 Diabetes with Chronic Kidney Disease: Mixed Methods Study.

BACKGROUND: Over 5 million patients in the United States have type 2 diabetes mellitus (T2D) with chronic kidney disease (CKD); antidiabetic drug selection for this population is complex and has important implications for outcomes. OBJECTIVE: To better understand how providers choose antidiabetic drugs in T2D with CKD DESIGN: Mixed methods. Interviews with providers underwent qualitative analysis using grounded theory to identify themes related to antidiabetic drug prescribing. A provider survey used vignettes and direct questions to quantitatively assess prescribers' knowledge and preferences. A retrospective cohort analysis of real-world prescribing data assessed the external validity of the interview and survey findings. PARTICIPANTS: Primary care physicians, endocrinologists, nurse-practitioners, and physicians' assistants were eligible for interviews; primary care physicians and endocrinologists were eligible for the survey; prescribing data were derived from adult patients with serum creatinine data. MAIN MEASURES: Interviews were qualitative; for the survey and retrospective cohort, proportion of patients receiving metformin was the primary outcome. KEY RESULTS: Interviews with 9 providers identified a theme of uncertainty about guidelines for prescribing antidiabetic drugs in patients with T2D and CKD. The survey had 105 respondents: 74 primary care providers and 31 endocrinologists. Metformin was the most common choice for patients with T2D and CKD. Compared to primary care providers, endocrinologists were less likely to prescribe metformin at levels of kidney function at which it is contraindicated and more likely to correctly answer a question about metformin's contraindications (71% versus 41%) (p < .05). Real-world data were consistent with survey findings, and further showed low rates of use of sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide 1 receptor agonists (<10%) in patients with eGFR below 60 ml/min/1.73m2. CONCLUSIONS: Providers are unsure how to treat T2D with CKD and incompletely informed as to existing guidelines. This suggests opportunities to improve care.

Overcoming barriers to the use of metformin: patient and provider perspectives.

BACKGROUND: Metformin is the first-line treatment for type 2 diabetes mellitus. Observational studies show lower rates of use than would be expected from clinical guidelines. OBJECTIVE: We undertook a qualitative study of barriers to metformin use from the patient and provider perspective. DESIGN: Patient focus group, patient individual interviews, provider interviews, and chart review. Purposive sampling of patients and providers in New York State. PARTICIPANTS: Seven one-on-one patient interviews, one focus group with 13 patients, 10 provider interviews, and manual review of 1259 charts. APPROACH: Grounded theory. RESULTS: Both providers and patients cited potential health benefits as strong reasons to take metformin and describe it as the first-line drug for diabetes. Patients and providers both cited gastrointestinal side effects as the primary barrier to metformin use. Patients described adapting to these side effects and taking metformin at a time that minimizes them. In contrast, providers emphasized dose titration and the use of extended-release formulation as tools for minimizing side effects but were uncertain about the effectiveness of these strategies. CONCLUSION: Metformin is positively viewed by patients and providers, but gastrointestinal side effects are a barrier to its use. There is some consensus on basic measures to improve its tolerability, but these measures are not consistently applied and lack evidence establishing their effectiveness. Pragmatic clinical trial research on optimal dose, formulation, and counseling for new metformin users should be considered.

Recent advances in managing benign prostatic hyperplasia: The Rezum System.

Benign Prostatic Hyperplasia is a common condition that affects 50% of men in their 50 th decade. There have been many advances in the treatment of this condition, which aim to improve the patient's quality of life. A new treatment that shows promising results is the Rezum System, a water vapor therapy for BPH. We present the most current literature on this therapy.

Patching a leak in an R1 university gateway STEM course.

A cognitively intensive companion service course has been introduced to the main fall general chemistry class at Cornell University. For years 2015 and 2016, priority students (those from groups under-represented and economically disadvantaged) show respectively improvement of +0.67 and +0.51 standard deviations in final course grade compared to priority students not in the program. Non-priority students show respectively a +0.66 and +0.62 standard deviation improvement. Progressive improvement (as measured by higher than expected Final Exam scores than what would have been expected solely from a given student's earlier Exam 1 score) demonstrates conclusively the service course's role in the enhanced outcomes. Progressive retention (as measured by the following year fall semester's organic chemistry exam scores compared to what would have been expected based on a given student's general chemistry final exam score) demonstrates that, on the average, the earlier observed progressive improvement is significantly retained in a chemistry course one year later. Preliminary retention statistics suggest a significant increase in first year to second year retention. A meta analysis of results from previously reported chemistry service courses indicate that such performance gains are difficult to achieve and hence common elements of the few effective programs may be of high value to the STEM education community.