Preventing Diabetes in Primary Care: Providers' Perspectives About Diagnosing and Treating Prediabetes.

IN BRIEF Offering patient-centered care to prevent diabetes will require collaborative decision-making between patients with prediabetes and their health care providers. From the perspective of primary care providers, prediabetes detection should be targeted to patients who are most likely to benefit from diagnosis and treatment. Improving access to lifestyle intervention programs and educating providers about evidence-based treatments for prediabetes and how to effectively discuss treatment options with patients may improve both providers' and patients' engagement in diabetes prevention.

The State of Diabetes Prevention Policy in the USA Following the Affordable Care Act.

Type 2 diabetes is a major public health problem in the USA, affecting over 12 % of American adults and imposing considerable health and economic burden on individuals and society. There is a strong evidence base demonstrating that lifestyle behavioral changes and some medications can prevent or delay the onset of type 2 diabetes in high risk adults, and several policy and healthcare system changes motivated by the Patient Protection and Affordable Care Act (ACA) have the potential to accelerate diabetes prevention. In this narrative review, we (1) offer a conceptual framework for organizing how the ACA may influence diabetes prevention efforts at the level of individuals, healthcare providers, and health systems; (2) highlight ACA provisions at each of these levels that could accelerate type 2 diabetes prevention nationwide; and (3) explore possible policy gaps and opportunity areas for future research and action.

Radiation Oncologists' Role in End-of-Life Care: A Perspective From Medical Oncologists.

PURPOSE: Multidisciplinary communication and collaboration are key to planning and delivering end-of-life care for patients with advanced and metastatic cancer. We sought to characterize medical oncologists' perspectives on the role of radiation oncologists in end-of-life care. MATERIALS AND METHODS: A sample of US medical oncologists was recruited using snowball sampling methods. Audio recordings of 4 professionally moderated focus groups were transcribed. Investigators from diverse backgrounds (medical oncology, radiation oncology, critical care medicine, palliative care, and public health) independently reviewed each transcript. Qualitative content analysis was used to create consensus codes that were applied to subsequent focus group transcripts in an iterative process. RESULTS: Medical oncologists expressed complex views regarding the role of radiation oncologists in end-of-life care. Identified themes included the limited role of radiation oncologists, territorial concerns, capability, and desire of radiation oncologists in this realm, and the need for communication between providers. Radiation oncologists were compared with surgeons, whose interaction with patients ceased after their service had been performed. In this regard, control of palliative care referral or end-of-life care discussions was thought to be in the territory of medical oncologists who had longitudinal relationships with patients from diagnosis. Medical oncologists were concerned about the capability of radiation oncologists to accurately prognosticate, and stated radiation oncologists lacked knowledge of subsequent lines of systemic therapy available to patients. Radiation oncologists' fear of upsetting medical oncologists was thought to be justified if they engaged in end-of-life care planning without direct permission from the referring medical oncologist. CONCLUSIONS: Participation of radiation oncologists in end-of-life care planning was viewed with skepticism by medical oncologists. Radiation oncologists should focus on increasing open communication and teamwork with medical oncologists and demonstrate their ability to prognosticate and counsel patients regarding end-of-life care decisions.

Association of Second-line Antidiabetic Medications With Cardiovascular Events Among Insured Adults With Type 2 Diabetes.

Importance: Understanding cardiovascular outcomes of initiating second-line antidiabetic medications (ADMs) may help inform treatment decisions after metformin alone is not sufficient or not tolerated. To date, no studies have compared the cardiovascular effects of all major second-line ADMs during this early decision point in the pharmacologic management of type 2 diabetes. Objective: To examine the association of second-line ADM classes with major adverse cardiovascular events. Design, Setting, and Participants: Retrospective cohort study among 132 737 insured adults with type 2 diabetes who started therapy with a second-line ADM after taking either metformin alone or no prior ADM. This study used 2011-2015 US nationwide administrative claims data. Data analysis was performed from January 2017 to October 2018. Exposures: Dipeptidyl peptidase 4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, sodium-glucose cotransporter 2 (SGLT-2) inhibitors, thiazolidinediones (TZDs), basal insulin, and sulfonylureas or meglitinides (both referred to as sulfonylureas hereafter). The DPP-4 inhibitors served as the comparison group in all analyses. Main Outcomes and Measures: The primary outcome was time to first cardiovascular event after starting the second-line ADM. This composite outcome was based on hospitalization for the following cardiovascular conditions: congestive heart failure, stroke, ischemic heart disease, or peripheral artery disease. Results: Among 132 737 insured adult patients with type 2 diabetes (men, 55%; aged 45-64 years, 58%; white, 63%), there were 3480 incident cardiovascular events during 169 384 person-years of follow-up. Patients were censored after the first cardiovascular event, discontinuation of insurance coverage, transition from International Classification of Diseases, Ninth Revision (ICD-9) to end of ICD-9 coding, or 2 years of follow-up. After adjusting for patient, prescriber, and health plan characteristics, the risk of composite cardiovascular events after starting GLP-1 receptor agonists was lower than DPP-4 inhibitors (hazard ratio [HR], 0.78; 95% CI, 0.63-0.96), but this finding was not significant in all sensitivity analyses. Cardiovascular event rates after starting treatment with SGLT-2 inhibitors (HR, 0.81; 95% CI, 0.57-1.53) and TZDs (HR, 0.92; 95% CI, 0.76-1.11) were not statistically different from DPP-4 inhibitors. The comparative risk of cardiovascular events was higher after starting treatment with sulfonylureas (HR, 1.36; 95% CI, 1.23-1.49) or basal insulin (HR, 2.03; 95% CI, 1.81-2.27) than DPP-4 inhibitors. Conclusions and Relevance: Among insured adult patients with type 2 diabetes initiating second-line ADM therapy, the short-term cardiovascular outcomes of GLP-1 receptor agonists, SGLT-2 inhibitors, and DPP-4 inhibitors were similar. Higher cardiovascular risk was associated with use of sulfonylureas or basal insulin compared with newer ADM classes. Clinicians may consider prescribing GLP-1 receptor agonists, SGLT-2 inhibitors, or DPP-4 inhibitors more routinely after metformin rather than sulfonylureas or basal insulin.

Correlates of second-line type 2 diabetes medication selection in the USA.

OBJECTIVE: Past research provides insufficient evidence to inform second-line diabetes medication prescribing when metformin is no longer sufficient. We evaluated patient, prescriber, and health plan characteristics associated with selection of second-line diabetes medications in the USA. RESEARCH DESIGN AND METHODS: We used a multiple case-comparison study design to identify characteristics associated with the probability of starting each of six second-line diabetes medication alternatives within 77 744 adults enrolled in commercial or Medicare Advantage health plans from 2011 to 2015. National administrative data were provided by a large commercial health payer. Multinomial logistic regression models were used to identify characteristics independently associated with selecting each diabetes drug class. RESULTS: From 2011 to 2015, sulfonylureas still represented 47% of all second-line drug starts, with proportionately higher use in patients ≥75 years of age (63% of drug starts). Basal insulin was more likely to be selected when a past A1c test result was >10% (13.0% vs 4.5% for those with A1c <8%; p<0.001). Initiation of a glucagon-like peptide-1 receptor agonist was associated with being female (10.1% vs 6.0% for male; p<0.001) and having a diagnosis code for obesity (10.8% vs 6.9% for no diagnosis; p<0.001). For all drug classes, the recent prescribing behavior of the provider was a strong correlate of subsequent second-line drug selection. CONCLUSIONS: Sulfonylureas continue to represent almost half of second-line diabetes medication starts in the USA. This could reflect overuse for some groups such as older adults, for whom some alternatives may be safer, although more costly and potentially less effective. Future research should compare outcomes of medication choices and conditions under which particular classes are most effective.

Patient Perceptions About Prediabetes and Preferences for Diabetes Prevention.

PURPOSE: The purpose of this study was to explore how adults with prediabetes perceive their risk of developing diabetes and examine their preferences for evidence-based treatment options to prevent diabetes. METHODS: A qualitative study was conducted in 2 large Midwest primary care practices, involving in-depth semistructured interviews with 35 adult patients with prediabetes. RESULTS: This ethnically diverse (77% nonwhite) sample of middle-aged primary care patients exhibited multiple diabetes risk factors. Knowledge gaps about prediabetes and its medical management were pervasive. Most patients overestimated the risk of developing diabetes and were not familiar with evidence-based treatment options for prediabetes. They suggested that receiving brief, yet specific information about these topics during the study interview motivated them to act. The majority of participants considered both intensive lifestyle intervention and metformin acceptable treatment options. Many preferred initial treatment with intensive lifestyle intervention but would take metformin if their efforts at lifestyle change failed and their primary care physician recommended it. Some participants expressed wanting to combine both treatments. CONCLUSIONS: This qualitative study highlights potential opportunities to promote patient-centered dialogue about prediabetes in primary care settings. Providing patients specific information about the risk of developing diabetes and evidence-based treatment options to prevent or delay its onset may encourage action. Physicians' prediabetes counseling efforts should be informed by the finding that most patients consider both intensive lifestyle intervention and metformin acceptable treatment options.