Trends in Drug Utilization, Glycemic Control, and Rates of Severe Hypoglycemia, 2006-2013.

ObjectiveTo examine temporal trends in utilization of glucose-lowering medications, glycemic control, and rate of severe hypoglycemia among patients with type 2 diabetes (T2DM).Research design and methodsUsing claims data from 1.66 million privately insured and Medicare Advantage patients with T2DM from 2006 to 2013, we estimated the annual 1) age- and sex-standardized proportion of patients who filled each class of agents; 2) age-, sex-, race-, and region-standardized proportion with hemoglobin A1c (HbA1c) <6%, 6 to <7%, 7 to <8%, 8 to <9%, ≥9%; and 3) age- and sex-standardized rate of severe hypoglycemia among those using medications. Proportions were calculated overall and stratified by age-group (18-44, 45-64, 65-74, and ≥75 years) and number of chronic comorbidities (zero, one, and two or more).ResultsFrom 2006 to 2013, use increased for metformin (from 47.6 to 53.5%), dipeptidyl peptidase 4 inhibitors (0.5 to 14.9%), and insulin (17.1 to 23.0%) but declined for sulfonylureas (38.8 to 30.8%) and thiazolidinediones (28.5 to 5.6%; all P < 0.001). The proportion of patients with HbA1c <7% declined (from 56.4 to 54.2%; P < 0.001) and with HbA1c ≥9% increased (9.9 to 12.2%; P < 0.001). Glycemic control varied by age and was poor among 23.3% of the youngest and 6.3% of the oldest patients in 2013. The overall rate of severe hypoglycemia remained the same (1.3 per 100 person-years; P = 0.72), declined modestly among the oldest patients (from 2.9 to 2.3; P < 0.001), and remained high among those with two or more comorbidities (3.2 to 3.5; P = 0.36).ConclusionsDuring the recent 8-year period, the use of glucose-lowering drugs has changed dramatically among patients with T2DM. Overall glycemic control has not improved and remains poor among nearly a quarter of the youngest patients. The overall rate of severe hypoglycemia remains largely unchanged

Engaging emergency medical services to improve postacute management of behavioural health emergency calls: a protocol of a scoping literature review

Introduction The public health crisis of escalating mental health, behavioural and substance-related emergencies has revealed the need to approach these complex events from a health perspective, rather than the traditional criminal justice standpoint. Despite law enforcement officers often being the first responders to emergency calls concerning self or bystander harm, they are not optimally equipped to manage these crises holistically or to connect affected individuals to necessary medical treatment and social support. Paramedics and other emergency medical services (EMS) providers are well positioned to deliver comprehensive medicosocial care during and in the immediate aftermath of these emergencies, moving beyond their traditional role in emergency evaluation, stabilisation and transport to a higher level of care. The role of EMS in bridging this gap and helping shift emphasis to mental and physical health needs in crisis situations has not been examined in prior reviews.Methods and analysis In this protocol, we delineate our approach to describing existing EMS programmes that focus specifically on supporting individuals and communities experiencing mental, behavioural and substance-related health crises. The databases to be searched are EBSCO CINAHL, Ovid Cochrane Central Register of Controlled Trials, Ovid Embase, Ovid Medline, Ovid PsycINFO and Web of Science Core Collection, with search date limits being from database inception to 14 July 2022. A narrative synthesis will be completed to characterise populations and situations targeted by the programmes, describe programme staffing and composition, detail the interventions and identify collected outcomes.Ethics and dissemination All data in the review will be publicly accessible and published previously, so approval by a research ethics board is not needed. Our findings will be published in a peer-reviewed journal and shared with the public.Trial registration number https://doi.org/10.17605/OSF.IO/UYV4

Evaluation of pharmacist consults within a collaborative enhanced primary care team model to improve diabetes care.

BackgroundAn enhanced primary care team model was implemented to provide proactive, longitudinal care to patients with diabetes, grounded in close partnership between primary care providers (PCPs), nurses, and Medication Management Services (MMS) pharmacists. The purpose of this study is to evaluate the impact of the MMS pharmacist involvement in the enhanced primary care model for patients with diabetes.MethodsThis retrospective cohort study compared the quality of diabetes care between patients referred to a pharmacist and propensity score matched controls who were not. Eligible patients were adults (age 18 to 75 years) enrolled in the enhanced primary care team process who did not meet at least one of four diabetes quality indicators at 13 Mayo Clinic Rochester primary care practice locations. The intervention examined was asynchronous e-consults by pharmacists affiliated with the primary care practice.Main measuresThe primary outcome was change in the proportion of patients meeting the composite of four diabetes treatment goals (D4), including hemoglobin A1c (HbA1c) control, blood pressure control, aspirin use, and statin use at six months from enrollment among patients who received pharmacist intervention compared to matched patients who did not. Secondary outcomes were each of the D4 goal individually.ResultsThe proportion of patients meeting the D4 increased with pharmacist e-consults (N = 85) compared to matched controls with no review (N = 170) (27% vs 7.0%, pConclusionsPharmacist engagement in the enhanced primary care team improved diabetes management. This supports the inclusion and utilization of pharmacists in multidisciplinary efforts to improve diabetes care

Variation in hypoglycemia ascertainment and report in type 2 diabetes observational studies: a meta-epidemiological study

Introduction Observational studies constitute an important evidence base for hypoglycemia in diabetes management. This requires consistent and reliable ascertainment and reporting methodology, particularly in studies of type 2 diabetes where hypoglycemia risk is heterogeneous. Therefore, we aimed to examine the definitions of hypoglycemia used by observational studies of patients with type 2 diabetes. Research design and methods We conducted a meta-epidemiological review of observational studies reporting on hypoglycemia or evaluating glucose-lowering medications in adults with type 2 diabetes. MEDLINE and Google Scholar were searched from January 1970 to May 2018. The definitions of non-severe, severe and nocturnal hypoglycemia were examined.Results We reviewed 243 studies: 47.7% reported on non-severe hypoglycemia, 77.8% on severe hypoglycemia and 16.9% on nocturnal hypoglycemia; 5.8% did not specify. Among 116 studies reporting non-severe hypoglycemia, 18.1% provided no definition, 23.3% used glucose values, 38.8% relied on patient-reported symptoms, 17.2% accepted either glucose values or patient-reported symptoms and 2.6% relied on International Classification of Disease (ICD) codes. Among 189 studies reporting severe hypoglycemia, 11.1% provided no definition, 53.4% required symptoms needing assistance, 3.7% relied on glucose values, 14.8% relied on ICD codes, 2.6% relied on ICD codes or glucose values and 15.9% required both symptoms needing assistance and glucose values. Overall, 38.2% of non-severe and 67.7% of severe hypoglycemia definitions were consistent with the International Hypoglycemia Study Group.Conclusions The marked heterogeneity in how hypoglycemia is defined in observational studies may contribute to the inadequate understanding and correction of hypoglycemia risk factors among patients with type 2 diabetes

Advances in the management of type 2 diabetes in adults

Type 2 diabetes is a chronic and progressive cardiometabolic disorder that affects more than 10% of adults worldwide and is a major cause of morbidity, mortality, disability, and high costs. Over the past decade, the pattern of management of diabetes has shifted from a predominantly glucose centric approach, focused on lowering levels of haemoglobin A 1c (HbA 1c ), to a directed complications centric approach, aimed at preventing short term and long term complications of diabetes, and a pathogenesis centric approach, which looks at the underlying metabolic dysfunction of excess adiposity that both causes and complicates the management of diabetes. In this review, we discuss the latest advances in patient centred care for type 2 diabetes, focusing on drug and non-drug approaches to reducing the risks of complications of diabetes in adults. We also discuss the effects of social determinants of health on the management of diabetes, particularly as they affect the treatment of hyperglycaemia in type 2 diabetes

1022-P: Trends in Glucagon Fill Rates among U.S. Adults with Diabetes and End-Stage Kidney Disease on Dialysis

Patients with diabetes (DM) and end-stage kidney disease (ESKD) on dialysis have a high risk of severe hypoglycemia and more than 70% are treated with insulin therapy. While not all hypoglycemic events can be prevented, glucagon is recommended for patients at high risk for hypoglycemia to revert and prevent hospitalization with severe hypoglycemic events. Prior studies have shown low rates of glucagon utilization, but excluded patients with ESKD who are at highest risk for these events. We used the USRDS, the most comprehensive nationwide database of patients with ESKD in the US, to examine the quarterly rates of glucagon fills among U.S. adults with DM and ESKD receiving dialysis. Among 254,195 adults (≥18 years) with ESKD and type 1 DM (N=27,538) or type 2 DM (N=226,657), with 76.9% using insulin therapy, between 2013-2017. Fewer than 2% of patients with type 2 DM and fewer than 4% of patients with type 1 DM filled a glucagon prescription, with declining fill rates over time among patients with type 2 DM and stable rates among patients with type 1 DM. Clinical Characteristics and trends in glucagon prescriptions are shown in Table 1. Our findings suggest an urgent and critical need for education of clinicians, patients, and caregivers to improve the prescribing and use of glucagon: a life-saving rescue medication. Disclosure R.J.Galindo: Consultant; Novo Nordisk, Eli Lilly and Company, Sanofi, Pfizer Inc., Bayer Inc., WW (Weight Watchers), Research Support; Novo Nordisk, Eli Lilly and Company, Dexcom, Inc. S.Inselman: None. B.Moazzami: None. M.K.Ali: Advisory Panel; Bayer Inc., Eli Lilly and Company, Research Support; Merck & Co., Inc. G.Umpierrez: Research Support; Abbott, Dexcom, Inc., Baxter. R.G.Mccoy: Consultant; Emmi

Use and continuity of weight‐modifying medications among adults with diabetes and overweight/obesity: US population study

Abstract Objective Trends in use and continuity of use of diabetes‐specific and non‐diabetes weight‐reducing (WR), weight‐inducing (WI), and weight‐neutral (WN) medications were examined among US adults with diabetes and overweight/obesity. Methods Serial cross‐sectional data from Medical Expenditure Panel Surveys (2010–2019) for adults (≥18 years) with diabetes and BMI ≥27 kg/m 2 (≥25 kg/m 2 for Asians) were analyzed. Results Among 7402 US adults with diabetes and overweight/obesity (mean age 60.0 years [SD 13], 50% female), 64.9% of participants used any WI medications, decreasing from 68.9% (95% CI: 64.3%–73.5%) in 2010 to 58.6% (95% CI: 54.7%–62.5%) in 2019. It was estimated that 13.5% used WR medications, increasing 3.31‐fold, from 6.4% (95% CI: 4.1%–8.7%) to 21.2% (95% CI: 18.0%–24.4%) and that 73.1% used WN medications, ranging from 70.5% (95% CI: 66.5–74.6) to 75.0% (95% CI: 71.7%–78.4%). Among adults using diabetes‐specific WI (53.7%), WR (7.1%), and WN (62.4%) medications during the first year, 7.3%, 16.4%, and 9.0% discontinued it in the second year, respectively. Conclusions Over 2010–2019, 64.9% of adults with diabetes and overweight/obesity were treated with WI medications, 13.5% with WR medications, and 73.1% with WN medications. Discontinuation of WR medications was nearly twice that of WI medications