medwireNews: Improving how type 2 diabetes care is used and delivered may be more important to achieving glycemic control than addressing inflexible patient and clinical characteristics often considered in clinical practice, researchers have discovered.
Reporting in JAMA Network Open, Julie Lauffenburger (Brigham and Women’s Hospital, Boston, Massachusetts, USA) and co-workers maintain that “these results suggest that the nature of care that patients receive may be important and potentially modifiable.”
They add: “Moreover, the findings from this study also suggest several patient-centered quality improvement interventions that could be relevant to improving glycemic control.”
The subgroup analysis involved 1423 individuals with type 2 diabetes who were enrolled in the 6000-patient TARGIT-Diabetes trial, originally designed to evaluate three pharmacist-delivered interventions on insulin persistence and glycated hemoglobin (HbA1c) levels.
Modifiable factors relating to the delivery of diabetes care that were significantly and independently associated with adequate glycemic control (HbA1c below 8%) included persistent use of basal insulin (adjusted relative risk [RR]=1.20), more frequent filling of glucose self-testing supplies (adjusted RR per unit increase=1.01), visiting an endocrinologist (adjusted RR=1.41), and receipt of insulin prescriptions by mail order (adjusted RR=1.23).
Of note, the team found that the association between visiting an endocrinologist and adequate glycemic control appeared to be stronger in men (adjusted RR=1.45) and was not statistically significant in women.
Conversely, use of mail order pharmacy services was significantly associated with adequate glycemic control in women (adjusted RR=1.39) but not men.
Unmodifiable patient factors examined included demographic characteristics, clinical comorbidities, and indicators associated with disease progression. Of these, age was the only factor associated with adequate glycemic control, at a RR of 1.01 per unit increase.
The trial participants had at least one HbA1c value recorded before randomization, had continuous health insurance for at least a year before their latest HbA1c test, and filled a basal insulin prescription in the 180 to 365 days before this test.
The researchers summarize: “We found that the most notable factors appeared to be the nature of patients’ interactions with the health care system and behaviors in the health care system.
“Specifically, insulin persistence, greater use of glucose self-testing supplies, receipt of prescriptions by mail order, and visiting an endocrinologist were the factors most strongly associated with adequate diabetes control.”
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