Breaking Down Patient and Physician Barriers to Optimize Glycemic Control in Type 2 Diabetes

doi:10.1016/j.amjmed.2013.06.012

The American Journal of Medicine

Volume 126, Issue 9, Supplement 1, September 2013, Pages S38-S48

https://doi.org/10.1016/j.amjmed.2013.06.012 Get rights and content

Abstract

Approximately half of patients with type 2 diabetes (T2D) do not achieve globally recognized blood glucose targets, despite the availability of a wide range of effective glucose-lowering therapies. Failure to maintain good glycemic control increases the risk of diabetes-related complications and long-term health care costs. Patients must be brought under glycemic control to improve treatment outcomes, but existing barriers to optimizing glycemic control must first be overcome, including patient nonadherence to treatment, the failure of physicians to intensify therapy in a timely manner, and inadequacies in the health care system itself. The reasons for such barriers include treatment side effects, complex treatment regimens, needle anxiety, poor patient education, and the absence of an adequate patient care plan; however, newer therapies and devices, combined with comprehensive care plans involving adequate patient education, can help to minimize barriers and improve treatment outcomes.

Section snippets

Matching Treatment to Pathophysiology

Type 2 diabetes is a complex disease in which several pathophysiological abnormalities are evident, including reduced insulin secretion, hyperglucagonemia, increased hepatic glucose production, and insulin resistance.¹⁶ These underlying defects lead to hyperglycemia, which is strongly associated with an increased risk of diabetic complications.¹⁷ Findings from a 10-year follow-up to the UK Prospective Diabetes Study (UKPDS) suggest that an early, intensive glucose-lowering strategy offers

Getting to Goal

Guidelines for the treatment of T2D published by the ADA²¹ and the Canadian Diabetes Association²² recommend that A1C levels be maintained at ≤7.0% to reduce the risk of microvascular and macrovascular disease (a lower A1C target of ≤6.5% is recommended by the American Association of Clinical Endocrinologists [AACE]).23, 24 A number of effective treatments are available to help patients with T2D achieve their glycemic goals, yet almost half of patients in the US and Canada (45%-47%) do not have

Hypoglycemia

Hypoglycemia has a considerable impact on morbidity, mortality, and quality of life, and is a major barrier to optimal glycemic control in T2D.²⁵ Fear of hypoglycemia can lead to reduced treatment adherence and reluctance to intensify therapy on the part of both patients and physicians.²⁶ It is therefore essential that measures be taken to reduce the risk and severity of hypoglycemia while still achieving an acceptable level of glycemic control.

All glucose-lowering therapies carry some risk of

Feelings of Guilt or Failure

Patients commonly associate intensification of T2D therapy with personal failure to successfully manage their disease, which may make them reluctant to intensify therapy and could have a negative impact on glycemic control.9, 53 Such feelings of guilt or failure can stem from the perception of treatment intensification as a threat to patients who are noncompliant with their diet and exercise modifications. The key to overcoming this barrier is patient education, whether in the clinic or via

Effective Diabetes Education

It is important that patients with T2D are educated about their medication regimens, the purpose of each of their drugs, and how they work in conjunction with other medications and lifestyle changes to manage their disease. Education should focus not only on information and technical skills, but also on problem-solving to enable patients to effectively self-manage their diabetes.⁷¹ While it is not always clear who is best suited to carry out this education, and who should be responsible for its

Overcoming Clinical Inertia

Clinical inertia (also known as benign neglect) is defined as recognition of a problem but failure to act upon it.⁸⁰ A 3-year retrospective study at a diabetes clinic showed that pharmacotherapy was intensified in only 50% of visits at which patients with T2D clearly met the criteria for advancement of therapy,⁸¹ and in the Diabetes in Canada Evaluation,⁸² a cross-sectional audit study of primary care practice, 49% of patients with T2D were identified as above A1C target. When primary care

Conclusions

Although it has been demonstrated that maintaining glycemic control can reduce the risk of microvascular and macrovascular complications associated with diabetes,1, 2 almost half of patients with T2D are not reaching the recommended A1C targets. To improve disease outcomes, more patients must improve glycemic control. To do this, the barriers to optimal control must be overcome.

A comprehensive care plan is the key to achieving treatment targets, and an organized multidisciplinary team is

Acknowledgment

The author takes full responsibility for this article but is grateful to Watermeadow Medical (supported by Novo Nordisk Inc.) for writing assistance.

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Effect of intravenous infusion of exenatide (synthetic exendin-4) on glucose-dependent insulin secretion and counterregulation during hypoglycemia

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Practical strategies to normalize hyperglycemia without undue hypoglycemia in type 2 diabetes mellitus

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When oral agents fail: practical barriers to starting insulin

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Half-unit dose accuracy with HumaPen® Luxura™ HD: an insulin pen for patients who need precise dosing

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Cited by (113)

A Nationwide Cross-sectional Survey of Knowledge and Practices of Diabetes Drug Injection Techniques of Patients, Nurses, and Physicians: The China IT Improve Study
2023, Mayo Clinic Proceedings
To investigate the knowledge and practices of diabetes drug injection techniques of diabetes patients, nurses, and physicians to support formulating national guidelines for standardized diabetes drug injection techniques.
In this nationwide multicenter cross-sectional survey conducted between November and December 2020, patients, nurses, and physicians were randomly chosen from 250 primary, 150 secondary, and 100 tertiary care hospitals using the stratified cluster sampling method. Their knowledge and/or practices of diabetes drug injection techniques were surveyed using the Diabetes Drug Injection Knowledge and Practice Questionnaire for Physicians, Nurses, and Patients.
In total, 10,694, 2643, and 2816 eligible questionnaires were collected from patients, physicians, and nurses, respectively. Overall, 78.2% (7588/9709) type 2 diabetes patients failed to attain the target hemoglobin A_1c. Hypoglycemic episodes and lipohypertrophy occurred in 19.8% and 34.7% of the patients, respectively. Needle reuse (odds ratio, 1.19; 95% CI, 1.07 to 1.33) and incorrect injection site rotation (odds ratio, 1.32; 95% CI, 1.16 to 1.51) were associated with failure to attain the target hemoglobin A_1c. Overall, 48.9% physicians and 20.4% nurses had a poor knowledge domain score. Care setting and training, diabetes care experience, and regions were significant determinants of diabetes drug injection knowledge domain scores in both physicians and nurses.
Poor glycemic control, occurrences of injection-associated complications in diabetes patients, and poor knowledge domain scores of a subset of physicians and nurses highlight the importance of regular assessment and education regarding diabetes drug injection techniques for physicians and nurses and development of national guidelines for diabetes drug injection.
Chictr.org.cn (ChiCTR2100045302).
Impact of anthocyanin component and metabolite of Saskatoon berry on gut microbiome and relationship with fecal short chain fatty acids in diet-induced insulin resistant mice
2023, Journal of Nutritional Biochemistry
Previous studies demonstrated that oral administration of Saskatoon berry powder (SBp) reduced fasting plasma glucose (FPG), insulin resistance, lipids, and inflammatory markers in diet-induced insulin resistant rodents. Mechanism for the beneficial effects of SB remains unclear. The present study examined the effects of high fat-high sucrose (HFHS) diet supplemented with or without 5% SBp, cyanidin-3-glucoside (C3G, an anthocyanin rich in SBp) at a dosage of C3G in 5% SBp, or equimolar concentration of protocatechuic acid (PCA, a relatively stable metabolite of C3G) for 11 weeks on FPG, cholesterol, triglycerides, insulin, homeostatic model assessment of insulin resistance (HOMA-IR), circulatory inflammatory markers, fecal microbiota, and short chain fatty acids in mice. HFHS diet significantly enhanced FPG, insulin, HOMA-IR, lipids and inflammatory markers, but reduced the abundance of fecal Bacteroidetes, Muribaculaceae and propionate compared to low fat diet. Supplementation of SBp, C3G or PCA significantly attenuated HFHS diet induced metabolic and inflammatory markers, and increased the abundances of fecal Muribaculaceae and propionate compared to HFHS diet alone. The abundances of fecal Muribaculaceae negatively correlated with FPG, lipids, HOMA-IR and inflammatory markers in the mice. The abundances of fecal propionate positively correlated with fecal Muribaculaceae and negatively correlated with the metabolic and inflammatory markers. The findings suggest that C3G in SBp and PCA contribute to the metabolic and anti-inflammatory effect of SBp in mice. The increases in fecal Muribaculaceae and propionate may play important regulatory roles in the anti-diabetic and anti-inflammatory benefits of SBp, C3G, and PCA in mice.
A Cross-sectional Survey to Assess Reasons for Therapeutic Inertia in People With Type 2 Diabetes Mellitus and Preferred Strategies to Overcome It From the Perspectives of Persons With Diabetes and General/Family Practitioners: Results From the MOTION Study
2022, Canadian Journal of Diabetes
Although multiple causes of therapeutic inertia in type 2 diabetes mellitus (T2DM) have been identified, few studies have addressed the behavioural aspects of treatment-intensification decisions among persons with type 2 diabetes (PwT2DM) and general practitioners/family practitioners (GPFPs).
A quantitative online survey was developed to capture from 300 PwT2DM and 100 GPFPs the following information: 1) perspectives on shared decision-making (SDM) related to treatment intensification, using the 9-item Shared Decision Making Questionnaire and the Shared Decision Making Questionnaire---physician version; 2) intentions to intensify treatments, using the Theory of Planned Behaviour (TPB); and 3) preferred strategies to overcome causes of therapeutic inertia in T2DM. Regression methods were applied post hoc to examine correlations with SDM scores, behavioural intentions and behaviours.
SDM scores showed a significantly lower level of perceived involvement in decision-making related to treatment intensification among PwT2DM compared with GPFPs. The TPB identified that, for PwT2DM, attitudes, perceived behavioural control and age were associated with variation in intention to intensify treatment and, for GPFPs, perceived behavioural control and not being in a shared/group practice were associated with intentions to intensify treatment. PwT2DM behaviour, measured as hesitancy to intensify treatment, was associated with age. PwT2DM want more information to become more comfortable with the treatment decision-making process, whereas GPFPs desired support from other health professionals, and more time to address issues among PwT2DM.
Strategies directed at providing GPFPs with tools/approaches to increase PwT2DM involvement in the decision-making process, such as behavioural coaching, decision aids and goal setting, may increase acceptance of treatment intensification, leading to a reduction in therapeutic inertia in T2DM.
Bien que plusieurs causes de l’inertie thérapeutique dans la prise en charge du diabète sucré de type 2 (DST2) aient été cernées, peu d’études ont porté sur les aspects comportementaux des décisions relatives à l’intensification du traitement des personnes atteintes du diabète sucré de type 2 (PDST2) et des médecins généralistes/médecins de famille (MGMF).
Nous avons élaboré une enquête quantitative en ligne auprès de 300 PDST2 et de 100 MGMF pour recueillir les informations suivantes : 1) les points de vue sur la prise de décision partagée relative à l’intensification du traitement à l’aide du questionnaire sur la prise de décision partagée à 9 questions (SDM-Q-9, de l’anglais 9-item Shared Decision Making Questionnaire et du questionnaire sur la prise de décision partagée — version médecin; 2) les intentions en matière d’intensification du traitement à l’aide de la théorie du comportement planifié (TCP); 3) les stratégies privilégiées pour surmonter les causes de l’inertie thérapeutique dans la prise en charge du DST2. Nous avons ensuite appliqué les méthodes de régression pour examiner les corrélations entre les scores au SDM-Q-9, les intentions comportementales et les comportements.
Les scores au SDM-Q-9 ont montré un degré de participation perçue significativement plus faible dans la prise de décision relative à l’intensification du traitement des PDST2 par rapport aux MGMF. La TCP a permis de déterminer que pour les PDST2 les attitudes, la maîtrise comportementale perçue et l’âge étaient associés à la variabilité des intentions en matière d’intensification du traitement et que pour les MGMF la maîtrise comportementale perçue et le fait de ne pas être en cabinet partagé/de groupe étaient associés aux intentions en matière d’intensification du traitement. Le comportement des PDST2, qui a été évalué en fonction de l’hésitation à intensifier le traitement, était associé à l’âge. Les PDST2 voulaient plus d’informations pour se sentir plus à l’aise dans le processus de prise de décision du traitement, alors que les MGMF souhaitaient obtenir l’aide d’autres professionnels de la santé, et avoir plus de temps pour répondre aux préoccupations des PDST2.
Les stratégies qui visaient à fournir aux MGMF les outils/approches pour accroître la participation des PDST2 dans le processus de prise de décision tels que le coaching comportemental, l’aide à la décision et la détermination des objectifs, peut accroître l’acceptation de l’intensification du traitement et ainsi permettre de diminuer l’inertie thérapeutique dans la prise en charge du DST2.
Persons With Diabetes and General/Family Practitioner Perspectives Related to Therapeutic Inertia in Type 2 Diabetes Mellitus Using Qualitative Focus Groups and the Theoretical Domains Framework: Results From the MOTION Study
2022, Canadian Journal of Diabetes
Therapeutic inertia in type 2 diabetes (T2DM) is the failure to receive timely treatment intensification as indicated according to T2DM treatment guidelines. Multifactorial causes of therapeutic inertia in T2DM have been documented at the level of persons with diabetes (PwD), health-care providers and health-care systems.
We developed a 3-part mixed-methods research program, called the Moving to Overcome Therapeutic Inertia Obstacles Now in T2DM (MOTION) study, to inform the development of strategies to address therapeutic inertia in T2DM. We present the results from focus groups with the following objectives: 1) understanding PwD and general practitioner/family practitioner (GPFP) determinants of behaviour related to treatment intensification using the Theoretical Domains Framework (TDF); and 2) identifying the sources of behaviours contributing to therapeutic inertia in T2DM, as proposed by the Behaviour Change Wheel (BCW). Two focus groups with PwD and 4 with GPFPs were conducted. Transcripts from the focus groups were coded independently by 2 investigators to identify themes, then mapped to TDF domains and linked using the BCW.
For PwD, the most commonly coded TDF domains were intentions, goals, knowledge, beliefs about consequences and social influences. For GPFPs, the most common domains were intentions, environmental context and resources and social/professional role and identity. The BCW identified that PwD interventions should include reflective motivation, psychological capability and social opportunity; GPFP interventions should include physical opportunity, social opportunity and reflective motivation.
Comprehensive strategies that target both PwD and GPFP barriers would encourage a more collaborative approach toward treatment intensification decisions and reducing therapeutic inertia.
Conformément aux recommandations en matière de traitement du diabète de type 2 (DT2), l’inertie thérapeutique dans la prise en charge du DT2 est l’absence d’intensification au moment opportun du traitement d’une personne. Les causes multifactorielles de l’inertie thérapeutique dans la prise en charge du DT2 ont été établies selon le point de vue des personnes avec le diabète (PD), des prestataires de soins de santé et des systèmes de soins de santé.
Nous avons élaboré un programme de recherche par les méthodes mixtes en 3 parties, appelé l’étude MOTION (Moving to Overcome Therapeutic Inertia Obstacles Now in T2DM), pour contribuer à l’élaboration de stratégies qui portent sur l’inertie thérapeutique dans la prise en charge du DT2. Nous présentons les résultats issus des groupes de discussion dont les objectifs étaient les suivants : 1) la compréhension des déterminants du comportement lié à l’intensification du traitement à l’aide du cadre des domaines théoriques (TDF, de l’anglais Theoretical Domains Framework) par les PD et les médecins généralistes/médecins de famille (MGMF); 2) la détermination des sources de comportements qui contribuent à l’inertie thérapeutique dans la prise en charge du DT2 selon la roue du changement de comportement (BCW, de l’anglais Behaviour Change Wheel). Nous avons mené 2 groupes de discussion formés de PD et 4 groupes formés de MGMF. Deux chercheurs ont procédé de façon indépendante au codage des transcriptions issues des groupes de discussion pour définir les thèmes, les cartographier entre les domaines du TDF et les coupler à l’aide de la BCW.
Pour les PD, les domaines du TDF les plus fréquemment codés étaient les intentions, les objectifs, les connaissances, les croyances sur les conséquences et les influences sociales. Pour les MGMF, les domaines les plus fréquents étaient les intentions, le contexte environnemental et les ressources et le rôle social/professionnel et l’identité. La BCW a permis de déterminer que les interventions des PD devraient inclure la motivation réfléchie, la capacité psychologique et l’opportunité sociale; les interventions des MGMF devraient inclure l’opportunité physique, l’opportunité sociale et la motivation réfléchie.
Des stratégies globales axées sur les obstacles des PD et des MGMF contribueraient à encourager une approche plus collaborative à la prise de décisions concernant l’intensification du traitement et à réduire l’inertie thérapeutique.
Individualized HbA1c target selection and achievement in the Multinational Observational Study Assessing Insulin Use (MOSA1c) type 2 diabetes study
2021, Journal of Diabetes and its Complications
To identify which individual-, physician-, and the healthcare system-related factors can predict individualized hemoglobin A1c (HbA1c) targets and the likelihood of reaching those targets after initial insulin therapy over a two-year follow-up period.
Real-world data, including baseline characteristics of people with type 2 diabetes mellitus (T2DM), psychosocial data, and diabetes medication use, collected from the Multinational Observational Study Assessing Insulin Use (MOSA1c) study in 18 countries were analyzed.
Overall, 225 of 1194 people with T2DM (18.8%) who received initial insulin therapy for ≥3 months reached HbA1c targets at two-year follow-up; most were likely to be White (64.9%) and perceptions of their relationship with physicians were less positive than those who did not reach HbA1c targets. Higher baseline HbA1c (>8%) was the strongest predictor of being assigned an HbA1c target >7% (odds ratio [OR] 6.06, 95% confidence interval [CI] 3.97, 9.26). A smaller difference between baseline and target HbA1c levels was the strongest predictor of reaching an HbA1c target at two-year follow-up (large vs small difference, OR 0.28, 95% CI 0.17, 0.47).
Several factors were significantly associated with establishing individualized HbA1c targets and reaching these targets. A small proportion of people with T2DM on insulin therapy reached their HbA1c target. Personalized management of glycemic targets necessitates the adoption of multi-factorial strategies, as several factors could influence an individual's glycemic outcome.
NCT01400971
Current barriers to initiating insulin therapy in individuals with type 2 diabetes
2024, Frontiers in Endocrinology

View all citing articles on Scopus

: Funding: The publication of this article was funded by Novo Nordisk Inc.

: Conflict of Interest: SAR has attended speaker bureaus, and advisory boards for Novo Nordisk, Eli Lilly, Merck, Boehringer, and Sanofi-Aventis (∼$5000–10,000 for each company); and has received research funding from Novo Nordisk, Eli Lilly, Merck, Boehringer, and Sanofi-Aventis. Research funding goes directly to SAR's institute's parent organization, LMC endocrinology.

: Authorship: The author takes full responsibility for the content of this manuscript. Writing support was provided by Watermeadow Medical.

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Supplement reviewBreaking Down Patient and Physician Barriers to Optimize Glycemic Control in Type 2 Diabetes

Abstract

Section snippets

Matching Treatment to Pathophysiology

Getting to Goal

Hypoglycemia

Feelings of Guilt or Failure

Effective Diabetes Education

Overcoming Clinical Inertia

Conclusions

Acknowledgment

Lancet

Can J Cardiol

Am J Med

Prim Care Diabetes

Am J Geriatr Pharmacother

Am J Med

Clin Ther

Lancet

Clin Ther

Clin Ther

Am J Kidney Dis

Lancet

Diabetes Res Clin Pract

Diabetes Res Clin Pract

Lancet

Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes

N Engl J Med

Economic and clinical impact of innovative pharmacy benefit designs in the management of diabetes pharmacotherapy

Am J Manag Care

Is glycemic control improving in US adults?

Diabetes Care

Position statement: management of hyperglycaemia in type 2 diabetes: a patient-centered approach. Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

Diabetologia

Comparison of drug adherence rates among patients with seven different medical conditions

Pharmacotherapy

Barriers to insulin initiation: the translating research into action for diabetes insulin starts project

Diabetes Care

Clinical inertia in patients with T2DM requiring insulin in family practice

Can Fam Physician

Nonadherence, clinical inertia, or therapeutic inertia?

J Manag Care Pharm

Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care

JAMA

Defects in insulin secretion and action in the pathogenesis of type 2 diabetes mellitus

Curr Diab Rep

Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study

BMJ

10-year follow-up of intensive glucose control in type 2 diabetes

N Engl J Med

From the triumvirate to the ominous octet: a new paradigm for the treatment of type 2 diabetes mellitus

Diabetes

Standards of medical care in diabetes—2012

Diabetes Care

Clinical practice guidelines for the prevention and management of diabetes in Canada

Can J Diabetes

American Association of Clinical Endocrinologists medical guidelines for clinical practice for developing a diabetes mellitus comprehensive care plan

Endocr Pract

AACE comprehensive diabetes management algorithm 2013

Endocr Pract

Hypoglycaemia in type 2 diabetes

Diabet Med

Negotiating the barrier of hypoglycemia in diabetes

Diabetes Spectr

Effect of intravenous infusion of exenatide (synthetic exendin-4) on glucose-dependent insulin secretion and counterregulation during hypoglycemia

Diabetes

Practical strategies to normalize hyperglycemia without undue hypoglycemia in type 2 diabetes mellitus

Curr Diab Rep

The barrier of hypoglycemia in diabetes

Diabetes

When oral agents fail: practical barriers to starting insulin

Int J Obes

Half-unit dose accuracy with HumaPen® Luxura™ HD: an insulin pen for patients who need precise dosing

Diabetes Sci Technol

Reduced hypoglycemia risk with insulin glargine: a meta-analysis comparing insulin glargine with human NPH insulin in type 2 diabetes

Diabetes Care

Three-year efficacy of complex insulin regimens in type 2 diabetes

N Engl J Med

The relationship of body mass index to diabetes mellitus, hypertension and dyslipidaemia: comparison of data from two national surveys

Int J Clin Pract

Supplement review
Breaking Down Patient and Physician Barriers to Optimize Glycemic Control in Type 2 Diabetes