American Diabetes Association Standards Research Articles

5040 Leveraging Continuous Glucose Monitoring Data as an Additional Source for Glucagon Prescription Behavior

Abstract Disclosure: J. Ambalavanan: None. J. Rusticelli: None. D. Isaacs: Consulting Fee; Self; Medtronic Diabetes, Lilly USA, LLC, Novo Nordisk, Insulet Corporation, Abbott Laboratories, Dexcom. H. Xiao: None. J. Bena: None. Z. Jin: None. C. Babiuch: None. M. Lansang: Consulting Fee; Self; Glooko. Research Investigator; Self; Abbott Laboratories, Dexcom, Xeris. Background: Hypoglycemia is a major source of anxiety in, and can be life-threatening for, patients with diabetes (DM). Even though the American Diabetes Association (ADA) recommends glucagon be made available to all individuals taking insulin or at high risk for hypoglycemia (level E evidence), few patients have access to this life-saving medication. Given the rapid adoption of continuous glucose monitoring (CGM) in the management of DM, we aimed to 1) evaluate glucagon prescription by identifying patients with hypoglycemia on CGM reports, and 2) deliver an educational letter to the providers. Methods: Our study had a retrospective chart review and a quality improvement (QI) component. From Mar-Oct 2023, we identified adult patients in the Cleveland Clinic Ohio health system with type 1 or type 2 DM on insulin (including insulin pumps), sulfonylurea, or meglitinide, and hypoglycemia defined as time below range (TBR) ≥4% on CGM reports. We evaluated the percentages of pre-existing and incident glucagon prescription among those patients. For the QI component, we contacted providers individually via letter if the patients did not have a glucagon prescription and shared with them the ADA Standards of Care on hypoglycemia along with information about various forms of glucagon. Whether to prescribe glucagon was left to the clinical judgement of the providers. Information was collected 4 weeks later to see whether there was any change in the prescription practice. Results: Patients numbered 1543, with170 patients having TBR ≥4%. Among patients with hypoglycemia, 37% had pre-existing prescription and 14% incident glucagon prescription, compared with patients without hypoglycemia (p<0.001). Significant (p<0.001) risk factors for hypoglycemia included type 1 DM, insulin-only therapy, use of conventional insulin pumps, and lower A1c. Among patients with TBR ≥4%, 66 (39%) had level 1 hypoglycemia (54 to <70 mg/dl), 88 (52%) had level 2, and 16 (9%) had level 3 (hospitalization or ER admission for hypoglycemia). Pre-existing or incident glucagon prescription was seen in 28% without hypoglycemia, 38% with level 1 hypoglycemia, 49% with level 2, and 63% with level 3 (p<0.001 level 1 vs level 3; level 2 vs no hypoglycemia; level 3 vs no hypoglycemia). Among 70 patients whose providers received education letters, 27 (39%) prescribed glucagon after education. Glucagon emergency kit, glucagon autoinjector, and inhaled glucagon were the top prescription choices. A greater proportion of advanced practice providers responded to our education than physicians (p=0.021). Conclusion: Glucagon prescription remains suboptimal though better than in other studies even among patients with documented hypoglycemia on CGM reports. Effective provider education and communication can increase glucagon prescription. Provider and patient factors should be studied next to determine steps for further improvement. Presentation: 6/1/2024

Understanding primary care provider’s knowledge and perceptions of diabetes self-management education and support

ObjectiveThe American Diabetes Association Standards of Care recommends that individuals with diabetes receive self-management education, but the utilization of these services remains low. This study explores primary care providers’ knowledge and perceptions of diabetes self-management education and support (DSMES). Study designA convergent mixed methods study design grounded in the Theoretical Domains Framework was conducted with an initial provider survey, followed by semi-structured interview of a purposeful sub-sample of providers. The survey was distributed via REDCap and interviews were recorded and transcribed verbatim. ResultsA total of 140 PCP’s responded to the survey (response rate 37.63 %) and 17 participated in interviews. The average knowledge score of the correct selection of DSMES referral time points was 70.35 %. Five themes emerged in provider interviews: procedural knowledge, ability, beliefs, reinforcement, and cultural norms. Providers wanted bidirectional communication with the DSMES program and were more likely to refer if they had a cultural norm of referring. ConclusionProviders have limited knowledge of the appropriate time to refer to DSMES but expressed a willingness to refer. They emphasized the importance of providing their patients with appropriate self-management education and support.

Enhancing pharmacist intervention targeting based on patient clustering with unsupervised machine learning

ABSTRACT Objectives Adherence to the American Diabetes Association (ADA) Standards of Medical Care is low. This study aimed to assist pharmacists in identifying patients for diabetes control interventions using unsupervised machine learning. Methods This study analyzed the 2021 Medical Expenditure Panel Survey and used a k-mode cluster analysis. Patient features analyzed were adherence to a select set of preventive measures from the ADA Standards of Medical Care (HbA1c test, foot examination, blood cholesterol test, dilated eye examination, and influenza vaccination) and some patient characteristics (age, gender, health insurance, insulin use, and diabetes-related complications). Results The study included 1,219 patients with self-reported diabetes, and the adherence rate to the ADA standards was 33.72%. Five distinct clusters emerged: (A) moderate-complexity, privately insured male; (B) moderate-complexity, publicly insured female; (C) low-complexity, privately insured female; (D) high-complexity, publicly insured female; (E) moderate-complexity, publicly insured male. Groups B, C, and E exhibited nonadherence. Conclusions Pharmacists can target publicly insured elderly (Groups B and E) and privately insured middle-aged females (Group C) for interventions. For instance, pharmacists may help patients in Groups B and E locate existing resources in their insurance program and remind those in Group C of the importance of adequate diabetes care.

Clinician-Reported Barriers and Needs for Implementation of Continuous Glucose Monitoring.

Continuous glucose monitoring (CGM) for patients with type 1 and type 2 diabetes is associated with improved clinical, behavioral, and psychosocial patient health outcomes and is part of the American Diabetes Association's Standards of Medical Care. CGM prescription often takes place in endocrinology practices, yet 50% of adults with type 1 diabetes and 90% of all people with type 2 diabetes receive their diabetes care in primary care settings. This study examined primary care clinicians' perceptions of barriers and resources needed to support CGM use in primary care. This qualitative study used semistructured interviews with primary care clinicians to understand barriers to CGM and resources needed to prescribe. Participants were recruited through practice-based research networks. Rapid qualitative analysis was used to summarize themes from interview findings. We conducted interviews with 55 primary care clinicians across 21 states. Participants described CGM benefits for patients with varying levels of diabetes self-management and engagement. Major barriers to prescribing included lack of insurance coverage for CGM costs to patients, and time constraints. Participants identified resources needed to foster CGM prescribing, for example, clinician education, support staff, and EHR compatibility. Primary care clinicians face several challenges to prescribing CGM, but they are interested in learning more to help them offer it to their patients. This study reinforces the ongoing need for improved clinician education on CGM technology and continued expansion of insurance coverage for people with both type 1 and type 2 diabetes.

Type 2 diabetes mellitus: Prevalence and risk factors associated, among patients at Franceville Amissa Bongo regional Hospital, Gabon

Introduction: To assess the type 2 diabetes mellitus prevalence and risk factors associated, among patients, at Franceville Amissa Bongo regional Hospital Gabon, A prospective and cross-sectional study was carried out between June and September 2023. Materials and Methods: Blood glucose was measured using blood drawn from each participant, according to American Diabetes Association standards. As elsewhere, correlations between type 2 diabetes mellitus prevalence and the variables obtained, were carried out using R software version 3.6.1. Odds ratios were calculated within a 95% interval, and results were considered significant when the p-value ≤ 0, 05. Results: Blood samples from 328 people, with a mean age of 48.24 ± 13.8 years, were collected for this study. The type 2 diabetes mellitus prevalence was 13.72% (95% CI: [0.10- 0.18]), (n=45). After univariate analysis, adjustment of variables by binary multivariate logistic regression, indicated female gender (Ajusted OR = 0.53; 95% CI [1.52; 39.41] p = 0.014*), cohabiting (Ajusted OR = 92.73 ; 95% CI [2.9; 29.05] p = 0.010*), inactive (Ajusted OR = 9.17; 95% CI: [1.11; 75.05] p = 0.040*), overweight/obese (Ajusted OR = 0. 017; 95% CI: [0.002; 0.18] p = 0.010*), a family history of type 2 diabetes mellitus (Ajusted OR = 50.13; 95% CI [8.87; 283.50] p = 0.000*) and high triglyceride levels (Ajusted OR = 0.03; 95% CI [0.003; 0.36] p = 0.005*), as type 2 diabetes mellitus potential risk factors, in the present study. Conclusion: The type 2 diabetes mellitus prevalence in the study population was high. Prevention and control of this disease through early detection are essential.

Evaluating adherence to American Diabetes Association standards of care in diabetes and impacts of social determinants of health on patients at two nurse practitioner-owned clinics.

The COVID-19 pandemic created barriers in the management of type 2 diabetes mellitus (T2DM) and worsened social determinants of health (SDOH). A New Hampshire primary care office worked to adhere to T2DM standards of care and began screening for SDOH. This project assessed adherence to quality metrics, hemoglobin A1C, and SDOH screening as telehealth utilization decreased. A1C values have increased at the practice, especially since COVID-19. The practice also began screening for SDOH at every visit, but there was need to assess how needs were being documented and if/how they were addressed. A retrospective chart review of patients with T2DM was performed. Demographic data and T2DM metrics were collected and compared with previous years and compared new versus established patients. Charts were reviewed to evaluate documentation of SDOH and appropriate referral. The practice transitioned from an increased utliization of telehealth back to prioritizing in-office visits. The practice also began routinely screening for SDOH in 2020; however, this process had not been standardized or evaluated. Adherence to nearly all quality metrics improved. Glycemic control improved after a year of nurse practitioner (NP) care, especially in new patients. All patients were screened for SDOH, but documentation varied, and affected patients had higher A1Cs, despite receiving comparable care. Nurse practitioners at this practice are adhering to American Diabetes Association guidelines, and A1C values improve under their care. Social determinants of health continue to act as unique barriers that keep patients from improving glycemic control, highlighting the need for individualized treatment of SDOH in T2DM care.

Improving care practices of the patient with type 2 diabetes in community health centers.

Diabetes ranks seventh in morbidity and mortality in the United States. In addition, more than 25 million Americans living with diabetes depend on community health centers (CHCs) for primary care. Preimplementation data in a group of CHCs indicated poor adherence to standards of care practices as recommended by the American Diabetes Association (ADA) with quarterly A1c (33.1%), annual serum laboratory tests (66.6%), and annual urine microalbumin (26.5%). Using a pre- and postimplementation comparison method, a NP-led practice improvement project was conducted in a group of CHCs, which sought to (1) identify adherence to ADA care standards; (2) determine whether an intervention could affect adherence to ADA standards; and (3) compare pre- and postimplementation occurrences of hemoglobin A1c greater than 7.1% and greater than 9%. Intervention composed of an educational component, standing orders to facilitate care practice changes, and electronic health record utilization changes. Postimplementation data reveal statistically significant improvements in quarterly hemoglobin A1c (93.6%), annual serum laboratory tests (96.5%), and annual urine microalbumin screening (85.5%). Improvements in translation to care for standardized guidelines facilitate improvements in health outcomes for patients. This project demonstrated improvements that can decrease the morbidity and mortality experienced by persons living with diabetes and being seen within a CHC. In addition, this project demonstrated that advanced practice nurses have the training and occupy a unique position within health care to spearhead initiatives for translation of evidence into care practices.

Does Second Trimester Maternal Serum Zonulin Level Predict Gestational Diabetes Mellitus?

Zonulin, a protein that regulates intestinal permeability, has attracted attention as a potential biomarker for GDM. Therefore, this study aims to investigate whether there are differences in zonulin levels between the GDM group and control groups, especially between those receiving different treatments (diet and insulin). Based on this idea, we included 90 patients with a gestational age between 24 and 28 weeks in our study. While GDM was not detected in 33 of these patients, as a result of OGTT, 57 patients were diagnosed with GDM and these patients were followed throughout their pregnancy. Gestational diabetes was diagnosed by an OGTT performed between 24 and 28 weeks of gestation according to American Diabetes Association (ADA) standards. During follow-up, GDM patients were divided into two groups according to whether they required insulin treatment. Plasma zonulin levels were determined using enzyme-linked immunosorbent assay (ELISA) techniques. The GDM group had significantly higher plasma zonulin levels than the control group (p < 0.005). According to our research, zonulin may be a non-invasive biomarker involved in the etiology of GDM. Large-scale research on this topic is still needed.

8. Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes: Standards of Care in Diabetes-2024.

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes-2024.

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

17. Diabetes Advocacy: Standards of Care in Diabetes-2024.

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2024.

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

14. Children and Adolescents: Standards of Care in Diabetes-2024.

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

6. Glycemic Goals and Hypoglycemia: Standards of Care in Diabetes-2024.

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

1. Improving Care and Promoting Health in Populations: Standards of Care in Diabetes-2024.

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at https://professional.diabetes.org/SOC.

12. Retinopathy, Neuropathy, and Foot Care: Standards of Care in Diabetes-2024.

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

7. Diabetes Technology: Standards of Care in Diabetes-2024.

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

13. Older Adults: Standards of Care in Diabetes-2024.

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Care in Diabetes-2024.

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2024.

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.