Diabetes Practice Guidelines Research Articles

Effects of Practice Ownership and Integration of Health Services on Adherence to Diabetes Guidelines.

There has been a trend toward hospital systems and insurers acquiring privately owned physician practices and subsequently converting them into vertically integrated practices. The purpose of this study is to observe whether this change in ownership of a medical practice influences adherence to clinical guidelines for the management of type 1 and type 2 diabetes. This is an observational study using pooled cross-sectional data (2014-2016 and 2018-2019) from the National Ambulatory Medical Care Survey, a nationally representative probability sample of US office-based physician visits. A total of 7499 chronic routine follow ups and preventative care visits to non-integrated (solo and group physician practices) and integrated practices were analyzed to see whether guideline concordant care was provided. Measures included 7 services that are recommended annually for individuals with type 1 and type 2 diabetes (HbA1c, lipid panel, serum creatinine, depression screening, influenza immunization, foot examination, and BMI). Compared to non-integrated physician practices, vertically integrated practices had higher rates of hemoglobin A1C testing (odds ratio 1.58 [95% CI 1.07-2.33], P < .05), serum creatine testing (odds ratio 1.53 [95% CI 1.02-2.29], P < .05), foot examinations (odds ratio 2.03 [95% CI 0.98-4.22], P = .058), and BMI measuring (odds ratio 1.54 [95% CI 0.99-2.39], P = .054). There was no significant difference in lipid panel testing, depression screenings, or influenza immunizations. Our results show that integrated medical practices have a higher adherence to diabetes practice guidelines than non-integrated practices. However, rates of services provided regardless of ownership were low.

2023 Clinical Practice Guidelines for Diabetes: Continuous Glucose Monitoring and Insulin Pumps

With the expanding use of continuous glucose monitoring (CGM) and insulin pumps worldwide, several international guidelines dedicated to diabetes technology have been developed. Recently, the Korean Diabetes Association released a new version of their clinical practice guidelines including substantial changes in recommendations on the use of CGM and insulin pumps. Of note, continuous use of real-time CGM is now recommended to all people with diabetes using insulin, including people with type 2 diabetes using once daily basal insulin. Convincing evidence from recent automated insulin delivery (AID) trials supports the recommendation of AID as standard therapy in type 1 diabetes. This review summarizes the results of recent clinical studies on CGM and AID and their influence on the new clinical recommendations.

2023 Clinical Practice Guidelines for Diabetes: Recommendations for Pharmacological Treatment of Type 2 Diabetes

The 2023 clinical practice guidelines for diabetes in Korea are reviewed and updated biennially by the Committee of Clinical Practice Guidelines of the Korean Diabetes Association based on the latest scientific research and clinical trials. The 2023 guidelines include several updates to recommendations for pharmacological treatment of type 2 diabetes. The new guidelines make it clear that the treatment plan should include antidiabetic agents proven to reduce cardiorenal risk in adults with type 2 diabetes and established atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease. When considering injection-based combination therapy, GLP-1 receptor agonists (GLP-1 RAs) are recommended prior to basal insulin. If the target blood glucose level cannot be reached with GLP-1 RAs or basal insulin treatment alone, combination treatment with GLP-1 RAs and basal insulin is recommended. This review summarizes the recommendations for pharmacological treatment for type 2 diabetes in the 2023 Korean Diabetes Association treatment guidelines, focusing on major revisions.

#4441 KIDNEY DISEASE OUTCOMES WITH SEMAGLUTIDE VERSUS PLACEBO ACROSS BASELINE KDIGO RISK CATEGORIES: A POST HOC ANALYSIS OF SUSTAIN 6

Abstract Background and Aims The Kidney Disease: Improving Global Outcomes (KDIGO) risk categories classify risk of progression of chronic kidney disease (CKD) and cardiovascular (CV) complications based on estimated glomerular filtration rate (eGFR) and urinary albumin:creatinine ratio (UACR). Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are recommended by the KDIGO 2022 Clinical Practice Guidelines for Diabetes and CKD in patients with type 2 diabetes (T2D) and CKD who need better glycaemic control or CV risk reduction. In patients with T2D, once-weekly (OW) semaglutide, a GLP-1RA, reduces albuminuria and may preserve eGFR compared with placebo, irrespective of baseline eGFR or UACR. The aim of this analysis was to assess the treatment effects on kidney outcomes of OW semaglutide by KDIGO risk category at baseline compared with placebo. Method In a post hoc analysis from the SUSTAIN 6 trial (NCT01720446), randomised patients with T2D (N = 3,297) treated with OW semaglutide (0.5 and 1.0 mg) or placebo were stratified by baseline KDIGO risk category (low, moderate, high, and very high). The median follow-up time was 2.1 years. The treatment effect on the adjudicated endpoint of time to first new or worsening nephropathy (a composite of macroalbuminuria onset, doubling of serum creatinine and eGFR &amp;lt;45 mL/min/1.73 m2, need for kidney replacement therapy, or death due to kidney disease) across KDIGO categories was analysed using Cox regression. Analyses of treatment for eGFR slope and change in UACR (log-transformed) across KDIGO categories were performed using random slope modelling and mixed models adjusted for baseline UACR and assessed at 104 weeks. Results Participants with baseline eGFR and UACR values (N = 3,238) were stratified in to the low (n = 1,596 [49%]; 60% male; mean 64 years), moderate (n = 831 [26%]; 62% male; mean 65 years), high (n = 445 [14%]; 62% male; mean 66 years) and very high (n = 366 [11%]; 59% male; mean 67 years) KDIGO risk categories. Regardless of treatment group, participants in the moderate-, high- and very high-risk groups were more likely to experience the new or worsening nephropathy endpoint vs participants in the low-risk group at end of trial (hazard ratios [95% confidence intervals] 15.7 [8.0;35.7], 15.7 [7.7;36.6] and 23.9 [11.5;55.9], respectively). The treatment effect of OW semaglutide vs placebo was comparable in the low-, moderate-, high- and very high-risk categories (n = 785, 433, 227 and 171 for semaglutide and n = 811, 398, 218 and 195 for placebo, respectively) for new or worsening nephropathy (pinteraction = 0.28), eGFR slope (pinteraction = 0.44) and change in UACR (pinteraction = 0.84; Figure). Conclusion Participants in the higher risk groups had substantially greater hazards of adverse kidney outcomes compared with participants in the low-risk group, as predicted by KDIGO risk category classification. The treatment effect of OW semaglutide vs placebo on risk of new or worsening nephropathy, eGFR slope and change in UACR was consistent across KDIGO risk categories. The ongoing FLOW kidney outcomes trial has a population with T2D and CKD that corresponds to the high- and very high-risk KDIGO categories, and it will provide primary outcome data on potential kidney-protective effects of OW semaglutide; results are anticipated in 2024.

Transitioning to GLP-1 RAs and SGLT2 Inhibitors as the First Choice for Managing Cardiometabolic Risk in Type 2 Diabetes.

This forward-looking review summarizes existing evidence from cardiovascular outcome trials on cardiometabolic risk-reduction in type 2 diabetes (T2DM) management, with attention to updating and personalizing recommendations from recent diabetes practice guidelines issued by cardiology societies. T2DM management has shifted towards cardiometabolic outcome improvement rather than purely glycemic control. According to large clinical trials, sodium-glucose cotransporter-2 inhibitors showed robust results in reducing heart failure (HF) hospitalization and chronic kidney disease (CKD) progression, while glucagon-like peptide-1 receptor agonists demonstrated the largest effects on HbA1c reduction, weight loss, and atherosclerotic cardiovascular disease outcomes prevention, including stroke. Considering the distinct features of these new cardiometabolic agents, initial selection of therapy should be targeted to each individual patient, with consideration of combination therapy for the highest risk patients. Moreover, future studies should investigate the addition of obesity-predominant risk, in conjunction with coronary artery disease, stroke, CKD, and HF, as a new influential indicator for choosing the optimal cardiometabolic agent.

Clinical Nutrition Therapy for Weight Control in Obese Diabetic Patients

Clinical Practice Guidelines for Diabetes recommend that overweight or obese adults lose more than 5% of their body weight and reduce their total caloric intake to maintain the reduced body weight. In diabetic patients, the goal of weight control is not simply to lose weight, but to achieve health benefits by controlling blood sugar well and reducing the risk of complications and other comorbidities. An extremely calorie-restricted diet, whose long-term effectiveness has not been verified, is not recommended as it may increase the risk of hypoglycemia and ketoacidosis. For weight control in obese diabetic patients, it is important to follow diabetic diet guidelines while setting actionable energy goals that prevent hypoglycemia and do not increase health risks. The energy target should be adjusted in consideration of individual conditions such as daily intake, body size, and activity level.

138-LB: Improving Type 2 Diabetes Medication Prescribing

Background: For people with type 2 diabetes, implementing best practice guidelines for diabetes and cardiovascular comorbidities is important to reduce the risks of complications. Two adult medical clinics used population health EMR data reports to increase medication prescribing for statins, ACE &amp; ARB, SGLT2 &amp; GLP-1. Methods: The clinics tracked measures and used data analytics to identify a cohort population and medication needs for 6241 patients. Table 1 reflects data from a one-year pilot. Patients with a diagnosis of type 2 diabetes, duration of disease for at least one year, ages 18-75, with at least one in-person or telehealth visit were included. Results: Three medication prescribing baselines were tracked to improve type 2 diabetes and heart disease management. Prescribing rates of SGLT2 and GLP1 increased by 2%, ACE-I and ARB use increased by 1% and statins rates remained at 73%. Conclusion: The clinics used data to identify the cohort and prescribe necessary medications. Partnering with clinical pharmacists helped to support patients, educate providers, and standardize medication prescribing workflows. Planning care so that the teams consistently identified appropriate medications for diabetes and cardiovascular disease management were clinical priorities. While the goal rate of medication prescribing has not been achieved yet, new reporting workflows are now incorporated, setting up the clinics for continued improvement. Disclosure N. Rioles: None. M. Desimone: None. E. J. Hess: None. C. V. Iwummadu: None. E. L. Ospelt: None. S. Rompicherla: None. M. Greenfield: None. S. Tsai: None. Funding Helmsley Charitable Trust

107-LB: Progression of Position of Basal Insulin in the Treatment of Type 2 Diabetes—A Real-World Analysis

Background: In the past 5 years, type 2 diabetes practice guidelines have shifted to prioritize agents with cardiovascular (CV) and renal benefit. This study assessed whether real-world medication use has changed in line with these evolving guidelines. Methods: We retrospectively examined the treatment patterns (12 months pre and post) of people with T2D (PwT2D) who initiated basal insulin (BI) in either 2015 (cohort 1) , 2017 (cohort 2) , or 2019 (cohort 3) using IBM® MarketScan® Databases. Between-group differences were analyzed via t-test or chi-square as appropriate. Results: In the study period, 6,396,441 PwT2D were identified. The number of PwT2D initiating BI was 17,801/948,805 (1.88%) in 2015 vs. 10,870/622,455 (1.75%) in 2019 and a progressively larger share of BI initiators had prior GLP-1RA use (14.8% in cohort 1 vs. 25.2% in cohort 3; p &amp;lt; 0.001) or SGLT-2i use (11.4% in cohort 1 vs. 20.5% in cohort 3; p &amp;lt; 0.001) . Furthermore, in patients without prior GLP-1RA, SGLT-2i, or bolus use who initiated GLP-1RA or SGLT-2i in the first year of BI, time to first GLP-1RA (132.4 days in cohort 1 vs. 120.5 days in cohort 3; p = 0.02) or SGLT-2i (131.5 days in cohort 1 vs. 113.3 days in cohort 3; p = 0.002) decreased. Conclusions: Real-world data suggests growing and earlier use of GLP-1RA and SGLT-2i among BI users, and a growing proportion of PwT2D on BI-GLP-1RA combination treatment, in line with changing practice guidelines. Disclosure D. Schapiro: Employee; Eli Lilly and Company. A. Meeks: Employee; Eli Lilly and Company. D. Liu: Employee; Eli Lilly and Company, Stock/Shareholder; Eli Lilly and Company. F. Gelsey: Employee; Eli Lilly and Company, Stock/Shareholder; Eli Lilly and Company. R. Juneja: Employee; Eli Lilly and Company, Stock/Shareholder; Eli Lilly and Company. M. Perez-nieves: Employee; Eli Lilly and Company, Stock/Shareholder; Eli Lilly and Company. A. Huang: None. Funding Eli Lilly and Company

2021 Clinical Practice Guidelines for Diabetes: Pharmacotherapy and the Korean Diabetes Association Support System

The most important change introduced in the pharmacotherapy session for the 2021 Clinical Practice Guidelines for Diabetes is the recommendation of two different strategies according to the patient’s condition. One approach is to optimize the blood glucose levels, while the other approach is to reduce adverse cardiovascular events or mortality, especially in patients with comorbidities (e.g., heart failure, atherosclerotic cardiovascular disease, or chronic kidney disease). We suggest four algorithms that take into account the patient’s condition (algorithms 1 to 4). The Korean Diabetes Association (KDA) developed a web-based clinical decision support system, known as the KDA support system (KDASS), which helps with the diagnosis of diabetes or gestational diabetes and whether to use glucose-lowering agents according to the patient’s condition.

Análisis comparativo de las guías ADA 2020 y ALAD 2019 sobre la terapia médica nutricional del paciente adulto con diabetes tipo 1 y 2 con énfasis en los patrones de alimentación

Introducción: las guías de manejo del paciente diabético incluyen la terapia farmacológica y la no farmacológica. Esta última se conoce como terapia médica nutricional (TMN) y se caracteriza por promover intervenciones sobre el estilo de vida que a través de la evidencia científica demuestran impacto en la mejoría del control metabólico y glucémico. En las guías de la Asociación Latinoamericana de Diabetes (ALAD) y la Asociación Americana de Diabetes (ADA) nos presentan diferentes patrones de alimentación orientados a mejorar los desenlaces asociados con la diabetes. Objetivo: comparar cualitativamente la TMN recomendada por la ALAD y por la ADA, y destacar las características de los patrones de alimentación recomendados en estas guías. Metodología: se realizó un análisis cualitativo de ambas guías y se presentaron los hallazgos más relevantes. Se seleccionaron los patrones de alimentación recomendados y se presentó un resumen con sus características. Resultados: la TMN personalizada es el pilar fundamental del tratamiento del paciente diabético. No existe una distribución ideal de macronutrientes. Se recomienda el consumo de frutas, vegetales, granos enteros, legumbres, carnes blancas y grasas mono- y poliinsaturadas, y se restringe el consumo de carnes rojas, embutidos, almidones refinados y grasas saturadas y trans. La TMN se asocia con una mejoría del control glucémico y disminución de la hemoglobina glucosilada, del riesgo cardiovascular, del peso y de la presión arterial. Conclusión: es indispensable establecer una TMN individualizada que permita cubrir las necesidades nutricionales del paciente con diabetes y que incluya alimentos asociados con la mejoría del control metabólico.

The purchase of the Diabetic Healthy Food Basket in Cyprus results in cost savings: is it affordable among the low-income population?

The main objective was to assess the cost, acceptability and affordability of the Cypriot Diabetic Healthy Food Basket (DHFB). The development of DHFB was based on the Cypriot HFB with adjustments based on the nutritional guidelines for diabetes as developed by the American Diabetes Association (ADA) and information retrieved through the questionnaires. Two DHFB were constructed for adult women and adult men (±40 years) diagnosed with diabetes. Affordability was defined as the cost of DHFB as a percentage of the Guaranteed Minimum Income (GMI). Cyprus. 422 diabetic patients aged 18-87 years from different socioeconomic backgrounds. DHFB consists of eight food categories, similar to Cypriot HFB, but different specific food items. The total monthly budget for a diabetic woman is about 15 % (25·68 Euros less) lower compared with HFB, and the relative percentage for a diabetic man is about 16 % (37·58 Euros less). The total monthly budget for a diabetic woman is about 30 % lower (60·32 Euros less) compared with that of a diabetic man. For low-income adults receiving GMI, the proportion of income that would need to be spent on DHFB ranges from around 30 to 42 % for women and men, respectively. The cost of DHFB is lower compared with HFB, meaning that nutritional treatment based on the practice guidelines for diabetes could be a cost-efficient therapy for these patients. DHFB is still not affordable among low-income persons.

New Diabetes Canada Clinical Practice Guidelines for Diabetes and Pregnancy - What's Changed?

New Diabetes Canada Clinical Practice Guidelines for Diabetes and Pregnancy - What's Changed?

Role of Kidney Biopsies for Biomarker Discovery in Diabetic Kidney Disease.

Although estimated glomerular filtration rate and albuminuria are well-established biomarkers of diabetic kidney disease (DKD), additional biomarkers are needed, especially for the early stages of the disease when both albuminuria and estimated glomerular filtration rate may still be in the normal range and are less helpful for identifying those at risk of progression. Traditional biomarker studies for early DKD are challenging because of a lack of good early clinical end points, and most rely on changes in existing imprecise biomarkers to assess the value of new biomarkers. There are well-characterized changes in kidney structure, however, that are highly correlated with kidney function, always precede the clinical findings of DKD and, at preclinical stages, predict DKD progression. These structural parameters may thus serve as clinically useful end points for identifying new biomarkers of early DKD. In addition, investigators are analyzing tissue transcriptomic data to identify pathways involved in early DKD which may have associated candidate biomarkers measurable in blood or urine, and differentially expressed microRNAs and epigenetic modifications in kidney tissue are beginning to yield important observations which may be useful in identifying new clinically useful biomarkers. This review examines the emerging literature on the use of kidney tissue in biomarker discovery in DKD.

Importance of an alternative approach to measuring quality in a volume-to-value world: a case study of diabetes care.

BackgroundTo develop a statistical tool that allows practitioners and/or their practice managers to easily select the relevant range in which volume and value are maximised.MethodsData for the study were based on 55 primary care practices that participated in the Colorado Improving Performance in Practice programme in 2014. We used two composite variables including the volume of processes of care variables listed in Diabetes Practice Guidelines and value (quality) as measured by changes in the intermediate outcomes. We assessed volume/value trade-offs using a multilevel model with a time-varying covariate partitioned into a between-practice and within-practice effect.ResultsThe study revealed a strong linear relationship between volume and value (P<0.0001). Specifically, practices with an above-average volume of care as measured by their process of care scores also had above-average quality outcomes (expected value 57; average volume 49.48) as quantified by their intermediate outcome scores. Additionally, in those months when practices provided a volume of care that exceeded their average process of care score, further improvements occurred in quality as measured by intermediate outcome scores (P<0.0001).ConclusionSuch findings suggest an inherent linkage between volume of care and quality. This statistical approach, if provided as an app containing an easy-to-use statistical calculator, will allow practice managers and clinicians to systematically identify volume/quality trade-offs, thereby reducing undertreatment and/or overtreatment among patients with chronicities.

Quantitative assessment of dietary intake in adults with Type 1 diabetes following flexible insulin therapy education with an active promotion of dietary freedom

Clinical practice guidelines for diabetes include dietary guidelines to address the increased risk of cardiovascular disease. AimsTo identify impact of flexible insulin education with an active promotion of dietary freedom on energy and macronutrient intake and achievement of nutrient recommendations in adults with Type 1 diabetes. MethodsDietary assessment was performed prior to and 12months following flexible insulin education. Nutrient intake and the proportion achieving the European Association for the Study of Diabetes (EASD) nutrient guidelines were compared at baseline and post course. ResultsDietary data were available for 46 participants. Post course reductions were seen in median [IQR] energy kcal/d (1799 [1521–1931] to 1592 [1378–1940], p=0.002), fibre g/1000kcal (14 [12–16] to 13 [11–15], p=0.047), protein g/day (89 ([78–108] to 82 [74–93], p=0.001) and carbohydrate g/day (198 [172–330] to 162 [143–204], p=<0.001). The proportion experiencing at least 1 severe hypoglycaemia event over 12months was significantly reduced (χ2=7.7, p=0.006) from baseline (n=13, 26%) to post course (n=3, 6%). Achievement of EASD guidelines was poor and did not change post course. ConclusionsFlexible insulin education with an active promotion of dietary freedom does not appear to ‘worsen’ the achievement of EASD nutrition guidelines in adults with Type 1 diabetes. On the contrary, the dietary changes observed were reductions in energy, carbohydrate and protein intake. Flexible insulin education may offer benefits in enabling reduced energy intake without increasing hypoglycaemia.

Potential Overtreatment of Older, Complex Adults With Diabetes.

Potential Overtreatment of Older, Complex Adults With Diabetes.

Evaluating the Role of Clinical Practice Guidelines for Diabetes in Pregnancy: A Survey of Specialist Physicians

Evaluating the Role of Clinical Practice Guidelines for Diabetes in Pregnancy: A Survey of Specialist Physicians

Acuerdos y desacuerdos de las principales guías de práctica clínica

Diabetes mellitus has an enormous health and social impact and its incidence is rising exponentially in the industrialized world as a result of unhealthy lifestyles. In the last few years, research in this field has increased, leading to the development of new drugs and new indications. Consequently, numerous updates of clinical practice guidelines for diabetes have been published in the last 12 months, which provide health professionals with an up-to-date view of therapeutic possibilities. The present article reviews the guidelines with the greatest scientific impact and discusses areas of agreement and disagreement among these documents.

Indonesian Clinical Practice Guidelines for Diabetes in Pregnancy

Diabetes Mellitus (DM) in pregnancy has serious impact on both mother and baby if not optimally managed. The Indonesian Task Force on Reproductive Diseases determined that diabetes in pregnancy represents a priority area in need of updated evidence-based practice guidelines. The aim of the guidelines is to provide the best evidence-based recommendations for diagnostic evaluation and management of diabetes in pregnancy. The following article summarizes the guidelines.

Diabetes management in Australian rural aged care facilities: A cross--sectional audit.

There is gap in the literature regarding the current practice of diabetes management of the elderly in Australia and its compliance with available Australian diabetes practice guidelines. The aims of this study were to describe the pharmacological management of elderly residents with diabetes living in aged care facilities and to identify areas for improvement in the current management as recommended by the current diabetes management guidelines in Australia. Residents with diabetes from three rural aged care facilities were identified by nursing staff. A cross-sectional medical record audit was carried out to obtain data of residents diagnosed with diabetes. Thirty-four medical records were audited from three aged care facilities.Data including demographics, medical histories and medications were collected and analysed. This study had two key findings; Firstly, it showed that about a third of residents with type 2 diabetes are managed with diet only. Secondly, of the residents who are managed with medications, less than half of those audited (41%) were managed according to the current diabetes guidelines in terms of pharmacological treatment which included anti- hypertensive, lipid lowering and anti- platelet therapies. Of those patients with a history of CVD, all were receiving an antihypertensive medication, 71% were not managed for their lipids and 20% were not on any prophylactic anti- platelet therapy. Management of patients with diabetes living in rural aged care facilities is inconsistent with the current management guidelines. Educational interventions targeting health professionals and patients might be beneficial to increase compliance with the current diabetes guidelines.