Cardiometabolic treatment decisions in patients with type 2 diabetes: the role of repeated measurements and medication burden

Voorham, Jaco; Haaijer‐Ruskamp, Flora; Wolffenbuttel, Bruce H. R.; Stolk, Ronald P.; Denig, Petra

doi:10.1136/qshc.2008.030106

Cited by 9 publications

(9 citation statements)

References 33 publications

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“…In previous studies, we have found indications for a glucose-centered approach to diabetes risk factor management, 1,25 which also has been reported by other investigators. 26,27 Such a management strategy may lead to more attention and, thereby, higher awareness of adherence problems for glucose-regulating medication.…”

Section: Discussionsupporting

confidence: 80%

Medication Adherence Affects Treatment Modifications in Patients With Type 2 Diabetes

Voorham

Haaijer‐Ruskamp

Wolffenbuttel

et al. 2011

Clinical Therapeutics

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Section: Discussionsupporting

confidence: 80%

Medication Adherence Affects Treatment Modifications in Patients With Type 2 Diabetes

Voorham

Haaijer‐Ruskamp

Wolffenbuttel

et al. 2011

Clinical Therapeutics

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“…Other explanations have been suggested, such as uncertainty regarding elevated risk factor levels, disagreement with guideline recommendations, the inability to intensify treatment in some patients, and refusal by patients [9], [42], [43]. Previous studies in our study population showed, however, that factors such as medication burden and medication non-adherence were not associated with lower treatment intensification rates [11], [44]. We excluded patients who were already on maximum treatment or returned to control, but there may still be some patients who did not tolerate or wanted to receive a treatment intensification.…”

Section: Discussionmentioning

confidence: 55%

A Longitudinal Study Examining Adherence to Guidelines in Diabetes Care According to Different Definitions of Adequacy and Timeliness

et al. 2011

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BackgroundPerformance indicators assessing quality of diabetes care often look at single processes, e.g. whether an HbA1c test was conducted. Adequate care, however, consists of consecutive processes which should be taken in time (clinical pathways). We assessed quality of diabetes care by looking at single processes versus clinical pathways. In addition, we evaluated the impact of time period definitions on this quality assessment.MethodologyWe conducted a cohort study in 2007–2008 using the GIANTT (Groningen Initiative to Analyse type 2 diabetes Treatment) database. Proportions of patients adequately managed for HbA1c, systolic blood pressure (SBP), LDL-cholesterol (LDL-C), and albumin/creatinin ratio (ACR) were calculated for the pathway of (1) risk factor level testing, (2) treatment intensification when indicated, (3) response to treatment evaluation. Strict and wide time periods for each step were defined. Proportions of patients adequately managed regarding the overall pathway and single steps, using strict or wide time periods were compared using odds ratios (OR) with 95% confidence intervals.FindingsOf 11176 patients diagnosed with type 2 diabetes, 9439 with complete follow-up were included. The majority received annual examination of HbA1c (86%) and SBP (86%), whereas this was 67% for LDL-C and 49% for ACR. Adequate management regarding the three-step pathway was observed in 73%, 53%, 46%, 41% of patients for HbA1c, SBP, LDL-C, and ACR respectively. Quality scores reduced significantly due to the second step (OR 0.43, 0.18, 0.44, 0.74), but were not much further reduced by the third step. Timely treatment evaluation occurred in 88% for HbA1c, 87% for SBP, 83% for LDL-C, and 76% for ACR. The overall score was not significantly changed by using strict time windows.ConclusionQuality estimates of glycemic, blood pressure and cholesterol management are substantially reduced when looking at clinical pathways as compared to estimates based on commonly used simple process measures.

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“…This could be indicative of a higher priority that may be put on glycemic over hypertensive management. Indications for such prioritization have been reported before [2], [17], [29], [30]. This is worrisome since adequate hypertensive management is especially important to prevent cardiovascular and renal complications in this patient population.…”

Section: Discussionmentioning

confidence: 99%

“…Although considerable progress has been achieved in the quality of diabetes care, there remains a gap between what treatment guidelines indicate as appropriate care and what is observed in practice [1], [2]. There is concern that comorbidities may affect the quality of care, and interfere with adequate treatment in insufficiently controlled patients [3].…”

Section: Introductionmentioning

confidence: 99%

Differential Effects of Comorbidity on Antihypertensive and Glucose-Regulating Treatment in Diabetes Mellitus – A Cohort Study

et al. 2012

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BackgroundComorbidity is often mentioned as interfering with “optimal” treatment decisions in diabetes care. It is suggested that diabetes-related comorbidity will increase adequate treatment, whereas diabetes-unrelated comorbidity may decrease this process of care. We hypothesized that these effects differ according to expected priority of the conditions.MethodsWe evaluated the relationship between comorbidity and treatment intensification in a study of 11,248 type 2 diabetes patients using the GIANTT (Groningen Initiative to Analyse type 2 diabetes Treatment) database. We formed a cohort of patients with a systolic blood pressure ≥140 mmHg (6,820 hypertensive diabetics), and a cohort of patients with an HbA1c ≥7% (3,589 hyperglycemic diabetics) in 2007. We differentiated comorbidity by diabetes-related or unrelated conditions and by priority. High priority conditions include conditions that are life-interfering, incident or requiring new medication treatment. We performed Cox regression analyses to assess association with treatment intensification, defined as dose increase, start, or addition of drugs.ResultsIn both the hypertensive and hyperglycemic cohort, only patients with incident diabetes-related comorbidity had a higher chance of treatment intensification (HR 4.48, 2.33–8.62 (p<0.001) for hypertensives; HR 2.37, 1.09–5.17 (p = 0.030) for hyperglycemics). Intensification of hypertension treatment was less likely when a new glucose-regulating drug was prescribed (HR 0.24, 0.06–0.97 (p = 0.046)). None of the prevalent or unrelated comorbidity was significantly associated with treatment intensification.ConclusionsDiabetes-related comorbidity induced better risk factor treatment only for incident cases, implying that appropriate care is provided more often when complications occur. Diabetes-unrelated comorbidity did not affect hypertension or hyperglycemia management, even when it was incident or life-interfering. Thus, the observed “undertreatment” in diabetes care cannot be explained by constraints caused by such comorbidity.

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Cardiometabolic treatment decisions in patients with type 2 diabetes: the role of repeated measurements and medication burden

Cited by 9 publications

References 33 publications

Medication Adherence Affects Treatment Modifications in Patients With Type 2 Diabetes

Medication Adherence Affects Treatment Modifications in Patients With Type 2 Diabetes

A Longitudinal Study Examining Adherence to Guidelines in Diabetes Care According to Different Definitions of Adequacy and Timeliness

Differential Effects of Comorbidity on Antihypertensive and Glucose-Regulating Treatment in Diabetes Mellitus – A Cohort Study

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