RESUMEN
AIMS: Address treatment burden and general perceptions of pharmacological treatment in patients with diabetes. METHODS: We surveyed adult patients with diabetes cared for in a tertiary academic medical center about: i) knowledge about the impact of glucose-lowering medication use on diabetes control and complications, ii) common beliefs about natural medicine and insulin use, iii) attitudes towards glucose-lowering medications, iv) burden of treatment, v) general knowledge of diabetes pharmacological treatment, and vi) perceptions of shared decision-making. RESULTS: Two hundred-four participants completed the survey. While most (90%) agreed that adherence to medication would control diabetes and improve quality of life, 30-40% were not certain that it would translate to fewer disease complications. About one of three thought medications could be harmful (29.4%). Over 50% agreed or was unsure that natural remedies were as good/better than prescribed medications. About 30% acknowledged difficulties taking their diabetes medications and monitoring blood glucose, and over 50% were concerned about treatment costs. Nearly 30% denied receiving a detailed explanation from their clinician regarding their disease and is treatment. CONCLUSIONS: Our results highlight the importance of patient education regarding pharmacological treatment for diabetes, and eliciting sources of distress and treatment burden among patients with diabetes.
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Diabetes Mellitus Tipo 2 , Diabetes Mellitus , Adulto , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/tratamiento farmacológico , Glucosa , Conocimientos, Actitudes y Práctica en Salud , Humanos , Hipoglucemiantes/efectos adversos , Cumplimiento de la Medicación , Calidad de VidaRESUMEN
AIMS: Examine the efficacy of metformin compared to placebo or other glucose-lowering medications on microvascular outcomes in patients with Type 2 Diabetes Mellitus (T2DM). METHODS: MEDLINE, EMBASE, Web of Science, and Scopus were searched from database inception to March 2020. We included randomized clinical trials of patients with T2DM receiving metformin compared with another active glucose-lowering treatment or placebo in which a microvascular outcome was assessed. The risk of bias was assessed using the Cochrane Risk of Bias tool. Microvascular complications included kidney-related outcomes, retinopathy, and peripheral neuropathy. An inverse-weighted variance random-effect meta-analysis was performed to estimate drugs effect over microvascular disease. PROSPERO (CRD42019120365). RESULTS: Nineteen RCTs (n = 18,181) were included. Metformin increased estimated glomerular filtration rate (eGFR) by a mean difference (MD) of 1.08 (95% CI 0.84 to 1.33 ml/min/1.73 m2) after 24 weeks. No effect was found on urinary albumin-creatinine ratio, serum creatinine, and end-stage kidney disease; Patient-important outcomes regarding kidney disease, retinal outcomes, peripheral neuropathy or quality of life were not assessed by any of the included studies and could not be analyzed. CONCLUSIONS: There is no evidence of clinically significant beneficial effect of metformin therapy as compared to other glucose-lowering medications or placebo on the examined microvascular complications.
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Diabetes Mellitus Tipo 2 , Metformina , Diabetes Mellitus Tipo 2/complicaciones , Glucosa/uso terapéutico , Humanos , Hipoglucemiantes/uso terapéutico , Metformina/uso terapéutico , Calidad de VidaRESUMEN
PURPOSE OF REVIEW: Present the value of a person-centered approach in diabetes management and review current evidence supporting its practice. RECENT FINDINGS: Early evidence from glycemic control trials in diabetes resulted in most practice guidelines adopting a glucose-centric intensive approach for management of the disease, consistently relying on HbA1c as a marker of metabolic control and success. This paradigm has been recently dispelled by new evidence that shows that intensive glycemic control does not provide a significant benefit regarding patient-important microvascular and macrovascular hard outcomes when compared to moderate glycemic targets. The goals of diabetes therapy are to reduce the risks of acute and chronic complications and increase quality of life while incurring least burden of treatment and disruption to the patient's life. A person-centered approach to diabetes management is achieved through shared decision making, integration of evidence-based care and patient´s needs, values and preferences, and minimally disruptive approaches to diabetes care and at the same time offer practical guidance to clinicians and patients on achieving this type of care.
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Diabetes Mellitus Tipo 2 , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Control Glucémico , Humanos , Hipoglucemiantes , Atención Dirigida al Paciente , Calidad de VidaRESUMEN
Diabetes is a major and costly health concern worldwide, with high morbidity, disability, mortality, and impaired quality of life. The vast majority of people living with diabetes have type 2 diabetes. Historically, the main strategy to reduce complications of type 2 diabetes has been intensive glycemic control. However, the body of evidence shows no meaningful benefit of intensive (compared with moderate) glycemic control for microvascular and macrovascular outcomes important to patients, with the exception of reduced rates of non-fatal myocardial infarction. Intensive glycemic control does, however, increase the risk of severe hypoglycemia and incurs additional burden by way of polypharmacy, side effects, and cost. Additionally, data from cardiovascular outcomes trials showed that cardiovascular, kidney, and mortality outcomes may be improved with use of specific classes of glucose lowering drugs largely independently of their glycemic effects. Therefore, delivering evidence based, patient centered care to people with type 2 diabetes requires a paradigm shift and departure from the predominantly glucocentric view of diabetes management. Instead of prioritizing intensive glycemic control, the focus needs to be on ensuring access to adequate diabetes care, aligning glycemic targets to patients' goals and situations, minimizing short term and long term complications, reducing the burden of treatment, and improving quality of life.
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Complicaciones de la Diabetes/prevención & control , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Hipoglucemia/epidemiología , Hipoglucemiantes/administración & dosificación , Calidad de Vida , Glucemia/análisis , Glucemia/efectos de los fármacos , Complicaciones de la Diabetes/sangre , Diabetes Mellitus Tipo 2/sangre , Diabetes Mellitus Tipo 2/complicaciones , Medicina Basada en la Evidencia/métodos , Medicina Basada en la Evidencia/normas , Humanos , Hiperglucemia/sangre , Hiperglucemia/tratamiento farmacológico , Hipoglucemia/inducido químicamente , Hipoglucemiantes/efectos adversos , Incidencia , Metaanálisis como Asunto , Atención Dirigida al Paciente/métodos , Atención Dirigida al Paciente/normas , Guías de Práctica Clínica como Asunto , Revisiones Sistemáticas como Asunto , Resultado del TratamientoRESUMEN
Importance: Differences in readmission rates among racial and ethnic minorities have been reported, but data among people with diabetes are lacking despite the high burden of diabetes and its complications in these populations. Objectives: To examine racial/ethnic differences in all-cause readmission among US adults with diabetes and categorize patient- and system-level factors associated with these differences. Design, Setting, and Participants: This retrospective cohort study includes 272â¯758 adult patients with diabetes, discharged alive from the hospital between January 1, 2009, and December 31, 2014, and stratified by race/ethnicity. An administrative claims data set of commercially insured and Medicare Advantage beneficiaries across the United States was used. Data analysis took place between October 2016 and February 2019. Main Outcomes and Measures: Unplanned all-cause readmission within 30 days of discharge and individual-, clinical-, economic-, index hospitalization-, and hospital-level risk factors for readmission. Results: A total of 467â¯324 index hospitalizations among 272â¯758 adults with diabetes (mean [SD] age, 67.7 [12.7]; 143â¯498 [52.6%] women) were examined. The rates of 30-day all-cause readmission were 10.2% (33â¯683 of 329â¯264) among white individuals, 12.2% (11â¯014 of 89â¯989) among black individuals, 10.9% (4151 of 38â¯137) among Hispanic individuals, and 9.9% (980 of 9934) among Asian individuals (P < .001). After adjustment for all factors, only black patients had a higher risk of readmission compared with white patients (odds ratio, 1.05; 95% CI, 1.02-1.08). This increased readmission risk among black patients was sequentially attenuated, but not entirely explained, by other demographic factors, comorbidities, income, reason for index hospitalization, or place of hospitalization. Compared with white patients, both black and Hispanic patients had the highest observed-to-expected (OE) readmission rate ratio when their income was low (annual household income <$40â¯000 among black patients: OE ratio, 1.11; 95% CI, 1.09-1.14; among Hispanic patients: OE ratio, 1.11; 95% CI, 1.07-1.16) and when they were hospitalized in nonprofit hospitals (black patients: OE ratio, 1.10; 95% CI, 1.08-1.12; among Hispanic patients: OE ratio, 1.08; 95% CI, 1.05-1.12), academic hospitals (black patients: OE ratio, 1.16; 95% CI, 1.13-1.20; Hispanic patients: OE ratio, 1.12; 95% CI, 1.06-1.19), or large hospitals (ie, with ≥400 beds; black patients: OE ratio, 1.11; 95% CI, 1.09-1.14; Hispanic patients: OE ratio, 1.09; 95% CI, 1.04-1.14). Conclusions and Relevance: In this study, black patients with diabetes had a significantly higher risk of readmission than members of other racial/ethnic groups. This increased risk was most pronounced among lower-income patients hospitalized in nonprofit, academic, or large hospitals. These findings reinforce the importance of identifying and addressing the many reasons for persistent racial/ethnic differences in health care quality and outcomes.