SUPPLEMENT INTRODUCTION

The Increasing Role of Primary Care Physicians in Caring for Patients With Type 2 Diabetes Mellitus

Amongst elderly people with type 2 diabetes (T2D) over prescribing can result in emergency ambulance call-outs, falls and fractures and increased mortality, particularly in frail patients. Current clinical guidelines, however, remain focused on medication intensification rather than deintensification where appropriate. This study aims to evaluate the effectiveness of an electronic decision-support system and training for the deintensification of potentially inappropriate medications amongst older frail people with T2D, when compared to ‘usual’ care at 12-months.

This study is an open-label, multi-site, two-armed pragmatic cluster-randomised trial. GP practices randomised to the ‘enhanced care’ group have an electronic decision support system installed and receive training on the tool and de-intensification of diabetes medications. The system flags eligible patients for possible deintensification of diabetes medications, linking the health care professional to a clinical algorithm. The primary outcome will be the number of patients at 12-months who have had potentially inappropriate diabetes medications de-intensified.

Study recruitment commenced in June 2022. Data collection commenced in January 2023. Baseline data have been extracted from 40 practices (3145 patients).

Digital technology, involving computer decision systems, may have the potential to reduce inappropriate medications and aid the process of de-intensification.

International Standard Randomised Controlled Trial Number: ISRCTN53221378. Available at: https://www.isrctn.com/ISRCTN53221378.

To examine glucagon prescribing trends among patients at high risk of severe hypoglycemia and assess if a glucagon prescription is associated with lower rates of severe hypoglycemia requiring hospital care.

Retrospective analysis of electronic health records from a large integrated healthcare system between May 2019 and August 2021. We included adults (≥18 years) with type 1 diabetes or with type 2 diabetes treated with short-acting insulin and/or recent history of hypoglycemia-related emergency department visit or hospitalization. We calculated rates of glucagon prescribing overall and by patient characteristics. We then matched 1:1 those who were and were not prescribed glucagon and assessed subsequent hypoglycemia-related hospitalization.

Of 9,200 high risk adults, 2063 (22.4%) were prescribed glucagon. Among patients more likely to be prescribed glucagon were those younger, female, White, living in urban areas, with prior severe hypoglycemia, and with a recent endocrinology specialist visit. In the matched cohort (N = 1707 per arm), 62 prescribed glucagon and 33 not prescribed glucagon were hospitalized for hypoglycemia (adjusted incidence rate ratio 1.71, 95% CI 1.10–2.66; P = 0.018).

Glucagon prescribing was infrequent with significant racial and rural disparities. Patients with glucagon prescriptions did not have lower rates of hospitalization for hypoglycemia.

Diabetes is a serious chronic disease with high associated burden and disproportionate costs to communities based on socioeconomic, gender, racial, and ethnic status. Addressing the complex challenges of global inequity in diabetes will require intentional efforts to focus on broader social contexts and systems that supersede individual-level interventions. We codify and highlight best practice approaches to achieve equity in diabetes care and outcomes on a global scale. We outline action plans to target diabetes equity on the basis of the recommendations established by The Lancet Commission on Diabetes, organising interventions by their effect on changing the ecosystem, building capacity, or improving the clinical practice environment. We present international examples of how to address diabetes inequity in the real world to show that approaches addressing the individual within a larger social context, in addition to addressing structural inequity, hold the greatest promise for creating sustainable and equitable change that curbs the global diabetes crisis.

Type 2 Diabetes (T2D) is associated with significant health complications and socioeconomic costs. Previous research conducted through an outpatient research facility demonstrated use of a low carbohydrate (LC) diet and exercise plan delivered in the format of an education book combined with use of real-time continuous glucose monitoring (RT-CGM) is an effective self-management intervention to improve weight and blood glucose management in patients with T2D. Primary health care remains the central access point for patient management of T2D, but General Practitioners (GPs) lack access to effective evidenced-based, self-management programs that can be prescribed to improve patient outcomes.

A single-arm, within-participant pilot intervention study will be conducted to evaluate the changes in metabolic health, acceptability and feasibility of a prescriptive LC diet and lifestyle program combined with RT-CGM (LC-RTC) delivered via GP practices. Forty adults with T2D will be recruited from GP practices and prescribed the LC-RTC intervention for 12 weeks. Outcomes will be assessed at baseline and 12-weeks post intervention. Changes in metabolic health will be assessed by changes in glycosylated hemoglobin (primary outcome), body weight, blood pressure, blood lipids, and medication usage. Post-intervention, participants will complete questionnaires and participate in focus groups to explore their experience of the LC-RTC program including acceptance, perceived benefits/barriers, limitations, financial feasibility, intervention drop-out rates, participant and GP engagement with the program (clinic attendance and contacts made to clinic for program support) and RT-CGM use and wear time acceptance. GPs and clinical staff involved will participate focus groups to evaluate the perceived value and feasibility of the LC-RTC program.

This trial will provide a powered evaluation of the changes in metabolic health, acceptability, and feasibility of the LC-RTC program for patients with T2D delivered via GP practices.

ANZCTR: 12622000635763 (Website Link to full registration: ANZCTR - Registration). Registered 29^th April 2022. Overall trial status: Commenced; Recruitment Status: Commenced 1^st May 2022, with 40 participants recruited as of 2^nd May 2023 using a rolling recruitment approach.

Diabetes is one of the most common chronic conditions worldwide. Due to biological, psychological, and social factors that stem from having diabetes and the behaviors involved in successful self-management, it has been conceptualized as a chronic stressor, and people with diabetes are at an increased risk for mental health conditions and symptoms at a higher rate than the general population. Race, ethnicity, socioeconomic status, and culture are important to consider in understanding and successfully treating mental health symptoms in people with diabetes. Information about appropriate screening tools for use by primary care providers and endocrinologists, and evidence-based treatments, are provided.

There is a consensus that fee-for-service reimbursement does too little to encourage the provision of high-value care. Our Enterprise, an integrated payer-provider based in Pittsburgh, created an alternative compensation model for endocrinologists. Our plan introduces a gradual shift in the role of endocrinologists from clinical duties to a more collaborative role with their primary care colleagues. Considering that most patients with diabetes are managed under primary care, this shift allows endocrinologists to support primary care physicians (PCPs) in managing patients with diabetes and other endocrine-related illnesses while decreasing the number of traditional in-office referrals to endocrinology. Despite the unexpected changes brought on by COVID, in first 9 months of the compensation model, we observed its impact on care delivery as well as the relationship between participating specialists and PCPs. Practice- and provider-level quality data has shown improvement in diabetes-specific quality metrics. In one year, 16 out of 54 target practices earned NCQA recognition for diabetes management. A total of 88% of participating PCPs reported a satisfaction score > 90% with the new plan. Ultimately, our model shows promise as a replacement for fee-for-service compensation, with a likelihood of lowering costs and improved quality of care.