Diabetes

Permanent URI for this collectionhttps://hdl.handle.net/20.500.12503/32543

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    Type II Diabetes Mellitus and COVID-19: A Case Series Exploring Insulin Management in Patients from Two Family Medicine Clinics
    (2024-03-21) Nukala, Nihitha
    Purpose: About 37 million Americans have diabetes and out of this population, over 90% of them have type 2 diabetes. An estimated $200 billion per year is spent on managing this disease. There is limited data on factors that could explain whether diabetic patients experienced better HgbA1C control during the COVID-19 pandemic. The relationship between diabetes medications (DM) and diabetes outcomes during the COVID era is not well-characterized. In this case series, we aimed to evaluate type II diabetes outcomes pre-COVID-19 vs. COVID-19 era. Methods: This case series was conducted in two family medicine clinics that included patients with type II diabetes. The following data from all patients at least 18 years or older on 3/1/2019 were extracted: hemoglobin A1c, medication prescriptions (insulin use patterns, non-insulin prescription patterns oral diabetes medications), and number of prescriptions discontinued. We followed a guidance statement from the American College of Physicians in terms of how outpatient diabetes is managed and used A1c of less than 8% as the threshold to assess the clinical outcomes for this outpatient population. A1c values were compared between two cohorts, a pre-COVID-19 cohort (March 1, 2019-March 13, 2020) and a COVID-19 era cohort (March 14, 2020-March 31, 2021). An analysis was performed on all patients whose A1c control status was changed, defined as the last A1c in each of the two study periods changed either from > 8% to =< 8% (got better), or from =< 8% to > 8% (got worse). For each of the patients with A1c control status change, we identified patterns of diabetic medication prescriptions during the COVID-19 era: (1) insulin and other DM medications, (2) no insulin but other DM medication, or (3) insulin-only prescriptions. Results: Eighty-one patients fulfilled the study criteria. Fifty-three patients got better, and 28 patients got worse. Of the 52 cases, 28 got better due to insulin use. Eighteen of these patients discontinued their insulin at some point during the study period. Of the 28 patients that got worse. Out of the 26 cases, 10 of them got worse while on insulin. Nine out of 10 of these patients discontinued their insulin at some point during the study period. Only 1 patient was on their insulin medication throughout the entire study. Out of the 28 cases with some form of diabetes management therapy, 16 of them were on non-insulin medications. Thirteen out of 16 of these patients discontinued at least one of their medications at some point during the study period. 23 out of 26 patients discontinued at least one prescription. Conclusion: This case series demonstrates how two family medicine clinics treated diabetic patients during a pandemic. The majority were using insulin throughout COVID-19 era and did experience changes to their medication profile with other DM medications. A1c levels did change significantly from pre-COVID-19 to COVID-19 era, while prescriptions for diabetic treatment were reduced. This study identified the importance of keeping insulin and other DM medication prescriptions through a pandemic and how COVID-19 impacted Hemoglobin A1C and overall diabetes care.
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    The Impact of ADA Guideline Changes and Utilization Management on the Use of First-Line Antidiabetic Medication Classes for the Treatment of Type 2 Diabetes Mellitus in a Commercial Population
    (2024-03-21) Tran, An; Rasu, Rafia
    Purpose: While metformin has a long track record regarding its efficacy and safety, newer classes like sodium-glucose cotransporter 2 (SGLT2) inhibitors, dipeptidyl peptidase-4 (DPP-4) inhibitors, and glucagon-like peptide-1 (GLP-1) receptor agonists have also proven to not only be very effective in lowering A1c, but certain agents may provide additional cardiovascular, renal, and weight loss benefits as well. Recent 2023 American Diabetes Association (ADA) guidelines de-emphasized metformin as the de facto first-line pharmacologic agent in favor of selecting first-line agents based on patient-specific factors and treatment goals. Analysis of the prescription claims data can provide insight into the prescribing patterns of these newer agents over the past 2 years for any shifts in therapy in response to the changes in the guidelines. The objectives of this study is to compare the changes in utilization of different first-line antidiabetic classes in the treatment of Type 2 Diabetes Mellitus (T2DM), as monotherapy or combination therapy, in commercial population from January 1, 2021, and June 30, 2023. Methods: This study is a retrospective analysis of prescription claims data identifying utilization of first-line antidiabetic classes. The classes of interest are biguanides, SGLT2, GLP-1, DPP-4, thiazolidinediones (TZD), and sulfonylureas (SU). Insulins and GLP-1 indicated for anti-obesity are excluded. The two study groups are plans with an initial metformin Step Therapy and plans with no utilization management in place. The primary objective will be to assess the changes in the proportion of 30-day supply claims for each class among the total antidiabetic utilizers from 2021 to 2023 between the two study groups. Key secondary objective include the difference in the proportion of non-metformin monotherapy for new antidiabetic utilizers. Another secondary objective is the difference between the proportion of utilizers for different type of combination therapy. Secondary endpoints will be reported as per utilizer per month (PUPM). Results: Work-in-progress, N/A Conclusion: Work-in-progress, N/A
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    Weighing Inequities: The Role of Obesity, Social Determinants of Health, with Glucagon-like Peptide-1 Receptor Agonist Use in Adults with Type 2 Diabetes in the United States
    (2024-03-21) Collins, Dallas; Kelly, Brittany; Aguiniga, Ashlyn; Pinnamraju, Jahnavi; Sambamoorthi, Usha
    Title Weighing Inequities: The Role of Obesity, Social Determinants of Health, with Glucagon-like Peptide-1 Receptor Agonist Use in Adults with Type 2 Diabetes in the United States Authors Dallas Collins, Brittany Kelly, Ashlyn Aguiniga, Jahnavi Pinnamraju, Usha Sambamoorthi Abstract Background Glucagon-like peptide-1 receptor agonists (GLP-1) contribute to glycemic control and weight loss in patients with type 2 diabetes mellitus (T2DM). Although obesity is an important determinant of GLP-1 use, research studies have suggested racial, ethnic, and socioeconomic inequities in GLP-1 use may also exist. The purpose of this study is to determine associations of obesity and social determinants of health (SDOH) with GLP-1 use in a large, nationally representative sample of US households. Methods This is a cross-sectional analysis of adults (age > 18 years) with T2DM using pooled data from multiple years of the Medical Expenditure Panel Survey (2016, 2018, and 2020). The MEPS is a nationally representative survey of civilian non-institutionalized households in the US. Diabetes was identified from both medical conditions and household files. GLP-1 use was extracted from prescription drug event files using the multum classification therapeutic sub-sub class codes. Obesity was measured using body mass index categories using the CDC standards. We restricted our analysis to adults without missing data on body mass index. Rao-Scott chi-square tests were used to assess the unadjusted associations of categorical variables with GLP-1 use. Multivariable logistic regression with survey weights was conducted to analyze the association of obesity and SDOH variables (education, poverty, health insurance, metro area, and marital status) after controlling for gender, age, and health conditions. All analyses were conducted with SAS 9.4 survey procedures. Results There were 7,298 participants representing ~27.3 million US adults with T2DM. Overall, 7.7% of adults reported using GLP-1 and 55.2% had obesity. A higher percentage of obese adults reported GLP-1 use compared to normal and underweight adults (10.2% vs. 4.2%). Those with college education had higher rates of GLP-1 use compared to those with less than high school education (10.2 vs. 4.0%). Multivariable fully adjusted logistic regression confirmed that obesity was associated with higher odds of GLP-1 use (AOR=2.44, 95% CI= 1.58-3.76 p < 0.001) and lower less than high school (AOR=0.40, 95% CI=0.25-0.62 p <0.001) and high school education (AOR=0.72, 95% CI= 0.52-0.99, p=0.0434) were associated with lower odds of GLP-1 use. Conclusion Approximately one in 14 adults used GLP-1, with obesity being an important correlate. Our study findings suggest that socioeconomic status may act as a barrier to a medication with established benefits and may contribute to exasperating inequalities in diabetes care leading to disparities in health outcomes of adults with diabetes. Cohort studies may be needed to better understand the association of SDOH with GLP-1 use.
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    The Differential Effects of Type II Diabetes Between Ethnicities: A Descriptive Study Comparing Hispanics, African American, and Non-Hispanic White Older Adults with Type II Diabetes
    (2024-03-21) Sharma, Monish; Large, Stephanie; O'Bryant, Sid
    Abstract Purpose: Type II diabetes mellitus (T2DM) is a significant risk factor for cognitive impairment. Individuals with T2DM have an increased risk for developing depression and depressive episodes. Additionally, T2DM worsens other comorbid conditions such as hypertension and high cholesterol. To gain a better understanding of the etiology and risk factors for the complications of T2DM, it is important to assess how T2DM impacts different ethnic groups. This study aims to explore how T2DM effects Hispanics (H), Non-Hispanic Whites (NHW), and African American (AA) older adults regarding self-reported health and past medical history, objective measures, and clinical blood work. Methods: Data was collected from 767 (187 AA, 161 NHW, 419 H) participants with T2DM from the Health and Aging Brain Study: Health Disparities, baseline studies. T2DM was defined as an HbA1C of greater than or equal to 6.5 or by self-report. The participants had an average age of 65 years. One-way ANOVAS were run to examine group differences in demographics, physical activity (RAPA), affect (Geriatric Depression Scale: depression; Penn State Worry Questionnaire: worry), blood pressure, and clinical blood work. Results: ANOVAs demonstrated significant differences in education between H (M = 8.84, SD = 4.51), NHW (M = 15.32, SD = 2.62), AA (M = 14.57, SD = 2.66) groups (F = 246.74, p <0.001). Significant differences in income were also recorded between H (M= 30,530.31, SD = 28,055.79), NHW (M =65,265.45, SD = 53,241.75), AA (M = 61,423.46, SD = 69,393.76) groups (F = 44.63, p < 0.001). Clinically, significant differences in systolic blood pressure were found between H (M = 140.83, SD = 20.98), NHW (M = 137.58, SD = 18.69), AA (M = 136.44, SD = 20.56) groups (F = 3.52, p = 0.03). The cholesterols (total cholesterol, HDL, triglycerides, LDL, HDL ratios, and non-HDL) were all statistically significant between groups (F range 3.35 – 21.13, p range <0.001 – 0.036). ANOVAs also highlighted significant differences in physical activity (RAPA) between H (M = 3.84, SD = 1.49), NHW (M = 4.18, SD = 1.52), AA (M = 4.18, SD = 1.62) groups (F = 4.61, p = 0.01). Lastly, significant differences in affect (GDS) were found between H (M = 7.73, SD = 6.72), NHW (M = 5.84, SD = 6.02), AA (M = 6.81, SD = 5.76) groups (F = 5.42, p = 0.01). Conclusion: This study demonstrates that Hispanic older adults with T2DM exhibit a greater decline in overall health and wellness compared to their AA and NHW counterparts. Future research should compare type II diabetic Hispanics with non-diabetic Hispanics to determine if Hispanics are already at a baseline risk for potential health complications.
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    Primary Care Physician Density per Capita and its Effects on Diabetic Complications
    (2024-03-21) Conley, Mark; Van Alfen, Braden; Fulda, Kimberly; Yockey, Andrew
    Introduction: The state of Texas has a severe shortage of primary care physicians that has worsened in recent years, with only 4 of 254 counties demonstrating a sufficient number of primary care physicians, based on federal guidelines. This number is more pronounced in rural areas. A striking 82% of Texas counties have less than one primary care physician per 3,500 patients (1). In addition, the state of Texas has a significant population of diabetic patients needing physician management. Over 2 million people in Texas have diagnosed diabetes, with over 500,000 that are undiagnosed (2). Without sufficient treatment and surveillance, diabetes can progress to a host of problems including coronary artery disease, chronic kidney disease, retinopathy, amongst other morbidities. Researchers have elucidated the benefits of preventative care for stroke, heart disease, and cancer, but its correlation to diabetic outcomes has not been well documented. Therefore, we wanted to assess the effects of an increased number of primary care physicians per capita on preventing adverse diabetic outcomes in Texas counties. Methods: To further evaluate the effect of primary care physicians on preventing worse diabetic outcomes, we collected data from Texas Health Data on the admission rate for uncontrolled diabetic admissions in both adult diabetics and the lower extremity amputations for uncontrolled adult diabetics per county in 2019 (3). We then collected the ratio of patients to primary care physicians in each county in the state of Texas in 2019, using the county health rankings database (4). We compiled data from both sources and performed a statistical analysis to evaluate the correlation between primary care physicians per capita and diabetic admissions and amputations in each Texas county. Descriptive statistics were estimated to describe sample characteristics. We estimated the predicted ratio of admissions and amputation rates using bootstrapped ratio testing generated with 50 samples. All data were analyzed in Stata and the level of significance was set at p <.05. Results: An average population of 295,998 individuals across the state of Texas were part of the final analytic sample. Results showed the mean risk-adjusted admissions per 100,000 were 52.3 (SD = 25.9). Bootstrapped ratio testing indicated a significant ratio of increased amputees and admissions (Bootstrapped Observed ratio: 0.00042, bootstrapped standard error: 0.00001, 95% CI 0.00040, 0.00043), X2= 99.9, p <.0001, given an increased ratio of patients to physicians. Conclusion: These data further establish the importance of having a sufficient number of primary care providers in rural and underserved areas. The state of Texas and Texas medical schools should establish further methods to encourage physicians to practice in rural areas to decrease the amount of uncontrolled diabetes and amputations in our populations. Given these findings, we hypothesize that there is an association between the number of physicians per capita and diabetic outcomes. We would like to further evaluate which counties specifically have the least access to primary care physicians, higher diabetic rates, and most unfavorable outcomes. As we perform further research, we would also like to evaluate other confounding variables that were not considered.