medwireNews: Customised approaches that specifically address barriers to care result in improved metabolic control in patients with Type 2 diabetes, shows the DROP A1C study.
“No single barrier or the overall number of barriers was found to be associated with the degree of baseline hyperglycemia, indicating that for refractory patients, individualized assessment of barriers is ideally needed to improve outcomes”, write the researchers in Diabetes Care.
The Canadian study involved 155 patients, identified from a registry, who had a glycated haemoglobin (HbA1c) level of 9.0% or more, despite taking at least two antidiabetic medications. Care barriers most commonly reported by the patients included psychological/support (93%), socioeconomic (87%) and accessibility (82%).
Certified diabetes educators, who served as the participants’ case managers, identified the same barriers for the most part, but were more likely than the patients to cite lack of diabetes education as a problem (66 vs 27%) and less likely to identify anxiety as an issue (4 vs 54%).
During the following 12 months, patients received a care plan that targeted the specific barriers they had identified. For example, the approach for patients citing accessibility barriers included home visits, remote consultation, organisation of transport and life coaching.
This resulted in an overall HbA1c reduction from 10.9% to 9.4%, in 146 patients with available measurements. This 1.5% reduction was significantly greater than the 0.5% reduction achieved by an additional 966 patients from the same registry who met the study inclusion criteria but had not received the intervention.
“[A] wide range of care path steps and interventions were used, with most patients requiring multiple care paths”, say Ronnie Aronson (LMC Diabetes & Endocrinology, Toronto, Ontario) and study co-authors.
The most commonly used care pathways addressed socioeconomic barriers (87.1%), psychological/support barriers (60.7%) and comorbidity barriers (36.1%).
“No particular care path intervention, nor the number of care path steps used, were linked to improved glycemic control”, the researchers note. They say this suggests either that refractory patients are so heterogeneous that individualised care is essential or that the improvements arose mainly from the increased frequency and intensity of care, rather than the individualisation.
Improved glycaemic control occurred without an increase in the average number of oral antidiabetic medications used. Insulin users significantly increased their average number of daily injections from 2.9 to 3.3 and their daily dose from 82.7 to 106.8 units.
By Eleanor McDermid
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