Novel primary care pathway steps up insulin initiation in type 2 diabetes
medwireNews: Using existing primary care resources in a novel way can increase insulin initiation rates and improve glycated hemoglobin (HbA1c) levels without worsening emotional wellbeing in patients with type 2 diabetes, research shows.
John Furler (University of Melbourne, Victoria, Australia) and colleagues say their findings have “important implications for policymakers, funders, and practitioners seeking innovative ways to provide the best care for people with type 2 diabetes in primary care.”
The “Stepping Up” model of care intervention has three core components and is designed to support insulin initiation among patients with type 2 diabetes in primary care who had HbAc1 levels of at least 7.5% despite maximum oral treatment.
The core components include an enhanced role for the practice nurse in leading discussions with patients about insulin initiation and titration, simple clinical protocols for initiation and up-titration, and reorientation of the role of the specialist registered nurse with diabetes educator credentials to mentoring the practice nurse, instead of providing direct patient care.
This reorientation allowed “additional time to be spent with patients, within existing resources,” the researchers explain. They also note that the 74 practices involved in the study received just one 60–90 minute training session before implementing the intervention.
After 12 months, the 151 patients randomly assigned to “Stepping Up” had a significantly greater improvement in HbA1c than the 115 who received usual care. Specifically, mean HbA1c fell from 8.7% to 7.4% in patients who received the intervention, compared with a fall from 8.5% to 8.0% in those who received usual care, for a mean difference of –0.6%.
Furthermore, the patients treated at intervention practices were a significant 8.3 times more likely to have started insulin at 12 months than those treated at control practices, at 70% versus 22%. This was “despite a higher patient to [general practitioner] ratio in intervention practices,” Furler et al note.
The researchers set a target HbA1c level of 7%, which was reached by just 36% of intervention participants and 19% control participants (odds ratio=2.2). This suggests that “practitioners and patients were judicious in the way they approached progressive treatment intensification, within the new model of care,” the authors write.
The team also notes that there was no worsening of depressive symptoms in either arm, nor were there any differences in physical health or diabetes-specific distress, but there was a significantly greater improvement in patient-reported mental health with the intervention over usual care.
Moreover, there were no severe hypoglycemic or other adverse events reported in either study arm.
“Our results indicate that, with appropriate support and redesign of the practice system, insulin initiation can become part of routine diabetes management in primary care, obviating the need to refer to specialist services with geographical, cost, and accessibility barriers,” Furler and co-authors conclude in The BMJ.
By Laura Cowen
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