medwireNews: A primary care-based diabetes quality improvement (QI) initiative using a shared medical appointment (SMA) approach leads to increased insulin use and reduced glycated hemoglobin (HbA1c) in patients with poorly controlled type 2 diabetes, research shows.
Interestingly, lead author Uma Gunasekaran, from the University of Texas Southwestern Medical Center in Dallas, USA, believes that the improvements observed by her team were due to increased awareness of insulin in general, rather than the use of the SMAs, specifically.
Speaking at the ADA’s 78th Scientific Sessions in Orlando, Florida, she explained that the first phase of the 18-month project focussed on increasing provider education through a lecture on ADA Standards in Medical Care and interactive insulin training.
Providers then “retained that information and applied it in all clinical settings and not just SMAs,” which contributed to the increase in insulin use, she said.
The second phase of the training focussed on how to conduct SMAs.
Of the 23,611 individuals included in the study, 27% had poorly controlled diabetes, defined as an HbA1c level above 9%. There were more women (58%) than men (42%), 55% were Hispanic, 29% were Black, and only 10% had commercial health insurance. The median age was 56 years.
At baseline, only 18% of the patients with poorly controlled diabetes were receiving insulin, which Gunasekaran put down to clinical inertia.
She said that when care providers were interviewed, around 20% said in each case that they believed insulin therapy was unnecessary until there was evidence of β-cell inadequacy, that they felt training patients to administer insulin was too complicated, and that their staff would not have enough time to properly educate patients.
At the end of the follow-up period, a further 18 months after the project was rolled out to the last participating clinic, the proportion receiving insulin had increased to approximately 30%. Gunasekaran noted, however, that the difference from baseline did not become statistically significant until almost a year after the project was completely rolled out.
The increased insulin use was accompanied by a significant fall in the proportion of patients with poorly controlled diabetes, to approximately 23%, and a significant decrease in mean HbA1c, from 8.3% to 8.0%.
Gunasekaran told medwireNews that her team has now adapted the way they provide training opportunities to their care providers; it still addresses how to improve glycemic control, but not necessarily through SMA.
By Laura Cowen
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