- Email: [email protected]
Personalizing Obesity Assessment and Care Planning in Primary Care: Patient Experience and Self-management Outcomes
S60
Abstracts / Can J Diabetes 41 (2017) S22–S83
Background: Diabetic ketoacidosis (DKA) occurs most often with type 1 diabetes mellitus (DM), however, patients with type 2 DM may also experience DKA. Aim: To compare the clinical characteristics and outcomes of adult patients with DKA. Methods: A retrospective cohort study of patients admitted with DKA from 2014 to 2016. Results: 129 consecutive patients with a total of 186 admissions for DKA were analyzed; 62% with type 1. Patients with DKA and type 2 were significantly older (mean age 57 versus 37 years, p<0.01). With type 1, the most common precipitants for DKA were insulin omission (46%), infection (17.5%), other (12.5%), intoxication (8.75%), and insulin pump failure (8.75%). With type 2, the most common precipitants infection (22.4%), and other (22.4%). Mean blood glucose at initial assessment were similar for type 1 and 2 (32.6 vs. 31.2 mmol/L, NS). There was no difference in mean anion gap (23.4 vs. 22.4 mmol/L), serum bicarbonate (13.1 vs. 14.5 mmol/L), and eGFR (49.5 vs. 45 ml/min/1.73m2). Severity of DKA (by anion gap and pH) was similar (x2=1.27, p=0.53) Length of stay was longer with type 2 (11.4 vs. 5.7 days, p=0.01). There was no in-hospital mortality in either group. Conclusions: Type 2 DM was not uncommon in patients admitted with DKA, occurring in 38%, and was associated with a longer length of stay. 155
★
HbA1c Levels, Persistence, Treatment Progression, and Durability of HbA1c Control in Patients with T2DM Initiated on Canagliflozin or a GLP-1 in a Real-world Setting CAROL H. WYSHAM, PATRICK LEFEBVRE, DOMINIC PILON, MARIE-HELENE LAFEUILLE, BRUNO EMOND, RHIANNON KAMSTRA, MICHAEL PFEIFER, MIKE INGHAM Titusville, NJ This study compared real-world persistence and HbA1c goal attainment in adult patients with type 2 diabetes mellitus initiated on canagliflozin 300mg (CANA) versus a GLP-1 (with initiation date as index date) through QuintilesIMS EMRs–US database (03/29/2012– 04/30/2016). Inverse probability of treatment weighting, Cox models (hazard ratios [HRs] and confidence intervals [CIs]), and Kaplan Meier curves were used to compare time to: HbA1c<8%, discontinuation (gap>90 days), add/switch to a new antihyperglycemic agent (AHA), and the composite of failure to maintain HbA1c<8% or add/switch to a new AHA. Attaining HbA1c<8% was evaluated among patients with baseline HbA1c≥8%. Failure to maintain HbA1c<8% was evaluated among patients starting at HbA1c<8% (from index date) or reaching HbA1c<8% (from first day below goal). Of the 11,435 CANA and 11,582 GLP-1 patients (62.6% liraglutide), time to HbA1c<8% was comparable (HR [95% CI]: 0.98 [0.91– 1.06]; p=0.642) as was failure to maintain HbA1c<8% (HR [95% CI]: 1.00 [0.90–1.11]; p=0.988). CANA patients were 30% less likely to discontinue than GLP-1 patients (HR [95% CI]: 0.70 [0.66–0.74]; p<0.001; median time to discontinuation 12.4 vs. 8.6 months) and were 28% less likely to add/switch to a new AHA (HR [95% CI]: 0.72 [0.68–0.77]; p<0.001; median 21.3 vs. 15.1 months). CANA patients were 17% less likely to either fail to maintain HbA1c<8% or add/ switch to a new AHA (HR [95% CI]: 0.83 [0.77–0.90]; p<0.001; median 15.4 vs. 12.6 months). 156 Personalizing Obesity Assessment and Care Planning in Primary Care: Patient Experience and Self-management Outcomes THEA LUIG, ROBIN ANDERSON, ARYA M. SHARMA†, DENISE L. CAMPBELL-SCHERER*,† Edmonton, AB
Background: Obesity is a complex, chronic disease, significantly associated with diabetes. Clinical consultation approaches in primary care have not been effective in obesity prevention and management. To address this, it is essential to understand how consultations can be personalized to maximize impact on patients’ everyday efforts to improve health. Integrating the 5As of Obesity Management with Collaborative Deliberation to develop an approach, this study examines how patients perceive interpersonal work, communication, and content; and how this impacts selfmanagement as a result. Findings inform a planned randomized control trial. Methods: 20 patients with obesity purposefully sampled for diversity. Video-recorded consultations followed by semi-structured patient and clinician interviews; documentation of everyday life impact through diaries and two follow-up interviews over 6–8 weeks. Thematic analysis using inductive and deductive coding in NVIVO11. Results: Emergent themes point to interpersonal processes as decisive for supporting patients’ everyday self-management: (1) patient story was central in anchoring assessment and care planning; (2) collaborative deliberation about barriers, strengths, and preferences resulted in shared decisions about care strategies that fit patient context; (3) approach shifted patients toward increased awareness of how life context, emotions, and weight interact, more realistic expectations for weight management, and increased selfefficacy, resulting in successes with implementing their care plan Conclusions: Collaborative, personalized obesity consultations are key in supporting patient self-efficacy and self-care and foundational for optimizing interdisciplinary clinical care to improve health outcomes. 157 Uptake of Vascular Protection Recommendations from CDA Guidelines 2013 by Primary Care Practitioners and the Impact of an Interdisciplinary Diabetes Team SOPHIA FRANCIS-PRINGLE*, CHERYL BARNET†, KRISTEN IMFELD, MARGARET CHEUNG Mississauga, ON Background: The 2013 Canadian Diabetes Association Guidelines recommended pharmacological vascular protection therapies for many individuals with diabetes. Our study aims to measure the response of primary care practitioners (PCP) and members of an interdisciplinary diabetes team to these recommendations. Our focus was on the use of statins and angiotensin converting enzyme inhibitor / aldosterone receptor blocker (ACEI/ARB) therapies. Method: We conducted a retrospective chart review on patients referred by PCPs and seen at the Centre for Complex Diabetes Care (CCDC), Trillium Health Partners, between January 2014 and January 2016. A total of 793 patients were seen and included. The percentage change was calculated. Changes in therapy were done either by the diabetes team or PCP. Results: Patients on statin increased from 46% to 87% (absolute difference 41%). While patients on ACEI/ARB increased from 43% to 81.8% (absolute difference 38.8%). Therapy was initiated in approximately 72% of patients (statin 73.6%; ACEI/ARB 68%).
Patients on statin Patients on ACEI/ARB
Admission n=794
End of study n=794
% change
372 (46.8%) 343 (43.2%)
694 (87.4%) 650 (81.8%)
41 39
Conclusion: With admission to CCDC there is evidence of increase use of statin and ACEI/ARB therapy since release of CDA 2013 Guidelines. However, due to the design of our study we cannot say whether the observed change was a direct result of CCDC involvement. Future
Abstracts / Can J Diabetes 41 (2017) S22–S83
Background: Diabetic ketoacidosis (DKA) occurs most often with type 1 diabetes mellitus (DM), however, patients with type 2 DM may also experience DKA. Aim: To compare the clinical characteristics and outcomes of adult patients with DKA. Methods: A retrospective cohort study of patients admitted with DKA from 2014 to 2016. Results: 129 consecutive patients with a total of 186 admissions for DKA were analyzed; 62% with type 1. Patients with DKA and type 2 were significantly older (mean age 57 versus 37 years, p<0.01). With type 1, the most common precipitants for DKA were insulin omission (46%), infection (17.5%), other (12.5%), intoxication (8.75%), and insulin pump failure (8.75%). With type 2, the most common precipitants infection (22.4%), and other (22.4%). Mean blood glucose at initial assessment were similar for type 1 and 2 (32.6 vs. 31.2 mmol/L, NS). There was no difference in mean anion gap (23.4 vs. 22.4 mmol/L), serum bicarbonate (13.1 vs. 14.5 mmol/L), and eGFR (49.5 vs. 45 ml/min/1.73m2). Severity of DKA (by anion gap and pH) was similar (x2=1.27, p=0.53) Length of stay was longer with type 2 (11.4 vs. 5.7 days, p=0.01). There was no in-hospital mortality in either group. Conclusions: Type 2 DM was not uncommon in patients admitted with DKA, occurring in 38%, and was associated with a longer length of stay. 155
★
HbA1c Levels, Persistence, Treatment Progression, and Durability of HbA1c Control in Patients with T2DM Initiated on Canagliflozin or a GLP-1 in a Real-world Setting CAROL H. WYSHAM, PATRICK LEFEBVRE, DOMINIC PILON, MARIE-HELENE LAFEUILLE, BRUNO EMOND, RHIANNON KAMSTRA, MICHAEL PFEIFER, MIKE INGHAM Titusville, NJ This study compared real-world persistence and HbA1c goal attainment in adult patients with type 2 diabetes mellitus initiated on canagliflozin 300mg (CANA) versus a GLP-1 (with initiation date as index date) through QuintilesIMS EMRs–US database (03/29/2012– 04/30/2016). Inverse probability of treatment weighting, Cox models (hazard ratios [HRs] and confidence intervals [CIs]), and Kaplan Meier curves were used to compare time to: HbA1c<8%, discontinuation (gap>90 days), add/switch to a new antihyperglycemic agent (AHA), and the composite of failure to maintain HbA1c<8% or add/switch to a new AHA. Attaining HbA1c<8% was evaluated among patients with baseline HbA1c≥8%. Failure to maintain HbA1c<8% was evaluated among patients starting at HbA1c<8% (from index date) or reaching HbA1c<8% (from first day below goal). Of the 11,435 CANA and 11,582 GLP-1 patients (62.6% liraglutide), time to HbA1c<8% was comparable (HR [95% CI]: 0.98 [0.91– 1.06]; p=0.642) as was failure to maintain HbA1c<8% (HR [95% CI]: 1.00 [0.90–1.11]; p=0.988). CANA patients were 30% less likely to discontinue than GLP-1 patients (HR [95% CI]: 0.70 [0.66–0.74]; p<0.001; median time to discontinuation 12.4 vs. 8.6 months) and were 28% less likely to add/switch to a new AHA (HR [95% CI]: 0.72 [0.68–0.77]; p<0.001; median 21.3 vs. 15.1 months). CANA patients were 17% less likely to either fail to maintain HbA1c<8% or add/ switch to a new AHA (HR [95% CI]: 0.83 [0.77–0.90]; p<0.001; median 15.4 vs. 12.6 months). 156 Personalizing Obesity Assessment and Care Planning in Primary Care: Patient Experience and Self-management Outcomes THEA LUIG, ROBIN ANDERSON, ARYA M. SHARMA†, DENISE L. CAMPBELL-SCHERER*,† Edmonton, AB
Background: Obesity is a complex, chronic disease, significantly associated with diabetes. Clinical consultation approaches in primary care have not been effective in obesity prevention and management. To address this, it is essential to understand how consultations can be personalized to maximize impact on patients’ everyday efforts to improve health. Integrating the 5As of Obesity Management with Collaborative Deliberation to develop an approach, this study examines how patients perceive interpersonal work, communication, and content; and how this impacts selfmanagement as a result. Findings inform a planned randomized control trial. Methods: 20 patients with obesity purposefully sampled for diversity. Video-recorded consultations followed by semi-structured patient and clinician interviews; documentation of everyday life impact through diaries and two follow-up interviews over 6–8 weeks. Thematic analysis using inductive and deductive coding in NVIVO11. Results: Emergent themes point to interpersonal processes as decisive for supporting patients’ everyday self-management: (1) patient story was central in anchoring assessment and care planning; (2) collaborative deliberation about barriers, strengths, and preferences resulted in shared decisions about care strategies that fit patient context; (3) approach shifted patients toward increased awareness of how life context, emotions, and weight interact, more realistic expectations for weight management, and increased selfefficacy, resulting in successes with implementing their care plan Conclusions: Collaborative, personalized obesity consultations are key in supporting patient self-efficacy and self-care and foundational for optimizing interdisciplinary clinical care to improve health outcomes. 157 Uptake of Vascular Protection Recommendations from CDA Guidelines 2013 by Primary Care Practitioners and the Impact of an Interdisciplinary Diabetes Team SOPHIA FRANCIS-PRINGLE*, CHERYL BARNET†, KRISTEN IMFELD, MARGARET CHEUNG Mississauga, ON Background: The 2013 Canadian Diabetes Association Guidelines recommended pharmacological vascular protection therapies for many individuals with diabetes. Our study aims to measure the response of primary care practitioners (PCP) and members of an interdisciplinary diabetes team to these recommendations. Our focus was on the use of statins and angiotensin converting enzyme inhibitor / aldosterone receptor blocker (ACEI/ARB) therapies. Method: We conducted a retrospective chart review on patients referred by PCPs and seen at the Centre for Complex Diabetes Care (CCDC), Trillium Health Partners, between January 2014 and January 2016. A total of 793 patients were seen and included. The percentage change was calculated. Changes in therapy were done either by the diabetes team or PCP. Results: Patients on statin increased from 46% to 87% (absolute difference 41%). While patients on ACEI/ARB increased from 43% to 81.8% (absolute difference 38.8%). Therapy was initiated in approximately 72% of patients (statin 73.6%; ACEI/ARB 68%).
Patients on statin Patients on ACEI/ARB
Admission n=794
End of study n=794
% change
372 (46.8%) 343 (43.2%)
694 (87.4%) 650 (81.8%)
41 39
Conclusion: With admission to CCDC there is evidence of increase use of statin and ACEI/ARB therapy since release of CDA 2013 Guidelines. However, due to the design of our study we cannot say whether the observed change was a direct result of CCDC involvement. Future