The DE-PLAN-CAT project (Diabetes in Europe-Prevention using lifestyle, physical activity and nutritional intervention-Catalonia) has shown that an intensive lifestyle intervention is feasible in the ...primary care setting and substantially reduces the incidence of diabetes among high-risk Mediterranean participants. The DP-TRANSFERS project (Diabetes Prevention-Transferring findings from European research to society) is a large-scale national programme aimed at implementing this intervention in primary care centres whenever feasible.
A multidisciplinary committee first evaluated the programme in health professionals and then participants without diabetes aged 45-75 years identified as being at risk of developing diabetes: FINDRISC (Finnish Diabetes Risk Score)>11 and/or pre-diabetes diagnosis. Implementation was supported by a 4-channel transfer approach (institutional relationships, facilitator workshops, collaborative groupware, programme website) and built upon a 3-step (screening, intervention, follow-up) real-life strategy. The 2-year lifestyle intervention included a 9-hour basic module (6 sessions) and a subsequent 15-hour continuity module (10 sessions) delivered by trained primary healthcare professionals. A 3-level (centre, professionals and participants) descriptive analysis was conducted using cluster sampling to assess results and barriers identified one year after implementation.
The programme was started in June-2016 and evaluated in July-2017. In all, 103 centres covering all the primary care services for 1.4 million inhabitants (27.9% of all centres in Catalonia) and 506 professionals agreed to develop the programme. At the end of the first year, 83 centres (80.6%) remained active and 305 professionals (60.3%) maintained regular web-based activities. Implementation was not feasible in 20 centres (19.4%), and 5 main barriers were prioritized: lack of healthcare manager commitment; discontinuity of the initial effort; substantial increase in staff workload; shift in professional status and lack of acceptance. Overall, 1819 people were screened and 1458 (80.1%) followed the lifestyle intervention, with 1190 (81.6% or 65.4% of those screened) participating in the basic module and 912 in the continuity module (62.5% or 50.1%, respectively).
A large-scale lifestyle intervention in primary care can be properly implemented within a reasonably short time using existing public healthcare resources. Regrettably, one fifth of the centres and more than one third of the professionals showed substantial resistance to performing these additional activities.
Abstract
Traditionally, treatment for type 2 diabetes (T2D) centered on the failure of insulin secretion from the beta cells of the pancreas and insulin resistance. Though effective in certain ...respects, these treatments are marred by multiple undesirable side effects. The discovery of the incretin defect and the role of glucagon in T2D shifted the focus to therapies that addressed not only the beta cell defect but also the alpha cell defect in the pancreas. Therapies addressing these defects, simultaneously, have switched the entire focus of T2D therapy by not only improving glycemic control but also reducing the risk of hypoglycemia and weight gain and improving outcomes. These newer modalities of treatment started off with dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists (GLP1-RAs), and now further treatments in the form of twincretins (GLP1/GIP dual agonists) and triple agonists (GLP1/GIP/glucagon agonists) are unraveling. This article provides a summary of the evidence available with these newer antidiabetics, which address the glucagon defect in T2D.
Diabetes is a major risk factor for chronic kidney disease (CKD), which is a leading cause of global morbidity and mortality and also associated with substantial costs to healthcare systems. Despite ...the current best practice standards of care, management of CKD in diabetes in the primary care setting remains an ongoing challenge. Using an online survey, we aimed to assess the self-rated knowledge and competence of primary care professionals involved in the management of CKD in diabetes in the European region.
An online anonymous survey was developed by the Primary Care Diabetes Europe research group and administered to primary care professionals involved in managing CKD in diabetes from 23rd March 2022–9 th October 2022. Descriptive statistics were used to summarise questionnaire responses. Factors influencing ability to initiate treatment strategies were evaluated using logistic regression.
A total of 266 respondents (51.9% males) completed the questionnaire. Most respondents were GPs (82.7%) followed by nurses (9.4%). The age of respondents ranged from 25 to 72 years with a median of 51 years. About a third of respondents indicated that they were fully confident in the screening and diagnosis of CKD in diabetes. With regards to CKD presentation, staging and prognosis, 16.5–21.8% of respondents stated they were fully confident in this area; however, about 11% of respondents were not confident on how to predict CKD prognosis using established clinical guidelines. About a third of respondents stated they were confident without support regarding the complications of kidney disease in diabetes and it being a risk multiplier; just a quarter of respondents were fully confident. A third of respondents stated they were fully confident regarding appropriate management strategies for preventing or slowing down the progression of CKD and the initiation of newer agents. In multivariable analyses, confidence in the knowledge of the stages of kidney disease and criteria for the diagnosis of kidney disease were each associated with an increased odds in the confidence to select and initiate appropriate management strategies.
With regards to almost all aspects of management of CKD in diabetes, only up to a third of primary care professionals stated they are fully confident and are able to teach others; the majority are confident but would like to know more or require extra support. This may be a contributor to the challenges faced in providing optimal CKD care in people with diabetes in the primary care setting. Effective interventions that can promote the uptake of best practice clinical guidelines in primary care are urgently needed.
•The care for people with early stage chronic kidney disease (CKD) is mostly done in primary care.•In this primary care survey, only about a third of respondents were fully confident in the screening and diagnosis of CKD.•Only up to about a quarter were fully confident in CKD presentation, staging and prognosis.•Only a third of respondents were fully confident regarding appropriate management strategies.•Knowledge of the staging and diagnosis of CKD predicts ability to initiate right management.
Recent advances in type 2 diabetes (T2D) research have highlighted the benefits of sodium‐glucose co‐transporter‐2 (SGLT‐2) inhibitors, including cardiovascular and renal protection. However, uptake ...rates of these drugs remain low in patients with T2D, particularly in subpopulations most likely to benefit from them. This review considers the potential barriers to prescribing SGLT‐2 inhibitors in T2D in clinical practice and outlines potential multidisciplinary recommendations to overcome these barriers. Safety concerns and a lack of clarity in and divergence of guidelines around the introduction of SGLT‐2 inhibitors into treatment regimens may represent a barrier to uptake from the clinicians' perspective, including a general lack of understanding of the benefits associated with SGLT‐2 inhibitors. Patient characteristics, such as socioeconomic status, may influence uptake because of the cost of SGLT‐2 inhibitors, especially in the United States, where health insurance coverage could be a concern. SGLT‐2 inhibitor prescription rates vary between clinical specialty (endocrinology, primary care, cardiology, and nephrology) and country, with cardiologists the lowest prescribers, and endocrinologists the highest. Primary care practitioners may experience more challenges in following SGLT‐2 inhibitor‐related guidelines than diabetes specialists as there may be fewer opportunities for education on how this drug class improves cardiovascular and renal outcomes in patients with T2D. Uptake rates appear to vary between countries because of differences in guidelines and health insurance systems. The amendment of SGLT‐2 inhibitor‐related guidelines for more multidisciplinary use and the implementation of patient and clinician education may encourage uptake of these drugs, potentially improving long‐term health outcomes among patients with T2D.
•La pandemia de COVID-19 nos ha obligado a diseñar nuevas formas de dispensar cuidados médicos. En este contexto, la telemedicina se propone como principal alternativa a la clásica atención sanitaria ...presencial.•El colapso de los centros sanitarios durante la pandemia ha dificultado el seguimiento de los problemas crónicos de salud como la diabetes tipo 2, impidiendo un seguimiento o tratamiento adecuado.•Adaptar las guías de práctica clínica en forma de recomendaciones y algoritmos de decisión adaptados al nuevo escenario profesional permite homogeneizar y estandarizar la atención sanitaria que se ofrece a los pacientes con diabetes tipo 2.
Las circunstancias actuales provocadas por la COVID-19 nos obligan a los profesionales de atención primaria a idear nuevas formas de garantizar la atención sanitaria de nuestros pacientes con diabetes tipo 2 (DM2). Existen evidencias que respaldan la eficacia de la telemedicina en el control glucémico de los pacientes con DM2. Ante la rápida adaptación de la práctica clínica al uso de la telemedicina, el Grupo de Trabajo de Diabetes de la Sociedad Española de Medicina Familiar y Comunitaria (SemFyC) optó por elaborar un documento de consenso plasmado en un algoritmo de actuación/seguimiento telemático en la atención de los pacientes con DM2.
The current circumstances cause by the COVID-19 force primary care doctors to find out new ways to guarantee the health care of our type 2 diabetes patients. There is evidence that supports the remote consultation efficacy in the glycemic control in patients with type 2 diabetes. Facing the rapid adaptation of clinical practice to the remote consultation use, from de Diabetes Group of the Spanish Society of Family and Community Medicine (SemFyC), we have prepared a document embodied in a telematic action / monitoring algorithm in the care of patients with type 2 diabetes.
Type 2 diabetes is an important preventable disease and a growing public health problem. Based on information provided by clinical trials, we know that Type 2 diabetes can be prevented or delayed by ...lifestyle intervention. In view of translating the findings of diabetes prevention research into real-life it is necessary to carry out community-based evaluations so as to learn about the feasibility and effectiveness of locally designed and implemented programmes. The aim of this project was to assess the effectiveness of an active real-life primary care strategy in high-risk individuals for developing diabetes, and then evaluate its efficiency.
Cost-Effectiveness analysis of the DE-PLAN (Diabetes in Europe - Prevention using Lifestyle, physical Activity and Nutritional intervention) project when applied to a Mediterranean population in Catalonia (DE-PLAN-CAT). Multicenter, longitudinal cohort assessment (4 years) conducted in 18 primary health-care centres (Catalan Health Institute). Individuals without diabetes aged 45-75 years were screened using the Finnish Diabetes Risk Score - FINDRISC - questionnaire and a 2-h oral glucose tolerance test. All high risk tested individuals were invited to participate in either a usual care intervention (information on diet and cardiovascular health without individualized programme), or the intensive DE-PLAN educational program (individualized or group) periodically reinforced. Oral glucose tolerance test was repeated yearly to determine diabetes incidence. Besides measuring the accumulated incidence of diabetes, information was collected on economic impact of the interventions in both cohorts (using direct and indirect cost questionnaires) and information on utility measures (Quality Adjusted Life Years). A cost-utility and a cost-effectiveness analysis will be performed and data will be modelled to predict long-term cost-effectiveness.
The project was intended to evidence that a substantial reduction in Type 2 diabetes incidence can be obtained at a reasonable cost-effectiveness ratio in real-life primary health care setting by an intensive lifestyle intervention. As far as we know, the DE-PLAN-CAT/PREDICE project represents the first assessment of long-term effectiveness and cost-effectiveness of a public healthcare strategy to prevent diabetes within a European primary care setting.
•About 89% of studies reported a decline in hospitalisations for cardiovascular diseases during the pandemic.•Severe presentation, less use of cardiovascular procedures and longer delays were common ...during the pandemic.•Most studies reported no change in in-hospital mortality among hospitalised patients.•Further restructuring needs to be done to maintain high standards of care and prepare for future pandemics.
The Coronavirus disease 2019 (COVID-19) pandemic has led to a dramatic crisis in health care systems worldwide. These may have significant implications for the management of cardiometabolic diseases. We conducted a systematic review of published evidence to assess the indirect impact of the COVID-19 pandemic on hospitalisations for cardiovascular diseases and their management.
Studies that evaluated volume of hospitalisations for cardiometabolic conditions and their management with comparisons between the COVID-19 and pre-COVID periods were identified from MEDLINE, Embase and the reference list of relevant studies from January 2020 to 25 February 2021.
We identified 103 observational studies, with most studies assessing hospitalisations for acute cardiovascular conditions such as acute coronary syndrome, ischemic strokes and heart failure. About 89% of studies reported a decline in hospitalisations during the pandemic compared to pre-pandemic times, with reductions ranging from 20.2 to 73%. Severe presentation, less utilization of cardiovascular procedures, and longer patient- and healthcare-related delays were common during the pandemic. Most studies reported shorter length of hospital stay during the pandemic than before the pandemic (1–8 vs 2–12 days) or no difference in length of stay. Most studies reported no change in in-hospital mortality among hospitalised patients.
Clinical care of patients for acute cardiovascular conditions, their management and outcomes have been adversely impacted by the COVID-19 pandemic. Patients should be educated via population-wide approaches on the need for timely medical contact and health systems should put strategies in place to provide timely care to patients at high risk.
PROSPERO 2021: CRD42021236102
•SGLT2 inhibition is associated with a transient decrease in eGFR.•SGLT2 inhibition prevents deterioration of renal function and death from kidney disease.•In populations with renal impairment, ...SGLT2-Is are associated with preservation of renal function.•SGLT2-Is are associated with improvement in UACR in populations with renal impairment.
Sodium–glucose co-transporter 2 (SGLT2) inhibitors may have renal protective effects in people with impaired kidney function. We assessed the use of SGLT2 inhibitors in people with type 2 diabetes with or without renal impairment defined as estimated glomerular filtration rate (eGFR) of ≥30 and <60ml/min/1.73m2 and/or UACR>300 and ≤5000mg/g by conducting a systematic review and meta-analysis of available studies.
Randomised controlled trials (RCTs) were identified from MEDLINE, EMABASE, Web of Science, the Cochrane Library, and search of bibliographies to March 2017. No relevant observational study was identified. Summary measures were presented as mean differences and narrative synthesis performed for studies that could not be pooled.
42 articles which included 40 RCTs comprising 29,954 patients were included. In populations with renal impairment, SGLT2 inhibition compared with placebo was consistently associated with an initial decrease in eGFR followed by an increase and return to baseline levels. In pooled analysis of 17 studies in populations without renal impairment, there was no significant change in eGFR comparing SGLT2 inhibitors with placebo (mean difference, 0.51ml/min/1.73m2; 95% CI: −0.69, 1.72; p=403). SGLT2 inhibition relative to placebo was associated with preservation in serum creatinine levels or initial increases followed by return to baseline levels in patients with renal impairment, but levels were preserved in patients without renal impairment. In populations with or without renal impairment, SGLT2 inhibitors (particularly canagliflozin and empagliflozin) compared with placebo were associated with decreased urine albumin, improved albuminiuria, slowed progression to macroalbuminuria, and reduced the risk of worsening renal impairment, the initiation of kidney transplant, and death from renal disease.
Emerging data suggests that with SGLT2 inhibition, renal function seems to be preserved in people with diabetes with or without renal impairment. Furthermore, SGLT2 inhibition prevents further renal function deterioration and death from kidney disease in these patients.
To explore reasons behind treatment inertia in current approaches to early cardiorenal risk management in type 2 diabetes (T2D).
A global, web-based, quantitative panel survey of primary care ...physicians (PCPs) and primary care diabetes specialists treating people living with T2D. The questions covered current management of T2D, particularly the use of sodium–glucose co-transporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and dipeptidyl peptidase-4 inhibitors as second-/third-line therapies.
Of 1677 respondents from 18 countries who completed the survey, 73.4% were responsible for second-/third-line therapy initiation. Two thirds had modified treatment decisions based on recent cardiovascular outcomes trials (CVOTs). Respondents cited restricted access to therapies and limits on regular appointments as the greatest barriers to second-/third-line therapy prescription. Although 81.6% agreed that early intensification to second-/third-line therapies is associated with clinical benefits, 46.1% of respondents still reserve these for later lines of therapy, and 23.8% would not consider changing therapeutic approach in patients with well-controlled T2D but increasing cardiovascular risk.
Substantial barriers still prevent optimization of primary setting T2D patient care. Education programs which enable PCPs to translate CVOT evidence into clinical benefits for patients with T2D could address many of the remaining knowledge gaps identified.
•Recent guidelines recommend glucose-lowering therapies with cardiorenal benefits.•Most primary care physicians (PCPs) are aware of recent cardiovascular outcomes trials.•Some PCPs remain unsure of the clinical implications of these trials.•PCPs may resist adjusting therapies even as patient cardiovascular risk increases.•Healthcare/insurer restrictions are a key barrier contributing to treatment inertia.
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