Taking Control Of Your Diabetes: An Innovative Approach to Improving Diabetes Care Through Educating, Motivating, and Making the Connection Between Patients and Health Care Providers

摘要

Introduction: Our Diabetes Toolbox Has Grown, But A1C in the United States Has Remained Flat The gold-standard goal of diabetes management has been to achieve meaningful and sustained glycemic control to reduce the risk of long-term complications. Unfortunately, results from the National Health and Nutrition Examination Survey indicate that only ～50% of adults with diabetes in the United States, mostly with type 2 diabetes, are achieving an A1C &7.0%, and this percentage has not changed over the past decade ( 1 ). In addition, the proportion of patients meeting individualized targets has declined according to the American Diabetes Association and American Association of Clinical Endocrinologists, and the overall proportion of patients in very poor control, defined as an A1C &9%, has actually increased ( 2 , 3 ). The Healthcare Effectiveness Data and Information Set results, with data from &1,000 health plans covering &171 million lives, are even more striking, demonstrating that, in 2014, ～40% of commercially insured health maintenance organization patients and 30% of government insured patients achieved an A1C &7.0, again reflecting no change in the past 10 years ( 4 ). All of this has occurred despite the introduction of &40 new treatment options for people with type 2 diabetes. This fact is quite shocking and difficult to understand, especially given that our armamentarium of effective and safe type 2 medications has expanded over the same time period to include dipeptidyl peptidase 4 (DPP-4) inhibitors, sodium glucose cotransporter 2 inhibitors, designer insulins, inhaled insulin, and glucagon-like peptide 1 (GLP-1) receptor agonists. Reduced Sense of Urgency in People With Type 2 Diabetes Although there may be many reasons why these new treatment options haven’t made a dent in the glycemic control of our patients with type 2 diabetes during these past 10 years, I feel strongly that the basic and primary issue is a lack of patient education, motivation, and activation. Type 2 diabetes is a silent condition with few or no symptoms caused by poor glucose, blood pressure, and lipid control. Thus, there is little or no sense of urgency, and this is a key issue. People with type 2 diabetes are asked to take a handful of pills, give themselves injections, and prick their fingers to measure their blood glucose several times a day. However, they do not feel any different whether they follow or don’t follow the orders we, their health care providers (HCPs), give them. In addition, there is a negative attitude and actual fear of prescription drugs, most of which are also extremely costly. Don’t you love those television commercials that are repeatedly played throughout the day and night from lawyers who are planning class action lawsuits against pharmaceutical companies? This type of information just adds to unfounded fears. Meanwhile, many people with type 2 diabetes search for a miracle cure on TV, on the Internet, or in vitamin stores and are grabbing on to the unproven or outright false claims that accompany such products. The sale of over-the-counter supplements that are not regulated by the U.S. Food and Drug Administration and have no proven benefits is a multibillion-dollar industry. Large Health Care Administrative Claims Databases Tell Us That Our Patients Are Not Taking Their Medication One consistent theme that is revealed when large health care databases profile our patients with type 2 diabetes is that they are not taking their medications. Adherence is shockingly low. The most common method of measuring medication adherence is by “proportion of days covered” based on pharmacy refill records. Patients are labeled as “poorly adherent” if that proportion is &80% of the time ( 5 ). Of course, there is no guarantee that medications picked up from the pharmacy are actually taken. Additionally, patients cannot be labeled poorly adherent if they never fill their prescriptions in the first place, which is incredibly common, occurring up to 30% of the time in some studies. These two issues contribute to an underestimation of the problem of poor adherence. The data on injectable agents such as basal insulin and GLP-1 receptor agonists show that adherence with these medications is typically only 25–30% after 1 year of treatment ( 6 ). Data also consistently show that, for oral medications used for treating type 2 diabetes, adherence is ～50% after 1 year, even for DPP-4 inhibitors, which are dosed once daily and have practically no side effects ( 6 ). To put it bluntly, people with type 2 diabetes are not taking their medications, including those for other medical problems such as hypertension and dyslipidemia. The large body of evidential data that powerfully links poor adherence to the complications of diabetes, including coronary heart disease, hospitalizations, absenteeism, presenteeism (working while sick), disability claims, and other costs to the health c