VOLUME 9 NUMBER 3 • SEPTEMBER 2012
131
SA JOURNAL OF DIABETES & VASCULAR DISEASE
ADA WATCH
FOCUS ON QUALITY OF CARE
How to improve diabetes out-
comes: a systematic review of strat-
egies that work, presented as part
of the ADA/
Lancet
symposium
This meta-analysis emphasised that initia-
tives aimed at improving health systems and
involving patients in their care offered the
greatest improvement in glycaemic control
in more than 140 published clinical trials.
The measures used to determine quality
improvements, referred to as quality-of-care
indicators, included blood pressure con-
trol, LDL-cholesterol levels, medication use
and monitoring for diabetes complications
(
retinopathy, renal and foot screening).
Expanded statin usage and smoking-ces-
sation programmes also resulted in clinically
important benefits (see the BARI 2D and statin
usage studies below). Interestingly, the value
of the benefits of education and training of
healthcare practitioners differed depending
on how poor overall glycaemic control was
at baseline. For example, clinicians’ educa-
tion, and audit and feedback mechanisms
achieved improvements when baseline HbA
1
c
levels were > 8%, while this strategy was less
effective when HbA
1
c
levels were < 8%. Inter-
ventions targeting patients were beneficial at
any level of HbA
1
c
control.
The second most important quality-of-
care improvement strategy was intervening
across the entire system of chronic disease
management, which achieved the second-
largest benefit irrespective of baseline HbA
1
c
level. The authors noted that their review
could only address the type of intervention,
not how to deliver it. This remains the realm
of experienced healthcare practitioners.
Source: Tricco AC,
et al
.
Effectiveness of quality improve-
ment strategies on the management of diabetes: a sys-
tematic review and meta-analysis. e-published
Lancet
9
June 2012. DOI: 10.1016/50140-6736(12).60480-2.
NHANES casts spotlight on risk of
diabetes from exposure to tobacco
smoke (passive smoking)
This US National Health and Nutrition
Examination Survey (NHANES) used the
objective measure of serum cotinine levels
in never-smokers to assess diabetes risk.
The study found that higher cotinine levels
were positively associated with occurrence
of diabetes (404 patients) in this cohort of
3 151
patients.
Source: Omayma O,
et al
.
The association of serum
cotinine levels and diabetes in never smokers (Abstract
16-
OR: abstract of oral presentation).
Baroreflex sensitivity (BRS) in type
2
diabetes improves on statin
therapy (low-dose atorvastatin)
Little is known on the effect of statin
therapy on BRS. This study examined the
effects of low-dose atorvastatin over a
period of a year. Atorvastatin significantly
reduced total cholesterol levels (27.3%)
as expected, as well as triglyceride levels.
Normal BRS was significantly improved in
atorvastatin patients, while diet had no
influence on BRS values.
Source: Grigoropoulon P,
et al
.
Long-term atorvastatin
administration improves baroreflex sensitivity in sub-
jects with type 2 diabetes and dyslipidaemia (Abstract
47-
OR).
Global survey finds one in four
type 2 diabetes patients do not
take basal insulin as prescribed
and more than a third suffer from
hypoglycaemia
One in four people with type 2 diabetes
had missed or had not dosed their basal
insulin correctly in the previous 30 days,
according to a new global survey funded
by Novo Nordisk. The GAPP2™ (Global
Attitudes of Patients and Physicians) survey
also found that more than a third experi-
enced hypoglycaemia. The data were pre-
sented at the late-breaking poster session
of the 72nd scientific sessions.
Key findings from the GAPP2
TM
survey
included:
Dosing irregularities are not uncommon
•
in people with type 2 diabetes taking
basal insulin. In the previous 30 days,
22%
had missed a dose, 24% had mis-
timed a dose by more than two hours
and 14% had reduced a basal insulin
dose.
Self-treated hypoglycaemia remains a
•
significant management challenge in
type 2 diabetes and 36% of those sur-
veyed had experienced an event in the
previous 30 days.
There is a correlation between hypogly-
•
caemia and dosing irregularities. Those
who had missed a basal insulin dose
in the previous 30 days were signifi-
cantly more likely to report self-treated
hypoglycaemia over the same period as
well (41 compared to 34%).
‘
A considerable proportion of people
with type 2 diabetes are missing or mis-
timing their long-acting insulin’, said lead
researcher and health psychologist Dr
Meryl Brod of the Brod Group. ‘The chal-
lenges of addressing dosing irregularities
and self-treated hypoglycaemia are critical
for improving patient care as they greatly
impact on the achievement of optimal gly-
caemic control.’
Source: Brod M, Barnett AH, Rana A, Peyrot M.
GAPP2TM: Global survey finds in the last month one
in four type 2 diabetes patients do not take basal insu-
lin as prescribed and over a third suffer hypoglycaemia
(
Abstract: 2012-LB-5579-Diabetes).
ORIGIN trial shows safety and effi-
cacy of insulin glargine: no adverse
cardiovascular outcomes after a 6.2-
year follow up of early insulin use
The ORIGIN trial, a large trial in patients
with high cardiovascular risk and dysglycae-
mia, using an intervention of initial basal
insulin (glargine) in impaired fasting glu-
cose (IFG), impaired glucose tolerance (IGT)
or early-stage type 2 diabetes, has shown
no cardiovascular benefits or adverse car-
diovascular outcomes. However, a reduc-
tion of progression to diabetes did occur in
patients with IFG or IGT who were treated
with insulin, actively targeting normogly-
caemia of < 5.3 mmol/l, compared to those
treated with standard care and mainly oral
agents.
Importantly, the long-term use of insu-
lin glargine was shown to be efficacious
in lowering glucose levels safely over the
six-year period. There was no increase in
the incidence of cancer or cardiovascular
events in the more than 5 000 patients
treated over this extended period.
The trial showed that better glucose con-
trol was achieved using a daily injection of
basal insulin (with or without oral agents)
in high-risk patients who self-titrated their
insulin dosage to a fasting plasma glucose
(
FPG) level of < 5.3 mmol/l compared to
those offered standard care. However, in
both groups, a mean HbA
1
c
level of ≤ 6.5%
was achieved over the duration of the
study.
In those in the glargine arm of the study,
the median insulin dose rose from 0.31 U/
kg by year one to 0.40 U/kg by year six.
Importantly, 83.6% (5 230 patients) were
adherent to their insulin glargine therapy
at year six; 19% did however permanently
discontinue their insulin therapy. In the
standard-care group, 11% of patients were
using insulin at the end of the study.
With regard to the co-primary compos-
ite: cardiovascular outcomes of death from
cardiovascular causes, non-fatal myocardial
