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CME / ABIM MOC / CE

Prediabetes Awareness in the Primary Care Setting

  • Authors: News Author: Nicola M. Parry, DVM; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 10/18/2019
  • Valid for credit through: 10/18/2020
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This article is intended for primary care physicians, endocrinologists, nurses, pharmacists, and other clinicians who treat and manage patients with prediabetes.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  • Analyze primary care physicians' knowledge and practices regarding prediabetes
  • Evaluate the success of a shared decision-making program for the treatment of prediabetes
  • Outline implications for the healthcare team


Disclosures

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Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.


News Author

  • Nicola M. Parry, DVM

    Freelance writer, Medscape, LLC

    Disclosures

    Disclosure: Nicola M. Parry, DVM, has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine
    Irvine, California

    Disclosures

    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Johnson & Johnson Pharmaceutical Research & Development, L.L.C.; Genentech; GlaxoSmithKline
    Served as a speaker or a member of a speakers bureau for: Shire

Editor

  • Esther Nyarko, PharmD

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Disclosure: Esther Nyarko, PharmD, has disclosed no relevant financial relationships.

Nurse Planner

  • Hazel Dennison, RN

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Disclosure: Hazel Dennison, DNP, RN, FNP, CPHQ, CNE, has disclosed no relevant financial relationships.

CME Reviewer

  • Samantha Mattiucci, PharmD, CHCP

    Content Reviewer

    Disclosures

    Disclosure: Samantha Mattiucci, PharmD, CHCP, has disclosed no relevant financial relationships

Medscape, LLC staff have disclosed that they have no relevant financial relationships.


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This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

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  • Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.  

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

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  • Awarded 0.25 contact hour(s) of continuing nursing education for RNs and APNs; none of these credits is in the area of pharmacology.

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This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 70% on the post-test.

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CME / ABIM MOC / CE

Prediabetes Awareness in the Primary Care Setting

Authors: News Author: Nicola M. Parry, DVM; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 10/18/2019

Valid for credit through: 10/18/2020

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Clinical Context

Approximately 1 in 3 US adults has prediabetes, yet many of these patients are unaware of this condition. Can healthcare providers be contributing to the lack of action around prediabetes? Tseng and colleagues sent surveys to 1000 primary care physicians to assess their knowledge and practice habits regarding prediabetes. The survey response rate was 33%.

Of 15 possible risk factors to prompt screening for prediabetes, physicians recognized an average of 10, with factors around race/ethnicity being the most commonly missed. Less than half of physicians recognized the laboratory value cutoffs used to define prediabetes.

Only 36% of physicians referred patients to a diabetes lifestyle prevention program, even though such programs have the best history of efficacy for the prevention of diabetes, and 43% reported discussing the initiation of metformin with patients, which is also an evidence-based strategy. Ninety percent of physicians thought that easier access to diabetes prevention programs would be helpful, with nearly as many supporting coordination for the management of referrals to such programs.

Clearly, there are barriers to primary care physicians appropriately treating prediabetes. Another study by Moin and colleagues evaluates the efficacy of a shared decision-making (SDM) program run by pharmacists to increase the uptake of treatment for prediabetes.

Study Synopsis and Perspective

Despite more than 2 decades of studies showing that type 2 diabetes can be prevented or delayed by intensive lifestyle change such as the Diabetes Prevention Program (DPP), metformin therapy, or both, uptake of these remains quite low among US patients.

Indeed, study findings published online September 9 in the Journal of General Internal Medicine identified substantial gaps in prediabetes management at the primary care provider (PCP) level that significantly affect the care of this patient population.[1]

Eva Tseng, MD, MPH, from Johns Hopkins University School of Medicine, Baltimore, Maryland, and colleagues found knowledge gaps related to prediabetes in key areas, including screening, laboratory diagnostic criteria, and patient management recommendations.

Dr Tseng told Medscape Medical News these findings were similar to those from the group's previous regional survey of PCPs.[2]

"Some important findings to highlight include that 25% of PCPs may be identifying patients as having prediabetes when they have diabetes," she said.

"Additionally, only about a third of PCPs refer patients with prediabetes to diabetes prevention lifestyle change programs for their initial management approach."

In their current study, Dr Tseng and colleagues evaluated survey data collected from 298 US PCPs. Eligible participants included general practitioners who had completed residency training, general internists, and family physicians.

The survey questioned PCPs about risk factors for prediabetes screening, laboratory criteria for diagnosis of prediabetes, and recommendations for managing prediabetes. It also addressed their practice behaviors for managing the condition and identified what PCPs perceive as barriers and potential interventions to improve its management.

More than 15% of respondents correctly identified all 15 risk factors for prediabetes screening; typically, PCPs selected 10 of the 15 risk factors.

Similarly, only about 50% of respondents were aware of the laboratory criteria for diagnosing diabetes, and even fewer correctly identified the fasting glucose (42%) and Hb1Ac (31%) levels that would indicate prediabetes.

In addition, only 8% of PCPs were aware that the American Diabetes Association recommends patients aim to lose at least 7% of their body weight as part of a diabetes prevention lifestyle change program.

In fact, more than 20% of respondents were not following recommendations from any professional organization for the screening and management of prediabetes.

With respect to the practice behaviors of PCPs related to the initial management of prediabetes, only about one third (36%) reported referring patients to a diabetes prevention lifestyle change program, and 43% reported discussing metformin therapy.

Respondents identified key patient-level (especially lack of motivation, 94%) and system-level (especially lack of weight loss resources, 61%) barriers to managing prediabetes.

Interventions identified by respondents as useful for improving prediabetes management included increased availability of diabetes prevention programs (90%), insurance coverage for these programs (90%), better nutrition resources (88%), access to weight loss programs (86%), and coordination of referral to lifestyle change programs (84%).

Dr Tseng said possible solutions for closing these gaps include not only systematic education efforts for PCPs at the institutional level but also leveraging of tools through health information technology that place less burden on PCPs.

"Such tools may be able to facilitate automatic ordering of follow-up labs and referral of patients to local diabetes prevention lifestyle change programs," she explained.

"These types of tools require system-level changes and resources, which we want to emphasize as being extremely important for overcoming many of the barriers to type 2 diabetes prevention."

SDM Could Help Patients Manage Prediabetes

Tannaz Moin, MD, MBA, MSHS, from the David Geffen School of Medicine at the University of California, Los Angeles, also stressed the need to bridge these gaps.

In an interview with Medscape Medical News, Dr Moin said, "We really need to increase prediabetes awareness nationally and to ensure that both patients and providers understand the evidence-based options for diabetes prevention."

With this in mind, Dr Moin and colleagues conducted the cluster randomized controlled Prediabetes Informed Decision and Education (PRIDE) trial to assess the effectiveness of SDM in diabetes prevention.

Most US adults are not even aware they have prediabetes; therefore, the researchers hypothesized that SDM would help patients become prediabetes aware and empower them to make informed diabetes prevention choices aligned with their preferences.

Dr Moin and colleagues published 12-month results from the trial online August 30 in the Journal of General Internal Medicine.[3]

The trial took place across 20 primary care clinics within a large regional health system; it included 351 patients who attended 10 clinics randomly assigned to provide pharmacist-led SDM and 1028 control patients who attended 10 clinics that were randomly assigned to deliver usual care.

All patients were overweight or obese (body mass index of 24 kg/m2 or higher) and had a glycated hemoglobin level of 5.7% to 6.4%, consistent with prediabetes.

Each patient in the SDM group had a private visit with a pharmacist who used an interactive decision aid to discuss prediabetes with the patient. The pharmacist also outlined 4 diabetes prevention options (DPP), DPP±metformin, metformin alone, or usual care) and helped patients decide among the choices.

As a result of this intervention, at 4-month follow-up, the researchers found that more than 83% of patients in the SDM group picked a diabetes prevention strategy: 38% chose DPP (with or without metformin), 23% chose DPP, and 19% chose metformin. Approximately one third (32%) participated in 9 or more DPP sessions.

In contrast, only 0.4% of patients in the control group engaged in any lifestyle change (such as DPP or any other weight loss program).

When Dr Moin's team analyzed weight change outcomes at 12-month follow-up, they found significantly higher weight loss among SDM participants overall compared with control individuals (−5.2 lb vs −0.2 lb; P < .001).

This was irrespective of the diabetes prevention choice, she said, because the analysis also included patients who chose to take no action.

"Thus, it's possible that even patients who chose to take no action also made some lifestyle changes to improve their health and lower their type 2 diabetes risk."

Although SDM has been investigated in a variety of other clinical conditions, Dr Moin believes this is the first study to apply it in the area of diabetes prevention. 

"I believe we are also one of the first studies to link a clinical outcome, such as 12-month weight loss, with an SDM intervention for overweight patients with prediabetes," she noted. 

SDM for diabetes prevention should be disseminated more broadly, she emphasized. 

"Incorporating allied health professionals, such as pharmacists or nurses, in SDM delivery may also address the burden faced by PCPs trying to address prediabetes in addition to numerous other health issues during time-constrained visits."

The PRIDE trial was supported by the National Institute of Diabetes and Digestive and Kidney Diseases, and the national survey study was supported by a Johns Hopkins Primary Care Consortium grant. Three authors report receiving grant support from the Department of Veterans Affairs; the UCLA Resource Centers for Minority Aging Research, Center for Health Improvement of Minority Elderly, through the National Institutes of Health (NIH)/National Institute on Aging; the NIH/National Center for Advancing Translational Sciences; an NIH Career Development Award; and the Barbara A. Levey and Gerald S. Levey Endowed Chair in Medicine at the University of California, Los Angeles. One author reports serving as a member of the US Preventive Services Task Force. The remaining authors have disclosed no relevant financial relationships.

J Gen Intern Med. Published online September 9, 2019.

J Gen Intern Med. Published online August 30, 2019.

Study Highlights

  • The study was conducted in a primary care network of clinics in Southern California between 2015 and 2018. Patients were eligible for study participation if they had overweight or obesity, prediabetes, and age between 18 and 74 years.
  • Patients with chronic kidney disease, eating disorders, or polycystic ovary disease or who were pregnant or planned to become pregnant were excluded from the study protocol.
  • 10 clinics were randomly assigned to the SDM protocol, and 10 were randomized as a control group. Eligible patients in the SDM clinics were invited to a 45-minute discussion with a pharmacist, which featured an interactive computer-based decision aid focused on the potential harms and management of prediabetes.
  • The clinic-based pharmacists then guided the patient toward 1 of the following interventions: lifestyle alone, metformin alone, lifestyle plus metformin, or usual care.
  • The main study outcome was adoption of metformin therapy or the lifestyle intervention (with at least 9 subsequent lifestyle training sessions) in the intervention vs control clinics at 4 months after randomization.
  • Researchers also followed participants' body weight at 12 months.
  • Among 680 participants in the intervention group, 351 completed the SDM intervention. This cohort was compared with 1028 patients in the control group.
  • The mean age of all participants was 56 years, and the majority were women. The study cohort was diverse in terms of race/ethnicity.
  • More than 83% of participants in the SDM intervention chose the lifestyle plan, metformin, or both treatments. Among the 260 participants who selected lifestyle, 83 (32%) completed at least 9 sessions.
  • At 4 months, rates of uptake for lifestyle interventions in comparing the SDM and control groups were 23.4% and 0.4%, respectively. The respective rates of using metformin at 4 months were 18.8% and 1.6%.
  • The average changes in body weight at 12 months in the intervention and control groups were −5.2 and −0.2 lbs, respectively. The intervention group experienced a relative 2.7% loss of body weight vs the control group.
  • Secondary analyses based on age, sex, baseline HbA1c, and body mass index failed to alter the main study conclusions.

Clinical Implications

  • Knowledge about prediabetes appears to be lacking among primary care physicians. Only 36% of physicians in the study by Dr Tseng and colleagues referred patients to a diabetes lifestyle prevention program, and 43% reported discussing the initiation of metformin with patients.
  • The current study by Dr Moin and colleagues finds that SDM can improve uptake of metformin and a lifestyle program for prediabetes as well as body weight at 1 year.
  • Implications for the Healthcare Team: The current study on improving interventions for prediabetes was powered by pharmacists practicing SDM when embedded in an outpatient clinic. This model may be replicated elsewhere, using pharmacists orother qualified team members.

 

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