To the Editors:
I read with great interest the article by Tanumihardjo et al., “New Frontiers in Diabetes Care: Quality Improvement Study of a Population Health Team in Rural Critical Access Hospitals” published online in this journal[1]. The study attempts to determine if an innovative population health program that integrates medical and social care models improves clinical outcomes for patients with type 2 diabetes in a resource-constrained, frontier area. During the study, mean HbA1c of fully intervened patients significantly decreased from baseline to 12 months (7.9 to 7.6%, p < 0.01) and sustained reductions at 18 months, 24 months, 30 months, and 36 months. The authors concluded that the health program was associated with improved hemoglobin A1c among less well-controlled patients with diabetes.
The study team should be congratulated for their effort and results and I do not have any critical remarks about the study. Nevertheless, I would like to ask two questions and suggest a data sub-analysis related to the treatment of the study group.
In our observational study, focused on metabolic control of type 1 and type 2 diabetes patients treated with insulin in the Czech Republic and the Slovak Republic, we found a high level of clinical inertia resulting in a very small and clinically insignificant difference in mean HbA1c within three years[2]. Thus, we believe that any new intervention targeting long-term stabilised balance between the physician’s therapeutic approach and the corresponding patient response is important and might make positive results[3].
What were in the study authors’ opinions the most effective interventions influencing HbA1c in their program? Were medication dosage adjustments part of the intervention?
As the insulin-treated type 2 diabetes patients usually reach the worst level of metabolic control[4,5], it would be interesting to see the HbA1c analysis for insulin- and non-insulin-treated patients separately if such data are available.
We respectfully suggest taking this suggestion into account, especially if a study continuation is planned.
Jan Brož
Department of Internal Medicine, Second Faculty of Medicine, Charles University, Prague, Czech Republic
References
Tanumihardjo JP, Kuther S, Wan W, et al. New Frontiers in Diabetes Care: Quality Improvement Study of a Population Health Team in Rural Critical Access Hospitals. J Gen Intern Med. 202; 2:1–9. doi: https://doi.org/10.1007/s11606-022-07928-0.
Brož J, Janíčková Žďárská D, Urbanová J, et al. Current Level of Glycemic Control and Clinical Inertia in Subjects Using Insulin for the Treatment of Type 1 and Type 2 Diabetes in the Czech Republic and the Slovak Republic: Results of a Multinational, Multicenter, Observational Survey (DIAINFORM). Diabetes Ther. 2018;9(5):1897-1906. doi: https://doi.org/10.1007/s13300-018-0485-2.
Reach G, Pechtner V, Gentilella R, Corcos A, Ceriello A. Clinical inertia and its impact on treatment intensification in people with type 2 diabetes mellitus. Diabetes Metab. 2017;43(6):501–11. https://doi.org/10.1016/j.diabet.2017.06.0033.
Pablos-Velasco P, Parhofer KG, Bradley C, et al. Current level of glycaemic control and its associated factors in patients with type 2 diabetes across Europe: data from the PANORAMA study. Clin Endocrinol. 2014;80:47–56.
Selvin E, Parrinello ChM, Daya N, Bergenstal RM. Trends in insulin use and diabetes control in the US: 1988–1994 and 1999–2012. Diabetes Care. 2016;39(3):e33–e35. doi: https://doi.org/10.2337/dc15-2229.
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The article was supported by Ministry of Health, Czech Republic – conceptual development of research organization, Motol University Hospital, Prague, Czech Republic 00064203.
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Brož, J. New Frontiers in Diabetes Care. J GEN INTERN MED (2023). https://doi.org/10.1007/s11606-023-08251-y
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DOI: https://doi.org/10.1007/s11606-023-08251-y