How Do We Measure Successful Diabetes Care?

This content originally appeared on diaTribe. Republished with permission.

By Arvind Sommi, Andrew Briskin

Quality measures are tools to evaluate the effectiveness and quality of healthcare. Measures such as A1C, blood pressure, and cholesterol are used to understand health at the population level to ensure people with diabetes are getting the best care possible. At The diaTribe Foundation, we believe that Time in Range would be a valuable addition to the quality measures for diabetes care.

During a routine office visit, your healthcare provider may check certain health measures such as your A1C, blood pressure, and cholesterol. These tests are primarily used to assess your individual health and the effectiveness of your diabetes treatment plan. They are also used to evaluate the overall quality of care provided when these results are combined across all patients in a healthcare professional’s office, healthcare system, or health plan.

Recent advances in glucose monitoring, and the increasing use of continuous glucose monitors (CGM), has led to wider use of the metric Time in Range (TIR), which is a helpful supplement to A1C in assessing your glucose management. Because of this, TIR could be a valuable addition to the quality measures for diabetes care if it became a more widespread metric – a feat that is challenged by barriers to accessing CGM and integrating it into electronic health records.

What is a quality measure?

Quality measures can encompass many things but generally include different types of measurement domains, as outlined below.

Diabetes care

Source: diaTribe

Some tests, such as A1C screening or blood pressure monitoring, can serve as both a healthcare process and an outcome measure.

At the population level, outcome measures evaluate whether certain established goals are reached for a group of people. For example, this might be the percentage of patients in a healthcare practice with an A1C greater than or less than 9.0%. Quality measures, in this way, are used by insurance providers, people with diabetes looking for the best healthcare professionals to use, researchers, employers, and reporting agencies to better understand the effectiveness of diabetes treatments and evaluate how effective healthcare professionals or health systems are.

How are quality measures used in diabetes care?

Quality measures are important in diabetes care because achieving these goals can decrease the risk of diabetes complications and lead to improved health outcomes for everyone. There are several quality measures in diabetes care, many of which you may be familiar with through routine office visits with your healthcare team, such as:

Primarily, the combined data from these tests across many people with diabetes is used to determine if certain treatment methods are effective for the entire population. The data can also be used to reinforce or dispute established standards of diabetes care and respond to new care innovations (such as the latest technology or treatments).

Along with their use in evaluating treatments and standards of care, quality measures can also be used to evaluate healthcare professionals. In some cases, healthcare provider reimbursements from Medicare or other insurance providers may be tied to results, particularly under a value-based care model (learn more about value-based care here). For example, A1C screenings might be reimbursed only if enough patients meet A1C targets below certain thresholds.

Why might including Time in Range in quality measures be helpful to you?

While A1C is the current quality measure used to assess glucose management in people with diabetes, A1C has limitations. The accuracy of A1C measurements can vary based on factors such as race/ethnicity or chronic kidney disease. A1C tests are also generally limited to every two to three months and only represent an average blood glucose level over that time, which means daily highs and lows are not explicitly captured. Additionally, while low blood sugar may lower your A1C, it can also increase your risk of severe hypoglycemia – meaning a lower A1C may be dangerous if you experience frequent low blood sugars or mild hypoglycemia.

Time in Range is a glucose metric typically measured by a CGM. It is the amount of time you spend in the target range – generally between 70 and 180 mg/dL. The goal for most people with diabetes is to have at least 70% of your glucose readings within this range. Understanding your TIR as well as your time above and below range can help you and your healthcare provider assess how your body responds to medications, food choices, daily activities, stress, and a variety of other factors that affect your glucose. The increased use of TIR could help equip people with diabetes and their healthcare team with the information they need to make vital healthcare decisions and experience better diabetes care.

Time in Range allows for quick, actionable steps to improve diabetes management and corresponding health outcomes,” said Dr. Diana Isaacs, a diabetes care and education specialist from the Cleveland Clinic. “Time in Range can be assessed more frequently and provides more actionable insight into glucose management. Making it a quality measure would increase the utilization of this powerful tool. It has the potential to revolutionize how we take care of people with diabetes.”

Increases in TIR have been associated with a reduced risk of microvascular complications such as eye (retinopathy) and nerve disease (neuropathy), with similar evidence emerging for other macrovascular complications such as heart disease. Plus, the use of CGM has increased dramatically over the last few years (for example in people with type 1 diabetes in the T1D Exchange registry, this number rose from 6% in 2011 to 38% in 2018), allowing more people with diabetes to use TIR data on a regular basis.

However, there are still barriers to integrating TIR as a quality measure for diabetes care. One major challenge is the many barriers to using a CGM. For instance, most insurers cover CGM only for a limited number of people with diabetes (for example, those with type 1 diabetes who take insulin). Until access is substantially expanded and more people are able to use CGM who wish to, TIR adoption into the standard quality measures will be difficult.

An additional challenge is that TIR data is not integrated into most electronic health records (EHR) used by clinicians, making it difficult for providers to analyze TIR data for all patients and to assess TIR at the community level. Efforts are currently underway to change these systems so that TIR can be integrated into her systems, similar to metrics like A1C and blood pressure; at the ADA Scientific Sessions this year Dr. Amy Criego spoke to the success that the International Diabetes Center in Minnesota has had with integrating Abbott LibreView data into their EHR.

Through the efforts of the Time in Range Coalition, diaTribe is working to increase awareness and hopefully the eventual adoption of TIR as a meaningful quality measure in diabetes care.

Source: diabetesdaily.com

Great News: Trials Show Some Diabetes Drugs Can Actually Protect Your Kidneys

This content originally appeared on diaTribe. Republished with permission.

By Matthew Garza, Eliza Skoler, and Rhea Teng

More people with diabetes are taking drugs like Jardiance and Farxiga, originally developed to lower glucose in people with type 2 diabetes, because the latest data confirms that these drugs can protect your kidneys. A therapy still under investigation, finerenone, has been developed to protect the kidneys of people with and without diabetes

Recent research is showing that certain drugs can benefit your kidneys if you have type 2 diabetes. Diabetes is the leading cause of chronic kidney disease (CKD), and many people don’t receive adequate treatment for this condition, so advancements in therapy to treat and prevent kidney disease are important for the 800 million people worldwide who live with chronic kidney disease. We bring you some of the newest findings on finerenone, Jardiance, and Farxiga – three medications that have been shown to protect the kidneys in people with decreased kidney function, including those with diabetes and CKD.

Note: The latest results on Jardiance and Farxiga confirm earlier findings on two other SGLT-2 inhibitors – Invokana and Steglatro – which clearly show the kidney and heart benefits of this class of medication. As a result, SGLT-2 inhibitors are recommended for treating kidney disease in many people with diabetes. SGLT-2 inhibitors were a focus of the recent American Society of Nephrology’s virtual kidney conference. As research has shown an increased number of benefits of these medications – in terms of glucose levels, weight loss, hypoglycemia reduction, and heart and kidney health – new guidelines have rapidly developed (since 2013) for the use of these drugs in people with type 2 diabetes. And, in the case of Farxiga, SGLT-2s can also protect the kidneys in people without diabetes.

Finerenone

Finerenone is currently being tested to treat CKD in people with type 2 diabetes – it’s a new type of drug (called a non-steroidal MR antagonist) that interferes with the receptors that cause kidney cells to retain, or hold onto, excess salt and water. In the FIDELIO-DKD trial, almost 6,000 people with type 2 diabetes and kidney disease received either finerenone or placebo (a “nothing” pill) and were enrolled in the study for over two and a half years. The results from the trial demonstrated the benefits of finerenone:

  • Finerenone significantly reduced the risk of severe kidney outcomes by 18% over two and a half years.
  • Finerenone reduced the risk of severe heart outcomes by 14%, compared to the placebo.

The FIDELIO-DKD trial showed this medication to be helpful for people with type 2 diabetes. Given these positive results, finerenone has been submitted to the FDA and the European Medicines Agency for approval as a CKD treatment option for people with type 2 diabetes.

Jardiance

New findings from the EMPEROR-Reduced trial showed that Jardiance, an SGLT-2 inhibitor, improved heart and kidney outcomes in adults with heart failure with reduced ejection fraction (HFrEF, or a reduced ability to pump blood out of the heart), regardless of whether they had chronic kidney disease at the start of the trial. Of the 3,730 people enrolled in the trial – with or without type 2 diabetes – participants taking Jardiance showed:

  • A 22% reduced risk for severe heart outcomes among people with CKD, and a 28% reduced risk in those without CKD.
  • A 47% reduced risk for severe kidney outcomes in those with CKD, and a 54% reduced risk in those without CKD.

The variation in risk reduction was determined to be due to chance, rather than a difference in health outcomes between people with and without CKD. These results show that even though CKD increases a person’s risk for heart issues, Jardiance lowered that risk to the level of people without CKD.

Farxiga

New analysis of the DAPA-CKD trial found that Farxiga, another SGLT-2 inhibitor, protects the kidneys regardless of the cause of kidney disease, in people with or without type 2 diabetes. This builds on the positive results presented earlier this year on Farxiga’s ability to treat people with heart disease and CKD.

Why is this important?

More than 800 million people around the world live with chronic kidney disease, including 45 million people in the US (almost 14% of the US population). The need for effective medications that work for everyone, including those with or without diabetes, is high. Treatment with SGLT-2 inhibitors – or non-steroidal MR antagonists – could be key to helping these people.

Organizations like the American Diabetes Association and the European Association for the Study of Diabetes now recommend that people with type 2 diabetes and kidney issues be treated with SGLT-2 inhibitors or GLP-1 agonist medications. If you have diabetes or kidney disease, talk with your healthcare team about which of these treatment options may be helpful for you.

It’s important to catch kidney disease early so that it can be treated. If you have diabetes, ask your healthcare team to test your kidney function every year. To learn more about preventing kidney disease, view diaTribe’s helpful infographic. You can also read about UACR and eGFR, the two lab tests that are commonly used to evaluate kidney health.

Source: diabetesdaily.com

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