BOSTON—A range of factors affect whether type 2 diabetes patients are able to achieve optimal glycemic control, although many of them—including comorbidities, age, and sex—are not modifiable.

The news is not all bad, however. A new study in JAMA Network Open suggests, conversely, that many adjustable factors might matter even more, pointing out that “the structure of how diabetes care is delivered, such as whether patients visit an endocrinologist or how prescriptions are filled, is potentially modifiable, yet its associations with glycemic control have not been rigorously evaluated.”

Other studies have also suggested that enhanced systems for care management and coordination can help patients to achieve glycemic control.

“In our study, glycemic control appeared to be most strongly associated with the factors related to how diabetes care was delivered and used, rather than the nonmodifiable clinical characteristics that are often considered in clinical practice,” write Brigham and Women’s Hospital, Harvard Medical School–led authors.

In a retrospective cohort study, researchers set out to investigate the association of diabetes care delivery with glycemic control in type 2 diabetes patients using insulin. Baseline claims and laboratory insurer data were used to select those patients, who had data for at least one hemoglobin HbA1c test result from before trial randomization—July 1, 2014, to October, 5, 2016—as well as diabetes care delivery and behavioral factors measured before the HbA1c test. Analyses were conducted from February 4, 2017, to November 13, 2018.

Most associated, according to the results, with the ability to achieve glycemic control were:
• Frequency of glucose self-testing
• Insulin persistence
• Visiting an endocrinologist

“The associations that we observed of the diabetes care factors with adequate glycemic control could be explained in several ways. First, several of the factors we explored, such as more frequent use of glucose self-testing supplies or regular use of insulin, may represent greater patient engagement with the health care system,” the authors explain. “Previous studies have also observed that more consistent medication-taking is associated with fewer diabetes-related adverse outcomes. Other factors, such as endocrinologist involvement, use of mail-order pharmacy services, or use of basal insulin listed on the insurance drug formulary, may represent more collaborative or connected health care.”

“Given their potential for intervention in these modifiable factors, future efforts should focus on these potentially modifiable factors as points for intervention to improve diabetes outcomes,” the researchers conclude.

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