Get the highlights from the final two days of the American Diabetes Association's (ADA) 82nd Scientific Sessions.
As the American Diabetes Association’s (ADA) 82nd Scientific Sessions comes to a close, let’s take a look at some of the highlights from the final two days of the conference.
Disparities in the Use of Diabetes Medications & Technologies
Despite advances in diabetes treatment, new, effective medications and devices are not reaching patients equally. To help illustrate the challenges of these treatment gaps and provide potential solutions, Dr. Marina Basina of Stanford University hosted the session “Disparities in the Use of Diabetes Medications and Technologies” on Day 4 of the 2022 ADA Conference. Dr. Basina invited Drs. Colette DeJong, Sara Jane Cromer, and Ananta Addala present recent data highlighting the need for a level diabetes treatment playing field.
Limitations in Access to New Diabetes Therapies Across Different Ethnicities
Dr. Sara Jane Cromer, an endocrinologist at the Massachusetts General Hospital, presented information on access to insulin, GLP-1 agonists, and SGLT2 inhibitors. Dr. Cormer began by outlining troubling trends of medication rationing and underuse.
- More than 25% of diabetes patients ration insulin
- Low income and inadequate healthcare coverage are associated with higher rates of rationing
- Cost-related insulin underuse was associated with hA1c levels >9%
- Cost-related underuse of insulin is more common in racial and ethnic minorities
GLP-1 agonists and SGLT2 inhibitors are recommended by current ADA guidelines, but racial and ethnic minorities use these medications less than white non-Hispanic patients. According to Dr. Cromer, reasons these treatments are not reaching minority populations include:
- Patient is uninsured or underinsured
- Patient has distrust the healthcare system
- Provider makes assumptions regarding patient ability to afford or use medications
- Rising medication costs
- Disparities in funding for hospitals serving minority populations
Dr. Cromer concluded her presentation by underscoring the danger of inadequate medication access leading to poor glycemic control.
Out-of-Pocket Costs & Access to Diabetes Therapies Under Medicare Part D
Dr. Colette DeJong of the University of California, San Francisco, was the next to present and began by introducing a hypothetical case scenario. In this scenario, a 73-year-old woman covered by Medicare Part D insurance pays a total of $21 per month for lisinopril, atorvastatin, metformin, and glipizide.
If the patient wants to avoid insulin, the doctor should suggest SGLT2 and/or GLP-1 medication. However, this increases out-of-pocket costs. Medicare Part D patients are responsible for 25% of drug costs after an initial coverage limit is met. This is called the coverage gap, or “donut hole,” a period before catastrophic coverage kicks in.
If the patient adds just one of these new medications, it greatly increases her prescription costs.
- SGLT2 raises patient’s out-of-pocket costs 5x
- GLP-1 raises patient’s out-of-pocket costs 8x
As the median annual income for older adults in the U.S. is between $20K-$40k, such costs are a significant burden.
Dr. DeJong also focused on the high cost of insulin. While insulin was first discovered in 1921, gradual advances in safety, efficacy, and duration have driven up the price, and because insulin is a biologic, it cannot be manufactured generically
Strategies clinicians can use to ease the burden include:
- Openly discuss medication costs with your patients just as you would discuss side effects
- Determine which SGLT2 or GLP-1 is covered by the patient’s insurance
- Communicate with the pharmacy team
- If unsure about coverage, send a “test” prescription
According to Dr. DeJong, the exciting advances in diabetes treatment have led to a shift towards brand-name medication. Clinicians should be aware of the increased cost and include conversations about costs when starting a patient on new medications.
Racial-Ethnic Disparities in the Use of Diabetes Technology: How to Avoid Health Inequities in Diabetes Technology
Dr. Ananta Addala, a Division of Pediatric Endocrinology and Diabetes instructor at Stanford University, was the final presenter. She began by sharing data that shows non-Hispanic black patients and Latinx/Hispanic patients have higher A1c levels than non-Hispanic white patients. Potential reasons for a 2.26% A1c disparity between black young adults and non-Hispanic white young adults include:
- Socioeconomic status
- Treatment regimen
- Type of clinic
- Psychosocial factors
But Dr. Addala noted that 0.7% of the disparity could not be explained. She also noted that when comparing social economic status (SES), as the SES declines, there is a significant decrease in the use of pumps and continuous glucose monitors for diabetes patients.
To help overcome these disparities, Dr. Addala recommended that HCPs examine their own racial bias and insurance bias. She advocates for a greater patient perspective in treatment decision-making and encourages the recruitment of more diverse individuals into landmark trials.
Identifying the Primary Drivers of Disparities in Diabetes Treatment
Racial/ethnic bias and low-income levels directly relate to the treatment disparities of diabetes patients. To ensure all patients have access to high-quality care, these disparities must be identified, and patient perspectives must be included as part of any effective treatment plan. As diabetes medication and technology continue to advance, HCPs must carefully consider all factors that impact the patient when prescribing treatment.
Individualizing Diabetes Care & Education for Children, Teens, & Young Adults with Diabetes
Led by moderator Ms. Karen Kimmis, the “Individualizing Diabetes Care and Education for Children, Teens, and Young Adults with Diabetes” session reviewed essential educational strategies clinicians can use when caring for young patients with diabetes. Here’s a recap of what each presenter discussed.
Pediatric T2D: Educational Strategies for Patients with Diabetes, Family, & Caregivers
First up was registered nurse and Certified Diabetes Care and Education Specialist Mr. Paul McGuigan, who began by noting that between 3,600 and 5,000 children are diagnosed with type 2 diabetes (T2D) every year, according to the CDC.
But despite this high prevalence, there are several factors that can lead to a lack of understanding among youth with T2D and their families. One such element is the fact that 40 percent of these patients are asymptomatic at the time of diagnosis. This can often downplay the seriousness of the diagnosis, which only further underscores the importance of proper education.
To help demonstrate this, Mr. McGuigan discussed the African American Diabetes Intervention Project, in which a diabetes care provider from a similar ethnic background visited the home of a young patient with T2D one to two times per week over the course of 18 months. During these visits, the care provider would educate patients and their families and recommend management strategies. As a result of this mentorship, the rate of hospitalizations among study participants significantly decreased.
And while Mr. McGuigan noted that further evidence is needed to support peer and community-based care collaborators, he believes that this approach could provide an alternative way to provide essential education to patients, especially amid the healthcare workforce shortage that’s been exacerbated by the COVID-19 pandemic.
Diabetes Goes to College: Educating Teens & Parents for a Successful Transition
CEO and Founder of College Diabetes Network Ms. Christina Roth was up next. Ms. Roth has lived with type 1 diabetes (T1D) for close to 20 years, so she knows firsthand that college can present unique challenges for patients with diabetes. That’s why Ms. Roth founded the College Diabetes Network.
After working with and hearing directly from this patient population on how clinicians can help them prepare for the independence that college and young adulthood brings, Ms. Roth stressed the importance of starting the conversation early and shared the following three best practices:
- Create an intentional framework: Speaking directly to the patient—and not just the parent—can help the patient realize it’s their disease and empower them to take control over it. Structuring the visit so that there’s dedicated 1:1 time with the patient can also help.
- Meet them where they are: Validate patients’ knowledge and experience and use their goals and priorities to decide which treatment options might be best for them. This can help foster a coaching relationship that’s built on trust.
- Prepare for emergencies: It’s not about scaring patients; it’s about helping them create a safety net so that when the inevitable emergency occurs, they already have a support system in place that includes family, friends, and their clinician.
To conclude, Ms. Roth provided a list of resources that can help facilitate this conversation, including the College Diabetes Network’s “Off to College Guide” and “Off to Work Guide.”
Covering the Cost of Care: Health Insurance Literacy for the Transition to Adulthood
Rounding out the session was Dr. Julia Blanchette. Based on recent data, higher levels of financial stress negatively affect A1C in patients with T1D, and she believes that encouraging health insurance literacy (HIL) among these patients is the solution.
HIL is defined as the degree to which individuals have the knowledge, ability, and confidence to find and evaluate information about health insurance plans, select the best plan for their own financial and health circumstances, and use the plan once enrolled.
To test the impact of HIL, a study was conducted in which a T1D Financial Toolkit was created to be a financial and health insurance resource for young adults. The Toolkit featured 10 short videos recorded by young adults with T1D who spoke about a variety of topics, including self-advocacy, emotional support, diabetes costs, and tips on how to save money.
The 39 participants in the study found the Toolkit to be very user-friendly, easy to understand, and perhaps most importantly, relevant and helpful. In fact, all participants were satisfied with the Toolkit and would recommend it to others.
And while Dr. Blanchette noted that the T1D Financial Toolkit isn’t ready for a widespread rollout, she concluded by encouraging clinicians to implement financial and health insurance education or resources into their transition of care curriculums as it has the potential to make a great impact on patients’ HIL and financial stress.
Dementia and Diabetes—What Are the Causes and How Do We Prevent It?
In one of the final sessions of the meeting, Dr. Heather Ferris from the University of Virginia moderated a session on the relationship between dementia and diabetes. Here are some of the highlights from that session.
Impacts Of Obesity and Type 2 Diabetes on Brain Structure and Function
The session began with Dr. Auriel A. Willette from Iowa State University. Dr. Willette began by exploring the normal aging brain versus an aging dementia brain.
Dementia covers more than just Alzheimer's disease, and Dr. Willett defines dementia as a constellation of related syndromes that involved a significant decline in at least two cognitive domains and a progressive inability to do everyday things.
Dr. Willett then began reviewing obesity and its impacts on the brain. Based on emerging data, Dr. Willett has found that obesity has inconsistent associations with hippocampus memory and aging. However, the literature on obesity has shown consistent associations with the prefrontal cortex, “higher-order” thinking, and aging. Weight loss appears to reverse these issues with volume loss and problems with thinking.
He then went on to evaluate the impact of diabetes on brain structure and function. The risk of Alzheimer's disease in adults with diabetes alone is 1.5 times more likely, and in patients with both genetic risk factors and diabetes, the risk of Alzheimer's disease is 6 to 10 times more likely.
Dr. Willett concluded this session by reviewing potential therapies for these patients. While there are no established treatments or drugs for slowing Alzheimer's disease, some available therapeutics can help make symptoms milder at earlier stages. Some of these therapies included:
- Intranasal Insulin: This requires four months of treatment in patients with Alzheimer's disease but can lead to improved memory and function.
- Walking: Walking alone for at least one year has been shown to have benefits for patients with Alzheimer's disease.
Lifestyle And Dementia Prevention: The US Study to Protect Brain Health Through Lifestyle Intervention to Reduce Risk
Another session was led by Dr. Valory Pavlik from the Alzheimer's Disease and Memory Disorders Center in the Department of Neurology at Baylor College of Medicine.
Dr. Pavlik began by reviewing the burden of Alzheimer's disease and other dementias. According to the 2020 Alzheimer's Facts and Figures, the prevalence of Alzheimer's disease in the US is about 5.8 million patients. But she argues that it can be difficult together with the exact number due to undiagnosed cases and uncertain accuracy of diagnosis. Practical, effective prevention strategies targeting at-risk groups are still needed.
She then presented the following question to the audience: what are the outcome measures in dementia prevention? Some of these outcome measures include a clinical diagnosis of M CI or dementia, measurement based on cognitive performance or neuropsychological tests, and changes in biomarker levels.
The Lancet Commissions 2020 Evidence-Based Recommendations for Prevention of Dementia recommend the following:
- Reduce neuropathological damage by minimizing diabetes, treating hypertension, preventing head injury, and reducing midlife obesity
- Maintain frequent exercise to reduce the occurrence of depression and avoid excessive alcohol
- Increase and maintain cognitive reserve by treating hearing impairments, maintaining frequent social contact, and attaining a high level of education
Dietary and exercise interventions have also proven to aid in the prevention of dementia and Alzheimer's disease.
Dr. Pavlik then concluded her presentation by taking a look at the US Pointer study, which was developed to test whether findings from the FINGER study can be replicated in a heterogeneous cohort of older Americans who are at risk for cognitive decline and Alzheimer's disease.
The study assessed 2000 cognitively normal older adults from age 60 to 79 years old at increased risk for cognitive decline due to a sedentary lifestyle poor diet suboptimum cardiovascular health status in a first-degree family history of significant memory impairment. This study aimed to assess the effects of random assignment to self-guided versus structured lifestyle intervention focused on increasing physical exercise, a healthy diet, cognitive and social stimulation, and guideline-based health monitoring to manage cardiovascular risk factors on a two-year cognitive trajectory.
This study is still ongoing, but Dr. Pavlik expressed optimism about the direction in which it's headed and the results that can be derived from it.