The culture of faith and hope: patients' justifications for their high estimations of expected therapeutic benefit when enrolling in early phase oncology trials. Cancer. 2010;116:3702-3711.
In the heart of New York City, adjacent to the Chrysler Building (left), the famed architect Philip Johnson designed the Trylons "as a monument for 42nd Street… to give you the top of the Chrysler building at street level" via visual analogy with the chevron-ornamented spire of its namesake. It's one of many visual reminders that the epicenter of the COVID-19 pandemic in the US is still a bejeweled city.
Metformin is the first line treatment for type 2 diabetes (T2D). While earlier initiation is associated with achievement of glycemic targets and a delayed need for treatment escalation, metformin initiation and adherence remain suboptimal. We explored contributors to suboptimal metformin initiation and adherence during the year following a T2D diagnosis. From a population of adults diagnosed with T2D between 2014-2018, we randomly identified 100 individuals who were prescribed metformin during the year after diagnosis (starters) and 100 who were not (non-starters). Through physician review of electronic health record (EHR) notes from the year following diagnosis, we explored patient-provider discussions about metformin, reasons metformin was or was not ordered, and reasons for discontinuation. Metformin starters were younger (mean age 53.8 vs. 60.0 years, p<0.001), more likely to be men (64% vs. 50%, p=0.046), and had higher initial HbA1c values (9.1% vs. 7.0%, p<0.001). Though 94/100 starters filled the initial prescription, only 71 were still taking metformin at one year. The most common documented reason for stopping was side effects. Only 18/100 non-starters had a documented patient-provider discussion about metformin, with a desire to try lifestyle modification as the primary reason for not starting metformin. Among the 18 non-starters who discussed metformin, metformin treatment was only revisited with 3. Though our findings are limited by a small sample and the extent of clinical documentation in the EHR, we still captured aspects of metformin treatment not available using structured EHR variables. In conclusion, among metformin starters, efforts to mitigate side effects, including titration strategies or long-acting formulations, may improve metformin adherence. For most non-starters, there was no documented discussion regarding metformin. Strategies that prompt providers to have this important discussion may increase early initiation of this critical medication. Disclosure C. Gong: None. K. Gu: None. M. A. Blatchins: None. P. Mishra: None. R. W. Grant: None. A. Gopalan: None. Funding Kaiser Permanente Northern California
The disclosure of a new type 2 diabetes (T2D) diagnosis shapes patients’ T2D-related experiences, with more supportive approaches linked with better self-care and lower diabetes distress. Given changes in patient-provider communication and greater use of telemedicine, we examined the setting of T2D disclosures among adults in a large, integrated healthcare delivery system. Physicians reviewed charts of a random sample of 200 adults diagnosed with T2D between 2014-2018 to determine the diagnosis disclosure setting. Identified settings were an in-person visit, telemedicine visit (telephone/video), secure message via the online patient portal, mailed letter, or voicemail. These settings were further categorized into 2-way synchronous communication (in-person/telemedicine), 2-way asynchronous communication (secure message), and 1-way asynchronous communication (letter/voicemail). We examined differences in disclosure setting by patient demographics. The disclosure setting was discernible for 197/200 individuals; 55.3% received the diagnosis via 2-way synchronous communication (25.4% in-person, 29.9% telemedicine), 23.9% via 2-way asynchronous communication, and 20.8% via 1-way asynchronous communication (18.8% letter, 2% voicemail). Disclosure setting did not differ by age, gender, or level of neighborhood deprivation. Latinx individuals were overrepresented among those receiving the diagnosis via 1-way asynchronous communication (42.5% vs. 17.1% 2-way synchronous vs. 8.7% 2-way asynchronous, p=0.001) and had lower online patient portal enrollment (59%). The heterogeneity in T2D diagnosis disclosure setting suggests a lack of standard practices for communicating a T2D diagnosis. The common use of asynchronous modalities is concerning given the gravity of the diagnosis, especially when established best practices for communicating bad news to patients exist. Disclosure K. Gu: None. C. Gong: None. M. A. Blatchins: None. P. Mishra: None. R. W. Grant: None. A. Gopalan: None. Funding Kaiser Permanente Northern California
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