Participatory Medicine and Diabetes Care: A Clinician and Patient Education Initiative. Final Outcomes Assessment September 2017

Transcription

1 Participatory Medicine and Diabetes Care: A Clinician and Patient Education Initiative Final Outcomes Assessment September 2017 Novo Nordisk Grant ID:

2 CME Activity Page

3 Patient Education Activity

4 Program Information Activity Title: Participatory Medicine and Diabetes Care: A Clinician and Patient Education Initiative Launch Date: August 16, 2016 Expiration Date: August 16, 2017 Credit: 1.25 AMA PRA Category 1 Credit(s) TM Sponsored By: The Academy for Continued Healthcare Learning (ACHL) Supported by: Supported by an educational grant from Novo Nordisk Audience Generation: FreeCME: ACHL site: ProPatient:

5 Executive Summary Level 1 2 Outcomes CME Activity Participation Participants: 2052 Certificates awarded: 1568 Patient Education Participation Participants: 2108 Educational scenes visited: 25,202 Participant Satisfaction 84% of participants noted that the faculty s ability to effectively convey the subject matter and expertise on the subject matter was excellent/good 96% of participants would recommend this activity to a colleague Participants strongly agree/agree that all learning objectives were met, with an average rating of 3.47 out of 4.0.

6 Executive Summary (cont.) Level 3 5 Outcomes Changes made based on participation in this activity may impact up to 23,172 patients each month This activity was highly effective, with 58% of participants indicating that patient outcomes would be positively impacted Participants improved performance on all post test questions; the average score of all post test questions was 74% compared with 40% on all pretest questions. Participants demonstrated improvements in: Knowledge of the mechanisms of action and benefits of combination therapy regimens Post activity, more participants intend to implement combination therapy with two injectable agents in clinical practice Participants intend to continue involving their patients in shared decisionmaking

7 Executive Summary (cont.) Future Education Considerations Participants reported a need for education on the efficacy and safety of new therapies and patient education strategies; over one half of patient participants expressed a need for more education on side effects Focus education on available types of GLP 1 RAs and basal insulins, including clinical trial data of combination regimens Patient education strategies should highlight participatory medicine as data from the patient education activity indicate that patients do not understand its importance Incorporate CVD benefits of GLP 1 RAs into education to tie the increased awareness observed in this activity with recent expanded indications Consider case based and simulation activities to demonstrate individualized combination regimens and patient education strategies

8 Profession Total Participants Total Certificates Awarded % Profession 15% 32% Physician Physician Assistant Nurse 6% Nurse Practitioner Other 13% Unknown Other professions include: pharmacists, certified diabetes educators, faculty/educators, medical technicians, students, and case managers 27%

9 Specialty Specialty Family Practice/General Practice Internal Medicine 28% Emergency Medicine Surgery 41% Primary Care Other 13% 4% 7% 7%

10 Learning Objectives Please rate the following objectives to indicate if you are better able to: Apply strategies to overcome clinical inertia in the initiation of injectable therapies in patients with T2D Identify combinations of therapies with different safety and efficacy profiles for patients with T2D Develop strategies to enhance communication with patients and their caregivers Analysis of Respondents Rating Scale: 4 = Strongly Agree 1 = Strongly Disagree Participants strongly agree/agree that all learning objectives were met, with an average rating of N= 1444

11 Objectivity & Bias Did you Perceive Any Bias? Rating of Objectivity & Balance 100% 94% 100% 80% 80% 60% 40% 60% 40% 50% 36% 20% 0% 6% Yes No 20% 0% 12% 1% 1% Excellent Good Satisfactory Fair Poor This activity was perceived as objective, balanced, and non biased.

12 Faculty Evaluation Anne Peters, MD (Chair) Professor of Medicine Director, USC Clinical Diabetes Program Keck School of Medicine University of Southern California Los Angeles, CA Linda M. Siminerio, RN, PhD, CDE Professor of Medicine Executive Director, University of Pittsburgh Diabetes Institute Pittsburgh, PA 1% Ability to effectively convey the subject matter 49% 36% 13% 1% 2% Expertise on the subject matter 52% 32% 13% 1% Excellent Good Satisfactory Fair Poor Participants highly rated Dr. Peters and Dr. Siminerio s expertise and ability to convey the subject matter.

13 Pre/Post test Overview Overview of correct responses: 100% 75% 64% 75% 81% Pre 50% 25% 34% 43% 42% Post 0% Question Topic Pre Post % Change 1 Combination Regimens 34% 64% 88% 2 Injectable Therapies 43% 75% 74% 3 Efficacy and Safety 42% 81% 93% Participants demonstrated improved knowledge and competence on all three pre/post test questions and case vignettes.

14 Pre test vs. Post test 1. Which of the following best describes clinical trial findings with combination GLP 1 RAs and basal insulin regimens? Pre (N=1807) Post (N=1546) A. Significant HbA1c reduction has not been observed in patients with a baseline HbA1c between 7% 8% B. The long acting GLP 1 RAs provide greater benefits with basal insulin C. The short acting GLP 1 RAs have not shown benefits with basal insulin D. All types of GLP 1 RAs have been demonstrated to be beneficial in combination with basal insulin 100% 75% 50% 25% 22% 8% 33% 22% 11% 6% 34% 64% 0% A B C D Participants demonstrated improved knowledge of clinical trial results with GLP 1 RA and basal insulin combination regimens after participation in the activity; however, additional education on the GLP 1 RA formulations used may be warranted.

15 Pre test vs. Post test 2. AG, a 54 year old woman with a 6 year history of type 2 diabetes was initiated on metformin with basal insulin due to a baseline HbA1c of 9.2%. Her HbA1c continues to increase and is now 7.9% so she elects to add a GLP 1 RA to her basal insulin. Which of the following describes the mechanism by which the addition of a GLP 1 RA may improve her HbA1c? 100% Pre (N=1807) Post (N=1546) A. Via decreasing postprandial glucose (PPG) excursions B. Via reductions in fasting plasma glucose (FPG) C. Via weight loss D. Via increased glucagon secretion 75% 50% 25% 43% 75% 23% 19% 15% 9% 7% 9% 0% A B C D The percentage of participants correctly identifying the contribution of GLP 1 RAs to basal insulin therapy increased after participation in the activity, suggesting an increased awareness of the benefits of combination therapy.

16 Pre / Post / Follow up Survey 3. The LEADER clinical trial, which investigated the impact of liraglutide on cardiovascular outcomes in patients with type 2 diabetes, reported that liraglutide: A. Did not show any cardiovascular benefit B. Significantly reduced the risk of major adverse cardiovascular events C. Significantly reduced cardiovascular death, but not non fatal myocardial infarctions or strokes D. A trend in the reduction of cardiovascular death that did not reach significance 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Pre (N=1807) Post (N=1546) Follow Up (N=47) 81% 42% 40% 26% 18% 21% 25% 9% 15% 13% 4% 6% A B C D Immediately following this activity, the percentage of correct responses increased from 42% to 81%, suggesting increased knowledge of the benefits associated with GLP 1 RAs. In conjunction with the recent expanded indication for liraglutide, this increased awareness may translate into expanded use to reduce cardiovascular risks in type 2 patients. The decline on the follow up survey underscores the importance of continual reminders and reinforcement for adult learning. Education on the CVD benefits of therapies for type 2 diabetes may be particularly important given the accumulating number of clinical trials and expanded indications.

17 Pre / Post / & Follow up Survey 4. JH is a 57 year old man who initiated metformin and basal insulin due to an HbA1c of 9.0% at diagnosis. At his 3 month follow up appointment, his HbA1c is 8.6%. What next step would you recommend for him? Pre (N=1807) Post (N=1546) Follow up (N=47) A. Add an SGLT2 inhibitor B. Add a DPP IV inhibitor C. Add a GLP 1 RA D. Add prandial insulin 100% 75% 50% No correct answer, responses may vary 54% 50% 41% 25% 23% 24% 23% 14% 11% 6% 22% 11% 21% 0% A B C D The percentage of participants who would add a GLP 1 RA to basal insulin, instead of initiating prandial insulin, for a theoretical case patient requiring intensification of therapy increased from 41% to 54% following the activity. Approximately one third would add an oral therapy, indicating a need for continued education on the benefits of combining two injectable therapies.

18 Pre / Post / Follow up Survey 5. Before/following participation in this activity, how confident are you in your ability to use combination therapy with two injectable agents in your patients with type 2 diabetes? 75% Pre (N=1807) Post (N=1444) Follow up (N=47) 50% 25% 0% 51% 45% 42% 38% 31% 25% 18% 14% 19% 11% 4% 2% Very confident Somewhat confident Minimally confident Not at all confident The improved confidence with clinical application of two injectable therapies observed after participation in the activity continued in respondents to the follow up survey.

19 Pre test vs. Post test 6. Before/following participation in this activity, how often do you implement/plan to implement combination therapy with two injectable agents in your patients with type 2 diabetes? 75% Pre (N=1807) Post (N=1444) 50% 48% 25% 13% 27% 31% 37% 16% 19% 9% 0% Always Often Rarely Never More participants self reported an intention to implement combination therapy with two injectable agents in clinical practice after their participation: the percentage of participants intending to Always or Often implement this approach in practice increased from 44% to 76% post activity.

20 Pre test vs. Post test 7. Before/following participation in this activity, how often do engage/plan to engage your patients with type 2 diabetes in shared decision making? 50% 37% 46% Pre (N=1807) 40% 39% Post (N=1444) 25% 14% 9% 9% 6% 0% Always Often Rarely Never A high percentage of participants indicated engagement of patients in clinical decisionmaking before participating in the activity, with participants reporting that they intend to continue this shared decision making after the activity (78% pre to 85% post activity).

21 Follow up Survey Since your participation in this activity, have you increased the frequency in which you engage in shared decision making with your type 2 diabetes patients? 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 83% Yes Follow Up (N=47) 17% No More than three quarters of participants report having increased their engagement of patients in shared decision making after participation!

22 Follow up Survey How have you changed your shared decision making practices after participation in this activity? 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 47% Spend more time with patients Follow Up (N=47) 30% Provided educational resources 9% 14% Included a new strategy Involved other team members In addition to increasing the frequency of practicing shared decision making, participants indicated that they increased time spent with their patients and included new strategies.

23 Follow up Survey Have you shared the ProPatient type 2 diabetes educational activity with your patients? Follow Up (N=47) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 70% Yes 30% No 70% of participants have taken advantage of the patient education activity and shared it with their patients!

24 Impact of Activity This activity will increase my patient outcomes. If yes, please explain: Yes: 58% No: 15% Validated Practice: 27% N= 1444 I will get more pt.'s involvement to enhance compliance Control of glycemic targets Integral management of diet More willingness to add a 2nd or 3rd agent Increase use of other medical therapies Stressed the importance of improving communication with patients and provide proper education to patients and integrate them in decision making I will use the combination of injectables more readily Early addition of GLP l Significance of multi drug therapy More team centered approach in response to individual care towards education and motivation Selection of right group to receive GLP1 RA Socioeconomic challenges. Lack of interest in selfcare/participation in rural MS. "Just fix me attitude." Will consider GLP I sooner Pt's Increased awareness and sense of power over the plan for their health Patient preferences and understanding therapy choices help to better control diabetes More comfort in the step approach to therapy It will help me choose which medications is best to use for my patients Will improve A1c levels with addition of GLP 1 More willingness to add a GLP Proper assessment and selecting combination More patient involvement. Adding GLP 1 earlier Increased number of successful patient A1c values and decreases cardiovascular risk Glucose will be better controlled Will be easier to overcome clinical inertia Incorporate GLP 1 and Insulin combination to optimize glucose control This activity enhanced my awareness of non insulin agents I will better be able to explain to my patients how GLP 1 agonists work, as well as why they are important to use (decrease cardiovascular events and a1c) Monitor their HbA1c regularly I have a better understanding of multiple treatment options Decrease CV complications Help to better identify and treat pt with diabetes therefore help with diabetic neuropathy pain May initiate the SGLT2 earlier Will be able to utilize various techniques discussed in this presentation with future patients I will be treating More GLP 1 use

25 Impact of Activity (cont.) This activity will increase my patient outcomes. If yes, please explain: Yes: 58% No: 15% Validated Practice: 27% N= 1444 Greater chances of getting to goal HGBA1C The ability to start either basal insulin or GLP 1 RA as 2nd drug added may help reduce weight gain induced by basal insulin though both are injectables. This strategy may be more attractive to patients Better control of A1C Adding a 2nd treatment Helps me understand need for better team approach to Diabetes self management education Improved Hga1c, improved patient center care with decision making This CME helped broaden my options in dealing with patients who are either on monotherapy or on insulin, and the benefits of glp1 ra as per the latest research Better control of glucose level and hba1c Knowing that empathy plays such a large role in the management of Diabetes and making sure the patient takes an active role in their treatment Greater confidence in use of combination therapy Initiating a team approach allows a greater degree of coverage and education plus including the patient in their health management I will refer to dietician every time and increase injectable combo therapies when appropriate Because i will be in a position treat and monitor patients appropriately using HBIAC The learnings i have in this course could positively impact in the patient care as it provided knowledge on the do's and donts of the medication Help the patient to participate more actively in the decision making for care and increase the hours of diabetes education Increase patient decision making involvement as well as patient counseling/information sessions My patient will be more involved in the decision making which will make them appreciate the choices of diabetes management and control much better To have better a1c reduction Providing a better treatment plan based on findings Better communication. Give pt. a choice Involve team approach in treating diabetes Use combination therapy in type 2 diabetes Being part of a general management team for patient adherence I now have more confidence in prescribing and using newer anti hyperglycemic agents

26 Impact of Activity (cont.) This activity will increase my patient outcomes. If yes, please explain: Yes: 58% No: 15% Validated Practice: 27% Comprehensive review of the latest current therapies I will give greater consideration to GLP RA I better understand combination therapy to effectively lower HbAIC Of course, the HbA1c remains the most reliable indicator if Diabetes control and to see it lowered will give me a boost I will increase referrals to DSME/S providers, nutritionists and counselors I intend to implement the advice given in this lecture to benefit my patient population Lower HbA1c, weight loss, control glucose level, decease risk of any secondary diseases Will start prescribing more than 1 drug for DM Encourages more attention to post prandial glucose monitoring and strategies to reduce 4x/day insulin use Improve their HGA1c Will now have a better handle on patient's HgA1c who are already on insulin and metformin Was not confident that T2Ds would have enough impact Apparently, they do on A1C and cardiac Important benefit of basal insulin combined with GLP1 A Should have better diabetes control, better quality of life and better cardiovascular outcomes Supports spending more time on education and shared decision making Usually if patient failing basal insulin & metformin, I went to prandial insulin but now may institute GLP 1 first N= 1444

27 Perceived Clinical Barriers Please indicate any barriers you perceive in implementing changes in your practice: (Select all that apply) Cost 36% Lack of experience Lack of opportunity (patients) Lack of resources (equipment) 18% 14% 11% 88% of participants who perceived one or more barriers indicated that they will attempt to address those barriers in order to implement changes in their practice. Lack of administrative support 9% Lack of time to assess/counsel patients Reimbursement/insurance issues Patient compliance issues Lack of consensus or professional guidelines No barriers Other, please specify 3% 3% 15% 15% 16% 27% Of the participants that intend to address barriers to practice, identified strategies include: giving more emphasis to a team approach, increase interactions with CDE, thorough patient and family education, and becoming more familiar with current recommendations and available therapies. N=1444

28 Patient Impact Number of patients with T2D you see each month: 14% 9% 19% 0 1 to to to 50 >50 22% 36% Changes may impact up to 23,172 patients each month. This assumes data in chart above is representative of all participating healthcare professionals (2,070), who indicated their patient outcomes would increase as a result of this activity (58%). N=1444

29 Topics of Interest What topic areas would you like to see in future activities? Case based education Management of comorbidities 24% 25% Patient education strategies 35% Application of novel GLP Ras Application of novel insulins 24% 23% Efficacy and safety of new therapies 48% 0% 10% 20% 30% 40% 50% Efficacy and safety of new therapies, patient education strategies, and management of comorbidities were rated with highest interest for future education.

30 Key Takeaways Participants Comments What is one pearl you took away as a result of your participation? Combination GLP 1 agonist basal insulin therapy is effective Patient education and shared decision making is key to success Use basal insulin and glp1 together Do not let clinical inertia prevent you and the patient from achieving glycemic goals. Make necessary changes now. Importance of GLP 1's in diabetes management Dual therapy improves outcomes and decreases a1c That patients WANT to be educated, but are not getting it. Misconceptions about injectable therapies and combinations GLP 1 agonists used WITH basal insulin are very effective in reducing a1c and cardiovascular risk. Treatment should be based on individuals and supported by current evidence. All types of treatment play a role depends on the severity and levels of disease progression. 4 times to educate and reinforce diabetes education: at diagnosis, annually, with a complication, at transition of care

31 Patient Education Results Understanding and Managing your Diabetes provides patients & caregivers instant access to information on many diabetes topics at the time they are most interested in accessing that information. This final analytical report will reveal insights from 2,108 total users. The program consisted of almost 60 videos of ~15 seconds to 1 minute in duration. The videos connect together to create highly realistic simulated conversations and scenarios that are directed by, and unique to, each patient learner. Patients drive this self directed learning experience based on what they want to know. The videos in the simulation generated 25,200 separate video, or scene views.

32 Total Views by Topic Major Topics/Sections Views Basic information 6134 Types of treatment options 5034 How important are diet and exercise? 2987 Origin (intro to simulation) 2076 Types of medications 3167 Concerns about injectable therapy options 4126 Communication techniques to use with HCPs Views for the major topics/sections are shown above. 24% wanted to learn about basic diabetes information and terminology. Treatment options and concerns about injectable therapies were next in popularity, with viewers selecting those scenes at 20% and 16% respectively.

33 Scene Views within Topics Basic Information and Terminology Views Introduction 2001 What is diabetes? What is an A1c? What terms do I need to know? Factors affecting blood glucose ranges? What are healthy blood glucose ranges? Check my blood glucose levels Who is on my healthcare team? In the basic information and terminology section (n=6,134), viewers most wanted to learn about introductory diabetes concepts (33%), what is diabetes? (14%), A1c (13%) and what are healthy blood glucose ranges? (9%).

34 Scene Views within Topics Types of Treatment Options Views Two main types of treatments Injectable medication means disease is bad? Tell me about Step 3 Tell me about Step 2 What is Step 1 in diabetes progression? Recently diagnosed type 2 diabetes Talk to provider about treatment options Will my treatments change over time? Tell me about pancreatitis Type 2 diabetes disease progression Issues with a new regimen? Combo regiments (oral and injectable) Can I just take a pill? When to call a healthcare provider? In the types of treatment options section (n=5034), viewers were interested in understanding more about the two main types of treatment options (13%) and if injectable medication means the disease is bad (12%). Other topics had a fairly even spread of views, demonstrating viewers wanted to understand more details around each type of treatment option.

35 Scene Views within Topics How Important is Diet and Exercise Views Types of Medications Views How important are diet and exercise? 1038 Tell me about insulin 978 How important is weight loss? 598 Tell me about hypoglycemia 676 How important are diet changes? 498 Medical options right for me 876 How important is exercise? 455 What is prediabetes? 338 What about alternative treatment options? 398 Avoid mistakes with medication In the how important is diet and exercise section (n=2,987), many viewers were interested in understanding the basics of diet and exercise (35%) with more detailed topics on diet and exercise ranking fairly evenly among viewers. In the types of medications section (n=3,167), viewers were most interested in further information on insulin and medical options right for them.

36 Scene Views within Topics Concerns about Injectable Therapy Options Views I'm afraid of needles and injection pain Will I be on medication forever? Misconceptions about injectable therapies Will I gain weight? Are all injectables insulin? Prescribed insulin means disease is worse? In this section, which addresses learner concerns about using injectable medications to treat diabetes (n=4,126), viewers were most interested in learning how to manage fear of needles and injectable pain (28%), with the scene titled will I be on medication forever? taking second in popularity (20%). Communication techniques to use with HCPs Views How do I talk to my health team about diabetes? 756 Effective ways to communicate with your care team Only 5% of viewers visited the section titled communication techniques to use with HCPs (n=1,687). A compelling hypothesis here is that diabetes patients do not understand the importance of participatory medicine in their overall health and therapy success.

37 Scene Views within Topics Concerns about Injectable Therapy Options I'm afraid of needles and injection pain Will I be on medication forever? Misconceptions about injectable therapies Will I gain weight? Are all injectables insulin? Prescribed insulin means disease is worse? Views Communication techniques to use with HCPs How do I talk to my health team about diabetes? Effective ways to communicate with your care team 756 Views In this section, which addresses learner concerns about using injectable medications to treat diabetes (n=4,126), viewers were most interested in learning how to manage fear of needles and injectable pain (28%), with the scene titled will I be on medication forever? taking second in popularity (20%). Only 5% of viewers visited the section titled communication techniques to use with HCPs (n=1,687). A compelling hypothesis here is that diabetes patients do not understand the importance of participatory medicine in their overall health and therapy success.

38 Survey Question Results The survey data provides yet another dimension of insight into the program by actively soliciting the opinion of the learners within the context of the self directed and interactive video journey that each learner takes. Many of the survey questions attempted to determine if the patients have the tools they need to be participatory in their health care. 1. How do you feel about your knowledge of type 2 diabetes? A. I already know just about everything there is to know B. I am concerned about it and what more information C. I need more information because I m feeling overwhelmed D. I am interested in diabetes information and know very little about it D 27% C 20% A 12% B 41% Of the 728 patients who responded to this survey question only 12% felt that they know enough information about diabetes, with other learners sharing that they need to know more.

39 Survey Question Results 2. How do you feel about injectable therapies? A. Great, they don t bother me at all B. Okay, they don t make me feel comfortable anymore C. Scared, needles make me uncomfortable C 44% A 24% 3. Do you feel like you ve been adequately informed about the side effects of all your medications and treatments? A. Yes B. Somewhat C. No C 19% A 37% B 32% Out of 408 responses, 44% of participants fear the use of needles while 56% have at least started to overcome this fear. B 44% Of 528 responses, 37% of participants felt their doctor provided adequate information about medication side effects while 63% indicated they needed further information.

40 Survey Question Results 4. Do you feel that your doctor adequately explained your treatment options to you? A. Yes, my doctor explained all the options in a way that I understand B. I understand most of my options C. I don t understand what my doctor has been telling me D. No, my doctor didn t take enough time to explain my options C 11% B D 13% A 30% Out of 503 responses, 76% of participants believed their doctors adequately described their treatment options to them while 24% indicated a need for more explanation about treatment options. 5. What would keep you from seeking treatment? A. I don t have good medical access B. I am concerned about the cost of medicines C. I am embarrassed to talk about it D. I didn t think there was anything that could be done about it E. I always forget to mention it when I went to the doctor F. I am worried about the side effects of medications F 23% E 7% D 5% C 8% B 31% A 26% In terms of what keeps patients from seeking treatment out of the 634 responses in the survey cost was a large concern for learners. 31% of learners cited that cost was the main reason that they would keep them from seeking treatment. Other significant concerns included side effect worries (23%) and medical access (26%).

41 For questions, please contact: Amanda Kaczerski Director, Educational Strategy and Design Academy for Continued Healthcare Learning (ACHL) E: P: ext. 148

42 Appendix

43 Key Takeaways What is one pearl you took away as a result of your participation? Education (for both clinicians & patients) Reduce hga1c by glp1 It will better control outcome Consider use of GLP RAs Cooperative efforts among different members of the team Pt. participation and education I would take home a message that education is really important for patients with T2DM. Effectiveness of dual therapy The impact of empathy on patient's overall outcome from therapy. GLP 1 RA effects on cardiovascular health Help decrease barriers to care Patient Centered Approach shared decision making. GLP decreased cv deaths Effectiveness of GLP 1RA Combination GLP 1 agonist basal insulin therapy is effective Patients with weight loss did better Efficacy of product, good review Pt's do want to and will engage in their own management. Value of combination therapy Understanding of different types of 3rd level implementation I've learned that the short acting GLP 1 RA's have their greatest effect on postprandial blood glucose values. Better understanding of diabetic medications GLP can reduce cardiac events Adding a GLP can have a significant impact on A1C Dr. Peters is a great teacher the glp 1with basal insulin combo Can follow metformin with EITHER insulin or GGL RA then add the other if needed Patient education and shared decision making is key to success Keen observation of the insulin combination therapy Use basal insulin and glp1 together Do not let clinical inertia prevent you and the patient from achieving glycemic goals. Make necessary changes now. Importance of GLP 1's in diabetes management Dual therapy improves outcomes and decreases a1c That patients WANT to be educated, but are not getting it. Team based models support self management Application of novel GLP RAs Clinical inertia seems to be a major stumbling block to providing effective diabetes care Misconceptions about injectable therapies and combinations Universal acceptance of metformin as the preferred first line agent Information about new long acting injectable medications. Not to be afraid to add a second injectable GLP 1 agonists used WITH basal insulin are very effective in reducing a1c and cardiovascular risk.

44 Key Takeaways (cont.) What is one pearl you took away as a result of your participation? Combination therapies are underutilized. Goal for ideal glucose control Short and Long acting GLP 1 RA both beneficial Treatment should be based on individuals and supported by current evidence. All types of treatment play a role depends on the severity and levels of disease progression. Importance of community participation in decreasing the rates of diabetes and improving treatment compliance Focus on educating patients for proper diabetes management Do not let clinical inertia prevent you and the patient from achieving glycemic goals. Make necessary changes now. 2 injectable meds such as mentioned in study is beneficial in many ways including reduction of cardiac comorbidities. Remain open minded and ever evolving in the treatment of T2D. Confirm importance of diabetes educator working alongside PCP The idea that 2 injectables can be used in the highly motivated patient to achieve better baseline results. Situations which warrant diabetes education. Future insulin/ GLP RA combos being sued outside USA Long term HgA1c maintenance can be controlled in a variety of ways but ultimately patient compliance is vital. Don't be afraid to initiate injectables as a early intervention in DM treatment! The post prandial control of glp 1 ra drugs present a good choice of medication in daily practice apart from thiazolidinediones. GLP RA help reduce cardiovascular morbidity Avoiding inertia and being proactive Post prandial glucose is less influenced by longer than shorter acting glp2 ADA recommendations on diabetes which I wasn t aware of Engage patient in decision making and increase hours of education Outcomes of combination diabetes methods Cardiovascular benefits Very important to include patients in the decision making process (has long term benefits) Patient education is the important ingredient of management and include the spouse as well. Smarter approach to combination therapy Education. Education. Education. Do not hesitate to implement insulin therapy in younger population for better A1c. Combination therapy and patient decision making Using the GLP RA in combination with insulin The sequence of additive drug therapy as required Shared management is best for diabetes control

45 Key Takeaways (cont.) What is one pearl you took away as a result of your participation? I was unaware of the significant reduction in CV events with GLP RA therapy and the patient engagement data was great Combination therapy with Metformin, insulin and a GLP RAs can be very effective with lowering the HbAIC. DSME/S in T2D patients with A1C's above 7 significantly lowers A1C. Listen to the patient and their families and work with them to achieve a healthier lifestyle because ultimately, the patient is responsible for a great deal of their care. Basal insulin and GLP 1RA's work well together! Potential secondary benefits of liraglutide Consideration of liraglutide use in patients at higher risk of complications from arteriosclerosis I have gained more concerns and importance of educating patients and or community regarding Diabetes and possible therapies available. Also, I have learned more benefits of educating my patient pertaining the therapies presented. GLP RAs can be a significant addition to management. As good a job as I think I am doing, it probably is not enough and team approach produces better outcomes 4 times to educate and reinforce diabetes education: at diagnosis, annually, with a complication, at transition of care Use of GLP1 agonists in combination with basal insulin and metformin can be offered as an option when HgbA1Cs are not going down more than 2points