Can family physicians help patients initiate basal insulin therapy successfully?: randomized trial of patient-titrated insulin glargine compared with standard oral therapy: lessons for family practice from the Canadian INSIGHT trial.
Bibliographic record
Abstract
OBJECTIVE: To determine whether FPs could help patients implement bedtime basal insulin therapy as successfully as diabetes experts could. DESIGN: National, multicentre, randomized, open-label trial designed to assess use of bedtime basal insulin therapy compared with use of standard oral-agent therapy for patients with type 2 diabetes being treated by diabetes experts or FPs. SETTING: Nineteen endocrinologist or expert sites and 34 family practices. PARTICIPANTS: A total of 405 adult patients with hemoglobin A1c (HbA1c) values of 7.5% to 11.0% who were taking 0 to 2 oral agents. INTERVENTION: Participants were randomized to receive either basal insulin therapy using glargine self-titrated according to a patient algorithm or conventional therapy with physician-adjusted doses of oral agents for a period of 24 weeks. MAIN OUTCOME MEASURES: The primary outcome was time to achieve 2 consecutive HbA1c values < or = 6.5%. Secondary outcomes were the proportion of subjects who achieved these HbA1c values, a fasting plasma glucose level < or = 5.5 mmol/L, and 2 consecutive HbA1c values < or = 7.0%; incidence, rate, and severity of hypoglycemia; daily variations in blood-glucose levels; and participants' lipid profiles. Post-hoc analysis sought to determine whether patients' outcomes differed in terms of the above measures depending on whether they had been treated by diabetes experts or FPs. RESULTS: A total of 206 patients were randomized to the glargine group, and 199 to the oral agents group. In total, 145 patients were followed by experts and 260 by FPs. Mean reductions in HbA1c and fasting plasma glucose levels and rates of hypoglycemia were comparable in the 2 groups. Patients of both types of physicians achieved significantly greater reductions in fasting plasma glucose with glargine than with oral agents (FPs: -4.14 vs -2.45 mmol/L, P = .0001; experts: -3.47 vs -2.19 mmol/L, P = .0013). Patients of FPs achieved significantly greater reductions in HbA1c levels with glargine than with oral agents (FPs: -1.64 vs -1.26%, P = .0058; experts: -1.41 vs-1.24%, P = .3331). Final mean insulin doses were higheramong FPs' patients than among experts' patients (41.74vs 31.66 units, P = .015). Family physicians were more aggressive in their use of insulin, while experts used more oral agents. There were no significant differences inefficacy of treatment. CONCLUSION: In most settings, FPs could easily implement the patient-driven bedtime basal insulin protocol used in this study.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.003 | 0.007 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.003 | 0.002 |
| Bibliometrics | 0.000 | 0.001 |
| Science and technology studies | 0.001 | 0.002 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.002 | 0.001 |
| Research integrity | 0.003 | 0.003 |
| Insufficient payload (model declined to judge) | 0.008 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".