S6 Diabetes Care Volume 39, Supplement 1, January 2016

1. Strategies for Improving Care American Diabetes Association

Diabetes Care 2016;39(Suppl. 1):S6–S12 | DOI: 10.2337/dc16-S004

c A patient-centered communication style that incorporates patient prefer-
ences, assesses literacy and numeracy, and addresses cultural barriers to
care should be used. B
c Treatment decisions should be timely and based on evidence-based guide-
lines that are tailored to individual patient preferences, prognoses, and co-
morbidities. B
c Care should be aligned with components of the Chronic Care Model to ensure
productive interactions between a prepared proactive practice team and an

informed activated patient. A
c When feasible, care systems should support team-based care, community
involvement, patient registries, and decision support tools to meet patient
needs. B

In the following sections, different components of the clinical management of
patients with (or at risk for) diabetes are reviewed. Clinical practice guidelines are
key to improving population health; however, for optimal outcomes, diabetes care
must be individualized for each patient. The American Diabetes Association high-
lights the following three themes that clinicians, policymakers, and advocates
should keep in mind:

1. Patient-Centeredness: Practice recommendations, whether based on evi-
dence or expert opinion, are intended to guide an overall approach to
care. The science and art of medicine come together when the clinician is
faced with making treatment recommendations for a patient who would not
have met eligibility criteria for the studies on which guidelines were based.
Recognizing that one size does not fit all, these Standards provide guid-
ance for when and how to adapt recommendations. Because patients with
diabetes have greatly increased risk for cardiovascular disease, a patient-
centered approach should include a comprehensive plan to reduce cardio-
vascular risk by addressing blood pressure and lipid control, smoking prevention
and cessation, weight management, physical activity, and healthy lifestyle
2. Diabetes Across the Life Span: An increasing proportion of patients with type 1
diabetes are adults. For less salutary reasons, the incidence of type 2 diabetes is
increasing in children and young adults. Patients with type 1 diabetes and those
with type 2 diabetes are living well into older age, a stage of life for which there is
little evidence from clinical trials to guide therapy. All these demographic
changes highlight another challenge to high-quality diabetes care, which is the
need to improve coordination between clinical teams as patients transition
through different stages of the life span.
3. Advocacy for Patients With Diabetes: Advocacy can be defined as active support
and engagement to advance a cause or policy. Advocacy is needed to improve
the lives of patients with (or at risk for) diabetes. Given the tremendous toll that Suggested citation: American Diabetes Associa-
obesity, physical inactivity, and smoking have on the health of patients with tion. Strategies for improving care. Sec. 1. In
Standards of Medical Care in Diabetesd2016.
diabetes, efforts are needed to address and change the societal determinants
Diabetes Care 2016;39(Suppl. 1):S6–S12
at the root of these problems. Within the narrower domain of clinical practice
© 2016 by the American Diabetes Association.
guidelines, the application of evidence level grading to practice recommenda- Readers may use this article as long as the work
tions can help to identify areas that require more research (1). Refer to Section is properly cited, the use is educational and not
14 “Diabetes Advocacy.” for profit, and the work is not altered.

such as gram (NDEP) maintains an online re. foot. satisfaction. dupli. and necessary medica- jor barrier to optimal care is a delivery or lipid control (12). care goals (6. behavioral strategies sures and nonsmoking status (2).30). Delivery system design (moving Objective 2: Support Patient Behavior and high-quality care (33). practical strategies to achieve each. including quires an organized.25).28). and managing medications and. and multidisciplinary teams are best suited to grated approach that includes clinical only 14% meet targets for all three mea. the coordinated delivery of chronic care. removing fi- Chronic Care Model and appropriate intensification of life. Self-management support 1. 4. financial or other social . porating care management teams in. expanding the after adjusting for patient factors. tion. Initiatives such as the Patient-Centered The Chronic Care Model (CCM) has been lines and clinical information tools into Medical Home show promise for improv- shown to be an effective framework for the process of care (18–20). Healthy lifestyle choices (physical There has been steady improvement in 3. and LDL cholesterol. systematic approach . eye exams.gov) to help health care professionals of care (24). healthy eating. mary care and offer new opportunities Six Core Elements cluding nurses. Collaborative. blood pressure. tion Examination Survey (NHANES). nancial barriers and reducing patient Numerous interventions to improve ad. tobacco ces- the proportion of patients with diabetes evidence-based. effective care guide. or cultural barriers to care (14– styles (31).6% (60 mmol/mol) in 1999–2002 port to the care team) of glucose and blood pressure) to 7. ing outcomes through coordinated pri- improving the quality of diabetes care (7). blood glucose. reward the provision of appropriate 1. are sive disease management strategies abetes care across providers and prac. pharmacists. (23). Health systems (to create a quality.nih ful care systems is providing high quality comorbidities. content and skills. Prevention of diabetes complica- based on the National Health and Nutri. self-monitoring of have been implemented. However. in contrast to visit-based blood pressure. ditions such as diabetes and to facilitate (goal setting. and is poorly designed for meracy. self-monitoring from 7. lines) fective coping) mended levels of A1C.34). identifying and addressing language.22) have each been shown (32). and/or limited English profi. Certain patient groups. Changes that have been hardships. or cholesterol control. 6. 33–49% of patients still are fundamental to the successful imple. provide care for people with chronic con.care. and incor. based guidelines (18). as follows: (6. ment targets compared with older adults oriented culture) and immunizations) (2). may present particular chal. (identifying or developing resources tions (self-monitoring of foot health. Community resources and policies 3. blood pressure. a ma. with references to literature outlining role of teams to implement more inten- the persistent variation in quality of di. Disease self-management (taking and LDL cholesterol in the last 10 years registries that can provide patient. and identifying/developing/ system that is often fragmented. gagement with psychosocial concerns cardiovascular risk factor control (par. and other for team-based chronic disease care The CCM includes six core elements for providers (21. weight management. An institutional priority in most success- young adults and patients with complex source (www. engaging community resources and clinical information capabilities. tional DSME standards call for an inte- pressure. Behavior record tools (27. Additional strategies to improve di- the provision of optimal care of patients to optimize provider and team behavior abetes care include reimbursement with chronic disease: and thereby catalyze reductions in A1C. Decision support (basing care on activity. Three specific objectives. Even with diabetes.21. billing. Objective 3: Change the Care System (2. activating and The care team should prioritize timely educating patients (29. Strategies such as tions (6). Nevertheless. with to support healthy lifestyles) active participation in screening for younger adults less likely to meet treat. and glucose control. 17). and ef- treated with statins and achieving recom. Key Objectives ticularly tobacco use) may be slowing The National Diabetes Education Pro.diabetesjournals. The mean A1C nationally has declined specific and population-based sup. tematic approach to supporting patients’ Optimal diabetes management re- based approach) behavior change efforts. eficial levels of glucose. clinically appropriate. Evi. problem solving). lacks explicit goal setting with patients (13). when (2). This has been accompanied by im- provements in cardiovascular outcomes Redefining the roles of the health care High-quality diabetes self-management and has led to substantial reductions in delivery team and promoting self. education (DSME) has been shown to end-stage microvascular complications.3).org Strategies for Improving Care S7 CARE DELIVERY SYSTEMS 2. to design and implement more effective shown to increase quality of diabetes ciency. and renal complications. health care delivery systems for those care include basing care on evidence- lenges to goal-based care (4–6). and incen- from a reactive to a proactive care Change tives that accommodate personalized delivery system where planned visits Successful diabetes care requires a sys. blood mentation of the CCM (8). management on the part of the patient improve patient self-management. are coordinated through a team. style and/or pharmacological therapy out-of-pocket costs for diabetes educa- herence to the recommended standards for patients who have not achieved ben. implementing electronic health improvements. redesigning the care process tice settings indicates that there is potential for substantial system-level Objective 1 : Optimize Provider and Team (26).betterdiabetescare. structures that. public policy that support healthy life- cates services. integrating evidence-based guide. Clinical information systems (using 2. and en- dence also suggests that progress in patients’ self-management (9–11). Na- do not meet targets for glycemic.2% (55 mmol/mol) in 2007–2010 5. sation. nu. eye.

g. reduced psychosocial symptomatology. Although there TAILORING TREATMENT TO team of dedicated health care profes. intermediate outcomes. blood target. and adherence (6). either increase a drug dose or change a ment intensification should be consid. or lipids 1.36) have not identified a or take medications. religious.S8 Strategies for Improving Care Diabetes Care Volume 39. up-titration). frequently in women with prior gesta- managed care systems demonstrating ef. port leads to improved clinical outcomes. Socioeconomic and allowed for improvements in A1C. ing the barriers. DSME and diabetes self-management study confirmed the strong association 2. one kg/m2 (44). To drug class (37). Explore barriers to adherence with support services (53). number of pills prescribed divided by plex and include societal issues such as the days between first and last prescrip. including metabolic control examining the retina and feet. sex. cultural. of health care to individuals with diabe- Intermediate Outcomes and Thus. children with type 1 Treatment Intensification should continually monitor and prevent diabetes from racial/ethnic populations For intermediate outcomes.. directed interventions. find and track poor adherence and help are particularly well documented for car- based approaches that improve the to guide system improvement efforts to diovascular disease. hypertension. and pharmacy- Processes of Care Access to Health Care derived interventions improved ad- Processes of care included periodic test. the Translating Re. affect diabetes prevalence and out- search Into Action for Diabetes (TRIAD) cost. Women with diabetes. . then treat. and system factors comes. poor access to health NOT MET as 80% (40). diabetes education. medication factors ences and socioeconomic status may than others. and patient education re. blood pressure. This metric can be used to care. pared with men with diabetes. defined as a failure to adherence is 80% or above. and lay lead- in A1C. and Asian American) (43). and socio- herence but had a very small effect on ing of A1C. patient-centered. Significant did not perform as well in addressing A systematic approach to achieving in. Supplement 1. advising access and complication risk in people (41). Ethnic. poor adherence was and assess progress in reaching the language. Recent reviews of Barriers to adherence may include pa. blood pressure. discrimination. pos- associated with uncontrolled A1C. providers should seek evidence. antidepressant treatment subsequently sources) may influence providers to heart disease (45). economic differences affect health care outcomes.51). and smoking cessation. and adoption of healthier lifestyles (54). fears. institutional racism.35. tients with diabetes. itively influence patient outcomes (55). to improve adherence. Treatment intensifica. Nurse. and in certain racial/ethnic groups those that affected processes of care and men may improve adherence. (African American. improved A1C (39). In 35% of cases. Performance for testing for Asian Americans to $23 for a specific barrier. Structured interventions. and structured study found that when depression was care (e. Assess adherence. have a identified as a barrier. tional diabetes mellitus (42). systems tes (46). As a result. Type 2 diabetes develops more study provided objective data from large (inadequate follow-up or support). Strong social sup- between treatment intensification and the patient/caregiver and find a mutu. religion. socio- WHEN TREATMENT GOALS ARE tions. ethnic inequalities exist in the provision improve processes of care (6). Establish a follow-up plan that con. com- feedback. and culturally appropriate strategies. with diabetes. barriers and implementing treatments risk for poor metabolic control and poor tools that improved processes of care that are barrier specific and effective. consider initiating or changing to a dif. or side effects). and lipid control (10). peers (50. tailored to eth- Adherence firms the planned treatment change nic populations that integrate culture. Hispanic/Latino. Intermediate Outcomes and 3. such as or treat poor adherence by identifying with lower socioeconomic status are at A1C. diabetes management re- intensification. If medication overcome disparities. reminders. January 2016 and the involvement of a coordinated pressure. ers (52) may assist in the delivery of emia control (38). emotional functioning (47). then workers (49). However. Ethnic/Cultural/Sex/Socioeconomic quality improvement strategies in diabe. un- controlled A1C. Ethnic. If Therefore. “Adequate” adherence is defined economic status. racial differences and barriers exist in barriers to treatment intensification termediate outcomes involves three steps: self-monitoring and outcomes (48). (complexity. quires individualized. guidelines. Recent studies have rec- may be achieved if the patient and pro. and hyperlipid. Health Disparities patient-centered high-quality care is a ered (PDC). or lipids (40). community health tion was associated with improvement up-titration is not a viable option. found it useful to divide interventions into Simplifying a complex treatment regi. ommended lowering the BMI cut point TRIAD results suggest that providers vider agree on a targeted treatment control these activities. which is a measure of the The causes of health disparities are com- priority (6). home aides. blood pressure. are many ways to measure adherence VULNERABLE POPULATIONS sionals working in an environment where (40). TRIAD Improving Adherence als with hypertension or dyslipidemia. overcome the barriers to adherence. For example. formal case man.. clinical outcomes and quality of life of pa. A large multicenter ferent medication class. and sex differ- particular approach that is more effective or health beliefs). ered (e. and literacy skills. Adherence should Addressing Disparities were associated with a lack of treatment be addressed as the first priority. multiple daily dosing. In 23% of cases. depression. lipids. Medicare uses percent of days cov. religious. in individu- fective tools for specific targets (6). agreement on 40% greater risk of incident coronary agement. and lipid goals. ally agreeable approach to overcom. Disparities In general. cultural. Native American.g. tient factors (remembering to obtain Differences tes care (24. and lack of health insurance. Success in overcoming barriers on aspirin use. and urinary albumin.

Measuring Healthcare Disparities (56). tions. and anxiety/depression that services in multiple languages with the health care.. Caring lesterol levels should be carefully Food insecurity (FI) is the unreliable for those with type 1 diabetes in the set. cardiovascular risk. poor literacy. screening for FI. The with FI who are uninsured and homeless hyperglycemia are related to dementia. not filling antidiabetes med. abetes in this population. without resorting to socially unaccept. A lower the risk for hypoglycemia in those c In individuals with diabetes at high c Providers should recognize that with FI. peak when food is not available. without Alzheimer dementia. C pose solutions accordingly.5% higher A1C than binge eating. 50–60% were hypertensive. Those with type 2 diabe. Dementia Type 2 Diabetes. available.g. homeless patients with dia- groups are encouraged to use the National plicates diabetes management and seek betes need secure places to keep their Quality Forum’s National Voluntary Con. Over 14% (or one out of tes and FI can develop hypoglycemia for dysfunction is dementia. men should be reassessed. B Recommendations hydrate consumption following insulin c In individuals with poor cognitive c Providers should evaluate hyper. function or severe hypoglycemia. it is important to consider coverage for blood glucose monitoring carbohydrate-rich processed foods. may be benefits of statin therapy outweigh poor numeracy often occur with used immediately after consumption the risk of cognitive dysfunction. Type 1 Diabetes.S. Hispanic uninsured patients with dia. as op. whenever food becomes c If a second-generation antipsychotic resources should be made avail. The Action to are increased in those with diabetes who porary housing for their patients as a Control Cardiovascular Risk in Diabetes are also food insecure. Recommendations Food Insecurity and Hypoglycemia sure controlled by treatments to under c Intensive glucose control is not ad- 130 mmHg (58). in low-income households. A cost of insulin analogs should be weighed weight. limiting hyperglyce. The reverse is also true: peo- more energy. Homelessness often ac. The afford. consumption. ies in people with diabetes showed a 73% racial/ethnic minority groups including urea. individuals with type 2 diabetes. ication prescriptions owing to financial see such patients should work to develop able care act has improved access to constraint. and cho- against their potential advantages. may to avoid significant hypoglycemia.diabetesjournals. Additionally. In those with type 2 those with diabetes. interventions should Homelessness. and di- supplies have a 0. Therefore. the cardiovascular homelessness. practical steps to alleviate them in order Cognitive Dysfunction betes. glycemic control. FI and Lack of Health Insurance Food Insecurity and Hyperglycemia. Reasons for this with poor literacy and numeracy skills. Unfortunately. specific goal of preventing diabetes and without coverage. glycemia and hypoglycemia in the posed to shorter-acting insulin that may glycemic therapy should be tailored context of food insecurity and pro. more regularly obtain nutritious food (59). in companies the most severe form of FI. the degree and duration of mia and preventing hypoglycemia. A recent meta- every seven people in the U. proper housing. (ACCORD) study found that each 1% . focus on preventing diabetes and. administration. and preferably delivered by a pen. likely to develop diabetes than people In people with FI. but to improve glucose control. changes in able for patients with diabetes. Individuals without insurance include the steady consumption of Therefore. monitored and the treatment regi- availability of nutritious food and the ting of FI may mirror “sick day” manage. FI may involve a tradeoff between purchas. means to prevent and control diabetes. ple with Alzheimer dementia are more processed foods. Literacy and Numeracy Deficiencies. The risks of uncontrolled meracy should be well versed or have with both increased A1C and longer du- hyperglycemia and severe hypoglycemia access to social workers to facilitate tem. Short-acting insulin analogs. and appropriate of a meal.care. diabetes are more common among non- Not having health insurance affects the perglycemia is more common in those English speaking individuals and those processes and outcomes of diabetes with diabetes and FI. a African American and Latino popula- due to the shorter half-life. A food insecurity. only 22–37% had systolic blood pres. C inability to consistently obtain food ment protocols. the greater medication is prescribed. Programs that those with coverage (57). providers who care for those diabetes. risk for type 2 diabetes is increased two. If using a sulfonyl. Hyperglycemia. Glipizide 56% increased risk of Alzheimer dementia. Hy. all providers and Providers should recognize that FI com. More rapid cognitive decline is associated fold in those with FI. Long-acting insulin.org Strategies for Improving Care S9 To decrease disparities. The rate is higher in some hypoglycemic agents. thus limiting its tendency mentia compared with individuals without ing nutritious food for inexpensive and to produce hypoglycemia as compared diabetes (60). Individuals with type 1 vised for the improvement of poor diabetes and FI may develop hypoglycemia cognitive function in hyperglycemic Food Insecurity as a result of inadequate or erratic carbo. The most severe form of cognitive able practices. and individuals with poor literacy and nu. glyburide). glipizide is the preferred choice increased risk of all types of dementia.and carbohydrate-dense with longer-acting sulfonylureas (e.) are food similar reasons after taking certain oral analysis of prospective observational stud- insecure. In a recent study of Providers should be well versed in these building diabetes awareness in people predominantly African American or risk factors for hyperglycemia and take who cannot easily read or write in English. local resources that can help patients and diabetes supplies and refrigerator access sensus Standards for Ambulatory Cared the parents of patients with diabetes to to properly store their insulin. many remain lead to poor diabetes self-care behaviors. ration of diabetes (61). care. and can be taken immediately before meal and 127% increased risk of vascular de- in homes headed by a single mother. however.

Bullard KM. factors. and de. check.S. Mediterranean diet correlated with im- 1988-2008. 6. in U. Supplement 1. Ali MK. et al. in US primary care settings: a systematic review. 1999-2010. adherence to the and recent progress in blood pressure levels Diabetes Care in Patients With HIV among U. in turn. Prev Chronic Dis 2013. Risk of coronary artery disease in type 2 di- in people with schizophrenia. Coleman K. Piatt GA. Fernandez A. Saaddine JB. changes in weight. Lin EHB. Stopka C.33:940–947 low reporting rate for cognitive-related Diabetes risk is increased with certain 7. ing the recommendation that intensive more extensively in Section 3 “Founda. support. N Engl J Med hypoglycemia in individuals with cogni. in more than 5% of HIV-infected patients Evidence on the Chronic Care Model in the tions (68). Diabetes Care 2011. Long-term Nutrition. and those with poor ments for depression are effective in cognitive function have more severe hy.26:170–176 do not support an adverse effect of sta. physician-patient language tential link between statins and demen. For patients with HIV and ARV- glucose control should not be advised for tions of Care and Comprehensive Medical associated hyperglycemia. with statin therapy. Among lower cognitive function in individuals risk of incident depression (relative risk HIV patients with diabetes. Treat. and. Hypoglycemia. whereas more than 15% may have new millennium. key to effective management. bipolar disorder. dividual takes psychotropic medications. effects of new ARV agents. trolled trial. Stellefson M. Diabetes Educ 2010. Krein SL. Austin BT. If prediabetes is detected. mended (75). TRIAD Study Group. Kerr EA. gression to diabetes. re- hypoglycemia is associated with reduced Before making ARV substitutions. In one study. 10. Intern Med 2007. Brooks MM. Awareness of an individu. 3. the [RR] 5 1. patients tins on cognition. Beyond a recent Cochrane review found insuffi. and physical activity may reduce the a STARNet study. Geiss LS. severe Diabetes medications are effective. and psychosocial issues are discussed cular and macrovascular complications. Cheng YJ. should be reassessed if significant changes from 2005 to 2014. adults with diagnosed diabetes. Med Care 2007. PIs are associated with 28:75–85 insulin resistance and may also lead to 9. Depression critical to reduce the risks of microvas- and standard glycemic control.363:2611– with diabetes (69). disease should be placed on statin ther- apoptosis of pancreatic b-cells. which is as. Cowie CC. Anderson RM. Romero RR. Given the controversy over a po. diabetes care. so a 2620 11. JA. However. In type 2 diabetes. Katon WJ. Therefore individuals with on PIs. Pugh type 2 diabetes is two–three times higher proper screening protocol is recom. abetes and the delivery of care consistent with order. glycemic control. especially if an in.S. 2. poglycemia. However. The U. Trends in the evi- crease in risk of dementia (64). Individuals with HIV are at higher risk laborative care for patients with depression and pression is increased 1. Diabe- veillance databases have also revealed a tes Care 2010.34:1579–1581 proved cognitive function (66). Dipnarine K.38:6–8 poglycemia increased (65). Imperatore G. Wagner EH. and treating de. preventive with type 2 diabetes (62). Zeber JE.368:1613–1624 tive dysfunction. including cognitive dys. of Northern California (DISTANCE). et al. References severe hypoglycemia had a stepwise in.6) (71). diabetes and a high risk for cardiovascular prediabetes (74). Health systems. Gregg EW. E thesis of findings from the TRIAD study. Von Korff M. In those with prediabetes. and glycemic control among in- tia. improvements following a multifaceted diabe- also affect fat distribution (both lipohy- tes care intervention: results of a randomized con- Mental Illness pertrophy and lipoatrophy). the problematic ARV agents if safe and Medications effective alternatives are available (76). Wang J. it may be the improvement of cognitive function in Evaluation. Food and Drug 3–6 months to monitor for pro. sured Latinos with diabetes: the Diabetes Study systematic review has reported that data vised. Health Aff (Millwood) 2009. Achievement of goals cemic therapy may help to prevent al’s medication profile. is 2013. cholesterol levels should be carefully dence level for the American Diabetes Associa- the ACCORD trial found that as cognitive monitored and the treatment regimen tion’s “Standards of Medical Care in Diabetes” function decreased. Recommendation 4. et al. consider the possible effect on HIV viro- cognitive function. c Patients with HIV should be screened comorbidity counts: how do comorbidity type cient evidence to recommend any dietary for diabetes and prediabetes with a and severity influence diabetes patients’ treat- change for the prevention or treatment of fasting glucose level before starting ment priorities and self-management? J Gen cognitive dysfunction (67). and quality of care for diabetes: a syn- Administration (FDA) postmarketing sur. The prevalence of on antiretroviral (ARV) therapies. In some cases. The adverse events. If initial Language barriers.15). N Engl J Med 2010. Schillinger D. after starting or changing it. January 2016 higher A1C level was associated with analysis showed a significantly increased progression toward diabetes.” appropriate to consider discontinuing individuals with type 2 diabetes (63). Grant RW. logical control and the potential adverse patients with diabetes. mic control (72). J Gen Intern continue to measure levels every Med 2011.10:E26 similar to rates seen with other com. et al. bipolar dis. function or dementia. monly prescribed cardiovascular medica. et al.7-fold in people for developing prediabetes and diabetes chronic illnesses. depression was health care using an approach similar ACCORD study found no difference in associated with a significantly increased to that used in patients without HIV is cognitive outcomes between intensive risk of diabetes (RR 5 1. Statins. the risk of severe hy. and schizoaffective disorder than weight loss through healthy nutrition the chronic care model in primary care settings: in the general population (70). NRTIs 3-year follow-up of clinical and behavioral apy regardless of cognitive status.36:301–309 Severe mental disorder that includes sociated with insulin resistance. and 1. Kirkman MS. protease inhibitors (PIs) and nucleoside Chronic Care Model and diabetes management reverse transcriptase inhibitors (NRTIs). are noted (73). Col- schizophrenia. screening results are normal. Diabetes Care 2015. it is worth noting that a Cochrane ing fasting glucose each year is ad. New-onset diabetes is estimated to occur 8. carefully gardless of mental health status. Brach C. Tailoring gly. individuals antidiabetes agents may still be necessary. Warton EM. concordance.45:1129–1134 . A meta.S.S10 Strategies for Improving Care Diabetes Care Volume 39. Likewise. Parchman ML.22:1635–1640 antiretroviral therapy and 3 months 5. If a second-generation with one or more recorded episode of antipsychotic medication is prescribed. Heisler M. In a long-term study of older pression may improve short-term glyce- patients with type 2 diabetes.

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