OVERVIEW AAPA and The France Foundation held 30 live chapter meetings for PAs, NPs, family physicians, and osteopathic physicians. An implementation workshop followed a lecture, where participants identified barriers to optimal care of patients with T2DM. A follow-up survey assessed the impact on clinical practice. FINDINGS Participation: ~2000 learners (1400 evaluations)– PCPs, PAs, NPs Knowledge Gain: 25% Perceived Impact : 97% of learners predicted improved performance and patient outcomes Intended Practice Change: 90% of participants intended (or considered) changes to clinical practice Actual Practice Changes: 60% of the respondents to the 90 day survey reported practice changes in patient interactions, therapy, and multidisciplinary care Implementation Workshop:  Increased involvement and commitment to change  Time restraints was the #1 perceived provider barrier  Adherence was the #1 perceived patient barrier  Workshop participants created action plans to address: Education > adherence > lack of time N = 322 Knowledge N = Day Survey: Have you made a Change? Commitment to Addressing Barriers Knowledge Increased 26% Action Plans Addressed Barriers Learners Made Changes Disclosure: Supported by educational grants from AstraZeneca and Sanofi For additional information please contact: Marie-Michele Leger, MPS, PA-C | Education | AAPA | 52% 39% 70% 65% 56% 90% 60% 92% 84% 82% 0%10%20%30%40%50%60%70%80%90%100% What is an appropriate A1C goal for a 73-y/o with T2DM, a history of severe hypoglycemia, and retinopathy? (N = 1179) Which mechanism DOES NOT play a role in GLP-1 receptor agonist efficacy in T2DM? (N = 1143) Which is the primary mechanism of action of SGLT2 inhibitors in T2DM? (N = 513) GLP-Ras are known to slow gastric motility. This results in: (N =1164) Total Pretest Posttest

Objectives and Methods Objectives: Increase the knowledge of participants in the area of diabetes Enable and motivate participants to drive change in their practices Improve the clinical care of patients with T2DM. CME Learning Objectives: Explain the incretin and sodium glucose co-transporter pathways and the differences between agents whose mechanisms are based on them. Evaluate new safety and efficacy data related to available and emerging agents, in light of recent recommendations. Formulate a diabetes management plan that takes into account specific patient characteristics and dosing preferences. Explain the considerations for combination therapy in diabetes. Didactic Presentation Diabetes and therapy mechanisms Incretin and SGLT2 inhibitors ADA guidelines Implementation Workshop Identify barriers to care Formulate SMART objectives Commit to change using an action plan Knowledge Competence Pretest/Posttest Evaluation 90-day post-activity survey

Workshop Handout: Step 2, Action PlanWorkshop Handout: Step 1, Identification of Barriers Implementation Workshop Materials Methods, Continued

Figure 1. Knowledge Increased 25% Figure 6. Change in Practice. Of those who responded to the 90-day survey (N = 37), 60% said they made the following changes: Figure 2. Learners intended to change practices after didactic session (multiple selections allowed) Figure 3. Learners intended to address barriers after workshop 322 learners cited barriers Figure 4. Patient barriers to optimal care (N = 236). Left, overall barriers; Right, regional responses. Figure 5. Provider barriers to optimal care (N = 225). Left, overall barriers; Right, regional responses. Findings 52% 39% 70% 65% 56% 90% 60% 92% 84% 82% 0%10%20%30%40%50%60%70%80%90%100% What is an appropriate A1C goal for a 73-y/o with T2DM, a history of severe hypoglycemia, and retinopathy? (N = 1179) Which mechanism DOES NOT play a role in GLP-1 receptor agonist efficacy in T2DM? (N = 1143) Which is the primary mechanism of action of SGLT2 inhibitors in T2DM? (N = 513) GLP-Ras are known to slow gastric motility. This results in: (N = 1164) Total Percent Correct Pretest Posttest 89% 58% 51% 46% 43% 41% 38% 37% 35% 31% 0%10%20%30%40%50%60%70%80%90%100% Learners intending or considering changes Consider a new therapy for patients not at target HbA1C Seek more education on the new drugs Use a treatment plan before prescribing any therapy Apply ADA Guidelines and treatment algorithms Assess and address patient barriers Teach patients about self-care Seek more education on new pathways Consider combination therapy for patients not at goal Discuss diabetes risk factors when selecting treatment Assess practice barriers and make an action plan Percent of Respondents 1447 evaluations 1293 intended to make changes 21% 20% 17% 11% 10% 9% 5% 3% 0%5%10%15%20%25% Adherence Patient Education Provider Education Lack of Time Misc Financial/Resources Communication Not Relevant Clinical Skills Percent of Respondents 91% 78% 68% 67% 56% 47% 11% 0%10%20%30%40%50%60%70%80%90%100% Inadequate adherence Socioeconomic Comorbidities Knowledge/ health literacy/ culture/language Fears Attitudes and beliefs about T2DM Other Percent of Respondents Patient Factors 88% 77% 69% 58% 48% 12% 92% 75% 58% 37% 34% 11% 100% 86% 81% 76% 95% 76% 5% 0%10%20%30%40%50%60%70%80%90%100% Inadequate adherence Socioeconomic Comorbidities Knowledge/ health literacy/ culture/language Fears Attitudes and beliefs about T2DM Other Percent of Respondents Patient Regional Barriers South (N = 134) Central (N = 65) Northeast (N = 21) 76% 39% 33% 32% 28% 25% 22% 20% 18% 13% 0%10%20%30%40%50%60%70%80% Time restraints "Too many" medications choices/ complicated regimens Lack of resources Inadequate training, experience Fears/concerns Inadequate confidence Patient-provider interaction and communication Other Unfamiliar with published T2DM guidelines Beliefs, attitudes, opinions Percent of Respondents Provider Factors 75% 34% 32% 26% 25% 23% 22% 19% 14% 73% 45% 28% 25% 38 % 28% 16% 19% 23% 9% 75% 45% 50% 30% 15% 0%10%20%30%40%50%60%70%80% Time restraints "Too many" medications choices/ complicated regimens Lack of resources Fears/concerns Inadequate training, experience Inadequate confidence Patient-provider interaction and communication Unfamiliar with published T2DM guidelines Other Beliefs, attitudes, opinions Percent of Respondents Provider Regional Barriers South (N = 126) Central (N = 64) 8% 46% 51% 54% 57% 59% 0%10%20%30%40%50%60%70% I am not in clinical practice Help patients manage the cost of diabetes care Spend time on a treatment plan with patient before therapy Discuss risk factors with patients when selecting treatment Help my patients with medication adherence Share educational resources with patients Help my patients with lifestyle modifications Spend time teaching patients about the importance of self-care Assess patient barriers and formulate a plan to improve Patient Interactions 14% 24% 46% 51% 54% 59% 0%10%20%30%40%50%60%70% Seek more education on the incretin and SGLT2 pathways Seek more education on the GLP-1, DPP-4, and SGLT2 agents Consider combination therapy Apply ADA Guidelines and treatment algorithms Consider patient factors in individualizing therapy Consider one of the newer therapies Therapy I am not in clinical practice 11% 27% 62% 65% 0%10%20%30%40%50%60%70% I am not in clinical practice Engage a care team Assess barriers and formulate an action plan Refer patients for specialized care or education Multidisciplinary Care 59% 57% 54% 51% 46% 8% 59% 54% 51% 46% 14% 24%

Combined informational and behavioral education leads to high involvement and participant satisfaction Didactic activity – Overview of diabetes – Single and combination pharmacotherapy, new drugs – Guideline approaches to hyperglycemia Implementation workshop – Beyond traditional CME activities – Self-reflection, small group work, and moderated large group discussion of critical barriers to patient care – Identified behavioral and institutional barriers – Provided tools for addressing barriers Participants gave extremely high praise for the content and mixed format Outcomes assessed with qualitative and quantitative measures REFERENCES / MORE RESEARCH  Diabetes Treatment: Lund A, et al. Eur J Intern Med. 2014;25(5): , Nauck MA. Am J Med. 2011;124(1 Suppl):S3-18.  Basile JN. J Diabetes Complications. 2013;27(3): , ADA Care Guidelines 2015: ADA. Diabetes Care. 2015;38:S1-S93.  More education: Participation – > 2000 participants received CE credit after the 30 live chapter meetings – 1415 evaluations received – 63% primary care providers – 30% physicians/ 30% APNs/ 39% PAs – More than one third of the participants manage ≥ 100 patients with T2DM Satisfaction – ≥ 97% predicted a positive impact on Ability to apply lessons to practice Performance Patient outcomes Knowledge – Gain of 25% (Chi-square P = 4.6E-84) from over 1100 participants Competence – Almost 90% of the attendees intended (or were considering) changes after the activity – Time restraints was the #1 provider barrier – Adherence was the #1 patient barrier – Regional differences in perceived patient and provider barriers to optimal care Northeast providers identified more barriers Performance – Workshop participants created action plans to address: Education > adherence > lack of time – 60% reported making changes after 90 days Conclusions SUMMARY OF FINDINGS CONCLUSIONS