Outcome of COVID-19 infection in people with diabetes mellitus or obesity in the primary care setting in Catalonia,Spain: A retrospective cohort study of the initial three waves

AimWe estimate the incidence and risk factors for fatal and non-fatal events among the COVID-19 infected subjects based on the presence of obesity or diabetes during the initial three epidemiological waves in our region.MethodsThis was a retrospective cohort study. A primary care database was used to identify persons with COVID-19. We stratified for subjects who either had diabetes mellitus or obesity. The follow-up period for study events was up to 90 days from inclusion.ResultsIn total, 1238,710 subjects were analysed. Subjects with diabetes mellitus or obesity were older and had a worse comorbidity profile compared with groups without these conditions. Fatal events were more frequent among people with diabetes and during the first wave. In the second and third waves, the number of study events decreased. Diabetes was a risk factor for fatal events in all models, while obesity was only in the model adjusted for age, sex, diabetes and COVID-19 waves. HIV, cancer, or autoimmune diseases were risk factors for mortality among subjects with COVID-19 in the fully-adjusted model.ConclusionsDiabetes was an independent risk factor for mortality among people with COVID-19. The number of fatal events decreased during the second and third waves in our region, both in those with diabetes or obesity.     

Behavioral,psychological, and clinical outcomes of Arabic-speaking people with type 2 diabetes during COVID-19 pandemic

AimsAssess self-care activities, health behaviors, self-efficacy, diabetes distress, challenges, and changes in diabetes treatment and clinical parameters among Arabic-speaking people with T2DM during the COVID-19 pandemic.MethodsA cross-sectional study was conducted at a tertiary hospital in the United Arab Emirates. The study instrument collected self-reported data using validated tools about health behaviors, self-efficacy, and diabetes distress, and challenges in accessing and using healthcare services during the pandemic and documented clinical data and treatment before and during the pandemic from medical records.Results206 patients participated with a mean age of 58.7 years and 15.7 years since diabetes diagnosis. Non-adherence to healthful eating and exercise was reported by 38.3% and 73.7%, respectively. Exercise was the self-care activity that decreased the most (36.8%). Most participants had low diabetes distress (85.9%). There were no significant differences in clinical parameters before and during the pandemic, and diabetes treatment was unchanged for 72.8% of participants. Having two or more challenges with accessing and using diabetes healthcare services was significantly associated with decreased adherence to healthy eating (p = 0.025) and exercise (p = 0.003).ConclusionsArabic-speaking people with T2DM appeared to maintain relatively similar self-care levels, except exercise, with no deterioration in clinical parameters compared to pre-pandemic.     

Metabolic control of diabetic patients assisted by private and public health care systems during the COVID-19 pandemic: A retrospective cohort study

AimsWe sought to analyze the impacts of social restriction measures imposed by the pandemic COVID-19 on the control of metabolic parameters in diabetic patients.MethodsWe accessed the medical records of patients who underwent clinical follow-up in the public and private health systems between July 2019 and June 2021. The sample consisted of 288 patients (111 adults and 177 older individuals). A two-way ANOVA mixed model was used to test the effects of intra- (time: baseline and after 24 months) and inter-subject factors. Linear regression analysis was used to predict the difference in body weight considering age, sex, HbA1c, health care system and insulin use.ResultsAmong adults, we observed an increase in body weight and LDL-c levels, especially for insulin users (p ≤ 0.05). Adults assisted by the public health care system showed higher HbA1c levels (p = 0.001). Among older individuals using insulin, blood glucose levels decreased (p = 0.019). Body weight decreased in those assisted by the private system (p = 0.005), while glycemia decreased for patients assisted by both health care systems (p = 0.043). The linear regression model confirmed that the increase in body weight was more pronounced in adults than in older individuals.ConclusionThe social restriction measures imposed by the pandemic affected the metabolic control of diabetic patients, especially adults assisted by the public health care system.     

Impact of the COVID-19 pandemic on the quality of diabetes care: Insights from longitudinal data in Switzerland

In this population-based cohort study on diabetes care, self-reported quality indicators measured just before (2019) and during (2021) the COVID-19 pandemic were comparable, apart from a modest increase in seasonal influenza immunization and a small decline in patient-centeredness of care in 2021.     

Psychological adaptive difficulties and their management during COVID-19 pandemic in people with diabetes mellitus

Background and aimsPeople with diabetes have multiple psychosocial issues related to diabetes and its complications and this may be exacerbated during the COVID-19 pandemic.MethodsWe reviewed the psychological adaptative difficulties in people with diabetes especially during natural disasters including the prevailing COVID-19 pandemic.ResultsThere are significant concerns regarding worsening of glycemic control, unavailability of appropriate medicines, inaccessibility to health care or acquiring SARS- CoV-2 infection and subsequent poorer outcomes during the COVID-19 pandemic. Although there are some guidance documents for managing diabetes and associated complications during COVID-19 pandemic but very few address the psychological issues in people with diabetes. We discuss the psychological adaptive difficulties and an approach to address the psychosocial concerns in people with diabetes during the COVID-19 pandemic.ConclusionsPeople with diabetes have significant diabetes distress and psychological adaptive difficulties that is aggravated by the COVID-19 pandemic. An integrated multidisciplinary approach is needed to manage the prevailing psychological issues amongst people with diabetes during the COVID-19 pandemic.     

Adherence patterns to oral hypoglycemic agents among primary care patients with type 2 diabetes

AimsTo examine patterns of adherence to oral hypoglycemic agents among primary care patients with type 2 diabetes mellitus and to assess whether these patterns were associated with baseline intervention allocation, sociodemographic characteristics, and clinical indicators.MethodsAdherence patterns were examined by Medication Event Monitoring System (MEMS) caps at baseline and 12 weeks. Participants (n = 72) were randomly allocated to a Patient Prioritized Planning (PPP) intervention or a control group. The PPP intervention employed a card-sort task to identify health-related priorities that included social determinants of health to address medication nonadherence. Next, a problem-solving process was used to address unmet needs involving referral to resources. Multinomial logistic regression examined patterns of adherence in relation to baseline intervention allocation, sociodemographic characteristics, and clinical indicators.ResultsThree patterns of adherence were found: adherent, increasing adherence, and nonadherent. Participants assigned to the PPP intervention were significantly more likely to have a pattern of improving adherence (Adjusted Odds Ratio (AOR)= 11.28, 95% confidence interval (CI)= 1.78, 71.60) and adherence (AOR=4.68, 95% CI=1.15, 19.02) than participants assigned to the control group.ConclusionPrimary care PPP interventions incorporating social determinants may be effective in fostering and improving patient adherence.     

Antidiabetic treatment and COVID-19 Outcomes: A population-based cohort study in primary health care in Catalonia during the first wave of the pandemic

AimsTo analyse if antidiabetic treatment was associated with better COVID-19 outcomes in type 2 diabetic patients, measured by hospital admission and mortality rates as severe outcomes.MethodsCohort study including COVID-19 patients registered in the Primary Care electronic records, in March-June 2020, comparing exposed to metformin in monotherapy with exposed to any other antidiabetic. Data source: SIDIAP (Information System for Research in Primary Care), which captures clinical information of 5,8 million people from Catalonia, Spain.ResultsWe included 31,006 diabetic patients infected with COVID-19, 43.7% previously exposed to metformin, 45.5% of them in monotherapy. 16.4% were admitted to hospital and 15.1% died. Users of insulin in monotherapy (OR 1.29, 95% CI 1.11–1.50), combined with metformin (OR 1.38, 1.13–1.69) or IDPP4 alone (OR 1.29, 1.03–1.63) had higher risk of severe outcomes than those in metformin monotherapy. Users of any insulin (OR 1.61, 1.32–1.97) or combined with metformin (OR 1.69, 1.30–2.20) had a higher risk of mortality.ConclusionsPatients receiving metformin monotherapy in our study showed a lower risk of hospitalization and death in comparison to those treated with other frequent antidiabetic agents.We cannot distinguish if better outcomes are related with the antidiabetic therapy or with other factors, such as metabolic control or interventions applied during the hospital admission.     

Covid-19 pandemic,diabetes and glycemic control: Results of a retrospective cohort study of 230.000 persons with diabetes in tuscany

Background and aimsThe COVID-19 pandemic affected the processes of routine care for chronic patients due to disrupted delivery care. The aim of the present study is to verify the COVID-19 pandemic effects on diabetes control and management.Methods and resultsThe study was designed as a retrospective observational study, performed on two cohorts of patients with diabetes in 2019 and 2020. Data used for the analyses were gathered from administrative and laboratory databases, which do not include any sensible information on COVID-19. The Tuscany Regional Health Agency is data controller for current administrative databases and has been working to produce available information for policy decision-making.In 2020, in comparison with 2019, a relevant reduction of the number of patients measuring HbA1c was observed during the March–April lockdown, and again during the second pandemic wave in Autumn. A similar pattern was observed for specialist visits for diabetes, for which the introduction of televisits only partly compensated for the reduction of traditional office visits. The number of patients receiving drugs for diabetes each week in 2020 was very similar to 2019. The mean HbA1c values and the proportion of HbA1c values > 8% for each week, were higher during the 2020 Spring and Autumn lockdown.ConclusionCOVID-19 pandemic negatively impacts diabetes management, reducing specialist visits and HbA1c determinations during the first and second pandemic wave. Despite a satisfactory continuity in pharmacological treatment, short-term impairment of average glycemic control was detected, particularly in Autumn.     

Management of obesity in patients with type 2 diabetes mellitus in primary care

AimsObesity and being overweight is the most powerful risk factor accounting for 80–90% of patients with type 2 diabetes mellitus (T2DM). The epidemic of obesity is driving the diabetes epidemic to alarming levels and primary care is becoming an important setting for obesity management in T2DM in India. Yet many primary care providers feel ill-equipped or inadequately supported to address obesity in patients with diabetes. This article reviews the most recent and strongest evidence-based strategies that may aid physicians in management of obesity in patients with T2DM in primary care.Material and methodsA systematic literature search of MEDLINE using the search terms Obesity, Obesity in T2DM, weight loss and Primary Care was conducted. The American Diabetes Association, National Institute for Health, National Institute of Health and Excellence (NICE), Scottish Intercollegiate Guidelines Network (SIGN) and World Health Organization websites were also searched. Most studies in this area are observational in design with few randomized controlled trials (RCTs). Articles and studies involving meta-analysis or RCTs were preferred over other types.Results and conclusionEffective weight management treatment in T2DM patient can be implemented in the primary care setting. Evidence based individualized lifestyle and pharmacologic measures supported by behavioral intervention and counseling with appropriate and informed surgical referrals has the potential to improve the success of weight management within primary care.     

Management of kidney disease in patients with diabetes in the primary care setting

AimsTo evaluate the performance of general practitioners (GPs) in the care of diabetic patients in areas represented or unrepresented by quality indicators.MethodsAn observational study in primary care practices. The study population was comprised of GPs who cared for 1799 patients with diabetes mellitus co-existing with stage 3 chronic kidney disease, hypertension, and cardiovascular disease. The performance of GPs was monitored twice during a 6-month interval using a regional computerized clinical data base according to the measurement and treatment of blood pressure, LDL-cholesterol level, proteinuria, hematuria, and anemia.ResultsThose parameters which were familiar to the GPs for several years as part of the Quality Indicators Program (QIP) were measured and treated at a high rate compared to parameters not included in the QIP. For example, measurement of blood pressure and testing for glycosylated hemoglobin were 99% and 98% respectively at the end point. In contrast the rate of performance of specific kidney disease-focused activities, such as referral of patients with proteinuria to nephrologic consultation was 36% at the end point.ConclusionGood performance in areas monitored by Quality Indicators does not imply good quality of care in other areas for the same patients. Attention should be paid to initiating activities to raise the awareness of GPs with respect to important health parameters which are not included in the Quality Indicators Program.     

新型冠状病毒肺炎疫情期间糖尿病基层管理专家建议

自2019年12月以来,我国发生新型冠状病毒肺炎(COVID-19)疫情。糖尿病患者COVID-19感染风险增高,且预后差。COVID-19疫情期间,基层医疗在糖尿病预防和血糖控制管理方面面临严峻挑战。中国糖尿病专家、基层医疗服务提供者和公共卫生管理者提出专家建议,旨在提高全国基层医疗卫生机构在COVID-19疫情期间的临床诊治能力并提供标准化的基本公共卫生和医疗服务。本建议的主要内容包括管理的基本要求、健康管理的工作流程、转诊、治疗和长期随访。     

The sex-related discrepancy in laboratory parameters of severe COVID-19 patients with diabetes: A retrospective cohort study

AimThis study aimed at providing evidence to consider sex differences in interpretations of laboratory parameters of severe COVID-19 patients with diabetes.MethodsFor 118 diabetic patients, laboratory measurements and clinical outcomes were compared between males and females. This study also compared inflammatory ratios obtained from combinations of six inflammatory markers between the two groups. The risk factors for mortality were identified through logistic regression.ResultsMales were 54 (45.8%) and females were 64 (54.2%). Males showed a significant increase in ALT (P = 0.003), CRP (P = 0.03), mean platelet volume (MPV)-to-lymphocyte ratio (P = 0.001), and C-reactive protein-to-albumin ratio (P = 0.044), whereas females had a significant increase in lymphocytes (P < 0.005) and MPV (P = 0.01). In all participants, multivariate analysis illustrated that older age, male sex, increased serum total bilirubin, and decreased PO₂ were significant independent predictors of mortality (P < 0.05).ConclusionIn severe COVID-19 patients with diabetes, there were significant sex differences in many laboratory characteristics with a higher risk of mortality among males.     

Six-monthly diabetes monitoring of well-controlled patients: Experiences of primary care providers

AimsTo examine experiences of primary care providers with six-monthly diabetes monitoring of well-controlled patients.MethodsThis study was part of the EFFIMODI study, examining whether six-monthly monitoring of well-controlled (HbA1c ≤58 mmol/mol, systolic blood pressure ≤145 mmHg and total cholesterol ≤5.2 mmol/l) type 2 diabetes patients results in equivalent cardiometabolic control compared to three-monthly monitoring. Primary care providers completed a questionnaire about their experiences with six-monthly diabetes monitoring, whether they want to continue six-monthly monitoring and for which type of patients six-monthly monitoring is sufficient.ResultsOf 163 questionnaires, 157 (96.3%) were completed and returned. Only 14 (8.9%) primary care providers were negative about the six-monthly monitoring and 102 (65.0%) would like to continue six-monthly monitoring. Primary care providers disagreed about patients’ ability to determine their own monitoring frequency and whether six-monthly monitoring was suitable for all well-controlled type 2 diabetes patients. Practical concerns emerged such as the inability to declare healthcare costs and the unsuitability of electronic health record systems.ConclusionsAlmost two out of three primary care providers would like to continue six-monthly monitoring of well-controlled type 2 diabetes patients. However, some diabetes care providers should be convinced and some practical concerns should be solved.     

Association between intensive glycemic control and mortality in elderly diabetic patients in the primary care: A retrospective cohort study

ObjectiveTo examine the association between the most recent HbA1c values and the mortality of elderly Type 2 Diabetic (T2DM) patients managed in the public primary care setting and to explore the associating risk factors.DesignRetrospective cohort study.SubjectsAll T2DM patients aged 65 or above, who attended a public primary care clinic for regular follow up from 01/01/2012 to 31/12/2012 were included. Their follow up status till 31/12/2017 was reviewed. Those who were deceased on or before 31/12/2017 were matched randomly with controls that were alive in the same cohort for comparison.Main Outcome MeasuresPatients’ demographics, smoking status, duration of T2DM, biochemical parameters including the most recent HbA1c, lipid profile, renal function test, drug profile, co-morbidities and all-cause mortality were retrieved from Hospital Authority’s CDARS and CMS systems.ResultsBoth high (>8.0%) and low (<6.5%) HbA1c values were associated with increased odd ratio of all-cause mortality among T2DM elderly patients treated in the primary care. There was a 3-fold increase in odd ratio when the HbA1c reading was very low (<6.0%). Associated risk factors for all-cause mortality in elderly T2DM patients included smoker status, lower BMIs, and higher LDL levels and use of sulphonylureas.ConclusionsGlycemic target for elderly T2DM patients should be approached cautiously. Over-aggressive treatment may lead to increased mortality among elderly T2DM patients.     

Predictors of hypoglycaemia in insulin-treated type 2 diabetes patients in primary care: A retrospective database analysis

AimsTo investigate the frequency and predictors (diabetes care and treatment, comorbidity) of documented hypoglycaemia in primary care patients with insulin-treated type 2 diabetes.MethodsData from 32,545 patients (mean age: 70 (SD 11) years, 50.3% males) from 1072 practices were retrospectively analyzed (Disease Analyzer database Germany: 09/2011–08/2012). Logistic regression (≥1 documented hypoglyemia) was used to adjust for confounders (age, sex, practice characteristics, diabetes treatment regimen).ResultsThe prevalence of patients (12 months) with at least one reported hypoglycaemia was 2.2% (95% CI: 2.0–2.4%). The adjusted odds of having hypoglycemia were increased for renal failure (OR; 95% CI: 1.26; 1.16–1.37), autonomic neuropathy (1.34; 1.20–1.49), and adrenocortical insufficiency (3.08; 1.35–7.05). Patients with mental disorders including dementia (1.49; 1.31–1.69), depression (1.24; 1.13–1.35), anxiety (1.18; 1.01–1.37), and affective disorders (1.80; 1.36–2.38) also showed an increased odds of having hypoglycemia. Location of the practice in an urban area was associated with a lower odds ratio (0.74; 0.68–0.80).ConclusionsBoth individual patient characteristics (e.g. comorbidity) and regional factors (practice location) have a substantial impact on hypoglycaemia in primary care patients with insulin therapy.