GPs' approach to insulin prescribing in older patients: a qualitative study

BACKGROUND: Evidence suggests that insulin is under-prescribed in older people. Some reasons for this include physician's concerns about potential side-effects or patients' resistance to insulin. In general, however, little is known about how GPs make decisions related to insulin prescribing in older people. AIM: To explore the process and rationale for prescribing decisions of GPs when treating older patients with type 2 diabetes. DESIGN OF STUDY: Qualitative individual interviews using a grounded theory approach. SETTING: Primary care. METHOD: A thematic analysis was conducted to identify themes that reflected factors that influence the prescribing of insulin. RESULTS: Twenty-one GPs in active practice in Ontario completed interviews. Seven factors influencing the prescribing of insulin for older patients were identified: GPs' beliefs about older people; GPs' beliefs about diabetes and its management; gauging the intensity of therapy required; need for preparation for insulin therapy; presence of support from informal or formal healthcare provider; frustration with management complexity; and GPs' experience with insulin administration. Although GPs indicated that they would prescribe insulin allowing for the above factors, there was a mismatch in intended approach to prescribing and self-reported prescribing. CONCLUSION: GPs' rationale for prescribing (or not prescribing) insulin is mediated by both practitioner-related and patient-related factors. GPs intended and actual prescribing varied depending on their assessment of each patient's situation. In order to improve prescribing for increasing numbers of older people with type 2 diabetes, more education for GPs, specialist support, and use of allied health professionals is needed.     

Dietary knowledge,attitude and practice among type 2 diabetes mellitus patients in Sudan: a hospital-based cross-sectional study

BackgroundIn Sudan, the prevalence of diabetes in adults was estimated at 19.1% in 2015. This study assessed dietary knowledge, attitude, and practices (KAP) of type 2 diabetes mellitus (T2DM) patients in Sudan.MethodsWe randomly selected 238 T2DM patients from a list of 2460 patients from the Jabber Abulizz Hospital. We interviewed them face-to-face using a structured questionnaire. Multivariate logistic regression analyses were performed to investigate the determinants of KAP regarding the recommended diets for T2DM patients.ResultsMajority of the patients demonstrated good knowledge (54.6%), positive attitude (79%); and good practice (58%). The result revealed that patients with formal education had 3.0 (95% CI: 1.6–5.7) times higher odds of having good diabetic dietary knowledge than those with informal education. While patients who had good knowledge and a positive attitude were respectively 4.7 (95% CI: 2.4–8.9) and 3.2 (95% CI: 1.5–6.7) times more likely to follow dietary recommendations than the patients with poor knowledge and negative attitudes.ConclusionIrrespective of the socio-demographic position, the good knowledge and the positive attitude towards the recommended diet, all the T2DM patients complied with the dietary recommendations. These findings highlight the need for improving knowledge and promoting positive attitudes towards the recommended diet among T2DM patients.     

Screening and identifying diabetes in optometric practice: a prospective study

Background

Unconventional settings, outside general medical practice, are an underutilised resource in the attempt to identify the large numbers of people with undiagnosed diabetes worldwide.

Aim

The study investigated the feasibility of using optometry practices (opticians) as a setting for a diabetes screening service.

Design and setting

Adults attending high street optometry practices in northern England who self-reported at least one risk factor for diabetes were offered a random capillary blood glucose (rCBG) test. Those with raised rCBG levels were asked to visit their GP for further investigations.

Results

Of 1909 adults attending practices for sight tests, 1303 (68.2%) reported risk factors for diabetes, of whom 1002 (76.9%) had rCBG measurements taken. Of these, 318 (31.7%) were found to have a rCBG level of ≥6.1 mmol/l, a level where further investigations are recommended by Diabetes UK; 1.6% of previously undiagnosed individuals were diagnosed with diabetes or pre-diabetes as a result of the service. Refining the number of risk factors for inclusion would have reduced those requiring screening by half and still have identified nearly 70% of the new cases of diabetes and pre-diabetes.

Conclusion

Screening in optometric practices provides an efficient opportunity to screen at-risk individuals who do not present to conventional medical services, and is acceptable and appropriate. Optometrists represent a skilled worldwide resource that could provide a screening service. This service could be transferable to other settings.     

A cluster randomised controlled trial of the effect of a treatment algorithm for hypertension in patients with type 2 diabetes

BACKGROUND: Good blood pressure (BP) control reduces the risk of complications in people with type 2 diabetes, yet many do not achieve this. Guidelines for managing hypertension recommend increasing antihypertensive medications until control is achieved, but the effect of such recommendations in routine primary care is unknown. AIM: To evaluate the effectiveness of a BP treatment algorithm in primary care patients with type 2 diabetes. DESIGN OF STUDY: A cluster randomised controlled trial of 1534 patients with type 2 diabetes. SETTING: Forty-two practices in Nottingham, UK. METHOD: Practices were randomised to continue usual care or to use a treatment algorithm designed so that practice nurses and GPs would increase antihypertensive treatment in steps until the target of 140/80 mmHg was reached. Participants were assessed by a clinical interview and case note review at recruitment and at 1 year. The primary outcome measure was the proportion of participants achieving target BP at 1 year. RESULTS: At 1 year there was no difference between the proportions of participants with well controlled BP in the intervention and control arms (36.6% versus 34.3%; P = 0.27). Mean systolic and diastolic blood pressures were identical in the two arms (143/78 mmHg). There was some evidence that participants in the intervention arm were more likely to be receiving higher doses of their antihypertensive drugs, although there was no significant difference in the number of different antihypertensive drugs prescribed. Participants in the intervention arm had a higher rate of primary care BP-related consultations over 12 months than those receiving usual care (rate ratio = 1.55, 95% confidence interval [CI] = 1.26 to 1.88, P<0.001). CONCLUSION: Despite increased monitoring and possibly higher doses of medication there was no improvement in blood pressure control. Improvements achieved by specialist nurse-led clinics in secondary care may not translate to people with type 2 diabetes in primary care settings.     

Management of type 2 diabetes with multiple oral hypoglycaemic agents or insulin in primary care: retrospective cohort study

BACKGROUND: Intensive glycaemic control can reduce the risk of microvascular complications in people with type 2 diabetes. AIM: To examine the extent of monitoring and glycaemic control of patients with type 2 diabetes prescribed oral agents and/or insulin, and to investigate transition to insulin. DESIGN OF STUDY: Retrospective cohort study. SETTING: A total of 154 general practices in the UK contributing to the DIN-LINK database between 1995 and 2005. METHOD: People with type 2 diabetes were identified using Read codes and prescribing data. Outcome measures were: glycaemic monitoring and control on multiple oral agents and/or insulin, and transition to insulin. RESULTS: A total of 14 824 people with type 2 diabetes were prescribed multiple oral agents concurrently, of whom 5064 (34.16%) had haemoglobin A(1c) (HbA(1c)) assessments 6 months before and following initiation of their last oral therapy. Mean HbA(1c) before therapy was 9.07%, which dropped to 8.16% following therapy (mean difference 0.91%, 95% confidence interval [CI] = 0.86 to 0.95, P <0.0001). Of the patients with HbA(1c) assessments, 3153 (62.26%) had evidence of poor glycaemic control following therapy. Median time to insulin for patients prescribed multiple oral agents was 7.7 years (95% CI = 7.4 to 8.5 years); 1513 people began insulin during the study and had HbA(1c) assessments 6 months before and following insulin. Mean HbA(1c) before insulin was 9.85% (standard deviation [SD] 1.96%) which decreased by 1.34%, (95% CI = 1.24% to 1.44%) following therapy, but 1110 people (73.36%) still had HbA(1c) > or =7.5%. CONCLUSION: Many people with type 2 diabetes received inadequate monitoring and had poor glycaemic control. Intensive management is required to reduce the risk of microvascular complications.     

Patient reactions to a web-based cardiovascular risk calculator in type 2 diabetes: a qualitative study in primary care

Background

Use of risk calculators for specific diseases is increasing, with an underlying assumption that they promote risk reduction as users become better informed and motivated to take preventive action. Empirical data to support this are, however, sparse and contradictory.

Aim

To explore user reactions to a cardiovascular risk calculator for people with type 2 diabetes. Objectives were to identify cognitive and emotional reactions to the presentation of risk, with a view to understanding whether and how such a calculator could help motivate users to adopt healthier behaviours and/or improve adherence to medication.

Design and setting

Qualitative study combining data from focus groups and individual user experience. Adults with type 2 diabetes were recruited through website advertisements and posters displayed at local GP practices and diabetes groups.

Method

Participants used a risk calculator that provided individualised estimates of cardiovascular risk. Estimates were based on UK Prospective Diabetes Study (UKPDS) data, supplemented with data from trials and systematic reviews. Risk information was presented using natural frequencies, visual displays, and a range of formats. Data were recorded and transcribed, then analysed by a multidisciplinary group.

Results

Thirty-six participants contributed data. Users demonstrated a range of complex cognitive and emotional responses, which might explain the lack of change in health behaviours demonstrated in the literature.

Conclusion

Cardiovascular risk calculators for people with diabetes may best be used in conjunction with health professionals who can guide the user through the calculator and help them use the resulting risk information as a source of motivation and encouragement.     

Integrating preconception care for women with diabetes into primary care: a qualitative study

Background

National guidelines emphasise the need to deliver preconception care to women of childbearing age. However, uptake of the services among women with diabetes in the UK is low. Questions arising include how best to deliver preconception care and what the respective roles of primary versus secondary caregivers might be.

Aim

To explore the perspective of GPs and secondary care health professionals on the role of GPs in delivering preconception care to women with diabetes.

Design of study

Qualitative, cross-sectional study.

Setting

A London teaching hospital and GP practices in the hospital catchment area.

Method

Semi-structured interviews with GPs and members of the preconception care team in secondary care. Thematic analysis using the framework approach.

Results

GPs and secondary care professionals differ in their perception of the number of women with diabetes requiring preconception care and the extent to which preconception care should be integrated into GPs'' roles. Health professionals agreed that GPs have a significant role to play and that delivery of preconception care is best shared between primary and secondary care. However, the lack of clear guidelines and shared protocols detailing the GP''s role presents a challenge to implementing ‘shared’ preconception care.

Conclusion

GPs should be more effectively involved in providing preconception care to women with diabetes. Organisational and policy developments are required to support GPs in playing a role in preconception care. This study''s findings stress the importance of providing an integrated approach to ensure continuity of care and optimal pregnancy preparation for women with diabetes.     

Prediction of complicated lower respiratory tract infections in older patients with diabetes

BACKGROUND: Patients with diabetes have an elevated risk of developing complicated lower respiratory tract infections (LRTIs). However, up until now, GPs have not had the tools to assess individual risks. AIM: To assess the applicability of an existing prediction rule for complicated LRTI among patients with diabetes. DESIGN OF STUDY: Retrospective cohort study. SETTING: The Utrecht GP Research Network. METHOD: An existing rule that was used estimates the risk of 30-day hospitalisation or death following an episode of LRTI. Predictors were exacerbation of chronic obstructive pulmonary disease, or pneumonia, increasing age, heart failure, number of hospitalisations in the previous year, use of antibiotics in the previous month, diabetes medication, and prednisone use. Discriminative capacity of the rule was estimated in patients with diabetes. Other potential predictors from the original study were examined, to test for a potentially improved model. RESULTS: Of 445 episodes of LRTI in patients with diabetes, 68 had an outcome of hospitalisation or death within 30 days of diagnosis of LRTI (15.3%). Results showed good reliability of the model (goodness of fit test P=0.16) and discriminative properties (area under the receiver operating characteristic curve: 0.79, 95% confidence interval=0.73 to 0.86). No other predictors could be added. Patients with a lower-risk assignment (scoreor=7) had a probability of 36.6% for the composite endpoint of hospitalisation or death within 30 days of diagnosis of LRTI. CONCLUSION: The use of a prediction rule may help GPs to assess the risk of hospitalisation or death in patients with diabetes who have an episode of LRTI.     

Randomised controlled trial of intensive multifactorial treatment for cardiovascular risk in patients with screen-detected type 2 diabetes: 1-year data from the ADDITION Netherlands study

Background

A growing body of evidence suggests that earlier diagnosis and treatment of diabetes may be beneficial; however, definitive evidence is lacking.

Aim

To evaluate the effectiveness of an intensified multifactorial treatment on cardiovascular risk factors in patients with screen-detected type 2 diabetes.

Design of study

Randomised controlled trial.

Setting

Seventy-nine general practices in the southwestern region of the Netherlands.

Method

In this randomised trial, patients diagnosed with diabetes by screen-detection were assigned to intensified (n = 255) or routine treatment (n = 243), and followed over 1 year. Intensified treatment consisted of pharmacological treatment combined with lifestyle education to achieve haemoglobin A1c (HbA1c) <7.0%, blood pressure <135/85 mmHg, and cholesterol <5.0 mmol/l (4.5 mmol/l if cardiovascular disease was present). Health-related quality of life (HRQoL) was assessed using the Short Form (SF)-36. Analyses were performed using generalised estimating equations models.

Results

Changes in body mass index were 0.2 (routine care) versus −1.4 kg/m² (intensified treatment), P<0.001; systolic blood pressure −19 versus −33 mmHg, P<0.001; diastolic blood pressure −7 versus −12 mmHg, P<0.001; HbA1c −0.9% versus −1.1%, P = 0.03; cholesterol −0.5 versus −1.2 mmol/l, P<0.001; high-density lipoprotein cholesterol 0.1 versus 0.1 mmol/l, P = 0.26; low-density lipoprotein cholesterol −0.5 versus −1.0 mmol/l, P<0.001; triglycerides −0.3 versus −0.4 mmol/l, P = 0.71. No difference in HRQoL between the two groups was reported.

Conclusion

Intensified multifactorial treatment of patients with screen-detected diabetes in general practice reduces cardiovascular risk factor levels significantly without worsening HRQoL.     

Overall quality of diabetes care in a defined geographic region: different sides of the same story.

BACKGROUND: In diabetes care, knowledge about what is achievable in primary and secondary care is important. There is a need for an objective method to assess the quality of care in different settings. A quality-of-care summary score has been developed based on process and outcome measures. An adapted version of this score was used to evaluate diabetes management in different settings. AIM: To evaluate the quality of diabetes management in primary and secondary care in a defined geographic region in the Netherlands, using a quality score. DESIGN OF STUDY: Cross-sectional study. SETTING: Thirty general practices in the Netherlands. METHOD: A study of 2042 patients with type 2 diabetes (1640 primary care and 402 secondary care) was conducted. Quality of diabetes management was assessed by a score of process and outcome indicators (range 0-40). Clustering at practice level and differences in patient characteristics (case mix) were taken into account. RESULTS: At the outpatient clinic, patients were younger (mean age 64.1 years, standard deviation (SD)=12.5 years, versus mean age 67.1 years, SD=11.7, P<0.001), had more diabetes-related complications (macrovascular: 39.7% versus 24.3%, P<0.001; and microvascular: 25.9% versus 7.3%, P<0.001), and lower quality-of-life scores (EuroQol-5D: mean=0.60, SD=0.29, versus mean=0.80, SD=0.21, P<0.001). After adjusting for case mix and clustering, there was a weak association between the setting of treatment and haemoglobin A1c (primary care: mean 7.1%, SD=1.1, versus secondary care: mean 7.6%, SD=1.2, P<0.016), and between setting and systolic blood pressure (primary: mean 145.7 mmHg, SD=19.2, versus secondary care: 147.77 mmHg, SD 21.0, P<0.035). Quality-of-care summary scores in primary and secondary care differed significantly, with a higher score in primary care (mean 19.6, SD=8.5 versus, mean 18.1, SD=8.7, P<0.01). However, after adjusting for case mix and clustering, this difference lost significance. CONCLUSION: GPs and internists are treating different categories of patients with type 2 diabetes. However, overall quality of diabetes management in primary and secondary care is equal. There is much room for improvement. Future guidelines may differentiate between different categories of patients.     

Syncope and near-syncope as a multifactorial problem in geriatric inpatients: Systemic hypotension is an underrated predictor for syncope exclusively

PurposeSyncope (SC) and near-syncope (NS) are still misunderstood syndromes. Aim of study was to determine the risk factors for SC, NS, as well as for both entities (SC/NS) in geriatric inpatients reporting these events within the last year, irrespectively of the reason of admission to hospital.Material and methodsThe retrospective study covered 250 patients, consecutively admitted to the geriatric ward. Patients were assigned to the three models: SC and/or NS in total, n=106; isolated NS, n=72; SC with co-existing NS, if any, n=34, and compared with patients without any such events (n=144). The patients underwent a comprehensive geriatric assessment and complete clinical investigation. The binary logistic regression was applied to predict risk factors for each of the models.ResultsFalls were most predictive for NS model (OR 35.4; 95% CI 10.3-121.1), and systemic hypotension for SC model (OR 92.9; 95% CI 6.1-1421.0). The highest specificity (85%) and sensitivity (81%) were found for the SC/NS model, with the highest contribution by falls (OR 18.1; 95% CI, 7.6-45.2), orthostatic hypotension (OR 8.1; 95% CI, 3.5-18.5), a history of stroke or transient ischemic attack, treatment with an angiotensin receptor blocker, plasma creatinine >1.4mg/dL, negatively self-rated health, vertigo, pathology of carotid arteries, and lack of hypertension.ConclusionsSyncope and near-syncope in geriatric inpatients have multifactorial and cumulative aetiology, with blurred, frequently overlapping boundaries between them. The falls, postural hypotension, and/or brain hypoperfusion of different origin seem to be most predictive of the both events, however low systemic blood pressure was predictive for the syncope exclusively.     

Nursing consultations and control of diabetes in general practice: a retrospective observational study

Background

Diabetes affects around 3.6 million people in the UK. Previous research found that general practices employing more nurses delivered better diabetes care, but did not include data on individual patient characteristics or consultations received.

Aim

To examine whether the proportion of consultations with patients with diabetes provided by nurses in GP practices is associated with control of diabetes measured by levels of glycated haemoglobin (HbA1c).

Design and setting

A retrospective observational study using consultation records from 319 649 patients with diabetes from 471 UK general practices from 2002 to 2011.

Method

Hierarchical multilevel models to examine associations between proportion of consultations undertaken by nurses and attaining HbA1c targets over time, controlling for case-mix and practice level factors.

Results

The proportion of consultations with nurses has increased by 20% since 2002 but patients with diabetes made fewer consultations per year in 2011 compared with 2002 (11.6 versus 16.0). Glycaemic control has improved and was more uniformly achieved in 2011 than 2002. Practices in which nurses provide a higher proportion of consultations perform no differently to those where nurse input is lower (lowest versus highest nurse contact tertile odds ratio [OR] [confidence interval {95% CI}]: HbA1c ≤53 mmol/mol (7%) 2002, 1.04 [95% CI = 0.87 to 1.25] and 2011, 0.95 [95% CI = 0.87 to 1.03]; HbA1c ≤86 mmol/mol (10%) 2002, 0.97 [95% CI = 0.73 to 1.29] and 2011, 0.95 [95% CI = 0.86 to 1.04]).

Conclusion

Practices that primarily use GPs to deliver diabetes care could release significant resources with no adverse effect by switching their services towards nurse-led care.     

Barriers to effective management of type 2 diabetes in primary care: qualitative systematic review

Background

Despite the availability of evidence-based guidance, many patients with type 2 diabetes do not achieve treatment goals.

Aim

To guide quality improvement strategies for type 2 diabetes by synthesising qualitative evidence on primary care physicians’ and nurses’ perceived influences on care.

Design and setting

Systematic review of qualitative studies with findings organised using the Theoretical Domains Framework.

Method

Databases searched were MEDLINE, Embase, CINAHL, PsycInfo, and ASSIA from 1980 until March 2014. Studies included were English-language qualitative studies in primary care of physicians’ or nurses’ perceived influences on treatment goals for type 2 diabetes.

Results

A total of 32 studies were included: 17 address general diabetes care, 11 glycaemic control, three blood pressure, and one cholesterol control. Clinicians struggle to meet evolving treatment targets within limited time and resources, and are frustrated with resulting compromises. They lack confidence in knowledge of guidelines and skills, notably initiating insulin and facilitating patient behaviour change. Changing professional boundaries have resulted in uncertainty about where clinical responsibility resides. Accounts are often couched in emotional terms, especially frustrations over patient compliance and anxieties about treatment intensification.

Conclusion

Although resources are important, many barriers to improving care are amenable to behaviour change strategies. Improvement strategies need to account for differences between clinical targets and consider tailored rather than ‘one size fits all’ approaches. Training targeting knowledge is necessary but insufficient to bring about major change; approaches to improve diabetes care need to delineate roles and responsibilities, and address clinicians’ skills and emotions around treatment intensification and facilitation of patient behaviour change.     

Crystallization of oral fluid components in patients with type 2 diabetes mellitus

Crystal aggregations of oral fluid from normal subjects and patients with type 2 diabetes mellitus were examined. Morphological signs characterizing crystal aggregations of salivary pools from patients with type 2 diabetes mellitus are described and classified.Translated from Byulleten Eksperimentalnoi Biologii i Meditsiny, Vol. 138, No. 9, pp. 345–347, September, 2004     

Diagnostic inertia in obesity and the impact on cardiovascular risk in primary care: a cross-sectional study

BackgroundPrevalence of diagnostic inertia (DI), defined as a failure to diagnose disease, has not been analysed in patients with obesity.AimTo quantify DI for cardiovascular risk factors (CVRF) in patients with obesity, and determine its association with the cardiovascular risk score.MethodAll patients with obesity attending during the first 6 months of the preventive programme were analysed. Participants had to be free of CVD (myocardial ischaemia or stroke) and aged 40–65 years; the criteria used to measure SCORE (Systematic COronary Risk Evaluation). Three subgroups of patients with obesity with no personal history of CVRF but with poor control of risk factors were established. Outcome variable was DI, defined as poor control of risk factors and no action taken by the physician. Secondary variables were diabetes, fasting blood glucose (FBG), body mass index (BMI), and SCORE. Adjusted odds ratios (OR) was determined using multivariate logistic regression models.ResultsOf 8687 patients with obesity in the programme, 6230 fulfilled SCORE criteria. Prevalence of DI in the three subgroups was: hypertension, 1275/1816 (70.2%) patients affected (95% CI = 68.1 to 72.3%); diabetes, 335/359 (93.3%) patients affected (95% CI = 90.7 to 95.9%); dyslipidaemia subgroup, 1796/3341 (53.8%) patients affected (95% CI = 52.1 to 55.4%. Factors associated with DI for each subgroup were: for hypertension, absence of diabetes, higher BMI, and greater cardiovascular risk; for dyslipidaemia, diabetes, higher BMI, and greater cardiovascular risk (SCORE); and for diabetes, lower FBG levels, lower BMI, and greater cardiovascular risk.ConclusionThis study quantified DI in patients with obesity and determined that it was associated with a greater cardiovascular risk.     

Crystallization of oral fluid components in patients with type 2 diabetes mellitus

Crystal aggregations of oral fluid from normal subjects and patients with type 2 diabetes mellitus were examined. Morphological signs characterizing crystal aggregations of salivary pools from patients with type 2 diabetes mellitus are described and classified. Translated fromByulleten’ Eksperimental’noi Biologii i Meditsiny, Vol. 138, No. 9, pp. 345–347, September, 2004     

Reduction in self-monitoring of blood glucose in type 2 diabetes: an observational controlled study in east London

BackgroundSelf-monitoring of blood glucose (SMBG) confers no benefit for many people with type 2 diabetes not being treated with insulin. It accounts for 21% of diabetes prescribing costs.AimTo improve care quality at reduced cost for type 2 diabetes by reducing unnecessary SMBG.MethodIn total, 19 602 people with type 2 diabetes not being treated with insulin were recruited from two intervention CCGs; 16 033 were recruited from a control CCG. The intervention (from 2010 to 2013) comprised implementation of a locally developed guideline, including IT support and peer feedback of performance. Data on practice prescribing SMBG testing strips were gathered using GP electronic health records. Information on costs were obtained via the ePACT electronic database.ResultsOver 4 years, in all non-insulin type 2 diabetes treatment groups, use of SMBG was reduced in the two intervention CCGs from 42.8% to 16.5%, and in the control CCG from 56.4% to 47.2%. In people on metformin alone or no treatment, intervention CCGs reduced SMBG use from 29.6% to 6.0%, and in the control CCG use dropped from 47.1% to 38.7% (P<0.001). From 2009 to 2012 the total cost of all SMBG prescribing (type 1 and type 2 diabetes, including users of insulin) was reduced by 4.9% (£62 476) in the two intervention CCGs and increased in the control CCG by 5.0% (£42 607); in England, the total cost increased by 13.5% (£19.4 million). In total, 20% (3865 of 19 602) fewer patients used SMBG in the intervention CCGs.ConclusionThis low-cost programme demonstrated a major reduction in unnecessary prescribing of SMBG, along with cost savings. If replicated nationally, this would avoid unnecessary testing in 340 000 people and prescribing costs that total £21.8 million.     

Change in cardiovascular risk factors following early diagnosis of type 2 diabetes: a cohort analysis of a cluster-randomised trial

Background

There is little evidence to inform the targeted treatment of individuals found early in the diabetes disease trajectory.

Aim

To describe cardiovascular disease (CVD) risk profiles and treatment of individual CVD risk factors by modelled CVD risk at diagnosis; changes in treatment, modelled CVD risk, and CVD risk factors in the 5 years following diagnosis; and how these are patterned by socioeconomic status.

Design and setting

Cohort analysis of a cluster-randomised trial (ADDITION-Europe) in general practices in Denmark, England, and the Netherlands.

Method

A total of 2418 individuals with screen-detected diabetes were divided into quartiles of modelled 10-year CVD risk at diagnosis. Changes in treatment, modelled CVD risk, and CVD risk factors were assessed at 5 years.

Results

The largest reductions in risk factors and modelled CVD risk were seen in participants who were in the highest quartile of modelled risk at baseline, suggesting that treatment was offered appropriately. Participants in the lowest quartile of risk at baseline had very similar levels of modelled CVD risk at 5 years and showed the least variation in change in modelled risk. No association was found between socioeconomic status and changes in CVD risk factors, suggesting that treatment was equitable.

Conclusion

Diabetes management requires setting of individualised attainable targets. This analysis provides a reference point for patients, clinicians, and policymakers when considering goals for changes in risk factors early in the course of the disease that account for the diverse cardiometabolic profile present in individuals who are newly diagnosed with type 2 diabetes.     

Variability in fasting lipid and glycogen contents in hepatic and skeletal muscle tissue in subjects with and without type 2 diabetes: a 1H and 13C MRS study

The measurement of tissue lipid and glycogen contents and the establishment of normal levels of variability are important when assessing changes caused by pathology or treatment. We measured hepatic and skeletal muscle lipid and glycogen levels using ¹H and ¹³C MRS at 3 T in groups of subjects with and without type 2 diabetes. Within‐visit reproducibility, due to repositioning and instrument errors was determined from repeat measurements made over 1 h. Natural variability was assessed from separate measurements made on three occasions over 1 month. Hepatic lipid content was greater in subjects with diabetes relative to healthy subjects (p = 0.03), whereas levels of hepatic and skeletal muscle glycogen, and of intra‐ and extra‐myocellular lipid, were similar. The single‐session reproducibility values (coefficient of variation, CV) for hepatic lipid content were 12% and 7% in groups of subjects with and without diabetes, respectively. The variability of hepatic lipid content over 1 month was greater than the reproducibility, with CV = 22% (p = 0.08) and CV = 44% (p = 0.004) in subjects with and without diabetes, respectively. Similarly, levels of variation in basal hepatic glycogen concentrations (subjects with diabetes, CV = 38%; healthy volunteers, CV = 35%) were significantly larger than single‐session reproducibility values (CV = 17%, p = 0.02 and CV = 13%, p = 0.05, respectively), indicating substantial biological changes in basal concentrations over 1 month. There was a decreasing correlation in measurements of both hepatic lipid and glycogen content with increasing time between scans. Levels of variability in intra‐ and extra‐myocellular lipid in the soleus muscle, and glycogen concentrations in the gastrocnemius muscle, tended to be larger than expected from single‐session reproducibility, although these did not reach significance. Copyright © 2013 John Wiley & Sons, Ltd.