Use of hospital care among Dutch diabetes patients

Aim

To provide insight into healthcare resource utilization and hospital expenditure of patients treated for diabetes in Dutch hospitals.

Materials and methods

We conducted an observational cohort study of 193 840 patients aged ≥18 years and treated for diabetes mellitus in 65 Dutch hospitals in 2019 to 2020, using real-world reimbursement data. Consultations, hospitalizations, technology use, total hospital and diabetes care costs (encompassing all care for diabetes itself) were assessed during 1-year follow-up. In addition, expenditure was compared with that in the general Dutch population.

Results

Total hospital costs for all patients with diabetes were €1 352 690 257 (1.35 billion) per year, and 15.9% (€214 963 703) was associated with treatment of diabetes. Mean yearly costs per patient were €6978, with diabetes care costs of €1109. Mean hospital costs of patients exceeded that of the Dutch population three- to sixfold. Total hospital costs increased with age, whereas diabetes expenditure decreased with age (18-40 years, €1575; >70 years, €932). Of all patients with diabetes, 51.3% (n = 99 457) received care related to cardiovascular complications. Micro- and macrovascular complications, or a combination, increased hospital costs (1.4-5.3 times higher).

Conclusions

The hospital resource use of Dutch diabetes patients is high, with a large burden of cardiovascular complications. Resource use is rooted mainly in hospital care of diabetes-related complications, not in the treatment of diabetes. Early treatment and prevention of complications remain imperative to taper future healthcare expenditure on patients with diabetes.     

Trends and disparities in telehealth use among Louisiana Medicaid beneficiaries with type 2 diabetes

Aim

To examine trends in telehealth use among Medicaid beneficiaries with type 2 diabetes (T2D) before and during the coronavirus disease 2019 (COVID-19) pandemic and identify factors related to telehealth use.

Methods

We compared monthly proportions of outpatient visits delivered by telehealth by race/ethnicity, geography and age among Louisiana Medicaid beneficiaries with T2D using claims data from January 2018 to August 2021. We also examined the changes in provider types delivering telehealth. Multivariable logistic regression was conducted to identify individual level and zip code-level factors associated with telehealth use during the COVID-19 pandemic.

Results

The monthly proportion of outpatient visits delivered by telehealth was low (< 1%) before the pandemic, spiked in April 2020 (> 15%), then remained at approximately 5%. Telehealth use varied across different racial/ethnic groups, geography and age groups over years. Older beneficiaries were less probable to use telehealth during the pandemic (adjusted odds ratio [AOR] = 0.874, 95% confidence interval [CI]: 0.831-0.919). Females used more telehealth than males (AOR = 1.359, 95% CI: 1.298-1.423). Black beneficiaries used more telehealth than White beneficiaries (AOR = 1.067, 95% CI: 1.000-1.139). More telehealth services were used by Medicaid beneficiaries who were living in urban areas, with more primary care utilization, and with more chronic conditions at baseline.

Conclusions

We found disparities in the uptake of telehealth during the COVID-19 pandemic, but they might have been narrowed for some groups (Hispanic and rural) among Louisiana Medicaid beneficiaries with T2D. Future studies should explore strategies to improve access to telehealth services and reduce related disparities for the low-income population.     

Liver fibrosis markers and all cause mortality in people with type 2 diabetes: A population based study (The Ayrshire Diabetes Outcomes Cohort (ADOC) Study)

Aims

To describe the distribution of the biomarker scores Fibrosis-4 (FIB4), nonalcoholic fatty liver disease (NAFLD) fibrosis score (NFS), and aspartate aminotransferase to platelet ratio index (APRI), and the associations between risk categories and all-cause mortality.

Materials and Methods

This was a retrospective cohort study of 12 589 patients, with follow-up from January 2012 until November 2021. The cut-off points used to identify low risk were: FIB4 <1.3 if aged <65 years or <2.0 if aged ≥65 years; NFS < −1.455 if aged <65 years or <0.12 if aged ≥ 65 years; APRI <1 (independent of age). High-risk cut-off points were FIB4 >2.67, NFS >0.676 and APRI ≥1 (all independent of age). Multivariable Cox regression analysis was performed to assess the association between liver fibrosis scores and all-cause mortality.

Results

The mean ± standard deviation age was 65.2 ± 12.1 years, 54.5% were men and the median (interquartile range) diabetes duration was 5.8 (2.8–9.3) years. The prevalence of high-risk categories was 6.1% for FIB4, 23.5% for NFS and 1.6% for APRI. During a median follow-up of 9.8 years, 3925 patients (31.1%) died, resulting in a crude mortality rate of 40.4 per 1000 person-years. The overall adjusted all-cause mortality hazard ratios (95% confidence intervals [CIs]) in the high- compared with low-fibrosis-risk groups were 3.69 (1.95–2.75) for FIB4, 2.32 (2.88–4.70) for NFS, and 3.92 (2.88–5.34) for APRI. Stratified adjusted all-cause mortality hazard ratios for individuals under 65 years and people over 65 years of age at cohort entry were 3.89 (95% CI 2.99–5.05) and 1.44 (95% CI 1.28–1.61) for FIB4, 2.50 (95% CI 1.89–3.18) and 1.35 (95% CI 1.24–1.48) for NFS and 3.74 (95% CI 2.73–5.14) and 1.64 (95% CI 1.24–2.17) for APRI.

Conclusions

All three fibrosis risk scores were positively associated with all-cause mortality in people with type 2 diabetes, with higher relative risks in younger than older people. Effective interventions are required to minimize excess mortality in people at high risk of liver fibrosis.     

Impact of pre-existing type 2 diabetes with and without cardiovascular disease on patients with COVID-19

Aim

To compare adverse outcomes among COVID-19 patients with pre-existing type 2 diabetes (T2D) only, T2D and cardiovascular disease (CVD), or neither.

Methods

This retrospective cohort study used administrative claims, laboratory and mortality data from the HealthCore Integrated Research Database. Patients with COVID-19 were identified from 3 January 2020 to 31 May 2021 and stratified by the presence of T2D and CVD. Outcomes included hospitalization, intensive care unit (ICU) admission, mortality and complications following COVID-19 infection. Propensity score matching and multivariable analyses were performed.

Results

A total of 321 232 COVID-19 patients were identified (21 651 T2D + CVD, 28 184 T2D only, and 271 397 neither) with a mean (SD) follow-up of 5.4 (3.0) months. After matching, 6 967 patients were identified for each group, and residual baseline differences remained. Adjusted analyses showed that COVID-19 patients with T2D + CVD were 59% more probable to be hospitalized, 74% more probable to be admitted to the ICU, and had a 26% higher mortality risk than those with neither. COVID-19 patients with T2D only were 28% and 32% more probable to be admitted to the hospital and ICU than those with neither, respectively. Among all T2D + CVD patients, acute respiratory distress syndrome (31%) and acute kidney disease (24%) were observed.

Conclusion

Our study highlights the incrementally poorer outcomes associated with pre-existing T2D + CVD in COVID-19 patients compared with those without T2D/CVD and suggests consideration of a more optimal management approach in these patients.     

Increasing incidence of abnormal glucose tolerance in women with prior abnormal glucose tolerance during pregnancy: DIAGEST 2 study

Aims Mild blood glucose abnormalities during pregnancy may be linked to later glucose tolerance abnormalities or diabetes mellitus. Our aim was to determine the prevalence of diabetes mellitus (DM), impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) 6.75 years after delivery in women with differential blood glucose status during pregnancy. Methods We compared long‐term outcomes among control women (n = 221), women with abnormal glucose tolerance during pregnancy (AGT; n = 322) and women with gestational diabetes (GDM; n = 466) who participated in DIAGEST 1. Women were recruited from 15 public maternity units in France. Clinical parameters could be determined in 155 control, 220 AGT and 338 GDM subjects. Rates of DM, IGT, IFG and ‘Any Abnormality’ were compared between the groups (American Diabetes Association criteria). Results Adherence to follow‐up was 70.7%. Rates of DM, IGT and IFG were respectively 0.9% DM, 2.1% IGT and 3.6% IFG in the control group; rates in the AGT group were 6.3%, 11.3% and 6.3%. In GDM women, the rates of DM, IGT and IFG were, respectively, 18.0%, 13.4% and 8.5%. Predictors for DM were previous GDM, medical history of hypertension, age at delivery ≥ 33 years, family history of diabetes, fasting glucose during pregnancy ≥ 5.5 mmol/l and the severity of hyperglycaemia during pregnancy defined by the number of abnormal blood glucose values fasting, 1, 2 and 3 h during the glucose tolerance test at diagnosis of GDM. Conclusion This study has identified a high prevalence of glucose tolerance abnormalities after AGT during pregnancy. Compared with GDM women, women with AGT have an intermediate risk of later diabetes.     

Sulphonylureas versus metformin and the risk of ventricular arrhythmias among people with type 2 diabetes: A population-based cohort study

Aim

To determine whether the use of sulphonylurea monotherapy, compared with metformin monotherapy, is associated with an increased risk of ventricular arrhythmia (VA) among patients initiating pharmacotherapy for type 2 diabetes.

Research Design and Methods

We conducted a population-based cohort study using electronic health data extracted from the UK's Clinical Practice Research Datalink Aurum. Using the active comparator, new-user cohort design, we compared rates of VA among patients aged 18 years or older using sulphonylurea monotherapy with those using metformin monotherapy as their initial pharmacological treatment for type 2 diabetes from April 1998 to December 2019. We used a Cox proportional hazards model with inverse probability of treatment weighting by propensity score to estimate the adjusted hazard ratio (aHR) and a corresponding bootstrap 95% confidence interval (CI) for VA with sulphonylurea monotherapy versus metformin monotherapy.

Results

The cohort included 92 638 new users of sulphonylurea and 506 882 new users of metformin. A total of 279 VA events occurred among sulphonylurea users (rate per 10 000 person-years: 25.5, 95% CI: 22.7 to 28.7) and 1537 VA events occurred among metformin users (rate per 10 000 person-years: 18.5, 95% CI: 17.6 to 19.5). Compared with metformin, sulphonylureas were associated with an increased risk of VA (aHR: 1.42, 95% CI: 1.18 to 1.69).

Conclusions

Sulphonylureas are associated with an increased risk of VA when used as first-line therapy for type 2 diabetes relative to metformin use. This increased risk should be considered when prescribing sulphonylureas as an initial treatment for type 2 diabetes.     

Physical activity before and during pregnancy and risk of abnormal glucose tolerance among Hispanic women

AimWomen diagnosed with abnormal glucose tolerance and gestational diabetes mellitus are at increased risk for subsequent type 2 diabetes, with higher risks in Hispanic women. Studies suggest that physical activity may be associated with a reduced risk of these disorders; however, studies in Hispanic women are sparse.MethodsWe prospectively evaluated this association among 1241 Hispanic participants in Proyecto Buena Salud. The Pregnancy Physical Activity Questionnaire was used to assess pre, early, and mid pregnancy physical activity. Medical records were abstracted for pregnancy outcomes.ResultsA total of 175 women (14.1%) were diagnosed with abnormal glucose tolerance and 57 women (4.6%) were diagnosed with gestational diabetes. Increasing age and body mass index were strongly and positively associated with risk of gestational diabetes. We did not observe statistically significant associations between total physical activity or meeting exercise guidelines and risk. However, after adjusting for age, BMI, gestational weight gain, and other important risk factors, women in the top quartile of moderate-intensity activity in early pregnancy had a decreased risk of abnormal glucose tolerance (odds ratio = 0.48, 95% Confidence Interval 0.27–0.88, P_trend = 0.03) as compared to those in the lowest quartile. Similarly, women with the highest levels of occupational activity in early pregnancy had a decreased risk of abnormal glucose tolerance (odds ratio = 0.48, 95% Confidence Interval 0.28–0.85, P_trend = 0.02) as compared to women who were unemployed.ConclusionIn this Hispanic population, total physical activity and meeting exercise guidelines were not associated with risk. However, high levels of moderate-intensity and occupational activity were associated with risk reduction.     

2型糖尿病患者口服糖耐量试验胰升糖素和生长抑素水平的变化

检测60例2型糖尿病患者和34名正常对照者空腹及口服75 g葡萄糖2h后胰升糖素、生长抑素(SS)和C肽水平。结果显示,与对照组比较,糖尿病组空腹胰升糖素、SS及糖负荷后2 h SS明显降低（均P＜0.01）,空腹及2 h C肽明显升高（均P＜0.01）。两组糖负荷后2 h激素水平均显著高于空腹(均P＜0.01),与对照组比较,糖尿病组胰升糖素（1.40±0.48对1.20±0.30,P＜0.05）和SS(2.79±2.17对1.14±0.22,P＜0.01)餐后增加倍数更高,C肽增加倍数较低（3.58±3.10对8.33±6.99,P＜0.01）;两组空腹胰升糖素水平与SS呈正相关（均P＜0.01）。以上结果提示,2型糖尿病患者不仅β细胞功能紊乱,尚存在α、δ细胞相关激素紊乱。