Is Prehypertension a Risk Factor for the Development of Type 2 Diabetes?

OBJECTIVE

Prehypertension is associated with cardiovascular disease and insulin resistance. However, whether subjects with prehypertension have more diabetes risk is not known. We examine whether prehypertension is a risk factor for developing type 2 diabetes.

RESEARCH DESIGN AND METHODS

Incident diabetes was examined in nondiabetic normotensive participants in the San Antonio Heart Study (n = 2,767; aged 25–65 years; median follow-up 7.8 years).

RESULTS

Incident diabetes was 12.4% in subjects with prehypertension and 5.6% in subjects with normal blood pressure. The odds of incident diabetes were 2.21 greater for individuals with prehypertension than for those with normal blood pressure (95% CI 1.63–2.98) after adjusting for age, sex, and ethnicity. Prehypertension was not associated with incident diabetes after additional adjustment for BMI, impaired glucose tolerance, insulin resistance and secretion, and family history of diabetes (odds ratio 1.42 [95% CI 0.99–2.02]).

CONCLUSIONS

Subjects with prehypertension are at increased risk of diabetes. Much of this risk is explained by disorders related to the insulin resistance syndrome.Hypertension predicts future cardiovascular disease (1,2) and type 2 diabetes (3). Prehypertension (systolic blood pressure [SBP] 120–139 mmHg and/or diastolic blood pressure [DBP] 80–89 mmHg), a novel blood pressure category of “The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report” (4), is also associated with increased cardiovascular risk (5,6) and insulin resistance (7). Furthermore, results from the Framingham Heart Study indicate that cardiovascular risk may be more relevant in individuals with SBP 130–139 mmHg and/or DBP 85–89 mmHg (8). Therefore, we investigated the relationship between prehypertension and incident type 2 diabetes in the San Antonio Heart Study (SAHS).     

Are Cardiometabolic Markers of Allostatic Load Associated With Pronociceptive Processes in Native Americans?: A Structural Equation Modeling Analysis From the Oklahoma Study of Native American Pain Risk

Native Americans (NAs) experience higher rates of chronic pain than the general U.S. population, but the risk factors for this pain disparity are unknown. NAs also experience high rates of stressors and cardiovascular and metabolic health disparities (eg, diabetes, cardiovascular disease) consistent with allostatic load (stress-related wear-and-tear on homeostatic systems). Given that allostatic load is associated with chronic pain, then allostatic load may contribute to their pain disparity. Data from 302 healthy, pain-free men and women (153 NAs, 149 non-Hispanic Whites [NHW]) were analyzed using structural equation modeling to determine whether cardiometabolic allostatic load (body mass index, blood pressure, heart rate variability) mediated the relationship between NA ethnicity and experimental measures of pronociceptive processes: temporal summation of pain (TS-pain) and the nociceptive flexion reflex (TS-NFR), conditioned pain modulation of pain (CPM-pain) and NFR (CPM-NFR), and pain tolerance. Results indicated that NAs experienced greater cardiometabolic allostatic load that was related to enhanced TS-NFR and impaired CPM-NFR. Cardiometabolic allostatic load was unrelated to measures of pain perception (CPM-pain, TS-pain, pain sensitivity). This suggests cardiometabolic allostatic load may promote spinal sensitization in healthy NAs, that is not concomitant with pain sensitization, perhaps representing a unique pain risk phenotype in NAs.PerspectiveHealthy, pain-free Native Americans experienced greater cardiometabolic allostatic load that was associated with a pronociceptive pain phenotype indicative of latent spinal sensitization (ie, spinal sensitization not associated with hyperalgesia). This latent spinal sensitization could represent a pain risk phenotype for this population.     

Deleterious Associations of Sitting Time and Television Viewing Time With Cardiometabolic Risk Biomarkers: Australian Diabetes, Obesity and Lifestyle (AusDiab) study 2004�C2005

OBJECTIVE

We examined the associations of sitting time and television (TV) viewing time with continuously measured biomarkers of cardio-metabolic risk in Australian adults.

RESEARCH DESIGN AND METHODS

Waist circumference, BMI, resting blood pressure, triglycerides, HDL cholesterol, fasting and 2-h postload plasma glucose, and fasting insulin were measured in 2,761 women and 2,103 men aged ≥30 years (mean age 54 years) without clinically diagnosed diabetes from the 2004–2005 Australian Diabetes, Obesity and Lifestyle (AusDiab) study. Multivariate linear regression analyses examined associations of self-reported sitting time and TV viewing time (hours per day) with these biomarkers, adjusting for potential confounding variables.

RESULTS

For both women and men, sitting time was detrimentally associated with waist circumference, BMI, systolic blood pressure, fasting triglycerides, HDL cholesterol, 2-h postload plasma glucose, and fasting insulin (all P < 0.05), but not with fasting plasma glucose and diastolic blood pressure (men only). With the exception of HDL cholesterol and systolic blood pressure in women, the associations remained significant after further adjustment for waist circumference. TV viewing time was detrimentally associated with all metabolic measures in women and all except HDL cholesterol and blood pressure in men. Only fasting insulin and glucose (men only) remained deleteriously associated with TV viewing time after adjustment for waist circumference.

CONCLUSIONS

In women and men, sitting time and TV viewing time were deleteriously associated with cardio-metabolic risk biomarkers, with sitting time having more consistent associations in both sexes and being independent of central adiposity. Preventive initiatives aimed at reducing sitting time should focus on both nonleisure and leisure-time domains.Sitting is ubiquitous in adults'' daily routines: watching television (TV), using computers, performing desk-bound occupational tasks, and commuting by automobile (1). The majority of studies on the metabolic consequences of sitting time have focused on associations with leisure-time sitting, primarily TV viewing time. High levels of TV viewing are associated with elevated risk of obesity, type 2 diabetes, and abnormal glucose metabolism (2–4); additionally, detrimental associations have been observed with continuous measures of glucose and insulin in healthy adults (5) and with waist circumference and systolic blood pressure in physically active men and women (4). Associations have generally been stronger and more consistent in women than in men (2,3).Prolonged sitting time is highly prevalent in contexts other than domestic TV viewing, including occupational sitting, which has been shown to be positively associated with a higher BMI, particularly in men (6). Studies examining sitting time across the whole day (including both leisure- and nonleisure contexts) have reported significant associations with overweight and obesity and with weight gain (7,8). However, the extent to which overall sitting time is associated with biomarkers of cardiovascular and diabetes risk has not been investigated. Furthermore, the extent to which both sitting and TV viewing time influence continuous measures of metabolic risk in the same population has not been explored.We examined concurrently the associations of sitting time and TV viewing time with biomarkers of cardio-metabolic risk (waist circumference, BMI, systolic and diastolic blood pressure, fasting serum triglycerides, HDL cholesterol, fasting and 2-h postload plasma glucose, and fasting serum insulin) in a large population-based sample of Australian women and men without diagnosed diabetes.     

Association of Vitamin D With Insulin Resistance and ��-Cell Dysfunction in Subjects at Risk for Type 2 Diabetes

OBJECTIVE

To examine cross-sectional associations of serum vitamin D [25-hydroxyvitamin D, 25(OH)D] concentration with insulin resistance (IR) and β-cell dysfunction in 712 subjects at risk for type 2 diabetes.

RESEARCH DESIGN AND METHODS

Serum 25(OH)D was determined using a chemiluminescence immunoassay. Insulin sensitivity/resistance were measured using the Matsuda insulin sensitivity index for oral glucose tolerance tests (IS_OGTT) and homeostasis model assessment of insulin resistance HOMA-IR. β-Cell function was determined using both the insulinogenic index (IGI) divided by HOMA-IR (IGI/IR) and the insulin secretion sensitivity index-2 (ISSI-2).

RESULTS

Linear regression analyses indicated independent associations of 25(OH)D with IS_OGTT and HOMA-IR (β = 0.004, P = 0.0003, and β = −0.003, P = 0.0072, respectively) and with IGI/IR and ISSI-2 (β = 0.004, P = 0.0286, and β = 0.003, P = 0.0011, respectively) after adjusting for sociodemographics, physical activity, supplement use, parathyroid hormone, and BMI.

CONCLUSIONS

Vitamin D may play a role in the pathogenesis of type 2 diabetes, as 25(OH)D concentration was independently associated with both insulin sensitivity and β-cell function among individuals at risk of type 2 diabetes.Emerging evidence suggests a role for vitamin D in the etiology of type 2 diabetes (1). However, associations of vitamin D with insulin resistance (IR) and especially β-cell dysfunction have been inconsistent (2–7). Therefore, our objective was to assess the association of serum vitamin D concentration with IR and β-cell dysfunction in a large, ethnically-diverse, North American cohort at risk of type 2 diabetes.     

Insulin Therapy in People With Type 2 Diabetes: Opportunities and Challenges?

Given the continued interest in defining the optimal management of individuals with type 2 diabetes, the Editor of Diabetes Care convened a working party of diabetes specialists to examine this topic in the context of insulin therapy. This was prompted by recent new evidence on the use of insulin in such people. The group was aware of evidence that the benefits of insulin therapy are still usually offered late, and thus the aim of the discussion was how to define the optimal timing and basis for decisions regarding insulin and to apply these concepts in practice. It was noted that recent evidence had built upon that of the previous decades, together confirming the benefits and safety of insulin therapy, albeit with concerns about the potential for hypoglycemia and gain in body weight. Insulin offers a unique ability to control hyperglycemia, being used from the time of diagnosis in some circumstances, when metabolic control is disturbed by medical illness, procedures, or therapy, as well as in the longer term in ambulatory care. For those previously starting insulin, various other forms of therapy can be added later, which offer complementary effects appropriate to individual needs. Here we review current evidence and circumstances in which insulin can be used, consider individualized choices of alternatives and combination regimens, and offer some guidance on personalized targets and tactics for glycemic control in type 2 diabetes.     

Risk Factors for the Relapse of Graves’ Disease Treated With Antithyroid Drugs: A Systematic Review and Meta-analysis

PurposeAntithyroid drugs (ATDs) are the first-line treatment for Graves’ disease (GD). A common problem with ATD treatment is the high relapse rate after drug withdrawal. The goal of this study was to analyze the influencing factors for the relapse of GD patients treated with ATD by using a systematic review and meta-analysis, provide some predictive indexes for the susceptibility of GD recurrence, and then further explore some useful methods to decrease the GD relapse rate after ATD treatment.MethodsArticles published in PubMed, EMBASE, The Cochrane Library, China National Knowledge Infrastructure, Wan Fang, and Chinese Biomedical Literature databases before January 2019 were collected. Patients newly diagnosed with GD, who were aged >16 years, were treated with ATD. Follow-up was then conducted for at least 12 months after ATD withdrawal. Only prospective or retrospective studies were eligible. The primary end point was the recurrence of GD during follow-up. All the data from the trials were analyzed via meta-analysis and meta-regression. p values < 0.05 were considered statistically significant, and statistical heterogeneity was assessed by using I² statistics.FindingsA total of 20 studies and 3242 patients were involved in this meta-analysis, with 1681 patients relapsed (incidence rate, 51.9%) during the follow-up time. Analysis of risk factors suggested that younger age (weighted raw mean difference [RMD], −3.51; 95% CI, −5.74 to −1.29), larger thyroid volume (RMD, 4.38; 95% CI, 1.68 to 7.08), bigger goiter size (1.94% risk; 95% CI, 0.43 to 3.46), higher free triiodothyronine level (RMD, 5.09; 95% CI, 4.42 to 5.77), and higher free thyroxine level (RMD, 4.21; 95% CI, 0.54 to 7.89) were associated with the higher relapse rate of GD. The block-replace ATD regimen (a fixed high dose of an ATD with levothyroxine supplementation to maintain euthyroidism) (risk ratio, 0.64; 95% CI, 0.52 to 0.78) exhibits a lower relapse rate than the titration regimen (an ATD used alone and dose adjusted according to thyroid function tests).ImplicationsThis analysis revealed that certain risk factors were associated with GD relapses such as younger age, larger goiter size or thyroid volume, and the higher free triiodothyronine or free thyroxine level in the diagnosing phase of GD. For patients with these clinical characteristics, early definitive treatment with radioactive iodine or surgery should be offered to those who are unlikely to achieve remission with ATDs only. In addition, more prospective cohort studies with different ATD regimens would help to determine the optimum ATD treatment for patients with GD. PROSPERO identifier: CRD 42019146825.     

Low Carbohydrate–Diet Scores and Long-term Risk of Type 2 Diabetes Among Women With a History of Gestational Diabetes Mellitus: A Prospective Cohort Study

OBJECTIVE

Low-carbohydrate diets (LCDs) may improve short-term glycemic control in patients with gestational diabetes mellitus (GDM), but the long-term effect on progression from GDM to type 2 diabetes mellitus (T2DM) is unknown. We aimed to examine the long-term risk of T2DM in association with a low-carbohydrate dietary pattern among women with a history of GDM.

RESEARCH DESIGN AND METHODS

Overall, 4,502 women with a history of GDM from the Nurses'' Health Study II (NHSII) cohort, as part of the Diabetes & Women’s Health (DWH) study, were followed up from 1991 to 2011. Overall, animal, or vegetable LCD scores, which represent adherence to different low-carbohydrate dietary patterns, were calculated using diet intake information assessed every 4 years since 1991 by validated food-frequency questionnaires. We used Cox proportional hazards models to estimate hazard ratios (HRs) and 95% CIs.

RESULTS

We documented 722 incident cases of T2DM during 68,897 person-years of observation. The multivariable-adjusted HRs (95% CIs) of T2DM, comparing the highest with lowest quintiles, were 1.36 (1.04–1.78) for overall LCD score (P = 0.003 for trend), 1.40 (1.06–1.84) for animal LCD score (P = 0.004 for trend), and 1.19 (0.91–1.55) for vegetable LCD score (P = 0.50 for trend).

CONCLUSIONS

Among women with a history of GDM, a low-carbohydrate dietary pattern, particularly with high protein and fat intake mainly from animal-source foods, is associated with higher T2DM risk, whereas a low-carbohydrate dietary pattern with high protein and fat intake from plant-source foods is not significantly associated with risk of T2DM.     

Are the Same Clinical Risk Factors Relevant for Incident Diabetes Defined by Treatment,Fasting Plasma Glucose,and HbA1c?

OBJECTIVE

To compare incidences and risk factors for diabetes using seven definitions, with combinations of pharmacological treatment, fasting plasma glucose (FPG) ≥7.0 mmol/L, and HbA_1c ≥6.5%.

RESEARCH DESIGN AND METHODS

Participants aged 30–65 years from the Data from an Epidemiological Study on the Insulin Resistance Syndrome (DESIR) cohort were followed for 9 years.

RESULTS

More men had incident diabetes as defined by FPG ≥7.0 mmol/L and/or treatment than by HbA_1c ≥6.5% and/or treatment: 7.5% (140/1,867) and 5.3% (99/1,874), respectively (P < 0.009); for women incidences were similar: 3.2% (63/1,958) and 3.4% (66/1,954). Known risk factors predicted diabetes for almost all definitions. Among those with incident diabetes by FPG alone versus HbA_1c alone, there were more men (78 vs. 35%), case patients were 8 years younger, and fewer were alcohol abstainers (12 vs. 35%) (all P < 0.005). A diabetes risk score discriminated well between those with and without incident diabetes for all definitions.

CONCLUSIONS

In men, FPG definitions yielded more incident cases of diabetes than HbA_1c definitions, in contrast with women. An FPG-derived risk score remained relevant for HbA_1c-defined diabetes.HbA_1c is proposed as the first of four diagnostic criteria for diabetes (1). Risk factors for diabetes as defined by self-reported diabetes, by treatment, by fasting plasma glucose (FPG), or by both fasting and 2-h glucose following an oral glucose tolerance test have been well studied, including in our own cohort (2–6). Risk factors for different definitions have not been compared; it is tacitly assumed they are the same.We compare seven definitions of diabetes, using combinations of pharmacologic treatment, FPG ≥7.0 mmol/L, and HbA_1c ≥6.5% to evaluate the incidences of diabetes and compare baseline risk factors for men and women separately. Furthermore, we evaluate the odds ratios of risk factors and the ability of the Data from an Epidemiological Study on the Insulin Resistance Syndrome (DESIR) clinical risk factor score (2) to discriminate those with and without incident diabetes.     

Preterm Birth—A Risk Factor for Type 2 Diabetes?: The Helsinki Birth Cohort Study

OBJECTIVE

The association between low birth weight and type 2 diabetes is well established. We studied whether preterm birth carries a similar risk.

RESEARCH DESIGN AND METHODS

The Helsinki Birth Cohort includes 13,345 men and women born between 1934 and 1944. Of them, 12,813 had adequate data on length of gestation, which we linked with data on special reimbursement for diabetes medication.

RESULTS

Of the subjects, 5.1% had received special reimbursement after age 40. In subjects born before 35 weeks of gestation, the odds ratio for diabetes was 1.68 (95% CI 1.06–2.65) compared with that in those born at term. After adjustment for birth weight relative to length of gestation, the odds ratio was 1.59 (1.00–2.52).

CONCLUSIONS

Preterm birth before 35 weeks of gestation is associated with an increased risk of type 2 diabetes in adult life. The risk is independent of that associated with slow fetal growth.Low birth weight is a risk factor for type 2 diabetes (1,2). It can be a consequence of slow fetal growth, short gestation, or both. Although the link between type 2 diabetes and slow fetal growth is well established, the link between it and preterm birth has been much less studied (1). Most, although not all (3), of the few existing studies support increasing rates of diabetes in people born preterm, but they have limitations: two focus on severe prematurity (4,5), one is limited to diagnoses in a hospital discharge register (6), and one is based on self-report (7). We assessed whether the rates of type 2 diabetes, according to special medication reimbursement, differ according to gestational age at birth.     

What Factors Are Associated With the Recovery of Autonomy After a Hip Fracture? A Prospective,Multicentric Cohort Study

Objective

To identify the factors associated with recovering autonomy in activities of daily living (ADL) in patients who have had a hip fracture.

Guidelines for the Management of Severe Head Injury: Are Emergency Physicians Following Them?

The Brain Trauma Foundation published "Guidelines for the Management of Severe Head Injury" in 1995. These evidence-based clinical guidelines (CGs) recommended against prophylactic hyperventilation and glucocorticoid use and advocated for aggressive blood pressure (BP) resuscitation, and the careful use of mannitol. OBJECTIVE: To survey Michigan emergency physicians (MEPs) to test their adherence to these guidelines. METHODS: An anonymous mail survey was sent to all 566 MEPs who are members of the American College of Emergency Physicians. Three clinical scenarios involving severe head injury were presented, all with Glasgow Coma Scale (GCS) scores of 8 or less. The physicians were asked to choose from 15 diagnostic and treatment options, which included: intubation and hyperventilation, BP resuscitation, intravenous (IV) mannitol administration, and IV glucocorticoid administration. RESULTS: Three hundred nineteen (56%) surveys were returned. Forty-six percent [95% confidence interval (95% CI) = 40% to 51%] of the MEPs elected to use prophylactic hyperventilation; very few administered IV glucocorticoids. Seventy-eight percent (95% CI = 75% to 81%) corrected hypotension with systolic BP < 90 mm Hg; 83% (95% CI = 80% to 86%) also administered mannitol appropriately. CONCLUSIONS: A majority of MEPs are managing severe head injury patients in accordance with the "Guidelines for the Management of Severe Head Injury," with the exception of avoiding prophylactic hyperventilation. More education and/or exposure to the evidence regarding prophylactic hyperventilation of severely head injured patients may improve adherence to the guidelines.     

Is Incretin-Based Therapy Ready for the Care of Hospitalized Patients With Type 2 Diabetes?: The time has come for GLP-1 receptor agonists!

Significant data suggest that overt hyperglycemia, either observed with or without a prior diagnosis of diabetes, contributes to an increase in mortality and morbidity in hospitalized patients. In this regard, goal-directed insulin therapy has remained as the standard of care for achieving and maintaining glycemic control in hospitalized patients with critical and noncritical illness. As such, protocols to assist in the management of hyperglycemia in the inpatient setting have become commonplace in hospital settings. Clearly, insulin is a known entity, has been in clinical use for almost a century, and is effective. However, there are limitations to its use. Based on the observed mechanisms of action and efficacy, there has been a great interest in using incretin-based therapy with glucagon-like peptide-1 (GLP-1) receptor agonists instead of, or complementary to, an insulin-based approach to improve glycemic control in hospitalized, severely ill diabetic patients. To provide an understanding of both sides of the argument, we provide a discussion of this topic as part of this two-part point-counterpoint narrative. In this point narrative as presented below, Drs. Schwartz and DeFronzo provide an opinion that now is the time to consider GLP-1 receptor agonists as a logical consideration for inpatient glycemic control. It is important to note the recommendations they propose under “incretin-based approach” with these agents represent their opinion for use and, as they point out, well-designed prospective studies comparing these agents with insulin will be required to establish their efficacy and safety. In the counterpoint narrative following Drs. Schwartz and DeFronzo’s contribution, Drs. Umpierrez and Korytkowski provide a defense of insulin in the inpatient setting as the unquestioned gold standard for glycemic management in hospitalized settings.—William T. CefaluEditor in Chief, Diabetes CareControversy exists concerning the role of intensified glycemic control in critically ill, hospitalized diabetic patients (1,2). Results with insulin therapy largely have been disappointing. In the current point-counterpoint debate, we advocate and provide evidence to support the use of glucagon-like peptide-1 (GLP-1) analogs because of their ability to control stress-induced hyperglycemia with minimal side effects, especially hypoglycemia.     

Is the Combination of Sulfonylureas and Metformin Associated With an Increased Risk of Cardiovascular Disease or All-Cause Mortality?: A meta-analysis of observational studies

OBJECTIVE—Observational studies assessing the association of combination therapy of metformin and sulfonylurea on all-cause and/or cardiovascular mortality in type 2 diabetes have shown conflicting results. We therefore evaluated the effects of combination therapy of sulfonylureas and metformin on the risk of all-cause mortality and cardiovascular disease (CVD) among people with type 2 diabetes.RESEARCH DESIGN AND METHODS—A MEDLINE search (January 1966–July 2007) was conducted to identify observational studies that examined the association between combination therapy of sulfonylureas and metformin on risk of CVD or all-cause mortality. From 299 relevant reports, 9 were included in the meta-analysis. In these studies, combination therapy of metformin and sulfonylurea was assessed, the risk of CVD and/or mortality was reported, and adjusted relative risk (RR) or equivalent (hazard ratio and odds ratio) and corresponding variance or equivalent was reported.RESULTS—The pooled RRs (95% CIs) of outcomes for individuals with type 2 diabetes prescribed combination therapy of sulfonylureas and metformin were 1.19 (0.88–1.62) for all-cause mortality, 1.29 (0.73–2.27) for CVD mortality, and 1.43 (1.10–1.85) for a composite end point of CVD hospitalizations or mortality (fatal or nonfatal events).CONCLUSIONS—The combination therapy of metformin and sulfonylurea significantly increased the RR of the composite end point of cardiovascular hospitalization or mortality (fatal and nonfatal events) irrespective of the reference group (diet therapy, metformin monotherapy, or sulfonylurea monotherapy); however, there were no significant effects of this combination therapy on either CVD mortality or all-cause mortality alone.Type 2 diabetes is associated with increased risk of all-cause mortality and cardiovascular disease (CVD). However, clinical trials to date have not demonstrated that achieving normal glucose levels can reduce the risk for cardiovascular events.In the UK Prospective Diabetes Study (UKPDS), intensive blood glucose reduction was achieved using metformin therapy in diet-treated overweight patients, resulting in a decreased risk of myocardial infarction and all-cause mortality. However, when a combination of metformin and sulfonylurea was prescribed in the same trial for glycemic control, there was a significant increased risk of diabetes-related death and all-cause mortality rather than a beneficial effect, a finding attributed by the investigators to be due to chance (1). In the UKPDS, sulfonylureas themselves were not associated with the risk of diabetes-related death or myocardial infarction (2), but in previous studies such as the University Group Diabetes Program (UGDP) some increased risk was seen (3), and a warning about increased risk of CVD is included in the Federal Drug Administration–approved label for this class of drugs.A recent systematic review of clinical trials of diabetes therapies noted that data on long-term outcomes were not available in most clinical trials (4). Observational studies investigating the association between combination therapy of metformin and sulfonylureas and risk of CVD and mortality have reported conflicting results. Some studies have reported that the use of this combination therapy increases the risk of all-cause and CVD mortality (5), while others have reported no association (6,7) or a decreased risk of mortality from all causes and CVD (8). Since these are likely the most commonly prescribed medications for type 2 diabetes, the possible increase in risk of all-cause mortality and cardiovascular events is troubling (1).Given these inconsistencies in the literature and the lack of clinical trials assessing the long-term effects of combination therapy of sulfonylureas and metformin, we conducted a meta-analysis of observational studies to examine the association between combination therapy of sulfonylureas and metformin and risk of CVD and all-cause mortality.     

What Elements of the Informational,Management, and Relational Continuity Are Associated With Patient Satisfaction With Rehabilitation Care and Global Rating Change?

Objective

To describe the quality of patients' continuity experiences in a population of outpatients receiving postacute rehabilitation care, and to check which elements and types of continuity most strongly determine their satisfaction with care and functional changes.

Design

Cross-sectional self-report survey.

Setting

Three postacute ambulatory centers in metropolitan areas.

Participants

Outpatients (N=218; mean age ± SD, 38.5±11.7y).

Interventions

Not applicable.

Main Outcome Measures

The questionnaire included experiences regarding aspects of informational (transference of information, accumulated knowledge), management (consistency and flexibility of care), and relational (established relation and consistency of provider) continuity, as well as questions concerning patients' sociodemographic characteristics, satisfaction with care, and global rating change.

Results

Respondents indicated more problems in terms of management and relational continuity than in informational continuity. For all patient groups, experiences regarding elements of management continuity (R²=15.3%–22.4%), followed by relational continuity (R²=14.3%–25.2%), explained most of the variance of satisfaction. Consistency and flexibility of care, together with an established relation, were the most determining elements of satisfaction. Experiences regarding elements of management continuity explained most of the variance of change (18.5%), and flexibility was the most decisive element.

Conclusions

Patient satisfaction and functional changes are related with experiences in aspects of management continuity, where there is room for improvement. Measures of management continuity may be promising as indicators of continuity, and they should be prioritized.