Renal haemodynamic response to sodium-glucose cotransporter-2 inhibition does not depend on protein intake: An analysis of three randomized controlled trials

High protein intake may increase intraglomerular pressure through dilation of the afferent arteriole. Sodium-glucose cotransporter-2 (SGLT2) inhibitors may reduce intraglomerular pressure through activation of tubuloglomerular feedback. Given these opposing effects, we assessed whether the effect of dapagliflozin on glomerular filtration rate (GFR) and urinary albumin-to-creatinine ratio (UACR) was modified by estimated dietary protein intake using data from three separate randomized controlled trials (DELIGHT, IMPROVE and DIAMOND). The median protein intake was 58.4, 63.6 and 90.0 g/d, respectively. In the DELIGHT trial (n = 233), dapagliflozin compared to placebo caused an acute and reversible dip in GFR of 2.1 and 2.2 mL/min/1.73 m², and reduced UACR by 20.5% and 28.4% in participants with high and low protein intake, respectively. Similarly, in IMPROVE (n = 30) and DIAMOND (n = 53), the effect of dapagliflozin on GFR and UACR was comparable in participants with high and low protein intake (all P for interaction > 0.40). This post hoc, exploratory analysis of three clinical trials suggests that dietary protein intake does not modify the individual response of clinical kidney variables to dapagliflozin.     

Does systematically organized care improve outcomes for women with diabetes?

Objective To investigate whether financial reimbursement for a bundle of diabetes care items self‐reported by general practitioners (GPs) leads to improved outcomes for women with diabetes. Methods Longitudinal cohort study of women in the Australian Longitudinal Study on Women's Health aged 45–50 and 70–75 years when recruited in 1996. Outcomes Short Form 36‐item (SF‐36), Medicare and pharmaceutical benefits costs 2002–2005, uptake of annual cycle of care for diabetes (ACC). Results Annual cycle of care claims were identified for 23% of 388 mid‐age, and 40% of 616 older women with diabetes. ACC was not associated with statistically significantly higher costs in either group. Women for whom the GP had received an ACC fee were more likely to have been overweight, had more GP visits, more medications, and more ‘no cost’ visits. Unlike older women, mid‐age women for whom the GP had received an ACC fee were more likely to have difficulty managing on their income and tended to have worse physical and social function scores prior to the time the ACC was introduced and compared with other women with diabetes continued to have poorer scores at subsequent surveys. There was no association between ACC, co‐morbidities or country of birth. Women who developed diabetes after the first survey (incident cases) tended to have better SF‐36 health profile scores and lower costs than those who reported diabetes on the first survey (prevalent cases). Conclusions General practitioners of women with diabetes, who have more health care encounters and poorer health‐related quality of life, have adopted ACC with little impact on the decline in quality of life of the women nor on health care costs.     

Missing in Action: A Case Study of the Application of Methods for Dealing With Missing Data to Trauma System Benchmarking

Background: Trauma registry data are usually incomplete. Various methods for dealing with missing data have been used, some of which lead to biased results. One method that reduces bias, multiple imputation (MI), has not been widely adopted. There is no standardization of the approach to missing data across trauma registries. Objectives: This study examined the effect of using selected methods for handling missing data on a recognized trauma outcome measure. Methods: Data from the Victorian State Trauma Registry (VSTR) were used for the period July 2003 to June 2008. Three methods for handling missing data were investigated: complete case analysis, single imputation, and MI. The latter was applied using five distinct models, each with a different combination of variables (Trauma and Injury Severity score [TRISS] variables; prehospital Glasgow Coma Scale [GCS], respiratory rate, and systolic blood pressure; arrival by ambulance; transfer to a second hospital; and whether the GCS was “legitimate” according to the TRISS definition). For each method, TRISS analysis (comparing actual and expected deaths) was performed; the W‐score and Z‐statistic were derived. A Z‐statistic greater than 1.96 in absolute value was considered statistically significant. Results: Of 10,180 cases, 2,398 (24%) were missing at least one of the component variables necessary for TRISS analysis. With the use of complete case analysis, the W‐score was 0.54 unexpected survivors for every 100 cases, with a Z‐statistic of ?1.96. Using two approaches to single imputation, the W‐scores were ?1.41, with Z‐statistics of ?5.19 and ?5.30. Applying four of the five combinations of variables used for MI, there was a statistically significant number of unexpected survivors (W = ?0.60, Z = ?2.23; W = ?0.52, Z = ?1.97; W = ?0.53, Z = ?1.97; W = ?0.63, Z = ?2.24). However, using MI confined to TRISS variables only, there was a statistically significant number of unexpected deaths (W = +0.52, Z = +1.98). Conclusions: Missing data methods can influence the assessment of trauma care performance and need to be reported in all analyses. It is important that validated standardized approaches to dealing with missing data are universally adopted and reported. ACADEMIC EMERGENCY MEDICINE 2010; 17:1122–1129 © 2010 by the Society for Academic Emergency Medicine     

Modelled economic evaluation of a virtual emergency department in Victoria

Objective

Virtual ED (VED) can potentially alleviate ED overcrowding which has been a public health challenge. The aim of the present study was to conduct a return-on-investment analysis of a VED programme developed in response to changing healthcare needs in Australia.

Methods

An economic model was developed based on initial patient outcome data to assess the healthcare costs, potential costs saved and return on investment (ROI) from the VED. The VED programme operating as part of Alfred Health Emergency Services. The participants were the first 188 patients accessing the Alfred Health VED. VED is the delivery of emergency assessment and management of specific patients virtually via audio-visual teleconferencing. ROI ratios that compare cost savings with intervention costs.

Results

The mean total operational cost of VED for 79 days for 188 patients was A$344 117 (95% uncertainty interval [UI] $296 800–$392 088). The VED led to a potential A$286 779 (95% UI $241 688–$330 568) healthcare cost saving from reductions in emergency visits and A$97 569 (95% UI $74 233–$123 117) cost saving in ambulance services. The ROI ratio was estimated at 1.12 (95% UI 0.96–1.32).

Conclusions

The VED was cost neutral in a conservatively modelled scenario but promising if any hospital admission could be saved. Ongoing research examining a larger cohort with community follow up is required to confirm this promising result.