Feasibility of using self-reported patient data in a national diabetes register

Background

In order to improve recruitment of patients to the Norwegian diabetes register for adults, a questionnaire was designed to collect data directly from patients. The main aim of this study was to assess the agreement of questionnaire data with data reported to the Register from health care personnel during routine consultations.

Methods

Patient data were obtained by sending a questionnaire with 27 of the 41 Register variables to 3714 members of the Norwegian Diabetes Association. Questionnaire data were compared with data already in the Register. Paired t-tests, percentages of total agreement, percentages of “positive” answers and kappa coefficients (k) were used for comparing data.

Results

Of the 1645 replies (44.3 %), the Register already had data on 324 patients for comparison. Response rate for most variables was better from patients (ranging from 76–100 %) compared with health care professionals (33–100 %). For 17 of 25 assessable variables including diabetes duration, height, weight, HbA1c, drug treatment and several diabetes complications, agreement was substantial or better with kappa >0.60. Data on family history of premature heart disease (k–0.59), foot examination (k = 0.26), foot ulcer (k = 0.32) and arterial surgery (k = 0.24) seemed to be difficult to answer by patients, whereas data on physical activity and self-monitoring of glucose seemed to be better when reported by patients.

Conclusions

Patient response rate was acceptable, and data had good concordance with data from health care professionals for most variables. However, registers using patient questionnaires should compare questionnaire data with data from professionals at regular intervals.

Glycaemic control of Type 1 diabetes in clinical practice early in the 21st century: an international comparison

AIMS

Improving glycaemic control in people with Type 1 diabetes is known to reduce complications. Our aim was to compare glycaemic control among people with Type 1 diabetes using data gathered in regional or national registries.

METHODS

Data were obtained for children and/or adults with Type 1 diabetes from the following countries (or regions): Western Australia, Austria, Denmark, England, Champagne-Ardenne (France), Germany, Epirus, Thessaly and Thessaloniki (Greece), Galway (Ireland), several Italian regions, Latvia, Rotterdam (The Netherlands), Otago (New Zealand), Norway, Northern Ireland, Scotland, Sweden, Volyn (Ukraine), USA and Wales) from population or clinic-based registries. The sample size with available data varied from 355 to 173 880. Proportions with HbA1c < 58 mmol/mol (< 7.5%) and ≥ 75 mmol/mol (≥ 9.0%) were compared by age and sex.

RESULTS

Data were available for 324 501 people. The proportions with HbA1c 58 mmol/mol (< 7.5%) varied from 15.7% to 46.4% among 44 058 people aged < 15 years, from 8.9% to 49.5% among 50 766 people aged 15-24 years and from 20.5% to 53.6% among 229 677 people aged ≥ 25 years. Sex differences in glycaemic control were small. Proportions of people using insulin pumps varied between the 12 sources with data available.

CONCLUSION

These results suggest that there are substantial variations in glycaemic control among people with Type 1 diabetes between the data sources and that there is room for improvement in all populations, especially in young adults.

The epidemiology and management of adult poisonings admitted to the short-stay ward of a large Scottish emergency department

BACKGROUND AND AIMS

The emergency department of Aberdeen Royal Infirmary receives around 68,000 new adult admissions annually. All poisoning cases are admitted to a 14-bedded short-stay ward, except those admitted to intensive care or immediately discharged. This study aimed to analyse epidemiological trends and management of short-stay ward admissions for poisonings.

METHOD AND RESULTS

Adult (>13 years) poisoning presentations admitted to the emergency department short-stay ward of Aberdeen Royal Infirmary from 1 January-31 December 2009 were retrospectively reviewed using patient discharge summaries. During 2009, there were 1062 poisoning cases, of which repeat episodes were responsible for 15%. The mean age of presentation was 33.9 years (SD 14.4) and there was a female preponderance (62%). Almost half of poisonings were polypharmacy, alcohol was involved in 40% of cases and overdoses most commonly involved paracetamol (43%). Management involved basic observations only (66%), N-acetylcysteine (24%), naloxone (4%) and activated charcoal (1%). Liaison psychiatry reviewed 84% presentations and admitted 9% to the psychiatric unit.

CONCLUSIONS

The short-stay ward is important for acute management of poisonings and the data gained from this study should help to direct patient services appropriately.

Treatment of type 1 diabetes in the specialist health service--data from the Norwegian Diabetes Register for Adults

BACKGROUND

The Norwegian Diabetes Register for Adults was established in 2005. The aim of the study is to assess the quality of treatment for adult patients with type 1 diabetes in the specialist health service based on register data.

MATERIAL AND METHOD

We included patients ≥ 18 years with type 1 diabetes in the specialist health service for whom the register has data for the period from 1 July 2010-to 31 December 2011. The patients were asked to consent to the transfer of data to the register when they attended a routine consultation. As of 31 December 2011, 95% of the patients asked gave their consent. It is not known how large a proportion of patients were asked.

RESULTS

We included the last registered data for 3,697 patients (46.8% women) from 24 outpatient clinics and specialist centres. The average age was 41.8 years and the average duration of diabetes was 20.8 years. Median HbA1c, systolic blood pressure and LDL cholesterol were 8.0%, 126 mm Hg and 2.8 mmol/l respectively. 9.8% achieved all treatment targets set out in the national guidelines for diabetes. 18% had HbA1c ≤ 7.0%, while 22% had HbA1c ≥ 9%. 39% of patients on statin therapy achieved the treatment target for LDL cholesterol. 19.6% smoked on a daily basis. 14.9% had received treatment for retinopathy and 5.8% had experienced coronary heart disease. There was no record of foot examination or ophthalmoscopy being performed in 33% and 29% of patients.

INTERPRETATION

The preliminary register data indicate that diabetes treatment should be improved both with respect to the implementation of recommended procedures and the proportion of patients who achieve the treatment targets.

The Norwegian Diabetes Register for Adults – an overview of the first years

The Norwegian Diabetes Register for Adults (NDR-A) was granted status as a consent-based National Quality Register by the Ministry of Health and Care Services and approved by the Data Inspectorate in 2005. The main aim of the register is to improve the quality of the treatment of people with diabetes in hospitals and primary care. NDR-A is the first national quality register in Norway to capture all data electronically, and it is also the first register to collect data from both primary health care and hospital/specialist services. We therefore think that experiences gained from developing and promoting the register will be of general interest. In this paper we describe the reasons for establishing the register, the register population and dataset, the electronic tools used for data capture, how recruitment is progressing, how we think the register can improve the care of patients with diabetes, and possibilities for future epidemiological research.

Pharmacological primary and secondary cardiovascular prevention among diabetic patients in a multiethnic general practice population: still room for improvements

BACKGROUND

Ethnic minority groups have higher prevalence of cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM). We assessed general practitioners' (GPs') performance with respect to the pharmacological prevention of CVD in patients with T2DM from different ethnic backgrounds in Oslo.

METHODS

Of 1653 T2DM patients cared for by 49 GPs in 2005, 380 had a diagnosis of CVD. Ethnicity was categorized as Norwegian, South Asian and other. Risk factor levels, medication use, achievement of treatment targets (HbA1c ≤ 7.5%, systolic blood pressure (SBP) ≤ 140 mmHg, total cholesterol/HDL-cholesterol < 4) and therapeutic intensity (number of drugs targeting each risk factor) were recorded. Chi-square, Wald tests and multiple linear regression analyses were used.

RESULTS

Of the 1273 patients receiving primary prevention, 1.5% had their Hb1Ac, 4.8% SBP and 12.7% lipids levels above treatment thresholds without relevant prescriptions. Among patients on pharmacological therapy, 66% reached the HbA1c, 62% SBP and 62% lipid target. Proportions not achieving the HbA1c target were 26% in Norwegians, 38% in South Asians and 29% in others (p = 0.008). Proportions not achieving the SBP target were 42% in Norwegians, 22% in South Asians and 25% in others (p ≤ 0.001). Of those not achieving the HbA1c and SBP targets, 43% and 35% respectively, used only one agent.

CONCLUSIONS

Norwegian GPs comply reasonably well with guidelines for pharmacological prevention of CVD in T2DM patients across ethnic groups. However, lipid-lowering therapy was generally underused, and the achievement of treatment targets for HbA1c in ethnic minorities and for BP in Norwegians could be improved.

Sledging is still a seasonal source of serious injury in Scottish children

In 2002 it was highlighted that sledging results in serious injuries in the paediatric population and safety recommendations were made. The aim of this study was to re-examine the number, severity and aetiology of sledging-related trauma. This was a retrospective study performed in the Paediatric Emergency Department (PED) of the Royal Aberdeen Children's Hospital (RACH) during two periods totalling 12 days, when there was continuous snow ground cover. Records of all attendances were scrutinized to identify patients with sledging injuries. The nature, mechanism and severity of injury, and subsequent management were then analysed. Of 403 PED attendances, 45 (11%) were sledging related with 16 (36%) fractures and 13 (29%) head injuries. Eight patients (18%) were admitted to hospital and three (7%) required an operation. Collision with a stationary object was the most common reason for injury (51%), followed by the adoption of a dangerous sledging position or use of a stationary jump. No patients were wearing a helmet. In conclusion, there has been little change in the epidemiology and aetiology of paediatric sledging injuries since 2002. Work is needed to inform parents of the previously recommended safety measures that could reduce the morbidity of this activity without detracting from the enjoyment.

Quality of care for patients with type 2 diabetes in general practice according to patients' ethnic background: a cross-sectional study from Oslo, Norway

Background

In recent decades immigration to Norway from Asia, Africa and Eastern Europe has increased rapidly. The aim of this study was to assess the quality of care for type 2 diabetes mellitus (T2DM) patients from these ethnic minority groups compared with the care received by Norwegians.

Methods

In 2006, electronic medical record data were screened at 11 practices (49 GPs; 58857 patients). 1653 T2DM patients cared for in general practice were identified. Ethnicity was defined as self-reported country of birth. Chi-squared tests, one-way ANOVAs, multiple regression, linear mixed effect models and generalized linear mixed models were used.

Results

Diabetes was diagnosed at a younger age in patients from the ethnic minority groups (South Asians (SA): mean age 44.9 years, Middle East/North Africa (MENA): 47.2 years, East Asians (EA): 52.0 years, others: 49.0 years) compared with Norwegians (59.7 years, p < 0.001). HbA1c, systolic blood pressure (SBP) and s-cholesterol were measured in >85% of patients in all groups with minor differences between minority groups and Norwegians. A greater proportion of the minority groups were prescribed hypoglycaemic medications compared with Norwegians (≥79% vs. 72%, p < 0.001). After adjusting for age, gender, diabetes duration, practice and physician unit, HbA1c (geometric mean) for Norwegians was 6.9% compared to 7.3-7.5% in the minority groups (p < 0.05). The proportion with poor glycaemic control (HbA1c > 9%) was higher in minority groups (SA: 19.6%, MENA: 18.9% vs. Norwegians: 5.6%, p < 0.001. No significant ethnic differences were found in the proportions reaching the combined target: HbA1c ≤ 7.5%, SBP ≤ 140 mmHg, diastolic blood pressure (DBP) ≤ 85 mmHg and total s-cholesterol ≤5.0 mmol/L (Norwegians: 25.5%, SA: 24.9%, MENA: 26.9%, EA: 26.1%, others:17.5%).

Conclusions

Mean age at the time of diagnosis of T2DM was 8-15 years younger in minority groups compared with Norwegians. Recording of important processes of care measures is high in all groups. Only one in four of most patient groups achieved all four treatment targets and prescribing habits may be sub-optimal. Patients from minority groups have worse glycaemic control than Norwegians which implies that it might be necessary to improve the guidelines to meet the needs of specific ethnic groups.

[Quality of diabetes care in Norwegian general practice]

BACKGROUND

The prevalence of diabetes is increasing. Good diabetes care reduces macro and microvascular complications. Quality of care was assessed against predefined review criteria based on key recommendations in national guidelines

MATERIAL AND METHODS

A cross-sectional study from four geographical areas in Norway, with electronic identification of all patients with diabetes mellitus and extraction of data from electronic patient records. All data were manually validated.

RESULTS

6892 patients with diabetes were identified, 5817 were cared for by the GPs and included in the study. 354 (6.0%) were classified as having type 1 diabetes and 5463 (94.0%) as type 2. For patients with type 1 mean Hb A1c was 7.8% and mean blood pressure 129/76 mm Hg; for type 2 the results were 7.1% and 139/79 mmHg. Among patients with type 2 diabetes and known cardiovascular disease, 69.7% were treated with statins and 60.6% with acetylsalicylic acid. About 90% of the study population had measured Hb A1c , blood pressure and lipids annually. 71% of patients with type 2 diabetes were referred to eye examination, smoking habits and weight were recorded in 57 and 54 % and urine albumin in 40% of the patients.

INTERPRETATION

The quality of care had improved substantially in 2005 from five and 10 years ago (when similar studies were performed), although 80 % of patients did not reach the combined treatment targets for Hb A1c , systolic blood pressure and total cholesterol.

Preoperative octreotide treatment in newly diagnosed acromegalic patients with macroadenomas increases cure short-term postoperative rates: a prospective, randomized trial

CONTEXT

Surgery is the primary treatment of acromegaly. However, it often fails to cure the patient. New strategies that improve surgical outcome are needed.

OBJECTIVE

Our objective was to investigate whether 6-month preoperative treatment with octreotide improves the surgical outcome in newly diagnosed acromegalic patients.

PATIENTS

During a 5-yr period (1999-2004), all newly diagnosed acromegalic patients between 18 and 80 yr of age in Norway were screened and invited to participate in the study. A total of 62 patients was included in the Preoperative Octreotide Treatment of Acromegaly study.

RESEARCH DESIGN AND METHODS

After a baseline evaluation, patients were randomized directly to transsphenoidal surgery (n = 30) or pretreatment with octreotide (n = 32) 20 mg im every 28th day for 6 months before transsphenoidal surgery. Cure was evaluated 3 months postoperatively primarily by IGF-I levels.

RESULTS

According to the IGF-I criteria, 14 of 31 (45%) pretreated patients vs. seven of 30 (23%) patients with direct surgery were cured by surgery (P = 0.11). In patients with microadenomas (< or = 10 mm), one of five (20%) pretreated vs. three of five (60%) with direct surgery were cured (P = 0.52). In patients with macroadenomas, 13 of 26 (50%) pretreated vs. four of 25 (16%) with direct surgery were cured (P = 0.017).

CONCLUSIONS

Six-month preoperative octreotide treatment might improve surgical cure rate in newly diagnosed acromegalic patients with macroadenomas. These results have to be confirmed in future studies.

[Hospital admission rates for cardiovascular diseases in Western Norway, 1992-2001]

BACKGROUND

The Regional Register of Cardiovascular Diseases of the Regional Health Authority of Western Norway was established to enable epidemiologic research on a national level before the recent advent of the Norwegian health register with personal identification. Hospital admission rates, and case-fatality were compared with regional mortality rates for cardiovascular diseases.

MATERIAL AND METHODS

The register contains data on 231,857 patients with cardiovascular diseases or diabetes mellitus admitted to hospitals in Western Norway (Rogaland, Hordaland and Sogn og Fjordane) 1972-2002. The hospital data were supplemented with data from the national cause of death register (national identification number was used to link up the information).

RESULTS

The admission rates for cardiovascular diseases increased moderately in Western Norway from 1992 through 2001. At the same time a marked reduction was seen in mortality rates for these diseases. For acute myocardial infarction, the admission rates decreased slightly from 1992 through 2000, and then increased in 2001. Case-fatality from acute infarction was substantially reduced throughout the decade, most notably for those aged 65 years or more. Among those who died of acute infarction the first 24 hours, the fraction who died outside of hospital was high (78.3%).

INTERPRETATION

Hospital admission rates for cardiovascular diseases do not parallel the simultaneous decrease in mortality rates. The Regional Register of Cardiovascular Diseases demonstrates the possibilities for etiological research and the limitation of mortality statistics alone.

How accurate are the references in Emergency Medical Journal?

OBJECTIVE

To determine the accuracy of references in Emergency Medicine Journal during 2003.

MATERIALS AND METHODS

All references cited in Emergency Medicine Journal during 2003 were examined carefully, and the accuracy of the citations was checked against reliable electronic and manual resources. References were categorised as correct or incorrect. The errors were classified as minor if the integrity of the reference was not greatly compromised and major if the error severely detracted from the quality of the reference.

RESULTS

Overall, errors were found in 19% of all citations checked (n = 2561), and in 8% the errors were major and markedly detracted from the quality of the reference.

CONCLUSIONS

Citation errors reflect badly on authors and the publishing journal and may reflect underlying flaws in other areas of the research published. It is hoped that identification of this problem will lead to attempts to improve the accuracy of reference citation in the emergency medicine literature and to an improvement in the credibility of research in our specialty.

Hyperphosphatemic familial tumoral calcinosis caused by a mutation in GALNT3 in a European kindred

Hyperphosphatemic familial tumoral calcinosis (HFTC) is an autosomal recessive metabolic disorder characterized by extensive phenotypic and genetic heterogeneity. HFTC was shown recently to result from mutations in two genes: GALNT3, coding for a glycosyltransferase responsible for initiating O-glycosylation, and FGF23, coding for a potent phosphaturic protein. All GALNT3 mutations reported so far have been identified in patients of either Middle Eastern or African-American extraction, corroborating numerous historical reports of the disorder in Africa and in the Middle East. In the present study, we describe a patient of Northern European origin displaying typical features of HFTC. Mutation analysis revealed that this patient carries a homozygous novel nonsense mutation in GALNT3 predicted to result in the synthesis of a significantly truncated protein. The present results expand the spectrum of known mutations in GALNT3 and demonstrate the existence of HFTC-causing mutations in this gene outside the Middle Eastern and African-American populations.

[Risk intervention in persons with diabetes mellitus in general practice]

BACKGROUND

Intervention against cardiovascular risk factors such as hypertension, dyslipidaemia and smoking is necessary to reduce the increased mortality associated with diabetes mellitus.

METHODS

The case notes of 2003 patients with diabetes in general practice in Rogaland, Salten and Aker were reviewed in order to assess the quality of diabetes care including the treatment of risk factors for cardiovascular disease.

RESULTS

287 out of 1417 patients below the age of 76 had known cardiovascular disease. Of these, 57.5% were treated with a statin and 61 % were taking aspirin. 118 patients had had a myocardial infarction, 69.5% were on a statin and 60.2% were taking aspirin. 776 (38.7%) of the patients in the study had been diagnosed as suffering from hypertension, 40.3% were on therapy with one anti-hypertensive agent, 28.6% received two agents and 12.1% were on three or more anti-hypertensive agents. Only 57.5% of patients, who according to current national guidelines ought to be on a statin as secondary prevention, received such a treatment. Smoking habits were recorded in 35.1% and weight in 45 % of the patients.

INTERPRETATION

There is considerable room for improvement with regard to intervention against known risk factors for cardiovascular disease in patients with diabetes treated in primary care.

Kaposiform haemangioendothelioma: case report and review of the literature

Kaposiform haemangioendothelioma (KHE) is a rare vascular tumour, predominantly of infancy and early childhood, that has a close association with Kasabach-Merritt syndrome. Despite benign histology, this tumour frequently behaves aggressively, causing significant morbidity and mortality as a result of the compression and invasion of surrounding structures as well as from associated haematological and lymphoproliferative syndromes. There is a need for a high index of suspicion when presented with large, enlarging or abnormal vascular lesions in infancy and, less commonly, in adulthood. An early diagnosis of KHE can lead to prompt treatment, which may be life saving. To date, there have been only four reported cases of KHE occurring in patients over the age of 18 years. We report an otherwise well 26-year-old woman who presented with a KHE of the left thigh, and briefly review the literature. We believe this to be the second reported case of KHE in the UK and the first in an adult patient.

Comparison of urinary albumin excretion rate in overnight urine and albumin creatinine ratio in spot urine in diabetic patients in general practice

OBJECTIVE

To evaluate whether measurement of albumin creatinine ratio (ACR) on a spot urine specimen can replace a timed overnight collection of urine albumin excretion rate (UAER) in patients with diabetes in primary care.

DESIGN

Patients with diabetes attending Rønvik Health Centre were asked to bring a timed overnight collection of urine for measurement of UAER. They were also asked to void a urine specimen for measurement of albumin creatinine ratio.

SETTING

Primary health care.

SUBJECTS

One-hundred-and-six persons with diabetes (47 women, 59 men) aged 13 to 78 years.

RESULTS

The sensitivity and specificity of ACR with cut-off values of 2.5 mg/mmol for men and 3.5 mg/mmol for women compared to UAER with cut-off value of 20 mg/24 h was 90%.

CONCLUSIONS

Spot urine ACR analysed on a DCA 2000 can replace a timed (overnight) collection of urine and measurement of UAER when diabetic patients are reviewed in general practice. This simplifies procedures for the patient as a timed urine collection is no longer necessary. Another advantage is that the results are available after 7 min.

Standards for the electronic health record, emerging from health care's Tower of Babel

This paper considers the standardization of an Electronic Health Record (EHR). Relations between several distinct medical datasets and information systems are mapped in order to derive a more precise definition of the EHR. Two international efforts to establish standards for the EHR are presented and critiqued. Strategies for standardizing the EHR are analyzed and recommendations are provided for approaching the standardization process.

[Guidelines for diagnosis and treatment of sore throat]

BACKGROUND

Available guidelines for the diagnosis and treatment of sore throat give conflicting recommendations. Our aim was to develop evidence-based guidelines.

MATERIAL AND METHODS

We searched The Cochrane Library, Medline and other sources for systematic reviews and other evidence that met explicit inclusion criteria for all of the relevant options and outcomes we identified. The validity of included studies was assessed. Draft recommendations based on assessment of this evidence were widely circulated and discussed in focus groups with patients and physician assistants.

RESULTS

Throat infections are self-limiting and complications rare. Penicillin shortens the duration of symptoms in tonsillitis caused by beta-haemolytic streptococci and reduces the risk of complications. Penicillin has adverse effects and increases the risk of reinfections. Patients with sore throat should usually be treated without antibiotics. Visiting a physician is normally unnecessary. Antibiotics should be considered in serious cases or if the patient prefers this, but should only be prescribed for throat infections caused by beta-haemolytic streptococci. The diagnosis should be based on clinical criteria and a rapid antigen test in cases of doubt.

INTERPRETATION

Benefits of antibiotics must be weighed against harms. Patients should be given good information and involved in decision/making if they want antibiotics.