Cardiovascular morbidity and mortality in patients with type 2 diabetes using novel antidiabetic medicines as add-on therapy: an observational real-world study

OBJECTIVE

To evaluate the effect of sodium-glucose co-transporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA), compared with dipeptidyl peptidase-4 inhibitors (DPP-4i) as add-on therapy on cardiovascular (CV) morbidity and mortality in patients with type 2 diabetes (T2D).

DESIGN AND SETTING

A nationwide cohort study using three linked healthcare databases from Slovenia (outpatient prescription claims data, hospitalisation claims data and death registry data).

PARTICIPANTS

Patients with T2D with newly introduced DPP-4i (n=3817), GLP-1RA (n=855) or SGLT2i (n=2851) add-on therapy between June 2014 and June 2018.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was a major adverse CV event (MACE), while the secondary outcomes were CV death and heart failure (HF). The effects of the antidiabetic medicine group on the risk of each outcome were estimated with Cox proportional hazards regression. Intention-to-treat and on-treatment approaches were used.

RESULTS

In the intention-to-treat analysis, SGLT2i as add-on therapy, when compared with DPP-4i, was associated with lower risk of MACE (HR=0.66; 95% CI 0.50 to 0.85; p=0.002) and CV death (HR=0.46; 95% CI 0.30 to 0.73; p=0.001). On-treatment analysis revealed lower HF risk in patients initiating SGLT2i (HR=0.54; 95% CI 0.30 to 0.99; p=0.047). In the intention-to-treat analysis, GLP-1RA add-on therapy was associated with a lower MACE risk when compared with DPP-4i (HR=0.64; 95% CI 0.43 to 0.97; p=0.034), but it had a non-significant effect on CV death (HR=0.62; 95% CI 0.34 to 1.14; p=0.128) and HF (HR=1.39; 95% CI 0.88 to 2.21; p=0.157). The results of on-treatment analyses were in agreement with the results of intention-to-treat analyses.

CONCLUSIONS

SGLT2i and GLP-1RA improved CV morbidity and mortality in patients with T2D when compared with DPP-4i as an add-on therapy. The results of this study may serve as a basis for the selection of an optimal add-on antidiabetic medicine to reduce CV morbidity and mortality in patients with T2D in clinical practice.

TRIAL REGISTRATION NUMBER

EUPAS32558.

Intensive versus standard blood pressure control in type 2 diabetes: a restricted mean survival time analysis of a randomised controlled trial

BACKGROUND

Restricted mean survival time analysis offers an intuitive and robust summary of treatment effect compared with HRs.

OBJECTIVE

To examine the effect of intensive versus standard blood pressure (BP) control on death or cardiovascular events in type 2 diabetes.

DESIGN

Secondary analysis of the Action to Control Cardiovascular Risk in Diabetes Blood Pressure trial.

SETTING

77 sites in the USA and Canada.

PARTICIPANTS

4733 adults with type 2 diabetes at high risk for cardiovascular events.

INTERVENTIONS

Systolic BP target <120 mm Hg (n=2371) versus <140 mm Hg (n=2362).

MEASUREMENTS

Composite endpoint of death, non-fatal myocardial infarction or non-fatal stroke.

RESULTS

The mean event-free survival time over 5 years (1825 days) was similar between intensive and standard BP control (1716 vs 1714 days; mean difference, 1.3 (95% CI -18.1 to 20.7) days). However, intensive BP treatment was more beneficial for those assigned to standard glycaemic control (1725 vs 1697 days; mean difference, 28.1 (95% CI 0.4 to 55.9) days), but not for those assigned to intensive glycaemic control (1706 vs 1731 days; mean difference, -25.2 (95% CI -52.3 to 1.9) days) (p=0.008 for interaction). In subgroup analysis, the mean event-free survival time difference between intensive and standard BP treatment was -76.0 (95% CI -131.8 to -20.3) days for those with cognitive impairment and 21.8 (95% CI -24.0 to 67.5) days for those with normal cognitive function (p=0.008 for interaction). The effect was not different by age, sex and baseline cardiovascular disease status.

CONCLUSIONS

Intensive BP treatment may reduce death and cardiovascular events among patients with type 2 diabetes receiving standard glycaemic treatment and without cognitive impairment.

TRIAL REGISTRATION NUMBER

NCT00000620; Post-results.

Trends in high deductible health plan enrolment and spending among commercially insured members with and without chronic conditions: a Natural Experiment for Translation in Diabetes (NEXT-D2) Study

OBJECTIVES

To examine trends in high deductible health plan (HDHP) enrolment among members with diabetes and cardiovascular disease (CVD) compared with healthy members and compare out-of-pocket (OOP) and total spending for members with chronic conditions in HDHPs versus low deductible plans.

DESIGN

Descriptive study with time trends.

SETTING

A large national commercial insurance database.

PARTICIPANTS

1.2 million members with diabetes, 4.5 million members with CVD (without diabetes) and 18 million healthy members (defined by a low comorbidity score) under the age of 65 years and insured between 2005 and 2013.

OUTCOME MEASURES

Percentage of members in an HDHP (ie, annual deductible ≥$1000) by year, annual mean OOP and total spending, adjusted for member sociodemographic and employer characteristics.

RESULTS

Enrolment in HDHPs among members in all disease categories increased by 5 percentage points a year and was over 50% by 2013. On average, over the study period, HDHP enrolment among members with diabetes and CVD was 2.84 (95% CI: 2.78 to 2.90) and 2.02 (95% CI: 1.98 to 2.05) percentage points lower, respectively, than among healthy members. HDHP members with diabetes, CVD and low morbidity had higher annual OOP costs ($636 (95% CI: 630 to 642), $539 (95% CI: 537 to 542) and $113 (95% CI: 112 to 113)) and lower total costs (-$529 (95% CI: -597 to -461), -$364 (95% CI: -385 to -342) and -$79 (95% CI: -81 to -76)), respectively, than corresponding low deductible members when averaged over the study period. Members with chronic diseases had yearly OOP expenditures that were five to seven times higher than healthier members.

CONCLUSION

High HDHP enrolment coupled with the high OOP costs associated with HDHPs may be particularly detrimental to the financial well-being of people with diabetes and CVD, who have more healthcare needs than healthier populations.

Cross-cultural adaptation and validation of the caregiver contribution to self-care of chronic illness inventory in China: a cross-sectional study

OBJECTIVE

Caregiver contribution (CC) is important for the self-care behaviors of chronic disease individuals, as it could enhance patient outcomes. Therefore, it is necessary to assess this CC by using a good validity and reliability instrument. The Caregiver Contribution to Self-Care Chronic Illness Inventory (CC-SC-CII) was designed to assess CC to self-care behaviors of patients with chronic illness in Italy. However, it was unclear whether this tool had sound psychometrics properties in the context of Chinese culture. Therefore, we performed the cross-cultural adaption of the CC-SC-CII and we tested its psychometric properties among Chinese caregivers of patients with chronic disease.

DESIGN

A cross-sectional observational design.

SETTINGS

Participants were recruited from communities and institutions in Pingdingshan, Henan Province, China.

PARTICIPANTS

301 caregivers of care recipients with chronic disease completed the Chinese version of the CC-SC-CII (C-CC-SC-CII).

PRIMARY AND SECONDARY OUTCOME MEASURES

The content validity index of items (I-CVI), the scale content validity index-average (S-CVI/Ave), exploratory factor analysis, confirmatory factor analysis (CFA), internal consistency and item analysis were tested.

RESULTS

The range of I-CVI was between 0.833 and 1.00, and the score of S-CVI was 0.991. In CFA, the C-CC to self-care monitoring scale had satisfactory fit indices. However, the C-CC to self-care maintenance and management scales had unsupported fit indices. The reliability coefficients of C-CC-SC-CII were 0.792, 0.880 and 0.870 for its three scales. Item-total correlations were all over 0.590. Test-retest reliability showed that the range of intraclass correlation coefficients was from 0.728 to 0.783.

CONCLUSION

The C-CC-SC-CII has sound psychometrics characteristics and is a culturally appropriate and reliable instrument for assessing CC to the self-care behaviours of patients with chronic disease in China.

Protocol for a prospective, international cohort study on the Management and Outcomes of Perioperative Care among European Diabetic Patients (MOPED)

INTRODUCTION

Diabetes is common (about 20 million patients in Europe) and patients with diabetes have more surgical interventions than the general population. There are plausible pathophysiological and clinical mechanisms suggesting that patients with diabetes are at an increased risk of postoperative complications. When postoperative complications occur in the general population, they increase major adverse events and subsequently increase 1-year mortality. This is likely to be worse in patients with diabetes. There is variation in practice guidelines in different countries in the perioperative management of patients with diabetes undergoing major surgery and whether this may affect postoperative outcome has not been investigated on a large scale. Neither is it known whether different strata of preoperative glycaemic control affects outcome.

METHODS AND ANALYSIS

A prospective, observational, international, multicentre cohort study, recruiting 5000 patients with diabetes undergoing elective or emergency surgery in at least n=50 centres. Inclusion criteria are any patient with diabetes undergoing surgery under any substantive anaesthetic technique. Exclusion criteria are not being a confirmed diabetic patient and patients with diabetes undergoing procedures under monitored sedation or local anaesthetic infiltration only. Follow-up duration is 30 days after surgery. Primary outcome is days at home at 30 days. Secondary outcomes are Comprehensive Complications Index, Quality of Recovery (QoR-15) score on Day 1 postoperatively, 30-day mortality, length of hospital stay and incidence of specific major adverse events (Myocardial Infarction (MI), Myocardial Injury after Non-cardiac Surgery (MINS), Acute Kidney Injury (AKI), Postoperative Pulmonary Complications (PPC), Cerebrovascular Accident (CVA), Pulmonary Embolism (PE), DVT, surgical site infection, postoperative pulmonary infection). Tertiary outcomes include time to resumption of normal diabetes therapy, incidence of diabetic ketoacidosis or hypoglycaemia, incidence and duration of use of intravenous insulin infusion therapy and change in diabetic management at 30 days.

ETHICS AND DISSEMINATION

This study will adhere to the principles of the Declaration of Helsinki (amendment 2013) by the World Medical Association and the ICH-Good Clinical Practice (GCP) Guidelines E6(R2). Specific national and local regulatory authority requirements will be followed as applicable. Ethical approval has been granted by the Institutional Review Board of the Mater Misericordiae University Hospital, Dublin, Ireland (Reference: 1/378/2167). As enrolment for this study is ongoing, ethical approval from additional centres is being added continuously. The main results of Management and Outcomes of Perioperative Care among European Diabetic Patients and its substudies will be published in peer-reviewed international medical journals and presented at Euroanaesthesia congress and other international and national meetings.

TRIAL REGISTRATION NUMBER

NCT04511312.

Protocol for a prospective observational study: the Australia and New Zealand Diabetic and Ischaemic Foot Outcomes Study (ANZ-DIFOS)

INTRODUCTION

Diabetic foot disease is a common condition globally and is over-represented in indigenous populations. The propensity for patients with diabetic foot disease to undergo minor or major limb amputation is a concern. Diabetic foot disease and lower limb amputation are debilitating for patients and have a substantial financial impact on health services. The purpose of this multicentre study is to prospectively report the presentation, management and outcomes of diabetic foot disease, to validate existing scoring systems and assess long term outcomes for these patients particularly in relation to major limb amputation.

METHODS AND ANALYSIS

This is a multisite, international, prospective observational study, being undertaken at Waikato Hospital, New Zealand (NZ); Sir Charles Gairdner Hospital, the Royal Adelaide Hospital and the Queen Elizabeth Hospital, Australia. Consecutive participants with diabetic foot disease that meet inclusion criteria and agree to participate will be recruited from multidisciplinary team diabetic foot clinic, vascular clinic, dialysis and admission to hospital. Follow-up of participants will occur at 1, 3, 6 and 12 months. At recruitment and follow-up reviews, information about service details, demographic and clinical history, wound data and discharge information will be recorded. The primary outcomes are the time to wound healing, major amputation, overall mortality and amputation-free survival at 12 months. This study started in NZ in August 2020 and will commence in Australian sites in early 2021.

ETHICS AND DISSEMINATION

New Zealand Central Health and Disability Ethics Committee (20/CEN/122), Waikato DHB Research Department (RDO020044), Quality Improvement HoD Sir Charles Gairdner Hospital (39715) and the Central Adelaide Local Health Network (CALHN) Human Research Ethics Committee (13928). Results will be presented at international conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12621000337875).

COVID-19 hinterland: surveilling the self-reported impacts of the pandemic on diabetes management in the USA (cross-sectional results of the iNPHORM study)

MAIN OBJECTIVE

To determine how and to what extent COVID-19 has affected real-world, self-reported glycaemic management in Americans with type 1 or type 2 diabetes taking insulin and/or secretagogues, with or without infection.

DESIGN

A cross-sectional substudy using data from the Investigating Novel Predictions of Hypoglycemia Occurrence using Real-world Models panel survey.

SETTING

USA.

PARTICIPANTS

Americans 18-90 years old with type 1 or 2 diabetes taking insulin and/or secretagogues were conveniently sampled from a probability-based internet panel.

PRIMARY OUTCOME MEASURE

A structured, COVID-19-specific questionnaire was administered to assess the impact of the pandemic (irrespective of infection) on socioeconomic, behavioural/clinical and psychosocial aspects of glycaemic management.

RESULTS

Data from 667 respondents (type 1 diabetes: 18%; type 2 diabetes: 82%) were analysed. Almost 25% reported A1c values ≥8.1%. Rates of severe and non-severe hypoglycaemia were 0.68 (95% CI 0.5 to 0.96) and 2.75 (95% CI 2.4 to 3.1) events per person-month, respectively. Ten respondents reported a confirmed or probable COVID-19 diagnosis. Because of the pandemic, 24% of respondents experienced difficulties affording housing; 28% struggled to maintain sufficient food to avoid hypoglycaemia; and 19% and 17% reported challenges accessing diabetes therapies and testing strips, respectively. Over one-quarter reported issues retrieving antihyperglycaemics from the pharmacy and over one-third reported challenges consulting with diabetes providers. The pandemic contributed to therapeutic non-adherence (14%), drug rationing (17%) and reduced monitoring (16%). Many struggled to keep track, and in control, of hypoglycaemia (12%-15%) and lacked social support to help manage their risk (19%). Nearly half reported decreased physical activity. Few statistically significant differences were observed by diabetes type.

CONCLUSIONS

COVID-19 was found to cause substantial self-reported deficiencies in glycaemic management. Study results signal the need for decisive action to restabilise routine diabetes care in the USA.

TRIAL REGISTRATION NUMBER

NCT04219514.

Integrated Measurement for Early Detection (MIDO) as a digital strategy for timely assessment of non-communicable disease profiles and factors associated with unawareness and control: a retrospective observational study in primary healthcare facilities in Mexico

OBJECTIVES

The Carlos Slim Foundation implemented the Integrated Measurement for Early Detection (MIDO), a screening strategy for non-communicable diseases (NCDs) in Mexico as part of CASALUD, a portfolio of digital health services focusing on healthcare delivery and prevention/management of NCDs. We investigated the disease profile of the screened population and evaluated MIDO's contribution to the continuum of care of the main NCDs.

DESIGN

Using data from MIDO and the chronic diseases information system, we quantified the proportion of the population screened and diagnosed with NCDs, and measured care linkage/retention and level of control achieved. We analysed comorbidity patterns and estimated prevalence of predisease stages. Finally, we estimated characteristics associated with unawareness and control of NCDs, and examined efficacy of the CASALUD model in improving NCD control.

SETTING

Public primary health centres in 27/32 Mexican states.

PARTICIPANTS

Individuals aged ≥20 years lacking healthcare access.

RESULTS

From 2014 to 2018, 743 000 individuals were screened using MIDO. A predisease or disease condition was detected in ≥70% of the population who were unaware of their NCD status. The screening identified 38 417 new cases of type 2 diabetes, 53 133 new cases of hypertension and 208 627 individuals with obesity. Dyslipidaemia was found in 77.3% of individuals with available blood samples. Comorbidities were highly prevalent, especially in people with obesity. Only 5.47% (n=17 774) of individuals were linked with their corresponding primary health centre. Factors associated with unawareness of and uncontrolled NCDs were sex, age, and social determinants, for example, rural/urban environment, access to healthcare service, and education level. Patients with type 2 diabetes treated at clinics under the CASALUD model were more likely to achieve disease control (OR: 1.32, 95% CI: 1.09 to 1.61).

CONCLUSION

Patient-centred screening strategies such as MIDO are urgently needed to improve screening, access, retention and control for patients with NCDs.

Benefits of the addition of continuous or flash glucose monitoring versus standard practice using self-monitored blood glucose and haemoglobin A1c in the primary care of diabetes mellitus: a systematic review protocol

INTRODUCTION

Studies demonstrate that optimal glycaemic control reduces morbidity from diabetes mellitus but remains elusive in a significant portion of patients. Although research shows that continuous glucose monitoring (CGM) and flash glucose monitoring (FGM) improves glycaemic control in selected subsets of patients with diabetes in specialty practices, we found no systematic reviews evaluating the use of CGM/FGM in primary care, where the majority of patients with diabetes are cared for.This systematic review aims to answer the questions: 'compared with usual care of self-monitoring blood glucose and haemoglobin A1c (HbA1c), does the addition of CGM/FGM use in the primary care of patients with diabetes improve glycaemic control, decrease rates of hypoglycaemia, and improve patient and physician satisfaction?' and if so, 'what subgroups of primary care patients with diabetes are most likely to benefit?'.

METHODS AND ANALYSIS

Aligning with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines, a search will be conducted in PubMed, EMBASE, Scopus, CINAHL, Cochrane Central Register of Controlled Trials and Web of Science. We will include studies investigating CGM/FGM use and reporting the primary outcome measure of HbA1c and secondary outcome measures of hypoglycaemia, time in range, time below range, time above range and patient/staff satisfaction. We will examine which patient populations appear to benefit from CGM/FGM. Three independent researchers will use the Covidence systematic review software for blinded screening and study selection. The National Heart, Lung, and Blood Institute quality assessment tool and Grading of Recommendations Assessment, Development and Evaluation will be used to assess the risk of bias and quality of evidence.

ETHICS AND DISSEMINATION

The systematic review methodology does not require ethics approval due to the nature of the study design. Study findings will be publicly available to a wide readership across disciplines and will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021229416.

Fatty liver index and progression to type 2 diabetes: a 5-year longitudinal study in Spanish workers with pre-diabetes

OBJECTIVE

The main aim of the study was to evaluate the association between non-alcoholic fatty liver disease (NAFLD), estimated by fatty liver index (FLI), and the development of type 2 diabetes (T2D) in a large cohort of adult workers with pre-diabetes.

DESIGN

Prospective cohort study.

SETTING

Occupational health services from Spain.

PARTICIPANTS

16 648 adult workers (aged 20-65 years) with pre-diabetes (fasting plasma glucose (FPG) of 100-125 mg/dL).

OUTCOME AND MEASURES

FLI was calculated based on measurements of triglycerides, body mass index, waist circumference and γ-glutamyltransferase. The population was classified into three categories: FLI<30 (no hepatic steatosis), FLI 30-60 (intermediate status) and FLI>60 (hepatic steatosis). Sociodemographic, anthropometric, dietary habits, physical activity and clinical data were collected from all subjects. The incidence rate of T2D was determined after 5 years of follow-up.

RESULTS

After 5 years of follow-up, 3706 of the 16 648 participants (22.2%) were diagnosed with T2D, corresponding to an annual rate of progression of 4.5%. FLI was strongly associated with T2D conversion. The incidence rates of T2D in the FLI<30, FLI 30-60 and FLI>60 groups were significantly different after 5 years of follow-up were 19/6,421 (0.3%), 338/4,318 (7.8%) and 3,349/5,909 (56.7%), respectively. This association remained significant for FLI>60 after adjustment for, age, diet, physical activity, FPG, blood pressure, social class and smoking habits (adjusted HR=6.879; 95% CI 5.873 to 8.057 for men, and HR=5.806; 95% CI 4.863 to 6.932 for women).

CONCLUSION

NAFLD assessed by FLI independently predicted the risk of conversion to T2D among people with pre-diabetes. FLI may be an easily determined and valuable early predictor for T2D in people with pre-diabetes. FLI-based assessment of NAFLD in subjects with pre-diabetes in routine clinical practice could allow the adoption of effective measures to prevent and reduce their progression to T2D.

Study on acupuncture in the treatment of painful diabetic peripheral neuropathy based on rs-fMRI: a protocol for systematic review and meta-analysis

INTRODUCTION

Studies have shown that acupuncture has significant therapeutic effects on painful diabetic peripheral neuropathy (PDPN) yet the precise mechanism of action underpinning these effects remains controversial. Resting-state functional MRI (rs-fMRI) is an advanced imaging technique that can be used to monitor changes in the activity of the brain, particularly in PDPN. However, the data from several studies remain inconclusive and there is currently no systematic review and meta-analysis for the use of rs-fMRI in PDPN.

METHODS AND ANALYSIS

In this study, we will select all eligible studies published on or before 30 June 2021. Four English and four Chinese databases will be searched, specifically, PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, WanFang database, China Science Technology Journal Database (VIP) and China Doctor/Master Dissertations Full-text Database. Only clinical trials and the first cycle of a cross-over trial linked to acupuncture for PDPN will be included in the analysis. The main outcomes include the amplitude of low-frequency fluctuation, regional homogeneity, functional connectivity of the brain, bilateral superficial peroneal nerve sensory nerve conduction velocity, bilateral dorsal current perception threshold values and the degree of subjective pain. The secondary outcomes include biochemical indicators, the degree of depression and anxiety and changes in efficiency. The study selection, data extraction and risk of bias assessment will be performed by two investigators. For statistical analyses, Review Manager V.5.4 software will be used. If necessary, heterogeneity testing, data synthesis, and subgroup analysis will be performed.

ETHICS AND DISSEMINATION

Our systematic review and meta-analysis will be based on published literature for data extraction and will not include the use of individual patient data and so no ethical approval required.

PROSPERO REGISTRATION NUMBER

CRD42021211644.

Association of metabolic syndrome with risk of cardiovascular disease mortality and all-cause mortality among Malaysian adults: a retrospective cohort study

OBJECTIVES

This study is aimed at determining the association between metabolic syndrome and risk of cardiovascular disease (CVD) mortality and all-cause mortality among Malaysian adults.

DESIGN

Retrospective cohort study.

SETTING

The Malaysian Non-Communicable Disease Surveillance (MyNCDS-1) 2005/2006.

PARTICIPANTS

A total of 2525 adults (1013 men and 1512 women), aged 24-64 years, who participated in the MyNCDS-1 2005/2006.

METHODS

Participants' anthropometric indices, blood pressure, fasting lipid profile and fasting blood glucose levels were evaluated to determine the prevalence of metabolic syndrome by the Harmonized criteria. Participants' mortality status were followed up for 13 years from 2006 to 2018. Mortality data were obtained via record linkage with the Malaysian National Registration Department. The Cox proportional hazards regression model was applied to determine association between metabolic syndrome (MetS) and risk of CVD mortality and all-cause mortality with adjustment for selected sociodemographic and lifestyle behavioural factors.

RESULTS

The overall point prevalence of MetS was 30.6% (95% CI: 28.0 to 33.3). Total follow-up time was 31 668 person-years with 213 deaths (111 (11.3%) in MetS subjects and 102 (6.1%) in non-MetS subjects) from all-causes, and 50 deaths (33 (2.9%) in MetS group and 17 (1.2%) in non-MetS group) from CVD. Metabolic syndrome was associated with a significantly increased hazard of CVD mortality (adjusted HR: 2.18 (95% CI: 1.03 to 4.61), p=0.041) and all-cause mortality (adjusted HR: 1.47 (95% CI: 1.00 to 2.14), p=0.048). These associations remained significant after excluding mortalities in the first 2 years.

CONCLUSIONS

Our study shows that individuals with MetS have a higher hazard of death from all-causes and CVD compared with those without MetS. It is thus imperative to prescribe individuals with MetS, a lifestyle intervention along with pharmacological intervention to improve the individual components of MetS and reduce this risk.

Association between fasting blood glucose levels and stroke events: a large-scale community-based cohort study from China

OBJECTIVES

Diabetes mellitus has been associated with stroke. However, the association between fasting blood glucose (FBG) and stroke risk in a general population remains not clear. The purpose of our study was to examine the FBG levels on subsequent stroke risk in a community-based cohort in China.

DESIGN

Prospective cohort study, employing Cox proportional hazard model to analyse the association of FBG levels with stroke risk.

SETTING

A community-based cohort study included adults participating in a baseline survey conducted in 2013 in Changshu, eastern China.

PARTICIPANTS

16 113 participants were recruited with a multistage sampling method, excluding participants with severe disability, severe cancer, severe psychiatric disturbance or previous stroke before enrolment.

PRIMARY OUTCOME MEASURES

Stroke events.

RESULTS

During a median follow-up of 5.5 years, 417 incident cases of stroke were identified. The adjusted HR for total and ischaemic stroke for participants in the fourth quartile of FBG compared with the first quartile was 1.44 (95% CI 1.07 to 1.94) and 1.57 (95% CI 1.11 to 2.21), respectively. FBG levels of ≥7.0 mmol/L were associated with an increased risk of stroke based on two clinical classifications (American Diabetes Association: 1.68 (1.24 to 2.27); WHO: 1.62 (1.21, 2.13)). In stratified analyses, risk associations existed in women (HR: 1.92, 95% CI 1.22 to 3.01) and postmenopausal women (HR: 1.68, 95% CI 1.06 to 2.68) for the fourth quartile versus the first. More importantly, the meta-analysis observed a positive association between FBG levels and stroke risk (pooled HR: 1.70, 95% CI 1.27 to 2.29; n=7)).

CONCLUSIONS

Higher FBG level was independently associated with an increased risk of stroke in Chinese adults, especially significant in women.

Treatment pathways in people with type 2 diabetes mellitus: a nationwide cohort study of new users of metformin monotherapy in New Zealand

OBJECTIVES

The aims of this study were to describe the following: (1) the time to change of therapy in patients with type 2 diabetes who had initiated metformin monotherapy as first-line treatment and (2) the sequence in which subsequent therapeutic regimens were introduced.

DESIGN

Cohort study.

SETTING

National study based on linked data from the New Zealand Ministry of Health's National Collections of health and pharmaceutical dispensing data.

PARTICIPANTS

People with type 2 diabetes mellitus who initiated metformin monotherapy between 1 January 2006 and 30 September 2014 (n=93 874).

PRIMARY OUTCOME MEASURES

Cumulative incidence curves were plotted to show the time taken to move from one regimen to another, while sunburst plots were used to illustrate the sequence in which regimens were introduced.

RESULTS

About 10% and 35% of cohort members had moved to a second regimen 1 year and 5 years, respectively, after initiating metformin monotherapy; the majority received a regimen recommended by New Zealand treatment guidelines (mostly metformin and a sulphonylurea). Of those who started a recommended second regimen, 37% and 67% had moved to a third regimen after 1 and 5 years, respectively; the corresponding proportions for those who started an 'other' (not listed as recommended) second regimen were 53% and 75%. Most of those who received a third regimen after a recommended second regimen were dispensed an 'other' third regimen. Of those who moved to a third regimen from an 'other' second regimen, similar proportions received recommended and 'other' third regimens.

CONCLUSIONS

Real-world type 2 diabetes treatment patterns in New Zealand are complex and not always consistent with guidelines.

Incidence of lower limb amputation in people with and without diabetes: a nationwide 5-year cohort study in Japan

INTRODUCTION

This study was conducted to investigate the incidence and time trend of lower limb amputation (LLA) among people with and without diabetes.

RESEARCH DESIGN AND METHODS

This retrospective population-based cohort study was based on the national claims data in Japan, comprising a total population of 150 million. Data of all individuals who had LLA from April 2013 to March 2018 were obtained. We analysed the sex-adjusted and age-adjusted annual LLA rate (every fiscal year) in people with and without diabetes for major and minor amputation. To test for time trend, Poisson regression models were fitted.

RESULTS

In the 5-year period, 30 187 major and 29 299 minor LLAs were performed in Japan. The sex-adjusted and age-adjusted incidence of major and minor LLAs was 9.5 (people with diabetes, 21.8 vs people without diabetes, 2.3, per 100 000 person-years) and 14.9 (people with diabetes, 28.4 vs people without diabetes, 1.9, per 100 000 person-years) times higher, respectively, in people with diabetes compared with those without. A significant decline in the annual major amputation rate was observed (p<0.05) and the annual minor amputation rate remained stable (p=0.63) when sex, age and people with and without diabetes were included as dependent variables.

CONCLUSIONS

This is the first report of the national statistics of LLAs in Japan. The incidence of major and minor LLAs was 10 and 15 times higher, respectively, in people with diabetes compared with those without. A significant decline in the major amputation rate was observed, and the annual minor amputation rate remained stable during the observation period. This information can help to create an effective national healthcare strategy for preventing limb amputations, which affect the quality of life of patients with diabetes and add to the national healthcare expenditure.

Combined association of obesity and other cardiometabolic diseases with severe COVID-19 outcomes: a nationwide cross-sectional study of 21 773 Brazilian adult and elderly inpatients

OBJECTIVES

To investigate the combined association of obesity, diabetes mellitus (DM) and cardiovascular disease (CVD) with severe COVID-19 outcomes in adult and elderly inpatients.

DESIGN

Cross-sectional study based on registry data from Brazil's influenza surveillance system.

SETTING

Public and private hospitals across Brazil.

PARTICIPANTS

Eligible population included 21 942 inpatients aged ≥20 years with positive reverse transcription-PCR test for SARS-CoV-2 until 9 June 2020.

MAIN OUTCOME MEASURES

Severe COVID-19 outcomes were non-invasive and invasive mechanical ventilation use, intensive care unit (ICU) admission and death. Multivariate analyses were conducted separately for adults (20-59 years) and elders (≥60 years) to test the combined association of obesity (without and with DM and/or CVD) and degrees of obesity with each outcome.

RESULTS

A sample of 8848 adults and 12 925 elders were included. Among adults, obesity with DM and/or CVD showed higher prevalence of invasive (prevalence ratio 3.76, 95% CI 2.82 to 5.01) and non-invasive mechanical ventilation use (2.06, 1.58 to 2.69), ICU admission (1.60, 1.40 to 1.83) and death (1.79, 1.45 to 2.21) compared with the group without obesity, DM and CVD. In elders, obesity alone (without DM and CVD) had the highest prevalence of ICU admission (1.40, 1.07 to 1.82) and death (1.67, 1.00 to 2.80). In both age groups, obesity alone and combined with DM and/or CVD showed higher prevalence in all outcomes than DM and/or CVD. A dose-response association was observed between obesity and death in adults: class I 1.32 (1.05 to 1.66), class II 1.41 (1.06 to 1.87) and class III 1.77 (1.35 to 2.33).

CONCLUSIONS

The combined association of obesity, diabetes and/or CVD with severe COVID-19 outcomes may be stronger in adults than in elders. Obesity alone and combined with DM and/or CVD had more impact on the risk of COVID-19 severity than DM and/or CVD in both age groups. The study also supports an independent relationship of obesity with severe outcomes, including a dose-response association between degrees of obesity and death in adults.

Effect of a smartphone application (Perx) on medication adherence and clinical outcomes: a 12-month randomised controlled trial

OBJECTIVE

To determine whether the Perx app improves medication adherence and clinical outcomes over 12 months compared with standard care in patients requiring polypharmacy.

DESIGN

Randomised controlled trial with 12-month follow-up.

SETTING

Outpatient clinics in three tertiary hospitals in Sydney, Australia.

PARTICIPANTS

Eligible participants were aged 18-75 years, with at least one chronic condition, taking ≥3 different medications (oral medications or injections), with smartphone accessibility. Participants were randomised in a 1:1 ratio.

INTERVENTIONS

The intervention group used the Perx app that contained customised reminders and gamified interactions to reward verified medication adherence.

MAIN OUTCOME MEASURES

The primary outcome was medication adherence over 12 months measured using pill counts. Secondary outcomes included clinical outcomes (haemoglobin A1c (HbA1c), cholesterol, blood glucose, triglycerides, creatinine, thyroid function, blood pressure and weight).

RESULTS

Of 1412 participants screened for eligibility, 124 participants were randomised; 45 in the Perx arm and 40 in the control arm completed the study. The average age was 59.5, 58.9% were women, chronic conditions were cardiovascular disease (78%), type 2 diabetes (75%), obesity (65%) or other endocrine disorders (18%). On average, participants were taking six medications daily. The Perx group had greater improvements in adherence at month 2 (Coef. 8%; 95% CI 0.01 to 0.15), month 3 (Coef. 7%; 95% CI 0.00 to 0.14) and month 12 (Coef. 7%; 95% CI 0.00 to 0.13). The probability of HbA1c ≤6.5% was greater in the Perx group at months 9 and 12 and cholesterol (total and low-density lipoprotein cholesterol) was lower in the Perx group at month 3. The intervention was particularly effective for those with obesity, taking medications for diabetes and taking ≤4 medications.

CONCLUSIONS

This study provides evidence that app-based behavioural change interventions can increase medication adherence and produce longer-term improvements in some clinical outcomes in adults managing multimorbidity. More trials are needed to build the evidence base.

TRIAL REGISTRATION NUMBER

ACTRN12617001285347.

Estimated total cardiovascular risk in a rural area of Bangladesh: a household level cross-sectional survey done by local community health workers

OBJECTIVE

The aim of this study was to estimate 10-year cardiovascular disease (CVD) risk among Bangladeshi rural community residents, using the 2014 WHO/International Society of Hypertension (WHO/ISH) risk prediction charts.

STUDY DESIGN

Cross-sectional population-based study done by local community healthcare workers engaging the lowest level facilities of the primary healthcare system.

SETTING AND PARTICIPANTS

A total of 1545 rural adults aged ≥40 years of Debhata upazila of Satkhira district of Bangladesh participated in this survey done in 2015. The community health workers collected data on age, smoking, blood pressure, blood glucose and treatment history of diabetes and hypertension.

PRIMARY OUTCOME MEASURES

We estimated total 10-year CVD risk using the WHO/ISH South East Asia Region-D charts without cholesterol and categorised the risk into low (<10%), moderate (10%-19.9%), high (20%-29.9%) and very high (≥30%).

RESULTS

The participants' mean age (±SD) was 53.9±11.6 years. Overall, the 10-year CVD risks (%, 95% CI) were as follows: low risk (81.6%, 95% CI 78.4% to 84.6%), moderate risk (9.9%, 95% CI 7.4% to 12.1%), high risk (5.8%, 95% CI 4.4% to 7.2%) and very high risk (2.8%, 95% CI 1.5% to 4.1%). In women, moderate to very high risks were higher (moderate 12.1%, high 6.1% and very high 3.7%) compared with men (moderate 7.5%, high 5.5% and very high 1.9%) but none of these were statistically significant. The age-standardised prevalence of very high risk increased from 2.9% (0.7%-5.2%) to 8.5% (5%-12%) when those with anti-hypertensive medication having controlled blood pressure (<140/90 mm Hg) added.

CONCLUSION

The very high-risk estimates could be used for planning resource for CVD prevention programme at upazila level. There is a need for a national level study, covering diversities of rural areas, to contribute to national planning of CVD prevention.

Using electronic health records to develop and validate a machine-learning tool to predict type 2 diabetes outcomes: a study protocol

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is a major cause of blindness, kidney failure, myocardial infarction, stroke and lower limb amputation. We are still unable, however, to accurately predict or identify which patients are at a higher risk of deterioration. Most risk stratification tools do not account for novel factors such as sociodemographic determinants, self-management ability or access to healthcare. Additionally, most tools are based in clinical trials, with limited external generalisability.

OBJECTIVE

The aim of this work is to design and validate a machine learning-based tool to identify patients with T2DM at high risk of clinical deterioration, based on a comprehensive set of patient-level characteristics retrieved from a population health linked dataset.

SAMPLE AND DESIGN

Retrospective cohort study of patients with diagnosis of T2DM on 1 January 2015, with a 5-year follow-up. Anonymised electronic healthcare records from the Whole System Integrated Care (WSIC) database will be used.

PRELIMINARY OUTCOMES

Outcome variables of clinical deterioration will include retinopathy, chronic renal disease, myocardial infarction, stroke, peripheral arterial disease or death. Predictor variables will include sociodemographic and geographic data, patients' ability to self-manage disease, clinical and metabolic parameters and healthcare service usage. Prognostic models will be defined using multidependence Bayesian networks. The derivation cohort, comprising 80% of the patients, will be used to define the prognostic models. Model parameters will be internally validated by comparing the area under the receiver operating characteristic curve in the derivation cohort with those calculated from a leave-one-out and a 10 times twofold cross-validation.

ETHICS AND DISSEMINATION

The study has received approvals from the Information Governance Committee at the WSIC. Results will be made available to people with T2DM, their caregivers, the funders, diabetes care societies and other researchers.

Global epidemiology of hip fractures: a study protocol using a common analytical platform among multiple countries

INTRODUCTION

Hip fractures are associated with a high burden of morbidity and mortality. Globally, there is wide variation in the incidence of hip fracture in people aged 50 years and older. Longitudinal and cross-geographical comparisons of health data can provide insights on aetiology, risk factors, and healthcare practices. However, systematic reviews of studies that use different methods and study periods do not permit direct comparison across geographical regions. Thus, the objective of this study is to investigate global secular trends in hip fracture incidence, mortality and use of postfracture pharmacological treatment across Asia, Oceania, North and South America, and Western and Northern Europe using a unified methodology applied to health records.

METHODS AND ANALYSIS

This retrospective cohort study will use a common protocol and an analytical common data model approach to examine incidence of hip fracture across population-based databases in different geographical regions and healthcare settings. The study period will be from 2005 to 2018 subject to data availability in study sites. Patients aged 50 years and older and hospitalised due to hip fracture during the study period will be included. The primary outcome will be expressed as the annual incidence of hip fracture. Secondary outcomes will be the pharmacological treatment rate and mortality within 12 months following initial hip fracture by year. For the primary outcome, crude and standardised incidence of hip fracture will be reported. Linear regression will be used to test for time trends in the annual incidence. For secondary outcomes, the crude mortality and standardised mortality incidence will be reported.

ETHICS AND DISSEMINATION

Each participating site will follow the relevant local ethics and regulatory frameworks for study approval. The results of the study will be submitted for peer-reviewed scientific publications and presented at scientific conferences.

Multimorbidity in Latin America and the Caribbean: a systematic review and meta-analysis

OBJECTIVE

To estimate the pooled prevalence of multimorbidity (≥2 non-communicable diseases in the same individual) among adults of the general population of Latin American and the Caribbean (LAC).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, Embase, Global Health, Scopus and LILACS up to 1 July 2020.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

The outcome was the prevalence of multimorbidity. Reports were selected whether they enrolled adult individuals (age ≥18 years) from the general population.

DATA EXTRACTION AND SYNTHESIS

Reviewers extracted relevant data and assessed risk of bias independently. A random-effects meta-analysis was conducted to report pooled prevalence estimates of multimorbidity; pooled estimates by pre-specified subgroups (eg, national studies) were also pursued.

RESULTS

From 5830 results, we selected 28 reports, mostly from Brazil and 16 were based on a nationally representative sample. From the 28 selected reports, 26 were further included in the meta-analysis revealing a pooled multimorbidity prevalence of 43% (95% CI: 35% to 51%; I²: 99.9%). When only reports with a nationally representative sample were combined, the pooled prevalence was 37% (95% CI: 27% to 47%; I²: 99.9%). When the ascertainment of multimorbidity was based on self-reports alone, the pooled prevalence was 40% (95% CI: 31% to 48%; I²: 99.9%); this raised to 52% (95% CI: 33% to 70%; I²: 99.9%) for reports including self-reported and objective diagnosis.

CONCLUSIONS

Our results complement and advance those from global efforts by incorporating much more reports from LAC. We revealed a larger presence of multimorbidity in LAC than previously reported.

PROSPERO REGISTRATION NUMBER

CRD42020196177.

Physician visits and medication prescriptions for major chronic diseases during the COVID-19 pandemic in Japan: retrospective cohort study

OBJECTIVES

There have been concerns that patients with chronic conditions may be avoiding in-person physician visits due to fear of COVID-19, leading to lower quality of care. We aimed to investigate changes in physician visits and medication prescriptions for chronic diseases before and during the COVID-19 pandemic at the population level.

DESIGN

Retrospective cohort study.

SETTING

Nationwide claims data in Japan, 2018-2020.

PARTICIPANTS

Working-age population (aged 18-74 years) who visited physicians and received any prescriptions for major chronic diseases (hypertension, diabetes and dyslipidaemia) before the pandemic.

OUTCOME MEASURES

The outcomes were the monthly number of physician visits, the monthly proportion of physician visits and the monthly proportion of days covered by prescribed medication (PDC) during the pandemic (April-May 2020, as the first state of emergency over COVID-19 was declared on 7 April, and withdrawn nationally on 25 May).

RESULTS

Among 10 346 patients who visited physicians for chronic diseases before the pandemic, we found a temporary decline in physician visits (mean number of visits was 1.9 in March vs 1.7 in April; p<0.001) and an increase in the proportion of patients who did not visit any physicians during the pandemic (15% in March vs 24% in April; p<0.001). Physician visits returned to the baseline in May (the mean number of visits: 1.8, and the proportion of patients who did not visit any physicians: 9%). We observed no clinically meaningful difference in PDC between before and during the pandemic (eg, 87% in March vs 87% in April; p=0.45). A temporary decline in physician visits was more salient in seven prefectures with a larger number of COVID-19 cases than in other areas.

CONCLUSIONS

Although the number of physician visits declined right after the COVID-19 outbreak, it returned to the baseline one month later; patients were not skipping medications during the pandemic.

Flash glucose monitoring with the FreeStyle Libre 2 compared with self-monitoring of blood glucose in suboptimally controlled type 1 diabetes: the FLASH-UK randomised controlled trial protocol

INTRODUCTION

Optimising glycaemic control in type 1 diabetes (T1D) remains challenging. Flash glucose monitoring with FreeStyle Libre 2 (FSL2) is a novel alternative to the current standard of care self-monitoring of blood glucose (SMBG). No randomised controlled trials to date have explored the potential benefits of FSL2 in T1D. We aim to assess the impact of FSL2 in people with suboptimal glycaemic control T1D in comparison with SMBG.

METHODS

This open-label, multicentre, randomised (via stochastic minimisation), parallel design study conducted at eight UK secondary and primary care centres will aim to recruit 180 people age ≥16 years with T1D for >1 year and glycated haemoglobin (HbA1c) 7.5%-11%. Eligible participants will be randomised to 24 weeks of FSL2 (intervention) or SMBG (control) periods, after 2-week of blinded sensor wear. Participants will be assessed virtually or in-person owing to the COVID-19 pandemic. HbA1c will be measured at baseline, 12 and 24 weeks (primary outcome). Participants will be contacted at 4 and 12 weeks for glucose optimisation. Control participants will wear a blinded sensor during the last 2 weeks. Psychosocial outcomes will be measured at baseline and 24 weeks. Secondary outcomes include sensor-based metrics, insulin doses, adverse events and self-report psychosocial measures. Utility, acceptability, expectations and experience of using FSL2 will be explored. Data on health service resource utilisation will be collected.

ANALYSIS

Efficacy analyses will follow intention-to-treat principle. Outcomes will be analysed using analysis of covariance, adjusted for the baseline value of the corresponding outcome, minimisation factors and other known prognostic factors. Both within-trial and life-time economic evaluations, informed by modelling from the perspective of the National Health Service setting, will be performed.

ETHICS

The study was approved by Greater Manchester West Research Ethics Committee (reference 19/NW/0081). Informed consent will be sought from all participants.

TRIAL REGISTRATION NUMBER

NCT03815006.

PROTOCOL VERSION

4.0 dated 29 June 2020.

Understanding factors critical to the implementation of ehealth in chronic disease management: a realist review protocol

INTRODUCTION

Canadians are living longer, many with multiple chronic conditions. This population of older, frail Canadians continues to grow in size as do concurrent demands for community-based, outpatient and ambulatory models of care. Ideally, a multifaceted, proactive, planned and integrated care model includes ehealth. Although several factors are known to facilitate the implementation of ehealth in chronic disease management (CDM), for example, adequate support, usability, alignment of programme objectives, there is a growing body of inconclusive evidence on what is critical for implementation. We aim to achieve a fulsome understanding of factors critical to implementation by conducting a realist review-an approach suitable for understanding complex interventions. Our proposed review will identify factors critical to the implementation of ehealth in CDM (heart failure, chronic obstructive pulmonary disease, chronic kidney disease and/or diabetes (type 1 or 2)) without limitations to care setting, language, publication year or geography. Findings will be presented in configurations of contexts, mechanisms and outcomes (CMOs).

METHODS AND ANALYSIS

A search strategy will be iteratively developed based on the concepts of 'implementation' and 'adoption' of 'ehealth' interventions used within 'CDM' to identify the peer-reviewed and grey literature published before 31 March 2021 from five databases (Medline, Embase, Cochrane, CINAHL and PsychInfo) on ehealth interventions actively involving a healthcare provider for CDM among adults. Data extraction and synthesis will be guided by Realist and Meta-review Evidence Synthesis: Evolving Standards (RAMESES) guidelines informing core concepts of CMOs, and a study output will include a middle-range-theory describing the implementation of ehealth in CDM.

ETHICS AND DISSEMINATION

Findings will be published in an open-access peer-reviewed journal and presented at relevant conferences. A multistakeholder (patients, caregivers, healthcare providers and practitioners, decision-makers and policy-makers) perspective will be used in our dissemination approach. No formal ethics approval is required for this review.

PROSPERO REGISTRATION NUMBER

CRD42020208275.