Predictors of hyperglycaemic individuals who do not follow up with physicians after screening in Japan: a cohort study

Predictors of and barriers to follow-up uptake: analysis of factors and perceived barriers among high-risk individuals with diabetes after screening in China

OBJECTIVE

The objective of this study was to identify variables that predict adherence to follow-up visits among people who are positive for diabetes during screening and to investigate barriers to follow-up.

STUDY DESIGN

A retrospective cohort study linking individual-level registry data was performed.

METHODS

First, we compared the characteristics of attenders and non-attenders. Second, we investigated perceived barriers using a questionnaire in a random sample of people who failed to attend the follow-up visit.

RESULTS

A total of 27,806 (16.4%) patients attended the follow-up visits. Multiple logistic regression analysis revealed that individuals aged ≥75 years were more likely to attend follow-up than were those aged 35-45 years (odds ratio [OR]: 1.97 [95% confidence interval {CI}: 1.82-2.15]), male (OR: 1.15 [95% CI: 1.12-1.18]), obese (OR: 1.36 [95% CI: 1.29-1.43]), had positive family history of diabetes (OR: 1.37 [95% CI: 1.30-1.45]), hypertension (OR: 1.05 [95% CI: 1.01-1.09]), high glucose levels (OR: 1.10 [95% CI: 1.09-1.11]), and high diabetes risk scores (OR: 1.02 [95% CI: 1.02-1.03]) facilitated follow-up. However, overweight (OR: 0.95 [95% CI: 0.92-0.99]) and central obesity (OR: 0.86 [95% CI: 0.83-0.90]) predicted no follow-up. Among nonattenders, diabetes beliefs, time restrictions and distance from home to hospitals were the top three barriers hindering follow-up visits.

CONCLUSIONS

Specific individual-level characteristics predicted adherence to follow-up visits, and some personal and sociocultural barriers hindered follow-up visits.

Effect of the national lifestyle guidance intervention for metabolic syndrome among middle-aged people in Japan

Background

Japan has implemented a national lifestyle guidance intervention programme for potential metabolic syndrome among adults aged 40-74 years; however, there is limited evidence regarding the causal impact of this intervention. The study aims to determine the causal effect of this intervention on health outcomes and health care utilisation.

Methods

We performed a regression discontinuity design study. A total of 46 975 adults with ≥1 cardiovascular risk factor in 2015 were included in the study. A two-stage evaluation process (stage 1: waist circumference ≥85 cm for men or ≥90 cm for women and ≥1 cardiovascular risk factor; stage 2: body mass index (BMI)≥25 kg/m2 and ≥2 cardiovascular risk factors) was applied. Changes in obesity, cardiovascular outcomes, and health care utilisation were evaluated in a one-year follow-up in the fiscal year 2016.

Results

Participants who received lifestyle guidance intervention based on the waist circumference had a statistically significant reduction in obesity outcomes (Δ weight: -0.30 kg, 95% CI = -0.46 to -0.11; Δ waist circumference: -0.26 cm, 95% CI = -0.53 to -0.02; Δ BMI = -0.09 kg/m2, 95% CI = -0.17 to -0.04) but not in other cardiovascular risk factors and health care utilisation. Analyses based on BMI and results according to demographic subgroups did not reveal significant findings.

Conclusions

The provision of this intervention had a limited effect on health improvement and a decrease in health care costs, health care visits, and length of stay. A more intensive intervention delivery could potentially improve the efficacy of this intervention programme.

Proportion of subsequent clinic visits among persons without regular clinic visits who were screened as having hyperglycemia: A retrospective cohort study

AIMS/INTRODUCTION

We aimed to examine the proportion of subsequent clinic visits for persons screened as having hyperglycemia based on glycated hemoglobin (HbA1c) levels at screening and the presence/absence of hyperglycemia at health checkups before 1 year of the screening among those without previous diabetes-related medical care and attending regular clinic visits.

MATERIALS AND METHODS

This retrospective cohort study used the 2016-2020 data of Japanese health checkups and claims. The study analyzed 8,834 adult beneficiaries aged 20-59 years without regular clinic visits who had never received diabetes-related medical care and whose recent health checkups showed hyperglycemia. The rates of 6-month subsequent clinic visits after health checkups were evaluated according to HbA1c levels and the presence/absence of hyperglycemia at checkups a year before.

RESULTS

The overall clinic visit rate was 21.0%. The HbA1c-specific rates were 17.0, 26.7, 25.4 and 28.4% for <7.0, 7.0-7.4, 7.5-7.9 and ≥8.0% (64 mmol/mol), respectively. Persons with hyperglycemia at a previous screening had lower clinic visit rates than those without hyperglycemia, particularly in the HbA1c category of <7.0% (14.4% vs 18.5%; P < 0.001) and 7.0-7.4% (23.6% vs 35.1%; P < 0.001).

CONCLUSIONS

The overall rate of subsequent clinic visits among those without previous regular clinic visits was <30%, including for participants with HbA1c ≥8.0%. Persons with previously detected hyperglycemia had lower clinic visit rates, despite requiring more health counseling. Our findings might be useful for designing a tailored approach to encourage high-risk individuals to seek diabetes care through clinic visits.

A Machine Learning-Based Predictive Model to Identify Patients Who Failed to Attend a Follow-up Visit for Diabetes Care After Recommendations From a National Screening Program

OBJECTIVE

Reportedly, two-thirds of the patients who were positive for diabetes during screening failed to attend a follow-up visit for diabetes care in Japan. We aimed to develop a machine-learning model for predicting people's failure to attend a follow-up visit.

RESEARCH DESIGN AND METHODS

We conducted a retrospective cohort study of adults with newly screened diabetes at a national screening program using a large Japanese insurance claims database (JMDC, Tokyo, Japan). We defined failure to attend a follow-up visit for diabetes care as no physician consultation during the 6 months after the screening. The candidate predictors were patient demographics, comorbidities, and medication history. In the training set (randomly selected 80% of the sample), we developed two models (previously reported logistic regression model and Lasso regression model). In the test set (remaining 20%), prediction performance was examined.

RESULTS

We identified 10,645 patients, including 5,450 patients who failed to attend follow-up visits for diabetes care. The Lasso regression model using four predictors had a better discrimination ability than the previously reported logistic regression model using 13 predictors (C-statistic: 0.71 [95% CI 0.69-0.73] vs. 0.67 [0.65-0.69]; P < 0.001). The four selected predictors in the Lasso regression model were lower frequency of physician visits in the previous year, lower HbA1c levels, and negative history of antidyslipidemic or antihypertensive treatment.

CONCLUSIONS

The developed machine-learning model using four predictors had a good predictive ability to identify patients who failed to attend a follow-up visit for diabetes care after a screening program.

Data resource profile: JMDC claims database sourced from health insurance societies

JMDC, Inc. (JMDC) has created a database, using data collected from health insurance societies in Japan, consisting of ledgers of insureds, claims (for hospitalization, outpatient treatment, drug preparation, and dental treatment), and health checkup results. The earliest data are from the claims in January 2005, except dental claims from December 2009 and health checkup results from April 2008. Currently (the end of June 2020), the number of insureds included is approximately 9.8 million. This database is unique for Japan and has the following characteristics: (a) the basic population can be ascertained; (b) standardization is carried out using a dictionary; and (c) anonymized individual IDs can be followed on the basis of a time-series over various periods, with the earliest starting date being January 2005. However, it has certain limitations, in that the disease status and test results cannot be ascertained, and there is insufficient access to data for elderly people.

Effect of reminder letters after health checkups on the consultation behavior of participants with possible hypertension, hyperglycemia, and dyslipidemia: A retrospective cohort study using administrative claims data in Japan

OBJECTIVES

Prevention of and early treatment for noncommunicable diseases such as hypertension, hyperglycemia, and dyslipidemia are important, as these diseases are asymptomatic in early stages but can lead to critical conditions such as macro- and microvascular disorders later on. While screening is conducted worldwide, low rates of hospital visits after screening is a common issue. We aimed to investigate the effect of reminder letters on the consultation behavior of screened participants.

METHODS

We used administrative claims data from a database managed by JMDC Inc for participants of health checkups in 2014, 2015, 2016, and 2017, who belonged to a health insurance society. Reminder letters were sent regularly 6 months after checkups to improve participant consultation behavior. Participants who screened positive for hypertension, hyperglycemia, and dyslipidemia, and who were not taking medication for any of these diseases at the time of health checkups, were included in the analyses.

RESULTS

A total of 1739 participants in 2014, 1693 in 2015, 2002 in 2016, and 2144 in 2017 were included in the analysis for hypertension. The cumulative proportion of hospital visits gradually increased over the course of 12 months after checkups in all years. After 2015, spikes, albeit very small ones, were observed at 6 months after checkups in accordance with the timing of reminder letters. Similar trends were observed for hyperglycemia and dyslipidemia.

CONCLUSIONS

Sending reminder letters is a potentially effective approach to increase hospital visits, but further improvements (ie, multiple reminders) may be necessary to affect enhancements in participant consultation behavior.

Relationship between number of contacts between previous dropouts with type 2 diabetes and health care professionals on glycaemic control: A cohort study in public primary health care

AIM

Previous study findings have shown that more frequent contacts with the diabetes care team predict better diabetes control. It is unknown whether this is true also for previous dropouts with type 2 diabetes (T2D). The aim of this study was to evaluate if those previous dropouts with T2D who succeeded to improve their glycaemic control had more frequent contacts with health care professionals in the public primary diabetes health care system than those dropouts who did not show improvement.

METHODS

In this "real life" retrospective cohort study, we identified 115 dropouts with T2D who were contacted by trained diabetes nurses and who returned to a public T2D-care system. Those previous dropouts who had baseline haemoglobin A_1c ≥53mmol/mol (7%) and had a reduction in HbA_1c≥6mmol/mol (0.5%) during the follow-up were compared with those with unsatisfactory change in HbA_1c (baseline HbA_1c≥53mmol/mol and change <6mmol/mol, or HbA_1c<53mmol/mol at the baseline measurement but above that in the end of the study period) or with those who remained at good glycaemic control over the study period. Trained diabetes nurses collected quantitative data from the patient records about visits and contacts during the follow-up.

RESULTS

Previous dropouts showing improvement had more visits to the diabetes nurse (p=0.003) and other nurses (p<0.001) than those with no improvement or those with satisfactory glycaemic control. Telephone calls not focusing on diabetes (p<0.001) were also more frequent among previous dropouts with improvement than among the others.

CONCLUSIONS

Especially previous dropouts with T2D who had poor glycaemic control, may benefit from more frequent contacts including visits and telephone calls. Recalling dropouts does not seem to lead to overuse of the T2D care-system by those recalled patients whose glycaemic control does not require special care.

Impact of intervention on metabolic outcomes among dropouts with type 2 diabetes

PURPOSE

The aim of this study was to evaluate the effect of an individual intervention given by health care professionals to dropouts with type 2 diabetes (T2D) on their metabolic profile.

MATERIALS/METHODS

In 2010, we identified 356 T2D dropouts in Vantaa Health Centre, Finland. At the baseline visit the participants' status was assessed including laboratory tests. Diabetes counseling was given, and drug treatment was enhanced when needed. The follow-up visit was performed 13 to 30 months later including the same assessments as performed at the baseline visit. The dropouts who attended the follow-up visit formed the study group. One third (n=115) of the dropouts participated in the follow-up visit.

RESULTS

The study participants (mean age 61.4 years) were older than the non-participants (mean age 58.5 years) (p=0.009). After the intervention the proportion of participants with hemoglobin A1c≥9% (75mmol/mol) decreased from 15.5% to 5.2% (p=0.004). Improvements were also observed in general in hemoglobin A1c, from 6.6% (49mmol/mol) to 6.3% (45mmol/mol) (p=0.001), in total cholesterol, from 4.9mmol/l to 4.5mmol/l (p=0.011), in low-density lipoprotein cholesterol, from 2.9mmol/l to 2.6mmol/l (p=0.015) and in diastolic blood pressure, from 90mmHg to 84mmHg (p=0.001).

CONCLUSIONS

Dropouts with T2D were difficult to bring back to the public health care system, especially men under the age of 60 years. Dropouts who participated in the intervention showed improvements in several metabolic outcomes.

Contacting dropouts from type 2 diabetes care in public primary health care: description of the patient population

OBJECTIVE

To characterize dropouts from type-2 diabetes (T2D) care in communal primary health care.

DESIGN

An observational study.

SETTING

In a Finnish city, patients with T2D who had not contacted the public primary health care system during the past 12 months were identified with a computer based search and contacted by a trained diabetes nurse.

SUBJECTS

Dropouts from T2D treatment.

MAIN OUTCOME MEASURES

Demographic factors, laboratory parameters, examinations, medications, and comorbidities.

RESULTS

Of the patients with T2D, 10% (n = 356) were dropouts and 60% of them were men. Median HbA1c was 6.5 (QR for 25% and 75%: 6.0, 7.7) %, (45 [42,61] mmol/mol). Of the dropouts, 14% had HbA1c ≥ 9.0% (75 mmol/mol), and these patients were younger than the other dropouts (mean age 54.4 [SD 10.8] years vs. 60.6 [9.4] years, p < 0.001). Median low-density lipoprotein (LDL) cholesterol level was 2.8 (QR 2.1, 3.4) mmol/l. Median systolic blood pressure (BP) was 142 (QR 130, 160) mm Hg. Median diastolic BP was 86 (78, 94) mm Hg. Of the dropouts, 83% had comorbidities and 62% were prescribed metformin as a treatment.

CONCLUSIONS

Ten percent of T2D patients were dropouts of whom those with a poor glycaemic control were younger than the other dropouts. BP and LDL cholesterol concentrations were non-optimal among the majority of the dropouts. Metformin was prescribed less frequently to the dropouts than is usual for T2D patients. The comorbidities were equally common among the dropouts as among the other T2D patients. KEY POINTS   Which kinds of patients are dropouts from type-2 diabetes care is not known. • One-tenth of the patients with T2D were dropouts and they generally had good glycaemic control. • Blood pressure and LDL cholesterol concentrations were non-optimal among the majority of the dropouts. • Fourteen percent of these dropouts had HbA1c > 9% (75 mmol/mol) and they were more often younger than the other dropouts.

Process quality of diabetes care under favorable access to healthcare: a 2-year longitudinal study using claims data in Japan

OBJECTIVE

To investigate the process quality of diabetes care provided to patients under universal health insurance coverage.

RESEARCH DESIGN AND METHODS

Using claim data for 570 363 beneficiaries aged 20-69 years who were covered by Health Insurance Societies between April 2010 and March 2012, we identified patients with type 2 diabetes who made follow-up visits at least every 3 months in the first year (subject-identification year). We assessed patient adherence to follow-up visits in the second year (quality-reporting year), calculated the proportion of patients that completed routine examinations for glycemic control and complications, and evaluated associations between characteristics of patients and quality indicators using multivariable logistic regression models.

RESULTS

We identified 12 909 patients with diabetes; in the subject-identification year, 1415 (11.0%) had prescriptions for insulin injections, 6049 (46.9%) had prescriptions for oral antihyperglycemic agents, and 5445 (42.2%) had no diabetes-related prescriptions. Among patients using medication, 474 (6.4%) dropped out in the quality-reporting year. The adjusted percentages of quality indicators among patients using oral antihyperglycemic agents were 95.8% for glycated hemoglobin, 35.6% for eye examinations, 15.4% for urine microalbumin excretion, and 90.6% for serum lipids; the percentages among patients taking insulin were the same or higher. Annual testing for glycated hemoglobin was less frequent in patients aged 40-49 years than in patients aged 60-69 years (OR 0.77; 95% CI 0.66 to 0.91). Fewer men than women (OR 0.59; 95% CI 0.54 to 0.64), and fewer patients aged 40-49 years than those aged 60-69 years (OR 0.56; 95% CI 0.50 to 0.63) tended to complete routine eye examinations.

CONCLUSIONS

Screening for retinopathy and nephropathy was less frequent than required despite favorable conditions for access to healthcare in Japan. Suboptimal quality of care appeared to depend on provider factors as well as patient factors, such as limited access to retinopathy prevention among working-age men with diabetes.