Treatment of type 2 diabetes mellitus in a primary care setting in Taiwan: comparison with secondary/tertiary care

Morbidity profile and pharmaceutical management of adult outpatients between primary and tertiary care levels in Sri Lanka: a dual-centre, comparative study

BACKGROUND

Outpatient care is central to both primary and tertiary levels in a health system. However, evidence is limited on outpatient differences between these levels, especially in South Asia. This study aimed to describe and compare the morbidity profile (presenting morbidities, comorbidities, multimorbidity) and pharmaceutical management (patterns, indicators) of adult outpatients between a primary and tertiary care outpatient department (OPD) in Sri Lanka.

METHODS

A comparative study was conducted by recruiting 737 adult outpatients visiting a primary care and a tertiary care facility in the Kandy district. A self-administered questionnaire and a data sheet were used to collect outpatient and prescription data. Following standard categorisations, Chi-square tests and Mann‒Whitney U tests were employed for comparisons.

RESULTS

Outpatient cohorts were predominated by females and middle-aged individuals. The median duration of presenting symptoms was higher in tertiary care OPD (10 days, interquartile range: 57) than in primary care (3 days, interquartile range: 12). The most common systemic complaint in primary care OPD was respiratory symptoms (32.4%), whereas it was dermatological symptoms (30.2%) in tertiary care. The self-reported prevalence of noncommunicable diseases (NCDs) was 37.9% (95% CI: 33.2-42.8) in tertiary care OPD and 33.2% (95% CI: 28.5-38.3) in primary care; individual disease differences were significant only for diabetes (19.7% vs. 12.8%). The multimorbidity in tertiary care OPD was 19.0% (95% CI: 15.3-23.1), while it was 15.9% (95% CI: 12.4-20.0) in primary care. Medicines per encounter at primary care OPD (3.86, 95% CI: 3.73-3.99) was higher than that at tertiary care (3.47, 95% CI: 3.31-3.63). Medicines per encounter were highest for constitutional and respiratory symptoms in both settings. Overall prescribing of corticosteroids (62.7%), vitamin supplements (45.8%), anti-allergic (55.3%) and anti-asthmatic (31.3%) drugs was higher in the primary care OPD, and the two former drugs did not match the morbidity profile. The proportion of antibiotics prescribed did not differ significantly between OPDs. Subgroup analyses of drug categories by morbidity largely followed these overall differences.

CONCLUSIONS

The morbidities between primary and tertiary care OPDs differed in duration and type but not in terms of multimorbidity or most comorbidities. Pharmaceutical management also varied in terms of medicines per encounter and prescribed categories. This evidence supports planning in healthcare and provides directions for future research in primary care.

Identifying Profiles of Patients With Uncontrolled Type 2 Diabetes Who Would Benefit From Referral to an Endocrinologist

OBJECTIVE

To compare the outcomes of glycemic uncontrolled diabetes mellitus type 2 patients receiving treatment from endocrinologists with those treated by primary care physicians. Additionally, this research aims to identify patient profiles that would benefit from personalized referral-a novel medical approach that aims to match the most suitable specialist for effectively managing patient while considering the patient's profile.

METHODS

This retrospective cohort study uses the Maccabi Healthcare Services diabetes registry to match 508 pairs of glycemic uncontrolled diabetes mellitus type 2 patients treated by endocrinologists (EndoG) and primary care physicians (PcPG). Using a generalized additive model, we analyzed the hemoglobin A1c (HbA1c) trend over 1 year for each group. We employed the odds ratio (OR) from conditional logistic regression to determine the likelihood of favorable outcomes in the EndoG compared to the PcPG, using the entire cohort and subcohort profiles.

RESULTS

The generalized additive model comparison indicated an improvement in HbA1c levels in both groups, with the EndoG outperforming the PcPG. Furthermore, the EndoG group had an OR = 2.27 (95% confidence interval, 1.6 to 3.2) for reducing HbA1c by at least 1% within a year and an OR = 1.68 (95% confidence interval, 1.02 to 2.76) for achieving low-density lipoprotein levels< 100 mg/dl. We identified 96 profiles with positive outcomes, all favoring treatment by endocrinologists.

CONCLUSIONS

EndoG demonstrated superior HbA1c control over time and achieved better outcomes compared to PcPG. The identification of 96 profiles benefiting from endocrinologist referral emphasizes the potential of personalized referral.

Validation of the revised Diabetes Self-Management Questionnaire (DSMQ-R) in the primary care setting

Background

Available tools measuring self-management in diabetes are often improperly validated or do not correlate with glucose metabolism. The Diabetes Self-Management Questionnaire (DSMQ-R) is a valid tool, that showed strong relationship with glucose metabolism in tertiary care among people with mostly type 1 diabetes.

Aim of the study

To validate the translated DSMQ-R questionnaire in a Hungarian sample of people with predominantly type 2 diabetes in primary care.

Methods

We enrolled 492 adults from 38 practices in this cross-sectional cohort study, who filled out the self-administered questionnaire, consisting of DSMQ-R and the Summary of Diabetes Self-Care Activities (SDSCA) questionnaires. Family doctors provided clinical data. The translation process was performed in six steps, reaching the expert committee appraisal. The validity of the questionnaire was evaluated by assessing reliability and construct validity.

Results

Cronbach’s alpha showed the questionnaire to reach good reliability (α = 0.845), although subscales had lower alphas. Contrary to the SDSCA questionnaire, the DSMQ-R sum scale differed significantly between persons on target vs not on target (median (interquartile range): 7.23 (6.17–8.44) vs 6.91 (5.91–8.02), and the DSMQ-R sum scale correlated significantly with BMI, HbA1c and SDSCA sum scale. In multivariate analysis higher DSMQ-R scores were significant predictor of achieving glycemic target goal.

Conclusion

The Hungarian translation of the DSMQ-R is a comprehensible tool to assess self-management of persons with diabetes. The questionnaire is valid and reliable in family practice, although its association with achievement of diabetes HbA1c target is weaker in primary than in tertiary care.

The Impact of the Indonesian Chronic Disease Management Program (PROLANIS) on Metabolic Control and Renal Function of Type 2 Diabetes Mellitus Patients in Primary Care Setting

BACKGROUND

Indonesia through its government National Health Insurance System has launched a non-communicable and chronic disease management program named Indonesian Chronic Disease Management Program (PROLANIS), with Type 2 Diabetes Mellitus (T2DM) and hypertension as the main focus. However, study that evaluates the clinical impact of PROLANIS in patients with T2DM is still scarce to this date. This study aims to evaluate the metabolic control and renal function of PROLANIS participants with T2DM every six month within the first 18-months of implementation.

METHODS

This study was a retrospective cohort study conducted at Wates sub-district, East Java using secondary data from PROLANIS group report from April 2018 to October 2019. The study population was T2DM patients who voluntarily joined the PROLANIS group in April 2018. The six-month-evaluation included metabolic parameters [body mass index (BMI), blood pressure, hemoglobin A1C, total cholesterol, high-density lipid, low-density lipid, and triglyceride (TG)] and renal parameters [blood urea nitrogen (BUN), creatinine serum, and urinary microalbumin]. Paired t-test and wilcoxon signed-rank test was used for the analysis, and the P-value was adjusted using Bonferroni correction. A P-value < .0015 was considered statistically significant, while a P-value between .0015 and .003 was considered as marginally significant.

RESULTS

A total of 30 participants were included in the analysis. Following the PROLANIS implementation, the only parameter of metabolic control that showed significant improvement was TG serum level (P < .001). Despite the worsening status of other metabolic parameters, the changes were not statistically significant except for BMI that was marginally significant (P = .002). From renal function, only BUN serum level was significantly deteriorated (P < .001), while the others did not significantly change.

CONCLUSION

PROLANIS implementation in our study population seems to be ineffective. Future study with more primary healthcare centers needs to be done to scrutinize the clinical impact of this program nationwide.

The international and domestic politics of type 2 diabetes policy reform in Brazil

Introduction

Understanding the international and domestic political factors influencing the evolution of type 2 diabetes policies and primary care institutions is a new area of scholarly research. This article contributes to this area of inquiry by illustrating how a government’s shifting foreign policy aspirations, that is, to establish the government’s reputation as an internationally recognised leader in type 2 diabetes policy, and presidential electoral incentives provide alternative insights into the evolution of type 2 diabetes treatment policies and primary care institutional reforms.

Methods

I conduct a single-case study analysis with the usage of qualitative data; quantitative statistical data on epidemiological trends and government policy spending is also provided as supportive evidence.

Results

The case of Brazil illustrates how a reduction in foreign policy commitment to international reputation building in health as well as presidential electoral incentives to use diabetes policy as an electoral strategy account for a decline in sustaining policy and primary care institutional innovations in response to type 2 diabetes.

Conclusion

Future scholars interested in understanding the lack of sustainability and effectiveness in type 2 diabetes programmes should consider investigating the complex international and domestic political factors influencing political interests, incentives and commitment to reform.

Development and validation of the DIabetes Severity SCOre (DISSCO) in 139 626 individuals with type 2 diabetes: a retrospective cohort study

OBJECTIVE

Clinically applicable diabetes severity measures are lacking, with no previous studies comparing their predictive value with glycated hemoglobin (HbA_1c). We developed and validated a type 2 diabetes severity score (the DIabetes Severity SCOre, DISSCO) and evaluated its association with risks of hospitalization and mortality, assessing its additional risk information to sociodemographic factors and HbA_1c.

RESEARCH DESIGN AND METHODS

We used UK primary and secondary care data for 139 626 individuals with type 2 diabetes between 2007 and 2017, aged ≥35 years, and registered in general practices in England. The study cohort was randomly divided into a training cohort (n=111 748, 80%) to develop the severity tool and a validation cohort (n=27 878). We developed baseline and longitudinal severity scores using 34 diabetes-related domains. Cox regression models (adjusted for age, gender, ethnicity, deprivation, and HbA_1c) were used for primary (all-cause mortality) and secondary (hospitalization due to any cause, diabetes, hypoglycemia, or cardiovascular disease or procedures) outcomes. Likelihood ratio (LR) tests were fitted to assess the significance of adding DISSCO to the sociodemographics and HbA_1c models.

RESULTS

A total of 139 626 patients registered in 400 general practices, aged 63±12 years were included, 45% of whom were women, 83% were White, and 18% were from deprived areas. The mean baseline severity score was 1.3±2.0. Overall, 27 362 (20%) people died and 99 951 (72%) had ≥1 hospitalization. In the training cohort, a one-unit increase in baseline DISSCO was associated with higher hazard of mortality (HR: 1.14, 95% CI 1.13 to 1.15, area under the receiver operating characteristics curve (AUROC)=0.76) and cardiovascular hospitalization (HR: 1.45, 95% CI 1.43 to 1.46, AUROC=0.73). The LR tests showed that adding DISSCO to sociodemographic variables significantly improved the predictive value of survival models, outperforming the added value of HbA_1c for all outcomes. Findings were consistent in the validation cohort.

CONCLUSIONS

Higher levels of DISSCO are associated with higher risks for hospital admissions and mortality. The new severity score had higher predictive value than the proxy used in clinical practice, HbA_1c. This reproducible algorithm can help practitioners stratify clinical care of patients with type 2 diabetes.

Current Management of Type 2 Diabetes Mellitus in Primary Care Clinics in Korea

BACKGROUND

This study investigated the overall status of diabetes control and screening for diabetic microvascular complications in patients with type 2 diabetes mellitus attending primary care clinics in Korea.

METHODS

In this cross-sectional observational study, 191 primary care clinics were randomly selected across Korea from 2015 to 2016. In total, 3,227 subjects were enrolled in the study.

RESULTS

The patients followed at the primary care clinics were relatively young, with a mean age of 61.4±11.7 years, and had a relatively short duration of diabetes (mean duration, 7.6±6.5 years). Approximately 14% of subjects had diabetic microvascular complications. However, the patients treated at the primary care clinics had suboptimal control of hemoglobin A1c levels, blood pressure, and serum lipid levels, along with a metabolic target achievement rate of 5.9% according to the Korean Diabetes Association guidelines. The screening rates for diabetic nephropathy, retinopathy, and neuropathy within the past 12 months were 28.4%, 23.3%, and 13.3%, respectively.

CONCLUSION

The overall status of diabetes management, including the frequency of screening for microvascular complications, was suboptimal in the primary care clinics. More efforts should be made and more resources need to be allocated for primary care physicians to promote adequate healthcare delivery, which would result in stricter diabetes control and improved management of diabetic complications.

Political party ambitions and type-2 diabetes policy in Brazil and Mexico

In the Americas, next to the United States, Brazil and Mexico have the highest prevalence of type-2 diabetes. In contrast to most studies, this article compares and analyzes the politics behind the implementation of type-2 diabetes self-care management programs (DSM), which is a new area of scholarly research. This article claims that Brazil outpaced Mexico with respect to the implementation of effective DSM programs, the product of positive policy spillover effects associated with the president and governing political party's popular anti-poverty programs, and the enduring legacy of centralized ministry of health financial and human resource assistance to primary care programs in a context of decentralization. Brazil also benefited from having a strong partnership with international health agencies. None of these factors was present in Mexico. Findings suggest that more research needs to go into understanding the complex political and inter-governmental contexts facilitating DSM program implementation, which is a neglected area of research.

Using electronic health records to quantify and stratify the severity of type 2 diabetes in primary care in England: rationale and cohort study design

INTRODUCTION

The increasing prevalence of type 2 diabetes mellitus (T2DM) presents a significant burden on affected individuals and healthcare systems internationally. There is, however, no agreed validated measure to infer diabetes severity from electronic health records (EHRs). We aim to quantify T2DM severity and validate it using clinical adverse outcomes.

METHODS AND ANALYSIS

Primary care data from the Clinical Practice Research Datalink, linked hospitalisation and mortality records between April 2007 and March 2017 for patients with T2DM in England will be used to develop a clinical algorithm to grade T2DM severity. The EHR-based algorithm will incorporate main risk factors (severity domains) for adverse outcomes to stratify T2DM cohorts by baseline and longitudinal severity scores. Provisionally, T2DM severity domains, identified through a systematic review and expert opinion, are: diabetes duration, glycated haemoglobin, microvascular complications, comorbidities and coprescribed treatments. Severity scores will be developed by two approaches: (1) calculating a count score of severity domains; (2) through hierarchical stratification of complications. Regression models estimates will be used to calculate domains weights. Survival analyses for the association between weighted severity scores and future outcomes-cardiovascular events, hospitalisation (diabetes-related, cardiovascular) and mortality (diabetes-related, cardiovascular, all-cause mortality)-will be performed as statistical validation. The proposed EHR-based approach will quantify the T2DM severity for primary care performance management and inform the methodology for measuring severity of other primary care-managed chronic conditions. We anticipate that the developed algorithm will be a practical tool for practitioners, aid clinical management decision-making, inform stratified medicine, support future clinical trials and contribute to more effective service planning and policy-making.

ETHICS AND DISSEMINATION

The study protocol was approved by the Independent Scientific Advisory Committee. Some data were presented at the National Institute for Health Research School for Primary Care Research Showcase, September 2017, Oxford, UK and the Diabetes UK Professional Conference March 2018, London, UK. The study findings will be disseminated in relevant academic conferences and peer-reviewed journals.

Assessing the influence of health systems on Type 2 Diabetes Mellitus awareness, treatment, adherence, and control: A systematic review

BACKGROUND

Type 2 Diabetes Mellitus (T2DM) is reported to affect one in 11 adults worldwide, with over 80% of T2DM patients residing in low-to-middle-income countries. Health systems play an integral role in responding to this increasing global prevalence, and are key to ensuring effective diabetes management. We conducted a systematic review to examine the health system-level factors influencing T2DM awareness, treatment, adherence, and control.

METHODS AND FINDINGS

A protocol for this study was published on the PROSPERO international prospective register of systematic reviews (PROSPERO 2016: CRD42016048185). Studies included in this review reported the effects of health systems factors, interventions, policies, or programmes on T2DM control, awareness, treatment, and adherence. The following databases were searched on 22 February 2017: Medline, Embase, Global health, LILACS, Africa-Wide, IMSEAR, IMEMR, and WPRIM. There were no restrictions on date, language, or study designs. Two reviewers independently screened studies for eligibility, extracted the data, and screened for risk of bias. Thereafter, we performed a narrative synthesis. A meta-analysis was not conducted due to methodological heterogeneity across different aspects of included studies. 93 studies were included for qualitative synthesis; 7 were conducted in LMICs. Through this review, we found two key health system barriers to effective T2DM care and management: financial constraints faced by the patient and limited access to health services and medication. We also found three health system factors that facilitate effective T2DM care and management: the use of innovative care models, increased pharmacist involvement in care delivery, and education programmes led by healthcare professionals.

CONCLUSIONS

This review points to the importance of reducing, or possibly eliminating, out-of-pocket costs for diabetes medication and self-monitoring supplies. It also points to the potential of adopting more innovative and integrated models of care, and the value of task-sharing of care with pharmacists. More studies which identify the effect of health system arrangements on various outcomes, particularly awareness, are needed.

Interactive role of diabetes mellitus and female sex in the risk of cholangiocarcinoma: A population-based nested case-control study

Diabetes mellitus (DM) has been associated with an increased risk of extrahepatic cholangiocarcinoma (ECC) and intrahepatic cholangiocarcinoma (ICC). However, the role of DM in a population with a lower incidence of ECC remains unclear. We investigated the role of DM and other risk factors for ECC and ICC by conducting a population-based, nested, case–control study in Taiwan, a region with a lower incidence but a higher proportion of ICC. We identified patients who received a diagnosis of cholangiocarcinoma (CC) from the Taiwan Cancer Registry between 2003 and 2009. A total of 6,093 CC cases (ICC: 4,695; ECC: 1,396) and 60,906 matched controls were included. Compared with the controls, the patients with ICC and ECC were more likely to have DM, with an adjusted OR of 1.22 [95% confidence interval (CI): 1.07–1.39] and 1.48 (95% CI: 1.18–1.85), respectively. DM was associated with an increased risk of CC in the women and patients without a history of biliary tract diseases. Moreover, compared with the controls, DM was not associated with an increased risk of ECC in the patients who received cholecystectomy. These findings strongly support the positive association between DM and the increased risk of both ICC and ECC; however, this association was not observed in the patients who received cholecystectomy.

The effectiveness of multimedia education for patients with type 2 diabetes mellitus

AIMS

The aim of this study was to explore the effectiveness of two types of health education on improving knowledge concerning diabetes and insulin injection, insulin injection skills and self-efficacy, satisfaction with health education and glycated haemoglobin (HbA1c) and creatinine levels among patients with type 2 diabetes who began insulin therapy using a pen injector.

BACKGROUND

Insulin therapy is recommended to facilitate the regulation of plasma glucose; however, patient's acceptance of insulin therapy is generally low. Healthcare providers should help them improve their knowledge of diabetes and insulin injection, as well as their insulin injection skills.

DESIGN

A randomized repeated measures experimental study design.

METHODS

The experimental (n = 21) and control (n = 21) groups received multimedia and regular health education programmes, respectively from October 2013-August 2014. Four structured questionnaires were used and videotapes were applied to demonstrate injection skills.

RESULTS

Generalized estimating equations showed that the experimental group's scores were significantly higher than those of the control group for diabetes and insulin injection knowledge, insulin injection skills, self-efficacy in insulin injection and satisfaction with health education. On the other hand, an analysis of covariance revealed glycated hemoglobin (HbA1c) and creatinine levels did not differ significantly between the two groups.

CONCLUSIONS

Implementation of a multimedia diabetes education programme could improve patients' diabetes and insulin injection knowledge, insulin injection skills, self-efficacy in insulin injection and satisfaction with health education. Healthcare providers should improve quality of patient care by providing multimedia diabetes health education.

Prediction of self-care behaviour on the basis of knowledge about chronic kidney disease using self-efficacy as a mediator

AIMS AND OBJECTIVES

This study was to investigate: (1) the important factors in the self-care of chronic kidney disease (CKD) patients and (2) the mediating effects of self-efficacy on knowledge and self-care.

BACKGROUND

Chronic kidney disease has become a major global health issue and is one of the top 10 leading causes of death in Taiwan where the dialysis population ranks first in the world. The number of patients with poor self-care behaviours continues to rise despite ongoing health education. Knowledge and self-efficacy are important factors that influence self-care behaviour; however, very few articles have examined the relationships among them.

DESIGN

Cross-sectional and correlational design.

METHODS

Subject recruitment was conducted by purposive sampling in the renal outpatient clinics and dialysis centres of two teaching hospitals in northern Taiwan. A total of 247 patients with chronic kidney disease (stages 1-5) were enrolled.

RESULTS

(1) Knowledge was positively correlated with self-efficacy (r = 0·41, p < 0·01) and with self-care (r = 0·18, p < 0·01). Self-efficacy (r = 0·44, p < 0·01) as well as age (r = 0·15, p < 0·01) were positively correlated with self-care. (2) The relationship between knowledge and self-care was fully mediated by self-efficacy (z = 4·82, p < 0·001) and the effect was 50%.

CONCLUSION

The results showed that self-efficacy was a crucial mediator between knowledge and self-care. In addition to providing knowledge to chronic kidney disease patients, healthcare professionals should also offer strategies that can enhance self-efficacy to increase self-care behaviours in chronic kidney disease patients and implement effective disease management.

RELEVANCE TO CLINICAL PRACTICE

Incorporate self-efficacy strategies into the process of health education to improve knowledge and the effectiveness of self-care. The findings of this study provide evidence of effectiveness of the use of group activity through self-management and self-efficacy enhancement programmes and may influence the policy makers to consider adding or modifying the reimbursement criteria.

Glycaemic control and associated factors among patients with diabetes at public health clinics in Johor, Malaysia

OBJECTIVES

To determine the prevalence of glycaemic control and factors associated with poor glycaemic control [glycosylated haemoglobin (HbA1c) ≥6.5%] among patients with type 2 diabetes treated in public health clinics in Johor, Malaysia.

STUDY DESIGN

Cross-sectional study.

METHODS

A review of all patients aged over 18 years and with a diagnosis of type 2 diabetes for >1 year. The National Diabetic Registry was used as the database for attendees at public health clinics in Johor Bahru between January and December 2013. A required sample of 660 was calculated, and a random sampling method was applied to acquire patient information across the 13 public health clinics in Johor Bahru. All relevant information (e.g. HbA1c, type of treatment and other parameters for glycaemic control) were abstracted from the registry.

RESULTS

Sixty-eight percent of 706 patients had HbA1c >6.5%, and mean HbA1c was 7.8%. Younger patients (72.3%) had poorer glycaemic control than older patients (63.0%), and most patients with poor glycaemic control were obese (79.2%). Approximately 31.7% of patients did not achieve the target blood pressure <130/80 mmHg, and 58.5% did not achieve the target lipid profile. Multiple logistic regression analysis revealed that age (<60 years), sex (male), duration of diabetes (>5 years), body mass index (obese), type of treatment (diet therapy vs combination therapy) and abnormal lipid profile were significantly associated with increased odds of HbA1C >6.5%.

CONCLUSIONS

More than half (68%) of the patients with diabetes had HbA1c >6.5%. This highlights the importance of providing organized care to manage patients with diabetes in the primary care setting, such as weight reduction programmes, proper prescribing treatment, and age- and gender-specific groups to ensure good glycaemic control.

DiabCare survey of diabetes management and complications in the Gulf countries

AIM

To describe the status of diabetes control and complications, and the quality of diabetes management in Saudi Arabia, Kuwait, and the United Arab Emirates, and to obtain an insight into the relationship between these factors.

METHODS

Patients with diabetes for>12 months were enrolled from specialist clinics and general hospitals. All available data from the patients' medical files including patient demographics; glycemic, lipid, and blood pressure status; diabetes-related complications; and diabetes management were recorded in data collection forms and analyzed.

RESULTS

Overall, 1290 patients with diabetes were enrolled with a mean (±standard deviation) age of 49.4 ± 12.3 years and duration of diabetes of 8.7 ± 5.9 years. Glycemic control was poor: Mean glycated hemoglobin A1c of 8.3 ± 2.0%, fasting and postprandial plasma glucose levels of 155.9 ± 57.1 mg/dL (8.7 ± 3.2 mmol/L), and 218.2 ± 87.4 mg/dL (12.1 ± 4.9 mmol/L), respectively. Diabetes-related complications such as neuropathy (34.9% of patients), background retinopathy (29.9%), and cataract (14.1%) were common. Cardiovascular complications were reported in <10% of patients, and microalbuminuria was detected in 34.4% of patients. Oral antidiabetic drug (OAD) monotherapy (43.3%) was the most common treatment, followed by insulin + OADs (39.3%) and insulin monotherapy (17.6%).

CONCLUSION

The status of diabetes care was found to be suboptimal. Further improvements in diabetes management are necessary to prevent or delay the development of diabetes-related complications.

Association of clinical symptomatic hypoglycemia with cardiovascular events and total mortality in type 2 diabetes: a nationwide population-based study

OBJECTIVE

Hypoglycemia is associated with serious health outcomes for patients treated for diabetes. However, the outcome of outpatients with type 2 diabetes who have experienced hypoglycemia episodes is largely unknown.

RESEARCH DESIGN AND METHODS

The study population, derived from the National Health Insurance Research Database released by the Taiwan National Health Research Institutes during 1998-2009, comprised 77,611 patients with newly diagnosed type 2 diabetes. We designed a prospective study consisting of randomly selected hypoglycemic type 2 diabetic patients and matched type 2 diabetic patients without hypoglycemia. We investigated the relationships of hypoglycemia with total mortality and cardiovascular events, including stroke, coronary heart disease, cardiovascular diseases, and all-cause hospitalization.

RESULTS

There were 1,844 hypoglycemic events (500 inpatients and 1,344 outpatients) among the 77,611 patients. Both mild (outpatient) and severe (inpatient) hypoglycemia cases had a higher percentage of comorbidities, including hypertension, renal diseases, cancer, stroke, and heart disease. In multivariate Cox regression models, including diabetes treatment adjustment, diabetic patients with hypoglycemia had a significantly higher risk of cardiovascular events during clinical treatment periods. After constructing a model adjusted with propensity scores, mild and severe hypoglycemia still demonstrated higher hazard ratios (HRs) for cardiovascular diseases (HR 2.09 [95% CI 1.63-2.67]), all-cause hospitalization (2.51 [2.00-3.16]), and total mortality (2.48 [1.41-4.38]).

CONCLUSIONS

Symptomatic hypoglycemia, whether clinically mild or severe, is associated with an increased risk of cardiovascular events, all-cause hospitalization, and all-cause mortality. More attention may be needed for diabetic patients with hypoglycemic episodes.

Trends of ABC control 2006-2011: a National Survey of Diabetes Health Promotion Institutes in Taiwan

AIMS

To understand the trends of ABC control in 5 years interval in Taiwan.

METHODS

We compared two waves of nationwide surveys (n=7541 and n=5599, mainly type 2 diabetes) to examine the trends of ABC control across 5 years in accredited Diabetes Health Promotion Institutes in Taiwan.

RESULTS

The percentages of subjects who had HbA1c lower than 7% (A), both SBP and DBP lower than 130/80 mmHg (B), and total cholesterol lower than 160 mg/dl or LDL cholesterol lower than 100mg/dl (C) increased by 6.5% (from 32.4% to 34.5%), 22.0% (from 30.9% to 37.7%), and 57.8% (from 35.3% to 55.7%), respectively, with a resulting total ABC attainment rate from 4.1% to 8.6%. A subgroup of 720 diabetic subjects who participated in both surveys showed the same pattern of changes in B and C but had a slight deterioration of glycemic control. Logistic regression analysis revealed that diagnosis of type 1 diabetes, lower BMI and individuals not requiring insulin were independently associated with attainment of ABC goals in 2006 and 2011. An accountabilities examination revealed that annular tests of HbA1c, BP and lipids were all above 90% in both surveys.

CONCLUSIONS

We observed an improvement of individual and overall attainments of ABC goals across 5 years in Taiwan owing to recent implementation of several diabetes care models and initiatives. We anticipate that these improvements will translate into reductions of both macrovascular and microvascular complications.

The role of adherence in the relationship between self-efficacy and self-management in diabetic patients undergoing CABG in Taiwan

OBJECTIVES

To determine the role of adherence and its significance in the relationship between self-efficacy and self-management of diabetic patients undergoing coronary artery bypass graft (CABG) in Taiwan.

DESIGN

Descriptive and correlational survey design.

SETTING

Three outpatient clinics in Taiwan.

PARTICIPANTS

Patients diagnosed with diabetes undergoing CABG at least 6 months before the study, 18 years of age or older, able to communicate verbally without any psychiatric problems, and with a life expectancy longer than 1 year.

MAIN OUTCOME MEASURES

Self-management assessment (self-efficacy for managing disease and adherence to guidelines and medication measured on a scale of 0-8), the higher aspects of self-management (keeping appointments, taking medication properly and keeping follow-up appointments) and the lower aspects of self-management (inability to share decisions with primary physician, inability to take correct actions when symptoms worsen and inability to adapt habits to improve health).

RESULTS

The mean score obtained for self-management among the 166 participants was 6.48, with 57 (34.3%) of them showing non-adherent behaviour. Self-efficacy accounts for 38% (R(2)=0.380, F(1,103)=63.124, p < 0.001), and 54% of good self-management was explained by self-efficacy and adherence in managing disease (R(2)=0.540, F(2,102)=56.937, p<0.001). Adherence accounts for 16% of better self-management, age and education combined account for 4.9% (R(2)=0.589, F(6.98)=23.399, p<0.001), and lifestyle items account for 5.2% (R(2)=0.641, F(14,90)=11.457, p<0.001). Disease-related variables contribute 3.4% (R(2)=0.674, F(17,87)=10.599, p<0.001). Thus self-efficacy, adherence, age, education, primary care provider and systolic pressure are considered significant predictors of self-management. With the exception of adherence, none of the variables had a statistically significant mediating effect.

CONCLUSIONS

The results confirm strong relationships between self-efficacy, adherence and self-management, with adherence having a significant mediating effect in post-CABG patients with diabetes in Taiwan.

Relationships among depression, anxiety, self-care behaviour and diabetes education difficulties in patients with type-2 diabetes: a cross-sectional questionnaire survey

BACKGROUND

Since psychosocial issues appear to be common among people with diabetes, addressing these problems may improve outcomes. Specifically, it is important to understand the factors associated with anxiety and depression in patients with diabetes.

OBJECTIVE

The purpose of this study was to investigate the relationships between self-care behaviour, diabetes education difficulties, depression and anxiety among patients with type-2 diabetes in Taiwan.

DESIGN

This study was cross-sectional and consisted of descriptive statistics and correlations in terms of analyses.

SETTING

Three teaching hospitals, one from each of the northern, middle and southern parts of Taiwan, were selected for data collection.

PARTICIPANT

A total of 312 patients diagnosed with type-2 diabetes were recruited to participate in this study. The inclusion criteria of the study subjects included a diagnosis of type-2 diabetes beyond the age of 18 years and the ability to communicate in Mandarin.

METHODS

Various questionnaires were used to assess demographic, disease characteristics, self-care behaviour, diabetes education difficulty, depression and anxiety data.

RESULTS

(1) Rates of disturbance for depression (10.6%) and anxiety (20.5%) among type-2 diabetes patients were lower than those in Western countries. (2) Anxiety was positively correlated with age (r=0.15, p<0.01), complications (r=0.27, p<0.01), diabetes education difficulty (r=0.39, p<0.01) and depression (r=0.54, p<0.01), but negatively correlated with body mass index (BMI) (r=0.20, p<0.01). (3) A total of 50.5% of variance in anxiety was explained by age, complications, BMI, diabetes education difficulty and depression. (4) A total of 42.8% of variance in depression was explained by BMI, diabetes education difficulty and anxiety.

CONCLUSION

Depression and anxiety are common among patients with diabetes and can have significant effects on the outcome of their medical illness. Addressing psychosocial factors of people with diabetes may improve effects of patient education and disease self-management.

ABC control of diabetes: survey data from National Diabetes Health Promotion Centers in Taiwan

We undertook nationwide surveys to evaluate the status of diabetes control in 7541 diabetes subjects among 114 accredited Diabetes Health Promotion Centers in Taiwan in 2006, focusing on characteristics of those who attained the "ABC" goals (n=310). The mean age was 62.8+/-12.4 years (mean+/-SD), BMI 25.9+/-0.4 kg/m(2) and HbA1c levels 7.9+/-1.7%. The percentage of subjects whose HbA1c levels met ADA goals was less than 7% (A), and both SBP and DBP less than 130/80 mmHg (B), total cholesterol less than 160 mg/dl or LDL cholesterol levels less than 100mg/dl (C) were 32.4%, 30.9% and 35.3%, respectively. Overall, the percentage of examined diabetic subjects who fulfilled current recommended ABC goals was 4.1% (95% CI, 3.66-4.56%). Results of logistic regression analysis that indicated factors significantly associated with ABC goals are diagnosis of type 1 diabetes (p=0.025), BMI less than 23 kg/m(2) (p=0.022) and subjects not requiring insulin (p=0.006). In conclusion, only 4.1% of subjects reached all ABC goals. Diabetic individuals with diagnosis of type 1 diabetes, lesser BMI and those not using insulin were more likely to attain all ABC goals.

Self-efficacy, outcome expectations and self-care behaviour in people with type 2 diabetes in Taiwan

AIMS

To explore differences in self-care behaviour according to demographic and illness characteristics; and relationships among self-care behaviour and demographic and illness characteristics, efficacy expectations and outcome expectations of people with type 2 diabetes in Taiwan.

BACKGROUND

Most people with diabetes do not control their disease appropriately in Taiwan. Enhanced self-efficacy towards managing diseases can be an effective way of improving disease control as proposed by the self-efficacy model which provides a useful framework for understanding adherence to self-care behaviours.

DESIGN AND METHODS

The sample comprised 145 patients with type 2 diabetes aged 30 years or more from diabetes outpatient clinics in Taipei. Data were collected using a self-administered questionnaire for this study. One-way anova, t-tests, Pearson product moment correlation and hierarchical regression were analysed for the study.

RESULTS

Significant differences were found: between self-care behaviour and complications (t = -2.52, p < 0.01) and patient education (t = -1.96, p < 0.05). Self-care behaviour was significantly and positively correlated with duration of diabetes (r = 0.36, p < 0.01), efficacy expectations (r = 0.54, p < 0.01) and outcome expectations (r = 0.44, p < 0.01). A total of 39.1% of variance in self-care behaviour can be explained by duration of diabetes, efficacy expectations and outcome expectations.

CONCLUSIONS

Findings support the use of the self-efficacy model as a framework for understanding adherence to self-care behaviour.

RELEVANCE TO CLINICAL PRACTICE

Using self-efficacy theory when designing patient education interventions for people with type 2 diabetes will enhance self-management routines and assist in reducing major complications in the future.