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Tibballs K, Jenum AK, Kirkebøen L, Berg TJ, Claudi T, Cooper JG, Nøkleby K, Sandberg S, Straand J, Buhl ES. High prevalence of retinopathy in young-onset type 2 diabetes and possible sex differences: insights from Norwegian general practice. BMJ Open Diabetes Res Care 2024; 12:e003624. [PMID: 38167605 PMCID: PMC10773319 DOI: 10.1136/bmjdrc-2023-003624] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 11/11/2023] [Indexed: 01/05/2024] Open
Abstract
INTRODUCTION People with young-onset type 2 diabetes (YOD), defined as diabetes diagnosis before age 40, have a high lifetime risk of vascular complications. We aimed to estimate the prevalence of YOD among adults with type 2 diabetes (T2D) in Norwegian general practice and explore associations between age at diabetes diagnosis and retinopathy overall and in men and women. RESEARCH DESIGN AND METHODS We collected cross-sectional data from general practice electronic medical records of 10 241 adults with T2D in 2014, and repeated measurements of hemoglobin A1c (HbA1c) from 2012 to 2014. Using multivariate logistic regression, we assessed associations between YOD and later-onset T2D, sex and retinopathy. RESULTS Of all individuals with T2D, 10% were diagnosed before 40 years of age in both sexes. Compared with later-onset T2D, HbA1c increased faster in YOD, and at the time of diagnosis HbA1c was higher in men, particularly in YOD. Retinopathy was found in 25% with YOD, twice as frequently as in later onset. After adjustments for confounders (age, country of origin, education, body mass index), OR of retinopathy was increased in both men with YOD (OR 2.6 (95% CI 2.0 to 3.5)) and women with YOD (OR 2.2 (1.5 to 3.0)). After further adjustments for potential mediators (diabetes duration and HbA1c), the higher OR persisted in men with YOD (OR 1.8 (1.3 to 2.4)) but was attenuated and no longer significant for women with YOD. CONCLUSIONS Retinopathy prevalence was more than twice as high in YOD as in later-onset T2D. The increased likelihood of retinopathy in YOD was partly mediated by higher HbA1c and longer T2D duration, but after accounting for these factors it remained higher in men with YOD.
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Affiliation(s)
- Katrina Tibballs
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Anne Karen Jenum
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | | | | | | | - John Graham Cooper
- Norwegian Organization for Quality Improvement of Laboratory Examinations, Bergen, Norway
| | - Kjersti Nøkleby
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Sverre Sandberg
- Norwegian Organization for Quality Improvement of Laboratory Examinations, Bergen, Norway
| | - Jørund Straand
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
- General Practice Research Unit, Oslo, Norway
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Jing S, Yu Y, Yuan B. Study on the determinants of health professionals' performance on diabetes management care in China. BMC PRIMARY CARE 2023; 24:172. [PMID: 37660002 PMCID: PMC10474730 DOI: 10.1186/s12875-023-02136-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 08/22/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND As the direct providers of diabetes management care in primary health care facilities (PHFs) in China, health professionals' performance on management care of diabetes determines the quality of services and patients' outcomes. This study aims to analyze the key determinants of health professionals' performance on diabetes management care in PHFs in China. METHODS We conducted a cross-sectional study in 72 PHFs in 6 cities that piloted the contracted family doctor service (CFDS). Self-developed questionnaire was used to measure three kinds of factors (capacity, motivation and opportunity) potentially influencing the performance of health professionals. The performance of diabetes management care in the study was measured as whether health professionals delivered 7 service items required by the National Basic Public Health Service Guideline with a total of 7 points and was divided into three grades of good, medium and bad. The questionnaire is self-administered by all the health professionals involved in the study with the number of 434. The Chi-square tests were used to compare differences of performance on diabetes management care among health professionals with different characteristics. The ordinal logistic regression was used to analyze the determinants on the performance of diabetes management care. RESULTS Health professionals who got higher score on diabetes knowledge test had odds of better performance on diabetes management care (OR = 1.529, P < 0.001). health professionals with higher degree of self-reported satisfaction on training (OR = 1.224, P < 0.05) and perception of decreasing workload (OR = 3.336, P < 0.01) had odds of better performance on diabetes management care. While health professionals with negative feeling on information system support had odds of worse performance on diabetes management care (OR = 0.664, P < 0.01). CONCLUSIONS Attention should be paid to the training of health professionals' knowledge on diabetes management capacity. Furthermore, measures to improve training for health professionals could satisfying their needs for self-growth and improve the motivation of health professionals. The information system supporting management care should be improved continuously to improve the health professionals' working opportunities and decrease the workload.
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Affiliation(s)
- Shanshan Jing
- College of Health Sciences, Shandong University of Traditional Chinese Medicine, 4655 Da Xue Road, University Science Park, Changqing District, Jinan, 250355, Shandong, China
| | - Yahang Yu
- China Center for Health Development Studies, Peking University, Xue Yuan Road 38, Haidian District, Box 505, Beijing, 100191, China
| | - Beibei Yuan
- China Center for Health Development Studies, Peking University, Xue Yuan Road 38, Haidian District, Box 505, Beijing, 100191, China.
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Faria-Neto JR, Yarleque C, Vieira LF, Sakane EN, Santos RD. Challenges faced by patients with dyslipidemia and systemic arterial hypertension in Brazil: a design of the patient journey. BMC Cardiovasc Disord 2022; 22:237. [PMID: 35597901 PMCID: PMC9124411 DOI: 10.1186/s12872-022-02669-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 04/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Non-communicable diseases like systemic arterial hypertension (SAH) and dyslipidemia are poorly studied in terms of patient journey aspects. This semi-systematic review provides evidence synthesis for the management of SAH and dyslipidemia in Brazil and also discusses challenges faced by patients at the local level along with a suggested care approach by local experts. METHODS A semi-systematic review using both structured literature databases (Embase and Medline) and unstructured scientific records (WHO, IPD, MOH and Google) on hypertension and dyslipidemia in the English language from 2010 to 2019 was performed by reviewers. After two-level screening based on pre-defined criteria, patient journey touchpoints and prevalence information were extracted from the included articles. Data gaps were bridged through the insights of local experts. RESULTS Prevalence of hypertension and dyslipidemia in Brazil were 23% and 40.8%, respectively. Awareness of dyslipidemia was found in a larger proportion (58.1%) than in SAH (22.2%). Similarly, screening for hypertension (97%) and dyslipidemia (55.4%) were found to be effective, while treatment was (62.9%) and (30.0%) for hypertension and dyslipidemia, respectively. CONCLUSION There were important gaps on patient awareness and treatment of dyslipidemia and hypertension. Limited patient education, regional disease distribution, and treatment allocation, along with limited resources for diagnosis and treatment are the key challenges.
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Affiliation(s)
- Jose Rocha Faria-Neto
- School of Medicine, Pontificial Catholic University of Parana (PUCPR), Curitiba, Brazil
| | - Carlos Yarleque
- Research, Development and Medical, Upjohn - A Division of Pfizer, Lima, Peru
| | | | | | - Raul D Santos
- Heart Institute (InCor) University of Sao Paulo Medical School Hospital, São Paulo, Brazil.
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
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Variability in the Control of Type 2 Diabetes in Primary Care and Its Association with Hospital Admissions for Vascular Events. The APNA Study. J Clin Med 2021; 10:jcm10245854. [PMID: 34945149 PMCID: PMC8703537 DOI: 10.3390/jcm10245854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/02/2021] [Accepted: 12/08/2021] [Indexed: 01/14/2023] Open
Abstract
Type 2 diabetes (T2D) is associated with increased cardiovascular morbidity, mortality, and hospital admissions. This study aimed to analyze how the differences in delivered care (variability of glycosylated hemoglobin (HbA1c) achieved targets) affect hospital admissions for cardiovascular events (CVEs) in T2D patients. Methods: We analyzed the electronic records in primary care health centers at Navarra (Spain) and hospital admission for CVEs. We followed 26,435 patients with T2D from 2012 to 2016. The variables collected were age, sex, health center, general practitioner practice (GPP), and income. The clinical variables were diagnosis of T2D, weight, height, body mass index (BMI), blood pressure (BP), HbA1c, low-density lipoprotein cholesterol (LDL-C), smoking, and antecedents of CVEs. We calculated, in each GPP practice, the proportion of patients with HbA1c ≥ 9. A non-hierarchical K-means cluster analysis classified GPPs into two clusters according to the level of compliance with HbA1C ≥ 9% control indicators. We used logistic and Cox regressions. Results: T2D patients had a higher probability of admission for CVEs when they belonged to a GPP in the worst control cluster of HbA1C ≥ 9% (HR = 1.151; 95% CI, 1.032–1.284).
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Tran AT, Berg TJ, Mdala I, Gjelsvik B, Cooper JG, Sandberg S, Claudi T, Jenum AK. Factors associated with potential over- and undertreatment of hyperglycaemia and annual measurement of HbA 1c in type 2 diabetes in norwegian general practice. Diabet Med 2021; 38:e14500. [PMID: 33354827 PMCID: PMC8359382 DOI: 10.1111/dme.14500] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 11/11/2020] [Accepted: 12/14/2020] [Indexed: 12/16/2022]
Abstract
AIMS To identify individual and general practitioner (GP) characteristics associated with potential over- and undertreatment of hyperglycaemia in type 2 diabetes and with HbA1c not being measured. METHODS A cross-sectional study that included 10233 individuals with type 2 diabetes attending 282 GPs. Individuals with an HbA1c measurement during the last 15 months were categorized as potentially overtreated if they were prescribed a sulphonylurea and/or insulin when the HbA1c was less than 53 mmol/mol (7%) when aged over 75 years or less than 48 mmol/mol (6.5%) when aged between 65 and 75 years. Potential undertreatment was defined as age less than 60 years and HbA1c > 64 mmol/mol (8.0%) or HbA1c > 69 mmol/mol (8.5%) and treated with lifestyle modification and/or monotherapy. We used multilevel binary and multinominal logistic regression models to examine associations. RESULTS Overall, 4.1% were potentially overtreated, 7.8% were potentially undertreated and 11% did not have HbA1c measured. Characteristics associated with potential overtreatment were as follows: long diabetes duration, prescribed antihypertensive medication, cardiovascular disease and renal failure. Potential undertreatment was associated with male gender, non-western origin and low educational level. Characteristics associated with not having an HbA1c measurement performed were male gender, age < 50 years and cardiovascular diseases. GP specialist status and GPs' use of a Noklus diabetes application reduced the risk of not having an HbA1c measurement performed. CONCLUSION Potential overtreatment in elderly individuals with type 2 diabetes was relatively low. Nevertheless, appropriate de-intensification or intensification of treatment and regular HbA1c measurement in identified subgroups is warranted.
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Affiliation(s)
- Anh T. Tran
- Department of General PracticeInstitute of Health and SocietyUniversity of OsloOsloNorway
| | - Tore J. Berg
- Institute of Clinical MedicineFaculty of MedicineUniversity of OsloOsloNorway
- Department of Endocrinology, Morbid Obesity and Preventive MedicineOslo University HospitalOsloNorway
| | - Ibrahimu Mdala
- Department of General PracticeInstitute of Health and SocietyUniversity of OsloOsloNorway
| | - Bjørn Gjelsvik
- Department of General PracticeInstitute of Health and SocietyUniversity of OsloOsloNorway
| | - John G. Cooper
- Norwegian Quality Improvement of Laboratory ExaminationsHaraldsplass Deaconess HospitalBergenNorway
- Department of MedicineStavanger University HospitalStavangerNorway
| | - Sverre Sandberg
- Norwegian Quality Improvement of Laboratory ExaminationsHaraldsplass Deaconess HospitalBergenNorway
- Department of Global Public Health and Primary CareUniversity of BergenBergenNorway
- Department of Clinical Biochemistry and PharmacologyHaukeland University HospitalBergenNorway
| | - Tor Claudi
- Department of MedicineNordland HospitalBodøNorway
| | - Anne K. Jenum
- Department of General PracticeInstitute of Health and SocietyUniversity of OsloOsloNorway
- General Practice Research Unit (AFE)Department of General PracticeInstitute of Health and Society, University of OsloOsloNorway
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Nøkleby K, Berg TJ, Mdala I, Tran AT, Bakke Å, Gjelsvik B, Claudi T, Cooper JG, Løvaas KF, Thue G, Sandberg S, Jenum AK. Variation between general practitioners in type 2 diabetes processes of care. Prim Care Diabetes 2021; 15:495-501. [PMID: 33349599 DOI: 10.1016/j.pcd.2020.11.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/29/2020] [Accepted: 11/30/2020] [Indexed: 11/18/2022]
Abstract
AIMS To explore variation in general practitioners' (GPs') performance of six recommended procedures in type 2 diabetes patients <75 years without cardiovascular disease. METHODS Cross-sectional study of quality of diabetes care in Norway based on electronic health records from 2014. GPs (clustered in practices) were divided in quintiles based on a composite measure of performance of six processes of care. We fitted a multilevel partial ordinal regression model to identify GP factors associated with being in quintiles with better performance. RESULTS We identified 6015 type 2 diabetes patients from 275 GPs in 77 practices. The GPs performed on average 63.4% of the procedures; on average 46% in the poorest quintile to 81% in the best quintile with a larger range in individual GPs. After adjustments, use of a structured follow-up form was associated with GPs being in upper three quintiles (OR 12.4 (95% CI 2.37-65.1). Routines for reminders were associated with being in a better quintile (OR 2.6 (1.37-4.92). GPs' age >60 years and heavier workload were associated with poorer performance. CONCLUSION We found large variations in GPs' performance of processes of care. Factors reflecting structure and workload were strongly associated with performance.
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Affiliation(s)
- Kjersti Nøkleby
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway.
| | - Tore Julsrud Berg
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Oslo, Norway
| | - Ibrahimu Mdala
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Anh Thi Tran
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Åsne Bakke
- Department of Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Bjørn Gjelsvik
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Tor Claudi
- Nordland Hospital, Department of Medicine, Bodø, Norway
| | - John G Cooper
- Department of Medicine, Stavanger University Hospital, Stavanger, Norway; Norwegian Quality Improvement of Laboratory Examinations, Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Karianne F Løvaas
- Norwegian Quality Improvement of Laboratory Examinations, Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Geir Thue
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Sverre Sandberg
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; Norwegian Quality Improvement of Laboratory Examinations, Haraldsplass Deaconess Hospital, Bergen, Norway; Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | - Anne K Jenum
- General Practice Research Unit (AFE), Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
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Ertmann RK, Nicolaisdottir DR, Kragstrup J, Siersma V, Overbeck G, Wilson P, Lutterodt MC. Selection bias in general practice research: analysis in a cohort of pregnant Danish women. Scand J Prim Health Care 2020; 38:464-472. [PMID: 33242291 PMCID: PMC7782229 DOI: 10.1080/02813432.2020.1847827] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE The aim of the present study was to examine selection in a general practice-based pregnancy cohort. DESIGN Survey linked to administrative register data. SETTING AND SUBJECTS In spring 2015, GPs were recruited from two Danish regions. They were asked to invite all pregnant women in their practice who had their first prenatal care visit before 15 August 2016 to participate in the survey. OUTCOME MEASURES The characteristics of GPs and the pregnant women were compared at each step in the recruitment process - the GP's invitation, their agreement to participate, actual GP participation, and the women's participation - with an uncertainty coefficient to quantify the step where the largest selection occurs. RESULTS Significant differences were found between participating and non-participating practices with regards to practice characteristics such as the number of patients registered with the practice, the age and sex of doctors, and the type of practice. Despite these differences, the characteristics of the eligible patients differed little between participating and non-participating practices. In participating practices significant differences were, however, observed between recruited and non-recruited patients. CONCLUSION The skewed selection of patients was mainly caused by a high number of non-participants within practices that actively took part in the study. We recommend that a focus on the sampling within participating practices be the most important factor in representative sampling of patient populations in general practice. Key points Selection among general practitioners (GPs) is often unavoidable in practice-based studies, and we found significant differences between participating and non-participating practices. These include practice characteristics such as the number of GPs, the number of patients registered with the GP practice, as well as the sex and age of the GPs. •Despite this, only small differences in the characteristics of the eligible patients were observed between participating and non-participating practices. •In participating practices, however, significant differences were observed between recruited and non-recruited patients. •Comprehensive sampling within participating practices may be the best way to generate representative samples of patients.
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Affiliation(s)
- Ruth K. Ertmann
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
- CONTACT Ruth K. Ertmann The Research Unit for General Practice, Øster Farimagsgade 5, Copenhagen KDK-1014, Denmark
| | - Dagny R. Nicolaisdottir
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
| | - Jakob Kragstrup
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
| | - Volkert Siersma
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
| | - Gritt Overbeck
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
| | - Philip Wilson
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
- Centre for Rural Health, University of Aberdeen, Aberdeen, Scotland
| | - Melissa C. Lutterodt
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark;
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Bonora E, Cataudella S, Marchesini G, Miccoli R, Vaccaro O, Fadini GP, Martini N, Rossi E. A view on the quality of diabetes care in Italy and the role of Diabetes Clinics from the 2018 ARNO Diabetes Observatory. Nutr Metab Cardiovasc Dis 2020; 30:1945-1953. [PMID: 32998821 DOI: 10.1016/j.numecd.2020.08.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/03/2020] [Accepted: 08/11/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUNDS AND AIMS To investigate relevant indicators of quality of care in a large population-based sample of people with diabetes representative of clinical practice in Italy in 2018. METHODS AND RESULTS We analyzed data from 11,300,750 subjects. All administrative healthcare claims collected in 2018 were scrutinized to identify subjects with diabetes and investigate several indicators of quality of care. Subjects with diabetes were identified by anti-hyperglycemic drug prescriptions, disease-specific co-payment exemption and hospital discharge codes. Indicators of quality of care pertained to monitoring (HbA1c, creatinine, lipid profile, microalbuminuria, eye examination, ECG, ultrasonography of carotid and lower limb arteries) and diabetes treatment (anti-hyperglycemic agents in subjects with cardiovascular disease, CVD). Subjects attending and nonattending Diabetes Clinics were compared. We identified 697,208 individuals with diabetes. HbA1c was assessed at least once in the year in 62.7%, creatinine in 62.3%, total cholesterol in 59.6%, microalbuminuria in 34.3%. Frequency of eye examination was 8.2%, ECG 23.5%, carotid ultrasonography 14.3%, lower limb ultrasonography 7.6%. Among anti-hyperglycemic drugs, SGLT-2 inhibitors were prescribed to ~5% and GLP-1 receptor agonists to ~5% although the proportion of subjects with CVD was ~45%. Subjects attending Diabetes Clinics had higher figures for all these monitoring and treatment indicators. CONCLUSIONS The implementation of national and international guidelines regarding disease monitoring and treatment is far from being satisfactory, especially among subjects nonattending Diabetes Clinics. Further efforts and investments are needed for better disseminating guidelines, more efficaciously engaging healthcare professionals and more strongly empowering the healthcare system to improve diabetes care.
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Affiliation(s)
| | | | | | | | | | | | | | - Elisa Rossi
- CINECA - Interuniversity Consortium, Bologna, Italy
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Ambrož M, de Vries ST, Sidorenkov G, Hoogenberg K, Denig P. Changes in blood pressure thresholds for initiating antihypertensive medication in patients with diabetes: a repeated cross-sectional study focusing on the impact of age and frailty. BMJ Open 2020; 10:e037694. [PMID: 32912988 PMCID: PMC7485238 DOI: 10.1136/bmjopen-2020-037694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 07/16/2020] [Accepted: 07/20/2020] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To assess trends in systolic blood pressure (SBP) thresholds at initiation of antihypertensive treatment in patients with type 2 diabetes and the impact of age and frailty on these trends. STUDY DESIGN AND SETTING A repeated cross-sectional cohort study (2007-2014) using the Groningen Initiative to Analyse Type 2 diabetes Treatment database was conducted. The influence of calendar year, age or frailty and the interaction between year and age or frailty on SBP thresholds were assessed using multilevel regression analyses adjusted for potential confounders. RESULTS We included 4819 patients. The mean SBP at treatment initiation was 157 mm Hg in 2007, rising to 158 mm Hg in 2009 and decreasing to 151 mm Hg in 2014. This quadratic trend was significant (p<0.001). Older patients initiated treatment at higher SBP, but similar decreasing trends after 2009 were observed in all age groups. There were no significant differences in SBP thresholds between patients with different frailty groups. The association between year and SBP threshold was not influenced by age or frailty. CONCLUSION After an initial rise, the observed SBP thresholds decreased over time and were not influenced by age or frailty. This is in contrast with changed guideline recommendations towards more personalised treatment during the study period and illustrates that changing prescribing practice may take considerable time. Patient-specific algorithms and tools focusing on when and when not to initiate treatment could be helpful to support personalised diabetes care.
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Affiliation(s)
- Martina Ambrož
- University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Sieta T de Vries
- University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Grigory Sidorenkov
- University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | | | - Petra Denig
- University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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Arai K, Nishikawa T, Yuasa S, Shirabe SI, Matsuzawa Y, Ohtsu S, Hirao K, Mori H. Nationwide Survey on Actual Interventions for Type 2 Diabetes by Japanese Practitioners (NSAID Study-1): Glycemic, Weight, and Blood Pressure Management. Diabetes Ther 2020; 11:1497-1511. [PMID: 32440836 PMCID: PMC7324449 DOI: 10.1007/s13300-020-00837-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Considering the increase in the number of patients with diabetes, the quality of diabetes care provided by general practitioners (GP) is critical for preventing complications. We performed a nationwide survey to determine whether the diabetic management provided to patients with type 2 diabetes mellitus (T2DM) by Japanese practitioners is appropriate. METHODS We randomly selected 463 clinics throughout Japan; 8070 patients with T2DM (6525 and 1545 under the care of GP and specialists [SP], respectively) were enrolled. We obtained information on hemoglobin A1c (HbA1c) levels, age, height, body weight, diabetes type and treatment modality, blood pressure (BP), and hypertension or dyslipidemia from each patient. Additionally, we surveyed the collaborations among physicians. RESULTS The median HbA1c level of patients treated by GP was lower than that of patients treated by SP (6.8 [6.2-7.3], median [interquartile range] vs. 6.9 [6.5-7.5], p < 0.0001). The percentage of patients receiving insulin therapy was also higher (23.8%) among patients treated by SP than among those treated by GP (8.6%). Patients not receiving insulin therapy showed lower median HbA1c levels than those receiving insulin therapy, irrespective of the care provider. The mean body mass index of patients with HbA1c levels < 6.9% or > 9.0% cared for by SP was lower than that of those cared for by GP. The rate of target BP (< 140/90 mmHg) achievement was 73.2% and 73.3% among patients with T2DM and hypertension cared for by GP and SP, respectively. Furthermore, 88.2% of GP reported that consulting with SP was easy. CONCLUSION The present study clearly demonstrated that many patients with T2DM are appropriately cared for by general practitioners instead of diabetes specialists in Japan, although the number of diabetes specialists is insufficient to cover all patients with diabetes.
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Affiliation(s)
- Keiko Arai
- Arai Clinic, Yokohama, Japan.
- Department of Clinical Research of Kanagawa Association of Medical and Dental Practitioners, Yokohama, Japan.
| | - Tetsuo Nishikawa
- Nisikawa Clinic, Yokohama, Japan
- Department of Clinical Research of Kanagawa Association of Medical and Dental Practitioners, Yokohama, Japan
| | - Shohei Yuasa
- Syohei Clinic, Kamakura, Japan
- Department of Clinical Research of Kanagawa Association of Medical and Dental Practitioners, Yokohama, Japan
| | - Shin-Ichiro Shirabe
- Health Education Center Science Clinic, Yokohama, Japan
- Department of Clinical Research of Kanagawa Association of Medical and Dental Practitioners, Yokohama, Japan
| | - Yoko Matsuzawa
- Matsuzawa Diabetes Clinic, Yokohama, Japan
- Department of Clinical Research of Kanagawa Association of Medical and Dental Practitioners, Yokohama, Japan
| | - Shigeyuki Ohtsu
- Nakanoshima Diabetes Clinic, Kawasaki, Japan
- Department of Clinical Research of Kanagawa Association of Medical and Dental Practitioners, Yokohama, Japan
| | - Koich Hirao
- Health Education Center Science Clinic, Yokohama, Japan
- Department of Clinical Research of Kanagawa Association of Medical and Dental Practitioners, Yokohama, Japan
| | - Hisao Mori
- Yokohama Sotetsu Building Clinic of Internal Medicine, Yokohama, Japan
- Department of Clinical Research of Kanagawa Association of Medical and Dental Practitioners, Yokohama, Japan
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Riordan F, McHugh SM, O'Donovan C, Mtshede MN, Kearney PM. The Role of Physician and Practice Characteristics in the Quality of Diabetes Management in Primary Care: Systematic Review and Meta-analysis. J Gen Intern Med 2020; 35:1836-1848. [PMID: 32016700 PMCID: PMC7280455 DOI: 10.1007/s11606-020-05676-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 12/03/2019] [Accepted: 01/19/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Despite evidence-based guidelines, high-quality diabetes care is not always achieved. Identifying factors associated with the quality of management in primary care may inform service improvements, facilitating the tailoring of quality improvement interventions to practice needs and resources. METHODS We searched MEDLINE, EMBASE, CINAHL and Web of Science from January 1990 to March 2019. Eligible studies were cohort studies, cross-sectional studies and randomised controlled trials (baseline data) conducted among adults with diabetes, which examined the relationship between any physician and/or practice factors and any objective measure(s) of quality. Studies which examined patient factors only were ineligible. Where possible, data were pooled using random-effects meta-analysis. RESULTS In total, 82 studies were included. The range of individual quality measures and the construction of composite measures varied considerably. Female physicians compared with males ((odds ratio (OR) = 1.07, 95% CI: 1.04, 1.10), 8 studies), physicians with higher diabetes volume compared with lower volume (OR = 1.24, 95% CI: 1.05-1.47, 4 studies) and practices with Electronic Health Records (EHR) versus practices without (OR = 1.43, 95% CI: 1.11-1.84, 4 studies) were associated with a higher quality of care. There was no association between physician experience, practice location and type of practice and quality. Based on the narrative synthesis, increasing physician age and higher practice socio-economic deprivation may be associated with lower quality of care. DISCUSSION Identification of physician- and practice-level factors associated with the quality of care (female gender, younger age, physician-level diabetes volume, practice deprivation and EHR use) may explain differences across practices and physicians, provide potential targets for quality improvement interventions and indicate which practices need specific supports to deliver improvements in diabetes care.
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Affiliation(s)
- F Riordan
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland.
| | - S M McHugh
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
| | | | - Mavis N Mtshede
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
| | - P M Kearney
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
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Tran AT, Berg TJ, Gjelsvik B, Mdala I, Thue G, Cooper JG, Nøkleby K, Claudi T, Bakke Å, Sandberg S, Jenum AK. Ethnic and gender differences in the management of type 2 diabetes: a cross-sectional study from Norwegian general practice. BMC Health Serv Res 2019; 19:904. [PMID: 31779621 PMCID: PMC6883677 DOI: 10.1186/s12913-019-4557-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/24/2019] [Indexed: 01/08/2023] Open
Abstract
Background Ethnic minority groups from Asia and Africa living in Western countries have a higher prevalence of type 2 diabetes (T2DM) than the general population. We aimed to assess ethnic differences in diabetes care by gender. Methods Population-based, cross-sectional study identified 10,161 individuals with T2DM cared for by 282 General Practitioners (GP) in Norway. Ethnicity was based on country of birth. Multilevel regression models adjusted for individual and GP factors were applied to evaluate ethnic differences by gender. Results Diabetes was diagnosed at a younger mean age in all other ethnic groups compared with Westerners (men: 45.9–51.6 years vs. 56.4 years, women: 44.9–53.8 years vs. 59.1 years). Among Westerners mean age at diagnosis was 2.7 years higher in women compared with men, while no gender difference in age at diagnosis was found in any minority group. Daily smoking was most common among Eastern European, South Asian and Middle East/North African men. In both genders, we found no ethnic differences in processes of care (GPs’ measurement of HbA1c, blood pressure, LDL-cholesterol, creatinine). The proportion who achieved the HbA1c treatment target was higher in Westerners (men: 62.3%; women: 66.1%), than in ethnic minorities (men 48.2%; women 53.5%). Compared with Western men, the odds ratio (OR) for achieving the target was 0.45 (95% CI 0.27 to 0.73) in Eastern European; 0.67 (0.51 to 0.87) in South Asian and 0.62 (0.43 to 0.88) in Middle Eastern/North African men. Compared with Western women, OR was 0.49 (0.28 to 0.87) in Eastern European and 0.64 (0.47 to 0.86) South Asian women. Compared with Westerners, the blood pressure target was more often achieved in South Asians and Middle Easterners/North Africans in both genders. Small ethnic differences in achieving the LDL-cholesterol treatment target by gender were found. Conclusion Diabetes was diagnosed at a considerably earlier age in both minority men and minority women compared with Westerners. Several minority groups had worse glycaemic control compared with Westerners in both genders, which implies that it is necessary to improve glucose lowering treatment for the minority groups. Smoking cessation advice should particularly be offered to men in most minority groups.
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Affiliation(s)
- Anh Thi Tran
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway.
| | - Tore Julsrud Berg
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Oslo, Norway
| | - Bjørn Gjelsvik
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Ibrahimu Mdala
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Geir Thue
- Norwegian Quality Improvement of Laboratory Examinations, Haraldsplass Deaconess Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - John Graham Cooper
- Norwegian Quality Improvement of Laboratory Examinations, Haraldsplass Deaconess Hospital, Bergen, Norway.,Department of Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Kjersti Nøkleby
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Tor Claudi
- Department of Medicine, Nordland Hospital, Bodø, Norway
| | - Åsne Bakke
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Department of Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Sverre Sandberg
- Norwegian Quality Improvement of Laboratory Examinations, Haraldsplass Deaconess Hospital, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Department of Clinical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
| | - Anne Karen Jenum
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway.,General Practice Research Unit (AFE), Department of General Practice, University of Oslo, Institute of Health and Society, Post Box 1130, Blindern, 0318, Oslo, Norway
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Kovács N, Varga O, Nagy A, Pálinkás A, Sipos V, Kőrösi L, Ádány R, Sándor J. The impact of general practitioners' gender on process indicators in Hungarian primary healthcare: a nation-wide cross-sectional study. BMJ Open 2019; 9:e027296. [PMID: 31494598 PMCID: PMC6731795 DOI: 10.1136/bmjopen-2018-027296] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES The objectives of our study were (1) to investigate the association between gender of the general practitioner (GP) and the quality of primary care in Hungary with respect to process indicators for GP performance and (2) to assess the size of the gender impact. STUDY DESIGN A nation-wide cross-sectional study was performed in 2016. SETTING AND PARTICIPANTS The study covered all general medical practices in Hungary (n=4575) responsible for the provision of primary healthcare (PHC) for adults. All GPs in their private practices are solo practitioners. MAIN OUTCOME MEASURES Multilevel logistic regression models were used to analyse the association between GP gender and process indicators of PHC, and attributable proportion (AP) was calculated. RESULTS 48% of the GPs (n=2213) were women in the study. The crude rates of care provided by female GPs were significantly higher for seven out of eight evaluated indicators than those provided by male GPs. Adjusted for practice, physician and patient factors, GP gender was associated with the haemoglobin A1c (HbA1c) measurement: OR=1.18, 95% CI (1.14 to 1.23); serum creatinine measurement: OR=1.14, 95% CI (1.12 to 1.17); lipid measurement: OR=1.14, 95% CI (1.11 to 1.16); eye examination: OR=1.06, 95% CI (1.03 to 1.08); mammography screening: OR=1.05, 95% CI (1.03 to 1.08); management of patients with chronic obstructive pulmonary disease: OR=1.05, 95% CI (1.01 to 1.09) and the composite indicator: OR=1.08, 95% CI (1.07 to 1.1), which summarises the number of care events and size of target populations of each indicator. The AP at the specific indicators varied from 0.97% (95% CI 0.49% to 1.44%) of influenza immunisation to 8.04% (95% CI 7.4% to 8.67%) of eye examinations. CONCLUSION Female GP gender was an independent predictor of receiving higher quality of care. The actual size of the gender effect on the quality of services seemed to be notable. Factors behind the gender effect should receive more attention in quality improvement particularly in countries where the primary care is organised around solo practices.
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Affiliation(s)
- Nóra Kovács
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Orsolya Varga
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Attila Nagy
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Anita Pálinkás
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Valéria Sipos
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - László Kőrösi
- National Institute of Health Insurance Fund Management, Budapest, Hungary
| | - Róza Ádány
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
- WHO Collaborating Centre on Vulnerability and Health, Debrecen, Hungary
- MTA-DE Public Health Research Group, University of Debrecen, Debrecen, Hungary
| | - János Sándor
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
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