Adherence to medication, glycaemic control and hospital attendance in young adults with type 2 diabetes

Diabetes type 2 prevalence is rising among young residents in Malmö, Sweden

AIM

Type 2 diabetes is becoming more prevalent in many parts of the world. Malmö's population has increased in recent years mainly because of migration from other parts of Sweden and the world in addition to increased birth rates. We aimed to explore diabetes prevalence in Malmö in 2011-2018 as well as the achieved treatment targets for selected diabetes-related outcomes.

METHOD

The current study is a part of the Cities Changing Diabetes Malmö project. Prevalence data were retrieved from the region's primary care and hospital diagnosis register, and data on treatment targets were collected from the National Diabetes Register. The inclusion criteria were either being a resident of Malmö or using a primary healthcare centre located in Malmö.

RESULTS

The prevalence of type 2 diabetes in 2018 doubled from 2011 in the entire Malmö population. During the same period, the prevalence of type 1 diabetes remained stable at 0.49 %. In 2011, the type 2 diabetes prevalence was 2.46 % (2.76 % for males and 2.28 % for females), and in 2018, it was 4.26 % (4.84 % for males and 3.82 % for females). The increase was 139 % for residents aged 0-29 years, 119.6 % for residents aged 30-39 years, 96.2 % for residents aged 40-49 years, 102 % for residents aged 50-59 years, 98.2 % for residents aged 60-69 years, and 115.5 % for those aged 70-79 years. Finally, the increase was 60.9 % for those aged 80-84 years and 90.7 % for residents 90 years of age and older. The National Diabetes Register reported that during 2019, 58 % of all patients with diabetes using primary care in Malmö reached HbA1c <52 mmol/mol, 20 % had albuminuria, 36 % had retinopathy, and 21 % had not had their feet inspected by a healthcare professional during the last year. The median HbA1c was 52.6 mmol/mol, and 17 % were registered as active smokers.

CONCLUSION

Diabetes prevalence in Malmö has increased markedly in recent years, exacerbated by a rise in type 2 diabetes mainly in the younger population. Targets regarding p-glucose lowering treatments were not met by 42 %. One patient out of three had microvascular complications in the eye, one out of five had impaired kidney function, one out of five had not had their feet inspected, and one out of five was an active smoker. Active diabetes treatments need to be improved to reduce the number of younger patients developing microvascular complications. Preventive activities need to target younger populations to counteract even more residents developing type 2 diabetes.

Overall Medication Adherence as an Indicator for Health Outcomes Among Elderly Patients With Hypertension and Diabetes

OBJECTIVES

The purpose of this research was to assess overall medication adherence as an indicator for emergency room (ER) visits, hospitalizations, and mortality among elderly patients.

METHODS

The study included individuals aged 75-90 years, diagnosed with diabetes or hypertension, who were treated with at least 1 antihypertensive, or antidiabetic medication in 2017. We determined personal adherence rates by calculating the mean adherence rates of the medications prescribed to each individual. We retrieved information on all ER visits and hospitalizations in internal medicine and surgical wards from 2017 to 2019 and mortality in 2019.

RESULTS

Of the 171,097 individuals included in the study, 60% were women. The mean age was 81.2 years. 93% had hypertension, 46% had diabetes, and 39% had both diabetes and hypertension. In 2017, 61,668 (36.0%) patients visited the ER, 44,910 (26.2%) were hospitalized in internal medicine wards, and 13,305 (7.8%) were hospitalized in surgical wards. Comparing the highest adherence quintile to the lowest, ORs were 0.69 (0.63, 0.76) for ER visits, 0.40 (0.36, 0.45) for hospitalization in internal medicine wards, and 0.61 (0.52, 0.72) for hospitalization in surgery wards. ORs were similar for the 3 consecutive years 2017, 2018, and 2019. The adjusted OR for all-cause mortality in 2019 comparing the highest adherence quintile to the lowest was 0.60 (0.54, 0.66).

CONCLUSIONS

Better medication adherence was associated with fewer ER visits and hospitalizations among elderly patients with diabetes and hypertension and lower mortality rates. Overall medication adherence is an indicator for health outcomes unrelated to the patient's underlying health status.

What are the perspectives of adults aged 18-40 living with type 2 diabetes in urban settings towards barriers and opportunities for better health and well-being: a mixed-methods study

OBJECTIVES

Delivered as part of the global assessment of diabetes in urban settings, this study explores different aspects of living with type 2 diabetes, for adults aged 18-40. Primary questions were as follows: (1) can we identify subgroups of adults under 40 years old sharing specific perspectives towards health, well-being and living with type 2 diabetes and (2) do these perspectives reveal specific barriers to and opportunities for better type 2 diabetes prevention and management and improved well-being?

DESIGN

The study employed a mixed-method design with data collected through demographic questionnaires, Q-sort statement sorting exercises, focus groups discussions and individual interviews.

SETTING

Primary care across Greater Manchester, UK.

PARTICIPANTS

Those aged between 18 and 40, with a confirmed type 2 diabetes diagnosis, and living in Greater Manchester were eligible to participate. A total of 46 people completed the Q-sort exercise and 43 were included in the final analysis. Of those, 29 (67%) identified as female and 32 (75%) as white. Most common time since diagnosis was between 5 and 10 years.

RESULTS

The Q-sort analysis categorised 35 of the 43 participants (81%) into five subgroups. Based on average statement sorts for each subgroup, perspectives were characterised as: (1) stressed and calamity coping (n=13), (2) financially disadvantaged and poorly supported (n=12), (3) well-intentioned but not succeeding (n=5), (4) withdrawn and worried (n=2) and (5) young and stigmatised (n=3). Holistic analysis of our qualitative data also identified some common issues across these subgroups.

CONCLUSIONS

Adults under 40 with type 2 diabetes are not a homogeneous group, but fall into five identifiable subgroups. They also experience issues specific to this age group that make it particularly difficult for them to focus on their own health. More tailored support could help them to make the necessary lifestyle changes and manage their type 2 diabetes better.

Trends in risk factor control and treatment among patients with non-alcoholic fatty liver disease and type 2 diabetes between 2000 and 2020: A territory-wide study

BACKGROUND & AIMS

We aimed to determine the trends in risk factor control and treatment among patients with non-alcoholic fatty liver disease (NAFLD) and type 2 diabetes (T2D) in 2000-2020.

METHODS

We conducted a territory-wide cohort study of adult patients with NAFLD and T2D diagnosed between 1 January 2000 and 31 July 2021 in Hong Kong. T2D was defined by use of any anti-diabetic agents, laboratory tests and/or diagnosis codes.

RESULTS

This study included 16,084 patients with NAFLD and T2D (mean age, 54.8 ± 12.0 years; 7124 male [44.3%]). The percentage of patients achieving individualised haemoglobin A_1c (HbA_1c ) targets increased from 44.5% (95% confidence interval [CI], 42.9-46.1) to 64.8% (95% CI, 64.1-65.5), and percentage of patients achieving individualised low-density lipoprotein-cholesterol (LDL-C) targets increased from 23.3% (95% CI, 21.9-24.7) to 54.3% (95% CI, 53.5-55.1) from 2000-2005 to 2016-2020, whereas percentage of patients achieving blood pressure control (<140/90 mm Hg) remained static at 53.1-57.2%. Combination therapy for diabetes increased, especially among those with poor glycaemic control, but there was no increase in combination therapy for hypertension. Fewer cirrhotic patients achieved blood pressure control and individualised LDL-C targets, but they were more likely to achieve individualised HbA_1c targets than non-cirrhotics. Metformin and statins were underused in cirrhotic patients. Younger patients (18-44 years) were less likely to achieve individualised HbA_1c targets than middle-aged (45-64 years) and older ones (≥65 years).

CONCLUSIONS

From 2000 to 2020, glycaemic and lipid control improved significantly, whereas blood pressure control remained static among patients with NAFLD and T2D.

Medication adherence in young adults with youth-onset type 2 diabetes: iCount, an observational study

AIMS

To assess prevalence of, and factors associated with, medication adherence of young adults with youth-onset type 2 diabetes.

METHODS

Oral hypoglycaemia agent (OHA) adherence was measured with unannounced telephone pill counts, insulin adherence was self-reported. Those taking ≥ 80% of pills/insulin were classified "high-adherent," <80% of pills/insulin "low-adherent." Analyses included unadjusted, and adjusted linear and logistic regressions assessing associations of participant factors with adherence.

RESULTS

For people taking OHAs (N = 212, mean age 26 yrs, 67% women, 18% non-Hispanic White, 35% non-Hispanic Black, 41% Hispanic), 69.8% were low-adherent. HbA1c was lower in the high-adherent group (9.2%/77 mmol/mol vs. 10.0%/86 mmol/mol, p < 0.04). More non-Hispanic Blacks were low-adherent (85.7%) than Hispanics (60.2%) and non-Hispanic whites (55.3%, p < 0.002); 91.4% of participants without healthcare coverage were low-adherent vs. 65.5% of those with coverage (p < 0.004). After adjustment, gender (p = 0.024), race/ethnicity (p < 0.001) and healthcare coverage (p = 0.001) remained related to OHA adherence. For insulin (N = 192), 37% were low-adherent. HbA1c was associated with insulin adherence (low = 11.2%/99 mmol/mol vs. high = 10.0%/86 mmol/mol, p < 0.001) with and without adjustment.

CONCLUSIONS

Young adults with youth-onset type 2 diabetes, especially females, non-Hispanic Blacks and those without healthcare coverage, commonly had low-OHA adherence. Glycaemic control was also poor. Interventions to improve medication adherence are needed for this vulnerable group.

Socioeconomic status and risk factors for complications in young people with type 1 or type 2 diabetes: a cross-sectional study

INTRODUCTION

Young people with type 2 diabetes (T2D) develop complications earlier than those with type 1 diabetes (T1D) of comparable duration, but it is unclear why. This apparent difference in phenotype could relate to relative inequality.

RESEARCH DESIGN AND METHODS

Cross-sectional study of young people referred to secondary diabetes services in Auckland, Aotearoa-New Zealand (NZ): 731 with T1D and 1350 with T2D currently aged <40 years, and diagnosed between 15 and 30 years. Outcome measures were risk factors for complications (glycemic control, urine albumin/creatinine ratio (ACR), cardiovascular disease (CVD) risk) in relation to a validated national index of deprivation (New Zealand Deprivation Index (NZDep)).

RESULTS

Young people with T2D were an average 3 years older than those with T1D but had a similar duration of diabetes. 71% of those with T2D were of Māori or Pasifika descent, compared with 24% with T1D (p<0.001). T1D cases were distributed evenly across NZDep categories. 78% of T2D cases were living in the lowest four NZDep categories (p<0.001). In both diabetes types, body mass index (BMI) increased progressively across the NZDep spectrum (p<0.002), as did mean glycated hemoglobin (HbA_1c) (p<0.001), the prevalence of macroalbuminuria (p≤0.01), and CVD risk (p<0.001). Adjusting for BMI, diabetes type, and duration and age, multiple logistic regression revealed deprivation was the strongest risk factor for poorly controlled diabetes (defined as HbA_1c >64 mmol/mol, >8%); OR 1.17, 95% CI 1.13 to 1.22, p<0.0001. Ordinal logistic regression showed each decile increase in NZDep increased the odds of a higher ACR by 11% (OR 1.11, 95% CI 1.06 to 1.16, p<0.001) following adjustment for BMI, blood pressure, diabetes type and duration, HbA_1c, and smoking status. Multiple linear regression indicated a 4% increase in CVD risk for every decile increase in NZDep, regardless of diabetes type.

CONCLUSIONS

The apparent more aggressive phenotype of young-onset T2D is at least in part explicable by relative deprivation.

Trends in diabetes care and education by primary health care nurses in Auckland, New Zealand

AIMS

To examine trends in the management of patients with diabetes by primary health care nurses, its association with diabetes education and how valued and supported nurses feel in Auckland, New Zealand.

METHODS

Two representative cross-sectional surveys of all nurses providing community-based care, and patients with diabetes they consult, were conducted in 2006-8 and 2016. All participants completed a self-administered questionnaire on biographical details and a telephone interview on their provision of diabetes care.

RESULTS

Significantly more nurses discussed serum glucose and medications with patients, planned follow-up and scheduled practice nurse appointments in 2016 compared with 2006-8, and fewer specialist diabetologist appointments were made (12% versus 2%). Fewer nurses in 2016 than in 2006-8 felt valued (62% versus 75%) and supported (78% versus 89%) when managing patients (p-values = 0.0004). Nurses diabetes education was associated with recommended practice and feeling valued. Significantly more patients were prescribed metformin (81%) and insulin (46%) in 2016 compared with 58% and 30% in 2006-8. Despite this, HbA_1c levels remained unchanged.

CONCLUSIONS

Prescribed glycaemic-related medications increased, and more nurses engaged with patients about glycaemic control and medications in 2016 compared with 2006-8. Nurses undertaking diabetes education was strongly associated with best management practices and nurses feeling valued.

Antidepressant dispensing before, during, and after pregnancy in New Zealand, 2005-2014

BACKGROUND

Depression during pregnancy is associated with a number of negative impacts on maternal and infant health, therefore good control of depression in pregnant women is crucial. There is a lack of population-level information about patterns of antidepressant use during pregnancy in New Zealand.

AIM

To describe antidepressant dispensing patterns before, during, and after pregnancy in New Zealand, 2005-2014.

MATERIALS AND METHODS

Antidepressant dispensing records from 270 days prior to pregnancy through to 360 days after pregnancy end were linked with 805 990 pregnancies in the New Zealand Pregnancy Cohort. Proportions (and 95% confidence intervals) with at least one dispensing were calculated for the periods before, during, and after pregnancy and compared over time and by maternal characteristics.

RESULTS

Dispensing during the first trimester was lower than in the pre-pregnancy and post-pregnancy periods, and dropped further in later trimesters. The proportion of pregnancies during which an antidepressant was dispensed rose from 3.1 to 4.9% over the study years. Around 80% of those with a dispensing received a selective serotonin reuptake inhibitor. Dispensing before, during, and after pregnancy varied by ethnicity, age, smoking status, and body mass index. Among women taking an antidepressant before pregnancy, younger women and those of Māori, Pacific, or Asian ethnicity were less likely to continue therapy during pregnancy.

CONCLUSIONS

This study has established a baseline for antidepressant use around pregnancy in New Zealand, documented increasing use over time, and demonstrated that known ethnic differences in antidepressant use are also evident in the pregnant population.

Higher patient assessed quality of chronic care is associated with lower diabetes distress among adults with early-onset type 2 diabetes: Cross-sectional survey results from the Danish DD2-study

AIM

Among adults aged 20-45 years with type 2 diabetes mellitus, we examined the perceived quality of chronic care, and its associations with (i) sociodemographic and clinical characteristics, and (ii) diabetes distress.

METHODS

In total, 216/460 (47%) completed a self-administered survey assessing sociodemographic characteristics, patient assessed chronic illness care (PACIC-20, scale of 1-5) and diabetes distress (PAID-20, scale of 0-100), and 197 had full quality of care data for assessment. We obtained clinical data from national registers and used linear and logistic regression models to examine associations.

RESULTS

The mean (SD) PACIC score was 2.6 (0.9) (score range 1-5). Lower PACIC scores were associated with female sex and current unemployment, and with receiving diabetes care in general practice compared with hospital outpatient clinics [mean difference: -0.4 (95% confidence interval (CI) (-0.7 to -0.2)]. People with upper quartile PACIC scores were less likely to report high diabetes distress compared with people with lower quartile PACIC scores [odds Ratio 0.3 95%CI (0.1-0.8)].

CONCLUSION

Higher quality of care was associated with lower diabetes distress among adults with early onset type 2 diabetes mellitus, but respondents reported less than optimal quality in several core areas of chronic care.

Comorbid Diabetes and Severe Mental Illness: Outcomes in an Integrated Health Care Delivery System

BACKGROUND

Diabetes prevalence is twice as high among people with severe mental illness (SMI) when compared to the general population. Despite high prevalence, care outcomes are not well understood.

OBJECTIVE

To compare diabetes health outcomes received by people with and without comorbid SMI, and to understand demographic factors associated with poor diabetes control among those with SMI.

DESIGN

Retrospective cohort study PARTICIPANTS: 269,243 adults with diabetes MAIN MEASURES: Primary outcomes included optimal glycemic control (A1c < 7) or poor diabetes control (A1c > 9) in 2014. Secondary outcomes included control of other cardiometabolic risk factors (hypertension, dyslipidemia, smoking) and recommended diabetes monitoring.

KEY RESULTS

Among this cohort, people with SMI (N = 4,399), compared to those without SMI (N = 264,844), were more likely to have optimal glycemic control, adjusting for various covariates (adjusted relative risk (aRR) 1.25, 95% CI 1.21-1.28, p < .001) and less likely to have poor control (aRR 0.92, 95% CI 0.87-0.98, p = 0.012). Better blood pressure and lipid control was more prevalent among people with SMI when compared to those without SMI (aRR 1.03; 95% CI 1.02-1.05, p < .001; aRR 1.02; 95% CI 1.00-1.05, p = 0.044, respectively). No differences were observed in recommended A1c or LDL testing, but people with SMI were more likely to have blood pressure checked (aRR 1.02, 95% CI 1.02-1.03, p < .001) and less likely to receive retinopathy screening (aRR 0.80, 95% CI 0.71-0.91, p < .001) than those without SMI. Among people with diabetes and comorbid SMI, younger adults and Hispanics were more likely to have poor diabetes control.

CONCLUSIONS

Adults with diabetes and comorbid SMI had better cardiometabolic control than people with diabetes who did not have SMI, despite lower rates of retinopathy screening. Among those with comorbid SMI, younger adults and Hispanics were more vulnerable to poor A1c control.