Effect of screening for Type 2 diabetes on population-level self-rated health outcomes and measures of cardiovascular risk: 13-year follow-up of the Ely cohort

Association of prior outpatient diabetes screening with cardiovascular events and mortality among people with incident diabetes: a population-based cohort study

BACKGROUND

Outcomes of diabetes screening in contemporary, multi-ethnic populations are unknown. We examined the association of prior outpatient diabetes screening with the risks of cardiovascular events and mortality in Ontario, Canada.

METHODS

We conducted a population-based cohort study using administrative databases among adults aged ≥ 20 years with incident diabetes diagnosed during 2014-2016. The exposure was outpatient diabetes screening performed within 3 years prior to diabetes diagnosis. The co-primary outcomes were (1) a composite of all-cause mortality and hospitalization for myocardial infarction, stroke, coronary revascularization, and (2) all-cause mortality (followed up until 2018). We calculated standardized rates of each outcome and conducted cause-specific hazard modelling to determine the adjusted hazard ratio (HR) of the outcomes, adjusting for prespecified confounders and accounting for the competing risk of death.

RESULTS

We included 178,753 Ontarians with incident diabetes (70.2% previously screened). Individuals receiving prior screening were older (58.3 versus 53.4 years) and more likely to be women (49.6% versus 40.0%) than previously unscreened individuals. Individuals receiving prior screening had relatively lower standardized event rates than those without prior screening across all outcomes (composite: 12.8 versus 18.1, mortality: 8.2 versus 11.1 per 1000 patient-years). After multivariable adjustment, prior screening was associated with 34% and 32% lower risks of the composite (HR 0.66, 0.63-0.69) and mortality (0.68, 0.64-0.72) outcomes. Among those receiving prior screening, a result in the prediabetes range was associated with lower risks of the composite (0.82, 0.77-0.88) and mortality (0.71, 0.66-0.78) outcomes than a result in the normoglycemic range.

CONCLUSIONS

Previously screened individuals with diabetes had lower risks of cardiovascular events and mortality versus previously unscreened individuals. Better risk assessment tools are needed to support wider and more appropriate uptake of diabetes screening, especially among young adults.

Association of prediabetes with death and diabetic complications in older adults: the pros and cons of active screening for prediabetes

BACKGROUND

active screening can improve health outcomes for people with prediabetes. However, its efficacy in older adults remains uncertain.

OBJECTIVE

the study aimed to analyse the progression from prediabetes to diabetes in older adults, including associated complications and mortality rates, to determine the benefits of active screening.

DESIGN

retrospective cohort study.

SETTING

Korean National Health Insurance Service claims database.

SUBJECTS

a total of 36,946 adults aged ≥65 years who underwent national health examinations from 2006 to 2008.

METHODS

follow-up was until 31 December 2015. Cox's proportional hazards models estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for death and diabetic complications.

RESULTS

over a median follow-up of 8.2 years, 19.3% of older adults with prediabetes progressed to diabetes. Compared with normoglycaemic adults, the multivariable-adjusted HRs (95% CI) for major adverse cardiovascular events were 1.01 (0.95-1.07), 1.08 (0.95-1.23), 1.14 (1.05-1.23) and 1.50 (1.35-1.68) in adults with prediabetes, newly diagnosed diabetes, diabetes not on insulin and diabetes on insulin, respectively. The corresponding HRs (95% CI) for diabetic retinopathy risk were 1.28 (1.15-1.43), 3.16 (2.71-3.69), 6.58 (6.02-7.19) and 9.17 (8.21-10.24). Diabetic nephropathy risk also significantly increased.

CONCLUSIONS

progression from prediabetes to diabetes is an important concern among older adults. Prediabetes is associated with the risk of microvascular complications, but not cardiovascular complications and mortality. Therefore, active regular screening for prediabetes is necessary to prevent microvascular complications.

Screening for type 2 diabetes mellitus

BACKGROUND

Diabetes mellitus, a metabolic disorder characterised by hyperglycaemia and associated with a heavy burden of microvascular and macrovascular complications, frequently remains undiagnosed. Screening of apparently healthy individuals may lead to early detection and treatment of type 2 diabetes mellitus and may prevent or delay the development of related complications.

OBJECTIVES

To assess the effects of screening for type 2 diabetes mellitus.

SEARCH METHODS

We searched CENTRAL, MEDLINE, LILACS, the WHO ICTRP, and ClinicalTrials.gov from inception. The date of the last search was May 2019 for all databases. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials involving adults and children without known diabetes mellitus, conducted over at least three months, that assessed the effect of diabetes screening (mass, targeted, or opportunistic) compared to no diabetes screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for potential relevance and reviewed the full-texts of potentially relevant studies, extracted data, and carried out 'Risk of bias' assessment using the Cochrane 'Risk of bias' tool. We assessed the overall certainty of the evidence using the GRADE approach.

MAIN RESULTS

We screened 4651 titles and abstracts identified by the search and assessed 92 full-texts/records for inclusion. We included one cluster-randomised trial, the ADDITION-Cambridge study, which involved 20,184 participants from 33 general practices in Eastern England and assessed the effects of inviting versus not inviting high-risk individuals to screening for diabetes. The diabetes risk score was used to identify high-risk individuals; it comprised variables relating to age, sex, body mass index, and the use of prescribed steroid and anti-hypertensive medication. Twenty-seven practices were randomised to the screening group (11,737 participants actually attending screening) and 5 practices to the no-screening group (4137 participants). In both groups, 36% of participants were women; the average age of participants was 58.2 years in the screening group and 57.9 years in the no-screening group. Almost half of participants in both groups were on antihypertensive medication. The findings from the first phase of this study indicate that screening compared to no screening for type 2 diabetes did not show a clear difference in all-cause mortality (hazard ratio (HR) 1.06, 95% confidence interval (CI) 0.90 to 1.25, low-certainty evidence). Screening compared to no screening for type 2 diabetes mellitus showed an HR of 1.26, 95% CI 0.75 to 2.12 (low-certainty evidence) for diabetes-related mortality (based on whether diabetes was reported as a cause of death on the death certificate). Diabetes-related morbidity and health-related quality of life were only reported in a subsample and did not show a substantial difference between the screening intervention and control. The included study did not report on adverse events, incidence of type 2 diabetes, glycosylated haemoglobin A1c (HbA1c), and socioeconomic effects.

AUTHORS' CONCLUSIONS

We are uncertain about the effects of screening for type 2 diabetes on all-cause mortality and diabetes-related mortality. Evidence was available from one study only. We are therefore unable to draw any firm conclusions relating to the health outcomes of early type 2 diabetes mellitus screening. Furthermore, the included study did not assess all of the outcomes prespecified in the review (diabetes-related morbidity, incidence of type 2 diabetes, health-related quality of life, adverse events, socioeconomic effects).

Factors Associated with Cancer- and Non-Cancer-Related Deaths among Taiwanese Patients with Diabetes after 17 Years of Follow-Up

OBJECTIVE

A previous 12-year follow-up of a large diabetes cohort in Taiwan suggested a survival advantage in the patients with obesity. The present study further investigated additional determinants for cancer and non-cancer death in the cohort after a follow-up of 17 years.

METHODS

A cohort of 92546 diabetes patients recruited since 1995 was followed for vital status by matching the National Death Certificate Database until 2011. Cox regression estimated the hazard ratios for the following variables: age at baseline, sex, diabetes type, screen-detected diabetes (diabetes diagnosed accidentally through epidemiological screening programs or during visits to medical settings without a history of diabetes), diabetes duration, body mass index, insulin use, hypertension, smoking, and living region. Fasting glucose and history of dyslipidemia were available for additional adjustment in a subcohort of the patients (n = 14559).

RESULTS

A total of 40229 diabetes patients (43.5% of the cohort) died during follow-up and 10.9% died under the age of 60. Insulin use and smoking significantly predicted cancer and non-cancer death. The adjusted hazard ratio (95% confidence interval) associated with insulin use was 1.161 (1.052-1.281) for cancer death and 1.469 (1.413-1.526) for non-cancer death. Screen-detected diabetes and body mass index were consistently associated with a lower risk, but diabetes duration a higher risk, for non-cancer death, with adjusted hazard ratio of 0.683 (0.666-0.702), 0.955 (0.951-0.958) and 1.018 (1.017-1.020), respectively. Diabetes type had a null association disregarding the causes of death and living in rural areas was significantly associated with a higher mortality from non-cancer death. Hypertension, fasting glucose and dyslipidemia showed differential impacts on cancer and non-cancer death, and were significantly predictive for non-cancer death.

CONCLUSIONS

Screen-detected diabetes and a higher body mass index provide a survival advantage, especially for non-cancer death. However, insulin use is associated with a significantly higher risk of either cancer or non-cancer death.

Russian multicentre type 2 diabetes screening program in patients with cardiovascular disease

Aim.To evaluate the prevalence of undiagnosed type 2 diabetes mellitus (T2DM) among patients with cardiovascular disease.Materials and methods.T2DM screening programs among patients with cardiovascular disease were held from 2013 to 2014 in several Russian cities. In total, 1001 patients aged ≥40 years with hypertension and/or atherosclerotic disease and without prior diagnosis of T2DM were screened in outpatient cardiology clinics. T2DM diagnosis was based on fasting plasma glucose levels, glycated haemoglobin (HbA1c) and/or oral glucose tolerance test (OGTT) results. Blood pressure (BP), family history of T2DM, cardiovascular disease, total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL) and triglyceride levels were analysed.Results.Fasting glucose was measured in 1000 (99.8%) patients, HbA1c was measured in in 623 (62.2%) and OGTT was performed in 286 (2.6%). Fasting glucose detected 8% of newly diagnosed T2DM; among patients who underwentHbA1c measurement, the prevalence of T2DM was 10.91%, and among patients who underwent OGTT, the prevalence was 13.99%. Depending on the chosen test, the prevalence of undiagnosed pre-diabetes (impaired fasting glycaemia and impaired glucose tolerance) was in the range of 14.4%–36.4%. The majority of patients with T2DM diagnosed by OGTT did not have target blood pressure and lipid levels; 67.5% had elevated systolic BP, 47.5% had elevated diastolic BP, 90.9% had high LDL (≥1.8 mmol/l) and 52.9% had high triglyceride levels (≥1.7 mmol/l).Conclusion.A high prevalence of undiagnosed T2DM (from 8% to 13.99%, depending on the diagnostic criteria) and pre-diabetic state in patients with cardiovascular disease may require screening for T2DM in this high-risk group.

Adherence to NICE guidelines on diabetes prevention in the UK: Effect on patient knowledge and perceived risk

BACKGROUND

NICE Guidelines for prevention of diabetes include identifying people at risk followed by cost-effective intervention if necessary. Based on assessment of risk via a questionnaire and/or blood test the intervention may comprise a brief discussion of risk factors and preventive advice or referral to intensive lifestyle intervention.

DESIGN AND SETTING

In this cross-sectional study 59 subjects recruited from local GP practices were invited by letter to attend a screening for a diabetes prevention study.

METHOD

Following a telephone screening during which subjects were asked whether they had been informed if they were at high-risk of type 2 diabetes, eligible subjects completed a Risk Perception Survey for Developing Diabetes (RPS-DD), a validated diabetes risk score and underwent an oral glucose tolerance test (OGTT) at a medical screening.

RESULTS

As measured by the Diabetes UK Risk Score, 44.1% were at high risk, 42.4% moderate risk and 13.6% at increased risk. 42% of patients had been informed they were at high-risk by a health professional. Those who had been informed of their risk had significantly higher perceived risk scores (p<0.001), higher knowledge scores (p<0.001) and decreased optimism scores (p=0.004), but were not more aware that diet (p=0.42) and weight management (p=0.57) can play a role in preventing diabetes.

CONCLUSIONS

People at high-risk of diabetes are not being informed of their risk status as recommended by NICE guidelines. There is scope for education for health professionals and the public.

Screening for Abnormal Blood Glucose and Type 2 Diabetes Mellitus: U.S. Preventive Services Task Force Recommendation Statement

DESCRIPTION

Update of the 2008 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for diabetes in asymptomatic adults.

METHODS

The USPSTF reviewed the evidence on screening for impaired fasting glucose, impaired glucose tolerance, and type 2 diabetes in asymptomatic, nonpregnant adults who are at average or high risk for diabetes and its complications.

POPULATION

This recommendation applies to adults aged 40 to 70 years seen in primary care settings who do not have symptoms of diabetes and are overweight or obese.

RECOMMENDATION

The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity. (B recommendation).

Design and baseline characteristics of the PerfectFit study: a multicenter cluster-randomized trial of a lifestyle intervention in employees with increased cardiovascular risk

BACKGROUND

The prevalence of unhealthy lifestyles and preventable chronic diseases is high. They lead to disabilities and sickness absence, which might be reduced if health promotion measures were applied. Therefore, we developed the PerfectFit health promotion intervention with a "blended care"-approach, which consists of a web-based health risk assessment (HRA) including tailored and personalized advice, followed by motivational interviewing (MI). We hypothesize that adding MI to a web-based HRA leads to better health outcomes. The objective is to describe the design and baseline characteristics of the PerfectFit study, which is being conducted among employees with high cardiovascular risk in the military workforce, the police organization and an academic hospital.

METHODS

PerfectFit is a cluster randomized controlled trial, consisting of two arms. Based on cardiovascular risk profiling, done between 2012 and 2014, we included employees based on one or more risk factors and motivation to participate. One arm is the 'limited' health program (control) that consists of: (a) an HRA as a decision aid for lifestyle changes, including tailored and personalized advice, and pros and cons of the options, and (b) a newsletter every 3 months. The other arm is the 'extensive' program (intervention), which is additionally offered MI-sessions by trained occupational physicians, 4 face-to-face and 3 by telephone, and is offered more choices of health promotion activities in the HRA. During the follow-up period, participants choose the health promotion activities they personally prefer. After six and twelve months, outcomes will be assessed by online questionnaires. After twelve months the cardiovascular risk profiling will be repeated. The primary outcome is self-reported general health. Secondary outcomes are self-reported work ability, CVD-risk score, sickness absence, productivity loss at work, participation in health promotion activities, changes in lifestyle (smoking, alcohol consumption, physical activity, stress management) and body mass index. Furthermore, a process evaluation and an economic analysis will be performed.

DISCUSSION

Additional coaching using MI is expected to be a key factor for success of the web-based HRA in employees with increased cardiovascular risk. This "blended care"-approach may be an essential strategy for effective health promotion activities.

TRIAL REGISTRATION

Dutch Trial Register by registration number NTR4894 , 14/11/2014.

Screening for type 2 diabetes mellitus: a systematic review for the U.S. Preventive Services Task Force

BACKGROUND

Screening for type 2 diabetes mellitus could lead to earlier identification and treatment of asymptomatic diabetes, impaired fasting glucose (IFG), or impaired glucose tolerance (IGT), potentially resulting in improved outcomes.

PURPOSE

To update the 2008 U.S. Preventive Services Task Force review on diabetes screening in adults.

DATA SOURCES

Cochrane databases and MEDLINE (2007 through October 2014) and relevant studies from previous Task Force reviews.

STUDY SELECTION

Randomized, controlled trials; controlled, observational studies; and systematic reviews.

DATA EXTRACTION

Data were abstracted by 1 investigator and checked by a second; 2 investigators independently assessed study quality.

DATA SYNTHESIS

In 2 trials, screening for diabetes was associated with no 10-year mortality benefit versus no screening (hazard ratio, 1.06 [95% CI, 0.90 to 1.25]). Sixteen trials consistently found that treatment of IFG or IGT was associated with delayed progression to diabetes. Most trials of treatment of IFG or IGT found no effects on all-cause or cardiovascular mortality, although lifestyle modification was associated with decreased risk for both outcomes after 23 years in 1 trial. For screen-detected diabetes, 1 trial found no effect of an intensive multifactorial intervention on risk for all-cause or cardiovascular mortality versus standard control. In diabetes that was not specifically screen-detected, 9 systematic reviews found that intensive glucose control did not reduce risk for all-cause or cardiovascular mortality and results for intensive blood pressure control were inconsistent.

LIMITATION

The review was restricted to English-language articles, and few studies were conducted in screen-detected populations.

CONCLUSION

Screening for diabetes did not improve mortality rates after 10 years of follow-up. More evidence is needed to determine the effectiveness of treatments for screen-detected diabetes. Treatment of IFG or IGT was associated with delayed progression to diabetes.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality.

Evaluation of health promotion programmes in severe mental illness: theory and practice

Health promotion programmes for patients with severe mental illness (HPP) are not uniformly evaluated. We discuss the evaluation of HPP in theory and practice, as a prerequisite for future uniform evaluation. We explored the expected outcome and mechanism of HPP in the current literature. Based on this theoretical exploration we selected measures assessing the expected outcome and mechanism in current practice. The individual properties of these measures were described. Based on our theoretical exploration the outcome of HPP can be expressed in several aspects of health. Health can be improved through several mechanisms. In the current evaluation of HPP only some of the expected outcomes were evaluated. The measures used for evaluation were not all representative for the constructs they should assess. Important aspects of HPP are currently not evaluated, based on a comparison between our theoretical exploration of expected outcome and mechanism and current practice. Additionally, not all measures in use are suitable for evaluation of HPP. Therefore, development and identification of suitable measures is necessary. Our framework offers valuable directions for the development of such measures and the future evaluation of HPP.

Screening for type 2 diabetes and pre-diabetes in general practice: a descriptive study of Maltese practices

OBJECTIVE

The aim of this research study was to ascertain the awareness of Maltese family doctors to the prevalence and significance of impaired glucose regulation and early diagnosis of type 2 diabetes and whether practices were influenced by employment status, post-graduate training in diabetes or years since graduation.

METHODS

A specially constructed questionnaire was distributed by mail to all the 298 family doctors listed as Specialists in Family Medicine in the Maltese Medical Council register. Participants had to be practising family medicine in Malta. Results were analysed using SPSS 20.0 aiming for a significance criterion of 0.05 and a power of 80%.

RESULTS

Valid replies were received from 154 GPs (51.7%). 93.2% claimed to offer their patients some form of screening. Screening levels reached up to 95.9% in the presence of specific risk factors (e.g., high previous HbA1c levels) but fell to between 46.2% and 58.7% in patients over 50, the physically inactive and those who suffer from polycystic ovarian syndrome. Screening using capillary glucose is widespread (70.8%) as opposed to the oral glucose tolerance test (23.4%). Results also show a high use of urinalysis in screening (53.2%) and a paradoxical lack of use of HbA1c in screening by young doctors and by those with recent extra training in diabetes.

CONCLUSIONS

The need for a structured screening programme in Malta and its viability need to be evaluated by further studies. Educational support to GPs together with logistic support for GPs needs to be improved.

Effectiveness of general practice-based health checks: a systematic review and meta-analysis

BACKGROUND

A recent review concluded that general health checks fail to reduce mortality in adults.

AIM

This review focuses on general practice-based health checks and their effects on both surrogate and final outcomes.

DESIGN AND SETTING

Systematic search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials.

METHOD

Relevant data were extracted from randomised trials comparing the health outcomes of general practice-based health checks versus usual care in middle-aged populations.

RESULTS

Six trials were included. The end-point differences between the intervention and control arms in total cholesterol (TC), systolic and diastolic blood pressure (SBP, DBP), and body mass index (BMI) were -0.13 mmol/l (95% confidence interval [CI] = -0.19 to -0.07), -3.65 mmHg (95% CI = -6.50 to -0.81), -1.79 mmHg (95% CI = -2.93 to -0.64), and -0.45 kg/m(2) (95% CI = -0.66 to -0.24), respectively. The odds of a patient remaining at 'high risk' with elevated TC, SBP, DBP, BMI or continuing smoking were 0.63 (95% CI = 0.50 to 0.79), 0.59 (95% CI = 0.28 to 1.23), 0.63 (95% CI = 0.53 to 0.74), 0.89 (95% CI = 0.81 to 0.98), and 0.91 (95% CI = 0.82 to 1.02), respectively. There was little evidence of a difference in total mortality (OR 1.03, 95% CI = 0.90 to 1.18). Higher CVD mortality was observed in the intervention group (OR 1.30, 95% CI = 1.02 to 1.66).

CONCLUSION

General practice-based health checks are associated with statistically significant, albeit clinically small, improvements in surrogate outcome control, especially among high-risk patients. Most studies were not originally designed to assess mortality.

Baseline comparison of three health utility measures and the feeling thermometer among participants in the Action to Control Cardiovascular Risk in Diabetes trial

Background

Health utility (HU) measures are used as overall measures of quality of life and to determine quality adjusted life years (QALYs) in economic analyses. We compared baseline values of three HUs including Short Form 6 Dimensions (SF-6D), and Health Utilities Index, Mark II and Mark III (HUI2 and HUI3) and the feeling thermometer (FT) among type 2 diabetes participants in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. We assessed relationships between HU and FT values and patient demographics and clinical variables.

Methods

ACCORD was a randomized clinical trial to test if intensive controls of glucose, blood pressure and lipids can reduce the risk of major cardiovascular disease (CVD) events in type 2 diabetes patients with high risk of CVD. The health-related quality of life (HRQOL) sub-study includes 2,053 randomly selected participants. Interclass correlations (ICCs) and agreement between measures by quartile were used to evaluate relationships between HU’s and the FT. Multivariable regression models specified relationships between patient variables and each HU and the FT.

Results

The ICCs were 0.245 for FT/SF-6D, 0.313 for HUI3/SF-6D, 0.437 for HUI2/SF-6D, 0.338 for FT/HUI2, 0.337 for FT/HUI3 and 0.751 for HUI2/HUI3 (P < 0.001 for all). Common classification by quartile was found for the majority (62%) of values between HUI2 and HUI3, which was significantly (P < 0.001) higher than between other HUs and the FT: SF-6D/HUI3 = 40.8%, SF-6D/HUI2 = 40.9%, FT/HUI3 = 35.0%, FT/HUI2 = 34.9%, and FT/SF-6D = 31.9%. Common classification was higher between SF-6D/HUI2 and SF-6D/HUI3 (P < 0.001) than between FT/SF-6D, FT/HUI2, and FT/HUI3. The mean difference in HU values per patient ranged from −0.024 ± 0.225 for SF-6D/ HUI3 to −0.124 ± 0.133 for SF-6D/HUI2. Regression models were significant; clinical and demographic variables explained 6.1% (SF-6D) to 7.7% (HUI3) of the variance in HUs.

Conclusions

The agreements between the different HUs were poor except for the two HUI measures; therefore HU values derived different measures may not be comparable. The FT had low agreement with HUs. The relationships between HUs and demographic and clinical measures demonstrate how severity of diabetes and other clinical and demographic factors are associated with HUs and FT measures.

Trial registration

ClinicalTrials.gov Identifier: NCT00000620

TRAF4 functions as an intermediate of GITR-induced NF-kappaB activation

Members of the tumor necrosis factor receptor (TNFR) family regulate the activation, differentiation, and function of many cell types, including cells of the immune system. TNFR-associated factors (TRAFs) function as adapter molecules controlling signaling pathways triggered by TNFR family members, such as activation of nuclear factor kappaB (NF-kappaB). Despite intensive research, the function of TRAF4 in signaling pathways triggered by TNFR-related proteins remains enigmatic. Intriguingly, our functional studies indicated that TRAF4 augments NF-kappaB activation triggered by glucocorticoid-induced TNFR (GITR), a receptor expressed on T cells, B cells, and macrophages. Further analyses revealed that TRAF4-mediated NF-kappaB activation downstream of GITR depends on a previously mapped TRAF-binding site in the cytoplasmic domain of the receptor and is inhibited by the cytoplasmic protein A20. GITR is thought to inhibit the suppressive function of regulatory T cells (Treg cells) and to promote activation of T cells. Taken together, our studies provide the first indications that TRAF4 elaborates GITR signaling and suggest that TRAF4 can modulate the suppressive functions of Treg cells.