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Bergonsi de Farias C, Coelli S, Satler F, Brondani L, Zelmanovitz T, Silveiro SP. Glycated Hemoglobin and Blood Pressure Levels in Adults With Type 2 Diabetes: How Many Patients Are on Target? Can J Diabetes 2020; 45:334-340. [PMID: 33277195 DOI: 10.1016/j.jcjd.2020.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 09/29/2020] [Accepted: 10/02/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Achieving glycated hemoglobin (A1C) and blood pressure targets is an important strategy for preventing chronic vascular complications in diabetes. Our aim in this study was to determine the proportion of type 2 diabetes patients who meet the recommended A1C and arterial blood pressure targets and to identify the determinants of failure to do so. METHODS A cross-sectional study was conducted in an outpatient endocrine clinic at a university hospital. The A1C goal was 7% in general and 8% for patients with advanced chronic complications. Regarding blood pressure, the overall expected target was 140/90 mmHg. RESULTS A total of 602 type 2 diabetes patients were analyzed: 62% were female, 14% self-reported as black, mean age was 63±11 years, mean diabetes duration was 17±9 years and median A1C was 8.0% (interquartile range, 7.0% to 9.5%). Macrovascular disease was present in 33% of the patients, diabetic retinopathy in 47%, peripheral neuropathy in 43% and diabetic kidney disease in 56%. Regarding metabolic control, 403 (67%) patients were not at the adjusted target A1C level, and being female, black, young and an insulin user were the main determinants of poor glycemic control. Regarding blood pressure, 348 (58%) patients were not at the recommended targets, and a more advanced age was the main associated factor. CONCLUSIONS Because more than half of type 2 diabetes outpatients do not meet the recommended A1C and blood pressure target values, there is a major call to overcome the therapeutic inertia and target treatment of patients on an individual basis.
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Affiliation(s)
- Camila Bergonsi de Farias
- Programa de Pós-graduação em Ciências Médicas: Endocrinologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Sabrina Coelli
- Programa de Pós-graduação em Ciências Médicas: Endocrinologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Fabiola Satler
- Programa de Pós-graduação em Ciências Médicas: Endocrinologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; Endocrine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil.
| | - Leticia Brondani
- Programa de Pós-graduação em Ciências Médicas: Endocrinologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Themis Zelmanovitz
- Programa de Pós-graduação em Ciências Médicas: Endocrinologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; Endocrine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Sandra Pinho Silveiro
- Programa de Pós-graduação em Ciências Médicas: Endocrinologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; Endocrine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
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Relevant patient characteristics for guiding tailored integrated diabetes primary care: a systematic review. Prim Health Care Res Dev 2018; 19:424-447. [PMID: 29405097 PMCID: PMC6452927 DOI: 10.1017/s146342361800004x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Aim To identify which patient-related effect modifiers influence the outcomes of integrated care programs for type 2 diabetes in primary care. Background Integrated care is a widespread management strategy for the treatment of type 2 diabetes. However, most integrated care programs are not tailored to patients’ needs, preferences and abilities. There is increasing consensus that such a patient-centered approach could improve the management of type 2 diabetes. Thus far, it remains unclear which patient-related effect modifiers should guide such an approach. Methods PubMed, CINAHL and EMBASE were searched for empirical studies published after 1998. A systematic literature review was conducted according to the PRISMA guidelines. Findings In total, 23 out of 1015 studies were included. A total of 21 studies measured the effects of integrated diabetes care programs on hemoglobin A1c (HbA1c) and three on low-density lipoprotein cholesterol, systolic blood pressure and health-care utilization. In total, 49 patient characteristics were assessed as potential effect modifiers with HbA1c as an outcome, of which 46 were person or health-related and only three were context-related. Younger age, insulin therapy and longer disease duration were associated with higher HbA1c levels in cross-sectional and longitudinal studies. Higher baseline HbA1c was associated with higher HbA1c at follow-up in longitudinal studies. Information on context- and person-related characteristics was limited, but is necessary to help identify the care needs of individual patients and implement an effective integrated type 2 diabetes tailored care program.
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Boels AM, Hart HE, Rutten GE, Vos RC. Personalised treatment targets in type 2 diabetes patients: The Dutch approach. Prim Care Diabetes 2017; 11:71-77. [PMID: 27633894 DOI: 10.1016/j.pcd.2016.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 05/23/2016] [Accepted: 08/02/2016] [Indexed: 12/17/2022]
Abstract
AIMS To compare the proportion of cardiometabolic well-controlled type 2 diabetes mellitus (T2DM) patients according to a clearly defined, simple personalised approach, versus the 'one-size-fits-all' approach. METHODS Observational study using routine data of primary care type 2 diabetes patients in the Netherlands. The proportions of patients that reach the targets for HbA1c, systolic blood pressure and low-density lipoprotein cholesterol in the two different approaches were compared. RESULTS Of the 890 patients (54.7% men, mean age 62.7 years), 31.8% were well-controlled according to the individualised approach and 24.8% according to the 'one-size-fits-all' approach. For specific subgroups personalising the treatment led to a 5.2%, 27.3% and 45.6% increase of patients achieving low-density lipoprotein cholesterol, HbA1c and systolic blood pressure goals respectively. CONCLUSIONS A clearly defined and relatively simple personalised approach leads to a higher proportion of T2DM patients considered as cardiometabolic well-controlled. This approach may especially be beneficial for patients aged ≥70 years on more than metformin monotherapy (HbA1c) and for patients aged ≥80 years (SBP). Precisely these patients are suggested not to benefit from stricter HbA1c or SBP targets, whereas they may experience more adverse effects (e.g. hypoglycaemia, postural hypotension) when a stricter target value is pursued.
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Affiliation(s)
- Anne Meike Boels
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands.
| | - Huberta E Hart
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands; Leidsche Rijn Julius Health Centers, Eerste Oosterparklaan 78, 3544 AK Utrecht, The Netherlands.
| | - Guy E Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands.
| | - Rimke C Vos
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands.
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Zhang XE, Cheng B, Wang Q. Relationship between high blood pressure and cardiovascular outcomes in elderly frail patients: A systematic review and meta-analysis. Geriatr Nurs 2016; 37:385-392. [DOI: 10.1016/j.gerinurse.2016.05.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 05/24/2016] [Accepted: 05/31/2016] [Indexed: 11/26/2022]
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de Vries ST, de Vries FM, Dekker T, Haaijer-Ruskamp FM, de Zeeuw D, Ranchor AV, Denig P. The Role of Patients' Age on Their Preferences for Choosing Additional Blood Pressure-Lowering Drugs: A Discrete Choice Experiment in Patients with Diabetes. PLoS One 2015; 10:e0139755. [PMID: 26445349 PMCID: PMC4596700 DOI: 10.1371/journal.pone.0139755] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 09/15/2015] [Indexed: 01/18/2023] Open
Abstract
Objectives To assess whether patients’ willingness to add a blood pressure-lowering drug and the importance they attach to specific treatment characteristics differ among age groups in patients with type 2 diabetes. Materials and Methods Patients being prescribed at least an oral glucose-lowering and a blood pressure-lowering drug completed a questionnaire including a discrete choice experiment. This experiment contained choice sets with hypothetical blood pressure-lowering drugs and a no additional drug alternative, which differed in their characteristics (i.e. effects and intake moments). Differences in willingness to add a drug were compared between patients <75 years (non-aged) and ≥75 years (aged) using Pearson χ2-tests. Multinomial logit models were used to assess and compare the importance attached to the characteristics. Results Of the 161 patients who completed the questionnaire, 151 (72%) could be included in the analyses (mean age 68 years; 42% female). Aged patients were less willing to add a drug than non-aged patients (67% versus 84% respectively; P = 0.017). In both age groups, the effect on blood pressure was most important for choosing a drug, followed by the risk of adverse drug events and the risk of death. The effect on limitations due to stroke was only significant in the non-aged group. The effect on blood pressure was slightly more important in the non-aged than the aged group (P = 0.043). Conclusions Aged patients appear less willing to add a preventive drug than non-aged patients. The importance attached to various treatment characteristics does not seem to differ much among age groups.
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Affiliation(s)
- Sieta T. de Vries
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Folgerdiena M. de Vries
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Thijs Dekker
- Institute for Transport Studies, University of Leeds, Leeds, United Kingdom
| | - Flora M. Haaijer-Ruskamp
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Adelita V. Ranchor
- Department of Health Psychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- * E-mail:
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Frontoni S, Solini A, Fioretto P, Natali A, Zuccalà A, Cosentino F, Penno G. The ideal blood pressure target to prevent cardiovascular disease in type 2 diabetes: a neutral viewpoint. Nutr Metab Cardiovasc Dis 2014; 24:577-584. [PMID: 24582686 DOI: 10.1016/j.numecd.2014.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 12/27/2013] [Accepted: 01/06/2014] [Indexed: 11/17/2022]
Abstract
Type 2 diabetes mellitus (T2DM) and essential hypertension are often associated, and retrospective data analyses suggest an association between lower blood pressure (BP) values and lower cardiovascular (CV) risk in patients with T2DM. However, the most recent intervention trials fail to demonstrate a further CV risk reduction, for BP levels <130/80 mm Hg, when compared to levels <140/90 mm Hg. Moreover, a J-shaped, rather than a linear, relationship of BP reduction with incident CV events has been strongly suggested. We here debate the main available evidences for and against the concept of 'the lower the better', in the light of the main intervention trials and meta-analyses, with a particular emphasis on the targets to be pursued in elderly patients. Finally, the most recent guidelines of the scientific societies are critically discussed.
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Affiliation(s)
- S Frontoni
- Department of Systems Medicine, University of Rome Tor Vergata - AFAR, Fatebenefratelli Hospital, Rome, Italy.
| | - A Solini
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - P Fioretto
- Department of Medicine, University of Padova, Padova, Italy
| | - A Natali
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - A Zuccalà
- Nephrology Dialysis Unit, Civil Hospital Imola, Imola, Italy
| | - F Cosentino
- Cardiology, Department of Clinical and Molecular Medicine, University of Rome Sapienza, Rome, Italy
| | - G Penno
- Department of Clinical and Experimental Medicine, Section of Diabetes and Metabolic Disease, University of Pisa, Pisa, Italy
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van Hateren KJJ, Drion I, Kleefstra N, Groenier KH, Houweling ST, van der Meer K, Bilo HJG. A prospective observational study of quality of diabetes care in a shared care setting: trends and age differences (ZODIAC-19). BMJ Open 2012; 2:e001387. [PMID: 22936821 PMCID: PMC3432849 DOI: 10.1136/bmjopen-2012-001387] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 07/25/2012] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE The Zwolle Outpatient Diabetes project Integrating Available Care (ZODIAC) study was initiated in 1998 to investigate the effects of shared care for patients with type 2 diabetes mellitus (T2DM) in the Netherlands, and to reduce the number of diabetes-related complications. Benchmarking the performance of diabetes care was and is an important aspect of this study. We aimed to investigate trends in diabetes care, within the ZODIAC study for a wide variety of quality indicators during a long follow-up period (1998-2008), with special interest for different age groups. DESIGN Prospective observational cohort study. SETTING Primary care, Zwolle, The Netherlands. PARTICIPANTS Patients with T2DM. METHODS A dataset of quality measures was collected annually during the patient's visit to the practice nurse or general practitioner. Linear time trends from 1998 to 2008 were estimated using linear mixed models in which we adjusted for age and gender. Age was included in the model as a categorical variable: for each follow-up year all participants were categorised into the categories <60, 60-75 and >75 years. Differences in trends between the age categories were investigated by adding an interaction term to the model. RESULTS The number of patients who were reported to participate increased in the period 1998-2008 from 1622 to 27 438. All quality indicators improved in this study, except for body mass index. The prevalence albuminuria decreased in an 11-year-period from 42% to 21%. No relevant differences between the trends for the three age categories were observed. During all years of follow-up, mean blood pressure and body mass index were the lowest and highest, respectively, in the group of patients <60 years (data not shown). CONCLUSIONS Quality of diabetes care within the Dutch ZODIAC study, a shared care project, has considerably improved in the period 1998-2008. There were no relevant differences between trends across various age categories.
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Affiliation(s)
| | - Iefke Drion
- Diabetes Centre, Isala Clinics, Zwolle, The Netherlands
| | - Nanne Kleefstra
- Diabetes Centre, Isala Clinics, Zwolle, The Netherlands
- Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Klaas H Groenier
- Department of General Practice, University Medical Center Groningen, Groningen, The Netherlands
| | - Sebastiaan T Houweling
- Diabetes Centre, Isala Clinics, Zwolle, The Netherlands
- Langerhans Medical Research Group, Zwolle, The Netherlands
- Department of General Practice, University Medical Center Groningen, Groningen, The Netherlands
| | - Klaas van der Meer
- Department of General Practice, University Medical Center Groningen, Groningen, The Netherlands
| | - Henk J G Bilo
- Diabetes Centre, Isala Clinics, Zwolle, The Netherlands
- Department of Internal Medicine, University Medical Center Groningen, Groningen, The Netherlands
- Department of Internal Medicine, Isala Clinics, Zwolle, The Netherlands
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