Pharmacological primary and secondary cardiovascular prevention among diabetic patients in a multiethnic general practice population: still room for improvements

Ethnic and gender differences in the management of type 2 diabetes: a cross-sectional study from Norwegian general practice

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.

Comparison of primary versus secondary prevention of cardiovascular disease in patients with type2 diabetes: Focus on achievement of ABC goals

BACKGROUND

Primary and secondary prevention of cardiovascular disease is of utmost importance in the management of patients with diabetes.

OBJECTIVES

We studied a group of Iranian patients with type2 diabetes to provide an overview of the current status of secondary prevention of cardiovascular disease in the Middle East.

METHODS

This is a cross-sectional study of 2029 Patients with type2 diabetes including 323 patients with coronary artery disease (CAD) were recruited. Achievement of goals in HbA1c (A), blood pressure (B) and LDL-cholesterol(C) was assessed.

RESULTS

The study showed 25.3% of CAD positive patients achieved HbA1c <7% compared to 30% in CAD negative patients. The achievement of blood pressure ≤140/90 mmHg was 53.2% and 52.8% in CAD positive and CAD negative patients respectively. There was no difference in the achievement of all three ABC goals between the two groups (p = 0.733). After logistic regression analysis, history of hypertension had the highest odds ratio for CAD.

CONCLUSION

Although ABC control has an important impact on the prevention of cardiovascular outcomes, the ideal goal needs further efforts to be achieved.

Combined use of polypill components in patients with type 2 diabetes mellitus

Objectives

A polypill containing aspirin, a statin and blood pressure (BP)-lowering agents has been proposed for the prevention of cardiovascular disease. To increase adherence and reduce the gaps between indicated and used therapy, a polypill might be of interest for patients with type 2 diabetes (T2DM). Our aim was to assess the prevalence of the combined use of polypill components in patients with T2DM over time.

Methods

The combined use of polypill components was assessed between 1996 and 2015 in patients with T2DM in the prospective SMART cohort ( n = 1828). The results were dichotomized into patients without ( n = 568) and with ( n = 1260) vascular disease. The patient characteristics associated with the use of polypill components were evaluated.

Results

In total, 19% of patients with T2DM without vascular disease received a statin and ≥2 BP-lowering agents (‘cardiovascular polypill’) and 13% received additional oral glucose-lowering therapy (‘diabetic polypill’). Of the patients with T2DM with vascular disease, 42% received the combination of an antiplatelet agent, a statin and ≥2 BP-lowering agents (‘cardiovascular polypill’) and 30% received additional glucose-lowering therapy (‘diabetic polypill’). The prevalence of the use of the cardiovascular and diabetic polypill combination has substantially increased between 1996 and 2015 to 36 and 32% in patients without vascular disease and to 67 and 57% in patients with vascular disease.

Conclusions

Patients with T2DM frequently use polypill components, often together with oral glucose-lowering agents, and this rate of use has increased steadily between 1996 and 2015. Introducing a cardiovascular or diabetic polypill for patients with T2DM seems to be highly relevant.

Are general practitioners characteristics associated with the quality of type 2 diabetes care in general practice? Results from the Norwegian ROSA4 study from 2014

OBJECTIVE

To explore the associations between general practitioners (GPs) characteristics such as gender, specialist status, country of birth and country of graduation and the quality of care for patients with type 2 diabetes (T2DM).

DESIGN

Cross-sectional survey.

SETTING AND SUBJECTS

The 277 GPs provided care for 10082 patients with T2DM in Norway in 2014. The GPs characteristics were self-reported: 55% were male, 68% were specialists in General Practice, 82% born in Norway and 87% had graduated in Western Europe. Of patients, 81% were born in Norway and 8% in South Asia. Data regarding diabetes care were obtained from electronic medical records and manually verified.

MAIN OUTCOME MEASURES

Performance of recommended screening procedures, prescribed medication and level of HbA1c, blood pressure and LDL-cholesterol stratified according to GPs characteristics, adjusted for patient and GP characteristics.

RESULT

Female GPs, specialists, GPs born in Norway and GPs who graduated in Western Europe performed recommended procedures more frequently than their counterparts. Specialists achieved lower mean HbA1c (7.14% vs. 7.25%, p < 0.01), a larger proportion of their patients achieved good glycaemic control (HbA1c = 6.0%-7.0%) (49.1% vs. 44.4%, p = 0.018) and lower mean systolic blood pressure (133.0 mmHg vs. 134.7 mmHg, p < 0.01) compared with non-specialists. GPs who graduated in Western Europe achieved lower diastolic blood pressure than their counterparts (76.6 mmHg vs. 77.8 mmHg, p < 0.01).

CONCLUSION

Several quality indicators for type 2 diabetes care were better if the GPs were specialists in General Practice. Key Points Research on associations between General Practitioners (GPs) characteristics and quality of care for patients with type 2 diabetes is limited. Specialists in General Practice performed recommended procedures more frequently, achieved better HbA1c and blood pressure levels than non-specialists. GPs who graduated in Western Europe performed screening procedures more frequently and achieved lower diastolic blood pressure compared with their counterparts. There were few significant differences in the quality of care between GP groups according to their gender and country of birth.

Differential utilization of primary health care services among older immigrants and Norwegians: a register-based comparative study in Norway

BACKGROUND

Aging in an unfamiliar landscape can pose health challenges for the growing numbers of immigrants and their health care providers. Therefore, better understanding of how different immigrant groups use Primary Health Care (PHC), and the underlying factors that explain utilization is needed to provide adequate and appropriate public health responses. Our aim is to describe and compare the use of PHC between elderly immigrants and Norwegians.

METHODS

Registry-based study using merged data from the National Population Register and the Norwegian Health Economics Administration database. All 50 year old or older Norwegians with both parents from Norway (1,516,012) and immigrants with both parents from abroad (89,861) registered in Norway in 2008 were included. Descriptive analyses were carried out. Immigrants were categorised according to country of origin, reason for migration and length of stay in Norway. Binary logistic regression analyses were conducted to study the utilization of PHC comparing Norwegians and immigrants, and to assess associations between utilization and both length of stay and reason for immigration, adjusting for other socioeconomic variables.

RESULTS

A higher proportion of Norwegians used PHC services compared to immigrants. While immigrants from high-income countries used PHC less than Norwegians disregarding age (OR from 0.65 to 0.92 depending on age group), they had similar number of diagnoses when in contact with PHC. Among immigrants from other countries, however, those 50 to 65 years old used PHC services more often (OR 1.22) than Norwegians and had higher comorbidity levels, but this pattern was reversed for older adults (OR 0.56 to 0.47 for 66-80 and 80+ years respectively). For all immigrants, utilization of PHC increased with longer stay in Norway and was higher for refugees (1.67 to 1.90) but lower for labour immigrants (0.33 to 0.45) compared to immigrants for family reunification. However, adjustment for education and income levels reduced most differences between groups.

CONCLUSIONS

Immigrants' lower utilization of PHC services might reflect better health among immigrants, but it could also be due to barriers to access that pose public health challenges. The heterogeneity of life courses and migration trajectories should be taken into account when developing public policies.

[Diabetes in general practice--were treatment goals reached?]

BACKGROUND

In Norway, most people with diabetes are treated by general practitioners. At our own general practice, we wanted to find out whether we were succeeding in following the Directorate of Health's 2009 clinical guidelines on treatment and management of diabetes.

MATERIAL AND METHOD

All patients with the diagnosis diabetes mellitus in our electronic archive between November 2009 and October 2010 were registered. Those patients on our general practice lists in October 2010 were identified. The patient records were manually reviewed and relevant data recorded.

RESULTS

In all, 271 patients with diabetes attended our surgery for check-ups in October 2010. 11% had type 1 diabetes and 88% had type 2 diabetes. HbA1c was measured in 99% of the diabetes patients, blood pressure in 98% and lipids in 93%. The measurements were taken at our surgery during the past year for 96% of the patients. The treatment goals for HbA1c, systolic blood pressure and LDL cholesterol were reached in, respectively, 55%, 55% and 49% of the patients. 13% reached all three treatment goals. 82% had a check-up with an ophthalmologist. Weight and smoking habits were documented in 85% and 90% respectively. 19% of the patients for whom we had documented data, smoked. Examinations of height, feet and microalbumin were documented in 57%, 35% and 28% of the patients respectively.

INTERPRETATION

The guidelines are being followed on most points to a high degree, and the proportion of patients reaching the stricter treatment goals is consistent with the results of earlier Norwegian surveys. There is the potential for further improvement of these results.