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Rautiainen E, Ryynänen OP, Rautiainen P, Laatikainena T. How do individuals with alcohol problems use social and healthcare services in Finland? Comparison of service use patterns between two high-need patient groups. NORDIC STUDIES ON ALCOHOL AND DRUGS 2022; 38:450-465. [PMID: 35308819 PMCID: PMC8900183 DOI: 10.1177/14550725211018593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 04/30/2021] [Indexed: 11/16/2022] Open
Abstract
Aims: Alcohol use disorders (AUDs) are associated with high risk of comorbidities and excess use of social and healthcare services. We examined health service use (HSU) frequencies of patients with AUD in comparison to those with type 2 diabetes mellitus (T2DM). Design: A random sample of individuals with AUD (n = 396) were identified based on ICD-10 codes and HSU patterns, morbidity and mortality were compared with age- and gender-matched T2DM controls (n = 792) using logistic regression analysis. Six years (2011–2016) of electronic health record (EHR) data from the North Karelia district in Finland were used. Results: Similarities in comorbidity patterns existed, although mental health comorbidity (odds ratio [OR] 1.86) was more prevalent in the AUD group. The average annual HSU varied according to the groups: T2DM patients had more continuous contact with public health nurses in primary care, whereas AUD patients were more likely to experience somatic specialised care hospitalisations (OR 11.30) and have frequent somatic primary healthcare doctor visits (OR 3.30) and frequent emergency room doctor visits in specialised care (OR 8.89). Furthermore, patients with AUD had a 7.5 times higher risk of death compared with T2DM patients. Conclusions: This study identified rather similar comorbidity status for the AUD and T2DM patients, but their HSU patterns differed noticeably. AUD patients had higher frequencies of hospitalisation periods and emergency service use and were at a higher risk of death compared with T2DM patients, indicating greater challenges in the organisation of care for AUD patients compared with those having T2DM.
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Affiliation(s)
- Elina Rautiainen
- University of Eastern Finland, Kuopio, Finland; and National Institute for Health and Welfare, Helsinki, Finland
| | - Olli-Pekka Ryynänen
- University of Eastern Finland, Kuopio, Finland; and Kuopio University Hospital, Finland
| | - Päivi Rautiainen
- Joint Municipal Authority for North Karelia Social and Health Services (Siun sote), Tikkamäentie, Joensuu, Finland
| | - Tiina Laatikainena
- Joint Municipal Authority for North Karelia Social and Health Services (Siun sote), Tikkamäentie, Joensuu, Finland; and National Institute for Health and Welfare, Helsinki, Finland
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Wrzal PK, Bunko A, Myageri V, Kukaswadia A, Neish CS, Ivers NM. Strategies to Overcome Therapeutic Inertia in Type 2 Diabetes Mellitus: A Scoping Review. Can J Diabetes 2020; 45:273-281.e13. [PMID: 33160883 DOI: 10.1016/j.jcjd.2020.08.109] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/31/2020] [Accepted: 08/31/2020] [Indexed: 12/17/2022]
Abstract
The objectives of this review were to: 1) examine recent strategies and component interventions used to overcome therapeutic inertia in type 2 diabetes mellitus (T2DM), 2) map strategies to the causes of therapeutic inertia they target and 3) identify causes of therapeutic inertia in T2DM that have not been targeted by recent strategies. A systematic search of the literature published from January 2014 to December 2019 was conducted to identify strategies targeting therapeutic inertia in T2DM, and key strategy characteristics were extracted and summarized. The search identified 46 articles, employing a total of 50 strategies aimed at overcoming therapeutic inertia. Strategies were composed of an average of 3.3 interventions (range, 1 to 10) aimed at an average of 3.6 causes (range, 1 to 9); most (78%) included a type of educational strategy. Most strategies targeted causes of inertia at the patient (38%) or health-care professional (26%) levels only and 8% targeted health-care-system-level causes, whereas 28% targeted causes at multiple levels. No strategies focused on patients' attitudes toward disease or lack of trust in health-care professionals; none addressed health-care professionals' concerns over costs or lack of information on side effects/fear of causing harm, or the lack of a health-care-system-level disease registry. Strategies to overcome therapeutic inertia in T2DM commonly employed multiple interventions, but novel strategies with interventions that simultaneously target multiple levels warrant further study. Although educational interventions are commonly used to address therapeutic inertia, future strategies may benefit from addressing a wider range of determinants of behaviour change to overcome therapeutic inertia.
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Affiliation(s)
- Paulina K Wrzal
- Medical Affairs, Novo Nordisk Canada, Inc, Mississauga, Ontario, Canada.
| | - Andrean Bunko
- Real World Solutions, IQVIA, Mississauga, Ontario, Canada
| | - Varun Myageri
- Real World Solutions, IQVIA, Mississauga, Ontario, Canada
| | | | - Calum S Neish
- Real World Solutions, IQVIA, Mississauga, Ontario, Canada
| | - Noah M Ivers
- Department of Family Medicine, Women's College Hospital and University of Toronto, Toronto, Ontario, Canada
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Polhuis CMM, Vaandrager L, Soedamah-Muthu SS, Koelen MA. Salutogenic model of health to identify turning points and coping styles for eating practices in type 2 diabetes mellitus. Int J Equity Health 2020; 19:80. [PMID: 32487086 PMCID: PMC7266427 DOI: 10.1186/s12939-020-01194-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 05/14/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND It is important for people with Type 2 Diabetes Mellitus (T2DM) to eat healthily. However, implementing dietary advice in everyday life is difficult, because eating is not a distinguishable action, but a chain of activities, embedded in social practices and influenced by previous life experiences. This research aims to understand why and how eating practices are developed over the life-course by investigating influential life experiences - turning points - and coping strategies for eating practices of people with T2DM. METHODS The Salutogenic Model of Health guided the study's objective, study design and analysis. Seventeen interviews were performed and analysed based on the principles of interpretative phenomenological analysis. Narrative inquiry and the creation of timelines and food boxes were used as tools to facilitate reflection on turning points and eating practices. RESULTS Turning points for unhealthier eating were experiences that strongly disturbed the participants' emotional stability. These experiences included psychosocial trauma, physical health disorders, job loss, and smoking cessation. Turning points for healthier eating were experiences that significantly changed participants views on life and made participants reflective about the effects of current eating practices on future health and life goals. These turning points included confrontation with ill-health, becoming a parent, psychosocial therapy, and getting married. Notably, turning points for healthier eating seemed only to happen when life was relatively stress-free. All participants experienced turning points for healthier eating, yet, not all participants succeeded in improving their diets. Two coping styles were distinguished: active and passive coping. Active coping individuals were able to act in line with their personal intentions, whereas passive coping individuals could not. Differences between active and passive coping styles seemed to be explained by differences in available resources important for adapting and maintaining a healthy diet. CONCLUSION Disadvantaged childhood and later life adversities together with the inability to manage the mental stress explained the development unhealthier eating practices. All participants experienced turning points for healthier eating that caused eating to become a priority in their life. Yet, the fact that not all were able to eat as they intended, advocates for nutritional guidance for people with T2DM, with a greater emphasis on reflexivity, psycho-social well-being and social support.
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Affiliation(s)
- C M M Polhuis
- Health and Society, Wageningen University, P.O. Box 8130, 6700 EW, Wageningen, The Netherlands.
| | - L Vaandrager
- Health and Society, Wageningen University, P.O. Box 8130, 6700 EW, Wageningen, The Netherlands
| | - S S Soedamah-Muthu
- Center of Research on Psychological and Somatic disorders (CORPS), Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
- Institute for Food, Nutrition and Health, University of Reading, Reading, UK
| | - M A Koelen
- Health and Society, Wageningen University, P.O. Box 8130, 6700 EW, Wageningen, The Netherlands
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Defining High Value Elements for Reducing Cost and Utilization in Patient-Centered Medical Homes for the TOPMED Trial. EGEMS 2019; 7:20. [PMID: 31106226 PMCID: PMC6498873 DOI: 10.5334/egems.246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction: Like most patient-centered medical home (PCMH) models, Oregon’s program, the Patient-Centered Primary Care Home (PCPCH), aims to improve care while reducing costs; however, previous work shows that PCMH models do not uniformly achieve desired outcomes. Our objective was to describe a process for refining PCMH models to identify high value elements (HVEs) that reduce cost and utilization. Methods: We performed a targeted literature review of each PCPCH core attribute. Value-related concepts and their metrics were abstracted, and studies were assessed for relevance and strength of evidence. Focus groups were held with stakeholders and patients, and themes related to each attribute were identified; calculation of HVE attainment versus PCPCH criteria were completed on eight primary care clinics. Analyses consisted of descriptive statistics and criterion validity with stakeholder input. Results: 2,126 abstracts were reviewed; 22 met inclusion criteria. From these articles and focus groups of stakeholders/experts (n = 49; 4 groups) and patients (n = 7; 1 group), 12 HVEs were identified that may reduce cost and utilization. At baseline, clinics achieved, on average, 31.3 percent HVE levels compared to an average of 87.9 percent of the 35 PCMH measures. Discussion: A subset of measures from the PCPCH model were identified as “high value” in reducing cost and utilization. HVE performance was significantly lower than standard measures, and may better calibrate clinic ability to reduce costs. Conclusion: Through literature review and stakeholder engagement, we created a novel set of high value elements for advanced primary care likely to be more related to cost and utilization than other models.
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Roze S, Duteil E, Smith-Palmer J, de Portu S, Valentine W, de Brouwer BFE, Reznik Y, de Valk HW. Cost-effectiveness of continuous subcutaneous insulin infusion in people with type 2 diabetes in the Netherlands. J Med Econ 2016; 19:742-9. [PMID: 26985982 DOI: 10.3111/13696998.2016.1167695] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
AIMS Up to 30% of insulin-treated type 2 diabetes patients are unable to achieve HbA1c targets despite optimization of insulin multiple daily injections (MDI). For these patients the use of continuous subcutaneous insulin infusion (CSII) represents a useful but under-utilized alternative. The aim of the present analysis was to examine the cost-effectiveness of initiating CSII in type 2 diabetes patients failing to achieve good glycemic control on MDI in the Netherlands. METHODS Long-term projections were made using the IMS CORE Diabetes Model. Clinical input data were sourced from the OpT2mise trial. The analysis was performed over a lifetime time horizon. The discount rates applied to future costs and clinical outcomes were 4% and 1.5% per annum, respectively. RESULTS CSII was associated with improved quality-adjusted life expectancy compared with MDI (9.38 quality-adjusted life years [QALYs] vs 8.95 QALYs, respectively). The breakdown of costs indicated that ∼50% of costs were attributable to diabetes-related complications. Higher acquisition costs of CSII vs MDI were partially offset by the reduction in complications. The ICER was estimated at EUR 62,895 per QALY gained and EUR 60,474 per QALY gained when indirect costs were included. CONCLUSIONS In the Netherlands, CSII represents a cost-effective option in patients with type 2 diabetes who continue to have poorly-controlled HbA1c despite optimization of MDI. Since the ICER falls below the willingness-to-pay threshold of EUR 80,000 per QALY gained, CSII is likely to represent good-value for money in the treatment of poorly-controlled T2D patients compared with MDI.
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Affiliation(s)
- S Roze
- a HEVA HEOR , Lyon , France
| | | | - J Smith-Palmer
- b Ossian Health Economics and Communications , Basel , Switzerland
| | - S de Portu
- c Medtronic International Sàrl , Tolochenaz , Switzerland
| | - W Valentine
- b Ossian Health Economics and Communications , Basel , Switzerland
| | | | - Y Reznik
- e University of Caen Côte de Nacre Regional Hospital Center , Caen , France
| | - H W de Valk
- f University Medical Centre Heidelberglaan , Utrecht , The Netherlands
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Mast R, Danielle Jansen AP, Walraven I, Rauh SP, van der Heijden AAWA, Heine RJ, Elders PJM, Dekker JM, Nijpels G, Hugtenburg JG. Time to insulin initiation and long-term effects of initiating insulin in people with type 2 diabetes mellitus: the Hoorn Diabetes Care System Cohort Study. Eur J Endocrinol 2016; 174:563-71. [PMID: 26837781 DOI: 10.1530/eje-15-1149] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 02/02/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The aim of this study was to assess the time to insulin initiation in type 2 diabetes mellitus (T2DM) patients treated with oral glucose-lowering agents and to determine the baseline characteristics associated with time to insulin initiation. This was evaluated in T2DM patients with HbA1c levels consistently ≥7.0% during total follow up and in those with fluctuating HbA1c levels around 7.0%. DESIGN AND METHODS Prospective, observational study was performed, comprising 2418 persons with T2DM aged ≥40 years who entered the Diabetes Care System between 1998 and 2012 with a minimum follow up of at least 3 years, following the first HbA1c level ≥7.0%. Cox regression analyses were performed to assess the determinants of time to insulin initiation. Data related to long-term effects of insulin initiation were studied at baseline and at the end of follow up using descriptive summary statistics. RESULTS Two-thirds of the patients initiated insulin during follow up. The time to insulin varied from 1.2 years (range 0.3-3.1) in patients with HbA1c levels consistently ≥7.0% to 5.4 years (range 3.0-7.5) in patients with fluctuating HbA1c levels around 7.0%. Longer diabetes duration (hazard ratio (HR) 1.04 95% CI 1.03-1.05) and lower age (HR 1.00 95% CI 0.99-1.00) at baseline were associated with a shorter time to initiation. More insulin initiators had retinopathy compared with patients that remained on oral glucose-lowering agents during follow up. CONCLUSION The time to insulin initiation was short, and most of the patients with HbA1c levels consistently ≥7.0% were initiating insulin. Longer diabetes duration and younger age shortened the time to insulin.
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Affiliation(s)
- Ruth Mast
- EMGO Institute for Health and Care ResearchDepartments of Clinical Pharmacology and PharmacyGeneral Practice and Elderly Care MedicineEpidemiology and BiostatisticsOphthalmologyVU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The NetherlandsEli Lilly and Company893 S Delaware St, Indianapolis, Indiana, USA EMGO Institute for Health and Care ResearchDepartments of Clinical Pharmacology and PharmacyGeneral Practice and Elderly Care MedicineEpidemiology and BiostatisticsOphthalmologyVU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The NetherlandsEli Lilly and Company893 S Delaware St, Indianapolis, Indiana, USA
| | - A P Danielle Jansen
- EMGO Institute for Health and Care ResearchDepartments of Clinical Pharmacology and PharmacyGeneral Practice and Elderly Care MedicineEpidemiology and BiostatisticsOphthalmologyVU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The NetherlandsEli Lilly and Company893 S Delaware St, Indianapolis, Indiana, USA EMGO Institute for Health and Care ResearchDepartments of Clinical Pharmacology and PharmacyGeneral Practice and Elderly Care MedicineEpidemiology and BiostatisticsOphthalmologyVU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The NetherlandsEli Lilly and Company893 S Delaware St, Indianapolis, Indiana, USA
| | - Iris Walraven
- EMGO Institute for Health and Care ResearchDepartments of Clinical Pharmacology and PharmacyGeneral Practice and Elderly Care MedicineEpidemiology and BiostatisticsOphthalmologyVU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The NetherlandsEli Lilly and Company893 S Delaware St, Indianapolis, Indiana, USA EMGO Institute for Health and Care ResearchDepartments of Clinical Pharmacology and PharmacyGeneral Practice and Elderly Care MedicineEpidemiology and BiostatisticsOphthalmologyVU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The NetherlandsEli Lilly and Company893 S Delaware St, Indianapolis, Indiana, USA EMGO Institute for Health and Care ResearchDepartments of Clinical Pharmacology and PharmacyGeneral Practice and Elderly Care MedicineEpidemiology and BiostatisticsOphthalmologyVU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The NetherlandsEli Lilly and Company893 S Delaware St, Indianapolis, Indiana, USA
| | - Simone P Rauh
- EMGO Institute for Health and Care ResearchDepartments of Clinical Pharmacology and PharmacyGeneral Practice and Elderly Care MedicineEpidemiology and BiostatisticsOphthalmologyVU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The NetherlandsEli Lilly and Company893 S Delaware St, Indianapolis, Indiana, USA EMGO Institute for Health and Care ResearchDepartments of Clinical Pharmacology and PharmacyGeneral Practice and Elderly Care MedicineEpidemiology and BiostatisticsOphthalmologyVU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The NetherlandsEli Lilly and Company893 S Delaware St, Indianapolis, Indiana, USA
| | - Amber A W A van der Heijden
- EMGO Institute for Health and Care ResearchDepartments of Clinical Pharmacology and PharmacyGeneral Practice and Elderly Care MedicineEpidemiology and BiostatisticsOphthalmologyVU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The NetherlandsEli Lilly and Company893 S Delaware St, Indianapolis, Indiana, USA EMGO Institute for Health and Care ResearchDepartments of Clinical Pharmacology and PharmacyGeneral Practice and Elderly Care MedicineEpidemiology and BiostatisticsOphthalmologyVU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The NetherlandsEli Lilly and Company893 S Delaware St, Indianapolis, Indiana, USA
| | - Robert J Heine
- EMGO Institute for Health and Care ResearchDepartments of Clinical Pharmacology and PharmacyGeneral Practice and Elderly Care MedicineEpidemiology and BiostatisticsOphthalmologyVU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The NetherlandsEli Lilly and Company893 S Delaware St, Indianapolis, Indiana, USA EMGO Institute for Health and Care ResearchDepartments of Clinical Pharmacology and PharmacyGeneral Practice and Elderly Care MedicineEpidemiology and BiostatisticsOphthalmologyVU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The NetherlandsEli Lilly and Company893 S Delaware St, Indianapolis, Indiana, USA
| | - Petra J M Elders
- EMGO Institute for Health and Care ResearchDepartments of Clinical Pharmacology and PharmacyGeneral Practice and Elderly Care MedicineEpidemiology and BiostatisticsOphthalmologyVU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The NetherlandsEli Lilly and Company893 S Delaware St, Indianapolis, Indiana, USA EMGO Institute for Health and Care ResearchDepartments of Clinical Pharmacology and PharmacyGeneral Practice and Elderly Care MedicineEpidemiology and BiostatisticsOphthalmologyVU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The NetherlandsEli Lilly and Company893 S Delaware St, Indianapolis, Indiana, USA
| | - Jacqueline M Dekker
- EMGO Institute for Health and Care ResearchDepartments of Clinical Pharmacology and PharmacyGeneral Practice and Elderly Care MedicineEpidemiology and BiostatisticsOphthalmologyVU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The NetherlandsEli Lilly and Company893 S Delaware St, Indianapolis, Indiana, USA EMGO Institute for Health and Care ResearchDepartments of Clinical Pharmacology and PharmacyGeneral Practice and Elderly Care MedicineEpidemiology and BiostatisticsOphthalmologyVU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The NetherlandsEli Lilly and Company893 S Delaware St, Indianapolis, Indiana, USA
| | - Giel Nijpels
- EMGO Institute for Health and Care ResearchDepartments of Clinical Pharmacology and PharmacyGeneral Practice and Elderly Care MedicineEpidemiology and BiostatisticsOphthalmologyVU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The NetherlandsEli Lilly and Company893 S Delaware St, Indianapolis, Indiana, USA EMGO Institute for Health and Care ResearchDepartments of Clinical Pharmacology and PharmacyGeneral Practice and Elderly Care MedicineEpidemiology and BiostatisticsOphthalmologyVU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The NetherlandsEli Lilly and Company893 S Delaware St, Indianapolis, Indiana, USA
| | - Jacqueline G Hugtenburg
- EMGO Institute for Health and Care ResearchDepartments of Clinical Pharmacology and PharmacyGeneral Practice and Elderly Care MedicineEpidemiology and BiostatisticsOphthalmologyVU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The NetherlandsEli Lilly and Company893 S Delaware St, Indianapolis, Indiana, USA EMGO Institute for Health and Care ResearchDepartments of Clinical Pharmacology and PharmacyGeneral Practice and Elderly Care MedicineEpidemiology and BiostatisticsOphthalmologyVU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The NetherlandsEli Lilly and Company893 S Delaware St, Indianapolis, Indiana, USA
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Munch L, Arreskov AB, Sperling M, Overgaard D, Knop FK, Vilsbøll T, Røder ME. Risk stratification by endocrinologists of patients with type 2 diabetes in a Danish specialised outpatient clinic: a cross-sectional study. BMC Health Serv Res 2016; 16:124. [PMID: 27061722 PMCID: PMC4826533 DOI: 10.1186/s12913-016-1365-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 03/24/2016] [Indexed: 12/20/2022] Open
Abstract
Background To target optimised medical care the Danish guidelines for diabetes recommend stratification of patients with type 2 diabetes (T2D) into three levels according to risk and complexity of treatment. The aim was to describe the T2D population in an outpatient clinic, measure the compliance of the endocrinologists’ to perform risk stratification, and investigate the level of concordance between stratification performed by the endocrinologists and objective assessments. Methods A cross-sectional study with data collected from medical records and laboratory databases. The Danish risk stratification model contained the following criteria: HbA1c, blood pressure, metabolic complications, microvascular and macrovascular complications. Stratification levels encompassed: level 1 (uncomplicated), level 2 (intermediate risk) and level 3 (high risk). Objective assessments were conducted independently by two health professionals, and compared with the endocrinologists’ assessments. In order to test the degree of concordance, we conducted Cohen's kappa, McNemar’s test for marginal homogeneity, and Bowker’s test for symmetry. Results Of 245 newly referred patients, 209 (85 %) were stratified by the endocrinologists to level 1 (16 %), level 2 (55 %) and level 3 (29 %). By objective assessments, 4 % were stratified to level 1, 51 % to level 2 and 45 % to level 3. Of 419 long-term follow-up patients, 380 (91 %) were stratified by the endocrinologists to level 1 (5 %), level 2 (57 %), level 3 (38 %). By objective assessments, 3 % were stratified to level 1, 58 % to level 2 and 39 % to level 3. The concordance rate between endocrinologists’ and objective assessments was 63 % among newly referred (kappa 0.39; fair agreement) and 67 % for long-term follow-up (kappa 0.45; moderate agreement). Among newly referred patients, the endocrinologists stratified less patients at level 3 compared to objective assessments (p < 0.0001). There were no significant differences in marginal distribution within long-term follow-up patients. Conclusion Type 2 diabetes patients, newly referred to or allocated for long-term follow-up in the out-patient clinic, were mainly intermediate and high-risk, complicated patients (96 % and 95 %, respectively). Compliance of stratification by endocrinologists was high. The concordance between endocrinologists’ and objective assessments was not strong. Our data suggest that clinician-support for stratification level categorisation might be needed.
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Affiliation(s)
- Lene Munch
- Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark.,Institute of Nursing, University College Metropol, Tagensvej 86, DK-2200, Copenhagen, Denmark
| | - Anne B Arreskov
- Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark
| | | | - Dorthe Overgaard
- Institute of Nursing, University College Metropol, Tagensvej 86, DK-2200, Copenhagen, Denmark
| | - Filip K Knop
- Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark.,NNF Center for Basic Metabolic Research and Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3, DK-2200, Copenhagen, Denmark
| | - Tina Vilsbøll
- Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark
| | - Michael E Røder
- Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark.
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Walraven I, Mast MR, Hoekstra T, Jansen APD, van der Heijden AAWA, Rauh SP, Rutters F, van 't Riet E, Elders PJM, Moll AC, Polak BCP, Dekker JM, Nijpels G. Distinct HbA1c trajectories in a type 2 diabetes cohort. Acta Diabetol 2015; 52:267-75. [PMID: 25287012 DOI: 10.1007/s00592-014-0633-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 07/15/2014] [Indexed: 12/14/2022]
Abstract
AIMS The aim of this study was to identify subgroups of type 2 diabetes mellitus patients with distinct hemoglobin A1c (HbA1c) trajectories. Subgroup characteristics were determined and the prevalence of microvascular complications over time was investigated. STUDY DESIGN AND SETTING Data from a cohort of 5,423 type 2 diabetes patients from a managed primary care system were used [mean follow-up 5.7 years (range 2-9 years)]. Latent class growth modeling was used to identify subgroups of patients with distinct HbA1c trajectories. Multinomial logistic regression analyses were conducted to determine which characteristics were associated with different classes. RESULTS Four subgroups were identified. The first and largest subgroup (83 %) maintained good glycemic control over time (HbA1c ≤53 mmol/mol), the second subgroup (8 %) initially showed severe hyperglycemia, but reached the recommended HbA1c target within 2 years. Patients within this subgroup had significantly higher baseline HbA1c levels but were otherwise similar to the good glycemic control group. The third subgroup (5 %) showed hyperglycemia and a delayed response without reaching the recommended HbA1c target. The fourth subgroup (3.0 %) showed deteriorating hyperglycemia over time. Patients within the last two subgroups were significantly younger, had higher HbA1c levels and a longer diabetes duration at baseline. These subgroups also showed a higher prevalence of retinopathy and microalbuminuria. CONCLUSION Four subgroups with distinct HbA1c trajectories were identified. More than 90 % reached and maintained good glycemic control (subgroup one and two). Patients within the two subgroups that showed a more unfavorable course of glycemic control were younger, had higher HbA1c levels and a longer diabetes duration at baseline.
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Affiliation(s)
- Iris Walraven
- EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands,
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Bähler C, Huber CA, Brüngger B, Reich O. Multimorbidity, health care utilization and costs in an elderly community-dwelling population: a claims data based observational study. BMC Health Serv Res 2015; 15:23. [PMID: 25609174 PMCID: PMC4307623 DOI: 10.1186/s12913-015-0698-2] [Citation(s) in RCA: 282] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 01/12/2015] [Indexed: 12/13/2022] Open
Abstract
Background Chronic conditions and multimorbidity have become one of the main challenges in health care worldwide. However, data on the burden of multimorbidity are still scarce. The purpose of this study is to examine the association between multimorbidity and the health care utilization and costs in the Swiss community-dwelling population, taking into account several sociodemographic factors. Methods The study population consists of 229'493 individuals aged 65 or older who were insured in 2013 by the Helsana Group, the leading health insurer in Switzerland, covering all 26 Swiss cantons. Multimorbidity was defined as the presence of two or more chronic conditions of a list of 22 conditions that were identified using an updated measure of the Pharmacy-based Cost Group model. The number of consultations (total and divided by primary care physicians and specialists), the number of different physicians contacted, the type of physician contact (face-to-face, phone, and home visits), the number of hospitalisations and the length of stay were assessed separately for the multimorbid and non-multimorbid sample. The costs (total and divided by inpatient and outpatient costs) covered by the compulsory health insurance were calculated for both samples. Multiple linear regression modelling was conducted to adjust for influencing factors: age, sex, linguistic region, purchasing power, insurance plan, and nursing dependency. Results Prevalence of multimorbidity was 76.6%. The mean number of consultations per year was 15.7 in the multimorbid compared to 4.4 in the non-multimorbid sample. Total costs were 5.5 times higher in multimorbid patients. Each additional chronic condition was associated with an increase of 3.2 consultations and increased costs of 33%. Strong positive associations with utilization and costs were also found for nursing dependency. Multimorbid patients were 5.6 times more likely to be hospitalised. Furthermore, results revealed a significant age-gender interaction and a socioeconomic gradient. Conclusions Multimorbidity is associated with substantial higher health care utilization and costs in Switzerland. Quantified data on the current burden of multimorbidity are fundamental for the management of patients in health service delivery systems and for health care policy debates about resource allocation. Strategies for a better coordination of multimorbid patients are urgently needed. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-0698-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Caroline Bähler
- Department of Health Sciences, Helsana Insurance Group, P.O. Box, 8081, Zürich, Switzerland.
| | - Carola A Huber
- Department of Health Sciences, Helsana Insurance Group, P.O. Box, 8081, Zürich, Switzerland.
| | - Beat Brüngger
- Department of Health Sciences, Helsana Insurance Group, P.O. Box, 8081, Zürich, Switzerland.
| | - Oliver Reich
- Department of Health Sciences, Helsana Insurance Group, P.O. Box, 8081, Zürich, Switzerland.
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Affiliation(s)
- Paul Grant
- Royal Sussex County Hospital; Brighton UK
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