Comorbidity in patients with diabetes mellitus: impact on medical health care utilization

Factors Affecting Global Adherence for the Uptake of Diabetic Retinopathy Screening: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate diabetic retinopathy (DR) screening global adherence rate and the association between sociodemographic and clinical variables and adherence rates to DR screening in individuals with diabetes.

DESIGN

Systematic review and meta-analysis.

METHODS

This systematic review was registered with International Prospective Register of Systematic Reviews (ID: CRD42024507035). We conducted a systematic review of relevant literature from inception of databases to February 24, 2024, using electronic databases searches including PubMed, MEDLINE (Ovid), EMBASE, Web of Science, Cochrane CENTRAL, and CDSR and national level DR screening databases through Google searches following PRISMA guidelines. The articles were screened for title and abstract and then for the full-text reports by two independent reviewers and study quality was appraised. Meta-analysis was performed using random effects model to calculate the pooled effects size and 95% confidence interval (CI) of each finding.

RESULTS

Data from a total of 11,383,715 participants from 77 studies and two national websites from 28 countries over five continents were included. Global DR screening adherence rate was 66.9% in high-income countries and 39.3% in low-and-middle-income countries. DR screening adherence rate was lowest in Africa (36.1%) and was highest in Europe (81.3%). Older age (odds ratio [OR] 1.45, 95% CI 1.30-1.62), higher education level (OR = 1.65, 95% CI 1.45-1.78), marriage (OR = 1.42, 95% CI 1.14-1.77), living in an urban area (OR = 1.57, 95% CI 1.08-2.29), higher family income (OR = 1.29, 95% CI 1.24-1.35), having any health insurance (OR = 1.90, 95% CI 1.56-2.31), longer duration of diabetes (OR = 1.57, 95% CI 1.27-1.94), type 2 diabetes (OR = 1.68, 95% CI 1.34-2.10), family history of diabetes (OR = 2.25, 95% CI 1.56-3.25), vision impairment (OR = 2.07, 95% CI 1.43-2.98), history of eye diseases (OR = 1.99, 95% CI 1.36-2.90), insulin treatment (OR = 1.38, 95% CI 1.37-1.39), and good mental health (OR = 1.14, 95% CI 1.04-1.24) were associated with DR screening adherence.

CONCLUSION

This meta-analysis provides key information about which population subgroups may require more targeted intervention and highlights the urgent need to identify ways to improve adherence to DR screening.

REGISTRATION INFORMATION

PROSPERO; ref. no. CRD42024507035, (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=507035).

A community health worker led diabetes self-management education program: Reducing patient and system burden

AIMS

Conduct a secondary analysis of the TIME (Telehealth-supported, Integrated Community Health Workers (CHWs), Medication access, diabetes Education) made simple trial (SIMPLE) to evaluate healthcare utilization and explore variables that may have influenced HbA1c.

METHODS

Participants (N = 134 [67/group]) were low-income, uninsured Hispanics with or at risk for type 2 diabetes mellitus. We included in-person and telehealth clinician visits, other visits, missed visits, orders placed, and guideline-adherence (e.g., vaccinations, quarterly HbA1c for uncontrolled diabetes). Using multivariable models, we explored for associations between HbA1c changes and these measures.

RESULTS

The control arm had higher missed visits rates (intervention: 45 %; control: 56 %; p = 0.007) and missed telehealth appointments (intervention: 10 %; control: 27.4 %; p = 0.04). The intervention group received more COVID vaccinations than the control (p = 0.005). Other health measures were non-significant between groups. Intervention individuals' HbA1c improved with more missed visits (-0.60 %; p < 0.01) and worsened with improved guideline-adherent HbA1c measurements (HbA1c: 1.2 %; p = 0.057). The control group had non-significant HbA1c associations.

CONCLUSIONS

Findings suggest that the SIMPLE trial's improved HbA1c levels stemmed from a CHW-driven intervention and not additional healthcare contact. Exploratory outcomes resulted in seemingly counterintuitive HbA1c associations with missed visits and guideline-adherent measurements; these may suggest that an intervention that enhances communication provides support to reduce the amount of follow-up needed by participants without sacrificing clinical improvements.

Impact of diabetes on COVID-19 and glucocorticoids on patients with COVID-19 and diabetes during the Omicron variant epidemic: a multicenter retrospective cohort study in South China

BACKGROUND

To explore the impact of diabetes on the clinical features and prognosis of COVID-19 and assess the influence of glucocorticoid use on the prognosis of patients with COVID-19 and diabetes.

METHODS

This retrospective multicenter cohort study included patients admitted between December 2022 and January 2023. The patients were grouped according to diabetes and glucocorticoid use. The primary outcome was in-hospital mortality.

RESULTS

Among 400 patients with glucocorticoid data, 109 (27.3%) had diabetes. The inflammatory cytokines were higher in patients with diabetes, manifested by higher IL-6 (25.33 vs. 11.29 ng/L, p = 0.011), CRP (26.55 vs. 8.62 mg/L, p = 0.003), and PCT (0.07 vs. 0.04 ng/ml, p = 0.010), while CD4+ (319 vs. 506 /mL, p = 0.004) and CD8+ (141 vs. 261 /mL, p < 0.001) T lymphocytes were lower. The overall mortality rate of hospitalized COVID-19 patients with diabetes was 13.46%. The diabetic patients who received glucocorticoids vs. those who did not receive glucocorticoids had a similar mortality (15.00% vs. 11.39%, p = 0.591).

CONCLUSIONS

Patients with COVID-19 and diabetes are more likely to experience hyperinflammatory response and T cell reduction, especially those with severe/critical disease. Glucocorticoid use was not associated with the prognosis of COVID-19 in patients with diabetes. Still, glucocorticoids should be used cautiously in diabetic patients with severe/critical COVID-19.

A high-volume study on the impact of diabetes mellitus on clinical outcomes after surgical and percutaneous cardiac interventions

BACKGROUND

Type I and type II diabetes mellitus (DM) patients have a higher prevalence of cardiovascular diseases, as well as a higher mortality risk of cardiovascular diseases and interventions. This study provides an update on the impact of DM on clinical outcomes, including mortality, complications and reinterventions, using data on percutaneous and surgical cardiac interventions in the Netherlands.

METHODS

This is a retrospective, nearby nationwide study using real-world observational data registered by the Netherlands Heart Registration (NHR) between 2015 and 2020. Patients treated for combined or isolated coronary artery disease (CAD) and aortic valve disease (AVD) were studied. Bivariate analyses and multivariate logistic regression models were used to evaluate the association between DM and clinical outcomes both unadjusted and adjusted for baseline characteristics.

RESULTS

241,360 patients underwent the following interventions; percutaneous coronary intervention(N = 177,556), coronary artery bypass grafting(N = 39,069), transcatheter aortic valve implantation(N = 11,819), aortic valve replacement(N = 8,028) and combined CABG and AVR(N = 4,888). The incidence of DM type I and II was 21.1%, 26.7%, 17.8%, 27.6% and 27% respectively. For all procedures, there are statistically significant differences between patients living with and without diabetes, adjusted for baseline characteristics, at the expense of patients with diabetes for 30-days mortality after PCI (OR = 1.68; p <.001); 120-days mortality after CABG (OR = 1.35; p <.001), AVR (OR = 1.5; p <.03) and CABG + AVR (OR = 1.42; p =.02); and 1-year mortality after CABG (OR = 1.43; p <.001), TAVI (OR = 1.21; p =.01) and PCI (OR = 1.68; p <.001).

CONCLUSION

Patients with DM remain to have unfavourable outcomes compared to nondiabetic patients which calls for a critical reappraisal of existing care pathways aimed at diabetic patients within the cardiovascular field.

Comorbidities and use of health services in people with diabetes mellitus according to risk levels by adjusted morbidity groups

BACKGROUND

People with diabetes mellitus frequently have other comorbidities and involve greater use of primary and hospital care services. The aim of this study was to describe the comorbidities and use of primary and hospital care services of people with diabetes according to their risk level by adjusted morbidity groups (AMG) and to analyse the factors associated with the utilisation of these services.

METHODS

Cross-sectional study. People with diabetes were identified within the population of patients with chronic conditions of an urban health care centre by the AMG stratification tool integrated into the primary health care electronic clinical record of the Community of Madrid. Sociodemographic, functional, clinical characteristics and annual health care services utilisation variables were collected. Univariate, bivariate and Poisson regression analyses were performed.

RESULTS

A total of 1,063 people with diabetes were identified, representing 10.8% of patients with chronic conditions within the health centre. A total of 51.4% were female, the mean age was 70 years, 94.4% had multimorbidity. According to their risk level, 17.8% were high-risk, 40.6% were medium-risk and 41.6% were low-risk. The most prevalent comorbidities were hypertension (70%), dyslipidaemia (67%) and obesity (32.4%). Almost 50% were polymedicated. Regarding health services utilisation, 94% were users of primary care, and 59.3% were users of hospital care. Among the main factors associated with the utilisation of both primary and hospital care services were AMG risk level and complexity index. In primary care, utilisation was also associated with the need for primary caregivers, palliative care and comorbidities such as chronic heart failure and polymedication, while in hospital care, utilisation was also associated with comorbidities such as cancer, chronic obstructive pulmonary disease or depression.

CONCLUSIONS

People with diabetes were older, with important needs for care, many associated comorbidities and polypharmacy that increased in parallel with the patient's risk level and complexity. The utilisation of primary and hospital care services was very high, being more frequent in primary care. Health services utilization were principally associated with functional factors related to the need of care and with clinical factors such as AMG medium and high-risk level, more complexity index, some serious comorbidities and polymedication.

Real-World Treatment Patterns Among Patients with Type 2 Diabetes Mellitus Initiating Treatment with Oral Semaglutide

INTRODUCTION

The treatment landscape for type 2 diabetes mellitus (T2DM) is complex and constantly evolving, and real-world evidence of prescribing patterns is limited. The objectives of this study were to characterize lines of therapy (LOTs), calculate the length of time spent on each LOT, and identify the reasons for the LOT end among patients who initiated oral semaglutide for T2DM.

METHODS

This retrospective, claims-based study included commercial and Medicare Advantage adults with T2DM. Data from November 1, 2019, and June 30, 2020, were obtained from Optum Research Database. Patients with ≥ 1 claim for oral semaglutide and continuous health plan enrollment for ≥ 12 months prior to (baseline period) and ≥ 6 months following (follow-up period) the date of the first oral semaglutide claim were included. LOT 1 began on the date of the first oral semaglutide claim. The start date of any subsequent LOTs was the date of the first claim for an additional non-insulin anti-diabetic drug class or a reduction in drug class with use of commitment medications. The LOT ended at the first instance of medication class discontinuation, change in regimen or end of follow-up.

RESULTS

Of the 1937 patients who initiated oral semaglutide, 950 (49.0%) remained on their initial regimen over the 6-month follow-up period, 844 (43.6%) had at least one subsequent LOT, and 89 (4.6%) had at least two subsequent LOTs. Among patients with more than one LOT, approximately 20%-25% used oral semaglutide as monotherapy or combination therapy during LOTs 2 and 3. Metformin was frequently used during treatment across all LOTs.

CONCLUSION

This study provides insight for physicians and payers into the real-world prescribing practices within the first 6 months following oral semaglutide initiation and fills the gap in understanding the frequency of regimen changes in the constantly evolving and complex environment of T2DM care.

Cross-sectional, case-control and longitudinal associations between exposure to glucagon-like peptide-1 receptor agonists and the dispensing of antidepressants

AIM

To determine if the dispensing of glucagon-like peptide (GLP)-1 receptor agonists is associated with increased dispensing of antidepressants.

MATERIALS AND METHODS

We used cross-sectional, case-control and retrospective cohort study designs to examine the association between dispensed GLP-1 receptor agonists and antidepressants between 2012 and 2022 in the 10% random sample of the Australian Pharmaceutical Benefits Scheme (PBS) data. PBS-listed GLP-1 receptor agonists, exenatide, dulaglutide and semaglutide were the exposures. Outcomes were the odds ratio [ORs; 99% confidence interval (CI)] and hazard ratio (99% CI) of being dispensed any antidepressant. Analyses were adjusted for demographic measures and the dispensing of medicines to manage cardiovascular diseases or anxiety/insomnia. Statistical tests were two-sided at the 1% level of significance.

RESULTS

In total, 358 075 of 1 746 391 individuals were dispensed antidepressants, and 8495 of the 24 783 dispensed a GLP-1 receptor agonist were also dispensed an antidepressant in 2022 (OR 1.44; 99% CI 1.38-1.50); 24 103 of the 1 746 391 participants had been dispensed a GLP-1 receptor agonist between 2012 and 2021, and of these 8083 were dispensed antidepressants in 2022 (OR 1.52; 99% CI 1.46-1.59). The 2012 cohort included 1 213 316 individuals who had not been dispensed antidepressants that year. The hazard ratio of being dispensed an antidepressant between 2013 and 2022 following the dispensing of a GLP-1 receptor agonist was 1.19 (99% CI 1.12-1.27). Additional analyses restricting the time of exposure confirmed these associations for all PBS-listed GLP-1 receptor agonists.

CONCLUSIONS

Individuals exposed to GLP-1 receptor agonists are at greater risk of being dispensed antidepressants. The possible impact of GLP-1 receptor agonists on the mood of consumers requires ongoing vigilance and further research.

The Effect of Diabetes on Complications after Spinal Fusion: A Systematic Review and Meta-Analysis

OBJECTIVE

Spinal fusion procedures are used to treat a wide variety of spinal pathologies. Diabetes mellitus (DM) has been shown to be a significant risk factor for several complications following these procedures in previous studies. To the authors' knowledge, this is the first systematic review and meta-analysis elucidating the relationship between DM and complications occurring after spinal fusion procedures.

METHODS

Systematic literature searches of PubMed and EMBASE were performed from their inception to October 1, 2022, to identify studies that directly compared postfusion complications in patients with and without DM. Studies met the prespecified inclusion criteria if they reported the following data for patients with and without DM: (1) demographics; (2) postspinal fusion complication rates; and (3) postoperative clinical outcomes. The included studies were then pooled and analyzed.

RESULTS

Twenty-eight studies, with a cumulative total of 18,853 patients (2695 diabetic patients), were identified that met the inclusion criteria. Analysis showed that diabetic patients had significantly higher rates of total number of postoperative complications (odds ratio [OR] = 1.33; 95% confidence interval [CI] = 1.12-1.58; P = 0.001), postoperative pulmonary complications (OR=2.01; 95%CI=1.31-3.08; P = 0.001), postoperative renal complications (OR=2.20; 95%CI=1.27-3.80; P = 0.005), surgical site infection (OR=2.65; 95%CI=2.19-3.20; P < 0.001), and prolonged hospital stay (OR=1.67; 95%CI=1.47-1.90; P < 0.001).

CONCLUSIONS

Patients with DM had a significantly higher risk of developing complications after spinal fusion, particularly pulmonary and renal complications, in addition to surgical site infections and had a longer length of stay. These findings are important for informed discussions of surgical risks with patients and families before surgery.

A Quantitative Bias Analysis Approach to Informative Presence Bias in Electronic Health Records

Accurate outcome and exposure ascertainment in electronic health record (EHR) data, referred to as EHR phenotyping, relies on the completeness and accuracy of EHR data for each individual. However, some individuals, such as those with a greater comorbidity burden, visit the health care system more frequently and thus have more complete data, compared with others. Ignoring such dependence of exposure and outcome misclassification on visit frequency can bias estimates of associations in EHR analysis. We developed a framework for describing the structure of outcome and exposure misclassification due to informative visit processes in EHR data and assessed the utility of a quantitative bias analysis approach to adjusting for bias induced by informative visit patterns. Using simulations, we found that this method produced unbiased estimates across all informative visit structures, if the phenotype sensitivity and specificity were correctly specified. We applied this method in an example where the association between diabetes and progression-free survival in metastatic breast cancer patients may be subject to informative presence bias. The quantitative bias analysis approach allowed us to evaluate robustness of results to informative presence bias and indicated that findings were unlikely to change across a range of plausible values for phenotype sensitivity and specificity. Researchers using EHR data should carefully consider the informative visit structure reflected in their data and use appropriate approaches such as the quantitative bias analysis approach described here to evaluate robustness of study findings.

Drug Safety Evaluation of Sodium-Glucose Cotransporter 2 Inhibitors in Diabetic Comorbid Patients by Review of Systemic Extraglycemic Effects

Purpose

The aim of this study is to evaluate the safety of this drug in diabetic patients with comorbidities of all systems.

Method

In this review, the beneficial effects of this drug and its mechanism on the disorders of every system of humans in relation to diabetes have been studied, and finally, its adverse effects have also been discussed. The search for relevant information is carried out in the PubMed and Google Scholar databases by using the following terms: diabetes mellitus type 2, SGLT, SGLT2 inhibitors, (SGLT2 inhibitors) AND (Pleiotropic effects). All English-published articles from 2016 to 2023 have been used in this study. It should be noted that a small number of articles published before 2016 have been used in the introduction and general informations.

Results

Its beneficial effects on improving cardiovascular disease risk factors and reducing adverse events caused by cardiovascular and renal diseases have proven in most large clinical studies that these effects are almost certain. It also has beneficial effects on other human systems such as the respiratory system, the gastrointestinal system, the circulatory system, and the nervous system; more of them are at the level of clinical and pre-clinical trials but have not been proven in large clinical trials or meta-analyses.

Conclusion

With the exception of a few adverse effects, this drug is considered a good choice and safe for all diabetic patients with comorbidities of all systems.

A multidisciplinary, shared care clinic using personalized medicine and coordinated care in patients with concomitant type 2 diabetes and cardiovascular disease. Protocol and baseline characteristics

Background

Concomitant type 2 diabetes (T2DM) and cardiovascular disease (CVD) is frequent with a poor prognosis with high risk of comorbidities. Strict risk factor control reduces the risk for complications - yet many people do not achieve treatment targets. The complexity and fragmentation of the healthcare system may, together with the vulnerability of these patients, be a reason.

Objective

The purpose of this paper is to describe the protocol of a non-randomized interventional pilot study testing the feasibility and effect of a multidisciplinary, shared care clinic using personalized medicine and coordinated care in people living with concomitant T2D and CVD.

Methods

Participants were included from the Holbaek area in Denmark. People suffered from T2DM and CVD and were dysregulated regarding to HbA1c, cholesterol, micro/macroalbuminuaria or blood pressure. Participants went through a thorough evaluation to identify their needs and resources and received consultations every three months for one year.

Results

A total of 63 participants with T2DM and CVD were enrolled in the clinic. The participants had a mean age of 69 years and a BMI of 30.9 kg/m2. Almost 50 % had heart failure, 95 % dyslipidemia and 91 % hypertension. Around 54 % received GLP-1 agonists and 39 % received SGLT-2-inhibitors.

Perspectives

To our knowledge, a similar study with a multidisciplinary, shared care, outpatient clinic treating people living with concomitant T2DM and CVD, has not been performed previously. This study will provide information about the feasibility and efficacy of a multidisciplinary clinic based on changes in cardiovascular risk factors and medication.

Prevalence and co-prevalence of comorbidities among patients with type 2 diabetes mellitus living in Puerto Rico

This is a descriptive study using healthcare claims data from patients with T2DM from public and private healthcare insurance companies providing services in Puerto Rico in 2013, aimed to estimate the prevalence of comorbidities in this population. Descriptive analyses were performed by sociodemographic, and type of service variables using frequency and percent for categorical data or means (+/-SD) or median (IQR) for continuous variables. Chi-square, Fisher exact or two-sample t-tests were used for comparisons. A total of 3,100,636 claims were identified from 485,866 adult patients with T2DM. Patients older than 65 years represented 48% of the study population. Most patients were women (57%) and had private health insurance (77%). The regions of Metro Area (17%) and Caguas (16%) had the higher number of persons living with T2DM. The overall estimated prevalence of T2DM was 17.4%. The number of claims per patient ranged from 1 to 339. A mean of 6.3 claims (SD±9.99) and a median of 3 claims (Q1 1- Q3 8) per subject were identified. Of the 3,100,636 claims most (74%) were related to the diagnosis of diabetes (59%) and associated to outpatient services (88%). The most prevalent comorbidities were hypertension (48%), hyperlipidemia (41%), neuropathy (21%); renal disease (15%), and retinopathy (13%). A high prevalence and co-prevalence of comorbidities and use of healthcare services were identified in patients with T2DM, especially in older adults. Since most comorbidities were due to diabetes-related conditions, this analysis highlights the importance of early diagnosis and adequate management of T2DM patients to avoid preventable burden to the patient and to the healthcare system.

Uptake of diabetic retinopathy screening at a secondary level facility in Malawi

Diabetic retinopathy (DR) is a common microvascular complication of long-standing diabetes mellitus (DM). DR screening is a cost-effective intervention for preventing blindness from DR. We conducted a cross-sectional study to investigate the uptake and the predictors of uptake of annual DR screening in an opportunistic DR screening programme at a secondary-level diabetes clinic in Southern Malawi. Consecutive patients were interviewed using a structured questionnaire to record their demographic characteristics, medical details and data regarding; the frequency of clinic visits, knowledge of existence of DR screening services and a history of referral for DR screening in the prior one year. Univariate binary logistic regression was used to investigate predictors of DR screening uptake over the prior one year. Explanatory variables that had a P-value of < 0.1 were included into a multivariate logistic regression model. All variables that had a p-value of <0.05 were considered to be statistically significant. We recruited 230 participants over three months with a median age of 52.5 years (IQR 18-84) and a median duration of diabetes of 4 years (IQR 1-7). The average interval of clinic visits was 1.2 months (SD ± 0.43) and only 59.1% (n = 139) of the participants were aware of the existence of diabetic retinopathy screening services at the facility. The uptake for DR screening over one year was 20% (n = 46). The strongest predictors of uptake on univariate analysis were awareness of the existence of DR screening services (OR 10.05, P <0.001) and a history of being referred for DR screening (OR 9.02, P <0.001) and these remained significant on multivariable analysis. Interventions to improve uptake for DR screening should promote referral of patients for DR screening and strengthen knowledge about the need and availability of DR screening services.

A Payer-Provider Partnership for Endocrine Targeted Automatic eConsults: Implementation and Early Impact on Diabetes and Cost Outcomes

In the United States, many individuals with diabetes mellitus (DM) do not achieve treatment goals despite the availability of effective interventions. Provider clinical inertia is one cause of these unfavorable outcomes. Targeted automatic eConsults (TACos) are an emerging technology-based intervention with potential to address clinical inertia in primary care (PC). TACos prospectively identify at-risk patients and use unsolicited specialist recommendations to prompt treatment intensification. Through a payer-provider collaboration, a TACos intervention was piloted for adults with uncontrolled DM (HbA1c >8%) to understand impact on DM clinical inertia and outcomes. Clinical inertia was assessed by measuring whether a PC provider implemented recommended therapeutic changes. Six-month changes in HbA1c and health care costs per member per month were evaluated using an observational matched design and intention-to-treat (ITT) analysis. The analysis included 196 individuals who received a TACos between February 2021 and August 2021 (ITT group) matched to 392 controls based on clinical and demographic criteria. TACos recommendations were implemented 65% of the time. Median percent change in HbA1c was significantly greater for the ITT group versus controls (-10.9% vs. -10.2%; P = 0.0359). Median total costs were 7.9% lower in the ITT group (P = 0.0900). A per protocol analysis was done to examine effects between ITT group individuals with an implemented TACos recommendation (n = 126) and controls. Median percent change in HbA1c was significantly greater (-19.5% vs. -10.2%; P < 0.0001), but there was no difference in total costs (-7.9%; P = 0.1753). TACos may feasibly address clinical inertia in PC and improve HbA1c for uncontrolled DM.

Healthcare costs of diabetic foot disease in Italy: estimates for event and state costs

OBJECTIVE

This study aimed to estimate healthcare costs of diabetic foot disease (DFD) in a large population-based cohort of people with type-2 diabetes (T2D) in the Tuscany region (Italy).

DATA SOURCES/STUDY SETTING

Administrative healthcare data of Tuscany region, with 2018 as the base year.

STUDY DESIGN

Retrospective study assessing a longitudinal cohort of patients with T2D.

DATA COLLECTION/EXTRACTION METHODS

Using administrative healthcare data, DFD were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes.

METHODS

We examined the annual healthcare costs of these clinical problems in patients with T2D between 2015 and 2018; moreover, we used a generalized linear model to estimate the total healthcare costs.

PRINCIPAL FINDINGS

Between 2015 and 2018, patients with T2D experiencing DFD showed significantly higher average direct costs than patients with T2D without DFD (p < 0.0001). Among patients with T2D experiencing DFD, those who experienced complications either in 2015-2017 and in 2018 incurred the highest incremental costs (incremental cost of € 16,702) followed by those with complications in 2018 only (incremental cost of € 9,536) and from 2015 to 2017 (incremental cost of € 800).

CONCLUSIONS

DFD significantly increase healthcare utilization and costs among patients with TD2. Healthcare costs of DFD among patients with T2D are associated with the timing and frequency of DFD. These findings should increase awareness among policymakers regarding resource reallocation toward preventive strategies among patients with T2D.

Economic burden of type 2 diabetes in Iran: A cost-of-illness study

Background and Aims

Type 2 diabetes mellitus (T2DM) is a prevalent public health problem worldwide, and the economic burden of the disease poses one of the main challenges for health systems in low- and middle-income countries. This study aimed to estimate the economic burden of T2DM in Iran, in 2018.

Methods

This was a cost-of-illness study. Three hundred and seventy-five patients with T2DM who were referred to Imam Reza and Sina's educational and therapeutic centers and Asad Abadi clinic in Tabriz, Iran, in 2018 were included. A researcher-constructed checklist was used for data collection. Data were analyzed using EXCEL and SPSS software version 22.

Results

Total economic burden of diabetes was estimated at 152,443,862,480.3 (purchasing power parity [PPP], Current International $) (approximately 7.69% of GDP, PPP, Current International $). The mean total direct and indirect costs were 11,278.68 (PPP) (62.35% of mean total cost) and 6808.88 (PPP, Current International $) (37.64% of the total cost), respectively. The mean total direct medical cost and the direct nonmedical cost were 10,819.43 (PPP, Current International $) (59.81% of mean total cost) and 459.24 (PPP, Current International $) (2.53% of mean total cost) per patient, respectively. Besides, the mean direct medical cost was 6.18 times the total per capita expenditure on health, and the total direct medical cost was 8.9% times the total expenditure on health.

Conclusion

Diabetes imposes a substantial economic burden on patients, health systems, and the whole economy. Besides, since the cost of the disease in patients treated with insulin and those with diabetes complications is significantly higher, the reinforcement of self-care measures and focusing on modifying lifestyle (dietary modification and physical activity) in patients with T2DM can significantly reduce the costs of the disease.

Metformin adherence and the risk of cardiovascular disease: a population-based cohort study

Background

Metformin is a potent antiglycemic agent, but its importance has receded owing to the launch of novel antidiabetic medications. The benefit of metformin includes not only blood sugar control but also anti-inflammation, autophagy activation, and neuroprotection. This study investigated the risk of cardiovascular disease (CVD) in people with type II diabetes mellitus (T2DM) who adhered to metformin after adding on a second-line antiglycemic agent.

Objectives

The purpose of this study was to investigate the benefits of metformin in CVD prevention in patients with T2DM.

Design

We designed the study by comparing the incident rate of CVD events in patients with T2DM who received metformin continually and who ceased metformin during 2002-2014.

Methods

Medical information was obtained from the National Health Insurance Research Database, and patients with T2DM receiving second-line antiglycemic agents were categorized into metformin-adherent and nonadherent groups according to prescription claims. The study outcomes were the incidence of CVD hospitalization, including stroke (ischemic and hemorrhagic) and myocardial infarction (MI).

Results

A total of 31,384 patients with T2DM constituted the metformin-adherent group and were 1:1 matched to nonadherent patients. Metformin adherence was associated with a lower risk of hospitalization due to stroke [adjusted hazard ratio (aHR) = 0.51, 95% confidence interval (CI): 0.43-0.59, p < 0.001] and MI (aHR = 0.47, 95% CI: 0.43-0.53, p < 0.001). The risk reduction persisted in both ischemic and hemorrhagic strokes. Our subgroup analysis revealed that the protective effect on stroke and MI hospitalization persisted in metformin-adherent patients, both sexes, patients aged ⩽65 or >65 years, and patients with or without concurrent insulin treatment.

Conclusions

This study revealed that metformin adherence in patients with T2DM who required a first-line treatment may reduce the risk of subsequent CVD. Despite the availability of numerous novel antiglycemic agents, metformin adherence by patients who require a combination of antiglycemic agents provides an additional benefit of CVD protection.

Social inequalities between neighborhoods and cardiovascular disease: a multilevel analysis in a Latin American city

Studies analyzing relations between cardiovascular diseases (CVDs) and environmental aspects in Latin American cities are relatively recent and limited, since most of them are conducted in high-income countries, analyzing mortality outcomes, and comprising large areas. This research focuses on adults with diabetes and/or hypertension under clinical follow-up who live in deprived areas. At the individual level we evaluated sociodemographic and cardiovascular risk factors from patient's records, and at the neighborhood level, socioeconomic conditions from census data. A multilevel analysis was carried out to study CVD. More women than men were under clinical follow-up, but men had higher frequency, higher odds, and shorter time to CVD diagnosis. Multilevel analysis showed that residing in neighborhoods with worst socioeconomic conditions leads to higher odds of CVDs, even after controlling for individual variables: OR (CI95%) of CVD in quartile 2 (Q2) 3.9 (1.2-12.1); Q3 4.0 (1.3-12.3); Q4 2.3 (0.7-8.0) (vs. highest socioeconomic level quartile). Among individuals living in unequal contexts, we found differences in CVD, which makes visible inequalities within inequalities. Differences between women and men should be considered through a gender perspective.

Is Metformin Use Associated with Prolonged Overall Survival in Patients with Soft Tissue Sarcoma? A SEER-Medicare Study

BACKGROUND

Metformin, an oral drug used to treat patients with diabetes, has been associated with prolonged survival in patients with various visceral carcinomas. Although the exact mechanisms are unknown, preclinical translational studies demonstrate that metformin may impair tumor cellular metabolism, alter matrix turnover, and suppress oncogenic signaling pathways. Currently used chemotherapeutic agents have not been very successful in the adjuvant setting or for treating patients with metastatic sarcomas. We wanted to know whether metformin might be associated with improved survival in patients with a soft tissue sarcoma.

QUESTIONS/PURPOSES

In patients treated for a soft tissue sarcoma, we asked: (1) Is there an association between metformin use and longer survival? (2) How does this association differ, if at all, among patients with and without the diagnosis of diabetes?

METHODS

The Surveillance, Epidemiology, and End Results-Medicare (SEER-Medicare) database was used to identify patients with a diagnosis of soft tissue sarcoma from 2007 to 2016. Concomitant medication use was identified using National Drug Codes using the Medicare Part D event files. This database was chosen because of the large number of captured sarcoma patients, availability of tumor characteristics, and longitudinal linkage of Medicare data. A total of 14,650 patients were screened for inclusion. Patients with multiple malignancies, diagnosis at autopsy, or discrepant linkage to the Medicare database were excluded. Overall, 4606 patients were eligible for the study: 598 patients taking metformin and 4008 patients not taking metformin. A hazard of mortality (hazard ratio) was analyzed comparing patients taking metformin with those patient groups not taking metformin and expressed in terms of a 95% confidence interval. Cox regression analysis was used to control for patient-specific, disease-specific, and treatment-specific covariates.

RESULTS

Having adjusted for disease-, treatment-, and patient-specific characteristics, patients taking metformin experienced prolonged survival compared with all patients not taking metformin (HR 0.76 [95% CI 0.66 to 0.87]). Associated prolonged survival was also seen when patients taking metformin were compared with those patients not on metformin irrespective of a diabetes diagnosis (HR 0.79 [95% CI 0.66 to 0.94] compared with patients with a diagnosis of diabetes and HR 0.77 [95% CI 0.67 to 0.89] compared with patients who did not have a diagnosis of diabetes).

CONCLUSION

Without suggesting causation, we found that even after controlling for confounding variables such as Charlson comorbidity index, tumor grade, size, stage, and surgical/radiation treatment modalities, there was an association between metformin use and increased survival in patients with soft tissue sarcoma. When considered separately, this association persisted in patients not on metformin with and without a diabetes diagnosis. Although metformin is not normally prescribed to patients who do not have a diabetes diagnosis, these data support further study, and if these findings are substantiated, it might lead to the performance of multicenter, prospective clinical trials about the use of metformin as an adjuvant therapy for the treatment of soft tissue sarcoma in patients with and without a preexisting diabetes diagnosis.

LEVEL OF EVIDENCE

Level III, therapeutic study.

How do individuals with alcohol problems use social and healthcare services in Finland? Comparison of service use patterns between two high-need patient groups

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.

Delineating the Type 2 Diabetes Population in the Netherlands Using an All-Payer Claims Database: Specialist Care, Medication Utilization and Expenditures 2016-2018

OBJECTIVES

The aim of this study was to describe the healthcare utilization and expenditures related to medical specialist care and medication of the entire type 2 diabetes population in the Netherlands in detail.

METHODS

For this retrospective, observational study, we used an all-payer claims database. Comprehensive data on specialist care and medication utilization and expenditures of the type 2 diabetes population (n = 900,522 in 2018) were obtained and analyzed descriptively. Data were analyzed across medical specialties and for various types of diabetes medication (or glucose-lowering drugs [GLDs]) and other medication.

RESULTS

Specialist care utilization was diverse: different medical specialties were visited by a considerable fraction of the type 2 diabetes population. Total expenditures on specialist care were €2498 million in 2018 (i.e., 10.6% of the national specialist care expenditures). In total, 97.8% of patients used other medication (not GLDs) and 81.8% used GLDs; 25.6% of medication expenditures were for GLDs. For both specialist care and medication, mean expenditures per treated patient were higher than median expenditures, indicating a skewed distribution of spending.

CONCLUSION

Use of and expenditures on specialist care and medication of the type 2 diabetes population is diverse. These heterogeneous healthcare use patterns are likely caused by the presence of comorbidities. Additionally, we found that a small fraction of the population is responsible for a large share of the expenditures. A shift towards more patient-centered care could lead to health improvements and a reduction in overall costs, subsequently promoting the sustainability of healthcare systems.

Identifying and delineating the type 2 diabetes population in the Netherlands using an all-payer claims database: characteristics, healthcare utilisation and expenditures

OBJECTIVES

We aimed to identify and delineate the Dutch type 2 diabetes population and the distribution of healthcare utilisation and expenditures across the health system from 2016 to 2018 using an all-payer claims database.

DESIGN

Retrospective observational cohort study based on an all-payer claims database of the Dutch population.

SETTING

The Netherlands.

PARTICIPANTS

The whole Dutch type 2 diabetes population (n=900 522 in 2018), determined based on bundled payment codes for integrated diabetes care and medication use indicating type 2 diabetes.

OUTCOME MEASURES

Annual prevalence of type 2 diabetes, comorbidities and characteristics of the type 2 diabetes population, as well as the distribution of healthcare utilisation and expenditures were analysed descriptively.

RESULTS

In 2018, 900 522 people (6.5% of adults) were identified as having type 2 diabetes. The most common comorbidity in the population was heart disease (12.1%). Additionally, 16.2% and 5.6% of patients received specialised care for microvascular and macrovascular diabetes-related complications, respectively. Most patients with type 2 diabetes received pharmaceutical care (99.1%), medical specialist care (97.0%) and general practitioner consultations (90.5%). In total, €8173 million, 9.4% of total healthcare expenditures, was reimbursed for the type 2 diabetes population. Medical specialist care accounted for the largest share of spending (38.1%), followed by district nursing (12.4%), and pharmaceutical care (11.5%).

CONCLUSIONS

All-payer claims databases can be used to delineate healthcare use: this insight can inform health policy and practice and, thereby, support better decisions to promote long-term sustainability of healthcare systems. The healthcare utilisation of the Dutch type 2 diabetes population is distributed across the health system and utilisation of medical specialist care is high. This is likely to be due to presence of concurrent morbidities and complications. Therefore, a shift from a disease-specific approach to a person-centred and integrated care approach could be beneficial in the treatment of type 2 diabetes.

Correlation between TCM Syndromes and Type 2 Diabetic Comorbidities Based on Fully Connected Neural Network Prediction Model

Objective

To predict the major comorbidities of type 2 diabetes based on the distribution characteristics of syndromes, and to explore the relationship between TCM syndromes and comorbidities of type 2 diabetes.

Methods

Based on the electronic medical record data of 3413 outpatient visits from 995 type 2 diabetes patients with comorbidities, descriptive statistical methods were used to analyze the basic characteristics of the population, the distribution characteristics of comorbidities, and TCM syndromes. A neural network model for the prediction of type 2 diabetic comorbidities based on TCM syndromes was constructed.

Results

Patients with TCM syndrome of blood amassment in the lower jiao were diagnosed with renal insufficiency with 95% test sensitivity. The patients with spleen deficiency combined with ascending counterflow of stomach qi and cold-damp patterns were diagnosed with gastrointestinal lesions with 92% sensitivity. The patients with TCM syndrome group of spleen heat and exuberance of heart fire were diagnosed as type 2 diabetes complicated with hypertension with a sensitivity of 91%. In addition, the prediction accuracy of combined neuropathy, heart disease, liver disease, and lipid metabolism disorder reached 70∼90% in TCM syndrome groups.

Conclusion

The fully connected neural network model study showed that syndrome characteristics are highly correlated with type 2 diabetes comorbidities. Syndrome location is commonly in the heart, spleen, stomach, lower jiao, meridians, etc., while syndrome pattern manifests in states of deficiency, heat, phlegm, and blood stasis. The different combinations of disease location and disease pattern reflect the syndrome characteristics of different comorbidities forming the characteristic syndrome group of each comorbidity. Major comorbidities could be predicted with a high degree of accuracy through TCM syndromes. Findings from this study may have further implementations to assist with the diagnosis, treatment, and prevention of diabetic comorbidities at an early stage.

The underlying mechanisms for severe COVID-19 progression in people with diabetes mellitus: a critical review

Diabetes mellitus (DM) has a high incidence of comorbidities among patients with severe coronavirus disease 2019 (COVID-19). The elevated prevalence of DM in the world population makes it a significant risk factor because diabetic individuals appear to be prone to clinical complications and have increased mortality rates. Here, we review the possible underlying mechanisms involved in DM that led to worse outcomes in COVID-19. The impacts of hyperglycemia side effects, secondary comorbidities, weakened innate and adaptive immunity, chronic inflammation, and poor nutritional status, commonly present in DM, are discussed. The role of the SARS-CoV-2 receptor and its polymorphic variations on higher binding affinity to facilitate viral uptake in people with DM were also considered. Clinical differences between individuals with type 1 DM and type 2 DM affected by COVID-19 and the potential diabetogenic effect of SARS-CoV-2 infection were addressed.

Evaluation of Turkey diabetes self-management education in geriatrics with type 2 diabetes

BACKGROUND

This study was conducted to evaluate the diabetes education efficiency of individuals over 65 years old in Turkey, which has the highest prevalence of diabetes in Europe.

METHODS

We retrospectively evaluated 320 patients who attended Turkey diabetes self-management group education program (TDSMEP) between 2016 and 2020 in a secondary hospital. Participants who have been followed up for a maximum of 9 months are grouped as over 65 years old and under.

RESULTS

Of the 320 patients, 114 formed the geriatric group and 206 the non-geriatric group. After the training, the number of patients who had HbA1c ≤7% increased significantly in both the geriatric (28.1%-45.6%) and non-geriatric (19.9%-42.2%) (p = 0.001) groups. After the training, similar HbA1c goals were achieved in the geriatric and non-geriatric groups. The most significant HbA1c decrease was observed at the 3rd month of follow-up and remained stable until the 9th month. In logistic regression analysis, the factors affecting HbA1c failure (HbA1c >7%) after training in the geriatric group were long diabetes duration (OR = 1.07, 95% CI = 1.02-1.13, p = 0.01), high basal HbA1c levels (OR = 1.31, 95% CI = 1.03-1.67, p = 0.03), and low education level (OR = 3.88, 95% CI = 1.54-9.76, p = 0.001).

CONCLUSIONS

This is the first study to evaluate the effectiveness of TDSMEP for geriatric individuals whose HbA1c ≤7% increased from 28% to 45.6% during follow-up after the training. TDSMEP is recommended for all adult age groups, regardless of age range.

Rates and estimated cost of primary care consultations in people diagnosed with type 2 diabetes and comorbidities: A retrospective analysis of 8.9 million consultations

AIMS

To determine whether telephone and face-to-face primary care consultation rates, costs, and temporal trends during 2000 to 2018 differed by the number of comorbidities in people with type 2 diabetes (T2DM).

METHODS

A total of 120 409 adults with newly diagnosed T2DM between 2000 and 2018 were classified by the number of prevalent and incident comorbidities. Data on face-to-face and telephone primary care consultations with a nurse or physician were obtained. Crude and sex- and age-adjusted annual consultation rates and associated costs were calculated based on the number of comorbidities at the time of consultation.

RESULTS

The crude rate of face-to-face primary care consultations for patients without comorbidities was 10.3 (95% confidence interval [CI] 10.3-10.4) per person-year, 12.7 (95% CI 12.7-12.7) for patients with one comorbidity, 15.1 (95% CI 15.1-15.2) for those with two comorbidities, and 18.7 (95% CI 18.7-18.8) for those with three or more comorbidities. The mean annual inflation-adjusted cost for face-to-face consultations was £412.70 per patient without comorbidities, £516.80 for one comorbidity, £620.75 for two comorbidities, and £778.83 for three or more comorbidities. The age- and sex-adjusted face-to-face consultation rate changed by an average of -3.3% (95% CI -4.4 to -2.3) per year from 2000 to 2018 for patients without comorbidities, -2.7% (95% CI -4.0 to -1.3) for those with one comorbidity, -2.2% (95% CI -3.3 to -1.2) for those with two comorbidities, and -4.3% (95% CI -8.7 to +0.3) for those with three or more comorbidities.

CONCLUSIONS

Although consultation rates for all patients decreased from 2000 to 2018, there was a significant disparity between the rate for patients with and without comorbidities. Patients with T2DM and comorbidities may require different models of service delivery.

Occurrence of comorbidities in newly diagnosed type 2 diabetes patients and their impact after 11 years' follow-up

The burden of type 2 diabetes is growing, not only through increased incidence, but also through its comorbidities. Concordant comorbidities for type 2 diabetes, such as cardiovascular diseases, are considered expected outcomes of the disease or disease complications, while discordant comorbidities are not considered to be directly related to type 2 diabetes and are less extensively addressed under diabetes management. Here we show that the combination of concordant and discordant comorbidities appears frequently in persons with diabetes (75%). Persons with combined comorbidities visited family physicians more than persons with discordant, concordant or no comorbidity (17.3 ± 10.2, 11.6 ± 6.5, 8.7 ± 6.8, 6.3 ± 6.6 visits/person/year respectively, p < 0.0001). The risk of death during the study period was highest in persons with combined comorbidities and discordant only comorbidities (HR = 33.4; 95% CI 12.5–89.2 and HR = 33.5; 95% CI 11.7–95.8), emphasizing the contribution of discordant comorbidities to the outcome. Our study is unique as a long-term follow-up of an 11-year cohort of 9725 persons with new-onset type 2 diabetes. The findings highlight the contribution of discordant comorbidity to the burden of the disease. The high prevalence of the combination of both concordant and discordant comorbidities, and their appearance before the onset of type 2 diabetes, indicates a continuum of morbidity.

Comorbidities and their implications in patients with and without type 2 diabetes mellitus and heart failure with preserved ejection fraction. Findings from the rica registry

AIM

To determine if patients with heart failure and preserved ejection fraction (HFpEF) and type 2 diabetes mellitus (T2DM) have a higher comorbidity burden than those without T2DM, if other comorbidities are preferentially associated with T2DM and if these conditions confer a worse patient prognosis.

METHODS AND RESULTS

Cohort study based on the RICA Spanish Heart Failure Registry, a multicentre, prospective registry that enrols patients admitted for decompensated HF and follows them for 1 year. We selected only patients with HFpEF, classified as having or not having T2DM and performed an agglomerative hierarchical clustering based on variables such as the presence of arrhythmia, chronic obstructive pulmonary disease, dyslipidemia, liver disease, stroke, dementia, body mass index, haemoglobin levels, estimated glomerular filtration rate and systolic blood pressure. A total of 1934 patients were analysed: 907 had T2DM (mean age 78.4 ± 7.6 years) and 1027 did not (mean age 81.4 ± 7.6 years). The analysis resulted in four clusters in patients with T2DM and three in the reminder. All clusters of patients with T2DM showed higher BMI and more kidney disease and anaemia than those without T2DM. Clusters of patients without T2DM had neither significantly better nor worse outcomes. However, among the T2DM patients, clusters 2, 3 and 4 all had significantly poorer outcomes, the worst being cluster 3 (HR 2.0, 95% CI 1.36-2.93, P = .001).

CONCLUSIONS

Grouping our patients with HFpEF and T2DM into clusters based on comorbidities revealed a greater disease burden and prognostic implications associated with the T2DM phenotype, compared with those without T2DM.

The impact of the diabetes management incentive on diabetes-related services: evidence from Ontario, Canada

Financial incentives have been introduced in several countries to improve diabetes management. In Ontario, the most populous province in Canada, a Diabetes Management Incentive (DMI) was introduced to family physicians practicing in patient enrollment models in 2006. This paper examines the impact of the DMI on diabetes-related services provided to individuals with diabetes in Ontario. Longitudinal health administrative data were obtained for adults diagnosed with diabetes and their family physicians. The study population consisted of two groups: DMI group (patients enrolled with a family physician exposed to DMI for 3 years), and comparison group (patients affiliated with a family physician ineligible for DMI throughout the study period). Diabetes-related services was measured using the Diabetic Management Assessment (DMA) billing code claimed by patient's physician. The impact of DMI on diabetes-related services was assessed using difference-in-differences regression models. After adjusting for patient- and physician-level characteristics, patient fixed-effects and patient-specific time trend, we found that DMI increased the probability of having at least one DMA fee code claimed by patient's physician by 9.3% points, and the probability of having at least three DMA fee codes claimed by 2.1% points. Subgroup analyses revealed the impact of DMI was slightly larger in males compared to females. We found that Ontario's DMI was effective in increasing the diabetes-related services provided to patients diagnosed with diabetes in Ontario. Financial incentives for physicians help improve the provision of targeted diabetes-related services.

Costs and its drivers for diabetes mellitus type 2 patients in France and Germany: a systematic review of economic studies

BACKGROUND

Type 2 diabetes represents an increasingly critical challenge for health policy worldwide. It absorbs massive resources from both patients and national economies to sustain direct costs of the treatment of type 2 diabetes and its complications and indirect costs related to work loss and wages. More recently, there are innovations based on remote control and personalised programs that promise a more cost-effective diabetes management while reducing diabetes-related complications. In such a context, this work attempts to update cost analysis reviews on type 2 diabetes, focusing on France and Germany, in order to explore most significant cost drivers and cost-saving opportunities through innovations in diabetes care. Although both countries approach care delivery differently, France and Germany represent the primary European markets for diabetes technologies.

METHODS

A systematic review of the literature listed in MEDLINE, Embase and EconLit has been carried out. It covered interventional, observational and modelling studies on expenditures for type 2 diabetes management in France or Germany published since 2012. Included articles were analysed for annual direct, associated and indirect costs of type 2 diabetes patients. An appraisal of study quality was performed. Results were summarised narratively.

RESULTS

From 1260 records, the final sample was composed of 24 papers selected according to predefined inclusion/exclusion criteria. Both France and Germany revealed a predominant focus on direct costs. Comparability was limited due to different study populations and cost categories used. Indirect costs were only available in Germany. According to prior literature, reported cost drivers are hospitalisation, prescriptions, higher HbA1c and BMI, treatment with insulin and complications, all indicators of disease severity. The diversity of available data and included costs limits the results and may explain the differences found.

CONCLUSIONS

Complication prevention and glycaemic control are widely recognized as the most effective ways to control diabetes treatment costs. The value propositions of self-based supports, such as hybrid closed-loop metabolic systems, already implemented in type 1 diabetes management, are the key points for further debates and policymaking, which should involve the perspectives of caregivers, patients and payers.

Race Disparities in the Use of Prevention, Screening, and Monitoring Services in Michigan Medicare Beneficiaries With Type 2 Diabetes and Combinations of Multiple Chronic Conditions

People with diabetes need routine health care to prevent potential exacerbations of diabetes and detect or prevent the development of additional chronic conditions that can worsen the course of diabetes. Using 2012 Medicare claims data from the State of Michigan for 443,932 beneficiaries with type 2 diabetes, we determined that there are differences between white and racial/ethnic minority people with diabetes in accessing any preventive care and in the amount of service used once they do access care, even after adjusting for the presence of multiple chronic conditions.

Non-Targeted Metabolomic Analysis Reveals Serum Phospholipid Alterations in Patients with Early Stages of Diabetic Foot Ulcer

Diabetic foot ulcer (DFU) is a common complication of type 2 diabetes mellitus (T2DM) characterized by ulcer formation, which can lead to the amputation of lower extremities. However, the metabolic alterations related to this complication are not completely elucidated. Therefore, we carried out a metabolomic analysis of serum samples obtained from T2DM adult patients diagnosed with diabetic foot ulcer in a cross-sectional, observational, and comparative study. Eighty-four volunteers were classified into the following groups: without T2DM (control group, n = 30) and with T2DM and different stages of diabetic foot ulcer according to Wagner-Meggitt classification system: DFU G0 (n = 11), DFU G1 (n = 14), DFU G2 (n = 16), and DFU G3 (n = 13). The non-target metabolomic profile followed by chemometric analysis revealed that lysophosphatidylethanolamine (16:1) could be proposed as key metabolite related to the onset of diabetic foot ulcer; however, this phospholipid was not affected by diabetic foot ulcer progression. Therefore, further studies are necessary to validate these phospholipids as biomarker candidates for the early diagnosis of diabetic foot ulcer in T2DM patients.

Adverse Events and Healthcare Utilization Associated With Outpatient Parenteral Antimicrobial Therapy Among Older Versus Younger Adults

Among older (n = 204) versus younger (n = 253) adults, there was no difference in adverse events (adjusted odds ratio [aOR] = 0.98; 95% confidence interval [CI] = 0.6-1.6) or healthcare utilization (incidence rate ratio = 1.09; 95% CI = 0.9-1.3) within 30 days after discontinuing outpatient parenteral antimicrobial therapy. Vancomycin (aOR = 1.92) and oxacillin (aOR = 3.12) were independently associated with adverse events.

Impacts of doctor-shopping behavior on diabetic patients' health: A retrospective longitudinal study in Taiwan

The aim of this study was to clarify the relationship between doctor-shopping behavior and clinical conditions, and to clearly outline the effects of both the number of clinic visits and the number of doctor changes on patients' health conditions. Data from January 1, 2000 to December 31, 2004 was collected from the National Health Insurance Research Database in Taiwan. After randomly selecting one million people, we extracted 5-year longitudinal data, about the number of clinic visits, number of doctor changes, and changes in self-health status for each patient with diabetes over the age of 18. We developed a relationship among the variables by using the generalized estimating equation. The results revealed that the number of clinic visits on the change of health status is a U curve, suggesting that health condition could be optimal with an appropriate number of clinic visits. The effect of the number of doctor changes is linearly correlated with health deterioration. The results suggest that disease conditions can only be controlled with an adequate number of clinic visits. Excessively frequent clinic visits are not only unfavorable to patients' health status but are also wasteful of limited medical resources. For diabetic mellitus patients, the more they change doctors, the worse their health status. All of these results are important for patients to stay healthy and to save medical resources.

Eleven-year multimorbidity burden among 637 255 people with and without type 2 diabetes: a population-based study using primary care and linked hospitalisation data

OBJECTIVES

To compare the patterns of 18 physical and mental health comorbidities between people with recently diagnosed type 2 diabetes (T2D) and people without diabetes and how these change by age, gender and deprivation over time between 2004 and 2014. Also, to develop a metric to identify most prevalent comorbidities in people with T2D.

DESIGN

Population-based cohort study.

SETTING

Primary and secondary care, England, UK.

PARTICIPANTS

108 588 people with T2D and 528 667 comparators registered in 391 English general practices. Each patient with T2D aged ≥16 years between January 2004 and December 2014 registered in Clinical Practice Research Datalink GOLD practices was matched to up to five comparators without diabetes on age, gender and general practice.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence of 18 physical and mental health comorbidities in people with T2D and comparators categorised by age, gender and deprivation. Odds for association between T2D diagnosis and comorbidities versus comparators. A metric for comorbidities with prevalence of ≥5% and/or odds ≥2 in patients with T2D.

RESULTS

Overall, 77% of patients with T2D had ≥1 comorbidity and all comorbidities were more prevalent in patients with T2D than in comparators. Across both groups, prevalence rates were higher in older people, women and those most socially deprived. Conditional logistic regression models fitted to estimate (OR, 95% CI) for association between T2D diagnosis and comorbidities showed that T2D diagnosis was significantly associated with higher odds for all conditions including myocardial infarction (OR 2.13, 95% CI 1.85 to 2.46); heart failure (OR 2.12, 1.84 to 2.43); depression (OR 1.75, 1.62 to 1.89), but non-significant for cancer (OR 1.12, 0.98 to 1.28). In addition to cardiovascular disease, the metric identified osteoarthritis, hypothyroidism, anxiety, schizophrenia and respiratory conditions as highly prevalent comorbidities in people with T2D.

CONCLUSIONS

T2D diagnosis is associated with higher likelihood of experiencing other physical and mental illnesses. People with T2D are twice as likely to have cardiovascular disease as the general population. The findings highlight highly prevalent and under-reported comorbidities in people with T2D. These findings can inform future research and clinical guidelines and can have important implications on healthcare resource allocation and highlight the need for more holistic clinical care for people with recently diagnosed T2D.

Prevalence and Awareness of Stroke and Other Comorbidities Associated with Diabetes in Northwest India

Objectives  The main purpose of this study is to investigate the prevalence of comorbid conditions in diabetic, prediabetic, and nondiabetic individuals. Additionally, the current study examines the levels of awareness of those comorbidities among North Indian population.

Methods  As a part of a national study (Niyantrit Madhumeh Bharat [NMB] screening program), different comorbidity parameters were screened in the northern part of India between April and September 2017. There were 1,215 participants recruited in this study. Biochemical analyses of hemoglobin A1c (HbA1c) were conducted on the study subjects. Subsequently, the study subjects were divided into diabetic, prediabetic, and nondiabetic groups based on their HbA1c results.

Results  The study analysis reveals a higher prevalence of peripheral vascular disease (21.2%), ocular diseases (18%), and hypertension (13.4%) in diabetics with other comorbidities. Furthermore, the study found that a vast majority of the participants were unaware of the presence of hypertension (67.2%), dyslipidemia (84.5%), kidney disease (95.2%), peripheral vascular disease (34.5%), and stroke (95.1%).

Conclusion  The study concluded that in the northern India, the prevalence of multiple comorbid conditions, such as peripheral vascular disease and hypertension, is higher among diabetic population. Also, the level of awareness of diabetic comorbidities is surprisingly low, which has implications for policymakers, health practitioners, and educators of alternate medicine to increase awareness about diabetes, comorbid conditions, health risk, and possible solution at community and rural level, such as periodic screening programs in this population.

Impact of comorbidity on health-related quality of life among type 2 diabetic patients in primary care

BACKGROUND

Health-related quality of life (HRQL) is an important outcome for chronic diseases such as diabetes mellitus that is associated with complications, comorbidities, and lifelong care.

OBJECTIVES

The present study aims to explore the impact of comorbidities on the different dimensions of HRQL among type 2 diabetic patients attending primary care.

METHODS

A total of 912 type 2 diabetic patients attending primary care centers in India were assessed using a predesigned and pretested questionnaire - Diabetes Comorbidity Evaluation Tool in Primary Care. The HRQL was measured by physical and mental health summary scores [physical component summary (PCS) and mental component summary (MCS)] of the Short Form Health Survey 12. The associations of sociodemographic variables and clinical variables with PCS and MCS were assessed, and a minimal difference of 5 in the scores (on a scale of 0-100) was kept as clinically relevant difference for this study. Mean differences in mental (MCS) and physical (PCS) scores of quality of life by number and type of comorbid conditions in type 2 diabetic patients were calculated.

RESULT

The presence of comorbid conditions was associated with lower scores of PCS and MCS (P < 0.001). Significant reduction in HRQL was found with increase in number of comorbid conditions, and negative association was established between the number of comorbidities and the PCS (r = -0.25, P < 0.0001) and MCS scores (r = -0.21, P < 0.0001). Among comorbidities, acid peptic disease, chronic lung disease, visual impairment, depression, and stroke had significantly and clinically relevant reduced scores. Duration of diabetes, use of insulin, and obesity were also associated with poor HRQL.

CONCLUSION

Comorbidities considerably impair the HRQL among type 2 diabetic patients. National programs designed for diabetes management should also take into account the challenges of coexisting chronic conditions and its substantial effect on HRQL.

Medical Costs of Patients with Type 2 Diabetes in a Single Payer System: A Classification and Regression Tree Analysis

BACKGROUND AND OBJECTIVES

Many studies and systematic reviews have estimated the healthcare costs of diabetes using a cost-of-illness approach. However, in the studies based on this approach patients' heterogeneity is rarely taken into account. The aim of this study was to stratify patients with type 2 diabetes into homogeneous cost groups based on demographic and clinical characteristics.

METHODS

We conducted a retrospective cost-of-illness study by linking individual data on health services utilization retrieved from the administrative databases of Emilia-Romagna Region (Italy). Direct medical costs (either all-cause or diabetes-related) were calculated from the perspective of the regional health service, using tariffs for hospitalizations and outpatient services and the unit costs of prescriptions for drugs. The determinants of costs identified in a generalized linear regression model were used to characterize subgroups of patients with homogeneous costs in a classification and regression tree analysis.

RESULTS

The study population consisted of a cohort of 101,334 patients with type 2 diabetes, followed up for 1 year, with a mean age of 70.9 years. Age, gender, complications, comorbidities and living area accounted significantly for cost variability. The classification tree identified ten patient subgroups with different costs, ranging from a median of €483 to €39,578. The two subgroups with highest costs comprised dialysis patients, and the largest subgroup (57.9%) comprised patients aged ≥ 65 years without renal, cardiovascular and cerebrovascular complications.

CONCLUSIONS

Classification of patients into homogeneous cost subgroups can be used to improve the management of, and budget allocation for, patients with type 2 diabetes.

Comorbidity in patients with type 2 diabetes mellitus and heart failure with preserved ejection fraction. Cluster analysis of the RICA registry. Opportunities for improvement

AIM

The heterogeneity of patients with heart failure and preserved ejection fraction (HFpEF) is high, thusthis entity tends to be grouped into phenotypes to act with precision. Within these groups, patients with type 2 diabetes mellitus (T2DM) hold this heterogeneity. Our aim is to describe subgroups of patients with HFpEF and T2DM based on other comorbidities.

MATERIAL AND METHODS

Patients were recruited from the national registry of heart failure (RCIA). Patients with ejection fraction greater than or equal to 50% without valvular disease and with T2DM were included. A hierarchical agglomerative analysis was performed with Ward's method including the following variables: dyslipidemia, liver disease, Chronic obstructive pulmonary disease (COPD), dementia, cerebrovascular disease, arrhythmia, systolic blood pressure, body mass index (BMI), estimation of glomerular filtration and hemoglobin.

RESULTS

1934 patients with ICFEP were included, of which 907 (46.9%) had T2DM with a predominance of women (60.9%) and with a BMI of 31.1 (5.9) Kg / m2. Four groups were obtained, two with high vascular risk (one with arrhythmia and the other without it) with 263 patients the first and 201 the second. A third group had a predominance of COPD (140 patients) and a last group with 303 patients older but with less comorbidity.

CONCLUSIONS

In our patients with ICFEP and T2DM, obesity and female sex predominated. All four groups offered treatment chances to improve their prognosis not only based on the use of new antidiabetic drugs but also on other options that may be a starting point for further research.

The impact of diabetes on multiple avoidable admissions: a cross-sectional study

BACKGROUND

Multiple admissions for ambulatory care sensitive conditions (ACSC) are responsible for an important proportion of health care expenditures. Diabetes is one of the conditions consensually classified as an ACSC being considered a major public health concern. The aim of this study was to analyse the impact of diabetes on the occurrence of multiple admissions for ACSC.

METHODS

We analysed inpatient data of all public Portuguese NHS hospitals from 2013 to 2015 on multiple admissions for ACSC among adults aged 18 or older. Multiple ACSC users were identified if they had two or more admissions for any ACSC during the period of analysis. Two logistic regression models were computed. A baseline model where a logistic regression was performed to assess the association between multiple admissions and the presence of diabetes, adjusting for age and sex. A full model to test if diabetes had no constant association with multiple admissions by any ACSC across age groups.

RESULTS

Among 301,334 ACSC admissions, 144,209 (47.9%) were classified as multiple admissions and from those, 59,436 had diabetes diagnosis, which corresponded to 23,692 patients. Patients with diabetes were 1.49 times (p < 0,001) more likely to be admitted multiple times for any ACSC than patients without diabetes. Younger adults with diabetes (18-39 years old) were more likely to become multiple users.

CONCLUSION

Diabetes increases the risk of multiple admissions for ACSC, especially in younger adults. Diabetes presence is associated with a higher resource utilization, which highlights the need for the implementation of adequate management of chronic diseases policies.

Analysis of disease comorbidity patterns in a large-scale China population

BACKGROUND

Disease comorbidity is popular and has significant indications for disease progress and management. We aim to detect the general disease comorbidity patterns in Chinese populations using a large-scale clinical data set.

METHODS

We extracted the diseases from a large-scale anonymized data set derived from 8,572,137 inpatients in 453 hospitals across China. We built a Disease Comorbidity Network (DCN) using correlation analysis and detected the topological patterns of disease comorbidity using both complex network and data mining methods. The comorbidity patterns were further validated by shared molecular mechanisms using disease-gene associations and pathways. To predict the disease occurrence during the whole disease progressions, we applied four machine learning methods to model the disease trajectories of patients.

RESULTS

We obtained the DCN with 5702 nodes and 258,535 edges, which shows a power law distribution of the degree and weight. It further indicated that there exists high heterogeneity of comorbidities for different diseases and we found that the DCN is a hierarchical modular network with community structures, which have both homogeneous and heterogeneous disease categories. Furthermore, adhering to the previous work from US and Europe populations, we found that the disease comorbidities have their shared underlying molecular mechanisms. Furthermore, take hypertension and psychiatric disease as instance, we used four classification methods to predicte the disease occurrence using the comorbid disease trajectories and obtained acceptable performance, in which in particular, random forest obtained an overall best performance (with F1-score 0.6689 for hypertension and 0.6802 for psychiatric disease).

CONCLUSIONS

Our study indicates that disease comorbidity is significant and valuable to understand the disease incidences and their interactions in real-world populations, which will provide important insights for detection of the patterns of disease classification, diagnosis and prognosis.

Prediction of Disease Comorbidity Using HeteSim Scores based on Multiple Heterogeneous Networks

Background:

Accumulating experimental studies have indicated that disease comorbidity causes additional pain to patients and leads to the failure of standard treatments compared to patients who have a single disease. Therefore, accurate prediction of potential comorbidity is essential to design more efficient treatment strategies. However, only a few disease comorbidities have been discovered in the clinic.

Objective:

In this work, we propose PCHS, an effective computational method for predicting disease comorbidity.

Materials and Methods:

We utilized the HeteSim measure to calculate the relatedness score for different disease pairs in the global heterogeneous network, which integrates six networks based on biological information, including disease-disease associations, drug-drug interactions, protein-protein interactions and associations among them. We built the prediction model using the Support Vector Machine (SVM) based on the HeteSim scores.

Results and Conclusion:

The results showed that PCHS performed significantly better than previous state-of-the-art approaches and achieved an AUC score of 0.90 in 10-fold cross-validation. Furthermore, some of our predictions have been verified in literatures, indicating the effectiveness of our method.

Implications of multimorbidity patterns on health care utilisation and quality of life in middle-income countries: cross-sectional analysis

Background

Past studies have demonstrated how single non-communicable diseases (NCDs) affect health care utilisation and quality of life (QoL), but not how different NCD combinations interact to affect these. Our study aims to investigate the prevalence of NCD dyad and triad combinations, and the implications of different NCD dyad combinations on health care utilisation and QoL.

Methods

Our study utilised cross-sectional data from the WHO SAGE study to examine the most prevalent NCD combinations in six large middle-income countries (MICs). Subjects were mostly aged 50 years and above, with a smaller proportion aged 18 to 49 years. Multivariable linear regression was applied to investigate which NCD dyads increased or decreased health care utilisation and QoL, compared with subjects with only one NCD.

Results

The study included 41 557 subjects. Most prevalent NCD combinations differed by subgroups, including age, gender, income, and residence (urban vs rural). Diabetes, stroke, and depression had the largest effect on increasing mean number of outpatient visits, increasing mean number of hospitalisation days, and decreasing mean QoL scores, respectively. Out of the 36 NCD dyads in our study, thirteen, four, and five dyad combinations were associated with higher or lower mean number of outpatient visits, mean number of hospitalisations, or mean QoL scores, respectively, compared with treating separate patients with one NCD each. Dyads of depression were associated with fewer mean outpatient visits, more hospitalisations, and lower mean QoL scores, compared to patients with one NCD. Dyads of hypertension and diabetes were also associated with a reduced mean number of outpatient visits.

Conclusions

Certain NCD combinations increase or decrease health care utilisation and QoL substantially more than treating separate patients with one NCD each. Health systems should consider the needs of patients with different multimorbidity patterns to effectively respond to the demands on health care utilisation and to mitigate adverse effects on QoL.

Patient-Physician Agreement in Reporting and Prioritizing Existing Chronic Conditions

PURPOSE

In this study, we aimed to assess (1) the agreement between patient self-reports and general practitioner (GP) reports of the chronic conditions affecting the patients and (2) the agreement between patients and GPs on health priorities in a primary care setting.

METHOD

Patients were recruited in the Parisian area of France by a convenience sample of GPs; eligibility criteria required that the GP was the patient's listed primary care provider for at least 12 months. Participants were asked to report all the patient's current chronic conditions by using a previously developed list of 124 chronic conditions and write a list of up to 3 priority conditions.

RESULTS

From April to May 2017, 233 patients were recruited from 16 GP practices. Agreement between the number of conditions reported by patients and by GPs was moderate (intraclass correlation coefficient 0.59, 95% CI, 0.50 to 0.69). Agreement between patient self-reports and GP reports of each chronic condition ranged from very good (eg, κ = 0.85 for hypothyroidism) to poor (eg, κ = 0.12 for chronic anxiety disorder). Among the 153 patient-GP pairs for which both the patient and GP wrote a priority list, 45 (29.4%) of patients' first priorities did not appear anywhere on the corresponding GPs' lists, and 19 (12.4%) pairs had no matching priority condition.

CONCLUSIONS

Agreement between patients and their GPs varied widely depending on the diseases reported. Low agreement on health priorities suggests a need for improvement to ensure better alignment between patient and physician perspectives.

How are medication related problems managed in primary care? An exploratory study in patients with diabetes and primary care providers

BACKGROUND

Medication self-management is important for patients who are controlling diabetes. Achieving medication self-management goals, may depend on treatment complexity and patients' capacities such as health literacy, knowledge and attitude.

OBJECTIVES

The aims of this study were to explore how patients with diabetes self-manage their medications, how patients seek support when experiencing problems and how primary healthcare providers identify patients' medication related problems and provide support.

METHODS

Semi-structured interviews were conducted among patients with diabetes receiving primary care and with their primary healthcare providers - GPs, nurses, pharmacists and technicians - between January and June 2017. A purposive sampling strategy was used to identify and select participants. An interview guide based on the Cycle of Complexity model was developed. Interviews were audiotaped and transcribed verbatim. Transcripts were coded with a combination of deductive and inductive codes. A thematic analysis was performed to identify categories and themes in the data. Findings were compared with the Cycle of Complexity model.

RESULTS

Twelve patients and 27 healthcare providers were included in the study. From the transcripts 95 codes, 6 categories and 2 major themes were extracted. Patients used practical solutions and gaining knowledge to manage their medication. Their problems were often related to stress and concerns about using medications. A trusted relationship with the healthcare provider was essential for patients to share problems and ask for support. Informal support was sought from family and peer-patients. Healthcare providers perceive problem identification as challenging. They relied on patients coming forward, computer notifications, clinical parameters and gut-feeling. Healthcare providers were able to offer appropriate support if a medication management problem was known.

CONCLUSION

Patients are confident of finding their way to manage their medications. However, sharing problems with healthcare providers requires a trusted relationship. This is acknowledged by both patients and healthcare providers.

The comorbidity burden of type 2 diabetes mellitus: patterns, clusters and predictions from a large English primary care cohort

BACKGROUND

The presence of additional chronic conditions has a significant impact on the treatment and management of type 2 diabetes (T2DM). Little is known about the patterns of comorbidities in this population. The aims of this study are to quantify comorbidity patterns in people with T2DM, to estimate the prevalence of six chronic conditions in 2027 and to identify clusters of similar conditions.

METHODS

We used the Clinical Practice Research Datalink (CPRD) linked with the Index of Multiple Deprivation (IMD) data to identify patients diagnosed with T2DM between 2007 and 2017. 102,394 people met the study inclusion criteria. We calculated the crude and age-standardised prevalence of 18 chronic conditions present at and after the T2DM diagnosis. We analysed longitudinally the 6 most common conditions and forecasted their prevalence in 2027 using linear regression. We used agglomerative hierarchical clustering to identify comorbidity clusters. These analyses were repeated on subgroups stratified by gender and deprivation.

RESULTS

More people living in the most deprived areas had ≥ 1 comorbidities present at the time of diagnosis (72% of females; 64% of males) compared to the most affluent areas (67% of females; 59% of males). Depression prevalence increased in all strata and was more common in the most deprived areas. Depression was predicted to affect 33% of females and 15% of males diagnosed with T2DM in 2027. Moderate clustering tendencies were observed, with concordant conditions grouped together and some variations between groups of different demographics.

CONCLUSIONS

Comorbidities are common in this population, and high between-patient variability in comorbidity patterns emphasises the need for patient-centred healthcare. Mental health is a growing concern, and there is a need for interventions that target both physical and mental health in this population.

Prevalence of diabetes mellitus in Spanish primary care setting and its association with cardiovascular risk factors and cardiovascular diseases. SIMETAP-DM study

INTRODUCTION

The aims of this study were to determine the age- and sex-adjusted prevalence rates of DM, type-1 DM (T1DM), and type-2 DM (T2DM), and to compare the relationship with cardiovascular risk factors, cardiovascular diseases, chronic kidney disease, and metabolic diseases between populations with and without DM.

METHODS

SIMETAP-DM is a cross-sectional observational study conducted in a Primary Care setting with a random population-based sample of 10,579 adults. Response rate: 66%. The diagnoses of DM, T1DM and T2DM were based on clinical and biochemical criteria and/or the checking of these diagnoses in the medical records. The crude and age- and sex-adjusted (standardised for Spanish population) prevalence rates were calculated.

RESULTS

The crude prevalence rates of T1DM, T2DM, and DM were 0.87% (95% confidence interval [95% CI]: 0.67-1.13), 14.7% (95% CI: 13.9-15.6), and 15.6% (95% CI: 14.7-16.5), respectively. The age- and sex-adjusted prevalence rates of T1DM, T2DM, and DM were 1.0% (1.3% for men and 0.7% for women), 11.5% (13.6% for men and 9.7% for women), and 12.5% (14.9% for men and 10.5% for women), respectively. The prevalence of DM in the population≥70 years was double (30.3% [95% CI: 28.0-32.7]) that of the population between 40 and 69 years (15.3% [95% CI: 14.1-16.5]). Hypertension, peripheral arterial disease, increased waist-to-height ratio, albuminuria, coronary heart disease, atherogenic dyslipidaemia and hypercholesterolaemia were associated with DM.

CONCLUSIONS

In a Spanish primary care setting, the age-adjusted prevalences of T1DM, T2DM and DM in the adult population were 1.0, 11.5, and 12.5%, respectively. One-third (33%) of the population over 70 years had DM.

Association between area-level socioeconomic status, accessibility and diabetes-related hospitalisations: a cross-sectional analysis of data from Western Victoria, Australia

OBJECTIVE

Hospitalisation rates for many chronic conditions are higher in socioeconomically disadvantaged and less accessible areas. We aimed to map diabetes hospitalisation rates by local government area (LGA) across Western Victoria, Australia, and investigate their association with socioeconomic status (SES) and accessibility/remoteness.

DESIGN

Cross-sectional study METHODS: Data were acquired from the Victorian Admitted Episodes Dataset for all hospitalisations (public and private) with a diagnosis of type 1 or type 2 diabetes mellitus during 2011-2014. Crude and age-standardised hospitalisation rates (per 1000 population per year) were calculated by LGA for men, women and combined data. Associations between accessibility (Accessibility/Remoteness Index of Australia, ARIA), SES (Index of Relative Socioeconomic Advantage and Disadvantage, IRSAD) and diabetes hospitalisation were investigated using Poisson regression analyses.

RESULTS

Higher LGA-level accessibility and SES were associated with higher rates of type 1 and type 2 diabetes hospitalisation, overall and for each sex. For type 1 diabetes, higher accessibility (ARIA category) was associated with higher hospitalisation rates (men incidence rate ratio [IRR]=2.14, 95% CI 1.64 to 2.80; women IRR=2.45, 95% CI 1.87 to 3.19; combined IRR=2.30, 95% CI 1.69 to 3.13; all p<0.05). Higher socioeconomic advantage (IRSAD decile) was also associated with higher hospitalisation rates (men IRR=1.25, 95% CI 1.09 to 1.43; women IRR=1.32, 95% CI 1.16 to 1.51; combined IRR=1.23, 95% CI 1.07 to 1.42; all p<0.05). Similarly, for type 2 diabetes, higher accessibility (ARIA category) was associated with higher hospitalisation rates (men IRR=2.49, 95% CI 1.81 to 3.43; women IRR=2.34, 95% CI 1.69 to 3.25; combined IRR=2.32, 95% CI 1.66 to 3.25; all p<0.05) and higher socioeconomic advantage (IRSAD decile) was also associated with higher hospitalisation rates (men IRR=1.15, 95% CI 1.02 to 1.30; women IRR=1.14, 95% CI 1.01 to 1.28; combined IRR=1.13, 95% CI 1.00 to 1.27; all p<0.05).

CONCLUSION

Our observations could indicate self-motivated treatment seeking, and better specialist and hospital services availability in the advantaged and accessible areas in the study region. The determinants for such variations in hospitalisation rates, however, are multifaceted and warrant further research.