Additional impact of concomitant hypertension and osteoarthritis on quality of life among patients with type 2 diabetes in primary care in Germany - a cross-sectional survey

Periodontitis assessed with a new screening tool and oral health-related quality of life: cross-sectional findings among general-population adults

INTRODUCTION

Periodontitis, as a chronic, multifactorial inflammatory disease, has complex relationships with other diseases and ultimately with well-being. The aim of this cross-sectional study was to investigate the association between self-report periodontitis, as measured with the recently developed and validated modified Periodontal Screening Score (mPESS), and oral health-related quality of life (OHRQol) in a large population-based sample derived from the French NutriNet-Santé e-cohort.

METHODS

The sample was composed of 32,714 adults (75.5% women) with a mean age of 48.8 ± 13.9 years. Periodontitis was assessed based on age, smoking, and oral health status data obtained in 2011-2012, which allowed calculating the mPESS. An mPESS ≥ 5 was used to identify individuals at risk of severe periodontitis (main exposure). OHRQoL was measured with the Oral Health Impact Profile (OHIP-14) (main outcome) and the total score was dichotomized for analysis. Multivariable logistic regression analyses, considering physical health status, dietary and lifestyle confounding variables, were performed.

RESULTS

Overall, 6407 participants (19.6%) were at a high risk of severe periodontitis. A total of 7383 participants (22.6%) presented a relatively poor OHRQoL (OHIP-14 > 8, highest quartile). In the multivariable model, each of the following variables was independently and significantly associated with lower OHRQoL: older age (50-64 years), female sex, obesity, snacking between meals, frequent consumption of soft drinks and sweets/chocolate, risk of severe periodontitis, and having < 20 natural teeth were significantly. An mPESS ≥ 5 showed the highest odds for relatively poor OHRQoL (OR = 3.45; 95% CI 3.21-3.72).

CONCLUSION

The results support the association between periodontitis and OHRQoL in non-clinical samples. The use of mPESS could be tested in future prevention programs aiming at improving OHRQoL.

Prevalence of Upper Extremity Musculoskeletal Disorders in Patients with Type 2 Diabetes in General Practice

Background: One of the lesser recognized complications of diabetes mellitus are musculoskeletal (MSK) complications of the upper and lower extremity. No prevalence studies have been conducted in general practice. Thus, the aim of this study was to investigate the prevalence of upper extremity MSK disorders in patients with type 2 diabetes (T2DM) in the Netherlands. Methods: We conducted a cross-sectional study with two different approaches, namely a representative Dutch primary care medical database study and a questionnaire study among patients with T2DM. Results: In the database study, 2669 patients with T2DM and 2669 non-diabetes patients were included. MSK disorders were observed in 16.3% of patients with T2DM compared to 11.2% of non-diabetes patients (p < 0.001, OR 1.53, 95% CI 1.31, 1.80). In the questionnaire study, 200 patients with T2DM were included who reported a lifetime prevalence of painful upper extremity body sites for at least four weeks of 67.3%. Conclusion: We found that upper extremity MSK disorders have a high prevalence in Dutch patients with T2DM presenting in general practice. The prevalence ranges from 16% based on GP registered disorders and complaints to 67% based on self-reported diagnosis and pain. Early detection and treatment of these disorders may play a role in preventing the development of chronic MSK disorders.

What Is the Diagnosis in Patients with Type 2 Diabetes Who Have a Painful Shoulder? Results from a Prospective Cross-Sectional Study

Background: Patients with diabetes mellitus have higher risk of developing shoulder pathology. However, only adhesive capsulitis is addressed in shoulder pain guidelines as a disorder associated with diabetes. Yet, patients with diabetes are at risk of having several other shoulder disorders, including focal neuropathy. Our aim was to quantify the presence of shoulder disorders using physical examination and ultrasound imaging in patients with type 2 diabetes (T2DM) suffering from shoulder pain in general practice. Methods: In this prospective cross-sectional study, patients with T2DM who had had a painful shoulder for at least four weeks were included. Patients filled out a questionnaire and underwent a physical examination of the shoulders and feet and ultrasound imaging of the shoulder. Results: A total of 66 patients were included, of whom 40.9% (n = 27) had bilateral complaints resulting in 93 symptomatic shoulders. Subacromial pain syndrome was most frequently diagnosed by physical examination (66.6%, 95% CI 51.6–72.0%; p < 0.0001), while ultrasound imaging showed that subacromial disorders were statistically significantly the most prevalent (90.3%, 95% CI 81.9–95.2%). Only two patients (3%) were diagnosed with neuropathic shoulder pain. Conclusion: When choosing treatment, general practitioners should be aware that in patients with T2DM the subacromial region is most frequently affected.

Geospatial patterns of comorbidity prevalence among people with osteoarthritis in Alberta Canada

BACKGROUND

Knowledge of geospatial pattern in comorbidities prevalence is critical to an understanding of the local health needs among people with osteoarthritis (OA). It provides valuable information for targeting optimal OA treatment and management at the local level. However, there is, at present, limited evidence about the geospatial pattern of comorbidity prevalence in Alberta, Canada.

METHODS

Five administrative health datasets were linked to identify OA cases and comorbidities using validated case definitions. We explored the geospatial pattern in comorbidity prevalence at two standard geographic areas levels defined by the Alberta Health Services: descriptive analysis at rural-urban continuum level; spatial analysis (global Moran's I, hot spot analysis, cluster and outlier analysis) at the local geographic area (LGA) level. We compared area-level indicators in comorbidities hotspots to those in the rest of Alberta (non-hotspots).

RESULTS

Among 359,638 OA cases in 2013, approximately 60% of people resided in Metro and Urban areas, compared to 2% in Rural Remote areas. All comorbidity groups exhibited statistically significant spatial autocorrelation (hypertension: Moran's I index 0.24, z score 4.61). Comorbidity hotspots, except depression, were located primarily in Rural and Rural Remote areas. Depression was more prevalent in Metro (Edmonton-Abbottsfield: 194 cases per 1000 population, 95%CI 192-195) and Urban LGAs (Lethbridge-North: 169, 95%CI 168-171) compared to Rural areas (Fox Creek: 65, 95%CI 63-68). Comorbidities hotspots included a higher percentage of First Nations or Inuit people. People with OA living in hotspots had lower socioeconomic status and less access to care compared to non-hotspots.

CONCLUSIONS

The findings highlight notable rural-urban disparities in comorbidities prevalence among people with OA in Alberta, Canada. Our study provides valuable evidence for policy and decision makers to design programs that ensure patients with OA receive optimal health management tailored to their local needs and a reduction in current OA health disparities.

Health-related quality of life and health utilities in insulin-treated type 2 diabetes: the impact of related comorbidities/complications

OBJECTIVE

To evaluate the impact of multiple comorbidities/complications on health-related quality of life (HRQoL) and health utilities in insulin-treated type 2 diabetes (T2DM).

METHODS

In a non-interventional, epidemiological study, data were collected from medical records and via interviews for 938 subjects from various geographical areas of Greece. HRQoL and health utilities were explored with the EQ-5D-5L. Univariate associations were evaluated with the Mann-Whitney and Kruskal-Wallis tests for continuous and Chi-squared tests for nominal variables, and binary logistic regressions were employed to obtain marginal effects. Employing a split sample approach, various specifications of ordinary least squares regression models were evaluated in terms of goodness of fit, model specification, shrinkage and predictive and discriminative performance, to select the best model for mapping health utilities using the whole dataset.

RESULTS

Overall, the most important factors of impaired HRQoL and health utilities were higher age, female gender, obesity, poor glycemic control and increased duration of insulin treatment. History and increasing concurrence of all complications assessed were associated with exacerbated HRQoL problems, decreased health utilities and diminished health state, although it was not always statistically significant. The highest disutilities were associated with stroke (- 0.082), diabetic retinopathy (- 0.066), diabetic neuropathy (- 0.051) and severe hypoglycemia (- 0.050).

CONCLUSIONS

The deleterious impact of comorbidities on insulin-dependent T2DM subjects' HRQoL has been confirmed and clinicians should adapt the priorities of disease management accordingly. The derived health utility estimates may be valuable for conducting economic evaluations of interventions in the area of T2DM when data are not available.

Trend of the burden of chronic illnesses: using the Canadian Community Health Survey

OBJECTIVES

Burden of illnesses has been described in the literature using the health-related quality of life (HRQoL) in people with chronic conditions. However, the studies reporting trends of burden are sparse. The aim of this study was to explore the trends of burden of chronic illness from the perspective of HRQoL.

STUDY DESIGN

This was a secondary analysis of administrative database.

METHODS

Seven data sets of the Canadian Community Health Survey from 2001 to 2014 were obtained for the analysis. Multiple linear and logistic regression models were used on each data set to assess the burden of illness on the Health Utilities Index Mark III (HUI₃), life satisfaction (LS), and perceived health (PH).

RESULTS

People with the effect of stroke constantly had low scores on the HUI₃, LS, and PH. Regression analyses revealed that arthritis, back problem, and mood disorder have greater impact on the HUI₃ score. Effect of stroke, mood disorder, and anxiety disorder stably had the largest negative impact on LS, while chronic obstructive pulmonary disease (COPD), effect of stroke, and cancer had the largest effect on PH.

CONCLUSION

This study identified that arthritis, back pain, mood disorder, effect of stroke, and COPD constantly have high burden on health outcomes compared with other chronic condition over the past decade.

Insights on multimorbidity and associated health service use and costs from three population-based studies of older adults in Ontario with diabetes, dementia and stroke

Background

Most studies that examine comorbidity and its impact on health service utilization focus on a single index-condition and are published in disease-specific journals, which limit opportunities to identify patterns across conditions/disciplines. These comparisons are further complicated by the impact of using different study designs, multimorbidity definitions and data sources. The aim of this paper is to share insights on multimorbidity and associated health services use and costs by reflecting on the common patterns across 3 parallel studies in distinct disease cohorts (diabetes, dementia, and stroke) that used the same study design and were conducted in the same health jurisdiction over the same time period.

Methods

We present findings that lend to broader Insights regarding multimorbidity based on the relationship between comorbidity and health service use and costs seen across three distinct disease cohorts. These cohorts were originally created using multiple linked administrative databases to identify community-dwelling residents of Ontario, Canada with one of diabetes, dementia, or stroke in 2008 and each was followed for health service use and associated costs.

Results

We identified 376,434 indviduals wtih diabetes, 95,399 wtih dementia, and 29,671 with stroke. Four broad insights were identified from considering the similarity in comorbidity, utilization and cost patterns across the three cohorts: 1) the most prevalent comorbidity types were hypertension and arthritis, which accounted for over 75% of comorbidity in each cohort; 2) overall utilization increased consistently with the number of comorbidities, with the vast majority of services attributed to comorbidity rather than the index conditions; 3) the biggest driver of costs for those with lower levels of comorbidity was community-based care, e.g., home care, GP visits, but at higher levels of comorbidity the driver was acute care services; 4) service-specific comorbidity and age patterns were consistent across the three cohorts.

Conclusions

Despite the differences in population demographics and prevalence of the three index conditions, there are common patterns with respect to comorbidity, utilization, and costs. These common patterns may illustrate underlying needs of people with multimorbidity that are often obscured in literature that is still single disease-focused.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4149-3) contains supplementary material, which is available to authorized users.

Knee Osteoarthritis and Risk of Hypertension: A Longitudinal Cohort Study

Although previous research has indicated an association between osteoarthritis (OA) and cardiovascular disease, it remains unclear whether people with OA are at greater risk of developing hypertension. The aim of this study was to answer this uncertainity. We used the data of the Osteoarthritis Initiative, an ongoing public and private longitudinal study including people at higher risk of OA or having knee OA. Knee OA was defined through radiological and clinical assessment. Incident hypertension was defined as a systolic blood pressure ≥140 mmHg and/or a diastolic value ≥90 mmHg. Multivariate Cox's regression analyses were constructed considering the presence of knee OA as the exposure and incident hypertension as the outcome during a 96-month follow-up interval. A total of 3558 people with normative blood pressure values at baseline were analyzed (1930 OA/1628 controls). Incidence of hypertension within the follow-up interval was significantly higher in people with knee OA than in those without (60/[1000 person-years] vs. 55/[1000 person-years]; p < 0.0001). After adjusting for 13 confounders, people with knee OA had a 13% higher chance of developing hypertension (hazard ratio = 1.13; 95% confidence interval: 1.01-1.26; p = 0.03). Propensity score analysis did not alter these conclusions. In conclusion, this is the first longitudinal data analysis to demonstrate that people with knee OA have a higher chance of developing hypertension than those without OA. Our data suggest that monitoring blood pressure and prescribing health promotion interventions may be warranted among people with OA to mitigate the potential onset and adverse consequences of hypertension.

Systematic review of the impact of osteoarthritis on health outcomes for comorbid disease in older people

OBJECTIVE

A systematic review was undertaken examining the impact of comorbid osteoarthritis on health outcomes for people aged 50 years or older with cardiovascular disease, diabetes or obesity.

DESIGN

The protocol is registered in PROSPERO (CRD42015023417). Relevant electronic databases and grey literature were systematically searched for studies published in English between January 2005 and December 2016. Two reviewers independently screened studies for selection using predetermined inclusion and exclusion criteria, and independently completed methodological quality review. Data was extracted at study level by one reviewer and independently checked by a second reviewer, using a standardized form. The results across studies were qualitatively synthesized with outcomes described and summarized.

RESULTS

Of 1456 articles, we identified 15 relevant studies, with nine good to high quality studies describing significant negative impact of osteoarthritis on outcomes for cardiovascular diseases. There were too few studies focussing on diabetes and obesity to make conclusions in regard to these diseases.

CONCLUSIONS

This review provides evidence that osteoarthritis should not be overlooked when impacts of chronic disease on health outcomes and related health service use are considered. There is a clear need for more studies that consider the impacts of osteoarthritis on comorbid disease, especially those that consider the impact of osteoarthritis beyond the morbidity impacts. The management of comorbid osteoarthritis should be addressed for those with cardiovascular disease, and treatment choices considered given this association.

Effective factors in controlling diabetes progression among patients in the northwest of Iran

Background:

Diabetes is the fifth leading cause of death in the world. Hence, we investigated the factors affecting disease control among diabetic patients referred to Imam Reza Hospital (central hospital in the Northwest of Iran).

Materials and Methods:

One hundred and eight diabetic patients were evaluated. Patient's main medications including insulin, metformin, glibenclamide, and glytazon were registered and the levels of fasting blood sugar (FBS), glucose 2 h postprandial (pp), and hemoglobin A1c (HbA1c) were measured. All risk factors were evaluated by using a questionnaire completed by the patients.

Results:

The average of HbA1c, FBS, and glucose 2 h pp was 7.33%, 159 mg/dl, and 233.03 mg/dl, respectively. In patients whose disease was controlled, the family history of the disease, the type of medication, and the visits to family physician had a significant association with disease control. The average mean of HbA1c among patients with controlled and uncontrolled disease was 5.93% and 8.63 % respectively.

Conclusion:

Less stress, education, and weekly exercise had an essential role in controlling the disease in diabetic patients from the Northwest of Iran and noncompliance with the prescribed diet by the physician and lack of timely medicine intake were the main reasons for uncontrolled disease.

Impaired quality of life in systemic sclerosis and patient perception of the disease: A large international survey

OBJECTIVES

The purpose of this study was to assess health-related quality of life (HRQoL) and disease perception in a large, international group of patients with systemic sclerosis (SSc).

METHODS

We placed a standardized questionnaire on a website for patient access. Socio-demographic information, disease characteristics, and self-assessment questionnaires-the Short Form 36 (SF-36) and the Revised Illness Perception Questionnaire (IPQ-R)-were collected.

RESULTS

A total of 1902 patients from 60 countries were included. HRQoL appeared to be impaired in SSc, particularly for physical health (PCS, mean ± SD = 43.4 ± 23.4). SSc patients also had strong perceptions about the chronic nature and negative consequence of the disease, and experienced negative emotions due to SSc. Patients with diffuse cutaneous SSc had a poorer HRQoL than those with limited cutaneous SSc, for both physical (PCS, mean ± SD = 46.6 ± 23.7 vs. 39.8 ± 22.3; p < 0.0001) and mental components (MCS, mean ± SD = 53.8 ± 23.0 vs. 50.3 ± 23.2; p = 0.003). Late-stage SSc patients were more likely to perceive their disease chronic (p < 0.0001), less controllable (p = 0.03) and with more consequences (p = 0.008), but they had a better understanding of their disease and experienced fewer negative emotions. Raynaud's phenomenon and gastrointestinal complications were the organ involvements with the greatest impact on QoL, they were the two variables associated with the most negative perception of illness severity.

CONCLUSION

This study, performed on the largest group ever set up for this purpose, confirms the major impact on QoL and the negative perceptions of their disease expressed by SSc patients. However, the perception of this illness tended to improve with disease duration, suggesting that patients find effective coping strategies.

Association between diabetes mellitus and osteoarthritis: systematic literature review and meta-analysis

Objectives

To investigate the prevalence of osteoarthritis (OA) in patients with diabetes mellitus (DM) and prevalence of DM in patients with OA and whether OA and DM are associated.

Design

A systematic literature review and meta-analysis. We included cohort, case–control and cross-sectional studies assessing the number of patients with DM and/or OA. The mean prevalence of OA among patients with DM and DM among patients with OA was calculated. Data from trials assessing an association of diabetes and OA were pooled and results are presented as unadjusted OR and 95% CI.

Results

From the 299 publications, we included 49 studies in the analysis, including 28 cross-sectional studies, 11 cohort studies and 10 case–control studies. In all, 21, 5 and 23 articles involved patients with OA exclusively, patients with DM and the general population, respectively. For 5788 patients with DM, the mean OA prevalence was 29.5±1.2%. For 645 089 patients with OA, the prevalence of DM was 14.4±0.1%. The risk of OA was greater in the DM than non-DM population (OR=1.46 (1.08 to 1.96), p=0.01), as was DM in the OA than non-OA population (OR=1.41 (1.21 to 1.65), p<0.00 001). Among the 12 studies reporting an OR adjusted on at least the body mass index, 5 showed no association of DM and OA and 7 identified DM as an independent risk factor.

Conclusions

This meta-analysis highlights a high frequency of OA in patients with DM and an association between both diseases, representing a further step towards the individualisation of DM-related OA within a metabolic OA phenotype.

Comorbidity, health-related quality of life and self-care in type 2 diabetes: a cross-sectional study in an outpatient population

BACKGROUND

Comorbid conditions may be related (concordant) or unrelated (discordant) to diabetes. Comorbidity in patients with type 2 diabetes (T2DM) is associated with reduced health-related quality of life (HRQoL) and self-care.

AIM

To examine the impact of comorbidity on HRQoL and self-care in T2DM patients attending an outpatient setting.

METHODS

A cross-sectional questionnaire was sent to 498 patients with T2DM, aged 25-80 years, previously attending (August 2011-July 2012) an outpatient diabetes service in a Dublin hospital. The EuroQoL-5 Dimension (EQ-5D) and a modified summary of diabetes self-care activities scale were used to assess HRQoL and self-care, respectively. Comorbidity was assessed using a simplified version of the self-administered comorbidity Questionnaire. Mann-Whitney and Kruskal-Wallis tests were used to examine the association between EQ-5D index scores or self-care, and the number and type of comorbidities. Multiple linear regression, adjusting for age and sex, was used to examine the association between EQ-5D score, comorbidity score and type.

RESULT

EQ-5D scores decreased with an increasing number of comorbidities and with discordant comorbidity (P = 0.0001). Comorbidity type was associated with physical activity. The highest level of physical activity was reported in respondents with no comorbidity (median 4.5 IQR 3-6), while the lowest was in patients with both concordant and discordant comorbidity (median 2.5 IQR 0-5).

CONCLUSIONS

Health professionals should be aware of the fall in HRQoL associated with comorbidity. This should be taken into account in the management of patients. Patients with discordant comorbidity should be advised and supported to maintain levels of physical activity.

Health-related quality of life (HRQOL) decreases independently of chronic conditions and geriatric syndromes in older adults with diabetes: the Fujiwara-kyo Study

Background

Very few studies have investigated the association between diabetes and impaired health-related quality of life (HRQOL) in older adults, independent of chronic conditions and geriatric syndromes.

Methods

We conducted a self-administered questionnaire survey and structured interviews with 3946 people aged 65 years or older to obtain medical histories of diabetes, chronic conditions, and geriatric syndromes. Blood tests were performed to measure glycated hemoglobin (HbA1c) and plasma glucose levels. HRQOL was evaluated using the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36), and multiple logistic regression analysis was used to calculate adjusted odds ratios and 95% CIs for low HRQOL.

Results

A total of 3521 participants had not received a physician diagnosis of diabetes. Of these, 2345 participants with an HbA1c less than 5.7% were defined as the referent group. As compared with the referent group, 1029 participants with an HbA1c of at least 5.7% but less than 6.5% showed no significant decrease in QOL on the SF-36 physical, mental, and role component summaries, after adjustment for chronic conditions, geriatric syndromes, and other potential confounders. However, 572 patients who had received a physician diagnosis of diabetes and/or had an HbA1c of 6.5% or higher had a significantly higher adjusted odds ratio (1.48; 95% CI, 1.18–1.84) for the low physical component summary. No significant differences in relation to glycemic control, treatment regimen, or diabetes duration were found in any of the 3 component summaries among the 425 participants who were undergoing diabetes treatment.

Conclusions

Older Japanese adults with diabetes had decreased physical QOL, independent of chronic conditions and geriatric syndromes.

Correlates of health-related quality of life in French people with type 2 diabetes

AIM

Diabetes is known to impair health-related quality of life (HrQol). Our aim was to analyse a comprehensive set of potential determinants of HrQol in a large sample of patients with diabetes.

METHODS

This study is based on the ENTRED 2007 study, a representative sample of adults (18 years and older) with diabetes. Data were extracted from postal self-reported questionnaires (from patients and medical practitioners) and from reimbursements from the National health insurance data system. HrQol was assessed with the MOS SF-12 for mental (MCS) and physical (PCS) component summaries. Multivariate linear regression models were used to analyse the variables associated with HrQol.

RESULTS

SF-12 MCS and PCS were available in 2832 patients with T2DM, with a mean age 64 years (1715 males, 56%). Lower income, severe hypoglycaemic episodes, hospitalisation ≥24 h, instrumental daily living (IADL) restriction, low satisfaction for social support and an HbA1c within the 8.1-10.0% range were associated with lower MCS rating, whereas an older age and male gender were associated with higher MCS. Older age, female sex, higher BMI, lower income, insulin treatment, macrovascular complications, severe hypoglycaemic episodes, hospitalisation ≥24 h, and IADL restriction were associated with lower PCS values whereas having no need for social support was associated with higher PCS values.

DISCUSSION

HrQol associated factors are multiple but mainly linked with socio-demographic factors, diabetes complications and satisfaction for social support. A patient centred approach should be tested to prevent impairment of HrQol and thus to decrease the burden of diabetes. Assessment of social support should be included.

Co-morbidity but not dysglycaemia reduces quality of life in patients with type-2 diabetes treated with oral mono- or dual combination therapy--an analysis of the DiaRegis registry

Background

Type-2 diabetes mellitus has a major impact on health related quality of life (HRQoL). We aimed to identify patient and treatment related variables having a major impact.

Methods

DiaRegis is a prospective diabetes registry. The EQ-5D was used to describe differences in HRQoL at baseline. Odds ratios (OR) with 95% confidence intervals (CI) were determined from univariable regression analysis. For the identification of independent predictors of a low score on the EQ-5D, multivariable unconditional logistic regression analysis was performed.

Results

A total of 2,760 patients were available for the present analysis (46.7% female, median age 66.2 years). Patients had considerable co-morbidity (18.3% coronary artery disease, 10.6% heart failure, 5.9% PAD and 5.0% stroke/TIA). Baseline HbA1c was 7.4%, fasting- and postprandial plasma glucose 139 mg/dl and 183 mg/dl.

The median EQ-5D was 0.9 (interquartile range [IQR] 0.8–1.0). Independent predictors for a low EQ-5D were age > 66 years (OR 1.49; 95%CI 1.08–2.06), female gender (2.11; 1.55–2.86), hypertension (1.73; 1.03–2.93), peripheral neuropathy (1.62; 0.93–2.84) and clinically relevant depression (11.01; 3.97–30.50). There was no influence of dysglycaemia on the EQ-5D score.

Conclusion

The present study suggests, that co-morbidity but not average glycaemic control reduces health related quality of life in type 2 diabetes mellitus.

Both cardiovascular and non-cardiovascular comorbidity are related to health status in well-controlled type 2 diabetes patients: a cross-sectional analysis

BACKGROUND

Type 2 diabetes patients have a decreased health-related quality of life compared to healthy persons, especially regarding physical functioning and well-being. Health-related quality of life is even lower in type 2 diabetes patients when other diseases co-exist. In contrast to earlier studies, we assessed the associations between the number and type of comorbidities and health status in well-controlled type 2 diabetes patients, in whom treatment goals for HbA1c, blood pressure and cholesterol had been reached. Approximately one in five type 2 diabetes patients belongs to this group.

METHODS

Cross-sectional analysis was performed in 2086 well-controlled (HbA1c ≤58 mmol/mol, systolic blood pressure ≤145 mmHg, total cholesterol ≤5.2 mmol/l and not using insulin) type 2 diabetes patients in general practice. Both number and type (cardiovascular and non-cardiovascular) of comorbidities were determined for each patient. Health status was assessed with the questionnaires Short Form-36 (SF-36) and EuroQol (EQ). The SF-36 generates eight dimensions of health and a Physical and Mental Component Score (PCS and MCS), scale: 0-100. The EQ consists of two parts: EQ-5D and EQ Visual Analogue Scale. Multivariable linear regression analysis was used to assess if number and type of comorbidities were associated with health status.

RESULTS

Well-controlled type 2 diabetes patients with comorbidities had a much lower health status, with a decrease ranging from -1.5 for the MCS to -26.3 for role limitations due to physical problems, compared to those without. Health status decreased when the number of comorbidities increased, except for mental health, role limitations due to emotional problems, MCS and both EQ measures. In patients with both cardiovascular and non-cardiovascular comorbidity, physical functioning, role limitations due to physical problems and PCS were significantly lower than in patients with only cardiovascular comorbidity. Physical functioning was also lower compared to patients with only non-cardiovascular comorbidity.

CONCLUSIONS

Even acceptable values of HbA1c, blood pressure and cholesterol in type 2 diabetes patients are not necessarily related with a good health status. We have shown that comorbidities have a large impact on health status. Physicians may take into account patient's health status and integrate the impact of comorbidities into diabetes care.

The importance of social support for people with type 2 diabetes - a qualitative study with general practitioners, practice nurses and patients

OBJECTIVE

Social support is an important element of family medicine within a primary care setting, delivered by general practitioners and practice nurses in addition to usual clinical care. The aim of the study was to explore general practitioner's, practice nurse's and people with type 2 diabetes' views, experiences and perspectives of the importance of social support in caring for people with type 2 diabetes and their role in providing social support.

METHODS

Interviews with general practitioners (n=10) and focus groups with practice nurses (n=10) and people with diabetes (n=9). All data were audio-recorded, fully transcribed and thematically analysed using qualitative content analysis by Mayring.

RESULTS

All participants emphasized the importance of the concept of social support and its impacts on well-being of people with type 2 diabetes. Social support is perceived helpful for people with diabetes in order to improve diabetes control and give support for changes in lifestyle habits (physical activity and dietary changes). General practitioners identified a lack of information about facilities in the community like sports or self-help groups. Practice nurses emphasized that they need more training, such as in dietary counselling.

CONCLUSIONS

Social support given by general practitioners and practice nurses plays a crucial role for people with type 2 diabetes and is an additional component of social care. However there is a need for an increased awareness by general practitioners and practice nurses about the influence social support could have on the individual's diabetes management.

Health-related quality of life in subjects with and without Type 2 diabetes: pooled analysis of five population-based surveys in Germany

AIMS

To estimate population values of health-related quality of life (HRQL) in subjects with and without Type 2 diabetes mellitus across several large population-based survey studies in Germany. Systematic differences in relation to age and sex were of particular interest.

METHODS

Individual data from four population-based studies from different regions throughout Germany and the nationwide German National Health Interview and Examination Survey (GNHIES98) were included in a pooled analysis of primary data (N = 9579). HRQL was assessed using the generic index instrument SF-36 (36-item Short Form Health Survey) or its shorter version, the SF-12 (12 items). Regression analysis was carried out to examine the association between Type 2 diabetes and the two component scores derived from the SF-36/SF-12, the physical component summary score (PCS-12) and the mental component summary score (MCS-12), as well as interaction effects with age and sex.

RESULTS

The PCS-12 differed significantly by -4.1 points in subjects with Type 2 diabetes in comparison with subjects without Type 2 diabetes. Type 2 diabetes was associated with significantly lower MCS-12 in women only. Higher age was associated with lower PCS-12, but with an increase in MCS-12, for subjects with and without Type 2 diabetes.

CONCLUSIONS

Pooled analysis of population-based primary data offers HRQL values for subjects with Type 2 diabetes in Germany, stratified by age and sex. Type 2 diabetes has negative consequences for HRQL, particularly for women. This underlines the burden of disease and the importance of diabetes prevention. Factors that disadvantage women with Type 2 diabetes need to be researched more thoroughly.

Musculoskeletal pain in patients with type 2 diabetes

AIMS

The aims were to investigate the prevalence of musculoskeletal pain in patients with type 2 diabetes and demonstrate possible associated factors.

METHODS

Nine hundred fifty-one patients completed a validated questionnaire used in The Danish Health and Morbidity Survey and results were compared to data for 2923 matched subjects from the Danish population. Musculoskeletal pain was self-reported Pain in the shoulder and neck; Low-back pain; and Pain in the arm, hand, knee and/or hip.

RESULTS

Compared to the age, gender and region matched controls patients reported musculoskeletal pain 1.7-2.1 times as frequent (p<0.001). Pain was more frequently reported in women (p<0.001). Low-back pain and Pain in the arm, hand, knee and/or hip was associated with body mass index (p<0.005). Low-back pain was associated with a sedentary life style, impaired quality of life and reduced physical function (p<0.05).

CONCLUSIONS

The prevalence of musculoskeletal pain was seriously increased in patients with type 2 diabetes. It was associated with body mass index, reduced quality of life, low physical function and the ability to be physical active. Focus on musculoskeletal pain in clinical practice is therefore of major importance in lifestyle interventions in type 2 diabetes.

A systematic review of patient-reported and economic outcomes: value to stakeholders in the decision-making process in patients with type 2 diabetes mellitus

BACKGROUND

The need for an approach to measuring health results that incorporates patients' and payers' perspectives has generated a wide range of health care outcomes (HCOs), but it is yet unknown whether these HCOs are appropriate or valid for the health care decision-making process.

OBJECTIVE

The goal of this study was to assess HCOs, patient-reported outcomes (PROs), and economic outcomes in terms of validity and appropriateness to health care decision making in type 2 diabetes mellitus (T2DM).

METHODS

This systematic review of studies published between January 1, 1996, and November 1, 2010, comprised an electronic literature search of MEDLINE and Centre for Reviews and Dissemination databases. Studies included were clinical trials, observational studies, economic analyses, and studies on the development and validation of HCOs in T2DM in the adult population. HCOs were assessed and classified according to their relevance for decision makers in terms of feasibility for routine use, validity, sensitivity, reliability, understanding, and scope.

RESULTS

Two independent reviewers screened 4497 citations. Of these, 281 potentially eligible full articles were retrieved, and 185 met the inclusion criteria. A total of 121 HCOs in T2DM were identified: 80 (66.1%) PROs and 41 (33.9%) economic outcomes. Only 44.6% of the outcomes assessed were appropriate and valid for health care decision making. Greater deficiencies in evidence were found for PROs (61.3%), followed by economic outcomes (43.9%).

CONCLUSIONS

A large number of HCOs are being used in the health care decision-making process, but a significant proportion of these new outcomes have not been properly validated. Despite the fact that appropriate measures will depend on the specific needs of the decision makers, researchers need to use HCOs for which evidence of quality and appropriateness is available.

[General practitioners' opinion and attitude towards DMPs and the change in practice routines to implement the DMP "diabetes mellitus type 2"]

BACKGROUND

Effective implementation of disease management programmes (DMPs) in primary care practices often requires changes in practice workflows and responsibilities and acceptance by the parties involved. Within the ELSID study (evaluation study of the DMP diabetes mellitus type 2) the physicians' attitudes toward DMPs were obtained and an optimised implementation of DMPs was developed by conducting a quality management cycle with primary care practice teams. The aim was to investigate which practice workflows will have to be changed and what kind of barriers to implement these changes are perceived.

METHODS

In 78 primary care practices of the two German federal states of Rheinland-Pfalz and Sachsen-Anhalt a quality management cycle was conducted using a structured analysis of the current state of DMP workflows and the need for improvement identified. Subsequently, an optimised workflow was developed and targets were agreed upon. After 6 months, the study team called to inquire about the current state of implementation and, if appropriate, actual barriers to change.

RESULTS

After 6 months, 71 practices had been interviewed by phone. 64 of them (90.1%) had agreed on at least one target (e.g., to purchase new instrumentation, to regularly discuss feedback reports, to set up a patient registry). On average three targets had been formulated, and 2 out of 3 had been implemented in the meantime. In most cases lack of time was given as the reason for non-implementation.

CONCLUSIONS

The majority of surveyed practices perceived some need for improvement. But sufficient resources (time, staff and money) are required to ensure efficient implementation of DMPs in primary care practices and their integration with routine processes. A redefinition of responsibilities for DMPs will strengthen the role of medical assistants and promote high-quality implementation of these programmes.

The well-being and treatment satisfaction of diabetic patients in primary care

Background

The quality of life in patients with diabetes is reduced and emotional coping with the disease has great impact on patient well-being.

Objectives

The aim of this study was to assess the psychological well-being and treatment satisfaction in patients with type 2 diabetes mellitus in primary care.

Study Design and Setting

Patients (n = 112) with type 2 diabetes mellitus diagnosis for at least six months were enrolled. The Well-Being Questionnaire-22 and the Diabetes Treatment Satisfaction Questionnaire were used. Physical examination and laboratory investigations were performed.

Results

The rates of the achieved targets were 32.1% for hemoglobin A_1c, 62.5% for cholesterol and 20.5% for blood pressure. The mean scores for the general well-being, depression, anxiety, positive well-being and energy were 44.40 ± 13.23 (range = 16-62), 12.65 ± 3.80 (range = 5-18), 10.57 ± 4.47 (range = 1-18), 12.00 ± 4.01 (range = 2-18), and 9.16 ± 2.47 (range = 2-12), respectively. The mean scores for the treatment satisfaction, perception for hyperglycemia and perception for hypoglycemia were 22.37 ± 9.53 (range = 0.00-36.00), 1.71 ± 1.59 (range = 0-6), and 0.51 ± 0.98 (range = 0-6), respectively. There were significant associations between the depression score and the educational status, compliance to diet and physical exercise, and diabetic complications; between the anxiety score and the educational status, glycemic control, compliance to diet and physical exercise; between the energy score and the educational status, compliance to physical exercise, and diabetic complications; between the positive well-being score and the educational status, compliance to diet and physical exercise, complications and type of treatment; between the general well-being score and the educational status, compliance for diet and physical exercise, and complications. Treatment satisfaction was significantly associated to the educational status, glycemic control and compliance to diet and physical exercise. A significant correlation was found between the treatment satisfaction and the well-being.

Conclusions

Individualized care of patients with diabetes should consider improving the quality of life. Psychosocial support should be provided to the patients with type 2 diabetes and the negative effects of psychopathological conditions on the metabolic control should be lessened.

Health-related quality of life in hypertension, chronic kidney disease, and coexistent chronic health conditions

With the increasing prevalence of hypertension, there has been a growing interest in understanding the health-related quality of life (HRQOL) of patients with hypertension. Although hypertension is often perceived as asymptomatic, it is associated with impaired HRQOL because of complications or comorbidities, awareness of the diagnosis, and adverse effects from antihypertensive medications. This article focuses on the literature published since 2000, on HRQOL in elderly hypertensive individuals as well as hypertensives with co-existent diseases, including chronic kidney disease, cardiovascular disease, and diabetes mellitus. Most of the studies found that hypertensive individuals with co-existent co-morbidities tend to have lower HRQOL than those with hypertension alone, and identified the number of co-morbid illnesses as an independent determinant of HRQOL. The most pronounced effect was noted in the physical function domains of HRQOL. Studies have also examined the effects on HRQOL of specific classes of antihypertensive drugs without specific demonstration of superiority of one drug class over another in terms of HRQOL measures. Although there is evidence in favor of angiotensin-converting enzyme-inhibition for improving renal and cardiovascular outcomes in hypertensive patients, its role in ameliorating HRQOL outcomes remains to be established.

Comorbidity in the elderly with diabetes: Identification of areas of potential treatment conflicts

AIMS

To investigate the prevalence of comorbid conditions in the elderly with diabetes and the prescribing of potentially inappropriate medicines or treatment conflicts.

METHODS

A cross-sectional study of diabetics aged >or=65 years, using prescription dispensing data from the Australian Department of Veterans' Affairs. Comorbidities were determined using the comorbidity index Rx-Risk-V. Potentially inappropriate prescribing or treatment conflicts specific for the elderly were determined from guidelines or reference compendia, in addition to the 2003 updated Beers criteria.

RESULTS

Of 18,968 diabetics, the median number of comorbidities was 5 (IQR 3-8). Diabetes and associated cardiovascular medicines accounted for 41.9% of all medicine use. Associated cardiovascular diseases were highly prevalent comorbidities. 46% had gastro-oesophageal reflux disease, 25% depression, 20% chronic airways disease or chronic pain and 15% also had heart failure or inflammation-pain. At least 16% were dispensed a medicine associated with adverse effects in patients with diabetes and 22.7% were dispensed at least one potentially inappropriate medicine.

CONCLUSION

Significant comorbid conditions in elderly diabetic patients with potential for inappropriate prescribing or treatment conflicts include arthritis, heart failure, chronic airways diseases and diseases treatable with systemic corticosteroids. Appropriate management of comorbidity should be included in guidelines for the elderly with diabetes.

Impact of primary care-based disease management on the health-related quality of life in patients with type 2 diabetes and comorbidity

OBJECTIVE

This study examined the effectiveness of the German diabetes disease management program (DMP) for patients with varying numbers of other medical conditions with respect to their health-related quality of life (HRQoL).

RESEARCH DESIGN AND METHODS

A questionnaire, including the HRQoL-measured EQ-5D, was mailed to a random sample of 3,546 patients with type 2 diabetes (59.3% female). The EQ-5D score was analyzed by grouping patients according to those on a DMP and those receiving routine care.

RESULTS

The analysis showed that participation in the DMP (P < 0.001), the number of other medical conditions (P < 0.001), and the interaction between the DMP and the number of other conditions (P < 0.05) had a significant impact on the EQ-5D score.

CONCLUSIONS

Our findings suggest that the number of other medical conditions may have a negative impact on the HRQoL of patients with type 2 diabetes. The results demonstrate that the German DMP for type 2 diabetes may help counterbalance this effect.