Five-year change of clinical and complications profile of diabetic patients under primary care: a population-based longitudinal study on 127,977 diabetic patients

Understanding Gaps in the Hypertension and Diabetes Care Cascade: Systematic Scoping Review

BACKGROUND

Hypertension and diabetes are global health challenges requiring effective management to mitigate their considerable burden. The successful management of hypertension and diabetes requires the completion of a sequence of stages, which are collectively termed the care cascade.

OBJECTIVE

This scoping review aimed to describe the characteristics of studies on the hypertension and diabetes care cascade and identify potential interventions as well as factors that impact each stage of the care cascade.

METHODS

The method of this scoping review has been guided by the framework by Arksey and O'Malley. We systematically searched MEDLINE, Embase, and Web of Science using terms pertinent to hypertension, diabetes, and specific stages of the care cascade. Articles published after 2011 were considered, and we included all studies that described the completion of at least one stage of the care cascade of hypertension and diabetes. Study selection was independently performed by 2 paired authors. Descriptive statistics were used to elucidate key patterns and trends. Inductive content analysis was performed to generate themes regarding the barriers and facilitators for improving the care cascade in hypertension and diabetes management.

RESULTS

A total of 128 studies were included, with 42.2% (54/128) conducted in high-income countries. Of them, 47 (36.7%) focused on hypertension care, 63 (49.2%) focused on diabetes care, and only 18 (14.1%) reported on the care of both diseases. The majority (96/128, 75.0%) were observational in design. Cascade stages documented in the literature were awareness, screening, diagnosis, linkage to care, treatment, adherence to medication, and control. Most studies focused on the stages of treatment and control, while a relative paucity of studies examined the stages before treatment initiation (76/128, 59.4% vs 52/128, 40.6%). There was a wide spectrum of interventions aimed at enhancing the hypertension and diabetes care cascade. The analysis unveiled a multitude of individual-level and system-level factors influencing the successful completion of cascade sequences in both high-income and low- and middle-income settings.

CONCLUSIONS

This review offers a comprehensive understanding of hypertension and diabetes management, emphasizing the pivotal factors that impact each stage of care. Future research should focus on upstream cascade stages and context-specific interventions to optimize patient retention and care outcomes.

Five-year LDL-cholesterol trend and its predictors among type 2 diabetes patients in an upper-middle-income country: a retrospective open cohort study

Background

Patients with diabetes have increased risks of cardiovascular diseases (CVD), and their LDL-cholesterol (LDL-C) has to be treated to target to prevent complications. We aim to determine the LDL-C trend and its predictors among patients with type 2 diabetes (T2D) in Malaysia.

Methods

This was a retrospective open cohort study from 2013 to 2017 among T2D patients in public primary health care clinics in Negeri Sembilan state, Malaysia. Linear mixed-effects modelling was conducted to determine the LDL-C trend and its predictors. The LDL-C target for patients without CVD was <2.6 mmol/L, whereas <1.8 mmol/L was targeted for those with CVD.

Results

Among 18,312 patients, there were more females (55.9%), adults ≥60 years (49.4%), Malays (64.7%), non-smokers (93.6%), and 45.3% had diabetes for <5 years. The overall LDL-C trend reduced by 6.8% from 2.96 to 2.76 mmol/L. In 2017, 16.8% (95% CI: 13.2-21.0) of patients without CVD and 45.8% (95% CI: 44.8-46.8) of patients with CVD achieved their respective LDL-C targets. The predictors for a higher LDL-C trend were younger adults, Malay and Indian ethnicities, females, dyslipidemia, and diabetes treatment with lifestyle modification and insulin. Longer diabetes duration, obesity, hypertension, retinopathy, statin therapy, achievement of HbA1c target and achievement of BP target were independent predictors for a lower LDL-C trend.

Conclusions

The LDL-C trend has improved, but there are still gaps between actual results and clinical targets. Interventions should be planned and targeted at the high-risk populations to control their LDL-C.

Changes in body mass index, glycosylated hemoglobin A1C, blood pressure, and LDL-cholesterol among type 2 diabetes patients in Malaysia: A population-based longitudinal study

BACKGROUND

This study aimed to describe changes in body mass index, glycosylated hemoglobin A1C, blood pressure, and low-density lipoprotein (LDL)-cholesterol among type 2 diabetes patients in Malaysia.

METHODS

A five-year retrospective cohort study was conducted using data from the National Diabetes Registry. Type 2 diabetes patients aged ≥18 years and had ≥2 clinical audits between 2013 and 2017 were included in the analysis. The first audit information formed the baseline characteristics, and the last audit information was used for comparison. Individualized A1C, blood pressure, and LDL-cholesterol goals were adapted from Malaysian Clinical Practice Guidelines on Type 2 Diabetes Management 2020, American Diabetes Association 2020, and European Association for the Study of Diabetes 2019.

RESULTS

Of the 18 341 patients, 55.8% were female and 64.9% Malay ethnicity. The baseline mean age was 59.3 ± 10.6 years. During an average of 2.5 person-years of follow-up, the mean body mass index dropped by 0.16 kg/m² to 27.9 kg/m² , A1C increased by 0.16% to 8.0%, systolic blood pressure increased by 1.4 mm Hg to 136.2 mm Hg, diastolic blood pressure decreased by 1.0 mm Hg to 77.3 mm Hg and LDL-cholesterol reduced by 0.12 mmol/L to 2.79 mmol/L, P < 0.001 for all. Out of eight categories of individualized goals, most patients achieved the A1C goal of ≤8.0%. The new LDL-cholesterol goal of <1.4 mmol/L was least likely to be achieved.

CONCLUSIONS

The body mass index, A1C, blood pressure, and LDL-cholesterol performance remained suboptimal. Standards of care for these clinical parameters remain to be achieved by the majority of diabetes patients.

Predictors of glycosylated haemoglobin A1C trend among type 2 diabetes patients in a multi-ethnic country

Good control of glycosylated haemoglobin A1C in diabetes patients prevents cardiovascular complications. We aim to describe the A1C trend and determine the predictors of the trend among type 2 diabetes patients in Malaysia. Longitudinal data in the National Diabetes Registry from 2013 to 2017 were analysed using linear mixed-effects modelling. Among 17,592 patients, 56.3% were females, 64.9% Malays, and the baseline mean age was 59.1 years. The U-shaped A1C trend changed marginally from 7.89% in 2013 to 8.07% in 2017. The A1C excess of 1.07% as reported in 2017 represented about 22% higher risk of diabetes-related death, myocardial infarction, and stroke, which are potentially preventable. The predictors for higher baseline A1C were non-Chinese ethnicity, younger age groups, longer diabetes duration, patients on insulin treatment, polypharmacy use, patients without hypertension, and patients who were not on antihypertensive agents. Younger age groups predicted a linear increase in the A1C trend, whereas patients on insulin treatment predicted a linear decrease in the A1C trend. Specifically, the younger adults and patients of Indian and Malay ethnicities had the poorest A1C trends. Targeted interventions should be directed at these high-risk groups to improve their A1C control.

Trend in the clinical profile of type 2 diabetes in India - Study from a diabetes care centre in South India

BACKGROUND AND AIM

Study the changing clinical and therapeutic profiles of type 2 diabetes (T2D) patients during a 10-year period in a diabetes care centre in Southern India.

METHODS

Retrospective, cross-sectional data of newly registered and review patients at four periods between 2009 and 2018 were analysed (n = 50,322). Clinical findings, anthropometry, blood pressure (BP), glycaemia, lipids, treatment, and co-morbid conditions were analysed. We studied the trends in age and gender distributions, body mass index (BMI), glycaemia, (Glycosylated haemoglobin A1c (HbA1c) levels), BP, cholesterol, triglycerides and therapeutic regimen during this period. Trend analyses were done.

RESULTS

Approximately 60% of patients were men. Percentages in 30-40 years increased, ∼60% were aged 50-69 years and proportion of older patients decreased (p < 0.0001). In 10 years, 85.9% was overweight, obesity increased from 22.1% to 25.0% (p < 0.0001) and <13% maintained normal BMI. HbA1c <7.0% remained approximately at 22%, percentage with moderate glycaemic control (HbA1c 7.0-7.9%) increased significantly, HbA1c of ≥9.0% decreased from 35.1% to 29.1% (p < 0.0001). Use of monotherapy decreased. Prevalence of hypertension increased from 16.2% to 21.6% (p < 0.0001); use of Angiotensin Receptor Blockers (ARB) and calcium channel blockers increased, Angiotensin Converting Enzyme Inhibitors and thiazides decreased (p < 0.0001). Increased use of statins paralleled with reduction in total cholesterol and LDLc.

CONCLUSION

Increasing percentages of younger patients and obesity, use of multiple drugs and reduction in HbA1c were the important observations. Rising prevalence of hypertension, increased use of ARB and statins with better control of dyslipidaemia was observed. Achievement of ideal HbA1c and BP were suboptimal.

Effect of a multicomponent intervention on achievement and improvements in quality-of-care indices among people with Type 2 diabetes in South Asia: the CARRS trial

AIMS

To evaluate whether and what combinations of diabetes quality metrics were achieved in a multicentre trial in South Asia evaluating a multicomponent quality improvement intervention that included non-physician care coordinators to promote adherence and clinical decision-support software to enhance physician practices, in comparision with usual care.

METHODS

Using data from the Centre for Cardiometabolic Risk Reduction in South Asia (CARRS) trial, we evaluated the proportions of trial participants achieving specific and combinations of five diabetes care targets (HbA_1c <53 mmol/mol [7%], blood pressure <130/80 mmHg, LDL cholesterol <2.6 mmol/L, non-smoking status, and aspirin use). Additionally, we examined the proportions of participants achieving the following risk factor improvements from baseline: ≥11-mmol/mol (1%) reduction in HbA_1c , ≥10-mmHg reduction in systolic blood pressure, and/or ≥0.26-mmol/l reduction in LDL cholesterol.

RESULTS

Baseline characteristics were similar in the intervention and usual care arms. Overall, 12.3%, 29.4%, 36.5%, 19.5% and 2.2% of participants in the intervention group and 16.2%, 38.3%, 31.6%, 11.3% and 0.8% of participants in the usual care group achieved any one, two, three, four or five targets, respectively. We noted sizeable improvements in HbA_1c , blood pressure and cholesterol, and found that participants in the intervention group were twice as likely to achieve improvements in all three indices at 12 months that were sustained over 28 months of the study [relative risk 2.1 (95% CI 1.5,2.8) and 1.8 (95% CI 1.5,2.3), respectively].

CONCLUSIONS

The intervention was associated with significantly higher achievement of and greater improvements in composite diabetes quality care goals. However, among these higher-risk participants, very small proportions achieved the complete group of targets, which suggests that achievement of multiple quality-of-care goals is challenging and that other methods may be needed in closing care gaps.

From Hong Kong Diabetes Register to JADE Program to RAMP-DM for Data-Driven Actions

In 1995, the Hong Kong Diabetes Register (HKDR) was established by a doctor-nurse team at a university-affiliated, publicly funded, hospital-based diabetes center using a structured protocol for gathering data to stratify risk, triage care, empower patients, and individualize treatment. This research-driven quality improvement program has motivated the introduction of a territory-wide diabetes risk assessment and management program provided by 18 hospital-based diabetes centers since 2000. By linking the data-rich HKDR to the territory-wide electronic medical record, risk equations were developed and validated to predict clinical outcomes. In 2007, the HKDR protocol was digitalized to establish the web-based Joint Asia Diabetes Evaluation (JADE) Program complete with risk levels and algorithms for issuance of personalized reports to reduce clinical inertia and empower self-management. Through this technologically assisted, integrated diabetes care program, we have generated big data to track secular trends, identify unmet needs, and verify interventions in a naturalistic environment. In 2009, the JADE Program was adapted to form the Risk Assessment and Management Program for Diabetes Mellitus (RAMP-DM) in the publicly funded primary care clinics, which reduced all major events by 30-60% in patients without complications. Meanwhile, a JADE-assisted assessment and empowerment program provided by a university-affiliated, self-funded, nurse-coordinated diabetes center, aimed at complementing medical care in the community, also reduced all major events by 30-50% in patients with different risk levels. By combining universal health coverage, public-private partnerships, and data-driven integrated care, the Hong Kong experience provides a possible solution than can be adapted elsewhere to make quality diabetes care accessible, affordable, and sustainable.

Evolution of Diabetes Care in Hong Kong: From the Hong Kong Diabetes Register to JADE-PEARL Program to RAMP and PEP Program

The rapid increase in diabetes prevalence globally has contributed to large increases in health care expenditure on diabetic complications, posing a major health burden to countries worldwide. Asians are commonly observed to have poorer β-cell function and greater insulin resistance compared to the Caucasian population, which is attributed by their lower lean body mass and central obesity. This "double phenotype" as well as the rising prevalence of young onset diabetes in Asia has placed Asians with diabetes at high risk of cardiovascular and renal complications, with cancer emerging as an important cause of morbidity and mortality. The experience from Hong Kong had demonstrated that a multifaceted approach, involving team-based integrated care, information technological advances, and patient empowerment programs were able to reduce the incidence of diabetic complications, hospitalizations, and mortality. System change and public policies to enhance implementation of such programs may provide solutions to combat the burgeoning health problem of diabetes at a societal level.

Temporal trends in quality of primary care for patients with type 2 diabetes mellitus: A population-based retrospective cohort study after implementation of a quality improvement initiative

BACKGROUND

This study examined whether temporal trends exist in treatment of patients with type 2 diabetes (T2D) and quality of diabetes care after implementation of quality improvement initiative in primary care setting.

METHODS

We conducted a population-based retrospective cohort study of 202,284 patients with T2D who were routinely managed in primary care clinics. We examined the change over time and the variability between clinics in quality of care from Hospital Authority administrative data over a 5-year period (2009-2013) and used multilevel logistic regression to adjust for patient and clinic characteristics. Observational period was partitioned in 5 calendar years. Ten quality-of-care criteria were selected: adherence to 7 process of care criteria (HbA_1c test, renal function test, full lipid profile, urine protein analysis, retinal screening, lipid-lowering agent prescriptions among patients with hypercholesterolaemia, and angiotensin converting enzyme inhibitor/angiotensin receptor blocker prescriptions among patients with microalbuminuria) and 3 outcome of care criteria (HbA_1c  ≤ 7%, BP ≤ 130/80 mmHg, and LDL-C ≤ 2.6 mmol/L). Variability of standards between clinics was assessed by using intracluster correlation coefficients.

RESULTS

Characteristics of patients with T2D managed in primary care changed substantially during the observational period, with increasing age and usage of insulin and longer duration of diabetes but improved metabolic profiles (all P trend < .001). Performance rates of the 7 process and 3 clinical outcomes of care criteria increased remarkably over time (all P trend < .001). Variations in retinal screening delivery between clinics were considerable, albeit decreasing over time.

CONCLUSIONS

Coinciding with implementation of quality improvement initiative, quality of diabetes care improved significantly in the past 5 years, in part attributable to benefits of integrated multidisciplinary diabetes management.

Insulin-like growth factor-1 promotes the proliferation and odontoblastic differentiation of human dental pulp cells under high glucose conditions

Insulin-like growth factor-1 (IGF-1) promotes human dental pulp stem cell proliferation and osteogenic differentiation. However, the effects of IGF-1 on the proliferation, apoptosis and odontoblastic differentiation (mineralization) of dental pulp cells (DPCs) under high glucose (GLU) conditions remain unclear. In this study, isolated primary human DPCs were treated with various concentrations of high GLU. Cell proliferation and apoptosis were determined by Cell Counting Kit-8 and Annexin V-FITC/PI assays, respectively. The cells were cultured in odontoblastic induction medium containing various concentrations of high GLU. Odontoblastic differentiation was determined by alkaline phosphatase (ALP) activity assay. Mineralization formation was evaluated by von Kossa staining. The expression levels of IGF family members were measured by western blot analysis and RT-qPCR during proliferation and differentiation. The cells were then exposed to 25 mM GLU and various concentrations of IGF-1. Cell proliferation, apoptosis, ALP activity, mineralization formation and the levels of mineralization-related proteins were then evaluated. Our results revealed that high GLU significantly inhibited cell proliferation and promoted cell apoptosis. GLU (25 and 50 mM) markedly reduced ALP activity and mineralization on days 7 and 14 after differentiation. The levels of IGF family members were markedly decreased by high GLU during proliferation and differentiation. However, IGF-1 significantly reversed the effects of high GLU on cell proliferation and apoptosis. Additionally, IGF-1 markedly restored the reduction of ALP activity and mineralization induced by high GLU. Our findings thus indicate that IGF-1 attenuates the high GLU-induced inhibition of DPC proliferation, differentiation and mineralization.

Incidence of chronic kidney disease among people with diabetes: a systematic review of observational studies

AIMS

The aim was to systematically review published articles that reported the incidence of chronic kidney disease among people with diabetes.

METHODS

A systematic literature search was performed using MEDLINE, Embase and CINAHL databases. The titles and abstracts of all publications identified by the search were reviewed and 10 047 studies were retrieved.

RESULTS

A total of 71 studies from 30 different countries with sample sizes ranging from 505 to 211 132 met the inclusion criteria. The annual incidence of microalbuminuria and albuminuria ranged from 1.3% to 3.8% for Type 1 diabetes. For Type 2 diabetes and studies combining both diabetes types, the range was from 3.8% to 12.7%, with four of six studies reporting annual rates between 7.4% and 8.6%. In studies reporting the incidence of eGFR < 60 ml/min/1.73 m² using the Modification of Diet on Renal Disease (MDRD) equation, apart from one study which reported an annual incidence of 8.9%, the annual incidence ranged from 1.9% to 4.3%. The annual incidence of end-stage renal disease ranged from 0.04% to 1.8%.

CONCLUSIONS

The annual incidence of microalbuminuria and albuminuria is ~ 2-3% in Type 1 diabetes, and ~ 8% in Type 2 diabetes or mixed diabetes type. The incidence of developing eGFR < 60 ml/min/1.73 m² is ~ 2-4% per year. Despite the wide variation in methods and study design, within a particular category of kidney disease, there was only modest variation in incidence rates. These findings may be useful in clinical settings to help understand the risk of developing kidney disease among those with diabetes.

Efficacy and safety of fixed-dose combination therapy, alogliptin plus metformin, in Asian patients with type 2 diabetes: A phase 3 trial

This study evaluated the efficacy and safety of 26 weeks of twice-daily (BID) alogliptin + metformin fixed-dose combination (FDC) therapy in Asian patients with type 2 diabetes. Patients aged 18 to 75 years with hemoglobin A1c (HbA1c) of 7.5% to 10.0% after ≥2 months of diet and exercise and a 4-week placebo run-in were enrolled. Eligible patients were randomized (1:1:1:1) to placebo, alogliptin 12.5 mg BID, metformin 500 mg BID or alogliptin 12.5 mg plus metformin 500 mg FDC BID. The primary endpoint was change in HbA1c from baseline to end of treatment (Week 26). In total, 647 patients were randomized. The least-squares mean change in HbA1c from baseline to Week 26 was -0.19% with placebo, -0.86% with alogliptin, -1.04% with metformin and -1.53% with alogliptin + metformin FDC. Alogliptin + metformin FDC was significantly more effective ( P  < .0001) in lowering HbA1c than either alogliptin or metformin alone. The safety profile of alogliptin + metformin FDC was similar to that of the individual components alogliptin and metformin. The study demonstrated that treatment with alogliptin + metformin FDC BID resulted in better glycaemic control than either monotherapy and was well tolerated in Asian patients with type 2 diabetes.

Efficacy and safety of alogliptin in patients with type 2 diabetes mellitus: A multicentre randomized double-blind placebo-controlled Phase 3 study in mainland China, Taiwan, and Hong Kong

BACKGROUND

This study determined the efficacy and safety of once-daily oral alogliptin in patients from mainland China, Taiwan, and Hong Kong with type 2 diabetes mellitus.

METHODS

In this Phase 3 multicenter double-blind placebo-controlled 16-week trial, 506 patients were randomized to receive once-daily alogliptin 25 mg or placebo: 185 in the monotherapy group, 197 in the add-on to metformin group, and 124 in the add-on to pioglitazone group. The primary efficacy variable was the change from baseline (CFB) in HbA1c at Week 16; other efficacy measures included CFB to Week 16 in fasting plasma glucose (FPG), incidence of marked hyperglycemia (FPG ≥11.1 mmol/L), and the incidence of clinical HbA1c ≤6.5 % (48 mmol/mol) and ≤7.0 % (53 mmol/mol) at Week 16. Safety was assessed throughout the trial.

RESULTS

Alogliptin monotherapy provided a significantly greater decrease in HbA1c from baseline to Week 16 compared with placebo (-0.58 %; 95 % confidence interval [CI] -0.78 %, -0.37 %; P < 0.001). As an add-on to metformin or pioglitazone, alogliptin also significantly decreased HbA1c compared with placebo (-0.69 % [95 % CI -0.87 %, -0.51 %; P < 0.001] and -0.52 % [95 % CI -0.75 %, -0.28 %; P < 0.001], respectively). In any treatment group versus placebo, alogliptin led to greater decreases in FPG (P ≤ 0.004) and a higher percentage of patients who achieved an HbA1c target of ≤6.5 % and ≤7.0 % (P ≤ 0.003). No weight gain was observed in any treatment group. A similar percentage of patients experienced drug-related, treatment-emergent adverse events in the alogliptin and placebo arms. Four and two patients in the alogliptin and placebo arms, respectively, experienced mild or moderate hypoglycemia.

CONCLUSIONS

Alogliptin 25 mg once daily reduced HbA1c and FPG and enhanced clinical response compared with placebo when used as monotherapy or as an add-on to metformin or pioglitazone. Therapy with alogliptin was well tolerated.