Economic outcomes associated with microvascular complications of type 2 diabetes mellitus: results from a US claims data analysis

Incidence of Diabetic Retinopathy in Individuals with Type 2 Diabetes: A Study Using Real-World Data

Background/Objectives: This study aimed to assess the incidence of diabetic retinopathy (DR) in patients with type 2 diabetes (T2DM) treated in primary-care settings in Catalonia, Spain, and identify key risk factors associated with DR development. Methods: A retrospective cohort study was conducted using the SIDIAP (System for Research and Development in Primary Care) database. Patients aged 30-90 with T2DM who underwent retinal screening between 2010 and 2015 were included. Multivariable Cox regression analysis was used to assess the impact of clinical variables, including HbA1c levels, diabetes duration, and comorbidities, on DR incidence. Results: This study included 146,506 patients, with a mean follow-up time of 6.96 years. During this period, 4.7% of the patients developed DR, resulting in an incidence rate of 6.99 per 1000 person-years. Higher HbA1c levels were strongly associated with an increased DR risk, with patients with HbA1c > 10% having more than four times the risk compared to those with HbA1c levels < 7% (hazard ratio: 4.23; 95% CI: 3.90-4.58). Other significant risk factors for DR included greater diabetes duration, male sex, ex-smoker status, macrovascular disease, and chronic kidney disease. In contrast, obesity appeared to be a protective factor against DR, with an HR of 0.93 (95% CI: 0.89-0.98). Conclusions: In our real-world setting, the incidence rate of DR was 6.99 per 1000 person-years. Poor glycemic control, especially HbA1c > 10%, and prolonged diabetes duration were key risk factors. Effective management of these factors is crucial in preventing DR progression. Regular retinal screenings in primary care play a vital role in early detection and reducing the DR burden for T2DM patients.

Cost-Effectiveness of Once-Weekly Semaglutide 1 mg versus Canagliflozin 300 mg in Patients with Type 2 Diabetes Mellitus in a Canadian Setting

OBJECTIVE

Our objective was to evaluate the long-term cost-effectiveness of once-weekly semaglutide 1 mg versus once-daily canagliflozin 300 mg in patients with type 2 diabetes mellitus (T2DM) uncontrolled with metformin from the healthcare payer and societal perspectives in Canada.

METHODS

Head-to-head data from the SUSTAIN 8 randomised trial (NCT03136484) were extrapolated over 40 years using economic simulation modelling. The cost-effectiveness of once-weekly semaglutide 1 mg versus canagliflozin 300 mg for treating T2DM was estimated using the Swedish Institute for Health Economics-Diabetes Cohort Model (IHE-DCM) and the Economic and Health Outcomes Model of T2DM (ECHO-T2DM). Unit costs and disutility weights capturing treatments and key macro- and microvascular complications were sourced from the literature to best match the Canadian setting. A probabilistic base-case simulation and sensitivity analyses were conducted.

RESULTS

Once-weekly semaglutide 1 mg was associated with reductions in macro- and microvascular complications, yielding incremental cost-effectiveness ratios (ICERs) of (Canadian dollars [CAD]) CAD16,392 and 18,098 per incremental quality-adjusted life-year (QALY) gained versus canagliflozin 300 mg for IHE-DCM and ECHO-T2DM, respectively, from a healthcare payer perspective. Accounting for productivity loss as well, ICERs were CAD14,127 and 13,188 per QALY gained for IHE-DCM and ECHO-T2DM, respectively, from a societal perspective. Sensitivity analyses confirmed that the base-case results were robust to changes in input parameters and assumptions used.

CONCLUSIONS

At a willingness-to-pay threshold of CAD50,000 per QALY gained, once-weekly semaglutide 1 mg was cost-effective over 40 years versus once-daily canagliflozin 300 mg for the treatment of T2DM in patients failing to maintain glycemic control with metformin alone.

Assessing trends in medical expenditures and measuring the impact of health-related quality of life on medical expenditures for U.S. adults with diabetes associated chronic kidney disease using 2002–2016 medical expenditure panel survey data

Background

Chronic Kidney Disease (CKD) is one of the most expensive comorbidities of diabetes. The changes in medical expenditures over the years and the latest economic burden of CKD among diabetes are unknown.

Objectives

(1) To examine the trend and estimate the differences in medical expenditures between adults with diabetes-associated CKD and diabetes-no CKD from 2002 to 2016 using Medical Expenditure Panel Survey data (2) To study the impact of health-related quality of life (HRQOL) on medical expenditure for adults with diabetes-associated CKD.

Methods

This is a retrospective cross-sectional study. Descriptive statistics were used for studying the trend in medical expenditures from 2002 to 2016. HRQOL was measured using physical and mental component summary (PCS, MCS). Two-part model was utilized for estimating the incremental medical expenditure for diabetes patients by CKD status.

Key findings

A total of 35,112 diabetic adults were identified in the Medical Expenditure Panel Survey dataset. Among these, 3,489 individuals had CKD. The pooled mean expenditure for diabetes-associated CKD was $25,953 which was almost double of $12,170 for patients with diabetes and no CKD. Individuals with diabetes CKD had $12,109 higher adjusted direct incremental medical expenditure as compared to diabetes-no CKD. With respect to HRQOL, individuals in the highest quartile of PCS and MCS spent $18,076 and $10,307 lesser than those in the lowest quartile respectively.

Conclusions

Medical expenditures associated with CKD are a significant contributor to the financial burden among diabetes adults. Improvements in HRQOL also lead to lower healthcare costs in diabetes-associated CKD patients.

Increased levels of cytokines in the aqueous humor correlate with the severity of diabetic retinopathy

AIMS

To determine the associations between the levels of certain cytokines in the aqueous humor and the severity of diabetic retinopathy.

METHODS

A total of 103 patients (one eye per patient) who received intravitreal injection with ranibizumab for diabetic retinopathy were enrolled and divided into 3 groups: nonproliferative diabetic retinopathy (NPDR) with macular edema group (42 eyes), proliferative diabetic retinopathy (PDR) group (40 eyes) and neovascular glaucoma due to PDR (NVG-PDR) group (21 eyes). The concentrations of interleukin (IL)-6, IL-8, IL-10, vascular endothelial growth factor (VEGF), transforming growth factor-β (TGF-β), vascular cell adhesion molecule-1 (VCAM-1), intercellular adhesion molecule-1 (ICAM-1), and monocyte chemoattractant protein-1 (MCP-1) in the aqueous humor were measured.

RESULTS

In this study, 42, 40 and 21 patients (one eye per patient) were included in the NPDR, PDR and NVG-PDR groups, respectively. The median concentrations of IL-6, IL-8, IL-10, VEGF, TGF-β, VCAM-1, ICAM-1 and MCP-1 in the groups were measured. The levels of these 8 cytokines increased with the severity of diabetic retinopathy, especially in the NVG-PDR group. Compared with those in the NPDR group, the aqueous concentrations of these 8 cytokines were higher in the PDR group and were the highest in the NVG-PDR group. There were significant differences in all cytokines among the three groups (P < 0.05). Multivariate analysis showed that in the NPDR and PDR groups, the risk of PDR associated with elevated levels of TGF-β (P = 0.0004, OR 1.11, 95% CI [1.05-1.18]) and ICAM-1 (P = 0.0408, OR 10.75, 95% CI [1.10-104.61]). In the PDR and NVG groups, the risk of NVG associated with elevated levels of IL-10 (P = 0.0486, OR 0.7040, 95% CI [0.4966, 0.9979]), VEGF (P = 0.0279, OR 0.9963, 95% CI [0.9931, 0.9996]), and VCAM-1 (P = 0.0316, OR 0.9998, 95% CI [0.9996, 0.99998]). In the three groups, the risk of developing NVG associated with elevated levels of TGF-β (P < 0.001, OR 1.04, 95% CI [1.02, 1.05]).

CONCLUSIONS

The levels of these eight cytokines in the aqueous humor increased with the severity of diabetic retinopathy, especially in NVG-PDR. This study suggests that TGF-β, ICAM-1, IL-10, VEGF, and VCAM-1 may play a role in the progression of diabetic retinopathy, especially TGF-β, which may plays a significant role in NVG-PDR. These cytokines potentially may be used as biomarkers to predict the progress of diabetic retinopathy, contribute to the choice of treatment options and/or monitor treatment responses.

Healthcare Costs of Diabetes and Microvascular and Macrovascular Disease in Individuals with Incident Type 2 Diabetes Mellitus: A Ten-Year Longitudinal Study

OBJECTIVE

The objective of this study was to estimate the incremental long-term costs associated with T2DM attributable to vascular diseases.

RESEARCH DESIGN AND METHODS

This retrospective cohort study identified newly diagnosed (incident) T2DM patients in 2007 (baseline to 01/01/2006) using the HealthCore Integrated Research Database, a repository of nationally representative claims data. Incident T2DM patients were 1:1 exact matched on age, gender and other factors of interest to non-DM patients, and followed until the earlier of 8 follow-up years or death. Patients with documented vascular disease diagnosis were identified during the study period. All-cause and T2DM/vascular disease-related annual healthcare costs were examined for each follow-up year.

RESULTS

The study included 13,883 individuals with T2DM and matched non-DM controls. Among individuals with T2DM, 11,792 (85%) had vascular disease versus 9251 (66.6%) non-T2DM between 01/01/2006 and 12/31/2015. Among T2DM patients, mean all-cause annual costs were greater than in non-T2DM patients ($13,806 vs $7,243, baseline, $21,745 vs $8,524, post-index year 1, $12,756-$14,793 vs $8,349-$9,940 years 2-8, p< 0.001), respectively. A similar trend was observed for T2DM/vascular disease-related costs (p< 0. 001). T2DM/vascular disease-related costs were largest during post-index year 1, accounting for the majority of all-cause cost difference between T2DM patients and matched non-DM controls. Incident T2DM individuals without vascular disease at any time had significantly lower costs compared to non-DM controls (p< 0. 001) between years 2-8 of follow-up.

CONCLUSION

Vascular disease increased the cost burden for individuals with T2DM. The cost impact of diabetes and vascular disease was highest in the year after diagnosis, and persisted for at least seven additional years, while the cost of T2DM patients without vascular disease trended lower than for matched non-DM patients. These data highlight potential costs that could be offset by earlier and more effective detection and management of T2DM aimed at reducing vascular disease burden.

Does the Encounter Type Matter When Defining Diabetes Complications in Electronic Health Records?

BACKGROUND

Electronic health records (EHRs) and claims records are widely used in defining type 2 diabetes mellitus (T2DM) complications across different types of health care encounters.

OBJECTIVE

This study investigates whether using different EHR encounter types to define diabetes complications may lead to different results when examining associations between diabetes complications and their risk factors in patients with T2DM.

RESEARCH DESIGN

The study cohort of 64,855 adult patients with T2DM was created from EHR data from the Research Action for Health Network (REACHnet), using the Surveillance Prevention, and Management of Diabetes Mellitus (SUPREME-DM) definitions. Incidence of coronary heart disease (CHD) and stroke events were identified using International Classification of Diseases (ICD)-9/10 codes and grouped by encounter types: (1) inpatient (IP) or emergency department (ED) type, or (2) any health care encounter type. Cox proportional hazards regression was used to estimate associations between diabetes complications (ie, CHD and stroke) and risk factors (ie, low-density lipoprotein cholesterol and hemoglobin A1c).

RESULTS

The incidence rates of CHD and stroke in all health care settings were more than twice the incidence rates of CHD and stroke in IP/ED settings. The age-adjusted and multivariable-adjusted hazard ratios for incident CHD and stroke across different levels of low-density lipoprotein cholesterol and hemoglobin A1c were similar between IP/ED and all settings.

CONCLUSION

While there are large variations in incidence rates of CHD and stroke as absolute risks, the associations between both CHD and stroke and their respective risk factors measured by hazard ratios as relative risks are similar, regardless of alternative definitions.

Correlation of serum CF6 with blood lipid and glucose in patients with type 2 diabetic retinopathy

This study was to investigate the relationship of serum mitochondrial coupling factor 6 (CF6) with blood lipid and glucose in patients with type 2 diabetic retinopathy. A total of 180 patients with type 2 diabetes enrolled in our hospital from January 2015 to September 2017 were selected as the research objects. They were divided in accordance with fundus fluorescence angiography (FFA) into normal diabetic retinopathy (NDR) group, background diabetic retinopathy (BDR) group as well as proliferative diabetic retinopathy (PDR), with 60 cases in each group, and at the same time, another 60 healthy subjects were selected as normal control (NC) group. Serum CF6, fasting plasma glucose (FPG), 2 h postprandial plasma glucose (2hPG), glycosylated hemoglobin (HbA1c), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), total cholesterol as well as triglyceride were measured in the groups and the relationship of serum CF6 with related indicators was analyzed. The level of serum CF6 in type 2 diabetes group was higher than that in NC group and there was statistically significant difference among the groups with the occurrence and aggravation of retinopathy ( P < 0.05). Correlation analysis showed that serum CF6 was positively correlated with FPG, 2hPG, HbA1c, and LDL-C of statistical significance ( P < 0.05) and negatively correlated with HDL-C of statistical significance ( P < 0.05). The results of multiple step regression analysis showed that HbA1c and LDL-C were independent risk factors for CF6. In conclusion, the serum CF6 of patients with diabetic retinopathy increases with aggravation of the disease, taking a part in the occurrence and development of retinopathy together with the disorder of blood glucose and lipid metabolism.

Involvement of ciliary neurotrophic factor in early diabetic retinal neuropathy in streptozotocin-induced diabetic rats

Objective

Ciliary neurotrophic factor (CNTF) has been evaluated as a candidate therapeutic agent for diabetes and its neural complications. However, its role in diabetic retinopathy has not been fully elucidated.

Methods

This is a randomized unblinded animal experiment. Wistar rats with streptozocin (STZ)-induced diabetes were regularly injected with CNTF or vehicle control in their vitreous bodies beginning at 2 weeks after STZ injection. A total of five injections were used. In diabetic rats, the levels of CNTF and neurotrophin-3 (NT-3) were evaluated by enzyme-linked immunosorbent assays (ELISA) and real-time PCR. The abundance of tyrosine hydroxylase (TH) and β-III tubulin was detected by western blot. Transferase-mediated dUTP nick-end labeling staining (TUNEL) was used to detect cell apoptosis in the retinal tissue. The activation of caspase-3 was also measured.

Results

The protein and mRNA levels of CNTF in diabetic rat retinas were reduced compared to control rats. In addition, retinal ganglion cells (RGCs) and dopaminergic amacrine cells appeared to undergo degeneration in diabetic rat retinas, as revealed by transferase-mediated dUTP nick-end labeling staining (TUNEL). Tyrosine hydroxylase (TH) and β-III tubulin protein levels also decreased significantly. Intraocular administration of CNTF rescued RGCs and dopaminergic amacrine cells from neurodegeneration and counteracted the downregulation of β-III tubulin and TH expression, thus demonstrating its therapeutic potential.

Conclusion

Our study suggests that early diabetic retinal neuropathy involves the reduced expression of CNTF and can be ameliorated by an exogenous supply of this neurotrophin.

Diabetic retinopathy: new therapeutic perspectives based on pathogenic mechanisms

Diabetic retinopathy (DR) is the leading cause of visual impairment and preventable blindness and represents a significant socioeconomic cost for healthcare systems worldwide. In early stages of DR the only therapeutic strategy that physicians can offer is a tight control of the risk factors for DR (mainly blood glucose and blood pressure). The currently available treatments for DR are applicable only at advanced stages of the disease and are associated with significant adverse effects. Therefore, new treatments for the early stages of DR are needed. However, in early stages of DR invasive treatments such as intravitreal injections are too aggressive, and topical treatment seems to be an emerging route. In the present review, therapeutic strategies based on the main pathogenic mechanisms involved in the development of DR are reviewed. The main gap in the clinical setting is the treatment of early stages of DR and, therefore, this review emphasizes in this issue by giving an overview of potential druggable targets. By understanding of disease-specific pathogenic mechanisms, biological heterogeneity and progression patterns in early and advanced DR a more personalised approach to patient treatment will be implemented.

Retina and Choroid of Diabetic Patients Without Observed Retinal Vascular Changes: A Longitudinal Study

PURPOSE

To identify changes in choroidal thickness (CT) and all retinal layers of diabetic patients without diabetic retinopathy (DR) after 1 year of follow-up.

DESIGN

Prospective observational cohort study.

METHODS

Overall, 125 diabetic patients without DR were included. Two visits were scheduled: the first visit (V1) and a second visit after 12 months (V2). At both visits, patients received a complete ophthalmologic evaluation that included OCT. Each retinal layer thickness was calculated for 9 ETDRS sectors, and CT was measured at 13 locations. Generalized linear mixed-effects models were used.

RESULTS

Of the 125 patients, 103 completed the study, and 9 of the 103 developed DR (8.7%). CT was significantly higher at V2 than at V1, with an average value of 10-17 μm at almost half the locations (500, 1000, and 1500 μm temporal; 500 and 1000 μm nasal; and 1000 μm superior to the fovea) (P < .001-.003). The thicknesses of the ganglion cell layer (I3 and N6 sectors), inner plexiform layer (S6 and N6 sectors), inner nuclear layer (T6 and N6 sectors), and outer plexiform layer (S6 sector), as well as the overall retinal thickness (RT) (S3, N3, I3, S6, and T6 sectors), were decreased at V2 (P < .001). Visible retinopathy was negatively associated with overall RT (central, S3, T3, I3, and N3 sectors, P = .004-.024) and the thickness of the ONL (T6 and I6 sectors, P = .007 and P = .009) and photoreceptor layer (N6 sector, P = .038). The presence of DR decreased the overall RT by 13.04-16.63 μm.

CONCLUSIONS

Diabetic patients without DR showed a thicker choroid and a thinner retina, particularly in inner layers, after 1 year of follow-up. These structural changes may correspond to the early neurodegenerative phase of DR.

Risk Factors Associated With Corneal Nerve Alteration in Type 1 Diabetes in the Absence of Neuropathy: A Longitudinal In Vivo Corneal Confocal Microscopy Study

PURPOSE

The aim of this study was to determine alterations to the corneal subbasal nerve plexus (SNP) over 4 years using in vivo corneal confocal microscopy in participants with type 1 diabetes and to identify significant risk factors associated with these alterations.

METHODS

A cohort of 108 individuals with type 1 diabetes and no evidence of peripheral neuropathy at enrollment underwent laser-scanning in vivo corneal confocal microscopy, ocular screening, and health and metabolic assessment at baseline, and the examinations continued for 4 subsequent annual visits. At each annual visit, 8 central corneal images of the SNP were selected and analyzed to quantify corneal nerve fiber density, corneal nerve branch density and corneal nerve fiber length. Linear mixed model approaches were fitted to examine the relationship between risk factors and corneal nerve parameters.

RESULTS

A total of 96 participants completed the final visit and 91 participants completed all visits. No significant relationships were found between corneal nerve parameters and time, sex, duration of diabetes, smoking, alcohol consumption, blood pressure, or body mass index. However, corneal nerve fiber density was negatively associated with glycated hemoglobin (β = -0.76, P < 0.01) and age (β = -0.13, P < 0.01) and positively related to high-density lipids (β = 2.01, P = 0.03). Higher glycated hemoglobin (β = -1.58, P = 0.04) and age (β = -0.23, P < 0.01) also negatively impacted corneal nerve branch density. Corneal nerve fiber length was only affected by higher age (β = -0.06, P < 0.01).

CONCLUSIONS

Glycemic control, high-density lipid, and age have significant effects on SNP structure. These findings highlight the importance of diabetic management to prevent corneal nerve damage and the capability of in vivo corneal confocal microscopy for monitoring subclinical alterations in the corneal SNP in diabetes.

Comorbidity and its relationship with health service use and cost in community-living older adults with diabetes: A population-based study in Ontario, Canada

AIMS

This study describes the comorbid conditions in Canadian, community-dwelling older adults with diabetes and the association between the number of comorbidities and health service use and costs.

METHODS

This retrospective cohort study used multiple linked administrative data to determine 5-year health service utilization in a population-based cohort of community-living individuals aged 66 and over with a diabetes diagnosis as of April 1, 2008 (baseline). Utilization included physician visits, emergency department visits, hospitalizations, and home care services.

RESULTS

There were 376,421 cohort members at baseline, almost all (95%) of which had at least one comorbidity and half (46%) had 3 or more. The most common comorbidities were hypertension (83%) and arthritis (61%). Service use and associated costs consistently increased as the number of comorbidities increased across all services and follow-up years. Conditions generally regarded as nondiabetes-related were the main driver of service use. Over time, use of most services declined for people with the highest level of comorbidity (3+). Hospitalizations and emergency department visits represented the largest share of costs for those with the highest level of comorbidity (3+), whereas physician visits were the main costs for those with fewer comorbidities.

CONCLUSIONS

Comorbidities in community-living older adults with diabetes are common and associated with a high level of health service use and costs. Accordingly, it is important to use a multiple chronic conditions (not single-disease) framework to develop coordinated, comprehensive and patient-centred programs for older adults with diabetes so that all their needs are incorporated into care planning.

Drug usage patterns and treatment costs in newly-diagnosed type 2 diabetes mellitus cases, 2007 vs 2012: findings from a large US healthcare claims database analysis

Objective To explore trends in demographics, comorbidities, anti-diabetic drug usage, and healthcare utilization costs in patients with newly-diagnosed type 2 diabetes mellitus (T2DM) using a large US claims database. Methods For the years 2007 and 2012, Truven Health Marketscan Research Databases were used to identify adults with newly-diagnosed T2DM and continuous 12-month enrollment with prescription benefits. Variables examined included patient demographics, comorbidities, inpatient utilization patterns, healthcare costs (inpatient and outpatient), drug costs, and diabetes drug claim patterns. Results Despite an increase in the overall database population between 2007-2012, the incidence of newly-diagnosed T2DM decreased from 1.1% (2007) to 0.65% (2012). Hyperlipidemia and hypertension were the most common comorbidities and increased in prevalence from 2007 to 2012. In 2007, 48.3% of newly-diagnosed T2DM patients had no claims for diabetes medications, compared with 36.2% of patients in 2012. The use of a single oral anti-diabetic drug (OAD) was the most common diabetes medication-related claim (46.2% of patients in 2007; 56.7% of patients in 2012). Among OAD monotherapy users, metformin was the most commonly used and increased from 2007 (74.7% of OAD monotherapy users) to 2012 (90.8%). Decreases were observed for sulfonylureas (14.1% to 6.2%) and thiazolidinediones (7.3% to 0.6%). Insulin, predominantly basal insulin, was used by 3.9% of patients in 2007 and 5.3% of patients in 2012. Mean total annual healthcare costs increased from $13,744 in 2007 to $15,175 in 2012, driven largely by outpatient services, although costs in all individual categories of healthcare services (inpatient and outpatient) increased. Conversely, total drug costs per patient were lower in 2012 compared with 2007. Conclusions Despite a drop in the rate of newly-diagnosed T2DM from 2007 to 2012 in the US, increased total medical costs and comorbidities per individual patient suggest that the clinical and economic trends for T2DM are not declining.

Disparities in the prevalence of comorbidities among US adults by state Medicaid expansion status

INTRODUCTION

About 92% of US older adults have at least one chronic disease or medical condition and 77% have at least two. Low-income and uninsured adults in particular experience a higher burden of comorbidities, and the Medicaid expansion provision of the Affordable Care Act was designed to improve access to healthcare in this population group. However, a significant number of US states have declined expansion. The purpose of this study is to determine the distribution of low-income and uninsured adults in expanded versus non-expanded states, and evaluate the prevalence of comorbidities in both groups.

METHODS

Data from the 2013 Behavioral Risk Factor Surveillance System (BRFSS) dataset was analyzed, and Medicaid expansion status was assessed from the Center for Medicare and Medicaid Services report on State Medicaid and CHIP Income Eligibility Standards. Next, age adjusted mean number of comorbidities between expanded and non-expanded states was compared, with adjustment for socio-demographic differences.

RESULTS

Expanded states had a higher proportion of adults with income of at least $50,000 per year (39.6% vs. 35.5%, p<0.01) and a lower proportion of individuals with no health insurance coverage (15.2% vs. 20.3%, p<0.01) compared with non-expanded states. Among the uninsured, there was a higher proportion of obese (31.6% vs. 26.9%, p<001), and higher average number of comorbidities (1.62 vs. 1.52, p<0.01) in non-expanded states compared to expanded states. Overall, the prevalence of comorbidities was higher among BRFSS participants in states that did not expand Medicaid compared with those in expanded states.

CONCLUSION

States without Medicaid expansion have a greater proportion of poor, uninsured adults with more chronic diseases and conditions.

Circulating Biomarkers of Diabetic Retinopathy: An Overview Based on Physiopathology

Diabetic retinopathy (DR) is the main cause of working-age adult-onset blindness. The currently available treatments for DR are applicable only at advanced stages of the disease and are associated with significant adverse effects. In early stages of DR the only therapeutic strategy that physicians can offer is a tight control of the risk factors for DR. Therefore, new pharmacological treatments for these early stages of the disease are required. In order to develop therapeutic strategies for early stages of DR new diagnostic tools are urgently needed. In this regard, circulating biomarkers could be useful to detect early disease, to identify those diabetic patients most prone to progressive worsening who ought to be followed up more often and who could obtain the most benefit from these therapies, and to monitor the effectiveness of new drugs for DR before more advanced DR stages have been reached. Research of biomarkers for DR has been mainly based on the pathogenic mechanism involved in the development of DR (i.e., AGEs, oxidative stress, endothelial dysfunction, inflammation, and proangiogenic factors). This review focuses on circulating biomarkers at both early and advanced stages that could be relevant for the prediction or detection of DR.

Tools for Economic Analysis of Patient Management Interventions in Heart Failure Cost-Effectiveness Model: A Web-based program designed to evaluate the cost-effectiveness of disease management programs in heart failure

BACKGROUND

Heart failure disease management programs can influence medical resource use and quality-adjusted survival. Because projecting long-term costs and survival is challenging, a consistent and valid approach to extrapolating short-term outcomes would be valuable.

METHODS

We developed the Tools for Economic Analysis of Patient Management Interventions in Heart Failure Cost-Effectiveness Model, a Web-based simulation tool designed to integrate data on demographic, clinical, and laboratory characteristics; use of evidence-based medications; and costs to generate predicted outcomes. Survival projections are based on a modified Seattle Heart Failure Model. Projections of resource use and quality of life are modeled using relationships with time-varying Seattle Heart Failure Model scores. The model can be used to evaluate parallel-group and single-cohort study designs and hypothetical programs. Simulations consist of 10,000 pairs of virtual cohorts used to generate estimates of resource use, costs, survival, and incremental cost-effectiveness ratios from user inputs.

RESULTS

The model demonstrated acceptable internal and external validity in replicating resource use, costs, and survival estimates from 3 clinical trials. Simulations to evaluate the cost-effectiveness of heart failure disease management programs across 3 scenarios demonstrate how the model can be used to design a program in which short-term improvements in functioning and use of evidence-based treatments are sufficient to demonstrate good long-term value to the health care system.

CONCLUSION

The Tools for Economic Analysis of Patient Management Interventions in Heart Failure Cost-Effectiveness Model provides researchers and providers with a tool for conducting long-term cost-effectiveness analyses of disease management programs in heart failure.

The relationship between county-level contextual characteristics and use of diabetes care services

OBJECTIVES

To examine the relationship between county-level measures of social determinants and use of preventive care among US adults with diagnosed diabetes. To inform future diabetes prevention strategies.

METHODS

Data are from the Behavioral Risk Factor Surveillance System (BRFSS) 2004 and 2005 surveys, the National Diabetes Surveillance System, and the Area Resource File. Use of diabetes care services was defined by self-reported receipt of 7 preventive care services. Our study sample included 46 806 respondents with self-reported diagnosed diabetes. Multilevel models were run to assess the association between county-level characteristics and receipt of each of the 7 preventive diabetes care service after controlling for characteristics of individuals. Results were considered significant if P < .05.

RESULTS

Controlling for individual-level characteristics, our analyses showed that 7 of the 8 county-level factors examined were significantly associated with use of 1 or more preventive diabetes care services. For example, people with diabetes living in a county with a high uninsurance rate were less likely to have an influenza vaccination, visit a doctor for diabetes care, have an A1c test, or a foot examination; people with diabetes living in a county with a high physician density were more likely to have an A1c test, foot examination, or an eye examination; and people with diabetes living in a county with more people with less than high-school education were less likely to have influenza vaccination, pneumococcal vaccination, or self-care education (all P < .05).

CONCLUSIONS

Many of the county-level factors examined in this study were found to be significantly associated with use of preventive diabetes care services. County policy makers may need to consider local circumstances to address the disparities in use of these services.

Medical care expenditures associated with chronic kidney disease in adults with diabetes: United States 2011

OBJECTIVE

Approximately 1 in 3 adults with diabetes have CKD. However, there are no recent national estimates of the association of CKD with medical care expenditures in individuals with diabetes. Our aim is to assess the association of CKD with total medical expenditures in US adults with diabetes using a national sample and novel cost estimation methodology.

RESEARCH DESIGN AND METHODS

Data on 2,053 adults with diabetes in the 2011 Medical Expenditure Panel Survey (MEPS) was analyzed. Individuals with CKD were identified based on self-report. Adjusted mean health services expenditures per person in 2011 were estimated using a two-part model after adjusting for demographic and clinical covariates.

RESULTS

Of the 2,053 individuals with diabetes, approximately 9.7% had self-reported CKD. Unadjusted mean expenditures for individuals with CKD were $20,726 relative to $9,689.49 for no CKD. Adjusted mean expenditures from the 2-part model for individuals with CKD were $8473 higher relative to individuals without CKD. Additional significant covariates were Hispanic/other race, uninsured, urban dwellers, CVD, stroke, high cholesterol, arthritis, and asthma. The estimated unadjusted total expenditures for individuals with CKD were estimated to be in excess of $43 billion in 2011.

CONCLUSIONS

We showed that CKD is a significant contributor to the financial burden among individuals with diabetes, and that minorities and the uninsured with CKD may experience barriers in access to care. Our study also provides a baseline national estimate of CKD cost in Diabetes by which future studies can be used for comparison.

Is fenofibrate a reasonable treatment for diabetic microvascular disease?

Type 2 diabetes is a pandemic disease, and its prevalence is increasing mainly due to an increase in obesity and life expectancy. Diabetic complications and their comorbidities constitute the most important economic cost of the disease and represent a significant economic burden for the healthcare systems of developed countries. Despite improving standards of care, people with diabetes remain at risk of the development and progression of microvascular diabetic complications. Therefore, the identification of novel therapeutic approaches is necessary. The aim of this article is to provide an overview of the clinical benefits of fenofibrate on microvascular diabetic complications, with special emphasis on diabetic retinopathy. In addition, the potential mechanisms of action will be briefly discussed.

Novel approaches for treating diabetic retinopathy based on recent pathogenic evidence

Diabetic retinopathy remains as a leading cause of blindness in developed countries. Current treatments target late stages of DR when vision has already been significantly affected. A better understanding of the pathogenesis of DR would permit the development of more efficient preventional/interventional strategies against early stages of DR. In this article a critical review of the state of the art of this issue is provided along with a discussion of problems which have yet to be overcome. Neuroprotection as a new approach for the treatment of the early stages of DR has been particularly emphasized. The development and progression of DR is not homogeneous and, apart from blood glucose levels and blood pressure, it depends on genetic factors which remain to be elucidated. In addition, the role of the pathogenic pathways is not the same in all patients. All these factors should be taken into account in the near future when an individualized oriented treatment for DR could become feasible. The new techniques in retinal imaging acquisition, the identification of useful circulating biomarkers and the individualized analysis of biological samples could facilitate the development of early and personalized therapy in the setting of DR. Finally, it should be noted that only a coordinated action among ophthalmologists, diabetologists, basic researchers, experts in pharmaco-economics and health care providers addressed to the design of rational strategies targeting prevention and the early stages of DR will be effective in reducing the burden and improving the clinical outcome of this devastating complication of diabetes.

Impact of cardiovascular complications among patients with Type 2 diabetes mellitus: a systematic review

Macrovascular and microvascular complications that accompany Type 2 diabetes mellitus (T2DM) add to the burden among patients. The purpose of this systematic review is to conduct a comprehensive search of the medical literature investigating the prevalence of cardiovascular (CV) complications and assess their impact on healthcare costs, quality of life and mortality among patients with T2DM in the context of microvascular complications. A total of 76 studies and reports were used in this systematic review. Hypertension was the most prevalent complication among patients with T2DM. The additional cost burden due to CV complications was higher than any other complication except end-stage renal disease. Quality of life was much lower among patients with CV complications and T2DM, and mortality was higher than either illness alone.

Evaluation of the retinal nerve fibre layer and ganglion cell complex thickness in pituitary macroadenomas without optic chiasmal compression

PURPOSE

The aim of this prospective study was to measure the thickness of the circumpapillary retinal nerve fibre layer (cpRNFL) and the ganglion cell complex (GCC) using spectral domain optical coherence tomography (SD-OCT) in a cohort of consecutive de novo patients with pituitary macroadenomas without chiasmal compression.

PATIENTS AND METHODS

Twenty-two consecutive patients with pituitary macroadenoma without chiasmal compression (16 men, 6 women, aged 45.2±14.6 years, 43 eyes) entered the study between September 2011 and June 2013. Among them, 31.8% harboured a growth hormone-secreting pituitary adenoma, 27.3% a prolactin-secreting pituitary adenoma, 27.3% a corticotrophin-secreting pituitary adenoma, and 13.6% a non-secreting pituitary tumour. Eighteen subjects (nine females, nine males, mean age 36.47±6.37 years; 33 eyes) without pituitary adenoma, with normal ophthalmic examination, served as controls. In both patients and controls, cpRNFL and GCC thicknesses were measured by SD-OCT.

RESULTS

Patients were significantly older (P=0.02) than controls. Best corrected visual acuity, intraocular pressure, colour fundus photography, and automatic perimetry test were within the normal range in patients and controls. Conversely, cpRNFL (P=0.009) and GCC (P<0.0001) were significantly thinner in patients than in controls. The average GCC (r=0.306, P=0.046) significantly correlated with the presence of arterial hypertension. OCT parameters did not differ significantly between patients with a tumour volume above the median and those with a tumour volume below the median.

CONCLUSION

Pituitary macroadenomas, even in the absence of chiasmal compression, may induce GCC and retinal nerve fibre layer thinning. SD-OCT may have a role in the early diagnosis and management of patients with pituitary tumours.

Non-traditional systemic treatments for diabetic retinopathy: an evidence-based review

The rapid escalation in the global prevalence diabetes, with more than 30% being afflicted with diabetic retinopathy (DR), means it is likely that associated vision-threatening conditions will also rise substantially. This means that new therapeutic approaches need to be found that go beyond the current standards of diabetic care, and which are effective in the early stages of the disease. In recent decades several new pharmacological agents have been investigated for their effectiveness in preventing the appearance and progression of DR or in reversing DR; some with limited success while others appear promising. This up-to-date critical review of non-traditional systemic treatments for DR is based on the published evidence in MEDLINE spanning 1980-December 2014. It discusses a number of therapeutic options, paying particular attention to the mechanisms of action and the clinical evidence for the use of renin-angiotensin system blockade, fenofibrate and calcium dobesilate monohydrate in DR.

Somatostatin and diabetic retinopathy: current concepts and new therapeutic perspectives

Somatostatin (SST) is abundantly produced by the human retina, and the main source is the retinal pigment epithelium (RPE). SST exerts relevant functions in the retina (neuromodulation, angiostatic, and anti-permeability actions) by interacting with SST receptors (SSTR) that are also expressed in the retina. In the diabetic retina, a downregulation of SST production does exist. In this article, we give an overview of the mechanisms by which this deficit of SST participates in the main pathogenic mechanisms involved in diabetic retinopathy (DR): neurodegeneration, neovascularization, and vascular leakage. In view of the relevant SST functions in the retina and the reduction of SST production in the diabetic eye, SST replacement has been proposed as a new target for treatment of DR. This could be implemented by intravitreous injections of SST analogs or gene therapy, but this is an aggressive route for the early stages of DR. Since topical administration of SST has been effective in preventing retinal neurodegeneration in STZ-induced diabetic rats, it seems reasonable to test this new approach in humans. In this regard, the results of the ongoing clinical trial EUROCONDOR will provide useful information. In conclusion, SST is a natural neuroprotective and antiangiogenic factor synthesized by the retina which is downregulated in the diabetic eye and, therefore, its replacement seems a rational approach for treating DR. However, clinical trials will be needed to establish the exact position of targeting SST in the treatment of this disabling complication of diabetes.

Phenotypes and biomarkers of diabetic retinopathy

Diabetic retinopathy (DR) remains a major cause of blindness as the prevalence of diabetes is expected to approximately double globally between 2000 and 2030. DR progresses over time at different rates in different individuals with only a limited number developing significant vision loss due to the two major vision-threatening complications, clinically significant macular edema and proliferative retinopathy. Good metabolic control is important to prevent and delay progression, but whereas some patients escape vision loss even with poor control, others develop vision loss despite good metabolic control. Our research group has been able to identify three different DR phenotypes characterized by different dominant retinal alterations and different risks of progression to vision-threatening complications. Microaneurysm turnover has been validated as a prognostic biomarker of development of clinically significant macular edema, whereas subclinical macular edema identified by OCT and mfERG appear to be also good candidates as organ-specific biomarkers of DR. Hemoglobin A1c remains the only confirmed systemic prognostic biomarker of DR progression. The availability of biomarkers of DR progression and the identification of different phenotypes of DR with different risks for development of vision-threatening complications offers new perspectives for understanding DR and for its personalized management.

Neurodegeneration in the diabetic eye: new insights and therapeutic perspectives

Diabetic retinopathy (DR), one of the leading causes of preventable blindness, has been considered a microcirculatory disease of the retina. However, there is emerging evidence to suggest that retinal neurodegeneration is an early event in the pathogenesis of DR, which participates in the development of microvascular abnormalities. Therefore, the study of the underlying mechanisms leading to neurodegeneration and the identification of the mediators in the crosstalk between neurodegeneration and microangiopathy will be essential for the development of new therapeutic strategies. In this review, an updated discussion of the mechanisms involved in neurodegeneration, as well as the link between neurodegeneration and microangiopathy, is presented. Finally, the therapeutic implications and new perspectives based on identifying those patients with retinal neurodegeneration are given.

Estimating the prevalence of comorbid conditions and their effect on health care costs in patients with diabetes mellitus in Switzerland

BACKGROUND

Estimating the prevalence of comorbidities and their associated costs in patients with diabetes is fundamental to optimizing health care management. This study assesses the prevalence and health care costs of comorbid conditions among patients with diabetes compared with patients without diabetes. Distinguishing potentially diabetes- and nondiabetes-related comorbidities in patients with diabetes, we also determined the most frequent chronic conditions and estimated their effect on costs across different health care settings in Switzerland.

METHODS

Using health care claims data from 2011, we calculated the prevalence and average health care costs of comorbidities among patients with and without diabetes in inpatient and outpatient settings. Patients with diabetes and comorbid conditions were identified using pharmacy-based cost groups. Generalized linear models with negative binomial distribution were used to analyze the effect of comorbidities on health care costs.

RESULTS

A total of 932,612 persons, including 50,751 patients with diabetes, were enrolled. The most frequent potentially diabetes- and nondiabetes-related comorbidities in patients older than 64 years were cardiovascular diseases (91%), rheumatologic conditions (55%), and hyperlipidemia (53%). The mean total health care costs for diabetes patients varied substantially by comorbidity status (US$3,203-$14,223). Patients with diabetes and more than two comorbidities incurred US$10,584 higher total costs than patients without comorbidity. Costs were significantly higher in patients with diabetes and comorbid cardiovascular disease (US$4,788), hyperlipidemia (US$2,163), hyperacidity disorders (US$8,753), and pain (US$8,324) compared with in those without the given disease.

CONCLUSION

Comorbidities in patients with diabetes are highly prevalent and have substantial consequences for medical expenditures. Interestingly, hyperacidity disorders and pain were the most costly conditions. Our findings highlight the importance of developing strategies that meet the needs of patients with diabetes and comorbidities. Integrated diabetes care such as used in the Chronic Care Model may represent a useful strategy.

Health care costs in people with diabetes and their association with glycemic control and kidney function

OBJECTIVE

To determine the association between laboratory-derived measures of glycemic control (HbA1c) and the presence of renal complications (measured by proteinuria and estimated glomerular filtration rate [eGFR]) with the 5-year costs of caring for people with diabetes.

RESEARCH DESIGN AND METHODS

We estimated the cumulative 5-year cost of caring for people with diabetes using a province-wide cohort of adults with diabetes as of 1 May 2004. Costs included physician visits, hospitalizations, ambulatory care (emergency room visits, day surgery, and day medicine), and drug costs for people >65 years of age. Using linked laboratory and administrative clinical and costing data, we determined the association between baseline glycemic control (HbA1c), proteinuria, and kidney function (eGFR) and 5-year costs, controlling for age, socioeconomic status, duration of diabetes, and comorbid illness.

RESULTS

We identified 138,662 adults with diabetes. The mean 5-year cost of diabetes in the overall cohort was $26,978 per patient, excluding drug costs. The mean 5-year cost for the subset of people >65 years of age, including drug costs, was $44,511 (Canadian dollars). Cost increased with worsening kidney function, presence of proteinuria, and suboptimal glycemic control (HbA1c >7.9%). Increasing age, Aboriginal status, socioeconomic status, duration of diabetes, and comorbid illness were also associated with increasing cost.

CONCLUSIONS

The cost of caring for people with diabetes is substantial and is associated with suboptimal glycemic control, abnormal kidney function, and proteinuria. Future studies should assess if improvements in the management of diabetes, assessed with laboratory-derived measurements, result in cost reductions.

Molecular Implications of the PPARs in the Diabetic Eye

Diabetic retinopathy (DR) remains as the leading cause of blindness among working age individuals in developed countries. Current treatments for DR (laser photocoagulation, intravitreal corticosteroids, intravitreal anti-VEGF agents, and vitreoretinal surgery) are applicable only at advanced stages of the disease and are associated with significant adverse effects. Therefore, new pharmacological treatments for the early stages of the disease are needed. Emerging evidence indicates that peroxisome proliferator-activator receptors (PPARs) agonists (in particular PPARα) are useful for the treatment of DR. However, the underlying molecular mechanisms are far from being elucidated. This paper mainly focuses on PPARs expression in the diabetic eye, its molecular implications, and the effect of PPAR agonists as a new approach for the treatment of DR. The availability of this new strategy will not only be beneficial in treating DR but may also result in a shift towards treating earlier stages of diabetic retinopathy, thus easing the burden of this devastating disease (Cheung et al. (2010)).

Usefulness of the vitreous fluid analysis in the translational research of diabetic retinopathy

Diabetic retinopathy (DR) is the major cause of acquired blindness in working-age adults. Current treatments for DR (laser photocoagulation, intravitreal corticosteroids, intravitreal antivascular endothelial growth factor (VEGF) agents, and vitreo-retinal surgery) are applicable only at advanced stages of the disease and are associated with significant adverse effects. Therefore, new pharmacological treatments for the early stages of the disease are needed. Vitreous fluid obtained from diabetic patients undergoing vitreoretinal surgery is currently used to explore the events that are taking place in the retina for clinical research. However, several confounding factors such as vitreous haemorrhage and concentration of vitreous proteins should be considered in the analysis of the results. In this paper we will focus on the vitreous fluid as a tool for exploring the mediators of DR and in particular the molecules related to inflammatory pathways. In addition, their role in the pathogenesis of DR will be discussed. The usefulness of new technologies such as flow cytometry and proteomics in identifying new candidates involved in the inflammatory process that occurs in DR will be overviewed. Finally, a more personalized treatment based on vitreous fluid analysis aiming to reduce the burden associated with DR is suggested.

Neuroprotection in diabetic retinopathy

Diabetic retinopathy (DR) has been considered to be a microcirculatory disease of the retina. However, there is emerging evidence to suggest that retinal neurodegeneration is an early event in the pathogenesis of DR, which may antedate, and also participates in, the microcirculatory abnormalities that occur in DR. Therefore, the study of the underlying mechanisms that lead to neurodegeneration will be essential for identifying new therapeutic targets in the early stages of DR. Elevated levels of glutamate, oxidative stress, the overexpression of the renin-angiotensin system and the upregulation of RAGE play an essential role in the retinal neurodegeneration induced by diabetes. Finally, the balance between the neurotoxic and neuroprotective factors is crucial in determining the survival of retinal neurons. In this review we will focus on neurotrophic factors already synthesized by the retina in physiological conditions as a new therapy strategy for neuroprotection.

Fenofibrate - a potential systemic treatment for diabetic retinopathy?

PURPOSE

To review clinical and experimental data for fenofibrate as a possible systemic treatment for diabetic retinopathy.

DESIGN

Perspective.

METHODS

Review of clinical studies focused on 2 major randomized controlled trials: the FIELD (Fenofibrate Intervention and Event Lowering in Diabetes) and ACCORD (Action to Control Cardiovascular Risk in Diabetes)-Eye studies. Progression was defined in FIELD as laser treatment for proliferative retinopathy or macular edema or increase by ≥ 2 steps on the Early Treatment Diabetic Retinopathy Study (ETDRS) scale, and in ACCORD-Eye as ≥ 3 steps (ETDRS scale) or proliferative disease requiring laser or vitrectomy treatment. Experimental studies investigating the mode of action of fenofibrate were reviewed.

RESULTS

The 2 trials included 11 388 patients with type 2 diabetes mellitus, of whom 5701 were treated with fenofibrate (± statin) for up to 5 years. Fenofibrate reduced first laser treatment by 31% (P = .0002), and progression of diabetic retinopathy with absolute reductions of 5.0% over 5 years (P = .022, FIELD) and 3.7% over 4 years (P = .006, ACCORD-Eye). There was greater benefit in patients with than without preexisting retinopathy. The putative mechanisms implicated in the mode of action of fenofibrate involve lipid and nonlipid pathways, including beneficial effects on apoptosis, oxidative stress, inflammation, blood-retinal barrier breakdown, and neuroprotection.

CONCLUSIONS

There are now robust and consistent clinical data to recommend fenofibrate as an adjunctive treatment for early diabetic retinopathy in patients with type 2 diabetes mellitus, taking into account the risks vs benefits of therapy. Further elucidating its mode of action will help to refine how best to use fenofibrate in the management of diabetic retinopathy.

Diabetes care for older patients in America

BACKGROUND

Underuse of diabetes care was common for older patients. This study examined whether patient or physician practice characteristics predict the likelihood of diabetes care.

METHODS

We studied the 2006 and 2007 National Ambulatory Medical Care Survey data for a nationally-representative sample of 2912 visits by older patients with diabetes. We examined the patterns of diabetes care, including diagnostic testing (glucose, haemoglobinA1c, blood pressure and cholesterol) and patient counselling services (diet/nutrition, exercise). Multivariate analysis was performed to identify independent predictors of diabetes care, controlling for patient and physician practice characteristics. All analyses were adjusted for the complex survey design.

RESULTS

Having a designated primary care physician and the availability of electronic medical record or on-site laboratory testing were associated with more effective diabetes care (p < 0.05). If physician compensation relied on the productivity, physicians were less likely to provide diabetes care services (odds ratio = 0.5). The patterns of patient counselling and diagnostic testing services were similar (odds ratio = 2.5 and 18.2 for men; odds ratio = 1.8 and 9.6 for women). Older patients with diabetes were substantially more likely to receive diagnostic testing services than patient counselling.

CONCLUSION

A designated primary care physician is crucial for providing recommended diabetes care services for older patients. Strengthening structural capabilities of primary care practices and implementing patient-centred primary care initiatives in concert with health system reforms are necessary to deliver the co-ordinated diabetes care with maximised health outcomes.

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.

Diabetes preventive services and policy implications in the U.S

OBJECTIVE

To investigate whether the patient or physician practice characteristics predict the use of diabetes preventive care services.

RESEARCH DESIGN AND METHODS

This was a cross-sectional study of a nationally representative sample of 27,169 adult ambulatory care visits, using the 2007 National Ambulatory Medical Care Survey data. The outcome variable is whether any preventive care services, defined as diagnostic tests (glucose, urinalysis, A1C, and blood pressure) or patient education (diet/nutrition, exercise, and stress management), were ordered/provided. Multivariate analysis was performed to identify independent predictors of diabetes preventive care services, controlling for patient and physician practice characteristics. All analyses were adjusted for the complex survey design and analytic weights.

RESULTS

Compared with people without diabetes, diabetic patients were older (63 vs. 53 years; P < 0.01) and were more likely to be nonwhite and covered by Medicare insurance. In multivariate analyses, younger patients and the availability of primary care physicians, electronic medical records, and on-site laboratory tests were associated with more effective preventive care services (P < 0.05). If physician compensation relied on productivity, preventive care services were less likely (odds ratio 0.4 [95% CI 0.27-0.82 for men and 0.26-0.81 for women]). Although the patterns of patient education and diagnostic testing were similar, the provision of patient education was less likely than that of diagnostic testing.

CONCLUSIONS

Primary care physicians and practice features seem to steer diabetes preventive services. Given the time constraints of physicians, strategies to strengthen structural capabilities of primary care practices and enhance partnerships with public health systems on diabetic patient education are recommended.

The global burden of diabetes and its complications: an emerging pandemic

The number of patients with type 2 diabetes is increasing rapidly in both developed and developing countries around the world. The emerging pandemic is driven by the combined effects of population ageing, rising levels of obesity and inactivity, and greater longevity among patients with diabetes that is attributable to improved management. The vascular complications of type 2 diabetes account for the majority of the social and economic burden among patients and society more broadly. This review summarizes the burden of type 2 diabetes, impaired glucose tolerance, and their vascular complications. It is projected that by 2025 there will be 380 million people with type 2 diabetes and 418 million people with impaired glucose tolerance. Diabetes is a major global cause of premature mortality that is widely underestimated, because only a minority of persons with diabetes dies from a cause uniquely related to the condition. Approximately one half of patients with type 2 diabetes die prematurely of a cardiovascular cause and approximately 10% die of renal failure. Global excess mortality attributable to diabetes in adults was estimated to be 3.8 million deaths.

Confronting the type 2 diabetes epidemic: the emerging role of incretin-based therapies

This report highlights a roundtable discussion that occurred during the annual meeting of the International Diabetes Federation (IDF) in November 2009, in Montreal, Quebec, Canada. Participants included Bernard Zinman, MD, Michael A. Nauck, MD, PhD, Jorge Plutzky, MD, and Allison B. Goldfine, MD. The roundtable was chaired by Vivian A. Fonseca, MD. Among the topics discussed were the burden of type 2 diabetes mellitus and the importance of "appropriate therapy," which includes not only managing glycemia but also the management of concomitant risk factors such as hypertension and dyslipidemia. The discussants also identified issues that remain to be resolved, such as determining the nature of first-line therapy (e.g., should initial dual-agent therapy be encouraged?) and agreeing upon the most appropriate agent to be combined with metformin, which is the current standard of care. Among the new treatments discussed for type 2 diabetes were the analogues of the incretin hormones glucagonlike peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP), namely, the GLP-1 receptor agonists-as well as the inhibitors of dipeptidyl peptidase-4 (DPP-4), the enzyme that regulates the bioactivity of the endogenous incretin hormones. These agents have some interesting advantages; not only do they effectively lower glucose, but they also have demonstrated beneficial metabolic and cardiovascular effects. Particularly with respect to the GIP and GLP-1, weight loss, blood pressure reductions, and beta-cell function improvements have been observed in clinical trials. What remains to be determined, by means of additional clinical experience and perhaps additional head-to-head trials, are the long-term benefits of GLP-1 receptor agonists and DPP-4 inhibitors and the sorts of roles these 2 classes of agents may play in the type 2 diabetes therapeutic continuum.