Quality of diabetes care predicts the development of cardiovascular events: results of the AMD-QUASAR study

Quality of care and clinical inertia in the management of cardiovascular risk factors in patients with type 1 and type 2 diabetes: data from AMD annals

BACKGROUND

Cardiovascular disease is the leading cause of morbidity and mortality among patients with diabetes, and for this reason, all guidelines for CV risk management provide the same targets in controlling traditional CV risk factors in patients with type 1 or type 2 diabetes at equal CV risk class. Aim of our study was to evaluate and compare CV risk management in patients with type 1 and type 2 diabetes included in AMD Annals Database paying particular attention to indicators of clinical inertia.

METHODS

This was a multicenter, observational, retrospective study of AMD Annals Database during year 2022. Patients with diabetes were stratified on the basis of their cardiovascular risk, according to ESC-EASD guidelines. The proportion of patients not treated with lipid-lowering despite LDL cholesterol > to 100 mg/dl or the proportion of patients not treated with antihypertensive drug despite BP > 140/90 mmhg and proportion of patients with proteinuria not treated with angiotensin converting enzyme inhibitors or angiotensinogen receptor blockers (ACE/ARBs) were considered indicators of clinical inertia. The proportion of patients reaching at the same time HbA1c < 7% LDL < 70 mg/dl and BP < 130/80 mmhg were considered to have good multifactorial control. Overall quality of health care was evaluated by the Q-score.

RESULTS

Using the inclusion criteria and stratifying patients by ESC/EASD Cardiovascular Risk categories, we included in the analysis 118.442 patients at High Cardiovascular risk and 416.246 patients at Very High Cardiovascular risk. The proportion of patients with good multifactorial risk factor control was extremely low in both T1D and T2D patients in each risk class. At equal risk class, the patients with T1D had lower proportion of subjects reaching HbA1c, LDL, or Blood Pressure targets. Indicators of clinical inertia were significantly higher compared with patients with T2D at equal risk class. Data regarding patients with albuminuria not treated with RAAS inhibitors were available only for those at Very High risk and showed that the proportion of patients not treated was again significantly higher in patients with T1DM.

CONCLUSIONS

In conclusion, this study provides evidence of wide undertreatment of traditional cardiovascular risk factors among patients with diabetes included in AMD Annals Database. Undertreatment seems to be more pronounced in individuals with T1D compared to those with T2D and is frequently due to clinical inertia.

The quality of care in type 1 and type 2 diabetes - A 2023 update of the AMD Annals initiative

AIMS

An initiative of continuous monitoring of the quality of diabetes care, promoted by the Association of Medical Diabetologists, is in place in Italy since 2006 (AMD Annals). The initiative was effective in improving quality of care indicators, assessed periodically through standardized measures. Here, we show the 2023 AMD Annals data on type 2 (T2D) and type 1 (T1D) diabetes.

METHODS

A network of over 1/3 of diabetes centers in Italy periodically extracts anonymous data from electronic medical records, using a standardized software. Process, treatment and outcome indicators, and a validated score of overall care, the Q-score, were evaluated.

RESULTS

296 centers provided data on 573,164 T2D (mean age 69.7 ± 11.2 years) and 42,611 T1D subjects (mean age 48.6 ± 16.9 years). A HbA1c value ≤ 7.0 % was documented in 56.3 % of patients with T2D and 35.9 % of those with T1D. Only 6.6 % of T2D patients and 3.5 % of those with T1D reached the composite outcome of HbA1c ≤ 7.0 % + LDL-C < 70 mg/dl + BP < 130/80 mmHg. Notably, only 2.8 % and 3.2 % of T2D and T1D patients, respectively, showed a Q score < 15, which correlates with an 80 % higher risk of incident CVD events compared to scores > 25.

CONCLUSIONS

We documented an overall good quality of care in both T1D and T2D subjects. However, the failure to achieve the targets of the main risk factors, especially if combined, in a still too large proportion of patients testify the difficulty to apply the more and more stringent indications recommended by guidelines in the everyday clinical practice.

Digital Health in Diabetes and Cardiovascular Disease

BACKGROUND

Digital health technologies are rapidly evolving and transforming the care of diabetes and cardiovascular disease (CVD).

PURPOSE OF THE REVIEW

In this review, we discuss emerging approaches incorporating digital health technologies to improve patient outcomes through a more continuous, accessible, proactive, and patient-centered approach. We discuss various mechanisms of potential benefit ranging from early detection to enhanced physiologic monitoring over time to helping shape important management decisions and engaging patients in their care. Furthermore, we discuss the potential for better individualization of management, which is particularly important in diseases with heterogeneous and complex manifestations, such as diabetes and cardiovascular disease. This narrative review explores ways to leverage digital health technology to better extend the reach of clinicians beyond the physical hospital and clinic spaces to address disparities in the diagnosis, treatment, and prevention of diabetes and cardiovascular disease.

CONCLUSION

We are at the early stages of the shift to digital medicine, which holds substantial promise not only to improve patient outcomes but also to lower the costs of care. The review concludes by recognizing the challenges and limitations that need to be addressed for optimal implementation and impact. We present recommendations on how to navigate these challenges as well as goals and opportunities in utilizing digital health technology in the management of diabetes and prevention of adverse cardiovascular outcomes.

Precision prognostics for cardiovascular disease in Type 2 diabetes: a systematic review and meta-analysis

BACKGROUND

Precision medicine has the potential to improve cardiovascular disease (CVD) risk prediction in individuals with Type 2 diabetes (T2D).

METHODS

We conducted a systematic review and meta-analysis of longitudinal studies to identify potentially novel prognostic factors that may improve CVD risk prediction in T2D. Out of 9380 studies identified, 416 studies met inclusion criteria. Outcomes were reported for 321 biomarker studies, 48 genetic marker studies, and 47 risk score/model studies.

RESULTS

Out of all evaluated biomarkers, only 13 showed improvement in prediction performance. Results of pooled meta-analyses, non-pooled analyses, and assessments of improvement in prediction performance and risk of bias, yielded the highest predictive utility for N-terminal pro b-type natriuretic peptide (NT-proBNP) (high-evidence), troponin-T (TnT) (moderate-evidence), triglyceride-glucose (TyG) index (moderate-evidence), Genetic Risk Score for Coronary Heart Disease (GRS-CHD) (moderate-evidence); moderate predictive utility for coronary computed tomography angiography (low-evidence), single-photon emission computed tomography (low-evidence), pulse wave velocity (moderate-evidence); and low predictive utility for C-reactive protein (moderate-evidence), coronary artery calcium score (low-evidence), galectin-3 (low-evidence), troponin-I (low-evidence), carotid plaque (low-evidence), and growth differentiation factor-15 (low-evidence). Risk scores showed modest discrimination, with lower performance in populations different from the original development cohort.

CONCLUSIONS

Despite high interest in this topic, very few studies conducted rigorous analyses to demonstrate incremental predictive utility beyond established CVD risk factors for T2D. The most promising markers identified were NT-proBNP, TnT, TyG and GRS-CHD, with the highest strength of evidence for NT-proBNP. Further research is needed to determine their clinical utility in risk stratification and management of CVD in T2D.

The Burden of Obesity in Type 1 Diabetic Subjects: A Sex-specific Analysis From the AMD Annals Initiative

OBJECTIVE

Obesity is a growing emergency in type 1 diabetes (T1D). Sex differences in obesity prevalence and its clinical consequences in adult T1D subjects have been poorly investigated. The aim of this study was to investigate the prevalence of obesity and severe obesity, clinical correlates, and potential sex differences in a large cohort of T1D subjects participating to the AMD (Associazione Medici Diabetologi) Annals Initiative in Italy.

RESEARCH DESIGN AND METHODS

The prevalence of obesity [body mass index(BMI) ≥30 kg/m2] and severe obesity (BMI ≥ 35 kg/m2) according to sex and age, as well as obesity-associated clinical variables, long-term diabetes complications, pharmacological treatment, process indicators and outcomes, and overall quality of care (Q-score) were evaluated in 37 436 T1D subjects (45.3% women) attending 282 Italian diabetes clinics during 2019.

RESULTS

Overall, the prevalence of obesity was similar in the 2 sexes (13.0% in men and 13.9% in women; mean age 50 years), and it increased with age, affecting 1 out of 6 subjects ages >65 years. Only severe obesity (BMI >35 kg/m2) was more prevalent among women, who showed a 45% higher risk of severe obesity, compared with men at multivariate analysis. Cardiovascular disease risk factors (lipid profile, glucose, and blood pressure control), and the overall quality of diabetes care were worse in obese subjects, with no major sex-related differences. Also, micro- and macrovascular complications were more frequent among obese than nonobese T1D men and women.

CONCLUSIONS

Obesity is a frequent finding in T1D adult subjects, and it is associated with a higher burden of cardiovascular disease risk factors, micro- and macrovascular complications, and a lower quality of care, with no major sex differences. T1D women are at higher risk of severe obesity.

Precision Prognostics for Cardiovascular Disease in Type 2 Diabetes: A Systematic Review and Meta-analysis

Background Precision medicine has the potential to improve cardiovascular disease (CVD) risk prediction in individuals with type 2 diabetes (T2D). Methods We conducted a systematic review and meta-analysis of longitudinal studies to identify potentially novel prognostic factors that may improve CVD risk prediction in T2D. Out of 9380 studies identified, 416 studies met inclusion criteria. Outcomes were reported for 321 biomarker studies, 48 genetic marker studies, and 47 risk score/model studies. Results Out of all evaluated biomarkers, only 13 showed improvement in prediction performance. Results of pooled meta-analyses, non-pooled analyses, and assessments of improvement in prediction performance and risk of bias, yielded the highest predictive utility for N-terminal pro b-type natriuretic peptide (NT-proBNP) (high-evidence), troponin-T (TnT) (moderate-evidence), triglyceride-glucose (TyG) index (moderate-evidence), Genetic Risk Score for Coronary Heart Disease (GRS-CHD) (moderate-evidence); moderate predictive utility for coronary computed tomography angiography (low-evidence), single-photon emission computed tomography (low-evidence), pulse wave velocity (moderate-evidence); and low predictive utility for C-reactive protein (moderate-evidence), coronary artery calcium score (low-evidence), galectin-3 (low-evidence), troponin-I (low-evidence), carotid plaque (low-evidence), and growth differentiation factor-15 (low-evidence). Risk scores showed modest discrimination, with lower performance in populations different from the original development cohort. Conclusions Despite high interest in this topic, very few studies conducted rigorous analyses to demonstrate incremental predictive utility beyond established CVD risk factors for T2D. The most promising markers identified were NT-proBNP, TnT, TyG and GRS-CHD, with the highest strength of evidence for NT-proBNP. Further research is needed to determine their clinical utility in risk stratification and management of CVD in T2D.

Long-term quality-of-care score for predicting the occurrence of acute myocardial infarction in patients with type 2 diabetes mellitus

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death globally, and diabetes mellitus (DM) is a well-established risk factor. Among the risk factors for CVD, DM is a major modifiable factor. In the fatal CVD outcomes, acute myocardial infarction (AMI) is the most common cause of death.

AIM

To develop a long-term quality-of-care score for predicting the occurrence of AMI among patients with type 2 DM on the basis of the hypothesis that good quality of care can reduce the risk of AMI in patients with DM.

METHODS

Using Taiwan's Longitudinal Cohort of Diabetes Patient Database and the medical charts of a medical center, we identified incident patients diagnosed with type 2 DM from 1999 to 2003 and followed them until 2011. We constructed a summary quality-of-care score (with values ranging from 0 to 8) with process indicators (frequencies of HbA1c and lipid profile testing and urine, foot and retinal examinations), intermediate outcome indicators (low-density lipoprotein, blood pressure and HbA1c), and co-morbidity of hypertension. The associations between the score and the incidence of AMI were evaluated using Cox regression models.

RESULTS

A total of 7351 patients who had sufficient information to calculate the score were enrolled. In comparison with participants who had scores ≤ 1, those with scores between 2 and 4 had a lower risk of developing AMI [adjusted hazard ratio (AHR) = 0.71; 95% confidence interval (95%CI): 0.55-0.90], and those with scores ≥ 5 had an even lower risk (AHR = 0.37; 95%CI: 0.21-0.66).

CONCLUSION

Good quality of care can reduce the risk of AMI in patients with type 2 DM. The quality-of-care score developed in this study had a significant association with the risk of AMI and thus can be applied to guiding the care for these patients.

Uncovering Predictors of Lipid Goal Attainment in Type 2 Diabetes Outpatients Using Logic Learning Machine: Insights from the AMD Annals and AMD Artificial Intelligence Study Group

Identifying and treating lipid abnormalities is crucial for preventing cardiovascular disease in diabetic patients, yet only two-thirds of patients reach recommended cholesterol levels. Elucidating the factors associated with lipid goal attainment represents an unmet clinical need. To address this knowledge gap, we conducted a real-world analysis of the lipid profiles of 11.252 patients from the Annals of the Italian Association of Medical Diabetologists (AMD) database from 2005 to 2019. We used a Logic Learning Machine (LLM) to extract and classify the most relevant variables predicting the achievement of a low-density lipoprotein cholesterol (LDL-C) value lower than 100 mg/dL (2.60 mmol/L) within two years of the start of lipid-lowering therapy. Our analysis showed that 61.4% of the patients achieved the treatment goal. The LLM model demonstrated good predictive performance, with a precision of 0.78, accuracy of 0.69, recall of 0.70, F1 Score of 0.74, and ROC-AUC of 0.79. The most significant predictors of achieving the treatment goal were LDL-C values at the start of lipid-lowering therapy and their reduction after six months. Other predictors of a greater likelihood of reaching the target included high-density lipoprotein cholesterol, albuminuria, and body mass index at baseline, as well as younger age, male sex, more follow-up visits, no therapy discontinuation, higher Q-score, lower blood glucose and HbA1c levels, and the use of anti-hypertensive medication. At baseline, for each LDL-C range analysed, the LLM model also provided the minimum reduction that needs to be achieved by the next six-month visit to increase the likelihood of reaching the therapeutic goal within two years. These findings could serve as a useful tool to inform therapeutic decisions and to encourage further in-depth analysis and testing.

Pharmacological Treatment of Type-2-Diabetes and Cardiovascular Comorbidities: Differences between Undocumented Migrants and Natives in Italy

Diabetes prevalence is growing worldwide, especially in some populations. Though migrations seem to contribute to the presence in host countries of a significant number of patients with diabetes and its comorbidities, very little is known about the health conditions of undocumented migrants. We retrospectively studied 838 patients with type 2 diabetes mellitus (T2DM), 425 Italians followed by the diabetes clinic of a university hospital, and 413 undocumented migrants receiving assistance from a non-governmental organization. We analyzed their demographic and clinical data together with the medications they were on. The prevalence of the use of specific classes of drugs was compared between undocumented migrants and Italians by fitting a Poisson regression model, and the results were reported as prevalence rate ratios (PRRs) with a 95% confidence interval. Undocumented migrants with T2DM received fewer medications for cardiovascular (CV) conditions (PRR: 0.68, 0.60 to 0.76) than Italians, after correcting for confounding factors. Only sulfonylureas were more frequently used in undocumented migrants. The causes of these differences are not completely clear, but social, cultural, and economic factors can have an important role. More efforts are needed to provide appropriate treatment of diabetes and its CV comorbidities to undocumented migrants.

Role of telemedicine during COVID-19 pandemic in type 2 diabetes outpatients: The AMD annals initiative

AIMS

Telemedicine is advocated as a fundamental tool in modern clinical management. However, data on the effects of telemedicine vs face-to-face consultation on clinical outcomes in type 2 diabetes (T2DM) are still uncertain. This paper describes the use of telemedicine during the 2020 COVID-19 emergency and compares volume activity and quality indicators of diabetes care between face-to-face vs telemedicine counseling in the large cohort of T2DM patients from the AMD Annals Initiative.

METHODS

Demographic and clinical characteristics, including laboratory parameters, rate of the screening of long-term complications, current therapies and the Q-score, a validated score that measures the overall quality of care, were compared between 364,898 patients attending face-to-face consultation and 46,424 on telemedicine, during the COVID-19 pandemic.

RESULTS

Patients on telemedicine showed lower HbA1c levels (7.1 ± 1.2 % vs 7.3 ± 1.3 %, p < 0.0001), and they were less frequently treated with metformin, GLP1-RAs and SGLT2i and more frequently with DPP4i. The telemedicine group showed reduced monitoring of the various parameters considered as process indicators, especially, eye and foot examination. The proportion of patients with a good quality of care (Q score > 25) was higher among those receiving face-to-face consultation. Moreover, in the telemedicine group, all major clinical outcomes remained stable when further compared to those collected in the year 2019, when the same patients underwent a regular face-to-face consultation, suggesting that the care provided through telemedicine did not negatively affect the most important parameters.

CONCLUSIONS

During the COVID-19 pandemic, telemedicine provided an acceptable quality of diabetes care, comparable to that of patients attending face-to-face consultation, although a less frequent screening of complications seems to have occurred in subjects consulted by telemedicine.

Obesity among type 2 diabetes mellitus at Sidama Region, Southern Ethiopia

Background

Type 2 diabetes is becoming highly prevalent worldwide and it is one of the leading causes of mortality. The cause of mortality among these patients is mostly related to the dominant presence of modifiable cardiovascular risk factors such as obesity. The aim of the current study is therefore to determine the prevalence of obesity and its associated factors among patients with type 2 diabetes mellitus at Sidama region, Ethiopia.

Method

Institution-based cross-sectional study design was implemented to determine the prevalence of obesity and its associated factor among patients with type two diabetes at Hawassa University Comprehensive Specialized Hospital and Yirgalem General Hospital from October 16 2018 to December 21, 2018. A simple random sampling technique was implemented to select 314 study participants. After obtaining consent, different patients’ related data were collected using a questionnaire. Patients’ records were also reviewed. 4ml of the blood sample was collected from each study participant and analyzed for lipid profile test. Blood glucose level was done using COBAS INTEGRA 6000. A binary logistic regression was used to assess factors that have an association with obesity. A P-value of <0.05 was considered statistically significant.

Result

The majority of the study participants (67.2%) were male and 61.8% of the study participants were aged >45years. The overall prevalence of overweight and obesity among the study participants was 36.3% and 18.8% respectively. About 41% of the study participants have a normal BMI. Females were more obese (28.2% Vs 14.2%) than males and BMI stratification by sex was statistically significant (P = 0.02). Sex (AOR = 3.0, CI = 1.6–5.7, P-Value = 0.001) and TG (AOR = 3.6, CI = 1.6–8.3, P-Value = 0.003) are factors that were independently associated with obesity among type 2 DM patients.

Conclusion

Overweight and obesity among type two diabetic patients were prevalent. In addition, obesity and overweight disorder are common among T2DM and gender and triglycerides levels were associated with obesity.

Effect of inadequate care on diabetes complications and healthcare resource utilization during management of type 2 diabetes in the United States

OBJECTIVE

To estimate the effects of inadequate type 2 diabetes mellitus (T2D) care on health outcomes, utilizing a model that incorporates patient, physician, and health-system factors.

METHODS

The most recently available (years 2016 - 2018) Medical Expenditure panel survey longitudinal data was used to identify adults with type 2 diabetes who had received inadequate diabetes care. American Diabetes Association Standards of Diabetes guidelines were used to define inadequate care, resulting in five categories: lifestyle management, immunization, pharmacologic therapy, physical examination, and laboratory evaluation. For each of the five categories, propensity score 1:1 matching was used to match individuals who received inadequate care to similar individuals who did not. After matching, cohorts were followed for one year. The cohorts were compared by total healthcare expenditure change from baseline, total emergency healthcare visits change from baseline, total newly developed diabetes related complications, and total days absent from school or work change from baseline.

RESULTS

1,619 adults with T2D, representing 15,781,346 individuals met study inclusion criteria, of which 22.60%, 22.80%, 49.21%, 23,93%, and 23,45% received inadequate lifestyle management, immunizations, pharmacologic therapies, physical examinations, and laboratory tests, respectively. After propensity score matching, those who had received inadequate care had increased healthcare expenditure change from baseline and more new diabetes related complications in the following year. After adjusting for residual covariate imbalance, those that had received inadequate pharmacologic therapies had approximately 0.20 increased instances of emergency healthcare utilization and 0.10 increase in new diabetes related complications. Those that had received inadequate laboratory tests had 0.26 additional increased instances emergency healthcare utilization.

CONCLUSION

Inadequate T2D care is an extensive issue that may have substantial economic burden and may lead to increased diabetes related complications. Those who did not receive medications or laboratory tests that were consistent with ADA guidelines had significantly increased emergency healthcare utilization in the following year. These findings highlight the importance of careful monitoring of T2D.

Clinical profiles and quality of care of adults with type 1 diabetes according to their cardiovascular Risk: A Multicenter, Observational, retrospective study

AIMS

The European Society of Cardiology (ESC) recently defined cardiovascular risk classes for subjects with diabetes. Aim of this study was to explore the distribution of subjects with type 1 diabetes (T1D) by cardiovascular risk groups according to the ESC classification and to describe the quality indicators of care.

METHODS

The study is based on data extracted from electronic medical records of patients treated at the 258 Italian diabetes centers participating in the AMD (Associazione Medici Diabetologi) Annals initiative. Patients with T1D were stratified by cardiovascular risk. Measures of intermediate outcomes, intensity/appropriateness of pharmacological treatment, and overall quality of care were evaluated.

RESULTS

Overall, 29.368 subjects with type 1 diabetes (64.7% at very high cardiovascular risk, 28.5% at high risk and 6.8% at moderate risk) were evaluated. A lack of use of drugs in case of high values and an inadequate control despite the antihypertensive and lipid-lowering treatment was recognized. The overall quality of care tended to be lower as the level of cardiovascular risk increased.

CONCLUSION

A large proportion of subjects with T1D is at high or very high risk. Antihypertensive and lipid-lowering treatment seem not adequately used. Several actions are necessary to improve the quality of care.

Clinical profiles and quality of care of subjects with type 2 diabetes according to their cardiovascular risk: an observational, retrospective study

Background

The European Society of Cardiology (ESC) recently defined cardiovascular risk classes for subjects with diabetes. Aim of this study was to explore the distribution of subjects with type 2 diabetes (T2D) by cardiovascular risk groups according to the ESC classification and to describe the quality indicators of care, with particular regard to cardiovascular risk factors.

Methods

The study is based on data extracted from electronic medical records of patients treated at the 258 Italian diabetes centers participating in the AMD Annals initiative. Patients with T2D were stratified by cardiovascular risk. General descriptive indicators, measures of intermediate outcomes, intensity/appropriateness of pharmacological treatment for diabetes and cardiovascular risk factors, presence of other complications and overall quality of care were evaluated.

Results

Overall, 473,740 subjects with type 2 diabetes (78.5% at very high cardiovascular risk, 20.9% at high risk and 0.6% at moderate risk) were evaluated. Among people with T2D at very high risk: 26.4% had retinopathy, 39.5% had albuminuria, 18.7% had a previous major cardiovascular event, 39.0% had organ damage, 89.1% had three or more risk factors. The use of DPP4-i markedly increased as cardiovascular risk increased. The prescription of secretagogues also increased and that of GLP1-RAs tended to increase. The use of SGLT2-i was still limited, and only slightly higher in subjects with very high cardiovascular risk. The overall quality of care, as summarized by the Q score, tended to be lower as the level of cardiovascular risk increased.

Conclusions

A large proportion of subjects with T2D is at high or very high risk. Glucose-lowering drug therapies seem not to be adequately used with respect to their potential advantages in terms of cardiovascular risk reduction. Several actions are necessary to improve the quality of care.

Association between processes of diabetes care and health care utilization in patients with diabetes: Evidence from a nationally representative US sample

BACKGROUND

This study examined the association between quality of processes of diabetes care in terms of adherence to American Diabetes Association (ADA)-recommended guidelines and health care utilization in patients with diabetes.

METHODS

Adults with diabetes were identified from the pool of five panels of the Medical Expenditure Panel Survey, a nationally representative US sample, between 2012 and 2017. The Diabetes Care Survey was used to determine adherence to the ADA-recommended guidelines for processes of diabetes care if all of the following were performed annually: glycosylated hemoglobin check, foot examination, dilated eye examination, lipid panel, influenza immunization, blood pressure check, and dental examination. Health care utilization in terms of inpatient hospitalization, and emergency department (ED) and outpatient visits were estimated using two-part hurdle models.

RESULTS

An estimated 26.3 million adults with diabetes were derived from the pooled 5-panel data, of which 7.8% met the ADA-recommended guidelines for processes of diabetes care, and adherence rates of individual recommendations were generally below 50%. Overall, adults who adhered to the ADA-recommendations were older, non-Hispanic white, and married nonsmokers with private insurance and higher income. Mean inpatient hospital stays, ED, and outpatient visits between ADA-adherent vs nonadherent patients were 0.98 vs 1.62 (P < .001), 0.36 vs 0.39 (P = .074), and 17.9 vs 12.8 (P < .001), respectively.

CONCLUSIONS

Socioeconomic disadvantage and minority status were linked with nonadherence to the ADA-recommended processes of diabetes care. Adherence to the ADA recommendation was associated with significant reduction in inpatient hospitalization and a trend toward less ED visits. Our findings may apply to the United States and are likely to be different in other parts of the world.

Current Pharmacological Treatment of Type 2 Diabetes Mellitus in Undocumented Migrants: Is It Appropriate for the Phenotype of the Disease?

Type 2 diabetes is increasingly recognized as a spectrum of metabolic disorders sharing chronic hyperglycaemia. In Europe, the continually growing number of migrants from developing countries could affect diabetes phenotypes. We evaluated a population of 426 Italians and 412 undocumented migrants. Using 17 variables (with the exclusion of ethnic origin) we performed a multiple component analysis to detect potential clusters, independently from ethnicity. We also compared the two groups to evaluate potential ethnicity associated differences. We found five clusters of patients with different disease phenotypes. Comparing Italians with undocumented migrants, we noted that the first had more often cardiovascular risk factors and neurologic involvement, while the latter had a higher frequency of diabetic ulcers and renal involvement. Metformin was used in a comparable percentage of patients in all clusters, but other antidiabetic treatments showed some differences. Italians were more often on insulin, due to a larger use of long acting insulin, and received a larger number of oral antidiabetics in combination. Pharmacological treatment of comorbidities showed some differences too. We suggest that type 2 diabetes should be considered as a spectrum of diseases with different phenotypes also in heterogeneous populations, and that this is not due only to ethnic differences.

A performance score of the quality of inpatient diabetes care is a marker of clinical outcomes and suggests a cause-effect relationship between hypoglycaemia and the risk of in-hospital mortality

AIMS

To build a tool to assess the management of inpatients with diabetes mellitus and to investigate its relationship, if any, with clinical outcomes.

MATERIALS AND METHODS

A total of 678 patients from different settings, Internal Medicine (IMU, n = 255), General Surgery (GSU, n = 230) and Intensive Care (ICU, n = 193) Units, were enrolled. A work-flow of clinical care of diabetes was created according to guidelines. The workflow was divided into five different domains: (a) initial assessment; (b) glucose monitoring; (c) medical therapy; (d) consultancies; (e) discharge. Each domain was assessed by a performance score (PS), computed as the sum of the scores achieved in a set of indicators of clinical appropriateness, management and patient empowerment. Appropriate glucose goals were included as intermediate phenotypes. Clinical outcomes included: hypoglycaemia, survival rate and clinical conditions at discharge.

RESULTS

The total PS and those of initial assessment and glucose monitoring were significantly lower in GSU with respect to IMU and ICU (P < .0001). The glucose monitoring PS was associated with lower risk of hypoglycaemia (OR = 0.55; P < .0001), whereas both the PSs of glucose monitoring and medical therapy resulted associated with higher in-hospital survival only in the IMU ward (OR = 6.67 P = .001 and OR = 2.38 P = .03, respectively). Instrumental variable analysis with the aid of PS of glucose monitoring showed that hypoglycaemia may play a causal role in in-hospital mortality (P = .04).

CONCLUSIONS

The quality of in-hospital care of diabetes may affect patient outcomes, including glucose control and the risk of hypoglycaemia, and through the latter it may influence the risk of in-hospital mortality.

Cardiovascular risk factors control according to diabetes status and prior cardiovascular events in patients managed in different settings

AIMS

To document in recent cohorts the degree of control of major cardiovascular (CV) risk factors according to diabetes status and prior CV disease in different settings.

METHODS

We studied men and women aged 50-75 years of whom 3028 with type 2 diabetes mellitus (T2DM) managed at diabetes clinics participants of the TOSCA.IT (NCT00700856) study recruited in 2008-2014; 742 with T2DM managed mainly in primary care and 6753 without diabetes participating in the Moli-sani (NCT03242109) study and recruited in 2005-2010 from an adult general population.

RESULTS

Among people without a prior CV event people with diabetes managed at diabetes clinics have lower LDL-cholesterol and blood pressure and a more frequent use of lipid-lowering and antihypertensive medications as compared to people with diabetes managed mainly in primary care and to people without diabetes. The proportions achieving the recommended treatment targets are respectively 47.4% vs 33.4% vs 29.5% for LDL-cholesterol and 42.6% vs 9.5% vs 47.4% for blood pressure. Figures for the participants with prior CV events were 26.8% vs 15.1% vs 42.5% for LDL-cholesterol and 43.8% vs 8.5% vs 43.6% for blood pressure.

CONCLUSIONS

The study documents that in modern cohorts a large proportion of people with or without diabetes does not achieve the treatment targets for LDL-cholesterol and blood pressure, both in primary and secondary CV prevention. People with diabetes attending diabetes clinics achieve a better control of major CV risk factors than those managed mainly in primary care, thus highlighting the relevant role of a structured model of care.

Determinants of good metabolic control without weight gain in type 2 diabetes management: a machine learning analysis

INTRODUCTION

The aim of this study was to investigate the factors (clinical, organizational or doctor-related) involved in a timely and effective achievement of metabolic control, with no weight gain, in type 2 diabetes.

RESEARCH DESIGN AND METHODS

Overall, 5.5 million of Hab1c and corresponding weight were studied in the Associazione Medici Diabetologi Annals database (2005-2017 data from 1.5 million patients of the Italian diabetes clinics network). Logic learning machine, a specific type of machine learning technique, was used to extract and rank the most relevant variables and to create the best model underlying the achievement of HbA1c<7 and no weight gain.

RESULTS

The combined goal was achieved in 37.5% of measurements. High HbA1c and fasting glucose values and slow drop of HbA1c have the greatest relevance and emerge as first, main, obstacles the doctor has to overcome. However, as a second line of negative factors, markers of insulin resistance, microvascular complications, years of observation and proxy of duration of disease appear to be important determinants. Quality of assistance provided by the clinic plays a positive role. Almost all the available oral agents are effective whereas insulin use shows positive impact on glucometabolism but negative on weight containment. We also tried to analyze the contribution of each component of the combined endpoint; we found that weight gain was less frequently the reason for not reaching the endpoint and that HbA1c and weight have different determinants. Of note, use of glucagon-like peptide-1 receptor agonists (GLP1-RA) and glifozins improves weight control.

CONCLUSIONS

Treating diabetes as early as possible with the best quality of care, before beta-cell deterioration and microvascular complications occurrence, make it easier to compensate patients. This message is a warning against clinical inertia. All medications play a role in goal achievements but use of GLP1-RAs and glifozins contributes to overweight prevention.

Comparison and analyses of therapeutic effects between metabolic management center (MMC) and conventional management modes

AIMS

The past 3 decades witnessed the rapid growth of diabetes in China. To better serve large numbers of patients, the Chinese Medical Doctor Association launched metabolic management center (MMC) program which is featured with a one-stop and comprehensive diabetes management mode in 2016. It is worth exploring whether MMC model is better than conventional models in management.

METHODS

In this study, 228 patients with type 2 diabetes were recruited, and 193 patients completed the study. Therapeutic effects and health care costs were analyzed.

RESULTS AND CONCLUSIONS

Our results showed that decreases in HbA_1C and TG/HDL-C values were significantly greater in the MMC group than in the control group. The increase in HDL-C was significantly higher in the MMC group than in the control group. The percentage of patients whose HbA_1C lower than 7% was significantly higher in the MMC group. The results of the UKPDS model simulation showed that within 30 years, with the slight increases in treatment costs, the average life expectancy and total QALE of the MMC group are higher than those of the control group by 0.61 and 0.51 year, respectively. Further study showed that the drug intervention in the MMC group was significantly stronger. In addition, the questionnaires revealed that MMC group performed better in diabetes knowledge tests and have higher patient satisfaction rates of medical services. More patients in the MMC group adopted a more favorable diet strategy. These advantages enable MMC to achieve more short-term and long-term benefits in diabetes treatment than conventional mode.

Will undocumented migrants contribute to change epidemiology, presentation and pharmacologic treatment of diabetes in Western countries?

AIMS

Migrants from countries in which health and social conditions are unsatisfactory, and their offspring, are becoming a growing component of the western population. Available health data show that their morbidity is at least comparable to that of the host country population, with a significant contribution of chronic diseases as diabetes. The possibility that diabetes shows different features in undocumented migrants is the hypothesis that we tried to investigate in this study.

METHODS

We retrospectively analysed the data of 413 patients with type 2 diabetes mellitus (T2DM): 222 patients followed in a diabetes clinic at a University Hospital and 191 undocumented migrants cared for by a Charity in Milan, Italy.

RESULTS

We found that the onset of the disease was earlier in migrants; they showed a significant lower body mass index (BMI) and had lower socioeconomic conditions. They had a worse glycaemic control. The pattern of complications was also different between the two groups, with cardiovascular complications more frequent in Italians. Finally, also pharmacologic treatment differed significantly.

CONCLUSIONS

Age of onset, clinical manifestations and complications of T2DM in undocumented migrants and natives may show significant differences. This is important for both epidemiological and clinical reasons. If these preliminary observations are confirmed by larger studies, we can conclude that undocumented migrants should be screened for T2DM earlier than natives, and that therapies should be tailored to the specific features of their disease.

Overall Quality of Care Predicts the Variability of Key Risk Factors for Complications in Type 2 Diabetes: An Observational, Longitudinal Retrospective Study

OBJECTIVE

An association between variability in clinical parameters (HbA_1c, blood pressure, cholesterol, and uric acid) and risk of complications in type 2 diabetes has been reported. In this analysis, we investigated to what extent such variability is associated with overall quality of care.

RESEARCH DESIGN AND METHODS

The quality of care summary score (Q-score) represents a validated, overall quality of care indicator ranging between 0 and 40; the higher the score, the better the quality of care provided by the diabetes center. We identified patients with five or more measurements of clinical parameters after the assessment of the Q-score. Multiple linear regression analyses assessed the role of the Q-score in predicting the variability of the different parameters.

RESULTS

Overall, 273,888 patients were analyzed. The variability of all the parameters systematically increased with decreasing Q-score values. At multivariate linear regression analysis, compared with a Q-score >25, a score <15 was associated with a significantly larger variation in HbA_1c, blood pressure, uric acid, total cholesterol, and LDL cholesterol and a lower variation in HDL cholesterol. The analysis of standardized β coefficients show that the Q-score has a larger impact on the variability of HbA_1c (0.34; P < 0.0001), systolic blood pressure (0.21; P < 0.0001), total cholesterol (0.21; P < 0.0001), and LDL cholesterol (0.20; P < 0.0001).

CONCLUSIONS

The variability of risk factors for diabetic complications is associated with quality of care. Quality of care improvement initiatives should be targeted to increase the achievement of the recommended target while reducing such variability.

Adherence to quality of care measurements among 58,182 patients with new onset diabetes and its association with mortality

OBJECTIVES

Disease registry for diabetes care encourages transparency and benchmarking of quality of care (QoC) measurements for all service providers and seems to improve diabetes care. This study evaluate changes over time in QoC measurement performance in a large diabetes registry among newly diagnosed diabetics and it association with mortality.

METHODS

Retrospective cohort study of patients in a large health maintenance organization diabetes registry from years 2000 to 2013. We identified 58,182 patients diagnosed with diabetes from 2000-2008 and examined the level of performance for seven QoC measurements (HbA1c, LDL, albumin-creatinine-ratio, fundus/foot examinations, BMI and Blood-pressure) at diagnosis year. We also searched data regarding visits to dietitians or endocrinologists, and purchase of diabetes and statin medications. We used Mantel-Haenszel's χ2 test to assess QoC performance and mortality rate by calendar year of entry into the registry, and Cox regression to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause mortality up to 5 years from diagnosis adjusted for age, gender, socio-economic status and comorbidities.

RESULTS

The total QoC measurements improved from a mean of 2.71 tests performed in 2000 to 5.69 in 2008 (p<0.001). The mortality rate dropped from 7.7% in 2000 to 5.7% in 2008 (p<0.001). Patients with more QoC measurements performance who visited a dietitian and purchased statin medications had a lower mortality risk (HRs (95% CIs) 0.89 (0.87-0.92), 0.83 (0.76-0.91) and 0.70(0.65-0.75) respectively). Visits to endocrinologists and purchases of oral diabetes medication and insulin were associated with a higher risk of mortality (HRs (95% CIs) 1.20(1.07-1.35), 1.35(1.26-1.46) and 3.36(2.92-3.87) respectively).

CONCLUSION

Performance of QoC measurements including visiting a dietitian and purchase of statin medications were associated with lower mortality in patients with diabetes. It may be that the early active involvement of the patients in their care plays a protective role in long term mortality.

11th Annual Symposium on Self-Monitoring of Blood Glucose: April 12-14, 2018, Oslo, Norway

A panel of international experts in the field of diabetes and diabetes technology met in Oslo, Norway, for the 11th Annual Symposium on Self-Monitoring of Blood Glucose. The goal of these meetings is to share current knowledge, facilitate new collaborations, and encourage further research projects that can improve the lives of people with diabetes. The 2018 meeting comprised a comprehensive scientific program and four keynote lectures.

Long-term quality-of-care score predicts incident chronic kidney disease in patients with type 2 diabetes

Background

Chronic kidney disease (CKD) is a common complication of diabetes, and requires long-term medical care. However, besides the blood glucose level, no reliable method is currently available to link the quality of care and the development of CKD. We therefore developed a long-term quality-of-care score for predicting the occurrence of CKD in patients with type 2 diabetes.

Methods

In this retrospective cohort study, using Taiwan's Longitudinal Cohort of Diabetes Patients Database and the medical records in a medical center, we identified incident patients with type 2 diabetes during 1999-2003 and followed them until 2011. A quality-of-care score (from 0 to 8) was calculated according to process indicators (frequencies of HbA1c and lipid profile testing and urine, foot, and retinal examinations), intermediate outcome indicators (low-density lipoprotein, blood pressure, and HbA1c) and comorbidity of hypertension. We used Cox regression models to evaluate the association between the score and the incidence of CKD.

Results

Of the 4754 patients enrolled, 1407 developed CKD after a mean follow-up of 9.06 years. Compared with the risk of developing a CKD event in patients with scores ≤2, the risk was 69% lower in those with quality-of-care scores ≥5 (hazard ratio [HR] 0.31; 95% confidence interval [CI] 0.25-0.40) and 33% lower in those with scores between 3 and 4 (HR 0.67; 95% CI 0.59-0.77).

Conclusions

Good quality of care can reduce the risk of CKD in patients with type 2 diabetes. The score developed in this study had a significant association with the risk of CKD and thus can be applied to guide the care for these patients.

Prevalence of cardiovascular disease in type 2 diabetes: a systematic literature review of scientific evidence from across the world in 2007-2017

BACKGROUND

Cardiovascular disease (CVD) is a common comorbidity in type 2 diabetes (T2DM). CVD's prevalence has been growing over time.

PURPOSE

To estimate the current prevalence of CVD among adults with T2DM by reviewing literature published within the last 10 years (2007-March 2017).

METHODS

We searched Medline, Embase, and proceedings of major scientific meetings for original research documenting the prevalence of CVD in T2DM. CVD included stroke, myocardial infarction, angina pectoris, heart failure, ischemic heart disease, cardiovascular disease, coronary heart disease, atherosclerosis, and cardiovascular death. No restrictions were placed on country of origin or publication language. Two reviewers independently searched for articles and extracted data, adjudicating results through consensus. Data were summarized descriptively. Risk of bias was examined by applying the STROBE checklist.

RESULTS

We analyzed data from 57 articles with 4,549,481 persons having T2DM. Europe produced the most articles (46%), followed by the Western Pacific/China (21%), and North America (13%). Overall in 4,549,481 persons with T2DM, 52.0% were male, 47.0% were obese, aged 63.6 ± 6.9 years old, with T2DM duration of 10.4 ± 3.7 years. CVD affected 32.2% overall (53 studies, N = 4,289,140); 29.1% had atherosclerosis (4 studies, N = 1153), 21.2% had coronary heart disease (42 articles, N = 3,833,200), 14.9% heart failure (14 studies, N = 601,154), 14.6% angina (4 studies, N = 354,743), 10.0% myocardial infarction (13 studies, N = 3,518,833) and 7.6% stroke (39 studies, N = 3,901,505). CVD was the cause of death in 9.9% of T2DM patients (representing 50.3% of all deaths). Risk of bias was low; 80 ± 12% of STROBE checklist items were adequately addressed.

CONCLUSIONS

Globally, overall CVD affects approximately 32.2% of all persons with T2DM. CVD is a major cause of mortality among people with T2DM, accounting for approximately half of all deaths over the study period. Coronary artery disease and stroke were the major contributors.

A long-term quality-of-care score for predicting the occurrence of macrovascular diseases in patients with type 2 diabetes mellitus

AIMS

The aim of this study was to develop a long-term quality-of-care score to predict the occurrence of macrovascular diseases in patients with type 2 diabetes mellitus, on the basis of the hypothesis that good quality of care can reduce the risk of macrovascular complications.

METHODS

Using Taiwan's Longitudinal Cohort of Diabetes Patients Database and the medical records in a medical center, we identified the incident patients diagnosed with type 2 diabetes during 1999-2003 and followed them until 2011. A summary score (from 0 to 8) was calculated according to process indicators (frequencies of HbA1_c and lipid profile testing and urine, foot and retinal examinations), intermediate outcome indicators (low-density lipoprotein, blood pressure and HbA1_c), and the co-morbidity of hypertension. We used Cox regression models to evaluate the association between the score and the incidence of macrovascular complications.

RESULTS

Of the 4275 patients enrolled, 1928 developed macrovascular complication events after a mean follow-up period of 8.2 years. Compared to the risk of developing a macrovascular disease event in patients with scores ≤1, the risk was 64% lower in those with quality-of-care scores ≥5 (adjusted hazard ratio = 0.36; 95% confidence interval: 0.28-0.45).

CONCLUSIONS

Good quality of care can reduce the risk of macrovascular diseases in patients with type 2 diabetes. The score developed in this study had a significant association with the risk of macrovascular complications and thus can be applied to guiding the care for these patients.

Diabetic kidney disease in the elderly: prevalence and clinical correlates

BACKGROUND

Diabetic kidney disease (DKD) is a major burden in elderly patients with type 2 diabetes (T2DM). Low estimated glomerular filtration rate (eGFR+, < 60 mL/min/1.73 m2) and albuminuria (Alb+) are essential for the diagnosis of DKD, but their association with clinical variables and quality of care may be influenced by ageing.

METHODS

Here we investigated the association of clinical variables and quality of care measures with eGFR+ and Alb+ in 157,595 T2DM individuals participating to the Italian Association of Clinical Diabetologists (AMD) Annals Initiative, stratified by age.

RESULTS

The prevalence of eGFR+ and Alb+ increased with ageing, although this increment was more pronounced for low eGFR. Irrespective of age, both the eGFR+ and Alb + groups had the worst risk factors profile when compared to subjects without renal disease, showing a higher prevalence of out-of target values of HbA1c, BMI, triglycerides, HDL-C, blood pressure and more complex cardiovascular (CVD) and anti-diabetic therapies, including a larger use of insulin In all age groups, these associations differed according to the specific renal outcome examined: male sex and smoking were positively associated with Alb+ and negatively with eGFR+; age and anti-hypertensive therapies were more strongly associated with eGFR+, glucose control with Alb+, whereas BMI, and lipid-related variables with both abnormalities. All these associations were attenuated in the older (> 75 years) as compared to the younger groups (< 65 years; 65-75 years), and they were confirmed by multivariate analysis. Notably, Q-score values < 15, indicating a low quality of care, were strongly associated with Alb+ (OR 8.54; P < 0.001), but not with eGFR+.

CONCLUSIONS

In T2DM patients, the prevalence of both eGFR and Albuminuria increase with age. DKD is associated with poor cardiovascular risk profile and a lower quality of care, although these associations are influenced by the type of renal abnormality and by ageing. These data indicate that clinical surveillance of DKD should not be unerestimated in old T2DM patients.

State-of-the-Art Review on Diabetes Care in Italy

BACKGROUND

Diabetes is a significant health problem in Italy as in other western countries.

OBJECTIVE

To review available epidemiological data and the legislative framework for diabetes care in Italy.

METHODS

Review of Italian Health Ministry's official documents and analysis of epidemiological data published by Italian Scientific Societies.

FINDINGS

Diabetes affects more than 5% of the Italian population. The expenditures for the care of people with diabetes are about €10 billion ($US 11 billion) a year and are increasing over time. Italian law regulates the clinical care of people with diabetes and creates a clinical framework involving medical organizations, prevention programs, personnel training, and legal protection. The National Health Program is structured in essential levels of assistance that can be defined differently in the various regions. In 2013, the "National Diabetes Plan," defining priority areas for intervention, was approved and represents the main regulatory tool for the management of diabetes within the Italian National Health Service. In Italy, the status of diabetes care is being monitored using the data from 2 permanent observatories: the ARNO Observatory Diabetes and the Associazione Medici Diabetologi Annals.

CONCLUSIONS

A comprehensive approach to diabetes is offered to all citizens, consonant with the constitutionally guaranteed right to health. However, this important effort translates into a relevant financial burden for the National Health Service.

Quality of Diabetes Care for Individuals with Comorbid Chronic Psychotic Illness: A Sex-Based Analysis

BACKGROUND

Diabetes is common among individuals with chronic psychotic illness, yet they receive lower quality of diabetes care than those without psychosis. Men usually receive higher quality diabetes care than women, but whether this holds true in chronic psychotic illness populations is unknown. We aimed to determine whether quality of diabetes care differs between men and women with chronic psychotic illness.

METHODS

This population-based cohort study used Ontario health administrative data to compare women and men with comorbid chronic psychotic illness and diabetes mellitus (2011-2013). The primary outcome was adherence to diabetes monitoring guidelines, defined as ≥1 retinal exam, ≥4 hemoglobin A1c (HbA1c) tests, and ≥1 dyslipidemia test during a 2-year period. Logistic regression models compared women to men to generate adjusted odds ratios (aOR) and confidence intervals (95% CI), adjusting for potential confounding variables.

RESULTS

Women with chronic psychotic illness (n = 13,972) were slightly more likely to receive guideline-adherent diabetes monitoring than men (n = 12,287) (25.2% vs. 23.0%; aOR 1.20, 95% CI 1.10-1.30), including a greater likelihood of receiving ≥1 retinal exam (aOR 1.13, 95% CI 1.08-1.19) and ≥4 HbA1c tests (aOR 1.06, 95% CI 1.01-1.12). There was no difference in receipt of ≥1 dyslipidemia test (aOR 1.04, 95% CI 0.99-1.11).

CONCLUSIONS

Quality of diabetes monitoring is similarly poor in women and men with chronic psychotic illness, with women receiving only marginally more optimal monitoring than men. This differs from patterns in the general population, and could have implications when designing and implementing interventions to improve diabetes care in women and men with chronic psychotic illness.

Antihyperglycemic treatment in patients with type 2 diabetes in Italy: the impact of age and kidney function

We describe AHA utilization pattern according to age and renal function in type 2 diabetes mellitus (T2DM), in real-life conditions.

The analysis was performed using the data set of electronic medical records collected between 1 January and 31 December, 2011 in 207 Italian diabetes centers. The study population consisted of 157,595 individuals with T2DM. The AHA treatment regimens was evaluated. Kidney function was assessed by eGFR, estimated using the CKD-EPI formula. Other determinations: HbA1c, blood pressure (BP), low- density lipoprotein (LDL-c), total and high density lipoprotein cholesterol (TC and HDL-c), triglycerides (TG) and serum uric acid (SUA). Quality of care was assessed through Q score.

The proportion of subjects taking metformin declined progressively across age quartiles along with eGFR values, but remained high in oldest subjects (i.e. 54.5 %). On the other hand, the proportion of patients on secretagogues or insulin increased with aging (i.e. 54.7% and 37% in the fourth age quartile, respectively). The percentage of patients with low eGFR (i.e. <30 ml/min/1.73m2) taking either metformin or sulphonilureas/repaglinide was particularly high (i.e. 15.3% and 34.3% respectively).

In a large real-life cohort of T2DM, metformin or sulphonylureas/repaglinide, although not recommended, are frequently prescribed to elderly subjects with severe kidney disease.

Occurrence over time and regression of nonalcoholic fatty liver disease in type 2 diabetes

BACKGROUND

This analysis was aimed to assess the incidence, regression, and correlated factors of nonalcoholic fatty liver disease (NAFLD) in type 2 diabetes, which are poorly known.

METHODS

Nonalcoholic fatty liver disease (defined as fatty liver index [FLI] score ≥ 60) in patients with type 2 diabetes, and related factors was investigated in a nationwide database containing information from the Italian network of diabetes clinics. A 10% variation of FLI was the cut-off considered in the analyses of a cohort of 5030 patients, which was separately conducted for those who developed, maintained, or recovered from FLI-assessed NAFLD (FLI-NAFLD) over a 3-year period.

RESULTS

At baseline, FLI-NAFLD was diagnosed in 61.3% of patients. Within the 3-year study period, FLI-NAFLD occurred in 313 patients and remitted in 410. The FLI score remained unchanged in 4307. Body-mass index (odds ratio, 1.45 95%; confidence interval, 1.35-1.55), abdominal obesity (2.11; 1.64-2.72), low HDL cholesterol levels (1.38; 1.02-1.87), and triglycerides (1.20; 1.12-1.28) all emerged as notable negative prognostic factors for the development or maintenance of FLI-NAFLD. The regression rate of FLI-NAFLD was higher among patients who managed to partially control these factors. Male sex and established organ damage, especially kidney function (1.64; 1.12-2.42), were independent risk predictors. Unlike other diabetes complications, FLI-NAFLD was more frequent among younger patients or those with a shorter duration of diabetes.

CONCLUSIONS

FLI-assessed NAFLD is a dynamic condition, with about 5% of diabetic patients entering or leaving the status every year. Younger male patients with insulin resistance or organ damage have a higher risk of presenting with FLI-NAFLD at baseline, developing FLI-NAFLD within 3 years, and a lower probability of regression.

Cardiovascular complications and drug prescriptions in subjects with and without diabetes in a Northern region of Italy, in 2002 and 2012

BACKGROUND AND AIMS

In contrast to the well-documented global prevalence of diabetes, much less is known about the epidemiology of cardiovascular (CV) complications in recent years. We describe the incidence of major CV events, deaths and drug prescribing patterns from 2002 to 2012 in subjects with (DM) or without diabetes mellitus (No DM).

METHODS AND RESULTS

Subjects and outcomes were identified using linkable health administrative databases of Lombardy, a region in Northern Italy. A logistic regression model was used to compare myocardial infarction (MI), stroke, major amputation and death between DM and No DM in 2002 and 2012 and between the two index years in each population. The interaction between years and diabetes was introduced in the model. From 2002 to 2012 the incidence of major CV complications and death fell in both groups with a larger reduction among DM only for CV events: OR (95% CI) for the interaction 0.86 (0.79-0.93) for MI, 0.89 (0.82-0.96) for stroke, 0.78 (0.57-1.06) for major amputations. CV prevention drugs rose considerably from 2002 to 2012 particularly in DM and a switch towards safer antihyperglycemic drugs was also observed.

CONCLUSIONS

Major CV complications and death declined from 2002 to 2012 in both DM and No DM. This might be due to a larger increase in prescriptions of CV drugs in DM and a relevant change toward recommended antihyperglycemic drugs.

Gender-Disparities in Adults with Type 1 Diabetes: More Than a Quality of Care Issue. A Cross-Sectional Observational Study from the AMD Annals Initiative

We evaluated gender-differences in quality of type 1 diabetes (T1DM) care. Starting from electronic medical records of 300 centers, 5 process indicators, 3 favorable and 6 unfavorable intermediate outcomes, 6 treatment intensity/appropriateness measures and an overall quality score were measured. The likelihood of women vs. men (reference class) to be monitored, to reach outcomes, or to be treated has been investigated through multilevel logistic regression analyses; results are expressed as Odd Ratios (ORs) and 95% confidence intervals (95%CIs). The inter-center variability in the achievement of the unfavorable outcomes was also investigated. Overall, 28,802 subjects were analyzed (45.5% women). Women and men had similar age (44.5±16.0 vs. 45.0±17.0 years) and diabetes duration (18.3±13.0 vs. 18.8±13.0 years). No between-gender differences were found in process indicators. As for intermediate outcomes, women showed 33% higher likelihood of having HbA1c ≥8.0% (OR = 1.33; 95%CI: 1.25–1.43), 29% lower risk of blood pressure ≥140/90 mmHg (OR = 0.71; 95%CI: 0.65–0.77) and 27% lower risk of micro/macroalbuminuria (OR = 0.73; 95%CI: 0.65–0.81) than men, while BMI, LDL-c and GFR did not significantly differ; treatment intensity/appropriateness was not systematically different between genders; overall quality score was similar in men and women. Consistently across centers a larger proportion of women than men had HbA1c ≥8.0%, while a smaller proportion had BP ≥140/90 mmHg. No gender-disparities were found in process measures and improvements are required in both genders. The systematic worse metabolic control in women and worse blood pressure in men suggest that pathophysiologic differences rather than the care provided might explain these differences.

The Burden of NAFLD and Its Characteristics in a Nationwide Population with Type 2 Diabetes

OBJECTIVE

We studied the prevalence of nonalcoholic fatty liver disease (NAFLD) and its clinical correlates in a population of patients with type 2 diabetes mellitus (T2DM).

METHODS

Clinical data of 94,577 T2DM patients were retrieved from 160 diabetes clinics in Italy in a standardized format and centrally analyzed anonymously. After exclusion of 5967 cases (high or uncertain alcohol intake), in 38,880 the Fatty Liver Index (FLI) was used as a proxy for the diagnosis of NAFLD. Factors associated with FLI assessed NAFLD (FLI-NAFLD) were evaluated through multivariate analysis.

RESULTS

FLI-NAFLD was present in 59.6% of patients. Compared to non-NAFLD, FLI-NAFLD was associated with impairment in renal function, higher albumin excretion, HbA1c and blood pressure, lower HDL cholesterol, and poorer quality of care. ALT was within normal limits in 73.6% of FLI-NAFLD patients (45.6% if the updated reference values were used). The prevalence of FLI-NAFLD did not differ if the whole sample (94,577 cases) was examined, irrespective of alcohol intake.

CONCLUSIONS

FLI-NAFLD was present in the majority of T2DM patients of our sample and metabolic derangement, not alcohol consumption, was mainly associated with the disease. FLI-NAFLD patients have a worse metabolic profile. ALT levels are not predictive of NAFLD.

Older Adults Reporting More Diabetes Mellitus Care Have Greater 9-Year Survival

OBJECTIVES

To determine whether receiving more recommended diabetes mellitus (DM) care processes (tests and screenings) would translate into better 9-year survival for middle-aged and older adults.

DESIGN

Longitudinal mortality analysis using the Health and Retirement Study Diabetes Mailout Survey.

SETTING

Health and Retirement Study (HRS).

PARTICIPANTS

Individuals aged 51 and older (n = 1,879; mean age 68.8 ± 8.7, 26.5% aged ≥75) with self-reported DM who completed the Diabetes Mailout Survey and the core 2002 HRS survey.

MEASUREMENTS

A composite measure of five self-reported diabetes mellitus care process measures were dichotomized as greater (3-5 processes) versus fewer (0-2 processes) care processes provided. Cox proportional hazards models were used to test relationships between reported measures and mortality, controlling for sociodemographic characteristics, function, comorbidities, geriatric conditions, and insulin use.

RESULTS

Prevalence of self-reported care processes was 80.1% for glycosylated hemoglobin test, 75.9% for urine test, 67.5% for eye examination, 67.7% for aspirin counseling, and 48.2% for diabetes education. In 9 years, 32.1% respondents died. Greater care correlated with 24% lower risk of dying (adjusted hazard ratio = 0.76, 95% confidence interval = 0.64-0.91) at 9-year follow up. When respondents were age-stratified (≥75 vs <75) longer survival was statistically significant only in the older age group.

CONCLUSION

Although it is not possible to account for differences in adherence to care that may also affect survival, this study demonstrates that monitoring of and counseling about types of DM care processes are associated with long-term survival benefit even in individuals aged 75 and older with DM.

Do the classification of areas and distance matter to the assessment results of achieving the treatment targets among type 2 diabetes patients?

Background

Type 2 diabetes is a major health concern all over the world. The prevention of diabetes is important but so is well-balanced diabetes care. Diabetes care can be influenced by individual and neighborhood socio-economic factors and geographical accessibility to health care services. The aim of the study is to find out whether two different area classifications of urban and rural areas give different area-level results of achieving the targets of control and treatment among type 2 diabetes patients exemplified by a Finnish region. The study exploits geo-referenced patient data from a regional primary health care patient database combined with postal code area-level socio-economic variables, digital road data and two grid based classifications of areas: an urban–rural dichotomy and a classification with seven area types.

Methods

The achievement of control and treatment targets were assessed using the patient’s individual laboratory data among 9606 type 2 diabetes patients. It was assessed whether hemoglobin A1c (HbA1c) was controlled and whether the recommended level of HbA1c was achieved in patients by different area classes and as a function of distance. Chi square test and logistic regression analysis were used for testing.

Results

The study reveals that area-level inequalities exist in the care of type 2 diabetes in a detailed 7-class area classification but if the simple dichotomy of urban and rural is applied differences vanish. The patient’s gender and age, area-level education and the area class they belonged to were associated with achievements of control and treatment targets. Longer distance to health care services was not a barrier to good achievements of control or treatment targets.

Conclusions

A more detailed grid-based area classification is better for showing spatial differences in the care of type 2 diabetes patients. Inequalities exist but it would be misleading to state that the differences are simply due to urban or rural location or due to distance. From a planning point of view findings suggest that detailed geo-coded patient information could be utilized more in resourcing and targeting the health care services to find the area-level needs of care and to improve the cost-efficient allocation of resources.

Trends over 8 years in quality of diabetes care: results of the AMD Annals continuous quality improvement initiative

OBJECTIVE

Quality of care monitoring is a key strategy for health policy. In Italy, the AMD Annals continuous monitoring and quality improvement initiative has been in place since 2006. Results after 8 years are now available.

RESEARCH DESIGN AND METHODS

Quality of diabetes care indicators during the years 2004-2011 were extracted from electronic medical records of 300 diabetes clinics. From 200,000 to 500,000 patients with type 2 diabetes were analyzed per year. Six process indicators, eight intermediate outcome indicators, seven indicators of treatment intensity/appropriateness, and a quality of care summary score (Q score) were evaluated. Previous studies documented that the risk of developing a new cardiovascular event was 80 % higher in patients with a Q score <15 and 20 % higher in those with a score between 15 and 25, as compared to those with a score >25.

RESULTS

The proportion of patients with HbA1c ≤7 %, LDL cholesterol <100 mg/dl, and blood pressure ≥140/90 mmHg increased by 4.8, 21.9, and 10.0 %, respectively. Process and treatment intensity/appropriateness indicators consistently improved. The proportion of patients with a Q score <15 decreased from 13.5 to 6.5 %, while those with a Q score >25 increased from 22.9 to 38.5 %.

CONCLUSIONS

AMD Annals document the progress in quality of diabetes care. Longitudinal improvements in Q score can translate into less cardiovascular events, with evident clinical and economic implications. AMD Annals represent a physician-led effort not requiring allocation of extra-economic resources, which is easy to implement and deeply rooted in routine clinical practice. They are a potential case model for other healthcare systems.

Achievement of therapeutic targets in patients with diabetes and chronic kidney disease: insights from the Associazione Medici Diabetologi Annals initiative

BACKGROUND

Chronic kidney disease (CKD) entails a worse cardiovascular outcome. The aim of our work was to study the relationship between CKD and the achievement of recommended targets for glycated haemoglobin (HbA1c), low-density lipoprotein cholesterol (LDL-c) and blood pressure (BP) in a real-life sample of patients with type 2 diabetes mellitus (T2DM).

METHODS

We analysed a sample of 116 777 outpatients from the Network of the Italian Association of Clinical Diabetologists; all patients had T2DM and at least one measurement of HbA1c, LDL-c, BP, serum creatinine and albuminuria in the year 2010. The outcome was the achievement of HbA1c, LDL-c and BP values as recommended by International Guidelines.

RESULTS

In the entire sample, the mean value of HbA1c was 7.2 ± 1.2%, of LDL-c was 102 ± 33 mg/dL and of BP was 138/78 ± 19/9 mmHg. CKD and its components were associated with poor glycaemic and BP control, notwithstanding greater use of glucose and BP-lowering drugs, while no association was found with LDL-c values. Factors independently related to unsatisfactory glycaemic control included female gender, body mass index, duration of disease and high albuminuria. Men, older people and those taking statins were more likely to reach LDL-c target levels. Male gender, age and high albuminuria strongly affected the achievement of BP targets.

CONCLUSIONS

CKD or its components, mainly high albuminuria, are associated with failure to reach therapeutic targets, especially for HbA1c and BP, despite a greater use of drugs in patients with T2DM.

Health care delivery in type 2 diabetes. A survey in an Italian primary care practice

AIMS

Evidence-based guidelines provide targets and performance measures for the treatment of type 2 diabetic patients but a wide gap separates guidelines-driven recommendations from their clinical application, a phenomenon hindering the transfer of proven benefits to affected populations.

METHODS

We analyzed the quality of diabetic care delivered by 8 general practitioners joint in a group practice attending 571 diabetic patients (5.6% of the total enlisted subjects) by assessing process (% of HbA1c, SBP and LDL-C determinations) and intermediate outcome (% of patients with HbA1c <7% vs >8%, systolic BP <130 mmHg vs >140 mmHg, LDL-cholesterol <100 mg/dL vs >130 mg/dL) indicators.

RESULTS

HbA1c was at target in 49% of patients and >8% in 22%; SBP and LDL-C determination was available in about two-thirds of patients, only a minority at target for SBP and LDL-C. Antihyperglycemic and antihypertensive treatment was prescribed in most patients but only a third was on statins. During the post-evaluation phase, percentages of patients with HbA1c >8%, SBP < 130 mmHg and LDL-C < 100 mg/dL and the drug prescription pattern did not change.

CONCLUSIONS

Several weaknesses affect primary care delivery to type 2 diabetic patients and efforts are needed to improve the management of this high-risk group.

Algorithms for personalized therapy of type 2 diabetes: results of a web-based international survey

OBJECTIVE

In recent years increasing interest in the issue of treatment personalization for type 2 diabetes (T2DM) has emerged. This international web-based survey aimed to evaluate opinions of physicians about tailored therapeutic algorithms developed by the Italian Association of Diabetologists (AMD) and available online, and to get suggestions for future developments. Another aim of this initiative was to assess whether the online advertising and the survey would have increased the global visibility of the AMD algorithms.

RESEARCH DESIGN AND METHODS

The web-based survey, which comprised five questions, has been available from the homepage of the web-version of the journal Diabetes Care throughout the month of December 2013, and on the AMD website between December 2013 and September 2014. Participation was totally free and responders were anonymous.

RESULTS

Overall, 452 physicians (M=58.4%) participated in the survey. Diabetologists accounted for 76.8% of responders. The results of the survey show wide agreement (>90%) by participants on the utility of the algorithms proposed, even if they do not cover all possible needs of patients with T2DM for a personalized therapeutic approach. In the online survey period and in the months after its conclusion, a relevant and durable increase in the number of unique users who visited the websites was registered, compared to the period preceding the survey.

CONCLUSIONS

Patients with T2DM are heterogeneous, and there is interest toward accessible and easy to use personalized therapeutic algorithms. Responders opinions probably reflect the peculiar organization of diabetes care in each country.

Improving quality of care in people with Type 2 diabetes through the Associazione Medici Diabetologi-annals initiative: a long-term cost-effectiveness analysis

AIMS

The Associazione Medici Diabetologi-annals initiative is a physician-led quality-of-care improvement scheme that has been shown to improve HbA1c concentration, blood pressure, lipid profiles and BMI in enrolled people with Type 2 diabetes. The present analysis investigated the long-term cost-effectiveness of enrolling people with Type 2 diabetes in the Associazione Medici Diabetologi-annals initiative compared with conventional management.

METHODS

Long-term projections of clinical outcomes and direct costs (in 2010 Euros) were made using a published and validated model of Type 2 diabetes in people with Type 2 diabetes who were either enrolled in the Associazione Medici Diabetologi-annals initiative or who were receiving conventional management. Treatment effects were based on mean changes from baseline seen at 5 years after enrolment in the scheme. Costs and clinical outcomes were discounted at 3% per annum.

RESULTS

The Associazione Medici Diabetologi-annals initiative was associated with improvements in mean discounted life expectancy and quality-adjusted life expectancy of 0.55 years (95% CI 0.54-0.57) years and 0.48 quality-adjusted life years (95% CI 0.46-0.49), respectively, compared with conventional management. Whilst treatment costs were higher in the Associazione Medici Diabetologi-annals arm, this was offset by savings as a result of the reduced incidence and treatment of diabetes-related complications. The Associazione Medici Diabetologi-annals initiative was found to be cost-saving over patient lifetimes compared with conventional management [€ 37,289 (95% CI 37,205-37,372) vs € 41,075 (95% CI 40,956-41,155)].

CONCLUSIONS

Long-term projections indicate that the physician-led Associazione Medici Diabetologi-annals initiative represents a cost-saving method of improving long-term clinical outcomes compared with conventional management of people with Type 2 diabetes in Italy.

Benchmarking network for clinical and humanistic outcomes in diabetes (BENCH-D) study: protocol, tools, and population

Background

In the context of the DAWN-2 initiatives, the BENCH-D Study aims to test a model of regional benchmarking to improve not only the quality of diabetes care, but also patient-centred outcomes.

Methods/Design

As part of the AMD-Annals quality improvement program, 32 diabetes clinics in 4 Italian regions extracted clinical data from electronic databases for measuring process and outcome quality indicators. A random sample of patients with type 2 diabetes filled in a questionnaire including validated instruments to assess patient-centred indicators: SF-12 Health Survey, WHO-5 Well-Being Index, Diabetes Empowerment Scale, Problem Areas in Diabetes, Health Care Climate Questionnaire, Patients Assessment of Chronic Illness Care, Barriers to Medications, Patient Support, Diabetes Self-care Activities, and Global Satisfaction for Diabetes Treatment. Data were discussed with participants in regional meetings. Main problems, obstacles and solutions were identified through a standardized process, and a regional mandate was produced to drive the priority actions. Overall, clinical indicators on 78,854 patients have been measured; additionally, 2,390 patients filled-in the questionnaire. The regional mandates were officially launched in March 2012. Clinical and patient-centred indicators will be evaluated again after 18 months. A final assessment of clinical indicators will take place after 30 months.

Discussion

In the context of the BENCH-D study, a set of instruments has been validated to measure patient well-being and satisfaction with the care. In the four regional meetings, different priorities were identified, reflecting different organizational resources of the different areas. In all the regions, a major challenge was represented by the need of skills and instruments to address psychosocial issues of people with diabetes. The BENCH-D study allows a field testing of benchmarking activities focused on clinical and patient-centred indicators.

Kidney dysfunction and related cardiovascular risk factors among patients with type 2 diabetes

BACKGROUND

Kidney dysfunction is a strong predictor of end-stage renal disease and cardiovascular (CV) events. The main goal was to study the clinical correlates of diabetic kidney disease in a large cohort of patients with type 2 diabetes mellitus (T2DM) attending 236 Diabetes Clinics in Italy.

METHODS

Clinical data of 120 903 patients were extracted from electronic medical records by means of an ad hoc-developed software. Estimated glomerular filtration rate (GFR) and increased urinary albumin excretion were considered. Factors associated with the presence of albuminuria only, GFR < 60 mL/min/1.73 m(2) only or both conditions were evaluated through multivariate analysis.

RESULTS

Mean age of the patients was 66.6 ± 11.0 years, 58.1% were male and mean duration of diabetes was 11.1 ± 9.4 years. The frequency of albuminuria, low GFR and both albuminuria and low GFR was 36.0, 23.5 and 12.2%, respectively. Glycaemic control was related to albuminuria more than to low GFR, while systolic and pulse pressure showed a trend towards higher values in patients with normal kidney function compared with those with both albuminuria and low GFR. Multivariate logistic analysis showed that age and duration of disease influenced both features of kidney dysfunction. Male gender was associated with an increased risk of albuminuria. Higher systolic blood pressure levels were associated with albuminuria, with a 4% increased risk of simultaneously having albuminuria and low GFR for each 5 mmHg increase.

CONCLUSIONS

In this large cohort of patients with T2DM, reduced GFR and increased albuminuria showed, at least in part, different clinical correlates. A worse CV risk profile is associated with albuminuria more than with isolated low GFR.

Different prevalence of metabolic control and chronic complication rate according to the time of referral to a diabetes care unit in the elderly

The time of diagnosis is crucial for type 2 diabetes mellitus (T2DM) in terms of disease severity and chronic complications, as initial glycated haemoglobin (HbA1c) predicts 5-year cardiovascular mortality. The Italian health-care system relies on about 650 diabetes care units (DCU) interfacing with a large number of general practitioners (GPs). It may thus reach the goal of preventing complications easier than others by adopting a more comprehensive multifactorial approach. To assess whether the interval between diagnosis and referral to the DCU might influence the course of the disease in terms of HbA1c, associated cardiovascular risk factors, drug utilisation, and chronic complications in the elderly, the electronic records of 313 elderly T2DM patients (74.6 ± 4.9 years) followed by their GPs until referral to our DCU were retrospectively analysed for the above-mentioned parameters and divided into an early referral (ER) group (diagnosed within 12 months, n = 111) and a late referral (LR) group (diagnosed >12 months before, n = 202). A further set of 200 patients routinely taken care by our DCU, matched with the LR group for age, gender, and disease duration, was classified as "long-standing follow-up" (LSF) and compared to the others to rule out any confounding effects of long-standing disease per se on the clinical outcomes investigated in our study. About 35 % of T2DM patients referred to our DCU within 12 months of diagnosis; the rest did so some 5 years after diagnosis. LR patients displayed worse HbA1c levels (10.8 vs. 7.7 %, p < 0.01), used more drugs, and had more than twice as high complication rates as their ER counterparts. Almost all risk factors and complications were lower in the LSF (0.001 < p < 0.05) and ER groups than in the LR group. In both the ER and the LSF groups, we observed a lower burden of diabetes than in the LR group. This rules out the possibility that disease duration might play a major role per se in the burden of the disease in the elderly as opposed to the thoughtful patient care attitude exhibited by the DCU. A better and more efficient organisation has to be developed, including a strong interaction among GPs, diabetes specialists, and elderly people with T2DM allowing the latter to take charge of their own disease management through a sustained empowerment policy.

Sex disparities in the quality of diabetes care: biological and cultural factors may play a different role for different outcomes: a cross-sectional observational study from the AMD Annals initiative

OBJECTIVE

To investigate the quality of type 2 diabetes care according to sex.

RESEARCH DESIGN AND METHODS

Clinical data collected during the year 2009 were extracted from electronic medical records; quality-of-care indicators were evaluated. Multilevel logistic regression analysis was applied to estimate the likelihood of women versus men to be monitored for selected parameters, to reach clinical outcomes, and to be treated with specific classes of drugs. The intercenter variability in the proportion of men and women achieving the targets was also investigated.

RESULTS

Overall, 415,294 patients from 236 diabetes outpatient centers were evaluated, of whom 188,125 (45.3%) were women and 227,169 (54.7%) were men. Women were 14% more likely than men to have HbA1c>9.0% in spite of insulin treatment (odds ratio 1.14 [95% CI 1.10-1.17]), 42% more likely to have LDL cholesterol (LDL-C)≥130 mg/dL (1.42 [1.38-1.46]) in spite of lipid-lowering treatment, and 50% more likely to have BMI≥30 kg/m2 (1.50 [1.50-1.54]). Women were less likely to be monitored for foot and eye complications. In 99% of centers, the percentage of men reaching the LDL-C target was higher than in women, the proportion of patients reaching the HbA1c target was in favor of men in 80% of the centers, and no differences emerged for blood pressure.

CONCLUSIONS

Women show a poorer quality of diabetes care than men. The attainment of the LDL-C target seems to be mainly related to pathophysiological factors, whereas patient and physician attitudes can play an important role in other process measures and outcomes.

Quality of care of people with type 2 diabetes in eight European countries: findings from the Guideline Adherence to Enhance Care (GUIDANCE) study

OBJECTIVE

We sought to determine levels of adherence in eight European countries to recommendations for the management of type 2 diabetes and to investigate factors associated with key intermediate outcomes.

RESEARCH DESIGN AND METHODS

GUIDANCE was a cross-sectional study including retrospective data extraction from the medical records of people with type 2 diabetes recruited, using a shared protocol, from primary and specialist care sites in the following eight European countries: Belgium, France, Germany, Italy, Ireland, Sweden, the Netherlands, and the United Kingdom. The dataset for analysis comprised 7,597 cases. Proportions meeting process and outcome criteria were determined, including between-country variations. Logistic regression was used to investigate potential predictors of meeting targets for HbA1c, blood pressure, and LDL cholesterol.

RESULTS

In the total sample, adherence to process recommendations was high for some measures, for example, HbA1c recorded in past 12 months in 97.6% of cases. Target achievement for intermediate outcome measures was lower, with only 53.6% having HbA1c <7%. Considerable between-country variation was identified for both processes and outcomes. The following characteristics were associated with an increased likelihood of meeting targets for all three measures considered (HbA1c, blood pressure, LDL cholesterol): shorter diagnosis of diabetes; having one or more macrovascular complications; lower BMI; being prescribed lipid-lowering medication; and no current antihypertensive prescribing.

CONCLUSIONS

Compared with earlier reports, we have suggested some encouraging positive trends in Europe in relation to meeting targets for the management of people with type 2 diabetes, but there is still scope for further improvement and greater between-country consistency.

Achievement of goals in U.S. diabetes care, 1999-2010

BACKGROUND

Tracking national progress in diabetes care may aid in the evaluation of past efforts and identify residual gaps in care.

METHODS

We analyzed data for adults with self-reported diabetes from the National Health and Nutrition Examination Survey and the Behavioral Risk Factor Surveillance System to examine risk-factor control, preventive practices, and risk scores for coronary heart disease over the 1999-2010 period.

RESULTS

From 1999 through 2010, the weighted proportion of survey participants who met recommended goals for diabetes care increased, by 7.9 percentage points (95% confidence interval [CI], 0.8 to 15.0) for glycemic control (glycated hemoglobin level <7.0%), 9.4 percentage points (95% CI, 3.0 to 15.8) for individualized glycemic targets, 11.7 percentage points (95% CI, 5.7 to 17.7) for blood pressure (target, <130/80 mm Hg), and 20.8 percentage points (95% CI, 11.6 to 30.0) for lipid levels (target level of low-density lipoprotein [LDL] cholesterol, <100 mg per deciliter [2.6 mmol per liter]). Tobacco use did not change significantly, but the 10-year probability of coronary heart disease decreased by 2.8 to 3.7 percentage points. However, 33.4 to 48.7% of persons with diabetes still did not meet the targets for glycemic control, blood pressure, or LDL cholesterol level. Only 14.3% met the targets for all three of these measures and for tobacco use. Adherence to the recommendations for annual eye and dental examinations was unchanged, but annual lipid-level measurement and foot examination increased by 5.5 percentage points (95% CI, 1.6 to 9.4) and 6.8 percentage points (95% CI, 4.8 to 8.8), respectively. Annual vaccination for influenza and receipt of pneumococcal vaccination for participants 65 years of age or older rose by 4.5 percentage points (95% CI, 0.8 to 8.2) and 6.9 percentage points (95% CI, 3.4 to 10.4), respectively, and daily glucose monitoring increased by 12.7 percentage points (95% CI, 10.3 to 15.1).

CONCLUSIONS

Although there were improvements in risk-factor control and adherence to preventive practices from 1999 to 2010, tobacco use remained high, and almost half of U.S. adults with diabetes did not meet the recommended goals for diabetes care.