Impact of diabetes screening on quality of life

Need for HTA supported risk factor screening for hypertension and diabetes in Nepal: A systematic scoping review

Objective

Health Technology Assessment (HTA) is a comprehensive and important tool for assessment and decision-making in public health and healthcare practice. It is recommended by the WHO and has been applied in practice in many countries, mostly the developed ones. HTA might be an important tool to achieve universal health coverage (UHC), especially beneficial to low-and-middle-income countries (LMIC). Even though the Package for Essential Non-communicable Diseases (PEN) has already been initiated, there is a clear policy gap in the HTA of any health device, service, or procedure, including the assessment of cardiovascular risk factors (CVRFs) in Nepal. Hence, we carried out the review to document the HTA supported evidence of hypertension and diabetes screening, as CVRFs in Nepal.

Materials and methods

We searched in PubMed, Cochrane, and Google Scholar, along with some gray literature published in the last 6 years (2016–2021) in a systematic way with a controlled vocabulary using a well-designed and pilot tested search strategy, screened them, and a total of 53 articles and reports that matched the screening criteria were included for the review. We then, extracted the data in a pre-designed MS-Excel format, first in one, and then, from it, in two, with more specific data.

Results

Of 53 included studies, we reported the prevalence and/or proportion of hypertension and diabetes with various denominators. Furthermore, HTA-related findings such as cost, validity, alternative tool or technology, awareness, and intervention effectiveness have been documented and discussed further, however, not summarized due to their sparingness.

Conclusion

Overall, the prevalence of DM (4.4–18.8%) and HTN (17.2–70.0%) was reported in most studies, with a few, covering other aspects of HTA of DM/HTN. A national policy for establishing an HTA agency and some immediately implementable actions are highly recommended.

Health related quality of life in individuals at high risk of chronic liver disease: Impact of a community diagnostic pathway

Objectives

There is a lack of understanding of health related quality of life (HRQoL) in chronic liver disease (CLD). With the rising prevalence of alcohol and obesity driven CLD, and the increasing ability to screen for fibrosis, it is important to understand the impact of the diagnostic process for patients.

Study design

Prospective cohort study.

Methods

A cohort study conducted utilising the Nottingham Adult Liver Disease Stratification Pathway, UK. All patients referred as high risk for CLD (due to metabolic, alcohol or abnormal liver enzymes) completed the EQ-5D before diagnosis and at three and 12 months after. HRQoL was investigated by domain, CLD severity (transient elastography) and temporally.

Results

493 patients participated with 300 (60.9%) completing at least one follow-up HRQoL assessment.

Pre-diagnosis the median (IQR) utility index was 0.75 (0.61–0.85) and visual analogue scale was 75/100 (60–90). The median utility index was significantly lower amongst those with advanced liver disease compared to those without at all time points (baseline 0.68 vs 0.77, three-months 0.65 vs 0.79, 12-months 0.69 vs 0.84, all p ​< ​0.05). The majority of decrements in HRQoL score were in the pain domain.

Conclusions

There was no reduction, over three or 12 months, in HRQoL identified amongst high-risk individuals progressing through the diagnostic pathway. Overall the HRQoL of participants at high risk for the development of significant CLD was lower than the UK and regional (East Midlands) norms. Furthermore, we found reduced HRQoL in those going on to receive a diagnosis of advanced liver disease compared to those without.

Evaluation of the value of diabetes risk scores in screening for undiagnosed diabetes and prediabetes: a community-based study in southwestern China

OBJECTIVES

To evaluate the performance and cost-effectiveness of existing diabetes risk scores (DRSs) to screen for undiagnosed diabetes mellitus (UDM) and prediabetes (PD) in a community-based southwestern Chinese population.

METHODS

Participants in TIDE-Chengdu survey with requisite data and without known diabetes were included. Five Chinese-derived DRSs and six non-Chinese-derived DRSs were included for evaluation. Their performance in detecting UDM and UMD or PD (UDM/PD) was assessed using the C-statistic. The cost-effectiveness of the optimal DRS was compared with that of capillary fasting blood glucose (CFBG).

RESULTS

Of the 1,692 TIDE-Chengdu survey participants included, 177 (10.5%) had UDM and 339 (20.0%) had PD. The rural participants (N = 737) were more likely to have UDM (13.4% vs. 8.2%) and PD (24.8% vs. 16.3%) than their urban counterparts (N = 955) (P < 0.0001). In the full population, the included DRSs all showed good discrimination in detecting UDM (C-statistic: 0.699 to 0.762) and UDM/PD (C-statistic: 0.717 to 0.769), but the New Chinese DRS (NCDRS) performed best for both UDM and UDM/PD. The DRSs evaluated all showed better performance in urban participants than rural participants for both UDM (C-statistic: 0.718 to 0.795 vs. 0.642 to 0.720) and UDM/PD (C-statistic: 0.729 to 0.793 vs. 0.682 to 0.726) (all P < 0.05). The mean cost per UDM/PD case identified was lower with NCDRS at score 25 (¥503.3($71.9)) and 27 (¥490.5 ($70.1)) than CFBG at 5.0, 5.1, 5.2, or 5.3 mmol/L (¥631.7 ($90.2), ¥611.8 ($87.4), ¥579.2 ($82.7) and ¥551.9 ($78.8)), whereas the mean costs per UDM case identified was higher with NCDRS at score 25 (¥1379.3 ($197.0)) and 27 (¥1315.1 ($187.9)) than CFBG at 5.3, 5.4, or 5.5 mmol/L (¥1301.7 ($186.0), ¥1247.7 ($178.2) and ¥1173.3 ($167.6)).

CONCLUSION

The NCDRS represents a valid and cost-effective tool for use in southwestern China to identify high-risk patients with UDM or PD who need a diagnostic test.

Long-term cost-effectiveness of screening for fracture risk in a UK primary care setting: the SCOOP study

Community-based screening and treatment of women aged 70-85 years at high fracture risk reduced fractures; moreover, the screening programme was cost-saving. The results support a case for a screening programme of fracture risk in older women in the UK.

INTRODUCTION

The SCOOP (screening for prevention of fractures in older women) randomized controlled trial investigated whether community-based screening could reduce fractures in women aged 70-85 years. The objective of this study was to estimate the long-term cost-effectiveness of screening for fracture risk in a UK primary care setting compared with usual management, based on the SCOOP study.

METHODS

A health economic Markov model was used to predict the life-time consequences in terms of costs and quality of life of the screening programme compared with the control arm. The model was populated with costs related to drugs, administration and screening intervention derived from the SCOOP study. Fracture risk reduction in the screening arm compared with the usual management arm was derived from SCOOP. Modelled fracture risk corresponded to the risk observed in SCOOP.

RESULTS

Screening of 1000 patients saved 9 hip fractures and 20 non-hip fractures over the remaining lifetime (mean 14 years) compared with usual management. In total, the screening arm saved costs (£286) and gained 0.015 QALYs/patient in comparison with usual management arm.

CONCLUSIONS

This analysis suggests that a screening programme of fracture risk in older women in the UK would gain quality of life and life years, and reduce fracture costs to more than offset the cost of running the programme.

Impact assessment of pharmacist-supervised intervention on health-related quality of life of newly diagnosed diabetics: A pre-post design

Introduction:

Diabetics face a series of challenges that affect all aspects of their daily life. Diabetes related complications adversely affect patient’s health-related quality of life (HRQoL). Knowledge and self-care skills of diabetics are corner stones to improve their HRQoL.

Objective:

To assess the impact of pharmacist-supervised intervention on HRQoL of newly diagnosed diabetics using an Audit of Diabetes-Dependent Quality of Life (ADDQoL) questionnaire.

Materials and Methods:

A pre-post comparison study was conducted among the control group (CG), test 1 group (T1G) and test 2 group (T2G) patients with three treatment arms to explore the impact of pharmacist-supervised intervention on HRQoL of newly diagnosed diabetics for 18 months. Patients’ HRQoL scores were determined using ADDQoL questionnaire at baseline, 3, 6, 9 and 12-months. T1G patients received pharmacist’s intervention whereas T2G patients received diabetic kit demonstration in addition to pharmacist’s intervention. CG patients were deprived of pharmacist intervention and diabetic kit demonstration, and only received care from attending physician/nurses. Non-parametric tests were used to find the differences in an average weighted impact scores (AWIS) among the groups before and after the intervention at P ≤ 0.05.

Results:

Friedman test identified significant (P < 0.001) improvement in AWIS among the test groups’ patients. Differences in scores were significant between T1G and T2G at 6-months (P = 0.033), 9-months (P < 0.001) and 12-months (P < 0.001); between CG and T1G at 12-months (P < 0.001) and between CG and T2G at 9-months (P < 0.001) and 12-months (P < 0.0010) on Mann.Whitney U test.

Conclusion:

Pharmacist’s intervention improved AWIS of test groups’ diabetics. Diabetic kit demonstration strengthened the disease understanding and selfcare skills of T2G patients. Disease and self-care awareness among diabetics should be increased in Nepali healthcare system by involving pharmacists for better patient’s related outcomes.

The diagnosis of asymptomatic disease is associated with fewer healthy days: A cross sectional analysis from the national health and nutrition examination survey

OBJECTIVE

To examine the effect of the diagnosis of asymptomatic disease on health-related quality of life (HRQoL).

DESIGN

Secondary analysis of a national data set.

METHOD

We analysed adult participants in the 2011-2012 National Health and Nutrition Examination Survey (NHANES) of the civilian non-institutionalized US general population. Across three asymptomatic diseases (glucose intolerance, hyperlipidaemia, and hypertension), we examined four groups (without disease; with disease but no diagnosis; with disease and diagnosis but no treatment; and with disease, diagnosis, and treatment). For each asymptomatic disease, we examined group differences in self-rated health (ordinal logistic regression) and Healthy Days outcomes (number of the last 30 days that physical health was not good, mental health was not good, or inactive; regression). Models were adjusted for age, sex, smoking status, insurance status, income, education, race, body mass index, and comorbid conditions.

RESULTS

Analyses included 6012 respondents (glucose intolerance), 2772 respondents (hyperlipidaemia), and 5524 respondents (hypertension). In adjusted models, those who did not know about their disease had the same self-rated health scores as those without the disease, those with the disease without treatment, and those with disease and treatment. In adjusted analyses of the Healthy Days questions, those with unknown disease reported the same number of unhealthy days as those without disease with the exception of glucose intolerance. Conversely, in four of the nine possible comparisons, those with known disease without treatment reported more unhealthy days than those with who did not know about their disease.

CONCLUSIONS

In adjusted analyses, individuals knowing about their asymptomatic disease are more likely to experience decrements in healthy days compared to those without knowledge of their asymptomatic disease. Statement of contribution What is already known on this subject? There has been sparse evidence that diagnosis of asymptomatic diseases is related to reduced health-related quality of life in population studies. Previous studies have included patients receiving treatment, which impedes the ability to isolate the effects of diagnosis from the effects of treatment. What does this study add? This report examines three asymptomatic health conditions: glucose intolerance, hyperlipidaemia, and hypertension. Those who did not know about their health condition generally had the same health-related quality of life scores as those without health conditions. Conversely, those diagnosed with disease but not receiving treatment reported worse health-related quality of life.

Diabetes Self-Management: A Key to Better Health-Related Quality of Life in Patients with Diabetes

OBJECTIVE

The aims of this study were to assess health-related quality of life (HRQOL) among adult patients with diabetes attending primary health care diabetes clinics in Kuwait and to examine the factors associated with the HRQOL of patients with diabetes.

METHODS

This cross-sectional study was conducted among 503 patients with diabetes attending 26 primary health care diabetes clinics in Kuwait. A self- administered questionnaire on participants' socio-demographic and clinical characteristics, in addition to the Diabetes Self-Management Questionnaire (DSMQ) to assess patients' diabetes self-management (DSM), was used. The SF-12 was employed to assess the HRQOL, producing the following 2 outcomes: physical health composite (PHC) and mental health composite (MHC).

RESULTS

The mean age of participants was 52 ± 0.8 years, and 53.1% were males and 49.0% were Kuwaitis. The median DSM sum score was 6.5. Male patients with diabetes showed a significantly better median DSM sum score than female patients with diabetes. The overall median score of HRQOL was 61.7/100, with a better median PHC versus MHC score of quality of life (66.7/100 and 56.7/100, respectively). Multivariate analysis revealed a significant direct association between DSM and better primary health composite and MHC scores. It also showed that female gender and reporting 2 or more diabetic complications were significantly associated with a poor PHC.

CONCLUSIONS

Kuwaiti patients with diabetes showed a modest level of HRQOL. Patients' DSM, gender, and diabetes complications were significant independent correlates to HRQOL. Appraisal of the HRQOL of patients with diabetes as an essential component of diabetes management in clinical settings is suggested. Further studies to examine the impact of good DSM on HRQOL improvement are needed.

Clinico-epidemiological factors of health related quality of life among people with type 2 diabetes

AIM

To investigate the quality of life (QOL) and its clinical and epidemiological correlates among people with type 2 diabetes.

METHODS

This cross-sectional study was conducted in Tabriz, Northwest of Iran, including a total of 394 people with type 2 diabetes using convenient sampling method from November 2014 to March 2015. General information including demographic, socioeconomic status and lifestyle factors were collected by trained interviewers. Clinical information was retrieved from clinic’s record and QOL was assessed using the 26-item WHOQOL-BRIFE questionnaire. Univariate and multivariate linear regression were performed to assess the related factors and QOL dimensions.

RESULTS

The mean of overall health related QOL was 52.11 ± 11.53 and the maximum and minimum dimensions were respectively seen in psychological (60.38 ± 14.54) and social (38.32 ± 16.94) dimensions. The results of multiple linear regression showed a significant overall relationship between HRQOL and age (b = -1.48%, 95%CI: -0.03 and -2.93) level of education (b = 4.12%, 95%CI: 2.73 and 5.5), number of comorbidities (b = -2.41%, 95%CI: -3.89 and -9.41), and level of income (b = 1.98, 95%CI: 0.05 and 3.9), functional limitation (b = -3.59, 95%CI: -2.26 and -4.92) and psychological distress (b = -2.02%, 95%CI: -2.83 and -1.21). Level of education, functional limitation, psychological distress were associated with the score of physical, mental and environmental dimensions, and number of comorbidities was associated with the score of physical and mental dimensions.

CONCLUSION

Based on our findings, lifestyle modification and increasing facilities of clinics providing service can be effective steps to improve the QOL among people with type 2 diabetes.

Three approaches to glucose monitoring in non-insulin treated diabetes: a pragmatic randomized clinical trial protocol

Background

For the nearly 75% of patients living with type 2 diabetes (T2DM) that do not use insulin, decisions regarding self-monitoring of blood glucose (SMBG) can be especially problematic. While in theory SMBG holds great promise for sparking favorable behavior change, it is a resource intensive activity without firmly established patient benefits. This study describes our study protocol to assess the impact of three different SMBG testing approaches on patient-centered outcomes in patients with non-insulin treated T2DM within a community-based, clinic setting.

Methods/Design

Using stakeholder engagement approach, we developed and implemented a pragmatic trial of patient with non-insulin treated T2DM patients from five primary care practices randomized to one of three SMBG regimens: 1) no testing; 2) once daily testing with standard feedback consisting of glucose values being immediately reported to the patient through the glucose meter; and 3) once daily testing with enhanced patient feedback consisting of glucose values being immediately reported to the patient PLUS automated, tailored feedback messaging delivered to the patient through the glucose meter following each testing. Main outcomes assessed at 52 weeks include quality of life and glycemic control.

Discussion

This pragmatic trial seeks to better understand the value of SMBG in non-insulin treated patients with T2DM. This paper outlines the protocol used to implement this study in fifteen community-based primary care practices and highlights the impact of stakeholder involvement from the earliest stages of project conception and implementation. Plans for stakeholder involvement for result dissemination are also discussed.

Trial registration

ClinicalTrials.gov NCT02033499, January 9, 2014.

Effectiveness of individual and group interventions for people with type 2 diabetes

OBJECTIVE:

to compare the effectiveness of two educational interventions used by a healthcare provider in the monitoring of individuals with type 2 diabetes mellitus (T2DM), regarding knowledge of the disease, impact on quality of life and adoption of self-care actions.

METHODS:

comparative, longitudinal, prospective study performed with 150 subjects with type 2 diabetes, analyzed according to the type of participation in the program (individual and/or group). Participants of the individual intervention (II) received nursing consultations every six months and those of the group intervention (GI) took part in weekly meetings for three months. Data were collected through four questionnaires: Identification questionnaire, Problem Areas in Diabetes Questionnaire (PAID), Summary of Diabetes Self-Care Activities Questionnaire (SDSCA) and the Diabetes Knowledge Scale (DKN-A). Data were analyzed using the Friedman and Mann Whitney tests, considering a statistical significance of p ≤ 0.05.

RESULTS:

there was an increase in knowledge about the disease in the II (p<0.003) and GI (p<0.007), with reduction of the impact on the quality of life in the II (p<0.007) and improvement in self-care actions in the GI (p<0.001).

CONCLUSION:

in both intervention models improvements were observed in the indicators, over the six month monitoring period.

Quality of life and characteristics of diabetic patients

This study aimed to assess the association between quality of life and clinical and sociodemographic variables in type 2 diabetes patients, after they had started treatment in Primary and Specialized Health Care. This is an analytical cross-sectional study with a sampling of diabetic patients from Primary (n = 385) and Specialized (n = 385) Health Care. The dependent variable, quality of life, was evaluated by the Diabetes Quality of Life Measure - Brazil. Clinical and sociodemographic data were collected. Bivariate analysis by chi square test tested the association between the dependent variable with the independent ones. Next, we performed an analysis of multiple logistic regression. In Specialized Health Care, individuals who practice physical activity had less chance of having worse quality of life and those with less time of diagnosis presented higher chance of worse quality of life. In Primary Health Care, those who performed diets and presented glycated hemoglobin ≤ 7% had less chance of having worse quality of life. Women presented higher chances of worse quality of life than men. We concluded that with exception to the time of diagnosis and sex, other variables that influenced quality of life of diabetics were modifiable factors (glycated hemoglobin, alimentary diet and physical activity).

Work-Related Injuries and Health-Related Quality of Life Among US Workers: A Longitudinal Study of a Population-Based Sample

OBJECTIVE

The aim of this study is to examine health-related quality of life (HRQOL) among U.S. injured workers using a longitudinal study of a nationally representative sample.

METHODS

Employed adults with and without occupational injuries from the 2000 to 2011 Medical Expenditure Panel Survey (MEPS) were included. Outcomes were the physical and mental components of the SF-12. A within-person change using paired tests and a between-person change using multivariable regression were performed.

RESULTS

We estimate over 1.6 million injured workers per year. Sprains were the most common injury. Relative to noninjured workers, injured workers reported 3.0 and 1.0 points lower physical and mental component scores, respectively.

CONCLUSIONS

These results confirm that occupational injuries cause significant deficits in the physical component of HRQOL. This highlights the importance of preventing occupational injuries to reduce associated disabilities in the U.S.

Evaluation of Effective Indexes on Quality of Life Related to Health in Western Iran in 2013

BACKGROUND

Today, indexes regarding longevity and life expectancy have increased; the most important issue now is how to spend time loving or in other words quality of life.

OBJECTIVES

This study was aimed to evaluate effective indexes on quality of life related to health in western Iran in 2013.

MATERIALS AND METHODS

In this cross-sectional research, 918 families were selected among different counties of Ilam Province by multi-stage clustering sampling. The data collection instrument was a questionnaire used to measure the general economic and quality of life: the SF-36 health status questionnaire. Data were analyzed using multivariate regression models.

RESULTS

The mean age of the study participants was 32.97 ± 9.5 years, and the mean score for their quality of life was 61.74 ± 12.31. There was a significant statistical relationship between people's quality of life and their marital status, province of residency, income, economic situation, and life satisfaction (P < 0.05). Also, there was a significant and inverse correlation between people's age and quality of life (r = 0.21), physical health summary (r = 0.21) and mental health summary (r = 0.08).

CONCLUSIONS

The mean quality of life among the individuals studied was in the middle level, however, it is important to consider the different dimensions of their living situations, such as economic protections, social cooperation, ability to present suitable behaviors to solve problems, and living situation, especially among deprived people.

Evaluation of quality of life and depression levels in individuals with Type 2 diabetes

INTRODUCTION

Improving the quality of life in diabetic individuals is known to reduce morbidity and mortality. We aimed to investigate the quality of life and depression symptomatology situations and the related factors in patients with Type 2 diabetes mellitus (DM) in this study.

MATERIALS AND METHODS

In this study, 440 adult patients with Type 2 DM and under treatment admitted to Selcuk University Family Medicine Outpatient Diabetes Education Clinic were included in the study. A questionnaire containing sociodemographic characteristics of the participants, the Short Form 36 (SF-36) quality of life questionnaire was applied with Beck depression inventory face to face interviews.

RESULTS

Mean scores of females in all SF-36 subscales were statistically significantly lower than those of male patients. Physical function, physical role limitations, general health, social function, emotional role limitations, and mental health mean scores of the patients with 1-10 years duration of diabetes were found statistically significantly higher than those with 20 years and over duration of diabetes. Physical function, physical role limitations, pain, general health, and social function mean scores in patients using oral antidiabetic drug (OAD) was statistically significantly higher compared to patients using insulin + OAD. The average physical function scores of the patients with no complications were statistically significantly higher than those with two and more complications.

CONCLUSION

Quality of life and depression symptomatology are worse in females, the elderly, the overweight, people with lower level of education, in the widowed or divorced, homemakers, those with low incomes, those with longer duration of diabetes, patients using insulin, and those with two or more complications. There are many medical and sociodemographic factors affecting the quality of life and depressive symptomatology in the individuals with diabetes, so both health care workers and patients should pay the necessary attention to this issue.

Long-term effect of population screening for diabetes on cardiovascular morbidity, self-rated health, and health behavior

PURPOSE

There is limited trial evidence concerning the long-term effects of screening for type 2 diabetes on population morbidity. We examined the effect of a population-based diabetes screening program on cardiovascular morbidity, self-rated health, and health-related behaviors.

METHODS

We conducted a pragmatic, parallel-group, cluster-randomized controlled trial of diabetes screening (the ADDITION-Cambridge study) including 18,875 individuals aged 40 to 69 years at high risk of diabetes in 32 general practices in eastern England (27 practices randomly allocated to screening, 5 to no-screening for control). Of those eligible for screening, 466 (2.9%) were diagnosed with diabetes. Seven years after randomization, a random sample of patients was sent a postal questionnaire: 15% from the screening group (including diabetes screening visit attenders and non-attenders) and 40% from the no-screening control group. Self-reported cardiovascular morbidity, self-rated health (using the SF-8 Health Survey and EQ-5D instrument), and health behaviors were compared between trial groups using an intention-to-screen analysis.

RESULTS

Of the 3,286 questionnaires mailed out, 1,995 (61%) were returned, with 1,945 included in the analysis (screening: 1,373; control: 572). At 7 years, there were no significant differences between the screening and control groups in the proportion of participants reporting heart attack or stroke (OR = 0.90, 95% CI, 0.71-1.15); SF-8 physical health summary score as an indicator of self-rated health status (β -0.33, 95% CI, -1.80 to 1.14); EQ-5D visual analogue score (β: 0.80, 95% CI, -1.28 to 2.87); total physical activity (β 0.50, 95% CI, -4.08 to 5.07); current smoking (OR 0.97, 95% CI, 0.72 to 1.32); and alcohol consumption (β 0.14, 95% CI, -1.07 to 1.35).

CONCLUSIONS

Invitation to screening for type 2 diabetes appears to have limited impact on population levels of cardiovascular morbidity, self-rated health status, and health behavior after 7 years.

Impact of a diabetes screening program on a rural Chinese population: a 3-year follow-up study

BACKGROUND

Screening for type 2 diabetes helps detect previously unknown diabetes and identify people with pre-diabetes, but the adverse impact of such screening on individuals labelled as pre-diabetes or classified as normal, is less known. In this study the health-related quality of life (HRQoL), depression and lifestyle changes in a rural Chinese population are assessed three years after a screening program.

METHODS

A total of 647 (39.1%) individuals with pre-diabetes and 1009 (60.9%) individuals with normoglycaemia from a population-based diabetes screening program in 2009 were re-examined in 2012-2013. Changes at the end of 3 years in HRQoL, depression, BMI, weight, frequency of physical activity and vegetable intake were assessed.

RESULTS

In men with normoglycaemia the mean (SD) 15D scores were 0.974 (0.04) at baseline and 0.973 (0.05) at follow-up; and 0.971 (0.05) and 0.966 (0.06) for men with pre-diabetes. In women the scores were 0.973 (0.05) and 0.963 (0.06) for normoglycaemia and 0.959 (0.06) and 0.954 (0.07) for pre-diabetes, respectively. Compared to baseline, the HRQoL was slightly lower at 3 years in all groups but the change was not considered to be clinically important, and was only statistically significant for women with normoglycaemia (p < 0.05). The depression score was slightly elevated in women, but not in men. No significant changes in BMI were noticed, but weight increased slightly in the normoglycemia group (p < 0.05). Screening had a significant positive impact on physical activity and vegetable intake.

CONCLUSIONS

This population-based diabetes screening program generated long-term positive changes toward a healthy lifestyle as measured by physical activity and vegetable intake for all the participants without adverse effects on the HRQoL and depression.

Associations between disease awareness and health-related quality of life in a multi-ethnic Asian population

Background

Health related quality of life (HRQoL) is an important dimension of individuals' well-being, and especially in chronic diseases like diabetes and hypertension. The objective of this study was to evaluate the contributions of disease process, comorbidities, medication or awareness of the disease to HRQoL in diabetes mellitus, hypertension and dyslipidemia.

Methods

This was a cross-sectional study of 3514 respondents from the general community in Singapore, assessed for HRQoL, disease and comorbid conditions through self-report, clinical and laboratory investigations. HRQoL was assessed using SF-36 health survey version 2. For each condition, participants were categorized as having 1) no disease, 2) undiagnosed, 3) diagnosed, not taking medication, and 4) diagnosed, taking medication. Analysis used one-way ANOVA and multiple linear regression.

Results

Diagnosed disease was associated with lower physical health component summary (PCS) scores across all three conditions. After adjustment for comorbidities, this association remained significant only for those not on medication in diabetes (−2.7±1.2 points, p = 0.03) and dyslipidemia (−1.3±0.4 points, p = 0.003). Diagnosed hypertension (no medication −2.6±0.9 points, p = 0.002; medication −1.4±0.5 points, p = 0.004) and dyslipidemia (no medication −0.9±0.4 points, p = 0.03; medication −1.9±0.5 points, p<0.001) were associated with lower mental health component summary (MCS) scores. Undiagnosed disease was associated with higher MCS in diabetes (2.4±1.0 points, p = 0.01) and dyslipidemia (0.8±0.4 points, p = 0.045), and PCS in hypertension (1.2±0.4 points, p = 0.004).

Conclusions

Disease awareness was associated with lower HRQoL across the diseases studied, with PCS associations partially mediated by comorbidities. Equally importantly, undiagnosed disease was not associated with HRQoL deficits, which may partly explain why these individuals do not seek medical care.

Screening for type 2 diabetes in a high-risk population: effects of a negative screening test after 4 years follow-up

BACKGROUND

A negative diabetes screening test may unintentionally provide reassurance, resulting in reduced incentive to follow a healthy lifestyle.

PURPOSE

The purpose of this study is to assess negative test result effects on lifestyle and risk perception at 4 years follow-up.

METHODS

Risk perception and changes in smoking, physical activity, body mass index (BMI), and waist circumference were compared between 706 high-risk participants with a negative test result and 706 high-risk participants not offered screening (controls) in a randomized controlled trial of diabetes screening.

RESULTS

Negative-screened individuals experienced a small but significant increase in BMI and waist circumference, but there was no significant difference with controls. The negative-screened group had significantly higher perception of risk of developing diabetes (p = 0.009) than controls, but no differences were observed in perceived personal control, worry, and optimistic bias.

CONCLUSION

Screening negative for diabetes did not lead to overt long-term changes in lifestyle, despite a high perception of risk of developing diabetes. (ISRCTN75983009.).

Investigation on carbohydrate counting method in type 1 diabetic patients

OBJECTIVE

The results from Diabetes Control and Complications Trial (DCCT) have propounded the importance of the approach of treatment by medical nutrition when treating diabetes mellitus (DM). During this study, we tried to inquire carbohydrate (Kh) count method's positive effects on the type 1 DM treatment's success as well as on the life quality of the patients.

METHODS

22 of 37 type 1 DM patients who applied to Eskişehir Osmangazi University, Faculty of Medicine Hospital, Department of Endocrinology and Metabolism, had been treated by Kh count method and 15 of them are treated by multiple dosage intensive insulin treatment with applying standard diabetic diet as a control group and both of groups were under close follow-up for 6 months. Required approval was taken from the Ethical Committee of Eskişehir Osmangazi University, Medical Faculty, as well as informed consent from the patients. The body weight of patients who are treated by carbohydrate count method and multiple dosage intensive insulin treatment during the study beginning and after 6-month term, body mass index, and body compositions are analyzed. A short life quality and medical research survey applied. At statistical analysis, t-test, chi-squared test, and Mann-Whitney U test were used.

RESULTS

There had been no significant change determined at glycemic control indicators between the Kh counting group and the standard diabetic diet and multiple dosage insulin treatment group in our study.

CONCLUSION

As a result, Kh counting method which offers a flexible nutrition plan to diabetic individuals is a functional method.

The cost of type 2 diabetes in Brazil: evaluation of a diabetes care center in the city of São Paulo, Brazil

BACKGROUND

The worldwide increase of diabetes, a long duration, slow progression disease, impacts health care costs. The aim of this study was to estimate, from the society's perspective, the annual cost per patient with Type 2 Diabetes (T2DM) at a specialized, outpatient center in the city of São Paulo, capital of São Paulo state, Brazil.

METHODS

Data from 209 patients were collected during the years 2009 and 2010 in a São Paulo diabetes care center which is part of the tertiary sector of SUS, Brazil's National Health Care System. Data were collected by means of interviews and reviews of medical charts, and the quality of life was appraised using the SF36-v2 questionnaire. Direct medical costs were divided in five categories: 1) medication; 2) laboratory tests; 3) hospitalizations and procedures; 4) reactive strips for capillary blood glucose monitoring; and 5) medical consultations. Direct non-medical costs referred to transportation of patient and companion for treatment. Indirect costs included early retirements, sick leave and absenteeism in the workplace. Statistical analysis of the data was performed by the SPSS software, version 17.0.

RESULTS

Our sample comprised 122 women (58%) and 87 men (42%), with mean age of 63 years and average diabetes duration of 13 years. The mean annual cost was US$ 1,844 per patient, out of which US$ 1,012 corresponded to direct costs (55%) and US$ 831 to indirect costs (45%). From the direct medical costs, medications accounted for the greatest proportion (42%), followed by reactive strips (27%), hospitalizations and procedures (14%), laboratory tests and image examinations (7%), as well as medical consultations (4%). Non-medical costs (transportation) corresponded to 7% of the total direct costs. Besides, the results indicated that men have better quality of life than women.

CONCLUSION

This study demonstrated a high T2DM cost in Brazil, considering the governmental per capita expenses in health care, which accounted for US$ 466 in 2010 (World Health Statistics 2013 96-104 2013). Taking into account the high prevalence of the disease (IDF Diabetes Atlas. 5th edition. 29-48 2012), this survey recommends the enforcement of policies for the prevention of diabetes and its complications, and urges for better allocation of healthcare resources.

Qualidade de vida de pacientes com diabetes utilizando o instrumento Diabetes 39 (D-39)

Este estudo teve como objetivo investigar a qualidade de vida específica de pacientes com Diabetes Mellitus. Trata-se de estudo transversal, realizado de 02 a 28 de agosto de 2012, em duas unidades básicas de saúde do interior paulista. A amostra foi constituída por conveniência de 75 pacientes, com idade igual ou maior a 18 anos, de ambos os sexos, em um grupo de automonitorização da glicemia capilar. Utilizou-se o Instrumento de Avaliação de Diabetes 39 (D-39), contendo cinco dimensões: "energia e mobilidade" (15 itens), "controle do diabetes" (12), "ansiedade e preocupação" (4), "sobrecarga social" (5) e "funcionamento sexual" (3). A qualidade de vida se mostrou muito afetada nos itens relacionados à dimensão da sobrecarga social: constrangimento por ter diabetes, ser chamado de diabético e ter o diabetes interferindo em sua vida familiar. A elucidação dos fatores avaliados contribui para o planejamento de programas educativos, na medida em que tais fatores podem dificultar a obtenção do controle metabólico de pacientes com diabetes.

The association between motor vehicle injuries and health-related quality of life: a longitudinal study of a population-based sample in the United States

PURPOSE

As many as 3 million US residents are injured in traffic-related incidents every year leaving many victims with disabling conditions. To date, limited numbers of studies have examined the effects of traffic-related injuries on self-reported health. This study aims to examine the association between health-related quality of life (HRQOL) and traffic-related injuries longitudinally in a nationally representative sample of US adult population.

METHODS/APPROACH

This is a longitudinal study of adult participants (age ≥18) from seven panels (2000-2007) of the Medical Expenditure Panel Survey. The dependent variables included the physical and mental components of the SF-12, a measure of self-reported health. The outcome was assessed twice during the follow-up period: round 2 (~4-5 months into the study) and round 4 (~18 months into the study) for 62,298 individuals. Two methods estimate the association between traffic-related injuries and HRQOL: a within person change using paired tests and a between person change using multivariable regression adjusting for age, sex, income and educational level.

RESULTS

Nine hundred and ninety-three participants reported traffic-related injuries during the follow-up period. Compared to their pre-crash HRQOL, these participants lost 2.7 of the physical component score while their mental component did not change. Adjusted results showed significant deficits in the physical component (-2.84, p value = <.001) but not the mental component (-0.07, p value = .83) of HRQOL after controlling for potential confounders.

CONCLUSION

Traffic injuries were significantly associated with the physical component of HRQOL. These findings highlight the individual and societal burden associated with motor vehicle crash-related disability in the United States.

Impact of diagnosis of diabetes on health-related quality of life among high risk individuals: the Diabetes Prevention Program outcomes study

PURPOSE

The purpose of this study is to assess if diagnosis of type 2 diabetes affected health-related quality of life (HRQoL) among participants in the Diabetes Prevention Program/Diabetes Prevention Program Outcome Study and changes with treatment or diabetes duration.

METHODS

3,210 participants with pre-diabetes were randomized to metformin (MET), intensive lifestyle intervention (ILS), or placebo (PLB). HRQoL was assessed using the SF-36 including: (1) 8 SF-36 subscales; (2) the physical component (PCS) and mental component summary (MCS) scores; and (3) the SF-6D. The sample was categorized by diabetes free versus diagnosed. For diagnosed subgroup, mean scores in the diabetes-free period, at 6 months, 2, 4 and 6 years post-diagnosis, were compared.

RESULTS

PCS and SF-6D scores declined in all participants in all treatment arms (P < .001). MCS scores did not change significantly in any treatment arm regardless of diagnosis. ILS participants reported a greater decrease in PCS scores at 6 months post-diagnosis (P < .001) and a more rapid decline immediately post-diagnosis in SF-6D scores (P = .003) than the MET or PLB arms. ILS participants reported a significant decrease in the social functioning subscale at 6 months (P < .001) and two years (P < .001) post-diagnosis.

CONCLUSIONS

Participants reported a decline in measures of overall health state (SF-6D) and overall physical HRQoL, whether or not they were diagnosed with diabetes during the study. There was no change in overall mental HRQoL. Participants in the ILS arm with diabetes reported a more significant decline in some HRQoL measures than those in the MET and PLB arms that developed diabetes.

Associations of lifestyle factors, disease history and awareness with health-related quality of life in a Thai population

Background

The impact of the presence and awareness of individual health states on quality of life (HRQoL) is often documented. However, the impacts of different health states have rarely been compared amongst each other, whilst quality of life data from Asia are relatively sparse. We examined and compared the effects of different health states on quality of life in a Thai population.

Methods

In 2008–2009, 5,915 corporate employees were invited to participate in a survey where HRQoL was measured by the Short Form 36 (SF-36) questionnaire. The adjusted mean SF-36 scores were calculated for each self-reported illness, number of chronic conditions, lifestyle factors and awareness of diabetes and hypertension. The effect sizes (ES) were compared using Cohen's d.

Results

The response rate was 82% and 4,683 (79.1%) had complete data available for analysis. Physical and Mental Component Summary (PCS and MCS) scores decreased as the number of chronic conditions increased monotonically (p<0.0001). Diabetes and hypertension negatively influenced PCS (mean score differences −0.6 and −1.5, p<0.001 respectively) but not MCS, whereas awareness of diabetes and hypertension negatively influenced MCS (−2.9 and −1.6, p<0.005 respectively) but not PCS. Arthritis had the largest ES on PCS (−0.37), while awareness of diabetes had the largest ES on MCS (−0.36). CVD moderately affected PCS and MCS (ES −0.34 and −0.27 respectively). Obesity had a negative effect on PCS (ES −0.27). Exercise positively affected PCS and MCS (ES +0.08 and +0.21 (p<0.01) respectively).

Conclusion

Health promotion to reduce the prevalence of chronic diseases is important to improve the quality of life in Asian populations. Physical activity is an important part of such programs. Awareness of diseases may have greater impacts on mental health than having the disease itself. This has implications for the evaluation of the cost-benefit of screening and labeling of individuals with pre-disease states.

Effect of screening for Type 2 diabetes on population-level self-rated health outcomes and measures of cardiovascular risk: 13-year follow-up of the Ely cohort

AIMS

There is continuing uncertainty regarding the overall net benefits of population-based screening for Type 2 diabetes. We compared clinical measures, prescribed medication, cardiovascular morbidity and self-rated health in individuals without diabetes in a screened vs. an unscreened population.

METHODS

A parallel-group, cohort study of people aged 40-65 years, free of known diabetes, identified from the population register of a general practice in Ely, Cambridgeshire (n = 4936). In 1990-1992, one third (n = 1705), selected randomly, received an invitation for screening for diabetes and cardiovascular risk factors at 5-yearly intervals (screened population). From the remainder of the sampling frame, 1705 randomly selected individuals were invited to diabetes screening 10 years later (unscreened population). Patients without known diabetes from both populations were invited for a health assessment.

RESULTS

Of 3390 eligible individuals without diabetes, 1442 (43%) attended for health assessment, with no significant difference in attendance between groups. Thirteen years after the commencement of screening, self-rated functional health status and health utility were identical between the screened and unscreened populations. Clinical measures, self-reported medication and cardiovascular morbidity were similar between the two groups.

CONCLUSIONS

Screening for diabetes is not associated with long-term harms at the population level. However, screening has limited long-term impact on those testing negative; benefits may largely be restricted to those whose diabetes is detected early through screening.

Screening for type 2 diabetes and dysglycemia

Type 2 diabetes mellitus (T2DM) and dysglycemia (impaired glucose tolerance and/or impaired fasting glucose) are increasingly contributing to the global burden of diseases. The authors reviewed the published literature to critically evaluate the evidence on screening for both conditions and to identify the gaps in current understanding. Acceptable, relatively simple, and accurate tools can be used to screen for both T2DM and dysglycemia. Lifestyle modification and/or medication (e.g., metformin) are cost-effective in reducing the incidence of T2DM. However, their application is not yet routine practice. It is unclear whether diabetes-prevention strategies, which influence cardiovascular risk favorably, will also prevent diabetic vascular complications. Cardioprotective therapies, which are cost-effective in preventing complications in conventionally diagnosed T2DM, can be used in screen-detected diabetes, but the magnitude of their effects is unknown. Economic modeling suggests that screening for both T2DM and dysglycemia may be cost-effective, although empirical data on tangible benefits in preventing complications or death are lacking. Screening for T2DM is psychologically unharmful, but the specific impact of attributing the label of dysglycemia remains uncertain. Addressing these gaps will inform the development of a screening policy for T2DM and dysglycemia within a holistic diabetes prevention and control framework combining secondary and high-risk primary prevention strategies.

Screening for type 2 diabetes: an update of the evidence

A growing body of evidence on diabetes screening has been published during the last 10 years. Type 2 diabetes meets many but not all of the criteria for screening. Concerns about potential harms of screening have largely been resolved. Screening identifies a high-risk population with the potential to gain from widely available interventions. However, in spite of the findings of modelling studies, the size of the benefit of earlier initiation of treatment and the overall cost-effectiveness remains uncertain, in contrast to other screening programmes (such as for abdominal aortic aneurysms) that are yet to be fully implemented. There is also uncertainty about optimal specifications and implementation of a screening programme, and further work to complete concerning development and delivery of individual- and population-level preventive strategies. While there is growing evidence of the net benefit of earlier detection of individuals with prevalent but undiagnosed diabetes, there remains limited justification for a policy of universal population-based screening for type 2 diabetes at the present time. Data from ongoing studies should inform the key assumptions in existing modelling studies and further reduce uncertainty.

The association between quality of life, depressive symptoms and glycemic control in a group of type 2 diabetes patients

AIMS

Several studies have demonstrated worse perception of quality of life (QoL) among patients with type 2 diabetes mellitus (T2DM). The purpose of our study was to assess QoL in a clinical sample of patients with T2DM and its association with depressive symptoms and glycemic control.

METHODS

One hundred outpatients from a sequential sample underwent clinical and psychiatric evaluation. The Problem Areas of Diabetes scale (PAID) and the Beck Depression Inventory (BDI) were used to assess, respectively, QoL and the presence of overall psychopathology. The levels of glycated hemoglobin (HbA1c) were used as the main parameter of glycemic control.

RESULTS

The perception degree of the QoL related with diabetes was associated with the severity of depressive symptoms (r=0.503; p<0.001), but not with HbA1c levels (p=0.117). However, the severity of general psychopathology, evaluated through the BDI scores, predicted the metabolic control, measured by HbA1c levels, among the patients in our sample (r=0.233; p=0.019).

CONCLUSIONS

In our study, PAID was a valuable tool for the evaluation of QoL in T2DM and the screening of depressive symptoms. However, no correlation observed between PAID scores and HbA1c levels. Self-perception evaluation of T2DM patient can help to identify susceptible subjects to current depression.

Age at initiation and frequency of screening to detect type 2 diabetes: a cost-effectiveness analysis

BACKGROUND

No clinical trials have assessed the effects or cost-effectiveness of sequential screening strategies to detect new cases of type 2 diabetes. We used a mathematical model to estimate the cost-effectiveness of several screening strategies.

METHODS

We used person-specific data from a representative sample of the US population to create a simulated population of 325,000 people aged 30 years without diabetes. We used the Archimedes model to compare eight simulated screening strategies for type 2 diabetes with a no-screening control strategy. Strategies differed in terms of age at initiation and frequency of screening. Once diagnosed, diabetes treatment was simulated in a standard manner. We calculated the effects of each strategy on the incidence of type 2 diabetes, myocardial infarction, stroke, and microvascular complications in addition to quality of life, costs, and cost per quality-adjusted life-year (QALY).

FINDINGS

Compared with no screening, all simulated screening strategies reduced the incidence of myocardial infarction (3-9 events prevented per 1000 people screened) and diabetes-related microvascular complications (3-9 events prevented per 1000 people), and increased the number of QALYs (93-194 undiscounted QALYs) added over 50 years. Most strategies prevented a significant number of simulated deaths (2-5 events per 1000 people). There was little or no effect of screening on incidence of stroke (0-1 event prevented per 1000 people). Five screening strategies had costs per QALY of about US$10,500 or less, whereas costs were much higher for screening started at 45 years of age and repeated every year ($15,509), screening started at 60 years of age and repeated every 3 years ($25,738), or a maximum screening strategy (screening started at 30 years of age and repeated every 6 months; $40,778). Several strategies differed substantially in the number of QALYs gained. Costs per QALY were sensitive to the disutility assigned to the state of having diabetes diagnosed with or without symptoms.

INTERPRETATION

In the US population, screening for type 2 diabetes is cost effective when started between the ages of 30 years and 45 years, with screening repeated every 3-5 years.

FUNDING

Novo Nordisk, Bayer HealthCare, [corrected] and Pfizer.

The effects of depression on metabolic control and quality of life in indigent patients with type 2 diabetes

BACKGROUND

The objective of this study was to assess differences in metabolic control and health-related quality of life (QOL) among depressed and nondepressed adults in an indigent population with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Subjects completed validated surveys to assess depression and QOL. Depression was assessed with the Center for Epidemiological Studies-Depression Scale and defined as a score of > or =16. Metabolic control (hemoglobin A1C, total cholesterol, low-density lipoprotein [LDL] cholesterol, and high-density lipoprotein [HDL] cholesterol) measures were abstracted from medical records. We compared demographic characteristics, metabolic control, and QOL by depression status. Ordinary least squares regression was used to assess differences in QOL scores and metabolic control levels by depression status adjusting for covariates.

RESULTS

In the study sample (n = 201), approximately 20% (n = 40) were depressed. In unadjusted analyses, subjects with depression had significantly lower SF-12 physical component summary (PCS) scores (30.4 +/- 7.3 vs. 39.6 +/- 11.8, P < 0.001) and mental component summary (MCS) scores (32.8 +/- 10.5 vs. 48.9 +/- 9.2, P < or = 0.001) and significantly higher total cholesterol (209.3 +/- 72.1 vs. 186.6 +/- 50.9, P = 0.024) compared to those without depression. No significant differences were observed by depression status in hemoglobin A1C, LDL cholesterol, and HDL cholesterol. After adjustment for relevant covariates, depressed individuals continued to have lower SF-12 PCS (36.1 vs. 39.0, P < or = 0.001) and MCS (41.6 vs. 46.8, P < or = 0.001) scores, but the difference in total cholesterol levels was no longer significant.

CONCLUSIONS

In an indigent sample with type 2 diabetes, depression is significantly associated with decreased physical and mental components of QOL. This finding further reinforces the importance of addressing depression in all populations with type 2 diabetes.

Quality of life in glaucoma and three other chronic diseases: a systematic literature review

Chronic diseases have a long-term negative impact on quality of life (QOL). Decreased QOL is associated with increased financial burden on healthcare systems and society. However, few publications have investigated the impact of glaucoma on patients' QOL in comparison with other chronic diseases observed in patients with similar demographic characteristics. To this end, a systematic literature search to assess QOL in glaucoma and three other chronic diseases (osteoporosis, type 2 diabetes mellitus and dementia) was performed. A total of 146 publications were identified that reported QOL using six commonly used generic QOL instruments: 36-, 12- and 20-item Short-Form Health Surveys (SF-36, -12 and -20), EuroQoL (EQ-5D), Sickness Impact Profile (SIP) and the Health Utilities Index-Mark III (HUI-III). The publication breakdown was as follows: glaucoma (10%), osteoporosis (26%), diabetes (52%) and dementia (12%); one publication assessed QOL in glaucoma, diabetes and dementia. QOL was affected to a similar or slightly lesser degree by glaucoma than by osteoporosis, diabetes or dementia. Among the publications reporting SF-36, -12 and -20 evaluations, physical component scores were generally lower than mental component scores across all diseases. QOL was affected more in patients with glaucoma than in demographically matched non-glaucomatous controls according to SF-20 assessment. EQ-5D and SIP results showed that QOL decreased as the severity of glaucoma increased. Patients with glaucoma had the lowest scores on the SIP instrument, indicating better QOL than patients with osteoporosis or diabetes (no data were available on dementia). The HUI-III instrument identified poorer QOL in patients with dementia than other diseases, probably due to cognitive deficits. However, for some of the instruments, data were scarce, and interpretation of the results should be conservative. Although there are limited published QOL studies in glaucoma, its impact on QOL appears to be broadly similar to that of other serious chronic diseases. Development of a QOL instrument that measures vision-specific and general health aspects would better document the impact of glaucoma on QOL and would facilitate comparisons with other chronic disease states.

[Assessment instruments for a Health-Related Quality of Life in diabetes mellitus]

The assessment of Health-Related Quality of Life (HRQoL) has been increasingly used to measure the overall impact of diseases in people's life. Diabetes mellitus (DM) is a chronic disease associated with high morbidity, mortality, and HRQoL impairment in patients. In longitudinal studies, the psychosocial impact of DM predicts mortality. The objective of this review is to describe and to analyze the main instruments used for the HRQoL evaluation in patients with DM. Generic instruments such, as the Quality of Well-Being Scale (QWB), Medical Outcomes Study 36-item Short-Form Health Survey (SF-36), EuroQol (EQ-5D) and specific instruments as the Diabetes Care Profile (DCP), Diabetes Quality of Life Measure (DQOL), Diabetes Impact Measurement Scales (DIMS), Appraisal of Diabetes Scale (ADS), Audit of Diabetes-Dependent Quality of Life (ADDQoL), Diabetes Health Profile (DHP-1 and DHP-18), Questionnaire on Stress in Patients with Diabetes-Revised (QSD-R), Well-Being Enquiry goes Diabetics (WED), Diabetes-Specific Quality-of-life Scale (DSQOLS), Diabetes 39 (D-39) Problems Areas in Diabetes (PAID) were analyzed. PAID is the only translated and validated instrument available in Brazil. The generic and specific instruments have their stregths and shortcomings for evaluation of HRQL in patients with DM. The combined use of both generic (such as the SF-36) and specific (such as the PAID) appears to be a consistent way to evaluate HRQoL as a construct in Brazilian patients with DM. The present article reviews a variety of instruments and emphasizes the urgent need for validation studies of such instruments to be used in Brazilian subjects with DM.

The value of early detection of type 2 diabetes

PURPOSE OF REVIEW

To examine the value of early detection of type 2 diabetes from the perspective of potential benefits and harms to the individual, and from the perspective of the health system.

RECENT FINDINGS

Early detection of type 2 diabetes can be justified because diabetes is an important health problem, has a relatively long asymptomatic phase, interventions are available that have a proven beneficial effect on clinically meaningful outcomes and screening procedures are safe, acceptable and have adequate sensitivity and specificity. However, it remains controversial because of a lack of an established evidence base that detection earlier in the natural history of diabetes is indeed beneficial to individuals.

SUMMARY

Although there are many reasons why the earlier detection of diabetes could be beneficial, the magnitude of any potential benefit of early detection and treatment has yet to be quantitated in a randomized controlled trial and this information will be available in 2010 when the Anglo-Danish-Dutch Study of Intensive Treatment and Complication reports its findings.

Not all roads lead to Rome-a review of quality of life measurement in adults with diabetes

AIMS

Quality of life (QoL) is recognized widely as an important health outcome in diabetes, where the burden of self-management places great demands on the individual. However, the concept of QoL remains ambiguous and poorly defined. The aim of our review is to clarify the measurement of QoL in terms of conceptualization, terminology and psychometric properties, to review the instruments that have been used most frequently to assess QoL in diabetes research and make recommendations for how to select measures appropriately.

METHODS

A systematic literature search was conducted to identify the ten measures most frequently used to assess QoL in diabetes research (including clinical trials) from 1995 to March 2008.

RESULTS

Six thousand and eight-five abstracts were identified and screened for instrument names. Of the ten instruments most frequently used to assess 'QoL', only three actually do so [i.e. the generic World Health Organization Quality of Life (WHOQOL) and the diabetes-specific Diabetes Quality of Life (DQOL) and Audit of Diabetes-Dependent Quality of Life (ADDQoL)]. Seven instruments more accurately measure health status [Short-Form 36 (SF-36), EuroQoL 5-Dimension (EQ-5D)], treatment satisfaction [Diabetes Treatment Satisfaction Questionnaire (DTSQ)] and psychological well-being [Beck Depression Inventory (BDI), Hospital Anxiety and Depression Scale (HADS), Well-Being Questionnaire (W-BQ), Problem Areas in Diabetes (PAID)].

CONCLUSIONS

No single measure can suit every purpose or application but, when measures are selected inappropriately and data misinterpreted, any conclusions drawn are fundamentally flawed. If we value QoL as a therapeutic goal, we must ensure that the instruments we use are both valid and reliable. QoL assessment has the proven potential to identify ways in which treatments can be tailored to reduce the burden of diabetes. With careful consideration, appropriate measures can be selected and truly robust assessments undertaken successfully.

Randomised controlled trial of intensive multifactorial treatment for cardiovascular risk in patients with screen-detected type 2 diabetes: 1-year data from the ADDITION Netherlands study

BACKGROUND

A growing body of evidence suggests that earlier diagnosis and treatment of diabetes may be beneficial; however, definitive evidence is lacking.

AIM

To evaluate the effectiveness of an intensified multifactorial treatment on cardiovascular risk factors in patients with screen-detected type 2 diabetes.

DESIGN OF STUDY

Randomised controlled trial.

SETTING

Seventy-nine general practices in the southwestern region of the Netherlands.

METHOD

In this randomised trial, patients diagnosed with diabetes by screen-detection were assigned to intensified (n = 255) or routine treatment (n = 243), and followed over 1 year. Intensified treatment consisted of pharmacological treatment combined with lifestyle education to achieve haemoglobin A1c (HbA1c) <7.0%, blood pressure <135/85 mmHg, and cholesterol <5.0 mmol/l (4.5 mmol/l if cardiovascular disease was present). Health-related quality of life (HRQoL) was assessed using the Short Form (SF)-36. Analyses were performed using generalised estimating equations models.

RESULTS

Changes in body mass index were 0.2 (routine care) versus -1.4 kg/m(2) (intensified treatment), P<0.001; systolic blood pressure -19 versus -33 mmHg, P<0.001; diastolic blood pressure -7 versus -12 mmHg, P<0.001; HbA1c -0.9% versus -1.1%, P = 0.03; cholesterol -0.5 versus -1.2 mmol/l, P<0.001; high-density lipoprotein cholesterol 0.1 versus 0.1 mmol/l, P = 0.26; low-density lipoprotein cholesterol -0.5 versus -1.0 mmol/l, P<0.001; triglycerides -0.3 versus -0.4 mmol/l, P = 0.71. No difference in HRQoL between the two groups was reported.

CONCLUSION

Intensified multifactorial treatment of patients with screen-detected diabetes in general practice reduces cardiovascular risk factor levels significantly without worsening HRQoL.

Early diagnosis and prevention of diabetes in developing countries

Type 2 diabetes has an insidious onset with a long latent period of dysglycaemia. By the time the diagnosis of diabetes is made, diabetes-related tissue damage occurs in nearly half of the patients. Even after diagnosis, the glycaemic control is suboptimal in more than 50%, leading to the vascular complications. Evidences suggest that early detection of diabetes by appropriate screening methods, especially in subjects with high risk for diabetes will help to prevent or delay the vascular complications and thus reduce the clinical, social and economic burden of the disease. There are also evidences to show that intervention at the prediabetic stage is superior to diagnosis of diabetes.

Evaluation of an informed choice invitation for type 2 diabetes screening

OBJECTIVE

To evaluate an innovative invitation designed to facilitate informed choices for undergoing screening for type 2 diabetes.

METHODS

Four hundred and seventeen people aged 40-69 years (sex: F 53%/M 47%), without known diabetes, recruited from street locations. Participants were randomised to receive one of two hypothetical invitations for screening for type 2 diabetes; one based on General Medical Council guidelines and combined with a decisional balance sheet, the other a brief traditional invitation. Informed choice was assessed immediately after the invitation and 3 weeks later using measures of knowledge, attitudes and intentions.

RESULTS

Two weeks after receipt of the invitation, the proportion of informed choices was significantly higher among participants who received the informed choice invitation compared with those who received the traditional invitation (42.9% versus 11.2%; difference=31.7%, 95% CI: 22.5-40.5%; p<0.001). Mean knowledge scores were significantly higher after the receipt of the invitation designed to facilitate informed choices than after the traditional invitation (5.49 versus 3.90; t(405)=10.106, p<0.001). Intentions to participate in screening were unaffected by receipt of the informed choice invitation.

CONCLUSION

Compared with a traditional invitation, receipt of the invitation designed to facilitate informed choices increased the proportion of informed choices about type 2 diabetes screening attendance.

PRACTICE IMPLICATIONS

: Although the new invitation was associated with better knowledge of screening it had no differential effect on intention and its effect on attendance still requires evaluation.

Psychological impact of screening for type 2 diabetes: controlled trial and comparative study embedded in the ADDITION (Cambridge) randomised controlled trial

OBJECTIVE

To quantify the psychological impact of primary care based stepwise screening for type 2 diabetes.

DESIGN

Controlled trial and comparative study embedded in a randomised controlled trial.

SETTING

15 practices (10 screening, five control) in the ADDITION (Cambridge) trial in the east of England.

PARTICIPANTS

7380 adults (aged 40-69) in the top fourth for risk of having undiagnosed type 2 diabetes (6416 invited for screening, 964 controls).

INTERVENTIONS

Invited for screening for type 2 diabetes or not invited (controls), incorporating a comparative study of subgroups of screening attenders. Attenders completed questionnaires after a random blood glucose test and at 3-6 months and 12-15 months later. Controls were sent questionnaires at corresponding time points. Non-attenders were sent questionnaires at 3-6 months and 12-15 months.

MAIN OUTCOME MEASURES

State anxiety (Spielberger state anxiety inventory), anxiety and depression (hospital anxiety and depression scale), worry about diabetes, and self rated health.

RESULTS

No significant differences were found between the screening and control participants at any time-for example, difference in means (95% confidence intervals) for state anxiety after the initial blood glucose test was -0.53, -2.60 to 1.54, at 3-6 months was 1.51 (-0.17 to 3.20), and at 12-15 months was 0.57, -1.11 to 2.24. After the initial test, compared with participants who screened negative, those who screened positive reported significantly poorer general health (difference in means -0.19, -0.25 to -0.13), higher state anxiety (0.93, -0.02 to 1.88), higher depression (0.32, 0.08 to 0.56), and higher worry about diabetes (0.25, 0.09 to 0.41), although effect sizes were small. Small but significant trends were found for self rated health across the screening subgroups at 3-6 months (P=0.047) and for worry about diabetes across the screen negative groups at 3-6 months and 12-15 months (P=0.001).

CONCLUSIONS

Screening for type 2 diabetes has limited psychological impact on patients. Implementing a national screening programme based on the stepwise screening procedure used in the ADDITION (Cambridge) trial is unlikely to have significant consequences for patients' psychological health.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN99175498 [controlled-trials.com].

Prescreening tools for diabetes and obesity-associated dyslipidaemia: comparing BMI, waist and waist hip ratio. The D.E.S.I.R. Study

OBJECTIVE

To compare the sensitivities of BMI, waist circumference and waist hip ratio (WHR) in identifying subjects who should be screened for diabetes and/or for obesity-associated dyslipidaemia.

DESIGN

Cross-sectional study.

SETTING

Central-western France.

PARTICIPANTS

More than 3000 men and women, aged 40-64 years, from the French study: data from an epidemiological study on the insulin resistance syndrome (D.E.S.I.R.).

MAIN OUTCOME MEASURES

Sensitivity and specificity for screened diabetes (fasting plasma glucose>or=7.0 mmol/l) and screened dyslipidaemia (triglycerides>or=2.3 mmol/l and/or HDL-cholesterol <0.9/1.1 mmol/l (men/women)) according to BMI, waist circumference and WHR.

RESULTS

Sensitivities increased as more corpulent subjects were screened, but they increased slowly after screening the top 30%: body mass index (BMI)>or=27/26 kg/m(2) (men/women) or waist >or=96/83 cm or WHR>or=0.96/0.83. These values were chosen as thresholds. In men, BMI had a nonsignificantly higher sensitivity than waist or WHR for both diabetes and dyslipidaemia (77 vs 74 and 66% P<0.3, 0.09; 56 vs 54 and 49% P<0.5, 0.16). For women, waist had a slightly higher sensitivity than BMI or WHR (82 vs 77 and 77% P<0.8, 0.7) for diabetes; for dyslipidaemia, waist and WHR had similar sensitivities, higher than for BMI (65 and 67 vs 54% P<0.16, 0.13).

CONCLUSIONS

We propose that for screening in a French population 40-64 years of age, the more obese 30% of the population, identified either by BMI, waist or WHR be screened for diabetes and obesity-associated dyslipidaemia.

Utility and Validity of the Self-administered SF-36: Findings From an Older Population

Introduction: The objectives of this study were to assess the utility and validity of the self-administered SF-36 and the effect of visual or cognitive impairment on these measures in an older population. Materials and Methods: Attempt rates, completion rates and internal consistency (Cronbach α) were compared within the second cross-sectional, population-based Blue Mountains Eye Study (n = 3509, mean age 66.7 years, 57% women). Results: The SF-36 was attempted by 3162 (90.1%) participants, of which 2470 (78.1%) completed all items and 2873 (90.9%) completed sufficient items for calculation of all dimensions. In a multivariate model adjusting for age, sex, and presenting visual and cognitive impairments, women (P = 0.011) and participants with visual or cognitive impairments (P<0.0001) were less likely to attempt the questionnaire. Completion rates were significantly lower with increasing age (P <0.0001), in men (P ≤0.0005) and in those with cognitive impairment (P <0.0001). A high level of internal consistency (Cronbach α >0.85 for all dimensions) and construct validity was demonstrated, the latter distinguishing between those with and without medical conditions, disabilities or recent hospital admissions (P <0.01). As the prevalence of visual or cognitive impairment was relatively low in this population, we found no apparent effect of these impairments on the validity of SF-36. Conclusions: Attempt and completion rates, but not internal consistency and construct validity, of the SF-36 were influenced by age, gender, and presenting visual and cognitive impairments. The overall high attempt and completion rates, internal consistency and construct validity suggest that the self-administered SF-36 is a suitable health-related quality of life (HRQOL) measure in similar older community-living populations. Key words: Blood amino acid, Normal ranges, Reference values, Urine amino acids

The influence of ethnicity on health-related quality of life in diabetes mellitus: a population-based, multiethnic study

OBJECTIVES

The aims of this study were to evaluate the influence of ethnicity on health-related quality of life (HRQoL) in diabetic participants using both profile [the Short-Form 36 (SF-36)] and single-index (the SF-6D) instruments and to evaluate the usefulness of the SF-6D as a summary measure for the SF-36.

RESEARCH DESIGN AND METHODS

Using data from a cross-sectional, population-based survey of Chinese, Malay, and Indians in Singapore, we analyzed the influence of ethnicity and other variables on each SF-36 scale and SF-6D scores using linear regression models to adjust for the influence of known determinants of HRQoL.

RESULTS

Data from 309 diabetic respondents were analyzed. Compared with other ethnicities, Indians were most likely to report impaired HRQoL. The unadjusted influence of ethnicity on HRQoL exceeded the minimum clinically important difference (MCID) for all SF-36 scales (MCID: 5 points) and the SF-6D (MCID: 0.033 points). After adjusting for gender, age, and education, the influence of Chinese ethnicity exceeded the MCID for all SF-36 scales, except vitality (VT) and mental health (MH), as well as for the SF-6D. The influence of Malay ethnicity exceeded the MCID only for the SF-36 MH scale and the SF-6D. The influence of ethnicity on HRQoL persisted after adjusting further for other determinants of HRQoL. The SF-6D reflected the ethnic trends for some but not all SF-36 scales.

CONCLUSIONS

After adjusting for demographic, socioeconomic, and other factors known to influence HRQoL, ethnicity remained an important factor influencing HRQoL in this population-based multiethnic sample of diabetic Asians. Further studies to identify modifiable factors explaining the ethnic disparities in HRQoL among diabetic participants are needed. The SF-6D may be a useful summary measure for the SF-36.