1
|
Bates F. Nanomedicine: Revolutionary Interdiscipline. Nanomedicine (Lond) 2014. [DOI: 10.1007/978-1-4614-2140-5_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
|
2
|
Sheikh-Ali M, Raheja P, Borja-Hart N. Medical management and strategies to prevent coronary artery disease in patients with type 2 diabetes mellitus. Postgrad Med 2013; 125:17-33. [PMID: 23391668 DOI: 10.3810/pgm.2013.01.2621] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Coronary artery disease (CAD) in patients with type 2 diabetes mellitus (T2DM) is associated with increased immediate and long-term mortality compared with patients without T2DM. The amplified incidence of CAD stems partly from the aggregation of multiple risk factors, such as obesity, dyslipidemia, and hypertension, which occur in this population. In addition, there appear to be increased forces at play at the molecular and vascular levels in these individuals, which is evidenced by the increased thrombosis and inflammation that is seen in those with diabetic atherosclerosis. Hence, there is a growing need to emphasize early and vigilant risk factor management in patients with T2DM to help reduce their burden of cardiovascular-related mortality. In this article, we review the primary and secondary prevention measures as well as the management of CAD in patients with T2DM.
Collapse
Affiliation(s)
- Mae Sheikh-Ali
- Division of Endocrinology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL 32209, USA.
| | | | | |
Collapse
|
3
|
|
4
|
O'Connor JC, Johnson DR, Freund GG. Psychoneuroimmune implications of type 2 diabetes: redux. Immunol Allergy Clin North Am 2009; 29:339-58. [PMID: 19389586 DOI: 10.1016/j.iac.2009.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A sizable body of knowledge has arisen demonstrating that type 2 diabetes (T2D) is associated with alterations in the innate immune system. The resulting proinflammatory-leaning imbalance is implicated in the development of secondary disease complications and comorbidities, such as delayed wound healing, accelerated progress of atherosclerosis, and retinopathy, in people who have T2D. New experimental data and the results of recently published health-related quality-of-life surveys indicate that individuals who have T2D experience diminished feelings of happiness, well being, and satisfaction with life. These emotional and psychological consequences of T2D point to altered neuroimmunity as a previously unappreciated complication of T2D. This article discusses recent data detailing the impact of T2D on a person's PNI response.
Collapse
Affiliation(s)
- Jason C O'Connor
- Department of Animal Sciences, University of Illinois, 1201 West Gregory Drive, Urbana, IL 61801, USA
| | | | | |
Collapse
|
5
|
Park SK, Park MK, Suk JH, Kim MK, Kim YK, Kim IJ, Kang YH, Lee KJ, Lee HS, Lee CW, Kim BH, Lee KI, Kim MK, Kim DK. Cause-of-Death Trends for Diabetes Mellitus over 10 Years. KOREAN DIABETES JOURNAL 2009. [DOI: 10.4093/kdj.2009.33.1.65] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Su Kyung Park
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Mi-Kyoung Park
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Ji Hye Suk
- Department of Endocrinology, Maryknoll Hospital, Busan, Korea
| | - Mi Kyung Kim
- Department of Endocrinology, Maryknoll Hospital, Busan, Korea
| | - Yong Ki Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - In Ju Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Yang Ho Kang
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Kwang Jae Lee
- Department of Endocrinology, Daedong Hospital, Busan, Korea
| | - Hyun Seung Lee
- Department of Endocrinology, Daedong Hospital, Busan, Korea
| | - Chang Won Lee
- Department of Endocrinology, Busan St. Mary's Medical Center, Busan, Korea
| | - Bo Hyun Kim
- Department of Endocrinology, Busan St. Mary's Medical Center, Busan, Korea
| | - Kyung Il Lee
- Department of Endocrinology, Wallace Memorial Baptist Hospital, Busan, Korea
| | - Mi Kyoung Kim
- Department of Endocrinology, Wallace Memorial Baptist Hospital, Busan, Korea
| | - Duk Kyu Kim
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, Korea
| |
Collapse
|
6
|
The benefit of aspirin therapy in type 2 diabetes: What is the evidence? Int J Cardiol 2008; 129:172-9. [DOI: 10.1016/j.ijcard.2008.01.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2007] [Revised: 10/11/2007] [Accepted: 01/14/2008] [Indexed: 11/24/2022]
|
7
|
Abstract
BACKGROUND: To evaluate the prescription of aspirin for primary and secondary prevention of cardiovascular disorders in diabetic patients, in the light of American Diabetes Association guidelines. MATERIALS AND METHODS: In this retrospective analysis, presence of any cardiovascular disease or cardiovascular disease risk factor as defined in American Diabetes Association guidelines and the use of aspirin and other medication data were extracted from the case files of 100 patients with type 2 diabetes mellitus visiting two teaching hospitals. RESULTS: Of 100 patients studied, 58% were men and 42% women and all were ≥ 40 years of age. 45% had at least one cardiovascular disease and all (100%) were on aspirin for secondary prevention; 45% had one or more risk factors, of which 11% (05/45) had aspirin prescribed for primary prevention; remaining 10% had neither risk factors nor cardiovascular disease (but age ≥ 40 years) and no aspirin documentation. Reasons for not using aspirin/antiplatelet drug were not recorded. CONCLUSIONS: American Diabetes Association recommendations for aspirin use for secondary prevention of cardiovascular diseases were strictly adhered to, in contrast to that for primary prevention. Under-prescription of aspirin could be attributed to the physicians' concern about the burden of poly-pharmacy and toxic effects of aspirin on long-term use. Extensive efforts are necessary to enhance aspirin use in this regard.
Collapse
|
8
|
Persell SD, Denecke-Dattalo TA, Dunham DP, Baker DW. Patient-Directed Intervention Versus Clinician Reminders Alone to Improve Aspirin Use in Diabetes: A Cluster Randomized Trial. Jt Comm J Qual Patient Saf 2008; 34:98-105. [DOI: 10.1016/s1553-7250(08)34012-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
9
|
Johansen OE. Cardiovascular disease and type 2 diabetes mellitus: a multifaceted symbiosis. Scandinavian Journal of Clinical and Laboratory Investigation 2008; 67:786-800. [PMID: 17852797 DOI: 10.1080/00365510701408558] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Chronic hyperglycaemia (e.g. type 2 diabetes mellitus (T2DM) and prediabetes) in humans is associated with an increased risk of cardiovascular (CV) complications, and, vice versa, the presence of CV complications (e.g. myocardial infarction, stroke or intermittent claudication) among patients heightens the risk of T2DM or prediabetes. In both cases (i.e. chronic hyperglycaemia and CV complications), significant diagnostic and treatment challenges resulting from a broad range of factors may serve as barriers to reducing the deleterious societal impact of T2DM and prediabetes. These challenges often include clinicians: failing to intervene early and aggressively enough among patients with T2DM to achieve CV risk factor control; failing to efficaciously identify T2DM patients with already established CV complications; and failing proactively to assess individuals at high risk for T2DM. This review discusses the apparent symbiosis between CV disease and T2DM, with a focus on identifying patients with established T2DM or at risk for T2DM; traditional and novel risk factors and markers for CV disease in T2DM; challenges related to diagnosing CV disease in T2DM; and organization of T2DM care in order to prevent CV complications. These are issues that require attention because identifying patients at high risk for T2DM can halt or reduce their further glycaemic deterioration if addressed properly, and because novel markers and non-invasive tests could be applied in patients with T2DM as a means of detecting and possibly treating unrecognized CV disease in time. Furthermore, several approaches for T2DM care can be effective in controlling the CV risk factors contributing to CV complications.
Collapse
Affiliation(s)
- O E Johansen
- Medical Department, Asker and Baerum Hospital, Rud, Norway.
| |
Collapse
|
10
|
O'Connor JC, Sherry CL, Guest CB, Freund GG. Type 2 Diabetes Impairs Insulin Receptor Substrate-2-Mediated Phosphatidylinositol 3-Kinase Activity in Primary Macrophages to Induce a State of Cytokine Resistance to IL-4 in Association with Overexpression of Suppressor of Cytokine Signaling-3. THE JOURNAL OF IMMUNOLOGY 2007; 178:6886-93. [PMID: 17513737 DOI: 10.4049/jimmunol.178.11.6886] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Chronic elevation of proinflammatory markers in type 2 diabetes (T2D) is well defined, but the role of anti-inflammatory cytokines in T2D is less clear. In this study, we report that normal IL-4-dependent elaboration of IL-1 receptor antagonist (IL-1RA) requires IRS-2-mediated PI3K activity in primary macrophages. We also show that macrophages isolated from obese/diabetic db/db mice have impaired IRS-2-mediated PI3K activity and constitutively overexpress suppressor of cytokine signaling (SOCS)-3, which impairs an important IL-4 anti-inflammatory function. Peritoneal proinflammatory cytokine levels were examined in diabese (db/db) mice, and IL-6 was found to be nearly 7-fold higher than in nondiabese (db/+) control mice. Resident peritoneal macrophages were isolated from db/db mice and were found to constitutively overexpress IL-6 and were unable to elaborate IL-1RA in response to IL-4-like db/+ mouse macrophages. Inhibition of PI3K with wortmannin or blockage of IRS-2/PI3K complex formation with a cell permeable IRS-2-derived tyrosine phosphopeptide inhibited IL-4-dependent IL-1RA production in db/+ macrophages. Examination of IL-4 signaling in db/db macrophages revealed that IL-4-dependent IRS-2/PI3K complex formation and IRS-2 tyrosine phosphorylation was reduced compared with db/+ macrophages. SOCS-3/IL-4 receptor complexes, however, were increased in db/db mouse macrophages compared with db/+ mice macrophages as was db/db mouse macrophage SOCS-3 expression. These results indicate that in the db/db mouse model of T2D, macrophage expression of SOCS-3 is increased, and impaired IL-4-dependent IRS-2/PI3K formation induces a state of IL-4 resistance that disrupts IL-4-dependent production of IL-1RA.
Collapse
Affiliation(s)
- Jason C O'Connor
- Division of Nutritional Sciences, Integrative Immunology and Behavior Program, University of Illinois, Urbana, IL 61801, USA
| | | | | | | |
Collapse
|
11
|
Pongwecharak J, Maila-ead C, Sakulthap J, Sripanitkulchai N. Evaluation of the uses of aspirin, statins and ACEIs/ARBs in a diabetes outpatient population in southern Thailand. J Eval Clin Pract 2007; 13:221-6. [PMID: 17378868 DOI: 10.1111/j.1365-2753.2006.00680.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the uses of aspirin, statins and angiotensin converting enzymes inhibitors/angiotensin receptor blockers (ACEIs/ARBs) in a diabetes population in southern Thailand. METHODS A review of outpatient medical records at the diabetic clinics of the regional hospital (n=304) and a community hospital (n=313), and a review of pharmacy computerized diabetes prescribing data (n=398) of the teaching hospital. All were in the province of Songkhla, southern Thailand. RESULTS A total of 1015 diabetes patients, mean age (SD) 60.1 (12.1) years, were identified, with type 2 diabetes being most prevalent (93%). Females constituted 69%. Hypertension was a co-morbidity in almost half. Mean time (SD) since diagnosis was 5.8 (4.7) years. Where lipid profiles were available, less than one-third achieved the target LDL-C of <2.6 mmol L(-1). Almost all patients (96%) were candidates for treatment with a statin according to the American Diabetes Association (ADA) recommendation, whereas only 6.6 and 38.5% were actually taking one in the regional and the teaching hospital, respectively. Over 90% should have been taking primary prophylactic aspirin, whereas only 5.7-29% were actually prescribed one. A few had existing cardiovascular/cerebrovascular disease, and all were taking aspirin. There was no documented proteinuria status; however, 30-50% were on a ACEI/ARB, most likely as part of an antihypertensive regimen. CONCLUSIONS Aspirin as a primary prophylaxis of cardiovascular disease in diabetes is remarkably underused. Screening for albuminuria was apparently lacking. Statin therapy also presented a major deficiency. ACEI/ARB was probably prescribed for hypertension rather than in relation to proteinuria.
Collapse
Affiliation(s)
- J Pongwecharak
- Department of Clinical Pharmacy, Faculty of Pharmaceutical Science, Prince of Songkla University, Hatyai, Songkla, Thailand.
| | | | | | | |
Collapse
|
12
|
Leitão CB, Krahe AL, Nabinger GB, Picon PX, Pecis M, Zaslavsky LM, Gross JL, Canani LH. Aspirin therapy is still underutilized among patients with type 2 diabetes. ARQUIVOS BRASILEIROS DE ENDOCRINOLOGIA E METABOLOGIA 2007; 50:1014-9. [PMID: 17221106 DOI: 10.1590/s0004-27302006000600006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2005] [Accepted: 07/10/2006] [Indexed: 11/21/2022]
Abstract
The daily use of aspirin in patients with type 2 diabetes mellitus (DM2) reduces significantly cardiovascular events (CVE). In the absence of contraindications, American Diabetes Association (ADA) recommends the use of aspirin to all DM2 patients older than 40 years of age. To evaluate aspirin use among 636 out patients with DM2 who participate in a regional multicenter study in Southern Brazil, a standard questionnaire was used. Patients also underwent a physical examination and laboratorial tests. All patients were older than 40 years (mean 58 +/- 11 years old; 42% male) and by ADA guidelines most of them should be using aspirin. However, only 177 (27.5%) were on this medication. The use of aspirin was higher when any CVE were present. However, the percentage of users was still below the expected, not even reaching 50%. In conclusion, even though the use of aspirin is greater in patients with CVE, and its benefits are well documented, it is still underutilized. Strategies to enhance the use of aspirin should be developed to reduce the morbidity and mortality from cardiovascular diseases in patients with DM2.
Collapse
|
13
|
Sherlock M, Mylotte D, Mac Mahon J, Moore KB, Thompson CJ. Lipid lowering targets are easier to attain than those for treatment of hypertension in type 2 diabetes. Ir J Med Sci 2006; 175:36-41. [PMID: 17312827 DOI: 10.1007/bf03167965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AIM To assess the impact of therapeutic strategies to reduce cardiovascular risk in patients with type 2 diabetes. METHODS Five-hundred patients with type 2 diabetes were studied, using retrospective case note analysis in 1997 (followed by a unit policy targeting vascular risk) and again in 2001. RESULTS The mean BP of the hypertensive patients was unchanged, 151/83 +/- 23/12 mmHg (1997) and 149/84 +/- 19.1/9.8 mmHg (P=0.2) (2001) (despite increase in patients receiving 23 antihypertensives (4.2% to 18.0%, P<0.01). The mean cholesterol improved from 5.34 +/- 1.1 mmol/L to 4.72 +/- 0.94 mmol/L (P<0.01). 2.9% compared with 44.6% (P<0.01) of hypercholesterolaemic patients, achieved target cholesterol. Antiplatelet therapy increased from 27.6% to 61.2% (P<0.01). Reduced mean HbA1c, 7.91 +/- 1.61% to 7.12 +/- 1.41% (P<0.01). CONCLUSION Improved lipid profiles, aspirin uptake and glycaemic control, but no improvement in blood pressure targets were achieved. Additional strategies are required to achieve cardiovascular risk factor targets.
Collapse
Affiliation(s)
- M Sherlock
- Dept of Diabetes and Endocrinology, Beaumont Hospital Dublin
| | | | | | | | | |
Collapse
|
14
|
Abstract
The idea that type 2 diabetes is associated with augmented innate immune function characterized by increased circulating levels of acute phase reactants and altered macrophage biology is fairly well established, even though the mechanisms involved in this complex interaction still are not entirely clear. To date, the majority of studies investigating innate immune function in type 2 diabetes are limited to the context of wound healing, atherosclerosis, stroke, and other commonly identified comorbidities. Several important recurring themes come out of these data. First, type 2 diabetes is associated with a state of chronic, subclinical inflammation. Second, in macrophages, type 2 diabetic conditions enhance proinflammatory reactions and impair anti-inflammatory responses. Third, after acute activation of the innate immune system in type 2 diabetes, recovery or resolution of inflammation is impaired. The consequences of type 2 diabetes-associated inflammatory alterations on PNI processes have been recognized only recently. Given the impact of diminished emotional well-being on the quality of life in patients who have type 2 diabetes, diabetes-induced exacerbation of PNI responses should be considered a serious complication of type 2 diabetes that warrants further clinical attention.
Collapse
Affiliation(s)
- Jason C O'Connor
- Division of Nutritional Sciences, University of Illinois, Urbana, IL 61801, USA
| | | | | |
Collapse
|
15
|
Correa-de-Araujo R, Stevens B, Moy E, Nilasena D, Chesley F, McDermott K. Gender differences across racial and ethnic groups in the quality of care for acute myocardial infarction and heart failure associated with comorbidities. Womens Health Issues 2006; 16:44-55. [PMID: 16638521 DOI: 10.1016/j.whi.2005.04.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2004] [Revised: 02/24/2005] [Accepted: 04/18/2005] [Indexed: 10/24/2022]
Abstract
This paper provides important insights on gender differences across racial and ethnic groups in a Medicare population in terms of the quality of care received for acute myocardial infarction (AMI) and congestive heart failure (CHF) in association with diabetes or hypertension/end-stage renal disease (ESRD). Both race/ethnicity and gender are associated with differences in the diagnostic evaluation and treatment of Medicare recipients with these conditions. In the AMI group, non-Hispanic Black and Hispanic patients of both genders were less likely to receive aspirin or beta-blockers than non-Hispanic Whites. These differences persisted for Hispanic women and men even when they presented with ESRD or diabetes. Rates for smoking cessation counseling were among the lowest among non-Hispanic Blacks and Hispanics with AMI-diabetes and non-Hispanic blacks with AMI-hypertension/ESRD. Gender comparisons within racial groups for the AMI and AMI-diabetes groups show that among non-Hispanic Whites, women were less likely to receive aspirin and beta-blockers. No gender differences were noted among non-Hispanic Black and Hispanic Medicare recipients. In the CHF group, Hispanics were the racial/ethnic group least likely to have an assessment of left ventricular function (LVF), even if they had diabetes and had lower rates of angiotensin-converting enzyme inhibitor therapy or even if they had combined CHF-hypertension/ESRD. Gender comparisons in both the CHF and CHF-hypertension/ESRD groups show that non-Hispanic White women were less likely to have an LVF assessment than non-Hispanic White men. Among all subjects, having comorbidities with AMI was not associated with higher markers of quality cardiovascular care. Closing the many gaps in cardiovascular care must target the specific needs of women and men across racial and ethnic groups.
Collapse
|
16
|
Johnson ML, Pietz K, Battleman DS, Beyth RJ. Therapeutic Goal Attainment in Patients With Hypertension and Dyslipidemia. Med Care 2006; 44:39-46. [PMID: 16365611 DOI: 10.1097/01.mlr.0000188982.25397.37] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Recent guidelines emphasize the need to assess and treat overall risk for cardiovascular disease through the concomitant management of multiple risk factors. We sought to ascertain treatment patterns and attainment of therapeutic goals in patients with isolated and concomitant hypertension and dyslipidemia, both with and without diabetes mellitus (DM) and symptomatic cardiovascular disease. METHODS Inception cohorts of more than 41,000 newly diagnosed hypertension and dyslipidemia patients from 6 medical centers of the south-central Veterans Affairs health care system were evaluated. Treatment patterns and goal attainment for low-density lipoprotein cholesterol (LDL-C; Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults guidelines: <160, <130, or <or=100 mg/dL depending on risk factors) and blood pressure (BP; Joint National Committee 6: <140/90 or <130/85 mm Hg depending on risk factors) were measured at 1 year. Separate analyses were conducted in patients with and without DM and symptomatic cardiovascular disease. RESULTS Treatment rates in patients with and without DM and symptomatic disease ranged from 46.6% to 71.3% in patients with hypertension only, from 31.5% to 64.1% in patients with dyslipidemia only, and from 64.3% to 91.3% in patients with both conditions. Among asymptomatic patients, 40.6% of nondiabetics and 20.6% of patients with DM with isolated hypertension reached BP targets. Attainment of LDL-C goals was slightly higher and reached 52.8% among patients with DM with concomitant hypertension. Among symptomatic patients, attainment of all goals was <40% for all groups. The proportion of asymptomatic patients with concomitant disease reaching goal for both BP and LDL-C was 24.4% among nondiabetics and 15.4% among patients with DM; these proportions decreased to 13.6% and 13.4% respectively, among patients with symptomatic cardiovascular disease. CONCLUSIONS The majority of patients were receiving pharmacological treatment of hypertension and dyslipidemia, yet attainment of therapeutic goals was generally <50%. Further work is needed to determine factors related to improvement in management and outcomes of patients with multiple cardiovascular risk factors.
Collapse
Affiliation(s)
- Michael L Johnson
- Houston Center for Quality of Care and Utilization Studies, Michael E. DeBakey Veterans Affairs Medical Center and Department of Medicine, Section of Health Services Research, Baylor College of Medicine, Houston, Texas 77030, USA.
| | | | | | | |
Collapse
|
17
|
Miller SR, Littenberg B, MacLean CD. Prevalence of antiplatelet therapy in patients with diabetes. Cardiovasc Diabetol 2005; 4:18. [PMID: 16321162 PMCID: PMC1318485 DOI: 10.1186/1475-2840-4-18] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2005] [Accepted: 12/01/2005] [Indexed: 12/12/2022] Open
Abstract
Objective To determine the prevalence of, and patient characteristics associated with, antiplatelet therapy in a cohort of primary care patients with Type 1 or Type2 diabetes. Methods Subjects participating in a randomized trial of a decision support system were interviewed at home and medication usage verified by a research assistant. Eligibility for antiplatelet therapy was determined by American Diabetes Association criteria and clinical contraindications. The association between antiplatelet use and patient characteristics was examined using bivariate and multivariate logistic regression. Results The mean age of subjects was 64 years (range 31–93). The prevalence of antiplatelet use was 54% overall; 45% for subjects without known CVD vs. 78% for those with CVD; 46% for women vs. 63% for men; and 45% for younger subjects (age< 65) vs. 62% for senior citizens. After controlling for race/ethnicity, income, education, marital status, insurance status and prescription coverage, the following were associated with the use of antiplatelet therapy: presence of known CVD (OR 3.4 [2.2, 5.1]), male sex (OR 2.0 [1.4, 2.8]), and age > = 65 (OR 1.9 [1.3, 2.7]). The prevalence of antiplatelet therapy for younger women without CVD was 32.8% compared to a prevalence of 90.3% for older men with CVD. Conclusion Despite clinical practice guidelines recommending antiplatelet therapy for patients with diabetes, there are still many eligible patients not receiving this beneficial therapy, particularly patients under 65, women, and patients without known CVD. Effective methods to increase antiplatelet use should be considered at the national, community, practice and provider level.
Collapse
Affiliation(s)
- Shaun R Miller
- University of Vermont College of Medicine, Burlington, Vermont, USA
| | | | | |
Collapse
|
18
|
Rodondi N, Vittinghoff E, Cornuz J, Butler J, Ding J, Satterfield S, Newman AB, Harris TB, Hulley SB, Bauer DC. Aspirin use for the primary prevention of coronary heart disease in older adults. Am J Med 2005; 118:1288. [PMID: 16271917 DOI: 10.1016/j.amjmed.2005.06.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2004] [Revised: 06/15/2005] [Accepted: 06/15/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE Aspirin for the primary prevention of coronary heart disease (has a more favorable risk/benefit profile among adults with high coronary heart disease risk than among low-risk adults, but there is little information on the current patterns of aspirin use for primary prevention. We determined the prevalence of aspirin use in relation to coronary heart disease risk and changes over time. SUBJECTS AND METHODS We measured regular aspirin use in 2163 black and white older adults without cardiovascular disease in a population-based cohort from 1997 to 1998 and 2002 to 2003. We determined the 10-year coronary heart disease risk by using the Framingham risk score. RESULTS In 1997-1998, 17% of the cohort were regular aspirin users. Aspirin use increased with coronary heart disease risk from 13% in persons with a 10-year risk less than 6% (low risk) to 23% in those with a 10-year risk greater than 20% (highest risk) (P for trend < .001). Blacks were less likely to use aspirin (13%) than whites (20%). In multivariate analysis, black race was still associated with lower aspirin use (odds ratio 0.66, 95% confidence interval 0.49-0.89). In 1997-1998 and 2002 to 2003, aspirin use increased from 17% to 32% among those still free of coronary heart disease (P < .001), and the association with coronary heart disease risk continued (P for trend < .001). Despite their high coronary heart disease risk, diabetic persons were not more likely to use aspirin than nondiabetic persons, even in 2002 and 2003 (odds ratio 0.89, 95% confidence interval 0.56-1.40). CONCLUSION Regular use of aspirin by older adults with no history of cardiovascular disease has increased in recent years. Individuals at higher coronary heart disease risk are more likely to take aspirin, but there is room for considerable improvement in targeting those at high risk, particularly diabetic persons and blacks.
Collapse
Affiliation(s)
- Nicolas Rodondi
- Department of Epidemiology and Biostatistics, University of California, San Francisco, Calif, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Bruno A, Grassi G, Dani F, Degiovanni M, Maghenzani G, Pagano G. Use of antiplatelet therapy in a diabetic outpatient service of a large urban public hospital. Nutr Metab Cardiovasc Dis 2005; 15:42-46. [PMID: 15871850 DOI: 10.1016/j.numecd.2004.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2004] [Revised: 03/22/2004] [Accepted: 04/02/2004] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIM Cardiovascular disease is the most important cause of mortality in type 2 diabetes. Aspirin treatment is effective in diabetic patients with cardiovascular disease and it does not significantly increase the risk of retinal haemorrhage, gastrointestinal bleeding or hemorrhagic stroke. The American Diabetes Association (ADA) recommends the use of aspirin in all adult patients with diabetes and macrovascular disease, and suggests to start treatment with aspirin for primary prevention in diabetic patients >or=40 years of age and with one or more other cardiovascular risk factors in the absence of specific contraindications. METHODS In this observational retrospective study, we have selected from our database (17,732 clinical reports) all the type 2 diabetic patients 41--80 years of age, who had at least one visit to our outpatient service in the following two periods: A (from 1 July 1995 to 30 June 1996) and B (from 1 July 2002 to 30 June 2003), then analysed the patient-records for prescription of antiplatelet agents. RESULTS Our analysis has shown that antiplatelet agents were prescribed to 15% of the type 2 diabetic patients in period A (10.8% and 53.4% -- primary and secondary prevention, respectively) and to 22.8% of the patients in period B (19.1% and 60.5% -- primary and secondary prevention, respectively). CONCLUSIONS Patients with type 2 diabetes and high cardiovascular risk are not always under antiplatelet treatment despite the ADA recommendations, particularly for primary prevention. However, our data show an increased trend in prescriptions from 1997, when the first ADA specific guidelines for aspirin therapy were published.
Collapse
Affiliation(s)
- Alberto Bruno
- Diabetic Outpatient Department, San Giovanni Battista di Torino Hospital, Corso Bramante, 88, 10126 Turin, Italy.
| | | | | | | | | | | |
Collapse
|
20
|
Tang TS, Gillard ML, Funnell MM, Nwankwo R, Parker E, Spurlock D, Anderson RM. Developing a new generation of ongoing: Diabetes self-management support interventions: a preliminary report. THE DIABETES EDUCATOR 2005; 31:91-7. [PMID: 15779250 DOI: 10.1177/0145721704273231] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE The study examined the feasibility, acceptability, and potential impact of an innovative, community-based, ongoing self-management intervention aimed at enhancing and sustaining self-care behaviors over the long term among urban African Americans with type 2 diabetes. METHODS Sixty-two African American men and women completed the study. Participants were invited to attend 24 weekly, consecutive, diabetes self-management support/ education groups. The flow of the weekly group sessions was guided by questions and concerns of the patients. Baseline and 6-month follow-up metabolic functioning, lipid profiles, cardiovascular functioning, and self-care behaviors were assessed. RESULTS Ninety percent (n = 56) of the sample attended at least 1 session; 40% attended at least 12 or more sessions. Paired t tests found significant improvements in body mass index (P < .001), total cholesterol (P < .01), high-density lipoprotein (P < .05), and low-density lipoprotein (P < .001). Significant increases were also found for self-care behaviors (P < .05). CONCLUSIONS Preliminary evidence suggests that participation in this weekly problem-based, self-management support intervention can yield diabetes-related health benefits.
Collapse
Affiliation(s)
- Tricia S Tang
- The University of Michigan Department of Medical Education, University of Michigan Medical School, and Michigan
Research and Training Center
| | - Mary Lou Gillard
- The University of Michigan Department of Medical Education, University of Michigan Medical School, and Michigan
Research and Training Center
| | - Martha M Funnell
- The University of Michigan Department of Medical Education, University of Michigan Medical School, and Michigan
Research and Training Center
| | - Robin Nwankwo
- The University of Michigan Department of Medical Education, University of Michigan Medical School, and Michigan
Research and Training Center
| | - Ebony Parker
- The University of Michigan Department of Medical Education, University of Michigan Medical School, and Michigan
Research and Training Center
| | - David Spurlock
- The University of Michigan Department of Medical Education, University of Michigan Medical School, and Michigan
Research and Training Center
| | - Robert M Anderson
- The University of Michigan Department of Medical Education, University of Michigan Medical School, and Michigan
Research and Training Center
| |
Collapse
|
21
|
Tranche S, Galgo A, Mundet X, Sánchez-Zamorano MA. Cardiovascular risk factors in type 2 diabetic patients: Multifactorial intervention in primary care. Kidney Int 2005:S55-62. [PMID: 15613070 DOI: 10.1111/j.1523-1755.2005.09313.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cardiovascular disease is the main cause of morbidity and mortality in patients with type 2 diabetes mellitus (DM). Intervention on cardiovascular risk factors (CVRF) is essential to obtain clinical results reducing the excess of cardiovascular risk (CVR) in these patients. METHODS The objective of this study was to describe the association of type 2 DM with modifiable cardiovascular risk factors and the degree of control of these in a population of type 2 diabetics in attendance in primary care clinics, and also to establish prospectively whether an integral and multifactorial intervention on uncontrolled cardiovascular risk factors, carried out in conditions of routine clinical practice by applying an open protocol, could significantly reduce the estimated CVR according to the Framingham scale. The proposed intervention included both actions aimed at modifying habits, and pharmacologic intervention to achieve an optimum level of control in accordance with international recommendations for the objectives and treatment for type 2 diabetes. RESULTS A total of 3466 patients with a mean age of 58 +/- 7.5 years were studied and followed-up for 1 year. Of these, 90.4% of patients had high blood pressure; 60.1% of men and 32.7% of women presented CVR >20% in 10 years according to the Framingham scale by categories. Intervention at 1 year of follow-up had achieved statistically significant reductions in blood pressure, glycated hemoglobin, and lipid levels, but not of patients' body weight. After 1 year of follow-up, 29% of males and 24% of women with a high CVR (>20%) at the start of the study presented reduced risk levels. CONCLUSION The results of the study demonstrate that an integrated and multifactorial intervention in type 2 diabetic patients can achieve clinically significant reductions in CVR. However, conducted in effective conditions, it is not able to achieve optimum levels of control in spite of the initial proposal, possibly due to some degree of inertia in routine clinical practice.
Collapse
|
22
|
Vote BJ, Gamble GD, Polkinghorne PJ. Auckland Proliferative Diabetic Vitrectomy Fellow Eye Study. Clin Exp Ophthalmol 2004; 32:397-403. [PMID: 15281975 DOI: 10.1111/j.1442-9071.2004.00845.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND To review medical and ophthalmic findings of primary diabetic vitrectomy patients to examine indices important in progression to fellow eye surgery. METHODS A retrospective analysis was undertaken of all diabetic patients undergoing vitreoretinal surgery at Auckland Public Hospital between January 1992 and July 1996. Kaplan-Meier survival analysis was performed along with univariate and multivariate (Cox Proportional Hazards) data analysis. RESULTS One hundred and fourteen primary diabetic vitrectomy cases were reviewed with mean follow-up duration of 4 years. Thirty-eight per cent (n = 43) of the study group underwent fellow eye surgery at a mean time of 1.6 years after first eye surgery. Fourteen patients were already blind in the fellow eye at baseline, and five patients refused second eye surgery on intention to treat. Thus there were 62 (54%) patients with severe (surgical threshold) fellow eye disease diagnosed within the follow-up period. The presence of either tractional retinal detachment or combined rhegmatogenous/tractional retinal detachment but without vitreous haemorrhage in the presenting eye was, in this series, a risk factor for fellow eye surgery (OR 5.56; 95% CI 1.96-15.8). Maori and Pacific Islander ethnicity was significantly associated with traction retinal detachment (OR 2.23; 95% CI 1.05-4.7). At data analysis 57% (n = 60) of the study patients had died. The mean time to death was 4.3 years, with 84% of these patients having evidence of renal disease at the time of their first eye surgery. Good visual function in at least one eye was maintained in many patients. CONCLUSIONS A substantial proportion of diabetic vitrectomy patients require fellow eye surgery. Absence of vitreous haemorrhage in the presenting eye (i.e. tractional or combined rhegmatogenous/tractional retinal detachments but without vitreous haemorrhage) was predictive of need for fellow eye surgery. The need for diabetic vitrectomy correlates with poor survival in this study population.
Collapse
Affiliation(s)
- Brendan J Vote
- Department of Ophthalmology, University of Auckland, New Zealand
| | | | | |
Collapse
|
23
|
Abstract
BACKGROUND Cardiovascular disease (CVD) risk-reduction practices are suboptimal in populations at high risk for CVD, and this problem may be worse in women than in men. METHODS In 2003, CVD risk-reduction practices were compared between men and women after stratification by CVD risk status (high, intermediate, low) in a cross-sectional analysis of the 1999 Behavioral Risk Factor Surveillance System (BRFSS), a random-digit telephone survey of state population-based samples of the civilian non-institutionalized population of adults. This analysis included persons aged >40 years who answered questions regarding lipid and blood pressure screening, recommendations for lifestyle modification, that is, exercise and reduced fat intake, and aspirin use. Risk status was defined according to Adult Treatment Panel III definitions. RESULTS In the 97,387 adults included in this analysis, high CVD risk was associated with lipid and blood pressure screening, lifestyle modification, and aspirin use in both men and women compared to intermediate-risk and low-risk (p <0.001). Among high-risk adults, men and women reported similar frequency of blood pressure and cholesterol measurement and physician advice on lifestyle modification; among intermediate- and low-risk adults, women reported slightly more frequent screening and lifestyle modification than men (p <0.001). In all CVD risk categories, women reported significantly less aspirin use than in men (p <0.001). CONCLUSIONS Among people at high risk for CVD, women report lifestyle modification more often than men, while men report use of aspirin more often than women. These findings may assist with targeting interventions to reduce CVD risk to the unique needs of men and women.
Collapse
Affiliation(s)
- Catherine Kim
- Division of General Internal Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA.
| | | |
Collapse
|
24
|
Bueno H. [Underutilization of acetylsalicylic acid of cardiovascular prevention in patients with diabetes mellitus]. Med Clin (Barc) 2004; 122:101-3. [PMID: 14746700 DOI: 10.1016/s0025-7753(04)74157-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
25
|
Esmatjes E, Castell C, Franch J, Puigoriol E, Hernáez R. Consumo de ácido acetilsalicílico en pacientes con diabetes mellitus. Med Clin (Barc) 2004; 122:96-8. [PMID: 14746698 DOI: 10.1016/s0025-7753(04)74155-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Acetylsalicylic acid (ASA) has been recommended for primary (PP) and secondary prevention (SP) of cardiovascular disease (CVD) in diabetic patients. The consumption of ASA among Catalan diabetic people is described here. SUBJECTS AND METHOD We analyzed 1,718 questionnaires administered to members of the Catalonia's Diabetic Association. ASA intake, history of CVD and medical advice about the use of ASA were evaluated. RESULTS ASA was taken by 21% subjects (as PP in 14% and as SP in 53%). Medical advice had been received in 23% (15% as PP and 56% as SP). CONCLUSIONS ASA intake among diabetic patients is low in both PP and SP. Physicians should recommend its use to improve this situation.
Collapse
|
26
|
Klinke JA, Johnson JA, Guirguis LM, Toth EL, Lee TK, Lewanczuk RZ, Majumdar SR. Underuse of aspirin in type 2 diabetes mellitus: Prevalence and correlates of therapy in rural Canada. Clin Ther 2004; 26:439-46. [PMID: 15110137 DOI: 10.1016/s0149-2918(04)90040-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND Patients with type 2 diabetes mellitus (DM) have a markedly increased risk of cardiovascular morbidity and mortality. Guidelines of both the American and Canadian Diabetes Associations recommend the use of aspirin as antiplatelet therapy for all adults with type 2 DM. OBJECTIVES The aims of this study were to assess the rate of adherence to guidelines for aspirin use in DM patients in rural Canadian communities and to describe the independent correlates of aspirin use in this population. METHODS We collected information from a cohort of patients with type 2 DM living in 2 rural regions of northern Alberta, Canada, at the time of their enrollment in a multidisciplinary outreach program designed to improve their quality of care. Our primary outcome was self-reported use of antiplatelet therapy (aspirin or others). We use multivariate logistic regression analyses to examine the independent association between sociodemographic and clinical characteristics and self-reported use of antiplatelet agents. RESULTS Among 342 patients included in the study (who were typical of rural Canadian patients with type 2 DM), the mean age was 62.9 years; 149 (44%) were men, 84 (25%) were of indigenous origin, and the median time since diagnosis of DM was 8 years. Despite guideline recommendations, only 23% of the cohort (78 patients) were regularly taking aspirin alone or in combination with a thienopyridine (n = 74 and n = 2, respectively) or a thienopyridine alone (n = 2). The results of them ultivariate analyses showed that the only factors independently associated with the use of antiplatelet therapy were symptomatic coronary artery disease (adjusted odds ratio [AOR], 3.1; 95% CI, 1.1-8.7; P=0.033 ), older age (AOR, 2.0 per 10-year interval; 95% CI, 1.7-2.2; P<0.001 ); and male sex (AOR, 1.9; 95% CI, 1.1-3.5; P=0.026 ). CONCLUSIONS Aspirin is a safe, inexpensive, and readily available therapy that is effective for preventing cardiovascular disease, and patients with type 2 DM are particularly likely to benefit from such preventive therapy. However, we found significant underuse of aspirin therapy among our study population. Aspirin should be included and better promoted as a factor in high-quality, evidence-based DM management.
Collapse
Affiliation(s)
- Jennifer A Klinke
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | | | | | | | | | | |
Collapse
|
27
|
Abstract
Patients with diabetes mellitus (DM) have accelerated atherothrombotic disease of coronary, cerebral, leg, and other vessels. The major cause of death is cardiovascular, and the risk for a myocardial infarction (MI) in a patient with DM who has never had a MI is the same as a nondiabetic individual who has already had one. In this paper, we review the major reasons for a prothrombotic state in patients with DM: alterations in the intrinsic coagulation and fibrinolytic systems and many abnormalities of platelet function. Increased platelet thromboxane production as well as activation of platelet receptors for fibrinogen and or adenosine diphosphate (ADP) are often present, and can be treated with aspirin (acetylsalicylic acid) and/or receptor blockers. Review of the major primary prevention trials in DM indicates that a significantly reduced risk for MI or major cardiovascular events may be obtained by enteric-coated aspirin, 81-325 mg/day. There is emerging consensus that this is recommended strategy in adult (aged >30 years) patients with DM who are at high vascular risk. Surveys suggest that this includes virtually every patient with type 2 DM in the US, as well as many patients with complicated type 1 DM. These recommendations are also appropriate for secondary prevention. Data supporting the use of clopidogrel as an alternative drug in the case of aspirin allergy or other contraindications are reviewed. Evidence is presented in support of using aspirin plus clopidogrel in acute coronary syndromes (ACS), and a meta-analysis of six trials of platelet glycoprotein (GP) IIb/IIIa inhibitors and aspirin in diabetic patients with ACS establishes this regimen as an effective choice. Although bleeding episodes are more common with combined antiplatelet therapy for ACS than for aspirin alone, the benefit of a significant reduction in 30-day mortality appears to outweigh the risk of major bleeding. It is concluded that major advances in our understanding of the prothrombotic state in DM have been made. Evidence from controlled clinical trials supports the use of enteric-coated aspirin, 81-325 mg/day, as a primary and a secondary prevention strategy in adults with DM with high vascular risk. In ACS, combination therapy with aspirin plus clopidogrel or alternatively, aspirin plus a platelet GP IIb/IIIa inhibitor is supported by prospective trial data. These approaches should be added to the other multifactorial preventive strategies directed at lowering the risk for major vascular events in patients with DM.
Collapse
Affiliation(s)
- John A Colwell
- Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
28
|
Heisler M, Smith DM, Hayward RA, Krein SL, Kerr EA. Racial Disparities in Diabetes Care Processes, Outcomes, and Treatment Intensity. Med Care 2003; 41:1221-32. [PMID: 14583685 DOI: 10.1097/01.mlr.0000093421.64618.9c] [Citation(s) in RCA: 161] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Black Americans with diabetes have a higher burden of illness and mortality than do white Americans. However, the extent to which differences in medical care processes and treatment intensity contribute to poorer diabetes outcomes is unknown. OBJECTIVE To assess racial disparities in the quality of diabetes care processes, intermediate outcomes, and treatment intensity. METHODS We conducted an observational study of 801 white and 115 black patients who completed the Diabetes Quality Improvement Project survey (response rate=72%) in 21 Veterans Affairs (VA) facilities using survey data; medical record information on receipt of diabetes services (A1c, low-density lipoprotein [LDL], nephropathy screen, and foot and dilated eye examinations), and intermediate outcomes (glucose control measured by A1c; cholesterol control measured by LDL; and achieved level of blood pressure); and pharmacy data on filled prescriptions. RESULTS There were no racial differences in receipt of an A1c test or foot examination. Blacks were less likely than whites to have LDL checked in the past 2 years (72% vs. 80%, P<0.05) and to have a dilated eye examination (50% vs. 63%, P<0.01). Even after adjusting for patients' age, education, income, insulin use, diabetes self-management, duration, severity, comorbidities, and health services utilization, racial disparities in receipt of an LDL test and eye examination persisted. After taking into account the nested structure of the data using a random intercepts model, blacks remained significantly less likely to have LDL testing than whites who received care within the same facility (68% vs. 83%, P<0.01). In contrast, there were no longer differences in receipt of eye examinations, suggesting that black patients were more likely to be receiving care at facilities with overall lower rates of eye examinations. After adjusting for patient characteristics and facility effects, black patients were substantially more likely than whites to have poor cholesterol control (LDL > or =130) and blood pressure control (BP > or =140/90 mm Hg) (P<0.01). Among those with poor blood pressure and lipid control, blacks received as intensive treatment as whites for these conditions. CONCLUSIONS We found racial disparities in some diabetes care process and intermediate outcome quality measures, but not in intensity of treatment for those patients with poor control. Disparities in receipt of eye examinations were the result of black patients being more likely to receive care at lower-performing facilities, whereas for other quality measures, racial disparities within facilities were substantial.
Collapse
Affiliation(s)
- Michele Heisler
- Veterans Affairs Center for Practice Management & Outcomes Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan 48113-0170, USA.
| | | | | | | | | |
Collapse
|
29
|
Abstract
BACKGROUND National performance measures monitor the proportion of diabetic patients with low-density lipoprotein (LDL) levels >/=130 mg/dL, but such simple intermediate outcomes measure poor control, not necessarily poor care. "Tightly linked" quality measures define good quality either by a good intermediate outcome (LDL <130 mg/dL) or by evidence of appropriate responses to poor control (eg, starting or optimizing medications for high LDL or not doing so in the face of contraindications). OBJECTIVES We examined hyperlipidemia therapy for patients with diabetes to determine the relative accuracy of quality assessment using simple intermediate outcome versus tightly linked quality measures. RESEARCH DESIGN Retrospective longitudinal cohort. SUBJECTS A total of 1154 diabetic patients with an LDL test done between October 1, 1998, and March 31, 1999, in 2 large VA facilities. MEASURES LDL levels, medication treatment, and explanations for poor quality. RESULTS Although 27% (307 of 1154) of patients had an LDL >/=130 mg/dL using the simple intermediate outcome measure, only 13% (148 of 1154) were classified as having substandard quality using the tightly linked measure. Among the 159 reclassified to adequate quality, 117 had lipid-lowering medication started or increased within 6 months of an LDL >/=130 mg/dL, 8 were already on high-dose medication, 12 had a repeat LDL <130 mg/dL, and 22 had contraindications to treatment. CONCLUSION Simple intermediate outcome measures can be an inaccurate reflection of true quality of care, and many patients classified as having substandard quality by "poor control" might actually be receiving good quality of care.
Collapse
Affiliation(s)
- Eve A Kerr
- VA Center for Practice Management and Outcomes Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan 48113, USA.
| | | | | | | | | | | | | |
Collapse
|
30
|
Montori VM, Bryant SC, O'Connor AM, Jorgensen NW, Walsh EE, Smith SA. Decisional attributes of patients with diabetes: the aspirin choice. Diabetes Care 2003; 26:2804-9. [PMID: 14514583 DOI: 10.2337/diacare.26.10.2804] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The aim of this study was to determine personal characteristics and preferences that affect decision making (decisional attributes) in patients with diabetes. In particular, we were interested in relating these attributes to the choice of using aspirin to reduce cardiovascular risk. RESEARCH DESIGN AND METHODS We conducted a cross-sectional survey (70% response rate) of 206 diabetic patients (median age, 63 years; 42% women; 91% completed high school; median HbA(1c), 8%) attending a tertiary care diabetes clinic. Patients answered a 42-question survey exploring decisional attributes. Medical records provided the source of clinical information. We evaluated sociodemographic, clinical, and decisional predictors of aspirin use. We also conducted a multivariable analysis with aspirin use as a dependent variable. RESULTS Sixty-seven percent of patients surveyed used aspirin. Patients using aspirin were at higher risk of cardiovascular disease (odds ratio 1.4, 95% CI 1.0-2.1), knew more about the benefits of aspirin (1.9, 1.4-2.6) and less about the risks of aspirin (1.4, 1.2-1.8), and were more certain about using aspirin (0.5, 0.3-0.8) than patients not using aspirin. Patients using aspirin placed a higher value on preventing cardiovascular events than on avoiding the side effects of aspirin. Patients perceived that their diabetes provider and the American Diabetes Association had greater influence on their decision to use aspirin than family members or other patients with diabetes. CONCLUSIONS The decisional attributes of patients with diabetes are associated with aspirin use. Decisional attributes may be the target of research and interventions to reduce underutilization to levels consistent with patient preferences.
Collapse
Affiliation(s)
- Victor M Montori
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
| | | | | | | | | | | |
Collapse
|
31
|
Heisler M, Smith DM, Hayward RA, Krein SL, Kerr EA. How well do patients' assessments of their diabetes self-management correlate with actual glycemic control and receipt of recommended diabetes services? Diabetes Care 2003; 26:738-43. [PMID: 12610031 DOI: 10.2337/diacare.26.3.738] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Although patient diabetes self-management is a key determinant of health outcomes, there is little evidence on whether patients' own assessments of their self-management correlates with glycemic control and key aspects of high-quality diabetes care. We explored these associations in a nationwide sample of Veterans' Affairs (VA) patients with diabetes. RESEARCH DESIGN AND METHODS We abstracted information on achieved level of glycemic control (HbA(1c)) and diabetes processes of care (receipt of HbA(1c) test, eye examination, and nephropathy screen) from medical records of 1032 diabetic patients who received care from 21 VA facilities and had answered the Diabetes Quality Improvement Program survey in 2000. The survey included sociodemographic measures and a five-item scale assessing the patients' diabetes self-management (medication use, blood glucose monitoring, diet, exercise, and foot care [alpha = 0.68]). Using multivariable regression, we examined the associations of patients' reported self-management with HbA(1c) level and receipt of each diabetes process of care. We adjusted for diabetes severity and comorbidities, insulin use, age, ethnicity, income, education, use of VA services, and clustering at the facility level. RESULTS Higher patient evaluations of their diabetes self-management were significantly associated with lower HbA(1c) levels (P < 0.01) and receipt of diabetes services. Those in the 95th percentile for self-management had a mean HbA(1c) level of 7.3 (95% CI 6.4-8.3), whereas those in the 5th percentile had mean levels of 8.3 (7.4-9.2). For every 10-point increase in patients' ratings of their diabetes self-management, even after adjusting for number of outpatient visits, the odds of receiving an HbA(1c) test in the past year increased by 15% (4-27%), of receiving an eye examination increased by 16% (7-27%), and of receiving a nephropathy screen increased by 13% (2-26%). CONCLUSIONS In this sample, patients' assessments of their diabetes self-care using a simple five-question instrument were significantly associated both with actual HbA(1c) control and with receiving recommended diabetes services. These findings reinforce the usefulness of patient evaluations of their own self-management for understanding and improving glycemic control. The mechanisms by which those patients who are more actively engaged in their diabetes self-care are also more likely to receive necessary services warrant further study.
Collapse
Affiliation(s)
- Michele Heisler
- Veterans Affairs Center for Practice Management and Outcomes Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.
| | | | | | | | | |
Collapse
|
32
|
Bloom JM. Losartan for cardiovascular disease in patient's with and without diabetes in the LIFE study. Lancet 2002; 359:2201; author reply 2203-4. [PMID: 12091005 DOI: 10.1016/s0140-6736(02)09072-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|