The Norwegian Diabetes Register for Adults – an overview of the first years

Validation of Register-Based Diabetes Classifiers in Danish Data

Purpose

To validate two register-based algorithms classifying type 1 (T1D) and type 2 diabetes (T2D) in a general population using Danish register data.

Patients and Methods

After linking data on prescription drug usage, hospital diagnoses, laboratory results and diabetes-specific healthcare services from nationwide healthcare registers, diabetes type was defined for all individuals in Central Denmark Region age 18-74 years on 31 December 2018 according to two distinct register-based classifiers: 1) a novel register-based diabetes classifier incorporating diagnostic hemoglobin-A1C measurements, the Open-Source Diabetes Classifier (OSDC), and 2) an existing Danish diabetes classifier, the Register for Selected Chronic Diseases (RSCD). These classifications were validated against self-reported data from the Health in Central Denmark survey - overall and stratified by age at onset of diabetes. The source-code of both classifiers was made available in the open-source R package osdc.

Results

A total of 2633 (9.0%) of 29,391 respondents reported having any type of diabetes, divided across 410 (1.4%) self-reported cases of T1D and 2223 (7.6%) cases of T2D. Among all self-reported diabetes cases, 2421 (91.9%) were classified as diabetes cases by both classifiers. In T1D, sensitivity of OSDC-classification was 0.773 [95% CI 0.730-0.813] (RSCD: 0.700 [0.653-0.744]) and positive predictive value (PPV) 0.943 [0.913-0.966] (RSCD: 0.944 [0.912-0.967]). In T2D, sensitivity of OSDC-classification was 0.944 [0.933-0.953] (RSCD: 0.905 [0.892-0.917]) and PPV 0.875 [0.861-0.888] (RSCD: 0.898 [0.884-0.910]). In age at onset-stratified analyses of both classifiers, sensitivity and PPV were low in individuals with T1D onset after age 40 and T2D onset before age 40.

Conclusion

Both register-based classifiers identified valid populations of T1D and T2D in a general population, but sensitivity was substantially higher in OSDC compared to RSCD. Register-classified diabetes type in cases with atypical age at onset of diabetes should be interpreted with caution. The validated, open-source classifiers provide robust and transparent tools for researchers.

National diabetes registries: do they make a difference?

AIMS

The global epidemic of diabetes mellitus continues to expand, including its large impact on national health care. Measuring diabetes outcomes and their causes of variation highlights areas for improvement in care and efficiency gains; large registries carry this potential. By means of a systematic review, we aimed to give an overview of national registries worldwide by quantifying their data and assessing their influence on diabetes care.

METHODS

The literature on MEDLINE up to March 31, 2020, was searched, using keywords diabetes mellitus, national, registry, registration, and/or database. National disease-specific registries from corresponding articles were included. Database characteristics and clinical variables were obtained. All registries were compared to the ICHOM standard set of outcomes.

RESULTS

We identified 12 national clinical diabetes registries, comprising a total of 7,181,356 diabetic patients worldwide. Nearly all registries recorded weight, HbA1c, lipid profile, and insulin treatment; the recording of other variables varied to a great extent. Overall, registries corresponded fairly well with the ICHOM set. Most registries proved to monitor and improve the quality of diabetes care using guidelines as a benchmark. The effects on national healthcare policy were more variable and often less clear.

CONCLUSIONS

National diabetes registries confer clear insights into diagnostics, complications, and treatment. The extent to which registries influenced national healthcare policy was less clear. A globally implemented standard outcome set has the potential to improve concordance between national registries, enhance the comparison and exchange of diabetes outcomes, and allocate resources and interventions where most needed.

Trends in the process and outcome indicators of type 2 diabetes care: a cohort study from Eastern Finland, 2012-2017

Background

Evidence-based guidelines include concrete treatment targets that can be used as process and outcome indicators in the evaluation of the quality of healthcare services and diabetes care. Quality improvement can be evaluated by monitoring longitudinal trends in the care indicators on the system level. The aim of this study is to describe trends in the processes and outcomes of care among people with type 2 diabetes in North Karelia, Finland.

Methods

The data consist of all adults with type 2 diabetes (identified from the EHRs using ICD-10 codes) who used primary or specialized care services in North Karelia during 2012–2017. The diabetes care was evaluated using the measurement activity, treatment levels, and the achievement of the treatment targets for HbA1c and LDL as care indicators. Logistic and linear models with generalized estimating equations were used to assess the differences between years, sexes, and age groups.

Results

The proportion of patients with annual measurement varied between 75.8 and 78.1% for HbA1c and between 67.4 and 69.1% for LDL during a five-year follow-up. The changes in average levels were moderate: a 0.2% (2 mmol/mol) increase for HbA1c and a 0.1 mmol/l decrease for LDL. Anyway, the proportion of patients meeting the treatment target for HbA1c decreased from 72.7 to 67.3% (age-adjusted decrease: 5.7%p, 95% CI: 4.5–6.9) and for LDL it increased from 53.4 to 59.5% (age-adjusted increase: 5.6%p, 95% CI: 4.2–7.0). Women were measured and met the HbA1c target level more often compared with men. Conversely, men met the LDL target level more often than women, and the age-adjusted difference between sexes increased smoothly from 7.9%p to 11.7%p.

Conclusions

The achievements in relation to type 2 diabetes care in North Karelia are very good, but no major improvement was observed during follow-up. HbA1c levels had a rising tendency and LDL levels declining tendency indicating quality improvement in LDL management, but challenges in further improvement in glucose control.

Lifestyle Risk Factors for Type 2 Diabetes Mellitus and National Diabetes Care Systems in European Countries

Background. Diabetes is increasing by 3.09% per year in males and 1.92% in females. Lifestyle risk factors are related to diabetes. The aim of this work is to highlight within EU-28 countries the distribution percentages of some lifestyle risk factors and some components of diabetes health care. Methods. A literature search was conducted to highlight the presence of diabetes registries, which are fundamental tools for disease surveillance and health planning; the presence of a national diabetes plan (NDP); the care setting; and methods used for reimbursement of drugs, devices, and coverage of any comorbidities associated with diabetes. A multiple correspondence analysis (MCA) was carried out to evaluate the possible associations between the variables considered. Results. The highest percentages of diabetes (>10%) are registered in Bulgaria, Malta, and Hungary. Concerning the prevalence of overweight, no European country shows overall percentages of less than 50%. Regarding obesity, 57% of countries show prevalence rates of 25%. The record for physical inactivity belongs to Malta, with 45% of individuals being inactive. The percentage of physical inactivity for females is higher than for males across Europe. In total, 57% of the countries have an insurance-based health system, while 12 countries have public national health systems. Further, 57% of countries have an NDP, while 42% of the EU countries have established a prevalence register for diabetes. Conclusions. Prevalence rates for type 2 DM in the range of 8–9% are noted in 50% of EU-28 countries. In total, 21 out of EU countries show a high prevalence rate for overweight, while 7% of EU-28 countries have an obesity prevalence rate of 25%. Diabetes treatment is entrusted to general practitioners in most countries. The results of this work highlight the differences between countries, but also between genders.

Availability and analytical quality of hemoglobin A1c point-of-care testing in general practitioners’ offices are associated with better glycemic control in type 2 diabetes

Background

It is not clear if point-of-care (POC) testing for hemoglobin A1c (HbA1c) is associated with glycemic control in type 2 diabetes.

Methods

In this cross-sectional study, we linked general practitioner (GP) data on 22,778 Norwegian type 2 diabetes patients to data from the Norwegian Organization for Quality Improvement of Laboratory Examinations. We used general and generalized linear mixed models to investigate if GP offices’ availability (yes/no) and analytical quality of HbA1c POC testing (average yearly “trueness score”, 0–4), as well as frequency of participation in HbA1c external quality assurance (EQA) surveys, were associated with patients’ HbA1c levels during 2014–2017.

Results

Twenty-eight out of 393 GP offices (7%) did not perform HbA1c POC testing. After adjusting for confounders, their patients had on average 0.15% higher HbA1c levels (95% confidence interval (0.04–0.27) (1.7 mmol/mol [0.5–2.9]). GP offices participating in one or two yearly HbA1c EQA surveys, rather than the maximum of four, had patients with on average 0.17% higher HbA1c levels (0.06, 0.28) (1.8 mmol/mol [0.6, 3.1]). For each unit increase in the GP offices’ HbA1c POC analytical trueness score, the patients’ HbA1c levels were lower by 0.04% HbA1c (−0.09, −0.001) (−0.5 mmol/mol [−1.0, −0.01]).

Conclusions

Novel use of validated patient data in combination with laboratory EQA data showed that patients consulting GPs in offices that perform HbA1c POC testing, participate in HbA1c EQA surveys, and maintain good analytical quality have lower HbA1c levels. Accurate HbA1c POC results, available during consultations, may improve diabetes care.

Electronic capturing of patient-reported outcome measures on a touchscreen computer in clinical diabetes practice (the DiaPROM trial): a feasibility study

BACKGROUND

Living with type 1 diabetes (T1D) is demanding, and emotional problems may impair ability for diabetes self-management. Thus, diabetes guidelines recommend regular assessment of such problems. Using patient-reported outcome measures (PROMs) to assess diabetes-related distress and psychological well-being is considered useful. It has been proposed that future work should examine the use of PROMs to support the care of individual patients and improve the quality of health services. To our knowledge, the use of PROMs has not been systematically evaluated in diabetes care services in Norway. Electronically captured PROMs can be directly incorporated into electronic patient records. Thus, the study's overall aim was to examine the feasibility and acceptability of capturing PROMs electronically on a touchscreen computer in clinical diabetes practice.

METHODS

Adults with T1D age ≥ 40 years completed PROMs on a touchscreen computer at Haukeland University Hospital's diabetes outpatient clinic. We included 46 items related to diabetes-related distress, self-perceived diabetes competence, awareness of hypoglycaemia, occurrence of hyperglycaemia, hypoglycaemia and fluctuating glucose levels, routines for glucose monitoring, general well-being and health-related quality of life. Participants subsequently completed a paper-based questionnaire regarding comprehension and relevance of the PROMs, acceptance of the number of items and willingness to complete electronic PROMs annually. We wrote field notes in the outpatient clinic based on observations and comments from the invited participants.

RESULTS

During spring 2017, 69 participants (50.7% men), age 40 to 74 years, were recruited. Generally, the touchscreen computer functioned well technically. Median time spent completing the PROMs was 8 min 19 s. Twenty-nine (42.0%) participants completed the PROMs without missing items, with an 81.4% average instrument completion rate. Participants reported that the PROMs were comprehensible (n = 62) and relevant (n = 46) to a large or very large degree, with an acceptable number of items (n = 51). Moreover, 54 were willing to complete PROMs annually. Participants commented that the focus on living with diabetes was valued.

CONCLUSIONS

Capturing PROMs on a touchscreen computer in an outpatient clinic was technically and practically feasible. The participants found the PROMs to be relevant and acceptable with a manageable number of items, and reported willingness to complete PROMs annually.