Enhanced surveillance of hospitalized COVID-19 patients in Europe: an evaluation of the I-MOVE-COVID-19 surveillance network

BACKGROUND

A pre-existing, well-established European influenza surveillance network known as I-MOVE enabled the rapid implementation of a European multi-country COVID-19 hospital surveillance network for surveillance of hospitalized COVID-19 cases in early 2020. This network included 257 hospitals in 11 surveillance sites across nine countries. We aimed to identify whether the surveillance objectives were relevant to public health actions, whether the surveillance system met its objectives, where and how shortcomings could be improved, and whether the system was sustainable.

METHODS

We identified six key attributes (meeting objectives, usefulness, timeliness, data quality, simplicity and sustainability) to assess, using Centers for Disease Control and Prevention's evaluation framework. We analyzed pooled datasets, held interviews and group discussions with 10 participating and coordinating sites and gathered feedback through web surveys.

RESULTS

There was overall agreement that the surveillance objectives had been met and being involved in a network of European partners had additional important benefits for stakeholders. While the publication of the outputs was not always sufficiently timely, data submission processes were considered straightforward and the key surveillance variables (age, sex, hospital admission and mortality data) were complete. The main challenges were identified as the collection of the large number of variables, limited available human resources and information governance and data protection laws.

CONCLUSIONS

I-MOVE-COVID-19 delivered relevant and accurate data supporting the development and implementation of COVID-19 surveillance. Recommendations presented here identify learning opportunities to support preparedness and surveillance response for future pandemics. The applied evaluation framework in this study can be adapted for other European surveillance system evaluations.

Exploration of health and health behaviours of undergraduate nursing students: a multi-methods study in two countries

BACKGROUND

Nurses play a vital role in health promotion, and there may be a link between a nurse's own lifestyle practices and how they educate others. Supporting health and well-being in student nurses is critical given they will be educating others once registered and practicing.

OBJECTIVES

To explore the health and health behaviours of undergraduate nursing and midwifery students considering the demands of their profession, their public health role and their ability to be role models.

DESIGN

Multi-methods study.

METHODS

Undergraduate nursing students in the second and third years of their programme were invited to self-complete a health and health behaviour questionnaire in a Scottish and Australian Higher Education Institution. Qualitative data were collected from a convenience sample of 20 third-year nursing and midwifery students.

RESULTS

Two hundred and thirty-five Scottish students and 113 Australian students, 175 (85%) and 84 (74%), respectively, completed the questionnaire. Some differences and similarities were noted across groups, in particular, perceived physical health, the prevalence of binge drinking, smoking and being overweight/obese and some dietary measures were found to be less favourable among Scottish students. There were worryingly high levels of poor mental well-being at both higher education institutions, with scores on a mental well-being scale suggesting that (82) 34.7% of Scottish students and 33 (29.6%) of Australian students were at risk of depression. Nine Scottish students and 11 Australian students were interviewed. Key contributors and barriers to healthy behaviours were noted across both groups of students in relation to lifestyle. Students perceived that certain elements of their curriculum had implications on their ability or motivation to make healthy lifestyle choices.

CONCLUSION

The poor health and health behaviours of future nurses need to be addressed in their higher education to shape resilient role models for future nursing practice.

IMPACT STATEMENT

Priority should be given to supportive learning environments for student nurses that foster emotional support and encourage healthy lifestyles.

Postpartum opportunistic advice in primary care for women who have had gestational diabetes: a qualitative study of health care professionals' views

BACKGROUND

Women who have had gestational diabetes during pregnancy are at very high risk of developing type 2 diabetes later in life, but their understanding of the risks is often limited. In this study we explored the views of health care professionals regarding offering brief opportunistic advice to women after their pregnancy, during unrelated consultations in primary care, relating to reducing diabetes risk.

METHODS

The study took place in three Health Boards in Scotland. We conducted semi-structured one-to-one interviews (either face-to-face or telephone) with two health visitors, three practice nurses, two GPs, two diabetes consultants and two obstetricians. A focus group with five health visitors was also held. A topic guide was followed, covering the feasibility and acceptability of delivering brief opportunistic advice during a routine consultation, the optimal way to identify and recall women with previous gestational diabetes, and the possible content and timing of any such intervention. A thematic approach was used to analyse the qualitative data generated.

RESULTS

The interviews/discussion lasted from 15 to 51 min. There was widespread support from all participants for offering opportunistic advice, and general consensus that health visitors would be best placed to do this as part of the Universal Health Visiting Pathway in Scotland. Thematic analysis generated three significant points of discussion: implications for training of health visitors, the need for a systematic approach to identifying women with gestational diabetes, and the optimal timing of delivery. Despite an already demanding schedule of providing advice and education to women, health visitors were confident that they could offer educational advice, provided that they received appropriate training to do so. However, there would need to be a watertight system for identifying women in their care who had had gestational diabetes. In terms of timing, later visits around 6-8 months after delivery were considered most suitable.

CONCLUSIONS

There is support from health care professionals, and most pertinently from health visitors, that the frequency of routine visits with women during the Universal Health Visiting Pathway programme in Scotland provides potential opportunities for education around future diabetes risk to women who have had gestational diabetes.

How does the self-reported health of undergraduate nursing students change during their degree programme? Survey results from a Scottish University

BACKGROUND

The lifestyle behaviours, and the physical and mental health of nurses, are poorer than those of other allied health professionals, and of the general population. However, these were no less favourable among first year undergraduate nursing students at a Scottish Higher Education Institution (HEI) than among similar people of the same age. We compared health and health behaviours among the same cohort of undergraduate nursing students over the course of their degree.

METHODS

An anonymous self-complete repeat cross-sectional survey was administered during a timetabled teaching session at three time-points to undergraduate nursing students at the start of Years 1, 2 and 3 of their programme. They had received written information about the study previously.

RESULTS

Self-reported health did not change significantly over time, but there was a clear decline over the 3 years in the proportions of students rating their mental health as excellent/very good/good and a concomitant increase in those rating their mental health as fair/poor. Correspondingly, the mean WEMWBS wellbeing score declined over the 3 years, with the proportion of students with a score of < 46 (indicating either high risk of major depression, or in high risk of psychological distress and increased risk of depression) increasing from one quarter to one half. This effect was captured and described using a Bayesian regression analysis. The most noticeable change in health behaviours was a decline in physical activity levels over the study period. The proportion of students managing 150 min of weekly physical activity decreased from three quarters to two thirds. This was reflected in higher self-reported sedentary time, although there were no observable trends over time in mean BMI, or proportions of students categorised as overweight or obese.

CONCLUSIONS

This paper suggests that there may be a decline in mental health and in participation in physical activity among nursing students over the course of their degree. We recommend the incorporation of an intervention into the undergraduate nursing curriculum that promotes and encourages regular physical activity, offering students the opportunity to learn about health promotion and lifestyle change in practice, to improve their own physical health, and to address mental wellbeing.

Analysis of spontaneous, user-generated data about gestational diabetes on online forums: implications for diabetes prevention

AIMS

To explore the experiences and perceptions of gestational diabetes mellitus reported by women within online parental-support forums and, specifically, to analyse what women say about a diagnosis of gestational diabetes, their future risk of type 2 diabetes, and lifestyle behaviour for management of gestational diabetes and prevention of type 2 diabetes.

METHODS

The discussion boards of two parenting websites (Mumsnet and Netmums) were searched using the search term 'gestational diabetes or GD' in February 2019. Relevant posts made by users with gestational diabetes on or after 1 January 2017 were retained for analysis. Framework analysis using pre-existing framework from a previous study was used to organize and analyse the data.

RESULTS

A total of 646 posts generated by 282 unique users were included in the analysis. Analysis of the online content identified three important implicit messages that may be being conveyed to readers. The first is that gestational diabetes is not a serious diagnosis that warrants undue concern. Secondly, few users recognized the importance of their own behaviours or lifestyle, with others minimizing personal responsibility or attributing gestational diabetes to non-modifiable factors. Finally, there was a lack of acknowledgment of heightened risk of type 2 diabetes. These three messages will all directly mitigate against the efforts of clinicians (and others) to encourage women with gestational diabetes to improve their lifestyle behaviours in the longer term.

CONCLUSIONS

These findings highlight messages that are being widely disseminated and that are unlikely to support prevention of type 2 diabetes.

Is diagnosis of type 2 diabetes a "teachable moment"? A qualitative study

AIMS

To explore the potential of type 2 diabetes diagnosis to be a "teachable moment".

METHODS

Semi-structured interviews were conducted with 23 participants (10 people with type 2 diabetes, 13 relatives of people with type 2 diabetes) in Scotland, UK. They explored cognitive, emotional and behavioural changes following diagnosis of type 2 diabetes in oneself or in a relative. Data were analysed using Framework approach.

RESULTS

Strong emotional responses are not always related to the occurrence of a teachable moment. Risk perception and outcome expectancy were found to be teachable moment factors for patients with type 2 diabetes and their offspring, but not their partners. Change in self-concept increases the likelihood of type 2 diabetes diagnosis to be a teachable moment for patients but not for relatives. In some cases, type 2 diabetes is perceived as incompatible with current roles thus hindering diabetes self-management. Relatives often engage in caring for patients and "policing" their behaviour but did not report perceived changes in social roles.

CONCLUSIONS

The study suggests that diagnosis of type 2 diabetes is a teachable moment for some patients and their relatives. These findings have implications for interventions to address diabetes self-management in patients and primary prevention in their relatives.

Physical activity in paid work time for desk-based employees: a qualitative study of employers' and employees' perspectives

Background

Poor physical and mental health of employees create significant problems in the workplace. Physical activity (PA) has been shown as an effective strategy for preventing and treating numerous physical and mental health issues as well as work performance outcomes. However, there are many barriers to taking part in PA (such as lack of time) with participation rates typically low. Providing PA in paid work time might be a way to overcome these issues, yet employers’ and employees’ opinions of this concept are unknown. The aim of this study was to explore employee and employer perspectives of PA in paid work time.

Methods

Workplaces were recruited through existing contacts on the research team. Focus groups and interviews were conducted with employees and managers at one University and two executive non-departmental public bodies in central Scotland with mainly desk-based employees. Both managers and employees were involved to gain perspectives throughout the organisational hierarchy and were interviewed separately to reduce social desirability bias. All discussions were digitally recorded and transcribed verbatim. Data were analysed thematically for both managers and employees but due to significant overlap in themes between the groups, these are reported together in the results.

Results

Three out of five organisations approached took part in this qualitative study. Two individual interviews were held with strategic managers, five focus groups with middle managers (n = 16) and nine with employees (n = 45). Benefits were anticipated by managers and employees for both employees themselves and the organisation and included improved mental health, productivity and more favourable perceptions of the employer. Despite these widely acknowledged benefits, significant barriers were identified and included the structure and nature of the working day (high workload, front line job requirements), workplace culture and norms (resentment from colleagues, no break culture) and organisational concerns (cost of lost time, public perceptions).

Conclusion

This study suggests that there are significant barriers to PA in paid work time. Whilst numerous anticipated benefits were conveyed by both employees and managers, PA in paid work time is unlikely to become common place until changes in attitudes and the culture towards movement at work occur.

The development of an intervention for diabetes prevention among people with impaired glucose regulation: feasibility and acceptability of an intervention component

Background

As part of the design process of a low-cost minimal-contact diabetes prevention intervention, we issued a blood glucose meter to people with impaired glucose regulation (who are at high risk of type 2 diabetes). We conducted a feasibility study to assess the acceptability of this intervention component and whether and how recipients engaged with it.

Methods

A blood glucose meter was given to 19 people identified through primary care, who were asked to use the meter in an exploratory way during a 4-week trial period, to try to understand the effect of different foods on the body. They were advised that they could test as often or as little as they liked and were also asked to keep a food/exercise diary for at least 1 week. They were interviewed about their experiences afterwards.

Results

There was a high level of engagement with testing, with the total number of tests recorded ranging from 11 to 114 (median 74) among 18 participants. Fifteen participants tested almost every day during the 4-week period. The cognitive engagement was more limited. All participants commented on their own results, and most were able to relate high or low results to foods eaten and exercise taken, usually in response to prompting. However, there was limited thought or understanding beyond this in terms of longer-term patterns of diet and exercise, and testing was routine rather than experimental. Some participants were confused by conflicting or unexpected results. A few minor problems were reported by participants, such as soreness, inconvenience, and difficulty in getting blood, but never enough to discontinue testing. Several participants stated that the meter was a useful aid as a reminder that they were at high risk of diabetes and served as a prompt that needed to make and/or maintain behaviour changes.

Conclusions

The study suggests that blood glucose monitoring is acceptable to people with impaired glucose regulation and that they would engage with it as part of an intervention to improve their diet. The study has also uncovered potential mechanisms of action for behaviour change.

Patients' Illness Perceptions of Type 2 Diabetes: A Scoping Review

BACKGROUND

People's personal perceptions, or illness representations, of type 2 diabetes can act as barriers to successful self-management.

INTRODUCTION

Understanding patients' subjective perceptions of type 2 diabetes can aid the design of evidence-based care and appropriate educational programmes. This scoping review provides a narrative account of previous knowledge of patients' illness representations of type 2 diabetes.

METHODS

Quantitative and qualitative studies that explored patients' illness representations of type 2 diabetes, as defined by Leventhal's Common Sense Model, were included.

RESULTS

Thirty four studies were identified for this review, but only 14 studies were carried out in a general population of people with diabetes. Illness representations varied across study populations. While it is clear that the perceptions of ethnic minorities and marginalised groups are embedded in their historical and cultural backgrounds, it is also important to understand the views of the wider population.

CONCLUSION

The review highlights the need for self-management interventions to reflect the target population's representations of type 2 diabetes in order to inform interventions and clinical practice.

Texting to Reduce Alcohol Misuse (TRAM): main findings from a randomized controlled trial of a text message intervention to reduce binge drinking among disadvantaged men

AIMS

To test the effectiveness of a theoretically based text-message intervention to reduce binge drinking among socially disadvantaged men.

DESIGN

A multi-centre parallel group, pragmatic, individually randomized controlled trial.

SETTING

Community-based study conducted in four regions of Scotland.

PARTICIPANTS

A total of 825 men aged 25-44 years recruited from socially disadvantaged areas who had two or more episodes of binge drinking (> 8 UK units on a single occasion) in the preceding 28 days: 411 men were randomized to the intervention and 414 to the control.

INTERVENTION AND COMPARATOR

A series of 112 interactive text messages was delivered by mobile phone during a 12-week period. The intervention was structured around the Health Action Process Approach, a comprehensive model which allows integration of a range of evidence-based behaviour change techniques. The control group received 89 texts on general health, with no mention of alcohol or use of behaviour change techniques.

MEASUREMENTS

The primary outcome measure was the proportion of men consuming > 8 units on three or more occasions (in the previous 28 days) at 12 months post-intervention.

FINDINGS

The proportion of men consuming > 8 units on three or more occasions (in the previous 28 days) was 41.5% in the intervention group and 47.8% in the control group. Formal analysis showed that there was no evidence that the intervention was effective [odds ratio (OR) = 0.79, 95% confidence interval (CI) = 0.57-1.08; absolute reduction 5.7%, 95% CI = -13.3 to 1.9]. The Bayes factor for this outcome was 1.3, confirming that the results were inconclusive. The retention was high and similar in intervention (84.9%) and control (86.5%) groups. Most men in the intervention group engaged with the text messages: almost all (92%) replied to text messages and 67% replied more than 10 times.

CONCLUSIONS

A theoretically based text-messaging intervention aimed at reducing binge drinking in disadvantaged men was not found to reduce prevalence of binge drinking at 12-month follow-up.

Postnatal experiences, knowledge and perceptions of women with gestational diabetes

AIM

Women with gestational diabetes mellitus (GDM) are at increased risk of Type 2 diabetes. This study aimed to explore experiences, knowledge and perceptions of women with GDM to inform the design of interventions to prevent or delay Type 2 diabetes.

METHODS

Semi-structured interviews were carried out with 16 women with GDM who were recruited from a clinic in one Scottish health board. A framework approach was used to manage and analyse data according to themes informed by psychological theory (self-regulation model and theory of planned behaviour).

RESULTS

GDM is not seen as an important, or even real diagnosis among some women, and this perception may result from the perceived minimal impact of GDM on their lives. Some women did experience a bigger emotional and practical impact. Knowledge and understanding of Type 2 diabetes was poor in general and many women were unconcerned about their future risk. Lower concern appeared to be linked to a lower perceived impact of GDM. Lifestyle changes discussed by women mostly related to diet and were motivated primarily by concern for their baby's health. Many women did not maintain these changes postnatally, reporting significant barriers.

CONCLUSIONS

This study has suggested potential avenues to be explored in terms of content, timing and potential recipients of interventions. Educational interventions postnatally could address illness perceptions in women with GDM and redress the situation where lack of aftercare downplays its seriousness. For lifestyle interventions, the child's health could be used as a motivator within the context of later joint or family interventions.

Self-monitoring of blood glucose in insulin-treated diabetes: a multicase study

OBJECTIVE

To explore how and why self-monitoring of blood glucose (SMBG) is carried out in a real-world context.

RESEARCH DESIGN AND METHODS

We conducted a multicase study among ten people with type 1 and insulin-treated type 2 diabetes mellitus in Scotland, alongside seven nominated support people and four healthcare professionals. All participants were interviewed in depth and six participants provided SMBG diaries. Stones' version of structuration theory informed the analysis.

RESULTS

People with diabetes were able to provide immediate motives for SMBG at particular times, often having different motives on different occasions. We identified six such motives, including routine, in response to symptoms, associated with a diabetes review, to facilitate lifestyle, when a 'good' result was expected, and higher level motives for longer term glycemic control. These motives were influenced by underlying attitudes toward diabetes that included level of engagement and responsibility for diabetes, a desire not to be controlled by diabetes, resistance to diabetes, diabetes education and relationship with the health service, fear of hypoglycemia, and prevention of diabetes complications. Five responses to test results were identified, depending on the immediate motive and underlying attitudes.

CONCLUSIONS

People with insulin-treated diabetes do not necessarily self-monitor with an explicit goal of improving long-term glycemic control, but may have other motives that are important to them. An individualized understanding is therefore needed to advise people with diabetes how SMBG can be optimized for them.

Interventions for prevention of type 2 diabetes in relatives: A systematic review

The relatives and partners of people with type 2 diabetes are at increased risk of developing type 2 diabetes. This systematic review examines randomized controlled trials, written in English that tested an intervention, which aimed to modify behaviors known to delay or prevent type 2 diabetes, among the relatives or partners of people with type 2 diabetes. Study quality was assessed using the Cochrane Collaboration's tool for assessing risk of bias. Seven studies met the inclusion criteria. The majority of studies were at low risk of bias. Six studies tested an intervention in first-degree relatives of people with type 2 diabetes and one in partners. Intervention components and intervention intensity across studies varied, with those targeting diet and physical activity reporting the most significant changes in primary outcomes. Only one study did not observe significant changes in primary outcomes. There were three main recruitment approaches: advertising in the community, recruiting people through their relatives with diabetes, or identifying people as high risk by screening of their own health care contacts. Some evidence was found for potentially successful interventions to prevent type 2 diabetes among the relatives and partners of people with type 2 diabetes, although finding simple and effective methods to identify and recruit them remains a challenge. Future studies should explore the effect of patients' perceptions on their family members' behavior and capitalize on family relationships in order to increase intervention effectiveness.

How active are women who play bingo: a cross-sectional study from the Well!Bingo project

BACKGROUND

The benefits of physical activity are well established, yet large numbers of people are not sufficiently active to gain health benefits. Certain population groups are less physically active than others, including older women from areas of high economic deprivation. The Well!Bingo project was established with the aim of engaging such women in the development of a health promotion intervention in a bingo club. This paper reports on the assessment of health status, physical activity and sedentary behaviour of women attending a bingo club in central Scotland, UK as part of the Well!Bingo project.

METHODS

Women attending the bingo club were invited to provide information on demographic characteristics, and self-reported physical activity and sedentary behaviour via a self-complete questionnaire as part of a cross-sectional study (n = 151). A sub-sample (n = 29) wore an accelerometer for an average of 5.7 ± 1.4 days. Differences between younger (under 60 years) and older adults (60 years and over) were assessed using a chi-square test for categorical data and the independent samples t-test was used to assess continuous data (p < 0.05).

RESULTS

The mean age was 56.5 ± 17.7 years, with 57% living in areas of high deprivation (Scottish Index of Multiple Deprivation quintile one and two). Sixty-three percent of women (n = 87) reported they were meeting physical activity guidelines. However, objective accelerometer data showed that, on average, only 18.1 ± 17.3 min a day were spent in moderate to vigorous physical activity. Most accelerometer wear time was spent sedentary (9.6 ± 1.7 h). For both self-report and accelerometer data, older women were significantly less active and more sedentary than younger women. On average, older women spent 1.8 h more than younger women in sedentary activities per day, and took part in 21 min less moderate to vigorous physical activity (9.4 mins per day).

CONCLUSION

The findings of this study suggest that bingo clubs are settings that attract women from areas of high deprivation and older women in bingo clubs in particular would benefit from interventions to target their physical activity and sedentary behaviour. Bingo clubs may therefore be potential intervention settings in which to influence these behaviours.

Prevalence of gestational diabetes mellitus in Europe: A meta-analysis

AIMS

Estimates of the prevalence of gestational diabetes vary widely. It is important to have a clear understanding of the prevalence of this condition to be able to plan interventions and health care provision. This paper describes a meta-analysis of primary research data reporting the prevalence of gestational diabetes mellitus in the general pregnant population of developed countries in Europe.

METHODS

Four electronic databases were systematically searched in May 2016. English language articles reporting gestational diabetes mellitus prevalence using universal screening in general pregnant population samples from developed countries in Europe were included. All papers identified by the search were screened by one author, and then half screened independently by a second author and half by a third author. Data were extracted by one author. Values for the measures of interest were combined using a random effects model and analysis of the effects of moderator variables was carried out.

RESULTS

A total of 3258 abstracts were screened, with 40 studies included in the review. Overall prevalence of gestational diabetes mellitus was 5.4% (3.8-7.8). Maternal age, year of data collection, country, area of Europe, week of gestation at testing, and diagnostic criteria were found to have a significant univariate effect on GDM prevalence, and area, week of gestation at testing and year of data collection remained statistically significant in multivariate analysis. Quality category was significant in multivariate but not univariate analysis.

CONCLUSIONS

This meta-analysis shows prevalence of GDM that is at the upper end of previous estimates in Europe.

A quasi-experimental evaluation of dried blood spot testing through community pharmacies in the Tayside region of Scotland

OBJECTIVE

Comparison of uptake of dried blood spot testing (DBST) for hepatitis C virus (HCV) infection between community pharmacies and established services.

DESIGN

Quantitative evaluation of a service development with qualitative process evaluation undertaken in parallel.

SETTING

Six pharmacies from 36 community pharmacies within Dundee City, a large urban settlement with high levels of socioeconomic deprivation.

PARTICIPANTS

Patients in receipt of opioid substitution therapy (OST) not tested for HCV within 12 months. The 6 pharmacies provided OST for approximately 363 patients from a cohort of 1385 patients within Dundee City.

INTERVENTION

Provision of DBST by pharmacists.

MAIN OUTCOME MEASURE

Receipt of DBST between January and December 2014.

RESULTS

43 of 143 service users with no record of testing from the 6 community pharmacies accepted DBST. Of 561 from the remaining 1022 service users with no record of testing, 75 were tested for HCV (30% vs 13%). The OR for increased uptake of testing within the 6 pharmacies was 2.25 (95% CI 1.48 to 3.41, Z statistic=3.81, p=<0.0001) compared with other services. The DBST taken by the pharmacies provided 12 patients with a reactive test. The process evaluation identified key themes important to staff and recipients of the service. A logic model was constructed.

LIMITATIONS

Non-experimental service evaluation performed in community pharmacies records service activity in one location across a single time period.

INTERPRETATION

Some evidence that DBST from community pharmacies may be feasible. Service users received the service positively. Staff reported that DBST was straightforward and achievable.

A multifaceted intervention to improve sepsis management in general hospital wards with evaluation using segmented regression of interrupted time series

PROBLEM

Antibiotic administration to inpatients developing sepsis in general hospital wards was frequently delayed. We aimed to reproduce improvements in sepsis management reported in other settings.

CONTEXT

Ninewells Hospital, an 860-bed teaching hospital with quality improvement (QI) experience, in Scotland, UK. The intervention wards were 22 medical, surgical and orthopaedic inpatient wards.

DESIGN

A multifaceted intervention, informed by baseline process data and questionnaires and interviews with junior doctors, evaluated using segmented regression analysis of interrupted time series (ITS) data. MEASURES FOR IMPROVEMENT: Primary outcome measure: antibiotic administration within 4 hours of sepsis onset. Secondary measures: antibiotics within 8 hours; mean and median time to antibiotics; medical review within 30 min for patients with a standardised early warning system score .4; blood cultures taken before antibiotic administration; blood lactate level measured.

STRATEGIES FOR CHANGE

The intervention included printed and electronic clinical guidance, educational clinical team meetings including baseline performance data, audit and monthly feedback on performance.

EFFECTS OF CHANGE

Performance against all study outcome measures improved postintervention but differences were small and ITS analysis did not attribute the observed changes to the intervention.

LESSONS LEARNT

Rigorous analysis of this carefully designed improvement intervention could not confirm significant effects. Statistical analysis of many such studies is inadequate, and there is insufficient reporting of negative studies. In light of recent evidence, involving senior clinical team members in verbal feedback and action planning may have made the intervention more effective. Our focus on rigorous intervention design and evaluation was at the expense of iterative refinement, which likely reduced the effect. This highlights the necessary, but challenging, requirement to invest in all three components for effective QI.

Patterns of self-monitoring of blood glucose in insulin-treated diabetes: analysis of a Scottish population over time

Analysis of a diabetes clinical information system in Tayside, Scotland, shows that a significant proportion of insulin-treated patients with diabetes are not self-monitoring blood glucose according to current clinical guidance and recommendations, with some not self-monitoring their blood glucose at all. Although there has been an increase in the number of reagent strips dispensed over the past decade, this increase is mainly accounted for by increased testing frequency among people with diabetes already testing.

Accessing and engaging women from socio-economically disadvantaged areas: a participatory approach to the design of a public health intervention for delivery in a Bingo club

Background

Our aim was to use participatory methods to investigate the feasibility and acceptability of using Bingo clubs for the design and delivery of an evidence-based physical activity and/or healthy eating intervention to socio-economically disadvantaged women. This paper describes the participatory process that has resulted in a physical activity intervention for women aged >55 years, ready for pilot-testing in a Bingo club setting.

Methods

Studies using different quantitative and qualitative approaches were conducted among customers and staff of a Bingo club in a city of 85,000 inhabitants in central Scotland. These were designed to take the views of different stakeholders into account, with a view to enhancing uptake, engagement and effectiveness with any proposed intervention.

Results

Sixteen relevant studies were identified in a literature review that generated ideas for intervention components. A questionnaire completed by 151 women in the Bingo club showed that almost half (47 %) aged >55 years were not meeting physical activity guidelines; evidence backed up by accelerometer data from 29 women. Discussions in six focus groups attended by 27 club members revealed different but overlapping motivations for attending the Bingo club (social benefits) and playing Bingo (cognitive benefits). There was some scepticism as to whether the Bingo club was an appropriate setting for an intervention, and a dietary intervention was not favoured. It was clear that any planned intervention needed to utilise the social motivation and habitual nature of attendance at the Bingo club, without taking women away from Bingo games. These results were taken forward to a 5-h long participative workshop with 27 stakeholders (including 19 Bingo players). Intervention design (form and content) was then finalised during two round table research team meetings.

Conclusions

It was possible to access and engage with women living in areas of socio-economic disadvantage through a Bingo club setting. A physical activity intervention for women >55 years is realistic for recruitment, will address the needs of potential recipients in the Bingo club, appears to be feasible and acceptable to club members and staff, and has been designed with their input. A pilot study is underway, investigating recruitment, retention and feasibility of delivery.

Adherence to the Mediterranean diet by the Greek and Cypriot population: a systematic review

BACKGROUND

The traditional Mediterranean diet is defined as the dietary pattern in the countries of the Mediterranean basin between the 1950s and 1960s, and it is now widely accepted that has a beneficial effect on health. A debate exists from empirical and research data if the traditional Mediterranean diet remains the main dietary pattern of the region or if it has changed overtime.

AIMS

This systematic review addresses whether the people of Cyprus and Greece still follow the traditional Mediterranean diet or whether the diet has become more 'Westernised'.

METHODS

The MEDLINE database was searched using relevant free terms and independently reviewed by two authors. In addition, all reference lists of identified studies were hand-searched to identify additional, relevant studies.

RESULTS

The review resulted in 18 research papers that met the inclusion and exclusion criteria and represented 15 independent studies. The main outcome was consistent between studies and indicated moderate adherence of the Greek, and (probably) of the Cypriot, population to the Mediterranean diet. The majority of studies found no statistically significant differences by gender. There was an observed inter-study lower adherence to the Mediterranean diet by the younger population. Few studies addressed intra-study variations by age.

CONCLUSIONS

This review shows that adherence to the Mediterranean diet is moderate in Greece (and probably also in Cyprus).This suggests a continuing transition from dietary patterns in the 50 s-60 s towards a more Westernized diet.

The risk of total mortality and cardiovascular mortality associated with impaired glucose regulation in Tayside, Scotland, UK: a record-linkage study in 214 094 people

OBJECTIVE

Mortality among adults of all ages diagnosed with impaired glucose regulation (IGR) in Tayside, Scotland, UK, was evaluated using routinely collected healthcare data sets.

RESEARCH DESIGN AND METHODS

Using record-linked data in 2003-2008, all instances of blood glucose testing in the population defined 2 cohorts of patients aged 18+years: those with IGR (whether impaired fasting glucose or impaired glucose tolerance (IGT)) according to the WHO criteria, and those who were normoglycemic. They were followed in survival analyses for mortality or cardiovascular mortality (censoring deaths that occurred within a 30-day period of testing), to derive HRs (with 95% CI) for IGR status using Cox regression, adjusted for age, sex, and an area measure of deprivation.

RESULTS

There were 2 372 712 tests for 214 094 patients, with 196 799 patients in the non-IGR cohort and 50 080 in the IGR cohort. During follow-up, 19 147 (9.7%) and 8397 (16.8%) patients died in 2 cohorts, respectively, with mortality rates of 33.2/1000 patient-years and 70.7/1000 patient-years. In multivariable analyses, the overall adjusted risk of mortality for IGR was 1.16 (95% CI 1.13 to 1.20). However, it was 2.59 (95% CI 2.17 to 3.10) for people aged <45 years, decreasing to 0.94 (95% CI 0.85 to 1.00) in those aged 85+years. The HRs for cardiovascular mortality were lower overall, but they followed the same pattern, with statistically significant increased risks for patients aged <64 years only. The mortality risk was highest among patients with IGT.

CONCLUSIONS

IGR is associated with an increased mortality risk which declines with age. It is therefore important to prioritize young people with IGR for prevention; but less important to be aggressive about risk factor modification in older people.

Incidence of impaired glucose regulation and progression to type 2 diabetes mellitus in the Tayside region of Scotland

This study assessed incidence of impaired glucose regulation (IGR) and progression to type 2 diabetes (T2D) in adults in one region of Scotland using routinely collected health-care data. Incidence of IGR was 2720 per 100,000 person years. Nine percent of IGR patients progressed to T2D in a mean time of 34 months.

Self-monitoring of blood glucose in type 2 diabetes: patients' perceptions of 'high' readings

Among 207 non-insulin using patients with type 2 diabetes in Tayside, Scotland, who self-monitored blood glucose, we present evidence that many are tolerant of higher blood glucose levels than are clinically advisable; this may explain the lack of empirical evidence for the clinical benefits of self-monitoring in this group.

Case management vocational rehabilitation for women with breast cancer after surgery: a feasibility study incorporating a pilot randomised controlled trial

Background

There is a paucity of methodologically robust vocational rehabilitation (VR) intervention trials. This study assessed the feasibility and acceptability of a VR trial of women with breast cancer to inform the development of a larger interventional study.

Methods

Women were recruited in Scotland and randomised to either a case management VR service or to usual care. Data were collected on eligibility, recruitment and attrition rates to assess trial feasibility, and interviews conducted to determine trial acceptability. Sick leave days (primary outcome) were self-reported via postal questionnaire every 4 weeks during the first 6 months post-surgery and at 12 months. Secondary outcome measures were change in employment pattern, quality of life and fatigue.

Results

Of the 1,114 women assessed for eligibility, 163 (15%) were eligible. The main reason for ineligibility was age (>65 years, n = 637, 67%). Of those eligible, 111 (68%) received study information, of which 23 (21%) consented to participate in the study. Data for 18 (78%) women were analysed (intervention: n = 7; control: n = 11). Participants in the intervention group reported, on average, 53 fewer days of sick leave over the first 6 months post-surgery than those in the control group; however, this difference was not statistically significant (p = 0.122; 95% confidence interval −15.8, 122.0). No statistically significant differences were found for secondary outcomes. Interviews with trial participants indicated that trial procedures, including recruitment, randomisation and research instruments, were acceptable.

Conclusions

Conducting a pragmatic trial of effectiveness of a VR intervention among cancer survivors is both feasible and acceptable, but more research about the exact components of a VR intervention and choice of outcomes to measure effectiveness is required. VR to assist breast cancer patients in the return to work process is an important component of cancer survivorship plans.

Trial registration

ISRCTN29666484

Self-monitoring among non-insulin treated patients with type 2 diabetes mellitus: Patients' behavioural responses to readings and associations with glycaemic control

AIM

To investigate self-monitoring of blood glucose (SMBG) behaviour among non-insulin treated patients with type 2 diabetes mellitus, and to evaluate associations with glycaemic control.

METHODS

Eligible patients in 23 GP practices in Tayside, Scotland, were identified (18-75 years, no insulin treatment, SMBG reagent strips dispensed in 2009). Consenting patients were administered questionnaires addressing SMBG behaviour: these primary data were record-linked to clinical data (including HbA1c) from a validated population-based diabetes clinical information system, then anonymised.

RESULTS

Among 629 eligible patients, 207 were interviewed and analysed. Mean SMBG reagent strips dispensed in 12 months was 268. In response to a perceived high test result, 80 (38.8%) patients took no action or simply checked later with most of them (61.3%) indicating they did not know what action to take. Of the 126 (61.2%) patients who took some action, 101 made changes to diet, 12 increased physical activity, 10 made changes to medication and 12 mad a HCP appointment. A high score on a Diabetes Knowledge Test was a statistically significant predictor of taking action (odds ratio: 2.07). However, neither taking action nor increased SMBG frequency was associated with improved glycaemic control.

CONCLUSIONS

Responding to SMBG test results and increased testing frequency were not associated with improved glycaemic control in the short-term. There is a lack of knowledge surrounding SMBG in non-insulin treated patients.

Translating and testing the Liver Disease Symptom Index 2.0 for administration to people with liver cirrhosis in Egypt

The Liver Disease Symptom Index (LDSI) 2.0 is a simple, short and specific liver disease questionnaire in English, but an Arabic version does not exist, therefore we translated the LDSI-2.0 into Arabic and tested its psychometric properties in a pilot cross-sectional study. A convenience sample of 38 patients with liver cirrhosis from one hospital in Cairo, Egypt, were interviewed for approximately 45 min. Patients completed a background data sheet, the translated LDSI-2.0 and the Short Form (SF)-36v(2). Construct convergent validity was examined by correlating LDSI-2.0 items with the SF-36v(2) eight domains. Reliability was estimated using measures of internal consistency, test-retest reliability and internal consistency reliability. Median completion time was 10 min. The correlation between the translated LDSI-2.0 items and the SF-36 domains confirmed that there was moderate to high overlapping between the two measures, suggesting convergent validity of the LDSI-2.0. The LDSI-2.0 showed good to very good retest reliability (kappa value 0.62-0.94). Chronbach's alpha coefficient for the multi-item scales ranged from 0.73 to 0.96. The Arabic LDSI-2.0 therefore has satisfactory validity, retest reliability and internal consistency.

Self-monitoring of blood glucose in Type 2 diabetes: cross-sectional analyses in 1993, 1999 and 2009

AIM

To characterize the numbers of reagent strips dispensed for self-monitoring of blood glucose to patients with Type 2 diabetes in Tayside, Scotland, in 1993, 1999 and 2009.

METHODS

A diabetes clinical information system in Tayside, record-linked to electronic dispensed prescribing records, was used to collate all dispensed prescribing records for three cross-sectional samples of patients with Type 2 diabetes in 1993 (n = 5728), 1999 (n = 8109) and at 1 January 2009 (n = 16,450). The numbers of reagent strips dispensed during the relevant calendar year were calculated and patients stratified by treatment. We also explored whether age, sex or material and social deprivation were associated with whether a patient received strips.

RESULTS

Proportions of people who received self-monitoring reagent strips increased from 15.5% in 1993, to 24.2% in 1999 to 29.8% in 2009, as did numbers of strips dispensed. While the proportion of diet-treated patients who received reagent strips was still very low in 2009 (5.6%), the proportion among those treated with oral agents tripled from 9.4 to 27.4% between 1993 and 2009. Over 90% of patients treated with insulin received reagent strips and, among non-insulin-treated patients, this was more common among women, younger people and less deprived groups.

CONCLUSIONS

The numbers of reagent strips dispensed for self-monitoring of blood glucose has increased and almost all insulin-treated patients receive strips. While few diet-treated patients receive strips, they are more extensively dispensed to those treated with oral agents. Given that self-monitoring of blood glucose is no longer routinely recommended in non-insulin treated patients, strategies to reduce unnecessary dispensing of reagent strips are needed.

Prevalence and outcomes of use of potentially inappropriate medicines in older people: cohort study stratified by residence in nursing home or in the community

OBJECTIVES

To compare the prevalence of use of potentially inappropriate medicines (PIMs) between older patients living in their own homes versus those living in nursing or residential homes, and to test the association between exposure to PIMs and mortality.

DESIGN

Cohort study stratified by place of residence.

SETTING

Tayside, Scotland.

PARTICIPANTS

All people aged between 66 and 99 years who were resident or died in Tayside from 2005 to 2006.

MAIN OUTCOME MEASURES

The exposure variable was PIM use as defined by Beers' Criteria. All cause mortality was the main outcome measure.

RESULTS

70,299 people were enrolled in the cohort of whom 96% were exposed to any medicine and 31% received a PIM. Place of residence was not associated with overall risk of receiving PIMs, adjusted OR 0.94, 95% CI 0.87 to 1.01. Exposure to five of the PIMs (including long-acting benzodiazepines) was significantly higher in nursing homes whereas exposure to five other PIMs (including amitriptyline and NSAIDs) was significantly lower. Exposure to PIMs was similar (20-46%) across all 71 general practices in Tayside and was not associated with increased risk of mortality after adjustment for age, gender and polypharmacy (adjusted OR 0.98, 95% CI 0.92 to 1.05).

CONCLUSIONS

The authors question the validity of the full list of PIMs as an indicator of safety of medicines in older people because one-third of the population is exposed with little practice variation and no significant impact on mortality. Future studies should focus on management of a shorter list of genuinely high-risk medicines.

Drugs dispensed in primary care during pregnancy: a record-linkage analysis in Tayside, Scotland

BACKGROUND

For many regularly used drugs, evidence for safe use in pregnancy has not been established. Despite this, international studies have identified high levels of drug prescribing among pregnant women.

OBJECTIVE

To investigate the patterns of prescribing of drugs to women who gave birth in Tayside, Scotland, in 2007.

METHODS

Scottish maternity records were linked to dispensed prescribing data for all women who gave birth in Tayside in 2007. Drugs prescribed were coded according to the US FDA classification for risks of drugs in pregnancy. Patterns of prescribing were investigated during the 3 trimesters of pregnancy and the 3 months prior to conception.

RESULTS

Prescribing in pregnancy was common, with 21 093 prescriptions dispensed to 3356 (85.2%) of the 3937 women. The most frequently prescribed drugs were antacids, antibacterials, oral iron, folic acid preparations and analgesics. Category A drugs (positive evidence of safety in pregnancy) and Category B drugs (some evidence of safety in pregnancy) accounted for 19.6% and 26.9% of all prescriptions dispensed, respectively. Prescribing of Category X drugs (evidence of risk to the fetus; use contraindicated in women who are or may become pregnant) during pregnancy was rare, with 112 prescriptions dispensed to 68 women (1.7%). Most of these were oral contraceptives or sex hormones. Prescribing of Category X drugs fell markedly during the first trimester and remained very low thereafter. Category D drugs (evidence of risk to the fetus but benefits of therapy may outweigh the potential risk) [432] were dispensed to 166 women (4.2%) during pregnancy. The most commonly prescribed Category D drugs were anxiolytics, nicotine replacement therapy and antiepileptic drugs. The frequency of prescribing of Category D drugs reduced in the third trimester. Prescribing of Category C drugs (insufficient evidence to know whether they are harmful) was common. Thirty percent of women received a total of 3641 Category C prescriptions, which accounted for 17.3% of all prescriptions issued during pregnancy. Prescribing of Category C drugs showed only a very modest decline during pregnancy. No FDA code was available for 4035 prescriptions issued (87 different items), the majority of which were for antacids and preparations for indigestion. More than 40% of women received such medications.

CONCLUSIONS

Prescribing of drugs during pregnancy was very common, but the levels of prescribing of drugs that are known to be harmful were low. Much of the prescribing was for drugs related to the pregnancy. While this study provides some evidence that primary-care prescribers in Tayside are prescribing potentially harmful drugs appropriately and with caution during pregnancy, safety data during pregnancy are unavailable for many drugs that are commonly prescribed.

A 12-year follow-up study of all-cause and cardiovascular mortality among 10,532 people newly diagnosed with Type 2 diabetes in Tayside, Scotland

AIMS

To determine absolute and relative risks of all-cause and cardiovascular mortality among patients newly diagnosed with Type 2 diabetes.

METHODS

In an observational cohort study using record-linkage databases, based in Tayside, Scotland, UK, we identified newly diagnosed patients with Type 2 diabetes in 1993-2004. We also identified a set of non-diabetic comparators from lists of patients registered with a general practice, individually matched to the diabetic patients by sex, age and deprivation. We followed up patients for mortality and cardiovascular mortality over a 12-year period and calculated hazard ratios using Cox regression.

RESULTS

There were 10,532 patients with Type 2 diabetes and 21,056 non-diabetic comparators. Diabetic patients in every age/sex group had higher absolute mortality rates. Even taking deprivation into account, the hazard ratio for mortality was 1.32 (95% CI 1.25-1.40), decreasing to 1.15 (1.09-1.22) after adjusting for pre-existing cardiovascular disease. The hazard ratios for cardiovascular mortality were higher, decreasing from 1.51 (1.37-1.67) to 1.23 (1.11-1.36) after adjusting for pre-existing cardiovascular disease. The hazard ratios decreased with increasing age at diagnosis, although the difference in absolute rate of mortality increased slightly with age. Increased mortality risks were only evident 2 years after diagnosis and increased thereafter.

CONCLUSIONS

Patients with Type 2 diabetes have an increased risk of all-cause and cardiovascular mortality compared with non-diabetic comparators, although this is not observable immediately after diagnosis. Age at diagnosis and duration of the disease independently affect absolute and relative mortality risk.

New users of metformin are at low risk of incident cancer: a cohort study among people with type 2 diabetes

OBJECTIVE

The antidiabetic properties of metformin are mediated through its ability to activate the AMP-activated protein kinase (AMPK). Activation of AMPK can suppress tumor formation and inhibit cell growth in addition to lowering blood glucose levels. We tested the hypothesis that metformin reduces the risk of cancer in people with type 2 diabetes.

RESEARCH DESIGN AND METHODS

In an observational cohort study using record-linkage databases and based in Tayside, Scotland, U.K., we identified people with type 2 diabetes who were new users of metformin in 1994-2003. We also identified a set of diabetic comparators, individually matched to the metformin users by year of diabetes diagnosis, who had never used metformin. In a survival analysis we calculated hazard ratios for diagnosis of cancer, adjusted for baseline characteristics of the two groups using Cox regression.

RESULTS

Cancer was diagnosed among 7.3% of 4,085 metformin users compared with 11.6% of 4,085 comparators, with median times to cancer of 3.5 and 2.6 years, respectively (P < 0.001). The unadjusted hazard ratio (95% CI) for cancer was 0.46 (0.40-0.53). After adjusting for sex, age, BMI, A1C, deprivation, smoking, and other drug use, there was still a significantly reduced risk of cancer associated with metformin: 0.63 (0.53-0.75).

CONCLUSIONS

These results suggest that metformin use may be associated with a reduced risk of cancer. A randomized trial is needed to assess whether metformin is protective in a population at high risk for cancer.

Do general practice characteristics influence uptake of an information technology (IT) innovation in primary care?

INTRODUCTION

Recent evaluations of IT innovations in primary care have highlighted variations between centres and practices in uptake and use. We evaluated whether structural characteristics of a general practice were associated with variations in use of a web-based clinical information system underpinning a Managed Clinical Network in diabetes, between the years 2001 and 2003.

METHODS

Using a computerised audit trail, we calculated the numbers of web-based operations that occurred in each practice, stratified by staff type and year, and adjusted for the numbers of registered diabetic patients. In regression analyses, we determined whether total use was associated with structural characteristics of the practice (total list size, training status, numbers of GPs (general practitioners), mean age of the GPs, numbers of female GPs, level of deprivation of the population and whether staff had received advanced training in diabetes care).

RESULTS

Initially there were a few practices which made very frequent use of the information system, with relatively high numbers of practices using the facility infrequently. However, overall use gradually became more evenly spread. This effect was particularly evident among nurse users. Frequent use by GPs was evident in only a small number of practices, with mean GP use decreasing over the three years. In linear regression analyses, none of the general practice variables were associated with online use, either overall or stratified by staff type, except for the numbers of diabetes-educated staff. This was consistently associated with increased use by nurses and GPs.

CONCLUSIONS

The analyses show that structural characteristics of a practice are not associated with uptake of a new IT facility, but that its use may be influenced by post-graduate education in the relevant clinical condition. For this diabetes system at least, practice nurse use was critical in spreading uptake beyond initial GP enthusiasts and for sustained and rising use in subsequent years.

No differences in mortality between users of pancreatic-specific and non-pancreatic-specific sulphonylureas: a cohort analysis

To assess whether users of pancreatic-specific sulphonylureas are at reduced risk of mortality and cardiovascular mortality compared with users of non-specific sulphonylureas, we conducted a cohort study in the population of Tayside, Scotland. We identified 3331 patients with type 2 diabetes who were newly treated with sulphonylureas between 1994 and 2001 and categorized them into those treated with only pancreatic-specific sulphonylureas and those treated with only non-specific sulphonylureas. The risks of mortality and cardiovascular mortality were compared in a survival analysis. There were 2914 patients treated with pancreatic-specific sulphonylureas only, of which 683 (23.4%) died. Of 186 patients treated with non-specific drugs only, 40 (21.5%) died. After adjusting for confounding factors, the adjusted risk ratios (with 95% CI) for mortality and cardiovascular mortality were 0.84 (0.61 to 1.17) and 0.81 (0.59 to 1.11) among the non-specific users compared with the pancreatic-specific users. This provides no evidence that there are differences between the two sulphonylureas types.

Adherence to insulin and its association with glycaemic control in patients with type 2 diabetes

BACKGROUND

Good glycaemic control improves outcomes in patients with type 2 diabetes, but the extent to which this depends on adherence to insulin treatment is uncertain.

AIM

To investigate the association between adherence to insulin and glycaemic control in insulin-treated patients with type 2 diabetes.

DESIGN

Observational records-based study.

METHODS

We studied all patients with type 2 diabetes who were resident in Tayside, Scotland from 1 January 1995 to 30 September 2001, and who were treated with insulin. Adherence to insulin treatment was measured as the annual number of days of insulin coverage on the recommended dose, calculated from the amount of drug dispensed at community pharmacies and the recommended dose level for each patient. The association between glycaemic control (HbA1c), and adherence was determined, as was the influence of covariates, including age, sex, duration of diabetes and number of injections per day.

RESULTS

A total of 1099 people were studied: 574 (52%) males and 525 (48%) females, mean +/- SD age 62 +/- 12 years, diabetes duration 10 +/- 7 years. Median time in the study (time for which insulin was dispensed) was 1107 (range 366-2446) days. Insulin prescribed was 58.0 +/- 33.3 IU/day and insulin collected from pharmacies was 53.6 +/- 27.1 IU/day. Mean adherence to insulin was thus 70.6%+/-17.7%. Adherence to insulin (p = 0.0021), BMI (p = 0.0001) and diabetes duration (p = 0.0314) were all significant predictors of HbA1c.

DISCUSSION

Adherence to insulin appears poor in these type 2 diabetes patients, and there was a significant relationship between adherence and long-term metabolic control.

Increasing prevalence of type 2 diabetes in a Scottish population: effect of increasing incidence or decreasing mortality?

AIMS/HYPOTHESIS

We examined incidence, prevalence and mortality from type 2 diabetes mellitus in a Scottish population over 12 years, and evaluated the effects on prevalence of increasing incidence and decreasing mortality.

MATERIALS AND METHODS

We used a diabetes clinical information system in Tayside (population 387,908), Scotland, to identify new cases of type 2 diabetes between 1993 and 2004 and to calculate incidence rates and mid-year prevalence. We defined mortality rates as the number of deaths of diabetic people divided by mid-year prevalence. We used logistic and Poisson regression to analyse trends. We then modelled the increase in prevalence for each year for three scenarios, based on whether mortality or incidence rates remained unchanged from 1993.

RESULTS

There was a doubling in incidence and prevalence of type 2 diabetes in Tayside over the 12 years, with statistically significant increasing trends of 6.3 and 6.7% per year respectively. The mortality rate decreased. If incidence and mortality had remained at 1993 levels, there would have been an increase in prevalence of 855 per 100,000 in 2003, accounting for 60.1% of the actual increase of 1,423 per 100,000. If there had been no mortality decrease, prevalence in 2003 would have been very similar to the actual prevalence observed.

CONCLUSIONS/INTERPRETATION

Decreasing mortality rates in Tayside had less effect on the increase in prevalence than did increasing incidence. Even if incidence and mortality remain unchanged, prevalence will increase by over 20% in the next decade.

Mortality in people diagnosed with type 2 diabetes at an older age: a systematic review

OBJECTIVES

To review all published observational studies reporting on all-cause mortality in patients with type 2 diabetes to determine the degree of increased mortality when diagnosed at an older age.

DESIGN

Systematic literature search.

SETTING

The review included studies carried out in populations from Germany, United Kingdom, United States, Japan, Italy, Western Australia, Netherlands and Sweden.

MEASUREMENTS

Medline, CINAHL, EMBASE, National Research Register and Cochrane Reviews were systematically searched from 1975 to 2004. We identified observational studies that reported overall mortality for people diagnosed with type 2 diabetes when they were over the age of 60, compared with a non-diabetic population. Outcome measures were expressed as risk ratios or relative risks.

RESULTS

Among 14 eligible studies, one study reported reduced mortality for patients diagnosed with type 2 diabetes over the age of 60, whereas another found virtually no increased risk of mortality. However, 7 of the 14 studies reported increased mortality in all patients diagnosed when older, and 5 studies for certain subgroups only. A meta-analysis showed the combined relative risks (with 95% CI) of increased mortality for men diagnosed between the ages of 60 and 70 to be 1.38 (1.08-1.76) and 1.13 (0.88-1.45) for men diagnosed aged 70 years or older. A similar pattern was found for the same age groups for women, with combined relative risks of 1.40 (1.10-1.79) and 1.19 (0.93-1.52) respectively.

CONCLUSION

Increased mortality associated with a diagnosis of type 2 diabetes at an older age is lower than that reported for the general older diabetic population.

Risk of mortality and adverse cardiovascular outcomes in type 2 diabetes: a comparison of patients treated with sulfonylureas and metformin

AIMS/HYPOTHESIS

The aim of this study was to evaluate the risk of adverse cardiovascular outcomes in patients with type 2 diabetes newly treated with sulfonylureas and metformin.

SUBJECTS AND METHODS

The Diabetes Audit and Research in Tayside Scotland (DARTS) diabetes information system and the Medicines Monitoring Unit (MEMO) dispensed prescribing database for the population of Tayside, Scotland (400,000 people) were employed. Patients newly prescribed with oral hypoglycaemic agents between 1994 and 2001 were classified into five study cohorts according to the treatment received: metformin only, sulfonylureas only, sulfonylureas added to metformin, metformin added to sulfonylureas, and both drugs simultaneously. In Cox regression analyses, we estimated relative risks for all-cause mortality, cardiovascular mortality and cardiovascular hospital admission for patients in the five study cohorts, with metformin monotherapy as the reference group.

RESULTS

Of the 5,730 study patients, 1,000 died during a maximum of 8 years follow-up. Patients in the sulfonylureas only cohort had increased risks of mortality and cardiovascular mortality, with unadjusted relative risks of 3.12 (95% CI 2.54-3.84) and 3.71 (95% CI 2.64-5.22), respectively. After adjusting for differences between groups (age, sex, duration of diabetes, blood pressure, cholesterol, HbA(1c), smoking, previous hospital admission, treatment with cardiovascular medication), these relative risks were 1.43 (95% CI 1.15-1.77) and 1.70 (95% CI 1.18-2.45), respectively. Patients in the combination cohorts had significantly increased risks of cardiovascular hospital admission, as well as increased risks of mortality and cardiovascular mortality.

CONCLUSIONS/INTERPRETATION

In this cohort study of patients newly treated with oral hypoglycaemic agents, those treated with sulfonylureas only, or combinations of sulfonylureas and metformin, were at higher risk of adverse cardiovascular outcomes than those treated with metformin alone.

The annual incidence of diabetic complications in a population of patients with Type 1 and Type 2 diabetes

AIM

The DARTS diabetes register was used to determine incidence rates of diabetes and related complications in 1997.

METHODS

The diabetes register records detailed clinical information for all patients diagnosed with diabetes in Tayside, Scotland. The study population included patients who were alive and registered with a Tayside GP for the duration of 1997 or who died in Tayside during this time. Patients who had diabetes prior to 1997, those who developed diabetes in 1997, and those who developed diabetic complications in 1997, were identified.

RESULTS

In the Tayside population of 385 774 at the start of 1997, there were 942 and 6632 patients with Type 1 and Type 2 diabetes, with a further 29 and 744 patients diagnosed in 1997. The incidence rates (with 95% confidence intervals) of diabetic complications per 1000 patients with Type 1 and Type 2 diabetes, respectively, were: angina 8.8 (4.5-17.3) and 38.4 (33.4-44.2); myocardial infarction 8.6 (4.4-16.9) and 21.9 (18.4-25.9); cerebrovascular accident 1.1 (0.3-6.0) and 14.2 (11.6-17.5); lower extremity amputation 3.2 (1.2-9.4) and 3.1 (2.1-4.8); peripheral vascular disease 5.5 (2.4-12.8) and 13.6 (11.0-16.8); registered blindness 1.1 (0.3-5.9) and 1.6 (0.9-2.9); end-stage renal failure 6.4 (3.0-13.8) and 5.0 (3.6-7.0). Mortality was 14.6 per 1000 (9.6-25.7) in Type 1 diabetes and 50.0 per 1000 (45.1-55.3) in Type 2 diabetes.

CONCLUSION

This study provides baseline figures for rates of diabetic complications for Type 1 and Type 2 diabetes, and confirms the increased burden of macrovascular disease in Type 2 diabetes.

Diagnosis of type 2 diabetes at an older age: effect on mortality in men and women

OBJECTIVE

To compare the mortality of people who were diagnosed with type 2 diabetes over 65 years of age with that of nondiabetic individuals.

RESEARCH DESIGN AND METHODS

Using a population-based diabetes information system for an observational cohort study in Tayside, Scotland, people who were diagnosed with type 2 diabetes over the age of 65 years between 1993 and 2002 were identified. Nondiabetic comparators, matched for age and sex, were identified from the nondiabetic population. The two cohorts were followed up for mortality and cardiovascular mortality according to death certification records.

RESULTS

There were 3,594 people with type 2 diabetes (48% male) and 7,188 matched comparators identified in the study. Over a mean follow-up period of 4.6 +/- 2.9 years for 3,594 people with type 2 diabetes and 7,188 comparators, 909 (25.3%) patients in the diabetic cohort and 1,651 (23.0%) in the nondiabetic cohort died. The adjusted relative risk for mortality in the diabetic cohort compared with the nondiabetic cohort was 1.06 (95% CI 0.94-1.19) for men and 1.29 (1.15-1.45) for women. Cardiovascular deaths accounted for 49.4% of the deaths in people with and 45.2% in those without diabetes (adjusted relative risk 1.01 [0.93-1.10]).

CONCLUSIONS

Men diagnosed with type 2 diabetes over the age of 65 years have no excess mortality compared with their nondiabetic counterparts, a finding that was not replicated for women.

Adherence to oral hypoglycaemic agents prior to insulin therapy in Type 2 diabetes

AIM

To investigate whether patients require insulin as a result of poor adherence to oral hypoglycaemic agents (OHAs) in Type 2 diabetes.

METHODS

A diabetes information system and a database of drugs dispensed for the study period 1993-1996 were used in Tayside, Scotland (population 400 000). Patients aged over 34 years with Type 2 diabetes who had at least 6 months exclusive therapy with OHAs (sulphonylureas or metformin) prior to insulin treatment were identified. Intended duration of every OHA prescription was calculated from prescription details. Adherence was estimated by dividing total intended duration of OHA therapy by study time for each patient, and compared between those who did and did not convert to insulin.

RESULTS

There were 2537 patients on sulphonylureas (51% male, mean age 67 years). There was improved adherence in the 262 patients who commenced insulin, who had mean adherence of 88.3% (95% confidence interval (CI) 85.9-90.6%) compared with the remaining 2275 patients whose mean adherence was 87.4% (95% CI 86.7-88.2%). In a logistic regression analysis, the adjusted odds ratio (OR) for commencing insulin was 1.20 (95% CI 1.07-1.35) for a quartile increase in adherence. There were 1519 patients on metformin (49% male, mean age 64 years). Mean adherence was 79.7% (95% CI 76.4-83.1%) and 83.1% (95% CI 82.0-84.1%) in 169 patients who did and 1350 who did not commence insulin, respectively, with an adjusted OR for a quartile increase in adherence of 0.91 (95% CI 0.78-1.07).

CONCLUSION

Despite suboptimal adherence to OHAs in Type 2 diabetes, this is not associated with subsequent requirement for insulin.

Comparison of cardiovascular risk between patients with type 2 diabetes and those who had had a myocardial infarction: cross sectional and cohort studies

OBJECTIVE

To compare risks of cardiovascular outcomes between patients with type 2 diabetes and patients with established coronary heart disease.

DESIGN

Cross sectional study and cohort study using routinely collected datasets.

SETTING

Tayside, Scotland (population 400 000) during 1988-95.

SUBJECTS

In the cross sectional study, among patients aged 45-64, 1155 with type 2 diabetes were compared with 1347 who had had a myocardial infarction in the preceding 8 years. In the cohort study 3477 patients of all ages with newly diagnosed type 2 diabetes were compared with 7414 patients who had just had a myocardial infarction.

MAIN OUTCOME MEASURES

Risk ratios for death from all causes, cardiovascular death, and hospital admission for myocardial infarction were calculated by Cox proportional hazards analysis and adjusted for age and sex.

RESULTS

In the cross sectional study the adjusted risk ratio for death from all causes for patients who had myocardial infarction compared with those with diabetes was 1.33 (95% confidence interval 1.14 to 1.55) [corrected], and the risk ratio for hospital admission for myocardial infarction was 2.27 (1.82 to 2.83) [corrected]. In the cohort study, patients who had just had a myocardial infarction had a higher risk of death from all causes (adjusted risk ratio 1.35 (1.25 to 1.44)), cardiovascular death (2.93 (2.54 to 3.41)), and hospital admission for myocardial infarction (3.10 (2.57 to 3.73)).

CONCLUSIONS

Patients with type 2 diabetes were at lower risk of cardiovascular outcomes than patients with established coronary heart disease.