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Holland D, Fryer AA, Stedman M, Hanna FWF, Duff CJ, Green L, Scargill J, Halsall I, Gaskell N, Howe JD, Heald AH, Wu P. Correction to: Is the Current Cut Point for Glycated Haemoglobin (HbA1c) Correct for Diagnosing Diabetes Mellitus in Premenopausal Women? Evidence to Inform Discussion. Diabetes Ther 2024; 15:565-566. [PMID: 38038899 PMCID: PMC10838873 DOI: 10.1007/s13300-023-01498-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023] Open
Affiliation(s)
| | - Anthony A Fryer
- School of Medicine, Keele University, Keele, ST5 5BG, Staffordshire, UK
| | | | - Fahmy W F Hanna
- Centre for Health & Development, Staffordshire University, Stoke-on-Trent, ST4 2DF, Staffordshire, UK
- Department of Diabetes and Endocrinology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, ST4 6QG, Staffordshire, UK
| | - Christopher J Duff
- School of Medicine, Keele University, Keele, ST5 5BG, Staffordshire, UK
- Department of Clinical Biochemistry, North Midlands and Cheshire Pathology Services, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, ST4 6QG, Staffordshire, UK
| | - Lewis Green
- Department of Clinical Biochemistry, St. Helens & Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, L35 5DR, UK
| | - Jonathan Scargill
- Department of Clinical Biochemistry, The Royal Oldham Hospital, The Northern Care Alliance, Oldham, OL1 2JH, UK
| | - Ian Halsall
- Core Biochemical Assay Laboratory, Department of Clinical Biochemistry, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Neil Gaskell
- Department of Pathology, Warrington & Halton Teaching Hospitals NHS Foundation Trust, Warrington, WA5 1QG, UK
| | - Jonathon D Howe
- Department of Clinical Biochemistry, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK
| | - Adrian H Heald
- Department of Diabetes and Endocrinology, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK.
- The School of Medicine and Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, M13 9PL, UK.
| | - Pensee Wu
- School of Medicine, Keele University, Keele, ST5 5BG, Staffordshire, UK
- Department of Obstetrics & Gynaecology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, ST4 6QG, Staffordshire, UK
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Heald AH, Taylor P, Premawardhana L, Stedman M, Dayan C. Natural desiccated thyroid for the treatment of hypothyroidism? Front Endocrinol (Lausanne) 2024; 14:1309159. [PMID: 38260143 PMCID: PMC10801060 DOI: 10.3389/fendo.2023.1309159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 12/06/2023] [Indexed: 01/24/2024] Open
Abstract
Primary hypothyroidism affects about 3% of the general population in Europe. Early treatments in the late 19th Century involved subcutaneous as well as oral administration of thyroid extract. Until the early 1970s, the majority of people across the world with hypothyroidism were treated with natural desiccated thyroid (NDT) (derived from pig thyroid glands) in various formulations, with the majority of people since then being treated with levothyroxine (L-thyroxine). There is emerging evidence that may account for the efficacy of liothyronine (NDT contains a mixture of levothyroxine and liothyronine) in people who are symptomatically unresponsive to levothyroxine. While this is a highly selected group of people, the severity and chronicity of their symptoms and the fact that many patients have found their symptoms to be alleviated, can be viewed as valid evidence for the potential benefit of NDT when given after careful consideration of other differential diagnoses and other treatment options.
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Affiliation(s)
- Adrian H. Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford, United Kingdom
| | - Peter Taylor
- Thyroid Research Group, Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Lakdasa Premawardhana
- Thyroid Research Group, Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff, United Kingdom
| | | | - Colin Dayan
- Thyroid Research Group, Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff, United Kingdom
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3
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Holland D, Fryer AA, Stedman M, Hanna FWF, Duff CJ, Green L, Scargill J, Halsall I, Gaskell N, Howe JD, Heald AH, Wu P. Is the Current Cut Point for Glycated Haemoglobin (HbA1c) Correct for Diagnosing Diabetes Mellitus in Premenopausal Women? Evidence to Inform Discussion. Diabetes Ther 2024; 15:99-110. [PMID: 37777677 PMCID: PMC10786809 DOI: 10.1007/s13300-023-01482-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 09/26/2023] [Indexed: 10/02/2023] Open
Abstract
INTRODUCTION Women are on average diagnosed with diabetes mellitus at later age than men but have higher mortality. As the diagnosis of diabetes mellitus is primarily based on HbA1c, the use of a non-specific reference range and cut point for diabetes mellitus that does not account for gender differences in diabetes could potentially lead to underdiagnosis of diabetes mellitus in women and missed opportunities for intervention. We investigated whether a contributing factor to the later diagnosis in women may be a difference in distribution of HbA1c in premenopausal women versus men of the same age by comparing HbA1c values in men and women across multiple sites in the UK. METHODS We analysed the HbA1c levels of 146,907 individuals who underwent single testing only and had HbA1c ≤ 50 mmol/mol between 2012 and 2019 in one laboratory (cohort 1). This was replicated in six laboratories with 938,678 individuals tested between 2019 and 2021 (cohort 2). RESULTS In cohort 1, women < 50 years old had an HbA1c distribution markedly lower than that in men by a mean of 1.6 mmol/mol (p < 0.0001), while the difference in the distribution of HbA1c for individuals aged ≥ 50 years was less pronounced (mean difference 0.9 mmol/mol, p < 0.0001). For individuals under the age of 50, HbA1c in women lagged by up to 10 years compared to men. Similar findings were found in cohort 2. We estimated an additional 17% (n = 34,953) of undiagnosed women aged < 50 years in England and Wales could be reclassified to have diabetes mellitus, which may contribute to up to 64% of the difference in mortality rates between men/women with diabetes mellitus aged 16-50 years. CONCLUSION The HbA1c cut point for diagnosis of diabetes mellitus may need to be re-evaluated in women under the age of 50 years. Early identification of diabetes mellitus in women has the potential to improve women's health outcomes in the longer term.
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Affiliation(s)
| | - Anthony A Fryer
- School of Medicine, Keele University, Keele, ST5 5BG, Staffordshire, UK
| | | | - Fahmy W F Hanna
- Centre for Health & Development, Staffordshire University, Stoke-on-Trent, ST4 2DF, Staffordshire, UK
- Department of Diabetes and Endocrinology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, ST4 6QG, Staffordshire, UK
| | - Christopher J Duff
- School of Medicine, Keele University, Keele, ST5 5BG, Staffordshire, UK
- Department of Clinical Biochemistry, North Midlands and Cheshire Pathology Services, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, ST4 6QG, Staffordshire, UK
| | - Lewis Green
- Department of Clinical Biochemistry, St. Helens & Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, L35 5DR, UK
| | - Jonathan Scargill
- Department of Clinical Biochemistry, The Royal Oldham Hospital, The Northern Care Alliance, Oldham, OL1 2JH, UK
| | - Ian Halsall
- Core Biochemical Assay Laboratory, Department of Clinical Biochemistry, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Neil Gaskell
- Department of Pathology, Warrington & Halton Teaching Hospitals NHS Foundation Trust, Warrington, WA5 1QG, UK
| | - Jonathon D Howe
- Department of Clinical Biochemistry, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK
| | - Adrian H Heald
- Department of Diabetes and Endocrinology, Salford Royal NHS Foundation Trust, Salford, M6 8HD, UK.
- The School of Medicine and Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, M13 9PL, UK.
| | - Pensee Wu
- School of Medicine, Keele University, Keele, ST5 5BG, Staffordshire, UK
- Department of Obstetrics & Gynaecology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, ST4 6QG, Staffordshire, UK
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4
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Waheed U, Stedman M, Davies M, Solomon E, Taylor D, Heald A, Narayanan RP, Warner-Levy J. Changes in prescribing of psychotropic vs some physical health medication in primary care through the COVID-19 pandemic in England: a national-level survey. J Pharm Policy Pract 2023; 16:169. [PMID: 38124123 PMCID: PMC10734137 DOI: 10.1186/s40545-023-00655-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 11/07/2023] [Indexed: 12/23/2023] Open
Abstract
INTRODUCTION The COVID-19 pandemic globally impacted healthcare provision. Prescribing changes in common medications can be used as a marker for new diagnoses. We describe how the prescribing of specific psychotropics was impacted by the pandemic. METHODS Primary Care Prescribing data for different classes of drugs from March 2017 to February 2022 were considered. To capture the impact during periods of restricted access to health services for new diagnoses/existing conditions, repeat prescriptions/episodic prescribing were included with account taken of historical trends. The pre-pandemic prescriptions issued each month from March 2018 to February 2020 were linearly extrapolated forward to give an expected annual growth (EAG). The monthly average expected prescriptions for the pandemic period (March 2020-February 2022) were compared. RESULTS Physical health medications had lower monthly prescriptions during the pandemic, most markedly for antibiotics - 12.5% (EAG - 1.3%). Bronchodilator prescribing showed a marked increase in the early pandemic months from March 2020 of 5% (EAG 0.1%). Mental health medication prescribing increased above trend for hypnotics/anxiolytics by 0.2% (EAG - 2.3%), while antidepressants fell by - 0.2% (EAG 5.0%), with no net change for antipsychotics (EAG 2.8%), but a temporary increase in antipsychotic prescribing in the early pandemic period. For all the main antidepressants prescribed in England (Sertraline, Mirtazapine, Venlafaxine, Fluoxetine and Citalopram), prescribing actually decreased in the main pandemic period vs historical trend. CONCLUSIONS The increase in anxiolytic/hypnotic prescribing above trend links to pandemic effects on anxiety/worry. If anything, there was a slight fall in prescribing of the main antidepressants prescribed, which given prevailing circumstances at the time, suggests that access to services may have restricted access to timely assessment.
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Affiliation(s)
- Unaiza Waheed
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, M6 8HD, UK
| | - Mike Stedman
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | | | - Emma Solomon
- Department of Clinical Psychology, Salford Royal Hospital, Salford, UK
| | | | - Adrian Heald
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, M6 8HD, UK.
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK.
| | - Ram Prakash Narayanan
- St Helens and Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - John Warner-Levy
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
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Heald A, Stedman M, Okosieme B, Premawardhana L, Taylor P, Dayan C. Liothyronine prescribing in England: costs versus need. Lancet 2023; 402:2074-2075. [PMID: 37979592 DOI: 10.1016/s0140-6736(23)01792-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 08/21/2023] [Indexed: 11/20/2023]
Affiliation(s)
- Adrian Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester M14 4PX, UK; Department of Diabetes and Endocrinology, Salford Royal NHS Foundation Trust, Salford, UK.
| | | | - Buchi Okosieme
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Lakdasa Premawardhana
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Peter Taylor
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Colin Dayan
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
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Stedman M, Robinson A, Dunn G, Meza-Torres B, Gibson JM, Reeves ND, Jude EB, Feher M, Rayman G, Whyte MB, Edmonds M, Heald AH. Diabetes foot complications and standardized mortality rate in type 2 diabetes. Diabetes Obes Metab 2023; 25:3662-3670. [PMID: 37722968 DOI: 10.1111/dom.15260] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/07/2023] [Accepted: 08/12/2023] [Indexed: 09/20/2023]
Abstract
AIM To quantify the impact of foot complications on mortality outcomes in people with type 2 diabetes (T2D), and how routinely measured factors might modulate that risk. MATERIALS AND METHODS Data for individuals with T2D for 2010-2020, from the Salford Integrated Care Record (Salford, UK), were extracted for laboratory and clinical data, and deaths. Annual expected deaths were taken from Office of National Statistics mortality data. An index of multiple deprivation (IMD) adjusted the standardized mortality ratio (SMR_IMD). Life years lost per death (LYLD) was estimated from the difference between expected and actual deaths. RESULTS A total of 11 806 T2D patients were included, with 5583 new diagnoses and 3921 deaths during 2010-2020. The number of expected deaths was 2135; after IMD adjustment, there were 2595 expected deaths. Therefore, excess deaths numbered 1326 (SMR_IMD 1.51). No foot complications were evident in n = 9857. This group had an SMR_IMD of 1.13 and 2.74 LYLD. In total, 2979 patients had any foot complication recorded. In this group, the SMD_IMR was 2.29; of these, 2555 (75%) had only one foot complication. Patients with a foot complication showed little difference in percentage HbA1c more than 58 mmol/mol. In multivariate analysis, for those with a foot complication and an albumin-to-creatinine ratio of more than 3 mg/mmol, the odds ratio (OR) for death was 1.93, and for an estimated glomerular filtration rate of less than 60 mL/min/1.73m2 , the OR for death was 1.92. CONCLUSIONS Patients with T2D but without a foot complication have an SMR_IMD that is only slightly higher than that of the general population. Those diagnosed with a foot complication have a mortality risk that is double that of those without T2D.
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Affiliation(s)
| | - Adam Robinson
- Department of Diabetes and Endocrinology, Salford Royal Foundation Trust, Salford, UK
| | | | - Bernado Meza-Torres
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - J Martin Gibson
- Department of Diabetes and Endocrinology, Salford Royal Foundation Trust, Salford, UK
- Department of Medicine, University of Manchester, Manchester, UK
| | - Neil D Reeves
- Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK
| | - Edward B Jude
- Department of Medicine, University of Manchester, Manchester, UK
| | | | - Gerry Rayman
- The Ipswich Diabetes Centre and Research Unit, Ipswich Hospital NHS Trust, Ipswich, UK
| | - Martin B Whyte
- Diabetic Foot Clinic, King's College Hospital Foundation Trust, London, UK
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Michael Edmonds
- Diabetic Foot Clinic, King's College Hospital Foundation Trust, London, UK
| | - Adrian H Heald
- Department of Diabetes and Endocrinology, Salford Royal Foundation Trust, Salford, UK
- Department of Medicine, University of Manchester, Manchester, UK
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Heald AH, Stedman M, Horne L, Rea R, Whyte MB, Syed AA, Paisley A, Gibson JM, Anderson SG, Ollier W. The change in glycaemic control immediately after the 3rd COVID-19 vaccination in people with type 1 diabetes. Diabet Med 2023; 40:e15119. [PMID: 37083020 DOI: 10.1111/dme.15119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 04/12/2023] [Accepted: 04/18/2023] [Indexed: 04/22/2023]
Affiliation(s)
- A H Heald
- The School of Medicine and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
| | - M Stedman
- Res Consortium, Andover, Hampshire, UK
| | - L Horne
- Vernova Healthcare, Watersgreen Medical Centre, Macclesfield, UK
| | - R Rea
- Oxford Centre for Diabetes, Endocrinology and Metabolism and NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS FT, Oxford, UK
| | - M B Whyte
- Department of Clinical & Experimental Medicine, University of Surrey, Guildford, UK
| | - A A Syed
- The School of Medicine and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
| | - A Paisley
- The School of Medicine and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
| | - J M Gibson
- The School of Medicine and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
| | - S G Anderson
- Glasgow-Caribbean Centre for Development Research and The George Alleyne Chronic Disease Research Centre, University of the West Indies, Bridgetown, Barbados
- Division of Cardiovascular Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - W Ollier
- Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK
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Heald AH, Stedman M, Daly C, Warner-Levy JJ, Livingston M, Hussain L, Anderson S. First episode psychosis and weight gain a longitudinal perspective in Cheshire UK: a comparison between individuals with nonaffective versus affective psychosis. Cardiovasc Endocrinol Metab 2023; 12:e0286. [PMID: 37361477 PMCID: PMC10289689 DOI: 10.1097/xce.0000000000000286] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/26/2023] [Indexed: 06/28/2023]
Abstract
Early weight gain following initiation of antipsychotic treatment predicts longer-term weight gain, with attendant long-term consequences including premature cardiovascular events/death. An important question is whether there is a difference in weight change over time between people with affective versus nonaffective psychosis. Here we describe the results of a real-world analysis of the BMI change in the months postdiagnosis with affective versus nonaffective psychosis. Methods We undertook an anonymised search across one Primary Care Network in Cheshire, UK with a total population of 32 301 individuals. We reviewed the health records of anyone who had been diagnosed over a 10-year period between June 2012 and June 2022 for the first time with first episode nonaffective psychosis versus psychosis associated with depression or bipolar affective disorder (affective psychosis). Results The overall % change in BMI was +8% in nonaffective psychosis individuals and +4% in those with a diagnosis of affective psychosis - however, the distribution was markedly skewed for nonaffective psychosis patients. Using caseness as >30% increase in BMI; affective = 4% cases and nonaffective = 13% cases, there was a three-fold difference in terms of increase in BMI. In regression analysis, the r2 linking the initial BMI to % change in BMI was 0.13 for nonaffective psychosis and 0.14 for affective psychosis. Conclusion The differences observed here in the distribution of weight change over time between individuals with affective versus nonaffective psychosis may relate to underlying constitutional differences. The phenotypic and genetic factors underlying this difference remain to be defined.
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Affiliation(s)
- Adrian H. Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, Manchester University
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford
| | | | - Chris Daly
- Greater Manchester Mental Health, Prestwich Hospital, Greater Manchester
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Holland D, Heald AH, Hanna FFW, Stedman M, Wu P, Sim J, Duff CJ, Duce H, Green L, Scargill J, Howe JD, Robinson S, Halsall I, Gaskell N, Davison A, Simms M, Denny A, Langan M, Fryer AA. The Effect of the COVID-19 Pandemic on HbA1c Testing: Prioritization of High-Risk Cases and Impact of Social Deprivation. Diabetes Ther 2023; 14:691-707. [PMID: 36814045 PMCID: PMC9946287 DOI: 10.1007/s13300-023-01380-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/07/2023] [Indexed: 02/24/2023] Open
Abstract
INTRODUCTION Studies show that the COVID-19 pandemic disproportionately affected people with diabetes and those from disadvantaged backgrounds. During the first 6 months of the UK lockdown, > 6.6 M glycated haemoglobin (HbA1c) tests were missed. We now report variability in the recovery of HbA1c testing, and its association with diabetes control and demographic characteristics. METHODS In a service evaluation, we examined HbA1c testing across ten UK sites (representing 9.9% of England's population) from January 2019 to December 2021. We compared monthly requests from April 2020 to those in the equivalent 2019 months. We examined effects of (i) HbA1c level, (ii) between-practice variability, and (iii) practice demographics. RESULTS In April 2020, monthly requests dropped to 7.9-18.1% of 2019 volumes. By July 2020, testing had recovered to 61.7-86.9% of 2019 levels. During April-June 2020, we observed a 5.1-fold variation in the reduction of HbA1c testing between general practices (12.4-63.8% of 2019 levels). There was evidence of limited prioritization of testing for patients with HbA1c > 86 mmol/mol during April-June 2020 (4.6% of total tests vs. 2.6% during 2019). Testing in areas with the highest social disadvantage was lower during the first lockdown (April-June 2020; trend test p < 0.001) and two subsequent periods (July-September and October-December 2020; both p < 0.001). By February 2021, testing in the highest deprivation group had a cumulative fall in testing of 34.9% of 2019 levels versus 24.6% in those in the lowest group. CONCLUSION Our findings highlight that the pandemic response had a major impact on diabetes monitoring and screening. Despite limited test prioritization in the > 86 mmol/mol group, this failed to acknowledge that those in the 59-86 mmol/mol group require consistent monitoring to achieve the best outcomes. Our findings provide additional evidence that those from poorer backgrounds were disproportionately disadvantaged. Healthcare services should redress this health inequality.
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Affiliation(s)
| | - Adrian H Heald
- Department of Diabetes and Endocrinology, Salford Royal Hospital, The Northern Care Alliance NHS Foundation Trust, Salford, UK
- The School of Medicine and Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
| | - Fahmy F W Hanna
- Department of Diabetes and Endocrinology, University Hospitals of North Midlands NHS Trust, Stoke-On-Trent, Staffordshire, UK
- Centre for Health & Development, Staffordshire University, Staffordshire, UK
| | | | - Pensée Wu
- Department of Obstetrics & Gynaecology, University Hospitals of North Midlands NHS Trust, Stoke-On-Trent, Staffordshire, UK
- School of Medicine, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Julius Sim
- School of Medicine, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Christopher J Duff
- School of Medicine, Keele University, Keele, Staffordshire, ST5 5BG, UK
- Department of Clinical Biochemistry, North Midlands and Cheshire Pathology Services, University Hospitals of North Midlands NHS Trust, Stoke-On-Trent, Staffordshire, UK
| | - Helen Duce
- Department of Clinical Biochemistry, North Midlands and Cheshire Pathology Services, University Hospitals of North Midlands NHS Trust, Stoke-On-Trent, Staffordshire, UK
| | - Lewis Green
- Department of Clinical Biochemistry, St. Helens & Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, UK
| | - Jonathan Scargill
- Department of Clinical Biochemistry, The Royal Oldham Hospital, The Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - Jonathon D Howe
- Department of Clinical Biochemistry, Salford Royal Hospital, The Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - Sarah Robinson
- Department of Clinical Biochemistry, North Midlands and Cheshire Pathology Services, University Hospitals of North Midlands NHS Trust, Stoke-On-Trent, Staffordshire, UK
| | - Ian Halsall
- Department of Clinical Biochemistry, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Neil Gaskell
- Department of Pathology, Warrington & Halton Teaching Hospitals NHS Foundation Trust, Warrington, UK
| | - Andrew Davison
- Department of Clinical Biochemistry & Metabolic Medicine, Liverpool Clinical Laboratories, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Mark Simms
- Department of Clinical Biochemistry, Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, Wirral, UK
| | - Angela Denny
- Department of Clinical Biochemistry, Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, Wirral, UK
| | - Martin Langan
- Pathology Directorate, Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Anthony A Fryer
- School of Medicine, Keele University, Keele, Staffordshire, ST5 5BG, UK.
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10
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Holland D, Heald AH, Stedman M, Hanna F, Wu P, Duff C, Green L, Robinson S, Halsall I, Gaskell N, Pemberton J, Bloor C, Fryer AA. Assessment of the effect of the COVID-19 pandemic on UK HbA1c testing: implications for diabetes management and diagnosis. J Clin Pathol 2023; 76:177-184. [PMID: 34645702 PMCID: PMC8520598 DOI: 10.1136/jclinpath-2021-207776] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/08/2021] [Indexed: 01/23/2023]
Abstract
AIMS The COVID-19 pandemic, and the focus on mitigating its effects, has disrupted diabetes healthcare services worldwide. We aimed to quantify the effect of the pandemic on diabetes diagnosis/management, using glycated haemoglobin (HbA1c) as surrogate, across six UK centres. METHODS Using routinely collected laboratory data, we estimated the number of missed HbA1c tests for 'diagnostic'/'screening'/'management' purposes during the COVID-19 impact period (CIP; 23 March 2020 to 30 September 2020). We examined potential impact in terms of: (1) diabetes control in people with diabetes and (2) detection of new diabetes and prediabetes cases. RESULTS In April 2020, HbA1c test numbers fell by ~80%. Overall, across six centres, 369 871 tests were missed during the 6.28 months of the CIP, equivalent to >6.6 million tests nationwide. We identified 79 131 missed 'monitoring' tests in people with diabetes. In those 28 564 people with suboptimal control, this delayed monitoring was associated with a 2-3 mmol/mol HbA1c increase. Overall, 149 455 'screening' and 141 285 'diagnostic' tests were also missed. Across the UK, our findings equate to 1.41 million missed/delayed diabetes monitoring tests (including 0.51 million in people with suboptimal control), 2.67 million screening tests in high-risk groups (0.48 million within the prediabetes range) and 2.52 million tests for diagnosis (0.21 million in the pre-diabetes range; ~70 000 in the diabetes range). CONCLUSIONS Our findings illustrate the widespread collateral impact of implementing measures to mitigate the impact of COVID-19 in people with, or being investigated for, diabetes. For people with diabetes, missed tests will result in further deterioration in diabetes control, especially in those whose HbA1c levels are already high.
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Affiliation(s)
| | - Adrian H Heald
- Department of Diabetes and Endocrinology, Salford Royal NHS Foundation Trust, Salford, UK
- The School of Medicine and Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
| | | | - Fahmy Hanna
- Department of Diabetes and Endocrinology, Univerisity Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
- Centre for Health and Development, Staffordshire University Faculty of Health Sciences, Stoke-on-Trent, UK
| | - Pensee Wu
- Academic Department of Obstetrics and Gynaecology, Univerisity Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
- School of Medicine, Keele University, Keele, UK
| | - Christopher Duff
- School of Medicine, Keele University, Keele, UK
- Department of Clinical Biochemistry, Univerisity Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Lewis Green
- Department of Clinical Biochemistry, St Helens and Knowsley Teaching Hospitals NHS Trust, Prescot, UK
| | - Sarah Robinson
- Department of Clinical Biochemistry, Univerisity Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Ian Halsall
- Department of Clinical Biochemistry, Addenbrooke's Hospital, Cambridge, UK
| | - Neil Gaskell
- Department of Pathology, Warrington & Halton Teaching Hospitals NHS Foundation Trust, Warrington, UK
| | | | | | - Anthony A Fryer
- School of Medicine, Keele University, Keele, UK
- Department of Clinical Biochemistry, Univerisity Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
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Blong J, Sharpe A, Cairney-Hill J, Gorman A, Allen M, Haycocks S, Stedman M, Robinson A, Heald AH, Gee E. Saving the foot: Simple orthopaedic surgical intervention demonstrates improved outcomes and reduced costs. Foot Ankle Surg 2023; 29:218-222. [PMID: 36646595 DOI: 10.1016/j.fas.2023.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 12/08/2022] [Accepted: 01/08/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND Forefoot ulceration in diabetes requires significant resources, with high cost and low rates of success. The authors present the results of tendon procedures (percutaneous toe tenotomy and percutaneous tendo-achilles lengthening) under local anaesthetic to adjust mechanics in patients with diabetic neuropathic forefoot ulceration. METHODS Retrospective review of electronic patient record of 19 patients (22 feet) undergoing local anaesthetic tendon procedures between April 2019 and April 2021 with a 12 month follow up period. Size of ulcer, rate of ulcer healing, complication rates and ulcer recurrence were recorded and compared to a population of conservatively-managed patients (14 patients, 15 feet) treated prior to the introduction of tendon procedures. All clinical information obtained from electronic patient records. RESULTS All patients undergoing tendon procedures achieved complete ulcer healing at a mean time of 3.3 weeks for toe tip ulcers (after toe tenotomy) and 4.5 weeks for metatarsal head ulcers (after Achilles lengthening). There were no admissions for diabetic foot sepsis, reduced recurrence, reduced amputation rates and no mortality. Of the conservatively managed cohort, only 3 of the 15 achieved ulcer resolution without recurrence within the 12 month study period. The cohort managed conservatively had an average cost of £ 9902 per patient, per annum. The intervention cost was £ 1211 per patient, saving an average of £ 8691 per patient, per annum with ulcer resolution (88 % reduction in costs). CONCLUSION Significant patient benefit, reduction in resource use and cost saving was seen with this simple intervention, which merits full evaluation in a clinical trial. LEVEL OF EVIDENCE Level-IV.
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Affiliation(s)
- Jessica Blong
- Department of Trauma and Orthopaedic Surgery, Salford Royal Hospital, Stott Ln, Salford M6 8HD, UK.
| | - Andrew Sharpe
- Department of Podiatry, Salford Royal Hospital, Stott Ln, Salford M6 8HD, UK.
| | - Jess Cairney-Hill
- Department of Trauma and Orthopaedic Surgery, Salford Royal Hospital, Stott Ln, Salford M6 8HD, UK.
| | - Andy Gorman
- Department of Podiatry, Salford Royal Hospital, Stott Ln, Salford M6 8HD, UK.
| | - Matthew Allen
- Department of Podiatry, Salford Royal Hospital, Stott Ln, Salford M6 8HD, UK.
| | - Samantha Haycocks
- Department of Podiatry, Salford Royal Hospital, Stott Ln, Salford M6 8HD, UK.
| | - Mike Stedman
- Res Consortium, Fosse House, East Anton Court, Icknield Way, Andover SP10 5RG, UK.
| | - Adam Robinson
- Endocrine Medicine, Salford Royal Hospital, Stott Ln, Salford M6 8HD, UK.
| | - Adrian H Heald
- Endocrine Medicine, Salford Royal Hospital, Stott Ln, Salford M6 8HD, UK.
| | - Edward Gee
- Department of Trauma and Orthopaedic Surgery, Salford Royal Hospital, Stott Ln, Salford M6 8HD, UK.
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12
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Stedman M, Heald A, Robinson A, Davies M, Harnett P. Associations and mitigations: an analysis of the changing risk factor landscape for chronic kidney disease in primary care using national general practice level data. BMJ Open 2022; 12:e064723. [PMID: 36549719 PMCID: PMC9791436 DOI: 10.1136/bmjopen-2022-064723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Early recognition of chronic kidney disease (CKD) should be achieved by every modern healthcare system. The objective of this study was to investigate CKD risk factor trends in England using general practice level data. DESIGN Observational analysis of data at practice level for all general practices in England. Practice characteristics identified as potential CKD risk factors included comorbidities and local demography. Data were analysed using both univariate and multivariate analysis to identify significant factors that were associated with CKD diagnosis for the period 1 April 2019 to 31 March 2020. SETTING Publicly available data from UK primary care sources including Primary Care Quality and Outcomes Framework database, practice-level prescribing data from the British National Formulary and Public Health England health outcome data. PARTICIPANTS All data submitted from 6471 medium to large practices in England were included (over 46 million patients). RISK FACTOR ANALYSIS Potential risk factors were grouped into four classes based on existing literature: demographic factors, comorbidities, service and practice outcome factors, and prescribing data effects. RESULTS The original model's prediction of CKD improved from r2 0.38 to an r2 of 0.66 when updated factors were included. Positive associations included known risk factors with higher relative risk such as hypertension and diabetes, along with less recognised factors such as depression and use of opiates. Negative associations included NSAIDs which are traditionally associated with increased CKD risk, and prescribing of antibiotics, along with more northerly locations. CONCLUSIONS CKD is a preventable disease with high costs and consequences. These data and novel analysis give clearer relative risk values for different patient characteristics with some unexpected findings such as potential harmful association between CKD and opiates, and a more benign association with NSAIDs. A deeper understanding of CKD risk factors is important to update and implement local and national management strategies. Further research is required to establish the causal nature of these associations and to refine location appropriate actions to minimise harm from CKD on regional and local levels.
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Affiliation(s)
| | - Adrian Heald
- University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
| | | | | | - Patrick Harnett
- Department of Renal Medicine, Princess Elizabeth Hospital, Saint Andrews, Guernsey
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13
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Waheed U, Heald AH, Stedman M, Solomon E, Rea R, Eltom S, Gibson JM, Grady K, Nouwen A, Rayman G, Paisley A. Distress and Living with Diabetes: Defining Characteristics Through an Online Survey. Diabetes Ther 2022; 13:1585-1597. [PMID: 35831740 PMCID: PMC9281294 DOI: 10.1007/s13300-022-01291-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 06/15/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION There is considerable evidence for diabetes reducing quality of life. The impact of such a diagnosis on mental health is less well understood and was subsequently explored here. METHODS Online PHQ-9 scores (which calculate the severity of depression), Diabetes Distress Screening Scale (DDSS) and EQ-5D-5L (quality-of-life) questionnaires were completed by patients with diabetes, followed by the extraction of data where possible from responders' clinical records. RESULTS A total of 133 people submitted questionnaires. However, not all data items could be completed by each patient; 35% (45/130) had type I diabetes mellitus (T1DM); 55% (64/117) were women. The overall median age of 117 responders was 60 (IQR 50-68 years). The median aggregated response scores were: EQ-5D-5L 0.74 (IQR 0.64-0.85) (lower quality of life than UK population median of 0.83), DDSS 1.9 (IQR1.3-2.7) (≥ 2 indicates moderate distress) and PHQ-9 5 (IQR2-11) (≥ 5 indicates depression). Higher diabetes distress (DDSS)/lower quality of life EQ-5D-5L/higher depressive symptoms (PHQ-9) linked to female sex (DDSS 0.5/25% above median), younger age (< 50 years DDSS 0.7/35% above median), fewer years after diagnosis (< 10 years DDSS 0.8/40% above median), and obesity (BMI > 35 DDSS 0.6/30% above median). Additionally, a HbA1c reading of ≤ 48 mmol/mol was associated with higher DDSS scores, as did a reduction of more than 5 mmol/mol in HbA1c over the last three HbA1c measurements. The 30 individuals with a history of prescribed antidepressant medication also showed higher diabetes distress scores (DDSS 0.9, equating to 45% above the median). The DDSS score elevation came from an increase in emotional burden and regimen-related distress. DDSS scores were not significantly linked to diabetes type, insulin use, absolute level/change in blood glucose HbA1c. Physician-related distress showed a similar pattern. CONCLUSIONS A low level of stress in relation to diabetes management may be associated with lower HbA1c. The larger impact of diabetes on mental health in younger women/people with shorter diabetes duration should be noted when considering psychosocial intervention/behavior change messaging. Physician-related distress is a potentially remediable factor. However, this sample was self-selecting, limiting generalization to other samples.
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Affiliation(s)
- Unaiza Waheed
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, M6 8HD, UK
| | - Adrian H Heald
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, M6 8HD, UK.
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK.
| | | | - Emma Solomon
- Department of Clinical Psychology, Salford Royal Hospital, Salford, UK
| | - Rustam Rea
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, UK
| | - Saydah Eltom
- Pharmacy Department, Salford Royal Hospital, Salford, UK
| | - J Martin Gibson
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, M6 8HD, UK
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Katherine Grady
- Research for the Future, Northern Care Alliance NHS Group, Salford, UK
| | - Arie Nouwen
- Department of Psychology, Middlesex University, London, UK
| | - Gerry Rayman
- The Ipswich Diabetes Centre and Research Unit, Ipswich Hospital NHS Trust, Colchester, Essex, UK
| | - Angela Paisley
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, M6 8HD, UK
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
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14
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H. Heald A, Perrin R, Walther A, Stedman M, Hann M, Mukherjee A, Riste L. Reducing fatigue-related symptoms in Long COVID-19: a preliminary report of a lymphatic drainage intervention. Cardiovasc Endocrinol Metab 2022; 11:e0261. [PMID: 35441129 PMCID: PMC9010124 DOI: 10.1097/xce.0000000000000261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 02/21/2022] [Indexed: 11/26/2022]
Abstract
In the early days of the first global wave of the COVID-19 pandemic, the potential for a postviral syndrome to manifest following COVID-19 infection was first recognized. Here, we present an analysis of a case series of the first 20 patients' data collected in clinical practice to evaluate the potential of a possible alternative treatment for Long COVID. Methods Face-to-face treatment sessions with Perrin technique practitioners occurred weekly involving effleurage/other manual articulatory techniques. The individuals being treated also undertook daily self-massage along with gentle mobility exercises. Patients recorded symptom severity using the self-report 54-item profile of fatigue-related states (PFRS) before and after treatment. Results The mean age of male patients was 41.8 years (range, 29-53 years), and for female patients, 39.3 years (range, 28-50 years). None of the participants had a prior diagnosis of chronic fatigue syndrome, and all were new attendees to the clinics at the time of initial assessment. The average number of treatment sessions was 9.7 in men and 9.4 in women. The reduction in PFRS scores was 45% in men and 52% in women. The highest subscale scores on average were for fatigue, with the lowest for somatic symptoms. All subscale scores showed, on average, a similar reduction of approximately 50% postintervention, with the reduction in score relating to a decrease in the severity of symptoms. Conclusion Our findings suggest that a specific manual lymphatic drainage intervention may help to reduce fatigue symptoms related to Long COVID. Perhaps preventing acute symptoms through early intervention.
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Affiliation(s)
- Adrian H. Heald
- The School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford, UK
| | - Raymond Perrin
- The School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester
| | | | | | - Mark Hann
- The School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester
- Manchester Academic Health Sciences Centre, University of Manchester
| | - Annice Mukherjee
- The School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester
| | - Lisa Riste
- The School of Health Sciences, Faculty of Biology Medicine and Health, The University of Manchester, Manchester
- Manchester Academic Health Sciences Centre, University of Manchester
- Greater Manchester NIHR Patient Safety Translational Research Centre, The University of Manchester, Manchester, UK
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15
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Stedman M, Rea R, Duff CJ, Livingston M, McLoughlin K, Wong L, Brown S, Grady K, Gadsby R, Gibson JM, Paisley A, Fryer AA, Heald AH. The experience of blood glucose monitoring in people with type 2 diabetes mellitus (T2DM). Endocrinol Diabetes Metab 2022; 5:e00302. [PMID: 34921531 PMCID: PMC8917860 DOI: 10.1002/edm2.302] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/08/2021] [Accepted: 09/10/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Finger prick blood glucose (BG) monitoring remains a mainstay of management in people with type 2 diabetes (T2DM) who take sulphonylurea (SU) drugs or insulin. We recently examined patient experience of BG monitoring in people with type 1 diabetes (T1DM). There has not been any recent comprehensive assessment of the performance of BG monitoring strips or the patient experience of BG strips in people with T2DM in the UK. METHODS An online self-reported questionnaire containing 44 questions, prepared following consultation with clinicians and patients, was circulated to people with T2DM. 186 responders provided completed responses (25.5% return rate). Fixed responses were coded numerically (eg not confident = 0 fairly confident = 1). RESULTS Of responders, 84% were treated with insulin in addition to other agents. 75% reported having had an HbA1c check in the previous 6 months. For those with reported HbA1c ≥ 65 mmol/mol, a majority of people (70%) were concerned or really concerned about the shorter term consequences of running a high HbA1c This contrasted with those who did not know their recent HbA1c, of whom only 33% were concerned/really concerned and those with HbA1c <65 mmol/mol of whom 35% were concerned. Regarding BG monitoring/insulin adjustment, only 25% of responders reported having sufficient information with 13% believing that the accuracy and precision of their BG metre was being independently checked. Only 9% recalled discussing BG metre accuracy when their latest metre was provided and only 7% were aware of the International Standardisation Organisation (ISO) standards for BG metres. 77% did not recall discussing BG metre performance with a healthcare professional. CONCLUSION The group surveyed comprised engaged people with T2DM but even within this group there was significant variation in (a) awareness of shorter term risks, (b) confidence in their ability to implement appropriate insulin dosage (c) awareness of the limitations of BG monitoring technology. There is clearly an area where changes in education/support would benefit many.
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Affiliation(s)
| | - Rustam Rea
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, UK
| | - Christopher J Duff
- Department of Clinical Biochemistry, North Midlands and Cheshire Pathology Service, University Hospitals of North Midlands NHS Trust, Stoke on Trent, UK.,School of Medicine, Keele University, Keele, UK
| | - Mark Livingston
- Black Country Pathology Services, Walsall Manor Hospital, Walsall, UK
| | | | | | | | | | - Roger Gadsby
- Warwick Medical School, University of Warwick, West Midlands, UK
| | - John M Gibson
- Salford Royal Hospital, Salford, UK.,The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | | | - Anthony A Fryer
- Department of Clinical Biochemistry, North Midlands and Cheshire Pathology Service, University Hospitals of North Midlands NHS Trust, Stoke on Trent, UK.,School of Medicine, Keele University, Keele, UK
| | - Adrian H Heald
- Salford Royal Hospital, Salford, UK.,The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
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16
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Heald A, Stedman M, Robinson A, Davies M, Livingston M, Alshames R, Moreno G, Gadsby R, Rayman G, Gibson M, de Lusignan S, Whyte M. Mortality Rate Associated with Diabetes: Outcomes From a General Practice Level Analysis in England Using the Royal College of General Practitioners (RCGP) Database Indicate Stability Over a 15 Year Period. Diabetes Ther 2022; 13:505-516. [PMID: 35187627 PMCID: PMC8934837 DOI: 10.1007/s13300-022-01215-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 01/28/2022] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Total population mortality rates have been falling and life expectancy increasing for more than 30 years. Diabetes remains a significant risk factor for premature death. Here we used the Oxford Royal College of General Practitioners Research and Surveillance Centre (RCGP RSC) practices to determine diabetes-related vs non-diabetes-related mortality rates. METHODS RCGP RSC data were provided on annual patient numbers and deaths, at practice level, for those with and without diabetes across four age groups (< 50, 50-64, 65-79, ≥ 80 years) over 15 years. Investment in diabetes control, as measured by the cost of primary care medication, was also taken from GP prescribing data. RESULTS We included 527 general practices. Over the period 2004-2019, there was no significant change in life years lost, which varied between 4.6 and 5.1 years over this period. The proportion of all diabetes deaths by age band was significantly higher in the 65-79 years age group for men and women with diabetes than for their non-diabetic counterparts. For the year 2019, 26.6% of deaths were of people with diabetes. Of this 26.6%, 18.5% would be expected from age group and non-diabetes status, while the other 8.1% would not have been expected-pro rata to nation, this approximates to approximately 40,000 excess deaths in people with diabetes vs the general population. CONCLUSION There remains a wide variation in mortality rate of people with diabetes between general practices in UK. The mortality rate and life years lost for people with diabetes vs non-diabetes individuals have remained stable in recent years, while mortality rates for the general population have fallen. Investment in diabetes management at a local and national level is enabling us to hold the ground regarding the life-shortening consequences of having diabetes as increasing numbers of people develop T2DM at a younger age.
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Affiliation(s)
- Adrian Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, Manchester University, Manchester, UK.
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford, M6 8HD, UK.
| | | | - Adam Robinson
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford, M6 8HD, UK
| | | | - Mark Livingston
- Black Country Pathology Services, Walsall Manor Hospital, Walsall, UK
| | - Ramadan Alshames
- Biochemistry Department, Faculty of Dentistry, Tripoli University, Tripoli, Libya, UK
| | - Gabriela Moreno
- , Marina Nacional 162, Anáhuac Secc, Miguel Hidalgo, 11320, Mexico City, Mexico
| | - Roger Gadsby
- Warwick Medical School, University of Warwick, Warwick, UK
| | - Gerry Rayman
- The Ipswich Diabetes Centre and Research Unit, Ipswich Hospital NHS Trust, Colchester, Essex, UK
| | - Martin Gibson
- The School of Medicine and Manchester Academic Health Sciences Centre, Manchester University, Manchester, UK
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford, M6 8HD, UK
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Martin Whyte
- Clinical and Experimental Medicine, University of Surrey, Guildford, UK
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17
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Heald AH, Premawardhana L, Taylor P, Okosieme O, Bangi T, Devine H, Livingston M, Javed A, Moreno GYC, Watt T, Stedman M, Dayan C, Hughes DA. Is there a role for natural desiccated thyroid in the treatment of levothyroxine unresponsive hypothyroidism? Results from a consecutive case series. Int J Clin Pract 2021; 75:e14967. [PMID: 34626513 DOI: 10.1111/ijcp.14967] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/19/2021] [Accepted: 10/06/2021] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Some levothyroxine unresponsive individuals with hypothyroidism are prescribed a natural desiccated thyroid (NDT) preparation such as Armour Thyroid® or ERFA Thyroid® . These contain a mixture of levothyroxine and liothyronine in a fixed ratio. We evaluated the response to NDT in individuals at a single endocrine centre in terms of how the change from levothyroxine to NDT impacted on their lives in relation to quality of life (QOL) and thyroid symptoms. METHODS The ThyPRO39 (thyroid symptomatology) and EQ-5D-5L-related QoL/EQ5D5L (generic QOL) questionnaires were administered to 31 consecutive patients who had been initiated on NDT, before initiating treatment/6 months later. RESULTS There were 28 women and 3 men. The dose range of NDT was 60-180 mg daily. Age range was 26-77 years with length of time since diagnosis with hypothyroidism ranging from 2 to 40 years. One person discontinued the NDT because of lack of response; two because of cardiac symptoms. EQ-5D-5L utility increased from a mean (SD) of 0.214 (0.338) at baseline, to 0.606 (0.248) after 6 months; corresponding to a difference of 0.392 (95% CI 0.241-0.542), t = 6.82, P < .001. EQ-VAS scores increased from 33.4 (17.2) to 71.1 (17.5), a difference of 37.7 (95% CI 25.2-50.2), t = -4.9, P < .001. ThyPRO scores showed consistent fall across all domains with the composite QoL-impact Score improving from 68.3 (95% CI 60.9-75.7) to 25.2 (95% CI 18.7-31.7), a difference of 43.1 (95% CI 33-53.2) (t = 5.6, P < .001). CONCLUSION Significant symptomatic benefit and improvement in QOL was experienced by people with a history of levothyroxine unresponsive hypothyroidism treated with NDT, suggesting the need for further evaluation of NDT in this context.
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Affiliation(s)
- Adrian H Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford, UK
| | - Lakdasa Premawardhana
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Peter Taylor
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Onyebuchi Okosieme
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Tasneem Bangi
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford, UK
| | - Holly Devine
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford, UK
| | - Mark Livingston
- Department of Clinical Biochemistry, Black Country Pathology Services, Walsall Manor Hospital, Walsall, UK
| | - Ahmed Javed
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford, UK
| | - Gabriela Y C Moreno
- Coordinación Nacional de Investigación, Subdirección de Servicios de Salud, Petróleos Mexicanos, Ciudad de México, México
| | - Torquil Watt
- Department of Internal Medicine, Copenhagen University Hospital Herlev-Gentofte, Copenhagen, Denmark
| | | | - Colin Dayan
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Dyfrig A Hughes
- Centre for Health Economics & Medicines Evaluation, Bangor University, Bangor, UK
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Heald AH, Rea R, Horne L, Metters A, Steele T, Leivesley K, Whyte MB, Stedman M, Ollier W. Analysis of continuous glucose tracking data in people with type 1 diabetes after COVID-19 vaccination reveals unexpected link between immune and metabolic response, augmented by adjunctive oral medication. Int J Clin Pract 2021; 75:e14714. [PMID: 34375490 PMCID: PMC8420568 DOI: 10.1111/ijcp.14714] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/17/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION The COVID-19 vaccination programme is under way worldwide. Anecdotal evidence is increasing that some people with type 1 diabetes mellitus (T1DM) experience temporary instability of blood glucose (BG) levels post-vaccination which normally settles within 2-3 days. We report an analysis of BG profiles of 20 individuals before/after vaccination. METHODS We examined the BG profile of 20 consecutive adults (18 years of age or more) with T1DM using the FreeStyle Libre flash glucose monitor in the period immediately before and after COVID-19 vaccination. The primary outcome measure was percentage (%) BG readings in the designated target range 3.9-10 mmmol/L as reported on the LibreView portal for 7 days prior to the vaccination (week -1) and the 7 days after the vaccination (week +1). RESULTS There was a significant decrease in the %BG on target following the COVID-vaccination for the 7 days following vaccination (mean 45.2% ± SE 4.2%) vs pre-COVID-19 vaccination (mean 52.6% ± SE 4.5%). This was mirrored by an increase in the proportion of readings in other BG categories 10.1%-13.9%/≥14%. There was no significant change in BG variability in the 7days post-COVID-19 vaccination. This change in BG proportion on target in the week following vaccination was most pronounced for people taking Metformin/Dapagliflozin+basal-bolus insulin (-23%) vs no oral hypoglycaemic agents (-4%), and median age <53 vs ≥53 years (greater reduction in %BG in target for older individuals (-18% vs -9%)). CONCLUSION In T1DM, we have shown that COVID-19 vaccination can cause temporary perturbation of BG, with this effect more pronounced in patients talking oral hypoglycaemic medication plus insulin, and in older individuals. This may also have consequences for patients with T2DM who are currently not supported by flash glucose monitoring.
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Affiliation(s)
- Adrian H. Heald
- The School of Medicine and Manchester Academic Health Sciences CentreUniversity of ManchesterManchesterUK
- Department of Diabetes and EndocrinologySalford Royal HospitalSalfordUK
| | - Rustam Rea
- Oxford Centre for Diabetes, Endocrinology and Metabolism and NIHR Oxford Biomedical Research CentreOxford University Hospitals NHS FTOxfordUK
| | - Linda Horne
- Vernova HealthcareWatersgreen Medical CentreMacclesfieldUK
| | - Ann Metters
- Vernova HealthcareWatersgreen Medical CentreMacclesfieldUK
| | - Tom Steele
- Vernova HealthcareWatersgreen Medical CentreMacclesfieldUK
| | | | | | | | - William Ollier
- Faculty of Science and EngineeringManchester Metropolitan UniversityManchesterUK
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19
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Heald AH, Chang K, Jia T, Sun H, Zheng Q, Wang X, Xia J, Stedman M, Fachim H, Gibson M, Zhou X, Anderson SG, Peng Y, Ollier W. Longitudinal clinical trajectory analysis of individuals before and after diagnosis of Type 2 Diabetes Mellitus (T2DM) indicates that vascular problems start early. Int J Clin Pract 2021; 75:e14695. [PMID: 34338416 DOI: 10.1111/ijcp.14695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 07/30/2021] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Type 2 diabetes mellitus (T2DM) frequently associates with increasing multi-morbidity/treatment complexity. Some headway has been made to identify genetic and non-genetic risk factors for T2DM. However, longitudinal clinical histories of individuals both before and after diagnosis of T2DM are likely to provide additional insight into both diabetes aetiology/further complex trajectory of multi-morbidity. METHODS This study utilised diabetes patients/controls enrolled in the DARE (Diabetes Alliance for Research in England) study where pre- and post-T2DM diagnosis longitudinal data was available for trajectory analysis. Longitudinal data of 281 individuals (T2DM n = 237 vs matched non-T2DM controls n = 44) were extracted, checked for errors and logical inconsistencies and then subjected to Trajectory Analysis over a period of up to 70 years based on calculations of the proportions of most prominent clinical conditions for each year. RESULTS For individuals who eventually had a diagnosis of T2DM made, a number of clinical phenotypes were seen to increase consistently in the years leading up to diagnosis of T2DM. Of these documented phenotypes, the most striking were diagnosed hypertension (more than in the control group) and asthma. This trajectory over time was much less dramatic in the matched control group. Immediately prior to T2DM diagnosis, a greater indication of ischaemic heart disease proportions was observed. Post-T2DM diagnosis, the proportions of T2DM patients exhibiting hypertension and infection continued to climb rapidly before plateauing. Ischaemic heart disease continued to increase in this group as well as retinopathy, impaired renal function and heart failure. CONCLUSION These observations provide an intriguing and novel insight into the onset and natural progression of T2DM. They suggest an early phase of potentially related disease activity well before any clinical diagnosis of diabetes is made. Further studies on a larger cohort of DARE patients are underway to explore the utility of establishing predictive risk scores.
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Affiliation(s)
- Adrian H Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal NHS Foundation Trust, Salford, UK
| | - Kai Chang
- School of Computer and Information Technology, Beijing Jiaotong University, Beijing, China
| | - Ting Jia
- School of Computer and Information Technology, Beijing Jiaotong University, Beijing, China
| | - Hailong Sun
- School of Computer and Information Technology, Beijing Jiaotong University, Beijing, China
| | - Qiguang Zheng
- School of Computer and Information Technology, Beijing Jiaotong University, Beijing, China
| | - Xinyan Wang
- School of Computer and Information Technology, Beijing Jiaotong University, Beijing, China
| | - Jianan Xia
- School of Computer and Information Technology, Beijing Jiaotong University, Beijing, China
| | | | - Helene Fachim
- The School of Medicine and Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal NHS Foundation Trust, Salford, UK
| | - Martin Gibson
- The School of Medicine and Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal NHS Foundation Trust, Salford, UK
| | - Xuezhong Zhou
- School of Computer and Information Technology, Beijing Jiaotong University, Beijing, China
| | - Simon G Anderson
- The George Alleyne Chronic Disease Research Centre, Caribbean Institute of Health Research, The University of the West Indies, Cave Hill Campus, Bridgetown, Barbados
- Division of Cardiovascular Sciences, Faculty of Biology Medicine and Health, University of Manchester, Manchester, UK
| | - Yonghong Peng
- Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK
| | - William Ollier
- Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK
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20
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Heald AH, Stedman M, Horne L, Rea R, Whyte M, Gibson JM, Livingston M, Anderson SG, Ollier W. Analysis of Continuous Blood Glucose Data in People with Type 1 Diabetes (T1DM) After COVID-19 Vaccination Indicates a Possible Link Between the Immune and the Metabolic Response. J Diabetes Sci Technol 2021; 15:1204-1205. [PMID: 34323111 PMCID: PMC8411469 DOI: 10.1177/19322968211026291] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Adrian H. Heald
- The School of Medicine and Manchester
Academic Health Sciences Centre, University of Manchester, UK
- Department of Diabetes and Endocrinology,
Salford Royal Hospital, Salford, UK
- Adrian H. Heald, DM, Department of Diabetes and
Endocrinology, Salford Royal Hospital, Stott Lane, Salford M6 8HD, UK.
| | | | - Linda Horne
- Vernova Healthcare, Watersgreen Medical
Centre, Macclesfield, UK
| | - Rustam Rea
- Oxford Centre for Diabetes, Endocrinology and
Metabolism and NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS FT,
Oxford, UK
| | - Martin Whyte
- Department of Clinical & Experimental
Medicine, University of Surrey, Guildford, UK
| | - J. Martin Gibson
- The School of Medicine and Manchester
Academic Health Sciences Centre, University of Manchester, UK
- Department of Diabetes and Endocrinology,
Salford Royal Hospital, Salford, UK
| | - Mark Livingston
- Department of Clinical Biochemistry, Black
Country Pathology Services, Walsall Manor Hospital, Walsall, UK
| | - Simon G. Anderson
- University of the West Indies, Cavehill
Campus, Barbados, Saint Michael Barbados
- Division of Cardiovascular Sciences, Faculty
of Biology Medicine and Health, University of Manchester, UK
| | - William Ollier
- Faculty of Science and Engineering,
Manchester Metropolitan University, Manchester, UK
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21
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Stedman M, Taylor P, Premawardhana L, Okosieme O, Dayan C, Heald AH. Liothyronine and levothyroxine prescribing in England: A comprehensive survey and evaluation. Int J Clin Pract 2021; 75:e14228. [PMID: 33864324 PMCID: PMC9285455 DOI: 10.1111/ijcp.14228] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/28/2021] [Accepted: 04/12/2021] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION The approach to thyroid hormone replacement varies across centres, but the extent and determinants of variation is unclear. We evaluated geographical variation in levothyroxine (LT4) and liothyronine (LT3) prescribing across General Practices in England and analysed the relationship of prescribing patterns to clinical and socioeconomic factors. METHODS Data was downloaded from the NHS monthly General Practice Prescribing Data in England for the period 2011-2020. RESULTS The study covered a population of 19.4 million women over 30 years of age, attending 6,660 GP practices and being provided with 33.7 million prescriptions of LT4 and LT3 at a total cost of £90million/year. Overall, 0.5% of levothyroxine treated patients continue to receive liothyronine. All Clinical Commission Groups (CCGs) in England continue to have at least one liothyronine prescribing practice and 48.5% of English general practices prescribed liothyronine in 2019-2020. Factors strongly influencing more levothyroxine prescribing (model accounted for 62% of variance) were the CCG to which the practice belonged and the proportion of people with diabetes registered on the practice list plus antidepressant prescribing, with socioeconomic disadvantage associated with less levothyroxine prescribing. Whereas factors that were associated with increased levels of liothyronine prescribing (model accounted for 17% of variance), were antidepressant prescribing and % of type 2 diabetes mellitus individuals achieving HbA1c control of 58 mmol/mol or less. Factors that were associated with reduced levels of liothyronine prescribing included smoking and higher obesity rates. CONCLUSION In spite of strenuous attempts to limit prescribing of liothyronine in general practice a significant number of patients continue to receive this therapy, although there is significant geographical variation in the prescribing of this as for levothyroxine, with specific general practice and CCG-related factors influencing prescribing of both levothyroxine and liothyronine across England.
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Affiliation(s)
| | - Peter Taylor
- Thyroid Research GroupSystems Immunity Research InstituteCardiff University School of MedicineCardiffUK
| | - Lakdasa Premawardhana
- Thyroid Research GroupSystems Immunity Research InstituteCardiff University School of MedicineCardiffUK
| | - Onyebuchi Okosieme
- Thyroid Research GroupSystems Immunity Research InstituteCardiff University School of MedicineCardiffUK
| | - Colin Dayan
- Thyroid Research GroupSystems Immunity Research InstituteCardiff University School of MedicineCardiffUK
| | - Adrian H. Heald
- The School of MedicineManchester Academic Health Sciences CentreUniversity of ManchesterManchesterUK
- Department of Endocrinology and DiabetesSalford Royal HospitalSalfordUK
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22
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Tian Z, Heald AH, Stedman M, Fachim H, Livingston M, Gibson M, Peng Y, Ollier W. Age of people with type 2 diabetes and the risk of dying following SARS-CoV-2 infection. Int J Clin Pract 2021; 75:e14053. [PMID: 34289646 PMCID: PMC8420526 DOI: 10.1111/ijcp.14053] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Zixing Tian
- The School of Medicine and Manchester Academic Health Sciences CentreThe University of ManchesterManchesterUK
| | - Adrian H. Heald
- The School of Medicine and Manchester Academic Health Sciences CentreThe University of ManchesterManchesterUK
- Department of Diabetes and EndocrinologySalford Royal NHS Foundation TrustSalfordUK
| | | | - Helene Fachim
- Department of Diabetes and EndocrinologySalford Royal NHS Foundation TrustSalfordUK
| | - Mark Livingston
- Black Country Pathology ServicesWalsall Manor HospitalWalsallUK
- School of Medicine and Clinical Practice at the University of WolverhamptonUK
| | - Martin Gibson
- The School of Medicine and Manchester Academic Health Sciences CentreThe University of ManchesterManchesterUK
- Department of Diabetes and EndocrinologySalford Royal NHS Foundation TrustSalfordUK
| | - Yonghong Peng
- Faculty of Science and EngineeringManchester Metropolitan UniversityManchesterUK
| | - William Ollier
- Faculty of Science and EngineeringManchester Metropolitan UniversityManchesterUK
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23
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Stedman M, Rea R, Livingston M, McLoughlin K, Wong L, Brown S, Grady K, Gadsby R, Paisley A, Heald A. People with Type 2 Diabetes Mellitus (T2DM) Self-Reported Views on Their Own Condition Management Reveal a High Level of Insight into the Challenges Faced. J Diabetes Sci Technol 2021; 15:972-973. [PMID: 33998847 PMCID: PMC8252150 DOI: 10.1177/19322968211009261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - Rustam Rea
- Oxford Centre for Diabetes, Endocrinology and Metabolism and NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS FT, Oxford
| | - Mark Livingston
- Department of Clinical Biochemistry, Black Country Pathology Services, Walsall Manor Hospital, Walsall
- School of Medicine and Clinical Practice, Faculty of Science & Engineering, The University of Wolverhampton
| | | | | | | | | | - Roger Gadsby
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Adrian Heald
- Salford Royal Hospital, Salford, UK
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, UK
- Adrian Heald, DM, Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, M6 8HD, UK.
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24
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Holland D, Heald AH, Stedman M, Green L, Scargill J, Duff CJ, Hanna FWF, Wu P, Halsall I, Gaskell N, Fryer AA. Impact of the UK COVID-19 pandemic on HbA1c testing and its implications for diabetes diagnosis and management. Int J Clin Pract 2021; 75:e13980. [PMID: 33752297 DOI: 10.1111/ijcp.13980] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
| | - Adrian H Heald
- Department of Diabetes and Endocrinology, Salford Royal NHS Foundation Trust, Salford, UK
- The School of Medicine and Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
| | | | - Lewis Green
- St. Helens & Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, UK
| | - Jonathan Scargill
- Department of Clinical Biochemistry, The Royal Oldham Hospital, The Northern Care Alliance NHS Group, Oldham, UK
| | - Christopher J Duff
- School of Medicine, Keele University, Keele, Staffordshire, UK
- Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
| | - Fahmy W F Hanna
- Department of Diabetes and Endocrinology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
- Centre for Health & Development, Staffordshire University, Stoke-on-Trent, Staffordshire, UK
| | - Pensee Wu
- School of Medicine, Keele University, Keele, Staffordshire, UK
- Department of Obstetrics & Gynaecology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
| | - Ian Halsall
- Department of Clinical Biochemistry, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Neil Gaskell
- Department of Pathology, Warrington & Halton Teaching Hospitals NHS Foundation Trust, Warrington, UK
| | - Anthony A Fryer
- School of Medicine, Keele University, Keele, Staffordshire, UK
- Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
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25
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Heald A, Stedman M, Farman S, Ruzhdi N, Davies M, Taylor D. Seasonal Variation in Antidepressant Prescribing: Year on Year Analysis for England. Prim Care Companion CNS Disord 2021; 23. [PMID: 34000164 DOI: 10.4088/pcc.20m02790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/30/2020] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE The number of prescriptions for antidepressants in England has almost doubled in the past decade. The objective of this study was to examine if this growth and seasonal variation in prescribing rates of different antidepressants by general practice are linked. METHOD The number of prescriptions and quantity of antidepressants prescribed each month between January 1, 2014, and December 31, 2019 from the general practice prescribing data reports for each British National Formulary code and practice were analyzed. The data were aggregated to obtain the monthly total and analyzed to identify patterns by medication. RESULTS : We included all oral antidepressant medications prescribed in England in 2019 for a total of 74 million prescriptions, which was equivalent to 2.36 billion defined daily doses. Monthly variation in daily prescribing percentage of the annual average over the year in total and antidepressant medications showed small but generally consistent seasonal variation, an average of up to 1.61% in total items and 1.47% in defined daily dose (highest prescribing in November/December). The seasonality varied by agents, with agents having highest seasonality also showing the most growth (r2 = 0.5, P = .002). This relation was strongest for mirtazapine and sertraline. There was a clear relation between average seasonality and year on year growth in antidepressant medication prescribing for 2016-2019 (r2 = .536, P = .002). CONCLUSIONS The study confirmed seasonal variation in antidepressant prescribing with a peak in November/December. Growth in the antidepressant prescribing year on year was related to seasonality and requires further scrutiny in terms of understanding the factors that underlie the seasonal variation seen.
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Affiliation(s)
- Adrian Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, Manchester University, Manchester, United Kingdom.,Corresponding author: Adrian Heald, DM, Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK M68HD
| | - Mike Stedman
- Res Consortium, Research, Andover, United Kingdom
| | - Sanam Farman
- Mersey Deanery Psychiatry Rotation, United Kingdom
| | - Nadia Ruzhdi
- Saint Petersburg State University, St Petersburg, Russia
| | - Mark Davies
- Res Consortium, Research, Andover, United Kingdom
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26
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Stedman M, Rea R, Duff CJ, Livingston M, Brown S, Grady K, McLoughlin K, Gadsby R, Paisley A, Fryer AA, Heald AH. Self-Reported Views on Managing Type 1 Diabetes Mellitus. J Diabetes Sci Technol 2021; 15:198-200. [PMID: 32627591 PMCID: PMC7783012 DOI: 10.1177/1932296820937771] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Rustam Rea
- Oxford Centre for Diabetes, Endocrinology and Metabolism and NIHR Oxford Biomedical Research Centre, UK
| | - Christopher J. Duff
- Department of Clinical Biochemistry, University Hospitals of North Midlands, Stoke-on-Trent, UK
- School of Primary, Community and Social Care, Keele University, UK
| | - Mark Livingston
- Black Country Pathology Services, Walsall Manor Hospital, UK
- Salford Royal Hospital, UK
| | | | | | | | - Roger Gadsby
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Anthony A. Fryer
- Department of Clinical Biochemistry, University Hospitals of North Midlands, Stoke-on-Trent, UK
- School of Primary, Community and Social Care, Keele University, UK
| | - Adrian H. Heald
- Salford Royal Hospital, UK
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, UK
- Adrian H. Heald, DM, Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford M6 8HD, UK.
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27
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Stedman M, Rea R, Duff CJ, Livingston M, McLoughlin K, Wong L, Brown S, Grady K, Gadsby R, Paisley A, Fryer AA, Heald AH. People with Type Diabetes Mellitus (T1DM) self-reported views on their own condition management reveal links to potentially improved outcomes and potential areas for service improvement. Diabetes Res Clin Pract 2020; 170:108479. [PMID: 33002551 DOI: 10.1016/j.diabres.2020.108479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 09/10/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The self-management of type 1 diabetes (T1DM) has moved forward in many areas over the last 40 years. Our study asked people with T1DM what is their experience of blood glucose (BG) monitoring day to day and how this influences decisions about insulin dosing. METHODS An on-line self-reported questionnaire containing 44 questions prepared after consultation with clinicians and patients was circulated to people with T1DM 116 responders provided completed responses. Fixed responses were allocated specific values (e.g. not confident = 0 fairly confident = 1). Multivariate regression analysis was carried out. Only those 5 factors with p-value <0.05 were retained. RESULTS 59% of respondents were >50 years old and 66% had diabetes for >20 years, with 63% of patients reporting HbA1c results ≤8% or 64 mmol/mol. Findings included; 75% used only 1 m; 56% had used the same meter for ≥3 years; 10% had tried flash monitors; 47% were concerned about current BG level; 85% were concerned about long-term impact of higher BG. 72% of respondents keep BG level high to avoid hypoglycaemia; 25% used ≥7 mmol/L as pre-meal BG target to calculate dose; 65% were concerned they might be over/under-dosing; 83% did not discuss accuracy when choosing meter. However 85% were confident in their meter's performance. The factors that linked to LOWER HbA1c included LESS units of basal insulin (p < 0.001), HIGHER number of daily BG tests (p = 0.008), LOWER bedtime blood glucose (p = 0.009), HIGHER patient's concern over long-term impact of high BG (BG) (p < 0.009 but LOWER patient's concern over current BG values (p = 0.009). The final statistical model could explain 41% of the observed variation in HbA1c. CONCLUSION Many people still run their BG high to avoid hypoglycaemia. Concern about the longer-term consequences of suboptimal glycaemic control was associated with a lower HbA1c and is an area to explore in the future when considering how to help people with T1DM.
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Affiliation(s)
- M Stedman
- Res Consortium, Andover, Hampshire, United Kingdom
| | - R Rea
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, United Kingdom
| | - C J Duff
- Department of Clinical Biochemistry, Royal Stoke Hospital, Stoke on Trent, United Kingdom; Institute for Science and Technology in Medicine, Keele University, United Kingdom
| | - M Livingston
- Black Country Pathology Services, Walsall Manor Hospital, Walsall, United Kingdom
| | | | - L Wong
- Salford Royal Hospital, Salford, United Kingdom
| | - S Brown
- Salford Royal Hospital, Salford, United Kingdom
| | - K Grady
- Salford Royal Hospital, Salford, United Kingdom
| | - R Gadsby
- Warwick Medical School, University of Warwick, United Kingdom
| | - A Paisley
- Salford Royal Hospital, Salford, United Kingdom
| | - A A Fryer
- Department of Clinical Biochemistry, Royal Stoke Hospital, Stoke on Trent, United Kingdom; Institute for Science and Technology in Medicine, Keele University, United Kingdom
| | - A H Heald
- Salford Royal Hospital, Salford, United Kingdom; The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, United Kingdom.
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28
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Heald AH, Stedman M, Farman S, Khine C, Davies M, De Hert M, Taylor D. Links between the amount of antipsychotic medication prescribed per population at general practice level, local demographic factors and medication selection. BMC Psychiatry 2020; 20:528. [PMID: 33160310 PMCID: PMC7648310 DOI: 10.1186/s12888-020-02915-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 10/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antipsychotic medications are the first-line pharmacological intervention for severe mental illnesses (SMI) such as schizophrenia and other psychoses, while also being used to relieve distress and treat neuropsychiatric symptoms in dementia. Our aim was to examine the factors relating to antipsychotic prescribing in general practices across England and how cost changes in recent years have impacted on antipsychotic prescribing. METHODS The study examined over time the prescribing volume and prices paid for antipsychotic medication by agent in primary care. Monthly prescribing in primary care was consolidated over 5 years (2013-2018) and DDD amount from WHO/ATC for each agent was used to convert the amount to total DDD/practice. The defined Daily Dose (DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults. RESULTS We included 5750 general practices with practice population > 3000 and with > 30 people on their SMI register. In 2018/19 there were 10,360,865 prescriptions containing 136 million DDD with costs of £110 million at an average cost of £0.81/DDD issued in primary care. In 2017/18 there was a sharp increase in overall prices and they had not reduced to expected levels by the end of the 2018/19 evaluation year. There was a gradual increase in antipsychotic prescribing over 2013-2019 which was not perturbed by the increase in drug price in 2017/18. The strongest positive relation to increased prescribing of antipsychotics came from higher social disadvantage, higher population density (urban), and comorbidities e.g. chronic obstructive pulmonary disease (COPD). Higher % younger and % older populations, northerliness and non-white (Black and Minority Ethnic(BAME)) ethnicity were all independently associated with less antipsychotic prescribing. Higher DDD/general practice population was linked with higher proportion(%) injectable, higher %liquid, higher doses/prescription and higher %zuclopenthixol depot. Less DDD/population was linked with general practices using higher % risperidone and higher spending/dose of antipsychotic. CONCLUSIONS The levels of antipsychotic prescribing at general practice level are driven by social factors/comorbidities. We found a link between depot prescriptions with higher antipsychotic DDD and risperidone prescriptions with lower antipsychotic DDD. It is important that all prescribers are aware of these drivers / links.
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Affiliation(s)
- A. H. Heald
- grid.5379.80000000121662407Manchester University, The School of Medicine and Manchester Academic Health Sciences Centre, Manchester, UK ,Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK ,University Psychiatric Center, Leuven, KU Belgium
| | | | - S. Farman
- grid.466705.60000 0004 0633 4554Mersey Deanery Psychiatry Rotation, Manchester, UK
| | - C. Khine
- grid.415352.40000 0004 1756 4726Department of Medicine, Kings Mill Hospital, Mansfield, UK
| | - M. Davies
- Res Consortium, Research, Andover, USA
| | - M. De Hert
- grid.13097.3c0000 0001 2322 6764Institute of Psychiatry, Pharmacy, London, UK
| | - D. Taylor
- grid.13097.3c0000 0001 2322 6764Institute of Psychiatry, Pharmacy, London, UK
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Stedman M, Davies M, Heald A. "Not Wars, Water pumps"-From emotive to rational language in managing the Covid-19 pandemic. Int J Clin Pract 2020; 74:e13580. [PMID: 32502319 PMCID: PMC7300749 DOI: 10.1111/ijcp.13580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
| | | | - Adrian Heald
- Department of Diabetes and EndocrinologySalfordUK
- The Faculty of Biology, Medicine and Health and Manchester Academic Health Sciences CentreUniversity of ManchesterManchesterUK
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Stedman M, Whyte MB, Lunt M, Albanese M, Livingston M, Gadsby R, Hackett G, Anderson SG, Heald AH. The treatment rate of erectile dysfunction (ED) in younger men with type 2 diabetes is up to four times higher than the equivalent non-diabetes population. Int J Clin Pract 2020; 74:e13538. [PMID: 32431020 DOI: 10.1111/ijcp.13538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/14/2020] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Erectile dysfunction (ED) is common in older age and in diabetes mellitus (DM). Phosphodiesterase type 5-inhibitors (PDE5-is) are the first-line for ED. We investigated how the type of diabetes and age of males affect the PDE5-i use in the primary care setting. METHODS From 2018 to 2019, the general practice level quantity of all PDE5-i agents was taken from the general practice (GP) Prescribing Dataset in England. The variation in outcomes across practices was examined across one year, and for the same practice against the previous year. RESULTS We included 5761 larger practices supporting 25.8 million men of whom 4.2 million ≥65 years old. Of these, 1.4 million had T2DM, with 0.8 million of these >65. About 137 000 people had T1DM. About 28.8 million tablets of PDE5-i were prescribed within the 12 months (2018-2019) period in 3.7 million prescriptions (7.7 tablets/prescription), at total costs of £15.8 million (£0.55/tablet). The NHS ED limit of one tablet/user/wk suggests that 540 000 males are being prescribed a PDE5-i at a cost of £29/y each. With approximately 30 000 GPs practising, this is equivalent to one GP providing 2.5 prescriptions/wk to overall 18 males. There was a 3x variation between the highest decile of practices (2.6 tablets/male/y) and lowest decile (0.96 tablets/male/y). The statistical model captured 14% of this variation and showed that T1DM males were the largest users, while men age <65 with T2DM were being prescribed four times as much as non-DM. Those T2DM >65 were prescribed 80% of the non-DM amount. CONCLUSION There is a wide variation in the use of PDE5-is. With only 14% variance capture, other factors including wide variation in patient awareness, prescribing rules of local health providers, and recognition of the importance of male sexual health by GP prescribers might have a significant impact.
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Affiliation(s)
| | - Martin B Whyte
- Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Mark Lunt
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Marco Albanese
- Herzzentrum Hirslanden Zentralschweiz, Luzern, Switzerland
| | - Mark Livingston
- Black Country Pathology Services, Walsall Manor Hospital, Walsall, UK
| | - Roger Gadsby
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Simon G Anderson
- The George Alleyne Chronic Disease Research Centre, Caribbean Institute of Health Research, University of the West Indies, Bridgetown, Barbados
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Adrian H Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Salford Royal Hospital, Salford, UK
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Heald AH, Stedman M, Davies M, Farman S, Upthegrove R, Taylor D, Gadsby R. Influences on the use of antidepressants in primary care: All England general practice-level analysis of demographic, practice-level and prescriber factors. Hum Psychopharmacol 2020; 35:e2741. [PMID: 32495350 DOI: 10.1002/hup.2741] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 04/06/2020] [Accepted: 04/21/2020] [Indexed: 11/08/2022]
Abstract
INTRODUCTION General practice (GP) antidepressants (ADs) prescribing in England has almost doubled in the past decade: how does location, GP characteristics, and prescribing selection influence antidepressant prescribing rate (ADPR) and growth. METHODS Stepwise multivariate regression analysis was applied to national public relevant data for each general practice to establish associations between these factors and ADPR. The regression coefficient was applied to the actual change in the number of different ADs and costs/dose to extrapolate the impact of these on growth. RESULTS In 2017-2018, 2.1 billion doses of antidepressant were prescribed into a population of 52 million people in 6,146 larger practices. In the model, location demographics accounted for 62% of the variation in ADPR: including practice size and health raised this to 71%, and local prescribing behaviour to 80%. Practices using more different drugs and lower-cost/dose had higher ADPR. Extrapolation showed that 40% of growth in ADPR could be attributed to the historic changes in these factors. CONCLUSIONS While practice location factors do impact on AD prescription rates, local long-term physical health condition prevalence and prescribing behaviours are almost as important. We hope that our findings can provide insights that are helpful to local clinical behaviour and medicines management.
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Affiliation(s)
- Adrian H Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK.,Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
| | - Mike Stedman
- Res Consortium, Healthcare Improvement, Andover, UK
| | - Mark Davies
- Res Consortium, Healthcare Improvement, Andover, UK
| | - Sanam Farman
- Department of Psychiatry, Mersey Deanery Training Rotation, Liverpool, UK
| | - Rachel Upthegrove
- Institute for Mental Health, University of Birmingham, Birmingham, UK
| | - David Taylor
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Roger Gadsby
- Warwick University Medical School, University of Warwick, Coventry, UK
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Stedman M, Lunt M, Davies M, Gibson M, Heald A. COVID-19: Generate and apply local modelled transmission and morbidity effects to provide an estimate of the variation in overall relative healthcare resource impact at general practice granularity. Int J Clin Pract 2020; 74:e13533. [PMID: 32392377 DOI: 10.1111/ijcp.13533] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 04/28/2020] [Accepted: 05/09/2020] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is the name given to the 2019 novel coronavirus. COVID-19 is the name given to the disease associated with the virus. SARS-CoV-2 is a new strain of coronavirus not been previously identified in humans. METHODS Two key factors, case incidence and case morbidity, were analysed for England. When taken together they give an estimate of relative demand on healthcare utilisation. To analyse case incidence, the latest values for indicators that could be associated with infection transmission rates were collected from the Office of National Statistics (ONS) and Quality Outcome Framework (QOF) sources. These included population density, %age >16, at fulltime work/education, %age over 60, %BME ethnicity, social deprivation as IMD2019, location as latitude/longitude, and patient engagement as %self-confident in their own long-term condition management. Average case morbidity was calculated. To provide a comparative measure of overall healthcare resource impact, individual GP practice impact scores were compared against the median practice. RESULTS The case incidence regression is a dynamic situation but it currently shows that Urban, %Working, and age >60 were the strongest determinants of case incidence. The local population comorbidity remains unchanged. The range of relative healthcare impact was wide with 80% of practices falling at 20%-250% of the national median. Once practice population numbers were included we found that the top 33% of GP practices supporting 45% of the patient population would require 68% of COVID-19 healthcare resources. The model provides useful information about the relative impact of Covid-19 on healthcare workload at GP practice granularity in all parts of England. CONCLUSION Covid-19 is impacting on the utilisation of health/social care resources across the world. This model provides a way of predicting relative local levels of disease burden based on defined criteria, thereby providing a method for targeting limited care resources to optimise national/regional/local responses to the COVID-19 outbreak.
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Affiliation(s)
| | - Mark Lunt
- The Faculty of Biology, Medicine and Health and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | | | - Martin Gibson
- Department of Diabetes and Endocrinology, Salford, UK
| | - Adrian Heald
- The Faculty of Biology, Medicine and Health and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford, UK
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Stedman M, Davies M, Lunt M, Verma A, Anderson SG, Heald AH. A phased approach to unlocking during the COVID-19 pandemic-Lessons from trend analysis. Int J Clin Pract 2020; 74:e13528. [PMID: 32378252 PMCID: PMC7261991 DOI: 10.1111/ijcp.13528] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has led to radical political control of social behaviour. The purpose of this paper is to explore data trends from the pandemic regarding infection rates/policy impact, and draw learning points for informing the unlocking process. METHODS The daily published cases in England in each of 149 Upper Tier Local Authority (UTLA) areas were converted to Average Daily Infection Rate (ADIR), an R-value - the number of further people infected by one infected person during their infectious phase with Rate of Change of Infection Rate (RCIR) also calculated. Stepwise regression was carried out to see what local factors could be linked to differences in local infection rates FINDINGS: By the 19th April 2020 the infection R has fallen from 2.8 on 23rd March before the lockdown and has stabilised at about 0.8, sufficient for suppression. However there remain significant variations between England regions. Regression analysis across UTLAs found that the only factor relating to reduction in ADIR was the historic number of confirmed number infection/000 population, There is however wide variation between Upper Tier Local Authorities (UTLA) areas. Extrapolation of these results showed that unreported community infection may be 150 times higher than reported cases, providing evidence that by the end of the second week in April, 26.8% of the population may already have had the disease and so have increased immunityExtrapolation of these results showed that unreported community infection may be 150 times higher than reported cases, providing evidence that by the end of the second week in April, 26.8% of the population may already have had the disease and so have increased immunity. INTERPRETATION Analysis of current case data using infectious ratio has provided novel insight into the current national state and can be used to make better-informed decisions about future management of restricted social behaviour and movement.
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Affiliation(s)
| | | | - Mark Lunt
- Division of Musculoskeletal and Dermatological SciencesUniversity of ManchesterManchesterUK
| | - Arpana Verma
- Population Health, Health Services Research and Primary CareThe University of ManchesterManchesterUK
| | - Simon G. Anderson
- University of the West IndiesCave HillBarbados
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and HealthThe University of ManchesterManchesterUK
| | - Adrian H. Heald
- Department of Diabetes and EndocrinologySalford Royal HospitalSalfordUK
- The Faculty of Biology, Medicine and Health and Manchester Academic Health Sciences CentreUniversity of ManchesterManchesterUK
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Heald A, Livingstone M, Albanese M, Stedman M. P-02-83 Strong Link Identified in Family Doctors / General Practitioners Between Prescription of Treatments for Erectile Dysfunction and Hypogonadism. J Sex Med 2020. [DOI: 10.1016/j.jsxm.2020.04.228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Heald A, Livingstone M, Albanese M, Stedman M. P-02-56 Can Any Lessons Be Seen From the Variation Across Family/General Practices in Application of Treatments for Hypogonadism? J Sex Med 2020. [DOI: 10.1016/j.jsxm.2020.04.208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Stedman M, Lunt M, Davies M, Livingston M, Duff C, Fryer A, Anderson SG, Gadsby R, Gibson M, Rayman G, Heald A. Cost of hospital treatment of type 1 diabetes (T1DM) and type 2 diabetes (T2DM) compared to the non-diabetes population: a detailed economic evaluation. BMJ Open 2020; 10:e033231. [PMID: 32376746 PMCID: PMC7223153 DOI: 10.1136/bmjopen-2019-033231] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Other than age, diabetes is the largest contributor to overall healthcare costs and reduced life expectancy in Europe. This paper aims to more exactly quantify the net impact of diabetes on different aspects of healthcare provision in hospitals in England, building on previous work that looked at the determinants of outcome in type 1 diabetes (T1DM) and type 2 diabetes (T2DM). SETTING NHS Digital Hospital Episode Statistics (HES) in England was combined with the National Diabetes Audit (NDA) to provide the total number in practice of people with T1DM/T2DM. OUTCOME MEASURES We compared differences between T1DM/T2DM and non-diabetes individuals in relation to hospital activity and associated cost. RESULTS The study captured 90% of hospital activity and £36 billion/year of hospital spend. The NDA Register showed that out of a total reported population of 58 million, 2.9 million (6.5%) had T2DM and 240 000 (0.6%) had T1DM. Bed-day analysis showed 17% of beds are occupied by T2DM and 3% by T1DM. The overall cost of hospital care for people with diabetes is £5.5 billion/year. Once the normally expected costs including the older age of T2DM hospital attenders are allowed for this fell to £3.0 billion/year or 8% of the total captured secondary care costs. This equates to £560/non-diabetes person compared with £3280/person with T1DM and £1686/person with T2DM. For people with diabetes, the net excess impact on non-elective/emergency work is £1.2 billion with additional estimated diabetes-related accident & emergency attendances at 440 000 costing the NHS £70 million/year. T1DM individuals required five times more secondary care support than non-diabetes individuals. T2DM individuals, even allowing for the age, require twice as much support as non-diabetes individuals. CONCLUSIONS This analysis shows that additional cost of provision of hospital services due to their diabetes comorbidities is £3 billion above that for non-diabetes, and that within this, T1DM has three times as much cost impact as T2DM. We suggest that supporting patients in diabetes management may significantly reduce hospital activity.
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Affiliation(s)
| | - Mark Lunt
- ARC Epidemiology Unit, University of Manchester, Manchester, UK
| | - Mark Davies
- Health Research, Res Consortium, Andover, UK
| | - Mark Livingston
- Clinical Biochemistry, Walsall Healthcare NHS Trust, Walsall, Walsall, UK
| | - Christopher Duff
- Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
| | - Anthony Fryer
- Institute for Science & Technology in Medicine, Keele University, Stoke on Trent, UK
| | - Simon George Anderson
- The George Alleyne Chronic Disease Research Centre, University of the West Indies Cave Hill Campus, Bridgetown, Saint Michael, Barbados
| | - Roger Gadsby
- Medical School, University of Warwick, Coventry, Coventry, UK
| | - Martin Gibson
- Endocrinology and Diabetes, Salford Royal Hospital, Salford, UK
| | - Gerry Rayman
- The Ipswich Diabetes Centre and Research Unit, Ipswich Hospital NHS Trust, Colchester, Essex, UK
| | - Adrian Heald
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford, UK
- Faculty of Biology, Medicine & Health, and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
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Heald AH, Stedman M, Davies M, Livingston M, Taylor D, Gadsby R. Antidepressant Prescribing in England: Patterns and Costs. Prim Care Companion CNS Disord 2020; 22. [PMID: 32302071 DOI: 10.4088/pcc.19m02552] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 12/30/2019] [Indexed: 10/24/2022] Open
Abstract
Objective The number of prescriptions for antidepressants (ADs) in England and Wales has almost doubled in the past decade. The objective of this article is to describe the current prescribing rates of different antidepressants by general practice (GP) practice. Methods We collated the prescribing behavior in each GP practice in the year April 1, 2017, to March 31, 2018. The monthly GP practice prescribing data reports for medication prescribing for each British National Formulary code and practice, as well as the prescriptions, quantity, and costs were examined in relation to prescribing practice. Results The data showed that 2.1 billion doses of antidepressant were prescribed to a total population of 52 million people. That equates to 11% of individuals taking ≥ 1 antidepressants on any day. Selective serotonin reuptake inhibitors (SSRIs) were the most prescribed class of ADs, with sertraline the most prescribed SSRI. The other most prescribed ADs were citalopram, fluoxetine, and mirtazapine. Some older agents, such as trimipramine and doxepin, are prescribed at a very high tariff. Conclusions Broadly, the findings are in keeping with National Institute for Health and Care Excellence guidance in that the bulk of prescriptions were for SSRIs. Regular audit of patient treatment at a general practice level will ensure appropriate targeted use of licensed medications as supported by the evidence base.
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Affiliation(s)
- Adrian H Heald
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Stott Lane, Salford, Greater Manchester M6 8HD, UK. .,The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom.,Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, United Kingdom
| | - Mike Stedman
- Res Consortium, Healthcare Improvement, Andover, United Kingdom
| | - Mark Davies
- Res Consortium, Healthcare Improvement, Andover, United Kingdom
| | - Mark Livingston
- Black Country Pathology Services, Walsall Manor Hospital, Walsall, United Kingdom
| | - David Taylor
- South London and the Maudsley NHS Foundation Trust, Beckenham, United Kingdom
| | - Roger Gadsby
- Warwick University Medical School, University of Warwick, United Kingdom
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Heald A, Stedman M, Lunt M, Livingston M, Cortes G, Gadsby R. General practice (GP) level analysis shows that patients' own perceptions of support within primary care as reported in the GP patient survey (GPPS) are as important as medication and services in improving glycaemic control. Prim Care Diabetes 2020; 14:29-32. [PMID: 31133530 DOI: 10.1016/j.pcd.2019.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 04/25/2019] [Accepted: 04/26/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND The way that GP practices organize their services impacts as much on glycaemia in type 2 diabetes as does prescribing. AIM Our aim was to evaluate the link between patients' own perception of support within primary care and the % patients at each GP practice at target glycaemic control (TGC) and at high glycaemic risk (HGR). DESIGN AND SETTING Utilisation of National Diabetes Audit (NDA) available data combined with the General practitioner patient survey (GPPS). METHOD The NDA 2016_17 published data on numbers of type 2 patients, levels of local diabetes services and the target glycaemic control (TGC) % and high glycaemic risk (HGR) % achieved. The GPPS 2017 published % "No" responses from long term condition (LTC) patients to the question "In the last 6 months, had you enough support from local services or organisations to help manage LTCs?". Multivariate regression was used on the set of indicators capturing patients' demographics and services provided. RESULTS 6498 practices were included (with more than 2.5 million T2DM patients) and median values with band limits that included 95% practices for % "No" response to the question above was 12% (2%-30%), for TGC 67% (54%-78%) and for HGR 6% (2%-13%). The model accounted for 25% TGC variance and 26% HGR variance. The standardised β values shown as (TGC/HGR) (+=more people; -=less people) for older age (+0.24/-0.25), sulphonylurea use (-0.21/+0.14), greater social disadvantage (-0.09/+0.21), GPPS Support %No (-0.08/+0.12), %Completion 8 checks (+0.09/-0.12) and metformin use (+0.11/-0.05). CONCLUSION The relation between the person with diabetes and clinician in primary care is shown to be quantitatively potentially as important in influencing glycaemic outcome as the services provided and medication prescribed. We suggest that all of us in who work in the health care system can bear this in mind in our everyday work.
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Affiliation(s)
- Adrian Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom; Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, United Kingdom.
| | - Mike Stedman
- Res Consortium, Andover, Hampshire, United Kingdom
| | - Mark Lunt
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
| | - Mark Livingston
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, United Kingdom
| | - Gabriela Cortes
- High Speciality Regional Hospital of Ixtapaluca, Mexico City, Mexico
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Stedman M, Livingston M, Albanese M, Hackett G, Heald AH. Hypogonadism is not being sufficiently recognised in 99% of general practices/family doctor surgeries. Int J Clin Pract 2020; 74:e13445. [PMID: 31713967 DOI: 10.1111/ijcp.13445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
| | - Mark Livingston
- Black Country Pathology Services, Walsall Manor Hospital, Walsall, UK
| | - Marco Albanese
- Herzzentrum Hirslanden Zentralschweiz, Luzern, Switzerland
| | - Geoff Hackett
- Department of Sexual Urology, Heartlands Hospital, Birmingham, UK
| | - Adrian H Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
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Heald AH, Stedman M, Davies M, Farman S, Taylor D, Bailey S, Gadsby R. Quantifying the Impact of Patient-Practice Relationship Quality on the Levels of the Average Annual Antidepressant Practice Prescribing Rate in Primary Care in England. Prim Care Companion CNS Disord 2020; 22. [DOI: 10.4088/pcc.19m02528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 10/31/2019] [Indexed: 10/25/2022] Open
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Heald A, Davies M, Stedman M, Livingston M, Lunt M, Fryer A, Gadsby R. Analysis of English general practice level data linking medication levels, service activity and demography to levels of glycaemic control being achieved in type 2 diabetes to improve clinical practice and patient outcomes. BMJ Open 2019; 9:e028278. [PMID: 31494602 PMCID: PMC6731821 DOI: 10.1136/bmjopen-2018-028278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Evaluate relative clinical effectiveness of treatment options for type 2 diabetes mellitus (T2DM) using a statistical model of real-world evidence within UK general practitioner practices (GPP), to quantify the opportunities for diabetes care performance improvement. METHOD From the National Diabetes Audit in 2015-2016 and 2016-2017, GPP target glycaemic control (TGC-%HbA1c ≤58 mmol/mol) and higher glycaemic risk (HGR -%HbA1c results >86 mmol/mol) outcomes were linked using multivariate linear regression to prescribing, demographics and practice service indicators. This was carried out both cross-sectionally (XS) (within year) and longitudinally (Lo) (across years) on 35 indicators. Standardised β coefficients were used to show relative level of impact of each factor. Improvement opportunity was calculated as impact on TGC & HGR numbers. RESULTS Values from 6525 GPP with 2.7 million T2DM individuals were included. The cross-sectional model accounted for up to 28% TGC variance and 35% HGR variance, and the longitudinal model accounted for up to 9% TGC and 17% HGR variance. Practice service indicators including % achieving routine checks/blood pressure/cholesterol control targets were positively correlated, while demographic indicators including % younger age/social deprivation/white ethnicity were negatively correlated. The β values for selected molecules are shown as (increased TGC; decreased HGR), canagliflozin (XS 0.07;0.145/Lo 0.04;0.07), metformin (XS 0.12;0.04/Lo -;-), sitagliptin (XS 0.06;0.02/Lo 0.10;0.06), empagliflozin (XS-;0.07/Lo 0.09;0.07), dapagliflozin (XS -;0.04/Lo -;0.4), sulphonylurea (XS -0.18;-0.12/Lo-;-) and insulin (XS-0.14;0.02/ Lo-0.09;-). Moving all GPP prescribing and interventions to the equivalent of the top performing decile of GPP could result in total patients in TGC increasing from 1.90 million to 2.14 million, and total HGR falling from 191 000 to 123 000. CONCLUSIONS GPP using more legacy therapies such as sulphonylurea/insulin demonstrate poorer outcomes, while those applying holistic patient management/use of newer molecules demonstrate improved glycaemic outcomes. If all GPP moved service levels/prescribing to those of the top decile, both TGC/HGR could be substantially improved.
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Affiliation(s)
- Adrian Heald
- Department of Diabetes and Endocrinology, Salford Royal NHS Foundation Trust, Salford, UK
- The School of Medicine and Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
| | | | | | - Mark Livingston
- Clinical Biochemistry, Walsall Healthcare NHS Trust, Walsall, UK
| | - Mark Lunt
- The School of Medicine and Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
| | - Anthony Fryer
- Clinical Biochemistry, University Hospitals of North Midlands, Stoke on Trent, Staffordshire, UK
| | - Roger Gadsby
- Warwick Medical School, University of Warwick, Coventry, UK
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Heald A, Stedman M, Lunt M, Cortes G, Livingston M, Gadsby R. Patient perception of support within primary care is as important as medication and services in achieving good glycaemic control. Int J Clin Pract 2019; 73:e13356. [PMID: 31033111 DOI: 10.1111/ijcp.13356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Adrian Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
| | | | - Mark Lunt
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Gabriela Cortes
- High Speciality Regional Hospital of Ixtapaluca, Mexico City, Mexico
| | - Mark Livingston
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, West Midlands
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Stedman M, Lunt M, Livingston M, Fryer A, Moreno G, Anderson S, Gadsby R, Heald A. Demographic factor clustering at a GP practice level in England and its relation to glycaemic outcomes: What we can learn from this. Int J Clin Pract 2019; 73:e13303. [PMID: 30515926 DOI: 10.1111/ijcp.13303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 11/30/2018] [Indexed: 11/29/2022] Open
Affiliation(s)
| | - Mark Lunt
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Mark Livingston
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, UK
| | - Anthony Fryer
- Institute for Applied Clinical Sciences, Keele University, Keele, UK
| | - Gabriela Moreno
- High Speciality Regional Hospital of Ixtapaluca, Mexico City, Mexico
| | - Simon Anderson
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | | | - Adrian Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
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Stedman M, Lunt M, Livingston M, Fryer AA, Moreno G, Bailey S, Gadsby R, Heald A. The costs of drug prescriptions for diabetes in the NHS. Lancet 2019; 393:226-227. [PMID: 30663590 DOI: 10.1016/s0140-6736(18)33190-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 12/05/2018] [Indexed: 12/26/2022]
Affiliation(s)
| | - Mark Lunt
- School of Medical Sciences and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Mark Livingston
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, UK
| | - Anthony A Fryer
- Institute for Applied Clinical Sciences, Keele University, Keele, UK
| | - Gabriela Moreno
- High Speciality Regional Hospital of Ixtapaluca, Mexico City, Mexico
| | - Susan Bailey
- Choosing Wisely steering group, Academy of Medical Royal Colleges, London, UK
| | | | - Adrian Heald
- School of Medical Sciences and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK; Salford Royal Hospital, Salford M6 8HD, UK.
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Heald AH, Livingston M, Fryer A, Cortes G, Anderson SG, Gadsby R, Laing I, Lunt M, Young RJ, Stedman M. Real-world practice level data analysis confirms link between variability within Blood Glucose Monitoring Strip (BGMS) and glycosylated haemoglobin (HbA1c) in Type 1 Diabetes. Int J Clin Pract 2018; 72:e13252. [PMID: 30168887 PMCID: PMC6766879 DOI: 10.1111/ijcp.13252] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/13/2018] [Accepted: 07/31/2018] [Indexed: 01/06/2023] Open
Abstract
AIMS/HYPOTHESIS Our aim was to quantify the impact of Blood Glucose Monitoring Strips variability (BGMSV) at GP practice level on the variability of reported glycated haemoglobin (HbA1cV) levels. METHODS Overall GP Practice BGMSV and HbA1cV were calculated from the quantity of main types of BGMS being prescribed combined with the published accuracy, as % results within ±% bands from reference value for the selected strip type. The regression coefficient between the BGMSV and HbA1cV was calculated. To allow for the aggregation of estimated three tests/day over 13 weeks (ie, 300 samples) of actual Blood Glucose (BG) values up to the HbA1c, we multiplied HbA1cV coefficient by √300 to estimate an empirical value for impact of BGMSV on BGV. RESULTS Four thousand five hundred and twenty-four practice years with 159 700 T1DM patient years where accuracy data were available for more than 80% of strips prescribed were included, with overall BGMSV 6.5% and HbA1c mean of 66.9 mmol/mol (8.3%) with variability of 13 mmol/mol equal to 19% of the mean. At a GP practice level, BGMSV and HbA1cV as % of mean HbA1c (in other words, the spread of HbA1c) were closely related with a regression coefficient of 0.176, P < 0.001. Thus, greater variability in the BGMS at a GP practice level resulted in a greater spread of HbA1C readings in T1DM patients. Applying this factor for BGMS to the national ISO accepted standard where 95% results must be ≤±15% from reference, revealed that for BG, 95% results would be ≤±45% from the reference value. Thus, the variation in BG is three times that of the BGMS. For a patient with BG target @10 mmol/L using the worst performing ISO standard strips, on 1/20 occasions (average 1/week) actual blood glucose value could be >±4.5 mmol/L from target, compared with the best performing BGMS with BG >±2.2 mmol/L from reference on 1/20 occasions. CONCLUSION Use of more variable/less accurate BGMS is associated both theoretically and in practice with a larger variability in measured BG and HbA1c, with implications for patient confidence in their day-to-day monitoring experience.
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Affiliation(s)
- Adrian H. Heald
- The School of Medicine and Manchester Academic Health Sciences CentreUniversity of ManchesterManchesterUK
- Department of Diabetes and EndocrinologySalford Royal HospitalSalfordUK
| | | | - Anthony Fryer
- Institute for Applied Clinical SciencesKeele UniversityKeeleUK
| | - Gabriela Cortes
- Head of Medical DepartmentHigh Speciality Regional Hospital of IxtapalucaMexico CityMexico
| | - Simon G. Anderson
- Institute of Cardiovascular SciencesUniversity of ManchesterManchesterUK
| | - Roger Gadsby
- Warwick Medical SchoolUniversity of WarwickWiltshireUK
| | - Ian Laing
- Department of Diabetes and EndocrinologySalford Royal HospitalSalfordUK
| | - Mark Lunt
- The School of Medicine and Manchester Academic Health Sciences CentreUniversity of ManchesterManchesterUK
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Heald A, Stedman M, Farman S, Bailey S, Gadsby R. Quantifying the link between long-term condition (LTC) patient experience in primary care and their clinical outcomes as measured by the National Diabetes Audit. Int J Clin Pract 2018; 72:e13255. [PMID: 30216650 DOI: 10.1111/ijcp.13255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Adrian Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
| | | | - Sanam Farman
- Mersey Deanery Psychiatry Rotation, Liverpool, UK
| | - Sue Bailey
- Chair Choosing Wisely Steering Group of the Academy of Medical Royal Colleges, London, UK
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Heald AH, Fryer AA, Anderson SG, Livingston M, Lunt M, Davies M, Moreno GYC, Gadsby R, Young RJ, Stedman M. Sodium-glucose co-transporter-2 inhibitors, the latest residents on the block: Impact on glycaemic control at a general practice level in England. Diabetes Obes Metab 2018. [PMID: 29516618 DOI: 10.1111/dom.13281] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS To determine, using published general practice-level data, how differences in Type 2 diabetes mellitus (T2DM) prescribing patterns relate to glycaemic target achievement levels. METHODS Multiple linear regression modelling was used to link practice characteristics and defined daily dose (DDD) of different classes of medication in 2015/2016 and changes between that year and the year 2014/2015 in medication to proportion of patients achieving target glycaemic control (glycated haemoglobin A1c [HbA1c] ≤58 mmol/mol [7.5%]) and proportion of patients at high glycaemic risk (HbA1c >86 mmol/mol [10.0%]) for practices in the National Diabetes Audit with >100 people with T2DM on their register. RESULTS Overall, HbA1c outcomes were not different between the years studied. Although, in percentage terms, most practices increased their use of sodium-glucose co-transporter-2 (SGLT2) inhibitors (96%), dipeptidyl peptidase-4 (DPP-4) inhibitors (76%) and glucagon-like peptide 1 (GLP-1) analogues (53%), there was wide variation in the use of older and newer therapies. For example, 12% of practices used >200% of the national average for some newer agents. In cross-sectional analysis, greater prescribing of metformin and analogue insulin were associated with a higher proportion of patients achieving HbA1c ≤58 mmol/mol; the use of SGLT2 inhibitors and metformin was associated with a reduced proportion of patients with HbA1c >86 mol/mol; otherwise associations for sulphonylureas, GLP-1 analogues, SGLT2 inhibitors and DPP-4 inhibitors were neutral or negative. In year-on-year analysis there was ongoing deterioration in glycaemic control, which was offset to some extent by increased use of SGLT2 inhibitors and GLP-1 analogues, which were associated with a greater proportion of patients achieving HbA1c levels ≤58 mmol/mol and a smaller proportion of patients with HbA1c levels >86 mmol/mol. SGLT2 inhibitor prescribing was associated with significantly greater improvements than those found for GLP-1 analogues. CONCLUSION Greater use of newer agents was associated with improvement in glycaemic outcomes but was not sufficient to compensate for the prevailing decline. This may reflect wide variability in the prescribing of newer agents. We found that SGLT inhibitors may be superior to other oral agents in relation to HbA1c outcome. Serious consideration should be given to their use.
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Affiliation(s)
- Adrian H Heald
- School of Medicine Sciences and Manchester, Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
| | | | - Simon G Anderson
- School of Medicine Sciences and Manchester, Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Mark Livingston
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, UK
| | - Mark Lunt
- School of Medicine Sciences and Manchester, Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | | | - Gabriela Y C Moreno
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
- High Specialty Regional Hospital of Ixtapaluca, Mexico City, Mexico
| | - Roger Gadsby
- Warwick Medical School, University of Warwick, Warwick, UK
- National Diabetes Audit, London, UK
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Heald AH, Livingston M, Bien Z, Moreno GYC, Laing I, Stedman M. The pattern of prescribing of glucose modulating agents for type 2 diabetes in general practices in England 2016/17. Int J Clin Pract 2018. [PMID: 29537664 DOI: 10.1111/ijcp.13080] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In the financial year 2016/17 there were 52.0 million items prescribed for diabetes at a total net ingredient cost of £983.7 million - up from 28.9 million prescription items and £572.4 million in 2006/07. Anti-diabetes drugs (British National Formulary section 6.1.2) make up 45.1 per cent of the total £983.7 million net ingredient cost of drugs used in diabetes and account for 72.0 per cent of prescription items for all diabetes prescribing. METHODS We examined the way that agents licensed to treat type 2 diabetes were used across GP practices in England in the year 2016/2017. Analysis was at a GP practice level not at the level of patient data. RESULTS Annual prescribing costs / patient / medication type for monotherapy varied considerable from £11/year for gliclazide and glimepiride to £885/year for Liraglutide. The use of SGLT-2i agents grew strongly at 70% per annum to around 100,000 DDD with prescriptions seen in 95% of GP practices. Liraglutide expenditure (11% of total) was high for a relatively small number of patients (1.3% of Defined Daily Doses), with still significant spend on exenatide. Liraglutide use significantly exceeded that of other glucagon-like peptide-1 (GLP-1) agonists. CONCLUSIONS Our work demonstrates the significant cost of medication to modulate tissue glucose levels in type 2 diabetes and the dominance of some non-generic preparations in terms of number of prescriptions and overall spend. There are some older sulphonylureas in use, which should not generally be prescribed. Regular audit of patient treatment at a general practice level will ensure appropriate targeted use of licensed medications and of their cost effectiveness.
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Affiliation(s)
- Adrian H Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, England
| | - Mark Livingston
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, UK
| | | | - Gabriela Y C Moreno
- Head of Medical Department, High Specialty Regional Hospital, Ixtapaluca, Mexico City, Mexico
| | - Ian Laing
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
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Heald AH, Livingston M, Malipatil N, Becher M, Craig J, Stedman M, Fryer AA. Improving type 2 diabetes mellitus glycaemic outcomes is possible without spending more on medication: Lessons from the UK National Diabetes Audit. Diabetes Obes Metab 2018; 20:185-194. [PMID: 28730750 DOI: 10.1111/dom.13067] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/16/2017] [Accepted: 07/17/2017] [Indexed: 11/30/2022]
Abstract
AIMS To determine the factors at general practice level that relate to glycaemic control outcomes in people with type 2 diabetes (T2DM). METHODS Data were accessed from 4050 general practices (50% of total) covering 1.6 million patients with T2DM in the UK National Diabetes Audit 2013 to 2014 and 2014 to 2015. This audit reported characteristics, services and outcomes in the T2DM population, including percentage of patients who had total glycaemic control (TGC), defined as glycated haemoglobin (HbA1c) ≤7.5% (58 mmol/mol), and the percentage who were at higher glycaemic risk (HGR), defined as HbA1c >10% (86 mmol/mol); the respective figures were 67.2% and 6.2%. The medication data were examined in terms of annual defined daily doses (DDDs). Multivariate linear regression analysis was used to identify associations between DDD and patient and practice characteristics. RESULTS Over the period 2012/2013 to 2015/2016, patient numbers grew 4% annually and annual medication expenditure by 8%, but glycaemic control outcomes did not improve. The main findings were that practices with better outcomes: had a higher percentage of patients aged >65 years; provided more effective diabetes services (including case identification, care checks, patient education, percentage of patients with blood pressure and cholesterol under control and more patients with type 1 diabetes achieving target HbA1c levels); spent less overall on prescribing per patient with T2DM; and on average, prescribed fewer sulphonylureas, less insulin (for patients with T2DM), fewer glucagon-like peptide-1 agonists, more metformin, more dipeptidyl peptidase-4 inhibitors, and more blood glucose monitoring strips. Ethnicity and social disadvantage and levels of thiazolidinedione (glitazone) prescribing had no significant impact on outcomes. Sodium-glucose co-transporter-2 inhibitor use was too low for an effect to be observed in the period examined. CONCLUSIONS If all practices brought their service and medication to the level of the top decile practices, they could achieve 74.7% compared with the median of 67.3% of patients achieving TGC, showing an increase of 213 000 in patients achieving TGC, while reducing the number at HGR to 3.8% compared with 6.1%, benefiting 62 000 patients. This could have a major impact on the overall consequent healthcare costs of managing diabetes complications with their attendant mortality risks.
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Affiliation(s)
- Adrian H Heald
- School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford, UK
| | - Mark Livingston
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, UK
| | - Nagaraj Malipatil
- School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Michal Becher
- Robotics and Control Systems, Technical University of Wroclaw, Wroclaw, Poland
| | | | | | - Anthony A Fryer
- Keele University School of Medicine, Newcastle-under-Lyme, UK
- Department of Clinical Biochemistry, University Hospital of North Staffordshire, Stoke-on-Trent, UK
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Heald AH, Livingston M, Fryer A, Moreno GYC, Malipatil N, Gadsby R, Ollier W, Lunt M, Stedman M, Young RJ. Route to improving Type 1 diabetes mellitus glycaemic outcomes: real-world evidence taken from the National Diabetes Audit. Diabet Med 2018; 35:63-71. [PMID: 29120503 DOI: 10.1111/dme.13541] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2017] [Indexed: 02/01/2023]
Abstract
AIM To use general practice-level data for England, available through the National Diabetes Audit, and primary care prescribing data to identify prescription treatment factors associated with variations in achieved glucose control (HbA1c ). METHODS General practice-level National Diabetes Audit data on Type 1 diabetes, including details of population characteristics, services, proportion of people achieving target glycaemic control [HbA1c ≤58 mmol/mol (7.5%)] and proportion of people at high glycaemic risk [HbA1c >86 mmol/ml (10%)], were linked to 2013-2016 primary care diabetes prescribing data on insulin types and blood glucose monitoring for all people with diabetes. RESULTS A wide variation was found between the 10th percentile and the 90th percentile of general practices in both target glycaemic control (15.6% to 44.8%, respectively) and high glycaemic risk (4.8% to 28.6%, respectively). Our analysis suggests that, given the extrapolated total of 280 000 people with Type 1 diabetes in the UK, there may be the potential to increase the number of those within target glycaemic control from 80 000 to 101 000; 53% of this increase (11 000 people) would result from service improvements and 47% (10 000 people) from medication and technology changes. The same improvements would also provide the opportunity to reduce the number of people at high glycaemic risk from 42 000 to 26 500. A key factor associated with practice-level target HbA1c achievement would be greater use of insulin pumps for up to an additional 56 000 people. CONCLUSION If the HbA1c achievement rates in service provision, medication and use of technology currently seen in practices in the 90th percentile were to be matched with regard to HbA1c achievement rates in all general practices, glycaemic control might be improved for 36 500 people, with all the attendant health benefits.
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Affiliation(s)
- A H Heald
- School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
| | - M Livingston
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, UK
| | - A Fryer
- Institute for Applied Clinical Sciences, Keele University, Keele, UK
| | - G Y C Moreno
- Co-ordinator of the Obesity Clinic in the Medicine School of Instituto Politécnico Nacional, Mexico City, Mexico
| | - N Malipatil
- School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - R Gadsby
- Warwick Medical School, University of Warwick, Coventry, UK
| | - W Ollier
- School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - M Lunt
- School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - M Stedman
- RES Consortium, Andover, Wiltshire, UK
| | - R J Young
- National Diabetes Audit, Central Office Diabetes UK, London, UK
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