Impact of remission from type 2 diabetes on long-term health outcomes: findings from the Look AHEAD study

AIMS/HYPOTHESIS

We examined the association of attainment of diabetes remission in the context of a 12 year intensive lifestyle intervention with subsequent incidence of chronic kidney disease (CKD) and CVD.

METHODS

The Look AHEAD study was a multi-centre RCT comparing the effect of a 12 year intensive lifestyle intervention with that of diabetes support and education on CVD and other long-term health conditions. We compared the incidence of CVD and CKD among 4402 and 4132 participants, respectively, based on achievement and duration of diabetes remission. Participants were 58% female, and had a mean age of 59 years, a duration of diabetes of 6 year and BMI of 35.8 kg/m2. We applied an epidemiological definition of remission: taking no diabetes medications and having HbA1c <48 mmol/mol (6.5%) at a single point in time. We defined high-risk or very high-risk CKD based on the Kidney Disease Improving Global Outcomes (KDIGO) criteria, and CVD incidence as any occurrence of non-fatal acute myocardial infarction, stroke, admission for angina or CVD death.

RESULTS

Participants with evidence of any remission during follow-up had a 33% lower rate of CKD (HR 0.67; 95% CI 0.52, 0.87) and a 40% lower rate of the composite CVD measure (HR 0.60; 95% CI 0.47, 0.79) in multivariate analyses adjusting for HbA1c, BP, lipid levels, CVD history, diabetes duration and intervention arm, compared with participants without remission. The magnitude of risk reduction was greatest for participants with evidence of longer-term remission.

CONCLUSIONS/INTERPRETATION

Participants with type 2 diabetes with evidence of remission had a substantially lower incidence of CKD and CVD, respectively, compared with participants who did not achieve remission. This association may be affected by post-baseline improvements in weight, fitness, HbA1c and LDL-cholesterol.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00017953 DATA AVAILABILITY: https://repository.niddk.nih.gov/studies/look-ahead/.

Abstract 252: Use of a Chest Pain Score by Emergency Department and Hospitalist Physicians and Subsequent Utilization of Cardiac Imaging and Left Heart Catheterization at a Large Community Hospital

Background: Chest pain is the chief complaint of approximately 10% of all Emergency Department (ED) admissions. Optimal care is difficult to achieve in the ED environment and often requires involvement of hospitalists physicians to aid in triage decisions.

Hypothesis: Introduction of a web-based chest pain scoring system will result in decreased cardiac imaging and catheterizations.

Methods: ED physicians and hospitalists of a large community hospital were provided web-based copies of the chest pain score. The basis of the score was previously validated scores found in the published literature for patients presenting to an ED with chest pain.

All hospitalist consultations from the ED with a chief complaint of “chest pain” from 10/8/2014 to 2/1/2015 were assigned a chest pain score by ED providers. STEMI, emergent non-cardiac, and surgical causes were excluded (e.g. pneumothorax, acute trauma, aortic dissection). A hospitalist then assessed each consultation and assigned his or her own score. These scores corresponded with pre-specified disposition and management plans. When there were discrepancies in scoring, ED and the hospitalist collaborated on further work-up and disposition.

Primary variables of interest were the number of imaging studies and left heart catheterization performed. Imaging and catheterization data were captured from hospitalist physician Computerized Physician Order Entry (CPOE) and Electronic Medical Record (EMR) data. Imaging data were compared approximately four months prior to (6/1/2014-10/7/2014) and after (10/9/2014-2/1/15) initiation of the study. Catheterization data were compared approximately two months prior to (8/1/14-10/8/14) and after (10/8/14-11/25/14) initiation of the study.

Results: During the study period there was a decrease of 49% [(39-20)/39] in urgent catheterizations. Regarding imaging, there was a roughly 34% [(699-463)/699] decrease in all cardiac imaging and an approximately 46% [(585-317)/585] decrease in nuclear perfusion scanning. Notably there was a 28% [(146-114)/114] increase in the use of stress echo. These findings are summarized in Figure 1.

Conclusions: The findings show a significant decrease in left heart catheterizations and total number of cardiac imaging studies with a concurrent increase in use of stress echo.