Exploring the prospective acceptability of a healthy food incentive program from the perspective of people with type 2 diabetes and experiences of household food insecurity in Alberta, Canada

OBJECTIVE

FoodRx is a 12-month healthy food prescription incentive program for people with type 2 diabetes (T2DM) and experiences of household food insecurity. In this study, we aimed to explore potential users' prospective acceptability (acceptability prior to program use) of the design and delivery of the FoodRx incentive and identify factors influencing prospective acceptability.

DESIGN

We used a qualitative descriptive approach and purposive sampling to recruit individuals who were interested or uninterested in using the FoodRx incentive. Semi-structured interviews were guided by the theoretical framework of acceptability, and corresponding interview transcripts were analysed using differential qualitative analysis guided by the socioecological model.

SETTING

Individuals living in Alberta, Canada.

PARTICIPANTS

In total, fifteen adults with T2DM and experiences of household food insecurity.

RESULTS

People who were interested in using the FoodRx incentive (n 10) perceived it to be more acceptable than those who were uninterested (n 5). We identified four themes that captured factors that influenced users' prospective acceptability: (i) participants' confidence, views and beliefs of FoodRx design and delivery and its future use (intrapersonal), (ii) the shopping routines and roles of individuals in participants' social networks (interpersonal), (iii) access to and experience with food retail outlets (community), and (iv) income and food access support to cope with the cost of living (policy).

CONCLUSION

Future healthy food prescription programs should consider how factors at all levels of the socioecological model influence program acceptability and use these data to inform program design and delivery.

A comparison between different patient groups for diabetes management during phases of the COVID-19 pandemic: a retrospective cohort study in Ontario, Canada

BACKGROUND

With the onset of the COVID-19 pandemic and the large uptake in virtual care in primary care in Canada, the care of patients with type 2 diabetes has been greatly affected. This includes decreased in-person visits, laboratory testing and in-person assessments such as blood pressure (BP). No studies have investigated if these changes persisted with pandemic progression, and it is unclear if shifts impacted patient groups uniformly. The purpose of this paper was to examine changes in diabetes care pre, early, and later pandemic across different patient groups.

METHODS

A repeated cross-sectional design with an open cohort was used to investigate diabetes care in adults with type 2 diabetes for a 6-month interval from March 14 to September 13 over three consecutive years: 2019 (pre-pandemic period), 2020 (early pandemic period), and 2021 (later pandemic period). Data for this study were abstracted from the University of Toronto Practice-Based Research Network (UTOPIAN) Data Safe Haven, a primary care electronic medical records database in Ontario, Canada. Changes in diabetes care, which included primary care total visits, in-person visits, hemoglobin A1c (HbA1c) testing, and BP measurements were evaluated across the phases of the pandemic. Difference in diabetes care across patient groups, including age, sex, income quintile, prior HbA1c levels, and prior BP levels, were assessed.

RESULTS

A total of 39,401 adults with type 2 diabetes were included in the study. Compared to the 6-month pre-pandemic period, having any in-person visits decreased significantly early pandemic (OR = 0.079 (0.076-0.082)), with a partial recovery later pandemic (OR = 0.162 (95% CI: 0.157-0.169). Compared to the pre-pandemic period, there was a significant decrease early pandemic for total visits (OR = 0.486 (95% CI: 0.470-0.503)), HbA1c testing (OR = 0.401 (95% CI: 0.389-0.413)), and BP measurement (OR = 0.121 (95% CI: 0.116-0.125)), with partial recovery later pandemic.

CONCLUSIONS

All measures of diabetes care were substantially decreased early pandemic, with a partial recovery later pandemic across all patient groups. With the increase in virtual care due to the COVID-19 pandemic, diabetes care has been negatively impacted over 1-year after pandemic onset.

Increased Breast and Colorectal Cancer Risk in Type 2 Diabetes: Awareness Among Adults With and Without Diabetes and Information Provision on Diabetes Websites

BACKGROUND

People with type 2 diabetes mellitus (T2DM) have a higher risk of developing breast and bowel cancers but are less likely to participate in cancer screening.

PURPOSE

Two interlinked studies examined public awareness of the fact that T2DM increases breast and bowel cancer risk, and provision of this information on diabetes websites.

METHODS

Study-1: phase-1 surveyed awareness of T2DM-increased cancer risk in a nationally-representative British sample aged 50-74 (N = 1,458) and compared respondents with and without T2DM (n = 125 vs. n = 1,305); phase-2 surveyed an additional exclusively T2DM sample (N = 319). Study-2: High-ranking diabetes websites (N = 25) were reviewed to determine the rate of inclusion of cancer risk and cancer screening information in evident sections about diabetes-related health conditions.

RESULTS

A low proportion of respondents were aware that T2DM increases risk of breast (13.7%) and bowel (27.6%) cancers, compared to much higher awareness of other diabetes-related conditions such as sight loss (82.2%) and foot problems (81.8%). Respondents with T2DM were significantly more likely than those without T2DM to be aware of all the surveyed diabetes-related health conditions (e.g., sight loss, OR: 3.14, 95%CI: 1.61-6.15; foot problems, OR: 2.58, 95%CI: 1.38-4.81), except breast (OR: 0.82, 95%CI: 0.46-1.45) and bowel (OR: 0.95, 95%CI: 0.63-1.45) cancer, for which awareness was equally low among people with and without T2DM. Few diabetes websites with a section on diabetes-related health conditions included cancer in this section (n = 4/19), and fewer still included cancer screening among any noted cancer-protective behaviors (n = 2/4).

CONCLUSIONS

There is low public awareness that T2DM increases the risk of developing breast and bowel cancers, even among people with T2DM, which may be partly due to limited information provision regarding T2DM-increased cancer risk from diabetes care providers and organizations.

Outcomes in children of women with type 2 diabetes exposed to metformin versus placebo during pregnancy (MiTy Kids): a 24-month follow-up of the MiTy randomised controlled trial

BACKGROUND

Metformin is increasingly being used during pregnancy, with potentially adverse long-term effects on children. We aimed to examine adiposity in children of women with type 2 diabetes from the Metformin in Women with Type 2 Diabetes in Pregnancy (MiTy) trial, with and without in-utero exposure to metformin, up to 24 months of age.

METHODS

MiTy Kids is a follow-up study that included infants of women who participated in the MiTy randomised controlled trial, receiving either oral 1000 mg metformin twice daily or placebo. Caregivers and researchers remained masked to the type of medication (metformin or placebo) mothers received during their pregnancy. Anthropometric measurements, including weight, height, and skinfold thicknesses, were taken at 3, 6, 12, 18, and 24 months. At 24 months, linear regression was used to compare the BMI Z score and sum of skinfolds in the metformin versus placebo groups, adjusted for confounders. Fractional polynomials were used to assess growth trajectories. This study is registered with ClinicalTrials.gov, NCT01832181.

FINDINGS

Of the 465 eligible children, 283 (61%) were included from 19 centres in Canada and Australia. At 24 months, there was no difference between groups in mean BMI Z score (0·84 [SD 1·52] with metformin vs 0·91 [1·38] with placebo; mean difference 0·07 [95% CI -0·31 to 0·45], p=0·72) or mean sum of skinfolds (23·0 mm [5·2] vs 23·8 mm [5·4]; mean difference 0·8 mm [-0·7 to 2·3], p=0·31). Metformin was not a predictor of BMI Z score at 24 months of age (mean difference -0·01 [95% CI -0·42 to 0·37], p=0·92). There was no overall difference in BMI trajectory but, in males, trajectories were significantly different by treatment (p=0·048); BMI in the metformin group was higher between 6 and 24 months. Children of women with type 2 diabetes were approximately 1 SD heavier than the WHO reference population.

INTERPRETATION

Anthropometrics were similar in children exposed and those not exposed to metformin in utero; hence, overall, data are reassuring with regard to the use of metformin during pregnancy in women with type 2 diabetes and the long-term health of their children.

FUNDING

Canadian Institute for Health Research.

Improving diagnosis and treatment of knee osteoarthritis in persons with type 2 diabetes: development of a complex intervention

BACKGROUND

Symptomatic knee osteoarthritis (OA) commonly co-occurs in people with type 2 diabetes (T2DM) and increases the risk for diabetes complications, yet uptake of evidence-based treatment is low. We combined theory, stakeholder involvement and existing evidence to develop a multifaceted intervention to improve OA care in persons with T2DM. This was done in partnership with Arthritis Society Canada to leverage the existing infrastructure and provincial funding for community arthritis care.

METHODS

Each step was informed by a User Advisory Panel of stakeholder representatives, including persons with lived experience. First, we identified the target groups and behaviours through consulting stakeholders and current literature. Second, we interviewed persons living with T2DM and knee OA (n = 18), health professionals (HPs) who treat people with T2DM (n = 18) and arthritis therapists (ATs, n = 18) to identify the determinants of seeking and engaging in OA care (patients), assessing and treating OA (HPs) and considering T2DM in OA treatment (ATs), using the Theoretical Domains Framework (TDF). We mapped the content to behavioural change techniques (BCTs) to identify the potential intervention components. Third, we conducted stakeholder meetings to ascertain the acceptability and feasibility of intervention components, including content and modes of delivery. Fourth, we selected intervention components informed by prior steps and constructed a programme theory to inform the implementation of the intervention and its evaluation.

RESULTS

We identified the barriers and enablers to target behaviours across a number of TDF domains. All stakeholders identified insufficient access to resources to support OA care in people with T2DM. Core intervention components, incorporating a range of BCTs at the patient, HP and AT level, sought to identify persons with knee OA within T2DM care and refer to Arthritis Society Canada for delivery of evidence-based longitudinal OA management. Diverse stakeholder input throughout development allowed the co-creation of an intervention that appears feasible and acceptable to target users.

CONCLUSIONS

We integrated theory, evidence and stakeholder involvement to develop a multifaceted intervention to increase the identification of knee OA in persons with T2DM within diabetes care and improve the uptake and engagement in evidence-based OA management. Our partnership with Arthritis Society Canada supports future spread, scalability and sustainability. We will formally assess the intervention feasibility in a randomized pilot trial.

Formulating Knee Osteoarthritis Management Plans Taking Type 2 Diabetes Into Account: Qualitative Study of Arthritis Therapists Using Theoretical Domains Framework

OBJECTIVE

Delivering person-centered care in individuals with knee osteoarthritis (OA) necessitates consideration of other chronic conditions that frequently co-occur. We sought to understand the extent to which arthritis therapists consider type 2 diabetes mellitus (T2DM) when treating persons with knee OA and concomitant T2DM, and barriers to doing so.

METHODS

We conducted 18 semistructured telephone interviews with arthritis therapists working within a provincially funded arthritis care program (Arthritis Society Canada) in Ontario, Canada. We first analyzed interviews deductively using the Theoretical Domains Framework (TDF) to comprehensively identify barriers and enablers to health behaviors. Then, within TDF domains, we inductively developed themes.

RESULTS

We identified 5 TDF domains as prominently influencing the behavior of arthritis therapists considering concomitant T2DM when developing a knee OA management plan. These were as follows: therapists' perceived lack of specific knowledge around comorbidities including diabetes; the lack of breadth in skills in behavioral change techniques to help patients set and reach their goals, particularly when it came to physical activity; variable intention to factor a patient's comorbidity profile to influence their treatment recommendations; the perception of their professional role and identity as joint focused; and the environmental context with lack of formalized follow-up structure of the current Arthritis Society Canada program that limited sufficient patient monitoring and follow-up.

CONCLUSION

Within the context of a Canadian arthritis program, we identified several barriers to arthritis therapists considering T2DM in their management plan for persons with knee OA and T2DM. These results can help inform strategies to improve person-centered OA care and overall health outcomes.

Understanding the behavioural determinants of seeking and engaging in care for knee osteoarthritis in persons with type 2 diabetes mellitus: A qualitative study using the theoretical domains framework

Objectives

Symptomatic knee osteoarthritis (OA) frequently co-occurs in individuals with type 2 diabetes mellitus (T2DM). In the context of T2DM, OA is often underdiagnosed and undertreated. To elucidate strategies to improve OA care in persons with T2DM, we assessed their perceptions of the barriers and enablers to seeking and engaging in OA care.

Design

We conducted semi-structured interviews with 18 individuals with T2DM and symptomatic knee OA in Ontario, Canada. Transcripts were deductively coded using the Theoretical Domains Framework (TDF), an implementation science framework that incorporates theoretical domains of behaviour determinants, which can be linked to behaviour change techniques. Within each of the relevant domains, data were thematically analyzed to generate belief statements.

Results

Seven of the TDF domains prominently influenced the behaviour to seek and engage in OA care. Participants described insufficient receipt of OA knowledge to fully engage in care (knowledge), feeling incapable of participating in physical activity due to joint pain (beliefs about capabilities), uncertainty about effectiveness of therapies (optimism) and lack of guidance from health care providers and insufficient access to community programs/supports (environmental context and resources). Key enablers were strong social support (social influences), sources of accountability (behavioural regulation) and experiencing benefit from treatment (reinforcement). Participants did not see concomitant T2DM as limiting the desire to seek OA care.

Conclusions

Among individuals with symptomatic knee OA and T2DM, we identified behavioural determinants of seeking and engaging in OA care. These will be mapped to behavioural change techniques to inform development of a complex intervention.

Barriers and enablers to health care providers assessment and treatment of knee osteoarthritis in persons with type 2 diabetes mellitus: A qualitative study using the Theoretical Domains Framework

Objectives

Symptomatic knee osteoarthritis (OA) commonly co-exists in persons with Type 2 diabetes (T2DM) and may impede diabetes self-management. Yet, OA is often underdiagnosed and undertreated due to competing health care demands. We sought to determine healthcare providers' (HCPs') perceptions of the barriers and enablers to assessing and treating knee OA in persons with T2DM.

Design

We conducted 18 semi-structured telephone interviews with HCPs who manage persons with T2DM (family physicians, endocrinologists, diabetes educators). Interviews were analyzed deductively using Theoretical Domains Framework (TDF), a framework developed to comprehensively identify behavioural determinants. Within relevant domains, data were thematically analyzed to generate belief statements, and these were compared across the different HCP disciplines.

Results

Six TDF domains influenced HCPs behaviour to assess and treat knee OA in persons with T2DM. For all HCPs, important barriers included not seeing assessment/treatment of joint pain as a priority for their patients (intention), and insufficient access to required resources such as physiotherapy to treat OA (environmental context and resources). Endocrinologists and diabetes educators perceived having insufficient knowledge and skills to identify and manage OA (knowledge, skills), did not consider it within their professional role to do so (professional role and identity), and perceived other physicians would not want to receive a referral for OA care (social influences).

Conclusions

We identified barriers and enablers encountered by diabetes HCPs to assessing and treating knee OA in persons with T2DM involving multiple domains of the TDF. These will help inform development of a complex intervention to improve health outcomes.

A Healthy Food Prescription Incentive Program for Adults With Type 2 Diabetes Who Are Experiencing Food Insecurity: Protocol for a Longitudinal Qualitative Study

Objectives

Food insecurity is inadequate or insecure access to food due to financial constraints. Individuals experiencing food insecurity tend to have poorer diet quality compared to their food secure peers. Given the importance of maintaining healthful dietary patterns for optimal glycemic control, food insecurity is a considerable barrier to managing type 2 diabetes (T2DM). Healthy food prescription incentive programs aim to reduce such barriers by providing financial incentives to purchase healthy foods. The purpose of this study is to conduct longitudinal qualitative shop-along interviews among adults with T2DM who are experiencing food insecurity. We will explore experiences of redeeming healthy food incentives and factors influencing food purchasing patterns during participation in a healthy food prescription program in Alberta, Canada.

Methods

The healthy food prescription incentive program consists of two core elements: 1) A one-time healthy food prescription pamphlet outlining an evidence-based healthy dietary pattern; and 2) A healthy food incentive of $1.50/day/household member to purchase healthy foods in participating supermarkets for 6 months. Thirty participants aged 18–85 years will be purposefully recruited from primary care clinics. At baseline and 6-month follow-up, participants will take part in supermarket-based shop-along qualitative interviews. Participants will be asked to complete a usual grocery shop alongside a researcher. Using think-aloud principles, they will be asked to verbalize their thought processes for the shop's duration. Researchers will also collect naturalistic observations of participants, such as consulting nutrition labels. A post-shop interview will be completed to discuss experiences, decision-making rationale, and potential barriers and facilitators to food purchasing. Data will be analyzed iteratively and inductively at each time point. Further, a longitudinal analysis will compare emerging themes and identify changes occurring over time.

Results

N/A

Conclusions

This study will generate key data regarding if, how, and why such programs may address barriers to maintaining healthful dietary patterns. These findings will help to understand experiences of participating in healthy food incentive programs that can be used to improve future programs.

Funding Sources

Alberta Innovates.

In adults with overweight or obesity, adding weight-lowering drugs to lifestyle modification improves weight loss

SOURCE CITATION

Shi Q, Wang Y, Hao Q, et al. Pharmacotherapy for adults with overweight and obesity: a systematic review and network meta-analysis of randomised controlled trials. Lancet. 2022;399:259-69. 34895470.

Platelet Count and Survival after Cancer

Simple Summary

Platelets are cellular fragments circulating in the blood that are responsible for clotting. Previous research has shown that cancer patients with an abnormally high platelet count (thrombocytosis) have elevated rates of death from cancer. We aimed to investigate to what extent platelet counts are associated with survival after cancer. We followed a large provincial cohort of cancer patients with a platelet count recorded at the time of their diagnosis. We categorized patients according to platelet count (low, medium, high). Cancer patients in the ‘high’ platelet count category had the highest rate of cancer death, and cancer patients in the ‘low’ platelet count category had the lowest rate of cancer death. Platelet count may be used to predict survival in cancer patients.

Abstract

Thrombocytosis is associated with cancer progression and death for many cancer types. It is unclear if platelet count is also associated with cancer survival. We conducted a cohort study of 112,231 adults in Ontario with a diagnosis of cancer between January 2007 and December 2016. We included patients who had a complete blood count (CBC) completed in the 30 days prior to their cancer diagnosis. Subjects were assigned to one of three categories according to platelet count: low (≤25th percentile), medium (>25 to <75th percentile), and high (≥75th percentile). Study subjects were followed from the date of their cancer diagnosis for cancer-specific death. Of the 112,231 eligible cancer patients in the cohort study, 40,329 (35.9%) died from their cancer in the follow-up period. Relative to those with a medium platelet count, the rate of cancer-specific death was higher among individuals with a high platelet count (HR 1.52; 95%CI 1.48–1.55) and was lower among individuals with a low platelet count (HR 0.91; 95%CI 0.88–0.93). A high platelet count was associated with poor survival for many cancer types. Platelet count could potentially be used as a risk stratification measure for cancer patients.

Analysis of Platelet Count and New Cancer Diagnosis Over a 10-Year Period

IMPORTANCE

Individuals with cancer often have an elevated platelet count at the time of diagnosis. The extent to which an elevated platelet count is an indicator of cancer is unclear.

OBJECTIVE

To evaluate the association of an elevated platelet count with a cancer diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

This nested case-control study included Ontario residents enrolled in the provincial health insurance plan who had 1 or more routine complete blood count (CBC) tests performed between January 1, 2007, and December 31, 2017, with follow-up through December 31, 2018. Case patients were individuals with a new cancer diagnosis during the observation period. Eligible control individuals were cancer free before the date of diagnosis for a case patient to whom they were matched. One case patient was matched to 3 controls based on sex, age, and health care use patterns. Data were analyzed from September 24, 2020, to July 13, 2021.

EXPOSURES

Case patients and controls were assigned to 1 of 5 exposure groups based on age- and sex-specific platelet count distributions in the control population: very low (≤10th percentile), low (>10th to 25th percentile), medium (>25th to <75th percentile), high (75th to <90th percentile), and very high (≥90th percentile).

MAIN OUTCOMES AND MEASURES

Odds ratios (ORs) were estimated for specific cancer sites for each category of platelet count at intervals up to 10 years after a blood test.

RESULTS

Of the 8 917 187 eligible Ontario residents with a routine CBC record available, 4 971 578 (55.8%) were women; the median age at the first CBC was 46.4 years (IQR, 32.5-59.5 years). Among individuals with a routine CBC record available, 495 341 (5.6%) received a diagnosis of first primary cancer during the 10-year observation period. The OR for a solid tumor diagnosis associated with a very high platelet count vs a medium platelet count in the 6-month period before the diagnosis was 2.32 (95% CI, 2.28-2.35). A very high platelet count was associated with colon (OR, 4.38; 95% CI, 4.22-4.54), lung (OR, 4.37; 95% CI, 4.22-4.53), ovarian (OR, 4.62; 95% CI, 4.19-5.09), and stomach (OR, 4.27; 95% CI, 3.91-4.66) cancers. Odds ratios attenuated with increasing time from CBC test to cancer diagnosis.

CONCLUSIONS AND RELEVANCE

In this nested case-control study, an elevated platelet count was associated with increased risk of cancer at several sites. Our findings suggest that an elevated platelet count could potentially serve as a marker for the presence of some cancer types.

Glycaemic control in transition-aged versus early adults with type 1 diabetes and the effect of a government-funded insulin pump programme

AIM

To compare glycaemic control and adverse outcomes between transition-aged and early adults with type 1 diabetes, and the impact of continuous subcutaneous insulin infusion (CSII) therapy funded through a government Assisted Devices Program.

METHODS

This retrospective cohort study using healthcare administrative databases from Ontario, Canada included adults aged 18-35 with type 1 diabetes between 1 April 2011 and 31 March 2014. Mean HbA_1c was compared between transition-aged (18-24 years) and early adults (25-35 years), overall and stratified by whether or not they received government-funded CSII therapy (CSII vs. non-CSII). Secondary outcomes included rates of hospitalizations/emergency department visits for hyperglycaemia and hypoglycaemia over a 3-year follow-up. Comparisons were adjusted for relevant covariates.

RESULTS

Among 7157 participants with type 1 diabetes, mean HbA_1c was significantly higher for transition-aged compared to early adults (71 mmol/mol [8.68%] vs. 64 mmol/mol [8.04%], p < 0.0001). This difference was smaller among CSII compared to non-CSII users (p = 0.02 for interaction between age group and CSII use). The transition-age group were more likely to experience a hyperglycaemic event compared to early adults (adjusted risk ratio, aRR: 1.56, 95% confidence interval [CI]: 1.25-1.96), which was attenuated by CSII use (aRR: 1.13, 95% CI: 0.7-1.69).

CONCLUSIONS

Transition-aged adults with type 1 diabetes had a significantly higher mean HbA_1c and risk of hyperglycaemic events compared to early adults. This difference was attenuated for CSII users, indicating that a government-funded CSII programme is associated with narrowing of the gap in glycaemic control and associated adverse outcomes for this population.

A Subsidized Healthy Food Prescription Program for Adults With Type 2 Diabetes Who Are Experiencing Food Insecurity: Protocol for a Randomized Controlled Trial

Objectives

It is vital for individuals with type 2 diabetes (T2DM) to adhere to a healthy dietary pattern to maintain optimal blood glucose levels and overall health. Increasing costs of healthy foods, however, are a barrier to maintaining healthful dietary patterns, particularly for individuals with T2DM who are experiencing food insecurity. Poor diet quality may result in difficulties maintaining optimal blood glucose levels, leading to higher rates of diabetes complications, and increased acute care usage and costs. Although the adverse impacts of food insecurity on maintaining optimal blood glucose levels are well documented, effective strategies to this among individuals with T2DM are lacking. One approach is providing subsidies to purchase healthy foods through subsidized healthy food prescription programs. These programs may help reduce food insecurity and improve diet quality, thereby improving blood glucose levels and reducing diabetes complications over time.

Methods

A parallel group randomized controlled trial will examine the effectiveness of a subsidized healthy food prescription program compared to a healthy food prescription alone in improving average blood glucose levels (primary outcome), and other secondary outcomes among 404 adults who are experiencing food insecurity and persistent hyperglycemia. The subsidized healthy food prescription program consists of two core elements: 1) A one-time healthy food prescription pamphlet that outlines an evidence-based healthy dietary pattern; 2) A healthy food subsidy of $1.50/day/household member to purchase healthy foods in participating supermarkets for 6 months. At baseline and 6-month follow-up, participants will provide responses to sociodemographic and health-related items, and a variety of patient-reported outcomes. Biochemical and physical measurements will also be obtained.

Results

The study's theory of change posits that reducing food insecurity and improving diet quality will be key mediators in improving blood glucose levels, which may reduce diabetes complications, and healthcare usage and costs over time.

Conclusions

The results of this study will demonstrate if a subsidized healthy food prescription program results in meaningful changes in average blood glucose levels and other clinically relevant outcomes.

Funding Sources

Alberta Innovates, Alberta Health Services.

The quality of diabetes care among cancer survivors: a retrospective cohort study

BACKGROUND

As cancer survivorship continues to improve, management of co-morbid diabetes has become an increasingly important determinant of health outcomes for people with cancer. This study aimed to compare indicators of diabetes quality of care between people with diabetes and without a history of cancer.

METHODS

We used the Electronic Medical Record Administrative data Linked Database (EMRALD), a database of Ontario primary care EMR charts linked to administrative data, to identify people with diabetes and at least 1 year follow-up. Persons with a history of cancer were matched 1:2 on age, sex and diabetes duration to those without cancer. We compared recommended diabetes quality of care indicators between persons with and without cancer using a matched cohort analysis.

RESULTS

Among 229,627 people with diabetes, we identified 2275 people with cancer and 4550 matched controls; 86.5% had diabetes diagnosed after cancer. Compared to controls, cancer people with diabetes were significantly less likely to receive ACE inhibitors or angiotensin receptor blockers (OR 0.75 [95% CI 0.64-0.89]), receive statin therapy if age 50-80 years (OR 0.79 [95% CI 0.68-0.92]) and achieve an LDL cholesterol level <2.0 mmol/L (OR 0.82 [95% CI 0.74-0.91]). There were no differences in recommended clinical testing or achieving A1C and blood pressure targets between groups.

CONCLUSION

Cancer survivors with diabetes are less likely to receive recommended cardiovascular risk-reducing therapies compared to people with diabetes without cancer of similar age, sex and diabetes duration. Further studies are warranted to determine if these associations are linked to worse survival, cardiovascular outcomes and quality of life.

Risk of type 2 diabetes mellitus in women with prior hypertensive disorders of pregnancy: a systematic review and meta-analysis

AIMS/HYPOTHESIS

The association between a history of hypertensive disorders of pregnancy (HDP) and subsequent type 2 diabetes (referred to throughout as diabetes) remains inconclusive. We reviewed the most recent evidence to quantify the association of previous HDP with incident diabetes.

METHODS

A systematic search of MEDLINE, Embase and CINAHL was performed up to 17 February 2020 to identify observational studies of the association between HDP (pre-eclampsia or gestational hypertension) and incident diabetes. Studies of women with pre-pregnancy diabetes were excluded. Two independent reviewers screened citations and abstracted results. Study quality was assessed in duplicate using the Newcastle-Ottawa Scale. Random-effects models were used to pool effect estimates. Heterogeneity was assessed using the I² statistic.

RESULTS

After screening 4617 citations, 16 cohort studies with a total of 3,095,457 participants were included (unspecified HDP n = 5, pre-eclampsia only n = 4, gestational hypertension and pre-eclampsia n = 7). Risks of subsequent diabetes were significantly higher in women with a history of any HDP (HDP: adjusted hazard ratio [aHR] 2.24, 95% CI 1.95, 2.58; gestational hypertension: aHR 2.19 [95% CI 1.69, 2.84]; pre-eclampsia: aHR 2.56 [95% CI 2.02, 3.24]; preterm pre-eclampsia: aHR 3.05 [95% CI 2.05, 4.56]). The association between HDP and diabetes persisted in studies that adjusted for gestational diabetes mellitus (aHR 2.01 [95% CI 1.77, 2.28]).

CONCLUSIONS/INTERPRETATION

HDP are independently associated with a higher risk of diabetes. Further study is needed to determine how HDP contribute to diabetes risk prediction to develop evidence-based screening and prevention strategies. Graphical abstract.

Validation of a type 1 diabetes algorithm using electronic medical records and administrative healthcare data to study the population incidence and prevalence of type 1 diabetes in Ontario, Canada

INTRODUCTION

We aimed to develop algorithms distinguishing type 1 diabetes (T1D) from type 2 diabetes in adults ≥18 years old using primary care electronic medical record (EMRPC) and administrative healthcare data from Ontario, Canada, and to estimate T1D prevalence and incidence.

RESEARCH DESIGN AND METHODS

The reference population was a random sample of patients with diabetes in EMRPC whose charts were manually abstracted (n=5402). Algorithms were developed using classification trees, random forests, and rule-based methods, using electronic medical record (EMR) data, administrative data, or both. Algorithm performance was assessed in EMRPC. Administrative data algorithms were additionally evaluated using a diabetes clinic registry with endocrinologist-assigned diabetes type (n=29 371). Three algorithms were applied to the Ontario population to evaluate the minimum, moderate and maximum estimates of T1D prevalence and incidence rates between 2010 and 2017, and trends were analyzed using negative binomial regressions.

RESULTS

Of 5402 individuals with diabetes in EMRPC, 195 had T1D. Sensitivity, specificity, positive predictive value and negative predictive value for the best performing algorithms were 80.6% (75.9-87.2), 99.8% (99.7-100), 94.9% (92.3-98.7), and 99.3% (99.1-99.5) for EMR, 51.3% (44.0-58.5), 99.5% (99.3-99.7), 79.4% (71.2-86.1), and 98.2% (97.8-98.5) for administrative data, and 87.2% (81.7-91.5), 99.9% (99.7-100), 96.6% (92.7-98.7) and 99.5% (99.3-99.7) for combined EMR and administrative data. Administrative data algorithms had similar sensitivity and specificity in the diabetes clinic registry. Of 11 499 711 adults in Ontario in 2017, there were 24 789 (0.22%, minimum estimate) to 102 140 (0.89%, maximum estimate) with T1D. Between 2010 and 2017, the age-standardized and sex-standardized prevalence rates per 1000 person-years increased (minimum estimate 1.7 to 2.56, maximum estimate 7.48 to 9.86, p<0.0001). In contrast, incidence rates decreased (minimum estimate 0.1 to 0.04, maximum estimate 0.47 to 0.09, p<0.0001).

CONCLUSIONS

Primary care EMR and administrative data algorithms performed well in identifying T1D and demonstrated increasing T1D prevalence in Ontario. These algorithms may permit the development of large, population-based cohort studies of T1D.

Risks of preoperative anemia in women undergoing elective hysterectomy and myomectomy

BACKGROUND

Hysterectomy is one of the most common surgeries performed worldwide. Identification of modifiable risk factors for complications or readmissions could lead to targeted interventions to improve patient care and reduce health care costs. Preoperative anemia has been identified as a risk factor for adverse postoperative outcomes following noncardiac surgery. However, studies have not focused on young and healthy surgical populations, such as women undergoing gynecologic surgery for benign indications.

OBJECTIVE

The purpose of this study was to evaluate whether preoperative anemia in women undergoing elective hysterectomy or myomectomy for benign indications was associated with increased 30 day postoperative morbidity and mortality.

STUDY DESIGN

In this retrospective, population-based cohort study, we followed up adult women (≥18 years of age) who underwent elective hysterectomy or myomectomy (laparoscopic/laparotomy) between the years 2013 and 2015 for benign indications in Ontario, Canada. We used linked administrative data from a government-administered, single-payer provincial health care system using Canadian Classification of Health Interventions intervention codes, International Classification of Diseases, 10th revision, diagnostic codes, physician billing codes, and laboratory data from both community and hospital laboratories across the province. Our exposure of interest was preoperative anemia, defined as a hemoglobin value <12 g/dL on the complete blood count measured closest to the date of surgery. Our primary outcome was the composite of 30 day postoperative morbidity and mortality. Secondary outcomes were 5 individual components of the primary outcome: death, transfusion, surgical site infection, venothromboembolism, and return to the hospital within 30 days. To adjust for confounding, we generated a propensity score using a multiple logistic regression model in which the presence of anemia was regressed on all baseline characteristics. We matched anemic to nonanemic patients on the logit of the propensity score. Using an unadjusted log-binomial model estimated using generalized estimating equations to account for the matched pairs, we calculated the relative risk, 95% confidence intervals, and P values to evaluate the effect of anemia on outcomes.

RESULTS

Of the 16,218 women in the cohort, 3664 (22.6%) had anemia. After propensity matching, standardized differences in all baseline characteristics (n = 3261 per group) were <0.10. In the matched cohort, the primary outcome (death, complications, or readmission) occurred in 41.2% of anemic patients and 36.2% of nonanemic patients (relative risk, 1.14, 95% confidence interval, 1.07-1.21, P < .0001; absolute risk reduction, 5.03%, 95% confidence interval, 2.70-7.36; (number needed to harm = 20). The risk of transfusion was significantly higher in anemic patients (relative risk, 3.25, 95% confidence interval, 2.67-3.95, P < .0001; absolute risk reduction, 8.34%, 95% confidence interval, 7.06-9.63; number needed to harm = 12). There was no difference in other secondary outcomes. In a subgroup analysis (women >55 years vs ≤55, n = 736), older women were at increased risk of the primary outcome (relative risk, 1.40, 95% confidence interval, 1.12-1.76, P = .004), transfusion (relative risk, 4.20, 95% confidence interval, 1.65-10.72, P = .003), surgical site infection (relative risk, 1.35, 95% confidence interval, 1.01-1.81, P = .04), and return to the hospital (relative risk, 2.36, 95% confidence interval, 1.54-3.62, P < .0001).

CONCLUSION

Preoperative anemia in women undergoing elective hysterectomy/myomectomy was common and is an independent risk factor for 30 day postoperative adverse outcomes, especially in older women.

Denosumab and breast cancer risk in postmenopausal women: a population-based cohort study

BACKGROUND

Denosumab inhibits the receptor activator of nuclear factor κB (RANK) pathway and is used to treat osteoporosis. Emerging evidence suggests RANK-blockade may play a role in mammary tumourigenesis. Thus, we undertook a population-based study of denosumab use and breast cancer risk in a large cohort of postmenopausal women.

METHODS

We included women 67+ years with prior bisphosphonate use who filled a first prescription for denosumab. They were matched on age, date, cumulative prior use of and time since last use of a bisphosphonate to women with no history of denosumab. Cox proportional hazards was used to estimate the hazard ratio (HR) of breast cancer with denosumab use.

RESULTS

A total of 100,368 women were included in the analysis with 1271 incident breast cancer events. Denosumab use was associated with a 13% decreased breast cancer risk (HR = 0.87; 95% CI 0.76-1.00). There was no relationship between increasing number of denosumab doses and breast cancer risk (P-trend = 0.15).

CONCLUSION

These findings suggest a potential protective effect of ever denosumab use on breast cancer risk in a cohort of older women previously treated with bisphosphonates.

The impact of hip and knee osteoarthritis on the subsequent risk of incident diabetes: a population-based cohort study

AIMS/HYPOTHESIS

This study examined the relationship between hip/knee osteoarthritis and incident diabetes. We hypothesised that hip/knee osteoarthritis would be independently related to an increased risk of incident diabetes and that this relationship would be due, at least in part, to walking difficulty. We also hypothesised a stronger relationship with incident diabetes for knee than hip osteoarthritis because of the higher prevalence in the former of obesity/the metabolic syndrome.

METHODS

A population cohort aged ≥55 years recruited from 1996 to 1998 was followed through provincial health administrative data to 2014. Participants with baseline diabetes were excluded. Hip/knee osteoarthritis was defined as swelling, pain or stiffness in any joint lasting 6 weeks in the past 3 months and indication on a joint homunculus that a hip/knee was 'troublesome'. Walking limitation was defined as self-reported difficulty standing or walking in the last 3 months (yes/no). Using Cox regressions, we examined the relationship of baseline hip/knee osteoarthritis with incident diabetes as defined from health administrative data, controlling for age, sex, BMI, income, prior hypertension, cardiovascular disease and primary care exposure. We tested whether the observed effect was mediated through walking limitation.

RESULTS

In total, 16,362 participants were included: median age 68 years and 61% female. Of these, 1637 (10%) individuals met the criteria for hip osteoarthritis, 2431 (15%) for knee osteoarthritis and 3908 (24%) for walking limitation. Over a median follow-up of 13.5 years (interquartile range 7.3-17.8), 3539 individuals (22%) developed diabetes. Controlling for confounders, a significant relationship was observed between number of hip/knee joints with osteoarthritis and incident diabetes: HR for two vs no osteoarthritic hips 1.25 (95% CI 1.08, 1.44); HR for two vs no osteoarthritic knees 1.16 (95% CI 1.04, 1.29). From 37% to 46% of this relationship was explained by baseline walking limitation.

CONCLUSIONS/INTERPRETATION

In a large population cohort aged ≥55 years who were free of diabetes at baseline, and controlling for confounders, the presence and burden of hip/knee osteoarthritis was a significant independent predictor of incident diabetes. This association was partially explained by walking limitation. Increased attention to osteoarthritis and osteoarthritis-related functional limitations has the potential to reduce diabetes risk.

Abstract 2204: Influence of chronic comorbidities on colorectal cancer screening adherence in a population-based Canadian cohort

Background: Regular screening for colorectal cancer (CRC) is associated with a lower stage at diagnosis and improved survival. National guidelines recommend periodic screening for adults aged 50-74 years. Chronic diseases may distract from regular screening and increase CRC burden. We sought to determine whether having certain chronic conditions is associated with a lower rate of CRC screening adherence.

Methods: Using linked healthcare databases from Ontario, Canada, we assembled a population-based cohort of adults aged 50-74 years, who were eligible and overdue for routine CRC screening (fecal occult blood testing &gt; 2 years, sigmoidoscopy &gt; 5 years, or colonoscopy &gt; 10 years) at any point between April 1, 2004 and March 31, 2016. We implemented Andersen-Gill extended Cox models for recurrent events using an age time scale to examine the impact of chronic conditions on the relative rate (RR, 95% confidence interval, CI) of becoming adherent with periodic CRC tests, adjusted for the relevant time-varying covariates.

Results: During the 12-year observation window, included individuals contributed a total of 19,818,050 person-years spent overdue for CRC tests. Over 70% of all CRC tests performed during the study period were fecal occult blood tests. At baseline, of the 4,642,422 individuals that met the inclusion criteria, 31% had hypertension, 12% had diabetes, 9% had chronic obstructive pulmonary disease (COPD), 7% had mental illness, 5% had cardiovascular disease (CVD), 1.6% had congestive heart failure (CHF), and 0.1% had end-stage renal disease (ESRD). After adjustment for sociodemographic and health system factors, the highest rates of nonadherence were observed for ESRD on dialysis (RR 0.66, CI 0.63-0.68), CHF (RR 0.75, CI 0.75-0.76), COPD (RR 0.84, CI 0.83-0.84), CVD (RR 0.85, CI 0.84-0.85), diabetes (RR 0.86, CI 0.86-0.87), and mental illness (RR 0.88, CI 0.87-0.88). Hypertension (RR 0.98, CI 0.97-0.98) and ESRD with kidney transplant (RR 1.00, CI 0.84-1.19) were associated with modest to no risk.

Conclusion: The presence of a major chronic condition is associated with lower adherence to CRC screening. Future studies should explore reasons for lower CRC screening adherence in individuals with chronic conditions and the appropriateness of secondary cancer prevention and early diagnosis in this population.

Citation Format: Dominika Bhatia, Rinku Sutradhar, Jill Tinmouth, Simron Singh, Lorraine Lipscombe. Influence of chronic comorbidities on colorectal cancer screening adherence in a population-based Canadian cohort [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2204.

Osteoarthritis-related difficulty walking and risk for diabetes complications

OBJECTIVES

To examine the effect of Osteoarthritis (OA)-related difficulty walking on risk for diabetes complications in persons with diabetes and OA.

DESIGN

A population cohort aged 55+ years with symptomatic hip and knee OA was recruited 1996-98 and followed through provincial administrative data to 2015 (n = 2,225). In those with confirmed OA (examination and radiographs) and self-reported diabetes at baseline (n = 359), multivariate Cox regression modeling was used to examine the relationship between baseline difficulty walking (Health Assessment Questionnaire (HAQ) difficulty walking score; use of walking aid) and time to first diabetes-specific complication (hospitalization for hypo- or hyperglycemia, infection, amputation, retinopathy, or initiation of chronic renal dialysis) and cardiovascular (CV) events.

RESULTS

Participants' mean baseline age was 71.4 years; 66.9% were female, 77.7% had hypertension, 54.0% had pre-existing CV disease, 42.9% were obese and 15.3% were smokers. Median HAQ difficulty walking score was 2/3 indicating moderate to severe walking disability; 54.9% used a walking aid. Over a median 6.1 years, 184 (51.3%) experienced one or more diabetes-specific complications; 191 (53.2%) experienced a CV event over a median 5.7 years. Greater baseline difficulty walking was associated with shorter time to the first diabetes-specific complication (adjusted HR per unit increase in HAQ walking 1.24, 95% CI 1.04-1.47, P = 0.02) and CV event (adjusted HR for those using a walking aid 1.35, 95% CI 1.00-1.83, P = 0.04).

CONCLUSIONS

In a population cohort with OA and diabetes, OA-related difficulty walking was a significant - and potentially modifiable - risk factor for diabetes complications.

Choosing Wisely in oncology: Screening for a new primary cancer in patients with metastatic disease

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Background: The Choosing Wisely Canada (CWC) campaign aims to start conversations about unnecessary treatments and procedures in order to improve quality of care. In particular, the CWC campaign in cancer seeks to reduce interventions that are not supported by evidence and contribute to unnecessary rising costs of cancer care. We sought to document the performance of cancer screening for a new primary cancer in patients with existing metastatic cancer (CWC statement #2). Methods: We used population-based administrative health care databases from Ontario, Canada held at the Institute for Clinical Evaluative Sciences (ICES). The cohort included all adult residents of Ontario of eligible screening age (age 50 or older) diagnosed with incident, stage 4 (metastatic) colorectal cancer (CRC), lung, breast, or prostate cancer between January 1, 2007 and December 31, 2012. We examined screening tests for CRC and breast cancer in the first 1 and 3 years after diagnosis of an unrelated cancer. Given the high mortality rate in this population, screening rates were calculated using the cumulative incidence function which takes into account the competing risk of death or the occurrence of the cancer for which the patient was being screened (prior to being screened). Results: Among the 20,992 patients with stage 4 lung, breast, or prostate cancer, CRC screening within 1 year of cancer diagnosis occurred in 2.8%, 6.1%, and 13.0%, respectively. Within 3 years of diagnosis, screening rates were 3.9%, 11.9%, and 26.9%, respectively. Among the 10,034 women with metastatic CRC or lung cancer, breast cancer screening within 1 year of cancer diagnosis occurred in 8.0% and 8.7% of women, respectively. Within 3 years of diagnosis, screening rates were13.1% and 10.2%, respectively. Screening rates were higher in patients age 50-74 than those ≥75 years. Conclusions: Our findings indicate that up to one quarter of patients with metastatic cancer receive subsequent screening tests for other cancers, which are unnecessary as these patients are unlikely to benefit. Further studies are warranted to examine resource implications, potential patient and societal harms, and the future impact of the CWC campaign on this practice.

The relation between total joint arthroplasty and risk for serious cardiovascular events in patients with moderate-severe osteoarthritis: propensity score matched landmark analysis

STUDY QUESTION

What are the rates of serious cardiovascular events in those who undergo primary total joint arthroplasty (TJA) compared with those who do not within three years of initial assessment?

SUMMARY ANSWER

Undergoing elective primary TJA within three years of initial assessment was associated with a significant 12.4% absolute reduction in subsequent risk of serious cardiovascular events.

WHAT IS KNOWN AND WHAT THIS PAPER ADDS

Osteoarthritis is associated with increased mortality, particularly secondary to cardiovascular disease, with the risk for mortality proportional to the degree of disability secondary to the arthritis. This study suggests that management of hip or knee osteoarthritis with arthroplasty decreases the risk for subsequent serious cardiovascular events.

A population-based study of ethnicity and breast cancer stage at diagnosis in Ontario

BACKGROUND

Breast cancer stage at diagnosis is an important predictor of survival. Our goal was to compare breast cancer stage at diagnosis (by American Joint Committee on Cancer criteria) in Chinese and South Asian women with stage at diagnosis in the remaining general population in Ontario.

METHODS

We used the Ontario population-based cancer registry to identify all women diagnosed with breast cancer during 2005-2010, and we applied a validated surname algorithm to identify South Asian and Chinese women. We used logistic regression to compare, for Chinese or South Asian women and for the remaining general population, the frequency of diagnoses at stage ii compared with stage i and stages ii-iv compared with stage i.

RESULTS

The registry search identified 1304 Chinese women, 705 South Asian women, and 39,287 women in the remaining general population. The Chinese and South Asian populations were younger than the remaining population (mean: 54, 57, and 61 years respectively). Adjusted for age, South Asian women were more often diagnosed with breast cancer at stage ii than at stage i [odds ratio (or): 1.28; 95% confidence interval (ci): 1.08 to 1.51] or at stages ii-iv than at stage i (or: 1.27; 95% ci: 1.08 to 1.48); Chinese women were less likely to be diagnosed at stage ii than at stage i (or: 0.82; 95% ci: 0.72 to 0.92) or at stages ii-iv than at stage i (or: 0.73; 95% ci: 0.65 to 0.82).

CONCLUSIONS

Breast cancers were diagnosed at a later stage in South Asian women and at an earlier stage in Chinese women than in the remaining population. A more detailed analysis of ethnocultural factors influencing breast screening uptake, retention, and care-seeking behavior might be needed to help inform and evaluate tailored health promotion activities.

Higher potency statins and the risk of new diabetes: multicentre, observational study of administrative databases

OBJECTIVE

To evaluate the incremental increase in new onset diabetes from higher potency statins compared with lower potency statins when used for secondary prevention.

DESIGN

Eight population based cohort studies and a meta-analysis.

SETTING

Six Canadian provinces and two international databases from the UK and US.

PARTICIPANTS

136,966 patients aged ≥ 40 years newly treated with statins between 1 January 1997 and 31 March 2011.

METHODS

Within each cohort of patients newly prescribed a statin after hospitalisation for a major cardiovascular event or procedure, we performed as-treated, nested case-control analyses to compare diabetes incidence in users of higher potency statins with incidence in users of lower potency statins. Rate ratios of new diabetes events were estimated using conditional logistic regression on different lengths of exposure to higher potency versus lower potency statins; adjustment for confounding was achieved using high dimensional propensity scores. Meta-analytic methods were used to estimate overall effects across sites.

MAIN OUTCOME MEASURES

Hospitalisation for new onset diabetes, or a prescription for insulin or an oral antidiabetic drug.

RESULTS

In the first two years of regular statin use, we observed a significant increase in the risk of new onset diabetes with higher potency statins compared with lower potency agents (rate ratio 1.15, 95% confidence interval 1.05 to 1.26). The risk increase seemed to be highest in the first four months of use (rate ratio 1.26, 1.07 to 1.47).

CONCLUSIONS

Higher potency statin use is associated with a moderate increase in the risk of new onset diabetes compared with lower potency statins in patients treated for secondary prevention of cardiovascular disease. Clinicians should consider this risk when prescribing higher potency statins in secondary prevention patients.