Assessment of the management and clinical outcomes of patients with non-diabetic hyperglycaemia and newly diagnosed type 2 diabetes in primary care in England

Background It is unknown whether the detection of non-diabetic hyperglycaemia before the diagnosis of Type 2 diabetes is associated with vascular disease at time or following the diagnosis of Type 2 diabetes. Aim I assessed the association between glycaemic testing and detection of non-diabetic hyperglycaemia before the diagnosis of Type 2 diabetes is associated and vascular disease at time or following the diagnosis of Type 2 diabetes. Methods I identified 159,736 individuals with newly diagnosed Type 2 diabetes from the CPRD database in England between 2004 and 2017. I used logistic regression models to compare presence of vascular disease at the time of Type 2 diabetes diagnosis by prior glycaemic status. I employed time-partitioned Cox regression models to model differences in rates of vascular disease and mortality following the diagnosis of Type 2 diabetes. Results Half of the study population (49.9%) had at least one vascular disease, over one-third (37.4%) had microvascular disease, and almost a quarter (23.5%) had a diagnosed macrovascular disease at the time of Type 2 diabetes diagnosis. Individuals with prior non-diabetic hyperglycaemia were more likely to have microvascular disease and coronary heart disease at time of diagnosis of Type 2 diabetes. As compared with individuals with glycaemic values within the normal range in the three years before the diagnosis of Type 2 diabetes, those detected with non-diabetic hyperglycaemia had increased risk of microvascular disease that persisted up to 7.5 years. Conclusions Non-diabetic hyperglycaemia before diagnosis of Type 2 diabetes is associated with increased odds of microvascular disease and coronary heart disease in newly diagnosed Type 2 diabetes. It is also associated with increased rates of microvascular disease following the diagnosis of Type 2 diabetes. Detection of non-diabetic hyperglycaemia might represent an opportunity for a timely identification of NDH and specific clustering of NDH with other risk factors for T2D, which might prompt earlier assessment for risk factors and tailored cardiovascular risk reduction strategies during the NDH phase to reduce the burden of vascular disease.Open Acces

Economic evaluation of a community-based diagnostic pathway to stratify adults for non-alcoholic fatty liver disease: a Markov model informed by a feasibility study

Objectives: To assess the long-term cost-effectiveness of a risk stratification pathway, compared with standard care, for detecting non-alcoholic fatty liver disease (NAFLD) in primary care. Setting: Primary care general practices in England. Participants: Adults who have been identified in primary care to have a risk factor for developing NAFLD, that is, type 2 diabetes without a history of excessive alcohol use. Intervention: A community-based pathway, which utilises transient elastography and hepatologists to stratify patients at risk of NAFLD, has been implemented and demonstrated to be feasible (NCT02037867). Earlier identification could mean earlier treatments, referral to specialist, and enrolment into surveillance programmes. Design: The impact of earlier detection and treatment with the risk stratification pathway on progression to later stages of liver disease was examined using decision modelling with Markov chains to estimate lifetime health and economic effects of the two comparators. Data sources: Data from a prospective cross-sectional feasibility study indicating risk stratification pathway and standard care diagnostic accuracies, were combined with a Markov model that comprised the following states: no/mild liver disease, significant liver disease, compensated cirrhosis; decompensated cirrhosis, hepatocellular carcinoma, liver transplant and death. The model data were chosen from up-to-date UK sources, published literature and an expert panel. Outcome measure: An incremental cost-effectiveness ratio (ICER) indicating cost per quality adjusted life year (QALY) of the risk stratification pathway compared with standard care was estimated. Results: The risk stratification pathway was more effective than standard care, and cost ￡2,138 per QALY gained. The ICER was most sensitive to estimates of the rate of fibrosis progression and the effect of treatment on reducing this, and ranged from -￡1,895 to ￡7,032/QALY. The risk stratification pathway demonstrated an 85% probability of cost-effectiveness at the UK willingness-to-pay threshold of ￡20,000/QALY. Conclusions: Implementation of a community-based risk stratification pathway is likely to be cost effective

Badania przesiewowe dotyczące zaburzeń metabolizmu węglowodanów u mieszkańców domu pomocy społecznej w Rzeszowie

Introduction: To screen for undiagnosed type 2 diabetes and other disturbances of the glucose metabolism in welfare home residents in Rzeszów. Material and methods: 478 residents of four randomly selected welfare homes in Rzeszów were initially enrolled in the study. Among them were 66 residents with previously diagnosed diabetes. Of the remaining 412 adults, 191 (39 males) aged 66.0 ± 17.7 years were enrolled in the study having completed informed consent. All subjects underwent measurements of fasting glucose levels using a glucose meter (Roche Accu-Chek Active, Mannheim, Germany). In participants whose glucose levels exceeded 99 mg/dL, an oral glucose tolerance test (OGTT) was performed. The results of OGTT were qualified as impaired fasting glucose (IFG), impaired glucose tolerance (IGT), or diabetes mellitus (DM). Results: Among the 191 participants, we found 26 cases of IFG (13.6%), 25 of IGT (13.1%), and ten (5.2%) cases of newly diagnosed T2DM. Conclusions: This study highlights that in Polish welfare homes greater medical vigilance is needed in order to optimise the health of residents. (Endokrynol Pol 2012; 63 (6): 483–486)Wstęp: Celem pracy było określenie występowania zaburzeń metabolizmu węglowodanów oraz cukrzycy typu 2 u mieszkańców domów pomocy społecznej (DPS) w Rzeszowie. Materiał i metody: Badaniem objęto 478 mieszkańców z 4 losowo wybranych DPS w Rzeszowie. Wśród nich było 66 mieszkańców z wcześniej rozpoznaną cukrzycą. Spośród pozostałych 412 dorosłych osób do badania, po uzyskaniu świadomej zgody, włączono 191 osób (152 kobiety i 39 mężczyzn) w wieku 66,0 ± 17,7 roku. U wszystkich pacjentów wykonano pomiary stężenia glukozy na czczo przy użyciu glukometru (Roche Accu Chek Active Mannheim, Niemcy). U osób, u których stężenie glukozy przekraczało wartość 99 mg/dl, przeprowadzono doustny test tolerancji glukozy (OGTT).Wyniki OGTT kwalifikowano jako nieprawidłową glikemią na czczo (IFG), upośledzoną tolerancję glukozy (IGT) lub cukrzycę (DM). Wyniki: Wśród 191 uczestników badania stwierdzono 26 przypadków IFG (13,6%), 25 przypadków IGT (13,1%) i 10 (5,2%) przypadków nowo zdiagnozowanej cukrzycy typu 2. Wnioski: Badanie to wskazuje, że w domach opieki medycznej konieczna jest większa czujność diabetologiczna w celu optymalizacji zdrowia mieszkańców. (Endokrynol Pol 2012; 63 (6): 483–486

Engagement of private healthcare providers for case finding of tuberculosis and diabetes mellitus in Pakistan

Background: The rising co-epidemic of tuberculosis (TB) and diabetes mellitus (DM) is a challenge for constrained health systems in low and middle-income countries. Diabetes is a known risk factor for tuberculosis and associated with poor tuberculosis treatment outcomes, while tuberculosis is associated with worsening glycemic control. We investigated the performance of bi-directional TB and DM case finding approaches through a private-sector engagement model in Karachi, Pakistan.Methods: Between July 2016 and July 2018, private health care providers were engaged to generate referrals for bi-directional TB and DM screening at private diagnostic and treatment centers in Karachi, Pakistan. Individuals diagnosed with TB underwent glycated hemoglobin (HbA1c) testing at the time of anti-tuberculous treatment initiation and at three -month follow up stage. All individuals with a history of diabetes or random blood sugar of greater than 200 mg/dl were screened for TB using a chest X-ray and Xpert MTB/RIF.Results: A total of 6312 persons with tuberculosis were tested on HbA1c at treatment initiation, of whom 1516 (24%) were newly diagnosed with DM. About one third of those with HbA1c in the diabetic range (≥ 6.5%) at baseline were found to have a normal HbA1c (\u3c 5.7%) result at 3-month follow-up. A total of 3824 individuals with DM, of whom 2396 (63%) were known cases and 1428 (37%) were newly identified with random blood sugar \u3e 200 mg/dl, underwent chest x-ray and Xpert MTB/RIF testing, with 321 (13.4%) known and 54 (3.8%) new diabetics respectively identified with tuberculosis.Conclusion: This study demonstrates a high yield of TB and DM through bidirectional screening and the feasibility of engagement of private sector in finding missing cases of tuberculosis and diabetes. Given the high prevalence of undiagnosed DM in individuals with TB tuberculosis patients, there is a need to scale-up DM screening within TB programmes. Increased awareness of the high risk of TB among individuals with DM is needed among private health providers and screening for TB among diabetics should be strongly considered

Polypharmacy difference between older people with and without diabetes: evidence from the English Longitudinal Study of Ageing

Aim: To study the association between diabetes and the prevalence of and risk factors for polypharmacy among adults aged 50 and older in England. / Methods: A cross-sectional study (2012−2013) of the English Longitudinal Study of Ageing. Polypharmacy was defined as taking 5-9 long-term medications a day and heightened polypharmacy as 10 or more. Diabetes included diagnosed and undiagnosed cases (glycated haemoglobin ≥ 6.5% (48 mmol/mol)). / Results: Of 7729 participants, 1100 people had diabetes and showed higher prevalence rates of polypharmacy (41.1% vs 14.8%) and heightened polypharmacy (5.8% vs 1.7%) than those without diabetes, even when antihyperglycemic medications were excluded. Risk factors for polypharmacy also differed according to diabetes status. Among people with diabetes, risk factors for polypharmacy and heightened polypharmacy were having more long-term conditions (relative risk ratio (RRR) =1.86; 3.51) and being obese (RRR=1.68; 3.68), while females were less likely to show polypharmacy (RRR=0.51) and heightened polypharmacy (RRR=0.51) than males. Older age (RRR=1.04) was only related to polypharmacy among people without diabetes. / Conclusions: Adults with diabetes had higher prevalence rates of polypharmacy and heightened polypharmacy than those without diabetes, regardless of including antihyperglycemic drugs. Early detection of polypharmacy among older people with diabetes needs to focus on co-morbidities and obesity

Thyroid Dysfunction - Can it Help Explain the Gender Wage Gap?

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AN INVESTIGATION OF CHANGES IN DIABETES TRENDS AFTER THE AFFORDABLE CARE ACT

INTRODUCTION: Diabetes Mellitus (DM) is one of the fastest growing and most costly chronic diseases in the United States. DM is severely underdiagnosed, resulting in increased complications, costs, and mortality. Primary goals of the Affordable Care Act (ACA) were to increase health insurance coverage and access to care, and to improve chronic disease outcomes. However, the effects of the legislation have not been widely studied, particularly the relationship between proper diabetes diagnosis and a variety of health related factors. AIM: Determine the relationship between DM prevalence and under-diagnosis, to healthcare utilization, usual source of care, insurance, type of insurance, and population characteristics have changed since the implementation of the ACA. METHODS: Data collected between 2005 and 2016 in the National Health and Nutrition Examination Survey were used for this work. The Andersen behavioral health model was used as a theoretical framework and selection of study variables. Descriptive statistics and advanced statistical modeling techniques were applied. Distinct multilevel models were used to model the logit of the probability of DM and the logit of the probability of a proper DM diagnosis each as a function of study variables with an indicator of pre- or post-ACA included as a fixed effect. Marginal models are multilevel models that apply population averaged estimates for parameters. Marginal models were specified to account for clustering by time, and generalized estimating equations used to estimate model parameters. The quasi-likelihood under the null (QIC) statistic was estimated for model comparisons. The SAS Software System was used for data analysis and the level of significance set at .05. RESULTS: The sample consisted of 31,225 participants, with half pre-ACA (n=15,612) and half post-ACA. Females comprised 51.64% of the study sample with 43.50% White, 25.82% Hispanic, and 20.65% Black and a mean (standard deviation) age of 49.3 (17.9) years. About 11.45% of those in the Pre ACA period had a diagnosis of DM, while 13.5% of those in the Post ACA period had a diagnosis of DM. The percentage of uninsured was 23.95% in the Pre ACA period and 20.69% in the Post ACA time period. The prevalence of undiagnosed DM patients was 26.7% before the ACA, and 21.3% after. A multilevel model with DM status as the dependent outcome showed that sex (females vs males: OR=0.83, 95%CI=0.78,0.89,p =.02), USC (yes vs no: OR=1.28, 95%CI=1.03,1.59, p=.03), health insurance (yes vs no: OR=1.21, 95%CI=1.17,1.26, p =.02), and education level(college graduate vs less than high school: OR=0.79, 95%CI=0.64,0.97, p=.05, high school graduate vs less than high school: OR=0.97, 95%CI=0.93,1.03, p=.05) were significantly associated with presence of DM. Participants were more likely to have their DM properly diagnosed after the ACA: in the final multivariable multilevel model, only ACA time period had a significant effect on correct DM diagnosis (OR=1.51, 95%CI=1.24,1.85, p=.04). CONCLUSIONS: Although prevalence of DM has increased in recent years, under-diagnosis is less of an issue after the ACA. In the multivariable model comparing DM status (having the disease) to selected covariates, sex, health insurance, education, and USC were related to DM status. The ACA time period had no significant relationship with DM status in the multivariable model. However, in the multivariable model for correctly diagnosed DM, ACA time period was the only independent variable that had a significant association with correct DM diagnosis

Predictive Value of Bronchoalveolar Lavage in Excluding a Diagnosis of Pneumocystis carinii Pneumonia During Prophylaxis with Aerosolized Pentamidine

We assessed the negative predictive value of bronchoalveolar lavage (BAL) for Pneumocystis carinii pneumonia (PCP) during prophylaxis with aerosolized pentamidine. On the basis of the assumption that undiagnosed and untreated PCP would progress and become clinically apparent, for 3 months we prospectively followed 34 consecutive cases in which BAL had not detected PCP. All patients were immunodeficient, had a symptomatic human immunodeficiency virus infection, and were evaluated for possible PCP during prophylaxis with aerosolized pentamidine. No transbronchial biopsies were performed. In 32 of 34 cases, a diagnosis of PCP could be excluded because of other definite diagnoses or improvement during the follow-up. Despite negative results of an examination of their BAL fluid, two patients received empirical treatment that was active against PCP; these patients were regarded as possibly having undiagnosed PCP. Thus, the negative predictive value of BAL alone was at least 94% (32 of 34 cases) in excluding a diagnosis of PCP during prophylaxis with aerosolized pentamidin

The Use Of Non-Invasive Fibrosis Markers In Stratification Care Pathways For The Management Of Chronic Liver Disease

The health, societal and economic consequences of chronic liver disease (CLD) are substantial and increasing exponentially. Cirrhosis is typically detected in the latter stages when prognosis is poor. Timely diagnosis is hindered by reliance on non-discriminatory tests for fibrosis. I explored the role of non-invasive tests (NITs) of liver fibrosis in primary care to promote earlier disease detection. In this thesis, a systematic review revealed a paucity of published studies evaluating NIT in the community setting. A national survey demonstrated that UK specialists consider current fibrosis assessment methods to be sub-optimal, and NIT are important in improving disease stratification in primary care. To benchmark standard care, a one-year retrospective study of GP referrals for non-alcoholic fatty liver disease (NAFLD) established 93% of referrals to have non-significant fibrosis (Brunt ≤ F2) as assessed by liver specialists. Over two-thirds had a low-risk FIB-4 (<1.30) and could have avoided referral, although a quarter of patients with indeterminate FIB-4 (1.30 – 3.25) had significant liver fibrosis suggesting patients in this subgroup warrant further evaluation. As part of the Camden and Islington liver working group, I developed and evaluated a NAFLD pathway that employs FIB-4 and ELF to identify patients with advanced fibrosis or cirrhosis (Brunt ≥ F3 fibrosis). The pathway processed nearly 1500 patients over two years, resulting in a reduction in the proportion of total patients referred and an 81% decrease in referral of patients with non-significant fibrosis. The pathway achieved a 5-fold increase in the referral of patients with advanced fibrosis and 3-fold increase in the detection of liver cirrhosis. To further extrapolate these findings, I developed a probabilistic decision analytical model which tested FIB-4, ELF and fibroscan, either alone or in combination in primary care pathways. Cost consequence analyses revealed all strategies to be clinically effective and cost-saving compared to standard care