Deprescribing in cardiometabolic conditions in older patients: a systematic review

We conduct a systematic review to investigate current deprescribing practices and evaluate outcomes and adverse events with deprescribing of preventive medications in older patients with either an end-of-life designation or residing in long-term care facilities with cardiometabolic conditions. Studies were identified using a literature search of MEDLINE, EMBASE, Web of Science, clinicaltrials.gov.uk, CINAHLS, and the Cochrane Register from inception to March 2022. Studies reviewed included observational studies and randomised control trials (RCTs). Data was extracted on baseline characteristics, deprescribing rates, adverse events and outcomes, and quality of life indicators, and was discussed using a narrative approach. Thirteen studies were identified for inclusion. Deprescribing approaches included complete withdrawal, dose reduction or tapering, or switching to an alternative medication, for at least one preventive medication. Deprescribing success rates ranged from 27 to 94.7%. The studies reported no significant changes in laboratory values or adverse outcomes but did find mixed outcomes for hospitalisations and a slight increase in mortality rates when comparing the intervention and control groups. Lack of good-quality randomised control trials suggests that deprescribing in the older population residing in long-term care facilities with cardiometabolic conditions and multimorbidity is feasible when controlled and regularly monitored by an appropriate healthcare clinician, and that the benefits outweigh the potential harm in this cohort of patients. Due to the limited evidence and the heterogeneity of studies, a meta-analysis was not performed and as such further research is required to assess the benefits of deprescribing in this patient population. Systematic review registration: PROSPERO CRD42021291061.</p

Advancing quantitative methods for the evaluation of complex interventions

An understanding of the impact of health and care interventions and policy is essential for decisions about which to fund. In this essay we discuss quantitative approaches in providing evaluative evidence. Experimental approaches allow the use of ‘gold-standard’ methods such as randomised controlled trials to produce results with high internal validity. However, the findings may be limited with regard to generalisation: that is, feature reduced externality validity. Observational quantitative approaches, including matching, synthetic control and instrumental variables, use administrative, survey and other forms of ‘observational’ data, and produce results with good generalisability. These methods have been developing in the literature and are better able to address core challenges such as selection bias, and so improve internal validity. Evaluators have a range of quantitative methods available, both experimental and observational. It is perhaps a combination of these approaches that is most suited to evaluating complex interventions

Beliefs, practices, perceptions and motivations of healthcare professionals on medication deprescribing during end-of-life care: A systematic review

AimConduct a systematic review to investigate current beliefs, practices, perceptions, and motivations towards deprescribing practices from the healthcare professional perspective in older adults residing in long term care facilities with cardiometabolic conditions, using a narrative approach.MethodsStudies were identified using a literature search of MEDLINE, CINAHL and Web of Science from inception to June 2023 Two reviewers (EH and AA) independently extracted data from each selected study using a standardised self-developed data extraction proforma. Studies reviewed included cross-sectional and observational studies. Data was extracted on baseline characteristics, motivations and beliefs and was discussed using a narrative approach.ResultsEight studies were identified for inclusion. Deprescribing approaches included complete withdrawal, dose reduction, or switching to an alternative medication, for at least one preventive medication. Most healthcare professionals were willing to initiate deprescribing strategies and stated the importance of such interventions, however many felt inexperienced and lacked the required knowledge to feel comfortable doing so.ConclusionDeprescribing is a key strategy when managing older people with cardiometabolic and multiple long term conditions (MLTC). Overall, HCPs including specialists, were happy to explore deprescribing strategies if provided with the relevant training and development to do so. Barriers that still exist include communication and consultation skills, a lack of evidence-based guidance and trust based policies, and a lack of MDT communications and involvement.Systematic review registrationPROSPERO CRD42022335106

Incidence, prevalence, and potential risk factors for diabetic foot ulceration: A retrospective review at a multidisciplinary centre in Barbados

Objective Diabetes and lower extremity amputation rates in Barbados are among some of the highest globally, with peripheral neuropathy and peripheral vascular disease found to be independent risk factors for this population. Despite this, there is currently a lack of research evidence on rates of diabetic foot ulceration, which has amputation as its sequela. We aimed to evaluate the incidence and prevalence rates of active ulceration in a population of people with diabetes in Barbados. Secondly, we explored the risk factors for new/recurrent ulceration. Research Design and Methods Data were extracted from the electronic medical records for the period January 1, 2019 to December 31, 2020 for a retrospective cross-sectional study for patients of a publicly-funded diabetes management programme. Eligible records included people aged 18 years and above with a diagnosis of type 1 or 2 diabetes. Potential risk factors were explored using univariable logistic regression models. Results A total of 225 patients were included in the study (96% type 2 diabetes, 70.7% female, 98.7% Black Caribbean). The 1-year period prevalence of diabetic foot ulceration was 14.7% (confidence interval [CI]: 10.5, 20.1). Incidence of ulceration in the same period was 4.4% (CI: 4.4, 4.5). Risk factors associated with diabetic foot ulceration included: retinopathy (OR 3.85, CI: 1.24, 11.93), chronic kidney disease (OR 9.86, CI: 1.31, 74.22), aspirin use (OR 3.326, CI: 1.02, 10.85), and clopidogrel use (OR 3.13, CI: 1.47, 6.68). Conclusion This study provided some insight into potential risk factors for foot ulceration in this population, which previous studies have shown to have higher rates of lower extremity amputations. Further research in this understudied group through a larger prospective cohort would allow more meaningful associations with risk factors and would be useful for the creation of risk prediction models.</p

Temporal trends in admissions for atrial fibrillation and severe bleeding in England: an 18-year longitudinal analysis

Objective. Temporal trends in admissions for atrial fibrillation (AF) and severe bleeding associated with AF vary worldwide. We aimed to explore their temporal trends in England and their relation to the introduction of DOACs in 2014 in the UK. Design. This longitudinal ecological study utilised aggregated data that was extracted from the Hospital Episode Statistics database, which captured annual admissions for AF and severe bleeding associated with AF between 2001 and 2018. Trends in admissions over the study period and across age groups, gender and regions in England were assessed. Results. In total, there were 11,292,177 admissions for AF and 324,851 admissions for severe bleeding associated with AF. There was a steady rise in admissions for AF from 2001 to 2017 (204,808 to 1,109,295; p for trendp for trend Conclusions. There was a rise in admissions for AF and severe bleeding in England between 2001 and 2018. There is little evidence that the slight drop in admissions for severe bleeding between 2013 and 2014 may have been caused by the introduction of DOACs in 2014. Contributors to these trends need urgent exploration.</p

Progression to type 2 diabetes in women with a known history of gestational diabetes: systematic review and meta-analysis

Objective To estimate and compare progression rates to type 2 diabetes mellitus (T2DM) in women with gestational diabetes mellitus (GDM) and healthy controls.Design Systematic review and meta-analysis.Data sources Medline and Embase between January 2000 and December 2019, studies published in English and conducted on humans.Eligibility criteria for selecting studies Observational studies investigating progression to T2DM. Inclusion criteria were postpartum follow-up for at least 12 months, incident physician based diagnosis of diabetes, T2DM reported as a separate outcome rather than combined with impaired fasting glucose or impaired glucose tolerance, and studies with both a group of patients with GDM and a control group.Results This meta-analysis of 20 studies assessed a total of 1 332 373 individuals (67 956 women with GDM and 1 264 417 controls). Data were pooled by random effects meta-analysis models, and heterogeneity was assessed by use of the I2 statistic. The pooled relative risk for the incidence of T2DM between participants with GDM and controls was estimated. Reasons for heterogeneity between studies were investigated by prespecified subgroup and meta-regression analyses. Publication bias was assessed by funnel plots and, overall, studies were deemed to have a low risk of bias (P=0.58 and P=0.90). The overall relative risk for T2DM was almost 10 times higher in women with previous GDM than in healthy controls (9.51, 95% confidence interval 7.14 to 12.67, PConclusions Women with a history of GDM appear to have a nearly 10-fold higher risk of developing T2DM than those with a normoglycaemic pregnancy. The magnitude of this risk highlights the importance of intervening to prevent the onset of T2DM, particularly in the early years after pregnancy.</div

逆凸計画問題に対する内部近似法 (最適化のための連続と離散数理)

Additional file 1: Database Search - EMBASE/CINAH

Differential associations of risk factors with severe and nonsevere hypoglycaemia: HAT prospective observational study in people with insulin-treated type 1 and type 2 diabetes

AIMS: Severe and non-severe hypoglycaemia are closely related conditions but the extent to which they share risk factors is uncertain. We aimed to assess the differential association of risk factors with severe and non-severe hypoglycaemia. MATERIALS AND METHODS: The HAT study evaluated the risk of hypoglycaemia over a 4-week period in patients with type 1 (T1D) and 2 diabetes (T2D) on insulin in 24 countries. Negative binomial regressions were applied to examine associations of several risk factors with severe and non-severe hypoglycaemia. RESULTS: Median age was 41 years in 5,949 patients with T1D and 62 in 12,914 with T2D. The 4-week rates of non-severe hypoglycaemic were 5.57 and 1.40 episodes per person in T1D and T2D, respectively; corresponding rates for severe hypoglycaemia were 0.94 and 0.30. The excess risk was 42% higher for severe than non-severe hypoglycaemia in females vs males with T2D; 27% higher, in patients with T2D with vs without continuous glucose monitor (CGM); and 47% lower, in patients with T1D with vs without insulin pump. The excess risk also differed across geographical areas and was marginally lower for severe than non-severe hypoglycaemia for higher values of HbA1c in patients T2D. Associations with severity of hypoglycaemia were not different for age, diabetes and insulin therapy duration, previous hypoglycaemic episodes, and insulin regimen.  CONCLUSIONS: The risk of severe versus non-severe hypoglycaemia differs in patients with T1D and T2D, with sex, use of CGM and insulin pump, and geographical areas differently associated with one type of hypoglycaemia than the other.</p

Influence of sociodemographic characteristics on the preferred format of health education delivery in individuals with type 2 diabetes mellitus and or cardiovascular disease: a questionnaire study

AimTo examine the influence of sociodemographic factors of interest on preference for a particular health education format among people with type 2 diabetes and/or cardiovascular disease.MethodsA questionnaire was used to collect information on the influence of six sociodemographic factors of interest on the preference for health education formats in people with type 2 diabetes and/or cardiovascular disease. Chi‐squared tests were used to examine the distribution of preferences between groups. The characteristics of the population preferring the online format were then examined in more detail using logistic regression.ResultsResponses were received from 1559 participants. Overall the preferred health education format was one‐to‐one learning from a doctor or nurse (67%). Age, gender, diagnosis and educational level all affected the preferences expressed. The characteristics showing most consistent and significant influence were age and educational level. Overall, 29% ranked the online format highly (scores 1 or 2). This group were more likely to be aged ConclusionsSignificant differences between sociodemographic groups exist in preferences for health education formats among people with type 2 diabetes and/or cardiovascular disease. Preferences should be considered when designing educational interventions to ensure they are accessible to the target group and to avoid increases in health inequality.</div

MOESM3 of Relationship of cardiometabolic parameters in non-smokers, current smokers, and quitters in diabetes: a systematic review and meta-analysis

Additional file 3: Code for meta-regressio