Mortality and Cardiovascular Complications in Older Complex Chronic Patients with Type 2 Diabetes

Aims/Introduction. Determining the prevalence of diabetes and its cardiovascular complications and all-cause mortality in older chronic complex patients. Materials and Methods. We carried out a multicenter retrospective study and included a randomized sample of 932 CCP people. We assessed the prevalence of diabetes according to World Health Organization criteria. Data included demographics and functional, comorbidity, cognitive, and social assessment. Results. The prevalence of diabetes was 53% and average age 81.16±8.93 years. There were no significant differences in the survival of CCP patients with or without DM, with or without ischaemic cardiopathy, and with or without peripheral vascular disease. The prognostic factors of all-cause mortality in patients with DM were age ≥ 80 years [HR 1.47, 95% CI 1.02–2.13, p  0.038], presence of heart failure [HR 1.73, 95% CI 1.25–2.38, p  0.001], Charlson score [HR 1.20, 95% CI 1.06–1.36, p  0.003], presence of cognitive impairment [HR 1.73, 95% CI 1.24–2.40, p  0.001], and no treatment with statins [HR 1.49, 95% CI 1.08–2.04, p  0.038]. Conclusions. We found high prevalence of DM among CCP patients and the relative importance of traditional risk factors seemed to wane with advancing age. Recommendations may include relaxing treatment goals, providing family/patient education, and enhanced communication strategies

International longitudinal registry of patients with atrial fibrillation and treated with rivaroxaban: RIVaroxaban Evaluation in Real life setting (RIVER)

Background Real-world data on non-vitamin K oral anticoagulants (NOACs) are essential in determining whether evidence from randomised controlled clinical trials translate into meaningful clinical benefits for patients in everyday practice. RIVER (RIVaroxaban Evaluation in Real life setting) is an ongoing international, prospective registry of patients with newly diagnosed non-valvular atrial fibrillation (NVAF) and at least one investigator-determined risk factor for stroke who received rivaroxaban as an initial treatment for the prevention of thromboembolic stroke. The aim of this paper is to describe the design of the RIVER registry and baseline characteristics of patients with newly diagnosed NVAF who received rivaroxaban as an initial treatment. Methods and results Between January 2014 and June 2017, RIVER investigators recruited 5072 patients at 309 centres in 17 countries. The aim was to enroll consecutive patients at sites where rivaroxaban was already routinely prescribed for stroke prevention. Each patient is being followed up prospectively for a minimum of 2-years. The registry will capture data on the rate and nature of all thromboembolic events (stroke / systemic embolism), bleeding complications, all-cause mortality and other major cardiovascular events as they occur. Data quality is assured through a combination of remote electronic monitoring and onsite monitoring (including source data verification in 10% of cases). Patients were mostly enrolled by cardiologists (n = 3776, 74.6%), by internal medicine specialists 14.2% (n = 718) and by primary care/general practice physicians 8.2% (n = 417). The mean (SD) age of the population was 69.5 (11.0) years, 44.3% were women. Mean (SD) CHADS2 score was 1.9 (1.2) and CHA2DS2-VASc scores was 3.2 (1.6). Almost all patients (98.5%) were prescribed with once daily dose of rivaroxaban, most commonly 20 mg (76.5%) and 15 mg (20.0%) as their initial treatment; 17.9% of patients received concomitant antiplatelet therapy. Most patients enrolled in RIVER met the recommended threshold for AC therapy (86.6% for 2012 ESC Guidelines, and 79.8% of patients according to 2016 ESC Guidelines). Conclusions The RIVER prospective registry will expand our knowledge of how rivaroxaban is prescribed in everyday practice and whether evidence from clinical trials can be translated to the broader cross-section of patients in the real world

Análisis coste-efectividad de la automonitorización de la glucosa sanguínea en diabéticos tipo 2

Objetivo Comparar el coste-efectividad de la práctica de la automonitorización de glucosa en sangre capilar (MGS) frente a su no uso. Métodos Estudio descriptivo y retrospectivo durante el periodo 1995-1997 sobre 597 pacientes diabéticos tipo 2, de los que 286 practican la MGS y 311 no, seguidos ambulatoriamente en siete áreas básicas de salud (ABS) del ámbito territorial de la Dirección de Atención Primaria Tortosa del Institut Català de la Salut. Se cuantificaron los costes directos relacionados con el consumo de tiras reactivas para la práctica de MGS, visitas en su ABS de referencia, derivaciones al especialista, y pruebas complementarias protocolizadas por la European NIDDM Policy Group en la población usuaria de la MGS y la no-usuaria, así como los costes incremental, medio y total para el consumo de tiras reactivas y en el caso de la aplicación de un modelo ideal de cobertura cuantitativa y cualitativa según un consenso clínico, y la razón de coste-efectividad. Resultados Mientras el 78% de los diabéticos cumplen alguna indicación clínica para la prescripción de MGS, sólo la practican el 42,5%. El consumo de tiras pasó del 8% al 15% del gasto médico total de los diabéticos, que en la aplicación del modelo de cobertura ideal la MGS representaría un 30% del coste total. La efectividad lograda, un 27%, no fue significativamente diferente entre los usuarios de la MGS y los no usuarios. El coste-efectividad en los usuarios de la MGS pasó de 210.789 Ptas/año a 213.148 Ptas/año; y en los no usuarios de 162.019 Ptas/año a 162.051 Ptas/año. Si el nivel de efectividad se acercase al de eficacia y se aplicara el modelo ideal de cobertura, el coste-efectividad disminuiría en un 60%, de modo que en los MGS sería de 78.904 Ptas/año y en los no usuarios 54.682 Ptas/año. Conclusiones En las condiciones actuales elegiríamos la opción de no uso de la MGS; la tendencia al mayor coste-efectividad seguirá incrementándose si consideramos que los criterios de control metabólico tienen cada vez valores más bajos y difíciles de lograr; existen evidentes oportunidades para mejorar la gestión y motivar un uso eficiente de una tecnología cuyo consumo está fuertemente asociada a los fallos del mercado sanitario público; el modelo de cobertura ideal debería aplicarse junto a objetivos de mayor efectividad para unificar la eficiencia económica y la clínica.Objective Compare the cost-efectiveness of self-monitoring of blood glucose (MBG) with your non-use. Design Descriptive and retrospective study covering the period 1995-97 in the 597 type-2 diabetes patients: 286 practicing MBG on a stable basis and 311 not doing so. All are registered in seven health districts in the territorial ambit of Tortosa Primary Care. Werw quantified the direct costs in relation to comsumption of reagent strips for the practice of MBG, outpatients visits in your primary care center, derivations to specialist of reference and complementary test according to recomendations of the European NIDDM Policy Group in the population user of MBG and no-user; the annual cost increment, the average annual cost and the total annual cost in the population user of MBG and in the application of a ideal model of quantitative and qualitative cover according to clinical recommendations of the Gedaps; and the cost-effectiveness. Results While the 78% of the total diabetic population satisfy some clinical indication for prescribing MBG, only the 42,5% practice the MBG. The comsumption of reagent strips rising of 8% to 15% of the global cost of the diabetic population. In the aplication of the ideal model of cover, this cost increase up the 30% of global cost. The effectiveness obtained, an 27%, not are significatively different in the population user of MBG and no user. The cost-effectiveness in the user of MBG increased of 210.789 ptes/year to 213.148 ptes/year; and nouser of 162.019 ptes/year to 162.051 ptes/year. The application of ideal model of cover and the gain of an effectiveness near to possible level of efficiencie imply an descent average of cost-effectiveness of approximately 60%: 78.904 ptes/year in user MBG and 54.682 ptes/year in no-user. Conclusions 1. We choose in the presents conditions the option of no-user MBG. 2. The average cost-effectiveness per diabetic patient will increase by the needs of accomodate the therapy to new standards of metabolic control. 3. Are clear oportunity for the improve the management and to motivate an efficient use of tecnology associate to defects of public sanitary market. 4. The model of ideal cover associated to greater effectiveness are necessary for to unify the economic and clinic efficiency

Structured self monitoring of blood glucose in Iranian people with type 2 diabetes; A cost consequence analysis

<p>Abstract</p> <p>Background</p> <p>Self-Monitoring of Blood Glucose (SMBG) is considered as a key factor in management of people with diabetes which is a growing and cost demanding health problem. The purpose of this study was to investigate the effect of comprehensive patient management using structured SMBG on metabolic control as well as its cost consequence analysis.</p> <p>Methods</p> <p>Sixty subjects were recruited in an observational study for a period of 6 months. They were provided with the ACCU-CHEK 360° View tool to fill in the values of the 7-point blood glucose profiles in three consecutive days during the study on a monthly basis. Changes in metabolic control were assessed by HbA1c and lipid profile measurement at the beginning and at the end of the study. In addition, cost consequence analysis was done considering different level of health care professionals with or without insurance coverage. The Average Cost Effectiveness Ratio (ACER) as well as Cost saving analysis were calculated and compared.</p> <p>Results</p> <p>The analysis showed significant reduction in HbA1c during the 6-month period in all subjects (P = 0.000). Furthermore, a positive effect was observed on lipid profile. The cost of endocrinologist’s visit in private sector was estimated to be 265.76 USD while this figure was149.15 USD for general practitioner in public sector with insurance coverage. Total complications and mortality cost saving was 154.8 USD. The lowest ACER was calculated for intervention with general practitioner in public sector with insurance coverage.</p> <p>Conclusion</p> <p>Structured SMBG results in significant improvement of glycemic status. Moreover, it is more cost saving in public sector with insurance coverage. It seems that general practitioner visits with insurance coverage is the most affordable option for people with type 2 diabetes.</p

Atrial Fibrillation and Dementia: A Report From the AF-SCREEN International Collaboration

Growing evidence suggests a consistent association between atrial fibrillation (AF) and cognitive impairment and dementia that is independent of clinical stroke. This report from the AF-SCREEN International Collaboration summarizes the evidence linking AF to cognitive impairment and dementia. It provides guidance on the investigation and management of dementia in patients with AF on the basis of best available evidence. The document also addresses suspected pathophysiologic mechanisms and identifies knowledge gaps for future research. Whereas AF and dementia share numerous risk factors, the association appears to be independent of these variables. Nevertheless, the evidence remains inconclusive regarding a direct causal effect. Several pathophysiologic mechanisms have been proposed, some of which are potentially amenable to early intervention, including cerebral microinfarction, AF-related cerebral hypoperfusion, inflammation, microhemorrhage, brain atrophy, and systemic atherosclerotic vascular disease. The mitigating role of oral anticoagulation in specific subgroups (eg, low stroke risk, short duration or silent AF, after successful AF ablation, or atrial cardiopathy) and the effect of rhythm versus rate control strategies remain unknown. Likewise, screening for AF (in cognitively normal or cognitively impaired patients) and screening for cognitive impairment in patients with AF are debated. The pathophysiology of dementia and therapeutic strategies to reduce cognitive impairment warrant further investigation in individuals with AF. Cognition should be evaluated in future AF studies and integrated with patient-specific outcome priorities and patient preferences. Further large-scale prospective studies and randomized trials are needed to establish whether AF is a risk factor for cognitive impairment, to investigate strategies to prevent dementia, and to determine whether screening for unknown AF followed by targeted therapy might prevent or reduce cognitive impairment and dementia

Atrial Fibrillation and Dementia: A Report From the AF-SCREEN International Collaboration.

Growing evidence suggests a consistent association between atrial fibrillation (AF) and cognitive impairment and dementia that is independent of clinical stroke. This report from the AF-SCREEN International Collaboration summarizes the evidence linking AF to cognitive impairment and dementia. It provides guidance on the investigation and management of dementia in patients with AF on the basis of best available evidence. The document also addresses suspected pathophysiologic mechanisms and identifies knowledge gaps for future research. Whereas AF and dementia share numerous risk factors, the association appears to be independent of these variables. Nevertheless, the evidence remains inconclusive regarding a direct causal effect. Several pathophysiologic mechanisms have been proposed, some of which are potentially amenable to early intervention, including cerebral microinfarction, AF-related cerebral hypoperfusion, inflammation, microhemorrhage, brain atrophy, and systemic atherosclerotic vascular disease. The mitigating role of oral anticoagulation in specific subgroups (eg, low stroke risk, short duration or silent AF, after successful AF ablation, or atrial cardiopathy) and the effect of rhythm versus rate control strategies remain unknown. Likewise, screening for AF (in cognitively normal or cognitively impaired patients) and screening for cognitive impairment in patients with AF are debated. The pathophysiology of dementia and therapeutic strategies to reduce cognitive impairment warrant further investigation in individuals with AF. Cognition should be evaluated in future AF studies and integrated with patient-specific outcome priorities and patient preferences. Further large-scale prospective studies and randomized trials are needed to establish whether AF is a risk factor for cognitive impairment, to investigate strategies to prevent dementia, and to determine whether screening for unknown AF followed by targeted therapy might prevent or reduce cognitive impairment and dementia

Atrial Fibrillation and Dementia: A Report From the AF-SCREEN International Collaboration

Growing evidence suggests a consistent association between atrial fibrillation (AF) and cognitive impairment and dementia that is independent of clinical stroke. This report from the AF-SCREEN International Collaboration summarizes the evidence linking AF to cognitive impairment and dementia. It provides guidance on the investigation and management of dementia in patients with AF on the basis of best available evidence. The document also addresses suspected pathophysiologic mechanisms and identifies knowledge gaps for future research. Whereas AF and dementia share numerous risk factors, the association appears to be independent of these variables. Nevertheless, the evidence remains inconclusive regarding a direct causal effect. Several pathophysiologic mechanisms have been proposed, some of which are potentially amenable to early intervention, including cerebral microinfarction, AF-related cerebral hypoperfusion, inflammation, microhemorrhage, brain atrophy, and systemic atherosclerotic vascular disease. The mitigating role of oral anticoagulation in specific subgroups (eg, low stroke risk, short duration or silent AF, after successful AF ablation, or atrial cardiopathy) and the effect of rhythm versus rate control strategies remain unknown. Likewise, screening for AF (in cognitively normal or cognitively impaired patients) and screening for cognitive impairment in patients with AF are debated. The pathophysiology of dementia and therapeutic strategies to reduce cognitive impairment warrant further investigation in individuals with AF. Cognition should be evaluated in future AF studies and integrated with patient-specific outcome priorities and patient preferences. Further large-scale prospective studies and randomized trials are needed to establish whether AF is a risk factor for cognitive impairment, to investigate strategies to prevent dementia, and to determine whether screening for unknown AF followed by targeted therapy might prevent or reduce cognitive impairment and dementia. © 2022 Lippincott Williams and Wilkins. All rights reserved