Protocol and baseline data from The Inala Chronic Disease Management Service evaluation study: a health services intervention study for diabetes care

Background: Type 2 Diabetes Mellitus is one of the most disabling chronic conditions worldwide, resulting in significant human, social and economic costs and placing huge demands on health care systems. The Inala Chronic Disease Management Service aims to improve the efficiency and effectiveness of care for patients with type 2 diabetes who have been referred by their general practitioner to a specialist diabetes outpatient clinic. Care is provided by a multidisciplinary, integrated team consisting of an endocrinologist, diabetes nurse educators, General Practitioner Clinical Fellows (general practitioners who have undertaken focussed post-graduate training in complex diabetes care), and allied health personnel (a dietitian, podiatrist and psychologist)

A randomised controlled trial of potential for pharmacologic prevention of new-onset albuminuria, hypertension and diabetes in a remote Aboriginal Australian community, 2008–2013

Introduction: We conducted a double-blind randomised controlled trial in a remote-living Australian Aboriginal group at high risk for chronic disease to assess whether pharmacological treatment with angiotensin converting enzyme inhibitor (ACEi) could delay the onset of albuminuria, hypertension or diabetes in people currently free of those conditions. Methods: Eligibility criteria in 2008 were age =18yr, blood pressure =140/90 mm/Hg, urinary albumin creatinine ratio (ACR) < 3.4 mg/mmol, normal levels of glycosylated haemoglobin, and, in females, infertility. A 2011 amendment allowed enrolment of fertile females using long-term contraception. “Treatment” was the ACEi perindopril arginine, or placebo, and participant events were ACR =3.4 mg/mmol and/or blood pressure >140/90 mm Hg and/or haemoglobin A1c >6.5%, and/or cardiovascular events. Results were analysed in 125 randomised participants who commenced treatment. Results: Recruitment was low, especially of women, and dropout rates high: there were finally 60 and 65 people in the ACEi and placebo groups respectively. In females, there were no events among 10 in the ACEi group, versus 5 events among 17 in the placebo group, and longitudinal ACR, HbA1c and blood pressure levels supported probable benefit of ACEi. There was no benefit of ACEi in males, but a probable benefit on diabetes/hypertension events. With the genders combined, there was probable reduction of diabetes (zero vs 4 events, p = 0.068), and of diabetes or hypertension (zero vs 5 events, p = 0.037). Discussion: In this high-risk population, ACEi probably delays development of albuminuria, diabetes and hypertension in females, and of non-ACR events overall. Repeat investigation with a larger sample size is warranted

Exploring staff diabetes medication knowledge and practices in regional residential care: triangulation study

Aims and objectives: This study is drawn from a larger project that aimed to identify the staffing and organisational factors influencing the quality of diabetes care for older people living in residential care in regional Victoria, Australia. The focus of the current study is on medication management for residents with diabetes. Background: With a continuous rise in diabetes in the population, there is an associated increase in the prevalence of diabetes in aged care residential settings. However, there is little specific guidance on how to manage diabetes in older people living in institutional settings who experience multiple concurrent chronic conditions. Design: A triangulation strategy consisting of three phases. Methods: A one-shot cross-sectional survey (n = 68) focus group interviews and a case file audit (n = 20). Data were collected between May 2009-January 2010. Findings: Staff knowledge of diabetes and its contemporary medication management was found to be suboptimal. Challenges to managing residents with diabetes included limited time, resident characteristics and communication systems. Additionally, the variability in medical support available to residents and a high level of polypharmacy added to the complexity of medication management of resident. Conclusions: The current study suggests administering medicine to residents in aged care settings is difficult and has potentially serious medical, professional and economic consequences. Limitations to staff knowledge of contemporary diabetes care and medications potentially place residents with diabetes at risk of receiving less than optimal diabetes care. Relevance to clinical practice: Providing evidence-based guidelines about diabetes care in residential care settings is essential to achieve acceptable outcomes and increase the quality of life for residents in public aged care. Continuing education programs in diabetes care specifically related to medication must be provided to all health professionals and encompass scope of practice. © 2013 John Wiley & Sons Ltd

Cardiovascular risk among Aboriginal and non-Aboriginal smoking male prisoners: inequalities compared to the wider community

<p>Abstract</p> <p>Background</p> <p>Cardiovascular risk factors (CVRF) were collected as part of a randomised controlled trial of a multi-component intervention to reduce smoking among male prisoners. Cross-sectional baseline data on CVRF were compared among smoking male prisoners and males of similar age in the general population.</p> <p>Methods</p> <p>425 smoking prisoners were recruited (n = 407 in New South Wales; 18 in Queensland), including 15% of Aboriginal descent (mean age 33 years; median sentence length 3.6 years). We measured CVRF such as smoking, physical activity, blood pressure, risky alcohol use, symptoms of depression, and low socioeconomic status.</p> <p>Results</p> <p>We found that 39% of prisoners had 3+ CVRF, compared to 10% in a general community sample of most disadvantaged men of a similar age. Significantly more Aboriginal prisoners had 3+ CVRF than non-Aboriginal prisoners (55% vs 36%, p < 0.01) and were twice as likely to have 4+ CVRF (27% vs 12%). In addition to all prisoners in this study being a current smoker (with 70% smoking 20+ cigarettes per day), the prevalence of other CVRF was very high: insufficient physical activity (23%); hypertension (4%), risky drinking (52%), symptoms of depression (14%) and low socioeconomic status (SES) (44%). Aboriginal prisoners had higher levels of risky alcohol use, symptoms of depression, and were more likely to be of low SES.</p> <p>Conclusion</p> <p>Prisoners are at high risk for developing cardiovascular disease compared to even the most disadvantaged in their community and should be the focus of specific public health interventions.</p> <p>Trial Registration</p> <p>This trial is registered with the Australian New Zealand Clinical Trials Registry <a href="http://www.anzctr.org.au/ACTRN12606000229572.aspx">ACTRN#12606000229572</a>.</p

Correlates of preclinical cardiovascular disease in Indigenous and Non-Indigenous Australians: a case control study

Background. The high frequency of premature death from cardiovascular disease in indigenous Australians is often attributed to the high prevalence of risk factors, especially type II diabetes mellitus (DM). We evaluated the relationship of ethnicity to atherosclerotic burden, as evidenced by carotid intima-media thickness (IMT), independent of risk factor status. Methods. We studied 227 subjects (147 men; 50 ± 13 y): 119 indigenous subjects with (IDM, n = 54), and without DM (InDM, n = 65), 108 Caucasian subjects with (CDM, n = 52), and without DM (CnDM, n = 56). IMT was measured according to standard methods and compared with clinical data and cardiovascular risk factors. Results. In subjects both with and without DM, IMT was significantly greater in indigenous subjects. There were no significant differences in gender, body mass index (BMI), systolic blood pressure (SBP), or diastolic blood pressure (DBP) between any of the groups, and subjects with DM showed no difference in plasma HbA1c. Cardiovascular risk factors were significantly more prevalent in indigenous subjects. Nonetheless, ethnicity (β = -0.34; p < 0.0001), age (β = 0.48; p < 0.0001), and smoking (β = 0.13; p < 0.007) were independent predictors of IMT in multiple linear regression models. Conclusion. Ethnicity appears to be an independent correlate of preclinical cardiovascular disease, even after correction for the high prevalence of cardiovascular risk factors in indigenous Australians. Standard approaches to control currently known risk factors are vital to reduce the burden of cardiovascular disease, but in themselves may be insufficient to fully address the high prevalence in this population

Preconception care of women with diabetes: a review of current guideline recommendations

<p>Abstract</p> <p>Background</p> <p>The prevalence of type 2 diabetes mellitus (T2DM) continues to rise worldwide. More women from developing countries who are in the reproductive age group have diabetes resulting in more pregnancies complicated by T2DM, and placing both mother and foetus at higher risk. Management of these risks is best achieved through comprehensive preconception care and glycaemic control, both prior to, and during pregnancy. The aim of this review was to compare the quality and content of current guidelines concerned with the preconception care of women with diabetes and to develop a summary of recommendations to assist in the management of diabetic women contemplating pregnancy.</p> <p>Methods</p> <p>Relevant clinical guidelines were identified through a search of several databases (MEDLINE, SCOPUS and The Cochrane Library) and relevant websites. Five guidelines were identified. Each guideline was assessed for quality using the AGREE instrument. Guideline recommendations were extracted, compared and contrasted.</p> <p>Results</p> <p>All guidelines were assessed as being of high quality and strongly recommended for use in practice. All were consistent in counselling about the risk of congenital malformation related to uncontrolled blood sugar preconceptionally, ensuring adequate contraception until glycaemic control is achieved, use of HBA1C to monitor metabolic control, when to commence insulin and switching from ACE inhibitors to other antihypertensives. Major differences were in the targets recommended for optimal metabolic control and opinion regarding the usage of metformin as an adjunct or alternative treatment before or during pregnancy.</p> <p>Conclusions</p> <p>International guidelines for the care of women with diabetes who are contemplating pregnancy are consistent in their recommendations; however some are more comprehensive than others. Having established current standards for the preconception care of diabetic women, there is now a need to focus on guideline implementation through an examination of the barriers and enablers to successful implementation, and the applicability of the recommendations in the local setting.</p

Mental illness related disparities in diabetes prevalence, quality of care and outcomes: a population-based longitudinal study

<p>Abstract</p> <p>Background</p> <p>Health care disparity is a public health challenge. We compared the prevalence of diabetes, quality of care and outcomes between mental health clients (MHCs) and non-MHCs.</p> <p>Methods</p> <p>This was a population-based longitudinal study of 139,208 MHCs and 294,180 matched non-MHCs in Western Australia (WA) from 1990 to 2006, using linked data of mental health registry, electoral roll registrations, hospital admissions, emergency department attendances, deaths, and Medicare and pharmaceutical benefits claims. Diabetes was identified from hospital diagnoses, prescriptions and diabetes-specific primary care claims (17,045 MHCs, 26,626 non-MHCs). Both univariate and multivariate analyses adjusted for socio-demographic factors and case mix were performed to compare the outcome measures among MHCs, category of mental disorders and non-MHCs.</p> <p>Results</p> <p>The prevalence of diabetes was significantly higher in MHCs than in non-MHCs (crude age-sex-standardised point-prevalence of diabetes on 30 June 2006 in those aged ≥20 years, 9.3% vs 6.1%, respectively, <it>P </it>< 0.001; adjusted odds ratio (OR) 1.40, 95% CI 1.36 to 1.43). Receipt of recommended pathology tests (HbA_1c, microalbuminuria, blood lipids) was suboptimal in both groups, but was lower in MHCs (for all tests combined; adjusted OR 0.81, 95% CI 0.78 to 0.85, at one year; and adjusted rate ratio (RR) 0.86, 95% CI 0.84 to 0.88, during the study period). MHCs also had increased risks of hospitalisation for diabetes complications (adjusted RR 1.20, 95% CI 1.17 to 1.24), diabetes-related mortality (1.43, 1.35 to 1.52) and all-cause mortality (1.47, 1.42 to 1.53). The disparities were most marked for alcohol/drug disorders, schizophrenia, affective disorders, other psychoses and personality disorders.</p> <p>Conclusions</p> <p>MHCs warrant special attention for primary and secondary prevention of diabetes, especially at the primary care level.</p