The Epidemiology of Macrovascular Complications of Diabetes in Finland 1992-2002

The prevalence of diabetes is increasing rapidly in Finland. The increase is mainly due to a sedentary lifestyle and obesity, but other unknown factors most certainly also play a role, especially in diabetes of children and young adults. Diabetes is a strong risk factor for macrovascular complications. Since the incidences of acute coronary syndrome (ACS), stroke and major amputations are decreasing in Finland, it is important that diabetic patients benefit from these favourable developments as well as does the general population. To study the development, we analysed the trends in case fatality (CF) of the first ACS and first ischaemic stroke, the incidence of lower-extremity amputations and population attributable-fractions (PAFs) of ACS and ischaemic stroke due to diabetes. We executed a register study combining information from the national reimbursement registers of medicines, Hospital Discharge Register and Causes-of-Death Register to identify all persons that have been treated with hypoglycaemic medication or registered with a diabetes diagnosis, and their macrovascular complications from 1992 to 2002. Comparisons were made in both genders and various age groups in the nondiabetic population. Data for comparison were available through the National Cardiovascular Disease Register. Our main findings were that the diabetic population has benefited from the favourable development to the same extent as the nondiabetic population (I, II). Prognoses after the first ACS and the first ischaemic stroke are improving. The incidence of lower-extremity amputation is decreasing (III). The prognoses of patients with diabetes are still, however, far from the prognoses of the nondiabetic population. Patients with type 2 diabetes (T2DM) had a total 1-year CF of 65.2% compared with 56.5% among nondiabetic men after their first ACS (I). The corresponding figures for women were 61.0% and 48.3%. The risk ratio (RR) for 28-day CF after the first ACS was 1.34 (95% CI (confidence interval) 1.24 1.45) among T2DM men 35 64 years of age compared with nondiabetic men in the same age group, and 1.69 (95% CI 1.44 1.97) among T2DM women with nondiabetic women, again in the same age group. The difference was greatest in the younger age groups and became less clear in the older age groups. The risk of fatal outcome within a year for 28-day survivors was considerable in patients with T2DM, RR 2.87 (95% CI 2.19 3.75) among men and 5.84 (3.70 9.23) among women 35 64 years of age. There was a statistically significant downward trend in 28-day CF and in 1-year CF of 28-day survivors both among patients with T2DM and nondiabetic patients. The trends did not differ between patients with T2DM and nondiabetic persons. The total 1-year cardiovascular disease (CVD) CF after the first ischaemic stroke was 1.2 1.6 times higher among patients with T2DM compared with nondiabetic persons, depending on gender and age group (II). The 28-day CF was 1.1 1.3 times higher among patients with T2DM. The difference was biggest in the younger age group of men. The 1-year CVD CF of 28-day survivors was 1.4 2.2 times higher in patients with T2DM and this difference was biggest in the younger age group of women. There was a statistically significant downward trend during the study period in CF of the first ischaemic stroke at 0 27 days and 28 364 days after the stroke. The trends did not differ between patients with T2DM and nondiabetic persons. The crude rate of first amputations decreased from 924 to 387 per 100 000 diabetic persons (III). The decrease was similar in men and women. There were major differences in the pace of development among the hospital districts. The ratio of minor and major amputations had a positive development during the study period and the rate of first major amputations among diabetic patients decreased in the Finnish population. The PAF of the first CVD event due to diabetes showed an upward trend among men from 11.4% (95% CI 10.8 12.0%) to 13.8% (95% CI 13.2 14.5%), p for trend less than 0.0001, and a downward trend among women from 20.1% (95% CI 19.2 21.0%) to 16.9% (95% CI 15.9 17.8%), p for trend 0.0005 (IV). The upward trend was statistically significant in the first ACS event among men and the downward trend was statistically significant in the first ischaemic stroke in women. In conclusion, our results showed that the contribution of diabetes to the burden of first CVD events remained considerable. However, despite the increase in prevalence of diabetes, the PAF of the first CVD event decreased in women and increased only slightly in men. Strong actions should be taken to improve comprehensive treatment of risk factors after diagnosis of diabetes mellitus and efficiency of secondary prevention after a cardiovascular event. Special attention should be focused on better secondary prevention, because the largest difference between T2DM and nondiabetic persons was in 1-year prognosis of 28-day survivors after the first ACS or ischaemic stroke.Diabetes ja sydän- ja verisuonitaudit Suomessa 1992-2002 Diabeetikoiden määrä on ollut jatkuvassa nopeassa kasvussa Suomessa. Suurimpina syinä on pidetty lihavuutta ja liikunnan riittämättömyyttä. Diabetes on merkittävä riski sydän- ja verisuonisairauksille. Yleisesti tiedetään sydän- ja verisuonisairauksien vähentyneen Suomessa parantuneen ehkäisyn ja hoidon seurauksena. Pyrimme tutkimuksessamme selvittämään ovatko diabetesta sairastavat hyötyneet myönteisestä kehityksestä kuten muu väestö. Otimme tarkastelun kohteiksi äkillisten sydäntapahtumien ja aivoinfarktien kohtaustappavuuden, alaraaja-amputaatioiden ilmaantuvuuden ja diabeteksen aiheuttaman riskin äkillisiin sydäntapahtumiin ja aivoinfarkteihin väestössä. Tutkimuksessa hyödynnettiin kansallisia rekistereitä, Kelan lääkekorvausrekisterit, Terveyden ja hyvinvoinninlaitoksen (THL) hoitoilmoitusrekisteri ja Tilastokeskuksen kuolinsyyrekisteri. Rekisteritiedot yhdistettiin THL:n eettisen toimikunnan luvalla ja tietojen käsittely tapahtui ilman henkilöä tunnistavia tietoja. Diabeetikoiden lisäsairauksia verrattiin muun väestön lisäsairauksiin hyväksikäyttäen THL:n Sydän- ja verisuonitautirekisterin tietoja. Tutkimuksessa totesimme, että diabetes on edelleen merkittävä sydän- ja verisuonitautien riskitekijä. Myönteisenä havaintoja oli, että diabeetikot ovat hyötyneet parantuneesta ehkäisystä ja hoidosta samassa suhteessa kuin muu väestö. Äkillisten sydäntapahtumien ja aivoinfarktien ennuste on parantunut ja amputaatioiden määrä on vähentynyt. Silti diabeetikon ennuste on edelleen kaukana muun väestön ennusteesta. Kaksi kolmesta diabeetikosta kuoli vuoden sisällä ensimmäisestä sydäntapahtumastaan. Diabetesta sairastavien miesten kuolleisuus oli naisdiabeetikoita suurempi sekä ennen sairaalahoitoa että neljän viikon ja vuoden seurannassa. Suurin ero ei-diabeetikoiden ryhmään oli 35-74-vuotiaiden naisten ryhmässä, jossa ero oli 17 %-yksikköä. Diabeetikoiden yhden vuoden kuolleisuus aivoinfarktin jälkeen oli 20-60 % suurempi kuin ei-diabeetikoiden riippuen sukupuolesta ja iästä. Ero ei-diabeetikoihin oli suurimmillaan niiden 35-74-vuotiaiden naisten kohdalla, jotka olivat selvinneet hengissä neljä viikkoa ensimmäisestä sydäntapahtumastaan. Heidän kuolleisuutensa oli 2,2-kertainen. Diabetesta sairastavien naisten kuolleisuus aivoinfarktiin oli edelleen diabeetikkomiehiä suurempi, vaikka heidän kohdallaan kehitys on ollut suotuisampi. Diabeetikoiden amputaatiot ovat merkittävästi vähentyneet. Erityisesti pienten ja suurten amputaatioiden (nilkan ala- tai yläpuolinen) suhde on kehittynyt myönteisesti. Diabetesta sairastavat miehet ja naiset ovat hyötyneet kehityksestä yhtäläisesti. Myönteinen muutos on kuitenkin edennyt erilaisella nopeudella maan eri osissa. Diabeteksen aiheuttama riski miesväestölle saada äkillinen sydäntapahtuma tai aivoinfarkti on kasvanut 11,4 %:sta 13,8 %:iin vuodesta 1992 vuoteen 2002. Naisväestön lisäriski on samaan aikaan pienentynyt 20,1 %:sta 16,9 %:iin. Lisäriski on siis edelleen naisilla suurempi kuin miehillä. Myönteinen kehitys koski naisilla erityisesti aivoinfarktiriskin vähenemistä. Diabeetikot ovat hyötyneet ehkäisyn ja hoidon kehittymisestä samassa suhteessa kuin muu väestö, mutta ero ei-diabeetikoihin on pysynyt edelleen suurena. Erityisesti pitkänajan ennuste on diabeetikoilla huono, joten tehostuvan ehkäisyn ohella tarvitaan aggressiivista diabeetikoiden kokonaisriskin hoitamista

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Regional trends in avoidable hospitalisations due to complications among population with diabetes in Finland in 1996-2011 : a register-based cohort study

Objectives: Diabetes requires continuous medical care including prevention of acute complications and risk reduction for long-term complications. Diabetic complications impose a substantial burden on public health and care delivery. We examined trends in regional differences in hospitalisations due to diabetes-related complications among the total diabetes population in Finland. Research design: A longitudinal register-based cohort study 1996-2011 among a total population with diabetes in Finland. Participants: All persons with diabetes identified from several administrative registers in Finland in 1964-2011 and alive on 1 January 1996. Outcome measures: We examined hospitalisations due to diabetes-related short-term and long-term complications, uncomplicated diabetes, myocardial infarction, stroke, lower extremity amputation and end-stage renal disease (ESRD). We calculated annual age-adjusted rates per 10 000 person years and the systematic component of variation. Multilevel models were used for studying time trends in regional variation. Results: There was a steep decline in complication-related hospitalisation rates during the study period. The decline was relatively small in ESRD (30%), whereas rates of hospitalisations for short-term and long-term complications as well as uncomplicated diabetes diminished by about 80%. The overall correlation between hospital district intercepts and slopes in time was -0.72 (p Conclusions: Our study suggests that the prevention of complications among persons with diabetes has improved in Finland between 1996 and 2011. The results further suggest that the prevention of complications has become more uniform throughout the country.Peer reviewe

FinDM database on diabetes in Finland

This paper describes the collection of database of the Diabetes in Finland (FinDM) project which aims to identify all potential persons with diabetes from national registers in Finland between 1964 and 2017. Further, it lists the definitions used in the research of diabetes and its complications in the project

Amputations and socioeconomic position among persons with diabetes mellitus, a population-based register study

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Outcomes after coronary artery bypass grafting and percutaneous coronary intervention in diabetic and non-diabetic patients

AimsTo assess the prognosis of patients with coronary heart disease (CHD) after first myocardial revascularisation procedure in real world practice and to compare the differences in outcomes of coronary artery by-pass grafting (CABG) and percutaneous coronary intervention (PCI) among diabetic and non-diabetic patients.Methods and resultsA database was compiled from the national hospital discharge register to collect data on all cardiac revascularisations performed in Finland in 2000-2015. The outcomes (all-cause deaths, cardiovascular (CV) deaths, major CV events and need for repeat revascularisation) after the first revascularisation were identified from the national registers at 28-day, 1-year and 3-year time points.A total of 139,242 first-time revascularisations (89,493 PCI and 49,749 CABG) were performed during the study period. Of all the revascularized patients, 24% had diabetes, and 76% were non-diabetic patients. At day 28 the risk of fatal outcomes was lower after PCI than after CABG among non-diabetic patients, whereas no difference was seen among diabetic patients. In long-term follow-up the situation was reversed with PCI showing higher risk compared with CABG for most of the outcomes. In particular, at three-year follow-up the risk of all-cause deaths was elevated among diabetic patients (HR 1.30 (95% CI 1.22-1.38) comparing PCI with CABG) more than among non-diabetic patients (HR 1.09 (1.04-1.15)). The same was true for CV deaths (HR 1.29 (1.20-1.38) among diabetic patients, and HR 1.03 (0.98-1.08) among non-diabetic patients).ConclusionAlthough PCI was associated with better 28-day prognosis, CABG seemed to produce better long-term prognosis especially among diabetic patients.</p