The potential for deprescribing in care home residents with Type 2 diabetes

Background: Type 2 diabetes is a common diagnosis in care home residents that is associated with potentially inappropriate prescribing and thus risk of additional suffering. Previous studies found that diabetes medicines can be safely withdrawn in care home residents, encouraging further investigation of the potential for deprescribing amongst these patients. Objectives: Describe comorbidities and medicine use in care home residents with Type 2 diabetes; identify number of potentially inappropriate medicines prescribed for these residents using a medicines optimisation tool; assess clinical applicability of the tool. Setting Thirty care homes for older people, East Anglia, UK. Method: Data on diagnoses and medicines were extracted from medical records of 826 residents. Potentially inappropriate medicines were identified using the tool ‘Optimising Safe and Appropriate Medicines Use’. Twenty percent of results were validated by a care home physician. Main outcome measure: Number of potentially inappropriate medicines. Results: The 106 residents with Type 2 diabetes had more comorbidities and prescriptions than those without. Over 90 % of residents with Type 2 diabetes had at least one potentially inappropriate medication. The most common was absence of valid indication. The physician unreservedly endorsed 39 % of the suggested deprescribing, and would consider discontinuing all but one of the remaining medicines following access to additional information. Conclusion: UK care home residents with Type 2 diabetes had an increased burden of comorbidities and prescriptions. The majority of these patients were prescribed potentially inappropriate medicines. Validation by a care home physician supported the clinical applicability of the medicines optimisation tool

Type 2-diabetes i fastlegepraksis – en fokusgruppestudie

BAKGRUNN Nasjonal diabetesplan 2017–21 har iverksatt tiltak for å bedre diagnostisering og oppfølging av personer med type 2-diabetes i primærhelsetjenesten. Formålet med denne studien var å undersøke norske fastlegers erfaringer og tanker rundt diagnostisering og oppfølging av pasientgruppen. MATERIALE OG METODE I denne kvalitative studien ble det gjennomført tre fokusgruppeintervjuer med totalt 17 fastleger. Intervjuene ble tatt opp på bånd, transkribert og analysert med systematisk tekstkondensering. RESULTATER Fastlegene fortalte om en travel arbeidshverdag der målrettet identifikasjon av pasienter i risikosonen for sykdommen sjelden ble prioritert. De beskrev en pasientsentrert diabetesomsorg, hvor motivering til livsstilsendring ble ansett som en nødvendig, men krevende arbeidsoppgave. Legene problematiserte balansegangen mellom å følge generelle kliniske retningslinjer og det å individtilpasse oppfølging til den enkelte pasient. Samtidig uttrykte deltakerne at de var mindre faglig oppdatert enn de ønsket, grunnet tidspress. FORTOLKNING Fastlegene i studien beskrev en pasientsentrert diabetesomsorg som drives av klinisk erfaring. Retningslinjer har en veiledende, men ikke førende funksjon. En slik tilpasning muliggjør individualisert og tilpasset behandling, men kan også være en medvirkende årsak til mangelfull oppfølging i henhold til nasjonale retningslinjer.publishedVersio

Performance and user-friendliness of the rapid antigen detection tests QuickVue Dipstick Strep A test and DIAQUICK Strep A Blue Dipstick for pharyngotonsillitis caused by Streptococcus pyogenes in primary health care

Sensitivity and specificity of rapid antigen detection tests (RADTs) for detection of group A hemolytic streptococcus (GAS) vary. The purpose is to present the first SKUP (Scandinavian evaluation of laboratory equipment for point of care testing) evaluations concerning the assessment of the diagnostic performance and user-friendliness of two RADTs for detection of GAS when used under real-life conditions in primary health care. Throat samples were collected in duplicates at primary health care centers (PHCCs) from patients with symptoms of pharyngitis. The performance of QuickVue Dipstick Strep A test (307 samples) and DIAQUICK Strep A Blue Dipstick (348 samples) was evaluated using culture results at a clinical microbiology laboratory as comparison. The user-friendliness was evaluated using a questionnaire. The diagnostic sensitivity was 92% (90% confidence interval (CI) 87–96%) and 72% (90% CI 65–79%), while the diagnostic specificity was 86% (90% CI 81–90%) and 98% (90% CI 96–99%) for QuickVue Dipstick Strep A test and DIAQUICK Strep A Blue Dipstick, respectively. Both RADTs obtained acceptable assessments for user-friendliness and fulfilled SKUP’s quality goal for user-friendliness. The diagnostic sensitivity for QuickVue Dipstick Strep A test and the diagnostic specificity for DIAQUICK Strep A Blue Dipstick in this objective and supplier-independent evaluation were higher compared with previous meta-analyses of RADTs. However, the diagnostic specificity for QuickVue Dipstick Strep A test and the diagnostic sensitivity for DIAQUICK Strep A Blue Dipstick were lower compared with previous meta-analyses of RADTs.publishedVersio

Intensified follow-up of patients with type 1 diabetes and poor glycaemic control: A multicentre quality improvement collaborative based on data from the Norwegian Diabetes Register for Adults

Background Patients with type 1 diabetes mellitus (T1DM) and poor glycaemic control are at high risk of developing microvascular and macrovascular complications. The aim of this study was to determine if a quality improvement collaborative (QIC) initiated by the Norwegian Diabetes Register for adults (NDR-A) could reduce the proportion of patients with T1DM with poor glycaemic control (defined as glycated haemoglobin (HbA1c)≥75 mmol/mol) and reduce mean HbA1c at participating clinics compared with 14 control clinics. Method Multicentre study with controlled before and after design. Representatives of 13 diabetes outpatient clinics (n=5145 patients with T1DM) in the intervention group attended four project meetings during an 18-month QIC. They were required to identify areas requiring improvement at their clinic and make action plans. Continuous feedback on HbA1c outcomes was provided by NDR-A during the project. In total 4084 patients with type 1 diabetes attended the control clinics. Results Between 2016 and 2019, the overall proportion of patients with T1DM and HbA1c≥75 mmol/mol in the intervention group were reduced from 19.3% to 14.1% (p<0.001). Corresponding proportions in the control group were reduced from 17.3% (2016) to 14.4% (2019) (p<0.001). Between 2016 and 2019, overall mean HbA1c decreased by 2.8 mmol/mol (p<0.001) at intervention clinics compared with 2.3 mmol/mol (p<0.001) at control clinics. After adjusting for the baseline differences in glycaemic control, there were no significant differences in the overall improvement in glycaemic control between intervention and control clinics. Conclusions The registry linked QIC did not result in a significantly greater improvement in glycaemic control at intervention clinics compared with control clinics. However, there has been a sustained improvement in glycaemic control and importantly a significant reduction in the proportion of patients with poor glycaemic control at both intervention and control clinics during and after the QIC time frame. It is possible that some of this improvement may be due to a spillover effect from the QIC.publishedVersio

Aggregated data from the same laboratories participating in two glucose external quality assessment schemes show that commutability and transfers of values to control materials are decisive for the biases found

Objectives We report the results of glucose measurements performed during one year by the same measurement procedures (MPs) in 58 Norwegian hospital laboratories using control materials provided by external quality assessment (EQA) schemes from two different providers. The providers used materials with presumed vs. verified commutability and transfers of values using reference material vs. using a highest-order reference MP. Methods Data from six Labquality and three Noklus glucose EQA surveys were aggregated for each MP (Abbott Alinity, Abbott Architect, Roche Cobas, and Siemens Advia) in each scheme. For each EQA result, percent difference from target value (% bias) was calculated. Median percent bias for each MP per scheme was then calculated. Results The median % biases observed for each MP in the Labquality scheme were significantly larger than those in the Noklus scheme, which uses verified commutable control materials and highest-order reference MP target values. The difference ranged from 1.2 (Roche Cobas, 2.9 vs. 1.7 %) to 4.4 percentage points (Siemens Advia, 3.2 % vs. −1.2 %). The order of bias size for the various MPs was different in the two schemes. In contrast to the Labquality scheme, the median % biases observed in the Noklus scheme for Abbott Alinity (−0.1 %), Abbott Architect (−0.5 %), and Siemens Advia (−1.2 %) were not significantly different from target value (p>0.756). Conclusions This study underlines the importance of using verified commutable EQA materials and target values traceable to reference MPs in EQA schemes designed for assessment of metrological traceability of laboratory results.publishedVersio

Diabetes risk assessments and HbA1c-measurements in community pharmacies

Objectives Due to a lack of clear symptoms, type 2 diabetes (T2D) can remain undetected for many years. The aim of the study was to explore if Norwegian community pharmacies could identify individuals with a high risk of developing T2D by offering a diabetes risk assessment service. This study also investigated if the service recruited individuals that the national guideline recommends for diabetes risk assessment, and the proportion of participants who had visited their GP at least once a year. Methods During the inclusion period (September 2016 to the middle of April 2017), pharmacy customers 45 years or older wishing to participate contacted the pharmacy staff. Included participants completed a diabetes risk test and participants with a high risk were offered an HbA1c measurement. At two months after intervention, all participants were followed up. Key findings Of the 245 participants, 27% had a high risk of developing T2D. Of these, 46%, 43% and 9% had HbA1c values corresponding to normal (<39 mmol/mol [5.7%]), prediabetes (39–47 mmol/mol [5.7–6.4%]) or above cut-off for diabetes (≥48 mmol/mol [≥6.5%]), respectively. A total of 86% of the participants were in at least one category that the guideline recommends for a diabetes risk assessment, and 88% had visited their GP at least once a year. Conclusions Norwegian community pharmacies can identify individuals with a high risk of developing T2D by offering a diabetes risk assessment service. Individuals who sought out the service were within the relevant demographics for testing, and a high proportion visited their GP at least once a year.publishedVersio

Nursing home patients with diabetes: Prevalence, drug treatment and glycemic control

Aims: Determine prevalence of diabetes, and describe use of blood glucose lowering (BGL) drugs and glycemic control in Norwegian nursing homes. Methods: In this cross-sectional study we collected details of BGL drugs, capillary blood glucose measurements (CBGM) in the last four weeks and HbA1c measurements in the last 12 months from the medical records of patients with diabetes, within a population of 742 long-term care patients from 19 randomly selected nursing homes in Western Norway. Descriptive statistics were applied, and Pearson’s chi-squared (P 0.05) or non-overlapping 95% confidence intervals were interpreted as significant effects. Results: 116 patients (16%) had diabetes, 100 of these gave informed consent and medical data were available. BGL treatment was as follows: (1) insulin only (32%), (2) insulin and oral antidiabetics (OADs) (15%), (3) OADs only (27%) and (4) no drugs (26%). Patients with cognitive impairment were less likely to receive medical treatment (P = 0.04). CBGM and HbA1c measurements were performed for 73% and 77% of patients, respectively. Mean HbA1c was 7.3% (57 mmol/mol), 46% of patients had an HbA1c <7.0% (53 mmol/mol), and CBGM consistent with risk of hypoglycemia was found for 60% of these patients. Conclusions: Prevalence of diabetes and BGL treatment in Norwegian nursing homes is comparable to other European countries. Although special care seems to be taken when choosing treatment for patients with cognitive impairment, there are signs of overtreatment in the population as a whole. The strict glycemic control unveiled may negatively affect these frail patients’ quality of life and increase the risk of early death

Type 2-diabetes i fastlegepraksis – en fokusgruppestudie

BAKGRUNN Nasjonal diabetesplan 2017–21 har iverksatt tiltak for å bedre diagnostisering og oppfølging av personer med type 2-diabetes i primærhelsetjenesten. Formålet med denne studien var å undersøke norske fastlegers erfaringer og tanker rundt diagnostisering og oppfølging av pasientgruppen. MATERIALE OG METODE I denne kvalitative studien ble det gjennomført tre fokusgruppeintervjuer med totalt 17 fastleger. Intervjuene ble tatt opp på bånd, transkribert og analysert med systematisk tekstkondensering. RESULTATER Fastlegene fortalte om en travel arbeidshverdag der målrettet identifikasjon av pasienter i risikosonen for sykdommen sjelden ble prioritert. De beskrev en pasientsentrert diabetesomsorg, hvor motivering til livsstilsendring ble ansett som en nødvendig, men krevende arbeidsoppgave. Legene problematiserte balansegangen mellom å følge generelle kliniske retningslinjer og det å individtilpasse oppfølging til den enkelte pasient. Samtidig uttrykte deltakerne at de var mindre faglig oppdatert enn de ønsket, grunnet tidspress. FORTOLKNING Fastlegene i studien beskrev en pasientsentrert diabetesomsorg som drives av klinisk erfaring. Retningslinjer har en veiledende, men ikke førende funksjon. En slik tilpasning muliggjør individualisert og tilpasset behandling, men kan også være en medvirkende årsak til mangelfull oppfølging i henhold til nasjonale retningslinjer