Prognostic value of physicians' assessment of compliance regarding all-cause mortality in patients with type 2 diabetes: primary care follow-up study

BACKGROUND: Whether the primary care physician's assessment of patient compliance is a valuable prognostic marker to identify patients who are at increased risk of death, or merely reflects measurement of various treatment parameters such as HbA(1C )or other laboratory markers is unclear. The objective of this prospective cohort study was to investigate the prognostic value of the physicians' assessment of patient compliance and other factors with respect to all-cause mortality during a one year follow-up period. METHODS: A prospective cohort study was conducted among 1014 patients with type 2 diabetes aged 40 and over (mean age 69 years, SD 10.4, 45% male) who were under medical treatment in 11 participating practices of family physicians and internists working in primary care in a defined region in South Germany between April and June 2000. Baseline data were gathered from patients and physicians by standardized questionnaire. The physician's assessment of patient compliance was assessed by means of a 4-point Likert scale (very good, rather good, rather bad, very bad). In addition, we carried out a survey among physicians by means of a questionnaire to find out which aspects for the assessment of patient compliance were of importance to make this assessment. Active follow-up of patients was conducted after one year to determine mortality. RESULTS: During the one year follow-up 48 (4.7%) of the 1014 patients died. Among other factors such as patient type (patients presenting at office, nursing home or visited patients), gender, age and a history of macrovascular disease, the physician's assessment of patient compliance was an important predictor of all-cause mortality. Patients whose compliance was assessed by the physician as "very bad" (6%) were significantly more likely to die during follow-up (OR = 2.67, 95% CI 1.02–6.97) after multivariable adjustment compared to patients whose compliance was assessed as "rather good" (45%) or "very good" (18%). The HbA(1C)-value and the cholesterol level at baseline showed no statistically significant association with all-cause mortality. According to our survey for most of the physicians self-acceptance of disease, treatment adherence, patient's interest in physician's explanations, attendance at appointments, a good self-management, and a good physician-patient relationship were key elements in the assessment of patient compliance. CONCLUSION: The primary care physician's assessment of patient compliance is a valuable prognostic marker for mortality among patients with type 2 diabetes. Identification of patients in need of improved compliance may help to target preventive measures

Factors associated with initiation of antihyperglycaemic medication in UK patients with newly diagnosed type 2 diabetes

<p>Abstract</p> <p>Aim</p> <p>To assess the factors associated with antihyperglycaemic medication initiation in UK patients with newly diagnosed type 2 diabetes.</p> <p>Methods</p> <p>In a retrospective cohort study, patients with newly diagnosed type 2 diabetes were identified during the index period of 2003-2005. Eligible patients were ≥ 30 years old at the date of the first observed diabetes diagnosis (referred to as index date) and had at least 2 years of follow-up medical history (N = 9,158). Initiation of antihyperglycaemic medication (i.e., treatment) was assessed in the 2-year period following the index date. Adjusted Cox regression models were used to examine the association between time to medication initiation and patient age and other factors.</p> <p>Results</p> <p>Mean (SD) HbA_1cat diagnosis was 8.1% (2.3). Overall, 51% of patients initiated antihyperglycaemic medication within 2 years (65%, 55%, 46% and 40% for patients in the 30- < 45, 45- < 65, 65- < 75, 75+ age groups, respectively). Among the treated patients, median (25^th, 75^thpercentile) time to treatment initiation was 63 (8, 257) days. Of the patients with HbA_1c≥ 7.5% at diagnosis, 87% initiated treatment within 2 years. These patients with a higher HbA_1calso had shorter time to treatment initiation (adjusted hazard ratio (HR) = 2.44 [95% confidence interval (CI): 1.61, 3.70]; p < 0.0001). Increasing age (in years) was negatively associated with time to treatment initiation (HR = 0.98 [95% CI: 0.97, 0.99]; p < 0.001). Factors significantly associated with shorter time to treatment initiation included female gender and use of cardiovascular medications at baseline or initiated during follow up.</p> <p>Conclusions</p> <p>In this UK cohort of patients with newly diagnosed type 2 diabetes, only 51% had antihyperglycaemic medication initiated over a 2-year period following diagnosis. Older patients were significantly less likely to have been prescribed antihyperglycaemic medications. Elevated HbA_1cwas the strongest factor associated with initiating antihyperglycaemic medication in these patients.</p

Exenatide once weekly treatment maintained improvements in glycemic control and weight loss over 2 years

<p>Abstract</p> <p>Background</p> <p>The once-weekly (QW) formulation of the glucagon-like peptide-1 receptor agonist exenatide has been demonstrated to improve A1C, fasting plasma glucose (FPG), body weight, serum lipid profiles, and blood pressure in patients with type 2 diabetes through 52 weeks of treatment. In this report, we describe the 2-year results of the open-label, open-ended extension to the DURATION-1 trial of exenatide QW for type 2 diabetes.</p> <p>Methods</p> <p>A 2-stage protocol was used: patients received either exenatide QW (2 mg) or exenatide twice daily for 30 weeks (5 μg for the first 4 weeks and 10 μg thereafter), followed by 1.5 years of treatment with exenatide QW (2 mg), for a total of 2 years (104 weeks) of exenatide treatment. Of the 295 (intent-to-treat [ITT]) patients who entered the trial, 73% (n = 216) completed 2 years of treatment (completer population). Baseline characteristics (mean ± SE) for these patients were: A1C, 8.2 ± 0.1%; FPG, 168.4 ± 43.0 mg/dL; body weight, 101.1 ± 18.7 kg; and diabetes duration, 7 ± 5 years.</p> <p>Results</p> <p>In the completer population, significant improvements (LS mean ± SE [95% CI]) were maintained after 2 years of treatment in A1C (-1.71 ± 0.08% [-1.86 to -1.55%]), FPG (-40.1 ± 2.9 mg/dL [-45.7 to -34.5 mg/dL]), and body weight (-2.61 ± 0.52 kg [-3.64 to -1.58 kg]) compared with baseline. The percentages of patients who achieved an A1C of <7.0% and ≤6.5% at 2 years were 60% and 39%, respectively. A significant reduction in systolic blood pressure (SBP; -3.0 ± 1.0 mmHg [-4.9 to -1.1 mmHg]) was maintained through 2 years of treatment. Serum lipid profiles were also significantly improved, including triglycerides (geometric LS mean change from baseline, -15 ± 2.7% [-21% to -10%]), total cholesterol (-8.6 ± 2.8 mg/dL [-14.0 to -3.1 mg/dL]), and low-density lipoproteins (-4.5 ± 2.2 mg/dL [-8.9 to -0.01 mg/dL]). Changes in A1C, body weight, FPG, SBP, and lipids in the ITT population were similar to those seen in the completer population. Nausea (predominantly mild in intensity) was the most common adverse event, although the frequency and intensity of nausea decreased over time. No severe hypoglycemia was observed.</p> <p>Conclusions</p> <p>Exenatide QW was well tolerated during the 2-year treatment period. This study demonstrated sustained glucose control and weight loss throughout 2 years of treatment with exenatide QW.</p> <p>Trial Registration</p> <p>ClinicalTrials.gov <a href="http://www.clinicaltrials.gov/ct2/show/NCT00308139">NCT00308139</a></p

Is the ADA/EASD algorithm for the management of type 2 diabetes (January 2009) based on evidence or opinion? A critical analysis

The ADA and the EASD recently published a consensus statement for the medical management of hyperglycaemia in patients with type 2 diabetes. The authors advocate initial treatment with metformin monotherapy and lifestyle modification, followed by addition of basal insulin or a sulfonylurea if glycaemic goals are not met (tier 1 recommendations). All other glucose-lowering therapies are relegated to a secondary (tier 2) status and only recommended for selected clinical settings. In our view, this algorithm does not offer physicians and patients the appropriate selection of options to individualise and optimise care with a view to sustained control of blood glucose and reduction both of diabetes complications and cardiovascular risk. This paper critically assesses the basis of the ADA/EASD algorithm and the resulting tiers of treatment options

U.K Prospective Diabetes Study 22: effect of age at diagnosis on diabetic tissue damage during the first 6 years of NIDDM

Objective: to assess the effect of age at diagnosis on the initial prevalence and subsequent-risk of the progression of diabetic tissue damage in patients with NIDDM. Research design and method: the prevalence of Q- wave myocardial infarction, absent dorsalis pedis pulses, retinopathy, absent ankle jerks, hypertension, and microalbuminuria were determined at baseline and at 3 and 6 years of follow-up in five consecutive 6-year age-cohorts of 3,027 newly diagnosed white patients aged between 36 and 65 years recruited to the U.K. Prospective Diabetes Study. The effect of age at diagnosis on the initial prevalence and the risk of progression of these complications and associated conditions was analyzed using logistic regression and proportional odds methods, respectively. Results: Q-wave myocardial infarction and hypertension were more prevalent in older patients at presentation, but age at diagnosis did not have a significant effect on the increased risk of either after 6 years of NIDDM. Absent dorsalis pedis pulses and ankle jerks were also more prevalent in the older age-groups at presentation, but age at diagnosis was a significant predictor of the increasing prevalence of both during follow-up. The baseline prevalence of retinopathy and microalbuminuria was not related to age. The subsequent risk of retinopathy, but not microalbuminuria, increased significantly with age at diagnosis.Conclusions: age at diagnosis has a variable impact on different types of diabetic tissue damage and may thus be art important variable in epidemiological and intervention studies in NIDDM. Regular ophthalmologic surveillance and examination of the feet increase in importance with increasing age since the diagnosis of NIDDM.</p