Point-of-care Testing HbA1c screening for type 2 diabetes in urban and rural areas of China: a cost-effectiveness analysis

BackgroundPoint-of-care Testing (POCT) glycosylated hemoglobin (HbA1c) is a convenient, cheap, effective and accessible screening method for type 2 diabetes in rural areas and community settings that is widely used in the European region and Japan, but not yet widespread in China. The study is the first to evaluate the cost-effectiveness of POCT HbA1c, fasting capillary glucose (FCG), and venous blood HbA1c to screen for type 2 diabetes in urban and rural areas of China, and to identify the best socio-economically beneficial screening strategy.MethodsBased on urban and rural areas in China, economic models for type 2 diabetes screening were constructed from a social perspective. The subjects of this study were adults aged 18–80 years with undiagnosed type 2 diabetes. Three screening strategies were established for venous blood HbA1c, FCG and POCT HbA1c, and cost-effectiveness analysis was performed by Markov models. One-way sensitivity analysis and probabilistic sensitivity analysis were performed on all parameters of the model to verify the stability of the results.ResultsCompared with FCG, POCT HbA1c was cost-effective with an incremental cost-utility ratio (ICUR) of $500.06/quality-adjusted life year (QALY) in urban areas and an ICUR of$185.10/QALY in rural areas, within the willingness-to-pay threshold (WTP = $37,653). POCT HbA1c was cost-effective with lower cost and higher utility compared with venous blood HbA1c in both urban and rural areas. In the comparison of venous blood HbA1c and FCG, venous blood HbA1c was cost-effective (ICUR =$20,833/QALY) in urban areas but not in rural areas (ICUR = $41,858/QALY). Sensitivity analyses showed that the results of the study were stable and credible.ConclusionsPOCT HbA1c was cost-effective for type 2 diabetes screening in both urban and rural areas of China, which could be considered for future clinical practice in China. Factors such as geographic location, local financial situation and resident compliance needed to be considered when making the choice of venous blood HbA1c or FCG

Inadequate Weight Gain According to the Institute of Medicine 2009 Guidelines in Women with Gestational Diabetes: Frequency, Clinical Predictors, and the Association with Pregnancy Outcomes

Background: In the care of women with gestational diabetes mellitus (GDM), more attention is put on glycemic control than in factors such as gestational weight gain (GWG). We aimed to evaluate the rate of inadequate GWG in women with GDM, its clinical predictors and the association with pregnancy outcomes. Methods: Cohort retrospective analysis. Outcome variables: GWG according to Institute of Medicine 2009 and 18 pregnancy outcomes. Clinical characteristics were considered both as GWG predictors and as covariates in outcome prediction. Statistics: descriptive, multinomial and logistic regression. Results: We assessed 2842 women diagnosed with GDM in the 1985-2011 period. GWG was insufficient (iGWG) in 50.3%, adequate in 31.6% and excessive (eGWG) in 18.1%; length of follow-up for GDM was positively associated with iGWG. Overall pregnancy outcomes were satisfactory. GWG was associated with pregnancy-induced hypertension, preeclampsia, cesarean delivery and birthweight-related outcomes. Essentially, the direction of the association was towards a higher risk with eGWG and lower risk with iGWG (i.e., with Cesarean delivery and excessive growth). Conclusions: In this cohort of women with GDM, inadequate GWG was very common at the expense of iGWG. The associations with pregnancy outcomes were mainly towards a higher risk with eGWG and lower risk with iGWG

Inadequate Weight Gain According to the Institute of Medicine 2009 Guidelines in Women with Gestational Diabetes: Frequency, Clinical Predictors, and the Association with Pregnancy Outcomes

Background: In the care of women with gestational diabetes mellitus (GDM), more attention is put on glycemic control than in factors such as gestational weight gain (GWG). We aimed to evaluate the rate of inadequate GWG in women with GDM, its clinical predictors and the association with pregnancy outcomes. Methods: Cohort retrospective analysis. Outcome variables: GWG according to Institute of Medicine 2009 and 18 pregnancy outcomes. Clinical characteristics were considered both as GWG predictors and as covariates in outcome prediction. Statistics: descriptive, multinomial and logistic regression. Results: We assessed 2842 women diagnosed with GDM in the 1985–2011 period. GWG was insufficient (iGWG) in 50.3%, adequate in 31.6% and excessive (eGWG) in 18.1%; length of follow-up for GDM was positively associated with iGWG. Overall pregnancy outcomes were satisfactory. GWG was associated with pregnancy-induced hypertension, preeclampsia, cesarean delivery and birthweight-related outcomes. Essentially, the direction of the association was towards a higher risk with eGWG and lower risk with iGWG (i.e., with Cesarean delivery and excessive growth). Conclusions: In this cohort of women with GDM, inadequate GWG was very common at the expense of iGWG. The associations with pregnancy outcomes were mainly towards a higher risk with eGWG and lower risk with iGWG

Incremento ponderal en mujeres con diabetes mellitus pregestacional y gestacional. Variables predictoras y asociaciones con resultados perinatales

L'atenció endocrinològica a les dones amb diabetis pregestacional (DMP) i gestacional (DMG) se centra habitualment en aconseguir un control glucèmic el més normal possible, prestant-se menys atenció a altres variables com l'increment ponderal gestacional (IPG), definit el 2009 pel Institute of Medicine (IOM) com adequat, excessiu o insuficient segons els resultats gestacionals associats en població general. OBJECTIUS: Avaluar la distribució d'IPG segons IOM 2009 en dones amb DMG i DMP, les variables clíniques predictores de la mateixa (objectiu principal) i la seva associació amb els resultats de la gestació (objectiu secundari). METODOLOGIA: Anàlisi retrospectiva de dades recollides sistemàticament en dones amb DMG i DMP ateses a la Clínica de Malalties endocrinològiques i Gestació de l'Hospital de la Santa Creu i Sant Pau. RESULTATS: En dones amb DMG i DMP el IPG segons IOM va ser freqüentment inadequat, a costa d'IPG insuficient en dones amb DMG (48.1%) i d'IPG excessiu en dones amb DMP (50.7%). En dones amb DMG, els predictors d'IPG segons IOM van incloure factors comuns a la població general i un factor específic per DMG com és el temps de seguiment (OR per IPG insuficient 1.027 per setmana, IC 95% 1.010-1.043; OR per IPG excessiu 0.970, IC 95% 0.950-0.991). El IPG segons IOM es va associar amb resultats materns (malaltia hipertensiva de l'embaràs (EHE), preeclàmpsia (límit) i cesària) i fetals (nadó gran per l'edat gestacional (RN GEG), macrosomia i nadó petit per l'edat gestacional (RN PEG)). Excepte per RN PEG, el IPG excessiu es va associar amb risc més alt i el IPG insuficient amb risc més baix. Les fraccions atribuibles poblacionals (FAPs) i fraccions prevenibles poblacionals (FPPs) van ser moderades. En dones amb DMP, els predictors d'IPG segons IOM van incloure factors comuns a la població general i específics de DM com tipus de DM (OR de DM1 per IPG excessiu 3.093, IC 95% 1.325-7.222), dosi d'insulina en tercer trimestre (OR per IPG excessiu 2.551 per UI, IC 95% 1.292-5.036), temps de seguiment (OR per IPG insuficient 0.894 per setmana, IC 95% 0.837-0.955) i canvi en HbA1c (OR per IPG excessiu 0.768 per 1%, IC 95 % 0.611-0.966). El IPG segons IOM es va associar amb resultats materns i fetals. El IPG excessiu es va associar amb major risc de EHE, cesària, RN GEG i macrosomia, mentre que per PEG i destret respiratori l'augment de risc es va associar amb IPG insuficient. Les FAPs i FPPs van ser moderades-grans. CONCLUSIONS: En dones amb DMG i DMP, és freqüent que el IPG segons IOM sigui inadequat, a costa d'IPG insuficient en dones amb DMG i d'IPG excessiu en dones amb DMP. Entre les variables associades a IPG segons IOM hi ha variables que són predictors coneguts, comuns amb la població general i altres específiques de diabetis. La durada del seguiment durant l'embaràs és un predictor positiu de IPG insuficient en dones amb DMG i negatiu en dones amb DMP. A més, en dones amb DMP, el tipus de DM, el canvi d'HbA1c durant l'embaràs i la dosi d'insulina en el tercer trimestre, són variables predictores d'IPG excessiu. Sent els resultats globals de l'embaràs satisfactoris en dones amb DMG i bastant satisfactoris en dones amb DMP, el IPG excessiu s'associa a resultats desfavorables en els dos grups, mentre que el IPG insuficient s'associa a resultats favorables en dones amb DMG i mixtos en dones amb DMP. Les FAPs i FPPs d'IPG inadequat segons IOM són més altes en dones amb DMP.La atención endocrinológica a las mujeres con diabetes pregestacional (DMP) y gestacional (DMG) se centra habitualmente en conseguir un control glucémico lo más normal posible, prestándose menos atención a otras variables como el incremento ponderal gestacional (IPG), definido en 2009 por el Institute of Medicine (IOM) como adecuado, excesivo o insuficiente según los resultados gestacionales asociados en población general. OBJETIVOS: Evaluar la distribución de IPG según IOM 2009 en mujeres con DMG y DMP, las variables clínicas predictoras del mismo (objetivo principal) y su asociación con los resultados de la gestación (objetivo secundario). METODOLOGÍA: Análisis retrospectivo de datos recogidos sistemáticamente en mujeres con DMG y DMP antendidas en la Clínica de Enfermedades Endocrinológicas y Gestación del Hospital de la Santa Creu i Sant Pau. RESULTADOS: En mujeres con DMG y DMP el IPG según IOM fue frecuentemente inadecuado, a expensas de IPG insuficiente en mujeres con DMG (48.1%) y de IPG excesivo en mujeres con DMP (50.7%). En mujeres con DMG, los predictores de IPG según IOM incluyeron factores comunes a la población general y un factor específico para DMG como es el tiempo de seguimiento (OR para IPG insuficiente 1.027 por semana, IC 95% 1.010-1.043; OR para IPG excesivo 0.970, IC 95% 0.950-0.991). El IPG según IOM se asoció con resultados maternos (enfermedad hipertensiva del embarazo (EHE), preeclampsia (límite) y cesárea) y fetales (recién nacido grande para la edad gestacional (RN GEG), macrosomía y recién nacido pequeño para la edad gestacional (RN PEG)). Excepto para RN PEG, el IPG excesivo se asoció con riesgo más alto y el IPG insuficiente con riesgo más bajo. Las population attributable fractions (PAFs) y population preventable fractions (PPFs) fueron moderadas. En mujeres con DMP, los predictores de IPG según IOM incluyeron factores comunes a la población general y específicos de DM como tipo de DM (OR de DM1 para IPG excesivo 3.093, IC 95% 1.325-7.222), dosis de insulina en tercer trimestre (OR para IPG excesivo 2.551 por UI, IC 95%1.292-5.036), tiempo de seguimiento (OR para IPG insuficiente 0.894 por semana, IC 95% 0.837-0.955) y cambio en HbA1c (OR para IPG excesivo 0.768 por 1%, IC 95% 0.611-0.966). El IPG según IOM se asoció con resultados maternos y fetales. El IPG excesivo se asoció con mayor riesgo de EHE, cesárea, RN GEG y macrosomía, mientras que para PEG y distrés respiratorio el aumento de riesgo se asoció con IPG insuficiente. Las PAFs y PPFs fueron moderadas-grandes. CONCLUSIONES: En mujeres con DMG y DMP, es frecuente que el IPG según IOM sea inadecuado, a expensas de IPG insuficiente en mujeres con DMG y de IPG excesivo en mujeres con DMP. Entre las variables asociadas a IPG según IOM hay variables que son predictores conocidos, comunes con la población general y otras específicas de diabetes. La duración del seguimiento durante el embarazo es un predictor positivo de IPG insuficiente en mujeres con DMG y negativo en mujeres con DMP. Además, en mujeres con DMP, el tipo de DM, el cambio de HbA1c durante el embarazo y la dosis de insulina en el tercer trimestre, son variables predictoras de IPG excesivo. Siendo los resultados globales del embarazo satisfactorios en mujeres con DMG y bastante satisfactorios en mujeres con DMP, el IPG excesivo se asocia a resultados desfavorables en ambos grupos, mientras que el IPG insuficiente se asocia a resultados favorables en mujeres con DMG y mixtos en mujeres con DMP. Las PAFs y PPFs del IPG inadecuado según IOM son más altas en mujeres con DMP.Endocrinological care for women with pre-pregnancy diabetes (PDM) and gestational diabetes (GDM) is usually focused on achieving a glycemic control as normal as possible, and less attention is paid to other variables such as gestational weight gain (GWG), defined in 2009 by the Institute of Medicine (IOM) as adequate, excessive or insufficient according to the associated pregnancy outcomes in the general population. OBJECTIVES: To assess the distribution of GWG according to IOM 2009 in women with GDM and PDM, its predictive clinical variables (primary objective) and its association with pregnancy outcomes (secondary objective). METHODOLOGY: Retrospective analysis of data collected systematically in women with GDM and PDM attended at the Clinic for Endocrinological Diseases and Pregnancy of the Hospital de la Santa Creu i Sant Pau. RESULTS: In women with GDM and PDM, GWG according to IOM was frequently inadequate, at the expense of insufficient GWG in women with GDM (48.1%) and excessive GWG in women with PDM (50.7%). In women with GDM, the predictors of GWG according to IOM included factors common to the general population and a GDM-specific factor such as length of follow-up (OR for insufficient GWG 1.027 per week, 95% CI 1.010-1.043; OR for excessive GWG 0.970, 95% CI 0.950-0.991). GWG according to IOM was associated with maternal (pregnancy-induced hypertension (PIH), preeclampsia (borderline) and cesarean section) and fetal outcomes (large-for-gestational-age newborn (LGA), macrosomia and small-for-gestational age newborn (SGA)). Except for SGA, excessive GWG was associated with higher risk and insufficient GWG with lower risk. The population attributable fractions (PAFs) and population preventable fractions (PPFs) were moderate. In women with PDM, the predictors of GWG according to IOM included factors common to the general population and PDM-specific factors such as type of DM (OR of Type 1 DM for excessive GWG 3.093, 95% CI 1.325-7.222), insulin dose in the third trimester (OR for excessive GWG 2.551 per 1 IU, 95% CI 1.292-5.036), length of follow-up (OR for insufficient GWG 0.894 per week, 95% CI 0.837-0.955) and change of HbA1c (OR for excessive GWG 0.768 per 1%, 95% CI 0.611-0.966). GWG according to IOM was associated with both maternal and fetal outcomes. For PIH, cesarean section, LGA and macrosomia, excessive GWG was associated with increased risk, while for SGA and respiratory distress the increased risk was associated with insufficient GWG. The PAFs and PPFs were moderate-large. CONCLUSIONS: In women with GDM and PDM, GWG according to IOM is frequently inadequate, at the expense of insufficient GWG in women with GDM and excessive GWG in women with PDM. Among the variables associated with GWG according to IOM, there are variables that are well-known predictors, common to the general population and others, which are diabetes-specific. The length of follow-up during pregnancy is a positive predictor of insufficient GWG in women with GDM and a negative one in women with PDM. Furthermore, in women with PDM, type of DM , change of HbA1c during pregnancy and insulin dose in the third trimester are predictive variables for excessive GWG. With overall pregnancy outcomes being satisfactory in women with GDM and quite satisfactory in women with PDM, excessive GWG is associated with unfavorable results in both groups, while insufficient GWG is associated with favorable results in women with GDM and mixed ones in women with PDM. The PAFs and PPFs of inadequate GWG according to IOM are higher in women with PDM.Universitat Autònoma de Barcelona. Programa de Doctorat en Medicin

Gestational Weight Gain in Women with Type 1 and Type 2 Diabetes Mellitus - Supplemental material

Material suplementari d'un article enviat a la revista: Journal of Clinical Endocrinology and Metabolis

Inadequate Weight Gain According to the Institute of Medicine 2009 Guidelines in Women with Gestational Diabetes: Frequency, Clinical Predictors, and the Association with Pregnancy Outcomes

Background: In the care of women with gestational diabetes mellitus (GDM), more attention is put on glycemic control than in factors such as gestational weight gain (GWG). We aimed to evaluate the rate of inadequate GWG in women with GDM, its clinical predictors and the association with pregnancy outcomes. Methods: Cohort retrospective analysis. Outcome variables: GWG according to Institute of Medicine 2009 and 18 pregnancy outcomes. Clinical characteristics were considered both as GWG predictors and as covariates in outcome prediction. Statistics: descriptive, multinomial and logistic regression. Results: We assessed 2842 women diagnosed with GDM in the 1985-2011 period. GWG was insufficient (iGWG) in 50.3%, adequate in 31.6% and excessive (eGWG) in 18.1%; length of follow-up for GDM was positively associated with iGWG. Overall pregnancy outcomes were satisfactory. GWG was associated with pregnancy-induced hypertension, preeclampsia, cesarean delivery and birthweight-related outcomes. Essentially, the direction of the association was towards a higher risk with eGWG and lower risk with iGWG (i.e., with Cesarean delivery and excessive growth). Conclusions: In this cohort of women with GDM, inadequate GWG was very common at the expense of iGWG. The associations with pregnancy outcomes were mainly towards a higher risk with eGWG and lower risk with iGWG