scholarly journals Associations between attainment of incentivised primary care indicators and incident diabetic retinopathy in England: a population-based historical cohort study

BMC Medicine ◽  
2021 ◽  
Vol 19 (1) ◽  
Author(s):  
Ailsa J. McKay ◽  
Laura H. Gunn ◽  
Thirunavukkarasu Sathish ◽  
Eszter Vamos ◽  
Manjula Nugawela ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Type 2 Diabetes ◽  
Primary Care ◽  
Diabetic Retinopathy ◽  
Proportional Hazards ◽  
Cox Proportional Hazards ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
Historical Cohort

Abstract Background The associations between England’s incentivised primary care-based diabetes prevention activities and hard clinical endpoints remain unclear. We aimed to examine the associations between attainment of primary care indicators and incident diabetic retinopathy (DR) among people with type 2 diabetes. Methods A historical cohort (n = 60,094) of people aged ≥ 18 years with type 2 diabetes and no DR at baseline was obtained from the UK Clinical Practice Research Datalink (CPRD). Exposures included attainment of the Quality and Outcomes Framework (QOF) HbA1c (≤ 7.5% or 59 mmol/mol), blood pressure (≤ 140/80 mmHg), and cholesterol (≤ 5 mmol/L) indicators, and number of National Diabetes Audit (NDA) care processes completed (categorised as 0–3, 4–6, or 7–9), in 2010–2011. Outcomes were time to development of DR and sight-threatening diabetic retinopathy (STDR). Nearest neighbour propensity score matching was undertaken and Cox proportional hazards models then fitted using the matched samples. Concordance statistics were calculated for each model. Results 8263 DR and 832 STDR diagnoses were observed over mean follow-up periods of 3.5 (SD 2.1) and 3.8 (SD 2.0) years, respectively. HbA1c and blood pressure (BP) indicator attainment were associated with lower rates of DR (adjusted hazard ratios (aHRs) 0.94 (95% CI 0.89–0.99) and 0.87 (0.83–0.92), respectively), whereas cholesterol indicator attainment was not (aHR 1.03 (0.97–1.10)). All QOF indicators were associated with lower rates of STDR (aHRs 0.74 (0.62–0.87) for HbA1c, 0.78 (0.67–0.91) for BP, and 0.82 (0.67–0.99) for cholesterol). Completion of 7–9 vs. 0–3 NDA processes was associated with fewer STDR diagnoses (aHR 0.72 (0.55–0.94)). Conclusions Attainment of key primary care indicators is associated with lower incidence of DR and STDR among patients with type 2 diabetes in England.

scholarly journals Impact of Cardio-Renal-Metabolic Comorbidities on Cardiovascular Outcomes and Mortality in Type 2 Diabetes Mellitus

2019 ◽  
Vol 51 (1) ◽  
pp. 74-82 ◽  
Author(s):  
David Z.I. Cherney ◽  
Enrico Repetto ◽  
David C. Wheeler ◽  
Suzanne V. Arnold ◽  
Sharon MacLachlan ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Type 2 Diabetes ◽  
Type 2 Diabetes Mellitus ◽  
Proportional Hazards ◽  
Cox Proportional Hazards ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
Hazard Ratios ◽  
Cv Disease

Background: We evaluated the incremental contribution of chronic kidney disease (CKD) to the risk of major adverse cardiovascular (CV) events (MACE), heart failure (HF), and all-cause mortality (ACM) in type 2 diabetes mellitus (T2DM) patients and its importance relative to the presence of other cardio-renal-metabolic (CaReMe) comorbidities. Methods: Patients (≥40 years) were identified at the time of T2DM diagnosis from US (Humedica/Optum) and UK (Clinical Practice Research Datalink) databases. Patients were monitored post-diagnosis for modified MACE (myocardial infarction, stroke, ACM), HF, and ACM. Adjusted hazard ratios were obtained using Cox proportional-hazards regression to evaluate the relative risk of modified MACE, HF, and ACM due to CKD. Patients were stratified by the presence or absence of atherosclerotic CV disease (ASCVD) and age. Results: Between 2011 and 2015, of 227,224 patients identified with incident T2DM, 40,063 (17.64%) had CKD. Regardless of prior ASCVD, CKD was associated with higher risk of modified MACE, HF, and ACM; this excess hazard was more pronounced in older patients with prior ASCVD. In time-to-event analyses in the overall cohort, patients with T2DM + CKD or T2DM + CKD + hypertension + hyperlipidemia had increased risks for modified MACE, HF, and ACM versus patients with T2DM and no CaReMe comorbidities. Patients with CKD had higher risks for and shorter times to modified MACE, HF, and ACM than those without CKD. Conclusion: In T2DM patients, CKD presence was associated with higher risk of modified MACE, HF, and ACM. This may have risk-stratification implications for T2DM patients based on background CKD and highlights the potential importance of novel renoprotective strategies.

scholarly journals Prediction of type 2 diabetes risk in people with non-diabetic hyperglycaemia: model derivation and validation using UK primary care data

BMJ Open ◽  
2020 ◽  
Vol 10 (10) ◽  
pp. e037937
Author(s):  
Briana Coles ◽  
Kamlesh Khunti ◽  
Sarah Booth ◽  
Francesco Zaccardi ◽  
Melanie J Davies ◽  
...  
Keyword(s):  
Type 2 Diabetes ◽  
Primary Care ◽  
Prognostic Models ◽  
Predictor Variables ◽  
Validation Dataset ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
Primary Care Data

ObjectiveUsing primary care data, develop and validate sex-specific prognostic models that estimate the 10-year risk of people with non-diabetic hyperglycaemia developing type 2 diabetes.DesignRetrospective cohort study.SettingPrimary care.Participants154 705 adult patients with non-diabetic hyperglycaemia.Primary outcomeDevelopment of type 2 diabetes.MethodsThis study used data routinely collected in UK primary care from general practices contributing to the Clinical Practice Research Datalink. Patients were split into development (n=109 077) and validation datasets (n=45 628). Potential predictor variables, including demographic and lifestyle factors, medical and family history, prescribed medications and clinical measures, were included in survival models following the imputation of missing data. Measures of calibration at 10 years and discrimination were determined using the validation dataset.ResultsIn the development dataset, 9332 patients developed type 2 diabetes during 293 238 person-years of follow-up (31.8 (95% CI 31.2 to 32.5) per 1000 person-years). In the validation dataset, 3783 patients developed type 2 diabetes during 115 113 person-years of follow-up (32.9 (95% CI 31.8 to 33.9) per 1000 person-years). The final prognostic models comprised 14 and 16 predictor variables for males and females, respectively. Both models had good calibration and high levels of discrimination. The performance statistics for the male model were: Harrell’s C statistic of 0.700 in the development and 0.701 in the validation dataset, with a calibration slope of 0.974 (95% CI 0.905 to 1.042) in the validation dataset. For the female model, Harrell’s C statistics were 0.720 and 0.718, respectively, while the calibration slope was 0.994 (95% CI 0.931 to 1.057) in the validation dataset.ConclusionThese models could be used in primary care to identify those with non-diabetic hyperglycaemia most at risk of developing type 2 diabetes for targeted referral to the National Health Service Diabetes Prevention Programme.

scholarly journals Glucocorticoid use is associated with an increased risk of hypertension

Rheumatology ◽  
2020 ◽  
Vol 60 (1) ◽  
pp. 132-139
Author(s):  
Ruth E Costello ◽  
Belay B Yimer ◽  
Polly Roads ◽  
Meghna Jani ◽  
William G Dixon
Keyword(s):  
Blood Pressure ◽  
Cumulative Dose ◽  
Proportional Hazards ◽  
Proportional Hazards Model ◽  
Cox Proportional Hazards ◽  
Cox Proportional Hazards Model ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
Incident Hypertension ◽  
Increased Risk

Abstract Objectives Patients with RA are frequently treated with glucocorticoids (GCs), but evidence is conflicting about whether GCs are associated with hypertension. The aim of this study was to determine whether GCs are associated with incident hypertension in patients with RA. Methods A retrospective cohort of patients with incident RA and without hypertension was identified from UK primary care electronic medical records (Clinical Practice Research Datalink). GC prescriptions were used to determine time-varying GC use, dose and cumulative dose, with a 3 month attribution window. Hypertension was identified through either: blood pressure measurements >140/90 mmHg, or antihypertensive prescriptions and a Read code for hypertension. Unadjusted and adjusted Cox proportional hazards regression models were fitted to determine whether there was an association between GC use and incident hypertension. Results There were 17 760 patients in the cohort. A total of 7421 (42%) were prescribed GCs during follow-up. The incident rate of hypertension was 64.1 per 1000 person years (95% CI: 62.5, 65.7). The Cox proportional hazards model indicated that recent GC use was associated with a 17% increased hazard of hypertension (hazard ratio 1.17; 95% CI: 1.10, 1.24). When categorized by dose, only doses above 7.5 mg were significantly associated with hypertension. Cumulative dose did not indicate a clear pattern. Conclusion Recent GC use was associated with incident hypertension in patients with RA, in particular doses ≥7.5 mg were associated with hypertension. Clinicians need to consider cardiovascular risk when prescribing GCs, and ensure blood pressure is regularly monitored and treated where necessary.

scholarly journals Consultation rates in people with type 2 diabetes with and without vascular complications: a retrospective analysis of 141,328 adults in England

2022 ◽  
Vol 21 (1) ◽  
Author(s):  
Sophia Abner ◽  
Clare L. Gillies ◽  
Sharmin Shabnam ◽  
Francesco Zaccardi ◽  
Samuel Seidu ◽  
...  
Keyword(s):  
Type 2 Diabetes ◽  
Primary Care ◽  
Health Care ◽  
Average Length ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
Specialist Care ◽  
Primary Care Consultation ◽  
Care Consultation

Abstract Objective To assess trends in primary and specialist care consultation rates and average length of consultation by cardiovascular disease (CVD), type 2 diabetes mellitus (T2DM), or cardiometabolic multimorbidity exposure status. Methods Observational, retrospective cohort study used linked Clinical Practice Research Datalink primary care data from 01/01/2000 to 31/12/2018 to assess consultation rates in 141,328 adults with newly diagnosed T2DM, with or without CVD. Patients who entered the study with either a diagnosis of T2DM or CVD and later developed the second condition during the study are classified as the cardiometabolic multimorbidity group. Face to face primary and specialist care consultations, with either a nurse or general practitioner, were assessed over time in subjects with T2DM, CVD, or cardiometabolic multimorbidity. Changes in the average length of consultation in each group were investigated. Results 696,255 (mean 4.9 years [95% CI, 2.02–7.66]) person years of follow up time, there were 10,221,798 primary and specialist care consultations. The crude rate of primary and specialist care consultations in patients with cardiometabolic multimorbidity (N = 11,881) was 18.5 (95% CI, 18.47–18.55) per person years, 13.5 (13.50, 13.52) in patients with T2DM only (N = 83,094) and 13.2 (13.18, 13.21) in those with CVD (N = 57,974). Patients with cardiometabolic multimorbidity had 28% (IRR 1.28; 95% CI: 1.27, 1.31) more consultations than those with only T2DM. Patients with cardiometabolic multimorbidity had primary care consultation rates decrease by 50.1% compared to a 45.0% decrease in consultations for those with T2DM from 2000 to 2018. Specialist care consultation rates in both groups increased from 2003 to 2018 by 33.3% and 54.4% in patients with cardiometabolic multimorbidity and T2DM, respectively. For patients with T2DM the average consultation duration increased by 36.0%, in patients with CVD it increased by 74.3%, and in those with cardiometabolic multimorbidity it increased by 37.3%. Conclusions Annual primary care consultation rates for individuals with T2DM, CVD, or cardiometabolic multimorbidity have fallen since 2000, while specialist care consultations and average consultation length have both increased. Individuals with cardiometabolic multimorbidity have significantly more consultations than individuals with T2DM or CVD alone. Service redesign of health care delivery needs to be considered for people with cardiometabolic multimorbidity to reduce the burden and health care costs.

scholarly journals Variation in tests for people with type 2 diabetes, hypertension, or chronic kidney disease in UK primary care

2019 ◽  
Vol 69 (suppl 1) ◽  
pp. bjgp19X703193
Author(s):  
Rita Patel ◽  
Martha Elwenspoek ◽  
Jessica Watson ◽  
Ed Mann ◽  
Katharine Alsop ◽  
...  
Keyword(s):  
Type 2 Diabetes ◽  
Primary Care ◽  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Chronic Conditions ◽  
Practice Research ◽  
Clinical Practice Research Datalink ◽  
Patient Anxiety ◽  
The Uk

BackgroundRates of pathology testing are rising in the UK, with significant geographical variability. Around 50% of overall GP laboratory testing represents monitoring for chronic conditions such as high blood pressure, type 2 diabetes, and chronic kidney disease (CKD). Overuse of tests for monitoring chronic conditions may be a potential source of harm; causing patient anxiety, downstream tests/referrals, overdiagnosis, increase GP workload and increase health service costs. On the other hand, failure to test may lead to missed diagnoses, complications, patient harm and litigation.AimThis study aims to use an open cohort to examine current variation in the use of tests for individuals with type 2 diabetes, hypertension, and CKD>2 across the UK.MethodClinical Practice Research Datalink (CPRD) data will be used to consider what tests have been ordered for people with these conditions and look at variation over time, and by region, age, sex, ethnicity, and socioeconomic position using age–sex-standardised utilisation rates, descriptive statistics, and multilevel Poisson regression.ResultsAn estimated 1.2 million patients within the CPRD database have previously been diagnosed with any of the chronic conditions with over 11 million tests. Some 1 029 496 patients have hypertension, 344 613 with diabetes, and 271 897 with CKD>2, with much overlap. The results from this study will help to find what tests are currently used among patients with these conditions and to quantify variation in testing.ConclusionThis work will be used to inform the development of testing algorithms for patients with these conditions in primary care.

scholarly journals Long-term HbA1c variability and the development and progression of diabetic retinopathy in subjects with type 2 diabetes

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Han Ul Kim ◽  
Sung Pyo Park ◽  
Yong-Kyu Kim
Keyword(s):  
Type 2 Diabetes ◽  
Diabetic Retinopathy ◽  
Hba1c Level ◽  
Cox Proportional Hazards ◽  
Progression Rate ◽  
Absolute Increase ◽  
Hba1c Variability ◽  
Hba1c Levels

AbstractThis study aimed to investigate whether long-term HbA1c variability is associated with the development and progression of diabetic retinopathy (DR) in subjects with type 2 diabetes. We retrospectively reviewed 434 type 2 diabetes subjects without DR who underwent regular DR screening. We reviewed fundus findings, collected HbA1c levels, and calculated the coefficient of variation (CV) and average real variability (ARV) of each subject’s HbA1c level. DR was developed in 55 subjects and progressed to moderate nonproliferative DR or worse DR in 23 subjects. On Cox proportional hazards regression analysis, HbA1c ARV, but not HbA1c CV, was significantly associated with DR development. However, the association between HbA1c variability and the DR progression rate to moderate nonproliferative DR or worse DR was not significant. The inter-visit HbA1c difference value on consecutive examination predicted DR development well and more careful screening for DR is needed for those with an absolute value change of 2.05%, an absolute increase of 1.75%, and an absolute decrease of 1.45% in HbA1c levels on consecutive examination. These results indicate that long-term glucose variability measured by HbA1c ARV might be an independent risk factor for DR development in addition to the mean HbA1c level in early diabetic subjects.

scholarly journals Association Between Change in Accelerometer-Measured and Self-Reported Physical Activity and Cardiovascular Disease in the Look AHEAD Trial

2022 ◽  
Author(s):  
John M. Jakicic ◽  
Robert I. Berkowitz ◽  
Paula Bolin ◽  
George A. Bray ◽  
Jeanne M. Clark ◽  
...  
Keyword(s):  
Physical Activity ◽  
Type 2 Diabetes ◽  
Cardiovascular Disease ◽  
Proportional Hazards ◽  
Secondary Analysis ◽  
Cox Proportional Hazards ◽  
Self Report ◽  
Look Ahead ◽  
The Look

OBJECTIVE: To conduct <i>post-hoc</i> secondary analysis examining the association between change in physical activity (PA), measured with self-report and accelerometry, from baseline to 1 and 4 years and cardiovascular disease (CVD) outcomes in the Look AHEAD Trial. <p>RESEARCH DESIGN AND METHODS: Participants were adults with overweight/obesity and type 2 diabetes with PA data at baseline and year 1 or 4 (n = 1,978). Participants were randomized to diabetes support and education or intensive lifestyle intervention. Measures included accelerometry-measured moderate-to-vigorous PA (MVPA), self-reported PA, and composite (morbidity and mortality) CVD outcomes.</p> <p>RESULTS: In pooled analyses of all participants, using Cox proportional hazards models, each 100 MET-min/wk increase in accelerometry-measured MVPA from baseline to 4 years was associated with decreased risk of the subsequent primary composite outcome of CVD. Results were consistent for changes in total MVPA [HR=0.97 (95% CI: 0.95, 0.99)] and MVPA accumulated in <u>></u>10-minute bouts [HR=0.95 (95% CI: 0.91, 0.98)], with a similar pattern for secondary CVD outcomes. Change in accelerometry-measured MVPA at 1 year and self-reported change in PA at 1 and 4 years were not associated with CVD outcomes.</p> <p>CONCLUSIONS: Increased accelerometry-measured MVPA from baseline to year 4 is associated with decreased risk of CVD outcomes. This suggests the need for long-term engagement in MVPA to reduce the risk of CVD in adults with overweight/obesity and type 2 diabetes.</p>

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