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Multifactorial control and treatment intensity of type-2 diabetes in primary care settings in Catalonia.

ABSTRACT: BACKGROUND:Many studies on diabetes have demonstrated that an intensive control of glycaemia and the main associated risk factors (hypertension, dislipidaemia, obesity and smoking) reduce cardiovascular morbi-mortality. Different scientific societies have proposed a multifactorial approach to type 2 diabetes.The objective of this study was to identify the degree of control of glycosylated haemoglobin (HbA1c) and of cardiovascular risk factors in type 2 diabetic patients, using the GedapS 2004 guidelines, and to analyse the type and intensity of drug treatment. METHODS:This cross-sectional, multicentre, epidemiological study was conducted in a primary care setting in Vallès Occidental South, Catalonia. Data were collected of 393 patients aged 18 and above who were diagnosed with diabetes mellitus type 2. Biodemographic and clinical data, cardiovascular risk factors, associated cardiovascular disease, and treatment were assessed. Descriptive and multivariable analysis with logistic regression was realized. RESULTS:A total of 392 patients with a mean age of 66.8 years (SD = 10.6) (45.4% male patients) were analyzed. The duration of diabetes was 8.4 years (SD = 7.6). The degree of multifactorial control of risk factors was only 2.6%, although in more than 50% individual cardiovascular risk factor was controlled, except for LDL cholesterol (40.6%) and systolic blood pressure (29.6%). Furthermore, only 13.0% of subjects had an optimal BMI, 27.5% an optimal waist circumference. Treatment for diabetes was prescribed in 82.7% of patients, for hypertension 70.7%, for dyslipidaemia 47.2% and 40.1% were taking antiplatelets. CONCLUSION:Over 50% of type 2 diabetic patients presented optimal control of the majority of individual cardiovascular risk factors, although the degree of multifactorial control of diabetes was insufficient (2.6%) and should be improved. Drug treatment can be intensified using a larger number of combinations, particularly in patients with target organ damage and associated clinical cardiovascular disease.

SUBMITTER: Mengual L

PROVIDER: S-EPMC2858123 | biostudies-literature | 2010 Mar

REPOSITORIES: biostudies-literature

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Multifactorial control and treatment intensity of type-2 diabetes in primary care settings in Catalonia.

Mengual Lucas L Roura Pilar P Serra Marta M Montasell Montserrat M Prieto Gemma G Bonet Sandra S

Cardiovascular diabetology 20100329

<h4>Background</h4>Many studies on diabetes have demonstrated that an intensive control of glycaemia and the main associated risk factors (hypertension, dislipidaemia, obesity and smoking) reduce cardiovascular morbi-mortality. Different scientific societies have proposed a multifactorial approach to type 2 diabetes.The objective of this study was to identify the degree of control of glycosylated haemoglobin (HbA1c) and of cardiovascular risk factors in type 2 diabetic patients, using the GedapS ...[more]

PMID: 20350315

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Project description:ObjectiveTo assess the trends in cardiovascular risk factor control and drug therapy from 2007 to 2018 in subjects with type 2 diabetes mellitus (T2DM).Materials and methodsCross-sectional analysis using yearly clinical data and treatment obtained from the SIDIAP database. Patients aged ≥18 years with a diagnosis of T2DM seen in primary care in Catalonia, Spain.ResultsThe number of T2DM patients increased from 299,855 in 2007 to 394,266 in 2018. We also found an increasing prevalence of cardiovascular disease, heart failure, and chronic kidney disease (from 18.4 to 24.4%, from 4.5 to 7.3%, and from 20.2 to 31.3%, respectively). The achievement of glycemic targets (HbA1c<7%) scarcely changed (54.9% to 55.9%). Major improvements were seen in blood pressure (≤140/90 mmHg: from 55% to 71.8%), and in lipid control (low-density lipoprotein cholesterol <100 mg/dl: 33.4% to 48.4%), especially in people with established cardiovascular disease (48.8 to 69.7%). Simultaneous achievement of all three targets improved from 12.5% to 20.1% in the overall population and from 24.5% to 32.2% in those with cardiovascular disease but plateaued after 2013. There was an increase in the percentage of patients treated with any antidiabetic drug (70.1% to 81.0%), especially metformin (47.7% to 67.7%), and DPP4i (0 to 22.6%). The use of SGLT-2 and GLP-1ra increased over the years, but remained very low in 2018 (5.5% and 2.1% of subjects, respectively). There were also relevant increases in the use of statins (38.0% to 49.2%), renin-angiotensin system (RAS) drugs (52.5% to 57.2%), and beta-blockers (14.3% to 22.7%).ConclusionsDuring the 2007-2018 period, relevant improvements in blood pressure and lipid control occurred, especially in people with cardiovascular disease. Despite the increase in the use of antidiabetic and cardiovascular drugs, the proportion of patients in which the three objectives were simultaneously achieved is still insufficient and plateaued after 2013. The use of antidiabetic drugs with demonstrated cardio renal benefits (SGLT-2 and GLP-1ra) increased over the years, but their use remained quite low.

Project description:ImportanceMedication for opioid use disorder (MOUD) (eg, buprenorphine and naltrexone) can be offered in primary care, but barriers to implementation exist.ObjectiveTo evaluate an implementation intervention over 2 years to explore experiences and perspectives of multidisciplinary primary care (PC) teams initiating or expanding MOUD.Design, setting, and participantsThis survey-based and ethnographic qualitative study was conducted at 12 geographically and structurally diverse primary care clinics that enrolled in a hybrid effectiveness-implementation study from July 2020 to July 2022 and included PC teams (prescribing clinicians, nonprescribing behavioral health care managers, and consulting psychiatrists). Survey data analysis was conducted from February to April 2022.ExposureImplementation intervention (external practice facilitation) to integrate OUD treatment alongside existing collaborative care for mental health services.MeasuresData included (1) quantitative surveys of primary care teams that were analyzed descriptively and triangulated with qualitative results and (2) qualitative field notes from ethnographic observation of clinic implementation meetings analyzed using rapid assessment methods.ResultsSixty-two primary care team members completed the survey (41 female individuals [66%]; 1 [2%] American Indian or Alaskan Native, 4 [7%] Asian, 5 [8%] Black or African American, 5 [8%] Hispanic or Latino, 1 [2%] Native Hawaiian or Other Pacific Islander, and 46 [4%] White individuals), of whom 37 (60%) were between age 25 and 44 years. An analysis of implementation meetings (n = 362) and survey data identified 4 themes describing multilevel factors associated with PC team provision of MOUD during implementation, with variation in their experience across clinics. Themes characterized challenges with clinical administrative logistics that limited the capacity to provide rapid access to care and patient engagement as well as clinician confidence to discuss aspects of MOUD care with patients. These challenges were associated with conflicting attitudes among PC teams toward expanding MOUD care.Conclusions and relevanceThe results of this survey and qualitative study of PC team perspectives suggest that PC teams need flexibility in appointment scheduling and the capacity to effectively engage patients with OUD as well as ongoing training to maintain clinician confidence in the face of evolving opioid-related clinical issues. Future work should address structural challenges associated with workload burden and limited schedule flexibility that hinder MOUD expansion in PC settings.

Project description:BACKGROUND: Questions about the existence of supplier-induced demand emerge repeatedly in discussions about governing Swiss health care. This study therefore aimed to evaluate the interrelationship between structural factors of supply and the volume of services that are provided by primary care physicians in Switzerland. METHODS: The study was designed as a cross-sectional investigation, based on the complete claims data from all Swiss health care insurers for the year 2004, which covered information from 6087 primary care physicians and 4.7 million patients. Utilization-based health service areas were constructed and used as spatial units to analyze effects of density of supply. Hierarchical linear models were applied to analyze the data. RESULTS: The data showed that, within a service area, a higher density of primary care physicians was associated with higher mortality rates and specialist density but not with treatment intensity in primary care. Higher specialist density was weakly associated with higher mortality rates and with higher treatment intensity density of primary care physicians. Annual physician-level data indicate a disproportionate increase of supplied services irrespective of the size of the number of patients treated during the same year and, even in high volume practices, no rationing but a paradoxical inducement of consultations occurred. The results provide empirical evidence that higher densities of primary care physicians, specialists and the availability of out-patient hospital clinics in a given area are associated with higher volume of supplied services per patient in primary care practices. Analyses stratified by language regions showed differences that emphasize the effect of the cantonal based (fragmented) governance of Swiss health care. CONCLUSION: The study shows high volumes in Swiss primary care and provides evidence that the volume of supply is not driven by medical needs alone. Effects related to the competition for patients between primary care physicians, specialists and out-patient hospital clinics and an association with the system of reimbursing services on a fee-for-service basis can not be excluded.

Project description:BackgroundTo examine the association between the degree of risk factor control and cardiovascular disease (CVD) risk in type 2 diabetes and to assess if the presence of cardio-renal disease modifies these relationships.MethodsA retrospective cohort study using data from English practices from CPRD GOLD (Clinical Practice Research Datalink) and the SCI-Diabetes dataset (Scottish Care Information-Diabetes), with linkage to hospital and mortality data. We identified 101 749 with type 2 diabetes (T2D) in CPRD matched with 378 938 controls without diabetes and 330 892 with type 2 diabetes in SCI-Diabetes between 2006 and 2015. The main exposure was number of optimized risk factors: nonsmoker, total cholesterol ≤4 mmol/L, triglycerides ≤1.7 mmol/L, glycated haemoglobin (HbA1c) ≤53 mmol/mol (≤7.0%), systolic blood pressure <140mm Hg, or <130 mm Hg if high risk. Cox models were used to assess cardiovascular risk associated with levels of risk factor control.ResultsIn CPRD, the mean baseline age in T2D was 63 years and 28% had cardio-renal disease (SCI-Diabetes: 62 years; 35% cardio-renal disease). Over 3 years follow-up (SCI-Diabetes: 6 years), CVD events occurred among 27 900 (27%) CPRD-T2D, 101 362 (31%) SCI-Diabetes-T2D, and 75 520 (19%) CPRD-controls. In CPRD, compared with controls, T2D participants with optimal risk factor control (all risk factors controlled) had a higher risk of CVD events (adjusted hazard ratio, 1.21; 95% confidence interval, 1.12-1.29). In T2D participants from CPRD and SCI-Diabetes, pooled hazard ratios for CVD associated with 5 risk factors being elevated versus optimal risk factor control were 1.09 (95% confidence interval, 1.01-1.17) in people with cardio-renal disease but 1.96 (95% confidence interval, 1.82-2.12) in people without cardio-renal disease. People without cardio-renal disease were younger and more likely to have likely to have suboptimal risk factor control but had fewer prescriptions for risk factor modifying medications than those with cardio-renal disease.ConclusionsOptimally managed people with T2D have a 21% higher CVD risk when compared with controls. People with T2D without cardio-renal disease would be predicted to benefit greatly from CVD risk factor intervention.

Project description:ImportanceThe value of self-monitoring of blood glucose (SMBG) levels in patients with non-insulin-treated type 2 diabetes has been debated.ObjectiveTo compare 3 approaches of SMBG for effects on hemoglobin A1c levels and health-related quality of life (HRQOL) among people with non-insulin-treated type 2 diabetes in primary care practice.Design, setting, and participantsThe Monitor Trial study was a pragmatic, open-label randomized trial conducted in 15 primary care practices in central North Carolina. Participants were randomized between January 2014 and July 2015. Eligible patients with type 2 non-insulin-treated diabetes were: older than 30 years, established with a primary care physician at a participating practice, had glycemic control (hemoglobin A1c) levels higher than 6.5% but lower than 9.5% within the 6 months preceding screening, as obtained from the electronic medical record, and willing to comply with the results of random assignment into a study group. Of the 1032 assessed for eligibility, 450 were randomized.InterventionsNo SMBG, once-daily SMBG, and once-daily SMBG with enhanced patient feedback including automatic tailored messages delivered via the meter.Main outcomes and measuresCoprimary outcomes included hemoglobin A1c levels and HRQOL at 52 weeks.ResultsA total of 450 patients were randomized and 418 (92.9%) completed the final visit. There were no significant differences in hemoglobin A1c levels across all 3 groups (P = .74; estimated adjusted mean hemoglobin A1c difference, SMBG with messaging vs no SMBG, -0.09%; 95% CI, -0.31% to 0.14%; SMBG vs no SMBG, -0.05%; 95% CI, -0.27% to 0.17%). There were also no significant differences found in HRQOL. There were no notable differences in key adverse events including hypoglycemia frequency, health care utilization, or insulin initiation.Conclusions and relevanceIn patients with non-insulin-treated type 2 diabetes, we observed no clinically or statistically significant differences at 1 year in glycemic control or HRQOL between patients who performed SMBG compared with those who did not perform SMBG. The addition of this type of tailored feedback provided through messaging via a meter did not provide any advantage in glycemic control.Trial registrationclinicaltrials.gov Identifier: NCT02033499.

Project description:BACKGROUND:The management of hyperglycaemia and associated cardiovascular risk factors in patients with type 2 diabetes mellitus (T2DM) may reduce diabetes-related complications. The strategy to broaden the knowledge base of primary care professionals to improve health care has mainly been prompted by the current reality of limited resources and access to specialized care. The main objective of this study is to assess the effectiveness of comprehensive interventions focused on treatment intensification, decrease clinical inertia and reduce possible barriers to treatment adherence in patients with poorly controlled diabetes in a primary care setting. METHODS:This is a two-phase mixed method study, whose aims are the development of complex interventions and the assessment of their effectiveness. The main study outcome is a change in glycated haemoglobin (HbA1c) levels. The INTEGRA study is divided into two phases. Phase 1: A qualitative study with a phenomenological approach using semi-structured interviews with the objective of determining the factors related to the participants and health care professionals that influence the development and implementation of a specific intervention strategy aimed at patients with poor glycaemic control of T2DM in primary care. Phase 2: Exploratory intervention study to be conducted in Primary Health Care Centres in Catalonia (Spain), including 3 specific health care areas. The intervention study has two arms: Intervention Group 1 and 2. Each intervention group will recruit 216 participants (the same as in the control group) between the ages of 30 and 80?years with deficient glycaemic control (HbA1c > 9%). The control group will be established based on a randomized selection from the large SIDIAP (Sistema d'Informació per al desenvolupament de la Investigació en Atenció Primària) database of patients with comparable socio-demographic and clinical characteristics from the three provinces. DISCUSSION:This study is a comprehensive, pragmatic intervention based on glycaemic treatment intensification and the control of other cardiovascular risk factors. It is also aimed at improving treatment adherence and reducing clinical inertia, which could lead to improved glycaemic control and could likewise be feasible for implementation in the actual clinical practice of primary care. TRIAL REGISTRATION:Clinicaltrials.gov . registration number. NCT02663245; January 25, 2016.

Project description:Type 2 diabetes is impacting millions of people globally; however, many future cases can be prevented through lifestyle changes and interventions. Primary care is an important setting for diabetes prevention, for at-risk populations, because it is a patient's primary point of contact with the health care system and professionals can provide lifestyle counselling and support, as well as monitoring health outcomes. These are all essential elements for diabetes prevention for at-risk adults.To understand the factors related to the delivery and uptake of type 2 diabetes prevention interventions within primary care in higher income countries.For this narrative systematic review, we combined qualitative and quantitative studies of diabetes prevention within a primary care setting for patients at-risk of developing the condition. We used an iterative approach for evidence collection, which included using several databases (MEDLINE, Embase, Pysch info, BNI, SSCI, CINAHL, ASSIA), where we combined diabetes terms with primary care terms. Narrative and thematic synthesis were utilised to identify the prominent themes emerging from the data.A database of 6646 records was screened by the research team, and 18 papers were included. Three major themes were identified in this review. The first theme of context and setting of diabetes progression includes the risk and progression of diabetes, primary care as a setting, and where the responsibility for change is thought to lie. This review also found mixed views on the value of preventative services within primary care. The second theme focused on the various patient factors associated with diabetes prevention such as a patient's motivation to modify their current lifestyle, perceptions and knowledge (or lack thereof) of the impacts of diabetes, lack of follow-up in healthcare settings, and trust in healthcare professionals. The third theme was centred on professional factors impacting on diabetes prevention which included workload, time constraints, resources, self-efficacy and knowledge as well as professionals' perception of patient motivations towards change.This review explored the factors influencing diabetes prevention in primary care, and identified the context of prevention, as well as patient and professional factors related to preventative services being offered in primary care. This systematic review complements previous reviews of real-world settings by exploring the significant factors in prevention, and the findings are relevant to academics, policymakers, patients and practitioners interested in understanding the factors associated with the delivery and uptake of diabetes prevention interventions.

Project description:ObjectivesThe psychological distress of people living with diabetes is increased and associated with poorer glycemic outcomes and self-care. We aimed to examine the frequency of depression, anxiety, and diabetes-related distress (DRD) of individuals with type 2 diabetes (T2D) in primary care (PC) and their comparative associations with clinical, self-care, and socio-demographic characteristics, testing for possible different roles on glycemic control and self-care.MethodsThis is a cross-sectional study of 182 adults with a T2D diagnosis of at least six months, recruited between August 2019-March 2020 and May-October 2020, from an urban PC unit. Participants were screened for symptoms of depression (Patient Health Questionnaire-9 (PHQ-9)), anxiety (Generalized Anxiety Disorder-7 (GAD-7)), and DRD (Diabetes Distress Scale (DDS)). Clinical, self-care, and socio-demographic parameters were recorded.ResultsThe frequency of clinically significant symptoms of depression was 16.6%, (PHQ-9 score ⩾10), anxiety 17.7% (GAD-7 score ⩾10), and DRD 22.6% (DDS score ⩾2). All PHQ-9, GAD-7, and DDS scores intercorrelated, and higher scores were found to be associated with female gender, lower income, and prior diagnosis of depression. Higher PHQ-9 and GAD-7 scores were found to be associated with lower education, more hypoglycemia episodes, more blood glucose self-tests and antidepressant or benzodiazepine use. The retired/housewives scored significantly lower in GAD-7 and DDS compared to the unemployed participants. Higher DDS scores were associated with higher glycated hemoglobin, higher fasting plasma glucose, and insulin use. It was also noted that higher PHQ-9 scores were associated with lower uric acid levels and were significantly higher in the sedentary lifestyle group.ConclusionDRD was associated with poorer glycemic outcomes while depressive symptoms were associated with lower physical activity perhaps sharing different roles for glycemic control and self-care. The psychological burden of individuals with T2D may be considered in PC.

Dataset Information

Multifactorial control and treatment intensity of type-2 diabetes in primary care settings in Catalonia.

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Multifactorial control and treatment intensity of type-2 diabetes in primary care settings in Catalonia.

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