Objective To use admission inpatient glycated hemoglobin (HbA1c) testing to help investigate the prevalence of unrecognized diabetes, the cumulative prevalence of unrecognized and known diabetes, and the prevalence of poor glycemic control in both. Moreover, we aimed to determine the 6-month outcomes for these patients. Finally, we aimed to assess the independent association of diabetes with these outcomes. Research, design, and methods Prospective observational cohort study conducted in a tertiary hospital in Melbourne, Australia. Patients A cohort of 5082 inpatients ≥54 years admitted between July 2013 and January 2014 underwent HbA1c measurement. A previous diagnosis of diabetes was obtained from the hospital medical record. Patient follow-up was extended to 6 months. Results The prevalence of diabetes (known and unrecognized) was 34%. In particular, we identified that unrecognized but HbA1c-confirmed diabetes in 271 (5%, 95% CI 4.7% to 6.0%) patients, previously known diabetes in 1452 (29%, 95% CI 27.3% to 29.8%) patients; no diabetes in 3359 (66%, 95% CI 64.8–67.4%) patients. Overall 17% (95% CI 15.3% to 18.9%) of patients with an HbA1c of >6.5% had an HbA1c ≥8.5%. After adjusting for age, gender, Charlson Index score, estimated glomerular filtration rate, and hemoglobin levels, with admission unit treated as a random effect, patients with previously known diabetes had lower 6-month mortality (OR 0.69, 95% CI 0.56 to 0.87, p=0.001). However, there were no significant differences in proportions of intensive care unit admission, mechanical ventilation or readmission within 6 months between the 3 groups. Conclusions Approximately one-third of all inpatients ≥54 years of age admitted to hospital have diabetes of which about 1 in 6 was previously unrecognized. Moreover, poor glycemic control was common. Proportions of intensive care unit admission, mechanical ventilation, or readmission were similar between the groups. Finally, diabetes was independently associated with lower 6-month mortality.
Aims This study examines prehospital Emergency Medical Service (EMS) utilisation and patterns of demand for hyperglycaemia management, including characteristics of individuals and factors related to hospital transport. Materials and methods A state-wide, community-based observational study of all patients requiring prehospital EMS for hyperglycaemia during a 7 year study period (Jan 2009–Dec 2015) using electronic data from the Ambulance Victoria data warehouse was conducted. Pre-specified variables related to patient demographics, comorbidities, examination findings, paramedic treatment and transport outcomes were obtained. Logistic regression was used to assess factors associated with transport to hospital. Results There were 11,417 cases of hyperglycaemia attended by paramedics during the study period, accounting for 0.3–0.4% of the total annual EMS caseload, and equating to 0.54 attendances per 100 people with diabetes in the state of Victoria, Australia, per year. There was a significant increase in annual utilisation, with a rate ratio of 1.62 between 2009 (2.42 cases per 10,000 population) and 2015 (3.91 cases per 10,000 population). Fifty-one percent of cases had type 2 diabetes, 37% had type 1 diabetes, 4% had diabetes with the type unspecified and 8% had no recorded history of diabetes. Ninety percent of cases were transported to hospital. Factors associated with increased odds of transport to hospital included no known history of diabetes, regional/rural locations, case time between 0600 and <1800 hours, increasing number of comorbidities and increasingly unstable vital sign observations. Conclusion There is substantial utilisation of prehospital EMS for hyperglycaemia. With increased population prevalence of diabetes predicted, further research on opportunities for prevention, as well as optimal management in the prehospital environment is warranted.
Abstract Aims/hypothesis Few studies examine the association between age at diagnosis and subsequent complications from type 2 diabetes. This paper aims to summarise the risk of mortality, macrovascular complications and microvascular complications associated with age at diagnosis of type 2 diabetes. Methods Data were sourced from MEDLINE and All EBM (Evidence Based Medicine) databases from inception to July 2018. Observational studies, investigating the effect of age at diabetes diagnosis on macrovascular and microvascular diabetes complications in adults with type 2 diabetes were selected according to pre-specified criteria. Two investigators independently extracted data and evaluated all studies. If data were not reported in a comparable format, data were obtained from authors, presented as minimally adjusted ORs (and 95% CIs) per 1 year increase in age at diabetes diagnosis, adjusted for current age for each outcome of interest. The study protocol was recorded with PROSPERO International Prospective Register of Systematic Reviews (CRD42016043593). Results Data from 26 observational studies comprising 1,325,493 individuals from 30 countries were included. Random-effects meta-analyses with inverse variance weighting were used to obtain the pooled ORs. Age at diabetes diagnosis was inversely associated with risk of all-cause mortality and macrovascular and microvascular disease (all p < 0.001). Each 1 year increase in age at diabetes diagnosis was associated with a 4%, 3% and 5% decreased risk of all-cause mortality, macrovascular disease and microvascular disease, respectively, adjusted for current age. The effects were consistent for the individual components of the composite outcomes (all p < 0.001). Conclusions/interpretation Younger, rather than older, age at diabetes diagnosis was associated with higher risk of mortality and vascular disease. Early and sustained interventions to delay type 2 diabetes onset and improve blood glucose levels and cardiovascular risk profiles of those already diagnosed are essential to reduce morbidity and mortality.
Benchmarking clinical performance by comparing diabetes health outcomes across healthcare providers drives quality improvement. Non-care related patient risk factors are likely to confound clinical performance, but few studies have tested this. This cross-sectional study is the first Australian investigation to analyse the effect of risk-adjustment for non-care related patient factors on benchmarking. Data from 4,670 patients with type 2 (n = 3,496) or type 1 (n = 1,174) were analysed across 49 diabetes centres. Diabetes health outcomes (HbA1c levels, LDL-cholesterol levels, systolic blood pressure and rates of severe hypoglycaemia) were risk-adjusted for non-care related patient factors using multivariate stepwise linear and logistic regression models. Unadjusted and risk-adjusted funnel plots were constructed for each outcome to identify low-performing and high-performing outliers. Unadjusted funnel plots identified 27 low-performing outliers and 15 high-performing outliers across all diabetes health outcomes. After risk-adjustment, 22 (81%) low-performing outliers and 13 (87%) high-performing outliers became inliers. Additionally, one inlier became a low-performing outlier. Risk-adjustment of diabetes health outcomes significantly reduced false positives and false negatives for outlier performance, hence providing more accurate information to guide quality improvement activity.
This review examines the effects of statins on physical activity and/or fitness, as statins can have adverse muscle effects. A search was done of MEDLINE, Embase, and EBMR databases up to July 2018 for randomized controlled trials comparing statin with placebo or control, measuring physical activity and/or fitness in adults. Sixteen randomized controlled trials (total participants [N] = 2,944) were included, 6 randomized controlled trials contributed data for meta-analysis. Random effects meta-analysis examined differences in physical fitness, maximal exercise time (in seconds) in exercise testing, and maximal heart rate (in beats per minute) between statins and control. No significant difference between statin and control for maximal heart rate (mean difference = 2.8 beats per minute, 95% confidence interval [-7.4, 13.0]; p = .59) nor exercise time (mean difference = 82.8 s, 95% confidence interval [-31.9, 197.4]; p = .516) were seen. There were insufficient studies reporting habitual physical activity to perform a meta-analysis. This review found no evidence for an effect of statins on physical activity or fitness, but data availability is limited.
This study explores the prevalence of, and factors associated with, likely depression and diabetes distress in adults with type 2 diabetes in a large, national sample. Australian National Diabetes Audit data were analysed from adults with type 2 diabetes attending 50 diabetes centres. The Brief Case find for Depression and Diabetes Distress Score 17 were administered to screen for likely depression and diabetes-related distress, respectively. A total of 2,552 adults with type 2 diabetes participated: (mean ± SD) age was 63 ± 13 years, diabetes duration was 12 ± 10 years, and HbA1c was 8 ± 2%. Twenty-nine percent of patients had likely depression, 7% had high diabetes distress, and 5% had both. Difficulty following dietary recommendations, smoking, forgetting medications, and diabetes distress were all associated with greater odds of depression whereas higher own health rating was associated with lower odds (all p < 0.02). Female gender, increasing HbA1c, insulin use, difficulty following dietary recommendations and depression were all associated with greater odds of diabetes distress & older age, higher own health rating and monitoring blood glucose levels as recommended were associated with lower odds (all p < 0.04). Depression was associated with sub-optimal self-care, while diabetes distress was associated with higher HbA1c and sub-optimal self-care.
Abstract Aim This cross‐sectional study compares the self‐care practices of younger and older people with Type 2 diabetes. Methods Data were analysed from the Australian National Diabetes Audit ( ANDA ) including 2552 adults with Type 2 diabetes from Australian Diabetes Centres. Pre‐specified demographic and clinical variables were obtained. Self‐care variables (physical activity, following dietary recommendations, medication adherence and monitoring blood glucose levels) were compared in people ≤ 64 and > 64 years of age. Results Mean age (± sd ) of participants was 63 ± 13 years overall, 53 ± 9 years for the younger group and 73 ± 6 years for the older group. A greater proportion of younger people had HbA 1c levels > 53 mmol/mol (> 7.0%) (76% vs. 68%), reported difficulty following dietary recommendations (50% vs. 32%) and forgetting medications (37% vs. 22%) compared with older people (all P ‐values <0.001). A smaller proportion of younger compared with older people reported monitoring their blood glucose levels as often as recommended (60% vs. 70%, P < 0.001). Similar proportions of people aged ≤ 64 and > 64 years required insulin therapy (59% vs. 57%, P = 0.200). Younger age was associated with a twofold increase in the odds of not following the recommended self‐care practices after adjustment for gender, smoking, insulin therapy, depression and allied health attendance (all P < 0.001). Conclusions Despite shorter diabetes duration, younger age was associated with worse glycaemic control and poorer diabetes self‐care practices among people with Type 2 diabetes. Targeted strategies are required to optimize diabetes self‐care practices and thereby glycaemic control.
Objective To compare the glycaemic control and cardiovascular risk factor profiles of younger and older patients with type 2 diabetes. Cross-sectional analysis of data from the 2015 Australian National Diabetes Audit was undertaken. Methods Data were obtained from adults with type 2 diabetes presenting to Australian secondary/tertiary diabetes centres. Logistic regression examined associations with glycated haemoglobin A1c (HbA1c) >7% (53 mmol/mol) and cardiovascular risk factors. Results Data from 3492 patients were analysed. Mean (±SD) age was 62.9±12.5 years, mean diabetes duration 13.5±9.4 years and mean HbA1c 8.2%±1.8%. Mean HbA1c was 8.6%±2.1% and 8.0%±1.6% for the younger (<60 years) and older subgroups (≥60 years), respectively (p<0.001). The adjusted OR (aOR) of HbA1c above >7.0% was 1.5 times higher (95% CI 1.22 to 1.84) for younger patients compared with older patients after adjustment for gender, smoking, diabetes duration, renal function and body mass index. Younger patients were also more likely to have dyslipidaemia (aOR 2.02, 95% CI 1.53 to 2.68; p<0.001), be obese (aOR 1.25, 95% CI 1.05 to 1.49; p<0.001) and be current smokers (aOR 2.13 95% CI 1.64 to 2.77; p<0.001) than older patients. Conclusions Younger age was associated with poorer glycaemic control and adverse cardiovascular risk factor profiles. It is imperative to optimise and monitor treatment in order to improve long-term outcomes.
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