Indicators of quality of diabetes care in persons with type 2 diabetes with and without severe mental illness: a Danish nationwide register-based cohort study

Implementing physician-led medication reviews for patients with diabetes and severe mental disorder: A randomized controlled trial

AIMS

Patients with severe mental disorder and diabetes may be exposed to inappropriate polypharmacy increasing the risk of side effects and drug interactions. Although medication reviews may facilitate short-term deprescribing, they are not known to affect clinical outcomes. We investigated whether implementing physician-led medication reviews through interdisciplinary dialogue can change prescription patterns and improve pharmacological efficacy and tolerability in psychiatric outpatients with diabetes.

METHODS

Included in the study were 52 patients from an endocrinologist-psychiatrist outpatient clinic in Slagelse Region, Zealand, Denmark. Patients were allocated to an intervention group, where patients' pharmacological treatment was discussed at an interdisciplinary treatment conference based on a medication review conducted by a specialist in clinical pharmacology or a control group receiving standard care. All patients underwent psychometric testing, side effect screening, clinical interviews, and had drug regimens and biochemical test results extracted from the electronic health records at baseline and at 6 months follow up.

RESULTS

The trial was completed by 48 patients. Average time to follow up was 7 months (range 5-11 months). The intervention group had a median reduction of 1 drug (interquartile range [IQR] -4.00, 0.00) and 1 potentially inappropriate prescription (IQR -2.00, 0.00) compared to a median increase of 2 drugs (IQR 1.00, 3.00) and 2 potentially inappropriate prescriptions (IQR 0.00, 3.00) in the control group. The usage of both somatic and psychiatric drugs was reduced. We found no differences in clinical outcomes.

CONCLUSION

Deprescribing can be achieved without worsening psychiatric symptoms in psychiatric outpatients by implementing physician-led medication reviews through interdisciplinary dialogue. This study was registered on ClinicalTrials.gov: NCT (05243160).

The effectiveness of diabetes training of psychiatric health professionals on individuals with diabetes and psychiatric disorders - a pragmatic controlled trial in Denmark

BACKGROUND

Individuals with diabetes and co-existing psychiatric disorders have more diabetes complications and lower life expectancy than those with diabetes but no co-existing psychiatric disorders. Psychiatric health professionals may have a role in improving these outcomes but often lack diabetes knowledge and skills. This study aims to examine the effectiveness of a diabetes training course for psychiatric health professionals on their diabetes knowledge and skills and clinical outcomes, diabetes support and diabetes distress among individuals with diabetes and psychiatric disorders treated in psychiatric outpatient clinics.

METHODS

A pragmatic non-randomized controlled cluster trial was conducted in eight psychiatric outpatient clinics in Denmark. All psychiatric health professionals from four clinics participated in the diabetes training course (the intervention) and completed a questionnaire on experience of the training course and a 20-item pre- and post-test to measure diabetes knowledge and skills. Difference in pre- and post-tests were analyzed using t-tests. From August 2018 - June 2019, individuals with diabetes were recruited from the intervention clinics (n = 49) and from four control clinics continuing usual clinical practice (n = 57). Differences in clinical outcomes, diabetes support and diabetes distress between the intervention and control groups at six and 12 months after the training course, were analyzed using logistic and linear regression models adjusted for baseline levels.

RESULTS

Psychiatric health professionals (n = 64) had more correct answers after completing the course, with a mean increase of 6.3 [95% CI 5.6 to 7.0] correct answers. A total of 49 and 57 individuals were recruited for the intervention and control group, respectively. At follow-up, individuals treated in the intervention group had lower levels (clinical improvement) of systolic blood pressure, but had lower receipt of annual assessment of blood pressure, and body mass index (BMI) (worsening of process measures). While there were observed differences in odds and means for several other outcomes, none of these received statistical significance (see Table 2 and Fig. 2).

CONCLUSIONS

Training psychiatric health professionals in diabetes care improved their diabetes knowledge and skills and improved clinical levels of systolic blood pressure in individuals treated in the intervention group. However, this training intervention was associated with a lower likelihood of receiving annual assessment of blood pressure and BMI.

TRIAL REGISTRATION

ISRCTN registry registration number ISRCTN15523920, registration date: 02/10/2019.

Cardiovascular risk management among individuals with type 2 diabetes and severe mental illness: a cohort study

AIMS/HYPOTHESIS

The aim of this study was to compare cardiovascular risk management among people with type 2 diabetes according to severe mental illness (SMI) status.

METHODS

We used linked electronic data to perform a retrospective cohort study of adults diagnosed with type 2 diabetes in Scotland between 2004 and 2020, ascertaining their history of SMI from hospital admission records. We compared total cholesterol, systolic BP and HbA1c target level achievement 1 year after diabetes diagnosis, and receipt of a statin prescription at diagnosis and 1 year thereafter, by SMI status using logistic regression, adjusting for sociodemographic factors and clinical history.

RESULTS

We included 291,644 individuals with type 2 diabetes, of whom 1.0% had schizophrenia, 0.5% had bipolar disorder and 3.3% had major depression. People with SMI were less likely to achieve cholesterol targets, although this difference did not reach statistical significance for all disorders. However, people with SMI were more likely to achieve systolic BP targets compared to those without SMI, with effect estimates being largest for schizophrenia (men: adjusted OR 1.72; 95% CI 1.49, 1.98; women: OR 1.64; 95% CI 1.38, 1.96). HbA1c target achievement differed by SMI disorder and sex. Among people without previous CVD, statin prescribing was similar or better in those with vs those without SMI at diabetes diagnosis and 1 year later. In people with prior CVD, SMI was associated with lower odds of statin prescribing at diabetes diagnosis (schizophrenia: OR 0.54; 95% CI 0.43, 0.68, bipolar disorder: OR 0.75; 95% CI 0.56, 1.01, major depression: OR 0.92; 95% CI 0.83, 1.01), with this difference generally persisting 1 year later.

CONCLUSIONS/INTERPRETATION

We found disparities in cholesterol target achievement and statin prescribing by SMI status. This reinforces the importance of clinical review of statin prescribing for secondary prevention of CVD, particularly among people with SMI.

Trends in Incidence of Hospitalization for Hypoglycemia and Diabetic Ketoacidosis in Individuals With Type 1 or Type 2 Diabetes With and Without Severe Mental Illness in Denmark From 1996 to 2020: A Nationwide Study

OBJECTIVE

To examine trends in incidence of acute diabetes complications in individuals with type 1 or type 2 diabetes with and without severe mental illness (SMI) in Denmark by age and calendar year.

RESEARCH DESIGN AND METHODS

We conducted a cohort study using nationwide registers from 1996 to 2020 to identify individuals with diabetes, ascertain SMI status (namely, schizophrenia, bipolar disorder, or major depression) and identify the outcomes: hospitalization for hypoglycemia and diabetic ketoacidosis (DKA). We used Poisson regression to estimate incidence rates (IRs) and incidence rate ratios (IRRs) of recurrent hypoglycemia and DKA events by SMI, age, and calendar year, accounting for sex, diabetes duration, education, and country of origin.

RESULTS

Among 433,609 individuals with diabetes, 8% had SMI. Risk of (first and subsequent) hypoglycemia events was higher for individuals with SMI than for those without SMI (for first hypoglycemia event, IRR: type 1 diabetes, 1.77 [95% CI 1.56-2.00]; type 2 diabetes, 1.64 [95% CI 1.55-1.74]). Individuals with schizophrenia were particularly at risk for recurrent hypoglycemia events. The risk of first DKA event was higher in individuals with SMI (for first DKA event, IRR: type 1 diabetes, 1.78 [95% CI 1.50-2.11]; type 2 diabetes, 1.85 [95% CI 1.64-2.09]). Except for DKA in the type 2 diabetes group, IR differences between individuals with and without SMI were highest in younger individuals (<50 years old) but stable across the calendar year.

CONCLUSIONS

SMI is an important risk factor for acute diabetes complication and effective prevention is needed in this population, especially among the younger population and those with schizophrenia.

The development of type 2 diabetes management in people with severe mental illness in the Capital Region of Denmark from 2001 to 2015

BACKGROUND

Type 2 diabetes (T2D) treatment has changed markedly within the last decades. We aimed to explore whether people with severe mental illness (SMI) have followed the same changes in T2D treatment as those without SMI, as multiple studies suggest that people with SMI receive suboptimal care for somatic disorders.

METHODS

In this registry-based annual cohort study, we explored the T2D treatment from 2001 to 2015 provided in general practices of the Greater Copenhagen area. We stratified the T2D cohorts by their pre-existing SMI status. T2D was defined based on elevated glycated hemoglobin (≥48 mmol/mol) or glucose (≥11 mmol/L) using data from the Copenhagen Primary Care Laboratory Database. Individuals with schizophrenia spectrum disorders (ICD-10 F20-29) or affective disorders (bipolar disorder or unipolar depression, ICD-10 F30-33) were identified based on hospital-acquired diagnoses made within 5 years before January 1 each year for people with prevalent T2D or 5 years before meeting our T2D definition for incident patients. For comparison, we defined a non-SMI group, including people who did not have a hospital-acquired diagnosis of schizophrenia spectrum disorders, affective disorders, or personality disorders. For each calendar year, we assembled cohorts of people with T2D with or without SMI. We used Poisson regression to calculate the rates per 100 person-years of having at least one biochemical test (glycated hemoglobin, low-density lipoprotein cholesterol, estimated glomerular filtration rate, and urine albumin-creatinine ratio), having poor control of these biochemical results, taking glucose-lowering or cardiovascular medications, or experiencing a clinical outcome, including all-cause mortality and cardiovascular mortality. Three outcomes (cardiovascular events, cardiovascular mortality, and all-cause mortality) were additionally examined and adjusted for age and sex in a post hoc analysis.

RESULTS

From 2001 to 2015, 66,914 individuals were identified as having T2D. In 2015, 1.5% of the study population had schizophrenia spectrum disorder and 1.4% had an affective disorder. The number of people who used biochemical tests or had poor biochemical risk factor control was essentially unrelated to SMI status. One exception was that fewer LDL cholesterol tests were done on people with affective disorders and schizophrenia spectrum disorders at the beginning of the study period compared to people in the non-SMI group. This difference gradually diminished and was almost nonexistent by 2011. There was also a slightly slower rise in UACR test rates in the SMI groups compared to other people with T2D during the period. Throughout the study period, all groups changed their use of medications in similar ways: more metformin, less sulfonylurea, more lipid-lowering drugs, and more ACEi/ARBs. However, people with schizophrenia disorder consistently used fewer cardiovascular medications. Cardiovascular events were more common in the affective disorder group compared to the non-SMI group from 2009 to 2015 (rate ratio 2015 : 1.36 [95% CI 1.18-1.57]). After adjustment for age and sex, all-cause mortality was significantly higher among people with a schizophrenia spectrum disorder each year from 2003 to 2015 compared to the non-SMI group (rate ratio 2015 : 1.99 [95% CI 1.26-3.12]).

CONCLUSION

Persons with schizophrenia or affective disorders demonstrated the same treatment changes for T2D as those without SMI in general practice. The lower use of most types of cardiovascular medications among people with schizophrenia disorders indicates potential undertreatment of hypertension and dyslipidemia and remains throughout the study period. Cardiovascular events were most common among people with affective disorders, but this was not reflected in a higher proportion using cardiovascular preventive medications. This knowledge should be considered in the management of this vulnerable patient group.