Associations of HbA1c and educational level with risk of cardiovascular events in 32,871 drug-treated patients with Type 2 diabetes: a cohort study in primary care

Sex-dependent effect of socioeconomic status on cardiovascular event risk in a population-based cohort of patients with type 2 diabetes

BACKGROUND

Socioeconomic status (SES) factors often result in profound health inequalities among populations, and their impact may differ between sexes. The aim of this study was to estimate and compare the effect of socioeconomic status indicators on incident cardiovascular disease (CVD)-related events among males and females with type 2 diabetes (T2D).

METHODS

A population-based cohort from a southern European region including 24,650 patients with T2D was followed for five years. The sex-specific associations between SES indicators and the first occurring CVD event were modeled using multivariate Fine-Gray competing risk models. Coronary Heart Disease (CHD) and stroke were considered secondary outcomes.

RESULTS

Patients without a formal education had a significantly higher risk of CVD than those with a high school or university education, with adjusted hazard ratios (HRs) equal to 1.24 (95%CI: 1.09-1.41) for males and 1.50 (95%CI: 1.09-2.06) for females. Patients with <18 000€ income had also higher CVD risk than those with ≥18 000€, with HRs equal to 1.44 (95%CI: 1.29-1.59) for males and 1.42 (95%CI: 1.26-1.60) for females. Being immigrant showed a HR equal to 0.81 (95%CI: 0.66-0.99) for males and 1.13 (95%CI: 0.68-1.87) for females. Similar results were observed for stroke, but differed for CHD when income is used, which had higher effect in females.

CONCLUSION

Socioeconomic inequalities in CVD outcomes are present among T2D patients, and their magnitude for educational attainment is sex-dependent, being higher in females, suggesting the need to consider them when designing tailored primary prevention and management strategies.

Intensified glycemic control by HbA1c for patients with coronary heart disease and Type 2 diabetes: a review of findings and conclusions

The occurrence and development of coronary heart disease (CHD) are closely linked to fluctuations in blood glucose levels. While the efficacy of intensified treatment guided by HbA1c levels remains uncertain for individuals with diabetes and CHD, this review summarizes the findings and conclusions regarding HbA1c in the context of CHD. Our review showed a curvilinear correlation between regulated level of HbA1c and therapeutic effectiveness of intensified glycemic control among patients with type 2 diabetes and coronary heart disease. It is necessary to optimize the dynamic monitoring indicators of HbA1c, combine genetic profiles, haptoglobin phenotypes for example and select more suitable hypoglycemic drugs to establish more appropriate glucose-controlling guideline for patients with CHD at different stage of diabetes.

Are U-shaped relationships between risk factors and outcomes artifactual?

BACKGROUND

The objective of this study was to evaluate whether the observed nadir in a U- or J-shaped relationship between a particular risk factor and a future health outcome is a function of the distribution of the risk factor in the sample being analyzed.

METHODS

Data from the ORIGIN trial were used to assess the relationship between three risk factors (weight, systolic blood pressure, and serum insulin) and the hazard of a major cardiovascular event comprising a nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. Three spline curves were generated for each risk factor. The first was based on all available data, the second for a subgroup with a higher mean risk factor level, and the third for a subgroup with a lower mean risk factor level. Nadir levels of the risk factor (i.e., risk factor levels predicting the lowest hazard) were then identified for each spline curve.

RESULTS

When compared to the nadir values based on all available data, nadir values for all three risk factors were higher for the subgroups with higher mean levels and lower for those with lower mean levels.

CONCLUSIONS

The distribution of a risk factor in the population is an important determinant of its nadir value. Populations with high or low values may have high and low nadirs, respectively. Identification of a nadir for a modifiable risk factor from epidemiologic relationships may therefore arise from this distribution bias and is therefore unrelated to therapeutic targets.

Does optimal HbA1c in diabetes differ according to drug treatment? An evaluation of national electronic database in Malta

BACKGROUND AND AIMS

A J-shaped relationship between HbA_1c and mortality has been reported in subjects with type 2 diabetes. The postulated mechanism linking low HbA_1c with increased mortality is increased hypoglycaemia risk. We tested this hypothesis by comparing the relationship between low HbA_1c to mortality in patients on therapies with different hypoglycaemia risk.

METHODS

We selected patients on any type of treatment for diabetes from a national electronic database (n = 25,743) and linked to other databases, including laboratory database and the national mortality register.

RESULTS

We observed a J-shaped or U-shaped association between HbA_1c and all-cause mortality in the whole type 2 diabetes patient cohort as well as in patients on metformin monotherapy and in those on metformin-sulphonylurea combination therapy, but not in subjects on sulphonylurea monotherapy or in those on insulin.

CONCLUSIONS

Our data confirm the J-shaped relationship between HbA_1c and mortality in type 2 diabetes, but suggest that a low HbA_1c is deleterious even in absence of hypoglycaemia and that subjects with type 2 diabetes might require a slightly elevated blood glucose for optimal outcome. Our data also suggest that the increased mortality associated with sulphonylureas cannot be mediated solely through increased hypoglycaemia risk.

Glycemic Control and Risk of Sepsis and Subsequent Mortality in Type 2 Diabetes

OBJECTIVE

To investigate the nature of the relationship between HbA1c and sepsis among individuals with type 2 diabetes, and to assess the association between sepsis and all-cause mortality in such patients.

RESEARCH DESIGN AND METHODS

We included 502,871 individuals with type 2 diabetes recorded in the Swedish National Diabetes Register and used multivariable Cox regression and restricted cubic spline analyses to assess the association between time-updated HbA1c values and sepsis occurrence between 1 January 2005 and 31 December 2015. The association between sepsis and death was examined using multivariable Cox regression analysis.

RESULTS

Overall, 14,534 (2.9%) patients developed sepsis during the study period. On multivariable Cox regression analysis, compared with an HbA1c of 48-52 mmol/mol (6.5-6.9%), the adjusted hazard ratio for sepsis was 1.15 (95% CI 1.07-1.24) for HbA1c <43 mmol/mol (6.1%), 0.93 (0.87-0.99) for HbA1c 53-62 mmol/mol (7.0-7.8%), 1.05 (0.97-1.13) for HbA1c 63-72 mmol/mol (7.9-8.7%), 1.14 (1.04-1.25) for HbA1c 73-82 mmol/mol (8.8-9.7%), and 1.52 (1.37-1.68) for HbA1c >82 mmol/mol (9.7%). In the cubic spline model, a reduction of the adjusted risk was observed within the lower HbA1c range until 53 mmol/mol (7.0%), with a hazard ratio of 0.78 (0.73-0.82) per SD; it increased thereafter (P for nonlinearity <0.001). As compared with patients without sepsis, the adjusted hazard ratio for death among patients with sepsis was 4.16 (4.03-4.30).

CONCLUSIONS

In a nationwide cohort of individuals with type 2 diabetes, we found a U-shaped association between HbA1c and sepsis and a fourfold increased risk of death among those developing sepsis.

Factors associated with potential over- and undertreatment of hyperglycaemia and annual measurement of HbA1c in type 2 diabetes in norwegian general practice

AIMS

To identify individual and general practitioner (GP) characteristics associated with potential over- and undertreatment of hyperglycaemia in type 2 diabetes and with HbA1c not being measured.

METHODS

A cross-sectional study that included 10233 individuals with type 2 diabetes attending 282 GPs. Individuals with an HbA1c measurement during the last 15 months were categorized as potentially overtreated if they were prescribed a sulphonylurea and/or insulin when the HbA1c was less than 53 mmol/mol (7%) when aged over 75 years or less than 48 mmol/mol (6.5%) when aged between 65 and 75 years. Potential undertreatment was defined as age less than 60 years and HbA1c > 64 mmol/mol (8.0%) or HbA1c > 69 mmol/mol (8.5%) and treated with lifestyle modification and/or monotherapy. We used multilevel binary and multinominal logistic regression models to examine associations.

RESULTS

Overall, 4.1% were potentially overtreated, 7.8% were potentially undertreated and 11% did not have HbA1c measured. Characteristics associated with potential overtreatment were as follows: long diabetes duration, prescribed antihypertensive medication, cardiovascular disease and renal failure. Potential undertreatment was associated with male gender, non-western origin and low educational level. Characteristics associated with not having an HbA1c measurement performed were male gender, age < 50 years and cardiovascular diseases. GP specialist status and GPs' use of a Noklus diabetes application reduced the risk of not having an HbA1c measurement performed.

CONCLUSION

Potential overtreatment in elderly individuals with type 2 diabetes was relatively low. Nevertheless, appropriate de-intensification or intensification of treatment and regular HbA1c measurement in identified subgroups is warranted.

Socioeconomic position and first-time major cardiovascular event in patients with type 2 diabetes: a Danish nationwide cohort study

AIMS 

The association between socioeconomic position and cardiovascular disease has not been well studied in patients with type 2 diabetes. We aimed to examine the association between socioeconomic position and first-time major adverse cardiovascular events (MACE) in patients with type 2 diabetes.

METHODS AND RESULTS 

Through the Danish nationwide registers, we identified all residents with newly diagnosed type 2 diabetes between 2012 and 2017. Based on sex-stratified multivariable cause-specific Cox regression models, we calculated the standardized absolute 5-year risk of the composite outcome of first-time myocardial infarction, stroke, or cardiovascular mortality (MACE) according to income quartiles. A total of 57 106 patients with type 2 diabetes were included. During 155 989 person years, first-time MACE occurred in 2139 patients. Among both men and women, income was inversely associated with the standardized absolute 5-year risk of MACE. In men, the 5-year risk of MACE increased from 5.7% [95% confidence interval (CI) 4.9-6.5] in the highest income quartile to 9.3% (CI 8.3-10.2) in the lowest income group, with a risk difference of 3.5% (CI 2.4-4.7). In women, the risk of MACE increased from 4.2% (CI 3.4-5.0) to 6.1% (CI 5.2-7.0) according to income level, with a risk difference of 1.9% (CI 0.8-2.9).

CONCLUSION 

Despite free access to medical care in Denmark, low-socioeconomic position was associated with a higher 5-year risk of first-time MACE in patients with incident type 2 diabetes. Our results suggest prevention strategies could be developed specifically for patients with low-socioeconomic position.

Association between intensive glycemic control and mortality in elderly diabetic patients in the primary care: A retrospective cohort study

OBJECTIVE

To examine the association between the most recent HbA1c values and the mortality of elderly Type 2 Diabetic (T2DM) patients managed in the public primary care setting and to explore the associating risk factors.

DESIGN

Retrospective cohort study.

SUBJECTS

All T2DM patients aged 65 or above, who attended a public primary care clinic for regular follow up from 01/01/2012 to 31/12/2012 were included. Their follow up status till 31/12/2017 was reviewed. Those who were deceased on or before 31/12/2017 were matched randomly with controls that were alive in the same cohort for comparison.

MAIN OUTCOME MEASURES

Patients' demographics, smoking status, duration of T2DM, biochemical parameters including the most recent HbA1c, lipid profile, renal function test, drug profile, co-morbidities and all-cause mortality were retrieved from Hospital Authority's CDARS and CMS systems.

RESULTS

Both high (>8.0%) and low (<6.5%) HbA1c values were associated with increased odd ratio of all-cause mortality among T2DM elderly patients treated in the primary care. There was a 3-fold increase in odd ratio when the HbA1c reading was very low (<6.0%). Associated risk factors for all-cause mortality in elderly T2DM patients included smoker status, lower BMIs, and higher LDL levels and use of sulphonylureas.

CONCLUSIONS

Glycemic target for elderly T2DM patients should be approached cautiously. Over-aggressive treatment may lead to increased mortality among elderly T2DM patients.

The role of glucagon in the possible mechanism of cardiovascular mortality reduction in type 2 diabetes patients

AIM

Type 2 diabetes (T2D) is one of the major public health issues worldwide. The main cause of mortality and morbidity among T2D patients are cardiovascular (CV) causes. Various antidiabetics are used in T2D treatment, but until recently they lacked clear evidence of the reduction in CV mortality and all-cause mortality as independent study end-points. The aim of this article was to present and critically evaluate potential mechanisms behind the remarkable results documented in trials with new antidiabetics for the treatment of T2D.

METHODS

Relevant data were collected using the MEDLINE, PubMed, EMBASE, Web of Science, Science Direct, and Scopus databases with the key words: "type 2 diabetes," "mortality," "glucagon," "empagliflozin," "liraglutide," "insulin" and "QTc." Searches were not limited to specific publication types or study designs.

RESULTS

The EMPA-REG OUTCOME trial with empagliflozin and LEADER trial with liraglutide presented remarkable results regarding the reduction in mortality in T2D treatment. However, the potential mechanism for those beneficial effects is difficult to determine. It is not likely that improvements in classic CV risk factors are responsible for the observed effect. A potential mechanism may be caused by the elevation of postprandial (PP) glucagon concentrations that can be seen with an empagliflozin and liraglutide therapy, which could have beneficial effects considering the myocardial electrical stability in T2D patients.

CONCLUSION

This hypothesis throws new light upon possible mechanisms of reduction in mortality in T2D patients.

Haemoglobin A1c and hearing impairment: longitudinal analysis using a large occupational health check-up data of Japan

OBJECTIVES

The aim of this study was to determine whether haemoglobin A1c (HbA1c) level is associated with the incidence of hearing impairment accounting for smoking status and diabetic condition at baseline.

METHODS

Participants were 131 689 men and 71 286 women aged 30-65 years and free of hearing impairment at baseline (2008) who attended Japanese occupational annual health check-ups from 2008 to 2015. We defined low-frequency hearing impairment at a hearing threshold >30 dB at 1 kHz and high frequency at >40 dB at 4 kHz in the better ear in pure-tone audiometric tests. HbA1c was categorised into seven categories. The association between HbA1c and hearing impairment was assessed using the Cox proportional hazards model.

RESULTS

On 5 years mean follow-up, high HbA1c was associated with high-frequency hearing impairment. In non-smokers, HbA1c≥8.0% was associated with high-frequency hearing impairment, with a multivariable HR (95% CI) compared with HbA1c 5.0%-5.4% of 1.46 (1.10 to 1.94) in men and 2.15 (1.13 to 4.10) in women. There was no significant association between HbA1c and hearing impairment in smokers. A J-shaped association between HbA1c and high-frequency hearing impairment was observed for participants with diabetes at baseline. HbA1c was not associated with low-frequency hearing impairment among any participants.

CONCLUSIONS

HbA1c ≥8.0% of non-smokers and ≥7.3% of participants with diabetes was associated with high-frequency hearing impairment. These findings indicate that appropriate glycaemic control may prevent diabetic-related hearing impairment.

Prognostic impact of systolic blood pressure variability in people with diabetes

Objective

Blood pressure variability (BPV) has been associated with risk of cardiovascular events in observational studies, independently of mean BP levels. In states with higher autonomic imbalance, such as in diabetes, the importance of BP variability may theoretically be even greater. We aimed to investigate the incremental value of BPV for prediction of cardiovascular and all-cause mortality in patients with type 2 diabetes.

Methods

We identified 9,855 patients without pre-existing cardiovascular disease who did not change BP-lowering treatment during the observation period from a Swedish primary health care cohort of patients with type 2 diabetes. BPV was summarized as the standard deviation (SD), coefficient of variation (CV), or variation independent of mean (VIM). Patients were followed for a median of 4 years and associations with cardiovascular and all-cause mortality were investigated using Cox proportional hazards models.

Results

BPV was not associated with cardiovascular specific or all-cause mortality in the total sample. In patients who were not on BP-lowering drugs during the observation period (n = 2,949), variability measures were associated with all-cause mortality: hazard ratios were 1.05, 1.04 and 1.05 for 50% increases in SD, CV and VIM, respectively, adjusted for Framingham risk score risk factors, including mean BP. However, the addition of the variability measures in this subgroup only led to very minimal improvement in discrimination, indicating they may have limited clinical usefulness (change in C-statistic ranged from 0.000–0.003 in all models).

Conclusions

Although BPV was independently associated with all-cause mortality in diabetes patients in primary care who did not have pre-existing cardiovascular disease or BP-lowering drugs, it may be of minimal clinical usefulness above and beyond that of other routinely measured predictors, including mean BP.

Impact of differing glucose-lowering regimens on the pattern of association between glucose control and survival

AIMS

To characterize survival in relation to achieved glycated haemoglobin (HbA1c) level within alternative glucose-lowering regimens with differing risks of hypoglycaemia.

METHODS

Data were extracted from the UK Clinical Practice Research Datalink and the corresponding Hospital Episode Statistics. Patients with type 2 diabetes prescribed glucose-lowering therapy in monotherapy or dual therapy with metformin between 2004 and 2013 were identified. Risk of all-cause mortality within treatment cohorts was evaluated using the Cox proportional hazards model, introducing mean HbA1c as a quarterly updated, time-dependent covariable.

RESULTS

There were 6646 deaths in a total follow-up period of 374 591 years. Survival for lower (<7%) vs moderate HbA1c levels (≥7%, <8.5%) differed by cohort: metformin, adjusted hazard ratio (aHR) 1.03 (95% confidence interval [CI] 0.95-1.12); sulphonylurea, aHR 1.11 (95% CI 0.99-1.25); insulin, aHR 1.47 (95% CI 1.25-1.72); combined regimens with low hypoglycaemia risk, aHR 1.02 (95% CI 0.94-1.10); and combined regimens with higher hypoglycaemia risk excluding insulin, aHR 1.24 (95% CI 1.13-1.35) and including insulin, aHR 1.28 (95% CI 1.18-1.37). Higher HbA1c levels were associated with increased mortality in regimens with low hypoglycaemia risk. Post hoc analysis by HbA1c deciles revealed an elevated risk of all-cause mortality for the lowest deciles across all cohorts, but particularly in those regimens associated with hypoglycaemia. High HbA1c was associated with no difference, or a small increase in mortality risk in regimens with increased risk of hypoglycaemia.

CONCLUSIONS

The pattern of mortality risk across the range of HbA1c differed by glucose-lowering regimen. Lower HbA1c was associated with increased mortality risk compared with moderate control, especially in those regimens associated with hypoglycaemia. High levels of HbA1c were associated with the expected elevated mortality risk in regimens with low hypoglycaemia risk.

Relationship of Hyperglycaemia, Hypoglycaemia, and Glucose Variability to Atherosclerotic Disease in Type 2 Diabetes

OBJECTIVE

Type 2 diabetes mellitus (T2DM) is known to be associated with increased cardiovascular risk. The aim of this study was therefore to investigate the independent effects of hyperglycaemia, hypoglycaemia, and glucose variability on microvascular and macrovascular disease in T2DM.

METHODS

Subjects with T2DM of <10 years duration and on stable antiglycaemic treatment underwent carotid intima-media thickness (CIMT), ankle-brachial index (ABI), albumin-creatinine ratio (ACR), and HbA_1c measurement, as well as 72-hour continuous glucose monitoring. Macrovascular disease was defined as one or more of the following: history of ischaemic heart disease (IHD), cerebrovascular accident (CVA), ABI < 0.9, or abnormal CIMT.

RESULTS

The study population comprised 121 subjects with T2DM (89 males : 32 females). The mean age was 62.6 years, and the mean DM duration was 3.7 years. Macrovascular disease was present in 71 patients (58.7%). In multivariate logistic regression analysis, body surface area (BSA) (OR 18.88 (95% CI 2.20-156.69), p = 0.006) and duration of blood glucose (BG) < 3.9 mmol/L (OR 1.12 (95% CI 1.014-1.228), p = 0.024) were independent predictors of macrovascular disease. BSA (OR 12.6 (95% CI 1.70-93.54), p = 0.013) and duration of BG < 3.9 mmol/L (OR 1.09 (95% CI 1.003-1.187), p = 0.041) were independent predictors of abnormal CIMT. Area under the curve for BG > 7.8 mmol/L (β = 15.83, p = 0.005) was the sole independent predictor of albuminuria in generalised linear regression.

CONCLUSIONS

This study demonstrates that hypoglycaemia is associated with the occurrence of atherosclerotic disease while hyperglycaemia is associated with microvascular disease in a Caucasian population with T2DM of recent duration.

Impact of Glycemic Control on Risk of Infections in Patients With Type 2 Diabetes: A Population-Based Cohort Study

Infections are a major clinical challenge for type 2 diabetes patients, but little is known about the impact of glycemic control. We used Cox regression analyses to examine the association between baseline and time-varying hemoglobin A1c (HbA1c) values and development of community antiinfective-agent-treated and hospital-treated infections in 69,318 patients with type 2 diabetes diagnosed between 2000 and 2012 in Northern Denmark. Incidence rates were 394/1,000 patient-years for community-treated infections and 63/1,000 patient-years for hospital-treated infections. The adjusted hazard ratios for community-treated infection at an HbA1c level of ≥10.50%, as compared with 5.50%-<6.49%, were 0.97 (95% confidence interval (CI): 0.94, 1.00) for HbA1c measured at early baseline, 1.09 (95% CI: 1.03, 1.14) for updated mean HbA1c, 1.13 (95% CI: 1.08, 1.19) for updated time-weighted mean HbA1c, and 1.19 (95% CI: 1.14, 1.26) for the latest updated HbA1c. Corresponding estimates for hospital-treated infections were 1.08 (95% CI: 1.02, 1.14) for early baseline HbA1c, 1.55 (95% CI: 1.42, 1.71) for updated mean HbA1c, 1.58 (95% CI: 1.44, 1.72) for updated time-weighted mean HbA1c, and 1.64 (95% CI: 1.51, 1.79) for the latest updated HbA1c. Our findings provide evidence for an association between current hyperglycemia and infection risk in type 2 diabetes patients.

Early Glycemic Control and Magnitude of HbA1c Reduction Predict Cardiovascular Events and Mortality: Population-Based Cohort Study of 24,752 Metformin Initiators

OBJECTIVE

We investigated the association of early achieved HbA_1c level and magnitude of HbA_1c reduction with subsequent risk of cardiovascular events or death in patients with type 2 diabetes who initiate metformin.

RESEARCH DESIGN AND METHODS

This was a population-based cohort study including all metformin initiators with HbA_1c tests in Northern Denmark, 2000-2012. Six months after metformin initiation, we classified patients by HbA_1c achieved (<6.5% or higher) and by magnitude of HbA_1c change from the pretreatment baseline. We used Cox regression to examine subsequent rates of acute myocardial infarction, stroke, or death, controlling for baseline HbA_1c and other confounding factors.

RESULTS

We included 24,752 metformin initiators (median age 62.5 years, 55% males) with a median follow-up of 2.6 years. The risk of a combined outcome event gradually increased with rising levels of HbA_1c achieved compared with a target HbA_1c of <6.5%: adjusted hazard ratio (HR) 1.18 (95% CI 1.07-1.30) for 6.5-6.99%, HR 1.23 (1.09-1.40) for 7.0-7.49%, HR 1.34 (1.14-1.57) for 7.5-7.99%, and HR 1.59 (1.37-1.84) for ≥8%. Results were consistent for individual outcome events and robust by age-group and other patient characteristics. A large absolute HbA_1c reduction from baseline also predicted outcome: adjusted HR 0.80 (0.65-0.97) for Δ = -4, HR 0.98 (0.80-1.20) for Δ = -3, HR 0.92 (0.78-1.08) for Δ = -2, and HR 0.99 (0.89-1.10) for Δ = -1 compared with no HbA_1c change (Δ = 0).

CONCLUSIONS

A large initial HbA_1c reduction and achievement of low HbA_1c levels within 6 months after metformin initiation are associated with a lower risk of cardiovascular events and death in patients with type 2 diabetes.

The impact of level of education on vascular events and mortality in patients with type 2 diabetes mellitus: Results from the ADVANCE study

AIMS

The relationship between educational level and the risk of all-cause mortality is well established, whereas the association with vascular events in individuals with type 2 diabetes is not well described. Any association may reflect a link with common cardiovascular or lifestyle-based risk factors.

METHODS

The relationships between the highest level of educational attainment and major cardiovascular events, microvascular complications and all-cause mortality were explored in a cohort of 11,140 individuals with type 2 diabetes. Completion of formal education before the age of 16 was categorized as a low level of education. Regional differences between Asia, East Europe and Established Market Economies were also assessed.

RESULTS

During a median of 5years of follow up, 1031 (9%) patients died, 1147 (10%) experienced a major cardiovascular event and 1136 (10%) a microvascular event. After adjustment for baseline characteristics and risk factors, individuals with lower education had an increased risk of cardiovascular events (hazard ratio (HR) 1.31, 95% CI 1.16-1.48, p<0.0001), microvascular events (HR 1.23, 95% CI 1.08-1.39, p=0.0013) and all-cause mortality (HR 1.34, 95% CI 1.18-1.52, p<0.0001). In regional analyses the increased risk of studied outcomes associated with lower education was weakest in Established Market Economies and strongest in East Europe.

CONCLUSIONS

A low level of education is associated with an increased risk of vascular events and death in patients with type 2 diabetes, independently of common lifestyle associated cardiovascular risk factors. The effect size varies between geographical regions.

Increased healthcare utilization costs following initiation of insulin treatment in type 2 diabetes: A long-term follow-up in clinical practice

AIMS

To compare long-term changes in healthcare utilization and costs for type 2 diabetes patients before and after insulin initiation, as well as healthcare costs after insulin versus non-insulin anti-diabetic (NIAD) initiation.

METHODS

Patients newly initiated on insulin (n=2823) were identified in primary health care records from 84 Swedish primary care centers, between 1999 to 2009. First, healthcare costs per patient were evaluated for primary care, hospitalizations and secondary outpatient care, before and up to seven years after insulin initiation. Second, patients prescribed insulin in second line were matched to patients prescribed NIAD in second line, and the healthcare costs of the matched groups were compared.

RESULTS

The total mean annual healthcare cost increased from €1656 per patient 2 years before insulin initiation to €3814 seven years after insulin initiation. The total cumulative mean healthcare cost per patient at year 5 after second-line treatment was €13,823 in the insulin group compared to €9989 in the NIAD group.

CONCLUSIONS

Initiation of insulin in type 2 diabetes patients was followed by increased healthcare costs. The increases in costs were larger than those seen in a matched patient population initiated on NIAD treatment in second-line.

Socio-environmental factors associated with diabetes mellitus among patients hospitalized with schizophrenia in Japan

OBJECTIVE

This study aimed to examine epidemiologically socio-environmental factors associated with diabetes mellitus among patients hospitalized with schizophrenia in Japan.

METHODS

This was a cross-sectional study from a single psychiatric hospital. Study patients were adults aged ≥20 years who were hospitalized with schizophrenia one or more times between January 2013 and December 2014. From electronic medical records or health insurance claims, we extracted schizophrenia patients with an F2 code according to ICD-10, and assessed the association of various factors with diabetes mellitus among these patients in a multivariable analysis.

RESULTS

During the 2-year period, there were 1899 patients hospitalized with a psychiatric disorder one or more times. Of them, a total of 770 adults with schizophrenia (285 men and 485 women) were eligible for our analysis. The standardized prevalence ratio of diabetes mellitus was 2.0 [95 % confidence interval (CI) 1.6-2.5] among men and 3.0 (95 % CI 2.5-3.6) among women in this hospital. There were no socio-environmental factors associated with diabetes mellitus among men. Among women, factors such as a 730-day hospitalization [adjusted odds ratio (OR) 3.82: 95 % confidence interval (CI) 1.52-9.64], and a medical protection/compulsory/discrimination hospitalization (adjusted OR 0.60, 95 % CI 0.36-0.99) were associated with diabetes mellitus. Compared with women living alone, those who were unmarried and lived together with someone had a significantly lower adjusted OR (0.41, 95 % CI 0.21-0.81).

CONCLUSIONS

Socio-environmental factors such as length of hospitalization, type of hospitalization, and marital status and living arrangement were associated with diabetes mellitus among hospitalized women with schizophrenia.

Healthcare utilization and costs following newly diagnosed type-2 diabetes in Sweden: A follow-up of 38,956 patients in a clinical practice setting

AIMS

To describe healthcare resource use patterns and estimate healthcare costs of newly diagnosed Type 2 diabetes mellitus (T2DM) patients in Sweden.

METHODS

Patients with a newly diagnosed T2DM between 1999 and 2009 were identified from 84 Swedish primary care centres. Healthcare resource use data, excluding pharmaceuticals, were extracted from electronic patient records and a national patient register, and reported as per patient mean number of primary care contacts, laboratory tests and hospitalizations. Per patient mean healthcare costs are reported as annual and cumulative costs.

RESULTS

During a median (maximum) of 4.6 (9.0) years follow-up; 38,956 patients (183,513 patient years) on average made 81 primary care contacts, was hospitalized 2.14 times, and took 31 laboratory tests. Mean per patient annual healthcare costs were €4128 (95% CI, 4054-4199) the first year after diagnosis, €2708 (95% CI, 2641-2776) the second year, and €3030 (95% CI, 2854-3204) in year 9 (2012 values). Mean per patient cumulative healthcare costs were €26,503 (95% CI, 26,025-26,970) at 9 years of follow-up. Hospitalizations accounted for the majority of healthcare costs.

CONCLUSIONS

Although newly diagnosed T2DM patients require a substantial amount of healthcare services in primary care, hospitalizations account for the majority of healthcare costs.

Glucose-lowering with exogenous insulin monotherapy in type 2 diabetes: dose association with all-cause mortality, cardiovascular events and cancer

AIMS

To evaluate the association between insulin exposure and all-cause mortality, incident major adverse cardiovascular events (MACE) and incident cancer in people with type 2 diabetes treated with insulin monotherapy.

METHODS

For this retrospective study, people with type 2 diabetes who progressed to insulin monotherapy from the year 2000 were identified from the UK Clinical Practice Research Datalink. The risks of progression to serious adverse outcomes were compared using Cox proportional hazards models. In the main analysis, insulin exposure was introduced into the model as prescribed international units per kilogram per day, as a cumulative, continuous, annually updated, time-dependent covariable.

RESULTS

A total of 6484 subjects with type 2 diabetes who progressed to treatment with insulin monotherapy from the year 2000 onwards were followed for a mean of 3.3 years. The event numbers were as follows: deaths, n = 1110; incident MACE, n = 342; incident cancers, n = 382. Unadjusted event rates were 61.3 deaths per 1000 person-years, 26.4 incident MACE per 1000 person-years and 24.6 incident cancers per 1000 person-years. The adjusted hazard ratios in relation to 1-unit increases in insulin dose were 1.54 [95% confidence interval (CI) 1.32-1.78] for all-cause mortality, 1.37 (95% CI 1.05-1.81) for MACE and 1.35 (95% CI 1.04-1.75) for cancer.

CONCLUSIONS

There was an association between increasing exogenous insulin dose and increased risk of all-cause mortality, MACE and cancer in people with type 2 diabetes. The limitations of observational studies mean that this should be further investigated using an interventional study design.

Impaired glucose metabolism among those with and without diagnosed diabetes and mortality: a cohort study using Health Survey for England data

BACKGROUND

The extent that controlled diabetes impacts upon mortality, compared with uncontrolled diabetes, and how pre-diabetes alters mortality risk remain issues requiring clarification.

METHODS

We carried out a cohort study of 22,106 Health Survey for England participants with a HbA1C measurement linked with UK mortality records. We estimated hazard ratios (HRs) of all-cause, cancer and cardiovascular disease (CVD) mortality and 95% confidence intervals (CI) using Cox regression.

RESULTS

Average follow-up time was seven years and there were 1,509 deaths within the sample. Compared with the non-diabetic and normoglycaemic group (HbA1C <5.7% [<39 mmol/mol] and did not indicate diabetes), undiagnosed diabetes (HbA1C ≥6.5% [≥48 mmol/mol] and did not indicate diabetes) inferred an increased risk of mortality for all-causes (HR 1.40, 1.09-1.80) and CVD (1.99, 1.35-2.94), as did uncontrolled diabetes (diagnosed diabetes and HbA1C ≥6.5% [≥48 mmol/mol]) and diabetes with moderately raised HbA1C (diagnosed diabetes and HbA1C 5.7-<6.5% [39-<48 mmol/mol]). Those with controlled diabetes (diagnosed diabetes and HbA<5.7% [<39 mmol/mol]) had an increased HR in relation to mortality from CVD only. Pre-diabetes (those who did not indicate diagnosed diabetes and HbA1C 5.7-<6.5% [39-<48 mmol/mol]) was not associated with increased mortality, and raised HbA1C did not appear to have a statistically significant impact upon cancer mortality. Adjustment for BMI and socioeconomic status had a limited impact upon our results. We also found women had a higher all-cause and CVD mortality risk compared with men.

CONCLUSIONS

We found higher rates of all-cause and CVD mortality among those with raised HbA1C, but not for those with pre-diabetes, compared with those without diabetes. This excess differed by sex and diabetes status. The large number of deaths from cancer and CVD globally suggests that controlling blood glucose levels and policies to prevent hyperglycaemia should be considered public health priorities.

Body weight and risk of atrial fibrillation in 7,169 patients with newly diagnosed type 2 diabetes; an observational study

BACKGROUND

Obesity, type 2 diabetes and atrial fibrillation (AF) are closely associated, but the underlying mechanisms are not fully understood. We aimed to explore associations between body mass index (BMI) or weight change with risk of AF in patients with type 2 diabetes.

METHODS

A total of 7,169 participations with newly diagnosed type 2 diabetes were stratified according to baseline BMI, and after a second BMI measurement within 18 months, further grouped according to relative weight change as "weight gain" (>1 BMI unit), "stable weight" (+/- 1 BMI unit) and "weight loss" (<1 BMI unit). The mean follow-up period was 4.6 years, and the risk of AF was estimated using adjusted Cox regression models.

RESULTS

Average age at diabetes diagnosis was 60 years and the patients were slightly obese (mean BMI 30.2 kg/m(2)). During follow-up, 287 patients developed incident AF, and those with overweight or obesity at baseline had 1.9-fold and 2.9-fold higher risk of AF, respectively, than those with normal BMI. The 14% of the patients with subsequent weight gain had 1.5-fold risk of AF compared with those with stable weight or weight loss.

CONCLUSIONS

In patients with newly diagnosed type 2 diabetes, baseline overweight and obesity, as well as modest weight increase during the first 18 months after diagnosis, were associated with a substantially increased risk of incident AF. Patients with type 2 diabetes may benefit from efforts to prevent weight gain in order to reduce the risk of incident AF.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01121315.

Labor force participation and secondary education of gender inequality index (GII) associated with healthy life expectancy (HLE) at birth

BACKGROUND

What is the factor that affects healthy life expectancy? Healthy life expectancy (HLE) at birth may be influenced by components of the gender inequality index (GII). Notably, this claim is not tested on the between components of the GII, such as population at least secondary education (PLSE) with ages 25 and older, labor force participation rate (LFPR) with ages 15 and older, and the HLE in the world's countries. Thus, this study estimates the associations between the PLSE, LFPR of components of the GII and the HLE.

METHODS

The data for the analysis of HLE in 148 countries were obtained from the World Health Organization. Information regarding the GII indicators for this study was obtained from the United Nations database. Associations between these factors and HLE were assessed using Pearson correlation coefficients and regression models.

RESULTS

Although significant negative correlations were found between HLE and the LFPR, positive correlations were found between HLE and PLSE. Finally, the HLE predictors were used to form a model of the components of the GII, with higher PLSE as secondary education and lower LFPR as labor force (R(2) = 0.552, P <0.001).

CONCLUSIONS

Gender inequality of the attainment secondary education and labor force participation seems to have an important latent effect on healthy life expectancy at birth. Therefore, in populations with high HLE, the gender inequalities in HLE are smaller because of a combination of a larger secondary education advantage and a smaller labor force disadvantage in male-females.

Self-rated literacy level does not explain educational differences in health and disease

BACKGROUND

Although literacy is increasingly considered to play a role in socioeconomic inequalities in health, its contribution to the explanation of educational differences in health has remained unexplored. The aim of this study was to investigate the contribution of self-rated literacy to educational differences in health.

METHODS

Data was collected from the Healthy Foundation and Lifestyle Segmentation Dataset (n = 4257). Self-rated literacy was estimated by individuals' self-reported confidence in reading written English. We used logistic regression analyses to assess the association between educational level and health (long term conditions and self-rated health). Self-rated literacy and other potential explanatory variables were separately added to each model. For each added variable we calculated the percentage change in odds ratio to assess the contribution to the explanation of educational differences in health.

RESULTS

People with lower educational attainment level were more likely to report a long term condition (OR 2.04, CI 1.80-2.32). These educational differences could mostly be explained by age (OR decreased by 27%) and could only minimally be explained by self-rated literacy, as measured by self-rated reading skills (OR decreased by 1%). Literacy could not explain differences in cardiovascular condition or diabetes, and only minimally contributed to mental health problems and depression (OR decreased by 5%). The odds of rating ones own health more negatively was higher for people with a low educational level compared to those with a higher educational level (OR 1.83, CI 1.59-2.010), self-rated literacy decreased the OR by 7%.

CONCLUSION

Measuring self-rated reading skills does not contribute significantly to the explanation of educational differences in health and disease. Further research should aim for the development of objective generic and specific instruments to measure health literacy skills in the context of health care, disease prevention and health promotion. Such instruments are not only important in the explanation of educational differences in health and disease, but can also be used to identify a group at risk of poorer health through low basic skills, enabling health services and health information to be targeted at those with greater need.

The proarrhythmic effect of hypoglycemia: evidence for increased risk from ischemia and bradycardia

Hypoglycemia increases the risk for both overall and sudden death. At a cellular level, hypoglycemia causes alterations in the physiology of myocardial tissue that are identical to proarrhythmic medications. Reduced serum glucose blocks the repolarizing K(+) channel HERG, which leads to action potential and QT prolongation and is uniformly associated with risk for torsades de pointes ventricular tachycardia. The sympathetic response induced by hypoglycemia also increases the risk of arrhythmias from Ca(2+) overload, which occur with sympathomimetic medications and excessive beta adrenergic stimulation. Thus, hypoglycemia can be considered a proarrhythmic event. This review focuses on emerging evidence for two other important changes induced by hypoglycemia that promote arrhythmias: ischemia and bradycardia. Studies of patients with "insulin shock" therapy from the early twentieth century and other more recent data strongly suggest that hypoglycemia can cause ischemia of myocardial tissue, both in association with coronary artery obstructions and by cellular mechanisms. Ischemia induces multiple proarrhythmic responses. Since ischemia itself reduces the possibility of using energy substrates other than glucose, hypoglycemia may generate positive feedback for electrophyisologic destabilization. Recent studies also show that hypoglycemia can cause bradycardia and heart block. Bradycardia is known to cause action potential prolongation and potentiate the development of torsades de pointes, particularly with low-serum K(+) which can be induced by hypoglycemic episodes. Thus, hypoglycemia-induced bradycardia may also create a dynamic, positive feedback for the development of arrhythmias and sudden death. These studies further support the hypothesis that hypoglycemia is a proarrhythmic event.