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Keong F, Gander J, Wilson D, Durthaler J, Pimentel B, Barzilay JI. Albuminuria Screening in People With Type 2 Diabetes in a Managed Care Organization. AJPM FOCUS 2023; 2:100133. [PMID: 37790952 PMCID: PMC10546502 DOI: 10.1016/j.focus.2023.100133] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Introduction Albuminuria-an increased amount of urine albumin, in milligrams, adjusted for grams of urine creatinine-is an early marker of diabetic kidney disease. Several new classes of medications are now available that effectively lower albuminuria levels with the potential to delay or prevent the progression of diabetic kidney disease. However, screening for albuminuria in the U.S. is low in population-based studies (<10% to ∼50% at most). In this study, we examine whether screening for albuminuria was improved in an integrated model of healthcare delivery following the recommendations of the National Committee for Quality Assurance mandate (an umbrella group for the managed healthcare industry) to screen for albuminuria. Methods We examined screening for albuminuria over a 2-year period among people with Type 2 diabetes in a U.S. HMO with an electronic medical record, onto which automated laboratory ordering for albuminuria could be added when a patient appeared at the laboratory (for any reason) if albuminuria testing had not been obtained within the previous 365 days. Participants under this plan received diabetes education at no cost and panel managers to guide their diabetes care. Logistic regression using data from 2020 and 2021, separately, evaluated the relationship between patient characteristics and the likelihood of albuminuria screening. Results There were 20,688 and 22,487 participants with Type 2 diabetes mellitus in 2020 and 2021, respectively, who were analyzed. Approximately 80% were screened for albuminuria in both years. African American participants and those aged >64 years were more likely to have completed albuminuria screening. Screened individuals had lower HbA1c, blood pressure, and low-density lipoprotein cholesterol levels than those who were not screened. Conclusions In an integrated healthcare model, it is possible to achieve consistently high rates of albuminuria screening in people with Type 2 diabetes, especially in groups at high risk for kidney disease.
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Affiliation(s)
- Farrah Keong
- Business Intelligence Group, Kaiser Permanente of Georgia, Atlanta, Georgia
| | - Jennifer Gander
- Center for Research and Evaluation, Kaiser Permanente of Georgia, Atlanta, Georgia
| | - Daniel Wilson
- Division of Cardiorenal Medicine, U.S. Medical Affairs, Bayer Pharmaceuticals, LLC, Whippany, New Jersey
| | - Jeffrey Durthaler
- Division of Cardiorenal Medicine, U.S. Medical Affairs, Bayer Pharmaceuticals, LLC, Whippany, New Jersey
| | - Belkis Pimentel
- Department of Adult Medicine, Kaiser Permanente of Georgia, Atlanta, Georgia
- Department of Population Care Management, Kaiser Permanente of Georgia, Atlanta, Georgia
| | - Joshua I. Barzilay
- Division of Endocrinology, Kaiser Permanente of Georgia, Atlanta, Georgia
- Division of Endocrinology Metabolism and Lipids, Department of Medicine, Emory School of Medicine, Atlanta, Georgia
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Bundó D, Cunillera O, Arbiol-Roca A, Cobo-Guerrero S, Romano J, Gil-Terron N, Fulladosa X, Comas J, Rama I, Cruzado JM, Salvador-Gonzalez B. Final Stage of Chronic Kidney Disease with Conservative Kidney Management or Renal Replacement Therapy: A Primary-Care Population Study. J Clin Med 2023; 12:4602. [PMID: 37510717 PMCID: PMC10380812 DOI: 10.3390/jcm12144602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 06/29/2023] [Accepted: 07/02/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Studies focus on the incidence and risk factors (RFs) associated with reaching the final stage of chronic kidney disease (CKD-G5) and receiving kidney replacement therapy (KRT). Analysis of those related to reaching CKD-G5 while receiving conservative kidney management (CKM) has been neglected. METHODS Retrospective cohort study analysing electronic health records of individuals aged ≥ 50 with eGFR < 60 mL/min/m2. Cumulative incidence rates of CKD-G5, with and without KRT, were calculated. Multinomial regression models determined odds ratios (ORs) for CKD-G5 progression with KRT, CKM, or death. RESULTS Among 332,164 patients, the cumulative incidence of CKD-G5 was 2.79 cases per 100 person-years. The rates were 1.92 for CKD-G5 with KRT and 0.87 for CKD-G5 with CKM. Low eGFR and albuminuria were the primary RFs. Male gender and uncontrolled blood pressure had a greater impact on KRT (OR = 2.63 CI, 1.63) than on CKD-G5 with CKM (OR = 1.45 CI, 1.31). Increasing age and rurality reduced the probability of KRT but increased the probability of CKD-G5 with CKM. Higher incomes decreased the likelihood of developing CKD-G5 with and without KRT (OR = 0.49 CI). CONCLUSION One-third of CKD-G5 cases receive CKM. Those are typically older, female, rural residents with lower incomes and with lesser proteinuria or cardiovascular RF. The likelihood of receiving KRT is influenced by location and socioeconomic disparities.
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Affiliation(s)
- Daniel Bundó
- Centre Atenció Primària Alt Penedès, Direcció d'Atenció Primària Metropolitana Sud, Institut Català de la Salut, 08720 Vilafranca del Penedès, Barcelona, Spain
- Malaltia Cardiovascular i Renal en Atenció Primària (MACAP), Institut Universitari d'Investigació en Atenció Primària (IDIAP) Jordi Gol, 08007 Barcelona, Barcelona, Spain
- Unitat de Suport a la Recerca Metropolitana Sud, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Oriol Cunillera
- Malaltia Cardiovascular i Renal en Atenció Primària (MACAP), Institut Universitari d'Investigació en Atenció Primària (IDIAP) Jordi Gol, 08007 Barcelona, Barcelona, Spain
- Unitat de Suport a la Recerca Metropolitana Sud, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Ariadna Arbiol-Roca
- Malaltia Cardiovascular i Renal en Atenció Primària (MACAP), Institut Universitari d'Investigació en Atenció Primària (IDIAP) Jordi Gol, 08007 Barcelona, Barcelona, Spain
- Unitat de Suport a la Recerca Metropolitana Sud, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Laboratori Clínic Territorial Metropolitana Sud, Institut Català de la Salut, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Sílvia Cobo-Guerrero
- Malaltia Cardiovascular i Renal en Atenció Primària (MACAP), Institut Universitari d'Investigació en Atenció Primària (IDIAP) Jordi Gol, 08007 Barcelona, Barcelona, Spain
- Unitat de Suport a la Recerca Metropolitana Sud, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Centre Atenció Primària Gavarra, Direcció d'Atenció Primària Metropolitana Sud, Institut Català de la Salut, 08940 Cornellà de Llobregat, Barcelona, Spain
| | - Jose Romano
- Malaltia Cardiovascular i Renal en Atenció Primària (MACAP), Institut Universitari d'Investigació en Atenció Primària (IDIAP) Jordi Gol, 08007 Barcelona, Barcelona, Spain
- Unitat de Suport a la Recerca Metropolitana Sud, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Centre Atenció Primària Sant Josep, Direcció d'Atenció Primària Metropolitana Sud, Institut Català de la Salut, 08901 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Neus Gil-Terron
- Malaltia Cardiovascular i Renal en Atenció Primària (MACAP), Institut Universitari d'Investigació en Atenció Primària (IDIAP) Jordi Gol, 08007 Barcelona, Barcelona, Spain
- Unitat de Suport a la Recerca Metropolitana Sud, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Centre Atenció Primària El Pla, Direcció d'Atenció Primària Metropolitana Sud, Institut Català de la Salut, 08980 Sant Feliu de Llobregat, Barcelona, Spain
| | - Xavier Fulladosa
- Nephrology Department, Hospital Universitari de Bellvitge, Institut Català de la Salut, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Jordi Comas
- Organització Catalana de Trasplantaments (OCATT), 08005 Barcelona, Barcelona, Spain
| | - Inés Rama
- Nephrology Department, Hospital Universitari de Bellvitge, Institut Català de la Salut, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Josep M Cruzado
- Nephrology Department, Hospital Universitari de Bellvitge, Institut Català de la Salut, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
| | - Betlem Salvador-Gonzalez
- Malaltia Cardiovascular i Renal en Atenció Primària (MACAP), Institut Universitari d'Investigació en Atenció Primària (IDIAP) Jordi Gol, 08007 Barcelona, Barcelona, Spain
- Unitat de Suport a la Recerca Metropolitana Sud, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 08907 L'Hospitalet de Llobregat, Barcelona, Spain
- Direcció d'Atenció Primària Metropolitana Sud, Institut Català de la Salut, 08907 L'Hospitalet de Llobregat, Barcelona, Spain
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Association of renal function screening frequency with renal function decline in patients with type 2 diabetes: a real-world study in primary health care. BMC Nephrol 2022; 23:356. [PMCID: PMC9636837 DOI: 10.1186/s12882-022-02979-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022] Open
Abstract
Abstract
Aims
To examine the association of the screening frequency of estimated glomerular filtration rate (eGFR) with the substantial reduction in eGFR (≥ 25%) among type 2 diabetes (T2D) patients with normal (eGFR≥60 ml/min/1.73 m2) and impaired kidney function (eGFR< 60 ml/min/1.73 m2).
Methods
A longitudinal study involving 5104 T2D patients with follow-up period of 6.8 years (1.9 SD) were treated at the Rovaniemi Health Center, Rovaniemi, Finland during 2011–2019. The association between the screening frequency of eGFR (yearly vs. non-yearly) and the substantial reduction in eGFR was studied with logistical models and adjusted with biochemical variables and preventive medications.
Results
Among the T2D patients with normal kidney function, non-yearly eGFR screening was significantly associated with substantial eGFR reduction in both unadjusted (odds ratio [OR] 3.29, 95% confidence interval [CI] 2.54–4.33) and adjusted models (OR 2.06, 95% CI 1.21–3.73) compared with yearly screening frequency. In the group of patients with impaired kidney function in the unadjusted model, non-yearly eGFR screening was significantly associated with substantial eGFR reduction (OR 2.38, 95% CI 1.30–4.73), but became non-significant after adjustments (OR 1.89, 95% CI 0.61–7.21).
Conclusions
This study underscores the role of regular eGFR screening in the prevention of kidney function decline.
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Fried L, Schmedt N, Folkerts K, Bowrin K, Raad H, Batech M, Kovesdy C. High unmet treatment needs in patients with chronic kidney disease and type 2 diabetes: real-world evidence from a US claims database. Nephrol Dial Transplant 2022; 38:630-643. [PMID: 35389468 PMCID: PMC9976755 DOI: 10.1093/ndt/gfac140] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD), a serious complication of type 2 diabetes (T2D) increases the comorbid risk of cardiovascular disease (CVD) and end-stage kidney disease(ESKD). Treatment guidelines recommend renin-angiotensin blockade and antihyperglycemic treatment with metformin and sodium-glucose cotransporter 2 inhibitors (SGLT2is) as first-line treatment. We evaluated treatment initiation and discontinuation overall and in subgroups of T2D patients with incident CKD (incident cohort) and rates of clinical and economic outcomes in patients with T2D and any CKD (prevalent cohort). METHODS In this retrospective study of administrative claims in the USA between 1 January 2007 and 31 March 2019, we evaluated the proportion of patients with concomitant, newly initiated and discontinued use of antihypertensive [angiotensin-converting enzyme inhibitor (ACEi)/angiotensin II receptor blockers (ARBs), steroidal mineralocorticoid receptor antagonists (sMRAs)] and antidiabetic [SGLT2is, dipeptidyl peptidase-4 inhibitors (DPP4is), glucagon-like peptide-1 receptor agonists (GLP-1 RAs), insulin and sulfonylureas] medications, rates of clinical outcomes per 1000 person-years and mean total healthcare costs. RESULTS We identified 63 127 and 326 763 patients in the incident and prevalent CKD cohorts, respectively. Low initiation and high discontinuation rates were observed with 17.8% and 56.0% for ACEi/ARBs, 1.3% and 66.0% for sMRAs, 2.5% and 65.0% for SGLT2is, 3.7% and 66.8% for DPP4is, 2.31% and 69.0% for GLP-1 RAs, 4% and 75.7% for insulin and 5.5% and 56.9% for sulfonylureas. Similar results were seen by subgroups. Rates of clinical outcomes ranged from 35.07 per 1000 person-years for all-cause mortality to 104.19 for ESKD, with rates of hospitalization ranging from 36.61 for kidney hospitalizations to 283.14 for all-cause hospitalizations. Among patients with comorbidities, higher clinical and economic outcomes were found. CONCLUSION Our results highlight high unmet needs of CKD and T2D, particularly subgroups of patients with multimorbid CVD, high-risk CKD (low estimated glomerular filtration rate or high urinary albumin:creatinine ratio) or rapidly progressing CKD. Low initiation and high discontinuation of recommended treatments suggest that adherence to guidelines for halting CKD progression is suboptimal. These high-risk patients may benefit from further treatment options to improve morbidity and mortality and reduce the economic burden.
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Affiliation(s)
- Linda Fried
- VA Pittsburgh Healthcare System, University of Pittsburgh, Pittsburgh, PA, USA
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Kovesdy C, Schmedt N, Folkerts K, Bowrin K, Raad H, Batech M, Fried L. Predictors of cardio-kidney complications and treatment failure in patients with chronic kidney disease and type 2 diabetes treated with SGLT2 inhibitors. BMC Med 2022; 20:2. [PMID: 35000594 PMCID: PMC8744296 DOI: 10.1186/s12916-021-02191-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/17/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Clinical practice guidelines recommend sodium-glucose co-transporter 2 inhibitors (SGLT2is) to mitigate adverse kidney and cardiovascular outcomes in patients with type 2 diabetes (T2D), including patients with comorbid chronic kidney disease (CKD), also referred to as diabetic kidney disease (DKD), who are at even higher risk. In this study, we sought to identify predictors of cardio-kidney events, cardio-kidney complications, and treatment failure (i.e., addition/initiation of a new T2D class, insulin, or discontinuation of SGLT2is) after new initiation of SGLT2is in patients with CKD and T2D (DKD). METHODS In this retrospective cohort study, we identified adult patients with DKD who initiated SGLT2is between April 1, 2012, and June 30, 2019, in Optum claims data. Outcome rates per 1000 person-years (PY) are reported with 95% confidence intervals (CIs). Cox proportional hazards regression identified patient characteristics associated with each outcome. RESULTS The study population consisted of 6389 initiators of SGLT2is. The rate of CV hospitalization was 26.0 (95% CI 21.6, 30.4) per 1000 PY. Baseline characteristics associated with higher risk of CV hospitalization included age, atrial fibrillation, peripheral vascular disease (PVD), and cancer. The rate of kidney hospitalization was 12.0 (95% CI 9.0, 15.0) per 1000 PY. The risk increased significantly with baseline evidence of heart failure, hyperkalemia, respiratory failure, depression, and use of loop diuretics. In total, 55.0% of all SGLT2i initiators discontinued treatment during the follow-up period. The rate of treatment failure was 510.5 (95% CI 492.9, 528.1) per 1000 PY. Analysis of key time-dependent SGLT2i-associated adverse events showed that experiencing diabetic ketoacidosis and volume depletion were associated with risk of treatment failure. CONCLUSIONS Our study demonstrated high rates of residual cardio-kidney outcomes and treatment failure in patients with DKD treated with SGLT2is. Patients with high baseline CV risk and the presence of certain conditions, such as atrial fibrillation, PVD, and heart failure, were at higher risk for cardio-kidney events. Further research is needed to assess the potential relationship between adverse events and SGLT2i treatment failure.
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Affiliation(s)
- Csaba Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee, Memphis, TN, USA
| | | | | | | | | | | | - Linda Fried
- 7E121 VA Pittsburgh Healthcare System, University of Pittsburgh, University Drive Center, Pittsburgh, PA, 15240, USA.
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Chang YS, Li YH, Lee IT. A synergistic effect of variability in estimated glomerular filtration rate with chronic kidney disease on all-cause mortality prediction in patients with type 2 diabetes: a retrospective cohort study. Cardiovasc Diabetol 2021; 20:209. [PMID: 34663321 PMCID: PMC8524871 DOI: 10.1186/s12933-021-01399-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/08/2021] [Indexed: 12/28/2022] Open
Abstract
Background The combination of diabetes mellitus (DM) and chronic kidney disease (CKD) is associated with a high risk of mortality. Annual assessment of the estimated glomerular filtration rate (eGFR) is recommended for patients with DM. We investigated the effect of variability in annual eGFR values on all-cause mortality in patients with type 2 DM. Methods In this retrospective cohort study, we enrolled patients with eGFR data between 01 Aug 2017 and 31 July 2018. We defined the index eGFR as the first available eGFR value within the enrollment year and collected additional annual eGFR data from the previous three years. A total of 3592 patients with type 2 DM were enrolled, including 959 patients with CKD (index eGFR < 60 mL/min/1.73 m2) and 2633 patients without CKD. We assessed eGFR variability by using the standard deviation (SD) of the three annual eGFR and index eGFR values. We divided patients into subgroups according to the median SD of their annual eGFR (7.62 mL/min/1.73 m2). The primary endpoint was all-cause mortality after the index eGFR was assessed. Results During a median follow-up of 19 months (interquartile range: 18‒20 months), 127 (3.5%) deaths occurred among all 3592 enrolled patients. The highest mortality risk was observed in the high SD with CKD group, with a hazard ratio (HR) of 2.382 [95% confidence interval (CI) 1.346‒4.215] in comparison to the low SD without CKD group after adjusting for the associated factors. In patients without CKD, a high SD was an independent risk factor for mortality (HR = 2.105, 95% CI 1.256‒3.528). According to the C-index, the mortality prediction ability was better for the index eGFR + SD model than for the index eGFR alone model (0.671 vs. 0.629, P < 0.001). Conclusion There was a synergistic effect of eGFR variability with single-measured eGFR for the prediction of mortality in patients with type 2 DM. The SD of the annual eGFR values was also an independent predictor of mortality in patients with an eGFR > 60 mL/min/1.73 m2. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-021-01399-z.
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Affiliation(s)
- Yu-Shan Chang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, No. 1650, Section 4, Taiwan Boulevard, Taichung, 40705, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung City, 40201, Taiwan
| | - Yu-Hsuan Li
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, No. 1650, Section 4, Taiwan Boulevard, Taichung, 40705, Taiwan.,Department of Computer Science and Information Engineering, National Taiwan University, Taipei, 10617, Taiwan
| | - I-Te Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, No. 1650, Section 4, Taiwan Boulevard, Taichung, 40705, Taiwan. .,School of Medicine, Chung Shan Medical University, Taichung City, 40201, Taiwan. .,School of Medicine, National Yang Ming Chiao Tung University, Taipei, 11221, Taiwan.
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Kovesdy CP, Isaman D, Petruski-Ivleva N, Fried L, Blankenburg M, Gay A, Velentgas P, Folkerts K. Chronic kidney disease progression among patients with type 2 diabetes identified in US administrative claims: a population cohort study. Clin Kidney J 2021; 14:1657-1664. [PMID: 34084461 PMCID: PMC8162850 DOI: 10.1093/ckj/sfaa200] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD), one of the most common complications of type 2 diabetes (T2D), is associated with poor health outcomes and high healthcare expenditures. As the CKD population increases, a better understanding of the prevalence and progression of CKD is critical. However, few contemporary studies have explored the progression of CKD relative to its onset in T2D patients using established markers derived from real-world care settings. METHODS This retrospective, population-based cohort study assessed CKD progression among adults with T2D and with newly recognized CKD identified from US administrative claims data between 1 January 2008 and 30 September 2018. Included were patients with T2D and laboratory evidence of CKD as indicated by the established estimated glomerular filtration rate (eGFR) and urine albumin:creatinine ratio (UACR) criteria. Disease progression was described as transitions across the eGFR- and UACR-based stages. RESULTS A total of 65 731 and 23 035 patients with T2D contributed to the analysis of eGFR- and UACR-based CKD stage progression, respectively. CKD worsening was observed in approximately 10-17% of patients over a median follow-up of 2 years. Approximately one-third of patients experienced an increase in eGFR values or a decrease in UACR values during follow-up. CONCLUSIONS A relatively high proportion of patients were observed with disease progression over a short period of time, highlighting the need for better identification of patients at risk of rapidly progressive CKD. Future studies are needed to determine the clinical characteristics of these patients to inform earlier diagnostic and therapeutic interventions aimed at slowing disease progression.
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Affiliation(s)
- Csaba P Kovesdy
- Department of Medicine, Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | | | - Linda Fried
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael Blankenburg
- Medical Affairs & Pharmacovigilance, Pharmaceuticals, Bayer AG, Berlin, Germany
| | - Alain Gay
- Medical Affairs & Pharmacovigilance, Pharmaceuticals, Bayer AG, Berlin, Germany
| | | | - Kerstin Folkerts
- Market Access, Public Affairs & Sustainability, HEOR CV, Bayer AG, Wuppertal, Germany
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Migdalis IN, Papanas N, Ioannidis IM, Sotiropoulos AE, Raptis AE, Dimitriadis GD. Antidiabetic and Other Therapies Used in Subjects with Diabetes and Chronic Kidney Disease in a Hospital-Based Clinic Population in Greece. J Clin Med 2021; 10:2104. [PMID: 34068380 PMCID: PMC8153603 DOI: 10.3390/jcm10102104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/07/2021] [Accepted: 05/10/2021] [Indexed: 01/14/2023] Open
Abstract
(1) Background: Type 2 diabetes mellitus (T2DM) is the main cause of chronic kidney disease (CKD). In Greece, in a population from hospital-based diabetes clinics (n = 1759), the overall prevalence of diabetic chronic kidney disease (DCKD) was 45% including mild, moderate, and severe CKD. The aim of this study was to describe and analyze how T2DM patients with mild-to-severe CKD are managed by diabetologists in Greece and assess the achievement rates in glycemic, blood pressure and low-density lipoprotein-cholesterol (LDL-C) control. (2) Methods: This cross-sectional multicenter study took place from June 2015 to March 2016 and collected data from diabetes centers in public hospitals all over Greece. (3) Results: With regard to the anti-diabetes treatment, most participants were on metformin, DPP-4 (Dipeptidyl Peptidase-4 inhibitors) inhibitors and insulin. Angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers were the most prescribed medications for hypertension. For the management of dyslipidemia, most participants were on statins. For patients with DCKD, the levels of HbA1c, blood pressure and LDL-C were 7.2%, 137.7/76.9 mmHg and 95.9 mg/dL, respectively (mean values). (4) Conclusions: The outcomes of this study suggest that management of DCKD can be further improved and should be enhanced. These results may contribute to the whole health care system in Greece. In addition, the better understanding of therapeutic strategies used by diabetologists treating these patients offers educational benefits to primary care physicians, which can result in an overall more successful and efficient management of subjects with T2DM and DCKD.
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Affiliation(s)
- Ilias N. Migdalis
- Second Medical Department and Diabetes Centre, NIMTS Hospital, 11521 Athens, Greece
| | - Nikolaos Papanas
- Second Department of Internal Medicine and Diabetes Centre, University Hospital of Alexandroupolis, Democritus University of Thrace, 68132 Alexandroupolis, Greece;
| | - Ioannis M. Ioannidis
- First Department of Internal Medicine and Diabetes Centre, General Hospital of Nea Ionia Konstantopoulio-Patision, 14233 Athens, Greece;
| | | | - Athanasios E. Raptis
- Second Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.E.R.); (G.D.D.)
| | - George D. Dimitriadis
- Second Department of Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.E.R.); (G.D.D.)
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Zhou Y, Chen K, Du X, Tang J, Shi B. Risk Factors for Albuminuria in Normotensive Older Adults with Type 2 Diabetes Mellitus and Normal Renal Function: A Cross-Sectional Study. Diabetes Ther 2021; 12:697-705. [PMID: 33515179 PMCID: PMC7947076 DOI: 10.1007/s13300-021-01003-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/12/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Diabetes mellitus (DM) is prevalent in developed and developing countries, including China. However, few studies have examined the potential risk factors for albuminuria in normotensive older adults with type 2 DM and normal renal function. METHODS We recruited normotensive older adults (≥ 65 years) with type 2 DM and normal renal function from the First Affiliated Hospital of Soochow University from January to December 2019. We stratified participants according to their urine albumin to creatinine ratio (ACR) into the following groups: normal ACR (ACR1), microalbuminuria (ACR2), and macroalbuminuria (ACR3). Demographic characteristics, anthropometric parameters, and metabolic profiles were recorded. Creatinine clearance (Ccr) and homeostasis model assessment-insulin resistance (HOMA-IR) were calculated. Logistic regression was used to examine risk factors for albuminuria. RESULTS A total of 250 older adults were enrolled during the study period, including 124, 82, and 44 with normal albuminuria, microalbuminuria, and macroalbuminuria, respectively. We found that an extended duration of DM (odds ratio [OR] 1.085, 95% confidence interval [CI] 1.012-1.164, P = 0.022), elevated systolic blood pressure (OR 1.049, 95%CI 1.018-1.081, P < 0.01), elevated glycated hemoglobin (OR 1.734, 95% CI 1.332-2.258, P < 0.01), low insulin (OR 0.871, 95% CI 0.804-0.944, P < 0.01), and low C-peptide (OR 0.365, 95% CI 0.239-0.588, P < 0.01) were independent risk factors for albuminuria. CONCLUSION Elevated blood pressure, low insulin, low C-peptide, and poor glycemic control were significant risk factors for albuminuria. These parameters may serve as early indicators for intervention.
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Affiliation(s)
- Yingyi Zhou
- Endocrine Department, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Ke Chen
- Thoracic Surgery Department, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xuan Du
- Endocrine Department, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jiali Tang
- Endocrine Department, Xishan Hospital, Wuxi, China
| | - Bimin Shi
- Endocrine Department, The First Affiliated Hospital of Soochow University, Suzhou, China.
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10
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Farmer RE, Beard I, Raza SI, Gollop ND, Patel N, Tebboth A, McGovern AP, Kanumilli N, Ternouth A. Prescribing in Type 2 Diabetes Patients With and Without Cardiovascular Disease History: A Descriptive Analysis in the UK CPRD. Clin Ther 2021; 43:320-335. [PMID: 33581878 DOI: 10.1016/j.clinthera.2020.12.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/02/2020] [Accepted: 12/20/2020] [Indexed: 01/02/2023]
Abstract
PURPOSE Some classes of glucose-lowering medications, including sodium-glucose co-transporter 2 inhibitors (SGLT2is) and glucagon-like peptide 1-receptor agonists (GLP1-RAs) have cardio-protective benefit, but it is unclear whether this influences prescribing in the United Kingdom (UK). This study aims to describe class-level prescribing in adults with type 2 diabetes mellitus (T2DM) by cardiovascular disease (CVD) history using the Clinical Practice Research Datalink (CPRD). METHODS Four cross-sections of people with T2DM aged 18-90 and registered with their general practice for >1 year on 1st January 2017 (n = 166,012), 1st January 2018 (n = 155,290), 1st January 2019 (n = 152,602) and 31st December 2019 (n = 143,373) were identified. Age-standardised proportions for class use through time were calculated separately in those with and without CVD history and by total number of medications prescribed (one, two, three, four+). An analysis by UK country was also performed. FINDINGS Around 31% of patients had CVD history at each cross-section. Metformin was the most common treatment (>70% of those with and without CVD had prescriptions across all treatment lines). Overall use of SGLT2is and GLP1-RAs was low, with slightly less use in patients with CVD (SGLT2i: 9.8% and 13.8% in those with and without CVD respectively; GLP1-RA: 4.3% and 4.9%, December 2019). Use of SGLT2is as part of dual therapy was low but rose throughout the study. In January 2017, estimated use was 8.0% (95% CI 6.9-9.1%) and 8.9% (8.6-9.3%) in those with and without CVD. By December 2019 this reached 18.3% (17.0-19.5%) and 21.2% (20.6-21.7%) for those with and without CVD respectively. SGLT2i use as triple therapy increased: 22.7% (21.0-24.4%) and 25.9% (25.2-26.6%) in January 2017 to 41.3% (39.5-43.0%) and 45.5% (44.7-46.3%) in December 2019. GLP1-RA use also increased, but observed usage remained lower than SGLT2 inhibitors. Insulin use remained stable throughout, with higher use observed in those with CVD (16% vs 9.7% Dec 2019). Time trends in England, Wales, Scotland and Northern Ireland were similar, although class prevalence varied. IMPLICATIONS Although use of SGLT2is and GLP1-RAs has increased, overall usage remains low with slightly lower use in those with CVD history, suggesting there is opportunity to optimise use of these medicines in T2DM patients to manage CVD risk. Insulin use was substantially more prevalent in those with CVD despite no evidence of CVD benefit. Further investigation of factors influencing this finding may highlight strategies to improve patient access to the most appropriate treatments, including those with evidence of cardiovascular benefit.
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Affiliation(s)
- Ruth E Farmer
- Boehringer Ingelheim Ltd, Bracknell, United Kingdom.
| | - Ivan Beard
- Boehringer Ingelheim Ltd, Bracknell, United Kingdom
| | - Syed I Raza
- Boehringer Ingelheim Ltd, Bracknell, United Kingdom
| | | | - Niraj Patel
- Boehringer Ingelheim Ltd, Bracknell, United Kingdom
| | | | - Andrew P McGovern
- University of Exeter Medical School, Institute of Biomedical and Clinical Science, University of Exeter, Exeter, Devon, United Kingdom
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11
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Hagnäs M, Sundqvist H, Jokelainen J, Tumminia A, Vinciguerra F, Loreto C, Frittitta L, Russo GT, Mikkola I. The prevalence of chronic kidney disease and screening of renal function in type 2 diabetic patients in Finnish primary healthcare. Prim Care Diabetes 2020; 14:639-644. [PMID: 32527663 DOI: 10.1016/j.pcd.2020.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/22/2020] [Accepted: 05/17/2020] [Indexed: 11/18/2022]
Abstract
AIMS To estimate the prevalence of chronic kidney disease (CKD) in patients with type 2 diabetes (T2D) in Finnish primary healthcare, and to evaluate the screening for CKD and the proportions of patients receiving antihyperglycemic and cardiovascular preventive medication. MATERIAL AND METHODS T2D patients treated at the Rovaniemi Health Center, Finland during the years 2015-2019. Data included patient characteristics, blood pressure, HbA1c, lipid levels, kidney function and albuminuria, and medications prescribed. CKD was defined as estimated glomerular filtration rate (eGFR) <60 ml/min/1.72 m2 and/or albuminuria. RESULTS The study population comprised of 5112 T2D patients with a mean (SD) age of 66.7 (13.0) years. Of these, 60.2% were screened for CKD with both eGFR and albuminuria, and 30.1% of these patients had CKD. The prevalence of moderately increased and severely increased albuminuria was 19.6% and 3.2%, respectively. A total of 57.0% of the study population received angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB). CONCLUSIONS Screening for CKD with both recommended measures (eGFR and albuminuria) was insufficiently performed among this T2D population. Additionally, just over half of the study population had been prescribed ACE inhibitors or ARB. These results suggest an incongruity between the gold standard of diabetes care and real-world clinical practice.
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Affiliation(s)
- Maria Hagnäs
- Center for Life Course Health Research, University of Oulu, Oulu, Finland; Rovaniemi Health Center, Rovaniemi, Finland; Endocrine Section, Department of Clinical and Experimental Medicine, University of Catania, and Diabetes and Obesity Unit, Garibaldi Hospital, Catania, Italy.
| | | | - Jari Jokelainen
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | - Andrea Tumminia
- Endocrine Section, Department of Clinical and Experimental Medicine, University of Catania, and Diabetes and Obesity Unit, Garibaldi Hospital, Catania, Italy
| | - Federica Vinciguerra
- Endocrine Section, Department of Clinical and Experimental Medicine, University of Catania, and Diabetes and Obesity Unit, Garibaldi Hospital, Catania, Italy
| | - Carla Loreto
- Anatomy & Histology Section, Department of Biomedical and Biotechnological Sciences, University of Catania, Catania, Italy
| | - Lucia Frittitta
- Endocrine Section, Department of Clinical and Experimental Medicine, University of Catania, and Diabetes and Obesity Unit, Garibaldi Hospital, Catania, Italy
| | - Giuseppina T Russo
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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12
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Folkerts K, Petruski-Ivleva N, Kelly A, Fried L, Blankenburg M, Gay A, Kovesdy CP. Annual health care resource utilization and cost among type 2 diabetes patients with newly recognized chronic kidney disease within a large U.S. administrative claims database. J Manag Care Spec Pharm 2020; 26:1506-1516. [PMID: 33251992 PMCID: PMC10391265 DOI: 10.18553/jmcp.2020.26.12.1506] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Chronic kidney disease (CKD) is one of the most common complications of type 2 diabetes mellitus (T2D) and results in considerable economic burden. Current studies describing cost and health care resource utilization (HCRU) in T2D patients with CKD in real-world data are few. Even more scarce is evidence that takes into account disease severity and other comorbidities. OBJECTIVES: To (a) describe T2D patients with CKD identified in U.S. administrative claims data using laboratory test results for kidney function that are considered the gold standard criteria for kidney disease diagnosis and (b) estimate the annual HCRU and costs among these patients, overall and by disease severity and comorbidity subgroup. METHODS: Optum CDM data between the years 2008 and 2017 were used to identify T2D patients with newly recognized CKD, using laboratory test results for estimated glomerular filtration rate (eGFR) or urine albumin-to-creatinine ratio (UACR). The study estimated annualized total, inpatient, outpatient, and pharmacy costs and the number of outpatient, inpatient, and emergency room visits in the first year after CKD identification. Analyses were stratified by prevalent anemia, heart failure (HF), resistant hypertension, and by CKD stages. RESULTS: T2D patients with newly recognized CKD (n = 106,369) had a high prevalence of cardiovascular comorbidities and incurred on average $24,029 of total cost per person per year in the first year after CKD identification. Patients with HF and anemia incurred on average $41,951 and $31,127 of total annual cost, respectively. Patients identified at stage 5 CKD incurred on average $110,210 of total annual cost and had roughly a 7-fold higher annual inpatient hospitalization rate compared with patients identified at stage 1 CKD. CONCLUSIONS: Administrative claims data linked to laboratory results provide an opportunity to identify CKD patients using the gold standard criteria from clinical practice, minimizing potential misclassification of patients. Identified CKD patients, particularly those with HF, anemia, and more advanced CKD stage, incur high HCRU and cost. Better monitoring, earlier CKD diagnosis, and interventions that are effective in halting or slowing the progression of CKD, as well as at managing comorbid conditions, could be effective means to reduce the economic burden of CKD in T2D. DISCLOSURES: This study was funded by Bayer. Kelly is an employee of, and owns stock options in, Aetion, which was contracted by Bayer to conduct the study. Petruski-Ivleva was an employee of Aetion during the planning, analysis, and interpretation stages of the study. Kovesdy received honoraria from Amgen, Astra Zeneca, Bayer, Cara Therapeutics, Reata, Takeda, and Tricida. Fried received consultant fees from Bayer, Novo Nordisk, and Bristol-Meyers Squibb. Folkerts, Blankenburg, and Gay are Bayer employees. This work was presented as a poster at the annual European Association for the Study of Diabetes (EASD) conference held in Barcelona, Spain, on September 16-20, 2019.
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Affiliation(s)
| | | | | | | | | | | | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis
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13
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Spanopoulos D, Okhai H, Zaccardi F, Tebboth A, Barrett B, Busse M, Webb J, Khunti K. Temporal variation of renal function in people with type 2 diabetes mellitus: A retrospective UK clinical practice research datalink cohort study. Diabetes Obes Metab 2019; 21:1817-1823. [PMID: 30941882 PMCID: PMC6767485 DOI: 10.1111/dom.13734] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/19/2019] [Accepted: 03/31/2019] [Indexed: 11/27/2022]
Abstract
AIM To characterize the longitudinal variability of estimated glomerular filtration rate (eGFR) in people with type 2 diabetes mellitus (T2DM), including variation between categories and individuals. METHODS People with T2DM and sufficient recorded serum creatinine measurements were identified from the Clinical Practice Research Datalink (T2DM diagnosis from 1 January 2009 to 1 January 2011 with 5 years follow-up); eGFR was calculated using the CKD-EPI equation. RESULTS In total, 7766 individuals were included; 32.8%, 50.2%, 12.4%, 4.0% and 0.6% were in glomerular filtration rate (GFR) categories G1, G2, G3a, G3b and G4, respectively. Overall, eGFR decreased by 0.44 mL/min/1.73 m2 per year; eGFR increased by 0.80 mL/min/1.73 m2 between index and year 1, then decreased by 0.75 mL/min/1.73 m2 annually up to year 5. Category G1 showed a steady decline in eGFR over time; G2, G3a and G3b showed an increase between index and year 1, followed by a decline. Category G4 showed a mean eGFR increase of 1.85 mL/min/1.73 m2 annually. People in categories G3-G4 moved across a greater number of GFR categories than those in G1 and G2. Individual patients' eGFR showed a wide range of values (change from baseline at year 5 varied from -80 to +59 mL/min/1.73 m2 ). CONCLUSION Overall, eGFR declined over time, although there was considerable variation between GFR categories and individuals. This highlights the difficulty in prescribing many glucose-lowering therapies, which require dose adjustment for renal function. The study also emphasizes the importance of regular monitoring of renal impairment in people with T2DM.
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Affiliation(s)
| | - Hajra Okhai
- Diabetes Research CentreUniversity of LeicesterLeicesterUK
| | | | | | | | | | - Joanne Webb
- Medical AffairsEli Lilly and CompanyBasingstokeUK
| | - Kamlesh Khunti
- Diabetes Research CentreUniversity of LeicesterLeicesterUK
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14
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Ermini G, Tosetti C, Zocchi D, Mandreoli M, Caletti MT, Marchesini G. Type 2 diabetes treatment and progression of chronic kidney disease in Italian family practice. J Endocrinol Invest 2019; 42:787-796. [PMID: 30465248 DOI: 10.1007/s40618-018-0983-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 11/13/2018] [Indexed: 02/07/2023]
Abstract
AIMS Progressive chronic kidney disease represents a dreadful complication of type 2 diabetes mellitus (T2DM). We tested the pattern of use and the renal effects of old glucose-lowering drugs in T2DM patients cared for by Italian general practitioners (GPs). METHODS Data of 2606 T2DM patients were extracted from the databases of GPs, who do not have access to the most recent glucose-lowering drugs in Italy. The rate of kidney function decline was calculated by CKD-EPIcr, based on two consecutive creatinine values. RESULTS Metformin was used in 55% of cases, either alone or with sulfonylureas/repaglinide, across the whole spectrum of CKD (from 66% in stage G1 to only 8% in G4). Sulfonylurea use peaked at 21-22% in stage G2-G3a, whereas repaglinide use significantly increased from 8% in G1 to 22% in G4. The median rate of CKD decline was - 1.64 mL/min/1.73 m2 per year; it was higher in G1 (- 3.22 per year) and progressively lower with CKD severity. 826 cases (31.7%) were classified as fast progressors (eGFR decline more negative than - 5 mL/min/1.73 m2 per year). The risk of fast progressing CKD was associated with increasing BMI, albuminuria, and sulfonylurea use, alone (OR, 1.47; 95% confidence interval, 1.16-1.85), or in association with metformin (OR, 1.40; 95% CI 1.04-1.88). No associations were demonstrated for metformin, cardiovascular and lipid lowering drug use. CONCLUSION In the setting of Italian family practice, sulfonylurea use is associated with progressive CKD in patients with T2DM. Metformin, at doses progressively reduced according to CKD stages, as recommended by guidelines, is not associated with fast progression.
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Affiliation(s)
- G Ermini
- Section of the Italian College of General Practitioners and Primary Care, S.Orsola-Malpighi Hospital, "Alma Mater" University, 9, Via Massarenti, 40138, Bologna, Italy.
| | - C Tosetti
- Section of the Italian College of General Practitioners and Primary Care, S.Orsola-Malpighi Hospital, "Alma Mater" University, 9, Via Massarenti, 40138, Bologna, Italy
| | - D Zocchi
- Section of the Italian College of General Practitioners and Primary Care, S.Orsola-Malpighi Hospital, "Alma Mater" University, 9, Via Massarenti, 40138, Bologna, Italy
| | - M Mandreoli
- Nephrology and Dialysis Unit, S. Maria della Scaletta Hospital, Imola, Bologna, Italy
| | - M T Caletti
- Unit of Metabolic Diseases and Clinical Dietetics, "Alma Mater" University, Bologna, Italy
| | - G Marchesini
- Unit of Metabolic Diseases and Clinical Dietetics, "Alma Mater" University, Bologna, Italy
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15
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Spanopoulos D, Busse M, Webb J, Tebboth A, Gollop ND, Marcus MW. DPP-4 Inhibitor Dose Selection According to Manufacturer Specifications: A Contemporary Experience From UK General Practice. Clin Ther 2019; 41:1622-1630. [PMID: 31164243 DOI: 10.1016/j.clinthera.2019.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 05/10/2019] [Accepted: 05/14/2019] [Indexed: 01/08/2023]
Abstract
Recently, 2 dipeptidyl peptidase-4 (DPP-4) inhibitors, sitagliptin and saxagliptin, adjusted dosing specification from creatinine clearance to glomerular filtration rate, more typically reported in routine laboratory tests. This cross-sectional study examines all DPP-4 inhibitor initiations that require dose adjustment and the dose selection using data from UK general practice. Results indicate that 34% of patients taking a nonlinagliptin DPP-4 inhibitor were given a higher dose and 11% a lower dose than specified in the Summary of Product Characteristics. This reinforces the deviation from Summary of Product Characteristics prescription of DPP-4 inhibitors identified in earlier studies despite improvement in compatibility with routine reporting.
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Affiliation(s)
| | | | - Joanne Webb
- Eli Lilly and Company, Basingstoke, United Kingdom
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