1
|
Ben Mansour N, Sassi Mahfoudh A, Ben Romdhane H. Management of diabetics. Comparative study of two contrasting health structures. LA TUNISIE MEDICALE 2021; 99:129-138. [PMID: 33899180 PMCID: PMC8636952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
Abstract
BACKGROUND The proportion of total Tunisian with Diabetes reached 15.5% in 2016. The objective of this study was to analyze diabetic's management in contrasted health care settings. METHODS Mixed methodology (quantitative and qualitative) with explanatory design was used in contrasted health care structures (a primary health center (PHC) and the National Institute of Nutrition and Food Technologies (INNTA)). Interviews with health providers and patients were than condcuted in both centers to explain quantitative findings. RESULTS Quality of care assessement was performed among 100 patients in the PHC and 96 in the hospital. Glycemic control was reached in less than 30 % of the cases in both centers. Although clinical evaluation was better in the PHC, conducting ECGs, measuring of HbA1c and LDL-Ch were far from being optimal. The qualitative study did supply some hypotheses explaining these gaps: treatments shortage and lack of laboratory assessments specifically pointed in PHC settings, potentially lower its attractiveness, thus compounding overcrowding and stressful working conditions in hospitals. These last points as well as poor communication and overloaded clinics in hospital were major sources of providers and patient dissatisfaction. CONCLUSION This study made it clear that primary health care is a cornerstone in diabetes management. However, it is crucial to strengthen primary health care centers by operational technical support (laboratory equipements and quality information system) as well building capacities of health professionals in information, education and communication.
Collapse
|
2
|
Chiang JI, Furler J, Mair F, Jani BD, Nicholl BI, Thuraisingam S, Manski-Nankervis JA. Associations between multimorbidity and glycaemia (HbA1c) in people with type 2 diabetes: cross-sectional study in Australian general practice. BMJ Open 2020; 10:e039625. [PMID: 33243798 PMCID: PMC7692835 DOI: 10.1136/bmjopen-2020-039625] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES To explore the prevalence of multimorbidity as well as individual and combinations of long-term conditions (LTCs) in people with type 2 diabetes (T2D) attending Australian general practice, using electronic health record (EHR) data. We also examine the association between multimorbidity condition count (total/concordant(T2D related)/discordant(unrelated)) and glycaemia (glycated haemoglobin, HbA1c). DESIGN Cross-sectional study. SETTING Australian general practice. PARTICIPANTS 69 718 people with T2D with a general practice encounter between 2013 and 2015 captured in the MedicineInsight database (EHR Data from 557 general practices and >3.8 million Australian patients). PRIMARY AND SECONDARY OUTCOME MEASURES Prevalence of multimorbidity, individual and combinations of LTCs. Multivariable linear regression models used to examine associations between multimorbidity counts and HbA1c (%). RESULTS Mean (SD) age 66.42 (12.70) years, 46.1% female and mean (SD) HbA1c 7.1 (1.4)%. More than 90% of participants with T2D were living with multimorbidity. Discordant conditions were more prevalent (83.4%) than concordant conditions (69.9 %). The three most prevalent discordant conditions were: painful conditions (55.4%), dyspepsia (31.6%) and depression (22.8%). The three most prevalent concordant conditions were hypertension (61.4%), coronary heart disease (17.1%) and chronic kidney disease (8.5%). The three most common combinations of conditions were: painful conditions and hypertension (38.8%), painful conditions and dyspepsia (23.1%) and hypertension and dyspepsia (22.7%). We found no associations between any multimorbidity counts (total, concordant and discordant) or combinations and HbA1c. CONCLUSIONS Multimorbidity was common in our cohort of people with T2D attending Australian general practice, but was not associated with glycaemia. Although we did not explore mortality in this study, our results suggest that the increased mortality in those with multimorbidity and T2D observed in other studies may not be linked to glycaemia. Interestingly, discordant conditions were more prevalent than concordant conditions with painful conditions being the second most common comorbidity. Better understanding of the implications of different patterns of multimorbidity in people with T2D will allow more effective tailored care.
Collapse
Affiliation(s)
- Jason I Chiang
- Department of General Practice and Primary Health Care, University of Melbourne, Melbourne, Victoria, Australia
| | - John Furler
- Department of General Practice and Primary Health Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Frances Mair
- General Practice and Primary Care, University of Glasgow, Glasgow, UK
| | - Bhautesh D Jani
- General Practice and Primary Care, University of Glasgow, Glasgow, UK
| | - Barbara I Nicholl
- General Practice and Primary Care, University of Glasgow, Glasgow, UK
| | - Sharmala Thuraisingam
- Department of General Practice and Primary Health Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Jo-Anne Manski-Nankervis
- Department of General Practice and Primary Health Care, University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
3
|
Chiang JI, Manski-Nankervis JA, Thuraisingam S, Jenkins A, O'Neal D, Mair FS, Jani BD, Nicholl BI, Furler J. Multimorbidity, glycaemic variability and time in target range in people with type 2 diabetes: A baseline analysis of the GP-OSMOTIC trial. Diabetes Res Clin Pract 2020; 169:108451. [PMID: 32949650 DOI: 10.1016/j.diabres.2020.108451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/12/2020] [Accepted: 09/14/2020] [Indexed: 11/25/2022]
Abstract
AIMS To explore associations between multimorbidity condition counts (total; concordant (diabetes-related); discordant (unrelated to diabetes)) and glycaemia (HbA1c; glycaemic variability (GV); time in range (TIR)) using data from a randomised controlled trial examining effectiveness of continuous glucose monitoring (CGM) in people with type 2 diabetes (T2D). METHODS Cross-sectional study: 279 people with T2D using baseline data from the General Practice Optimising Structured MOnitoring To Improve Clinical outcomes (GP-OSMOTIC) trial from 25 general practices in Australia. Number of long-term conditions (LTCs) in addition to T2D used to quantify total/concordant/discordant multimorbidity counts. GV (measured by coefficient of variation (CV)) and TIR derived from CGM data. Multivariable linear regression models used to examine associations between multimorbidity counts, HbA1c (%), GV and TIR. RESULTS Mean (SD) age of participants 60.4 (9.9) years; 40.9% female. Multimorbidity was present in 89.2% of participants. Most prevalent comorbid LTCs: hypertension (57.4%), painful conditions (29.8%), coronary heart disease (22.6%) and depression (19.0%). No evidence of associations between multimorbidity counts, HbA1c, GV and TIR. CONCLUSIONS While multimorbidity was common in this T2D cohort, it was not associated with HbA1c, CV or TIR. Future studies should explore factors other than glycaemia that contribute to the increased mortality observed in those with multimorbidity and T2D.
Collapse
Affiliation(s)
- Jason I Chiang
- Department of General Practice, University of Melbourne, Australia.
| | | | | | - Alicia Jenkins
- NHMRC Clinical Trials Centre, University of Sydney, Australia
| | - David O'Neal
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Australia
| | - Frances S Mair
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, UK
| | - Bhautesh Dinesh Jani
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, UK
| | - Barbara I Nicholl
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, UK
| | - John Furler
- Department of General Practice, University of Melbourne, Australia
| |
Collapse
|
4
|
Kamal A, Fain C, Park A, Wang P, Gonzalez-Velez E, Leffler DA, Hutfless SM. Angiotensin II receptor blockers and gastrointestinal adverse events of resembling sprue-like enteropathy: a systematic review. Gastroenterol Rep (Oxf) 2019; 7:162-167. [PMID: 31217979 PMCID: PMC6573796 DOI: 10.1093/gastro/goz019] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 01/10/2019] [Accepted: 03/28/2019] [Indexed: 12/27/2022] Open
Abstract
Background Olmesartan, an angiotensin II receptor blocker (ARB), is associated with gastrointestinal symptoms resembling sprue-like enteropathy. Some have proposed that enteropathy may be a class effect rather than olmesartan-specific. We performed a systematic review to identify literature of sprue-like enteropathy for all ARBs. Methods Case reports, case series and comparative studies of ARBs were searched on PubMed and Embase databases through 21 November 2018 and then assessed. Results A total of 82 case reports and case series as well as 5 comparative studies, including 248 cases, were selected and analysed. The ARBs listed in the case reports were olmesartan (233 users; 94.0%), telmisartan (5 users; 2.0%), irbesartan (4 users; 1.6%), valsartan (3 users; 1.2%), losartan (2 users; 0.8%) and eprosartan (1 user; 0.4%). The periods between ARB initiation and onset of symptoms ranged from 2 weeks to 13 years. Histologic results were reported in 218 cases, in which 201 cases (92.2%) were villous atrophy and 131 cases (60.1%) were intraepithelial lymphocytosis. Human leucocyte antigen (HLA) testing was performed in 147 patients, among whom 105 (71.4%) had HLA-DQ2 or HLA-DQ8 haplotypes. Celiac-associated antibodies were tested in 169 patients, among whom 167 (98.8%) showed negative results. Gluten exclusion from the diet failed to relieve symptoms of enteropathy in 127 (97.7%) of 130 patients with information. Complete remission of symptoms after discontinuation of ARB was reported in 233 (97.4%) of the 239 patients with information. Seven cases (2.8%) reported recurrence of symptoms after restarting olmesartan; rechallenge was not reported for the non-olmesartan ARBs. The retrospective studies conducted worldwide had inconsistent study designs (e.g. differences in periods of study and case definition) and findings. Conclusions Although enteropathy is rare, clinicians should remain vigilant of this potential adverse event even years after medication initiation.
Collapse
Affiliation(s)
- Ayesha Kamal
- Department of Medicine, Division of Gastroenterology, Johns Hopkins University, Baltimore, MD, USA
| | - Christopher Fain
- Department of Medicine, Division of Gastroenterology, Johns Hopkins University, Baltimore, MD, USA
| | - Angela Park
- Johns Hopkins, Department of Surgery and Surgical Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Peiqi Wang
- Johns Hopkins, Department of Surgery and Surgical Sciences, Johns Hopkins University, Baltimore, MD, USA
| | - Eduardo Gonzalez-Velez
- Department of Medicine, Division of Gastroenterology, Johns Hopkins University, Baltimore, MD, USA
| | - Daniel A Leffler
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Susan M Hutfless
- Department of Medicine, Division of Gastroenterology, Johns Hopkins University, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
5
|
Chiang JI, Jani BD, Mair FS, Nicholl BI, Furler J, O’Neal D, Jenkins A, Condron P, Manski-Nankervis JA. Associations between multimorbidity, all-cause mortality and glycaemia in people with type 2 diabetes: A systematic review. PLoS One 2018; 13:e0209585. [PMID: 30586451 PMCID: PMC6306267 DOI: 10.1371/journal.pone.0209585] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 12/08/2018] [Indexed: 12/02/2022] Open
Abstract
Introduction Type 2 diabetes (T2D) is a major health priority worldwide and the majority of people with diabetes live with multimorbidity (MM) (the co-occurrence of ≥2 chronic conditions). The aim of this systematic review was to explore the association between MM and all-cause mortality and glycaemic outcomes in people with T2D. Methods The search strategy centred on: T2D, MM, comorbidity, mortality and glycaemia. Databases searched: MEDLINE, EMBASE, CINAHL Complete, The Cochrane Library, and SCOPUS. Restrictions included: English language, quantitative empirical studies. Two reviewers independently carried out: abstract and full text screening, data extraction, and quality appraisal. Disagreements adjudicated by a third reviewer. Results Of the 4882 papers identified; 41 met inclusion criteria. The outcome was all-cause mortality in 16 studies, glycaemia in 24 studies and both outcomes in one study. There were 28 longitudinal cohort studies and 13 cross-sectional studies, with the number of participants ranging from 96–892,223. Included studies were conducted in high or upper-middle-income countries. Fifteen of 17 studies showed a statistically significant association between increasing MM and higher mortality. Ten of 14 studies showed no significant associations between MM and HbA1c. Four of 14 studies found higher levels of MM associated with higher HbA1c. Increasing MM was significantly associated with hypoglycaemia in 9/10 studies. There was no significant association between MM and fasting glucose (one study). No studies explored effects on glycaemic variability. Conclusions This review demonstrates that MM in T2D is associated with higher mortality and hypoglycaemia, whilst evidence regarding the association with other measures of glycaemic control is mixed. The current single disease focused approach to management of T2D seems inappropriate. Our findings highlight the need for clinical guidelines to support a holistic approach to the complex care needs of those with T2D and MM, accounting for the various conditions that people with T2D may be living with. Systematic review registration International Prospective Register of Systematic Reviews CRD42017079500
Collapse
Affiliation(s)
- Jason I. Chiang
- Department of General Practice, University of Melbourne, Melbourne, Australia
- * E-mail:
| | - Bhautesh Dinesh Jani
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Frances S. Mair
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Barbara I. Nicholl
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - John Furler
- Department of General Practice, University of Melbourne, Melbourne, Australia
| | - David O’Neal
- Department of Medicine, St Vincent’s Hospital, University of Melbourne, Melbourne, Australia
| | - Alicia Jenkins
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | - Patrick Condron
- Brownless Biomedical Library, University of Melbourne, Melbourne, Australia
| | | |
Collapse
|