Multimorbidity and achievement of treatment goals among patients with type 2 diabetes: a primary care, real-world study

Modifiable and Non-Modifiable Risk Factors and Vascular Damage Progression in Type 2 Diabetes: A Primary Care Analysis

Background/Objectives: Type 2 diabetes mellitus (DM2) is characterized by the development of micro/macro-vascular complications over time. Factors influencing their course may present specific features in the primary care context. This study aims to identify predictive factors for the evolution of micro/macro-vascular pathology in DM2 patients and evaluate interventions implemented by general practitioners (GPs) in this context. Methods: From the medical records of 1169 DM2 patients from 13 Italian GPs, demographic, socio-environmental, and clinical data were recorded, along with the presence and degree of arterial hypertension and components of diabetic micro/macroangiopathy at the time of study entry and 5 years prior. Laboratory parameters and therapies from the last three years were recorded. Results: Compared to 5 years prior, at the study entry, the number of patients presenting at least one micro- or macro-vascular complication increased from 192 (16.4%) to 344 (29.4%) and from 245 (21.0%) to 350 (29.9%). At the logistic regression, microalbuminuria determination appeared to be the strongest predictor of vascular damage progression, followed by decreasing LDL cholesterol values induced by lipid-lowering therapy. Male gender, age >75 years, and smoking history were associated with greater vascular damage progression in the ANOVA repeated measures test. Conclusions: Advanced age, male gender, and smoking history proved strongly associated with the presence and extent of damage progression. GPs appear to adopt a more aggressive approach in treating risk factors (particularly lipid profile) for damage progression in these patients. Microalbuminuria has proven to be by far the marker most strongly associated with vascular damage progression.

Activation of the Insulin Receptor by Sarcopoterium spinosum Extract and Identification of Sarcocyanidin A as a Novel Active Compound

Sarcopoterium spinosum is a medicinal plant, presenting glucose-lowering properties. The study aimed to identify the active components and their mechanisms of action. Bioguided fractionation was utilized to isolate the active molecules, followed by NMR and HRESI MS for their identification and structural elucidation. Binding to the insulin receptor (IR) and activation of the receptor were measured in vitro. Glucose-lowering effects were validated in vivo. A novel procyanidin trimer, named sarcocyanidin A (1, catechin-(4α-8)-epicatechin-(4β-8)-epicatechin), was identified. Sarcocyanidin A (1) activated insulin signaling in CHO-IR and L6 myotubes, while the IR inhibitor abolished this effect. IR autofluorescence and cell-based thermal shift assays indicate a direct interaction of sarcocyanidin A (1) with IR. Sarcocyanidin A (1) also activated insulin signaling and reduced blood glucose in mice. Sarcocyanidin A, a novel procyanidin trimer, mediates at least part of the antidiabetic properties of SSE, through activation of IR.

Perceived benefits and barriers of multidisciplinary teams in the management of diabetes and comorbidities among physicians: A qualitative double-center study

Background

The dynamics of working within multidisciplinary teams (MDTs) to manage diabetes and comorbidities remain underexplored. Investigating physicians' experiences provide insights into the benefits and challenges of MDTs in this complex context, paving the way for improving current practices and shaping future interventions to better address the needs of this patient population.

Aim

To explore perceived benefits and barriers of MDTs in the management of people with diabetes and comorbidities among physicians.

Methods

Eleven semi-structured interviews (duration 26-38 min) were conducted online among physicians. Criterion sampling of physicians from relevant medical specialties and with experience from MDTs were included. Interviews were analyzed using thematic analysis.

Results

Four major themes emerged from the thematic analysis: (1) benefits of MDT, (2) challenges related to MDT, (3) the need for MDTs and cross-sectorial work, and (4) prerequisites for successful MDTs. Improved professional learning and relationships, enhanced capacity leverage, and optimized treatment were some of the major benefits. Siloed healthcare systems and cultures and resource demanding MDTs were considered barriers. Composition and outline of the MDTs, including the role of general practitioners (GPs), were considered important aspects of MDTs. The increase in multimorbidity, polypharmacy, and complexity in patient pathways necessitates MDTs and cross-sectorial work.

Conclusion

Our findings indicate several benefits and barriers of MDTs. MDTs and cross-sectorial work are needed prospectively in healthcare and hold the potential to embrace some of the challenges encountered by people with diabetes and comorbidities. Understanding and incorporating experiences of physicians could inform future improvements in care management.

Multimorbidity in elderly patients with or without T2DM: A real-world cross-sectional analysis based on primary care and hospitalisation data

Background

Shanghai's high level of ageing has given rise to a considerable number of elderly patients with type 2 diabetes mellitus (T2DM) who are confronted with the challenge of managing multimorbidity. We aimed to determine the prevalence of multimorbidity in elderly T2DM patients in a representative Pudong New Area community and critically evaluate current guidelines' inclusiveness in addressing major comorbidities.

Methods

Through the Shanghai Health Cloud platform, we extracted medical records of residents in the Huamu community (Pudong New Area, Shanghai) to screen elderly patients with at least three outpatient visits or one hospitalisation per year between 2019 and 2022. According to International Classification of Disease, 10th edition codes and personal identification number, we identified the status of T2DM and 12 other common chronic diseases, matched T2DM patients and non-T2DM patients 1:1 by age and gender, and then calculated the prevalence of multimorbidity status and annual prevalence of each comorbidity. We analysed associations between T2DM and specific chronic diseases using logistic regression models.

Results

More than 90% of elderly T2DM patients had at least one additional chronic disease. Multimorbidity was more frequent in women and older patients. Hyperlipidemia, hypertension, and ischaemic heart disease were the most prevalent comorbidities. The diagnosis of T2DM was significantly associated with both cardiovascular-kidney-metabolic and neuropsychiatric diseases. In addition, a higher prevalence and risk of chronic obstructive pulmonary disease (COPD) were consistently detected in elderly patients with T2DM, regardless of age and gender.

Conclusions

Multimorbidity in elderly patients with T2DM needs broader acknowledgement. Current guidelines focus more on cardiovascular-kidney-metabolic and neuropsychiatric diseases with inadequate guidance on COPD management. Hence, the pleiotropic effects of glucose-lowering drugs on COPD should be further investigated to optimise the comprehensive management strategy for this population.

Anxiety, Depression, and Quality of Life in Women with Breast Cancer and Type 2 Diabetes: A Pilot Study in North Greece

Introduction: The incidence of breast cancer, as well as diabetes mellitus (DM), has continuously increased in recent years. The concurrent study of these diseases is particularly important, as there is a strong correlation between them due to hormonal, biochemical, and environmental factors. Moreover, the underlying metabolic dysfunction in this case could affect the treatment of breast cancer, as well as overall survival. In addition, the relationship of these two diseases with depression is not well studied. Patients with DM and cancer patients both experience depressive symptoms that have an impact on their mental health, as well as their quality of life. Personalized medicine offers a potential solution to these challenges by tailoring treatments to individual patient profiles. The present study will attempt to fill a gap in the existing literature regarding the relationship of patients with concurrent breast cancer and DM experiencing depression. More specifically, it will attempt to answer the question of whether there is a strong correlation between breast cancer, DM, and mental health in patients from a large geographical division of the country. Methodology: This was a cross-sectional study. A total of 120 female patients participated in the research, 60 with type 2 diabetes mellitus (T2DM) (group B) and 60 with T2DM and breast cancer (group A). The DASS-21 questionnaire was used to determine their levels of anxiety and depression, and ADDQoL-19 was used to measure the patients' quality of life. Results: Regarding quality of life, women with T2DM and breast cancer showed a better quality of life (QoL) than women with T2DM. Women who were retired (p = 0.025) and consequently postmenopausal (p = 0.035) demonstrated the highest levels of QoL, while stage III cancer patients had lower ADDQoL-19 scores. Regarding mental health, in the women from group A, a positive correlation of treatment with the occurrence of anxiety and depression (p = 0.034) and a negative correlation of cancer stage with mental health was observed. The women in group B (those with T2DM only) showed better mental health outcomes related to their treatment (p = 0.009). However, both married and unmarried women in this study experienced mental health burdens, with no significant difference between the two groups in terms of mental health impact. These findings suggest that marital status did not significantly influence the mental health of the participants in this study. Conclusions: Women with T2DM and breast cancer generally presented a better clinical picture than women with T2DM alone. Therefore, the comorbidity of these two diseases did not seem to negatively affect the quality of life and mental health of these women.

Determinants of health-related quality of life of patients with type 2 diabetes and multimorbidity: a cross-sectional study

PURPOSE

To examine the determinants of health-related quality of life (HRQoL) of patients with type 2 diabetes (PwD) and multimorbidity (MM) (at least one co-occurring condition besides T2D) among sociodemographic, disease-related, and MM variables and the association of MM with therapeutic targets.

METHODS

A total of 179 PwD attending primary care (PC) in Greece answered the 15 dimension HRQoL (15D) questionnaire between August 2019 and October 2020. Sociodemographic, disease-related, and MM characteristics were recorded. MM was categorized as concordant or discordant based on whether or not it was related to the pathophysiology of T2D. Independent predictors of the 15D score were examined in stepwise regression models among sociodemographic, disease-related, and MM variables and the association of MM with glycated hemoglobin (A1C) and low-density lipoprotein cholesterol (LDL-C) was assessed.

RESULTS

The mean 15D score was 0.85 ± 0.11 and the mean MM count was 4.3 ± 1.8. Significant predictors of a higher 15D score were male gender, married state, higher monthly income, and more physical activity. Significant predictors of a lower 15D score were employment, depression, musculoskeletal disease, coronary artery disease, neuropathy, and MM count, but discordant had a stronger effect than concordant MM. Increasing MM count was not significantly correlated with A1C and was correlated with lower LDL-C.

CONCLUSION

Non-medical (physical activity and sociodemographic) rather than disease-related characteristics and discordant more than concordant co-occurring conditions affected HRQoL of multimorbid PwD who did not have worse (A1C) or achieved better (LDL-C) therapeutic targets. A generalist approach to the non-medical needs and overall health conditions of PwD could be promoted in PC within the social determinants of health and MM.

How valid is a prescription-based multimorbidity index (Rx-risk) in predicting mortality in the Outcomes and Multimorbidity In Type 2 diabetes (OMIT) study? A nation-wide registry-based cohort study from Norway

OBJECTIVE

The prescription-based Rx-risk index has previously been developed to measure multimorbidity. We aimed to adapt and evaluate the validity of the Rx-risk index in prediction of mortality among persons with type 2 diabetes.

DESIGN

Registry-based study.

SETTING

Adults with type 2 diabetes in Norway identified within the 'Outcomes and Multimorbidity In Type 2 diabetes' cohort, with linkage to prescriptions from the Norwegian Prescription Database and mortality from the Population Registry.

PARTICIPANTS

We defined a calibration sample of 42 290 adults diagnosed with type 2 diabetes 1950-2013, and a temporal validation sample of 7085 adults diagnosed 2014-2016 to evaluate the index validity over time PRIMARY OUTCOME MEASURE: All-cause mortality METHODS: For the calibration sample, dispensed drug prescriptions in 2013 were used to define 44 morbidity categories. Weights were estimated using regression coefficients from a Cox regression model with 5 year mortality as the outcome and all morbidity categories, age and sex included as covariates. The Rx-risk index was computed as a weighted sum of morbidities. The validity of the index was evaluated using C-statistic and calibration plots.

RESULTS

In the calibration sample, mean (SD) age at start of follow-up and duration of diabetes was 63.8 (12.4) and 10.1 (7.0) years, respectively. The overall C-statistic was 0.82 and varied from 0.74 to 0.85 when stratifying on age groups, sex, level of education and country of origin. In the validation sample, mean (SD) age and duration of diabetes was 59.7 (13.0) and 2.0 (0.8) years, respectively. Despite younger age, shorter duration of diabetes and later time period, the C-index was high both in the total sample (0.84) and separately for men (0.83) and women (0.84).

CONCLUSIONS

The Rx-risk index showed good discrimination and calibration in predicting mortality and thus presents a valid tool to assess multimorbidity among persons with type 2 diabetes.

Diabetes and Multiple Long-term Conditions: A Review of Our Current Global Health Challenge

Use of effective treatments and management programs is leading to longer survival of people with diabetes. This, in combination with obesity, is thus contributing to a rise in people living with more than one condition, known as multiple long-term conditions (MLTC or multimorbidity). MLTC is defined as the presence of two or more long-term conditions, with possible combinations of physical, infectious, or mental health conditions, where no one condition is considered as the index. These include a range of conditions such as cardiovascular diseases, cancer, chronic kidney disease, arthritis, depression, dementia, and severe mental health illnesses. MLTC has major implications for the individual such as poor quality of life, worse health outcomes, fragmented care, polypharmacy, poor treatment adherence, mortality, and a significant impact on health care services. MLTC is a challenge, where interventions for prevention and management are lacking a robust evidence base. The key research directions for diabetes and MLTC from a global perspective include system delivery and care coordination, lifestyle interventions and therapeutic interventions.

Cardiometabolic, functional, and psychosocial effects of a remotely supervised home-based exercise program in individuals with type 2 diabetes (RED study): study protocol for a randomized clinical trial

BACKGROUND

Type 2 diabetes mellitus (T2D) is a serious global health problem, and exercise is considered an essential non-pharmacological tool in T2D prevention and treatment. During periods of social isolation experienced by the COVID-19 pandemic, home-based exercise programs were strongly recommended as a strategy to facilitate exercise practice and reduce the negative impacts of social isolation. Remotely supervised exercise stands out as an easily accessible strategy after the pandemic, as it is a tool that aims to facilitate access to exercise by this population. The purpose of the RED study is to verify the effects of a remotely supervised home-based exercise program compared to a control group on cardiometabolic, functional, and psychosocial outcomes in patients with T2D.

METHODS

Participants are randomized into the control group (CG) and the intervention group (IG). Participants allocated to the CG receive recommendations for the practice of physical activity based on information from chapters of the Physical Activity Guide for the Brazilian Population, while the IG will perform a 12-week home-based exercise program supervised remotely by video call. The intervention has a weekly frequency of two sessions per week on non-consecutive days during the first 6 weeks and three sessions per week on non-consecutive days for the remaining 6 weeks. The RED study has HbA1c as the primary outcome, and the participants' cardiometabolic, functional, and psychosocial parameters are assessed at baseline (week 0) and post-intervention (week 13).

DISCUSSION

Expected results of the proposed study will provide the knowledge base of health professionals and deliver more evidence for a growing area, i.e., home-based exercise and T2D. Additionally, this protocol aims to verify and demonstrate whether this program can be accessible and effective for different health outcomes in patients with T2D.

TRIAL REGISTRATION

The RED study protocol was prospectively registered at ClinicalTrials.gov (NCT05362071). Date registered April 6, 2022. https://clinicaltrials.gov/ct2/show/NCT05362071 .

The multidisciplinary team in diagnosing and treatment of patients with diabetes and comorbidities: A scoping review

Background

Multidisciplinary Teams (MDTs) has been suggested as an intervention to overcome some of the complexities experienced by people with diabetes and comorbidities in terms of diagnosis and treatment. However, evidence concerning MDTs within the diabetes field remains sparse.

Objective

This review aims to identify and map available evidence on key characteristics of MDTs in the context of diagnosis and treatment in people with diabetes and comorbidities.

Methods

This review followed the PRISMA-ScR guidelines. Databases PubMed, EMBASE, and CINAHL were systematically searched for studies assessing any type of MDT within the context of diagnosis and treatment in adult people (≥ 18 years) with diabetes and comorbidities/complications. Data extraction included details on study characteristics, MDT interventions, digital health solutions, and key findings.

Results

Overall, 19 studies were included. Generally, the MDTs were characterized by high heterogeneity. Four overall components characterized the MDTs: Both medical specialists and healthcare professionals (HCPs) of different team sizes were represented; interventions spanned elements of medication, assessment, nutrition, education, self-monitoring, and treatment adjustment; digital health solutions were integrated in 58% of the studies; MDTs were carried out in both primary and secondary healthcare settings with varying frequencies. Generally, the effectiveness of the MDTs was positive across different outcomes.

Conclusions

MDTs are characterized by high diversity in their outline yet seem to be effective and cost-effective in the context of diagnosis and treatment of people with diabetes and comorbidities. Future research should investigate the cross-sectorial collaboration to reduce care fragmentation and enhance care coordination.

Multimorbidity, Frailty and Diabetes in Older People-Identifying Interrelationships and Outcomes

Multimorbidity and frailty are highly prevalent in older people with diabetes. This high prevalence is likely due to a combination of ageing and diabetes-related complications and other diabetes-associated comorbidities. Both multimorbidity and frailty are associated with a wide range of adverse outcomes in older people with diabetes, which are proportionally related to the number of morbidities and to the severity of frailty. Although, the multimorbidity pattern or cluster of morbidities that have the most adverse effect are not yet well defined, it appears that mental health disorders enhance the multimorbidity-related adverse outcomes. Therefore, comprehensive diabetes guidelines that incorporate a holistic approach that includes screening and management of mental health disorders such as depression is required. The adverse outcomes predicted by multimorbidity and frailty appear to be similar and include an increased risk of health care utilisation, disability and mortality. The differential effect of one condition on outcomes, independent of the other, still needs future exploration. In addition, prospective clinical trials are required to investigate whether interventions to reduce multimorbidity and frailty both separately and in combination would improve clinical outcomes.

Association of renal function screening frequency with renal function decline in patients with type 2 diabetes: a real-world study in primary health care

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.

Association of musculoskeletal pain with the achievement of treatment targets for type 2 diabetes among primary care patients

AIMS

To assess the association of diagnosed musculoskeletal (MS) pain (low back, neck, shoulder, and knee pain; and the number of pain sites) with the achievement of targets for glycosylated haemoglobin A1c (HbA1c), low-density-lipoprotein cholesterol (LDL), and systolic blood pressure (SBP) among primary care patients with type 2 diabetes (T2D).

METHODS

The cross-sectional study population consisted of 3478 patients with a registry-based T2D diagnosis and available registry-based data on MS pain diagnoses, covariates, and outcomes between 2016 and 2019. Logistic regression analysis was used to evaluate the study aims.

RESULTS

Overall, 22% had at least one of the four types of MS pain, and 73%, 57%, and 51% achieved the treatment targets of HbA1c, LDL, and SBP, respectively. T2D patients with or without MS pain did not differ in their achievement of T2D treatment goals. Of pain locations, low back pain was associated with higher rates of achievement of the LDL target (OR 1.29, 95% CI 1.01-1.65), but the association was attenuated in the adjusted model.

CONCLUSIONS

MS pain was relatively prevalent among primary care patients with T2D, but did not influence the achievement of T2D treatment goals.