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Angibaud M, Jourdain M, Girard S, Rouxel L, Mouhib A, Nogueira A, Rat C, Huon JF. Involving community pharmacists in interprofessional collaboration in primary care: a systematic review. BMC PRIMARY CARE 2024; 25:103. [PMID: 38561676 PMCID: PMC10983710 DOI: 10.1186/s12875-024-02326-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 02/28/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND The World Health Organization supports interprofessional collaboration in primary care. On over the past 20 years, community pharmacists had been taking a growing number of new responsibilities and they are recognized as a core member of collaborative care teams as patient-centered care providers. This systematic review aimed to describe interprofessional collaboration in primary care involving a pharmacist, and its effect on patient related outcomes. METHODS A systematic review of randomized controlled trials cited in the MEDLINE, EMBASE, PsycInfo and CINAHL in English and French was conducted from inception to November 2022. Studies were included if they described an intervention piloted by a primary care provider and included a pharmacist and if they evaluated the effects of intervention on a disease or on patient related outcomes. The search generated 3494 articles. After duplicates were removed and titles and abstracts screened for inclusion, 344 articles remained. RESULTS Overall, 19 studies were included in the review and assessed for quality. We found 14 studies describing an exclusive collaboration between physician and pharmacist with for all studies a three-step model of pharmacist intervention: a medication review, an interview with the patient, and recommendations made to physician. Major topics in the articles eligible for inclusion included cardiovascular diseases with blood pressure, diabetes, dyslipidemia, and risk of cardiovascular diseases. Positive effects concerned principally blood pressure. CONCLUSIONS Collaboration involving pharmacists is mainly described in relation to cardiovascular diseases, for which patient-centered indicators are most often positive. It underscores the need for further controlled studies on pharmacist-involved interprofessional collaboration across various medical conditions to improve consensus on core outcomes measures.
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Affiliation(s)
- Morgane Angibaud
- Primary Care Federative Department, Faculty of Medicine, Nantes Université, Nantes, France.
- National Institute for Health and Medical Research, INSERM U1302 Team 2, INCIT, Team 2, Nantes, France.
| | - Maud Jourdain
- Department of General Practice, Faculty of Medicine, Nantes Université, Nantes, France
| | - Solene Girard
- Department of General Practice, Faculty of Medicine, Nantes Université, Nantes, France
| | - Louise Rouxel
- Department of General Practice, Faculty of Medicine, Nantes Université, Nantes, France
| | - Adam Mouhib
- Clinical Pharmacy Unit, Faculty of Pharmacy, Nantes Université, Nantes, France
| | - Antoine Nogueira
- Department of General Practice, Faculty of Medicine, Nantes Université, Nantes, France
| | - Cédric Rat
- National Institute for Health and Medical Research, INSERM U1302 Team 2, INCIT, Team 2, Nantes, France
- Department of General Practice, Faculty of Medicine, Nantes Université, Nantes, France
| | - Jean-François Huon
- Nantes Université, CHU Nantes, Pharmacie, F-44000, France
- UMR INSERM 1246 SPHERE "methodS in Patient-centered Outcomes and HEalth ResEarch, Nantes Université, Université de Tours, Tours, France
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Allory E, Scheer J, De Andrade V, Garlantézec R, Gagnayre R. Characteristics of self-management education and support programmes for people with chronic diseases delivered by primary care teams: a rapid review. BMC PRIMARY CARE 2024; 25:46. [PMID: 38297228 PMCID: PMC10829293 DOI: 10.1186/s12875-024-02262-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 01/02/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND Primary care actors can play a major role in developing and promoting access to Self-Management Education and Support (SMES) programmes for people with chronic disease. We reviewed studies on SMES programmes in primary care by focusing on the following dimensions: models of SMES programmes in primary care, SMES team's composition, and participants' characteristics. METHODS For this mixed-methods rapid review, we searched the PubMed and Cochrane Library databases to identify articles in English and French that assessed a SMES programme in primary care for four main chronic diseases (diabetes, cancer, cardiovascular disease and/or respiratory chronic disease) and published between 1 January 2013 and 31 December 2021. We excluded articles on non-original research and reviews. We evaluated the quality of the selected studies using the Mixed Methods Appraisal Tool. We reported the study results following the PRISMA guidelines. RESULTS We included 68 studies in the analysis. In 46/68 studies, a SMES model was described by focusing mainly on the organisational dimension (n = 24). The Chronic Care Model was the most used organisational model (n = 9). Only three studies described a multi-dimension model. In general, the SMES team was composed of two healthcare providers (mainly nurses), and partnerships with community actors were rarely reported. Participants were mainly patients with only one chronic disease. Only 20% of the described programmes took into account multimorbidity. Our rapid review focused on two databases and did not identify the SMES programme outcomes. CONCLUSIONS Our findings highlight the limited implication of community actors and the infrequent inclusion of multimorbidity in the SMES programmes, despite the recommendations to develop a more interdisciplinary approach in SMES programmes. This rapid review identified areas of improvement for SMES programme development in primary care, especially the privileged place of nurses in their promotion. TRIAL REGISTRATION PROSPERO 2021 CRD42021268290 .
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Affiliation(s)
- Emmanuel Allory
- Department of General Practice, Univ Rennes, 2 Av. du Professeur Léon Bernard, Rennes, 35000, France.
- CHU Rennes, Inserm, CIC 1414 (Centre d'Investigation Clinique de Rennes), Rennes, 35000, France.
- LEPS (Laboratoire d'Education Et Promotion en Santé), University of Sorbonne Paris Nord, Villetaneuse, UR, 3412, F-93430, France.
| | - Jordan Scheer
- Department of General Practice, Univ Rennes, 2 Av. du Professeur Léon Bernard, Rennes, 35000, France
- CHU Rennes, Inserm, CIC 1414 (Centre d'Investigation Clinique de Rennes), Rennes, 35000, France
| | - Vincent De Andrade
- LEPS (Laboratoire d'Education Et Promotion en Santé), University of Sorbonne Paris Nord, Villetaneuse, UR, 3412, F-93430, France
| | - Ronan Garlantézec
- CHU de Rennes, Univ Rennes, Inserm, EHESP (Ecole Des Hautes Etudes en Santé Publique), Irset - UMR_S 1085, Rennes, 35000, France
| | - Rémi Gagnayre
- LEPS (Laboratoire d'Education Et Promotion en Santé), University of Sorbonne Paris Nord, Villetaneuse, UR, 3412, F-93430, France
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Bouton C, Journeaux M, Jourdain M, Angibaud M, Huon JF, Rat C. Interprofessional collaboration in primary care: what effect on patient health? A systematic literature review. BMC PRIMARY CARE 2023; 24:253. [PMID: 38031014 PMCID: PMC10685527 DOI: 10.1186/s12875-023-02189-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 10/20/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND In a period of change in the organization of primary care, Interprofessional Collaboration (IPC) is presented as one of the solutions to health issues. Although the number of inter-professional interventions grounded in primary care increases in all developed countries, evidence on the effects of these collaborations on patient-centred outcomes is patchy. The objective of our study was to assess the effects of IPC grounded in the primary care setting on patient-centred outcomes. METHODS We conducted a systematic literature review using the PubMed, Embase, PsycINFO and CINAHL databases from 01/01/1995 to 01/03/2021, according to the PRISMA guidelines. Studies reporting the effects of IPC in primary care on patient health outcomes were included. The quality of the studies was assessed using the revised Downs and Black checklist. RESULTS Sixty-five articles concerning 61 interventions were analysed. A total of 43 studies were prospective and randomized. Studies were classified into 3 main categories as follows: 1) studies with patients at cardiovascular risk (28 studies)-including diabetes (18 studies) and arterial hypertension (5 studies); 2) studies including elderly and/or polypathological patients (18 studies); and 3) patients with symptoms of mental or physical disorders (15 studies). The number of included patients varied greatly (from 50 to 312,377). The proportion of studies that reported a positive effect of IPC on patient-centred outcomes was as follows: 23 out of the 28 studies including patients at cardiovascular risk, 8 out of the 18 studies of elderly or polypathological patients, and 11 out of the 12 studies of patients with mental or physical disorders. CONCLUSIONS Evidence suggests that IPC is effective in the management of patients at cardiovascular risk. In elderly or polypathological patients and in patients with mental or physical disorders, the number of studies remains very limited, and the results are heterogeneous. Researchers should be encouraged to perform studies based on comparative designs: it would increase evidence on the positive effect and benefits of IPC on patient variables.
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Affiliation(s)
- Céline Bouton
- Department of General Practice, Faculty of Medicine, University of Nantes, 1, Rue Gaston Veil, 44035, Nantes, France.
- Primary Care Federative Department, Faculty of Medicine, University of Nantes, Nantes, France.
| | - Manon Journeaux
- Department of General Practice, Faculty of Medicine, University of Nantes, 1, Rue Gaston Veil, 44035, Nantes, France
| | - Maud Jourdain
- Department of General Practice, Faculty of Medicine, University of Nantes, 1, Rue Gaston Veil, 44035, Nantes, France
- Primary Care Federative Department, Faculty of Medicine, University of Nantes, Nantes, France
| | - Morgane Angibaud
- Primary Care Federative Department, Faculty of Medicine, University of Nantes, Nantes, France
| | - Jean-François Huon
- Primary Care Federative Department, Faculty of Medicine, University of Nantes, Nantes, France
- Faculty of Pharmacy, University of Nantes, Nantes, France
| | - Cédric Rat
- Department of General Practice, Faculty of Medicine, University of Nantes, 1, Rue Gaston Veil, 44035, Nantes, France
- Primary Care Federative Department, Faculty of Medicine, University of Nantes, Nantes, France
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Chen M, Weissglass D, Li C, Li D, Wu Z, Zhang L. A multisectoral and multidisciplinary endeavor: a review of diabetes self-management apps in China. BMC Public Health 2023; 23:1859. [PMID: 37749494 PMCID: PMC10521460 DOI: 10.1186/s12889-023-16735-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 09/11/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND While the use of self-management apps has considerable promise to efficiently reduce the diabetes burden that disproportionally affects low- and middle-income countries (LMICs), and the multisectoral and multidisciplinary approaches have been encouraged to be used in diabetes management, little is known about the status of the integration of these approaches in the existing diabetes self-management apps. This review examines the diabetes apps in China as an indication of the current status of integrating multisectoral and multidisciplinary approaches in diabetes mHealth care in LMICs. METHODS Eligible diabetes apps were searched on major Chinese app stores up to December 23, 2022. The app comprehensiveness index (ranging 0-80) regarding the app functions and diabetes management domains was created. The multisectoral and multidisciplinary features were summarized using indices derived from current guidance. RESULTS Sixty-six apps were reviewed, all developed by private companies. The average comprehensiveness score was 16, with many major self-management domains and functions not represented among the reviewed apps. Forty apps (61%) involved multiple sectoral entities, with public/private and private/private collaborations being the most common collaborative combinations. Thirty-seven apps (56%) involved multiple disciplines, among which endocrinology/metabolism, nutrition, and cardiovascular medicine were the top three most common disciplines. Compared to non-multidisciplinary apps, multidisciplinary apps tended to provide more comprehensive services in apps (6.14 vs. 5.18, p = 0.0345). Different sectors and disciplines tended to work independently, without robust interactions, in providing diabetes management services in the reviewed apps. CONCLUSION Multisectoral and multidisciplinary features has presented in the current diabetes self-management apps in China; however, it is still in its infancy and significant limitations existed. More engagement of civil society organizations and community groups and innovative collaborations between sectors and disciplines are needed to provide comprehensive, continuous, and patient-centered mHealth care for patients with diabetes in LMICs like China. Clear guidance for integrating and evaluating the multisectoral and multidisciplinary efforts in self-management apps is necessary to ensure the effective use of mHealth solutions for diabetes management in LMICs.
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Affiliation(s)
- Meifang Chen
- Division of Social Science, Global Health Research Center, Duke Kunshan University, 8 Duke Avenue, Suzhou, 215316, Jiangsu, China.
| | - Daniel Weissglass
- Division of Arts and Humanities, Duke Kunshan University, 8 Duke Avenue, Suzhou, Jiangsu, China
| | - Chengyi Li
- Duke Kunshan University, 8 Duke Avenue, Suzhou, Jiangsu, China
| | - Di Li
- Duke Kunshan University, 8 Duke Avenue, Suzhou, Jiangsu, China
| | - Zixuan Wu
- Duke Kunshan University, 8 Duke Avenue, Suzhou, Jiangsu, China
| | - Li Zhang
- Department of Endocrinology, The First People's Hospital of Kunshan, 188 Jijie St., Suzhou, Jiangsu, China
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Wong AKC, Wong FKY, Liang J, Tong DWK, Chan ML, Chu TK, Wong BC, Chan RSY, Ho WH, Tang CYS, Chiang SC. Outcomes of a risk assessment and management program using telecare consultation among patients with diabetes mellitus in general out-patient clinic: a hybrid effectiveness-implementation study protocol. Ann Med 2023; 55:2262088. [PMID: 37748120 PMCID: PMC10521334 DOI: 10.1080/07853890.2023.2262088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 09/16/2023] [Indexed: 09/27/2023] Open
Abstract
Diabetes Mellitus (DM) is a chronic disease characterized by abnormally uncontrolled high blood glucose level. The Risk Assessment and Management Program (RAMP) in Hong Kong has been providing long-term face-to-face follow-up to DM patients in the government out-patient clinics since 2009. However, under the current outbreak of COVID-19, these face-to-face consultations were ceased over and over again to lower the risk of disease transmission. With the advancement in technology, the recent emergence of telecare has provided an alternative to replace the conventional consultations in the clinics. Its clinical effectiveness on DM patients has also been supported by numerous studies. Yet, there is only a paucity of literatures discussing the practicality of such implementation design in the real-world settings. This study aims at studying both the effectiveness and implementation outcomes of telecare in Hong Kong DM patients. It adopts a type 2 hybrid effectiveness-implementation design. It will be conducted in seven government out-patient clinics in Hong Kong. The subjects will be randomly assigned to an intervention group or a control group when they 1) are aged 18 or above, 2) have a confirmed diagnosis of diabetes, and 3) are having regular follow-up appointment in the clinic. Subjects in the intervention group will receive a 84-week Risk Assessment and Management Program (RAMP) in an alternate telecare and face-to-face consultations mode, while the control group will receive the same program but in usual face-to-face consultation mode. RE-AIM is employed as the implementation and effectiveness outcome evaluation framework. The primary outcome measure will be HbA1c. Data will be collected pre-intervention (T1), 42-week (T2), and 84-week (T3). The study will provide effectiveness-implementation assessment of telecare mode for DM patients in Hong Kong, as an alternative or in addition to conventional face-to-face consultations. It also aimed to provide insights for the future adoption in a broader health care setting.
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Affiliation(s)
| | | | - Jun Liang
- New Territories West Cluster, Hospital Authority, Homantin, Hong Kong
| | | | - Man Li Chan
- New Territories West Cluster, Hospital Authority, Homantin, Hong Kong
| | - Tsun kit Chu
- New Territories West Cluster, Hospital Authority, Homantin, Hong Kong
| | - Bo Chu Wong
- New Territories West Cluster, Hospital Authority, Homantin, Hong Kong
| | - Rinis Sin Yi Chan
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
| | - Wai Hing Ho
- New Territories West Cluster, Hospital Authority, Homantin, Hong Kong
| | | | - Sau Ching Chiang
- New Territories West Cluster, Hospital Authority, Homantin, Hong Kong
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2023; 148:e9-e119. [PMID: 37471501 DOI: 10.1161/cir.0000000000001168] [Citation(s) in RCA: 110] [Impact Index Per Article: 110.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Affiliation(s)
| | | | | | | | | | | | - Dave L Dixon
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | - William F Fearon
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | - Dhaval Kolte
- AHA/ACC Joint Committee on Clinical Data Standards
| | | | | | | | - Daniel B Mark
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | | | | | | | - Mariann R Piano
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
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7
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2023; 82:833-955. [PMID: 37480922 DOI: 10.1016/j.jacc.2023.04.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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8
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Willey VJ, Crowley MJ. Observational Evaluations of Disease Management Programs for Diabetes: The Proof Is in the Concept. Diabetes Care 2022; 45:2808-2810. [PMID: 36455130 PMCID: PMC9998843 DOI: 10.2337/dci22-0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Affiliation(s)
| | - Matthew J. Crowley
- Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC
- Division of Endocrinology, Department of Medicine, Duke University School of Medicine, Durham, NC
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Tang EHM, Mak IL, Tse ETY, Wan EYF, Yu EYT, Chen JY, Chin WY, Chao DVK, Tsui WWS, Ha TKH, Wong CKH, Lam CLK. Ten-Year Effectiveness of the Multidisciplinary Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) on Macrovascular and Microvascular Complications and All-Cause Mortality: A Population-Based Cohort Study. Diabetes Care 2022; 45:2871-2882. [PMID: 35972235 DOI: 10.2337/dc22-0387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 06/30/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) is a protocol-driven, risk-stratified, and individualized management program offered by a multidisciplinary team in addition to usual care for primary care patients with diabetes. This study aimed to evaluate the effectiveness of RAMP-DM for preventing complications and mortality over 10 years. RESEARCH DESIGN AND METHODS A population-based, prospective cohort study of adult patients with type 2 diabetes managed in the Hong Kong public primary health care system between 2009 and 2010 was conducted. RAMP-DM participants and usual care patients were matched using one-to-one propensity score matching and followed for 10 years. Risks of macrovascular and microvascular complications and all-cause mortality were estimated by Cox proportional hazards regression. RESULTS A total of 36,746 patients (18,373 in each group) were included after propensity score matching, with a median follow-up of 9.5 years and 306,802 person-years. RAMP-DM participants had significantly lower risks of macrovascular (hazard ratio [HR] 0.52, 95% CI 0.50-0.54) and microvascular (HR 0.68, 95% CI 0.64-0.72) complications and all-cause mortality (HR 0.45, 95% CI 0.43-0.47) than patients who received usual care only. However, the effect of RAMP-DM on macrovascular and microvascular complications attenuated after the 9th and 8th year of follow-up, respectively. RAMP-DM participants also showed better control of hemoglobin A1c, blood pressure, triglycerides, and BMI and a slower decline in renal function. CONCLUSIONS Significant reductions in diabetes-related complications and all-cause mortality were observed among RAMP-DM participants over a 10-year follow-up, yet the effect of preventing complications attenuated after 8 years.
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Affiliation(s)
- Eric Ho Man Tang
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Ivy Lynn Mak
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Emily Tsui Yee Tse
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.,Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Eric Yuk Fai Wan
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.,Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.,Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong Special Administrative Region, China
| | - Esther Yee Tak Yu
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Julie Yun Chen
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Weng Yee Chin
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - David Vai Kiong Chao
- Department of Family Medicine and Primary Health Care, United Christian Hospital, Kowloon East Cluster, Hospital Authority, Hong Kong Special Administrative Region, China
| | - Wendy Wing Sze Tsui
- Department of Family Medicine and Primary Healthcare, Queen Mary Hospital, Hong Kong West Cluster, Hospital Authority, Hong Kong Special Administrative Region, China
| | - Tony King Hang Ha
- Primary and Community Services, Hospital Authority, Hong Kong Special Administrative Region, China
| | - Carlos King Ho Wong
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.,Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.,Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong Special Administrative Region, China
| | - Cindy Lo Kuen Lam
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.,Department of Family Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
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Longhini J, Canzan F, Mezzalira E, Saiani L, Ambrosi E. Organisational models in primary health care to manage chronic conditions: A scoping review. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e565-e588. [PMID: 34672051 DOI: 10.1111/hsc.13611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 10/06/2021] [Accepted: 10/08/2021] [Indexed: 06/13/2023]
Abstract
Chronic diseases are increasing incessantly, and more efforts are needed in order to develop effective organisational models in primary health care, which may address the challenges posed by the consequent multimorbidity. The aim of this study was to assess and map methods, interventions and outcomes investigated over the last decade regarding the effectiveness of chronic care organisational models in primary care settings. We conducted a scoping review including systematic reviews, clinical trials, and observational studies, published from 2010 to 2020, that evaluated the effectiveness of organisational models for chronic conditions in primary care settings, including home care, community, and general practice. We included 67 international studies out of the 6,540 retrieved studies. The prevalent study design was the observational design (25 studies, 37.3%), and 62 studies (92.5%) were conducted on the adult population. Four main models emerged, called complex integrated care models. These included models grounded on the Chronic Care Model framework and similar, case or care management, and models centred on involvement of pharmacists or community health workers. Across the organisational models, self-management support and multidisciplinary teams were the most common components. Clinical outcomes have been investigated the most, while caregiver outcomes have been detected in the minority of cases. Almost one-third of the included studies reported only significant effects in the outcomes. No sufficient data were available to determine the most effective models of care. However, more complex models seem to lead to better outcomes. In conclusion, in the development of more comprehensive organisational models to manage chronic conditions in primary health care, more efforts are needed on the paediatric population, on the inclusion of caregiver outcomes in the effectiveness evaluation of organisational models and on the involvement of social community resources. As regarding the studies investigating organisational models, more detailed descriptions should be provided with regard to interventions, and the training, roles and responsibilities of health and lay figures in delivering care.
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Affiliation(s)
- Jessica Longhini
- Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Federica Canzan
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Elisabetta Mezzalira
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Luisa Saiani
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Elisa Ambrosi
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
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11
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Xu Z, Zhang D, Lee ATC, Sit RWS, Wong C, Lee EKP, Yip BHK, Tiu JYS, Lam LCW, Wong SYS. A pilot feasibility randomized controlled trial on combining mind-body physical exercise, cognitive training, and nurse-led risk factor modification to reduce cognitive decline among older adults with mild cognitive impairment in primary care. PeerJ 2020; 8:e9845. [PMID: 33194354 PMCID: PMC7482623 DOI: 10.7717/peerj.9845] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/11/2020] [Indexed: 01/10/2023] Open
Abstract
Objectives To examine the feasibility and preliminary effectiveness of (1) combining cognitive training, mind-body physical exercise, and nurse-led risk factor modification (CPR), (2) nurse-led risk factor modification (RFM), and (3) health advice (HA) on reducing cognitive decline among older adults with mild cognitive impairment (MCI). Methods It was a 3-arm open-labeled pilot randomized controlled trial in the primary care setting in Hong Kong. Nineteen older adults with MCI were randomized to either CPR (n = 6), RFM (n = 7), or HA (n = 6) for 6 months. The primary outcome was the feasibility of the study. Secondary outcomes included the Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog), the Montreal Cognitive Assessment Hong Kong version (HK-MoCA), the Clinical Dementia Rating (CDR), the Disability Assessment for Dementia (DAD), quality of life, depression, anxiety, physical activity, health service utilization, and diet. Results Nineteen out the 98 potential patients were recruited, with a recruitment rate of 19% (95% CI [12-29]%, P = 0.243). The adherence rate of risk factor modification was 89% (95% CI [65-98]%, P = 0.139) for CPR group and 86% (95% CI [63-96]%, P = 0.182) for RFM group. In the CPR group, 53% (95% CI [36-70]%, P = 0.038) of the Tai Chi exercise sessions and 54% (95% CI [37-71]%, P = 0.051) of cognitive sessions were completed. The overall dropout rate was 11% (95% CI [2-34]%, P = 0.456). Significant within group changes were observed in HK-MoCA in RFM (4.50 ± 2.59, P = 0.008), cost of health service utilization in CPR (-4000, quartiles: -6800 to -200, P = 0.043), fish and seafood in HA (-1.10 ± 1.02, P = 0.047), and sugar in HA (2.69 ± 1.80, P = 0.015). Group × time interactions were noted on HK-MoCA favoring the RFM group (P = 0.000), DAD score favoring CPR group (P = 0.027), GAS-20 favoring CPR group (P = 0.026), number of servings of fish and seafood (P = 0.004), and sugar (P < 0.001) ate per day. Conclusions In this pilot study, RFM and the multi-domain approach CPR were feasible and had preliminary beneficial effects in older adults with MCI in primary care setting in Hong Kong. Trial registration Chinese Clinical Trial Registry (ChiCTR1800015324).
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Affiliation(s)
- Zijun Xu
- Division of Family Medicine and Primary Health Care, JC School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Dexing Zhang
- Division of Family Medicine and Primary Health Care, JC School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Allen T C Lee
- Department of Psychiatry, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Regina W S Sit
- Division of Family Medicine and Primary Health Care, JC School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Carmen Wong
- Division of Family Medicine and Primary Health Care, JC School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Eric K P Lee
- Division of Family Medicine and Primary Health Care, JC School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Benjamin H K Yip
- Division of Family Medicine and Primary Health Care, JC School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Jennifer Y S Tiu
- Division of Family Medicine and Primary Health Care, JC School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
| | - Linda C W Lam
- Department of Psychiatry, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Samuel Y S Wong
- Division of Family Medicine and Primary Health Care, JC School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, China
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12
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Mehta G, Hirji A. The Outcome of Structured Education in Adults With Type 2 Diabetes Mellitus and Substance Use Disorder: A Literature Review. Can J Diabetes 2020; 44:487-493. [PMID: 32792102 DOI: 10.1016/j.jcjd.2020.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 04/12/2020] [Accepted: 05/21/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Structured diabetes education for patients is a cornerstone of therapy; it empowers the patients by giving them appropriate tools for the self-management of the illness. The objective of this work was to determine how substance use disorder influences the outcome of structured diabetes education in patients with type 2 diabetes mellitus, and whether patients with substance use disorder are less likely to benefit because of their addiction issues. METHODS Only clinical trials involving substance use, which were randomized, in the context of type 2 diabetes mellitus were included. RESULTS Literature was only available for alcohol use disorder, and there were no studies available on any other recreational substance use disorders and its effects on structured diabetes education. Out of 3 relevant studies, in the context of alcohol use disorder, 2 studies identified alcohol use by the patients as a limiting factor in receiving structured diabetes education. One study did not show any impact of alcohol on structured diabetes education. CONCLUSIONS More high-quality randomized controlled trials with better sample sizes are required to say with confidence if alcohol use affects the patient's ability to participate in structured educational programs for type 2 diabetes mellitus management.
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Affiliation(s)
- Gaurav Mehta
- Department of Psychiatry, University of Toronto, Newmarket, Ontario, Canada.
| | - Alyssa Hirji
- Department of Psychiatry, University of Toronto, Newmarket, Ontario, Canada
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13
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Chou CW, Kung PT, Chou WY, Tsai WC. Pay-for-performance programmes reduce stroke risks in patients with type 2 diabetes: a national cohort study. BMJ Open 2019; 9:e026626. [PMID: 31619415 PMCID: PMC6797306 DOI: 10.1136/bmjopen-2018-026626] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES A pay-for-performance (P4P) programme is a management strategy that encourages healthcare providers to deliver high quality of care. In Taiwan, the P4P programme has been implemented for diabetes, and certified diabetes physicians voluntarily enrol patients with diabetes into the P4P programme. The objectives of this study were to compare the risk of stroke and its related factors in patients with type 2 diabetes who were enrolled in a P4P programme compared with those who were not. STUDY DESIGN This study is a natural experiment in Taiwan. A retrospective cohort investigation was conducted from 2002 to 2013, which included 459 726 patients with type 2 diabetes, who were grouped according to P4P enrolment status following a propensity score matching process. METHODS We reviewed patients ≥45 years of age newly diagnosed with type 2 diabetes mellitus (DM) from the National Health Insurance Research Database in Taiwan. A Cox proportional hazards model was used to compare the relative risk of stroke between patients with type 2 DM enrolled in the P4P programme and those who were not enrolled. RESULTS Compared with the patients not enrolled, there was a significantly lower stroke risk in P4P participants (HR=0.97, 95% CI 0.95 to 0.99). Although a significantly lower risk of haemorrhagic stroke was observed (HR=0.87, 95% CI 0.82 to 0.93) in P4P participants, no statistically significant difference for the risk of ischaemic stroke between P4P and non-P4P patients (HR=0.99, 95% CI 0.97 to 1.02) was found. Following stratification analysis, a significantly reduced stroke risk was observed in male patients with type 2 diabetes, but not in women. CONCLUSIONS Participants in Taiwan's Diabetes P4P programme displayed a significantly reduced stroke risk, especially haemorrhagic stroke. We recommend the continual promotion of this programme to the general public and to physicians.
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Affiliation(s)
- Chien-Wen Chou
- Department of Health Services Administration, China Medical University, Taichung, Taiwan
- Nantou Hospital, Ministry of Health and Welfare, Nantou, Taiwan
| | - Pei-Tseng Kung
- Department of Healthcare Administration, Asia University, Taichung, Taiwan
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Wen-Yu Chou
- Department of Health Services Administration, China Medical University, Taichung, Taiwan
| | - Wen-Chen Tsai
- Department of Health Services Administration, China Medical University, Taichung, Taiwan
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14
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Jiao F, Wan EYF, Fung CSC, Chan AKC, McGhee SM, Kwok RLP, Lam CLK. Cost-effectiveness of a primary care multidisciplinary Risk Assessment and Management Program for patients with diabetes mellitus (RAMP-DM) over lifetime. Endocrine 2019; 63:259-269. [PMID: 30155847 DOI: 10.1007/s12020-018-1727-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 08/14/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE The multidisciplinary Risk Assessment and Management Program for patients with diabetes mellitus (RAMP-DM) was found to be cost-saving in comparison with usual primary care over 5 years' follow-up. This study aimed to estimate the cost-effectiveness of RAMP-DM over lifetime. METHODS We built a Discrete Event Simulation model to evaluate the cost-effectiveness of RAMP-DM over lifespan from public health service provider's perspective. Transition probabilities among disease states were extrapolated from a cohort of 17,140 propensity score matched participants in RAMP-DM and those under usual primary care over 5-year's follow-up. The mortality of patients with specific DM-related complications was estimated from a cohort of 206,238 patients with diabetes. Health preference and direct medical costs of DM patients referred to our previous studies among Chinese DM patients. RESULTS RAMP-DM individuals gained 0.745 QALYs and cost US$1404 less than those under usual care. The probabilistic sensitivity analysis found that RAMP-DM had 86.0% chance of being cost-saving compared to usual care under the assumptions and estimates used in the model. The probability of RAMP-DM being cost-effective compared to usual care would be over 99%, when the willingness to pay threshold is HK$20,000 (US$ 2564) or higher. CONCLUSION RAMP-DM added to usual primary care was cost-saving in managing people with diabetes over lifetime. These findings support the integration of RAMP-DM as part of routine primary care for all patients with diabetes.
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Affiliation(s)
- Fangfang Jiao
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F., 161 Main Street, Ap Lei Chau Clinic, Ap Lei Chau, Hong Kong, Hong Kong
| | - Eric Yuk Fai Wan
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F., 161 Main Street, Ap Lei Chau Clinic, Ap Lei Chau, Hong Kong, Hong Kong.
| | - Colman Siu Cheung Fung
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F., 161 Main Street, Ap Lei Chau Clinic, Ap Lei Chau, Hong Kong, Hong Kong
| | - Anca Ka Chun Chan
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F., 161 Main Street, Ap Lei Chau Clinic, Ap Lei Chau, Hong Kong, Hong Kong
| | - Sarah Morag McGhee
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 5/F, William MW Mong Block, 21 Sassoon Road, Hong Kong, Hong Kong
| | - Ruby Lai Ping Kwok
- Primary and Community Services, Hospital Authority Head Office, Hong Kong Hospital Authority, Hospital Authority Building, 147B Argyle Street, Kowloon, Hong Kong, Hong Kong
| | - Cindy Lo Kuen Lam
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F., 161 Main Street, Ap Lei Chau Clinic, Ap Lei Chau, Hong Kong, Hong Kong
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15
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Wan EYF, Yu EYT, Chin WY, Fung CSC, Kwok RLP, Chao DVK, Chan KH, Hui EMT, Tsui WWS, Tan KCB, Fong DYT, Lam CLK. Ten-year risk prediction models of complications and mortality of Chinese patients with diabetes mellitus in primary care in Hong Kong: a study protocol. BMJ Open 2018; 8:e023070. [PMID: 30327405 PMCID: PMC6194459 DOI: 10.1136/bmjopen-2018-023070] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Diabetes mellitus (DM) is a major disease burden worldwide because it is associated with disabling and lethal complications. DM complication risk assessment and stratification is key to cost-effective management and tertiary prevention for patients with diabetes in primary care. Existing risk prediction functions were found to be inaccurate in Chinese patients with diabetes in primary care. This study aims to develop 10-year risk prediction models for total cardiovascular diseases (CVD) and all-cause mortality among Chinese patients with DM in primary care. METHODS AND ANALYSIS A 10-year cohort study on a population-based primary care cohort of Chinese patients with diabetes, who were receiving care in the Hospital Authority General Outpatient Clinic on or before 1 January 2008, were identified from the clinical management system database of the Hospital Authority. All patients with complete baseline risk factors will be included and followed from 1 January 2008 to 31 December 2017 for the development and validation of prediction models. The analyses will be carried out separately for men and women. Two-thirds of subjects will be randomly selected as the training sample for model development. Cox regressions will be used to develop 10-year risk prediction models of total CVD and all-cause mortality. The validity of models will be tested on the remaining one-third of subjects by Harrell's C-statistics and calibration plot. Risk prediction models for diabetic complications specific to Chinese patients in primary care will enable accurate risk stratification, prioritisation of resources and more cost-effective interventions for patients with DM in primary care. ETHICS AND DISSEMINATION The study was approved by the Institutional Review Board of the University of Hong Kong-the Hospital Authority Hong Kong West Cluster (reference number: UW 15-258). TRIAL REGISTRATION NUMBER NCT03299010; Pre-results.
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Affiliation(s)
- Eric Yuk Fai Wan
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong
| | - Esther Yee Tak Yu
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong
| | - Weng Yee Chin
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong
| | | | - Ruby Lai Ping Kwok
- Department of Primary and Community Services, Hospital Authority Head Office, Hospital Authority, Hong Kong
| | - David Vai Kiong Chao
- Department of Family Medicine and Primary Healthcare, Kowloon East Cluster, Hospital Authority, Hong Kong
| | - King Hong Chan
- Department of Family Medicine & Primary Healthcare, Kowloon Central Cluster, Hospital Authority, Hong Kong
| | - Eric Ming-Tung Hui
- Department of Family Medicine, New Territories East Cluster, Hospital Authority, Hong Kong
| | - Wendy Wing Sze Tsui
- Department of Family Medicine and Primary Healthcare, Hong Kong West Cluster, Hospital Authority, Hong Kong
| | | | | | - Cindy Lo Kuen Lam
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong
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16
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de Lagasnerie G, Aguadé AS, Denis P, Fagot-Campagna A, Gastaldi-Menager C. The economic burden of diabetes to French national health insurance: a new cost-of-illness method based on a combined medicalized and incremental approach. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2018; 19:189-201. [PMID: 28190188 PMCID: PMC5813074 DOI: 10.1007/s10198-017-0873-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 01/24/2017] [Indexed: 05/04/2023]
Abstract
A better understanding of the economic burden of diabetes constitutes a major public health challenge in order to design new ways to curb diabetes health care expenditure. The aim of this study was to develop a new cost-of-illness method in order to assess the specific and nonspecific costs of diabetes from a public payer perspective. Using medical and administrative data from the major French national health insurance system covering about 59 million individuals in 2012, we identified people with diabetes and then estimated the economic burden of diabetes. Various methods were used: (a) global cost of patients with diabetes, (b) cost of treatment directly related to diabetes (i.e., 'medicalized approach'), (c) incremental regression-based approach, (d) incremental matched-control approach, and (e) a novel combination of the 'medicalized approach' and the 'incremental matched-control' approach. We identified 3 million individuals with diabetes (5% of the population). The total expenditure of this population amounted to €19 billion, representing 15% of total expenditure reimbursed to the entire population. Of the total expenditure, €10 billion (52%) was considered to be attributable to diabetes care: €2.3 billion (23% of €10 billion) was directly attributable, and €7.7 billion was attributable to additional reimbursed expenditure indirectly related to diabetes (77%). Inpatient care represented the major part of the expenditure attributable to diabetes care (22%) together with drugs (20%) and medical auxiliaries (15%). Antidiabetic drugs represented an expenditure of about €1.1 billion, accounting for 49% of all diabetes-specific expenditure. This study shows the economic impact of the assumption concerning definition of costs on evaluation of the economic burden of diabetes. The proposed new cost-of-illness method provides specific insight for policy-makers to enhance diabetes management and assess the opportunity costs of diabetes complications' management programs.
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Affiliation(s)
- Grégoire de Lagasnerie
- Strategy and Research Department, National Health Insurance (CNAMTS), 50 Avenue du Pr André Lemierre, 75986, Paris Cedex 20, France
| | - Anne-Sophie Aguadé
- Strategy and Research Department, National Health Insurance (CNAMTS), 50 Avenue du Pr André Lemierre, 75986, Paris Cedex 20, France
| | - Pierre Denis
- Strategy and Research Department, National Health Insurance (CNAMTS), 50 Avenue du Pr André Lemierre, 75986, Paris Cedex 20, France
| | - Anne Fagot-Campagna
- Strategy and Research Department, National Health Insurance (CNAMTS), 50 Avenue du Pr André Lemierre, 75986, Paris Cedex 20, France
| | - Christelle Gastaldi-Menager
- Strategy and Research Department, National Health Insurance (CNAMTS), 50 Avenue du Pr André Lemierre, 75986, Paris Cedex 20, France.
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17
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Wong CKH, Fung CSC, Yu EYT, Wan EYF, Chan AKC, Lam CLK. Temporal trends in quality of primary care for patients with type 2 diabetes mellitus: A population-based retrospective cohort study after implementation of a quality improvement initiative. Diabetes Metab Res Rev 2018; 34. [PMID: 28925010 DOI: 10.1002/dmrr.2952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Revised: 08/24/2017] [Accepted: 09/10/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND This study examined whether temporal trends exist in treatment of patients with type 2 diabetes (T2D) and quality of diabetes care after implementation of quality improvement initiative in primary care setting. METHODS We conducted a population-based retrospective cohort study of 202,284 patients with T2D who were routinely managed in primary care clinics. We examined the change over time and the variability between clinics in quality of care from Hospital Authority administrative data over a 5-year period (2009-2013) and used multilevel logistic regression to adjust for patient and clinic characteristics. Observational period was partitioned in 5 calendar years. Ten quality-of-care criteria were selected: adherence to 7 process of care criteria (HbA1c test, renal function test, full lipid profile, urine protein analysis, retinal screening, lipid-lowering agent prescriptions among patients with hypercholesterolaemia, and angiotensin converting enzyme inhibitor/angiotensin receptor blocker prescriptions among patients with microalbuminuria) and 3 outcome of care criteria (HbA1c ≤ 7%, BP ≤ 130/80 mmHg, and LDL-C ≤ 2.6 mmol/L). Variability of standards between clinics was assessed by using intracluster correlation coefficients. RESULTS Characteristics of patients with T2D managed in primary care changed substantially during the observational period, with increasing age and usage of insulin and longer duration of diabetes but improved metabolic profiles (all P trend < .001). Performance rates of the 7 process and 3 clinical outcomes of care criteria increased remarkably over time (all P trend < .001). Variations in retinal screening delivery between clinics were considerable, albeit decreasing over time. CONCLUSIONS Coinciding with implementation of quality improvement initiative, quality of diabetes care improved significantly in the past 5 years, in part attributable to benefits of integrated multidisciplinary diabetes management.
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Affiliation(s)
- Carlos K H Wong
- Department of Family Medicine and Primary Care, The University of Hong Kong, Ap Lei Chau, Hong Kong
| | - Colman S C Fung
- Department of Family Medicine and Primary Care, The University of Hong Kong, Ap Lei Chau, Hong Kong
| | - Esther Y T Yu
- Department of Family Medicine and Primary Care, The University of Hong Kong, Ap Lei Chau, Hong Kong
| | - Eric Y F Wan
- Department of Family Medicine and Primary Care, The University of Hong Kong, Ap Lei Chau, Hong Kong
| | - Anca K C Chan
- Department of Family Medicine and Primary Care, The University of Hong Kong, Ap Lei Chau, Hong Kong
| | - Cindy L K Lam
- Department of Family Medicine and Primary Care, The University of Hong Kong, Ap Lei Chau, Hong Kong
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18
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Jiao FF, Fung CSC, Wan EYF, Chan AKC, McGhee SM, Kwok RLP, Lam CLK. Five-Year Cost-effectiveness of the Multidisciplinary Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM). Diabetes Care 2018; 41:250-257. [PMID: 29246949 DOI: 10.2337/dc17-1149] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 10/20/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To estimate the cost-effectiveness of the multidisciplinary Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) in primary care patients with type 2 diabetes in comparison with usual primary care in a cohort with 5 years' follow-up. RESEARCH DESIGN AND METHODS We conducted a prospective cohort study among 17,140 propensity score-matched participants in RAMP-DM and those under usual primary care. The effectiveness measures were cumulative incidences of complications and all-cause mortality over 5 years. In a bottom-up approach, we estimated the program costs of RAMP-DM and health service utilization from the public health service provider's perspective. The RAMP-DM program costs included the setup costs, ongoing intervention costs, and central administrative costs. We calculated the incremental cost-effectiveness ratio by dividing the incremental costs by the incremental effectiveness of the RAMP-DM group compared with those of the usual-care group. RESULTS There were significantly lower cumulative incidences of individual on any complications (15.34% vs. 28.65%, P < 0.001) and all-cause mortality (7.96% vs. 21.35%, P < 0.001) in the RAMP-DM group compared with the usual-care group. The mean program cost of RAMP-DM was 157 U.S. dollars (range 66-209) per participant over 5 years. The costs of health service utilization among participants in RAMP-DM group was 7,451 USD less than that of the usual-care group, resulting in a net savings of 7,294 USD per individual. CONCLUSIONS RAMP-DM added to usual primary care was a cost-saving intervention in managing diabetes in patients over 5 years. These findings support the integration of RAMP-DM as part of routine primary care for all patients with diabetes.
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Affiliation(s)
- Fang Fang Jiao
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Colman Siu Cheung Fung
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Eric Yuk Fai Wan
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Anca Ka Chun Chan
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Sarah Morag McGhee
- Li Ka Shing Faculty of Medicine, School of Public Health, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Ruby Lai Ping Kwok
- Primary and Community Services Department, Hospital Authority Head Office, Hong Kong Hospital Authority, Hong Kong, People's Republic of China
| | - Cindy Lo Kuen Lam
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
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Wan EYF, Fung CSC, Jiao FF, Yu EYT, Chin WY, Fong DYT, Wong CKH, Chan AKC, Chan KHY, Kwok RLP, Lam CLK. Five-Year Effectiveness of the Multidisciplinary Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) on Diabetes-Related Complications and Health Service Uses-A Population-Based and Propensity-Matched Cohort Study. Diabetes Care 2018; 41:49-59. [PMID: 29138274 DOI: 10.2337/dc17-0426] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 09/23/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate the 5-year effectiveness of a multidisciplinary Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) in primary care patients with type 2 diabetes. RESEARCH DESIGN AND METHODS A 5-year prospective cohort study was conducted with 121,584 Chinese primary care patients with type 2 DM who were recruited between August 2009 and June 2011. Missing data were dealt with multiple imputations. After excluding patients with prior diabetes mellitus (DM)-related complications and one-to-one propensity score matching on all patient characteristics, 26,718 RAMP-DM participants and 26,718 matched usual care patients were followed up for a median time of 4.5 years. The effect of RAMP-DM on nine DM-related complications and all-cause mortality were evaluated using Cox regressions. The first incidence for each event was used for all models. Health service use was analyzed using negative binomial regressions. Subgroup analyses on different patient characteristics were performed. RESULTS The cumulative incidence of all events (DM-related complications and all-cause mortality) was 23.2% in the RAMP-DM group and 43.6% in the usual care group. RAMP-DM led to significantly greater reductions in cardiovascular disease (CVD) risk by 56.6% (95% CI 54.5, 58.6), microvascular complications by 11.9% (95% CI 7.0, 16.6), mortality by 66.1% (95% CI 64.3, 67.9), specialist attendance by 35.0% (95% CI 33.6, 36.4), emergency attendance by 41.2% (95% CI 39.8, 42.5), and hospitalizations by 58.5% (95% CI 57.2, 59.7). Patients with low baseline CVD risks benefitted the most from RAMP-DM, which decreased CVD and mortality risk by 60.4% (95% CI 51.8, 67.5) and 83.6% (95% CI 79.3, 87.0), respectively. CONCLUSIONS This naturalistic study highlighted the importance of early optimal DM control and risk factor management by risk stratification and multidisciplinary, protocol-driven, chronic disease model care to delay disease progression and prevent complications.
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Affiliation(s)
- Eric Yuk Fai Wan
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Colman Siu Cheung Fung
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Fang Fang Jiao
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Esther Yee Tak Yu
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Weng Yee Chin
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Daniel Yee Tak Fong
- School of Nursing, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Carlos King Ho Wong
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Anca Ka Chun Chan
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Karina Hiu Yen Chan
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Ruby Lai Ping Kwok
- Primary and Community Services Department, Hospital Authority Head Office, Hong Kong Hospital Authority, Hong Kong, People's Republic of China
| | - Cindy Lo Kuen Lam
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
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Jiao F, Wong CKH, Tang SCW, Fung CSC, Tan KCB, McGhee S, Gangwani R, Lam CLK. Annual direct medical costs associated with diabetes-related complications in the event year and in subsequent years in Hong Kong. Diabet Med 2017. [PMID: 28636749 DOI: 10.1111/dme.13416] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIM To develop models to estimate the direct medical costs associated with diabetes-related complications in the event year and in subsequent years. METHODS The public direct medical costs associated with 13 diabetes-related complications were estimated among a cohort of 128 353 people with diabetes over 5 years. Private direct medical costs were estimated from a cross-sectional survey among 1825 people with diabetes. We used panel data regression with fixed effects to investigate the impact of each complication on direct medical costs in the event year and subsequent years, adjusting for age and co-existing complications. RESULTS The expected annual public direct medical cost for the baseline case was US$1,521 (95% CI 1,518 to 1,525) or a 65-year-old person with diabetes without complications. A new lower limb ulcer was associated with the biggest increase, with a multiplier of 9.38 (95% CI 8.49 to 10.37). New end-stage renal disease and stroke increased the annual medical cost by 5.23 (95% CI 4.70 to 5.82) and 5.94 (95% CI 5.79 to 6.10) times, respectively. History of acute myocardial infarction, congestive heart failure, stroke, end-stage renal disease and lower limb ulcer increased the cost by 2-3 times. The expected annual private direct medical cost of the baseline case was US$187 (95% CI 135 to 258) for a 65-year-old man without complications. Heart disease, stroke, sight-threatening diabetic retinopathy and end-stage renal disease increased the private medical costs by 1.5 to 2.5 times. CONCLUSIONS Wide variations in direct medical cost in event year and subsequent years across different major complications were observed. Input of these data would be essential for economic evaluations of diabetes management programmes.
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Affiliation(s)
- F Jiao
- Department of Family Medicine and Primary Care, University of Hong Kong, Ap Lei Chau, Hong Kong
| | - C K H Wong
- Department of Family Medicine and Primary Care, University of Hong Kong, Ap Lei Chau, Hong Kong
| | - S C W Tang
- Department of Medicine, University of Hong Kong, Ap Lei Chau, Hong Kong
| | - C S C Fung
- Department of Family Medicine and Primary Care, University of Hong Kong, Ap Lei Chau, Hong Kong
| | - K C B Tan
- Department of Medicine, University of Hong Kong, Ap Lei Chau, Hong Kong
| | - S McGhee
- School of Public Health, University of Hong Kong, Ap Lei Chau, Hong Kong
| | - R Gangwani
- Department of Ophthalmology, University of Hong Kong, Ap Lei Chau, Hong Kong
| | - C L K Lam
- Department of Family Medicine and Primary Care, University of Hong Kong, Ap Lei Chau, Hong Kong
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21
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Health-related quality of life and health preference of Chinese patients with diabetes mellitus managed in primary care and secondary care setting: decrements associated with individual complication and number of complications. Health Qual Life Outcomes 2017; 15:125. [PMID: 28610625 PMCID: PMC5470199 DOI: 10.1186/s12955-017-0699-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 06/04/2017] [Indexed: 01/19/2023] Open
Abstract
Background Health-related quality of life (HRQoL) and health preference of patients with diabetes mellitus (DM) are essential in health economic evaluations but data on Chinese population is rare. This study aims to evaluate HRQoL and health preference of diabetic patients with different diabetic complications in Chinese population. Methods A cross-sectional study was conducted in 1275 patients with DM, including 518 subjects with various DM-related complications. HRQoL and health preference were estimated using SF-12 and SF-6D questionnaires, respectively. Disease status of DM and complications were identified from documented clinical diagnosis. Multivariable regression was used to investigate the effects of specific complications on HRQoL and health preference, adjusting for socio-demographic and clinical parameters. Results The presence of any diabetic complication was associated with lower physical component summary (−3.81 points, P < 0.01), and end-stage renal disease (ESRD) showed greatest reduction (−7.05 points, P < 0.01). Mental component summary and mental health (MH) scores were not decreased in any of the diabetic complications. The health preference score for diabetic subjects without complications was 0.882 (95% CI, 0.778 to 0.989). The reductions of health preference score were significant for stroke (−0.042, 95% CI -0.072 to −0.012), ESRD (−0.055, 95% CI -0.093 to −0.017), and sight-threatening diabetic retinopathy (STDR) (−0.043, 95% CI -0.075 to −0.010), while heart disease had an insignificant reduction (−0.017, 95% CI -0.042 to 0.008). Conclusions The presence of any of the four major diabetic complications (heart disease, stroke, ESRD and STDR) was associated with lower HRQoL and health preference scores. Findings of this study facilitated the cost-effectiveness studies of alternative management strategies for prevention of diabetic complications in Chinese population. Electronic supplementary material The online version of this article (doi:10.1186/s12955-017-0699-4) contains supplementary material, which is available to authorized users.
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Eberhardt O, Topka H. Neurological outcomes of antidiabetic therapy: What the neurologist should know. Clin Neurol Neurosurg 2017; 158:60-66. [PMID: 28477558 DOI: 10.1016/j.clineuro.2017.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 03/05/2017] [Accepted: 04/15/2017] [Indexed: 02/09/2023]
Abstract
Considering the causative or contributory effects of diabetes mellitus on common neurological diseases such as polyneuropathy, stroke and dementia, modern antidiabetic drugs may be expected to reduce incidence or progression of these conditions. Nevertheless, most observed benefits have been small, except in the context of therapy for diabetes mellitus type I and new-onset polyneuropathy. Recently, semaglutide, a GLP-1 analog, has been shown to significantly reduce stroke incidence in a randomized controlled trial. Beneficial effects of antidiabetic drugs on stroke severity or outcome have been controversial, though. The level of risk conferred by diabetes mellitus, the complex pathophysiology of neurological diseases, issues of trial design, side-effects of antidiabetic drugs as well as co-medication might be interacting factors that determine the performance of antidiabetic therapy with respect to neurological outcomes. It might be speculated that early treatment of prediabetes might prevent cerebral arteriosclerosis, cognitive decline or polyneuropathy more effectively, but this remains to be demonstrated.
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Affiliation(s)
- Olaf Eberhardt
- Department for Neurology, Clinical Neurophysiology, Clinical Neuropsychology and Stroke Unit, Klinikum Bogenhausen Englschalkinger Str. 77, München, 81925, Germany.
| | - Helge Topka
- Department for Neurology, Clinical Neurophysiology, Clinical Neuropsychology and Stroke Unit, Klinikum Bogenhausen Englschalkinger Str. 77, München, 81925, Germany
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Lau IT. A Clinical Practice Guideline to Guide a System Approach to Diabetes Care in Hong Kong. Diabetes Metab J 2017; 41:81-88. [PMID: 28447435 PMCID: PMC5409002 DOI: 10.4093/dmj.2017.41.2.81] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 01/02/2017] [Indexed: 01/14/2023] Open
Abstract
The Hospital Authority of Hong Kong is a statutory body that manages all the public medical care institutions in Hong Kong. There are currently around 400,000 diabetic patients under its care at 17 hospitals (providing secondary care for 40%) and 73 General Outpatient Clinics (providing primary care for 60%). The patient population has been growing at 6% to 8% per year over the past 5 years, estimated to include over 95% of all diagnosed patients in Hong Kong. In order to provide equitable and a minimal level of care within resources and local system factors constraints, a Clinical Practice Guideline on the management of type 2 diabetes mellitus was drawn in 2013 to guide a system approach to providing diabetes care. There is an algorithm for the use of various hypoglycemic agents. An organizational drug formulary governs that less expansive options have to be used first. A number of clinical care and patient empowerment programs have been set up to support structured and systematic diabetes care. With such a system approach, there have been overall improvements in diabetes care with the percentage of patients with glycosylated hemoglobin <7% rising from 40% in 2010 to 52% in 2015.
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Affiliation(s)
- Ip Tim Lau
- Department of Medicine, Tseung Kwan O Hospital, Hong Kong
- Central Committee on Diabetic Services, Hong Kong Hospital Authority, Hong Kong.
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Wan EYF, Fung CSC, Wong CKH, Choi EPH, Jiao FF, Chan AKC, Chan KHY, Lam CLK. Effectiveness of a multidisciplinary risk assessment and management programme-diabetes mellitus (RAMP-DM) on patient-reported outcomes. Endocrine 2017; 55:416-426. [PMID: 27699706 DOI: 10.1007/s12020-016-1124-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 09/14/2016] [Indexed: 01/11/2023]
Abstract
Little is known about how the patient-reported outcomes is influenced by multidisciplinary-risk-assessment-and-management-programme for patients with diabetes mellitus (RAMP-DM). This paper aims to evaluate the effectiveness of RAMP-DM on patient-reported outcomes. This was a prospective longitudinal study on 1039 diabetes mellitus patients (714/325 RAMP-DM/non-RAMP-DM) managed in primary care setting. 536 and 402 RAMP-DM participants, and 237 and 187 non-RAMP-DM participants were followed up at 12 and 24 months with completed survey, respectively. Patient-reported outcomes included health-related quality of life, change in global health condition and patient enablement measured by Short Form-12 Health Survey version-2 (SF-12v2), Global Rating Scale, Patient Enablement Instrument respectively. The effects of RAMP-DM on patient-reported outcomes were evaluated by mixed effect models. Subgroup analysis was performed by stratifying haemoglobin A1c (HbA1c) (optimal HbA1c < 7 % and suboptimal HbA1c ≥ 7 %). RAMP-DM with suboptimal HbA1c was associated with greater improvement in SF-12v2 physical component summary score at 12-month (coefficient:3.80; P-value < 0.05) and 24-month (coefficient:3.82;P-value < 0.05), more likely to feel more enabled at 12-month (odds ratio: 2.57; P-value < 0.05), and have improved in GRS at 24-month (odds ratio:4.05; P-value < 0.05) compared to non-RAMP-DM participants. However, there was no significant difference in patient-reported outcomes between RAMP-DM and non-RAMP-DM participants with optimal HbA1c. Participation in RAMP-DM is effective in improving physical component of HRQOL, Global Rating Scale and patient enablement among diabetes mellitus patients with suboptimal HbA1c, but not in those with optimal HbA1c. Patients with sub-optimal diabetes mellitus control should be the priority target population for RAMP-DM. This observational study design may have potential bias in the characteristics between groups, and randomized clinical trial is needed to confirm the results.
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Affiliation(s)
- Eric Yuk Fai Wan
- Department of Family Medicine and Primary Care, The University of Hong Kong, Ap Lei Chau Clinic, 3/F., 161 Main Street, Ap Lei Chau, Hong Kong.
| | - Colman Siu Cheung Fung
- Department of Family Medicine and Primary Care, The University of Hong Kong, Ap Lei Chau Clinic, 3/F., 161 Main Street, Ap Lei Chau, Hong Kong
| | - Carlos King Ho Wong
- Department of Family Medicine and Primary Care, The University of Hong Kong, Ap Lei Chau Clinic, 3/F., 161 Main Street, Ap Lei Chau, Hong Kong
| | - Edmond Pui Hang Choi
- School of Nursing, The University of Hong Kong, 4/F William MW Mong Block, 21 Sassoon Road, Pokfulam, Hong Kong
| | - Fang Fang Jiao
- Department of Family Medicine and Primary Care, The University of Hong Kong, Ap Lei Chau Clinic, 3/F., 161 Main Street, Ap Lei Chau, Hong Kong
| | - Anca Ka Chun Chan
- Department of Family Medicine and Primary Care, The University of Hong Kong, Ap Lei Chau Clinic, 3/F., 161 Main Street, Ap Lei Chau, Hong Kong
| | - Karina Hiu Yen Chan
- Department of Family Medicine and Primary Care, The University of Hong Kong, Ap Lei Chau Clinic, 3/F., 161 Main Street, Ap Lei Chau, Hong Kong
| | - Cindy Lo Kuen Lam
- Department of Family Medicine and Primary Care, The University of Hong Kong, Ap Lei Chau Clinic, 3/F., 161 Main Street, Ap Lei Chau, Hong Kong
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McGill M, Blonde L, Chan JCN, Khunti K, Lavalle FJ, Bailey CJ. The interdisciplinary team in type 2 diabetes management: Challenges and best practice solutions from real-world scenarios. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2016; 7:21-27. [PMID: 29067246 PMCID: PMC5651292 DOI: 10.1016/j.jcte.2016.12.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 12/01/2016] [Accepted: 12/02/2016] [Indexed: 11/03/2022]
Abstract
Interdisciplinary teams (IDTs) should aim to implement a patient-centred approach. IDTs can enable improved glycaemic control and reduced cardiometabolic risk. Successful IDTs require strong leadership, good communication and shared goals.
The Global Partnership for Effective Diabetes Management has previously recommended the implementation of an interdisciplinary team (IDT) approach to type 2 diabetes (T2DM) management as one of 10 practical steps for health care professionals to help more people achieve their glycaemic goal. This article discusses some of the key contributors to success and also the challenges faced when applying IDT care, by examining case studies and examples from around the world. The real-world practices discussed show that implementing successful interdisciplinary care in diabetes is possible despite significant barriers such as established hierarchal structures and financial resource constraints. Instituting collaborative, integrated working relationships among multiple disciplines under strong leadership, together with enhanced and active communication and improved patient access to appropriate specialties is essential. Patients have a crucial role in the management of their own disease and including them as part of the treatment team is also critical. IDTs in diabetes care improve patient outcomes in terms of control of glycaemia and cardiometabolic risk factors, and decreased risk of diabetes complications. Ensuring access to an appropriate IDT, in whatever form, is paramount to enable the best care to be delivered.
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Affiliation(s)
- Margaret McGill
- Diabetes Centre, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
| | - Lawrence Blonde
- Ochsner Diabetes Clinical Research Unit, Frank Riddick Diabetes Institute, Department of Endocrinology, Ochsner Medical Centre, New Orleans, LA, USA
| | - Juliana C N Chan
- Department of Medicine and Therapeutics, Hong Kong Institute of Diabetes and Obesity and Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China
| | - Kamlesh Khunti
- Leicester Diabetes Centre, University of Leicester, Leicester, UK
| | - Fernando J Lavalle
- Departamento de Medicina Interna, Hospital Universitario Dr. José Eleuterio, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Clifford J Bailey
- School of Life and Health Sciences, Aston University, Birmingham, UK
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Jiao F, Fung C, Wan Y, McGhee S, Wong C, Dai D, Kwok R, Lam C. Effectiveness of the multidisciplinary Risk Assessment and Management Program for Patients with Diabetes Mellitus (RAMP-DM) for diabetic microvascular complications: A population-based cohort study. DIABETES & METABOLISM 2016; 42:424-432. [DOI: 10.1016/j.diabet.2016.07.030] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 06/30/2016] [Accepted: 07/14/2016] [Indexed: 11/28/2022]
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Wong CKH, Fung CSC, Kung K, Wan EYF, Yu EYT, Chan AKC, Lam CLK. Quality of care and volume for patients with diabetes mellitus in the primary care setting: A population based retrospective cohort study. Diabetes Res Clin Pract 2016; 120:171-81. [PMID: 27568647 DOI: 10.1016/j.diabres.2016.07.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 07/04/2016] [Accepted: 07/30/2016] [Indexed: 11/17/2022]
Abstract
AIMS To examine the association of patient volume with quality of diabetes care in the primary care setting. METHODS We analyzed population-based data from Hospital Authority administrative database using a Hong Kong representative sample of 187,031 diabetic patients managed in 74 primary care general outpatient clinics between 04/2011 and 03/2012. We assessed the associations between annual clinic-based patient volume and quality of care in terms of adherence to care criteria of process (HbA1c test, renal function test, full lipid profile, urine protein analysis, diabetic retinopathy screening, and appropriate drug prescription) and clinical outcomes (HbA1c⩽7%, BP⩽130/80mmHg, LDL-C⩽2.6mmol/L) of care criteria, with and without adjustment for patient and clinic characteristics. RESULTS Patient volume was associated with three of seven process of care criteria; however, when compared to clinics in higher volume quartiles, those in lowest-volume quartile had more odds of HbA1c test (odds ratios (OR): 0.781, 0.655 and 0.646 for quartile from 2 to 4, respectively), renal function test (OR: 0.357, 0.367 and 0.590 for quartile from 2 to 4, respectively), and full lipid profile test (OR: 0.508, 0.612 and 0.793 for quartile from 2 to 4, respectively). There was no significant association between patient volume and the standards of achieving of HbA1c, BP and LDL-C outcome targets. CONCLUSIONS Disparities in volume and quality of diabetes care were observed in public primary care setting. Lower patient volumes at clinic level were associated with greater adherence to three process criteria but a volume-outcome association was not present.
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Affiliation(s)
- Carlos K H Wong
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong.
| | - Colman S C Fung
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong
| | - Kenny Kung
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong
| | - Eric Y F Wan
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong
| | - Esther Y T Yu
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong
| | - Anca K C Chan
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong
| | - Cindy L K Lam
- Department of Family Medicine and Primary Care, The University of Hong Kong, Hong Kong
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Affiliation(s)
- Cindy L K Lam
- Department of Family Medicine and Primary Care, The University of Hong Kong
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29
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Kang YM, Kim YJ, Park JY, Lee WJ, Jung CH. Mortality and causes of death in a national sample of type 2 diabetic patients in Korea from 2002 to 2013. Cardiovasc Diabetol 2016; 15:131. [PMID: 27618811 PMCID: PMC5020435 DOI: 10.1186/s12933-016-0451-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 09/06/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We aimed to investigate the mortality rate (MR), causes of death and standardized mortality ratio (SMR) in Korean type 2 diabetic patients from 2002 to 2013 using data from the Korean National Health Insurance Service-National Sample Cohort (NHIS-NSC). METHODS From this NHIS-NSC, we identified 29,807 type 2 diabetic subjects from 2002 to 2004. Type 2 diabetes was defined as a current medication history of anti-diabetic drugs and the presence of International Classification of Diseases (ICD)-10 codes (E11-E14) as diagnosis. Specific causes of death were recorded according to ICD-10 codes as the following: diabetes, malignant neoplasm, disease of the circulatory system, and other causes. RESULTS A total of 7103 (23.8 %) deaths were recorded. The MR tended to increase with age. In particular, the ratio of MR for men versus women was the highest in their 40s-50s. The overall SMR was 2.32 and the SMRs attenuated with increasing age. The causes of death ascribed to diabetes, malignant neoplasm, ischemic heart disease, cerebrovascular disease, and other causes were 22.0, 24.8, 6.2, 11.2 and 31.3 %, respectively. The SMRs according to each cause of death were 9.73, 1.76, 2.60, 2.04 and 1.89, respectively. CONCLUSIONS The MRs among type 2 diabetic subjects increased with age, and diabetic men exhibited a higher mortality risk than diabetic women in Korea. Subjects with type 2 diabetes exhibited an excess mortality when compared with the general population. Approximately 78.0 % of the diabetes-related deaths was not ascribed to diabetes, and malignant neoplasm was the most common cause of death among those not recorded as diabetes.
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Affiliation(s)
- Yu Mi Kang
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, South Korea
| | - Ye-Jee Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, South Korea
| | - Joong-Yeol Park
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, South Korea
| | - Woo Je Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, South Korea
| | - Chang Hee Jung
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, South Korea
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Riedl R, Robausch M, Berghold A. The Evaluation of the Effectiveness of Austrians Disease Management Program in Patients with Type 2 Diabetes Mellitus - A Population-Based Retrospective Cohort Study. PLoS One 2016; 11:e0161429. [PMID: 27532885 PMCID: PMC4988720 DOI: 10.1371/journal.pone.0161429] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 08/05/2016] [Indexed: 01/20/2023] Open
Abstract
AIM To evaluate the effectiveness of the Austrian Disease Management Program (DMP) 'Therapie aktiv-Diabetes im Griff' for patients with type 2 diabetes mellitus concerning patient-relevant outcomes (mortality, myocardial infarction and stroke) and costs. METHODS Based on routine health insurance data, we conducted a population-based retrospective cohort study using a propensity score (PS) matched control group design. The DMP-group consists of participants enrolled in the program during 2008 and 2009 (n = 7181). Out of 208.532 patients with no participation in the DMP up to 2013, PS-matched controls were selected with a matching ratio 1:3. In the PS-model, patient's characteristics, form of antidiabetic drug therapy, several prescriptions, the number of hospital admissions and days, main discharge diagnoses and costs at baseline were included. RESULTS Over a follow-up period of four years, we observed a significantly lower mortality rate in the DMP-group (9.4%) in comparison with the control group (15.9%, p<0.001). The cumulative number of hospital days and mean annual hospital costs were lower for DMP-participants resulting in significantly lower mean annual total costs, amounting to € 8226.80 per patient in the DMP-group and € 9231.10 in the control group respectively (p<0.001). CONCLUSIONS The evaluation shows a survival benefit and an average reduction of costs for participants in the DMP compared with the control-group. Despite we took great effort to ensure comparable groups, we cannot entirely rule out an influence by residual and unmeasured confounding due to the observational study design and the use of routine data. However, the results indicate that the disease management program implemented in Austria improves quality of care for patients with type 2 diabetes mellitus.
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Affiliation(s)
- Regina Riedl
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Martin Robausch
- Controlling Department (ÄIRCON), Lower Austria Health Insurance Fund, St. Pölten, Austria
| | - Andrea Berghold
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
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Continued efforts to translate diabetes cardiovascular outcome trials into clinical practice. Cardiovasc Diabetol 2016; 15:111. [PMID: 27514514 PMCID: PMC4982334 DOI: 10.1186/s12933-016-0431-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 08/02/2016] [Indexed: 12/17/2022] Open
Abstract
Diabetic patients suffer from a high rate of cardiovascular events and such risk increases with HbA1c. However, lowering HbA1c does not appear to yield the same benefit on macrovascular endpoints, as observed for microvascular endpoints. As the number of glucose-lowering medications increases, clinicians have to consider several open questions in the management of type 2 diabetes, one of which is the cardiovascular risk profile of each regimen. Recent placebo-controlled cardiovascular outcome trials (CVOTs) have responded to some of these questions, but careful interpretation is needed. After general disappointment around CVOTs assessing safety of DPP-4 inhibitors (SAVOR, TECOS, EXAMINE) and the GLP-1 receptor agonist lixisenatide (ELIXA), the EMPA-REG Outcome trial and the LEADER trial have shown superiority of the SGLT2-I empagliflozin and the GLP-1RA liraglutide, respectively, on the 3-point MACE outcome (cardiovascular death, non-fatal myocardial infarction or stroke) and cardiovascular, as well as all-cause mortality. While available mechanistic studies largely support a cardioprotective effect of GLP-1, the ability of SGLT2 inhibitor(s) to prevent cardiovascular death was unexpected and deserves future investigation. We herein review the results of completed CVOTs of glucose-lowering medications and suggest a possible treatment algorithm based on cardiac and renal co-morbidities to translate CVOT findings into clinical practice.
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Wong CKH, Wong WCW, Wan EYF, Chan AKC, Chan FWK, Lam CLK. Macrovascular and microvascular disease in obese patients with type 2 diabetes attending structured diabetes education program: a population-based propensity-matched cohort analysis of Patient Empowerment Programme (PEP). Endocrine 2016; 53:412-22. [PMID: 26785847 DOI: 10.1007/s12020-015-0843-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 12/21/2015] [Indexed: 02/05/2023]
Abstract
Patient Empowerment Programme (PEP) in primary care was effective in preventing diabetes-related complications in patients with diabetes. Nevertheless, the effect of PEP on glycaemic control, weight control, and complications was unclear in obese type 2 diabetic patients. We aimed to assess whether PEP reduced all-cause mortality, first macrovascular and microvascular disease events. A cohort of 6372 obese type 2 diabetic patients without prior occurrence of macrovascular or microvascular disease events on or before baseline study recruitment date was linked to the administrative database from 2008 to 2013. Non-PEP participants were matched one-to-one with the PEP participants using propensity score method with respect to their baseline covariates. Cox proportional hazard regressions were performed to estimate the associations of the PEP intervention with the occurrence of first macrovascular or microvascular disease events and death from any cause, controlling for demographic and clinical characteristics. During a median 31.5 months of follow-up, 350 (PEP/non-PEP: 151/199) patients suffered from a first macrovascular or microvascular disease event while 95 patients (PEP/non-PEP: 34/61) died from any cause. After adjusting for confounding variables, PEP participants had lower incidence rates of all-cause mortality [hazard ratio (HR): 0.589, 95 % confidence interval (CI) 0.380-0.915, P = 0.018] and first macrovascular or microvascular disease events (HR: 0.782, 95 % CI 0.632-0.968, P = 0.024) than those with PEP. Enrolment to PEP was an effective approach in reducing all-cause mortality and first macrovascular or microvascular disease events in obese patients with type 2 diabetes.
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Affiliation(s)
- Carlos K H Wong
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Ap Lei Chau Main Street, Ap Lei Chau, Hong Kong.
| | - William C W Wong
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Ap Lei Chau Main Street, Ap Lei Chau, Hong Kong
| | - Eric Y F Wan
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Ap Lei Chau Main Street, Ap Lei Chau, Hong Kong
| | - Anca K C Chan
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Ap Lei Chau Main Street, Ap Lei Chau, Hong Kong
| | - Frank W K Chan
- Integrated Care Programs, Hospital Authority Head Office, Hong Kong Hospital Authority, Kowloon, Hong Kong
| | - Cindy L K Lam
- Department of Family Medicine and Primary Care, The University of Hong Kong, 3/F, Ap Lei Chau Clinic, 161 Ap Lei Chau Main Street, Ap Lei Chau, Hong Kong
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Munch L, Arreskov AB, Sperling M, Overgaard D, Knop FK, Vilsbøll T, Røder ME. Risk stratification by endocrinologists of patients with type 2 diabetes in a Danish specialised outpatient clinic: a cross-sectional study. BMC Health Serv Res 2016; 16:124. [PMID: 27061722 PMCID: PMC4826533 DOI: 10.1186/s12913-016-1365-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 03/24/2016] [Indexed: 12/20/2022] Open
Abstract
Background To target optimised medical care the Danish guidelines for diabetes recommend stratification of patients with type 2 diabetes (T2D) into three levels according to risk and complexity of treatment. The aim was to describe the T2D population in an outpatient clinic, measure the compliance of the endocrinologists’ to perform risk stratification, and investigate the level of concordance between stratification performed by the endocrinologists and objective assessments. Methods A cross-sectional study with data collected from medical records and laboratory databases. The Danish risk stratification model contained the following criteria: HbA1c, blood pressure, metabolic complications, microvascular and macrovascular complications. Stratification levels encompassed: level 1 (uncomplicated), level 2 (intermediate risk) and level 3 (high risk). Objective assessments were conducted independently by two health professionals, and compared with the endocrinologists’ assessments. In order to test the degree of concordance, we conducted Cohen's kappa, McNemar’s test for marginal homogeneity, and Bowker’s test for symmetry. Results Of 245 newly referred patients, 209 (85 %) were stratified by the endocrinologists to level 1 (16 %), level 2 (55 %) and level 3 (29 %). By objective assessments, 4 % were stratified to level 1, 51 % to level 2 and 45 % to level 3. Of 419 long-term follow-up patients, 380 (91 %) were stratified by the endocrinologists to level 1 (5 %), level 2 (57 %), level 3 (38 %). By objective assessments, 3 % were stratified to level 1, 58 % to level 2 and 39 % to level 3. The concordance rate between endocrinologists’ and objective assessments was 63 % among newly referred (kappa 0.39; fair agreement) and 67 % for long-term follow-up (kappa 0.45; moderate agreement). Among newly referred patients, the endocrinologists stratified less patients at level 3 compared to objective assessments (p < 0.0001). There were no significant differences in marginal distribution within long-term follow-up patients. Conclusion Type 2 diabetes patients, newly referred to or allocated for long-term follow-up in the out-patient clinic, were mainly intermediate and high-risk, complicated patients (96 % and 95 %, respectively). Compliance of stratification by endocrinologists was high. The concordance between endocrinologists’ and objective assessments was not strong. Our data suggest that clinician-support for stratification level categorisation might be needed.
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Affiliation(s)
- Lene Munch
- Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark.,Institute of Nursing, University College Metropol, Tagensvej 86, DK-2200, Copenhagen, Denmark
| | - Anne B Arreskov
- Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark
| | | | - Dorthe Overgaard
- Institute of Nursing, University College Metropol, Tagensvej 86, DK-2200, Copenhagen, Denmark
| | - Filip K Knop
- Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark.,NNF Center for Basic Metabolic Research and Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3, DK-2200, Copenhagen, Denmark
| | - Tina Vilsbøll
- Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark
| | - Michael E Røder
- Center for Diabetes Research, Gentofte Hospital, University of Copenhagen, Kildegårdsvej 28, DK-2900, Hellerup, Denmark.
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van Giessen A, Boonman-de Winter LJM, Rutten FH, Cramer MJ, Landman MJ, Liem AH, Hoes AW, Koffijberg H. Cost-effectiveness of screening strategies to detect heart failure in patients with type 2 diabetes. Cardiovasc Diabetol 2016; 15:48. [PMID: 27001409 PMCID: PMC4802923 DOI: 10.1186/s12933-016-0363-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 03/08/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Heart failure (HF), especially with preserved ejection fraction (HFpEF) is common in older patients with type 2 diabetes (T2DM), but often not recognized. Early HF detection in older T2DM patients may be worthwhile because treatment may be initiated in an early stage, with clear beneficial treatment in those with reduced ejection fraction (HFrEF), but without clear prognostic beneficial treatment in those with HFpEF. Because both types of HF may be uncovered in older T2DM, screening may improve health outcomes at acceptable costs. We assessed the cost-effectiveness of five screening strategies in patients with T2DM aged 60 years or over. METHODS We built a Markov model with a lifetime horizon based on the prognostic results from our screening study of 581 patients with T2DM, extended with evidence from literature. Cost-effectiveness was calculated from a Dutch healthcare perspective as additional costs (Euros) per additional quality-adjusted life-year (QALY) gained. We performed probabilistic sensitivity analysis to assess robustness of these outcomes. Scenario analyses were performed to assess the influence of the availability of effective treatment of heart failure with preserved ejection fraction. RESULTS For willingness to pay values in the range of €6050/QALY-€31,000/QALY for men and €6300/QALY-€42,000/QALY for women, screening-based checking the electronic medical record for patient characteristics and medical history plus the assessment of symptoms had the highest probability of being cost-effective. For higher willingness-to-pay values, direct echocardiography was the preferred screening strategy. Cost-effectiveness of all screening strategies improved with the increase in effectiveness of treatment for HFpEF. CONCLUSIONS Screening for HF in older community-dwelling patients with T2DM is cost-effective at the commonly used willingness-to-pay threshold of €20.000/QALY by checking the electronic medical record for patient characteristics and medical history plus the assessment of symptoms. The simplicity of such a strategy makes it feasible for implementation in existing primary care diabetes management programs.
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Affiliation(s)
- Anoukh van Giessen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands. .,Department of Clinical Epidemiology and Medical Technology Assessment, University Medical Center Maastricht, Maastricht, The Netherlands.
| | - Leandra J M Boonman-de Winter
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Scientific and Contract Research, Center for Diagnostic Support in Primary Care (SHL-Groep), Etten-Leur, The Netherlands.,Amphia Academy, Amphia Hospital, Breda, The Netherlands
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maarten J Cramer
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Anho H Liem
- Department of Cardiology, Sint Franciscus Hospital, Rotterdam, The Netherlands
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hendrik Koffijberg
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Health Technology and Services Research, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
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