Abstract
To conduct an analysis to assess whether the completion of recommended diabetes care processes (glycated haemoglobin [HbA1c], creatinine, cholesterol, blood pressure, body mass index [BMI], smoking habit, urinary albumin, retinal and foot examinations) at least annually is associated with mortality. A cohort from the National Diabetes Audit of England and Wales comprising 179 105 people with type 1 and 1 397 790 people with type 2 diabetes, aged 17 to 99 years on January 1, 2009, diagnosed before January 1, 2009 and alive on April 1, 2013 was followed to December 31, 2019. Cox proportional hazards models adjusting for demographic characteristics, smoking, HbA1c, blood pressure, serum cholesterol, BMI, duration of diagnosis, estimated glomerular filtration rate, prior myocardial infarction, stroke, heart failure, respiratory disease and cancer, were used to investigate whether care processes recorded January 1, 2009 to March 31, 2010 were associated with subsequent mortality. Over a mean follow-up of 7.5 and 7.0 years there were 26 915 and 388 093 deaths in people with type 1 and type 2 diabetes, respectively. Completion of five or fewer, compared to eight, care processes (retinal screening not included as data were not reliable) had a mortality hazard ratio (HR) of 1.37 (95% confidence interval [CI] 1.28-1.46) in people with type 1 and 1.32 (95% CI 1.30-1.35) in people with type 2 diabetes. The HR was higher for respiratory disease deaths and lower in South Asian ethnic groups. People with diabetes who have fewer routine care processes have higher mortality. Further research is required into whether different approaches to care might improve outcomes for this high-risk group.
Highlights
In England, the National Institute for Health and Care Excellence (NICE) recommends that people with type 1 diabetes[4] and type 2 diabetes[5] are offered nine annual processes, and the completion of these has been incentivized in primary care.[8]
Further adjustment to include smoking habit, HbA1c, systolic blood pressure, serum cholesterol, body mass index (BMI) and duration of diagnosed diabetes increased the hazard ratio (HR) for all-cause mortality associated with having five or fewer care processes to 1.38 for type 1 diabetes, and decreased it to 1.33 for type 2 diabetes
This large national population-based cohort of people with type 1 diabetes and type 2 diabetes followed up for means of 7.6 and 6.9 years, respectively, following 15 months of routine care, finds that having five or fewer recorded care processes during that baseline period was associated with subsequent 7-year hazards of all-cause mortality approximately one-third higher compared to having all eight care processes after accounting for demographic characteristics. This higher mortality persists after adjustment for clinical factors known to affect the risk of diabetes-related complications (HbA1c, systolic blood pressure, serum cholesterol, BMI, smoking habit), and cardiovascular and renal comorbidities were taken into account
Summary
In England, the National Institute for Health and Care Excellence (NICE) recommends that people with type 1 diabetes[4] and type 2 diabetes[5] are offered nine annual processes (measurement of HbA1c, lipids, creatinine, albuminuria, blood pressure and body mass index [BMI], ascertainment of smoking status, and examination of the feet and retinae), and the completion of these has been incentivized in primary care.[8] Most international guidelines stress the importance of these care processes Whilst their regular completion might seem intuitively sensible, the level of evidence to support the guideline- recommended processes, including their effect on clinical outcomes, is usually not known or is rated at the lowest standard of evidence (“expert consensus” or “clinical experience”).[7]
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