Australian National Diabetes Audit Research Articles

ANDA-Evaluating Facilitated Feedback Enhancement - a Cluster randomised Trial (ANDA-EFFECT): protocol for a cluster randomised trial of audit feedback augmented with education and support, compared to feedback alone, on acceptability, utility and health outcomes in diabetes centres in Australia

BackgroundPeople living with diabetes must manage a range of factors for optimal control of glycaemia and to minimise the risk of diabetes-related complications. Diabetes practitioners are expected to follow guidelines for the key process of care and clinical outcomes, to help people living with diabetes achieve clinical targets. In Australia, the performance of diabetes centres against guidelines is evaluated by the Australian National Diabetes Audit, an annual clinical audit and feedback activity. Previous work has identified areas for improvement in the feedback provided to participating diabetes centres and suggested additional educational and support resources to assist in using audit feedback for the development of quality improvement activities. This cluster randomised trial will test the acceptability, utility and impact on selected clinical outcomes of the developed study intervention (audit feedback and a tailored educational and peer support cointervention).MethodsTwo-armed cluster randomised trial with Australian Diabetes Centres that participated in the Australian National Diabetes Audit in 2021 as the clusters, stratified by location and type of centre. We aim to recruit 35 diabetes centres in each arm. Both the intervention and control arms will receive an augmented feedback report, accompanied by a partially pre-populated slide deck. In addition, the intervention arm will receive a tailored theory-based intervention designed to address identified, modifiable barriers to utilising and implementing the recommendations from diabetes audit feedback. The co-primary outcomes are (1) HbA1c at the patient level, measured at 6 months after delivery of the intervention, and (2) the acceptability and utility of the augmented feedback and cointerventions at the practitioner level, measured at 3 months after delivery of the intervention.DiscussionThis trial aims to test the effects of systematic development and implementation of theory and evidence-informed changes to the audit feedback delivered to diabetes centres participating in an established national clinical diabetes audit. Potential benefits of improved audit feedback include more optimal engagement with the feedback by end clinical users which, ultimately, may lead to improvements in care for people living with diabetes.Trial registrationAustralian and New Zealand Clinical Trials Registry ACTRN12621000765820. Prospectively registered on June 21, 2021

Type 1 diabetes management and hospitalisation in the over 25’s at an Australian outer urban diabetes clinic

AimsTo describe clinic management and referral pathways among adults with type 1 diabetes (T1D) aged > 25 years attending a public outpatient diabetes service.MethodsRetrospective cohort study of people with T1D aged > 25 years seen by endocrinologists in one Australian urban public outpatient in 2017. Electronic and paper medical records were reviewed using a dataset adapted from the UK National Institute for Health and Care Excellence 2015 guidelines.ResultsAmong the 111 people with T1D (mean age 41 ± 13 years, 55% men, mean body mass index 27.1 ± 5.6 kg/m2), mean HbA1c was 8.1 ± 1.9% (66 ± 19 mmol/mol) (lower than the Australian National Diabetes Audit: 8.5%/69 mmol/mol) with 25.5% meeting the guideline target of < 53 mmol/mol (7.0%). Most people had seen a diabetes educator (80.2%) or dietitian (73.0%) and had complication screening. Complication rates were high (nephropathy 20.4%, retinopathy 27.4%, peripheral neuropathy 30.1%, ischaemic heart disease/acute infarction 10.5%). Overall, 27% of referrals occurred following an acute inpatient admission or emergency department presentation and 13% for management of diabetes in pregnancy.ConclusionsA high proportion of people with T1D accessed public specialist care either during pregnancy or after a largely avoidable acute glycaemia-related hospital presentation. Subsequent care was in line with national specialist standards. This area has a “wait for acute event” rather than “complication prevention” model of care, associated with under-referral to the local multidisciplinary specialist service. Understanding how widespread this model of care is, and ways to reduce its prevalence, are urgently required.

Making the most of audit and feedback to improve diabetes care: a qualitative study of the perspectives of Australian Diabetes Centres

BackgroundDiabetes has high burden on the health system and the individual, and many people living with diabetes struggle to optimally manage their condition. In Australia, people living with diabetes attend a mixture of primary, secondary and tertiary care centres. Many of these Diabetes Centres participate in the Australian National Diabetes Audit (ANDA), a quality improvement (QI) activity that collects clinical information (audit) and feeds back collated information to participating sites (feedback). Despite receiving this feedback, many process and care outcomes for Diabetes Centres continue to show room for improvement. The purpose of this qualitative study was to inform improvement of the ANDA feedback, identify the needs of those receiving feedback and elicit the barriers to and enablers of optimal feedback use.MethodsSemi-structured interviews were conducted with representatives of Australian Diabetes Centres, underpinned by the Consolidated Framework for Implementation Research (CFIR). De-identified transcripts were analysed thematically, underpinned by the domains and constructs of the CFIR.ResultsRepresentatives from 14 Diabetes centres participated in this study, including a diverse range of staff typical of the Diabetes Centres who take part in ANDA. In general, participants wanted a shorter report with a more engaging, simplified data visualisation style. Identified barriers to use of feedback were time or resource constraints, as well as access to knowledge about how to use the data provided to inform the development of QI activities. Enablers included leadership engagement, peer mentoring and support, and external policy and incentives. Potential cointerventions to support use include exemplars from clinical change champions and peer leaders, and educational resources to help facilitate change.ConclusionsThis qualitative study supported our contention that the format of ANDA feedback presentation can be improved. Healthcare professionals suggested actionable changes to current feedback to optimise engagement and potential implementation of QI activities. These results will inform redesign of the ANDA feedback to consider the needs and preferences of end users and to provide feedback and other supportive cointerventions to improve care, and so health outcomes for people with diabetes. A subsequent cluster randomised trial will enable us to evaluate the impact of these changes.

Exploring HbA1c variation between Australian diabetes centres: The impact of centre-level and patient-level factors.

Increasing global diabetes incidence has profound implications for health systems and for people living with diabetes. Guidelines have established clinical targets but there may be variation in clinical outcomes including HbA1c, based on location and practice size. Investigating this variation may help identify factors amenable to systemic improvement interventions. The aims of this study were to identify centre-specific and patient-specific factors associated with variation in HbA1c levels and to determine how these associations contribute to variation in performance across diabetes centres. This cross-sectional study analysed data for 5,872 people with type 1 (n = 1,729) or type 2 (n = 4,143) diabetes mellitus collected through the Australian National Diabetes Audit (ANDA). A linear mixed-effects model examined centre-level and patient-level factors associated with variation in HbA1c levels. Mean age was: 43±17 years (type 1), 64±13 (type 2); median disease duration: 18 years (10,29) (type 1), 12 years (6,20) (type 2); female: 52% (type 1), 45% (type 2). For people with type 1 diabetes, volume of patients was associated with increases in HbA1c (p = 0.019). For people with type 2 diabetes, type of centre was associated with reduction in HbA1c (p <0.001), but location and patient volume were not. Associated patient-level factors associated with increases in HbA1c included past hyperglycaemic emergencies (type 1 and type 2, p<0.001) and Aboriginal and Torres Strait Islander status (type 2, p<0.001). Being a non-smoker was associated with reductions in HbA1c (type 1 and type 2, p<0.001). Centre-level and patient-level factors were associated with variation in HbA1c, but patient-level factors had greater impact. Interventions targeting patient-level factors conducted at a centre level including sick-day management, smoking cessation programs and culturally appropriate diabetes education for and Aboriginal and Torres Strait Islander peoples may be more important for improving glycaemic control than targeting factors related to the Centre itself.

Benchmarking care outcomes for young adults with type 1 diabetes in Australia after transition to adult care.

AimTo determine advantages conferred by a youth‐specific transition clinic model for young adults with type 1 diabetes (T1D) at Westmead Hospital (WH) as compared with Australian registry data.MethodsProspectively collected data included age, diabetes duration, visit frequency, post code, BMI, mode of insulin delivery, continuous glucose monitoring, HbA1c, albumin creatinine ratio, BP, retinopathy and diabetic ketoacidosis (DKA) for all WH T1D clinic attendees aged 16–25 between January 2017 and June 2018 (n = 269). Results were compared with data collected during the same time period from 2 separate Australian data registries, one longitudinal (Australasian Diabetes Data Network, ADDN) and one a spot survey (the Australian National Diabetes Audit, ANDA).ResultsAcross the three cohorts, HbA1c was similar (respectively, WH, ADDN, ANDA; 8.7%[72mmol/mol], 8.7%[72mmol/mol], 8.5%[69mmol/mol]) and HbA1c was significantly higher in young adults <21 years (8.7–8.9%[73‐75mmol/mol]) as compared with ≥21 years (8.5%[69mmol/mol], p < .002). In the WH cohort, median interval between visits was shorter than in ADDN (4.5 vs. 9.0 months) and DKA was lower (respectively, 3.6 and 9.2/100 patient years; p < .001).ConclusionsWhile suboptimal HbA1c was recorded in all centres, the WH model of care saw increased attendance and reduced admissions with DKA as compared with other Australian adult centres.

356Impact of site-specific and patient-specific factors in explaining HbA1c variation in Australian diabetes centres

Abstract Background Management of glycaemia remains the mainstay of optimal diabetes care. As reported by the Australian National Diabetes Audit (ANDA) average glycaemia is suboptimal for many people living with diabetes. Whether centre-specific factors influence HbA1c variation among patients attending Australian primary, secondary or tertiary diabetes centres, is not known. Methods Data for 5,872 people with Type 1 or Type 2 diabetes (DM1/DM2) was collected for ANDA over a 4-6 week period. A linear mixed-effects model was built to examine the relative contribution of centre-specific (type of centre, location and volume of patients) and patient-specific factors in explaining variation in HbA1c, by diabetes type. Results Mean age of the cohort was 57.5±17.2 years, median disease duration 14 years (7,21) with 47% female. For people with DM1, number of patients was the only centre-specific factor that significantly contributed to HbA1c variation (p = 0.019). In contrast, for people with DM2, type of centre significantly contributed toHbA1c variation (p &amp;lt; 0.001). Patient-specific factors contributing to HbA1c variation included prior hyperglycaemic emergencies, being a non-smoker and Aboriginal or Torres Strait Islander status. Conclusions Unlike patient factors, centre factors such as type, location and volume of patients appear to have less actionable impact on HbA1c variation. Key messages Centre-level interventions to target patient-specific factors (such as sick day management education to prevent acute hyperglycaemia, smoking cessation programs and culturally appropriate diabetes education) rather than centre-specific factors may be more important for improving glycaemia.

Trends in glycaemic control and drug use in males and females with type 2 diabetes: Results of the Australian National Diabetes Audit from 2013 to 2019.

To investigate temporal changes in glycaemic control and the use of antihyperglycaemic therapies in females and males with type 2 diabetes from 2013 to 2019. Data from adult patients with type 2 diabetes (n=11 930; 44.9% females, mean [SD] age of 62.9 [12.9] years) were analysed from the 2013 to 2019 biennial cross-sectional Australian National Diabetes Audit. Mean HbA1c remained similar throughout the years examined and between the sexes (7.8%-8.3%, 62-67 mmol/mol; P > .05). The number of antihyperglycaemic agents used by both sexes increased from 2013 to 2019 (P < .001), with more agents used by males (P=.014). From 2013 to 2019, there were increasing proportions of both sexes using dipeptidyl peptidase-4 inhibitors (females: 11.7%-25.7%, P=.045; males: 11.6%-29.5%, P=.036) and glucagon-like peptide-1 receptor agonists (females: 5.9%-15.3%; males: 4.9%-11.1%; P=.043 for both). Sodium-glucose co-transporter-2 inhibitors were not available in 2013; however, their use increased substantially from 2015 to 2019 in both females (4.9%-26.3%, P=.013) and males (4.7%-32.2%, P=.019). From 2013 to 2019, mean HbA1c levels remained unchanged despite a concurrent increase in the number of antihyperglycaemic medications used. Overall, there was a trend towards preferencing newer agents with some differences in treatment regimens relating to sex and renal function.

What Gets Measured Gets Improved-Setting Standards and Accreditation for Quality Improvement for Diabetes Services in Australia.

The purpose of this article is to illustrate that setting standards of care is the cornerstone for excellence in diabetes management. This is underpinned by 3 activities: a standards and accreditation process, an audit and benchmarking program and a linked quality improvement plan. While there are many examples of local auditing and quality improvement programs, there are very few that are at a national level. The National Association of Diabetes Centres (NADC) was formed by the Australian Diabetes Society and the Australian Diabetes Educators Association to set standards of diabetes care in Australia. A rigorous accreditation process was put in place to recognize primary, secondary, and tertiary level diabetes centers that meet these standards. The NADC accreditation process is underpinned by a quality improvement plan, which must be submitted for accreditation to be granted and is informed by the Australian National Diabetes Audit (ANDA). ANDA is conducted annually to gather information about treatments, complications, self-care practices and quality of life outcomes and provides a national as well as an individual report to the participating center that is used to benchmark against other like centers. The ANDA reports are important to inform national policy and advocacy for diabetes care and to also provide information for quality improvement purposes for the individual participating center. We believe that the NADC Standards and Accreditation can be an exemplar for other countries to adapt and adopt to standardize diabetes care at the highest level.

Glycaemia and utilisation of technology across the lifespan of adults with type 1 diabetes: Results of the Australian National Diabetes Audit (ANDA)

AimsTo evaluate the utilisation of technologies and associated glycaemia among adults with type 1 diabetes. MethodsDe-identified data from adults with type 1 diabetes (≥18 years old) in the Australian National Diabetes Audit (ANDA)–2019 were analysed. Proportions using insulin pumps or injections with continuous glucose monitoring (CGM) or capillary-glucose testing were compared. Technology use among adults was compared to young people (<21 years old) with subsidised CGM. Glycaemia and complication-burden were assessed across management strategies. Results1,693 adults were analysed. Mean(±SD) age, diabetes duration, and HbA1c were 43.3 ± 17.0 years, 20.3 ± 14.3 years and 8.4% ± 1.7 [68 ± 19 mmol/mol], respectively. Among adults, 40% used at least one device, 27% used insulin pumps, and 23% used CGM. CGM was used by 62% of young people with subsidised access. Mean HbA1c was consistently lower among adults using CGM, insulin pumps, or combined insulin pump and CGM compared to standard care (8.3% ± 1.6 [67 ± 18 mmol/mol], 8.2% ± 1.4 [66 ± 15 mmol/mol], and 7.8% ± 1.4 [62 ± 15 mmol/mol] respectively compared to 8.6% ± 1.8 [70 ± 20 mmol/mol], p < 0.001). Technology use was not associated with diabetic ketoacidosis but CGM was associated with more hypoglycaemia. ConclusionsGovernment subsidy is an important consideration for utilisation of technologies among adults with type 1 diabetes. Technology use across the adult lifespan was associated with lower HbA1c than insulin injections and capillary-glucose testing.

The association of smoking status with glycemic control, metabolic profile and diabetic complications– Results of the Australian National Diabetes Audit (ANDA)

BackgroundTobacco smoking and diabetes mellitus contribute significantly to the overall health burden and mortality of Australians. We aimed to assess the relationship of smoking with glycemic control, metabolic profile and complications in Australian patients living with diabetes. MethodsWe analysed the 2011–2017 biennial Australian National Diabetes Audit cross-sectional data. Patients were classified as current, past or never smokers. Linear (or quantile) and logistic regression models were used to assess for associations. ResultsData from 15,352 patients were analysed, including 72.2% with type 2 diabetes. Current smokers comprised 13.5% of the study population. Current and past smokers had a median HbA1c that was 0.49% and 0.14% higher than never smokers, respectively, as well as higher triglyceride and lower HDL levels (all p values < .0001). Compared to never smokers, current smokers had higher odds of severe hypoglycemia and current and past smokers had higher odds of myocardial infarction, stroke, peripheral vascular disease, lower limb amputation, erectile dysfunction and peripheral neuropathy (all p values ≤.001), with no significant change over time. ConclusionWhen compared to never smokers, current and past smokers had poorer glycemic and lipid control and higher odds of macrovascular and microvascular complications. Despite this, current smoking remains prevalent among Australians with diabetes.

2408-PUB: Benchmarking Care Outcomes for Youth with Diabetes after Transition to Adult Care in Australia

In 2001 a model of care for transition of youth with diabetes (YWD) was implemented at Westmead Hospital and published in 2007. In 2017, Australian National Diabetes audit (ANDA) conducted a month survey of all people with diabetes attending participating centers. The Australian Diabetes Data Network (ADDN) is a newly established national database. Aim: To determine if benefits are conferred by a youth specific transition care model as compared with other Australian adult health care settings for YWD age 16-25. Methods: An audit of all T1D Westmead clinic attendees aged 16-25 in 2017 including age, duration diabetes, HbA1c, urine microalbumin/creatinine ratio in the last 12 months, BP, most recent retinal review and results compared with the ANDA outcomes for youth attending adult health care settings for management of diabetes. Subjects within 1 year diagnosis and pregnancy excluded. Results: Key: HbA1c median (25th-75th centile), [n] missing * p&amp;lt;0.05. HbA1c did not differ across all adult centers. In subgroup analysis only MDI treated were lower in the ANDA centers. A significantly greater proportion had urine microalbumin screening and BP screening, in the Westmead cohort. Conclusion: Similar levels of diabetes control were achieved regardless of center indicating importance of follow-up in this age group although control was suboptimal. Complications screening was more effective with a dedicated transition. Disclosure J. Holmes-Walker: None. P. Rueter: None. K. Farrell: None.

MON-166 Excess Cardiovascular Events Despite Good Glycaemic Control

The Royal Australasian College of General Practitioners (RACGP) have published standards of care for patients with type II diabetes. Data from rural Australia are limited. In the light of recent trials such as EMPA-REG standards of care in routine clinical practice in regional Queensland were compared to RACGP standards and the presence of cardiovascular complications noted. Methods: We retrospectively analyzed data from 258 patients in a single, primary care setting in regional Queensland, Australia. Data were collected for glycaemic control, lipids, BMI,blood pressure, lipids, microalbuminuria and presence of cardiovascular complications. In total 258 patients were identified. The average BMI was 32.4 kg/m2, age 63, 120 female, 138 male. Only 3 smoked but 67 (25%) consumed more than 2 standard drinks per day. Average BP was 136/81 though 42% exceeded the systolic BP target of 140 mmHg and 19% exceeded the diastolic target of 90 mmHg. Average HbA1c achieved was 6.8% with 53% at or below the target of 7%. Average total cholesterol was 4.4 (170), HDL 1.2 (46), LDL 2.3 (89) and triglyceride 2.0 (77) mmol/L (mg/dL). Microalbumin was elevated in 20% of female and 40% of male subjects. The prevalence of ischaemic heart disease was 25%, cerebrovascular disease 5%, peripheral vascular disease 6% and chronic kidney disease 7%. The majority were treated with sulphonylureas, metformin and insulin with relatively little use of SGLT2 inhibitors or GLP1 analogues. Glycaemic control was better than reported in the Australian National Diabetes Audit (ANDA) (HbA1c 8.1%). Smoking rates were low however blood pressure targets were often not met. Females suffered 26% of IHD burden, compared to 2% in the general female population aged 45-54. The prevalence of microalbuminuria in male subjects is twice the typical rate for Australia. In summary, despite achieving target levels of glycaemic control or exceeding them, there remains a high burden of cardiovascular complications when diabetes is treated with traditional agents. Ischaemic heart disease in female patients and microalbuminuria in male subjects may be suitable targets for SGLT2 inhibition given the published evidence of benefits. We intend to repeat our survey after a targeted intervention in these areas of interest.

Age-related differences in glycaemic control, cardiovascular disease risk factors and treatment in patients with type 2 diabetes: a cross-sectional study from the Australian National Diabetes Audit

ObjectiveTo compare the glycaemic control and cardiovascular risk factor profiles of younger and older patients with type 2 diabetes. Cross-sectional analysis of data from the 2015 Australian National Diabetes Audit...

Younger Patients with Type 2 Diabetes Have Poorer Self-Care Practices Compared with Older Patients—Results from the Australian National Diabetes Audit

Introduction: Type 2 diabetes is increasingly diagnosed among younger people. Patient engagement with self-care practices is crucial for the optimal management of type 2 diabetes. This study examines the self-care practices of younger and older patients with type 2 diabetes. Methods: Data were analysed from the Australian National Diabetes Audit (ANDA) that included 2552 adult patients with type 2 diabetes from 56 participating Diabetes Centres. Pre-specified demographic and clinical variables were obtained. Self-care variables (physical activity, following dietary recommendations, medication adherence and monitoring blood glucose levels) were compared in patients ≤64 years and &amp;gt;64 years of age. Results: Mean age (±SD) of participants was 63±13 years overall, 53±9 years for the younger group and 73±6 years for the older group. Mean diabetes duration was 9±8 years and 15±10 years for younger and older patients, respectively (p&amp;lt;0.01). A greater proportion of younger patients had HbA1c levels above 7.0% compared with older patients (76% vs. 68%, p&amp;lt;0.001). A greater proportion of younger compared to older patients reported difficulty following dietary recommendations (50% vs. 32%) and forgetting medications (37% vs. 22%) (all p values &amp;lt;0.001). A smaller proportion of younger compared with older patients reported monitoring their blood glucose levels as often as recommended (60%vs. 70%, p&amp;lt;0.001). Younger age was associated with a 2-fold increase in the odds of not following the recommended self-care practices after adjustment for gender, smoking, insulin therapy, depression and allied health attendance (all p values &amp;lt;0.001). Conclusion: Despite shorter diabetes duration, younger age was associated with worse glycaemic control and poorer diabetes self-care practices among patients with type 2 diabetes. Targeted strategies are urgently required to optimise diabetes self-care practices and thereby improve glycaemic control. Disclosure N. Nanayakkara: None. A.J. Pease: None. S. Ranasinha: None. N. Wischer: None. B. de Courten: None. S. Zoungas: Advisory Panel; Self; AstraZeneca.

Burden of Cardiovascular Risk Factors and Disease in Type 1 Diabetes—Results of the Australian National Diabetes Audit (ANDA)

Aims: To evaluate burden of cardiovascular risk factors and associations with cardiovascular disease (CVD) among adults with type 1 diabetes attending Australian diabetes centers. Methods: De-identified, prospectively collected data from patients with type 1 diabetes aged ≥18 years included in ANDA-2015 were analysed. Cardiovascular risk factors (age, sex, diabetes duration, HbA1c, BP, high density lipoprotein-cholesterol (HDL-C), BMI, smoking status and albuminuria) and associations with CVD inclusive of stroke, myocardial infarction, coronary artery bypass graft/angioplasty and peripheral vascular disease were assessed. Likelihood ratio test and restricted cubic splines assessed for interactions and non-linear associations. Discriminatory ability of multivariate models was assessed with area under the receiver operating characteristic curves (AUC). Results: Data from 1,169 patients were analysed. Median (IQR) age and diabetes duration were 37.0 (24.9-52.0) and 16.0 (8.0-27.0) years respectively. Cardiovascular risk factors were prevalent including hypertension (22%), dyslipidemia (89%), overweight or obesity (56%), ever smoking (39%), albuminuria (31%), and an HbA1c &amp;gt;7.0% (53mmol/mol) (81%). Older age, longer diabetes duration, smoking and antihypertensive use were positively associated, while higher HDL-C was negatively associated with CVD (all p&amp;lt;0.05). Association with CVD and diabetes duration remained constant until 20 years when a linear increase was noted. The multivariate model demonstrated good discriminatory ability for CVD (AUC 0.88; 95% CI 0.85-0.92). Conclusions: Cardiovascular risk factors were prevalent and strongly associated with CVD among adults with type 1 diabetes. Given the approximate J-shaped association between diabetes duration and CVD, the impact of cardiovascular risk stratification and management before and after 20 years duration will need to be further assessed. Disclosure A.J. Pease: None. A. Earnest: None. N. Nanayakkara: None. S. Ranasinha: None. J.R. Flack: None. W.A. Davis: Speaker's Bureau; Self; Eli Lilly and Company. Speaker's Bureau; Spouse/Partner; Novo Nordisk A/S. Advisory Panel; Spouse/Partner; Novo Nordisk A/S. Research Support; Spouse/Partner; Novo Nordisk A/S. Other Relationship; Spouse/Partner; Novo Nordisk A/S. Speaker's Bureau; Spouse/Partner; Merck Sharp &amp; Dohme Corp.. Advisory Panel; Spouse/Partner; Merck Sharp &amp; Dohme Corp.. Speaker's Bureau; Spouse/Partner; AstraZeneca. Advisory Panel; Spouse/Partner; AstraZeneca. Speaker's Bureau; Spouse/Partner; Boehringer Ingelheim GmbH, Pfizer Inc.. G.M. Kilmartin: None. N. Wischer: None. S. Zoungas: Advisory Panel; Self; AstraZeneca.

Burden of cardiovascular risk factors and disease among patients with type 1 diabetes: results of the Australian National Diabetes Audit (ANDA)

BackgroundCardiovascular risk stratification is complex in type 1 diabetes. We hypothesised that traditional and diabetes-specific cardiovascular risk factors were prevalent and strongly associated with cardiovascular disease (CVD) among adults with type 1 diabetes attending Australian diabetes centres.MethodsDe-identified, prospectively collected data from patients with type 1 diabetes aged ≥ 18 years in the 2015 Australian National Diabetes Audit were analysed. The burden of cardiovascular risk factors [age, sex, diabetes duration, glycated haemoglobin (HbA1c), blood pressure, lipid profile, body mass index, smoking status, retinopathy, renal function and albuminuria] and associations with CVD inclusive of stroke, myocardial infarction, coronary artery bypass graft surgery/angioplasty and peripheral vascular disease were assessed. Restricted cubic splines assessed for non-linearity of diabetes duration and likelihood ratio test assessed for interactions between age, diabetes duration, centre type and cardiovascular outcomes of interest. Discriminatory ability of multivariable models were assessed with area under the receiver operating characteristic (ROC) curves.ResultsData from 1169 patients were analysed. Mean (± SD) age and median diabetes duration was 40.0 (± 16.7) and 16.0 (8.0–27.0) years respectively. Cardiovascular risk factors were prevalent including hypertension (21.9%), dyslipidaemia (89.4%), overweight/obesity (56.4%), ever smoking (38.5%), albuminuria (31.1%), estimated glomerular filtration rate < 60 mL/min/1.73 m2 (10.3%) and HbA1c > 7.0% (53 mmol/mol) (81.0%). Older age, longer diabetes duration, smoking and antihypertensive therapy use were positively associated with CVD, while high density lipoprotein-cholesterol and diastolic blood pressure were negatively associated (p < 0.05). Association with CVD and diabetes duration remained constant until 20 years when a linear increase was noted. Longer diabetes duration also had the highest population attributable risk of 6.5% (95% CI 1.4, 11.6). Further, the models for CVD demonstrated good discriminatory ability (area under the ROC curve 0.88; 95% CI 0.84, 0.92).ConclusionsCardiovascular risk factors were prevalent and strongly associated with CVD among adults with type 1 diabetes attending Australian diabetes centres. Given the approximate J-shaped association between type 1 diabetes duration and CVD, the impact of cardiovascular risk stratification and management before and after 20 years duration needs to be further assessed longitudinally. Diabetes specific cardiovascular risk stratification tools incorporating diabetes duration should be an important consideration in future guideline development.

Younger people with Type 2 diabetes have poorer self‐care practices compared with older people: results from the Australian National Diabetes Audit

This cross-sectional study compares the self-care practices of younger and older people with Type 2 diabetes. Data were analysed from the Australian National Diabetes Audit (ANDA) including 2552 adults with Type 2 diabetes from Australian Diabetes Centres. Pre-specified demographic and clinical variables were obtained. Self-care variables (physical activity, following dietary recommendations, medication adherence and monitoring blood glucose levels) were compared in people ≤64 and >64years of age. Mean age (±sd) of participants was 63±13years overall, 53±9years for the younger group and 73±6years for the older group. A greater proportion of younger people had HbA1c levels >53mmol/mol (>7.0%) (76% vs. 68%), reported difficulty following dietary recommendations (50% vs. 32%) and forgetting medications (37% vs. 22%) compared with older people (all P-values <0.001). A smaller proportion of younger compared with older people reported monitoring their blood glucose levels as often as recommended (60% vs. 70%, P<0.001). Similar proportions of people aged ≤64 and >64years required insulin therapy (59% vs. 57%, P=0.200). Younger age was associated with a twofold increase in the odds of not following the recommended self-care practices after adjustment for gender, smoking, insulin therapy, depression and allied health attendance (all P<0.001). Despite shorter diabetes duration, younger age was associated with worse glycaemic control and poorer diabetes self-care practices among people with Type 2 diabetes. Targeted strategies are required to optimize diabetes self-care practices and thereby glycaemic control.

Depression and diabetes distress in adults with type 2 diabetes: results from the Australian National Diabetes Audit (ANDA) 2016

This study explores the prevalence of, and factors associated with, likely depression and diabetes distress in adults with type 2 diabetes in a large, national sample. Australian National Diabetes Audit data were analysed from adults with type 2 diabetes attending 50 diabetes centres. The Brief Case find for Depression and Diabetes Distress Score 17 were administered to screen for likely depression and diabetes-related distress, respectively. A total of 2,552 adults with type 2 diabetes participated: (mean ± SD) age was 63 ± 13 years, diabetes duration was 12 ± 10 years, and HbA1c was 8 ± 2%. Twenty-nine percent of patients had likely depression, 7% had high diabetes distress, and 5% had both. Difficulty following dietary recommendations, smoking, forgetting medications, and diabetes distress were all associated with greater odds of depression whereas higher own health rating was associated with lower odds (all p < 0.02). Female gender, increasing HbA1c, insulin use, difficulty following dietary recommendations and depression were all associated with greater odds of diabetes distress & older age, higher own health rating and monitoring blood glucose levels as recommended were associated with lower odds (all p < 0.04). Depression was associated with sub-optimal self-care, while diabetes distress was associated with higher HbA1c and sub-optimal self-care.

Age, age at diagnosis and diabetes duration are all associated with vascular complications in type 2 diabetes

BackgroundType 2 diabetes (T2DM) is increasingly diagnosed in younger patients. The trajectory of complications in patients diagnosed at a younger or older age is not well understood. We examine the associations between age, age at diagnosis and diabetes duration and vascular complications in patients with T2DM. MethodsA cross-sectional study of pre-specified demographic and clinical data, from 3419 adults with T2DM participating in the Australian National Diabetes Audit (2015). Factors associated with diabetes complications were analysed using logistic regression. ResultsMean (±SD) current age was 62.9±12.5years, age at diagnosis was 49.4±12.3years and mean diabetes duration was 13.5±9.4years. Macrovascular complications were more prevalent in patients who were older at diabetes diagnosis whereas microvascular complications were more prevalent in patients who were younger at diabetes diagnosis. Age, age at diagnosis and diabetes duration were all independently associated with increased risk of macrovascular complications after adjustment for sex, smoking, BMI and microvascular complications (all p<0.001). In contrast, only diabetes duration was independently associated with microvascular complications after adjustment for sex, smoking, BMI and macrovascular complications (p<0.001). ConclusionsAge, age at diagnosis, and diabetes duration were all independently associated with macrovascular complications whereas only diabetes duration was independently associated with microvascular complications.

A comparison of characteristics of patients seen in a tertiary hospital diabetes telehealth service versus specialist face-to-face outpatients.

This study aimed to describe patient-related characteristics of those attending the diabetes telehealth service delivered from a tertiary hospital and compare these with the characteristics of patients attending face-to-face visits at the same hospital's diabetes outpatient service. This analysis could inform diabetes telehealth service improvements. To our knowledge, there has been no prior evaluation of a diabetes telehealth service in Australia. A cross-sectional survey was conducted as part of the Australian National Diabetes Audit in May 2016 for all patients attending the diabetes telehealth service and diabetes outpatient service. The diabetes telehealth service was serving a greater proportion of females, indigenous people and patients with a longer mean duration of type 2 diabetes mellitus. Type 2 diabetes mellitus patients in the diabetes telehealth service group had a higher average glycated haemoglobin of 9.1% (76 mmol/mol) vs 8.1% (65 mmol/mol) in the diabetes outpatient service group. The diabetes telehealth service had more people with initial visits; had higher self-reported smoking rates in type 2 diabetes mellitus patients; and had adequate access to allied health supports as recommended for diabetes management. Diabetes telehealth service patients had more complex diabetes as evidenced by a higher proportion of indigenous clients, higher glycated haemoglobin and longer mean duration of diabetes.