Diabetic Patients In Primary Care Research Articles

Trends in Outpatient Prescription Drug Costs in Diabetic Patients in Germany, 1994–2004

New antidiabetic medications have been introduced during the last decade, but their impact on health care cost is largely unknown. Prescription costs in diabetic patients in primary care in Germany were evaluated (1994-2004). A total of 46,017 diabetic patients and 46,017 age- and sex-matched control subjects in 400 nationwide practices (2004) were compared with 29,956 diabetic patients and 13,226 control subjects (361 practices) in 1994 (data from IMS HEALTH). Inflation-adjusted age- and sex-standardized costs (ex-manufacturer prices) were calculated. Mean annual total prescription costs per diabetic patient were 559 euros in 2004 (372 euros in 1994), equaling a 60% (standardized) increase (P < 0.01). Average costs for antidiabetic medication were 172 euros in 2004, a 100% increase (P < 0.01). The major antidiabetic cost factor was insulin and analogs, which accounted for 22% of total drug costs in diabetic patients in 2004 (17% in 1994). All oral antidiabetic drugs together accounted for 8% of total costs (6% in 1994). New drugs (glitazones, glinides, and insulins) accounted for 15% of total costs (40% of antidiabetic drugs) in 2004. A 40% increase (387 euros vs. 286) in all non-diabetes-related drugs was due mainly to cardiovascular and lipid-lowering drugs. In nondiabetic patients, only a 30% cost increase was found (210 euros vs. 147; P < 0.01). Prescription drug costs among diabetic patients increased 60% during the last decade, which was twofold higher than the increase in nondiabetic patients. New types of antidiabetic drugs accounted for a substantial cost share of the overproportional increase for diabetes treatment. Progress in pharmacological therapy is a key driver of drug expenditure growth in diabetes treatment.

Ethnic differences in glycaemic control in adult Type 2 diabetic patients in primary care: a 3‐year follow‐up study

To evaluate ethnic differences and characteristics related to glycaemic control in patients with Type 2 diabetes in primary care. Prospective cohort study; 500 adult patients with Type 2 diabetes, who were not on insulin therapy, were followed up annually for 3 years. HbA(1c) at baseline and 3-year changes and subsequent insulin therapy were related to baseline characteristics. Malay patients had significantly higher HbA(1c) (mean 8.7% +/- sd 1.66) compared with Chinese (8.2 +/- sd 1.67) and Indian (8.2 +/- sd 1.55) (P = 0.032) at baseline, and consistently for all years of HbA(1c) assessment (P = 0.017). At baseline, Malay patients were significantly more obese than Chinese or Indians (P < 0.001); fewer of them received structured shared-care intervention (P = 0.001), but they had a significantly higher glucose control educational score (P < 0.05). Multivariable analyses showed that HbA(1c) at baseline was significantly related to age (P = 0.001), BMI (P = 0.031) and ethnicity (P = 0.002). HbA(1c) declined significantly over 3 years in the whole population and in all ethnic groups. Significantly greater HbA(1c) declines were associated with higher baseline HbA(1c), structured shared-care intervention and non-insulin therapy. Correcting for differences on these factors, the decline in HbA(1c) in Malays was significantly less than in the Chinese. Insulin therapy was associated with higher baseline HbA(1c) and higher BMI. Malay ethnicity was associated with persistently poor glycaemic control. Sociocultural and behavioural factors should be addressed in improving care for patients with poorly controlled diabetes.

Influenza and pneumococcal vaccination rates among Greek diabetic patients in primary care

Diabetic MedicineVolume 22, Issue 1 p. 110-111 Influenza and pneumococcal vaccination rates among Greek diabetic patients in primary care A. Sotiropoulos, A. Sotiropoulos Diabetes Centre, 3rd Department of Internal Medicine and Department of General Practice Residency, Saint Panteleimon General Hospital, Nicea-Piraeus, Search for more papers by this authorP. Merkouris, P. Merkouris Diabetes Centre, 3rd Department of Internal Medicine and Department of General Practice Residency, Saint Panteleimon General Hospital, Nicea-Piraeus, Search for more papers by this authorA. Gikas, A. Gikas Health Centre of Salamis, Search for more papers by this authorS. Skourtis, S. Skourtis Diabetes Centre, 3rd Department of Internal Medicine and Department of General Practice Residency, Saint Panteleimon General Hospital, Nicea-Piraeus, Search for more papers by this authorE. Skliros, E. Skliros Health Centre of Nemea, Search for more papers by this authorL. Lanaras, L. Lanaras Department of Internal Medicine, Regional Hospital of Lamia, Search for more papers by this authorT. Nikolaou, T. Nikolaou Hippokrateion General Hospital of Athens, Greece E-mail: [email protected]; [email protected]Search for more papers by this authorS. Pappas, S. Pappas Diabetes Centre, 3rd Department of Internal Medicine and Department of General Practice Residency, Saint Panteleimon General Hospital, Nicea-Piraeus, Search for more papers by this author A. Sotiropoulos, A. Sotiropoulos Diabetes Centre, 3rd Department of Internal Medicine and Department of General Practice Residency, Saint Panteleimon General Hospital, Nicea-Piraeus, Search for more papers by this authorP. Merkouris, P. Merkouris Diabetes Centre, 3rd Department of Internal Medicine and Department of General Practice Residency, Saint Panteleimon General Hospital, Nicea-Piraeus, Search for more papers by this authorA. Gikas, A. Gikas Health Centre of Salamis, Search for more papers by this authorS. Skourtis, S. Skourtis Diabetes Centre, 3rd Department of Internal Medicine and Department of General Practice Residency, Saint Panteleimon General Hospital, Nicea-Piraeus, Search for more papers by this authorE. Skliros, E. Skliros Health Centre of Nemea, Search for more papers by this authorL. Lanaras, L. Lanaras Department of Internal Medicine, Regional Hospital of Lamia, Search for more papers by this authorT. Nikolaou, T. Nikolaou Hippokrateion General Hospital of Athens, Greece E-mail: [email protected]; [email protected]Search for more papers by this authorS. Pappas, S. Pappas Diabetes Centre, 3rd Department of Internal Medicine and Department of General Practice Residency, Saint Panteleimon General Hospital, Nicea-Piraeus, Search for more papers by this author First published: 14 December 2004 https://doi.org/10.1111/j.1464-5491.2005.01365.xCitations: 7Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article.Citing Literature Volume22, Issue1January 2005Pages 110-111 RelatedInformation

High Prevalence of Peripheral Arterial Disease and Low Treatment Rates in Elderly Primary Care Patients with Diabetes

Representative data on peripheral arterial disease (PAD) in community-based office practice are scarce while at the same time of high interest. Thus, we aimed to determine the prevalence of peripheral arterial disease (PAD), comorbidity of atherothrombotic manifestations, and treatment intensity among elderly diabetic patients in primary care. In this monitored cross-sectional study, 344 general practitioners throughout Germany determined the ankle-brachial index (ABI) of 6880 consecutive, unselected patients aged 65 years or older with bilateral Doppler ultrasound measurements. PAD was defined according to the recent American Heart Association guidelines (using the higher of the 2 systolic ankle pressures: ABI < 0.9) or peripheral revascularisation, or amputation because of PAD. Coronary events (CAD) and cerebrovascular events (CVD) were taken from the patient's history without additional diagnostic measures. Diabetes was defined according to the clinical diagnosis of the physician and/or HbA1c > or = 6.5 % and/or intake of oral antidiabetic medication and/or application of insulin. 1.743 patients were classified as diabetics: the median disease duration was 6 years (1st; 3rd quartile: 2; 11), median HbA1c 6.6 % (5.9; 7.3), mean age 72.5 +/- 5.4 years, and 51.4 % were females. Diabetics had in comparison with non-diabetics a higher prevalence of PAD defined as ABI < 0.9 (26.3 % vs. 15.3 %, univariate odds ratio 2.0 [95 % confidence interval: 1.7; 2.3]), intermittent claudication (5.1 % vs. 2.1 %, OR: 2.5 [1.9; 3.4]), known CAD (16.1 % vs. 10.6 %, OR: 1.6 [1.4; 1.9]), and known CVD (6.8 % vs. 4.8 %; OR: 1.4 [1.2; 1.8]). 57.4 % of the diabetics with previously known PAD (as only atherothrombotic manifestation) received antiplatelet therapy (vs. 75.1 % with CAD and/or CVD only). The ABI was suitable as screening measure in the primary care setting. In elderly diabetics in comparison to non-diabetics, the prevalence of PAD was very high. Despite the known benefits of antiplatelet therapy, PAD patients were less intensively treated than patients with CAD or CVD.

Racial and Ethnic Differences in Microalbuminuria Prevalence in a Diabetes Population

The objective of this study was to determine whether racial or ethnic differences in prevalence of diabetic microalbuminuria were observed in a large primary care population in which comparable access to health care exists. A cross-sectional analysis of survey and automated laboratory data 2969 primary care diabetic patients of a large regional health maintenance organization was conducted. Study data were analyzed for racial/ethnic differences in microalbuminuria (30 to 300 mg albumin/g creatinine) and macroalbuminuria (>300 mg albumin/g creatinine) prevalence among diabetes registry-identified patients who completed a survey that assessed demographics, diabetes care, and depression. Computerized pharmacy, hospital, and laboratory data were linked to survey data for analysis. Racial/ethnic differences in the odds of microalbuminuria and macroalbuminuria were assessed by unconditional logistic regression, stratified by the presence of hypertension. Among those tested, the unadjusted prevalence of micro- or macroalbuminuria was 30.9%, which was similar among the various racial/ethnic groups. Among those without hypertension, microalbuminuria was twofold greater (odds ratio [OR] 2.01; 95% confidence interval [CI] 1.14 to 3.53) and macroalbuminuria was threefold greater (OR 3.17; 95% CI 1.09 to 9.26) for Asians as compared with whites. Among those with hypertension, adjusted odds of microalbuminuria were greater for Hispanics (OR 3.82; 95% CI 1.16 to 12.57) than whites, whereas adjusted odds of macroalbuminuria were threefold greater for blacks (OR 3.32; 95% CI 1.26 to 8.76) than for whites. For most racial/ethnic minorities, hypertriglyceridemia was significantly associated with greater odds of micro- and macroalbuminuria. Among a large primary care population, racial/ethnic differences exist in the adjusted prevalence of microalbuminuria and macroalbuminuria depending on hypertension status. In this setting, racial/ethnic differences in early diabetic nephropathy were observed despite comparable access to diabetes care.

Effectiveness of a disease management programme for patients with type 2 diabetes mellitus and albuminuria in primary care - the PROSIT project (Proteinuria Screening and Intervention).

Aims. To evaluate the structured PROSIT(R) disease management programme for high-risk diabetic patients in primary care with respect to the cardio-vascular risk profile and mortality. Subjects and Methods. Retrospectively 55 albuminuric Type 2 diabetic patients included into the PROSIT(R) programme from 1994 to 1999 (intervention group: age 66.6 +/- 10.5 years, known duration of diabetes 8.9 +/- 6.5 years) were compared with 58 albuminuric patients not participating in the PROSIT(R) programme (control group: age 68.5 +/- 10.4 years, known duration of diabetes 8.5 +/- 6.7 years). Within PROSIT(R) a structured multifactorial intervention programme was applied. The main characteristics of this intervention were strict follow-ups of the patient's risk profile every three months and the use of quality management methods (definition of target values, structured documentation, central data feedback with diagnostic and therapeutic recommendations based on European guidelines). The cardio-vascular risk profile, therapeutic intervention, and secondary diabetic complications were compared between both groups in 1994 and 1999. Results. In the period from 1994 to 1999 the intervention group showed a significant improvement in the vascular risk profile, while the control group did not. In 1999 the mean arterial blood pressure was significantly lower compared to the control group (115 +/- 13 mm Hg vs. 125 +/- 16 mm Hg, p < 0.05). The HbA1c improved only in the intervention group and in 1999 it was significantly lower than in the control group (7.0 +/- 1.3 % vs. 8.4 +/- 1.8 %, p < 0.01). Moreover, the occurrence of clinical endpoints in the intervention group could be reduced: Both the mortalitly rate (14.5 % vs. 34.5 %, p < 0.05) and the rate of new myocardial infarctions (6 % vs. 20 %, p < 0.05) of the intervention group were significantly lower. Conclusions. Participation of albuminuric Type 2 diabetic patients and their physicians in a structured intervention programme showed positive effects on the cardio-vascular risk profile and endpoints compared with a group of non-participating patients and physicians.

Physician, organizational, and patient factors associated with suboptimal blood pressure management in type 2 diabetic patients in primary care.

To assess the quality of hypertension care in patients with type 2 diabetes in general practice and identify physician, organizational, and patient factors associated with suboptimal care. Data from 895 randomly selected diabetic patients were extracted from the electronic medical records of 95 general practitioners. Physician and organizational characteristics were collected with a questionnaire. We conducted a multilevel analysis to identify associations with blood pressure registration, hypertension treatment, and achievement of target blood pressure levels. For 652 patients (73%), a blood pressure measurement was recorded in the last year. Of these patients, 132 (20%) reached a target level of 135/85 mmHg. In total, 595 patients were classified as having hypertension, of whom 192 received no treatment (32%), 193 received an ACE inhibitor (32%), and 210 received other antihypertensives. Patients visiting a diabetes facility, referred to a specialist, with a female general practitioner, or with a general practitioner with </=10 years work experience had better recordings of their blood pressure. Suboptimal treatment was higher in older patients and smoking patients. Treatment was better in patients with coronary comorbidity, hyperlipidemia, or those referred to a specialist. Not achieving the blood pressure target was related to older age of the patients. Hypertension management of type 2 diabetic patients in primary care is suboptimal. Characteristics of general practitioners as well as additional care provided by a diabetes facility or a specialist are associated with better processes of care, but blood pressure outcomes are not as clearly related to these factors.

Book Review: Type 2 Diabetes in Practice

In the UK, the prevalence of all types of diabetes is 3-7%. It is even higher in certain ethnic groups, whilst the indirect costs of diabetes are currently estimated at 9% of total healthcare budgets. The aims of treatment for type 2 diabetes, which accounts for more than 90% of all patients with diabetes, are focused on optimizing quality of life, tight control of blood glucose and attention to a syndrome of associated risk factors. This requires input from a broad spectrum of disciplines and much of the work in improving diabetes care involves primary-care-led services—a strategy requiring much education and substantial resources. Many of these issues will be addressed by the Department of Health's soon-to-be-published National Service Framework (NSF) in Diabetes, so Krentz and Bailey's book is very timely. Type 2 Diabetes in Practice is the first in a series to be published by the RSM Press with the aim of presenting opinion-leader advice relevant to everyday clinical practice. It serves as a concise but comprehensive review of all aspects of the management of type 2 diabetes and is likely to be of greatest interest to those looking after diabetic patients in primary care. I approached this book as a consultant diabetologist who has been asked to coordinate diabetes care in the community. Although not detailed enough for a specialist's textbook, Type 2 Diabetes in Practice provides sufficient basic information to allow an understanding of all aspects of the management of type 2 diabetes, with evidence-based guidelines where available. It is clear that, although the most complex patients are managed within secondary care, the NSF will recognize that the greatest opportunities for improvement in quality and efficiency lie in refocusing the hospital services to the areas of greatest need. As a result, increasing numbers of patients with type 2 diabetes will be managed in primary care. The chapters deal with aetiology, pathophysiology and natural history while providing numerous evidence-based guidelines for management of all aspects of type 2 diabetes. Main points are highlighted, and brief but comprehensive references are provided. The tables and diagrams, particularly those dealing with molecular mechanisms, are clear. I was impressed by the references to recent trials suggesting benefits from ACE inhibitors such as HOPE and MICROHOPE and the inclusion of American Diabetes Association guidelines on glycaemic control. The NICE guidelines for the glitazones were obviously published after the book was written but a discussion of their potential role is included. In areas where evidence was less clear-cut I found myself agreeing with the practical advice being offered. Inevitably there are a few areas where omissions have occurred—for example the use of the anticonvulsant gabapentin in painful peripheral neuropathy. In conclusion, I will find this book very useful in the preparation of teaching programmes for primary care colleagues within my district.

Depression and diabetes: impact of depressive symptoms on adherence, function, and costs.

Depression is common among patients with chronic medical illness. We explored the impact of depressive symptoms in primary care patients with diabetes on diabetes self-care, adherence to medication regimens, functioning, and health care costs. We administered a questionnaire to 367 patients with types 1 and 2 diabetes from 2 health maintenance organization primary care clinics to obtain data on demographics, depressive symptoms, diabetes knowledge, functioning, and diabetes self-care. On the basis of automated data, we measured medical comorbidity, health care costs, glycosylated hemoglobin (HbA(1c)) levels, and oral hypoglycemic prescription refills. Using depressive symptom severity tertiles (low, medium, or high), we performed regression analyses to determine the impact of depressive symptoms on adherence to diabetes self-care and oral hypoglycemic regimens, HbA(1c) levels, functional impairment, and health care costs. Compared with patients in the low-severity depression symptom tertile, those in the medium- and high-severity tertiles were significantly less adherent to dietary recommendations. Patients in the high-severity tertile were significantly distinct from those in the low-severity tertile by having a higher percentage of days in nonadherence to oral hypoglycemic regimens (15% vs 7%); poorer physical and mental functioning; greater probability of having any emergency department, primary care, specialty care, medical inpatient, and mental health costs; and among users of health care within categories, higher primary (51% higher), ambulatory (75% higher), and total health care costs (86% higher). Depressive symptom severity is associated with poorer diet and medication regimen adherence, functional impairment, and higher health care costs in primary care diabetic patients. Further studies testing the effectiveness and cost-effectiveness of enhanced models of care of diabetic patients with depression are needed. Arch Intern Med. 2000;160:3278-3285.

The effectiveness of a primary-care-based diabetes education service.

The efficacy of structured education for 158 Type 2 diabetic patients in primary care (80 male, mean age 63 yr, median diabetes duration 3 yr) was assessed with respect to change in knowledge of diabetes, weight, and haemoglobin A1 over a 6-month period. The programme supplemented a primary care initiative in our semi-rural population. Teaching was carried out by a Diabetes Nurse Educator within primary care health centres (141 patients) and a hospital diabetes clinic (17 patients). For all patients mean baseline questionnaire score (maximum possible 12) was 6.2 rising after the programme to 10.5 (p < 0.01). At 6 months mean score fell to 9.5 (p < 0.01 compared to end of the programme), but still significantly better than baseline (p < 0.01). For patients on the primary-care-based programme mean haemoglobin A1 at baseline was 10.7% (normal range 6%-9%) decreasing after 6 months to 9.6% (p < 0.01). No significant changes were found in mean weight. Unlike many previous studies, these results demonstrate a highly beneficial effect not only on knowledge but also on metabolic control in patients who received their education in the primary-care setting. These results have obvious implications for patients residing in rural or semi-rural populations.