Personalized Diabetes Care Research Articles

Socio-demographic determinants and effect of structured personal diabetes care: a 19-year follow-up of the randomized controlled study diabetes Care in General Practice (DCGP)

BackgroundWe investigated how four aspects of socio-demography influence the effectiveness of an intervention with structured personal diabetes care on long-term outcomes.MethodsThe Diabetes Care in General Practice (DCGP) study is a cluster-randomized trial involving a population-based sample of 1381 patients with newly diagnosed type 2-diabetes mellitus. We investigated how education, employment, cohabitation status and residence influenced the effectiveness of 6 years of intervention with structured personal diabetes care, resembling present day recommendations. Outcomes were incidence of any diabetes-related endpoint and death during 19 years after diagnosis, and cardiovascular risk factors, behaviour, attitudes and process-of-care variables 6 years after diagnosis.ResultsStructured personal care reduced the risk of any diabetes-related endpoint and the effect of the intervention was modified by geographical area (interaction p = 0.034) with HR of 0.71 (95%CI: 0.60–0.85) and of 1.07 (95%CI: 0.77–1.48), for patients in urban and rural areas, respectively. Otherwise, there was no effect modification of education, employment and civil status on the intervention for the final endpoints. There were no noticeable socio-demographic differences in the effect of the intervention on cardiovascular risk factors, behaviour, attitudes, and process-of-care.ConclusionStructured personal care reduced the aggregate outcome of any diabetes-related endpoint and independent of socio-demographic factors similar effect on cardiovascular risk factors, behaviour, attitudes and process of care, but the intervention did not change the existing inequity in mortality and morbidity. Residence modified the uptake of the intervention with patients living in urban areas having more to gain of the intervention than rural patients, further investigations is warranted.Trial registrationClinicalTrials.gov registration no. NCT01074762 (February 24, 2010).

Depressive symptom trajectories in the first 10 years of diabetes diagnosis: antecedent factors and link with future disability in Taiwan.

This study identified depressive symptom trajectories in the years after diabetes diagnosis, examined factors that predict the probability for people following a specific trajectory, and investigated how the trajectories are associated with subsequent disability. We drew data from a nationally representative survey in Taiwan to identify adults aged 50 and older diagnosed with diabetes; 487 patients newly diagnosed with diabetes during 1996-2007 were included. Time axis was set to zero when diabetes was first reported in any given wave in the survey, and data related to depressive symptoms after that were recorded. We used group-based semi-parametric mixture models to identify trajectories of depressive symptoms and multinomial logistic regressions to examine factors associated with the trajectories. Older adults with newly diagnosis of diabetes in Taiwan follow different trajectories of depressive symptoms over time. Being female, lower educated, not married/partnered, with lower self-rated health, hospitalizations, more limitations in physical function, less regular exercise before diagnosis, and not regularly using anti-diabetic medication at the beginning of their diagnosis were factors associated with increasing or high stable depressive symptom trajectories. Those who experienced high depressive symptoms were more likely than individuals with stable depressive symptoms to have physical limitations in the last follow-up interview. Depressive symptom trajectories after diabetes diagnosis were associated with select sociodemographic, health, and lifestyle factors before diagnosis, and also predicted subsequent disability. Risk groups identified in the present study may be used for personalized diabetes care that prevents diabetes-related distress and future disability.

Personalised diabetes care: What is it, and does it ‘work’?

Personalised diabetes care: What is it, and does it ‘work’?

Sex and Gender Differences in Risk, Pathophysiology and Complications of Type 2 Diabetes Mellitus.

The steep rise of type 2 diabetes mellitus (T2DM) and associated complications go along with mounting evidence of clinically important sex and gender differences. T2DM is more frequently diagnosed at lower age and body mass index in men; however, the most prominent risk factor, which is obesity, is more common in women. Generally, large sex-ratio differences across countries are observed. Diversities in biology, culture, lifestyle, environment, and socioeconomic status impact differences between males and females in predisposition, development, and clinical presentation. Genetic effects and epigenetic mechanisms, nutritional factors and sedentary lifestyle affect risk and complications differently in both sexes. Furthermore, sex hormones have a great impact on energy metabolism, body composition, vascular function, and inflammatory responses. Thus, endocrine imbalances relate to unfavorable cardiometabolic traits, observable in women with androgen excess or men with hypogonadism. Both biological and psychosocial factors are responsible for sex and gender differences in diabetes risk and outcome. Overall, psychosocial stress appears to have greater impact on women rather than on men. In addition, women have greater increases of cardiovascular risk, myocardial infarction, and stroke mortality than men, compared with nondiabetic subjects. However, when dialysis therapy is initiated, mortality is comparable in both males and females. Diabetes appears to attenuate the protective effect of the female sex in the development of cardiac diseases and nephropathy. Endocrine and behavioral factors are involved in gender inequalities and affect the outcome. More research regarding sex-dimorphic pathophysiological mechanisms of T2DM and its complications could contribute to more personalized diabetes care in the future and would thus promote more awareness in terms of sex- and gender-specific risk factors.

The impact of gender on the long-term morbidity and mortality of patients with type 2 diabetes receiving structured personal care: a 13 year follow-up study.

The aim of this study was to assess gender differences in mortality and morbidity during 13 follow-up years after 6 years of structured personal care in patients with type 2 diabetes mellitus. In the Diabetes Care in General Practice (DCGP) multicentre, cluster-randomised, controlled trial (ClinicalTrials.gov registration no. NCT01074762), 1,381 patients newly diagnosed with type 2 diabetes were randomised to receive 6 years of either structured personal care or routine care. The intervention included regular follow-up, individualised goal setting and continuing medical education of general practitioners participating in the intervention. Patients were re-examined at the end of intervention. This observational analysis followed 970 patients for 13 years thereafter using national registries. Outcomes were all-cause mortality, incidence of diabetes-related death, any diabetes-related endpoint, myocardial infarction, stroke, peripheral vascular disease and microvascular disease. In women, but not men, a lower HR for structured personal care vs routine care emerged for any diabetes-related endpoint (0.65, p = 0.004, adjusted; 73.4 vs 107.7 events per 1,000 patient-years), diabetes-related death (0.70, p = 0.031; 34.6 vs 45.7), all-cause mortality (0.74, p = 0.028; 55.5 vs 68.5) and stroke (0.59, p = 0.038; 15.6 vs 28.9). This effect was different between men and women for diabetes-related death (interaction p = 0.015) and all-cause mortality (interaction p = 0.005). Compared with routine care, structured personal diabetes care reduced all-cause mortality and diabetes-related death in women but not in men. This gender difference was also observed for any diabetes-related outcome and stroke but was not statistically significant after extensive multivariate adjustment. These observational results from a post hoc analysis of a randomised controlled trial cannot be explained by intermediate outcomes like HbA1c alone, but involves complex social and cultural issues of gender. There is a need to rethink treatment schemes for both men and women to gain benefit from intensified treatment efforts.

Turning big data into personalised diabetes care

Turning big data into personalised diabetes care

The excess mortality of patients with diabetes and concurrent psychiatric illness is markedly reduced by structured personal diabetes care: A 19-year follow up of the randomized controlled study Diabetes Care in General Practice (DCGP).

To assess the effectiveness of an intervention in Type 2 diabetic patients with concurrent psychiatric illness (PI) and compare this with the effectiveness in patients without PI. In the Diabetes Care in General Practice trial, 1381 patients newly diagnosed with Type 2 diabetes were randomized to 6 years of structured personal diabetes care or routine diabetes care (ClinicalTrials.gov NCT01074762). In this observational post-hoc analysis, the effectiveness of the intervention for diabetes in 179 patients with concurrent PI was analyzed. During the 19-year follow-up period, patients with PI in the structured personal care group experienced a lower risk for all-cause mortality [105.3 vs. 140.4 events per 1000 patient-years; hazard ratio (HR): 0.63, P=0.023, multivariably adjusted], diabetes-related death (66.0 vs. 95.1; HR: 0.57, P=0.015), any diabetes-related endpoint (169.5 vs. 417.5; HR: 0.47, P=0.0009) and myocardial infarction (54.1 vs. 104.4; HR: 0.48, P=0.013), compared to patients with PI in the routine care group. This translates into a number needed to treat over 10 years of three or lower for these outcomes. These findings suggest that in primary care, structured diabetes care allowing for individualization was highly effective among diabetic patients with co-occurring PI.

Genomic science: what are the implications for personalized diabetes care?

SUMMARY Developments in personalized medicine are adding to the clinician’s armamentarium and will allow for more individualized care for diabetes patients. The discovery of mutations causing many forms of monogenic diabetes now allows for the design of patient/mutation-specific targeted interventions. While many genetic loci are associated with Type 1 and 2 diabetes, and diabetes complications, these variants only modestly add to risk; therefore, genetic risk assessment for diabetes and its complications is not currently recommended in clinical practice. Genetic variants are also associated with drug metabolism, efficacy and side effects. Clinical studies are required to determine if genotype information improves day-to-day clinical management of diabetes and our overall approach to clinical practice. While the development of personalized medicine is promising for the future, a number of challenges remain that will need to be overcome before personalized medicine becomes standard of care in Type 1 and 2 ...

Structured personal care of type 2 diabetes: a 19 year follow-up of the study Diabetes Care in General Practice (DCGP)

This study is a 19 year observational follow-up of a pragmatic open multicentre cluster-randomised controlled trial of 6 years of structured personal diabetes care starting from diagnosis. A total of 1,381 patients aged ≥ 40 years and newly diagnosed with type 2 diabetes were followed up in national registries for 19 years. Clinical follow-up was at 6 and 14 years after diabetes diagnosis. The original 6 year intervention included regular follow-up and individualised goal setting, supported by prompting of doctors, clinical guidelines, feedback and continuing medical education (ClinicalTrials.gov NCT01074762). The registry-based endpoints were: incidence of any diabetes-related endpoint; diabetes-related death; all-cause mortality; myocardial infarction (MI); stroke; peripheral vascular disease; and microvascular disease. At 14 year clinical follow-up, group differences in risk factors from the 6 year follow-up had levelled out, although the prevalence of (micro)albuminuria and level of triacylglycerols were lower in the intervention group. During 19 years of registry-based monitoring, all-cause mortality was not different between the intervention and comparison groups (58.9 vs 62.3 events per 1,000 patient-years, respectively; for structured personal care, HR 0.94, 95% CI 0.83, 1.08, p = 0.40), but a lower risk emerged for fatal and non-fatal MI (27.3 vs 33.5, HR 0.81, 95% CI 0.68, 0.98, p = 0.030) and any diabetes-related endpoint (69.5 vs 82.1, HR 0.83, 95% CI 0.72, 0.97, p = 0.016). These differences persisted after extensive multivariable adjustment. In concert with features such as prompting, feedback, clinical guidelines and continuing medical education, individualisation of goal setting and drug treatment may safely be applied to treat patients newly diagnosed with type 2 diabetes to lower the risk of diabetes complications.

Men suffer more complications from diabetes than women despite similar glycaemic control and a better cardiovascular risk profile: the ADCM study 2008

BackgroundGender differences in glycaemic control and diabetes’ complications have been well studied overseas but not locally. Gender is one of the non-modifiable factors for the diabetes patient but it is an important factor for effective personalized diabetes care. This paper examined the gender differences in glycaemic control and diabetes’ complications. MethodsThis was a registry-based observational study from May–December 2008. An online standard case record form was available for site data providers to register their diabetes patients aged 18 years old and above annually. Demographic data, diabetes duration, treatment modalities, as well as various risk factors and diabetes complications were reported. Multivariate analysis was performed. ResultsA total of 20,646 diabetes patients were included. The majority (99.2%) had been diagnosed with type 2 diabetes mellitus (T2D); 42.8% of the sample were men; 57.1% were Malay. The mean age was 58.0 years (standard deviation (SD)=11.49) with 77.6% of the sample being 50 years old and above. Despite similar diabetes control (HbA1c < 6.5%), females suffered more microvascular complications (estimated glomerular filtration rate (eGFR) <60 mls/min: X2=753.54, P=<0.001) while men suffered more from macrovascular complications (ischaemic heart disease (X2=57.61, P=<0.001) and stroke (X2=13.87, P=<0.001)). Multivariate logistic regression analyses showed that T2D men were more likely to suffer from stroke (odds ratio (OR)=1.21, 95% confidence interval (CI)=0.89–1.64), ischaemic heart disease (OR=1.55, CI=1.35–1.78) and nephropathy (OR=1.59, CI=1.44–1.75). ConclusionWe observed that men suffered more diabetes-related complications despite similar glycaemic control and better risk factor control. This finding requires further verification from future studies.

Personalized medicine in Type 2 diabetes: what does the future hold?

The management of patients with Type 2 diabetes is based on a remarkably robust evidence base. Large clinical trials and lengthy observational cohort studies have clearly established the importance of glycemic, blood pressure and lipid level control. Indeed, most elements of guideline-based diabetes care can be supported by clinical research evidence. While such studies are critical for establishing treatment recommendations, the evidence derived from clinical trial participants applies to populations of patients rather than to the individual sitting before the clinician. An important next step in diabetes care would be to develop and implement a framework for personalizing care. In this article, we highlight the major reasons for personalization and discuss what the future of personalized diabetes care may hold.

Blood pressure, lipids and glucose in type 2 diabetes: how low should we go? Re-discovering personalized care

Epidemiological studies have clearly shown a direct relationship between the levels of blood pressure, glycaemia and LDL-cholesterol, and the complications of diabetes. Although 'lower should be better', the results of recent clinical trials examining the benefits of normalizing risk factor levels have been counter-intuitive and, at times, disturbing, and have called into question this notion. This review focuses on patients with type 2 diabetes who make up 90% of patients with diabetes. It aims to provide a clear summary and interpretation of recent trials to help clinicians to set targets for cardiovascular risk factors in individual patients. It highlights areas of agreement and disagreement between current guidelines. Recent data indicate that some patient subgroups might respond differently to aggressive risk factor management. Our challenge is how to identify these patients and deliver truly personalized diabetes care that maximizes benefit, and minimizes harm. Guidelines and position statements stress the value of setting personalized targets. We explore what this means, and how this might be achieved in practice by outlining some solutions to issues that currently limit the delivery of personalized care. We call for further research assessing the overall clinical impact of cardiovascular risk factor intervention by finding appropriate ways of combining data on mortality, complications, side-effects, quality of life, and cost-effectiveness.

Structured Personal Diabetes Care in Primary Health Care Affects Only Women's HbA1c

Diabetic men and women differ in lifestyle and attitudes toward diabetes and may benefit differently from interventions to improve glycemic control. We explored the relation between HbA1c (A1C), sex, treatment allocation, and their interactions with behavioral and attitudinal characteristics in patients with type 2 diabetes. Six years after their diabetes diagnosis, a population-based sample of 874 primary care patients cluster-randomized to receive structured personal care or routine care reported lifestyle, medication, social support, diabetes-related consultations, and attitudes toward diabetes. Multivariate analyses were applied, split by sex. A marked intervention effect on A1C was confined to the structured personal care women. The median A1C was 8.4% in structured personal care women and 9.2% in routine care women (P < 0.0001) and 8.5% in structured personal care men and 8.9% in routine care men (P = 0.052). Routine care women had a 1.10 times higher A1C than structured personal care women, (P < 0.0001, adjusted analysis). Structured personal care women had relatively more consultations than routine care women, but neither number of consultations nor other covariates helped to explain the sex difference in A1C. Irrespective of treatment allocation, women had more adaptive attitudes toward diabetes but lacked support compared with men. In this study, the observed effect of structured personal care on A1C was present only among women, possibly because they were more inclined to comply with regular follow-up and had a tendency to have a more adaptive attitude toward diabetes.

Structured Personal Diabetes Care in Primary Health Care Affects Only Women’s HbA1c

OBJECTIVE—Diabetic men and women differ in lifestyle and attitudes toward diabetes and may benefit differently from interventions to improve glycemic control. We explored the relation between HbA1c (A1C), sex, treatment allocation, and their interactions with behavioral and attitudinal characteristics in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS—Six years after their diabetes diagnosis, a population-based sample of 874 primary care patients cluster-randomized to receive structured personal care or routine care reported lifestyle, medication, social support, diabetes-related consultations, and attitudes toward diabetes. Multivariate analyses were applied, split by sex. RESULTS—A marked intervention effect on A1C was confined to the structured personal care women. The median A1C was 8.4% in structured personal care women and 9.2% in routine care women (P &amp;lt; 0.0001) and 8.5% in structured personal care men and 8.9% in routine care men (P = 0.052). Routine care women had a 1.10 times higher A1C than structured personal care women, (P &amp;lt; 0.0001, adjusted analysis). Structured personal care women had relatively more consultations than routine care women, but neither number of consultations nor other covariates helped to explain the sex difference in A1C. Irrespective of treatment allocation, women had more adaptive attitudes toward diabetes but lacked support compared with men. CONCLUSIONS—In this study, the observed effect of structured personal care on A1C was present only among women, possibly because they were more inclined to comply with regular follow-up and had a tendency to have a more adaptive attitude toward diabetes.

Encouraging structured personalised diabetes care in general practice

Scand J Prim Health Care 2003;21:000-000. ISSN 0281-3432 Objective r - r To evaluate the quality of diabetes care achieved on the process and outcomes of care in the context of a multifaceted intervention directed at general practitioners (GPs) encouraging regular follow-up and individualised goal-setting. Design r - r A 6-year follow-up study. Setting r - r A total of 243 Danish GPs and a population-based sample of 729 newly diagnosed, predominantly type 2 diabetic patients participated. Main outcome measures r - r Questionnaires and laboratory assessments were used to determine the proportion of patients reviewed regularly, and their pharmacological treatment and risk factors. Results r - r During the study, the proportion of patients who had an annual clinical examination decreased from 100% to 77%. The proportion given oral anti-diabetic agents or insulin increased from 43% to 71%. Median glycated haemoglobin (HbA 1c ) dropped in the 2nd year to 7.7% (normal range 5.4-7.4%), after which it increased gradually, but remained on average at 1.3% above the upper limit of the normal range. Median blood pressure (systolic/diastolic), total cholesterols and fasting triglycerides were maintained at 145-150/81-85 mmHg, 6.0-6.2 mmol/l and 1.66-1.96 mmol/l, respectively. Initial weight loss was partly regained over 6 years. Conclusion r - r Among centrally supported GPs, most patients were regularly reviewed and obtained acceptable levels of risk factors for at least 6 years, although glycaemic control progressively deteriorated after an initial drop to near-normal average level.