Insulin therapy decline is common, potentially leading to progression of hyperglycaemia and a delay in achievement of glycaemic control. Further investigation is needed to determine the reasons, risk factors and long-term outcomes of this important clinical phenomenon.
SummaryInformation Extraction methods can help discover critical knowledge buried in the vast repositories of unstructured clinical data. However, these methods are underutilized in clinical research, potentially due to the absence of free software geared towards clinicians with little technical expertise. The skills required for developing/using such software constitute a major barrier for medical researchers wishing to employ these methods. To address this, we have developed Canary, a free and open-source solution designed for users without natural language processing (NLP) or software engineering experience. It was designed to be fast and work out of the box via a user-friendly graphical interface. Citation: Malmasi S, Sandor NL, Hosomura N, Goldberg M, Skentzos S, Turchin A. Canary: an NLP platform for clinicians and researchers. Appl Clin Inform 2017; 8: 447–453 https://doi.org/10.4338/ACI-2017-01-IE-0018
Aim To determine the relationship between decline of insulin therapy by individuals with type 2 diabetes and subsequent blood glucose control. MethodsWe retrospectively studied adults with type 2 diabetes and suboptimal (HbA 1c ≥ 53 mmol/mol [7.0%]) glycaemic control followed at two academic hospitals between 2000 and 2014 who were recommended insulin therapy. Decline of insulin therapy recommendations was identified using natural language processing of provider notes. Time to HbA 1c < 53 mmol/mol (7.0%) served as the primary outcome.Results Of 5307 study participants, 2267 (42.7%) declined insulin therapy. Median time to HbA 1c control in individuals who declined vs. started insulin therapy was 50 vs. 38 months, respectively (P < 0.001). In multivariable analysis, decline of insulin therapy was associated with hazard ratio for HbA 1c control of 0.89 (95% CI 0.82 to 0.97; P = 0.008). Participants were more likely to accept insulin therapy recommendations if they had diabetes complications (OR 1.32; 95% CI 1.13 to 1.53; P < 0.001) or a higher HbA 1c (OR 1.10; 95% CI 1.07 to 1.13; P < 0.001), and less likely if they were older (OR 0.81; 95% CI 0.76 to 0.86; P < 0.001) or were taking more non-insulin diabetes medications (OR 0.78; 95% CI 0.74 to 0.83; P < 0.001).Conclusions Individuals with uncontrolled type 2 diabetes who declined insulin therapy subsequently had worse glycaemic control. These findings highlight the need to improve our understanding of the relationship of this common but poorly explored clinical phenomenon to blood glucose control and ultimately diabetes complications.
ImportanceMany patients at high cardiovascular risk—women more commonly than men—are not receiving statins. Anecdotally, it is common for patients to not accept statin therapy recommendations by their clinicians. However, population-based data on nonacceptance of statin therapy by patients are lacking.ObjectivesTo evaluate sex disparities in nonacceptance of statin therapy and assess their association with low-density lipoprotein (LDL) cholesterol control.Design, Setting, and ParticipantsA retrospective cohort study was conducted from January 1, 2019, to December 31, 2022, of statin-naive patients with atherosclerotic cardiovascular disease, diabetes, or LDL cholesterol levels of 190 mg/dL (to convert to millimoles per liter, multiply by 0.0259) or more who were treated at Mass General Brigham between January 1, 2000, and December 31, 2018.ExposureRecommendation of statin therapy by the patient’s clinician, ascertained from the combination of electronic health record prescription data and natural language processing of electronic clinician notes.Main Outcomes and MeasuresTime to achieve an LDL cholesterol level of less than 100 mg/dL.ResultsOf 24 212 study patients (mean [SD] age, 58.8 [13.0] years; 12 294 women [50.8%]), 5308 (21.9%) did not accept the initial recommendation of statin therapy. Nonacceptance of statin therapy was more common among women than men (24.1% [2957 of 12 294] vs 19.7% [2351 of 11 918]; P &lt; .001) and was similarly higher in every subgroup in the analysis stratified by comorbidities. In multivariable analysis, female sex was associated with lower odds of statin therapy acceptance (0.82 [95% CI, 0.78-0.88]). Patients who did vs did not accept a statin therapy recommendation achieved an LDL cholesterol level of less than 100 mg/dL over a median of 1.5 years (IQR, 0.4-5.5 years) vs 4.4 years (IQR, 1.3-11.1 years) (P &lt; .001). In a multivariable analysis adjusted for demographic characteristics and comorbidities, nonacceptance of statin therapy was associated with a longer time to achieve an LDL cholesterol level of less than 100 mg/dL (hazard ratio, 0.57 [95% CI, 0.55-0.60]).Conclusions and RelevanceThis cohort study suggests that nonacceptance of a statin therapy recommendation was common among patients at high cardiovascular risk and was particularly common among women. It was associated with significantly higher LDL cholesterol levels, potentially increasing the risk for cardiovascular events. Further research is needed to understand the reasons for nonacceptance of statin therapy by patients and to develop methods to ensure that all patients receive optimal therapy in accordance with their preferences and priorities.
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