Control of glycemia and blood pressure in British adults with diabetes mellitus and subsequent therapy choices: a comparison across health states

Abstract

BackgroundTo examine the intensity of glycemic and blood pressure control in British adults with diabetes mellitus and whether control levels or treatment deintensification rates differ across health states.MethodsRetrospective cohort study using primary care electronic medical records (the United Kingdom Health Improvement Network Database) for adults with diabetes diagnosed at least 6 months before the index HbA1C and systolic blood pressure (SBP) measurements (to give their primary care physicians time to achieve treatment goals). We used prescribing records for 6 months pre/post the index measurements to determine who had therapy subsequently deintensified (based on “glycemic therapy score” and “antihypertensive therapy score” derived from number and dosage of medications).ResultsOf 292,170 individuals with diabetes, HbA1C < 6% or SBP < 120 mmHg after at least 6 months of management was less common in otherwise fit patients (15.0 and 12.7%) than in those who were mildly frail (16.6 and 13.2%) or moderately–severely frail (20.2 and 17.0%, both p < 0.0001). In the next 6 months, only 44.7% of those with HbA1C < 6% had glycemic therapy reduced (44.4% of fit, 47.1% of mildly frail, and 41.5% of moderate-severely frail patients) and 39.8% of those with SBP < 120 had their antihypertensives decreased (39.3% of fit, 43.0% of mildly frail, and 46.7% of moderate-severely frail patients). On the other hand, more individuals exhibited higher than recommended levels for HbA1C or SBP after the first 6 months of therapy (37.3, 33.4, and 31.3% of fit, mildly frail, and moderately–severely frail patients had HbA1C > 7.5% and 46.6, 51.4, and 48.5% had SBP > 140 mmHg). The proportions of patients with HbA1C or SBP out of recommended treatment ranges changed little 6 months later despite frequent (median 14 per year) primary care visits.ConclusionsGlycemic and hypertensive control exhibited statistically significant but small magnitude differences across frailty states. Medication deintensification was uncommon, even in frail patients below SBP and HbA1C targets. SBP levels were more likely to be outside recommended treatment ranges than glycemic levels.Trial registration As this study is a retrospective secondary analysis of electronic medical record data and not a health care intervention trial it was not registeredElectronic supplementary materialThe online version of this article (10.1186/s12933-018-0673-4) contains supplementary material, which is available to authorized users.

Managing New-Onset Type 1 Diabetes During the COVID-19 Pandemic: Challenges and Opportunities

“…13 Direct input of data from CGM, connected insulin pens, [30][31][32] and insulin pumps to electronic medical records can and should improve timely utilization of data and clinical outcomes. 33 Is e-health an option only because quality of care is not currently good enough, [11][12][13][14][15][16][17][18][19][20][21] or does digital health/e-health offer options that traditional health does not? Does it change the paradigm by moving some of the responsibility away from the health-care professional to the patient by empowering the patient with information and decision support?…”

“…Hopefully, telehealth and digital diabetes care will better enable health-care providers to reach the millions of people with either type 1 or type 2 diabetes who currently do not achieve the desired level of glycemic control, thereby improving quality of care and reducing societal health-care costs. 10,[14][15][16][17][18][19][20][21] The COVID-19 pandemic has removed many longstanding regulatory burdens to telehealth and created an unprecedented surge in demand for this form of care from both patients and providers. Here, we present two cases (of the 13 seen at BDC in the last 2 weeks) of new-onset T1D management via telehealth, and then we discuss the potential of these COVID-19-associated changes to allow for broader improvements in diabetes care in the long term.…”

Paradox of glycemic management: multimorbidity, glycemic control, and high-risk medication use among adults with diabetes

“…Ideally, patients with multiple and/or advanced comorbidities would be treated less intensively, with glycemic targets that prioritize avoidance of symptomatic hypoglycemia and hyperglycemia, while patients with a lesser comorbidity burden and longer life expectancy would be treated more intensively 1–5. However, earlier studies exposed high rates of potential overtreatment among older adults and those who have serious comorbidities 6–13. At the same time, glycemic control among younger adults with diabetes is often worse than among older adults 14 15.…”

Cardiovascular risk factor control in British adults with diabetes mellitus: Retrospective cohort study

“…Because of this, we chose not to perform multivariate analyses to explore whether specific comorbidities or patient factors were associated with CV risk factor control to avoid potentially misleading conclusions. Third, although we focused on only one set of measurements approximately one year after diagnosis of diabetes and did not examine any changes over time, we previously reported in this cohort that the HbA1C or SBP values changed little when re‐measured later . Finally, we had to exclude 114 479 patients with type 2 diabetes in the THIN database as they did not have data on their SBP or HbA1C in the first year after diagnosis of their diabetes.…”

“…As described in detail elsewhere, we used de‐identified data from primary care electronic medical records (the United Kingdom Health Improvement Network [THIN] Database) to examine risk factor control in patients with diabetes mellitus aged 20 years or older at the time of diagnosis. We used read clinical encounter codes (entered by the clinician caring for the patient) and free word searching in the ontology navigator for any glucose‐lowering drug prescriptions to identify patients with a new diagnosis of diabetes.…”