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

Abstract

Aims/hypothesis 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. Methods 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. Results 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 diabetesrelated death (interaction p=0.015) and all-cause mortality (interaction p=0.005). Conclusions/interpretation 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 HbA 1c 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.

Structured therapeutic education in diabetes: is it time to re-write the chapter on the prevention of diabetic complications?

“…However, the present study has confirmed previous data on the effectiveness of PEP in decreasing complications and mortality in people with diabetes [7,8]. In the recent long-term study with a follow-up of about 13 years, a structured personal care delivered by general practitioners to 1381 newly diagnosed type 2 diabetic patients was able to reduce mortality and morbidity in women but not in men [9]. These findings should open an active debate and stimulate new research on the decisive role that TPE can play in the prevention of diabetic complications and in the reduction of mortality.…”

“…As reported, recent data suggest that TPE may even have a positive impact on the prevention of the complications of diabetes [6][7][8][9]. Nonetheless, in clinical practice, a structured TPE is not delivered to all people with diabetes.…”

“…Indeed, a synergic effect between medications and TPE on the reduction of complications and death can be hypothesized for at least two reasons: (1) both can improve outcomes in an independent manner and therefore the positive effect may be additive; (2) TPE can optimize effects of medications because of an improvement in adherence [16]. However, if we assume that TPE can prevent the complications, other investigations should explain whether the effectiveness of TPE reported in the published studies [1,[6][7][8][9] can be further increased. At the moment, the ideal characteristics of TPE to give the best results in the management of diabetes and in the prevention of its complications are not defined [1,10].…”

“…Therefore, other works are needed to definitively clarify these ideal characteristics: type of PTE (individual or group education, or both), themes, frequency and number of education sessions, contact time between educator and patient, background of educators, use of new technologies [1]. Another intriguing consideration regards the fact that TPE was able to significantly reduce the risks due to diabetes, even if in the abovementioned studies the program included some of the potential themes of education [6][7][8][9]. So, it is likely that a global, comprehensive education could give better results.…”

Self-care Practices of Type 2 Diabetes Patients by Socio-demographic and Clinical Factors: An Ordered Probit Model

“…In addition, management of diabetes and its risk factors remains suboptimal in Pakistan [9,10]. In 2016, complications related to diabetes were responsible for 7,210 male and 9,180 female deaths among persons aged 30-69 years and 9,560 male and 12,800 female deaths among persons aged 70 years and older [11].…”