Gender disparities in diabetes and coronary heart disease medication among patients with type 2 diabetes: results from the DIANA study.

BACKGROUND: Coronary heart disease (CHD) is one of the most common long-term complications in people with type 2 diabetes. We analyzed whether or not gender differences exist in diabetes and CHD medication among people with type 2 diabetes. METHODS: The study was based on data from the baseline examination of the DIANA study, a prospective cohort study of 1,146 patients with type 2 diabetes conducted in South-West Germany. Information on diabetes and CHD medication was obtained from the physician questionnaires. Bivariate and multivariate analyses using logistic regression were employed in order to assess associations between gender and prescribed drug classes. RESULTS: In total, 624 men and 522 women with type 2 diabetes with a mean age of 67.2 and 69.7 years, respectively, were included in this analysis. Compared to women, men had more angiopathic risk factors, including smoking, alcohol consumption and worse glycemic control, and had more often a diagnosed CHD. Bivariate analyses showed higher prescription of thiazolidinediones and oral combination drugs as well as of angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers and aspirin in men than in women. After full adjustment, differences between men and women remained significant only for ACE inhibitors (OR=1.44; 95%-confidence interval (CI): 1.11-1.88) and calcium channel blockers (OR=1.42, 95%-CI: 1.05-1.91). CONCLUSIONS: These findings contribute to current discussions on gender differences in diabetes care. Men with diabetes are significantly more likely to receive oral combination drugs, ACE inhibitors and calcium channel blockers in the presence of coronary heart disease, respectively. Our results suggest, that diabetic men might be more thoroughly treated compared to women. Further research is needed to focus on reasons for these differences mainly in treatment of cardiovascular diseases to improve quality of care.

Experiencing COVID-19, home isolation and primary health care: A mixed-methods study.

Objectives: Although the vast majority of COVID-19 cases are treated in primary care, patients' experiences during home isolation have been little studied. This study aimed to explore the experiences of patients with acute COVID-19 and to identify challenges after the initial adaptation of the German health system to the pandemic (after first infection wave from February to June 2020). Methods: A mixed-method convergent design was used to gain a holistic insight into patients experience. The study consisted of a cross-sectional survey, open survey answers and semi-structured telephone interviews. Descriptive analysis was performed on quantitative survey answers. Between group differences were calculated to explore changes after the first infection wave. Qualitative thematic analysis was conducted on open survey answers and interviews. The results were then compared within a triangulation protocol. Results: A total of 1100 participants from all German states were recruited by 145 general practitioners from August 2020 to April 2021, 42 additionally took part in qualitative interviews. Disease onset varied from February 2020 to April 2021. After the first infection wave, more participants were tested positive during the acute disease (88.8%; 95.2%; P < 0.001). Waiting times for tests (mean 4.5 days, SD 4.1; 2.7days, SD 2.6, P < 0.001) and test results (mean 2.4 days, SD 1.9; 1.8 days, SD 1.3, P < 0.001) decreased. Qualitative results indicated that the availability of repeated testing and antigen tests reduced insecurities, transmission and related guilt. Although personal consultations at general practices increased (6.8%; 15.5%, P < 0.001), telephone consultation remained the main mode of consultation (78.5%) and video remained insignificant (1.9%). The course of disease, the living situation and social surroundings during isolation, access to health care, personal resilience, spirituality and feelings of guilt and worries emerged as themes influencing the illness experience. Challenges were contact management and adequate provision of care during home isolation. A constant contact person within the health system helped against feelings of care deprivation, uncertainty and fear. Conclusions: Our study highlights that home isolation of individuals with COVID-19 requires a holistic approach that considers all aspects of patient care and effective coordination between different care providers.

Commentary: patient well-being and individual outcomes in the medical practice: impulses from philosophy.

In an everyday private practice setting, regularly also existential topics will emerge from doctor-patient encounters. These are often questions of coping with life and lifestyle. To enable a thorough discussion of such topics, an implicit, and sometimes also explicit reference to a philosophical background is needed. Philosophical concepts to be used in this realm are discussed. An individual patient-doctor interaction is used as an example to demonstrate the doctor's choice of hermeneutical and phenomenological philosophical concepts.

Prognostic value of physicians' assessment of compliance regarding all-cause mortality in patients with type 2 diabetes: primary care follow-up study.

BACKGROUND: Whether the primary care physician's assessment of patient compliance is a valuable prognostic marker to identify patients who are at increased risk of death, or merely reflects measurement of various treatment parameters such as HbA1C or other laboratory markers is unclear. The objective of this prospective cohort study was to investigate the prognostic value of the physicians' assessment of patient compliance and other factors with respect to all-cause mortality during a one year follow-up period. METHODS: A prospective cohort study was conducted among 1014 patients with type 2 diabetes aged 40 and over (mean age 69 years, SD 10.4, 45% male) who were under medical treatment in 11 participating practices of family physicians and internists working in primary care in a defined region in South Germany between April and June 2000. Baseline data were gathered from patients and physicians by standardized questionnaire. The physician's assessment of patient compliance was assessed by means of a 4-point Likert scale (very good, rather good, rather bad, very bad). In addition, we carried out a survey among physicians by means of a questionnaire to find out which aspects for the assessment of patient compliance were of importance to make this assessment. Active follow-up of patients was conducted after one year to determine mortality. RESULTS: During the one year follow-up 48 (4.7%) of the 1014 patients died. Among other factors such as patient type (patients presenting at office, nursing home or visited patients), gender, age and a history of macrovascular disease, the physician's assessment of patient compliance was an important predictor of all-cause mortality. Patients whose compliance was assessed by the physician as "very bad" (6%) were significantly more likely to die during follow-up (OR = 2.67, 95% CI 1.02-6.97) after multivariable adjustment compared to patients whose compliance was assessed as "rather good" (45%) or "very good" (18%). The HbA1C-value and the cholesterol level at baseline showed no statistically significant association with all-cause mortality. According to our survey for most of the physicians self-acceptance of disease, treatment adherence, patient's interest in physician's explanations, attendance at appointments, a good self-management, and a good physician-patient relationship were key elements in the assessment of patient compliance. CONCLUSION: The primary care physician's assessment of patient compliance is a valuable prognostic marker for mortality among patients with type 2 diabetes. Identification of patients in need of improved compliance may help to target preventive measures.

Younger patients with type 2 diabetes need better glycaemic control: results of a community-based study describing factors associated with a high HbA1c value.

This study of 845 patients with type 2 diabetes was conducted in 12 primary care general practices in a geographically cohesive region in Germany. It showed that about a fifth of these patients with known diabetes had a HbA1c of 8% or over, and therefore are in need of better glycaemic control. Younger patients seem to be at special risk for high HbA1c values, and they should receive particular attention with respect to preventive measures for better glycaemic treatment.

Effectiveness of a supportive telephone counseling intervention in type 2 diabetes patients: randomized controlled study.

OBJECTIVES: This randomized controlled trial investigated whether a patient-centered supportive counseling intervention comprising monthly telephone-based counseling sessions by practice nurses over 12 months improved diabetes-related medical and psycho-social outcomes above usual care in type 2 diabetes patients with poor glycemic control at baseline (HbA1c >7.5%) in a primary care setting. RESEARCH DESIGN: Patients were individually randomized into intervention (n = 103) and usual care group (n = 101). The primary outcome was change in HbA1c-concentration after 12 and 18 months. Secondary outcomes were lipid levels, blood pressure, health-related quality of life and symptoms of depression. Follow-up-measurements were carried out after 6, 12 and 18 months to assess potential immediate and maintained effects of the intervention. For the multivariate analysis, hierarchical linear models were computed for each outcome to assess within-group changes in outcomes over time and between-group differences in patterns of change. RESULTS: HbA1c (in %) decreased significantly from baseline to 12-month follow-up measurement both in the intervention (-0.44) and the usual care group (-0.51), but there was no significant between-group intervention effect. Significant improvements in the intervention group along with significant between-group differences were seen for health-related quality of life and, transiently, for systolic blood pressure and depression. CONCLUSIONS: Although we found no beneficial effect of the supportive telephone counseling in terms of a reduction of HbA1c above usual care, our findings suggest some beneficial effects on cardiovascular risk factors, quality of life and depression. Continuous efforts might be needed to sustain improvements in patient outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT00742547.

Medication non-adherence and poor glycaemic control in patients with type 2 diabetes mellitus.

AIMS: Our main aim was to analyse gender differences in the association of adherence and poor glycaemic control (PGC) in a cohort of patients with type 2 diabetes mellitus in Germany. METHODS: Baseline data of the DIANA-study, a prospective cohort study of type 2 diabetes mellitus patients in South-West Germany, were analysed. Information on medication adherence and factors related to PGC was obtained by self-administered questionnaire. PGC was defined as HbA(1c)≥7.5%. Bivariate and multivariate analyses using log-binomial regression were employed to assess overall and gender-specific associations of non-adherence and PGC. RESULTS: 624 men and 518 women were included in the analyses. In total, 147 men (24%) and 114 women (23%) reported non-adherence to medication. In men, PGC was found in 37% of the participants reporting non-adherence and in 19% reporting adherence (adjusted prevalence ratio (PR)=1.90, 95%-CI: 1.46-2.49). In women, PGC was found in 19% of the participants reporting non-adherence and in 18% reporting adherence (adjusted PR=0.97, 95%-CI: 0.65-1.46). CONCLUSIONS: Our results show gender-specific differences in the association of adherence and PGC. This underlines the need for efforts to improve glycaemic control in patients with type 2 diabetes mellitus with a particular focus on men.

Gender differences in healthcare utilization of patients with diabetes.

OBJECTIVES: To examine gender differences in healthcare utilization including outpatient and inpatient medical care for patients with type 2 diabetes mellitus (T2DM), despite participation in T2DM-specific disease management programs (DMP-DM). STUDY DESIGN: Baseline data from a cohort study in southwest Germany including 1146 patients with T2DM recruited between October 2008 and March 2010 were used. METHODS: After bivariate analyses, multivariate Poisson and logistic regression models were used to estimate the effect of sex on the number of general practitioner (GP) and medical specialist appointments, prescribed medications, hospitalizations, and inpatient rehabilitations, with additional consideration of glycemic control levels. Poor glycemic control (PGC) was defined as glycated hemoglobin ≥7.5%. RESULTS: In total, 905 participants had acceptable glycemic control and 237 participants had poor glycemic control. PGC was more prevalent in men than in women (23% vs 18%). Bivariate analyses among participants with PGC showed significantly fewer GP and medical specialist appointments, a lower number of medications, and longer rehabilitation stays in men than in women. Multivariate regression analyses among participants with PGC confirmed statistically significant gender differences for GP appointments and number of prescribed medications (P <.05) for men compared with women. Gender differences regarding inpatient care were less evident. CONCLUSIONS: Our data disclosed major gender differences in healthcare utilization of diabetes patients in Germany despite a high DMP-DM rate. Future research should focus attention on gender-specific approaches to healthcare delivery to improve quality and access to care.