Development of the simulation-based German albuminuria screening model (S-GASM) for estimating the cost-effectiveness of albuminuria screening in Germany.

BACKGROUND: Chronic kidney disease is often asymptomatic in its early stages but constitutes a severe burden for patients and causes major healthcare systems costs worldwide. While models for assessing the cost-effectiveness of screening were proposed in the past, they often presented only a limited view. This study aimed to develop a simulation-based German Albuminuria Screening Model (S-GASM) and present some initial applications. METHODS: The model consists of an individual-based simulation of disease progression, considering age, gender, body mass index, systolic blood pressure, diabetes, albuminuria, glomerular filtration rate, and quality of life, furthermore, costs of testing, therapy, and renal replacement therapy with parameters based on published evidence. Selected screening scenarios were compared in a cost-effectiveness analysis. RESULTS: Compared to no testing, a simulation of 10 million individuals with a current age distribution of the adult German population and a follow-up until death or the age of 90 shows that a testing of all individuals with diabetes every two years leads to a reduction of the lifetime prevalence of renal replacement therapy from 2.5% to 2.3%. The undiscounted costs of this intervention would be 1164.10 € / QALY (quality-adjusted life year). Considering saved costs for renal replacement therapy, the overall undiscounted costs would be-12581.95 € / QALY. Testing all individuals with diabetes or hypertension and screening the general population reduced the lifetime prevalence even further (to 2.2% and 1.8%, respectively). Both scenarios were cost-saving (undiscounted, - 7127.10 €/QALY and-5439.23 €/QALY). CONCLUSIONS: The S-GASM can be used for the comparison of various albuminuria testing strategies. The exemplary analysis demonstrates cost savings through albuminuria testing for individuals with diabetes, diabetes or hypertension, and for population-wide screening.

Sex Disparities in Cardiovascular Risk Factor Assessment and Screening for Diabetes-Related Complications in Individuals With Diabetes: A Systematic Review.

Background: Insight in sex disparities in the detection of cardiovascular risk factors and diabetes-related complications may improve diabetes care. The aim of this systematic review is to study whether sex disparities exist in the assessment of cardiovascular risk factors and screening for diabetes-related complications. Methods: PubMed was systematically searched up to April 2020, followed by manual reference screening and citations checks (snowballing) using Google Scholar. Observational studies were included if they reported on the assessment of cardiovascular risk factors (HbA1c, lipids, blood pressure, smoking status, or BMI) and/or screening for nephropathy, retinopathy, or performance of feet examinations, in men and women with diabetes separately. Studies adjusting their analyses for at least age, or when age was considered as a covariable but left out from the final analyses for various reasons (i.e. backward selection), were included for qualitative analyses. No meta-analyses were planned because substantial heterogeneity between studies was expected. A modified Newcastle-Ottawa Quality Assessment Scale for cohort studies was used to assess risk of bias. Results: Overall, 81 studies were included. The majority of the included studies were from Europe or North America (84%).The number of individuals per study ranged from 200 to 3,135,019 and data were extracted from various data sources in a variety of settings. Screening rates varied considerably across studies. For example, screening rates for retinopathy ranged from 13% to 90%, with half the studies reporting screening rates less than 50%. Mixed findings were found regarding the presence, magnitude, and direction of sex disparities with regard to the assessment of cardiovascular risk factors and screening for diabetes-related complications, with some evidence suggesting that women, compared with men, may be more likely to receive retinopathy screening and less likely to receive foot exams. Conclusion: Overall, no consistent pattern favoring men or women was found with regard to the assessment of cardiovascular risk factors and screening for diabetes-related complications, and screening rates can be improved for both sexes.

Evaluation of simple and cost-effective immuno- haematological markers to predict outcome in hospitalized severe COVID-19 patients, with a focus on diabetes mellitus - A retrospective study in Andhra Pradesh, India.

BACKGROUND AND AIMS: COVID-19 pandemic has strained the health infrastructure globally, providing an opportunity to identify cost-effective biomarkers. We aimed to identify simple hematological prognostic markers in hospitalized severe COVID-19 patients with and without diabetes. METHODS: Retrospective study of RT-PCR confirmed hospitalized severe COVID-19 patients (total: n = 154 patients, including diabetic subset n = 57) were analyzed. Clinically applicable cut-offs were derived using receiver operating characteristic (ROC) curve analysis for total leucocyte count (TLC), absolute neutrophil count (ANC), neutrophil lymphocyte ratio (NLR), and derived neutrophil lymphocyte ratio (dNLR) in order to prognosticate the outcome. RESULTS: Among 154 severe COVID-19 patients, significant association with mortality was seen with respect to TLC(p < 0.001), ANC (p < 0.001), NLR(p < 0.001) and dNLR(p < 0.001). In the total cohort, applicable cut-offs based on ROC curve in predicting outcome were, for TLC 8950 cells/mm3 (area under curve (AUC)-0.764, odds ratio (OR)-7.53), ANC 7679 cells/mm3 (AUC-0.789, OR-8.14), NLR 5.13 (AUC-0.741, OR-4.77), dNLR 3.44 (AUC -0.741, OR-4.43) respectively.In diabetic subset, the cut-offs for TLC was 8950 cells/mm3 (AUC -0.762, OR-14.9), ANC 6510 cells/mm3 (AUC -0.773, OR-16.8), NLR 5.13(AUC -0.678, OR-6) and dNLR 3.25(AUC -0.685, OR-4.7) respectively. CONCLUSIONS: In severe COVID-19 patients irrespective of diabetes, a simple, applicable total leucocyte count cut-off, 8950 cells/mm3 , together with easily derived cut-offs for ANC, NLR, dNLR may serve as cost-effective prognosticators of clinical outcome. A normal TLC may be misleading in the intensive care and the above applicable cut-off for TLC serves as an early warning tool for high-risk identification and better in-hospital management. Even with similar or lower cut-offs, diabetics had a higher mortality.

Association of diabetes type and chronic diabetes complications with early exit from the labour force: register-based study of people with diabetes in Finland.

AIMS/HYPOTHESIS: Diabetes and diabetes complications are a cause of substantial morbidity, resulting in early exits from the labour force and lost productivity. The aim of this study was to examine differences in early exits between people with type 1 and 2 diabetes and to assess the role of chronic diabetes complications on early exit. We also estimated the economic burden of lost productivity due to early exits. METHODS: People of working age (age 17-64) with diabetes in 1998-2011 in Finland were detected using national registers (Ntype 1 = 45,756, Ntype 2 = 299,931). For the open cohort, data on pensions and deaths, healthcare usage, medications and basic demographics were collected from the registers. The outcome of the study was early exit from the labour force defined as pension other than old age pension beginning before age 65, or death before age 65. We analysed the early exit outcome and its risk factors using the Kaplan-Meier method and extended Cox regression models. We fitted linear regression models to investigate the risk factors of lost working years and productivity costs among people with early exit. RESULTS: The difference in median age at early exit from the labour force between type 1 (54.0) and type 2 (58.3) diabetes groups was 4.3 years. The risk of early exit among people with type 1 diabetes increased faster after age 40 compared with people with type 2 diabetes. Each of the diabetes complications was associated with an increase in the hazard of early exit regardless of diabetes type compared with people without the complication, with eye-related complications as an exception. Diabetes complications partly but not completely explained the difference between diabetes types. The mean lost working years was 6.0 years greater in the type 1 diabetes group than in the type 2 diabetes group among people with early exit. Mean productivity costs of people with type 1 diabetes and early exit were found to be 1.4-fold greater compared with people with type 2 diabetes. The total productivity costs of incidences of early exits in the type 2 diabetes group were notably higher compared with the type 1 group during the time period (€14,400 million, €2800 million). CONCLUSIONS/INTERPRETATION: We found a marked difference in the patterns of risk of early exit between people with type 1 and type 2 diabetes. The difference was largest close to statutory retirement age. On average, exits in the type 1 diabetes group occurred at an earlier age and resulted in higher mean lost working years and mean productivity costs. The potential of prevention, timely diagnosis and management of diabetes is substantial in terms of avoiding reductions in individual well-being and productivity.

Not there yet: using data-driven methods to predict who becomes costly among low-cost patients with type 2 diabetes.

BACKGROUND: Diabetes is a leading cause of Medicare spending; predicting which individuals are likely to be costly is essential for targeting interventions. Current approaches generally focus on composite measures, short time-horizons, or patients who are already high utilizers, whose costs may be harder to modify. Thus, we used data-driven methods to classify unique clusters in Medicare claims who were initially low utilizers by their diabetes spending patterns in subsequent years and used machine learning to predict these patterns. METHODS: We identified beneficiaries with type 2 diabetes whose spending was in the bottom 90% of diabetes care spending in a one-year baseline period in Medicare fee-for-service data. We used group-based trajectory modeling to classify unique clusters of patients by diabetes-related spending patterns over a two-year follow-up. Prediction models were estimated with generalized boosted regression, a machine learning method, using sets of all baseline predictors, diabetes predictors, and predictors that are potentially-modifiable through interventions. Each model was evaluated through C-statistics and 5-fold cross-validation. RESULTS: Among 33,789 beneficiaries (baseline median diabetes spending: $4153), we identified 5 distinct spending patterns that could largely be predicted; of these, 68.1% of patients had consistent spending, 25.3% had spending that rose quickly, and 6.6% of patients had spending that rose progressively. The ability to predict these groups was moderate (validated C-statistics: 0.63 to 0.87). The most influential factors for those with progressively rising spending were age, generosity of coverage, prior spending, and medication adherence. CONCLUSIONS: Patients with type 2 diabetes who were initially low spenders exhibit distinct subsequent long-term patterns of diabetes spending; membership in these patterns can be largely predicted with data-driven methods. These findings as well as applications of the overall approach could potentially inform the design and timing of diabetes or cost-containment interventions, such as medication adherence or interventions that enhance access to care, among patients with type 2 diabetes.

Screening, assessment and management of type 2 diabetes mellitus in children and adolescents: Australasian Paediatric Endocrine Group guidelines.

INTRODUCTION: The incidence of type 2 diabetes mellitus has increased in children and adolescents due largely to the obesity epidemic, particularly in high risk ethnic groups. ß-Cell function declines faster and diabetes complications develop earlier in paediatric type 2 diabetes compared with adult-onset type 2 diabetes. There are no consensus guidelines in Australasia for assessment and management of type 2 diabetes in paediatric populations and health professionals have had to refer to adult guidelines. Recent international paediatric guidelines did not address adaptations to care for patients from Indigenous backgrounds. MAIN RECOMMENDATIONS: This guideline provides advice on paediatric type 2 diabetes in relation to screening, diagnosis, diabetes education, monitoring including targets, multicomponent healthy lifestyle, pharmacotherapy, assessment and management of complications and comorbidities, and transition. There is also a dedicated section on considerations of care for children and adolescents from Indigenous background in Australia and New Zealand. CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINES: Published international guidelines currently exist, but the challenges and specifics to care for children and adolescents with type 2 diabetes which should apply to Australasia have not been addressed to date. These include: recommendations regarding care of children and adolescents from Indigenous backgrounds in Australia and New Zealand including screening and management; tighter diabetes targets (glycated haemoglobin, ≤ 48 mmol/mol [≤ 6.5%]) for all children and adolescents; considering the use of newer medications approved for adults with type 2 diabetes under the guidance of a paediatric endocrinologist; and the need to transition adolescents with type 2 diabetes to a diabetes multidisciplinary care team including an adult endocrinologist for their ongoing care.

A Patient-Level Model to Estimate Lifetime Health Outcomes of Patients With Type 1 Diabetes.

OBJECTIVE: To develop a patient-level simulation model for predicting lifetime health outcomes of patients with type 1 diabetes and as a tool for economic evaluation of type 1 diabetes treatment based on data from a large, longitudinal cohort. RESEARCH DESIGN AND METHODS: Data for model development were obtained from the Swedish National Diabetes Register. We derived parametric proportional hazards models predicting the absolute risk of diabetes complications and death based on a wide range of clinical variables and history of complications. We used linear regression models to predict risk factor progression. Internal validation was performed, estimates of life expectancies for different age-sex strata were computed, and the impact of key risk factors on life expectancy was assessed. RESULTS: The study population consisted of 27,841 patients with type 1 diabetes with a mean duration of follow-up of 7 years. Internal validation showed good agreement between the predicted and observed cumulative incidence of death and 10 complications. Simulated life expectancy was ∼13 years lower than that of the sex- and age-matched general population, and patients with type 1 diabetes could expect to live with one or more complications for ∼40% of their remaining life. Sensitivity analysis showed the importance of preventing renal dysfunction, hypoglycemia, and hyperglycemia as well as lowering HbA1c in reducing the risk of complications and death. CONCLUSIONS: Our model was able to simulate risk factor progression and event histories that closely match the observed outcomes and to project events occurring over patients' lifetimes. The model can serve as a tool to estimate the impact of changing clinical risk factors on health outcomes to inform economic evaluations of interventions in type 1 diabetes.

Prevalence and awareness of chronic kidney disease among adult diabetic outpatients in Northeast Ethiopia.

BACKGROUND: Chronic kidney disease (CKD) is a serious complication of diabetes associated with adverse outcomes of renal failure, cardiovascular disease and mortality. Despite this, data regarding the burden and awareness of CKD among adults with diabetes in Sub-Saharan Africa countries are lacking. The aim of this study was, therefore to determine the prevalence and awareness of CKD among diabetic outpatients attending a hospital in Northeast Ethiopia. METHODS: We conducted a cross-sectional study on 323 diabetic adults at the diabetes clinic of a hospital in Northeast Ethiopia, from February 1 to July 30, 2016. Each patient provided a blood sample for serum creatinine and urine for albuminuria. Glomerular filtration rate (eGFR) was estimated using the Modification of Diet in Renal Disease (MDRD) equation. CKD was defined as eGFR < 60 ml/min/1.73 m2 and/or albuminuria. Awareness was defined as a positive response to "Has a doctor or other health care professional ever told you that you had kidney disease?" RESULTS: Of the 323 patients, 85 (26.3%) had Stage 1-5 CKD, 42 (13.0%) had eGFR < 60 ml/min/1.73m2 and 58 (18.0%) had albuminuria. In patients with eGFR < 60 ml/min/1.73m2 (stage 3-5 CKD), serum creatinine was abnormal (> 1.5 mg/dl) in 23.5% and albuminuria was absent in 31.8%. Of the patients with CKD, only 10.6% of them were aware of their CKD. The proportion of patients who were aware of their disease increased with worsening of CKD stages, from 3.4% of with stage 1 to 75.0% with stage 4. Awareness for all individuals with advanced stages of CKD was only 11.9%. Having albuminuria, high serum creatinine, a family history of kidney disease and being obese were significantly associated with CKD awareness. CONCLUSION: A high prevalence but low awareness of CKD was found in diabetic outpatients attending our clinic in Northeast Ethiopia. Our results highlight the need for more diagnostic strategies for CKD screening among diabetic adults and primary care education on the impact of detecting CKD in the early stage to prevent adverse outcomes and improve diabetes care.

Type 1 diabetes and hearing loss: Audiometric assessment and measurement of circulating levels of soluble receptor for advanced glycation end products.

BACKGROUND: We examined the hearing function in adults with and without type 1 diabetes (T1D) to investigate whether an association exists between hearing loss and duration of diabetes, haemoglobin A1C level, diabetes complications and levels of select serum and urinary biomarkers. METHODS: We measured pure tone audiometry (PTA) thresholds; serum levels of C-reactive protein (CRP), vascular endothelial growth factor (VEGF), soluble receptors for advanced glycation end-product (sRAGE); and urinary isoprostane in 30 adults with T1D (age 43.8 ± 11.4 years). We also measured PTA thresholds in 11 adults without diabetes (age 53 ± 5.5 years). RESULTS: 63.3% of adults with T1D had high-frequency hearing loss. Among adults with T1D, those with hearing loss were older (48.2 vs 36.2 years old, P < .01), had a longer duration of diabetes (30.7 vs 21.2 years, P = .02), a greater prevalence of peripheral neuropathy (57.9 vs 9.1%, P = .02) and significantly lower median levels of sRAGE (1054.27 vs 1306.83 pg/mL, P = .03) compared to those with normal hearing. Adults with T1D between the ages of 40 and 60 years old, who had diabetes for ≥35 years, had significantly higher PTA thresholds at both 500and 8000 Hz than age-matched adults without diabetes. CONCLUSIONS: A significant proportion of adults with T1D have high-frequency hearing loss before age of 60 that is positively associated with age, duration of diabetes and presence of peripheral neuropathy. Our results are in support of previous studies suggesting a potential protective role of sRAGE against AGE toxicity and diabetes complications.

Performance of High-Sensitivity Cardiac Troponin Assays to Reflect Comorbidity Burden and Improve Mortality Risk Stratification in Older Adults With Diabetes.

OBJECTIVE: Incorporation of comorbidity burden to inform diabetes management in older adults remains challenging. High-sensitivity cardiac troponins are objective, quantifiable biomarkers that may improve risk monitoring in older adults. We assessed the associations of elevations in high-sensitivity cardiac troponin I (hs-cTnI) and T (hs-cTnT) with comorbidities and improvements in mortality risk stratification. RESEARCH DESIGN AND METHODS: We used logistic regression to examine associations of comorbidities with elevations in either troponin (≥85th percentile) among 1,835 participants in the Atherosclerosis Risk in Communities (ARIC) Study with diabetes (ages 67-89 years, 43% male, 31% black) at visit 5 (2011-2013). We used Cox models to compare associations of high cardiac troponins with mortality across comorbidity levels. RESULTS: Elevations in either troponin (≥9.4 ng/L for hs-cTnI, ≥25 ng/L for hs-cTnT) were associated with prevalent coronary heart disease, heart failure, chronic kidney disease, pulmonary disease, hypoglycemia, hypertension, dementia, and frailty. Over a median follow-up of 6.2 years (418 deaths), both high hs-cTnI and high hs-cTnT further stratified mortality risk beyond comorbidity levels; those with a high hs-cTnI or hs-cTnT and high comorbidity were at highest mortality risk. Even among those with low comorbidity, a high hs-cTnI (hazard ratio 3.0 [95% CI 1.7, 5.4]) or hs-cTnT (hazard ratio 3.3 [95% CI 1.8, 6.2]) was associated with elevated mortality. CONCLUSIONS: Many comorbidities were reflected by both hs-cTnI and hs-cTnT; elevations in either of the troponins were associated with higher mortality risk beyond comorbidity burden. High-sensitivity cardiac troponins may identify older adults at high mortality risk and be useful in guiding clinical care of older adults with diabetes.

Screening for pulmonary tuberculosis in high-risk groups of diabetic patients.

BACKGROUND: The double burden of diabetes mellitus (DM) and tuberculosis (TB) has attracted increasing attention, because DM not only increases the risk of active TB but also affects treatment outcomes. Screening for TB among diabetic patients has been recommended, but requires real-world evidence by considering its cost-effectiveness, cost-utility ratio, and cost-benefit ratio. METHODS: A screening program was conducted in Jiangyin City of Jiangsu Province, China. A total of 14 869 diabetic patients received regular physical examinations for three consecutive years and were followed for the diagnosis of TB. The cost of screening and the effectiveness, utility, and social benefits attributed to the program were evaluated. In addition, a matched case-control study was conducted and the nomogram was used to identify high-risk groups that could be the target population for screening. RESULTS: Among the 14 869 diabetic patients who participated in this screening program, 22 were diagnosed with TB, resulting in an incremental cost-effectiveness ratio (ICER) of 83 910 CNY per disability-adjusted life-year (DALY) gained and a cost-benefit ratio of 0.50. If the screening program was limited to high-risk diabetic patients by considering body mass index (BMI), fasting blood glucose (FBG), and triglycerides, the ICER decreased to 34 303 CNY per DALY gained and the cost-benefit ratio increased to 1.22. CONCLUSIONS: Screening for TB using regular chest X-ray examinations is feasible but not economical in areas with a low incidence of TB. It is recommended that diabetic patients with a low BMI, high FBG, and low triglycerides are selected as subjects for TB screening.

Analysis for warning factors of type 2 diabetes mellitus complications with Markov blanket based on a Bayesian network model.

BACKGROUND AND OBJECTIVE: Type 2 diabetes mellitus (T2DM) complications seriously affect the quality of life and could not be cured completely. Actions should be taken for prevention and self-management. Analysis of warning factors is beneficial for patients, on which some previous studies focused. They generally used the professional medical test factors or complete factors to predict and prevent, but it was inconvenient and impractical for patients to self-manage. With this in mind, this study built a Bayesian network (BN) model, from the perspective of diabetic patients' self-management and prevention, to predict six complications of T2DM using the selected warning factors which patients could have access from medical examination. Furthermore, the model was analyzed to explore the relationships between physiological variables and T2DM complications, as well as the complications themselves. The model aims to help patients with T2DM self-manage and prevent themselves from complications. METHODS: The dataset was collected from a well-known data center called the National Health Clinical Center between 1st January 2009 and 31st December 2009. After preprocess and impute the data, a BN model merging expert knowledge was built with Bootstrap and Tabu search algorithm. Markov Blanket (MB) was used to select the warning factors and predict T2DM complications. Moreover, a Bayesian network without prior information (BN-wopi) model learned using 10-fold cross-validation both in structure and in parameters was added to compare with other classifiers learned using 10-fold cross-validation fairly. The warning factors were selected according the structure learned in each fold and were used to predict. Finally, the performance of two BN models using warning features were compared with Naïve Bayes model, Random Forest model, and C5.0 Decision Tree model, which used all features to predict. Besides, the validation parameters of the proposed model were also compared with those in existing studies using some other variables in clinical data or biomedical data to predict T2DM complications. RESULTS: Experimental results indicated that the BN models using warning factors performed statistically better than their counterparts using all other variables in predicting T2DM complications. In addition, the proposed BN model were effective and significant in predicting diabetic nephropathy (DN) (AUC: 0.831), diabetic foot (DF) (AUC: 0.905), diabetic macrovascular complications (DMV) (AUC: 0.753) and diabetic ketoacidosis (DK) (AUC: 0.877) with the selected warning factors compared with other experiments. CONCLUSIONS: The warning factors of DN, DF, DMV, and DK selected by MB in this research might be able to help predict certain T2DM complications effectively, and the proposed BN model might be used as a general tool for prevention, monitoring, and self-management.

Wireless motility capsule compared with scintigraphy in the assessment of diabetic gastroparesis.

BACKGROUND: Gastroparesis is a potentially severe late complication of diabetes mellitus. Today, delayed gastric emptying (GE) is mandatory for establishing the diagnosis. In this study, we compared wireless motility capsule (WMC) with gastric emptying scintigraphy (GES). METHODS: Seventy-two patients (49 women) with diabetes mellitus (59 type 1) and symptoms compatible with gastroparesis were prospectively included between 2014 and 2018. Patients were simultaneously examined with GES and WMC. Symptoms were assessed with the Patient Assessment of Upper Gastrointestinal Symptom Severity Index (PAGI-SYM) questionnaire. All patients were on intravenous glucose-insulin infusion during testing. KEY RESULTS: WMC and GES correlated r = .74, P < .001. Compared to GES, WMC at ordinary cutoff for delayed GE (300 minutes) had a sensitivity of 0.92, specificity 0.73, accuracy 0.80, and Cohen's kappa κ = 0.61 (P < .001). By receiver operating characteristics (ROC), the area under the curve was 0.95 (P < .001). A cutoff value for delayed GE of 385 minutes produced sensitivity 0.92, specificity 0.83, accuracy 0.86, and Cohen's kappa κ = 0.72 (P < .001). Inter-rater reliability for GE time with WMC was r = .996, κ = 0.97, both P < .001. There was no difference in symptom severity between patients with normal and delayed GE. CONCLUSIONS & INFERENCES: Our findings demonstrate the applicability of WMC as a reliable test to assess gastric emptying in diabetic gastroparesis showing very high inter-observer correlation. By elevating the cutoff value for delayed emptying from 300 to 385 minutes, we found higher specificity without reducing sensitivity.

4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Medical Care in Diabetes-2020.

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The Complexity of Diabetic Foot Management: From Common Care to Best Practice. The Italian Expert Opinion by Delphi Survey.

Diabetic foot is a major public health issue, driven by diabetes complications (neuropathy, peripheral vascular disease, foot deformity, and abnormal leucocyte function), which may lead to leg amputation, thus resulting in severe disability, reduced quality of life, and high health costs. The prevention of diabetes complications and the early detection and proper management of diabetic foot wounds are the milestones to avoid major amputations. Unfortunately, in many areas, the prevention of diabetic foot lesions is inadequate and wounds may proceed toward infection and chronicity, with limb- and life-threatening results. Using the Delphi method, we conducted a survey on diabetic foot among Italian experts, selected across different Italian clinical centers. This method was used to achieve a consensus on current opinion and clinical leanings on the diagnosis and management of diabetic foot ulcers. Specifically, the aim of the survey was to evaluate the current management of the diabetic foot syndrome; highlight the differences in the approach among a group of experts; evaluate the role of wound bed preparation and antisepsis; and discuss any areas of disagreement in which evidences are sparse and the clinical judgment plays a crucial role in the decision-making process.

Quantitative assessment of early Type 2 diabetic cataracts using T1,T2-mapping techniques.

OBJECTIVE: The purpose of this study was to explore the feasibility of T1 and T2-mapping techniques in evaluating early Type 2 diabetic cataracts. METHODS: Totally, 28 patients with Type 2 diabetes was prospectively collected, and 28 non-diabetic patients were collected as control group. All patients included had ophthalmological exploration and all patients underwent orbital MRI examination with T1 and T2-mapping on a Siemens-Skyra 3.0T scanner. T1 and T2 values of the lens nucleus were measured by region of interest (ROI) method based on Siemens-Syngo workstation. Two sample t-test was used to analyze the differences between groups. Pearson correlations were calculated between relaxation time (T1, T2) and clinical variables, such as fasting glucose, glycosylated hemoglobin etc. p < 0.01 was used to determine statistical significance. RESULTS: In Type 2 diabetes group, the T1 value was 626.7 ± 56.8, T2 value was 29.4 ± 5.6. In non-diabetic group, the T1 value was 581.6 ± 64.7, T2 value was 24.8 ± 8.6. The T1 and T2 values of the lens in diabetic group were significantly higher than those in control group (p < 0.01, T1 value: 626.7 ± 56.8 vs 581.6 ± 64.7; T2 value: 29.4 ± 5.6 vs 24.8 ± 8.6). The T1 and T2 values of lens in diabetic patients were significantly correlated with glycosylated hemoglobin (HbA1c), and the correlation coefficients were 0.502 and 0.396, respectively. CONCLUSION: T1 and T2-mapping technique can sensitively reflect the alterative relaxation time of lens in diabetic patients. This technique can find abnormal changes earlier than slit lamp, and may be effective diagnostic methods for early lens disease. ADVANCES IN KNOWLEDGE: T1 and T2-mapping techniques may be effective diagnostic methods for early lens disease, which can detect abnormal changes earlier than slit lamp examination.

Analysis of diabetes quality assessment findings and future directions for the appropriate management of diabetes in Korea.

BACKGROUND/AIMS: Due to recent increases in the disease burden of diabetes mellitus, the Health Insurance Review and Assessment Service (HIRA) of Korea implemented a quality assessment of the treatment of diabetes to improve patient care. The present study was conducted to identify any changes after the implementation of the diabetes quality assessment (DQA). METHODS: The present study evaluated eight quality assessment indicators that were proposed by the HIRA in all patients with diabetes who visited a university hospital in Korea between 2009 and 2014. The indicators were statistically compared according to the characteristics of the subjects. RESULTS: There were several significant differences in the indicators among the subjects according to their demographic characteristics. Female patients had a higher continuity of treatment (COT) than that of male patients, and the insulin-treated group had a higher COT than that of the non-treated group, as well as a higher rate of undergoing the diabetes complication tests (DCTs). Patients between 40 and 80 years of age had the highest COT, while patients under 40 years of age had the lowest COT but the highest rate of taking the DCTs. Patients receiving treatment from an endocrinologist exhibited higher numbers of DCTs performed but displayed lower proportions for the prescription indicators. CONCLUSION: The present analysis of the DQA findings revealed that endocrinologists combine prevention and management of diabetes complications with measures for glycemic control. Thus, the effective management of diabetes likely entails systematic joint treatment regimens that involve an endocrinologist.

Trajectory of Excess Medical Expenditures 10 Years Before and After Diabetes Diagnosis Among U.S. Adults Aged 25-64 Years, 2001-2013.

OBJECTIVE: We assessed the excess medical expenditures for adults newly diagnosed with diabetes, for up to 10 years before and after diabetes diagnosis. RESEARCH DESIGN AND METHODS: Using the 2001-2013 MarketScan data, we identified people with newly diagnosed diabetes among adults aged 25-64 years (diabetes cohort) and matched them with people who did not have diagnosed diabetes (control cohort) using 1:1 propensity score matching. We followed these two cohorts up to ±10 years from the index date, with annual matched cohort sizes ranging from 3,922 to 39,726 individuals. We estimated the yearly and cumulative excess medical expenditures of the diabetes cohorts before and after the diagnosis of diabetes. RESULTS: The per capita annual total excess medical expenditure for the diabetes cohort was higher for the entire 10 years prior to their index date, ranging between $1,043 in year -10 and $4,492 in year -1. Excess expenditure spiked in year 1 ($8,109), declined in year 2, and then increased steadily, ranging from $4,261 to $6,162 in years 2-10. The cumulative excess expenditure for the diabetes cohort during the entire 20 years of follow-up was $69,177 ($18,732 before and $50,445 after diagnosis). CONCLUSIONS: People diagnosed with diabetes had higher medical expenditures compared with their counterparts, not only after diagnosis but also up to 10 years prior to diagnosis. Managing risk factors for type 2 diabetes and cardiovascular disease before diagnosis, and for diabetes-related complications after diagnosis, could alleviate medical expenditure in people with diabetes.

4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Medical Care in Diabetes-2019.

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.