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1.
J Diabetes ; 10(3): 192-199, 2018 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-28976724

RESUMEN

BACKGROUND: The aim of the present study was to assess the longitudinal accumulation of diabetes-related complications and the effect of glycemic control on the Diabetes Complications Severity Index (DCSI) score in people with newly diagnosed type 2 diabetes (T2D). METHODS: A retrospective cohort study was conducted using electronic health records from a large integrated healthcare system. People with newly diagnosed T2D were identified between 2005 and 2016 and stratified by initial HbA1c category (<7%, <8%, ≥8%). The DCSI scores were determined for each study year, and the cumulative incidence of diabetes-related complications was assessed. A Cox proportional hazard model was used to evaluate the effect of baseline HbA1c and worsening glycemic (HbA1c) control on longitudinal changes in DCSI scores. RESULTS: Of 32 174 people identified as having newly diagnosed T2D, 14 016 (44%), 21 657 (67%), and 9983 (31%) had an initial or baseline HbA1c <7%, <8%, and ≥8%, respectively. Ten years after diabetes diagnosis, retinopathy, chronic kidney disease, coronary heart disease, and neuropathy were diagnosed in 22%, 29%, 24%, and 36% of people. Baseline HbA1c did not affect the observed trend in longitudinal changes in DCSI scores throughout the 11-year period. For people in each of the initial HbA1c groups (<7%, <8%, ≥8%), worsening or persistently poor glycemic control was significantly associated with a 10%, 19%, or 16% increase in the risk of experiencing an increased DCSI score, respectively (all P < 0.01). CONCLUSIONS: Baseline glycemic control had no apparent effect on longitudinal changes in DCSI score. Worsening or persistently poor glycemic control was associated with an increased risk of an increase in the DCSI score.


Asunto(s)
Complicaciones de la Diabetes/epidemiología , Diabetes Mellitus Tipo 2/complicaciones , Índice Glucémico , Hipoglucemiantes/uso terapéutico , Índice de Severidad de la Enfermedad , Anciano , Biomarcadores/metabolismo , Glucemia/metabolismo , Complicaciones de la Diabetes/diagnóstico , Complicaciones de la Diabetes/fisiopatología , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Femenino , Estudios de Seguimiento , Hemoglobina Glucada/análisis , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Estados Unidos/epidemiología
2.
BMJ Open ; 7(11): e017583, 2017 Nov 16.
Artículo en Inglés | MEDLINE | ID: mdl-29150468

RESUMEN

OBJECTIVE: To determine the prevalence of obesity and its related comorbidities among patients being actively managed at a US academic medical centre, and to examine the frequency of a formal diagnosis of obesity, via International Classification of Diseases, Ninth Revision (ICD-9) documentation among patients with body mass index (BMI) ≥30 kg/m2. DESIGN: The electronic health record system at Cleveland Clinic was used to create a cross-sectional summary of actively managed patients meeting minimum primary care physician visit frequency requirements. Eligible patients were stratified by BMI categories, based on most recent weight and median of all recorded heights obtained on or before the index date of 1July 2015. Relationships between patient characteristics and BMI categories were tested. SETTING: A large US integrated health system. RESULTS: A total of 324 199 active patients with a recorded BMI were identified. There were 121 287 (37.4%) patients found to be overweight (BMI ≥25 and <29.9), 75 199 (23.2%) had BMI 30-34.9, 34 152 (10.5%) had BMI 35-39.9 and 25 137 (7.8%) had BMI ≥40. There was a higher prevalence of type 2 diabetes, pre-diabetes, hypertension and cardiovascular disease (P value<0.0001) within higher BMI compared with lower BMI categories. In patients with a BMI >30 (n=134 488), only 48% (64 056) had documentation of an obesity ICD-9 code. In those patients with a BMI >40, only 75% had an obesity ICD-9 code. CONCLUSIONS: This cross-sectional summary from a large US integrated health system found that three out of every four patients had overweight or obesity based on BMI. Patients within higher BMI categories had a higher prevalence of comorbidities. Less than half of patients who were identified as having obesity according to BMI received a formal diagnosis via ICD-9 documentation. The disease of obesity is very prevalent yet underdiagnosed in our clinics. The under diagnosing of obesity may serve as an important barrier to treatment initiation.


Asunto(s)
Índice de Masa Corporal , Registros Electrónicos de Salud , Obesidad/epidemiología , Centros Médicos Académicos , Adulto , Trastornos Cerebrovasculares/complicaciones , Trastornos Cerebrovasculares/epidemiología , Comorbilidad , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/epidemiología , Estudios Transversales , Prestación Integrada de Atención de Salud/estadística & datos numéricos , Diabetes Mellitus/epidemiología , Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/epidemiología , Humanos , Hipertensión/complicaciones , Masculino , Persona de Mediana Edad , Obesidad/clasificación , Obesidad/complicaciones , Prevalencia
3.
Diabetes Obes Metab ; 19(11): 1555-1561, 2017 11.
Artículo en Inglés | MEDLINE | ID: mdl-28407414

RESUMEN

AIMS: To assess the potential impact of glucagon-like peptide-1 receptor agonist (GLP-1RA) exposure on cardiovascular disease (CVD) and mortality outcomes in patients with type 2 diabetes (T2D), using a large retrospective cohort. RESEARCH DESIGN AND METHODS: Patients who had T2D between 2005 and 2014 (N = 105 862) were identified from the electronic health record system at Cleveland Clinic using a validated electronic phenotype. A time-dependent, Cox, multiple regression analysis was used to assess the association between GLP-1RA exposure and risk of acute myocardial infarction (AMI), stroke/cerebrovascular accident (CVA), and overall mortality, as well as the composite of all three outcomes. The findings were further evaluated by assessing the effect of GLP-1RAs on the same variables in patients with and without prior CVD. The model adjusted for differences in demographic information, hypertension, laboratory/vital signs, history of outcomes, and T2D medications. RESULTS: There were significantly lower rates of AMI (hazard ratio [HR] 0.80, 95% confidence interval [CI] 0.65 to 0.99; P = .045), CVA (HR 0.82, 95% CI 0.74 to 0.91, P < .001), overall mortality (HR 0.48, 95% CI 0.41 to 0.57; P < .001), and the composite outcome (HR 0.82, 95% CI 0.74 to 0.91; P < .002) during the consolidated time that patients were exposed to GLP-1RAs compared to corresponding rates during intervals without GLP-1RA exposure. GLP-1RA treatment was associated with a significant decrease in CVA, mortality, and the composite outcome in patients with and without established CVD, not significantly affecting AMI in these subgroups. CONCLUSIONS: GLP-1RA exposure was found to be associated with a reduction in the risk of cardiovascular events observed and overall mortality among patients with T2D with and without established CVD, after adjusting for potential confounders.


Asunto(s)
Diabetes Mellitus Tipo 2/tratamiento farmacológico , Diabetes Mellitus Tipo 2/epidemiología , Receptor del Péptido 1 Similar al Glucagón/agonistas , Hipoglucemiantes/uso terapéutico , Infarto del Miocardio/epidemiología , Accidente Cerebrovascular/epidemiología , Adulto , Anciano , Prestación Integrada de Atención de Salud , Diabetes Mellitus Tipo 2/complicaciones , Angiopatías Diabéticas/mortalidad , Angiopatías Diabéticas/prevención & control , Femenino , Humanos , Masculino , Persona de Mediana Edad , Mortalidad , Infarto del Miocardio/prevención & control , Estudios Retrospectivos , Factores de Riesgo , Accidente Cerebrovascular/prevención & control
4.
Diabetes Care ; 39(9): 1527-34, 2016 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-27519447

RESUMEN

OBJECTIVE: "Clinical inertia" has been used to describe the delay in the intensification of type 2 diabetes treatment among patients with poor glycemic control. Previous studies may have exaggerated the prevalence of clinical inertia by failing to adequately monitor drug dose changes and nonmedication interventions. This project evaluated the intensification of diabetes therapy and hemoglobin A1c (A1C) goal attainment among patients with newly diagnosed type 2 diabetes when metformin monotherapy failed. RESEARCH DESIGN AND METHODS: The electronic health record at Cleveland Clinic was used to identify patients with newly diagnosed type 2 diabetes between 2005 and 2013 who failed to reach the A1C goal after 3 months of metformin monotherapy. A time-dependent survival analysis was used to compare the time until A1C goal attainment in patients who received early intensification of therapy (within 6 months of metformin failure) or late intensification. The analysis was performed for A1C goals of 7% (n = 1,168), 7.5% (n = 679), and 8% (n = 429). RESULTS: Treatment was intensified early in 62%, 69%, and 72% of patients when poor glycemic control was defined as an A1C >7%, >7.5%, and >8%, respectively. The probability of undergoing an early intensification was greater the higher the A1C category. Time until A1C goal attainment was shorter among patients who received early intensification regardless of the A1C goal (all P < 0.05). CONCLUSIONS: A substantial number of patients with newly diagnosed type 2 diabetes fail to undergo intensification of therapy within 6 months of metformin monotherapy failure. Early intervention in patients when metformin monotherapy failed resulted in more rapid attainment of A1C goals.


Asunto(s)
Diabetes Mellitus Tipo 2/tratamiento farmacológico , Hemoglobina Glucada/efectos de los fármacos , Hipoglucemiantes/administración & dosificación , Metformina/administración & dosificación , Tiempo de Tratamiento/estadística & datos numéricos , Adulto , Anciano , Diabetes Mellitus Tipo 2/sangre , Diabetes Mellitus Tipo 2/complicaciones , Registros Electrónicos de Salud , Femenino , Objetivos , Humanos , Hiperglucemia/tratamiento farmacológico , Hiperglucemia/etiología , Masculino , Persona de Mediana Edad , Factores de Tiempo , Insuficiencia del Tratamiento
5.
Artículo en Inglés | MEDLINE | ID: mdl-27398040

RESUMEN

To assess changes in the clinical characteristics and treatment patterns of patients with newly diagnosed type 2 diabetes (T2D), the electronic health record system at Cleveland Clinic was used to create cross-sectional summaries of all patients with new-onset T2D in 2008 and 2013. Differences between the 2008 and 2013 data sets were assessed after adjusting for age, gender, race, and income. Approximately one-third of patients with newly diagnosed T2D in 2008 and 2013 had an A1C ≥8%, suggesting the continued presence of a delayed recognition of the disease. Patients with newly diagnosed T2D in 2008 were older than those in 2013. Hypertension, cardiovascular disease, and neuropathy were highly prevalent among patients diagnosed with T2D. The prevalence of neuropathy, cerebrovascular disease, and peripheral vascular disease increased from 2008 to 2013. Metformin was the most commonly prescribed antidiabetic medication. Sulfonylurea usage remained unchanged, while use of thiazolidinediones decreased considerably.

6.
BMJ Open Diabetes Res Care ; 3(1): e000093, 2015.
Artículo en Inglés | MEDLINE | ID: mdl-26217493

RESUMEN

PURPOSE: To compare the prevalence of diabetes-related complications and comorbidities, clinical characteristics, glycemic control, and treatment patterns in patients with type 2 diabetes (T2D) within a large integrated healthcare system in 2008 vs 2013. METHODS: An electronic health record system was used to create a cross-sectional summary of all patients with T2D as on 1 July 2008 and 1 July 2013. Differences between the two data sets were assessed after adjusting for age, gender, race, and household income. RESULTS: In 2008 and 2013, 24 493 and 41 582 patients with T2D were identified, respectively, of which the majority were male (52.3% and 50.1%) and Caucasian (79% and 75.2%). The mean ages (years) were 64.8 and 64.3. The percentages of patients across the defined A1C categories were 64.3 and 66.7 for <7%, 21.1 and 18.8 for 7-7.9%, 7.8 and 7.5 for 8-8.9%, and 6.8 and 7.0 for ≥9% in 2008 and 2013, respectively. The most prevalent T2D-related comorbidities were hypertension (82.5% and 87.2%) and cardiovascular disease (26.9% and 22.3%) in 2008 and 2013, respectively. Thiazolidinedione and sulfonylurea use decreased, whereas metformin and dipeptidyl peptidase-4 inhibitor use increased in the 5-year period. CONCLUSIONS: Patients with T2D are characterized by a high number of comorbidities. Over 85% of the patients had an A1C<8% within our integrated health delivery system in 2008 and 2013. In 2008 and 2013, metformin therapy was the most commonly utilized antidiabetic agent, and sulfonylureas were the most commonly utilized oral antidiabetic agent in combination with metformin. As integrated health systems assume greater shared financial risk in newer payment models, achieving glycemic targets (A1C) and the management of comorbidities will become ever-more important, for preventing diabetes-related complications, as well as to ensure reimbursement for the medical care that is rendered to patients with diabetes.

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