The prevalence and incidence of pharmacologically treated diabetes among older people receiving home care services in Norway 2009-2014: a nationwide longitudinal study.

BACKGROUND: A substantial proportion of older people who receive home care services (HCS) has diabetes and requires diabetes specific monitoring, treatment and self-care assistance. However, the prevalence and incidence rates of diabetes among older people in HCS are poorly described. The aim of the study is to estimate prevalence, incidence and time trends of pharmacologically treated diabetes among older people receiving HCS in Norway 2009-2014. METHODS: This nationwide observational cohort study is based on data from two population registries. The study population consisted of persons registered in the Norwegian Information System for the Nursing and Care Sector aged ≥ 65 years receiving HCS during at least one of the years 2009-2014. The Norwegian Prescription Database was utilized to identify participants' prescriptions for glucose lowering drugs (GLD). The period prevalence was calculated each year as persons with one or more prescriptions of GLD in the current or previous year. Incident cases were defined as subjects receiving prescriptions of GLD for the first time in the given calendar year if there were no prescriptions of any GLD for that person during the previous two years. RESULTS: From 2009 to 2014, the number of older people receiving HCS increased from 112,487 to 125,593. The proportion of these who received GLD increased from 14.2% to 15.7% (p < 0.001) and was significantly higher among men than women. The annual incidence rate of diabetes among those receiving HCS showed a decreasing trend from 95.4 to 87.5 cases per 10,000 person-years from 2011 to 2014, but when stratifying on age group and gender, was significant only among the oldest women (age groups 85-89 years and 90 +). CONCLUSIONS: The increasing prevalence of older people with diabetes who receive HCS highlights the importance of attention to treatment and care related to diabetes in the HCS.

Pharmacologically treated diabetes and hospitalization among older Norwegians receiving homecare services from 2009 to 2014: a nationwide register study.

INTRODUCTION: The aim was to assess whether annual hospitalization (admissions, length of stay and total days hospitalized) among persons >65 years receiving home care services in Norway were higher for persons with diabetes than those without diabetes. Given the growing prevalence of diabetes, this issue has great importance for policy makers who must plan for meeting these needs. RESEARCH DESIGN AND METHODS: Data were obtained from national Norwegian registries, and the study population varied from 112 487 to 125 593 per calendar year during 2009-2014. Diabetes was defined as having been registered with at least one prescription for blood glucose lowering medication. Overall and cause-specific hospitalization were compared, as well as temporal trends in hospitalization. Hospitalization outcomes for persons with and without diabetes were compared using log-binomial regression or quantile regression, adjusting for age and gender. Results are reported as incidence rate ratios (IRRs). RESULTS: Higher total hospitalization rates (IRR 1.17; 95% CI 1.12 to 1.22) were found among persons with, versus without, diabetes, and this difference remained stable throughout the study period. Similar reductions over time in hospital length of stay were observed among persons with and without diabetes, but total annual days hospitalized decreased significantly (p=0.001) more among those with diabetes than among those without diabetes. CONCLUSIONS: Among older recipients of home care services in Norway, diabetes was associated with a higher overall risk of hospitalization and increased days in the hospital. Given the growing prevalence of diabetes, it is important for policy makers to plan for meeting these needs.

Documented diabetes care among older people receiving home care services: a cross-sectional study.

BACKGROUND: Home care services plays an important role in diabetes management, and to enable older adults remain home-dwellers. Adequate follow-up and systematic nursing documentation are necessary elements in high quality diabetes care. Therefore, the purpose of this study was to examine the diabetes treatment and management for older persons with diabetes receiving home care services. METHODS: A cross-sectional study was used to assess the diabetes treatment and management in a Norwegian municipality. Demographic (age, sex, living situation) and clinical data (diabetes diagnose, type of glucose lowering treatment, diabetes-related comorbidities, functional status) were collected from electronic home care records. Also, information on diabetes management; i.e. follow-up routines on glycated haemoglobin (HbA1c), self-monitoring of blood glucose, insulin administration and risk factors (blood pressure, body mass index and nutritional status) were registered. HbA1c was measured upon inclusion. Descriptive and inferential statistics were applied in the data analysis. RESULTS: A total of 92 home care records from older home-dwelling persons with diabetes, aged 66-99 years were assessed. Only 52 (57 %) of the individuals had the diabetes diagnosis documented in the home care record. A routine for self-monitoring of blood glucose was documented for 27 (29 %) of the individuals. Only 2 (2 %) had individual target for HbA1c documented and only 3 (3 %) had a documented routine for measuring HbA1c as recommended in international guidelines. Among 30 insulin treated older individuals, a description of the insulin regimen lacked in 4 (13 %) of the home care records. Also, documentation on who performed self-monitoring of blood glucose was unclear or lacking for 5 (17 %) individuals. CONCLUSIONS: The study demonstrates lack of documentation in home care records with respect to diagnosis, treatment goals and routines for monitoring of blood glucose, as well as insufficient documentation on responsibilities of diabetes management among older home-dwelling adults living with diabetes. This indicates that home care services may be suboptimal and a potential threat to patient safety.

Casual blood glucose and subsequent cardiovascular disease and all-cause mortality among 159 731 participants in Cohort of Norway (CONOR).

INTRODUCTION: Our aim was to assess the association between casual blood glucose level and subsequent cardiovascular disease (CVD) and mortality among community-dwelling adults without a diagnosis of diabetes. RESEARCH DESIGN AND METHODS: In this community-based cohort study, 159 731 individuals with a measurement of casual blood glucose were followed from their participation date in Cohort of Norway (CONOR) (1994-2003) until a CVD episode, death or 31 December 2009. All analyses were done using Cox proportional hazard regression, and the results are reported as multivariable-adjusted HRs with 95% CI. RESULTS: Compared with those with normal glucose levels (<7.8 mmol/L), participants categorized as having borderline (7.8-11.0 mmol/L) levels showed an increased risk of a stroke (HR 1.29; 95% CI 1.12 to 2.49) and cardiovascular (HR 1.29; 95% CI 1.12 to 2.48), and all-cause (HR 1.27; 95% CI 1.16 to 1.38) mortality, while participants with high glucose levels (>11.0 mmol/L) had an even more increased risk. One mmol/L increase in glucose level was associated with an increased risk of all four endpoints among participants with borderline as well as within normal glucose levels. In analyses stratified by sex and age group, the CVD risk estimates tended to be higher in women than in men and in those <65 years of age but no significant interactions were found. CONCLUSION: An increase in casual blood glucose levels, even within the range of normal and borderline levels, was positively associated with increased risk of CVD and mortality among community-dwelling adults without a known diagnosis of diabetes.

How patient and community involvement in diabetes research influences health outcomes: A realist review.

BACKGROUND: Patient and public involvement in diabetes research is an international requirement, but little is known about the relationship between the process of involvement and health outcomes. OBJECTIVE: This realist review identifies who benefits from different types of involvement across different contexts and circumstances. Search strategies Medline, CINAHL and EMBASE were searched to identify interventions using targeted, embedded or collaborative involvement to reduce risk and promote self-management of diabetes. People at risk/with diabetes, providers and community organizations with an interest in addressing diabetes were included. There were no limitations on date, language or study type. DATA EXTRACTION AND SYNTHESIS: Data were extracted from 29 projects using elements from involvement frameworks. A conceptual analysis of involvement types was used to complete the synthesis. MAIN RESULTS: Projects used targeted (4), embedded (8) and collaborative (17) involvement. Productive interaction facilitated over a sufficient period of time enabled people to set priorities for research. Partnerships that committed to collaboration increased awareness of diabetes risk and mobilized people to co-design and co-deliver diabetes interventions. Cultural adaptation increased relevance and acceptance of the intervention because they trusted local delivery approaches. Local implementation produced high levels of recruitment and retention, which project teams associated with achieving diabetes health outcomes. DISCUSSION AND CONCLUSIONS: Achieving understanding of community context, developing trusting relationships across sectors and developing productive partnerships were prerequisites for designing research that was feasible and locally relevant. The proportion of diabetes studies incorporating these elements is surprisingly low. Barriers to resourcing partnerships need to be systematically addressed.

Integrative review: Patient safety among older people with diabetes in home care services.

AIMS: To identify diabetes specific patient safety domains that need to be addressed to improve home care of older people; to assess research from primary studies to review evidence on patient safety in home care services for older people with diabetes. DESIGN: An integrative review. DATA SOURCES: Domains for patient safety in diabetes home care settings were identified by conducting two searches. We performed searches in: CINAHL, Medline, Embase, and Cochrane Library for the years 2000-2017. REVIEW METHODS: The first search identified frameworks or models on patient safety in home care services published up to October 2017. The second search identified primary studies about older people with diabetes in the home care setting published between 2000-2017. RESULTS: Data from the 21 articles populated and refined 13 predetermined domains of patient safety in diabetes home care. These were used to explore how the domains interact to either increase or reduce risk. The domains constitute a model of associations between aspects of diabetes home care and adverse events. The results highlight a knowledge gap in safety for older persons with diabetes, influenced by e.g. hypoglycaemia, falls, pain, foot ulcers, cognitive impairment, depression, and polypharmacy. Moreover, providers' inadequate diabetes-specific knowledge and assessment skills contribute to the risk of adverse events. CONCLUSION: Older persons with diabetes in home care are at risk of adverse events due to their reduced ability to self-manage their condition, adverse medication effects, the family's ability to take responsibility or home care service's suboptimal approaches to diabetes care.

Experiences of being a family member to an older person with diabetes receiving home care services.

AIM: To describe family members' experiences of attending to an old person with diabetes receiving home care services, including their interaction with the formal caregivers. METHODS AND RESULTS: The study has a qualitative descriptive design. From May to August 2015, eight family members were interviewed. Interviews were analysed using qualitative content analysis. To describe family members' experiences, the following four themes were identified: Security through patients' self-management skills and diabetes knowledge; Perceived burden due to the old persons' deteriorated health; Security through competent home care services; and Doubt due to personnel's inadequate approach and interaction. CONCLUSION: It is important for personnel in home care services to consider patients' self-management skills and the family members' diabetes knowledge as key aspects in order to limit experiences of burden when the older person with diabetes has deteriorating health. The findings underscore that interaction with home care personnel skilled in managing diabetes helps family members feel secure.

Differences in depression, treatment satisfaction and injection behaviour in adults with type 1 diabetes and different degrees of lipohypertrophy.

AIMS AND OBJECTIVES: To assess the prevalence of lipohypertrophy, and to compare differences in external, personal and regimen factors in adults with type 1 diabetes and different degrees of lipohypertrophy. BACKGROUND: Suboptimal insulin injection behaviour is associated with lipohypertrophy, which may affect insulin absorption and lead to blood glucose fluctuations. Few, if any studies have investigated how external, personal and regimen factors differ in people with type 1 diabetes and different degrees of lipohypertrophy. DESIGN: A cross-sectional study including adults with type 1 diabetes at a diabetes outpatient clinic in a Norwegian university hospital. METHODS: Participants (n = 215) were included consecutively at scheduled appointments. Sociodemographic, diabetes and insulin treatment data, and self-report questionnaires concerning patient activation (Patient Activation Measure), depression (Patient Health Questionnaire-2), diabetes distress (Diabetes Distress Scale), type D personality (14-item Type D scale), treatment satisfaction (Insulin Treatment Satisfaction Questionnaire) and motivation (Treatment Self-Regulation Questionnaire), were collected. Lipohypertrophic injection sites were identified by palpation by diabetes specialist nurses. RESULTS: Lipohypertrophy was present in 53% and was more frequent in insulin pen users (63%) compared to insulin pump users (34%). Participants with two or more lipohypertrophic areas had higher depression scores, lower treatment satisfaction with glycaemic control, higher bolus doses and reported suboptimal injection behaviour compared to those with no lipohypertrophic areas. There were no differences in patient activation, diabetes distress, type D personality or motivation between the groups. DISCUSSION AND CONCLUSION: Compared to pump treatment, pen treatment requires greater awareness of injection technique. Symptoms of depression and lower treatment satisfaction might affect diabetes self-management and glycaemic control, but the association with lipohypertrophy needs further exploration. RELEVANCE TO CLINICAL PRACTICE: Lipohypertrophy is more frequent in insulin pen users compared to pump users. Nurses should focus on injection technique education, and should also consider screening for depressive symptoms and treatment satisfaction as these factors could be associated with development of lipohypertrophy.

Lasting impact of an implemented self-management programme for people with type 2 diabetes referred from primary care: a one-group, before-after design.

BACKGROUND: Research interventions in uniform clinical settings and in patients fulfilling well-defined inclusion criteria might show a more pronounced effect than implementing the same intervention in existing practice. Diabetes Self-Management Education (DSME) is complex, and should be assessed in existing practice as it is an intervention widely implemented. OBJECTIVES: To examine the impact of an established group-based DSME in unselected people with type 2 diabetes referred from primary care. METHOD: A one-group, before-after design was used for assessments before, immediately after, and 3 months after participation in a group-based DSME programme conducted at two Learning and Mastering Centres in Norway between November 2013 and June 2014. Participants completed a questionnaire before (n = 115), immediately after (n = 95) and 3 months after (n = 42) the DSME programme. Primary outcome measure was diabetes knowledge (Michigan Diabetes Knowledge Test). Also patient activation (Patient Activation Measure [PAM]) and self-efficacy (General Self-Efficacy scale [GSE]) were measured. Changes in outcome measures were analysed using paired t-tests for normally distributed data and Wilcoxon signed-rank test for skewed data. RESULTS: Mean knowledge improved significantly from baseline (p < 0.001). Changes persisted at the 3-month assessment. Mean PAM scores improved significantly from baseline (p < 0.001), and changes persisted for 3 months. Mean GSE scores improved from baseline (p = 0.022) and persisted for 3 months. However, when results were stratified for participants who responded at all three time points, GSE showed no change during the study period. CONCLUSION: The complexity self-management in the individual is challenging to reflect in DSME. This implemented DSME programme for people with type 2 diabetes improved levels of diabetes knowledge and patient activation, persisting for at least 3 months. Hence, the DSME programme appears to be robust beyond standardised research settings, in educating unselected diabetes patients referred from primary care.

Involving people with diabetes and the wider community in diabetes research: a realist review protocol.

BACKGROUND: Patient and public involvement in diabetes research is now actively encouraged in different countries because it is believed that involving people with experience of the condition will improve the quality and relevance of the research. However, reviews of patient involvement have noted that inadequate resources, patients' and communities' lack of research knowledge, and researchers' lack of skills to involve patients and communities in research may present significant contextual barriers. Little is known about the extent of patient/community involvement in designing or delivering interventions for people with diabetes. A realist review of involvement will contribute to assessing when, how and why involvement works, or does not work, to produce better diabetes interventions. METHODS/DESIGN: This protocol outlines the process for conducting a realist review to map how patients and the public have been involved in diabetes research to date. The review questions ask the following: How have people with diabetes and the wider community been involved in diabetes research? What are the characteristics of the process that appear to explain the relative success or failure of involvement? How has involvement (or lack of involvement) in diabetes research influenced the development and conduct of diabetes research? The degree of support in the surrounding context will be assessed alongside the ways in which people interact in different settings to identify patterns of interaction between context, mechanisms and outcomes in different research projects. The level and extent of the involvement will be described for each stage of the research project. The descriptions will be critically reviewed by the people with diabetes on our review team. In addition, researchers and patients in diabetes research will be asked to comment. Information from researcher-patient experiences and documents will be compared to theories of involvement across a range of disciplines to create a mid-range theory describing how involvement (or lack of involvement) in diabetes research influences the development and conduct of diabetes research.

Relevance and variability of the severity of incontinence, and increased daytime and night-time voiding frequency, associated with quality of life in men with lower urinary tract symptoms.

OBJECTIVES: To estimate the distribution of the severity of urinary incontinence (UI) and daytime and night-time voiding in patients with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH); to estimate the proportion of 'subjectively relevant' symptoms within each severity category; to identify differences in quality of life (QoL) by degree of subjectively relevant daytime and night-time symptoms; and to identify differences in QoL in men with subjectively relevant UI or no UI. PATIENTS AND METHODS: Data from a group of 480 men awaiting urological assessment for LUTS suggestive of BPH were collected by questionnaire shortly after referral from their general practitioner in 1997-2000. The International Continence Society--Benign Prostatic Hyperplasia Index, Sandvik's Incontinence Severity Index, and the World Health Organization Quality of Life Survey--Abbreviated Version (WHOQoL-bref) were used to assess symptoms and QoL. RESULTS: There was a large heterogeneity of self-reported symptom severity and related bother in the three symptoms of UI, increased daytime voiding frequency and night-time voiding in these referred patients. The WHOQoL-bref showed significant group differences of subjectively relevant symptoms. CONCLUSION: The perception of increased night and daytime frequency, as measured by symptom severity and bother, varied greatly. The severity of UI and its effect on men waiting for a urological assessment of LUTS suggestive of BPH also varied widely. In general, the symptoms and their impact were slight to moderate. The WHOQoL-bref could be used to differentiate among groups of subjectively relevant symptoms, and in so doing supported information generated by the bother question.