Implementation and evaluation of a SARI surveillance system in a tertiary hospital in Scotland in 2021/2022.

OBJECTIVE: To set up and evaluate a new surveillance system for severe acute respiratory infection (SARI) in Scotland. STUDY DESIGN: Cross-sectional study and evaluation of surveillance system. METHODS: The SARI case definition comprised patients aged 16 years or over with an acute respiratory illness presentation requiring testing for influenza and SARS-CoV-2 and hospital admission. Data were collected from SARI cases by research nurses in one tertiary teaching hospital using a bespoke data collection tool from November 2021 to May 2022. Descriptive analyses of SARI cases were carried out. The following attributes of the surveillance system were evaluated according to Centers for Disease Control and Prevention (CDC) guidelines: stability, data quality, timeliness, positive predictive value, representativeness, simplicity, acceptability and flexibility. RESULTS: The final surveillance dataset comprised 1163 records, with cases peaking in ISO week 50 (week ending 19/12/2021). The system produced a stable stream of surveillance data, with the proportion of SARI records with sufficient information for effective surveillance increasing from 65.4% during the first month to 87.0% over time. Similarly, the proportion where data collection was completed promptly was low initially, but increased to 50%-65% during later periods. CONCLUSION: SARI surveillance was successfully established in one hospital, but for a national system, additional sentinel hospital sites across Scotland, with flexibility to ensure consistently high data completeness and timeliness are needed. Data collection should be automated where possible, and demands on clinicians minimised. SARI surveillance should be embedded and resourced as part of a national respiratory surveillance strategy.

Real-time surveillance of severe acute respiratory infections in Scottish hospitals: an electronic register-based approach, 2017-2022.

OBJECTIVES: The COVID-19 pandemic highlighted the importance of routine syndromic surveillance of respiratory infections, specifically new cases of severe acute respiratory infection (SARI). This surveillance often relies on questionnaires carried out by research nurses or transcriptions of doctor's notes, but existing, routinely collected electronic healthcare data sets are increasingly being used for such surveillance. We investigated how patient diagnosis codes, recorded within such data sets, could be used to capture SARI trends in Scotland. STUDY DESIGN: We conducted a retrospective observational study using electronic healthcare data sets between 2017 and 2022. METHODS: Sensitive, specific and timely case definition (CDs) based on patient diagnosis codes contained within national registers in Scotland were proposed to identify SARI cases. Representativeness and sensitivity analyses were performed to assess how well SARI cases captured by each definition matched trends in historic influenza and SARS-CoV-2 data. RESULTS: All CDs accurately captured the peaks seen in laboratory-confirmed positive influenza and SARS-CoV-2 data, although the completeness of patient diagnosis records was discovered to vary widely. The timely CD provided the earliest detection of changes in SARI activity, whilst the sensitive CD provided insight into the burden and severity of SARI infections. CONCLUSIONS: A universal SARI surveillance system has been developed and demonstrated to accurately capture seasonal SARI trends. It can be used as an indicator of emerging secondary care burden of emerging SARI outbreaks. The system further strengthens Scotland's existing strategies for respiratory surveillance, and the methods described here can be applied within any country with suitable electronic patient records.

Analysis of spontaneous, user-generated data about gestational diabetes on online forums: implications for diabetes prevention.

AIMS: To explore the experiences and perceptions of gestational diabetes mellitus reported by women within online parental-support forums and, specifically, to analyse what women say about a diagnosis of gestational diabetes, their future risk of type 2 diabetes, and lifestyle behaviour for management of gestational diabetes and prevention of type 2 diabetes. METHODS: The discussion boards of two parenting websites (Mumsnet and Netmums) were searched using the search term 'gestational diabetes or GD' in February 2019. Relevant posts made by users with gestational diabetes on or after 1 January 2017 were retained for analysis. Framework analysis using pre-existing framework from a previous study was used to organize and analyse the data. RESULTS: A total of 646 posts generated by 282 unique users were included in the analysis. Analysis of the online content identified three important implicit messages that may be being conveyed to readers. The first is that gestational diabetes is not a serious diagnosis that warrants undue concern. Secondly, few users recognized the importance of their own behaviours or lifestyle, with others minimizing personal responsibility or attributing gestational diabetes to non-modifiable factors. Finally, there was a lack of acknowledgment of heightened risk of type 2 diabetes. These three messages will all directly mitigate against the efforts of clinicians (and others) to encourage women with gestational diabetes to improve their lifestyle behaviours in the longer term. CONCLUSIONS: These findings highlight messages that are being widely disseminated and that are unlikely to support prevention of type 2 diabetes.

Postnatal experiences, knowledge and perceptions of women with gestational diabetes.

AIM: Women with gestational diabetes mellitus (GDM) are at increased risk of Type 2 diabetes. This study aimed to explore experiences, knowledge and perceptions of women with GDM to inform the design of interventions to prevent or delay Type 2 diabetes. METHODS: Semi-structured interviews were carried out with 16 women with GDM who were recruited from a clinic in one Scottish health board. A framework approach was used to manage and analyse data according to themes informed by psychological theory (self-regulation model and theory of planned behaviour). RESULTS: GDM is not seen as an important, or even real diagnosis among some women, and this perception may result from the perceived minimal impact of GDM on their lives. Some women did experience a bigger emotional and practical impact. Knowledge and understanding of Type 2 diabetes was poor in general and many women were unconcerned about their future risk. Lower concern appeared to be linked to a lower perceived impact of GDM. Lifestyle changes discussed by women mostly related to diet and were motivated primarily by concern for their baby's health. Many women did not maintain these changes postnatally, reporting significant barriers. CONCLUSIONS: This study has suggested potential avenues to be explored in terms of content, timing and potential recipients of interventions. Educational interventions postnatally could address illness perceptions in women with GDM and redress the situation where lack of aftercare downplays its seriousness. For lifestyle interventions, the child's health could be used as a motivator within the context of later joint or family interventions.

Patterns of self-monitoring of blood glucose in insulin-treated diabetes: analysis of a Scottish population over time.

Analysis of a diabetes clinical information system in Tayside, Scotland, shows that a significant proportion of insulin-treated patients with diabetes are not self-monitoring blood glucose according to current clinical guidance and recommendations, with some not self-monitoring their blood glucose at all. Although there has been an increase in the number of reagent strips dispensed over the past decade, this increase is mainly accounted for by increased testing frequency among people with diabetes already testing.

Incidence of impaired glucose regulation and progression to type 2 diabetes mellitus in the Tayside region of Scotland.

This study assessed incidence of impaired glucose regulation (IGR) and progression to type 2 diabetes (T2D) in adults in one region of Scotland using routinely collected health-care data. Incidence of IGR was 2720 per 100,000 person years. Nine percent of IGR patients progressed to T2D in a mean time of 34 months.

Differences in self-assessed health by socioeconomic group amongst people with and without a history of cancer: an analysis using representative data from Scotland.

INTRODUCTION: This paper considers socioeconomic inequalities in self-assessed health amongst people with and without a history of cancer using representative data from Scotland. METHODS: A cross-sectional analysis using the Scottish Health Survey was done. Cancer survivors were identified using linked Cancer Registry data. Bivariate and multivariate analysis was used to compare and contrast self-assessed health amongst those with a history of cancer to those without. RESULTS: Of the 17,505 survey participants, 432 (2.5 %) had a history of cancer. After taking into account potential confounders, those in the lowest socioeconomic group were more likely to report poor health than those in the highest group amongst those with a history of cancer [odds ratio, 2.96; confidence interval (CI), 1.82-4.80] and those with no history of cancer (odds ratio, 2.45; CI, 2.21-2.71). Those in the lowest socioeconomic group with no history of cancer had a greater propensity to report poor health than any of the highest groups that did have a history of cancer (p < 0.01). Differences in propensities to indicate poor health were particularly marked amongst those 4 years or more post-cancer diagnosis. CONCLUSIONS: Findings underline the scale of socioeconomic gradients in health. That disparities were so wide amongst those most temporally distant from initial diagnosis is particularly a concern given improving survival after a cancer diagnosis. IMPLICATIONS FOR CANCER SURVIVORS: Socioeconomic circumstances have a considerable influence on health and well-being. Practitioners and policy makers should consider socioeconomic circumstances in considering approaches to health and social care of cancer survivors.

Self-monitoring of blood glucose in Type 2 diabetes: cross-sectional analyses in 1993, 1999 and 2009.

AIM: To characterize the numbers of reagent strips dispensed for self-monitoring of blood glucose to patients with Type 2 diabetes in Tayside, Scotland, in 1993, 1999 and 2009. METHODS: A diabetes clinical information system in Tayside, record-linked to electronic dispensed prescribing records, was used to collate all dispensed prescribing records for three cross-sectional samples of patients with Type 2 diabetes in 1993 (n = 5728), 1999 (n = 8109) and at 1 January 2009 (n = 16,450). The numbers of reagent strips dispensed during the relevant calendar year were calculated and patients stratified by treatment. We also explored whether age, sex or material and social deprivation were associated with whether a patient received strips. RESULTS: Proportions of people who received self-monitoring reagent strips increased from 15.5% in 1993, to 24.2% in 1999 to 29.8% in 2009, as did numbers of strips dispensed. While the proportion of diet-treated patients who received reagent strips was still very low in 2009 (5.6%), the proportion among those treated with oral agents tripled from 9.4 to 27.4% between 1993 and 2009. Over 90% of patients treated with insulin received reagent strips and, among non-insulin-treated patients, this was more common among women, younger people and less deprived groups. CONCLUSIONS: The numbers of reagent strips dispensed for self-monitoring of blood glucose has increased and almost all insulin-treated patients receive strips. While few diet-treated patients receive strips, they are more extensively dispensed to those treated with oral agents. Given that self-monitoring of blood glucose is no longer routinely recommended in non-insulin treated patients, strategies to reduce unnecessary dispensing of reagent strips are needed.

Prevalence and outcomes of use of potentially inappropriate medicines in older people: cohort study stratified by residence in nursing home or in the community.

OBJECTIVES: To compare the prevalence of use of potentially inappropriate medicines (PIMs) between older patients living in their own homes versus those living in nursing or residential homes, and to test the association between exposure to PIMs and mortality. DESIGN: Cohort study stratified by place of residence. SETTING: Tayside, Scotland. PARTICIPANTS: All people aged between 66 and 99 years who were resident or died in Tayside from 2005 to 2006. MAIN OUTCOME MEASURES: The exposure variable was PIM use as defined by Beers' Criteria. All cause mortality was the main outcome measure. RESULTS: 70,299 people were enrolled in the cohort of whom 96% were exposed to any medicine and 31% received a PIM. Place of residence was not associated with overall risk of receiving PIMs, adjusted OR 0.94, 95% CI 0.87 to 1.01. Exposure to five of the PIMs (including long-acting benzodiazepines) was significantly higher in nursing homes whereas exposure to five other PIMs (including amitriptyline and NSAIDs) was significantly lower. Exposure to PIMs was similar (20-46%) across all 71 general practices in Tayside and was not associated with increased risk of mortality after adjustment for age, gender and polypharmacy (adjusted OR 0.98, 95% CI 0.92 to 1.05). CONCLUSIONS: The authors question the validity of the full list of PIMs as an indicator of safety of medicines in older people because one-third of the population is exposed with little practice variation and no significant impact on mortality. Future studies should focus on management of a shorter list of genuinely high-risk medicines.

A 12-year follow-up study of all-cause and cardiovascular mortality among 10,532 people newly diagnosed with Type 2 diabetes in Tayside, Scotland.

AIMS: To determine absolute and relative risks of all-cause and cardiovascular mortality among patients newly diagnosed with Type 2 diabetes. METHODS: In an observational cohort study using record-linkage databases, based in Tayside, Scotland, UK, we identified newly diagnosed patients with Type 2 diabetes in 1993-2004. We also identified a set of non-diabetic comparators from lists of patients registered with a general practice, individually matched to the diabetic patients by sex, age and deprivation. We followed up patients for mortality and cardiovascular mortality over a 12-year period and calculated hazard ratios using Cox regression. RESULTS: There were 10,532 patients with Type 2 diabetes and 21,056 non-diabetic comparators. Diabetic patients in every age/sex group had higher absolute mortality rates. Even taking deprivation into account, the hazard ratio for mortality was 1.32 (95% CI 1.25-1.40), decreasing to 1.15 (1.09-1.22) after adjusting for pre-existing cardiovascular disease. The hazard ratios for cardiovascular mortality were higher, decreasing from 1.51 (1.37-1.67) to 1.23 (1.11-1.36) after adjusting for pre-existing cardiovascular disease. The hazard ratios decreased with increasing age at diagnosis, although the difference in absolute rate of mortality increased slightly with age. Increased mortality risks were only evident 2 years after diagnosis and increased thereafter. CONCLUSIONS: Patients with Type 2 diabetes have an increased risk of all-cause and cardiovascular mortality compared with non-diabetic comparators, although this is not observable immediately after diagnosis. Age at diagnosis and duration of the disease independently affect absolute and relative mortality risk.

A cohort study of the risk of cancer associated with type 2 diabetes.

BACKGROUND: There is evidence to suggest that diabetes may increase the risk of incidence and mortality from cancer. METHODS: In a cohort study using record-linkage health-care datasets for Tayside, Scotland in 1993-2004, we followed up 9577 newly diagnosed patients with type 2 diabetes, and two matched non-diabetic comparators, in the national cancer register. RESULTS AND CONCLUSIONS: The risk ratio for any cancer, adjusted for deprivation, was 0.99 (95%CI 0.90-1.09). Significantly increased risks were observed for pancreatic, liver and colon cancer.

Reporting of diabetes on death certificates of 1872 people with type 2 diabetes in Tayside, Scotland.

BACKGROUND: It has been suggested that diabetes is under-recorded on death certificates. METHODS: We examined the death certificates of 1,872 people with type 2 diabetes in Tayside, Scotland, to determine how frequently diabetes was recorded. RESULTS: Diabetes was mentioned on the certificates of 42.8% and was the underlying cause of death for 6.4%. There was mention of diabetes for 51.3% of the 811 people for whom cardiovascular disease was the underlying cause of death. Being male was associated with less frequent mention of diabetes, with more frequent mention associated with increasing duration of diabetes, increasing age and underlying cardiovascular cause of death. CONCLUSIONS: This study highlights the limitations of using routine mortality data for monitoring the burden of diabetes in populations.

Adherence to insulin and its association with glycaemic control in patients with type 2 diabetes.

BACKGROUND: Good glycaemic control improves outcomes in patients with type 2 diabetes, but the extent to which this depends on adherence to insulin treatment is uncertain. AIM: To investigate the association between adherence to insulin and glycaemic control in insulin-treated patients with type 2 diabetes. DESIGN: Observational records-based study. METHODS: We studied all patients with type 2 diabetes who were resident in Tayside, Scotland from 1 January 1995 to 30 September 2001, and who were treated with insulin. Adherence to insulin treatment was measured as the annual number of days of insulin coverage on the recommended dose, calculated from the amount of drug dispensed at community pharmacies and the recommended dose level for each patient. The association between glycaemic control (HbA1c), and adherence was determined, as was the influence of covariates, including age, sex, duration of diabetes and number of injections per day. RESULTS: A total of 1099 people were studied: 574 (52%) males and 525 (48%) females, mean +/- SD age 62 +/- 12 years, diabetes duration 10 +/- 7 years. Median time in the study (time for which insulin was dispensed) was 1107 (range 366-2446) days. Insulin prescribed was 58.0 +/- 33.3 IU/day and insulin collected from pharmacies was 53.6 +/- 27.1 IU/day. Mean adherence to insulin was thus 70.6%+/-17.7%. Adherence to insulin (p = 0.0021), BMI (p = 0.0001) and diabetes duration (p = 0.0314) were all significant predictors of HbA1c. DISCUSSION: Adherence to insulin appears poor in these type 2 diabetes patients, and there was a significant relationship between adherence and long-term metabolic control.

Increasing prevalence of type 2 diabetes in a Scottish population: effect of increasing incidence or decreasing mortality?

AIMS/HYPOTHESIS: We examined incidence, prevalence and mortality from type 2 diabetes mellitus in a Scottish population over 12 years, and evaluated the effects on prevalence of increasing incidence and decreasing mortality. MATERIALS AND METHODS: We used a diabetes clinical information system in Tayside (population 387,908), Scotland, to identify new cases of type 2 diabetes between 1993 and 2004 and to calculate incidence rates and mid-year prevalence. We defined mortality rates as the number of deaths of diabetic people divided by mid-year prevalence. We used logistic and Poisson regression to analyse trends. We then modelled the increase in prevalence for each year for three scenarios, based on whether mortality or incidence rates remained unchanged from 1993. RESULTS: There was a doubling in incidence and prevalence of type 2 diabetes in Tayside over the 12 years, with statistically significant increasing trends of 6.3 and 6.7% per year respectively. The mortality rate decreased. If incidence and mortality had remained at 1993 levels, there would have been an increase in prevalence of 855 per 100,000 in 2003, accounting for 60.1% of the actual increase of 1,423 per 100,000. If there had been no mortality decrease, prevalence in 2003 would have been very similar to the actual prevalence observed. CONCLUSIONS/INTERPRETATION: Decreasing mortality rates in Tayside had less effect on the increase in prevalence than did increasing incidence. Even if incidence and mortality remain unchanged, prevalence will increase by over 20% in the next decade.

Risk of mortality and adverse cardiovascular outcomes in type 2 diabetes: a comparison of patients treated with sulfonylureas and metformin.

AIMS/HYPOTHESIS: The aim of this study was to evaluate the risk of adverse cardiovascular outcomes in patients with type 2 diabetes newly treated with sulfonylureas and metformin. SUBJECTS AND METHODS: The Diabetes Audit and Research in Tayside Scotland (DARTS) diabetes information system and the Medicines Monitoring Unit (MEMO) dispensed prescribing database for the population of Tayside, Scotland (400,000 people) were employed. Patients newly prescribed with oral hypoglycaemic agents between 1994 and 2001 were classified into five study cohorts according to the treatment received: metformin only, sulfonylureas only, sulfonylureas added to metformin, metformin added to sulfonylureas, and both drugs simultaneously. In Cox regression analyses, we estimated relative risks for all-cause mortality, cardiovascular mortality and cardiovascular hospital admission for patients in the five study cohorts, with metformin monotherapy as the reference group. RESULTS: Of the 5,730 study patients, 1,000 died during a maximum of 8 years follow-up. Patients in the sulfonylureas only cohort had increased risks of mortality and cardiovascular mortality, with unadjusted relative risks of 3.12 (95% CI 2.54-3.84) and 3.71 (95% CI 2.64-5.22), respectively. After adjusting for differences between groups (age, sex, duration of diabetes, blood pressure, cholesterol, HbA(1c), smoking, previous hospital admission, treatment with cardiovascular medication), these relative risks were 1.43 (95% CI 1.15-1.77) and 1.70 (95% CI 1.18-2.45), respectively. Patients in the combination cohorts had significantly increased risks of cardiovascular hospital admission, as well as increased risks of mortality and cardiovascular mortality. CONCLUSIONS/INTERPRETATION: In this cohort study of patients newly treated with oral hypoglycaemic agents, those treated with sulfonylureas only, or combinations of sulfonylureas and metformin, were at higher risk of adverse cardiovascular outcomes than those treated with metformin alone.

The annual incidence of diabetic complications in a population of patients with Type 1 and Type 2 diabetes.

AIM: The DARTS diabetes register was used to determine incidence rates of diabetes and related complications in 1997. METHODS: The diabetes register records detailed clinical information for all patients diagnosed with diabetes in Tayside, Scotland. The study population included patients who were alive and registered with a Tayside GP for the duration of 1997 or who died in Tayside during this time. Patients who had diabetes prior to 1997, those who developed diabetes in 1997, and those who developed diabetic complications in 1997, were identified. RESULTS: In the Tayside population of 385 774 at the start of 1997, there were 942 and 6632 patients with Type 1 and Type 2 diabetes, with a further 29 and 744 patients diagnosed in 1997. The incidence rates (with 95% confidence intervals) of diabetic complications per 1000 patients with Type 1 and Type 2 diabetes, respectively, were: angina 8.8 (4.5-17.3) and 38.4 (33.4-44.2); myocardial infarction 8.6 (4.4-16.9) and 21.9 (18.4-25.9); cerebrovascular accident 1.1 (0.3-6.0) and 14.2 (11.6-17.5); lower extremity amputation 3.2 (1.2-9.4) and 3.1 (2.1-4.8); peripheral vascular disease 5.5 (2.4-12.8) and 13.6 (11.0-16.8); registered blindness 1.1 (0.3-5.9) and 1.6 (0.9-2.9); end-stage renal failure 6.4 (3.0-13.8) and 5.0 (3.6-7.0). Mortality was 14.6 per 1000 (9.6-25.7) in Type 1 diabetes and 50.0 per 1000 (45.1-55.3) in Type 2 diabetes. CONCLUSION: This study provides baseline figures for rates of diabetic complications for Type 1 and Type 2 diabetes, and confirms the increased burden of macrovascular disease in Type 2 diabetes.

Adherence to oral hypoglycaemic agents prior to insulin therapy in Type 2 diabetes.

AIM: To investigate whether patients require insulin as a result of poor adherence to oral hypoglycaemic agents (OHAs) in Type 2 diabetes. METHODS: A diabetes information system and a database of drugs dispensed for the study period 1993-1996 were used in Tayside, Scotland (population 400 000). Patients aged over 34 years with Type 2 diabetes who had at least 6 months exclusive therapy with OHAs (sulphonylureas or metformin) prior to insulin treatment were identified. Intended duration of every OHA prescription was calculated from prescription details. Adherence was estimated by dividing total intended duration of OHA therapy by study time for each patient, and compared between those who did and did not convert to insulin. RESULTS: There were 2537 patients on sulphonylureas (51% male, mean age 67 years). There was improved adherence in the 262 patients who commenced insulin, who had mean adherence of 88.3% (95% confidence interval (CI) 85.9-90.6%) compared with the remaining 2275 patients whose mean adherence was 87.4% (95% CI 86.7-88.2%). In a logistic regression analysis, the adjusted odds ratio (OR) for commencing insulin was 1.20 (95% CI 1.07-1.35) for a quartile increase in adherence. There were 1519 patients on metformin (49% male, mean age 64 years). Mean adherence was 79.7% (95% CI 76.4-83.1%) and 83.1% (95% CI 82.0-84.1%) in 169 patients who did and 1350 who did not commence insulin, respectively, with an adjusted OR for a quartile increase in adherence of 0.91 (95% CI 0.78-1.07). CONCLUSION: Despite suboptimal adherence to OHAs in Type 2 diabetes, this is not associated with subsequent requirement for insulin.