A register-based study describing time trends in risk factor control and serious hypoglycaemia together with the effects of starting continuous glucose monitoring in people with type 1 diabetes in Norway.

AIMS: To describe trends in risk factor control and serious hypoglycaemia in people with type 1 diabetes and to assess the effect of starting continuous glucose monitoring (CGM) in the real-world setting. METHODS: Two cross-sectional surveys including 5746 individuals in 2012 and 18,984 individuals in 2020 based on data recorded in the Norwegian Diabetes Register for Adults (NDR-A) and an analysis of a longitudinal cohort of 2057 individuals where data on CGM and HbA1c were available in the NDR-A in 2012 and 2020. RESULTS: In the cross-sectional surveys mean HbA1c decreased from 66 mmol/mol (99% CI 65, 66) (8.2%) in 2012 to 61 mmol/mol (99% CI 61, 61) (7.7%) in 2020 (p < 0.0001). The proportion reporting serious hypoglycaemia decreased from 16.9 to 6.2% in 2020 (p < 0.0001). Mean LDL-cholesterol decreased from 2.80 (99% CI 2.78, 2.83) to 2.63 (99% CI 2.61, 2.65) mmol/l in 2020 (p < 0.0001). Mean blood pressure increased slightly. In the CGM cohort, we found a 3 mmol/mol (0.3%) greater improvement in mean HbA1c and a greater reduction in serious hypoglycaemia (-12.3% vs. -6.2%) among individuals that had started using CGM between 2013 and 2020 when compared with individuals that had not started using CGM. CONCLUSIONS: Between 2012 and 2020, we found marked improvements in glycaemic control and a considerable decrease in the proportion of individuals reporting serious hypoglycaemia. The proportion of individuals using CGM increased substantially and individuals that had started using CGM by 2020 showed greater improvement in glycaemic control and less serious hypoglycaemia.

Diabetes Distress and Associations With Demographic and Clinical Variables: A Nationwide Population-Based Registry Study of 10,186 Adults With Type 1 Diabetes in Norway.

OBJECTIVE: To estimate diabetes distress prevalence and associations with demographic and clinical variables among adults with type 1 diabetes in Norway. RESEARCH DESIGN AND METHODS: In this nationwide population-based registry study, the 20-item Problem Areas in Diabetes (PAID-20) questionnaire was sent to 16,255 adults with type 1 diabetes. Linear regression models examined associations of demographic and clinical variables with distress. RESULTS: In total, 10,186 individuals (62.7%) completed the PAID-20, with a mean score of 25.4 (SD 18.4) and 21.7% reporting high distress. Respondents endorsed worrying about the future and complications as the most problematic item (23.0%). Female sex, younger age, non-European origin, primary education only, unemployment, smoking, continuous glucose monitoring use, more symptomatic hypoglycemia, reduced foot sensitivity, treated retinopathy, and higher HbA1c were associated with higher distress. CONCLUSIONS: Diabetes distress is common among adults with type 1 diabetes and associated with clinically relevant factors, underlining that regular care should include efforts to identify and address distress.

Insulin initiation in patients with type 2 diabetes is often delayed, but access to a diabetes nurse may help-insights from Norwegian general practice.

Objective: We opted to study how support staff operational capacity and diabetes competences may impact the timeliness of basal insulin-initiation in general practice patients with type 2 diabetes (T2D).Design/Setting/Outcomes: This was an observational and retrospective study on Norwegian primary care patients with T2D included from the ROSA4-dataset. Exposures were (1) support staff size, (2) staff size relative to number of GPs, (3) clinic access to a diabetes nurse and (4) share of staff with diabetes course (1 and 2 both relate to staff operational capacity, whereas 3 and 4 are both indicatory of staff diabetes competences). Outcomes were 'timely basal insulin-initiation' (primary) and 'attainment of HbA1c<7%' after insulin start-up (secondary). Associations were analyzed using multiple linear regression, and directed acyclic graphs guided statistical adjustments.Subjects: Insulin naïve patients with 'timely' (N = 294), 'postponed' (N = 219) or 'no need of' (N = 3,781) basal insulin-initiation, respectively.Results: HbA1c [median (IQR)] increased to 8.8% (IQR, 8.0, 10.2) prior to basal insulin-initiation, which reduced HbA1c to 7.3 (6.8-8.1) % by which only 35% of the subjects reached HbA1c <7%. Adjusted risk of 'timely basal insulin-initiation' was more than twofold higher if access to a diabetes nurse (OR = 2.40, [95%CI, 1.68, 3.43]), but related only vaguely to staff size (OR = 1.01, [95%CI, 1.00, 1.03]). No other staff factors related significantly to neither the primary nor the secondary outcome.Conclusion: In Norwegian general practice, insulin initiation in people with T2D may be affected by therapeutic inertia but access to a diabetes nurse may help facilitating more timely insulin start-up.

In patients with type 2 diabetes (T2D) cared for by their general practice physician (GP), insulin therapy was susceptible to therapeutic inertia.In Norwegian general practice, chance of timely basal insulin-initiation was found more than two-fold higher if the GP had access to a diabetes nurse.In contrast, the timeliness of basal insulin-initiation in general practice patients with T2D seemed unaffected by share of support staff with diabetes course and by factors indicatory of support staff overall operational capacity.In Norwegian general practice, a diabetes nurse seems to offer unique clinical benefits to the care of insulin treated patients with T2D.

Level of education is associated with coronary heart disease and chronic kidney disease in individuals with type 2 diabetes: a population-based study.

INTRODUCTION: To study the relationship between education level and vascular complications in individuals with type 2 diabetes in Norway. RESEARCH DESIGN AND METHODS: Multiregional population-based cross-sectional study of individuals with type 2 diabetes in primary care. Data were extracted from electronic medical records in the period 2012-2014. Information on education level was obtained from Statistics Norway. Using multivariable multilevel regression analyses on imputed data we analyzed the association between education level and vascular complications. We adjusted for age, sex, HbA1c, low-density lipoprotein cholesterol, systolic blood pressure, smoking and diabetes duration. Results are presented as ORs and 95% CIs. RESULTS: Of 8192 individuals with type 2 diabetes included, 34.0% had completed compulsory education, 49.0% upper secondary education and 16.9% higher education. The prevalence of vascular complications in the three education groups was: coronary heart disease 25.9%, 23.0% and 16.9%; stroke 9.6%, 7.4% and 6.6%; chronic kidney disease (estimated glomerular filtration rate <60 mL/min/1.73 m2) 23.9%, 16.8% and 12.6%; and retinopathy 13.9%, 11.5% and 11.7%, respectively. Higher education was associated with lower odds for coronary heart disease (OR 0.59; 95% CI 0.49 to 0.71) and chronic kidney disease (OR 0.75; 95% CI 0.60 to 0.93) compared with compulsory education when adjusting for age, sex, HbA1c, low-density lipoprotein cholesterol, systolic blood pressure, smoking and diabetes duration. CONCLUSIONS: In a country with equal access to healthcare, high education level was associated with lower odds for coronary heart disease and chronic kidney disease in individuals with type 2 diabetes.

Fear of Covid 19 during the third wave of infection in Norwegian patients with type 1 diabetes.

OBJECTIVE: To study the fear of Covid 19 infection among Norwegian patients with type 1 diabetes. RESEARCH DESIGN AND METHODS: Fear of Covid 19 scale, a validated scale assessing the fear of Covid 19, was sent electronically to 16255 patients with type 1 diabetes in May 2021. The items are rated on a scale from 1 to 5 (total scores from 7 to 35). The higher the score, the greater the fear. RESULTS: 10145 patients, 52% of the Norwegian adult type 1 diabetes population, completed the questionnaire. The mean total fear score was 13.8 (SD 5.8). Women experienced more fear than men (OR 1.96), and fear increased significantly with increasing age for both genders (p<0.05). Fear increased with increasing BMI, more pronounced for men than women. Fear was positively correlated to HbA1c (Spearman rho 0.067, p<0.05), and significantly increased in patients with micro- and macrovascular complications, compared with patients without complications (p<0.05). Smokers showed increased fear compared with non-smokers, (1.59 (1.39-1.81)), and non-European patients reported more fear than Europeans (OR of 2.02 (95% CI 1.55-2.63). CONCLUSION: Assessment of fear of Covid 19 in the type 1 diabetes population in Norway revealed an overall low fear during the third wave of infection. Patients considered to be at high risk of serious disease, such as older individuals, smokers and obese individuals expressed more fear than low risk individuals. The degree of fear was also associated with sex, ethnicity, educational/working status, glycemic control and presence of complications.

Cohort profile: Outcomes & Multi-morbidity In Type 2 diabetes (OMIT) - a national registry-based observational cohort with focus on care and treatment of key high-risk groups in Norway.

PURPOSE: The 'Outcomes & Multi-morbidity in Type 2 Diabetes' (OMIT) is an observational registry-based cohort of Norwegian patients with type 2 diabetes (T2D) established to study high-risk groups often omitted from randomised clinical trials. PARTICIPANTS: The OMIT cohort includes 57 572 patients with T2D identified via linkage of Norwegian Diabetes Register for Adults and the Rogaland-Oslo-Salten-Akershus-Hordaland study, both offering data on clinical patient characteristics and drug prescriptions. Subsequently these data are further linked to the Norwegian Prescription Database for dispensed medications, the Norwegian Population Register for data on death and migration, Statistics Norway for data on socioeconomic factors and ethnicity and the Norwegian Directorate of Health for data on the general practices and clinical procedures involved in the care of cohort patients. OMIT offers large samples for key high-risk patient groups: (1) young-onset diabetes (T2D at age <40 years) (n=6510), (2) elderly (age >75 years) (n=15 540), (3) non-Western ethnic minorities (n=9000) and (4) low socioeconomic status (n=20 500). FINDINGS TO DATE: On average, patient age and diabetes duration is 67.4±13.2 and 12.3±8.3 years, respectively, and mean HbA1c for the whole cohort through the study period is 7.6%±1.5% (59.4±16.3 mmol/mol), mean body mass index (BMI) and blood pressure is 30.2±5.9 kg/m2 and 135±16.1/78±9.8 mm Hg, respectively. Prevalence of retinopathy, coronary heart disease and stroke is 10.1%, 21% and 6.7%, respectively. FUTURE PLANS: The OMIT cohort features 5784 subjects with T2D in 2006, a number that has grown to 57 527 in 2019 and is expected to grow further via repeated linkages performed every third to fifth year. At the next wave of data collection, additional linkages to Norwegian Patient Registry and Norwegian Cause of Death Registry for data on registered diagnoses and causes of death, respectively, will be performed.

International comparison of glycaemic control in people with type 1 diabetes: an update and extension.

AIMS: To update and extend a previous cross-sectional international comparison of glycaemic control in people with type 1 diabetes. METHODS: Data were obtained for 520,392 children and adults with type 1 diabetes from 17 population and five clinic-based data sources in countries or regions between 2016 and 2020. Median HbA1c (IQR) and proportions of individuals with HbA1c < 58 mmol/mol (<7.5%), 58-74 mmol/mol (7.5-8.9%) and ≥75 mmol/mol (≥9.0%) were compared between populations for individuals aged <15, 15-24 and ≥25 years. Logistic regression was used to estimate the odds ratio (OR) of HbA1c < 58 mmol/mol (<7.5%) relative to ≥58 mmol/mol (≥7.5%), stratified and adjusted for sex, age and data source. Where possible, changes in the proportion of individuals in each HbA1c category compared to previous estimates were calculated. RESULTS: Median HbA1c varied from 55 to 79 mmol/mol (7.2 to 9.4%) across data sources and age groups so a pooled estimate was deemed inappropriate. OR (95% CI) for HbA1c < 58 mmol/mol (<7.5%) were 0.91 (0.90-0.92) for women compared to men, 1.68 (1.65-1.71) for people aged <15 years and 0.81 (0.79-0.82) aged15-24 years compared to those aged ≥25 years. Differences between populations persisted after adjusting for sex, age and data source. In general, compared to our previous analysis, the proportion of people with an HbA1c  < 58 mmol/l (<7.5%) increased and proportions of people with HbA1c ≥ 75 mmol/mol (≥9.0%) decreased. CONCLUSIONS: Glycaemic control of type 1 diabetes continues to vary substantially between age groups and data sources. While some improvement over time has been observed, glycaemic control remains sub-optimal for most people with Type 1 diabetes.

Use of patient-reported outcome measures (PROMs) in clinical diabetes consultations: the DiaPROM randomised controlled pilot trial.

OBJECTIVE: To pilot test the proposed DiaPROM trial components and address uncertainties associated with conducting a full-scale randomised controlled trial (RCT) to evaluate whether such a trial is feasible. DESIGN: Two-arm pilot RCT. PARTICIPANTS: Adults aged ≥18-39 years, with minimum 1 year type 1 diabetes duration, attending outpatient follow-up. Exclusion criteria were pregnancy, severe cognitive, somatic or psychiatric conditions and impaired vision. RANDOMISATION AND INTERVENTION: All participants completed electronic Patient-Reported Outcome Measures (PROMs) prior to the annual diabetes consultation. Using computer-generated block-randomisation without blinding, we assigned participants in a 1:1 ratio stratified by sex to receive standard care or an intervention. Physicians reviewed diabetes distress scores (Problem Areas In Diabetes scale) and referred individuals with scores ≥30 or single item(s) ≥3 to minimum two diabetes nurse consultations where reported problems were reviewed and discussed. OUTCOMES: Recruitment and retention rates; participants perceptions about intervention components. Variance and estimated between-group differences in follow-up scores (Diabetes Distress Scale (DDS), WHO 5-Well-being Index, Perceived Competence for Diabetes Scale and glycaemic control) and DDS correlation with baseline scores, to assist sample size calculations. RESULTS: We randomised 80 participants to the control or intervention arm (one participant was later excluded). 23/39 intervention arm participants qualified for additional consultations and 17 attended. 67/79 attended the 12-month follow-up (15.2% attrition); 5/17 referred to additional consultations were lost to follow-up (29.4% attrition). Participants reported PROMs as relevant (84.6%) and acceptable (97.4%) but rated the usefulness of consultations as moderate to low. Baseline mean±SD DDS score was 2.1±0.69; DDS SD was 0.71 (95% CI: 0.60 to 0.86) at follow-up; correlation between baseline and follow-up DDS scores was 0.8 (95% CI: 0.7 to 0.9). CONCLUSIONS: The pilot trial revealed need for intervention modifications ahead of a full-scale trial to evaluate use of PROMs in diabetes consultations. Specifically, participant acceptability and intervention implementation need further investigation.

High adherence to recommended diabetes follow-up procedures by general practitioners is associated with lower estimated cardiovascular risk.

AIMS: To explore whether the general practitioners' (GPs') performance of recommended processes of care was associated with estimated risk of cardiovascular disease (CVD) and poor glycaemic control in patients with type 2 diabetes. METHODS: A cross-sectional study from Norwegian general practice including 6015 people with type 2 diabetes <75 years old, without CVD and their 275 GPs. The GPs were split into quintiles based on each GP's average performance of six recommended processes of care. The quintiles were the exposure variable in multilevel regression models with 10-year risk of cardiovascular events estimated by NORRISK 2 (total and modifiable fraction) and poor glycaemic control (HbA1c >69 mmol/mol (>8.5%)) as outcome variables. RESULTS: The mean total and modifiable estimated 10-year CVD risk was 12.3% and 3.3%, respectively. Compared with patients of GPs in the highest-performing quintile, patients treated by GPs in the lowest quintile had an adjusted total and modifiable CVD risk that was 1.88 (95% CI 1.17-2.60) and 1.78 (1.14-2.41) percent point higher. This represents a relative mean difference of 16.6% higher total and 74.8% higher modifiable risk among patients of GPs in the lowest compared with the highest quintile. For patients with GPs in the lowest-performing quintile, the adjusted odds of poor glycaemic control was 1.77 (1.27-2.46) times higher than that for patients with a GP in the highest quintile. CONCLUSIONS: We found a pattern of lower CVD risk and better glycaemic control in patients of GPs performing more recommended diabetes processes of care.

Variation between general practitioners in type 2 diabetes processes of care.

AIMS: To explore variation in general practitioners' (GPs') performance of six recommended procedures in type 2 diabetes patients <75 years without cardiovascular disease. METHODS: Cross-sectional study of quality of diabetes care in Norway based on electronic health records from 2014. GPs (clustered in practices) were divided in quintiles based on a composite measure of performance of six processes of care. We fitted a multilevel partial ordinal regression model to identify GP factors associated with being in quintiles with better performance. RESULTS: We identified 6015 type 2 diabetes patients from 275 GPs in 77 practices. The GPs performed on average 63.4% of the procedures; on average 46% in the poorest quintile to 81% in the best quintile with a larger range in individual GPs. After adjustments, use of a structured follow-up form was associated with GPs being in upper three quintiles (OR 12.4 (95% CI 2.37-65.1). Routines for reminders were associated with being in a better quintile (OR 2.6 (1.37-4.92). GPs' age >60 years and heavier workload were associated with poorer performance. CONCLUSION: We found large variations in GPs' performance of processes of care. Factors reflecting structure and workload were strongly associated with performance.

Making Use of Comparable Health Data to Improve Quality of Care and Outcomes in Diabetes: The EUBIROD Review of Diabetes Registries and Data Sources in Europe.

Background: Registries and data sources contain information that can be used on an ongoing basis to improve quality of care and outcomes of people with diabetes. As a specific task of the EU Bridge Health project, we carried out a survey of diabetes-related data sources in Europe. Objectives: We aimed to report on the organization of different sources of diabetes information, including their governance, information infrastructure and dissemination strategies for quality control, service planning, public health, policy and research. Methods: Survey using a structured questionnaire to collect targeted data from a network of collaborating institutions managing registries and data sources in 17 countries in the year 2017. Results: The 18 data sources participating in the study were most frequently academic centres (44.4%), national (72.2%), targeting all types of diabetes (61.1%) covering no more than 10% of the target population (44.4%). Although population-based in over a quarter of cases (27.8%), sources relied predominantly on provider-based datasets (38.5%), fewer using administrative data (16.6%). Data collection was continuous in the majority of cases (61.1%), but 50% could not perform data linkage. Public reports were more frequent (72.2%) as well as quality reports (77.8%), but one third did not provide feedback to policy and only half published ten or more peer reviewed papers during the last 5 years. Conclusions: The heterogeneous implementation of diabetes registries and data sources hampers the comparability of quality and outcomes across Europe. Best practices exist but need to be shared more effectively to accelerate progress and deliver equitable results for people with diabetes.

Availability and analytical quality of hemoglobin A1c point-of-care testing in general practitioners' offices are associated with better glycemic control in type 2 diabetes.

Background It is not clear if point-of-care (POC) testing for hemoglobin A1c (HbA1c) is associated with glycemic control in type 2 diabetes. Methods In this cross-sectional study, we linked general practitioner (GP) data on 22,778 Norwegian type 2 diabetes patients to data from the Norwegian Organization for Quality Improvement of Laboratory Examinations. We used general and generalized linear mixed models to investigate if GP offices' availability (yes/no) and analytical quality of HbA1c POC testing (average yearly "trueness score", 0-4), as well as frequency of participation in HbA1c external quality assurance (EQA) surveys, were associated with patients' HbA1c levels during 2014-2017. Results Twenty-eight out of 393 GP offices (7%) did not perform HbA1c POC testing. After adjusting for confounders, their patients had on average 0.15% higher HbA1c levels (95% confidence interval (0.04-0.27) (1.7 mmol/mol [0.5-2.9]). GP offices participating in one or two yearly HbA1c EQA surveys, rather than the maximum of four, had patients with on average 0.17% higher HbA1c levels (0.06, 0.28) (1.8 mmol/mol [0.6, 3.1]). For each unit increase in the GP offices' HbA1c POC analytical trueness score, the patients' HbA1c levels were lower by 0.04% HbA1c (-0.09, -0.001) (-0.5 mmol/mol [-1.0, -0.01]). Conclusions Novel use of validated patient data in combination with laboratory EQA data showed that patients consulting GPs in offices that perform HbA1c POC testing, participate in HbA1c EQA surveys, and maintain good analytical quality have lower HbA1c levels. Accurate HbA1c POC results, available during consultations, may improve diabetes care.

Exploring the relationship between coronary heart disease and type 2 diabetes: a cross-sectional study of secondary prevention among diabetes patients.

BACKGROUND: Coronary heart disease (CHD) and stroke are the major causes of death among people with diabetes. AIM: To describe the prevalence and onset of CHD and stroke among patients with type 2 diabetes mellitus (T2DM) in primary care in Norway, and explore the quality of secondary prevention. DESIGN & SETTING: A cross-sectional study of data was undertaken from electronic medical records (EMRs) of 10 255 patients with T2DM in general practice. The study took place in five counties of Norway (Oslo, Akershus, Rogaland, Hordaland, and Nordland). Quality of care was assessed based on national guideline recommendations. METHOD: Summary statistics with adjustments and binary logistic regression models were used. RESULTS: In total, 2260 patients (22.1%) had CHD and 759 (7.4%) had stroke. South Asians had significantly more CHD than ethnic Norwegians (29.5%, 95% confidence interval [CI] = 26.1 to 33.0 versus 21.5%, CI = 20.6 to 22.3) and other ethnic groups, and experienced onset of CHD or stroke at a mean of 7 years before Norwegians. In 47.9% of the patients, CHD was diagnosed before T2DM. Treatment target for low-density lipoprotein (LDL) cholesterol was reached for 30.0% and for systolic blood pressure (SBP) for 65.1% of the patients with CHD. Further, 20.9% of patients with CHD were present smokers, and only 5.0% of patients reached all four treatment targets (no smoking, HbA1c ≤7.0%, SBP <135 mmHg, LDL-cholesterol <1.8 mmol/l). CONCLUSION: The diagnosis of CHD preceded the diagnosis of T2DM in half of the patients. The prevalence of CHD was highest and onset earlier among ethnic South Asians. More intensive treatment of lipids, blood pressure, and smoking are needed in patients with T2DM and CHD.

Are general practitioners characteristics associated with the quality of type 2 diabetes care in general practice? Results from the Norwegian ROSA4 study from 2014.

OBJECTIVE: To explore the associations between general practitioners (GPs) characteristics such as gender, specialist status, country of birth and country of graduation and the quality of care for patients with type 2 diabetes (T2DM). DESIGN: Cross-sectional survey. SETTING AND SUBJECTS: The 277 GPs provided care for 10082 patients with T2DM in Norway in 2014. The GPs characteristics were self-reported: 55% were male, 68% were specialists in General Practice, 82% born in Norway and 87% had graduated in Western Europe. Of patients, 81% were born in Norway and 8% in South Asia. Data regarding diabetes care were obtained from electronic medical records and manually verified. MAIN OUTCOME MEASURES: Performance of recommended screening procedures, prescribed medication and level of HbA1c, blood pressure and LDL-cholesterol stratified according to GPs characteristics, adjusted for patient and GP characteristics. RESULT: Female GPs, specialists, GPs born in Norway and GPs who graduated in Western Europe performed recommended procedures more frequently than their counterparts. Specialists achieved lower mean HbA1c (7.14% vs. 7.25%, p < 0.01), a larger proportion of their patients achieved good glycaemic control (HbA1c = 6.0%-7.0%) (49.1% vs. 44.4%, p = 0.018) and lower mean systolic blood pressure (133.0 mmHg vs. 134.7 mmHg, p < 0.01) compared with non-specialists. GPs who graduated in Western Europe achieved lower diastolic blood pressure than their counterparts (76.6 mmHg vs. 77.8 mmHg, p < 0.01). CONCLUSION: Several quality indicators for type 2 diabetes care were better if the GPs were specialists in General Practice. Key Points Research on associations between General Practitioners (GPs) characteristics and quality of care for patients with type 2 diabetes is limited. Specialists in General Practice performed recommended procedures more frequently, achieved better HbA1c and blood pressure levels than non-specialists. GPs who graduated in Western Europe performed screening procedures more frequently and achieved lower diastolic blood pressure compared with their counterparts. There were few significant differences in the quality of care between GP groups according to their gender and country of birth.

Type 2 diabetes in general practice in Norway 2005-2014: moderate improvements in risk factor control but still major gaps in complication screening.

OBJECTIVE: To assess the status of type 2 diabetes care in general practice and changes in the quality of care between 2005 and 2014, and to identify areas of diabetes care requiring improvement. RESEARCH DESIGN AND METHODS: Two cross-sectional surveys were performed that included patients with type 2 diabetes in selected areas (n=9464 in 2014, n=5463 in 2005). Quality of care was assessed based on key recommendations in national guidelines. Differences in clinical performance between 2005 and 2014 were assessed in regression models adjusting for age, sex, counties and clustering within general practices. RESULTS: Treatment targets were achieved in a higher proportion of patients in 2014 compared with 2005: hemoglobin A1c ≤7.0% (≤53 mmol/mol) in 62.8% vs 54.3%, blood pressure ≤135/80 mm Hg in 44.9% vs 36.6%, and total cholesterol ≤4.5 mmol/L in 49.9% vs 33.5% (all adjusted P≤0.001). Regarding screening procedures for microvascular complications, fewer patients had recorded an eye examination (61.0% vs 71.5%, adjusted P<0.001), whereas more patients underwent monofilament test (25.9% vs 18.7%, adjusted P<0.001). Testing for albuminuria remained low (30.3%) in 2014. A still high percentage were current smokers (22.7%). CONCLUSIONS: We found moderate improvements in risk factor control for patients with type 2 diabetes in general practice during the last decade, which are similar to improvements reported in other countries. We report major gaps in the performance of recommended screening procedures to detect microvascular complications. The proportion of daily smokers remains high. We suggest incentives to promote further improvements in diabetes care in Norway.

Glycemic control and complications in patients with type 1 diabetes - a registry-based longitudinal study of adolescents and young adults.

OBJECTIVE: The main aims of this study were to assess longitudinal glycemic control and the prevalence of retinopathy and nephropathy in young people (aged 14-30 yr) with type 1 diabetes in Norway. METHOD: Data on 874 patients were obtained by linking two nationwide, population-based medical quality registries: The Norwegian Diabetes Register for Adults and The Norwegian Childhood Diabetes Registry. RESULTS: Median age was 23 yr, median diabetes duration 9 yr and 51% were male. Median HbA1c increased through adolescence to peak at ages of 17 yr for females and 19 yr for males, females had higher HbA1c than males: 9.3% (78 mmol/mol) vs. 9.1% (76 mmol/mol). Subsequently, median HbA1c declined but was still >8% (>64 mmol/mol) for patients approaching 30 yr. Half of the patients aged 14-17 yr and 40% of patients aged 18-25 yr had HbA1c >9% (75 mmol/mol). Retinopathy was found in 16% and nephropathy in 13% of the population. Patients transferring from the pediatric department to adult care between the ages of 14 and 17 yr had higher median HbA1c and prevalence of late complications than those transferring at ages 18-22 yr. Less than 40% of patients with albuminuria were treated with ACE inhibitors or angiotensin II receptor blocker. CONCLUSION: Our results demonstrate that treatment of adolescents and young adults with type 1 diabetes in Norway is not optimal, especially for patients in their late teens. We suggest that pediatricians and endocrinologists should critically assess the care offered to this group and consider new approaches to help them improve glycemic control.

Feasibility of using self-reported patient data in a national diabetes register.

BACKGROUND: In order to improve recruitment of patients to the Norwegian diabetes register for adults, a questionnaire was designed to collect data directly from patients. The main aim of this study was to assess the agreement of questionnaire data with data reported to the Register from health care personnel during routine consultations. METHODS: Patient data were obtained by sending a questionnaire with 27 of the 41 Register variables to 3714 members of the Norwegian Diabetes Association. Questionnaire data were compared with data already in the Register. Paired t-tests, percentages of total agreement, percentages of "positive" answers and kappa coefficients (k) were used for comparing data. RESULTS: Of the 1645 replies (44.3 %), the Register already had data on 324 patients for comparison. Response rate for most variables was better from patients (ranging from 76-100 %) compared with health care professionals (33-100 %). For 17 of 25 assessable variables including diabetes duration, height, weight, HbA1c, drug treatment and several diabetes complications, agreement was substantial or better with kappa >0.60. Data on family history of premature heart disease (k-0.59), foot examination (k = 0.26), foot ulcer (k = 0.32) and arterial surgery (k = 0.24) seemed to be difficult to answer by patients, whereas data on physical activity and self-monitoring of glucose seemed to be better when reported by patients. CONCLUSIONS: Patient response rate was acceptable, and data had good concordance with data from health care professionals for most variables. However, registers using patient questionnaires should compare questionnaire data with data from professionals at regular intervals.

Benchmarking by HbA1c in a national diabetes quality register--does measurement bias matter?

BACKGROUND: Bias in HbA1c measurement could give a wrong impression of the standard of care when benchmarking diabetes care. The aim of this study was to evaluate how measurement bias in HbA1c results may influence the benchmarking process performed by a national diabetes register. METHODS: Using data from 2012 from the Norwegian Diabetes Register for Adults, we included HbA1c results from 3584 patients with type 1 diabetes attending 13 hospital clinics, and 1366 patients with type 2 diabetes attending 18 GP offices. Correction factors for HbA1c were obtained by comparing the results of the hospital laboratories'/GP offices' external quality assurance scheme with the target value from a reference method. RESULTS: Compared with the uncorrected yearly median HbA1c values for hospital clinics and GP offices, EQA corrected HbA1c values were within ±0.2% (2 mmol/mol) for all but one hospital clinic whose value was reduced by 0.4% (4 mmol/mol). Three hospital clinics reduced the proportion of patients with poor glycemic control, one by 9% and two by 4%. CONCLUSIONS: For most participants in our study, correcting for measurement bias had little effect on the yearly median HbA1c value or the percentage of patients achieving glycemic goals. However, at three hospital clinics correcting for measurement bias had an important effect on HbA1c benchmarking results especially with regard to percentages of patients achieving glycemic targets. The analytical quality of HbA1c should be taken into account when comparing benchmarking results.

Treatment of type 1 diabetes in the specialist health service--data from the Norwegian Diabetes Register for Adults.

BACKGROUND: The Norwegian Diabetes Register for Adults was established in 2005. The aim of the study is to assess the quality of treatment for adult patients with type 1 diabetes in the specialist health service based on register data. MATERIAL AND METHOD: We included patients ≥ 18 years with type 1 diabetes in the specialist health service for whom the register has data for the period from 1 July 2010-to 31 December 2011. The patients were asked to consent to the transfer of data to the register when they attended a routine consultation. As of 31 December 2011, 95% of the patients asked gave their consent. It is not known how large a proportion of patients were asked. RESULTS: We included the last registered data for 3,697 patients (46.8% women) from 24 outpatient clinics and specialist centres. The average age was 41.8 years and the average duration of diabetes was 20.8 years. Median HbA1c, systolic blood pressure and LDL cholesterol were 8.0%, 126 mm Hg and 2.8 mmol/l respectively. 9.8% achieved all treatment targets set out in the national guidelines for diabetes. 18% had HbA1c ≤ 7.0%, while 22% had HbA1c ≥ 9%. 39% of patients on statin therapy achieved the treatment target for LDL cholesterol. 19.6% smoked on a daily basis. 14.9% had received treatment for retinopathy and 5.8% had experienced coronary heart disease. There was no record of foot examination or ophthalmoscopy being performed in 33% and 29% of patients. INTERPRETATION: The preliminary register data indicate that diabetes treatment should be improved both with respect to the implementation of recommended procedures and the proportion of patients who achieve the treatment targets.