Immediate postoperative hyperglycemia after peripheral arterial bypass is associated with short-term and long-term poor outcomes.

OBJECTIVE: Although the impact of poorly controlled diabetes on surgical outcomes of patients undergoing lower extremity revascularization is well-known, it is not clear if immediate postoperative hyperglycemia (IPH) itself can be used as a surrogate for poor outcomes after peripheral arterial bypass. We sought to examine the effect of IPH in this patient population with its impact on short-term and long-term outcomes. METHODS: Retrospective review was completed for 505 patients who underwent either suprainguinal bypass surgery or infrainguinal bypass surgery between July 2002 and April 2018 for the treatment of peripheral arterial disease. All patients were undergoing first-time open bypass grafting. Patients were stratified into those who were normoglycemic or hyperglycemic (glucose ≥ 140 mg/dL) within 24 hours after surgery. A comparative analysis was performed on comorbidities and outcomes. RESULTS: Of 505 patients who underwent bypass grafting, 255 patients (50.5%) were hyperglycemic. The mean age of patients was 63.5 ± 14.1 years. The median follow-up was 5.2 years (range, 0.0-15.2 years). The distribution of procedures was as follows: femoral to popliteal bypasses (29%), femoral to femoral bypasses (17%), femoral to tibial bypasses (12%), aortobifemoral bypasses (10%), iliofemoral bypasses (9%), and axillofemoral bypasses (7%). At 30 days, hyperglycemic patients had an increased incidence of limb loss (8.3% vs 4.0%) and myocardial infarction (4.8% vs 0.8%) and incurred higher costs of hospital stay ($27,701 vs $22,990) (all P < .05). At 10 years, these patients had a higher incidence of needing major amputations (15.4% vs 9.4%; P = .025). Hyperglycemia after infrainguinal bypass was associated with nearly twice the risk of limb loss at 5 years (hazard ratio, 1.91; P = .034). Among the cohort of patients who required major amputations, the time duration between index revascularization and amputation was significantly shorter as compared with normoglycemic patients (P = .003). CONCLUSIONS: In this single-institution study with long-term follow-up, IPH was associated with increased rates of 30-day amputation and myocardial infarction, as well as an increased cost of hospital stay. In the long term, postoperative hyperglycemia was associated with greater major limb loss. Among the cohort of patients who required major amputations, the time period between revascularization and amputation was shorter for those patients who had IPH. IPH is an independent marker for poor outcomes after lower extremity revascularization procedures.

Hyperglycemia requiring insulin during acute lymphoblastic leukemia induction chemotherapy is associated with increased adverse outcomes and healthcare costs.

BACKGROUND: Hyperglycemia is a complication of induction chemotherapy in 10%-50% of pediatric patients with acute lymphoblastic leukemia (ALL). Though hyperglycemia in ALL patients is usually transient, it may be associated with adverse health outcomes. However, the risk factors for and consequences of hyperglycemia are poorly understood. We hypothesized that hyperglycemia significant enough to require insulin therapy during induction chemotherapy would be associated with increased morbidity and mortality in pediatric ALL patients during induction chemotherapy and in subsequent care. METHODS: We abstracted clinical and resource utilization data from the Pediatric Health Information System (PHIS) database utilizing ICD-9 codes and medication charges. We used logistic regression analysis to predict the development of hyperglycemia. The effects of hyperglycemia on binary and count adverse outcomes following induction chemotherapy were modeled using mixed-effect regression models. RESULTS: An increased risk of hyperglycemia requiring insulin was associated with older age, female sex, higher risk group and trisomy 21. Patients on insulin for hyperglycemia had increased mortality following induction chemotherapy. These patients were more likely to have subsequent infectious complications, need for bone marrow transplant, and risk of disease relapse. They also had greater length of inpatient stay, higher cost of care, and were more likely to require intensive care unit admission during induction chemotherapy. CONCLUSIONS: Hyperglycemia requiring insulin during induction chemotherapy in pediatric ALL is associated with an increased risk of short-term and long-term complications. Prospective studies are needed to analyze formal screening, preventive measures, and optimal management practices for hyperglycemia during ALL induction chemotherapy.

Quality of Life and Glucose Control After 1 Year of Nationwide Reimbursement of Intermittently Scanned Continuous Glucose Monitoring in Adults Living With Type 1 Diabetes (FUTURE): A Prospective Observational Real-World Cohort Study.

OBJECTIVE: In 2016, nationwide reimbursement of intermittently scanned continuous glucose monitoring (isCGM) for people living with type 1 diabetes treated in specialist diabetes centers was introduced in Belgium. We undertook a 12-month prospective observational multicenter real-world study to investigate impact of isCGM on quality of life and glycemic control. RESEARCH DESIGN AND METHODS: Between July 2016 and July 2018, 1,913 adults with type 1 diabetes were consecutively recruited in three specialist diabetes centers. Demographic, metabolic, and quality of life data were collected at baseline, 6 months, and 12 months of standardized clinical follow-up. The primary end point was evolution of quality of life from baseline to 12 months. Secondary outcome measures were, among others, change in HbA1c, time spent in different glycemic ranges, occurrence of acute diabetes complications, and work absenteeism. RESULTS: General and diabetes-specific quality of life was high at baseline and remained stable, whereas treatment satisfaction improved (P < 0.0001). Admissions for severe hypoglycemia and/or ketoacidosis were rare in the year before study (n = 63 out of 1,913; 3.3%), but decreased further to 2.2% (n = 37 out of 1,711; P = 0.031). During the study, fewer people reported severe hypoglycemic events (n = 280 out of 1,913 [14.6%] vs. n = 134 out of 1,711 [7.8%]; P < 0.0001) or hypoglycemic comas (n = 52 out of 1,913 [2.7%] vs. n = 18 out of 1,711 [1.1%]; P = 0.001) while maintaining HbA1c levels. Fewer people were absent from work (n = 111 out of 1,913 [5.8%] vs. n = 49 out of 1,711 [2.9%]; P < 0.0001). Time spent in hypoglycemia significantly decreased in parallel with less time in range and more time in hyperglycemia. Eleven percent (n = 210) of participants experienced skin reactions, leading to stopping of isCGM in 22 participants (1%). CONCLUSIONS: Nationwide unrestricted reimbursement of isCGM in people with type 1 diabetes treated in specialist diabetes centers results in higher treatment satisfaction, less severe hypoglycemia, and less work absenteeism, while maintaining quality of life and HbA1c.

Association between income levels and irregular physician visits after a health checkup, and its consequent effect on glycemic control among employees: A retrospective propensity score-matched cohort study.

AIMS/INTRODUCTION: The present study aimed to evaluate the effects of income levels on physician visit patterns and to quantify the consequent impact of irregular physician visits on glycemic control among employees' health insurance beneficiaries in Japan. MATERIALS AND METHODS: We obtained specific health checkup data of untreated diabetes patients from the Fukuoka branch of the Japanese Health Insurance Association. We selected 2,981 insurance beneficiaries and classified 650 and 2,331 patients into, respectively, the regular visit and irregular visit group. We implemented propensity score matching to select an adequate control group. RESULTS: Compared with those with a standard monthly income <$2,000 (US$1 = ¥100), those with a higher monthly income were less likely to have irregular visits; $2,000-2,999: odds ratio 0.74 (95% confidence interval 0.56-0.98), $3,000-3,999: odds ratio 0.63 (95% confidence interval 0.46-0.87) and ≥$5,000: odds ratio 0.58 (95% confidence interval 0.39-0.86). After propensity score matching and adjusting for covariates, the irregular visit group tended to have poor glycemic control; increased glycated hemoglobin ≥0.5: odds ratio 1.90 (95% confidence interval 1.30-2.77), ≥1.0: odds ratio 2.75 (95% confidence interval 1.56-4.82) and ≥20% relatively: odds ratio 3.18 (95% confidence interval 1.46-6.92). CONCLUSIONS: We clarified that there was a significant relationship between income and irregular visits, and this consequently resulted in poor glycemic control. These findings would be useful for more effective disease management.

Switching from sitagliptin to liraglutide to manage patients with type 2 diabetes in the UK: A long-term cost-effectiveness analysis.

AIMS: The recent LIRA-SWITCH trial showed that switching from sitagliptin 100 mg to liraglutide 1.8 mg led to statistically significant and clinically relevant improvements in glycated haemoglobin (HbA1C) and body mass index (BMI). Based on these findings, the aim of the present study was to assess the long-term cost-effectiveness of switching from sitagliptin to liraglutide in patients with type 2 diabetes in the UK. MATERIALS AND METHODS: The IQVIA CORE Diabetes Model Version 8.5+ was used to project costs and clinical outcomes over patients' lifetimes. Baseline cohort characteristics and treatment effects were derived from the LIRA-SWITCH trial. Future costs and clinical benefits were discounted at 3.5% annually. Costs were accounted in pounds sterling (GBP) and expressed in 2016 values. One-way and probabilistic sensitivity analyses were performed. RESULTS: Model projections showed improved quality-adjusted life expectancy for patients with poorly controlled HbA1c upon switching from sitagliptin to liraglutide, compared with continuing sitagliptin treatment (9.18 vs 9.02 quality-adjusted life years [QALYs]). Treatment switching was associated with increased overall costs (GBP 24737 vs GBP 22362). Higher pharmacy costs were partially offset by reduced diabetes-related complication costs in patients who switched to liraglutide. Switching to liraglutide was associated with an incremental cost-effectiveness ratio of GBP 15423 per QALY gained vs continuing with sitagliptin treatment. CONCLUSIONS: Switching from sitagliptin 100 mg to liraglutide 1.8 mg in patients with poor glycaemic control was projected to improve clinical outcomes and is likely to be considered cost-effective in the UK setting and, therefore, a good use of limited NHS resources.

Mediators of medication adherence and glycaemic control and their implications for direct outpatient medical costs: a cross-sectional study.

AIMS: To investigate the effects of diabetes-related distress and perception of hyperglycaemia on self-reported medication adherence and glycaemic control, as measured by HbA1c , and to compare the cost outcomes in patients with sub-optimally vs uncontrolled Type 2 diabetes mellitus. METHODS: We conducted a retrospective cross-sectional study that involved the review of a chronic disease database in Singapore. Data on clinical characteristics, diabetes-related distress, perception of hyperglycaemia, self-reported medication adherence and costs were obtained from the database. Mediation analyses were conducted using a linear regression-based approach. A final path model was built to illustrate the sequential mediating effects of diabetes-related distress and perception on the association of medication adherence and HbA1c concentration. RESULTS: Diabetes-related distress and perception of hyperglycaemia were significantly associated with medication adherence and HbA1c concentration. Mediation analyses showed a significant indirect effect of diabetes-related distress and perception of hyperglycaemia on medication adherence and HbA1c concentration. People with uncontrolled diabetes were found to incur significantly higher total direct medical costs than those with sub-optimally controlled diabetes (P = 0.034), with medication cost as the main cost driver (66.6%). CONCLUSIONS: Identifying the influence of the sequential mediating effects of distress and perception was important in understanding the pathway between medication adherence and glycaemic control. This suggests the importance of a team-based approach to address these mediators and thus improve glycaemic control. Poor glycaemic control was also found to be associated with higher direct medical costs.

IDF Diabetes Atlas: Global estimates of diabetes prevalence for 2017 and projections for 2045.

INTRODUCTION: Since the year 2000, IDF has been measuring the prevalence of diabetes nationally, regionally and globally. AIM: To produce estimates of the global burden of diabetes and its impact for 2017 and projections for 2045. METHODS: A systematic literature review was conducted to identify published studies on the prevalence of diabetes, impaired glucose tolerance and hyperglycaemia in pregnancy in the period from 1990 to 2016. The highest quality studies on diabetes prevalence were selected for each country. A logistic regression model was used to generate age-specific prevalence estimates or each country. Estimates for countries without data were extrapolated from similar countries. RESULTS: It was estimated that in 2017 there are 451 million (age 18-99 years) people with diabetes worldwide. These figures were expected to increase to 693 million) by 2045. It was estimated that almost half of all people (49.7%) living with diabetes are undiagnosed. Moreover, there was an estimated 374 million people with impaired glucose tolerance (IGT) and it was projected that almost 21.3 million live births to women were affected by some form of hyperglycaemia in pregnancy. In 2017, approximately 5 million deaths worldwide were attributable to diabetes in the 20-99 years age range. The global healthcare expenditure on people with diabetes was estimated to be USD 850 billion in 2017. CONCLUSION: The new estimates of diabetes prevalence, deaths attributable to diabetes and healthcare expenditure due to diabetes present a large social, financial and health system burden across the world.

Patients lacking glycemic control place more burdens on health services with the use of medications.

INTRODUCTION: DM spending in the world is high, and Brazilian studies of public spending caused by DM are scarce. OBJECTIVE: To estimate the annual direct cost for the municipal health sphere, related to DM2 treatment, in patients with and without glycemic control. METHOD: A cross-sectional study carried out in a city in the interior of Minas Gerais state, with patients with DM2, being municipal PHS users. Data were collected from the computerized system of the municipality and patient records, and analyzed using the IBM SPSS v.19 statistical package. The response variable was categorized into controlled A1c (≤7%) and uncontrolled A1c (>7%). RESULTS: Glycemic control in 56.6% of the patients was unsatisfactory; the mean cost of pharmacotherapy for DM2 was US$ 3.14 per year for patients in the control group and US$ 45.54 per year for uncontrolled patients. CONCLUSION: Patients with unsatisfactory glycemic control are more expensive for the municipal health system.

Real-world evidence concerning clinical and economic outcomes of switching to insulin glargine 300 units/mL vs other basal insulins in patients with type 2 diabetes using basal insulin.

This retrospective cohort study compared real-world clinical and healthcare-resource utilization (HCRU) data in patients with type 2 diabetes using basal insulin (BI) who switched to insulin glargine 300 units/mL (Gla-300) or another BI. Data from the Predictive Health Intelligence Environment database 12 months before (baseline) and 6 months after (follow-up) the switch date (index date, March 1, 2015 to May 31, 2016) included glycated haemoglobin A1c (HbA1c), hypoglycaemia, HCRU and associated costs. Baseline characteristics were balanced using propensity score matching. Change in HbA1c from baseline was similar in both matched cohorts (n = 1819 in each). Hypoglycaemia incidence and adjusted event rate were significantly lower with Gla-300. Patients switching to Gla-300 had a significantly lower incidence of HCRU related to hypoglycaemia. All-cause and diabetes-related hospitalization and emergency-department HCRU were also favourable for Gla-300. Lower HCRU translated to lower costs in patients using Gla-300. In this real-world study, switching to Gla-300 reduced the risk of hypoglycaemia in patients with type 2 diabetes when compared with those switching to another BI, resulting in less HCRU and potential savings of associated costs.

Relation between cost of drug treatment and body mass index in people with type 2 diabetes in Latin America.

AIMS: Despite the frequent association of obesity with type 2 diabetes (T2D), the effect of the former on the cost of drug treatment of the latest has not been specifically addressed. We studied the association of overweight/obesity on the cost of drug treatment of hyperglycemia, hypertension and dyslipidemia in a population with T2D. METHODS: This observational study utilized data from the QUALIDIAB database on 3,099 T2D patients seen in Diabetes Centers in Argentina, Chile, Colombia, Peru, and Venezuela. Data were grouped according to body mass index (BMI) as Normal (18.5≤BMI<25), Overweight (25≤BMI<30), and Obese (BMI≥30). Thereafter, we assessed clinical and metabolic data and cost of drug treatment in each category. Statistical analyses included group comparisons for continuous variables (parametric or non-parametric tests), Chi-square tests for differences between proportions, and multivariable regression analysis to assess the association between BMI and monthly cost of drug treatment. RESULTS: Although all groups showed comparable degree of glycometabolic control (FBG, HbA1c), we found significant differences in other metabolic control indicators. Total cost of drug treatment of hyperglycemia and associated cardiovascular risk factors (CVRF) increased significantly (p<0.001) with increment of BMI. Hyperglycemia treatment cost showed a significant increase concordant with BMI whereas hypertension and dyslipidemia did not. Despite different values and percentages of increase, this growing cost profile was reproduced in every participating country. BMI significantly and independently affected hyperglycemia treatment cost. CONCLUSIONS: Our study shows for the first time that BMI significantly increases total expenditure on drugs for T2D and its associated CVRF treatment in Latin America.

Projected long-term outcomes in patients with type 1 diabetes treated with fast-acting insulin aspart vs conventional insulin aspart in the UK setting.

AIM: To assess the impact of faster aspart vs insulin aspart on long-term clinical outcomes and costs for patients with type 1 diabetes mellitus (T1DM) in the UK setting. METHODS: The QuintilesIMS CORE Diabetes Model was used to project clinical outcomes and costs over patient lifetimes in a cohort with data on baseline characteristics from the "onset 1" trial. Treatment effects were taken from the 26-week main phase of the onset 1 trial, with costs and utilities based on literature review. Future costs and clinical benefits were discounted at 3.5% annually. RESULTS: Projections indicated that faster aspart was associated with improved discounted quality-adjusted life expectancy (by 0.13 quality-adjusted life-years) vs insulin aspart. Improved clinical outcomes resulted from fewer diabetes-related complications and a delayed time to their onset with faster aspart. Faster aspart was found to be associated with reduced costs vs insulin aspart (cost savings of £1715), resulting from diabetes-related complications avoided and reduced treatment costs. CONCLUSIONS: Faster aspart was associated with improved clinical outcomes and cost savings vs insulin aspart for patients with T1DM in the UK setting.

Cost-effectiveness of exenatide twice daily vs insulin glargine as add-on therapy to oral antidiabetic agents in patients with type 2 diabetes in China.

AIMS: To estimate the long-term cost-effectiveness of exenatide twice daily vs insulin glargine once daily as add-on therapy to oral antidiabetic agents (OADs) for Chinese patients with type 2 diabetes (T2DM). METHODS: The Cardiff Diabetes Model was used to simulate disease progression and estimate the long-term effects of exenatide twice daily vs insulin glargine once daily. Patient profiles and treatment effects required for the model were obtained from literature reviews (English and Chinese databases) and from a meta-analysis of 8 randomized controlled trials comparing exenatide twice daily with insulin glargine once daily add-on to OADs for T2DM in China. Medical expenditure data were collected from 639 patients with T2DM (aged ≥18 years) with and without complications incurred between January 1, 2014 and December 31, 2015 from claims databases in Shandong, China. Costs (2014 Chinese Yuan [¥]) and benefits were estimated, from the payers' perspective, over 40 years at a discount rate of 3%. A series of sensitivity analyses were performed. RESULTS: Patients on exenatide twice daily + OAD had a lower predicted incidence of most cardiovascular and hypoglycaemic events and lower total costs compared with those on insulin glargine once daily + OAD. A greater number of quality-adjusted life years (QALYs; 1.94) at a cost saving of ¥117 706 gained was associated with exenatide twice daily vs insulin glargine once daily. (i.e. cost saving of ¥60 764/QALY) per patient. CONCLUSIONS: In Chinese patients with T2DM inadequately controlled by OADs, exenatide twice daily is a cost-effective add-on therapy alternative to insulin glargine once daily, and may address the problem of an excess of medical needs resulting from weight gain and hypoglycaemia in T2DM treatment.

Incidence, recurrence and cost of hyperglycaemic crises requiring emergency treatment in Andalusia, Spain.

AIMS: Hyperglycaemic crises (diabetic ketoacidosis and hyperosmolar hyperglycaemic state) are medical emergencies in people with diabetes. We aimed to determine their incidence, recurrence and economic impact. METHODS: An observational study of hyperglycaemic crises cases using the database maintained by the out-of-hospital emergency service, the Healthcare Emergency Public Service (EPES) during 2012. The EPES provides emergency medical services to the total population of Andalusia, Spain (8.5 million inhabitants) and records data on the incidence, resource utilization and cost of out-of-hospital medical care. Direct costs were estimated using public prices for health services updated to 2012. RESULTS: Among 1 137 738 emergency calls requesting medical assistance, 3157 were diagnosed with hyperglycaemic crises by an emergency coordinator, representing 2.9 cases per 1000 persons with diabetes [95% confidence intervals (CI) 2.8 to 3.0]. The incidence of diabetic ketoacidosis was 2.5 cases per 1000 persons with diabetes (95% CI 2.4 to 2.6) and the incidence of hyperosmolar hyperglycaemic state was 0.4 cases per 1000 persons with diabetes (95% CI 0.4 to 0.5). In total, 17.7% (n = 440) of people had one or more hyperglycaemic crisis. The estimated total direct cost was €4 662 151, with a mean direct cost per episode of €1476.8 ± 217.8. CONCLUSIONS: Hyperglycaemic crises require high resource utilization of emergency medical services and have a significant economic impact on the health system.

A cohort of children with type 1 diabetes in Greece: predictors of direct costs of care.

AIM: To examine the predictors of direct costs of pediatric type 1 diabetes (T1D) in a hospital-based outpatient clinic in Greece. METHODS: The outpatient records of 89 children and adolescents (mean age: 12.05 ± 5.15 y) with T1D followed in the Second Department of Pediatrics, University of Athens Medical School, were analyzed. RESULTS: The mean ± SD diabetes duration was 4.9 ± 3.88 y (range: 0.25-17) and glycated hemoglobin (HbA1c) was 8.2 ± 1.09% (66 ± 11.9 mmol/mol). A total of 80% of patients were on multiple daily injections regimen, 10% on pump therapy, and 10% on conventional regimen. Total direct costs per patient-year (ppy) were estimated at €2.712 [95% confidence interval (CI): 2.468-2.956]. Supply costs accounted for 73.7% of total costs and were the highest for pump therapy (P < .001). Multivariate linear regression analysis showed that costs were significantly higher for children (1) on multiple daily injections or pump therapy (r = 0.364, P < .001), (2) of older age (r = 0.25, P < .001) and (3) higher daily insulin dose (r = 0.46, P < .001). Patients on pump therapy had significantly higher costs €5.538 (95%CI 4480-6597) compared with patients on multiple daily injections €2.447 (95% CI 2320-2574) and conventional regimen €1.978.5 (95%CI 1682-2275) (P = .0001). Patients on pump therapy had better glycemic control compared with all other patients [HbA1c (mean ± SD): 7.2% ± 1.0 vs 8.3% ±1.5, P = .039]. CONCLUSION: The total T1D cost in this cohort of Greek children was €2712 ppy. The main factor that predicted direct cost was the use of pump. However, pump therapy was associated with better glycaemic control, which may decrease the risk of total long-term diabetes care cost.

The impact of insurance coverage and the family on pediatric diabetes management.

BACKGROUND/OBJECTIVE: The impact of family composition on glycemic control in children with type 1 diabetes remains unclear. We sought to evaluate the relationship between health insurance coverage, family composition, and insulin management, and assess their impact on glycemic control in a pediatric type 1 diabetes population. METHODS: A retrospective chart review was completed for patients seen in the Pediatric Endocrinology Clinic at the University of Louisville in 2012. RESULTS: The analysis included 729 patients with type 1 diabetes; 268 (37%) had public insurance while 461(63%) had private insurance. Compared with publicly insured patients, privately insured patients had higher rates of intensive insulin management with multiple daily injections (MDI) plans or pump devices (88 vs. 83.2%, p = 0.066) and lower HbA1c levels [8.57 vs. 9.39% (70 vs. 79 mmol/mol), p < 0.001]. Of the 729 patients, 243 were in single-adult homes (33%). Single-adult homes had higher HbA1c levels than two-adult homes, [9.3 vs. 8.6% (78 vs. 70 mmol/mol), p < 0.001]. Among publicly insured, there was no difference in HbA1c levels for single-adult vs. two-adult homes [9.4 (79 mmol/mol), p = 0.868]. For privately insured, patients in single-adult homes had higher HbA1c levels than peers in two-adult homes [9.2 vs. 8.4% (77 vs. 68), p < 0.001]. CONCLUSION: Insurance type and family composition have significant associative effects on glycemic control and insulin management that may be mitigated by insulin pump therapy. Identifying and addressing factors such as availability of resources, family education, and adult support and supervision, may help improve glycemic control in high-risk pediatric diabetes patients.

Association of good glycemic control and cost of diabetes care: Experience from a tertiary care hospital in Bangladesh.

AIM: The present study was undertaken to assess the cost-effectiveness of good glycemic control in a population of Bangladeshi people with type 2 diabetes mellitus (T2DM). METHODS: A cross-sectional study was conducted among 496 registered patients with >1year duration of diabetes. Glycated hemoglobin A1c level <7% was judged as the cut-off value for good glycemic control. All treatment-related records from the last year were collected from patients' guide books and all cost components were calculated. RESULTS: Among patients, 31% had good glycemic control. The average annual cost was US$ 314 per patient. Patients with poor glycemic control were significantly more likely to have complications [(p=0.049) OR 1.5] and comorbidities [(p=0.02) OR 1.5]. The annual cost increased rapidly with complications/comorbidities. In multivariable logistic regression analysis, gender (p=0.003) and cost of care (p=0.006) were significantly associated with glycemic control, and the presence of any comorbidities/complications was associated with 1.8-fold higher odds of poor glycemic control (p=0.013 95% CI: 1.131-2.786). CONCLUSION: Good glycemic control can lead to substantial cost saving through prevention and control of complications.

Assessment of response rates and yields for Two opportunistic Tools for Early detection of Non-diabetic hyperglycaemia and Diabetes (ATTEND). A randomised controlled trial and cost-effectiveness analysis.

AIMS: To assess the opportunistic use in primary care of a computer risk score versus a self-assessment risk score for undiagnosed type 2 diabetes. METHODS: We conducted a randomised controlled trial in 11 primary care practices in the UK. 577 patients aged 40-75years with no current diagnosis of type 2 diabetes were recruited to a computer based risk score (Leicester Practice Computer Risk Score (LPCRS)) or a patient self-assessment score (Leicester Self-Assessment Score (LSAS)). RESULTS: The rate of self-referral blood tests was significantly higher for the LPCRS compared to the LSAS, 118.98 (95% CI: 102.85, 137.64) per 1000 high-risk patient years of follow-up compared to 92.14 (95% CI: 78.25, 108.49), p=0.022. Combined rate of diagnosis of type 2 diabetes and those at risk of developing the disease (i.e. impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)) was similar between the two arms, 15.12 (95% CI: 9.11, 25.08) per 1000 high-risk patient years for LPCRS compared to 14.72 (95% CI: 9.59, 22.57) for the LSAS, p=0.699. For the base case scenario the cost per new case of type 2 diabetes diagnosed was lower for the LPCRS compared to the LSAS, £168 (95% Credible Interval (CrI): 76, 364), and £352 (95% CrI: 109, 1148), respectively. CONCLUSIONS: Compared to a self-assessment risk score, a computer based risk score resulted in greater attendance to an initial blood test and is potentially more cost-effective.

Optimizing management of glycaemia.

The global epidemic of type 2 diabetes (T2DM) continues largely unabated due to an increasingly sedentary lifestyle and obesogenic environment. A cost-effective patient-centred approach, incorporating glucose-lowering therapy and modification of cardiovascular risk factors, could help prevent the inevitable development and progression of macrovascular and microvascular complications. Glycaemic optimization requires patient structured education, self-management and empowerment, and psychological support along with early and proactive use of glucose lowering therapies, which should be delivered in a system of care as shown by the Chronic Care Model. From diagnosis, intensive glycaemic control and individualised care is aimed at reducing complications. In older people, the goal is maintaining quality of life and minimizing morbidity, especially as overtreatment increases hypoglycaemia risk. Maintaining durable glycaemic control is challenging and complex to achieve without hypoglycaemia, weight gain and other significant adverse effects. Overcoming patient and physician barriers can help ensure adequate treatment initiation and intensification. Cardiovascular safety studies with newer glucose-lowering agents are now mandatory, with a sodium glucose co-transporter-2 inhibitor (empagliflozin), and two glucagon like peptide-1 receptor agonists (liraglutide and semaglutide) being the first to demonstrate superior CV outcomes compared with placebo.

Health claims using the term 'sustained energy' are trending but glycaemic response data are being used to support: is this misleading without context?

One of the most recent food trends is the quest for products that provide 'sustained energy'; a term that is garnering considerable attention within the marketplace. Often, 'sustained energy' health claims are based on a food's post-prandial glycaemic response. However, are generalised health claims regarding 'sustained energy' valid when only supported by glycaemic response data? Without context, the short answer is: probably not. Health claims that link sustained energy to a glycaemic response, or any other attribute of a food or diet, require context to ensure that the public correctly interprets and experiences the claimed effect and is not misled in their quest for healthy foods that impose the desired physiological benefit.