How valid is a prescription-based multimorbidity index (Rx-risk) in predicting mortality in the Outcomes and Multimorbidity In Type 2 diabetes (OMIT) study? A nation-wide registry-based cohort study from Norway.

OBJECTIVE: The prescription-based Rx-risk index has previously been developed to measure multimorbidity. We aimed to adapt and evaluate the validity of the Rx-risk index in prediction of mortality among persons with type 2 diabetes. DESIGN: Registry-based study. SETTING: Adults with type 2 diabetes in Norway identified within the 'Outcomes and Multimorbidity In Type 2 diabetes' cohort, with linkage to prescriptions from the Norwegian Prescription Database and mortality from the Population Registry. PARTICIPANTS: We defined a calibration sample of 42 290 adults diagnosed with type 2 diabetes 1950-2013, and a temporal validation sample of 7085 adults diagnosed 2014-2016 to evaluate the index validity over time PRIMARY OUTCOME MEASURE: All-cause mortality METHODS: For the calibration sample, dispensed drug prescriptions in 2013 were used to define 44 morbidity categories. Weights were estimated using regression coefficients from a Cox regression model with 5 year mortality as the outcome and all morbidity categories, age and sex included as covariates. The Rx-risk index was computed as a weighted sum of morbidities. The validity of the index was evaluated using C-statistic and calibration plots. RESULTS: In the calibration sample, mean (SD) age at start of follow-up and duration of diabetes was 63.8 (12.4) and 10.1 (7.0) years, respectively. The overall C-statistic was 0.82 and varied from 0.74 to 0.85 when stratifying on age groups, sex, level of education and country of origin. In the validation sample, mean (SD) age and duration of diabetes was 59.7 (13.0) and 2.0 (0.8) years, respectively. Despite younger age, shorter duration of diabetes and later time period, the C-index was high both in the total sample (0.84) and separately for men (0.83) and women (0.84). CONCLUSIONS: The Rx-risk index showed good discrimination and calibration in predicting mortality and thus presents a valid tool to assess multimorbidity among persons with type 2 diabetes.

Intensified follow-up of patients with type 1 diabetes and poor glycaemic control: a multicentre quality improvement collaborative based on data from the Norwegian Diabetes Register for Adults.

BACKGROUND: Patients with type 1 diabetes mellitus (T1DM) and poor glycaemic control are at high risk of developing microvascular and macrovascular complications. The aim of this study was to determine if a quality improvement collaborative (QIC) initiated by the Norwegian Diabetes Register for adults (NDR-A) could reduce the proportion of patients with T1DM with poor glycaemic control (defined as glycated haemoglobin (HbA1c)≥75 mmol/mol) and reduce mean HbA1c at participating clinics compared with 14 control clinics. METHOD: Multicentre study with controlled before and after design. Representatives of 13 diabetes outpatient clinics (n=5145 patients with T1DM) in the intervention group attended four project meetings during an 18-month QIC. They were required to identify areas requiring improvement at their clinic and make action plans. Continuous feedback on HbA1c outcomes was provided by NDR-A during the project. In total 4084 patients with type 1 diabetes attended the control clinics. RESULTS: Between 2016 and 2019, the overall proportion of patients with T1DM and HbA1c≥75 mmol/mol in the intervention group were reduced from 19.3% to 14.1% (p<0.001). Corresponding proportions in the control group were reduced from 17.3% (2016) to 14.4% (2019) (p<0.001). Between 2016 and 2019, overall mean HbA1c decreased by 2.8 mmol/mol (p<0.001) at intervention clinics compared with 2.3 mmol/mol (p<0.001) at control clinics. After adjusting for the baseline differences in glycaemic control, there were no significant differences in the overall improvement in glycaemic control between intervention and control clinics. CONCLUSIONS: The registry linked QIC did not result in a significantly greater improvement in glycaemic control at intervention clinics compared with control clinics. However, there has been a sustained improvement in glycaemic control and importantly a significant reduction in the proportion of patients with poor glycaemic control at both intervention and control clinics during and after the QIC time frame. It is possible that some of this improvement may be due to a spillover effect from the QIC.

Seasonal variation in gestational diabetes mellitus among women in Norway: a national population-based study.

OBJECTIVES: Previous research on seasonal variation in the incidence of gestational diabetes mellitus (GDM) has shown inconclusive results. Furthermore, little is known about whether a seasonal variation in GDM might be associated with the maternal country of birth. We examined whether there was seasonal variation in GDM incidence by the maternal country background. DESIGN: National population-based registry study. SETTING AND PARTICIPANTS: We used national population-based data from the Medical Birth Registry of Norway (MBRN), n=1 443 857 (1990-2016) and data from four merged community-based studies (4GDM) with universal screening for GDM, n=2 978 (2002-2013). OUTCOME MEASURES: The association between season of pregnancy onset with incidence of GDM was examined separately in both datasets using logistic regression analyses, stratified by the mother's country background using two broad geographical categories (MBRN: Norwegian and immigrant; 4GDM: European and African/Asian ethnicity). Winter season was used as reference category. RESULTS: The incidence of GDM in MBRN was highest when the pregnancy started during the winter (Norwegian-born: 1.21%; immigrants: 3.32%) and lowest when pregnancy started during the summer for both Norwegian and immigrant women (Norwegian-born: 1.03% (OR 0.85, 95% CI 0.81 to 0.98); immigrants: 2.99% (OR 0.90, 95% CI 0.84 to 0.96)). The 4GDM data showed that women with European ancestry had the highest incidence of GDM when pregnancy started during autumn (10.7%, OR 1.01, 95% CI 0.69 to 1.46) and winter (10.6%), while ethnic African and Asian women had the highest incidence when pregnancy onset was during the summer (15.3%, OR 1.17, 95% CI 0.54 to 2.53). CONCLUSIONS: Based on national population-based data, this study suggests that GDM incidence varies by season in both Norwegian-born and immigrant women. The 4GDM dataset did not show a clear seasonal variation in GDM incidence, possibly due to the relatively small sample. Causes for the seasonal variation in GDM should be explored further.

Ankle fractures: a systematic review of patient-reported outcome measures and their measurement properties.

PURPOSE: Ankle fractures are commonly occurring fractures, especially in the aging population, where they often present as fragility fractures. The disease burden and economic costs to the patient and society are considerable. Choosing accurate outcome measures for the evaluation of the management of ankle fractures in clinical trials facilitates better decision-making. This systematic review assesses the evidence for the measurement properties of patient-reported outcome measures (PROMs) used in the evaluation of adult patients with ankle fractures. METHODS: Searches were performed in CINAHL, EMBASE, Medline and Google Scholar from the date of inception to July 2021. Studies that assessed the measurement properties of a PROM in an adult ankle fracture population were included. The included studies were assessed according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology for systematic reviews of PROMs. RESULTS: In total, 13 different PROMs were identified in the 23 included articles. Only the Ankle Fracture Outcome of Rehabilitation Measure (A-FORM) presented some evidence on content validity. The Olerud-Molander Ankle Score (OMAS) and Self-reported Foot and Ankle Score (SEFAS) displayed good evidence of construct validity and internal consistency. The measurement properties of the OMAS, LEFS and SEFAS were most studied. CONCLUSION: The absence of validation studies covering all measurement properties of PROMs used in the adult ankle fracture population precludes the recommendation of a specific PROM to be used in the evaluation of this population. Further research should focus on validation of the content validity of the instruments used in patients with ankle fractures.

The impact of educational concerns and satisfaction on baccalaureate nursing students' distress and quality of life during the Covid-19 pandemic; a cross-sectional study.

BACKGROUND: High levels of psychological distress and poor overall quality of life (QOL) have been identified among nursing students during the COVID-19 pandemic. The pandemic necessitated improvised reconstructions of educational curriculums and restrictions in clinical placement and training at campuses, possibly reducing educational quality. OBJECTIVES: We explored whether baccalaureate nursing students' concerns and satisfaction with the educational curriculum, focusing on the conduct of clinical training, were associated with perceived psychological distress and overall QOL. METHODS: Baccalaureate nursing students (N=6088) from five Norwegian universities were invited to an internet-based, cross-sectional survey during the second wave of the pandemic. The survey included COVID-19 specific questions on health, education and clinical training, the Fear of COVID-19 scale (FCV-19S), The Hopkins Symptom Checklist (SCL-5) and overall QOL. Data from national surveys on satisfaction with the educational curriculum, before and during the pandemic were used for comparison. RESULTS: In total, 2605 (43%) students responded, of whom 1591 (61%) had been engaged in clinical training during the pandemic. Overall, 53% were either satisfied or fully satisfied with their educational curriculum, with the level of satisfaction being significantly lower than pre-pandemic reference values. Also, 79% were concerned or highly concerned about the educational quality. In multiple regression analyses for all students, lower levels of satisfaction and higher levels of quality concerns were associated with worse SCL-5 scores. Furthermore, satisfaction with the educational curriculum was positively associated with overall QOL. For students engaged in clinical training, only concerns about infecting others were additionally associated with psychological distress. None of the items related to clinical training were associated with overall QOL. CONCLUSION: Nursing students' educational satisfaction and quality concerns may significantly impact perceived psychological distress and overall QOL during a pandemic. However, with necessary adaptations implemented, concerns regarding the conduct of clinical training account for little of these associations.

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.

Experiences and actions related to living with type 1 diabetes during the COVID-19 pandemic in Norway: a qualitative study conducted during July to December 2020.

OBJECTIVES: The aim of this study was to describe the experiences of adults with type 1 diabetes (T1DM) during the COVID-19 pandemic in Norway, and what actions they took to cope with the situation. DESIGN: An inductive, descriptive design applying the critical incident technique was used to collect qualitative data between July 2020 and December 2020. SETTING: A strategic selection was made from diabetes specialist outpatient clinics at three different hospitals in eastern Norway. The hospitals, two community hospitals and one university hospital, were situated in both rural and urban areas. PARTICIPANTS: Inclusion criteria were people with T1DM aged 18-65 years. Exclusion criteria were pregnancy, people with chronic pulmonary disorders, people with active cancer diseases and people diagnosed with a myocardial infarction or stroke during the previous 6 months. Semistructured individual interviews with 19 people with T1DM were conducted. RESULTS: Experiences were categorised into two main areas: 'increased psychosocial burden of T1DM during the COVID-19 pandemic' and 'changed conditions for T1DM treatment during the COVID-19 pandemic'. Uncertainty distress and social consequences from infection control measures contributed to the burden of T1DM. Disrupted T1DM follow-up and altered daily routines created challenges. However, having increased time to focus on T1DM self-management during lockdown represented an improvement. Actions to handle the situation were categorised into two main areas: 'actions to handle psychosocial strain related to T1DM and COVID-19' and 'actions to handle changed conditions for T1DM treatment during the COVID-19 pandemic'. CONCLUSIONS: Patients experienced an increased psychosocial burden of T1DM and difficulties from a disrupted daily life affecting T1DM self-management routines. Uncertainty-reducing behaviours and actions to adapt to the situation provided a general sense of coping despite these difficulties. Tailored information and follow-up by telephone or video call was emphasised to reduce uncertainly distress and support adequate diabetes T1DM self-management.

Is the risk of cardiovascular disease in women with pre-eclampsia modified by very low or very high offspring birth weight? A nationwide cohort study in Norway.

OBJECTIVES: To examine whether the risk of cardiovascular disease (CVD) in women with pre-eclampsia is modified by very low or very high offspring birth weight. Further, we studied whether diabetes in pregnancy modified this risk. DESIGN: Nationwide cohort study. SETTING: Norwegian population registries. PARTICIPANTS: 618 644 women who gave birth to their first child during 1980-2009. METHODS: The women were followed from delivery until the development of CVD or censoring, by linkage of the Medical Birth Registry of Norway to the Cardiovascular Disease in Norway project, and the Norwegian Cause of Death Registry. PRIMARY OUTCOME MEASURE: CVD. RESULTS: Compared with normotensive women with normal offspring birth weight, women with pre-eclampsia had increased risk of CVD (HR 2.16; 95% CI 2.05 to 2.26). The CVD risk was even higher when pre-eclampsia was accompanied with a large for gestational age offspring (LGA, z-score >2.0) (HR 2.57; 95% CI 2.08 to 3.18). Women with pre-eclampsia and a small for gestational age offspring (SGA, z-score <-2.0) had an HR of 1.54 (95% CI 1.23 to 1.93) compared with normotensive women with normal offspring birth weight.Also, women with diabetes had increased CVD risk, but no additional risk associated with an LGA or SGA offspring. CONCLUSIONS: Women with pre-eclampsia and an LGA offspring had higher risk of CVD than pre-eclamptic women with a normal weight (z-score -2.0 to 2.0) or SGA offspring. These findings suggest that factors causing pre-eclampsia and an LGA offspring are also linked to development of CVD.

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

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

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

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

Oral care training in the basic education of care professionals.

OBJECTIVE: To investigate the quantity and quality of oral care training in the basic education of future long-term care (LTC) professionals in Norway. BACKGROUND: The level of oral hygiene has often proved inadequate in LTC facilities. It has been maintained that this could be due to insufficient knowledge of oral care among care professionals. MATERIALS AND METHODS: A self-administered questionnaire was sent to all 270 schools in Norway which offered basic education of LTC personnel in 2004/05. Information on theoretical and practical oral care training, scope of oral care in teaching material and curriculum, educational background of the teaching staff and schools opinion regarding adequacy of their training programme was collected. RESULTS: Of the 203 respondents (75% response rate), 188 (participants) included oral care in their educational programme. Approximately two-thirds of the participating schools provided 3 h or more of oral care training and many of the important themes were presented in the textbooks that were recommended. Moreover, the practical exercises performed in practice placement supplemented the knowledge. CONCLUSION: The results could not confirm that LTC professional's basic education concerning oral care was inadequate. There may therefore be other explanations for the poor oral hygiene in many LTC facilities.