A Hybrid Model of In-Person and Telemedicine Diabetes Education and Care for Management of Patients with Uncontrolled Type 2 Diabetes Mellitus: Findings and Implications from a Multicenter Prospective Study.

Background: Patients with uncontrolled type 2 diabetes mellitus (T2DM) require close follow-up, support, and education to achieve glycemic control, especially during the initiation or intensification of insulin therapy and self-care management. This study aimed to describe and evaluate the impact of implementing a hybrid model of in-person and telemedicine care and education on glycemic control for patients with uncontrolled T2DM (hemoglobin A1c [HbA1c] ≥9%) during the coronavirus disease pandemic. Methods: This prospective multicenter-cohort pre-/post-intervention study was conducted on patients with uncontrolled T2DM. This study included three chronic illness centers affiliated with the Family and Community Medicine Department at Prince Sultan Military Medical City in Riyadh, Saudi Arabia. A hybrid model of in-person (onsite) and telemedicine care and education was developed. This involved implementing initial in-person care at the physicians' clinic and initial in-person education at the diabetes education clinic, followed by telemedicine services of tele-follow-ups, support, and education for an average 4-month follow-up period. Results: Of the enrolled 181 patients, more than half of the participants were women (n = 103, 56.9%). The mean age of participants (standard deviation) was 58.64 ± 11.23 years and the mean duration of diabetes mellitus was 13.80 ± 8.55 years. The majority of the patients (n = 144; 79.6%) were on insulin therapy. Overall, in all three centers, the hybrid model had significantly reduced HbA1c from 10.47 ± 1.23% to 7.87 ± 1.59% (mean difference of reduction 2.59% [95% confidence interval (CI) = 2.34-2.85%], p < 0.001). At the level of each center, HbA1c was reduced significantly with mean differences of 3.17% (95% CI = 2.81-3.53%), 2.49% (95% CI = 1.92-3.06%), and 2.16% (95% CI = 1.76-2.57%) at centers A, B, and C, respectively (all p < 0.001). Conclusion: The findings showed that the hybrid model of in-person and telemedicine care and education effectively managed uncontrolled T2DM. Consequently, the role of telemedicine in diabetes management could be further expanded as part of routine diabetes care in primary settings to achieve better glycemic control and minimize nonessential in-person visits when appropriate.

Cost-effectiveness of telemedicine care for patients with uncontrolled type 2 diabetes mellitus during the COVID-19 pandemic in Saudi Arabia.

BACKGROUND AND AIM: Telemedicine could be used to provide diabetes care with positive clinical outcomes. Consequently, this study evaluated the cost-effectiveness of telemedicine for patients with uncontrolled type 2 diabetes mellitus (i.e. HbA1c >9). PATIENTS AND METHODS: This was a retrospective chart review of patients with uncontrolled type 2 diabetes attending an outpatient integrated care clinic. The study consisted of two arms, namely a telemedicine care model and a traditional care model with 100 patients in each. The clinical effectiveness (i.e. reduction in HbA1c) and the total cost in both arms were determined, and the incremental cost-effectiveness ratio was calculated. This study adopted propensity score matching. RESULTS: The patients in the telemedicine care model had a mean reduction in their HbA1c level of 1.82 (95% CI = 1.56-2.09, p < 0.001), while those in the traditional care model had a mean reduction of 1.54 (95% CI = 1.23-1.85, p < 0.001). Consequently, the incremental effect was 0.28 (95% CI = -0.194 to 0.546). The mean total costs were SAR 4819.76 (US$1285.27) and SAR 4150.69 (US$1106.85) for patients in the telemedicine and traditional care models, respectively. Consequently, the incremental cost was SAR 669.07 (US$178.42) [95% CI = SAR 593.7 (US$158.32)-SAR 1013.64 (US$270.30)]. The ICER was estimated to be SAR 2372.52 (US$632.67) per 1% reduction in the level of HbA1c. Moreover, the telemedicine care model resulted in a higher cost and better outcome (i.e. reduction in the HbA1c level) with an 81.80% confidence level. CONCLUSION: Telemedicine care is cost-effective in managing type 2 patients with poorly controlled diabetes. Consequently, we believe that telemedicine care can be further expanded and incorporated into routine diabetes care.

Weekly Semaglutide vs. Liraglutide Efficacy Profile: A Network Meta-Analysis.

INTRODUCTION: Glucagon-like peptide 1 receptor agonist (GLP-1 RA) is a class of hypoglycemic medications. Semaglutide once-weekly (QW) and liraglutide once-daily (OD) significantly improved glycemic control compared to placebo. To date, no long-term phase III trials directly comparing semaglutide and liraglutide are available. This network meta-analysis (NMA) aims to compare the long-term efficacy of semaglutide and liraglutide. METHODS: PubMed, Embase, and Cochrane Library were searched from inception until June 2019 to identify relevant articles. Nine long-term randomized controlled trials comparing once-weekly semaglutide or liraglutide with placebo or other active comparisons were identified. The outcomes of interest were changes in HbA1c and weight after 52 weeks. A Bayesian framework and NMA were used for data synthesis. This is a sub-study of the protocol registered in PROSPERO (number CRD42018091598). RESULTS: The data showed significant superiority in HbA1c reduction of semaglutide 1 mg QW over liraglutide 1.2 and 1.8 mg with a treatment difference of 0.47% and 0.3%, respectively. Semaglutide 0.5 mg QW was found to be significantly superior to liraglutide 1.2 mg in HbA1c reduction with a treatment difference of 0.17%. Regarding weight reduction analysis, semaglutide 0.5 and 1 mg QW were significantly associated with a greater reduction than liraglutide 0.6 mg with a treatment difference of 2.42 and 3.06 kg, respectively. However, no significant reduction was found in comparison to liraglutide 1.2 and 1.8 mg. CONCLUSIONS: Semaglutide improved the control of blood glucose and body weight. The capacity of long-term glycemic control and body weight control of semaglutide appears to be more effective than other GLP-1 RAs, including liraglutide. However, considering the number of included studies and potential limitations, more large-scale, head-to-head, well-designed randomized-controlled trials (RCTs) are needed to confirm these findings.

Prevalence of retinopathy and associated risk factors among high- and low-risk patients with type 2 diabetes mellitus: An observational study.

OBJECTIVES: To assess the prevalence and risk factors of diabetic retinopathy (DR) in patients with type 2 diabetes mellitus (T2DM) of different risks, based on the level of glycated hemoglobin (HbA1c). METHODS: A cross-sectional study was conducted in in the chronic illness clinics in Saudi Arabia between January 2019 and February 2020. Data were extracted from 428 T2DM patients' medical records and random sampling were carried out using a ratio of 1:3, matched for gender and duration of DM. Patients with HbA1c level ≥9% were classified as 'high-risk' and HbA1c ≤7% as 'low-risk'. Retinopathy was confirmed by an ophthalmologist using fundus photography. RESULTS: The prevalence of DR in high-risk patient was 88.1% and 22.1% in low-risk patients. The prevalence of macular oedema was higher in the high-risk compared to low-risk patients (15.8% versus 4.9%, p<0.001). Patients' mean age was 61±11 years and duration of diabetes was 13±7 years. Hemoglobin A1c and low-density lipoprotein (LDL) levels were significantly higher in high-risk patients (p<0.0001) in bivariate but not multivariate analysis. CONCLUSION: High HbA1c and LDL levels were associated with DR risk. Further multicentre studies involving large samples are required to assess the risk factors associated with DR progression.

Sociodemographic and clinical predictors of refractory type 2 diabetes patients: Findings from a case-control study.

OBJECTIVES: To identify the sociodemographic and clinical predictors of uncontrolled diabetic patients, to identify high-risk and people with impaired glycemic control, to establish more effective strategies for reducing morbidity and mortality. METHODS: This case-control study of 8209 enrolled patients were included from the diabetes registry by Chronic Illness Center (CIC), Family and Community Medicin, Prince Sultan Military Medical City, Riyadh Saudi Arabia between February 2019 and February 2020. Cases are defined as patients with type II refractory diabetes having persistent HbA1c >9, not reach adequate glycemic control despite intensified therapy under specialist care (CIC) for at least 6 months. Controls were defined as patients with Hba1c ≤9. Multivariable regression analysis was used to identify predictors for patients with the persistent outcome of HbA1c >9%. RESULTS: Overall, a total of 1152 cases and 4555 controls were included. Patients with refractory diabetes were younger (mean: 58.5, standard deviation [SD]: 11.7) and females (63.4%). Duration of diabetes (13.3, SD: 7.4, p<0.001) and the mean value of low-density lipoprotein (LDL) (2.7, SD: 0.91, p<0.001) were significantly higher in the refractory group. The findings from the final model revealed that with every unit increase in age (odds ratio [OR]: 0.97, [95% confidence interval [CI]: 0.96-0.98]) and body mass index the odds of having refractory diabetes significantly reduced by 0.97 times (OR: 0.97, [95% CI: 0.95-0.99]). While with every unit increase in the duration of diabetes (OR: 1.03, [95% CI: 1.01-1.05]), systolic blood pressure (OR: 1.01, [95% CI: 1.00-1.02]) and LDL (OR: 1.42, [95% CI: 1.23-.62]) the odds of having refractory diabetes significantly increased by 1.03 and 1.42 times respectively compared to controls when adjusted for gender, albumin creatinine, diastolic blood pressure. CONCLUSION: The findings from this study helped classify the predictors of refractory patients with diabetes. Understanding refractory patients' predictors may help to develop new therapeutic strategies to boost their glycemic status safely.

Utilizing diabetes registry for exploring sociodemographic and clinical characteristics of type II diabetic patients in Saudi Arabia.

OBJECTIVES: To explore the sociodemographic and clinical characteristics as the process and outcomes of diabetic individuals. METHODS: Hospital Saudi Registry at Prince Sultan Military Medical City, Chronic Illness Clinics (Family and Community Medicine), Riyadh, Saudi Arabia database was started in February 2019 and data were collected until February 2020. The data were collected by trained diabetes nurse specialists. The registry includes all patients with type II diabetes mellitus (DM) and excluded patients with type I DM. Results: A total of 8,209 patients were enrolled in the registry with a higher proportion of females than males. The mean age was 59.3 years, BMI 32.5kg/m2, and HBA1c levels was 8.2%. Significant gender differences for BMI, duration of diabetes, blood pressure, LDL, smoking status, and medication intake. From the first to the third visit, BMI was raised; however, LDL, diastolic blood pressure, and albumin creatinine ratio were reduced. The mean HBA1c values plummeted for all patients and 33% of the patients had a reduction in the HbA1c levels. However, HbA1c levels increased for 24.7% of the patients' from baseline to the last visit. CONCLUSION: This registry provides great insights into the sociodemographic and clinical characteristics of diabetic patients in Saudi Arabia. This registry data can be used to investigate the associations between sociodemographic or clinical characteristics and glycemic control among T2DM patients in Saudi Arabia.

Impact of Ramadan-focused diabetes education on hypoglycemia risk and metabolic control for patients with type 2 diabetes mellitus: A systematic review.

BACKGROUND: Ramadan fasting is regarded as a form of worship amongst Muslims. However, patients with a high risk of diabetic complications are advised to avoid fasting, as the practice is associated with significant impacts on several health factors for type 2 diabetic patients, including glycaemic control. Thus, a lack of focused education before Ramadan may result in negative health outcomes. AIM: To evaluate the impact of a Ramadan-focused diabetes education programme on hypoglycaemic risk and other clinical and metabolic parameters. METHODS: A systematic literature search was performed using Scopus, PubMed, Embase, and Google Scholar to identify relevant studies meeting the inclusion criteria from inception. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and guidelines were followed when performing the search and identification of appropriate studies. RESULTS: Seventeen studies were included in this systemic review; five of them met the criteria to compile for a meta-analysis. The included studies were with various study designs, including randomised controlled trials, quasi-experimental and non-randomised studies. Overall, the results revealed a significant reduction of hypoglycemia risk (81% reduction) for fasting patients in intervention groups who received Ramadan-focused education compared with patients receiving conventional care (OR 0.19, 95% CI: 0.08-0.46). Moreover, HbA1c significantly improved amongst patients who received a Ramadan-focused diabetes education intervention, compared with those receiving conventional care. CONCLUSION: Ramadan-focused diabetes education had a significant impact on hypoglycemia and glycaemic control, with no significant effect on body weight, blood lipids or blood pressure.

Impact of Ramadan Focused Education Program on medications adjustment for patients with type 2 diabetes in a primary health care institution in Saudi Arabia.

AIMS: To examine the impact of Ramadan Focused Education Program (RFEP) on medications adjustment in type 2 diabetes patients in Ramadan. METHODS: This is a controlled, intervention based study. It was run on three phases: before, during, and after Ramadan on 262 type 2 diabetes patients. The intervention group (n = 140) received RFEP on medications doses & timing adjustment before and after Ramadan, while the control group (n = 122) received standard care. RESULTS: The dose of insulin glargine was reduced from 42.51 ±â€¯22.16 at the baseline to 40.11 ±â€¯18.51-units during Ramadan (p = 0.002) in the intervention group while it remained the same in the control group before Ramadan and during Ramadan (38.51 ±â€¯18.63 and 38.14 ±â€¯18.46, P = 0.428, respectively). The hypoglycemia score was 14.2 ± (8.5) pre-Ramadan in the intervention and reduced to 6.36 ±â€¯6.17 during Ramadan (p < 0.001) while in the control group, no significant changes were noted before and during Ramadan (14.01 ±â€¯5.10 versus 13.46 ±â€¯5.30). CONCLUSIONS: Ramadan Focused Education Program done at a primary healthcare setting had a positive impact on medication adjustment for dose and timing during fasting in Ramadan in diabetic patients, and it can be a useful tool to achieve better outcomes; less hypoglycemia and safe fasting among T2D patients during Ramadan.

Prevalence of cardiovascular autonomic neuropathy and gastroparesis symptoms among patients with type 2 diabetes who attend a primary health care center.

INTRODUCTION: Cardiovascular autonomic neuropathy (CAN) and gastroparesis are two types of diabetic autonomic neuropathy which could affect patients' quality of life and carry significant morbidity and mortality outcomes. The aim of this study was to estimate the prevalence and risk factors of both CAN and gastroparesis symptoms among patients with type 2 diabetes mellitus (T2DM) at primary health care level. METHODS: A cross-sectional study was conducted among 400 adults with T2DM from April 1, 2017 to March 20, 2018. CAN was defined by the presence of any of the followings: resting tachycardia, orthostatic hypotension or prolonged corrected QT interval in the electrocardiogram. Gastroparesis symptoms were assessed using a validated questionnaire: the Gastroparesis Cardinal Symptom Index. RESULTS: The mean age of study participants and disease duration were 55.26 ± 10.65 years and 10.77 ± 6.89 years, respectively. CAN was present in 15.3% of the participants. Hypertension, smoking, antihypertensive use, body mass index, dyslipidemia and albuminuria were significantly higher in participants with CAN than those without CAN (p<0.05). Prolonged disease duration (p = 0.007) and hypertension (p = 0.004) were independently associated with CAN. Gastroparesis symptoms were present in 6.3% of study participants and were significantly associated with those of female gender (P<0.05). Metformin use emerged as an independent predictor of the presence of at least one symptom (p = 0.001). CONCLUSION: Among Saudi adults with T2DM at primary care level, the prevalence of CAN is significant and is independently related to disease duration and hypertension, indicating the importance of CAN screening, especially for those with prolonged disease duration, and the importance of controlling blood pressure in order to prevent CAN or its consequences. The prevalence of gastroparesis symptoms is 6% and is independently related to metformin use, and therefore, symptomatic screening is required to decide which patients need further evaluation.

The association of metformin use with vitamin B12 deficiency and peripheral neuropathy in Saudi individuals with type 2 diabetes mellitus.

AIMS: To compare the prevalence of vitamin B12 deficiency and peripheral neuropathy between two groups of type 2 diabetes mellitus (T2DM) patients treated with or without metformin, and to determine factors associated with vitamin B12 deficiency therapy and dietary intake of vitamin B12. METHODS: In this retrospective study, we recruited 412 individuals with T2DM: 319 taking metformin, and 93 non-metformin users. Demographics, dietary assessment for vitamin B12 intakes, and medical history were collected. Participants were assessed for peripheral neuropathy. Blood specimens were collected and checked for serum vitamin B12 levels. The differences between the two groups were analyzed using an independent t-test for continuous data, and the Chi-squared or Fisher's exact test was used for categorical data. The relationship of vitamin B12 deficiency with demographics and clinical characteristics was modeled using logistic regression. RESULTS: The prevalence of B12 deficiency was 7.8% overall, but 9.4% and 2.2% in metformin users and non-metformin users, respectively. The odds ratio for serum vitamin B12 deficiency in metformin users was 4.72 (95% CI, 1.11-20.15, P = 0.036). There were no significant differences in a test of peripheral neuropathy between the metformin users and non-metformin users (P > 0.05). Low levels of vitamin B12 occurred when metformin was taken at a dose of more than 2,000 mg/day (AOR, 21.67; 95% CI, 2.87-163.47) or for more than 4 years (AOR, 6.35; 95% CI, 1.47-24.47). CONCLUSION: Individuals with T2DM treated with metformin, particularly those who use metformin at large dosages (> 2,000 mg/day) and for a longer duration (> 4 years), should be regularly screened for vitamin B12 deficiency and metformin is associated with B12 deficiency, but this is not associated with peripheral neuropathy.

Hypoglycemia in Type 2 Diabetes Mellitus patients: A review article.

Hypoglycemia is an essential issue for diabetic patients and considered a limiting factor in the glycemic management. Heterogeneity of the diseases in Type 2 Diabetes Mellitus can affect the frequency of hypoglycemia, especially when the patient has cardiovascular diseases. There are several factors that lead to hypoglycemia including sulfonylurea therapy, insulin therapy, delaying or missing a meal, physical exercise, or alcohol consumption. Long-term studies reported that repeated hypoglycemia could increase the risk of cardiovascular diseases. During Ramadan fasting, diabetic patients have high incidence of hypoglycemia. Therefore, focused education about hypoglycemia in routine life of diabetic patients and during fasting in Ramadan is important to reduce the complications.

Impact of an integrated care program on glycemic control and cardiovascular risk factors in patients with type 2 diabetes in Saudi Arabia: an interventional parallel-group controlled study.

BACKGROUND: Long intervals between patient visits and limited time with patients can result in clinical inertia and suboptimal achievement of treatment goals. These obstacles can be improved with a multidisciplinary care program. The present study aimed to assess the impact of such a program on glycemic control and cardiovascular risk factors. METHODS: In a randomized, parallel-group trial, we assigned 263 patients with poorly controlled type 2 diabetes mellitus (T2DM) to either a control group, standard care program, or a multidisciplinary care program involving a senior family physician, clinical pharmacy specialist, dietician, diabetic educator, health educator, and social worker. The participants were followed for a median of 10 months, between September 2013 and September 2014. Glycated hemoglobin (HbA1c), fasting blood glucose (FBG), lipid profiles, and blood pressure (BP) were measured. The assignment was blinded for the assessors of the study outcomes. The study registry number is. RESULTS: In the intervention group, there were statistically significant (p < 0.05) post-intervention (relative) reductions in the levels of HbA1c (-27.1%, 95% CI = -28.9%, -25.3%), FBG (-17.10%, 95% CI = -23.3%, -10.9%), total cholesterol (-9.93%, 95% CI = -12.7%, -7.9%), LDL cholesterol (-11.4%, 95% CI = -19.4%, -3.5%), systolic BP (-1.5%, 95% CI = -2.9%, -0.03%), and diastolic BP (-3.4%, 95% CI = -5.2%, -1.7%). There was a significant decrease in the number of patients with a HbA1c ≥10 (86 mmol/mol) from 167 patients at enrollment to 11 patients after intervention (p < 0.001). However, the intervention group experienced a statistically significant increase in body weight (3.7%, 95% CI = 2.9%, 4.5%). In the control group, no statistically significant changes were noticed in different outcomes with the exception of total cholesterol (-4.10%, p = 0.07). In the linear regression model, the intervention and the total number of clinic visits predicted HbA1c improvement. CONCLUSIONS: Implementation of a patient-specific integrated care program involving a multidisciplinary team approach, frequent clinic visits, and intensified insulin treatment was associated with marked improvement in glycemic control and cardiovascular risk factors of poorly controlled T2DM patients in a safe and reproducible manner. TRIAL REGISTRATION: ISRCTN Identifier: ISRCTN83437562 September 19, 2016 Retrospectively registered.

Microvascular and macrovascular complications of type 2 diabetic mellitus in Central, Kingdom of Saudi Arabia.

OBJECTIVES: To determine the prevalence of macrovascular and microvascular complications of type 2 diabetes mellitus and its associated determinants.  Methods: We evaluated the online medical records of patients with type 2 diabetes mellitus who have been seen in chronic disease unit between April and June 2014. Seven hundred and forty-eight participants satisfied the inclusion criteria. Of these, 317 (42.4%) were males with a mean age of 57.9 years, 681 (64.3%) were obese with body mass index (BMI) of greater than 30, while only 9.6% had normal BMI (less than 25).  Results: Only 158 (21.1%) had controlled hemoglobin A1c level. Retinopathy prevalence was 14.8% and neuropathy was 5.6%. Macrovascular complications accounted for 12.1%. Patients' age and duration of diabetes were main predictors of developing complications. Patients with more than 20 years  history of diabetes have 30% more odds of developing the complications when compared to patients with less than 10 years of diabetes history. Each increment in age by one year increases the odds of developing microvascular complications by 4% and macro vascular complication by 2%.  Conclusion: Our results showed diabetic patients with poor glycemic control, and longer duration of diabetic history had higher prevalence of both macrovascular and microvascular.

Impact of Ramadan focused education program on hypoglycemic risk and metabolic control for patients with type 2 diabetes.

BACKGROUND: Fasting during the month of Ramadan could lead to acute complications and increased hypoglycemic risk of patients with type 2 diabetes. Therefore, diabetes is one of the diseases that need careful observation and special considerations during Ramadan including patients' education and counseling. OBJECTIVES: To evaluate the impact of Ramadan focused education program on acute complications and biomedical parameters. METHODS: A prospective nonrandomized interventional controlled design was run on three phases: before, during, and after Ramadan on 262 type 2 diabetes patients. The intervention group (n=140) received focused individualized diabetic education sessions and antidiabetic medications adjustment before and after Ramadan, while the control group (n=122) received standard diabetic care. A validated hypoglycemia questionnaire was used in both groups to assess the change of the risk. Patients were advised to adjust the dosage and timing of antidiabetic agents according to the recommendations for management of diabetes during Ramadan. Primary outcomes were postintervention change of hypoglycemia score and HbA1c over 6-month follow-up. Data were presented as mean ± standard deviation. HbA1c was expressed in percentage. RESULTS: The hypoglycemic scores before, during, and after Ramadan were 14.21±8.50, 6.36±6.17, and 5.44±5.55 in the intervention group, respectively (P<0.001) and 14.01±5.10, 13.46±5.30, and 9.27±4.65 in the control group, respectively (P<0.001). HbA1c levels were 9.79±1.89, 8.26±1.54, and 8.52±1.61 before, during, and after Ramadan in the intervention group, respectively (P<0.001), and 10.04±1.47, 9.54±1.38, and 9.59±1.79 in the control group, respectively (P<0.001). Post-Ramadan reductions of HbA1c and hypoglycemic scores were significantly higher in the intervention group (-13.0% vs -4.5%, P=0.004 for HbA1c and -61.7% vs -33.8%, P<0.001 for hypoglycemic score). Low-density lipoprotein cholesterol improved in the intervention group from 2.41±0.91 mmol/L before Ramadan to 2.28±0.68 mmol/L after Ramadan (P<0.001). No statistically significant effects were observed on blood pressure or body weight in the intervention group. Also, no change was observed in the control group. CONCLUSION: Ramadan educational program had a positive impact with reduction of hypoglycemic risk, HbA1c, and low-density lipoprotein cholesterol. Therefore, it could be recommended for patients with increased risk of hypoglycemia during Ramadan fasting.

Ethnic specific differences in survival of patients with type 2 diabetes: analysis of data collected from an Australian multi-ethnic cohort over a 25 year period.

AIMS: To examine the survival of patients with type 2 diabetes from 7 ethnic groups, living in the shared environment of an Australian city. METHODS: Hazard ratio of death (HR) after diagnosis of diabetes was compared between Anglo-Celtic (n=5433), Indigenous Australian (n=439), Pacific Islander (n=354), Mediterranean (n=3138), Arabic (n=768), Indian (n=702) and Chinese (n=1632) patients who live in metropolitan Sydney. Mortality was ascertained by data-linkage with the Australian National Death Index. The modulating effects of glycaemic control, diabetes/vascular complications and risk factors, year of diabetes diagnosis and duration of diabetes on ethnic differences were analysed by Cox regression. Socio-economic status and competence in English were also examined. RESULTS: There were significant differences in survival between the ethnic groups; the Indigenous Australians had the highest HR for death (2.3, 95% CI 1.7-3.0) and the Chinese the lowest (0.4, 95% CI 0.4-0.5). The survival of the Anglo-Celtics (HR 1) was surprisingly poorer than for Indian (0.6, 95% CI 0.5-0.8), Arab (0.7, 95% CI 0.6-0.8) and Mediterranean groups (0.8, 95% CI 0.7-0.9). Prevalence of smoking and albuminuria were strongly associated with HR. The better survival of Chinese and Arab and the worse survival of Indigenous Australians remained after adjustment of risk factors. Need for an interpreter was a favourable risk factor for survival. CONCLUSIONS: Ethnicity is a significant determinant of survival in type 2 diabetes and this is substantially but not completely mediated by smoking and vascular risk factors. The favourable impact associated with less competence in English may represent a Healthy-migrant effect.