Alistair Emslie-Smith

Metformin and reduced risk of cancer in diabetic patients

Metformin, widely given to patients with type 2 diabetes, works by targeting the enzyme AMPK (AMP activated protein kinase), which induces muscles to take up glucose from the blood. A recent breakthrough has found the upstream regulator of AMPK to be a protein kinase known as LKB1.1 2 LKB1 is a well recognised tumour suppressor. Activation of AMPK by metformin and exercise requires LKB1, and this would also explain why exercise is beneficial in the primary and secondary prevention of certain cancers.3 We hypothesise that metformin use in patients with type 2 diabetes may reduce their risk of cancer. We tested this hypothesis using record linkage databases developed in Tayside, Scotland: a diabetes clinical information system (DARTS) and a database of dispensed prescriptions (MEMO).4 We did a pilot case-control study using previously validated methods.5 From 314 127 people who were resident (or died) in Tayside in …

The diabetes audit and research in Tayside Scotland (darts) study: electronic record linkage to create a diabetes register

Abstract Objectives: To identify all patients with diabetes in a community using electronic record linkage of multiple data sources and to compare this method of case ascertainment with registers of diabetic patients derived from primary care. Design: Electronic capture-recapture linkage of records included data on all patients attending hospital diabetes clinics, all encashed prescriptions for diabetes related drugs and monitoring equipment, all patients discharged from hospital, patients attending a mobile unit for eye screening, and results for glycated haemoglobin and plasma glucose concentrations from the regional biochemistry database. Diabetes registers from primary care were from a random sample of eight Tayside general practices. A detailed manual study of relevant records for the 35 144 patients registered with these eight general practices allowed for validation of the case ascertainment. Setting: Tayside region of Scotland, population 391 274 on 1 January 1996. Main outcome measures: Prevalence of diabetes; population of patients identified by different data sources; sensitivity and positive predictive value of ascertainment methods. Results: Electronic record linkage identified 7596 diabetic patients, giving a prevalence of known diabetes of 1.94% (0.21% insulin dependent diabetes, 1.73% non-insulin dependent): 63% of patients had attended hospital diabetes clinics, 68% had encashed diabetes related prescriptions, 72% had attended the mobile eye screening unit, and 48% had biochemical results diagnostic of diabetes. A further 701 patients had isolated hyperglycaemia (plasma glucose >11.1 mmol/l) but were not considered diabetic by general practitioners. Validation against the eight general practices (636 diabetic patients) showed electronic linkage to have a sensitivity of 0.96 and a positive predictive value of 0.95 for ascertainment of known diabetes. General practice lists had a sensitivity of 0.91 and a positive predictive value of 0.98. Conclusions: Electronic record linkage was more sensitive than general practice registers in identifying diabetic subjects and identified an additional 0.18% of the population with a history of hyperglycaemia who might warrant screening for undiagnosed diabetes. Key messages It has been recommended that regional registers of patients with diabetes are established in order to facilitate effective monitoring and treatment of diabetes In Tayside we created a diabetes register by record linkage of multiple data sources: all patients attending hospital diabetes clinics, all encashed prescriptions for diabetes related drugs and monitoring equipment, all patients discharged from hospital, patients attending a mobile unit for eye screening, and results for glycated haemoglobin and plasma glucose concentrations from the regional biochemistry database This register identified 7596 patients with diabetes in Tayside, giving a prevalence of diabetes of 1.94% Record linkage was more sensitive than general practice registers in ascertaining cases of known diabetes A unique patient identifier, the community health number, was fundamental for successful record linkage

ABC of arterial and venous disease: Vascular complications of diabetes

Adults with diabetes have an annual mortality of about 5.4% (double the rate for non-diabetic adults), and their life expectancy is decreased on average by 5-10 years. Although the increased death rate is mainly due to cardiovascular disease, deaths from non-cardiovascular causes are also increased. A diagnosis of diabetes immediately increases the risk of developing various clinical complications that are largely irreversible and due to microvascular or macrovascular disease. Duration of diabetes is an important factor in the pathogenesis of complications, but other risk factors—for example, hypertension, cigarette smoking, and hypercholesterolaemia—interact with diabetes to affect the clinical course of microangiopathy and macroangiopathy. View this table: Vascular complications of diabetes View this table: Risk of morbidity associated with all types of diabetes mellitus A continuous relation exists between glycaemic control and the incidence and progression of microvascular complications. Hypertension and smoking also have an adverse effect on microvascular outcomes. In the diabetes control and complications trial—a landmark study in type 1 diabetes—the number of clinically important microvascular endpoints was reduced by 34-76% in patients allocated to intensive insulin (that is, a 10% mean reduction in glycated haemoglobin (HbA1c) concentration from 8.0% to 7.2%). However, these patients also had more hypoglycaemic episodes. Similarly, in the UK prospective diabetes study of patients with type 2 diabetes, an intensive glucose control policy that lowered glycated haemoglobin concentrations by an average of 0.9% compared with conventional treatment (median HbA1c 7.0% v 7.9%) resulted in a 25% reduction in the overall microvascular complication rate. It was estimated that for every 1% reduction in HbA1c concentration there is a 35% reduction in microvascular disease. Relation between glycaemic control (HbA1c) and risk of progression of microvascular complications (retinopathy) and severe hypoglycaemia in patients with type 1 diabetes. Data from the diabetes control and complications trial. Dotted lines represent 95% confidence …

Contraindications to metformin therapy in patients with Type 2 diabetes—a population-based study of adherence to prescribing guidelines

Aims  To define the number of people in Tayside, Scotland (population 349 303) with Type 2 diabetes who use metformin, the incidence of contraindications to its continued use in these people and the proportion that discontinued metformin treatment following the development of a contraindication.

Screening uptake in a well-established diabetic retinopathy screening program: the role of geographical access and deprivation.

OBJECTIVE—To identify criteria that affect uptake of diabetes retinal screening in a community screening program using mobile retinal digital photography units. RESEARCH DESIGN AND METHODS—Data from the regional diabetes population-based retinal screening program and regional ophthalmology laser database were linked to patient postal code (zip code) data. We used distance from retinal screening event, social deprivation scores, and demographic information to identify risk factors for nonattendance at a diabetes retinal screening event. Patients were subdivided into urban (>125,000 population), other urban (3,000–125,000 population), or rural (<3,000 population) depending on where they lived. Data were collected from 2004 to 2006 inclusive and included 15,150 patients and 32,621 eye screening records. RESULTS—The mean ± SD age of patients was 63 ± 15 years, and 54% were male. Mean travel time to retinal screening event varied from 7.1 to 17.0 min. For 12% of missed appointments, patients were more likely to be younger, to have longer diabetes duration, to have poor A1C and blood pressure control, to be smokers, and to live in deprived areas. Poor attendance was not associated with sex or distance to retinal screening event. CONCLUSIONS—Social deprivation is strongly associated with poor attendance at retinal screening events. Time traveled to screening event was not associated with attendance in this study of a mobile retinal screening service, which visited general practitioner surgeries. This data can help inform population-based diabetes retinal screening programs about improving patient uptake.

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

Aim  The DARTS diabetes register was used to determine incidence rates of diabetes and related complications in 1997.

Do managed clinical networks improve quality of diabetes care? Evidence from a retrospective mixed methods evaluation

Problem: System-wide improvement of chronic disease care is challenging because it requires collaboration and communication across organisational and professional boundaries. Managed clinical networks are one potential solution, but there is little evidence of their effectiveness. Design and setting: Retrospective, mixed-methods evaluation of the form and impact of quality improvement in the Tayside Diabetes Managed Clinical Network (MCN) 1998–2005. Strategies for change: Progressive implementation of multiple quality improvement strategies predominately directed at individuals and clinical teams (guideline development and dissemination, education, clinical audit, encouragement of multidisciplinary team working, task redesign). Information technology played an important role in supporting QI activity, but participants identified it as facilitative rather than delivering QI by itself. More important was achieving widespread clinical engagement through persuasion and appeal to shared professional values by clinical leaders. Effects of change: Simple process measures such as glycated haemoglobin measurement rapidly improved. More complex process measures such as eye screening improved more slowly, and were more dependent on redesign of the care pathway. Improvement was greater for type 2 than type 1 diabetes. Significant shifts of care for type 2 diabetes into primary care were achieved, but were harder to achieve without additional resources. Lessons learnt: Delivering better care to whole populations across organisational and professional boundaries required sustained work over long periods, and at all levels of the system of care. Past network focus on clinical collaboration has been effective at improving clinical process and outcome, and the network is now prioritising work with managers and patients to support future redesign.

Which people with Type 2 diabetes achieve good control of intermediate outcomes? Population database study in a UK region

Aims  To measure quality of vascular risk factor measurement and control in people with Type 2 diabetes after comprehensive pay‐for‐performance implementation and to examine variation by patient and practice characteristics.

The problem of polypharmacy in type 2 diabetes

Evidence of improvements in outcomes gained by aggressive treatment of hypertension, hyperglycaemia and Edyslipidaemia in type 2 diabetic patients has encouraged the setting of ambitious targets fo...

Using web technology to support population-based diabetes care

Background: Managed clinical networks have been used to coordinate chronic disease management across geographical regions in the United Kingdom. Our objective was to review how clinical networks and multidisciplinary team-working can be supported by Web-based information technology while clinical requirements continually change. Methods: A Web-based population information system was developed and implemented in November 2000. The system incorporates local guidelines and shared clinical information based upon a national dataset for multispecialty use. Automated data linkages were developed to link to the master index database, biochemistry, eye screening, and general practice systems and hospital diabetes clinics. Web-based data collection forms were developed where computer systems did not exist. The experience over the first 10 years (to October 2010) was reviewed. Results: The number of people with diabetes in Tayside increased from 9694 (2.5% prevalence) in 2001 to 18,355 (4.6%) in 2010. The user base remained stable (~400 users), showing a high level of clinical utility was maintained. Automated processes support a single point of data entry with 10,350 clinical messages containing 40,463 data items sent to external systems during year 10. The system supported quality improvement of diabetes care; for example, foot risk recording increased from 36% in 2007 to 73.3% in 2010. Conclusions: Shared-care datasets can improve communication between health care service providers. Web-based technology can support clinical networks in providing comprehensive, seamless care across a geographical region for people with diabetes. While health care requirements evolve, technology can adapt, remain usable, and contribute significantly to quality improvement and working practice.