Alun Edwards

Association of socio-economic status with diabetes prevalence and utilization of diabetes care services

BackgroundLow income appears to be associated with a higher prevalence of diabetes and diabetes related complications, however, little is known about how income influences access to diabetes care. The objective of the present study was to determine whether income is associated with referral to a diabetes centre within a universal health care system.MethodsData on referral for diabetes care, diabetes prevalence and median household income were obtained from a regional Diabetes Education Centre (DEC) database, the Canadian National Diabetes Surveillance System (NDSS) and the 2001 Canadian Census respectively. Diabetes rate per capita, referral rate per capita and proportion with diabetes referred was determined for census dissemination areas. We used Chi square analyses to determine if diabetes prevalence or population rates of referral differed across income quintiles, and Poisson regression to model diabetes rate and referral rate in relation to income while controlling for education and age.ResultsThere was a significant gradient in both diabetes prevalence (χ2 = 743.72, p < 0.0005) and population rates of referral (χ2 = 168.435, p < 0.0005) across income quintiles, with the lowest income quintiles having the highest rates of diabetes and referral to the DEC. Referral rate among those with diabetes, however, was uniform across income quintiles. Controlling for age and education, Poisson regression models confirmed a significant socio-economic gradient in diabetes prevalence and population rates of referral.ConclusionLow income is associated with a higher prevalence of diabetes and a higher population rate of referral to this regional DEC. After accounting for diabetes prevalence, however, the equal proportions referred to the DEC across income groups suggest that there is no access bias based on income.

Effect of Vitamin D3 Supplementation on Improving Glucose Homeostasis and Preventing Diabetes: A Systematic Review and Meta-Analysis

CONTEXT Observational studies report consistent associations between low vitamin D concentration and increased glycemia and risk of type 2 diabetes, but results of randomized controlled trials (RCTs) are mixed. OBJECTIVE The objective of the study was to systematically review RCTs that report on the effects of vitamin D supplementation on glucose homeostasis or diabetes prevention. DATA SOURCES Sources of data for the study were MEDLINE, EMBASE, SCOPUS, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Health Technology Assessment, and Science Citation Index from inception to June 2013. STUDY SELECTION Study selection was trials that compared vitamin D3 supplementation with placebo or a non-vitamin D supplement in adults with normal glucose tolerance, prediabetes, or type 2 diabetes. DATA EXTRACTION AND SYNTHESIS Two reviewers collected data and assessed trial quality using the Cochrane Risk of Bias tool. Random-effects models were used to estimate mean differences (MDs) and odds ratios. The main outcomes of interest were homeostasis model assessment of insulin resistance, homeostasis model assessment of β-cell function, hemoglobin A1c levels, fasting blood glucose, incident diabetes, and adverse events. DATA SYNTHESIS Thirty-five trials (43 407 patients) with variable risk of bias were included. Vitamin D had no significant effects on insulin resistance [homeostasis model assessment of insulin resistance: MD -0.04; 95% confidence interval (CI) -0.30 to 0.22, I-squared statistic (I(2)) = 45%], insulin secretion (homeostasis model of β-cell function: MD 1.64; 95% CI -25.94 to 29.22, I(2) = 40%), or hemoglobin A1c (MD -0.05%; 95% CI -0.12 to 0.03, I(2) = 55%) compared with controls. Four RCTs reported on the progression to new diabetes and found no effect of vitamin D (odds ratio 1.02; 95% CI 0.94 to 1.10, I(2) = 0%). Adverse events were rare, and there was no evidence of publication bias. CONCLUSIONS Evidence from available trials shows no effect of vitamin D3 supplementation on glucose homeostasis or diabetes prevention. Definitive conclusions may be limited in the context of the moderate degree of heterogeneity, variable risk of bias, and short-term follow-up duration of the available evidence to date.

Self-monitoring in Type 2 diabetes : a randomized trial of reimbursement policy

Aim  Self‐monitoring of blood glucose is often considered a cornerstone of self‐care for patients with diabetes. We assessed whether provision of free testing strips would improve glycaemic control in non‐insulin‐treated Type 2 diabetic patients.

Clinical and medication profiles stratified by household income in patients referred for diabetes care.

BackgroundLow income individuals with diabetes are at particularly high risk for poor health outcomes. While specialized diabetes care may help reduce this risk, it is not currently known whether there are significant clinical differences across income groups at the time of referral. The objective of this study is to determine if the clinical profiles and medication use of patients referred for diabetes care differ across income quintiles.MethodsThis cross-sectional study was conducted using a Canadian, urban, Diabetes Education Centre (DEC) database. Clinical information on the 4687 patients referred to the DEC from May 2000 – January 2002 was examined. These data were merged with 2001 Canadian census data on income. Potential differences in continuous clinical parameters across income quintiles were examined using regression models. Differences in medication use were examined using Chi square analyses.ResultsMultivariate regression analysis indicated that income was negatively associated with BMI (p < 0.0005) and age (p = 0.023) at time of referral. The highest income quintiles were found to have lower serum triglycerides (p = 0.011) and higher HDL-c (p = 0.008) at time of referral. No significant differences were found in HBA1C, LDL-c or duration of diabetes. The Chi square analysis of medication use revealed that despite no significant differences in HBA1C, the lowest income quintiles used more metformin (p = 0.001) and sulfonylureas (p < 0.0005) than the wealthy. Use of other therapies were similar across income groups, including lipid lowering medications. High income patients were more likely to be treated with diet alone (p < 0.0005).ConclusionOur findings demonstrate that low income patients present to diabetes clinic older, heavier and with a more atherogenic lipid profile than do high income patients. Overall medication use was higher among the lower income group suggesting that differences in clinical profiles are not the result of under-treatment, thus invoking lifestyle factors as potential contributors to these findings.

Association between participation in a brief diabetes education programme and glycaemic control in adults with newly diagnosed diabetes.

To determine the association between participation in a brief introductory didactic diabetes education programme and change in HbA1c among individuals with newly diagnosed diabetes.

The impact of new guidelines for glucose tolerance testing on clinical practice and laboratory services

The Canadian Diabetes Associations 2003 clinical practice guidelines for diabetes mellitus were published in mid-December 2003.[1][1] These guidelines retain the fasting plasma glucose test for the diagnosis of diabetes, and the criterion for diagnosis (fasting plasma glucose level of 7.0 mmol/L or

Patient navigators for people with chronic disease: protocol for a systematic review and meta-analysis

BackgroundIndividuals with chronic diseases may have difficulty optimizing their health and getting the care they need due to a combination of patient, provider, and health system level barriers. Patient navigator programs, in which trained personnel assess and assist patients in overcoming barriers to care, may improve care and outcomes for patients with chronic disease by providing an alternative approach to conventional information and support resources.MethodsThis systematic review will evaluate the evidence for patient navigator programs, compared to usual care, in patients with chronic disease. We will include RCTs, cluster RCTs, and quasi-randomized RCTs that study the effects of patient navigator programs on clinical outcomes, patient experience, and markers of adherence to care. Studies will be identified by searching MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, PsycINFO, Social Work Abstracts, and the references of included studies. Two authors will screen titles and abstracts independently. Full texts will be reviewed for relevance and data extraction will be done independently by two authors. Studies will be included if they assess patients of any age with one or more chronic diseases. Outcomes will be categorized into groups characterized by their proximity to mechanism of action of the intervention: patient-level outcomes, intermediate outcomes, and process outcomes. Descriptive data about the elements of the patient navigator intervention will also be collected for potential subgroup analyses. Risk of bias will be assessed using the Effective Practice and Organisation of Care Group (EPOC) risk of bias tool. Data will be analyzed using random effects meta-analysis (relative risk for dichotomous data and mean difference for continuous data), if appropriate.DiscussionA comprehensive review of patient navigator programs, including a summary of the elements of programs that are associated with a successful intervention, does not yet exist. This systematic review will synthesize the evidence of the effect of patient navigator interventions on clinical and patient-oriented outcomes in populations across a comprehensive set of chronic diseases.Systematic Review RegistrationPROSPERO CRD42013005857.

Association of Median Household Income With Burden of Coronary Artery Disease Among Individuals With Diabetes

Background—Low income is associated with adverse cardiovascular outcomes. Diabetes is more prevalent among low income groups, and low income patients with diabetes have been shown to have a greater burden of cardiovascular risk factors and worse cardiovascular outcomes. The objective of this study was to determine whether income status was associated with burden of coronary atherosclerosis in patients with diabetes. Methods and Results—All patients with diabetes presenting for cardiac catheterization between January 1, 2000, and December 31, 2002, in Calgary, Canada, were identified through the use of the Alberta Provincial Project for Assessing Outcomes in Coronary Heart Disease (APPROACH) database. This clinical database was merged with Canadian 2001 Census data on median household income per dissemination area using patient postal code data, and income quintiles were derived. Clinical profiles, severity of coronary atherosclerosis, and myocardial jeopardy were compared across income quintiles. Mean scores for severity and jeopardy were compared across income quintiles using analysis of variance. Multivariate linear regression was used to control for baseline differences across income groups.A total of 4596 patients were eligible for inclusion in this study. Clinical profiles differed significantly across income quintiles, with the highest income quintile being younger (P<0.0005), more likely to be male (P=0.029), and having a lower prevalence of smoking (P=0. 039). Low income groups were more likely to report a history of myocardial infarction (P<0.0005) or congestive heart failure (P<0.0005). The highest income groups has significantly less coronary atherosclerosis as measured by the weighted Duke index (6.67 versus 7.38, P<0.002), but there were no differences in lesion severity as measured by the Duke severity scale (2.31 versus 2.41, P=0.334). High income patients has significantly less myocardial jeopardy compared with the lowest income group as measured by the Duke and APPROACH scores (36.44 versus 46.23, P=0.0187, and 39.96 versus 45.36, P=0.0182, respectively). These differences remained significant even after controlling for baseline clinical differences in cardiovascular risk factor burden. Conclusions—Low income is associated with a greater degree of atherosclerosis and greater myocardial jeopardy in patients with diabetes. More needs to be done to reduce cardiovascular risk factor burden in this vulnerable population.

Multi-professional education in diabetes

Multi-professional education (MPE) is a forward-looking educational strategy that is both innovative and clinically needed. The primary goal of this program was to assess the potential of MPE in diabetes care. Objectives included knowledge increase in type 2 diabetes care and examining the effect of uni-professional versus multi-professional small groups on learning outcomes. A total of 61 baccalaureate nursing students, four pharmacy students and 56 family practice residents participated in a half-day program. Participants were randomly assigned to multi-versus uni-professional groups. A questionnaire assessing knowledge, attitudes and perceived role responsibilities was anonymously completed in a pre-test/post-test manner. The program was delivered in two sessions that combined larger and small group activities. Quantitative data were analyzed using repeated measures Anova/Manova, Wilcoxon signed rank and Pearson chi-square tests. Participants and educators showed interest in multi-professional education. While no change in knowledge was found, moderate changes in attitudes (with a lessening of attitudinal differences) and significant changes in perceptions of role (from uni-professional responsibility to shared responsibilities) were noted. Nurses in uni-professional groups demonstrated the greatest attitudinal and role perception changes. The contribution of the patient as teacher was prominent. Further exploration and rigorous analysis of the utility of MPE in diverse settings is warranted.

Prevalence and Timing of Screening and Diagnostic Testing for Gestational Diabetes Mellitus: A Population-Based Study in Alberta, Canada

OBJECTIVE The extent to which pregnant women are screened for gestational diabetes mellitus (GDM) at the population level is not known. We examined the rate, type, and timing of GDM screening and diagnostic testing in the province of Alberta, Canada. Geographic and temporal differences in screening rates, and maternal risk factors associated with lower likelihood of screening, were also determined. RESEARCH DESIGN AND METHODS Our retrospective linked-database cohort study included 86,842 primiparous women with deliveries between 1 October 2008 and 31 December 2012. Multivariable logistic regression analysis was used to examine maternal factors associated with lower likelihood of GDM screening. RESULTS Overall, 94% (n = 81,304) of women underwent some form of glycemic assessment in the 270 days prior to delivery. The majority (91%) received a 50-g glucose screen (GDS). Women not screened were younger and more likely to smoke and had lower maternal weight and median household income. When a diagnostic 75-g oral glucose tolerance test (OGTT) was indicated, it occurred a median of 10 (interquartile range 7, 15) days after the screen. CONCLUSIONS GDS occurred widely in a system where it was universally recommended and paid for publicly. When indicated, a 75-g OGTT was completed within 15 days in 75% of cases. Our finding that this two-step approach was widely implemented in a timely fashion supports continued endorsement of a two-step approach to screening and diagnosis of GDM. Further research is merited to assess whether the one-step GDM diagnostic approach results in different rates and timing of the 75-g OGTT and affects pregnancy outcomes.