Eszter P. Vamos

Changes in the Incidence of Lower Extremity Amputations in Individuals With and Without Diabetes in England Between 2004 and 2008

OBJECTIVE To describe recent trends in the incidence of nontraumatic amputations among individuals with and without diabetes and estimate the relative risk of amputations among individuals with diabetes in England. RESEARCH DESIGN AND METHODS We identified all patients aged >16 years who underwent any nontraumatic amputation in England between 2004 and 2008 using national hospital activity data from all National Health Service hospitals. Age- and sex-specific incidence rates were calculated using the total diabetes population in England every year. To test for time trend, we fitted Poisson regression models. RESULTS The absolute number of diabetes-related amputations increased by 14.7%, and the incidence decreased by 9.1%, from 27.5 to 25.0 per 10,000 people with diabetes, during the study period (P > 0.2 for both). The incidence of minor and major amputations did not significantly change (15.7–14.9 and 11.8–10.2 per 10,000 people with diabetes; P = 0.66 and P = 0.29, respectively). Poisson regression analysis showed no statistically significant change in diabetes-related amputation incidence over time (0.98 decrease per year [95% CI 0.93–1.02]; P = 0.12). Nondiabetes-related amputation incidence decreased from 13.6 to 11.9 per 100,000 people without diabetes (0.97 decrease by year [0.93–1.00]; P = 0.059). The relative risk of an individual with diabetes undergoing a lower extremity amputation was 20.3 in 2004 and 21.2 in 2008, compared with that of individuals without diabetes. CONCLUSIONS This national study suggests that the overall population burden of amputations increased in people with diabetes at a time when the number and incidence of amputations decreased in the aging nondiabetic population.

Trends in lower extremity amputations in people with and without diabetes in England, 1996–2005

AIMS To examine trends in non-traumatic lower extremity amputations over a 10-year-period in people with and without diabetes (DM) in England. METHODS All individuals admitted to NHS hospitals for non-traumatic amputations between 1996 and 2005 in England were identified using hospital activity data. Postoperative and 1-year mortality were examined between 2000 and 2004. RESULTS There was a reduction in minor and major amputations during the study period. The number of type 1 DM- and non-DM-related minor amputations decreased by 11.4% and 32.4%, respectively, while the number of type 2 DM-related minor amputations almost doubled. The incidence of type 1- and non-DM-related minor amputations decreased from 1.5 to 1.2 and from 8.1 to 5.1/100,000 population, respectively, while type 2 DM-related amputations increased from 2.4 to 4.1/100,000 population. The number of type 1- and non-DM-related major amputations declined by 41% and 22%, respectively, whereas type 2 DM-related amputations increased by 43%. The incidence of type 2 DM-related amputations increased from 2.0 to 2.7/100,000 population. Overall perioperative and 1-year mortality did not significantly change between 2000 and 2004. CONCLUSIONS While several factors may explain the increase in type 2 DM-related LEAs, these findings highlight the importance of diabetes prevention strategies and controlling risk factors for LEAs in people with diabetes.

Association of systolic and diastolic blood pressure and all cause mortality in people with newly diagnosed type 2 diabetes: retrospective cohort study

Objective To examine the effect of systolic and diastolic blood pressure achieved in the first year of treatment on all cause mortality in patients newly diagnosed with type 2 diabetes, with and without established cardiovascular disease. Design Retrospective cohort study. Setting United Kingdom General Practice Research Database, between 1990 and 2005. Participants 126 092 adult patients (age ≥18 years) with a new diagnosis of type 2 diabetes who had been registered with participating practices for at least 12 months. Main outcome measure All cause mortality. Results Before diagnosis, 12 379 (9.8%) patients had established cardiovascular disease (myocardial infarction or stroke). During a median follow-up of 3.5 years, we recorded 25 495 (20.2%) deaths. In people with cardiovascular disease, tight control of systolic (<130 mm Hg) and diastolic (<80 mm Hg) blood pressure was not associated with improved survival, after adjustment for baseline characteristics (age at diagnosis, sex, practice level clustering, deprivation score, body mass index, smoking, HbA1c and cholesterol levels, and blood pressure). Low blood pressure was also associated with an increased risk of all cause mortality. Compared with patients who received usual control of systolic blood pressure (130-139 mm Hg), the hazard ratio of all cause mortality was 2.79 (95% confidence interval 1.74 to 4.48, P<0.001) for systolic blood pressure at 110 mm Hg. Compared with patients who received usual control of diastolic blood pressure (80-84 mm Hg), the hazard ratios were 1.32 (1.02 to 1.78, P=0.04) and 1.89 (1.40 to 2.56, P<0.001) for diastolic blood pressures at 70-74 mm Hg and lower than 70 mm Hg, respectively. Similar associations were found in people without cardiovascular disease. Subgroup analyses of people diagnosed with hypertension and who received treatment for hypertension confirmed initial findings. Conclusion Blood pressure below 130/80 mm Hg was not associated with reduced risk of all cause mortality in patients with newly diagnosed diabetes, with or without known cardiovascular disease. Low blood pressure, particularly below 110/75 mm Hg, was associated with an increased risk for poor outcomes.

Symptoms of Depression in Kidney Transplant Recipients: A Cross-sectional Study

BACKGROUND Depression is associated with impaired quality of life and increased morbidity and mortality in patients with end-stage renal disease. Little is known about the prevalence and correlates of depression in kidney transplant recipients. In this study, we aimed to compare depressive symptoms between kidney transplant recipients and wait-listed dialysis patients and identify the correlates of depressive symptoms in the transplant recipient population. STUDY DESIGN Observational cross-sectional study using the Center for Epidemiologic Studies Depression Scale (CES-D) to assess the severity of depressive symptoms. A cutoff score of 18 was used to identify the presence of depression. SETTING & PARTICIPANTS 1,067 kidney transplant recipients and 214 wait-listed dialysis patients were asked to participate; the final analysis included 854 kidney transplant and 176 wait-listed dialysis patients, respectively. PREDICTORS Sociodemographic and clinical variables. OUTCOME Severity of depressive symptoms and presence of depression (CES-D score > or = 18). RESULTS The prevalence of depression was 33% versus 22% in wait-listed versus transplant patients, respectively (P = 0.002). In multivariate regression, number of comorbid conditions, estimated glomerular filtration rate, perceived financial situation, and marital status were significant and independent predictors of depression in the transplant recipient group. Treatment modality was associated significantly with the presence of depression, even after adjustment for clinical and sociodemographic variables (OR, 2.01; 95% CI, 1.25-3.23; P = 0.004). LIMITATIONS Self-reported measurement of depressive symptoms. CONCLUSIONS The prevalence of depression is lower in transplant recipients than in wait-listed patients. However, one-fifth of transplant patients are still at high risk of clinically significant depression. Comorbid conditions, socioeconomic status, and treatment modality predicted depressive symptoms in patients with end-stage renal disease.

Depressive Symptoms and Mortality in Patients After Kidney Transplantation: A Prospective Prevalent Cohort Study

Objective: To analyze in a prospective cohort study if depressive symptoms are an independent predictor of mortality in kidney transplant recipients. Methods: Data from 840 transplanted patients followed at a single outpatient transplant center were analyzed. Sociodemographic parameters and clinical data were collected at enrollment (between August 2002 and February 2003). Participants completed the Center for Epidemiologic Studies-Depression (CES-D) scale. Depression was defined as CES-D score of ≥18. Data on 5-year outcomes (death censored graft loss or mortality) were collected. Results: The prevalence of depression was 22%. Mortality was higher (21% versus 13%; p = .004) in patients with versus without depression. In a multivariate Cox proportional hazard model, both the baseline CES-D score (hazard ratiofor each 1-point increase = 1.02; 95% confidence interval, 1.00–1.04) and the presence of depression at baseline (hazard ratiopresence = 1.66; 95% confidence interval, 1.12–2.47) were significantly associated with mortality. The baseline CES-D score also significantly predicted death censored graft loss (hazard ratiofor each 1-point increase = 1.03; 95% confidence interval, 1.01–1.05). Conclusion: Depressive symptoms are an independent predictor of mortality in kidney transplanted patients. CES-D = Center for Epidemiologic Studies-Depression scale; CKD = chronic kidney disease; CNI = calcineurin inhibitor; CRP = C-reactive protein; CsA = cyclosporine A; DOPPS = Dialysis Outcomes and Practice Patterns Study; GFR = estimated glomerular filtration rate; ESRD = end-stage renal disease; ESRD-SI = End-Stage Renal Disease Severity Index; Hb = hemoglobin; HLA = human leukocyte antigen; HR = hazard ratio; IQR = interquartile range.

Nationwide Study on Trends in Hospital Admissions for Major Cardiovascular Events and Procedures Among People With and Without Diabetes in England, 2004–2009

OBJECTIVE It is unclear whether people with and without diabetes equally benefitted from reductions in cardiovascular disease (CVD). We aimed to compare recent trends in hospital admission rates for angina, acute myocardial infarction (AMI), stroke, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) among people with and without diabetes in England. RESEARCH DESIGN AND METHODS We identified all patients aged >16 years with cardiovascular events in England between 2004–2005 and 2009–2010 using national hospital activity data. Diabetes- and nondiabetes-specific rates were calculated for each year. To test for time trend, we fitted Poisson regression models. RESULTS In people with diabetes, admission rates for angina, AMI, and CABG decreased significantly by 5% (rate ratio 0.95 [95% CI 0.94–0.96]), 5% (0.95 [0.93–0.97]), and 3% (0.97 [0.95–0.98]) per year, respectively. Admission rates for stroke did not significantly change (0.99 [0.98–1.004]) but increased for PCI (1.01 [1.005–1.03]) in people with diabetes. People with and without diabetes experienced similar proportional changes for all outcomes, with no significant differences in trends between these groups. However, diabetes was associated with an ~3.5- to 5-fold risk of CVD events. In-hospital mortality rates declined for AMI and stroke, remained unchanged for CABG, and increased for PCI admissions in both groups. CONCLUSIONS This national study suggests similar changes in admissions for CVD in people with and without diabetes. Aggressive risk reduction is needed to further reduce the high absolute and relative risk of CVD still present in people with diabetes.

Association of practice size and pay-for-performance incentives with the quality of diabetes management in primary care.

Background: Not enough is known about the association between practice size and clinical outcomes in primary care. We examined this association between 1997 and 2005, in addition to the impact of the Quality and Outcomes Framework, a pay-for-performance incentive scheme introduced in the United Kingdom in 2004, on diabetes management. Methods: We conducted a retrospective open-cohort study using data from the General Practice Research Database. We enrolled 422 general practices providing care for 154 945 patients with diabetes. Our primary outcome measures were the achievement of national treatment targets for blood pressure, glycated hemoglobin (HbA1c) levels and total cholesterol. Results: We saw improvements in the recording of process of care measures, prescribing and achieving intermediate outcomes in all practice sizes during the study period. We saw improvement in reaching national targets after the introduction of the Quality and Outcomes Framework. These improvements significantly exceeded the underlying trends in all practice sizes for achieving targets for cholesterol level and blood pressure, but not for HbA1c level. In 1997 and 2005, there were no significant differences between the smallest and largest practices in achieving targets for blood pressure (1997 odds ratio [OR] 0.98, 95% confidence interval [CI] 0.82 to 1.16; 2005 OR 0.92, 95% CI 0.80 to 1.06 in 2005), cholesterol level (1997 OR 0.94, 95% CI 0.76 to 1.16; 2005 OR 1.1, 95% CI 0.97 to 1.40) and glycated hemoglobin level (1997 OR 0.79, 95% CI 0.55 to 1.14; 2005 OR 1.05, 95% CI 0.93 to 1.19). Interpretation: We found no evidence that size of practice is associated with the quality of diabetes management in primary care. Pay-for-performance programs appear to benefit both large and small practices to a similar extent.

Epidemiology of end-stage renal disease in the countries of the Gulf Cooperation Council: a systematic review

Objectives To describe the epidemiology of end stage renal disease (ESRD). Design Mixed-methods systematic review. Setting The countries of the Gulf Cooperation Council (GCC) which consist of Saudi Arabia, the United Arab Emirates, Kuwait, Qatar, Bahrain, and Oman. Participants Defined to have ESRD or patients on regular dialysis for a minimum dialysis period of at least three months. Since many outcomes were reviewed, studies that estimated the incidence and prevalence of ESRD as outcomes should not have defined the study population as ESRD population or patients on regular dialysis. Studies where the study population mainly comprised children or pregnant woman were excluded. Main outcome measures The trends of the incidence, prevalence, and mortality rate of ESRD; also, causes of mortality, primary causes and co-morbid conditions associated with ESRD. Results 44 studies included in this review show that the incidence of ESRD has increased while the prevalence and mortality rate of ESRD in the GCC has not been reported sufficiently. The leading primary causes of ESRD recorded in the countries of the GCC is diabetes with the most prevalent co-morbid conditions being Hypertension and Hepatitis C Virus infection; the most common cause of death was cardiovascular disease and sepsis. Conclusions This review highlights that the lack of national renal registries data is a critical issue in the countries of the GCC. The available data also do not provide an accurate and updated estimate for relevant outcomes. Additionally, considering the increasing burden of chronic kidney disease (CKD), these results stressed the needs and the importance of preventative strategies for leading causes of ESRD. Furthermore, more studies are needed to describe the epidemiology of ESRD and for assessing the overall quality of renal care.

Impact of a Pay-for-Performance Incentive Scheme on Age, Sex, and Socioeconomic Disparities in Diabetes Management in UK Primary Care.

We examined the impact of a major pay-for-performance initiative introduced into UK primary care in 2004 on disparities in diabetes management between age, sex, and socioeconomic groups in this retrospective cohort study. We used data from the General Practice Research Database enrolling 422 family practices. Existing disparities in risk factor management (HbA1c, blood pressure, cholesterol) narrowed between men and women. Younger patients (<45 years) with diabetes appear to have benefited less from Quality and Outcomes Framework than older patients, resulting in some widening of existing age group disparities. Patients living in affluent and deprived areas appeared to have derived a similar level of benefit from pay for performance.

Impact of the National Health Service Health Check on cardiovascular disease risk: a difference-in-differences matching analysis.

Background: The National Health Service Health Check program in England is the largest cardiovascular risk assessment and management program in the world. We assessed the effect of this program on modelled risk of cardiovascular disease, individual risk factors for cardiovascular disease, prescribing of relevant medications and diagnosis of vascular disease. Methods: We obtained retrospective electronic medical records for a randomly selected sample of 138 788 patients aged 40–74 years registered with 462 English general practices participating in the Clinical Practice Research Datalink between 2009 and 2013. We used a quasi-experimental design of difference-indifferences matching analysis to compare changes in outcomes between Health Check attendees and nonattendees, with a median follow-up time of 2 years. Results: Overall, 21.4% of the eligible population attended a Health Check. After matching (n = 29 672 in each group), attendees had a significant absolute reduction in modelled risk for cardiovascular disease (−0.21%, 95% confidence interval [CI] −0.24% to −0.19%) and individual risk factors: systolic blood pressure (−2.51 mm Hg, 95% CI −2.77 to −2.25 mm Hg), diastolic blood pressure (−1.46 mm Hg, 95% CI −1.62 to −1.29 mm Hg), body mass index (−0.27, 95% CI −0.34 to −0.20) and total cholesterol (−0.15 mmol/L, 95% CI −0.18 to −0.13 mmol/L). Statins were prescribed for 39.9% of attendees who were at high risk for cardiovascular disease. The program resulted in significantly more diagnoses of selected vascular diseases among attendees, with the largest increases for hypertension (2.99%) and type 2 diabetes mellitus (1.31%). Interpretation: The National Health Service Health Check program had statistically significant but clinically modest impacts on modelled risk for cardiovascular disease and individual risk factors, although diagnosis of vascular disease increased. Overall program performance was substantially below national and international targets, which highlights the need for careful planning, monitoring and evaluation of similar initiatives internationally.