Jeremiah Hwee

Trends in Incidence of Diabetes in Pregnancy and Serious Perinatal Outcomes: A Large, Population-Based Study in Ontario, Canada, 1996–2010

OBJECTIVE Women with diabetes in pregnancy have high rates of pregnancy complications. Our aims were to explore trends in the incidence of diabetes in pregnancy and examine whether the risk of serious perinatal outcomes has changed. RESEARCH DESIGN AND METHODS We performed a population-based cohort study of 1,109,605 women who delivered in Ontario, Canada, between 1 April 1996 and 31 March 2010. We categorized women as gestational diabetes (GDM) (n = 45,384), pregestational diabetes (pre-GDM) (n = 13,278), or no diabetes (n = 1,050,943). The annual age-adjusted rates of diabetes in pregnancy were calculated, and rates of serious perinatal outcomes were compared between groups and by year using Poisson regression. RESULTS The age-adjusted rate of both GDM (2.7–5.6%, P < 0.001) and pre-GDM (0.7–1.5%, P < 0.001) doubled from 1996 to 2010. The rate of congenital anomalies declined by 23%, whereas the rate of perinatal mortality did not change significantly. However, compared with women with no diabetes, women with pre-GDM and GDM faced an increased risk of congenital anomalies (relative risk 1.86 [95% CI 1.49–2.33] and 1.26 [1.09–1.45], respectively), and perinatal mortality remained elevated in women with pre-GDM (2.33 [1.59–3.43]). CONCLUSIONS The incidence of both GDM and pre-GDM in pregnancy has doubled over the last 14 years, and the overall burden of diabetes in pregnancy on society is growing. Although congenital anomaly rates have declined in women with diabetes, perinatal mortality rates remain unchanged, and the risk of both remains significantly elevated compared with nondiabetic women. Increased efforts are needed to reduce these adverse outcomes.

Preeclampsia as a Risk Factor for Diabetes: A Population- Based Cohort Study

Denice Feig and colleagues assess the association between gestational diabetes, gestational hypertension, and preeclampsia and the development of future diabetes in a database analysis of pregnant women in Ontario, Canada.

Diabetes education through group classes leads to better care and outcomes than individual counselling in adults: A population-based cohort study

OBJECTIVE: Self-management education, supported by multidisciplinary health care teams, is essential for optimal diabetes management. We sought to determine whether acute diabetes complications or quality of care differed for patients in routine clinical care when their self-management education was delivered through group diabetes education classes versus individual counselling.METHODS: With the use of population-level administrative and primary data, all diabetic patients in Ontario who attended a self-management education program in 2006 were identified and grouped according to whether they attended group classes (n=12,234), individual counselling (n=55,761) or a mixture of both (n=9,829). Acute complications and quality of care in the following year were compared among groups.RESULTS: Compared with those attending individual counselling, patients who attended group classes were less likely to have emergency department visits for hypo/hyperglycemia (odds ratio 0.54, 95% confidence interval [CI]: 0.42–0.68), hypo/hyperglycemia hospitalizations (OR 0.49, CI: 0.32–0.75) or foot ulcers/cellulitis (OR 0.64, CI: 0.50–0.81). They were more likely to have adequate HbA1c testing (OR 1.10, CI: 1.05–1.15) and lipid testing (OR 1.25, CI: 1.19–1.32), and were more likely to receive statins (OR 1.22, CI: 1.07–1.39).CONCLUSION: Group self-management education was associated with fewer acute complications and some improvements in processes of care. Group sessions can offer care to more patients with reduced human resource requirements. With increased pressure to find efficiencies in health care delivery, group diabetes education may provide an opportunity to deliver less resource-intensive care that simultaneously improves patient care.RésuméOBJECTIF: Une éducation à l’auto-prise en charge, appuyée par une équipe de soins de santé multidisciplinaire, est essentielle à une prise en charge optimale du diabète. Nous avons cherché à déterminer si les complications aiguës du diabète ou la qualité des soins diffèrent chez les patients recevant les soins cliniques habituels lorsque leur éducation à l’auto-prise en charge leur est offerte en groupe dans des classes d’éducation au diabète, plutôt que sous forme de counseling individuel.MÉTHODE: À l’aide de données primaires et administratives populationnelles, nous avons identifié tous les patients diabétiques de l’Ontario ayant assisté à un programme d’éducation à l’auto-prise en charge en 2006 et nous les avons regroupés selon qu’ils ont assisté à des classes en groupe (n=12 234), reçu du counseling individuel (n=55 761) ou un mélange des deux (n=9 829). Nous avons comparé les complications aiguës et la qualité des soins au cours de l’année suivante dans ces trois groupes.RÉSULTATS: Comparativement à ceux qui ont reçu du counseling individuel, les patients ayant assisté à des classes en groupe étaient moins susceptibles de s’être rendus à l’urgence pour cause d’hypo- ou d’hyperglycémie (rapport de cotes 0,54, intervalle de confiance de 95 % [IC]: 0,42–0,68), d’être hospitalisés pour hypo- ou hyperglycémie (RC 0,49, IC: 0,32–0,75) ou de souffrir de plaies du pied ou de cellulite (RC 0,64, IC: 0,50–0,81). Ils étaient aussi plus susceptibles d’avoir fait faire un test d’HbA1c (RC 1,10, IC: 1,05–1,15) et un bilan lipidique (RC 1,25, IC: 1,19–1,32), et plus susceptibles de recevoir des statines (RC 1,22, IC: 1,07–1,39).CONCLUSION: L’éducation à l’auto-prise en charge reçue en groupe était associée à un moindre nombre de complications aiguës et à certaines améliorations du processus de soins. Les séances en groupe permettent de servir davantage de patients et exigent moins de ressources humaines. Étant donné les pressions accrues pour réaliser des économies dans la prestation des soins de santé, l’éducation au diabète en groupe peut être l’occasion d’offrir des services avec moins de ressources tout en améliorant les soins aux patients.

Factors associated with undiagnosed and overdiagnosed COPD

Worldwide, studies have shown that about 60–86% of people with chronic obstructive pulmonary disease (COPD) have not been diagnosed, which represents a missed opportunity to decrease disease burden through optimal management, including smoking cessation support and prescription medications [1–3]. Overdiagnosed COPD is also common, with prevalence estimates ranging from 4% to 64% in the general population and primary care settings [4, 5]. Overdiagnosis can lead to unnecessary COPD treatments with their own risks and costs, poor health-related quality of life and missed detection and treatment of other diseases [6]. Several factors are associated with undiagnosed and overdiagnosed COPD http://ow.ly/4mW6lu

Diabetes self-management education is not associated with a reduction in long-term diabetes complications: an effectiveness study in an elderly population.

RATIONALE, AIMS AND OBJECTIVES The efficacy of diabetes self-management education on glycaemic control, self-care behaviour and knowledge has been established by short-term studies in experimental settings. The objective of this study was to assess its effectiveness to improve quality of care and reduce the risk of long-term diabetes complications in unselected older patients with recently diagnosed diabetes in routine clinical care. METHODS Using population-level health care administrative databases and registries, all patients aged ≥66 years in Ontario, Canada with diabetes for <5 years were identified. Self-management education programme attendees (n = 8485) in 2006 were matched with non-attendees using high-dimensional propensity scores, creating extremely well-balanced study arms. Quality of care measures and the long-term risk of diabetes complications were compared. RESULTS Self-management programme attendees were more likely than non-attendees to achieve process measures of quality of care such as retinal screening examinations (75.3% versus 70.3%, adjusted relative risk 1.05, 99% confidence interval 1.03-1.08), and ≥2 glycated haemoglobin tests (57.5% versus 53.3%, adjusted relative risk 1.08, 99% confidence interval 1.05-1.11). However, with a median follow-up of 5.3 years, diabetes complications and mortality were not different between arms. CONCLUSIONS In real-world clinical care, self-management education for older patients with recently diagnosed diabetes was associated with modest improvements in quality of care, but no reductions in long-term clinical events.

Trends in Socioeconomic Status–related Differences in Mortality among People with Chronic Obstructive Pulmonary Disease

RATIONALE Previous studies have demonstrated that people of higher socioeconomic status (SES) have better chronic obstructive pulmonary disease (COPD) health outcomes than those of lower SES. Mortality of people with COPD has decreased over the last decade; however, it is not known if all individuals with COPD have benefitted equally. OBJECTIVE The objective of the current study was to examine the impact of SES on mortality trends of individuals with COPD. METHODS We conducted a population-based study using health administrative data from Ontario, Canada, between 1996/7 and 2011/12. Individuals with COPD were identified using a previously validated case definition. SES was determined using average household income of the individuals neighborhood as per the Canadian Census. Trends in standardized COPD mortality rates among different SES quintiles were observed over time. MEASUREMENTS AND MAIN RESULTS Overall, age- and sex-standardized mortality of people with COPD decreased from 5.7% (95% confidence interval [CI], 5.5-5.8) in 1996/7 to 3.7% (95% CI, 3.6-3.8) in 2011/12, representing a 35% relative decrease. The mortality difference between the lowest and highest income quintiles increased from 67 per 10,000 individuals in 1996/7 to 86 per 10,000 individuals in 2011/12, representing a 28% relative increase (P < 0.001). CONCLUSIONS Mortality in people with COPD has decreased faster in people with the highest compared with the lowest SES, causing increased disparity between rich and poor. Further study and strategies are needed to explore and address factors responsible for this increasing disparity in the COPD population.

Mortality trends in women and men with COPD in Ontario, Canada, 1996–2012

Importance COPD is the third leading cause of death worldwide. Mortality trends offer an indication of how well a society is doing in fighting a disease. Objective To examine trends in all-cause, lung cancer, cardiovascular and COPD mortalities in people with COPD, overall and in men and women. Design, setting, participants Population, cohort study using health administrative data from Ontario, Canada, 1996 to 2011. Exposure A previously validated COPD case definition was used to identify all people with COPD. Main outcomes and measures All-cause, lung cancer, cardiovascular and COPD mortality rates were determined annually from 1996 to 2011 overall, and in men and women. All-cause trends were compared with all-cause trends in the non-COPD population. All rates were standardised to the 2006 Ontario population. Results The prevalence of COPD was 11.0% in 2011. Over the study period, all-cause mortality decreased significantly more in men with COPD than the non-COPD population. The same was not observed in women. COPD-specific and lung cancer mortalities, which started higher in men with COPD, decreased faster in them than in women with COPD with the two rates becoming more similar over time. Cardiovascular disease mortality declined at a relatively equal rate in both sexes. Conclusions and relevance Mortality in people with COPD has decreased; however, the decrease has been greater in men than in women. Public health interventions and medical care appear to be improving mortality in individuals with COPD but more research is needed to determine if they are benefiting both sexes equally.

Socioeconomic Status, Sex, Age and Access to Medications for COPD in Ontario, Canada

Abstract Disparities in COPD health outcomes have been found with older individuals, men and those of lower socioeconomic status doing worse. We sought to determine if this was due to differences in access to COPD medications. We conducted a retrospective cohort study using population health administrative data from Ontario, Canada, a province with universal prescription drug coverage for older adults. All individuals with COPD aged 67 years and older in 2008 who were not taking inhaled long-acting bronchodilators or inhaled corticosteroids were followed for 2 years. Poisson regression was used to determine the effects of age, sex, and socioeconomic status on the likelihood of initiating one of these medications, after adjusting for potential confounders. Over the study period, 54,050 of 185,698 (29.1%) older individuals with COPD not previously taking any inhaled long-acting bronchodilators or corticosteroids were initiated on one or more of these medications. After adjustment, individuals of low socioeconomic status, measured using neighborhood income level quintiles, were slightly more likely to initiate COPD medications than those of high socioeconomic status (relative risk (RR) 1.05; 95% confidence interval (95% CI) 1.02–1.08). While men received COPD medication at a consistent rate across all age groups, the likelihood that a woman received medication decreased with increasing age. With the exception of older women, there was minimal disparity in prescription for COPD medications. Disparity in health outcomes among Ontario COPD patients is not clearly explained by differences in medication access by socioeconomic status, sex or age.

Forecasting Hospitalization and Emergency Department Visit Rates for Chronic Obstructive Pulmonary Disease. A Time-Series Analysis

Rationale: Knowing trends in and forecasting hospitalization and emergency department visit rates for chronic obstructive pulmonary disease (COPD) can enable health care providers, hospitals, and health care decision makers to plan for the future. Objectives: We conducted a time‐series analysis using health care administrative data from the Province of Ontario, Canada, to determine previous trends in acute care hospitalization and emergency department visit rates for COPD and then to forecast future rates. Methods: Individuals aged 35 years and older with physician‐diagnosed COPD were identified using four universal government health administrative databases and a validated case definition. Monthly COPD hospitalization and emergency department visit rates per 1,000 people with COPD were determined from 2003 to 2014 and then forecasted to 2024 using autoregressive integrated moving average models. Results: Between 2003 and 2014, COPD prevalence increased from 8.9 to 11.1%. During that time, there were 274,951 hospitalizations and 290,482 emergency department visits for COPD. After accounting for seasonality, we found that monthly COPD hospitalization and emergency department visit rates per 1,000 individuals with COPD remained stable. COPD prevalence was forecasted to increase to 12.7% (95% confidence interval [CI], 11.4‐14.1) by 2024, whereas monthly COPD hospitalization and emergency department visit rates per 1,000 people with COPD were forecasted to remain stable at 2.7 (95% CI, 1.6‐4.4) and 3.7 (95% CI, 2.3‐5.6), respectively. Forecasted age‐ and sex‐stratified rates were also stable. Conclusions: COPD hospital and emergency department visit rates per 1,000 people with COPD have been stable for more than a decade and are projected to remain stable in the near future. Given increasing COPD prevalence, this means notably more COPD health service use in the future.

Identifying diabetes cases from administrative data: a population-based validation study

BackgroundHealth care data allow for the study and surveillance of chronic diseases such as diabetes. The objective of this study was to identify and validate optimal algorithms for diabetes cases within health care administrative databases for different research purposes, populations, and data sources.MethodsWe linked health care administrative databases from Ontario, Canada to a reference standard of primary care electronic medical records (EMRs). We then identified and calculated the performance characteristics of multiple adult diabetes case definitions, using combinations of data sources and time windows.ResultsThe best algorithm to identify diabetes cases was the presence at any time of one hospitalization or physician claim for diabetes AND either one prescription for an anti-diabetic medication or one physician claim with a diabetes-specific fee code [sensitivity 84.2%, specificity 99.2%, positive predictive value (PPV) 92.5%]. Use of physician claims alone performed almost as well: three physician claims for diabetes within one year was highly specific (sensitivity 79.9%, specificity 99.1%, PPV 91.4%) and one physician claim at any time was highly sensitive (sensitivity 93.6%, specificity 91.9%, PPV 58.5%).ConclusionsThis study identifies validated algorithms to capture diabetes cases within health care administrative databases for a range of purposes, populations and data availability. These findings are useful to study trends and outcomes of diabetes using routinely-collected health care data.