Ritchie McAlpine

Diabetes and Lower-Limb Amputations in the Community: A retrospective cohort study

OBJECTIVE There are few U.K. data on the incidence rates of amputation in diabetic subjects compared with the nondiabetic population. RESEARCH DESIGN AND METHODS We performed a historical cohort study of first lower-extremity amputations based in Tayside, Scotland (population 364,880) from 1 January 1993 to 31 December 1994. The Diabetes Audit and Research in Tayside Scotland (DARTS) database was used to identify a prevalence cohort of 7,079 diabetic patients on 1 January 1993. We estimated age-specific and standardized incidence rates of lower-limb amputations in the diabetic and nondiabetic cohorts. Results were compared with a previous study that evaluated lower-extremity amputations in diabetic patients in Tayside in 1980–1982. RESULTS There were 221 subjects who underwent a total of 258 nontraumatic amputations. Of the 221 subjects, 60 (27%) patients were diabetic (93% NIDDM), and 63% were first amputations. The median duration of diabetes was 6 years (range: newly diagnosed to 41 years). Nonhealing ulceration (31%) and gangrene (29%) were the two main indications for amputation in the diabetic subjects. Of the 161 nondiabetic subjects, 140 (80%) underwent first amputations. The adjusted incidences in the diabetic and nondiabetic groups were 248 and 20 per 100,000 person-years, respectively. Tayside patients with diabetes thus had a 12.3-fold risk of an amputation compared with nondiabetic residents (95% Cl 8.6–17.5). The estimated proportion of diabetic patients in the population rose from 0.81% in 1980–1982 to 1.94% in 1993–1994, whereas the absolute rate of amputation in diabetic subjects was unchanged from that in 1980–1982. CONCLUSIONS These population-based U.K. amputation data are similar to amputation rates in the U.S. Amputation rates appear to have decreased significantly since 1980–1982. The impact of diabetes education and prevention programs that target the processes leading to amputation can now be evaluated.

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.

Diabetic Retinopathy: More Patients, Less Laser: A longitudinal population-based study in Tayside, Scotland

OBJECTIVE—We aim to correlate the incidence of diabetic retinopathy and maculopathy requiring laser treatment with the control of risk factors in the diabetic population of Tayside, Scotland, for the years 2001–2006. RESEARCH DESIGN AND METHODS—Retinal laser treatment, retinal screening, and diabetes care databases were linked for calendar years 2001–2006. Primary end points were the numbers of patients undergoing first or any laser treatment for diabetic retinopathy or maculopathy. Mean A1C and blood pressure and retinal screening rates were followed over the study period. RESULTS—Over 6 years, the number of patients with diabetes in Tayside increased from 9,694 to 15,207 (57% increase). The number of patients receiving laser treatment decreased from 222 to 138 and first laser treatments decreased from 100 (1.03% of diabetic population) to 56 (0.37%). The number of patients with type 2 diabetes treated for maculopathy decreased from 180 in 2001 to 103 in 2006 (43% reduction, P = 0.03). Mean A1C decreased for type 1 and type 2 diabetic populations (P < 0.01) and a reduction in blood pressure was observed in type 2 diabetic patients (P < 0.01). The number of patients attending annual digital photographic retinopathy screening increased from 3,012 to 11,932. CONCLUSIONS—Laser treatment for diabetic maculopathy in type 2 diabetic patients has decreased in Tayside over a six-year period, despite an increased prevalence of diabetes and increased screening effort. We propose that earlier identification of type 2 diabetes and improved risk factor control has reduced the incidence of maculopathy severe enough to require laser treatment.

Fear of visual loss in patients with diabetes: results of the prevalence of diabetic eye disease in Tayside, Scotland (P-DETS) study.

Aims  To describe the relationship between fear of visual loss and dependent variables (visual acuity, retinopathy treatment, severity of retinopathy) in community‐based diabetic patients.

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.

Impact of socioeconomic deprivation on the development of diabetic retinopathy: a population-based, cross-sectional and longitudinal study over 12 years

Objective To study the association between socioeconomic deprivation and prevalence of diabetic retinopathy (DR). Design Population-based, cross-sectional observational study and retrospective longitudinal analysis over 12 years. Setting Primary care, East of Scotland. Methods Outcome data from DR screening examinations (digital retinal photography) were collected from the Scottish regional diabetes electronic record from inception of database to December 2012. The overall Scottish Index of Multiple Deprivation (SIMD) 2012 score for each patient was obtained using their residential postcode. Multiple binary logistic regression was used to analyse the relationship between overall SIMD score and prevalence of DR, adjusting for other variables: age, gender, glycated haemoglobin, cholesterol levels and duration of disease. Primary outcome Any retinopathy (R1 and above) in either eye. Results A total of 1861 patients with type 1 diabetes mellitus (DM) and 18 197 patients with type 2 DM were included in the study. Prevalence of DR in type 1 and type 2 DM were 56.3% and 25.5%, respectively. Increased prevalence of DR in type 1 DM was associated with higher overall SIMD score (p=0.002), with an OR for the most deprived relative to the least deprived of 2.40 (95% CI 1.36 to 4.27). In type 2 DM, the overall SIMD score was not significantly associated with increased prevalence of DR, with an OR for the most deprived relative to the least deprived of 0.85 (95% CI 0.71 to 1.02, p=0.07). Conclusions Socioeconomic deprivation is associated with increased prevalence of DR in patients with type 1 DM and this occurs earlier. This highlights the need for targeted interventions to address inequalities in eye healthcare.

A study to determine the sensitivity and specificity of hospital discharge diagnosis data used in the MICA study

Aims—To determine the sensitivity and specificity of each ICD9 code for a diagnosis of definite or possible myocardial infarction (MI) from the perspective of the Myocardial Infarction Causality Study (MICA) and to use these data to estimate the likely number of MICA cases in Scotland that would be undetected were these codes omitted from the study.

Do H2-receptor antagonists cause acute pancreatitis?

The aim of this study was to investigate the association between H2‐receptor antagonists and acute pancreatitis. The automated database of the Medicines Monitoring Unit (MEMO) was used to carry out a case‐control study, supplemented with information on possible confounding factors from hospital and GP medical records. Cases were patients hospitalized with a computerized diagnosis of acute pancreatitis, and two sets of controls were drawn from (1) the study population and from (2) the same GP practice as the case. Current or 60‐day exposure to cimetidine and ranitidine was analysed. In adjusted analyses, cimetidine exposure and ranitidine exposure were associated with an increased risk of hospitalization for acute pancreatitis, as were alcohol abuse and cholelithiasis. The risks were lower in unadjusted analyses, suggesting that the association is confounded, although they did not disappear completely. A possible explanation is that data on confounding were incomplete. This study cannot discount the existence of an association between H2‐antagonists and acute pancreatitis, and highlights the difficulties involved in obtaining complete and accurate data on confounding factors that are not collected routinely. Copyright

Prevalence of Diabetic Eye disease in Tayside, Scotland (P‐DETS) Study: methodology

Aims  To describe the use of a validated diabetes register for sampling frame generation and assessment of the representative nature of participants in a fieldwork study of diabetic eye disease.

Stratification of foot ulcer risk in patients with diabetes: a population-based study: Stratification of Foot Ulcer Risk

This trial assessed whether a simple clinical tool can be used to stratify patients with diabetes, according to risk of developing foot ulceration. This was a prospective, observational follow‐up study of 3526 patients with diabetes (91% type 2 diabetes) attending for routine diabetes care. Mean age was 64.7 (range 15–101) years and duration of diabetes was 8.8 (±1.5 SD) years. Patients were categorised into ‘low’ (64%), ‘moderate’ (23%) or ‘high’ (13%) risk of developing foot ulcers by trained staff using five clinical criteria during routine patient care. During follow‐up (1.7 years), 166 (4.7%) patients developed an ulcer. Foot ulceration was 83 times more common in high risk and six times more in moderate risk, compared with low‐risk patients. The negative predictive value of a ‘low‐risk score’ was 99.6% (99.5–99.7%; 95% confidence interval). This clinical tool accurately predicted foot ulceration in routine practice and could be used direct scarce podiatry resources towards those at greatest need.