Weiyu Qiu

Collaborative Care Versus Screening and Follow-up for Patients With Diabetes and Depressive Symptoms: Results of a Primary-Care Based Comparative Effectiveness Trial

OBJECTIVE Depressive symptoms are common and, when coexisting with diabetes, worsen outcomes and increase health care costs. We evaluated a nurse case-manager–based collaborative primary care team model to improve depressive symptoms in diabetic patients. RESEARCH DESIGN AND METHODS We conducted a controlled implementation trial in four nonmetropolitan primary care networks. Eligible patients had type 2 diabetes and screened positive for depressive symptoms, based on a Patient Health Questionnaire (PHQ) score of ≥10. Patients were allocated using an “on-off” monthly time series. Intervention consisted of case-managers working 1:1 with patients to deliver individualized care. The main outcome was improvement in PHQ scores at 12 months. A concurrent cohort of 71 comparable patients was used as nonscreened usual care control subjects. RESULTS Of 1,924 patients screened, 476 (25%) had a PHQ score >10. Of these, 95 were allocated to intervention and 62 to active control. There were no baseline differences between groups: mean age was 57.8 years, 55% were women, and the mean PHQ score was 14.5 (SD 3.7). Intervention patients had greater 12-month improvements in PHQ (7.3 [SD 5.6]) compared with active-control subjects (5.2 [SD 5.7], P = 0.015). Recovery of depressive symptoms (i.e., PHQ reduced by 50%) was greater among intervention patients (61% vs. 44%, P = 0.03). Compared with trial patients, nonscreened control subjects had significantly less improvement at 12 months in the PHQ score (3.2 [SD 4.9]) and lower rates of recovery (24%, P < 0.05 for both). CONCLUSIONS In patients with type 2 diabetes who screened positive for depressive symptoms, collaborative care improved depressive symptoms, but physician notification and follow-up was also a clinically effective initial strategy compared with usual care.

Age at stroke onset influences the clinical outcome and health-related quality of life in pediatric ischemic stroke survivors.

Stroke in children occurs across different phases of brain development. Age at onset may affect outcome and health‐related quality of life (HRQL). We evaluated the influence of age at stroke onset on the long‐term neurological outcomes and HRQL of pediatric stroke survivors.

The Alberta's Caring for Diabetes (ABCD) Study: Rationale, Design and Baseline Characteristics of a Prospective Cohort of Adults with Type 2 Diabetes

OBJECTIVE To better understand the factors that affect care and outcomes in patients with type 2 diabetes, we developed the prospective Albertas Caring for Diabetes (ABCD) cohort to collect, monitor and analyze data concerning several sociodemographic, behavioural, psychosocial, clinical and physiological factors that might influence diabetes care and outcomes. METHODS We recruited 2040 individuals with type 2 diabetes through primary care networks, diabetes clinics and public advertisements. Data are being collected through self-administered surveys, including standardized measures of health status and self-care behaviours, and will eventually be linked to laboratory and administrative healthcare data and other novel databases. RESULTS The average age of respondents was 64.4 years (SD=10.7); 45% were female, and 91% were white, with average duration of diabetes of 12 years (SD=10.0). The majority (76%) were physically inactive, and 10% were smokers. Most (88%) reported 2 or more chronic conditions in addition to diabetes, and 18% screened positively for depressive symptoms. The majority (92%) consented to future linkage with administrative data. Based on the literature and comparison with other surveys, the cohort appeared to fairly represent the general Alberta population with diabetes. CONCLUSIONS The ABCD cohort will serve as the basis for explorations of the multidimensional and dynamic nature of diabetes care and complications. These data will contribute to broader scientific literature and will also help to identify local benchmarks and targets for intervention strategies, helping to guide policies and resource allocation related to the care and management of patients with type 2 diabetes in Alberta, Canada.

Increase in Daily Steps After an Exercise Specialist Led Lifestyle Intervention for Adults With Type 2 Diabetes In Primary Care: A Controlled Implementation Trial

OBJECTIVE To determine the effectiveness of an exercise specialist led lifestyle program for adults with type 2 diabetes in primary care. METHODS Eligible participants from 4 primary care networks in Alberta, Canada were assigned to either a lifestyle program or a control group. The program targeted increased daily walking through individualized daily pedometer step goals for the first 3 months and brisk walking speed, along with substitution of low-relative to high-glycemic index foods over the next 3 months. The outcomes were daily steps, diet, and clinical markers, and were compared using random effects models. RESULTS 198 participants were enrolled (102 in the intervention and 96 in the control). For all participants, (51% were women), mean age 59.5 (SD 8.3) years, A1c 6.8% (SD 1.1), BMI 33.6 kg/m(2) (SD 6.5), systolic BP 125.6 mmHg (SD 16.2), glycemic index 51.7 (4.6), daily steps 5879 (SD 3130). Daily steps increased for the intervention compared with the control at 3-months (1292 [SD 2698] vs. 418 [SD 2458] and 6-months (1481 [SD 2631] vs. 336 [SD 2712]; adjusted P = .002). No significant differences were observed for diet or clinical outcomes. CONCLUSIONS A 6-month lifestyle program delivered in primary care by an exercise specialist can be effective for increasing daily walking among adults with recently diagnosed type 2 diabetes. This short-term increase in daily steps requires longer follow-up to estimate the potential impact on health outcomes.

Severe Obesity Is Associated With Increased Risk of Early Complications and Extended Length of Stay Following Coronary Artery Bypass Grafting Surgery

Background Better understanding of the relationship between obesity and postsurgical adverse outcomes is needed to provide quality and efficient care. We examined the relationship of obesity with the incidence of early adverse outcomes and in‐hospital length of stay following coronary artery bypass grafting surgery. Methods and Results We analyzed data from 7560 patients who underwent coronary artery bypass grafting. Using body mass index (BMI; in kg/m2) of 18.5 to 24.9 as a reference, the associations of 4 BMI categories (25.0–29.9, 30.0–34.9, 35.0–39.9, and ≥40.0) with rates of operative mortality, overall early complications, subgroups of early complications (ie, infection, renal and pulmonary complications), and length of stay were assessed while adjusting for clinical covariates. There was no difference in operative mortality; however, higher risks of overall complications were observed for patients with BMI 35.0 to 39.9 (adjusted odds ratio 1.35, 95% CI 1.11–1.63) and ≥40.0 (adjusted odds ratio 1.56, 95% CI 1.21–2.01). Subgroup analyses identified obesity as an independent risk factor for infection (BMI 30.0–34.9: adjusted odds ratio 1.60, 95% CI 1.24–2.05; BMI 35.0–39.9: adjusted odds ratio 2.34, 95% CI 1.73–3.17; BMI ≥40.0: adjusted odds ratio 3.29, 95% CI 2.30–4.71). Median length of stay was longer with BMI ≥40.0 than with BMI 18.5 to 24.9 (median 7.0 days [interquartile range 5 to 10] versus 6.0 days [interquartile range 5 to 9], P=0.026). Conclusions BMI ≥40.0 was an independent risk factor for longer length of stay, and infection was a potentially modifiable risk factor. Greater perioperative attention and intervention to control the risks associated with infection and length of stay in patients with BMI ≥40.0 may improve patient care quality and efficiency.

Objectively measured sleep and health-related quality of life in older adults with type 2 diabetes: a cross-sectional study from the Alberta's Caring for Diabetes Study

Background and aim: Sleep is an important behavior for metabolic control and mental health in type 2 diabetes. The aim was to examine the relationship of objective estimates of sleep quantity and quality with health‐related quality of life (HRQL) in adults with type 2 diabetes. Materials and methods: Participants completed a survey where HRQL was measured using the EQ‐5D‐5 L index score, and the SF‐12 v2, which provides physical and mental composite summary (PCS and MCS) scores. Participants also wore wrist actigraphy (Actigraph GT3X+) during sleep to derive estimates of total sleep time (TST), sleep latency (SLAT), and sleep efficiency (SEFF) and wake after sleep onset (WASO). Adjusted multivariable linear regression models were used to examine the associations among actigraphy‐derived sleep parameters with PCS, MCS, and EQ‐5D‐5 L index scores. Results: On average, participants (N = 168) were 65 years old (standard deviation [SD] 10), 46% were female, with a diabetes duration of 13 years (SD 9) and body mass index of 31 kg/m2 (SD 6.5). Mean (SD) TST and SLAT were 7.5 (1.0) hours and 9.9 (7.6) minutes, respectively, SEFF was 82.7 (6.1) percent and WASO was 86.7 (53.4) minutes. An inverse association between TST and PCS was found where every additional 60 minutes of sleep was associated with 1.3‐unit lower PCS (P = .04). SEFF was positively associated with both PCS and MCS, where a 10% greater SEFF was associated with 2.6‐unit higher PCS (P = .008), and 1.8‐unit higher MCS (P = .056). Conclusions: Among this population, better sleep efficiency was associated with better physical and mental health.

Comparative performance of the EQ-5D-5L and SF-6D index scores in adults with type 2 diabetes

PurposeTo explore the comparative performance including discriminative and longitudinal validity of EQ-5D-5L and SF-6D index scores in adults with type 2 diabetes.MethodsData from an on-going cohort study of adults with type 2 diabetes in Alberta, Canada, were used. Known-groups approach was used to examine discriminative validity. Correlation and agreement indices and scatter and Bland–Altman plots were used to examine the relationship between the two measures. Longitudinal validity was explored using Wilcoxon signed-rank test, effect size, and standardized response mean.ResultsIn 1832 participants at baseline (age 64.3, standard deviation 10.6 years; 45% female), median EQ-5D-5L score was 0.85 [interquartile range (IQR) 0.17], and floor and ceiling effects of 0.1 and 16.1%, respectively; median SF-6D score was 0.72 (IQR 0.24), and floor and ceiling effects of 0.1 and 3.2%, respectively. EQ-5D-5L and SF-6D index scores were significantly correlated with an overall Spearman correlation coefficient of 0.73, and an ICC of 0.62 (95% CI 0.42–0.74). Both EQ-5D-5L and SF-6D scores demonstrated statistically significant differences in self-reported chronic conditions, depressive symptoms, and diabetes-related distress, and were able to detect changes in depressive symptoms and diabetes distress across all change groups.ConclusionsBoth EQ-5D-5L and SF-6D index scores provide valid measurement in this patient population. Considerable overlap between the measures means it is not necessary to include both in surveys, however, the advantages and disadvantages of each should be considered.

Health-related quality of life and its determinants in paediatric arterial ischaemic stroke survivors

Objective Health-related quality of life (HRQL) instruments are patient or proxy-reported outcome measures that provide a comprehensive and subjective assessment of patient’s well-being and hence vital for health outcomes evaluation. A clear and thorough understanding of HRQL and its determinants is especially important to appropriately guide health-improving interventions. In this study, HRQL of paediatric arterial ischaemic stroke survivors was assessed using guidelines recommended for interpretation and reporting of the patient-reported outcome data. Determinants of HRQL were also explored. Methods Children diagnosed with arterial ischaemic stroke between 2003 and 2012 were assessed at least 1 year poststroke using the parent–proxy report versions of the Pediatric Quality of Life Inventory 4.0 and Pediatric Stroke Recurrence and Recovery Questionnaire. HRQL data were compared with population norms and used as outcome in multiple linear regression analysis. Results 59 children were evaluated. Mean age at diagnosis of stroke was 2.2 years. Mean age at assessment and time elapsed since stroke was 7 years and 5 years, respectively. A total of 41% children had normal global outcome, whereas 51% had moderate to severe deficits. A lower overall HRQL was observed in both self and proxy reports. Parents reported the maximum impairment in emotional domain, whereas children indicated physical functioning to be the most affected. Neurological outcome, site of stroke and socioeconomic status were independently associated with overall HRQL. Conclusions Lower HRQL was demonstrated in children who survived arterial ischaemic stroke. Socioeconomic status of families was an important determinant of HRQL, over and above clinical parameters.

Body Mass Index Is Associated With Differential Rates of Coronary Revascularization After Cardiac Catheterization

BACKGROUND The association of obesity with coronary revascularization procedures is not clear. We examined rates of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) associated with obesity while accounting for the severity of coronary disease and diabetes status. METHODS Patients who underwent cardiac catheterization were stratified according to coronary anatomy risks and diabetes status. Within each stratum, using normal body mass index (BMI) (18.5-24.9 kg/m2) as a reference, the associations of overweight (25.0-29.9 kg/m2), obese class I (30.0-34.9 kg/m2), obese class II (35.0-39.9 kg/m2), and obese class III (≥ 40.0 kg/m2) with the likelihood of receiving CABG and PCI were assessed while adjusting for clinical covariates. RESULTS Of 56,722 patients analyzed, overall use of revascularization was higher in the overweight, obese class I, and obese class II groups (overweight: adjusted hazard ratio [aHR], 1.10; 95% confidence interval [CI], 1.06-1.13; obese class I: aHR, 1.08; 95% CI, 1.05-1.12; obese class II: aHR,1.05; 95% CI, 1.01-1.10), whereas it was lower in the obese class III group (aHR, 0.91; 95% CI, 0.85-0.97) compared with normal BMI. In the subgroup with high-risk coronary anatomy and diabetes, all obese classes had higher rates of PCI (obese class I: aHR,1.24; 95% CI, 1.08-1.42; obese class II: aHR,1.27; 95% CI, 1.07-1.49, obese class III: aHR,1.37; 95% CI, 1.12-1.67) than the normal BMI group. CONCLUSIONS Our results showed that BMI is associated with differential rates of coronary revascularization. In patients with high-risk coronary anatomy and diabetes, clinical appropriateness of higher rates of PCI associated with obesity warrants further investigation.

Differences in Short‐ and Long‐Term Mortality Associated With BMI Following Coronary Revascularization

Background The association between obesity and mortality risks following coronary revascularization is not clear. We examined the associations of BMI (kg/m2) with short‐, intermediate‐, and long‐term mortality following coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) in patients with different coronary anatomy risks and diabetes mellitus status. Methods and Results Data from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry were analyzed. Using normal BMI (18.5–24.9) as a reference, multivariable‐adjusted hazard ratios for all‐cause mortality within 6 months, 1 year, 5 years, and 10 years were individually calculated for CABG and PCI with 4 prespecified BMI categories: overweight (25.0–29.9), obese class I (30.0–34.9), obese class II (35.0–39.9), and obese class III (≥40.0). The analyses were repeated after stratifying for coronary risks and diabetes mellitus status. The cohorts included 7560 and 30 258 patients for CABG and PCI, respectively. Following PCI, overall mortality was lower in patients with overweight and obese class I compared to those with normal BMI; however, 5‐ and 10‐year mortality rates were significantly higher in patients with obese class III with high‐risk coronary anatomy, which was primarily driven by higher mortality rates in patients without diabetes mellitus (5‐year adjusted hazard ratio, 1.78 [95% CI, 1.11–2.85] and 10‐year adjusted hazard ratio, 1.57 [95% CI, 1.02–2.43]). Following CABG, overweight was associated with lower mortality risks compared with normal BMI. Conclusions Overweight was associated with lower mortality following CABG and PCI. Greater long‐term mortality in patients with obese class III following PCI, especially in those with high‐risk coronary anatomy without diabetes mellitus, warrants further investigation.