Mcgovern AP, Hinton W, van Vlymen J, Munro N, Whyte M, de Lusignan S (2016) Real-world evidence on prescribing trends in sodium glucose cotransporter 2 inhibitors in UK primary care, DIABETIC MEDICINE33pp. 165-165 WILEY-BLACKWELL
McGovern AP, Hinton W, Tippu Z, Whyte MB, de Lusignan S (2016) Ethnic disparities in medication persistence for Type 2 diabetes: non-whites have reduced persistence., American Diabetes Association
The use of glucagon-like peptide-1 (GLP-1)
agonists in type 2 diabetes is increasing.
We present a description of their current
use and prescribing trends in UK primary
care and compare the characteristics of
people prescribed GLP-1 agonists with
phase 3 trial populations.
Aims: The sodium glucose cotransporter 2 (SGLT2) inhibitors are a
new class of oral diabetes medication. Prescribing of these agents was
initially limited to secondary care but is now moving into primary
care. We analyse the current use of this drug class in primary care.
Hinton W, McGovern AP, Whyte MB, Curtis BH, McCullough K, van Brunt K, Calderara S, de Lusignan S (2016) What are the HbA1c thresholds for initiating insulin therapy in people with type 2 diabetes in UK primary care?, European Association for Study Diabetes
Purpose: The Royal College of General
Practitioners Research and Surveillance Centre
(RCGP RSC) is one of the longest established
primary care sentinel networks. In 2015, it
established a new data and analysis hub at the
University of Surrey. This paper evaluates the
representativeness of the RCGP RSC network
against the English population.
Participants and method: The cohort includes
1 042 063 patients registered in 107 participating
general practitioner (GP) practices. We compared
the RCGP RSC data with English national data in
the following areas: demographics; geographical
distribution; chronic disease prevalence,
management and completeness of data recording;
and prescribing and vaccine uptake. We also
assessed practices within the network participating
in a national swabbing programme.
Findings to date: We found a small overrepresentation
of people in the 25?44 age band,
under-representation of white ethnicity, and of less
deprived people. Geographical focus is in London,
with less practices in the southwest and east of
England. We found differences in the prevalence of
diabetes (national: 6.4%, RCPG RSC: 5.8%),
learning disabilities (national: 0.44%, RCPG RSC:
0.40%), obesity (national: 9.2%, RCPG RSC: 8.0%),
pulmonary disease (national: 1.8%, RCPG RSC:
1.6%), and cardiovascular diseases (national: 1.1%,
RCPG RSC: 1.2%). Data completeness in risk factors
for diabetic population is high (77?99%). We found
differences in prescribing rates and costs for
infections (national: 5.58%, RCPG RSC: 7.12%), and
for nutrition and blood conditions (national: 6.26%,
RCPG RSC: 4.50%). Differences in vaccine uptake
were seen in patients aged 2 years (national: 38.5%,
RCPG RSC: 32.8%). Owing to large numbers, most
differences were significant ( p<0.00015).
Future plans: The RCGP RSC is a representative
network, having only small differences with the
national population, which have now been quantified
and can be assessed for clinical relevance for
specific studies. This network is a rich source for
research into routine practice.
McGovern AP, Hinton W, van Vlymen J, Munro N, Whyte M, de Lusignan S (2016) Real-world evidence on the disparities in prescribing of dipeptidylpeptidase-4 inhibitors in UK primary care, DIABETIC MEDICINE33pp. 183-183 WILEY-BLACKWELL
Aims: The relationship between glycaemic control and lipid
metabolism in diabetes is complicated and yet to be fully
elucidated. Here we aim to characterise the relationship between
glycaemic control and serum triglyceride levels in a population
with Type 2 diabetes
Purpose The University of Surrey-Lilly Real World Evidence (RWE) diabetes cohort has been established to provide insights into the management of type 2 diabetes mellitus (T2DM). There are 3 areas of study due to be conducted to provide insights into T2DM management: exploration of medication adherence, thresholds for changing diabetes therapies, and ethnicity-related or socioeconomic-related disparities in management. This paper describes the identification of a cohort of people with T2DM which will be used for these analyses, through a case finding algorithm, and describes the characteristics of the identified cohort. Participants A cohort of people with T2DM was identified from the Royal College of General Practitioners Research and Surveillance Centre (RCGP RSC) data set. This data set comprises electronic patient records collected from a nationally distributed sample of 130 primary care practices across England with scope to increase the number of practices to 200. Findings to date A cohort (N=58?717) of adults with T2DM was identified from the RCGP RSC population (N=1?260?761), a crude prevalence of diabetes of 5.8% in the adult population. High data quality within the practice network and an ontological approach to classification resulted in a high level of data completeness in the T2DM cohort; ethnicity identification (82.1%), smoking status (99.3%), alcohol use (93.3%), glycated haemoglobin (HbA1c; 97.9%), body mass index (98.0%), blood pressure (99.4%), cholesterol (87.4%) and renal function (97.8%). Data completeness compares favourably to other, similarly large, observational cohorts. The cohort comprises a distribution of ages, socioeconomic and ethnic backgrounds, diabetes complications, and comorbidities, enabling the planned analyses. Future plans Regular data uploads from the RCGP RSC practice network will enable this cohort to be followed prospectively. We will investigate medication adherence, explore thresholds and triggers for changing diabetes therapies, and investigate any ethnicity-related or socioeconomic-related disparities in diabetes management.
Aim: To examine whether diabetes and the degree of glycaemic control is associated with
an increased risk of acute eye infection, and prescribing of ocular antimicrobial agents.
Design and setting: A retrospective cohort study was carried out using the Royal College of
General Practitioners Research and Surveillance Centre database (RCGP RSC), a large primary
care database in the United Kingdom. We compared ocular infection rates in people aged
e15 years without diabetes to those with diabetes, both type 1 and type 2. We developed
logistic regression models to assess the excess risk in diabetes of: conjunctivitis, blepharitis,
stye/chalzion, periorbital cellulitis, keratitis/keratoconjunctivitis, lacrimal gland infection,
endopthalmitis, and ocular antimicrobial prescriptions over a six-year period (2010?2015).
We also analysed the impact of glycaemic control on infection rates in those with diabetes.
All models were adjusted for potential confounders.
Results: We analysed infection risk in 889,856 people without diabetes and 48,584 people with
diabetes (3273 type 1, and 45,311 type 2). After adjustment for confounders both type 1 and
type 2 were associated with increased incidence of conjunctivitis (OR 1.61; 95% CI 1.38?1.88;
p < 0.0001 and OR 1.11; 95% CI 1.06?1.16; p < 0.0001 respectively). No association was found
with blepharitis, stye/chalzion, periorbital cellulitis, keratitis/keratoconjunctivitis, lacrimal
gland infection, and endopthalmitis in the whole population. In subgroup analyses blepharitis
was more common in those with type 1 diabetes under 50 years old and endopthalmitis
in those under 50 with type 2 diabetes. Glycaemic control was not found to be associated
with any infection. Diabetes was also associated with an increased incidence of antimicrobial
prescriptions (Type 1 OR 1.69; 95% CI 1.51?1.88; p < 0.0001 and type 2 OR 1.17; 95% CI
1.13?1.20; p < 0.0001).
Conclusions: Conjunctivitis is recorded more frequently in people with diabetes. However, no
substantial increase in recording of other ocular infections was noted. Infection risk was
not found to be associated with the degree of glycaemic control
Limited medication adherence and persistence with treatment are barriers to successful
management of type 2 diabetes (T2D). We searched MEDLINE, EMBASE, the Cochrane Library,
the Register of Controlled Trials, PsychINFO and CINAHL for observational and interventional
studies that compared the adherence or persistence associated with 2 or more glucose-lowering
medications in people with T2D. Where 5 or more studies provided the same comparison, a
random-effects meta-analysis was performed, reporting mean difference (MD) or odds ratio
(OR) for adherence or persistence, depending on the pooled study outcomes. We included a total
of 48 studies. Compared with metformin, adherence (%) was better for sulphonylureas (5 studies;
MD 10.6%, 95% confidence interval [CI] 6.5-14.7) and thiazolidinediones (TZDs; 6 studies; MD
11.3%, 95% CI 2.7%-20.0%). Adherence to TZDs was marginally better than adherence to sulphonylureas
(5 studies; MD 1.5%, 95% CI 0.1-2.9). Dipeptidyl peptidase-4 inhibitors had better adherence
than sulphonylureas and TZDs. Glucagon-like peptide-1 receptor agonists had higher rates of
discontinuation than long-acting analogue insulins (6 studies; OR 1.95; 95% CI 1.17-3.27). Longacting
insulin analogues had better persistence than human insulins (5 studies; MD 43.1 days;
95% CI 22.0-64.2). The methods used to define adherence and persistence were highly variable.
The Institute of Medicine framework defines six dimensions of quality for healthcare systems: (1) safety, (2) effectiveness, (3) patient centeredness, (4) timeliness of care, (5) efficiency, and (6) equity. Large health datasets provide an opportunity to assess quality in these areas.Objective:
To perform an international comparison of the measurability of the delivery of these aims, in people with type 2 diabetes mellitus (T2DM) from large datasets.Method:
We conducted a survey to assess healthcare outcomes data quality of existing databases and disseminated this through professional networks. We examined the data sources used to collect the data, frequency of data uploads, and data types used for identifying people with T2DM. We compared data completeness across the six areas of healthcare quality, using selected measures pertinent to T2DM management.Results:
We received 14 responses from seven countries (Australia, Canada, Italy, the Netherlands, Norway, Portugal, Turkey and the UK). Most databases reported frequent data uploads and would be capable of near real time analysis of healthcare quality.
The majority of recorded data related to safety (particularly medication adverse events) and treatment efficacy (glycaemic control and microvascular disease). Data potentially measuring equity was less well recorded. Recording levels were lowest for patient-centred care, timeliness of care, and system efficiency, with the majority of databases containing no data in these areas. Databases using primary care sources had higher data quality across all areas measured.Conclusion:
Data quality could be improved particularly in the areas of patient-centred care, timeliness, and efficiency. Primary care derived datasets may be most suited to healthcare quality assessment.
To characterize the risk uveitis, scleritis or episcleritis in relation to diabetes, glycaemic control, and co-existence of retinopathy.
Using the Royal College of General Practitioners Research and Surveillance Centre database, we established the prevalence of acute uveitis and scleritis or episcleritis over a six-year period among populations without(n/=/889,856) and with diabetes(n/=/48,584). We evaluated the impact of glycaemic control on disease risk. Regression modeling was used to identify associations, adjusting for clinical and demographic confounders.
Incidence of acute uveitis was higher among patients with diabetes; Type 1 OR:2.01 (95% CI 1.18?3.41; p/=/0.009), and Type 2 OR:1.23 (1.05?1.44; p/=/0.01). Glycaemic control was established as an important effect modifier for uveitis risk, whereby those with poorer control suffered higher disease burden. Results confirmed a dose-response relationship such that very poor glycaemic control OR:4.72 (2.58?8.65; p/0.001), poor control OR:1.57 (1.05?2.33; p/=/0.03) and moderate control OR:1.20 (0.86?1.68; p/=/0.29) were predictive of uveitis. Similar results were observed when evaluating retinopathy staging: proliferative retinopathy OR:2.42 (1.25?4.69; p/=/0.01). These results were not maintained for scleritis or episcleritis.
Acute uveitis is more common in patients with diabetes; at highest risk are those with type 1 disease with poor glycaemic control. Glycaemic improvements may prevent recurrence.
In the UK, type 2 diabetes mellitus (T2D) is largely managed in primary care. Delay in the intensification to injectable therapy, a form of clinical inertia, is associated with worse glycaemic control. UK general practice is highly computerised, with care being recorded on computerised medical record systems; this allows for quantitative analysis of clinical care but not of the underpinning decision-making process. The aim of this study is to investigate perceptions of patients and clinicians in primary care on the initiation of injectable therapies in T2D, and the context within which those decisions are made.
This is a mixed methods study, taking a ?realist evaluation? approach. The qualitative components comprise focus groups, interviews, and video recordings of simulated surgeries; the quantitative analysis: an overview of participating practices, elements of the video recording, and an online survey. We will recruit primary care clinicians (general practitioners and nurses) and patients from a representative sample of practices within the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network. Participants will be patients with T2D, and primary care clinicians. Focus groups and semi-structured interviews will be recorded, transcribed verbatim and analysed using Framework Analysis. The simulated surgeries will include cases that might be escalated to injectable therapy. The consultation will be reviewed using the Calgary-Cambridge model to assess communication and determination of adherence to national prescribing guidelines. We will conduct multi-channel video recording including screen capture, clinician and patient facial expressions, wide angle view of the consultation, and the computerised medical record screen. This allows annotation and qualitative analysis of the video recordings, and statistical analyses for the quantitative data. We will also conduct an online survey of primary care clinicians? attitudes to, and perceptions of, initiation of injectable therapies, which will be analysed using summary statistics.
Results aim to provide a detailed insight into the dynamic two-way decision-making process underpinning use of injectable therapy for T2D. The study will provide insights into clinical practice and enable the development of training, interventions and guidelines that may facilitate, where appropriate, the intensification to injectable therapy.