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30. The impact of the COVID-19 pandemic and associated disruptions in health-care provision on clinical outcomes in people with diabetes: a systematic review

Author

Hartmann-Boyce, Jamie, primary, Highton, Patrick, additional, Rees, Karen, additional, Onakpoya, Igho, additional, Suklan, Jana, additional, Curtis, Ffion, additional, O'Mahoney, Lauren, additional, Morris, Elizabeth, additional, Kudlek, Laura, additional, Morgan, Jessica, additional, Lynch, Rosie, additional, Marpadga, Sanjana, additional, Seidu, Samuel, additional, and Khunti, Kamlesh, additional

Published
2024
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38. Evaluating the effects of a multi-factorial quality improvement (QI) strategy targeted at primary care health care professionals on management of people with diabetes

Author

Seidu, Samuel Iddrisu, Khunti, Kamlesh, and Davies, Melanie

Subjects
362.1964
Abstract

Diabetes has now been recognised as an epidemic globally. The burden of the disease and its complications are outstripping health care systems all over the world. The rising prevalence coupled with the increasing life expectancy makes it impossible for specialist centres to cope with the demands of diabetes care, which was the case until 20-30 years ago, thus necessitating a “left shift” to primary care. The aim of this research is to critically appraise the evidence on the effectiveness of interventions targeting primary care professionals on improvement of cardio-metabolic risk factors including glycated Haemoglobin (HbA1c), blood pressure and total or LDL-cholesterol. A further aim is to quantify the effect of intensive glucose lowering either alone or as part of a multifactorial intervention on non-fatal myocardial infarction (MI), non-fatal stroke, cardiovascular disease (CV) mortality and all-cause mortality in patients with type 2 diabetes. Finally, the impact of any interventions effective in controlling the cardio-metabolic risk factors will be considered in a real world restructured diabetes service on non-elective bed days, outpatient attendances and hospitalisation for diabetes and its complications will be assessed. This thesis used 2 methodologies. In the first instance, a systematic review of interventions targeting primary care professionals on improvement of cardio-metabolic risk factors, and another systematic review and meta-analysis of studies on intensive glucose lowering and multifactorial interventions on cardiovascular and mortality outcomes were conducted. Secondly, a before- and-after study of general practices on non-elective bed days, outpatient attendances and hospitalisation for diabetes and its complications was also conducted. Main findings: 1. A systematic review of interventions targeting primary careprofessionals on improvement of cardio-metabolic risk factorsshowed that multifaceted professional interventions were moreeffective than single interventions targeting single primary orcommunity care professionals in improving glycaemic control. 2. A meta-analysis of studies on intensive glucose lowering andmultifactorial interventions on cardiovascular and mortalityoutcomes showed that apart from non-fatal myocardial infarctions,there was no evidence that intensive treatment reduced the risk ofcardiovascular and mortality outcomes. Compared to standardcare, intensive glucose lowering and multi-factorial interventionreduced the risk of non-fatal MI (RR 0.89, 95% CI 0.83 to 0.96) butnot non-fatal stroke (RR 0.96, 95% CI 0.86 to 1.07), CV mortality(RR 1.01, 95% CI 0.91 to 1.13) or all-cause mortality (RR 1.01, 95%CI 0.94 to 1.08). The predictions indicated that, intensive glucoselowering is more likely to be beneficial in populations where thebaseline incidence of CVD mortality is greater than 6.3 deaths per1000 person-years. 3. A before-and-after analysis of a structured diabetes shared careservice redesign, involving enhanced diabetes-skilled primary carephysicians, nurses and health care assistants in primary caresettings was conducted. Compared to an integrated specialist–community care core diabetes service, the new enhanced servicedid not show an increase hospitalisation (the difference betweenthe non-elective bed days in core practices and that in enhancedpractices was not significant, mean = 2.20 per 100 patients, p =0.14)), first outpatients’ attendances (the difference between the mean first outpatient attendance in the core practices and that in enhanced practices was 0.02 per 100 patients p=0.92) and admissions for diabetes related complications (the difference was 0.30 per 100 patients, p=0.55). Conclusion: The rising demand of diabetes care requires a primary care well organised to deliver a diabetes services without compromising quality. A well-organised multidisciplinary diabetes-skilled primary care team, using multi-faceted interventions, can deliver a diabetes service without increasing diabetes related complications, out-patient attendances and hospitalisations. Cardio-metabolic risk factor control is an essential part of diabetes management. Intensive glucose lowering and multifactorial interventions can reduce non-fatal myocardial infarctions.

Published
2016

41. Blood pressure levels and adverse cardiovascular outcomes in heart failure: A systematic review and meta‐analysis.

Author

Seidu, Samuel, Lawson, Claire A., Kunutsor, Setor K., Khunti, Kamlesh, and Rosano, Giuseppe M.C.

Subjects
*BLOOD pressure, *DIASTOLIC blood pressure, *HEART failure, *BLOOD pressure measurement, *MORTALITY
Abstract

Aim: Existing data on the association between blood pressure levels and adverse cardiovascular outcomes in patients with heart failure (HF) are inconsistent. The optimal blood pressure targets for patients with HF remain uncertain. This study sought to assess the associations between blood pressure (systolic [SBP] and diastolic blood pressure [DBP]) levels and adverse cardiovascular disease (CVD) outcomes in patients with HF. Methods and results: A systematic review and meta‐analysis were conducted using MEDLINE, Embase, the Cochrane Library, and Web of Science databases up to 5 May 2023. The outcomes of interest included adverse cardiovascular events and all‐cause mortality. Pooled relative risks (RRs) with corresponding 95% confidence intervals (CIs) were calculated. Forty‐three unique observational cohort studies, comprising 120 643 participants with HF, were included. The pooled RRs (95% CIs) for SBP thresholds of ≥140 mmHg versus <140 mmHg were 0.92 (0.83–1.01) for all‐cause mortality, 0.83 (0.67–1.04) for CVD death, and 0.98 (0.80–1.21) for HF hospitalization. The pooled RR (95% CI) for SBP thresholds of ≥160 mmHg versus <160 mmHg and all‐cause mortality was 0.67 (0.62–0.74). SBP levels below <130, <120, and <110 mmHg were each associated with an increased risk of various cardiovascular endpoints and all‐cause mortality. The pooled RR (95% CI) for DBP thresholds of ≥80 mmHg versus <80 mmHg and all‐cause mortality was 0.86 (0.67–1.10). A 10 mmHg increase in SBP or DBP was associated with a reduction in all‐cause mortality and other cardiovascular endpoints. Conclusions: The findings suggest that lower and normal baseline SBP levels (<130, <120, and <110 mmHg) may be associated with future risk of worse outcomes in patients with HF. Optimal baseline blood pressure levels for these patients may lie within the range of ≥140 mmHg for SBP. In the absence of observational studies with repeated blood pressure measurements or definitive trials evaluating optimal blood pressure targets, individualized blood pressure targets based on patients' unique circumstances are warranted in HF management. [ABSTRACT FROM AUTHOR]

Published
2024
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42. Deintensification of potentially inappropriate medications amongst older frail people with type 2 diabetes: Protocol for a cluster randomised controlled trial (D-MED study).

Author

O'Mahoney, Lauren, Highton, Patrick, Abdala, Ruksar, Dallosso, Helen, Gillies, Clare L., Ragha, Seema, Munday, Fiona, Robinson, John, Marshall, Andrew, Sheppard, James P., Khunti, Kamlesh, and Seidu, Samuel

Abstract

Amongst elderly people with type 2 diabetes (T2D) over prescribing can result in emergency ambulance call-outs, falls and fractures and increased mortality, particularly in frail patients. Current clinical guidelines, however, remain focused on medication intensification rather than deintensification where appropriate. This study aims to evaluate the effectiveness of an electronic decision-support system and training for the deintensification of potentially inappropriate medications amongst older frail people with T2D, when compared to 'usual' care at 12-months. This study is an open-label, multi-site, two-armed pragmatic cluster-randomised trial. GP practices randomised to the 'enhanced care' group have an electronic decision support system installed and receive training on the tool and de-intensification of diabetes medications. The system flags eligible patients for possible deintensification of diabetes medications, linking the health care professional to a clinical algorithm. The primary outcome will be the number of patients at 12-months who have had potentially inappropriate diabetes medications de-intensified. Study recruitment commenced in June 2022. Data collection commenced in January 2023. Baseline data have been extracted from 40 practices (3145 patients). Digital technology, involving computer decision systems, may have the potential to reduce inappropriate medications and aid the process of de-intensification. International Standard Randomised Controlled Trial Number: ISRCTN53221378. Available at: https://www.isrctn.com/ISRCTN53221378. • Overprescribing of diabetes medications causes hypoglycaemia, falls. • Problem in older, frail patients, yet limited guidance for deprescribing. • Limited long-term benefit of tight glycaemic control in older patients. • Electronic decision support and training may guide deprescribing. [ABSTRACT FROM AUTHOR]

Published
2024
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50. An Update to the Overview of Reviews: Risks of and From SARS-COV-2 Infection and COVID-19 in People With Diabetes

Author

Hartmann-Boyce, Jamie, primary, Rees, Karen, additional, Onakpoya, Igho, additional, Otunla, Afolarin, additional, Morris, Elizabeth, additional, Morgan, Jessica, additional, Highton, Patrick, additional, Suklan, Jana, additional, Curtis, Ffion, additional, Goyder, Clare, additional, O’Mahoney, Lauren, additional, James, Olivia, additional, Sreejith, Nayanika, additional, Seidu, Samuel, additional, and Khunti, Kamlesh, additional

Published
2023
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