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Transplant referral and evaluation are critical steps to waitlisting yet remain an elusive part of the transplant process. Despite calls for more data collection on pre-waitlisting steps, there are currently no national surveillance data to aid in understanding the causes and potential solutions for the extreme variation in access to transplantation. As population health scientists, epidemiologists, clinicians, and ethicists we submit that the transplant community has an obligation to better understand disparities in transplant access as a first necessary step to effectively mitigating these inequities. Our position is grounded in a population health approach, consistent with several new overarching national policy and quality initiatives. The purpose of this Perspective is to (1) provide an overview of how a population health approach should inform current multisystem policies impacting kidney transplantation and demonstrate how these efforts could be enhanced with national data collection on pre-waitlisting steps; (2) demonstrate the feasibility and concrete next steps for pre-waitlisting data collection; and (3) identify potential opportunities to use these data to implement effective population-level interventions, policies, and quality measures to improve equity in access to kidney transplantation.

BACKGROUND: Geographic and neighborhood-level factors, such as poverty and education, have been associated with an increased risk for incident ESKD, likelihood of receiving pre-ESKD care, and likelihood of receiving a transplant. However, few studies have examined whether these same factors are associated with ESKD mortality. In this study, we examined county-level variation in ESKD mortality and identified county-level characteristics associated with this variation. METHODS: We identified 1,515,986 individuals (aged 18–84 years) initiating RRT (dialysis or transplant) between 2010 and 2018 using the United States Renal Data System. Among 2781 counties, we estimated county-level, all-cause, age-standardized mortality rates (ASMR) among patients with ESKD. We then identified county-level demographic (e.g., percent female), socioeconomic (e.g., percent unemployed), healthcare (e.g., percent without health insurance), and health behavior (e.g., percent current smokers) characteristics associated with ASMR using multivariable hierarchic linear mixed models and quantified the percentage of ASMR variation explained by county-level characteristics. RESULTS: County-level ESKD ASMR ranged from 45 to 1022 per 1000 person-years (PY) (mean, 119 per 1000 PY). ASMRs were highest in counties located in the Tennessee Valley and Appalachia regions, and lowest in counties located in New England, the Pacific Northwest, and Southern California. In fully adjusted models, county-level characteristics significantly associated with higher ESKD mortality included a lower percentage of Black residents (−4.94 per 1000 PY), lower transplant rate (−4.08 per 1000 PY), and higher healthcare expenditures (5.21 per 1000 PY). Overall, county-level characteristics explained 19% of variation in ESKD mortality. CONCLUSIONS: Counties with high ESKD-related mortality may benefit from targeted and multilevel interventions that combine knowledge from a growing evidence base on the interplay between individual and community-level factors associated with ESKD mortality.

Background The number of people with diabetes-related end-stage kidney disease (ESKD-DM) has doubled in the last two decades. We examined changes in excess mortality for people with ESKD-DM in the USA and Australia. Methods In this retrospective cohort study, we included adults (ages 20–84 years) receiving renal replacement therapy (RRT) for ESKD-DM in the USA (n = 1 178 860 from the United States Renal Data System, 2002–17) and Australia (n = 10 381 from the Australia and New Zealand Dialysis and Transplant Registry, 2002–13). ESKD-DM was defined as those with diagnosed diabetes at time of RRT initiation and mortality status was captured from national death registries. Annual standardized mortality ratios (SMR) were stratified by treatment modality, and age, sex and race (USA only). Trends were assessed using join point regression and annual percent change (APC) was reported. Results Overall, in the dialysis population SMR decreased from 2006 to 2014 in the USA (from 12.0 to 10.1; APC −2.1) and from 2002 to 2013 in Australia (from 12.0 to 9.4; APC −3.4). In the transplant population, SMR decreased from 6.2 to 4.0 from 2002 to 2013 in the USA, and did not significantly change from 2002 to 2013 in Australia. By subgroup, excess mortality was higher in women (versus men), younger (versus older) adults, dialysis (versus transplant) patients, and in Asian or Pacific Islanders and American Indian or Alaskan Natives (AI/AN) (versus Whites and Blacks). SMRs declined similarly across all subgroups excluding AI/AN (USA) and transplant patients (Australia), where relative declines were smaller. Conclusions Excess mortality for people with ESKD-DM treated with dialysis or transplant has decreased in the USA and Australia, but progress has stalled from ∼2013 in the USA. Nevertheless, mortality remains more than nine times higher in ESKD-DM versus the general population, with important variations by subgroups. Given the increasing burden of diabetes in the population, a focus on reducing excess mortality risk in the ESKD-DM population is needed.

Purpose of review Despite numerous targeted interventions and policy reforms, underrepresented minorities and patients with low socioeconomic status (SES) continue to have unequal access to kidney transplant. In this review, we summarize the most recent evidence on barriers to early kidney transplant steps (i.e. referral and evaluation) among underrepresented racial and ethnic minorities and low SES groups in the United States. Recent findings This review highlights the interconnectedness of several patient-level (e.g. medical mistrust, transplant knowledge, access to care), provider-level (e.g. dialysis profit status, patient--provider communication; staff accessibility), and system-level (e.g. center-specific criteria, healthcare logistics, neighborhood poverty, healthcare logistics) factors associated with lower rates of referral and evaluation among underrepresented minorities and low SES groups, and the influence of systemic racism operating at all levels. Summary Collection of national surveillance data on early transplant steps, as well as routinely captured data on upstream social determinants of health, including the measurement of racism rather than race, is necessary to enhance our understanding of barriers to referral and evaluation. A multipronged approach (e.g. targeted and systemwide interventions, and policy change) implemented at multiple levels of the healthcare system will be necessary to reduce disparities in early transplant steps.

Some evidence suggests that diabetes may be a risk factor for the development of post-acute sequelae of COVID-19 (PASC). Recent data also indicate that new-onset diabetes may be a complication of COVID-19. Here, we review the existing evidence. Following PRISMA guidelines, we conducted a systematic review through August 8, 2022. We included longitudinal studies reporting on the risk of PASC (i.e., sequelae that extend beyond four weeks after initial infection) in people with and without diabetes, and studies reporting on the risk of new-onset diabetes in people with vs without COVID-19 with a minimum of 4-weeks of follow-up. All studies were published in English. Among 5,532 studies screened, 39 were included in the final review. Among 25 studies reporting on diabetes and PASC, 44 % (n = 11) identified diabetes as a significant risk factor for PASC (increased relative risk ranging from 7 % to 342 %) while 56 % (n = 14) did not. Among 14 studies reporting on new-onset diabetes, 12 (86 %) reported that COVID-19 (vs no COVID) was significantly associated with new-onset diabetes with increased risks ranging from 11 % to 276 %. COVID-19 survivors may be at increased risk for new-onset diabetes, but whether pre-existing diabetes is also a risk factor for PASC remains unclear.

Background: Diabetes is a key risk factor for severe COVID-19 (i.e., hospitalization, mortality) . Whether diabetes is also a risk factor for post-acute sequelae of COVID-19 (PASC) , also known as long COVID, is unknown. Methods: We conducted a scoping literature review on January 27, 2022 using the keyword terms ‘long hauler’, ‘long COVID-19’, ‘post-acute sequalae’, and ‘persistent COVID-19’ combined with the operator OR, with AND ‘diabetes’, AND ‘COVID-19 [MeSH Term]’. We included all peer-reviewed full-text observational research studies published in English between January 1, 2020 and January 27, 2022 that reported on the risk of PASC in people with and without diabetes with a minimum of 4-weeks follow-up after COVID-19 diagnosis, and narratively synthesized results. Results: Among 39 studies identified, seven were included in the review and are summarized in Table 1. Overall, we found that 43% of studies identified diabetes as a potent risk factor for PASC (all odds ratios were >4) . However, this conclusion is limited by the heterogeneity of studies with regard to PASC definitions (e.g., ongoing symptoms of fatigue, cough, dyspnea etc.) , populations at risk (hospitalized vs. non-hospitalized populations) , and follow-up times (range 4 weeks to 7 months) . Conclusions: More high-quality studies across multiple populations and settings are needed to determine if diabetes is indeed a risk factor for PASC. In the meantime, careful monitoring of people with diabetes for development of PASC may be advised. Disclosure J. L. Harding: None. M. K. Ali: Advisory Panel; Bayer AG, Research Support; Merck & Co., Inc. J. C. Gander: None. R. E. Patzer: None.

Background In the United States, the COVID-19 pandemic has magnified the disproportionate and long-standing health disparities experienced by Black communities. Although it is acknowledged that social determinants of health (SDOH) rather than biological factors likely contribute to this disparity, few studies using rigorous analytic approaches in large, information-rich community-based data sets are dedicated to understanding the underlying drivers of these racial disparities. Objective The overall aim of our study is to elucidate the mechanisms by which racial disparities in severe COVID-19 outcomes arise, using both quantitative and qualitative methods. Methods In this protocol, we outline a convergent parallel mixed methods approach to identifying, quantifying, and contextualizing factors that contribute to the dramatic disparity in COVID-19 severity (ie, hospitalization, mortality) in Black versus white COVID-19 patients within the integrated health care system of Kaiser Permanente Georgia (KPGA). Toward this end, we will generate two quantitative cohorts of KPGA members with a confirmed COVID-19 diagnosis between January 1, 2020, and September 30, 2021: (1) an electronic medical record (EMR) cohort including routinely captured data on diagnoses, medications, and laboratory values, and a subset of patients hospitalized at Emory Healthcare to capture additional in-hospital data; and (2) a survey cohort, where participants will answer a range of questions related to demographics (eg, race, education), usual health behaviors (eg, physical activity, smoking), impact of COVID-19 (eg, job loss, caregiving responsibilities), and medical mistrust. Key outcomes of interest for these two cohorts include hospitalization, mortality, intensive care unit admission, hospital readmission, and long COVID-19. Finally, we will conduct qualitative semistructured interviews to capture perceptions of and experiences of being hospitalized with COVID-19 as well as related interactions with KPGA health care providers. We will analyze and interpret the quantitative and qualitative data separately, and then integrate the qualitative and quantitative findings using a triangulation design approach. Results This study has been funded by a Woodruff Health Sciences grant from December 2020 to December 2022. As of August 31, 2022, 31,500 KPGA members diagnosed with COVID-19 have been included in the EMR cohort, including 3028 who were hospitalized at Emory Healthcare, and 482 KPGA members completed the survey. In addition, 20 KPGA members (10 Black and 10 white) have been interviewed about their experiences navigating care with COVID-19. Quantitative and qualitative data cleaning and coding have been completed. Data analysis is underway with results anticipated to be published in December 2022. Conclusions Results from this mixed methods pilot study in a diverse integrated care setting in the southeastern United States will provide insights into the mechanisms underpinning racial disparities in COVID-19 complications. The quantitative and qualitative data will provide important context to generate hypotheses around the mechanisms for racial disparities in COVID-19, and may help to inform the development of multilevel strategies to reduce the burden of racial disparities in COVID-19 and its ongoing sequelae. Incorporating contextual information, elucidated from qualitative interviews, will increase the efficacy, adoption, and sustainability of such strategies. International Registered Report Identifier (IRRID) RR1-10.2196/38914

BackgroundExcess mortality in people with vs without type 2 diabetes (T2DM) has fallen, but it is unclear whether men/women at all ages have benefited and which causes of death have driven these trends.MethodsAll-cause and cause-specific mortality rates and excess mortality [by mortality rate ratios (MRRs) relative to the non-diabetic general population] were examined in 1 268 018 Australians with T2DM registered on the National Diabetes Services Scheme (2002–2014).ResultsAge-standardized mortality decreased in men (−2.2%/year; Ptrend < 0.001) and women with T2DM (−1.3%/year; Ptrend < 0.001) throughout 2002–14, which translated to declines in the MRRs (from 1.51 to 1.45 in men; 1.59 to 1.46 in women; Ptrend < 0.05 for both). Declining mortality rates in T2DM were observed in men aged 40+ years and women aged 60+ years (Ptrends ConclusionsDeclining excess mortality attributable to T2DM from 2002–14 was driven entirely by reductions in those aged 80+ years. Declines in total mortality among those with T2DM were apparent in more age groups, but often to a lesser extent than in the general population, thereby serving to increase the excess risk associated with T2DM.

BACKGROUND The epidemiology of adult-onset type 1 diabetes (T1D) incidence is not well-characterized due to the historic focus on T1D as a childhood-onset disease. PURPOSE We assess the incidence of adult-onset (≥20 years) T1D, by country, from available data. DATA SOURCES A systematic review of MEDLINE, Embase, and the gray literature, through 11 May 2021, was undertaken. STUDY SELECTION We included all population-based studies reporting on adult-onset T1D incidence and published from 1990 onward in English. DATA EXTRACTION With the search we identified 1,374 references of which 46 were included for data extraction. Estimates of annual T1D incidence were allocated into broad age categories (20–39, 40–59, ≥60, or ≥20 years) as appropriate. DATA SYNTHESIS Overall, we observed the following patterns: 1) there is a paucity of data, particularly in low- and middle-income countries; 2) the incidence of adult-onset T1D is lowest in Asian and highest in Nordic countries; 3) adult-onset T1D is higher in men versus women; 4) it is unclear whether adult-onset T1D incidence declines with increasing age; and 5) it is unclear whether incidence of adult-onset T1D has changed over time. LIMITATIONS Results are generalizable to high-income countries, and misclassification of diabetes type cannot be ruled out. CONCLUSIONS From available data, this systematic review suggests that the incidence of T1D in adulthood is substantial and highlights the pressing need to better distinguish T1D from T2D in adults so that we may better assess and respond to the true burden of T1D in adults.

Accurate data on type 1 diabetes prevalence, incidence, associated mortality and life expectancy are crucial to inform public health policy, but these data are scarce. We therefore developed a model based on available data to estimate these values for 201 countries for the year 2021 and estimate the projected prevalent cases in 2040.We fitted a discrete-time illness-death model (Markov model) to data on type 1 diabetes incidence and type 1 diabetes-associated mortality to produce type 1 diabetes prevalence, incidence, associated mortality and life expectancy in all countries. Type 1 diabetes incidence and mortality data were available from 97 and 37 countries respectively. Diagnosis rates were estimated using data from an expert survey. Mortality was modelled using random-forest regression of published type 1 diabetes mortality data, and life expectancy was calculated accordingly using life tables. Estimates were validated against observed prevalence data for 15 countries. We also estimated missing prevalence (the number of additional people who would be alive with type 1 diabetes if their mortality matched general population rates).In 2021, there were about 8·4 (95% uncertainty interval 8·1-8·8) million individuals worldwide with type 1 diabetes: of these 1·5 million (18%) were younger than 20 years, 5·4 million (64%) were aged 20-59 years, and 1·6 million (19%) were aged 60 years or older. In that year there were 0·5 million new cases diagnosed (median age of onset 39 years), about 35 000 non-diagnosed individuals died within 12 months of symptomatic onset. One fifth (1·8 million) of individuals with type 1 diabetes were in low-income and lower-middle-income countries. Remaining life expectancy of a 10-year-old diagnosed with type 1 diabetes in 2021 ranged from a mean of 13 years in low-income countries to 65 years in high-income countries. Missing prevalent cases in 2021 were estimated at 3·7 million. In 2040, we predict an increase in prevalent cases to 13·5-17·4 million (60-107% higher than in 2021) with the largest relative increase versus 2021 in low-income and lower-middle-income countries.The burden of type 1 diabetes in 2021 is vast and is expected to increase rapidly, especially in resource-limited countries. Most incident and prevalent cases are adults. The substantial missing prevalence highlights the premature mortality of type 1 diabetes and an opportunity to save and extend lives of people with type 1 diabetes. Our new model, which will be made publicly available as the Type 1 Diabetes Index model, will be an important tool to support health delivery, advocacy, and funding decisions for type 1 diabetes.JDRF International.

Dialysis-requiring acute kidney injury (AKI-D) has increased substantially in the United States. We examined trends in and comorbid conditions associated with hospitalizations and in-hospital mortality in the setting of AKI-D among people with versus without diabetes.Cross-sectional study.Nationally representative data from the National Inpatient Sample and National Health Interview Survey were used to generate 16 cross-sectional samples of US adults (aged ≥18 years) between 2000 and 2015.Diabetes, defined using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes.AKI-D, defined using ICD-9-CM diagnosis and procedure codes.Annual age-standardized rates of AKI-D and AKI-D mortality were calculated for adults with and without diabetes, by age and sex. Data were weighted to be representative of the US noninstitutionalized population. Trends were assessed using join point regression with annual percent change (Δ/y) reported.In adults with diabetes, AKI-D increased between 2000 and 2015 (from 26.4 to 41.1 per 100,000 persons; Δ/y, 3.3%; P 0.001), with relative increases greater in younger versus older adults. In adults without diabetes, AKI-D increased between 2000 and 2009 (from 4.8 to 8.7; Δ/y, 6.5%; P 0.001) and then plateaued. AKI-D mortality significantly declined in people with and without diabetes. In adults with and without diabetes, the proportion of AKI-D hospitalizations with liver, rheumatic, and kidney disease comorbid conditions increased between 2000 and 2015, while the proportion of most cardiovascular comorbid conditions decreased.Lack of laboratory data to corroborate AKI diagnosis; National Inpatient Sample data are hospital-level rather than person-level data; no data for type of diabetes; residual unmeasured confounding.Hospitalization rates for AKI-D have increased considerably while mortality has decreased in adults with and without diabetes. Hospitalization rates for AKI-D remain substantially higher in adults with diabetes. Greater AKI risk-factor mitigation is needed, especially in young adults with diabetes.

Accumulating data suggest that type 2 diabetes mellitus (T2DM) in younger people (aged

Men (vs. women) are more likely to be waitlisted or receive a kidney transplant. Whether gender disparities exist in earlier transplant steps (i.e., referral) and whether age, race, or obesity factors play a role are unknown.Adults (18-80 years;Overall, 37.0% and 41.5% of women and men, respectively, were referred within 12 months. In fully adjusted models, women (vs. men) were 14% less likely to be referred (odds ratio [OR]: 0.86; 95% CI: 0.82-0.90). Women (vs. men) aged 45 to 64 years and 65 to 80 years were 0.93 (0.87-0.99) and 0.72 (0.66-0.77) less likely to be referred, respectively. Women (vs. men) of non-Hispanic White and non-Hispanic Black race were 0.76 (0.71-0.82) and 0.93 (0.88-0.99) less likely to be referred, respectively. For other race (Hispanic, other) and age (18-44 years) subgroups, and all obesity subgroups, no gender differences in referral rates were observed.In the Southeast, women are less likely to be referred for a transplant, and this disparity is specific to older non-Hispanic Black and White women. These findings have important implications for known gender disparities in upstream (i.e., waitlisting) transplant steps and in the design of interventions to reduce gender disparities in transplant.

IntroductionHeart failure (HF) is a major contributor to cardiovascular morbidity and mortality in people with diabetes. In this study, we estimated trends in the incidence of HF inpatient admissions and emergency department (ED) visits by diabetes status.Research design and methodsPopulation-based age-standardized HF rates in adults with and without diabetes were estimated from the 2006–2017 National Inpatient Sample, Nationwide ED Sample and year-matched National Health Interview Survey, and stratified by age and sex. Trends were assessed using Joinpoint.ResultsHF inpatient admissions did not change in adults with diabetes between 2006 and 2013 (from 53.9 to 50.4 per 1000 persons; annual percent change (APC): −0.3 (95% CI −2.5 to 1.9) but increased from 50.4 to 62.3 between 2013 and 2017 (APC: 4.8 (95% CI 0.3 to 9.6)). In adults without diabetes, inpatient admissions initially declined (from 14.8 in 2006 to 12.9 in 2014; APC −2.3 (95% CI −3.2 to –1.2)) and then plateaued. Patterns were similar in men and women, but relative increases were greatest in young adults with diabetes. HF-related ED visits increased overall, in men and women, and in all age groups, but increases were greater in adults with (vs without) diabetes.ConclusionsCauses of increased HF rates in hospital settings are unknown, and more detailed data are needed to investigate the aetiology and determine prevention strategies, particularly among adults with diabetes and especially young adults with diabetes.

IntroductionLittle is known about the role diabetes (type 1 (T1D) and type 2 (T2D)) plays in modifying prognosis among kidney transplant recipients. Here, we compare mortality among transplant recipients with T1D, T2D and non-diabetes-related end-stage kidney disease (ESKD).Research design and methodsWe included 254 188 first-time single kidney transplant recipients aged ≥18 years from the US Renal Data System (2000–2018). Diabetes status, as primary cause of ESKD, was defined using International Classification of Disease 9th and 10th Clinical Modification codes. Multivariable-adjusted Cox regression models (right-censored) computed risk of death associated with T1D and T2D relative to non-diabetes. Trends in standardized mortality ratios (SMRs) (2000–2017), relative to the general US population, were assessed using Joinpoint regression.ResultsA total of 72 175 (28.4%) deaths occurred over a median survival time of 14.6 years. 5-year survival probabilities were 88%, 85% and 77% for non-diabetes, T1D and T2D, respectively. In adjusted models, mortality was highest for T1D (HR=1.95, (95% CI: 1.88 to 2.03)) and then T2D (1.65 (1.62 to 1.69)), as compared with non-diabetes. SMRs declined for non-diabetes, T1D, and T2D. However, in 2017, SMRs were 2.38 (2.31 to 2.45), 6.55 (6.07 to 7.06), and 3.82 (3.68 to 3.98), for non-diabetes, T1D and T2D, respectively.ConclusionsIn the USA, diabetes type is an important modifier in mortality risk among kidney transplant recipients with highest rates among people with T1D-related ESKD. Development of effective interventions that reduce excess mortality in transplant recipients with diabetes is needed, especially for T1D.

Objective Diabetes is a leading cause of non-traumatic lower extremity amputation (NLEA) in the United States. After a period of decline, some national US data show that diabetes-related NLEA have recently increased, particularly among young and middle-aged adults. However, the trend for older adults is less clear. Research Design and Methods To examine NLEA trends among older adults with diabetes (≥67 years), we used 100% Medicare claims for beneficiaries enrolled in Parts A and B, also known as Fee for Service (FFS). NLEA was defined as the highest-level amputation per patient per calendar year. Annual NLEA rates were estimated from 2000 to 2017 and stratified by age group, sex, race/ethnicity, NLEA level (toe, foot, below the knee (BKA), above the knee (AKA)), and state. All rates were age and sex standardized to the 2000 Medicare population. Trends over time were assessed using Joinpoint regression and annual percent change (APC) reported. Results NLEA rates (per 1,000 people with diabetes) decreased by half from 8.5 in 2000 to 4.4 in 2009 (APC -7.9, p-value Conclusions This study of the US Medicare FFS population shows that recent increases in diabetes-related NLEAs are also occurring in older populations but at a less severe rate than among younger adults (

IntroductionLittle research has been done to systematically evaluate concerns of people living with diabetes through social media, which has been a powerful tool for social change and to better understand perceptions around health-related issues. This study aims to identify key diabetes-related concerns in the USA and primary emotions associated with those concerns using information shared on Twitter.Research design and methodsA total of 11.7 million diabetes-related tweets in English were collected between April 2017 and July 2019. Machine learning methods were used to filter tweets with personal content, to geolocate (to the USA) and to identify clusters of tweets with emotional elements. A sentiment analysis was then applied to each cluster.ResultsWe identified 46 407 tweets with emotional elements in the USA from which 30 clusters were identified; 5 clusters (18% of tweets) were related to insulin pricing with both positive emotions (joy, love) referring to advocacy for affordable insulin and sadness emotions related to the frustration of insulin prices, 5 clusters (12% of tweets) to solidarity and support with a majority of joy and love emotions expressed. The most negative topics (10% of tweets) were related to diabetes distress (24% sadness, 27% anger, 21% fear elements), to diabetic and insulin shock (45% anger, 46% fear) and comorbidities (40% sadness).ConclusionsUsing social media data, we have been able to describe key diabetes-related concerns and their associated emotions. More specifically, we were able to highlight the real-world concerns of insulin pricing and its negative impact on mood. Using such data can be a useful addition to current measures that inform public decision making around topics of concern and burden among people with diabetes.

Diabetes is the leading cause of non-traumatic lower extremity amputation (NLEA) in the United States. After a period of decline, some U.S. data show that diabetes-related NLEA has recently increased, particularly among young and middle-aged adults. However, the trend for older adults is less clear. To examine NLEA trends among older adults with diabetes (≥67 years), we used 100% Medicare claims for beneficiaries enrolled in Parts A and B during 2000-2017. NLEA was defined as the highest-level amputation per patient per calendar year. NLEA rates were stratified by sex, race and ethnicity, and NLEA level. All rates were age-sex standardized to the 2000 Medicare population. Trends over time were assessed using Joinpoint regression and annual percent change (APC) reported. NLEA rates (per 1,000 persons) halved from 8.5 in 2000 to 4.4 in 2009 (APC -7.9, p value Disclosure J. Harding: None. L.J. Andes: None. D.B. Rolka: None. G. Imperatore: None. Y. Li: None. E. Gregg: None. A.L. Albright: None.

Non-traumatic lower extremity amputations (NLEA) are an important complication of diabetes. After a period of decline, some national U.S. data show that rates of diabetes-related NLEA have recently increased. Whether this varies by state is unknown. We used 100% Medicare claims for beneficiaries enrolled in Parts A and B during 2000-2017 to examine state-specific NLEA trends among adults ≥67 years with diabetes. NLEA was defined as the highest-level amputation per patient per calendar year. All rates were age-sex standardized to the 2000 study population. Trends were assessed using Joinpoint regression. National diabetes-related NLEA rates (per 1,000 persons) decreased from 8.5 in 2000 to 4.4 in 2009 (APC - 7.9, p Disclosure L.J. Andes: None. J. Harding: None. D.B. Rolka: None. G. Imperatore: None. Y. Li: None. E.W. Gregg: None. A.L. Albright: None.

OBJECTIVE Diabetes is a leading cause of nontraumatic lower-extremity amputation (NLEA) in the U.S. After a period of decline, some national U.S. data have shown that diabetes-related NLEAs have recently increased, particularly among young and middle-aged adults. However, the trend for older adults is less clear. RESEARCH DESIGN AND METHODS To examine NLEA trends among older adults with diabetes (≥67 years), we used 100% Medicare claims for beneficiaries enrolled in Parts A and B, also known as fee for service (FFS). NLEA was defined as the highest-level amputation per patient per calendar year. Annual NLEA rates were estimated from 2000 to 2017 and stratified by age-group, sex, race/ethnicity, NLEA level (toe, foot, below-the-knee amputation [BKA], or above-the-knee amputation [AKA]), and state. All rates were age and sex standardized to the 2000 Medicare population. Trends over time were assessed using Joinpoint regression and annual percent change (APC) reported. RESULTS NLEA rates (per 1,000 people with diabetes) decreased by half from 8.5 in 2000 to 4.4 in 2009 (APC −7.9, P < 0.001). However, from 2009 onward, NLEA rates increased to 4.8 (APC 1.2, P < 0.01). Trends were similar across most age, sex, and race/ethnic groups, but absolute rates were highest in the oldest age-groups, Blacks, and men. By NLEA type, overall increases were driven by increases in rates of toe and foot NLEAs, while BKA and AKA continued to decline. The majority of U.S. states showed recent increases in NLEA, similar to national estimates. CONCLUSIONS This study of the U.S. Medicare FFS population shows that recent increases in diabetes-related NLEAs are also occurring in older populations but at a less severe rate than among younger adults (

Accumulating data suggest that type 2 diabetes mellitus (T2DM) in younger people (aged40 years), referred to as young-onset T2DM, has a more rapid deterioration of β-cell function than is seen in later-onset T2DM. Furthermore, individuals with young-onset T2DM seem to have a higher risk of complications than those with type 1 diabetes mellitus. As the number of younger adults with T2DM increases, young-onset T2DM is predicted to become a more frequent feature of the broader diabetes mellitus population in both developing and developed nations, particularly in certain ethnicities. However, the magnitude of excess risk of premature death and incident complications remains incompletely understood; likewise, the potential reasons for this excess risk are unclear. Here, we review the evidence pertaining to young-onset T2DM and its current and future burden of disease in terms of incidence and prevalence in both developed and developing nations. In addition, we highlight the associations of young-onset T2DM with premature mortality and morbidity.

We examined all-cause mortality trends in people with diabetes and compared them with trends among people without diabetes.MEDLINE, EMBASE and CINAHL databases were searched for observational studies published from 1980 to 2019 reporting all-cause mortality rates across ≥2 time periods in people with diabetes. Mortality trends were examined by ethnicity, age and sex within comparable calendar periods.Of 30,295 abstracts screened, 35 studies were included, providing data on 69 separate ethnic-specific or sex-specific populations with diabetes since 1970. Overall, 43% (3/7), 53% (10/19) and 74% (32/43) of the populations studied had decreasing trends in all-cause mortality rates in people with diabetes in 1970-1989, 1990-1999 and 2000-2016, respectively. In 1990-1999 and 2000-2016, mortality rates declined in 75% (9/12) and 78% (28/36) of predominantly Europid populations, and in 14% (1/7) and 57% (4/7) of non-Europid populations, respectively. In 2000-2016, mortality rates declined in 33% (4/12), 65% (11/17), 88% (7/8) and 76% (16/21) of populations aged40, 40-54, 55-69 and ≥70 years, respectively. Among the 33 populations with separate mortality data for those with and without diabetes, 60% (6/10) of the populations with diabetes in 1990-1999 and 58% (11/19) in 2000-2016 had an annual reduction in mortality rates that was similar to or greater than in those without diabetes.All-cause mortality has declined in the majority of predominantly Europid populations with diabetes since 2000, and the magnitude of annual mortality reduction matched or exceeded that observed in people without diabetes in nearly 60% of populations. Patterns of diabetes mortality remain uncertain in younger age groups and non-Europid populations.PROSPERO registration ID CRD42019095974. Graphical abstract.

IntroductionLittle research has been done to systematically evaluate concerns of people living with diabetes through social media, which has been a powerful tool for social change and to better understand perceptions around health-related issues. This study aims to identify key diabetes-related concerns in the USA and primary emotions associated with those concerns using information shared on Twitter.Research Design and MethodsA total of 11.7 million diabetes-related tweets in English were collected between April 2017 and July 2019. Machine learning methods were used to filter tweets with personal content, to geolocate (to the US) and to identify clusters of tweets with emotional elements. A sentiment analysis was then applied to each cluster.ResultsWe identified 46,407 tweets with emotional elements in the USA from which 30 clusters were identified; five clusters (18% of tweets) were related to insulin pricing with both positive emotions (joy, love) referring to advocacy for affordable insulin and sadness emotions related to the frustration of insulin prices, five clusters (12% of tweets) to solidarity and support with a majority of joy and love emotions expressed. The most negative topics (10% of tweets) were related to diabetes distress (24% sadness, 27% anger, 21% fear elements), to diabetic and insulin shock (45% anger, 46% fear) and comorbidities (40% sadness).ConclusionsUsing social media data, we have been able to describe key diabetes-related concerns and their associated emotions. More specifically, we were able to highlight the real-world concerns of insulin pricing and its negative impact on mood. Using such data can be a useful addition to current measures that inform public decision making around topics of concern and burden among people with diabetes.Significance of StudyWhat is already known about this subject?It is very challenging to collect representative data at a population level to understand what are the key concerns of people with diabetes in real life.Social media platforms, such as Twitter, may serve as a relevant source of information to supplement traditional population health studies.There are worldwide inequalities in access to insulin.What are the new findings?With 18% of the tweets related to insulin pricing, this is a major concern in the diabetes community in the USA.People regularly express fear, anger and sadness about potential diabetes-related complications and comorbidities.However, there is a lot of support and solidarity among the diabetes online community, with numerous posts related to positive emotionsHow might these results change the focus of research or clinical practice?Our work presents a reproducible approach to easily capture information about key diabetes-related concerns, that is usually not available in typical clinical or epidemiological studies. This information can supplement data from clinical or epidemiological studies to inform public health strategies to deal with diabetes-related prevention, management and treatment

Acute kidney injury is a sudden decrease in kidney function with or without kidney damage, occurring over a few hours or days. Diabetes, hypertension, and advanced age are primary risk factors for acute kidney injury. It is increasingly recognized as an in-hospital complication of sepsis, heart conditions, and surgery (1,2). Its most severe stage requires treatment with dialysis. Acute kidney injury is also associated with higher likelihood of long-term care, incidence of chronic kidney disease and hospital mortality, and health care costs (1,2). Although a number of U.S. studies have indicated an increasing incidence of dialysis-treated acute kidney injury since the late 1990s (3), no data are available on national trends in diabetes-related acute kidney injury. To estimate diabetes- and nondiabetes-related acute kidney injury trends, CDC analyzed 2000-2014 data from the National Inpatient Sample (NIS) (4) and the National Health Interview Survey (NHIS) (5). Age-standardized rates of acute kidney injury hospitalizations increased by 139% (from 23.1 to 55.3 per 1,000 persons) among adults with diagnosed diabetes, and by 230% (from 3.5 to 11.7 per 1,000 persons) among those without diabetes. Improving both patient and provider awareness that diabetes, hypertension, and advancing age are frequently associated with acute kidney injury might reduce its occurrence and improve management of the underlying diseases in an aging population.

Current evidence suggests that type 2 diabetes may have a greater impact on those with earlier diagnosis (longer duration of disease), but data are limited. We examined the effect of age at diagnosis of type 2 diabetes on the risk of all-cause and cause-specific mortality over 15 years. The data of 743,709 Australians with type 2 diabetes who were registered on the National Diabetes Services Scheme (NDSS) between 1997 and 2011 were examined. Mortality data were derived by linking the NDSS to the National Death Index. All-cause mortality and mortality due to cardiovascular disease (CVD), cancer and all other causes were identified. Poisson regression was used to model mortality rates by sex, current age, age at diagnosis, diabetes duration and calendar time. The median age at registration on the NDSS was 60.2 years (interquartile range [IQR] 50.9–69.5) and the median follow-up was 7.2 years (IQR 3.4–11.3). The median age at diagnosis was 58.6 years (IQR 49.4–67.9). A total of 115,363 deaths occurred during 7.20 million person-years of follow-up. During the first 1.8 years after diabetes diagnosis, rates of all-cause and cancer mortality declined and CVD mortality was constant. All mortality rates increased exponentially with age. An earlier diagnosis of type 2 diabetes (longer duration of disease) was associated with a higher risk of all-cause mortality, primarily driven by CVD mortality. A 10 year earlier diagnosis (equivalent to 10 years’ longer duration of diabetes) was associated with a 1.2–1.3 times increased risk of all-cause mortality and about 1.6 times increased risk of CVD mortality. The effects were similar in men and women. For mortality due to cancer (all cancers and colorectal and lung cancers), we found that earlier diagnosis of type 2 diabetes was associated with lower mortality compared with diagnosis at an older age. Our findings suggest that younger-onset type 2 diabetes increases mortality risk, and that this is mainly through earlier CVD mortality. Efforts to delay the onset of type 2 diabetes might, therefore, reduce mortality.

Background In the United States (US), barriers in access to later steps in the kidney transplantation process (i.e. waitlisting) have been well documented. Barriers in access to earlier steps (i.e. referral and evaluation) are less well described due to the lack of national surveillance data. In this review, we summarize the available literature on non-medical barriers in access to kidney transplant referral and evaluation. Methods Following PRISMA guidelines, we conducted a scoping review of the literature through June 3, 2021. We included all studies (quantitative and qualitative) reporting on barriers to kidney transplant referral and evaluation in the US published from 1990 onwards in English and among adult end-stage kidney disease (ESKD) patients (PROSPERO registration number: CRD42014015027). We narratively synthesized results across studies. Results We retrieved information from 33 studies published from 1990 to 2021 (reporting data between 1990 and 2018). Most studies (n = 28, 85%) described barriers among patient populations, three (9%) among provider populations, and two (6%) included both patients and providers. Key barriers were identified across multiple levels and included patient- (e.g. demographic, socioeconomic, sociocultural, and knowledge), provider- (e.g. miscommunication, staff availability, provider perceptions and attitudes), and system- (e.g. geography, distance to care, healthcare logistics) level factors. Conclusions A multi-pronged approach (e.g. targeted and systemwide interventions, and policy change) implemented at multiple levels of the healthcare system will be necessary to reduce identified barriers in access to early kidney transplant steps. Collection of national surveillance data on these early kidney transplant steps is also needed to enhance our understanding of barriers to referral and evaluation.

Cancer-related death is higher among people with vs without diabetes. However, it is not known if this excess risk has changed over time or what types of cancer may be driving these changes. To estimate rates of site-specific cancer mortality in adults with vs without self-reported diagnosed diabetes, we used data from adults aged ≥18 years at the time of the interview who participated in the 1985—2012 National Health Interview Survey. Participants’ data were linked to the National Death Index by the National Center for Health Statistics to determine vital status and cause of death through to the end of 2015. Cancer deaths were classified according to underlying cause of death. Death rates for five time periods (1988–1994, 1995–1999, 2000–2004, 2005–2009, 2010–2015) were estimated using discrete Poisson regression models adjusted for age, sex and race/ethnicity with p for linear trend reported (ptrend). Site-specific cancer mortality rates were stratified by diabetes status and period, and total cancer mortality rates were additionally stratified by sex, race/ethnicity, education and BMI status. Among adults with diabetes, age-adjusted cancer mortality rates (per 10,000 person-years) declined 25.5% from 39.1 (95% CI 30.1, 50.8) in 1988–1994 to 29.7 (26.6, 33.1) in 2010–2015, ptrend

Cancer-related mortality is higher among people with diabetes (DM) than people without DM. However, it is not known if this excess risk has changed over time. To estimate rates of cancer mortality in people with and without self-reported DM, we used data from adults aged ≥18 years who participated in the 1985-2012 National Health Interview Survey. Participants were linked to the National Death Index to determine vital status through the end of 2015. Cancer deaths were classified according to underlying cause of death. Death rates for five time periods (1988-1994, 1995-1999, 2000-2004, 2005-2009, 2010-2012) were estimated by survival analysis using Poisson regression models adjusted for age, sex and race/ethnicity with p for trend reported. Among people with DM, overall cancer mortality (per 1,000 person-years) declined 34.1% from 4.1 (95% CI: 3.0-5.3) in 1988-1994 to 2.7 (2.3-3.2) in 2010-2015, ptrend Disclosure J.L. Harding: None. L.J. Andes: None. Y.J. Cheng: None. K.M. Bullard: None. E. Gregg: None. H.K. Weir: None. N. Burrows: None. G. Imperatore: None.

Several studies have suggested a fall or stabilisation of diabetes incidence rates in the last decade. We therefore conducted a multi-country analysis of trends in diabetes incidence over time. Data from 16 countries comprising 17 administrative sources and one set of annual surveys were analysed according to a standard protocol mainly from the period 1995-2015. We modelled incidence rates using age and calendar time as quantitative variables (scored as the midpoint of each interval), and using restricted cubic splines with 6 knots for age and one knot per 4 years of observation for calendar time. The estimated rates from the models were presented as age- and sex-standardized rates (standardized to the 2010 EU population) for each centre to provide an overview of general trends. To formally assess temporal changes in incidence rates, we also fitted joinpoint models with joinpoints at one of the dates 2009, 2010, 2011, and 2012, estimating the average trend before and after the joinpoint. Among the 18 populations we assembled, 4 of the studies were from predominantly non-Europid populations (Taiwan, Korea, Singapore, Hong Kong) and only 2 of the studies were from middle-income countries (Ukraine and Latvia). In general, from 2000 (or when data were available) until 2010 we saw increasing trends in incidence rates in populations from the U.S., Canada, Australia, Denmark, UK, Spain, Scotland and Latvia, while we saw decreasing incidence rates in Israel, Italy, UK, Hong Kong, Taiwan and Korea. In contrast, after 2010, incidence rates appeared stable or decreasing in 14/18 centres, with U.S. (Kaiser Permanente Healthcare), Ukraine, Singapore, and Taiwan showing increasing trend of diabetes incidence. In conclusion, incidence rates of diabetes have shown a tendency to stabilise or even fall across some high-income populations in Europe, Asia, Canada and Australia. Patterns in low to middle income countries may be different, but little information is currently available from these. Disclosure D.J. Magliano: None. R.M. Islam: None. L. Chen: None. B. Carstensen: Consultant; Self; Leo Pharma. Speaker's Bureau; Self; Novo Nordisk A/S. Stock/Shareholder; Self; Novo Nordisk Inc. M.E. Pavkov: None. E.W. Gregg: None. M. Tabesh: None. D. Koye: None. J.L. Harding: None. J.E. Shaw: Advisory Panel; Self; Abbott, Merck Sharp & Dohme Corp. Speaker's Bureau; Self; AstraZeneca, Mylan, Roche Diabetes Care, Sanofi-Aventis. Funding Centers for Disease Control and Prevention

Some studies have reported falling mortality among populations with diabetes, but the consistency of this trend is unclear. We systematically reviewed studies published from 1980-2017 reporting all-cause mortality across 2 time-periods in people with diabetes. A total of 35 studies were found, providing data on 56 sex-specific or total populations with diabetes or type 2 diabetes. All studies were from high-income countries. Mortality declined in 80% of populations with diabetes in the 1980s, 53% in the 1990s, and 85% from 2000 onwards (Table). Falling mortality in diabetes occurred in 87% of Europid populations and in 10% of non-Europid populations. Of 25 populations with age-specific data, mortality declined in 29% of populations aged 60% of populations aged >55 years. Of 37 populations that reported on those with and without diabetes, greater or similar mortality reduction was observed among those with diabetes than without diabetes in 70% of populations. In conclusion, mortality has declined in the majority of Europid populations with diabetes since 1980. However, most non-Europid and most younger populations show no such declines. Disclosure L. Chen: None. R.M. Islam: None. J. Wang: None. T.R. Hird: None. M.E. Pavkov: None. E.W. Gregg: None. M. Tabesh: None. D. Koye: None. J.L. Harding: None. J.W. Sacre: None. E.L. Barr: None. D.J. Magliano: None. J.E. Shaw: Advisory Panel; Self; Abbott, Merck Sharp & Dohme Corp. Speaker's Bureau; Self; AstraZeneca, Mylan, Roche Diabetes Care, Sanofi-Aventis. Funding Centers for Disease Control and Prevention

OBJECTIVE Vascular complications of diabetes have declined substantially over the past 20 years. However, the impact of modern medical treatments on infectious diseases in people with diabetes remains unknown. RESEARCH DESIGN AND METHODS We estimated rates of infections requiring hospitalizations in adults (≥18 years) with versus without diabetes, using the 2000–2015 National Inpatient Sample and the National Health Interview Surveys. Annual age-standardized and age-specific hospitalization rates in groups with and without diabetes were stratified by infection type. Trends were assessed using Joinpoint regression with the annual percentage change (Δ%/year) reported. RESULTS In 2015, hospitalization rates remained almost four times as high in adults with versus without diabetes (rate ratio 3.8 [95% CI 3.8–3.8]) and as much as 15.7 times as high, depending on infection type. Overall, between 2000 and 2015, rates of hospitalizations increased from 63.1 to 68.7 per 1,000 persons in adults with diabetes and from 15.5 to 16.3 in adults without diabetes. However, from 2008, rates declined 7.9% in adults without diabetes (from 17.7 to 16.3 per 1,000 persons; Δ%/year −1.5, P < 0.01), while no significant decline was noted in adults with diabetes. The lack of decline in adults with diabetes in the later period was driven by significant increases in rates of foot infections and cellulitis as well as by lack of decline for pneumonia and postoperative wound infections in young adults with diabetes. CONCLUSIONS Findings from this study highlight the need for greater infectious risk mitigation in adults with diabetes, especially young adults with diabetes.

OBJECTIVE Nontraumatic lower-extremity amputation (NLEA) is a complication of end-stage renal disease (ESRD) and diabetes. Although recent data show that NLEA rates in the U.S. ESRD population are declining overall, trends in diabetes and diabetes subgroups remain unclear. RESEARCH DESIGN AND METHODS We estimated annual rates of NLEA hospitalizations during 2000–2015 among >2 million adults (≥18 years) with ESRD from the U.S. Renal Data System. Age, sex, and race-adjusted NLEA rates were stratified by diabetes status, age, sex, race, and level of amputation (toe, foot, below the knee, and above the knee). Time trends were assessed using Joinpoint regression with annual percent changes (APC) reported. RESULTS Among adults with diabetes, NLEA rates declined 43.8% between 2000 and 2013 (from 7.5 to 4.2 per 100 person-years; APC −4.9, P < 0.001) and then stabilized. Among adults without diabetes, rates of total NLEAs declined 25.5% between 2000 and 2013 (from 1.6 to 1.1; APC −3.0, P < 0.001) and then stabilized. These trends appear to be driven by a slowing or stagnation in declines of minor NLEAs (toe and foot) in more recent years, while major NLEAs (above the knee) continue to decline. CONCLUSIONS Despite an initial period of decline, this analysis documents a stall in progress in NLEA trends in recent years in a high-risk population with both ESRD and diabetes. Increased attention to preventive foot care in the ESRD population should be considered, particularly for those with diabetes.

OBJECTIVE To analyze changes by age-group in all-cause and cause-specific mortality rates from 2000–2011 in people with diabetes. RESEARCH DESIGN AND METHODS A total of 1,189,079 (7.3% with type 1 diabetes) Australians with diabetes registered on the National Diabetes Service Scheme between 2000 and 2011 were linked to the National Death Index. Mortality rates in the total population were age standardized to the 2001 Australian population. Mortality rates were calculated for the following age-groups: 0 to RESULTS For type 1 diabetes, all-cause, cardiovascular disease (CVD), and diabetes age-standardized mortality rates (ASMRs) decreased each year by 0.61, 0.35, and 0.14 per 1,000 person-years (PY), respectively, between 2000 and 2011, Ptrend < 0.05, while cancer mortality remained unchanged. By age, significant decreases in all-cause, CVD, and diabetes mortality rates were observed in all age-groups, excluding diabetes mortality in age-group 0–40 years. For type 2 diabetes, all-cause, CVD, and diabetes ASMRs decreased per year by 0.18, 0.15, and 0.03 per 1,000 PY, respectively, Ptrend < 0.001, while cancer remained unchanged. By age, these decreases were observed in all age-groups, excluding 0–40 years, where significant increases in all-cause and cancer mortality were noted and no change was seen for CVD and diabetes mortality. CONCLUSIONS All-cause, CVD, and diabetes ASMRs in type 1 and type 2 diabetes decreased between 2000 and 2011, while cancer ASMRs remained unchanged. However, younger populations are not benefiting from the same improvements as older populations. In addition, the absence of a decline in cancer mortality warrants urgent attention.

The aim of this work was to estimate the life expectancy (LE) and disability-free life expectancy (DFLE) for adults with and without diabetes.The Chiang method and the adapted Sullivan method were used to estimate LE and DFLE by age and sex. Mortality data in 2011 were available from the National Diabetes Services Scheme for diabetes and from standard national mortality datasets for the general population. Data on prevalence of disability and severe or profound core activity limitation were derived from the 2012 Australian Survey of Disability, Ageing and Carers (SDAC). The definitions of disability used in the SDAC followed the International Classification of Functioning, Disability and Health. Data on diabetes prevalence were derived from the Australian Diabetes, Obesity and Lifestyle study.The estimated LE and DFLE (with 95% uncertainty interval [UI]) at age 50 years were 30.2 (30.0, 30.4) and 12.7 (11.5, 13.7) years, respectively, for men with diabetes, and the estimates were 33.9 (33.6, 34.1) and 13.1 (12.3, 13.9) years, respectively, for women with diabetes. The estimated loss of LE associated with diabetes at age 50 years was 3.2 (3.0, 3.4) years for men and 3.1 (2.9, 3.4) years for women, as compared with their counterparts without diabetes. The corresponding estimated loss of DFLE was 8.2 (6.7, 9.7) years for men and 9.1 (7.9, 10.4) years for women. Women with diabetes spent a greater number of absolute years and a greater proportion of their life with disability as compared with men with diabetes and women without diabetes. The gains in LE and DFLE across the whole population at age 50 years after hypothetically eliminating diagnosed diabetes were 0.6 (0.5, 0.6) years and 1.8 (1.0, 2.8) years.In adults, diabetes results in a modest reduction in LE and a substantial reduction in DFLE. Efforts to identify the specific causes of disability and effective interventions are needed.

Purpose To estimate prevalence and severity of diabetic retinopathy (DR) among U.S. adults with diabetes and with or without chronic kidney disease (CKD), and assess associated risk of mortality. Design Cross-sectional study with national survey data. Methods The cohort included adults ≥40 years old with diabetes in the National Health and Nutrition Examination Surveys (NHANES) 2005–2008. Vital status was determined through December 31, 2011. We defined diabetes as hemoglobin A1c ≥6.5% or self-report and CKD by urinary albumin/creatinine ≥30 mg/g or glomerular filtration rate Results Prevalence of DR was 27.8% (95% CI 24.3–31.7), 36.2% (95%CI 30.1–42.7), and 23.4% (95% CI 19.2–28.1), overall, with and without CKD. Prevalence of vision-threatening DR was 4.2% (95% CI 3.2–5.5), 8.2% (95% CI 5.4–12.2), and 2.0% (95% CI 1.2–3.5), respectively. In a multivariable adjusted model, DR was positively but nonsignificantly associated with CKD (OR = 1.1, 95% CI 0.7–1.7), was 40% higher per 1% increase in hemoglobin A1c (OR = 1.4, 95% CI 1.1–1.6), was 30% higher per 5 years additional diabetes duration (OR = 1.3, 95% CI 1.1–1.5), was 30% higher per 10 mm Hg increase in systolic blood pressure (OR = 1.3, 95% CI 1.1–1.5), and was 6-fold higher with insulin treatment (OR = 6.2, 95% CI 2.6–14.8). Compared with diabetic participants with neither DR nor CKD, those with DR and CKD had a 3.6-fold (95% CI 1.5–9.1) increased adjusted risk for all-cause mortality. Conclusions Over one third of persons with diabetes and CKD had DR. The risk of death was higher with than without CKD and DR. Many of the studied risk factors associated with DR are modifiable.

In recent decades, large increases in diabetes prevalence have been demonstrated in virtually all regions of the world. The increase in the number of people with diabetes or with a longer duration of diabetes is likely to alter the disease profile in many populations around the globe, particularly due to a higher incidence of diabetes-specific complications, such as kidney failure and peripheral arterial disease. The epidemiology of other conditions frequently associated with diabetes, including infections and cardiovascular disease, may also change, with direct effects on quality of life, demands on health services and economic costs. The current understanding of the international burden of and variation in diabetes-related complications is poor. The available data suggest that rates of myocardial infarction, stroke and amputation are decreasing among people with diabetes, in parallel with declining mortality. However, these data predominantly come from studies in only a few high-income countries. Trends in other complications of diabetes, such as end-stage renal disease, retinopathy and cancer, are less well explored. In this review, we synthesise data from population-based studies on trends in diabetes complications, with the objectives of: (1) characterising recent and long-term trends in diabetes-related complications; (2) describing regional variation in the excess risk of complications, where possible; and (3) identifying and prioritising gaps for future surveillance and study.

Non-traumatic lower extremity amputation (NLEA) is a complication of end-stage renal disease (ESRD) and diabetes mellitus (DM). Global data suggest hospitalization rates for NLEA among people with DM are declining. Contemporary data from the U.S. and among those with ESRD is lacking. We estimated NLEA hospitalizations during 2000-2014 in adults aged ≥18 years with ESRD and DM (ESRD-DM) and in the broader DM population. We determined NLEA hospitalisations rates (ICD-9 CM procedure codes: 8411-8419, excluding diagnosis codes 895-897) for ESRD-DM using the U.S. Renal Data System and for DM using the U.S. National Health Interview Survey and the National Inpatient Sample. We assessed trends over time using Joinpoint regression. In the ESRD-DM population, age-standardised NLEA rates per 1,000 persons decreased from 61.5 (95% CI: 59.8-63.2) in 2000 to 39.7 (38.4-41.0) in 2014 (Figure). In the DM population, NLEA rates decreased from 10.8 (9.2-12.4) in 2000 to 6.1 (5.1-7.0) in 2009, and then increased to 8.7 (7.7-9.6) by 2014. NLEA rates remained 4.6 times (95% CI: 4.5-4.7) higher in ESRD-DM compared with DM only. Rates of NLEA hospitalisations declined during 2000-2014 in ESRD-DM, while they declined then increased in the population with DM. Increased attention to preventive care among ESRD-DM and DM populations is needed. Disclosure J.L. Harding: None. M.E. Pavkov: None. N. Burrows: None. E.W. Gregg: None. I.A. Hora: None.

OBJECTIVE Evidence indicates an increased risk of certain cancers among people with type 2 diabetes. Evidence for rarer cancers and for type 1 diabetes is limited. We explored the excess risk of site-specific cancer incidence and mortality among people with type 1 and type 2 diabetes, compared with the general Australian population. RESEARCH DESIGN AND METHODS Registrants of a national diabetes registry (953,382) between 1997 and 2008 were linked to national death and cancer registries. Standardized incidence and mortality ratios (SIRs/SMRs) are reported. RESULTS For type 1 diabetes, significant elevated SIRs were observed for pancreas, liver, esophagus, colon and rectum (females only [F]), stomach (F), thyroid (F), brain (F), lung (F), endometrium, and ovary, and decreased SIRs were observed for prostate in males. Significantly increased SMRs were observed for pancreas, liver, and kidney (males only), non-Hodgkin’s lymphoma, brain (F), and endometrium. For type 2 diabetes, significant SIRs were observed for almost all site-specific cancers, with highest SIRs observed for liver and pancreas, and decreased risks for prostate and melanoma. Significant SMRs were observed for liver, pancreas, kidney, Hodgkin’s lymphoma, gallbladder (F), stomach (F), and non-Hodgkin’s lymphoma (F). Cancer risk was significantly elevated throughout follow-up time but was higher in the first 3 months postregistration, suggesting the presence of detection bias and/or reverse causation. CONCLUSIONS Type 1 and type 2 diabetes are associated with an excess risk of incidence and mortality for overall and a number of site-specific cancers, and this is only partially explained by bias. We suggest that screening for cancers in diabetic patients is important.

OBJECTIVE With improvements in cardiovascular disease (CVD) rates among people with diabetes, mortality rates may also be changing. However, these trends may be influenced by coding practices of CVD-related deaths on death certificates. We analyzed trends of mortality over 13 years in people with diabetes and quantified the potential misclassification of CVD mortality according to current coding methods. RESEARCH DESIGN AND METHODS A total of 1,136,617 Australians with diabetes registered on the National Diabetes Services Scheme between 1997 and 2010 were linked to the National Death Index. Excess mortality relative to the Australian population was reported as standardized mortality ratios (SMRs). Potential misclassification of CVD mortality was determined by coding CVD according to underlying cause of death (COD) and then after consideration of both the underlying and other causes listed in part I of the death certificate. RESULTS For type 1 diabetes, the SMR decreased in males from 4.20 in 1997 to 3.08 in 2010 (Ptrend < 0.001) and from 3.92 to 3.46 in females (Ptrend < 0.01). For type 2 diabetes, the SMR decreased in males from 1.40 to 1.21 (Ptrend < 0.001) and from 1.56 to 1.22 in females (Ptrend < 0.001). CVD deaths decreased from 35.6 to 31.2% and from 31.5 to 27.2% in males and females with type 1 diabetes, respectively (Ptrend < 0.001 for both sexes). For type 2 diabetes, CVD decreased from 44.5 to 29.2% in males and from 45.5 to 31.6% in females (Ptrend < 0.001 for both sexes). Using traditional coding methods, ∼38 and 26% of CVD deaths are underestimated in type 1 diabetes and type 2 diabetes, respectively. CONCLUSIONS All-cause and CVD mortality has decreased in diabetes. However, the total CVD mortality burden is underestimated when only underlying COD is considered. This has important ramifications for understanding mortality patterns in diabetes.

Objective: The aim of this study is to determine the validity of self‐reported cancer data by comparing it to the Australian Cancer Database (ACD). Methods: Self‐reported data were obtained from the Australian Diabetes, Obesity and Lifestyle (AusDiab) study, which were then linked to the ACD up until 31 December 2010. Positive predictive value, negative predictive value, sensitivity and specificity were calculated. Cohen's kappa coefficient (ĸ) was also calculated to assess the agreement between self‐reported cancer and the ACD. Logistic regression was used to examine the determinants associated with false negative and false positive reporting. Results: The overall sensitivity of self‐report cancer was 71.1%, and sensitivities showed great variation by cancer site. Higher sensitivities were observed for breast (90.7%), bowel (77.8%) and prostate (77.1%) cancers, whereas the lowest sensitivity was observed for melanoma of the skin (36.9%). Similarly, the kappa coefficient analysis showed substantial agreement for self‐reported breast cancer (ĸ= 0.79) and moderate agreement for melanoma (ĸ= 0.45) against the ACD. Years since cancer diagnosis and older age were associated with false negative reporting and older age was associated with false positive reporting. Conclusions and implications: The use of self‐reported cancer to collect cancer outcomes has varying reliability, depending on cancer type and population. The findings presented here may assist medical researchers in making informed decisions when conducting research using self‐reported cancer data in Australia where the acquisition of registry data is not feasible.

Summary Background According to previous reports, the risk of disability as a result of diabetes varies from none to double. Disability is an important measure of health and an estimate of the risk of disability as a result of diabetes is crucial in view of the global diabetes epidemic. We did a systematic review and meta-analysis to estimate this risk. Methods We searched Ovid, Medline, Embase, Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature up to Aug 8, 2012. We included studies of adults that compared the risk of disability—as measured by activities of daily living (ADL), instrumental activities of daily living (IADL), or mobility—in people with and without any type of diabetes. We excluded studies of subpopulations with specific illnesses or of people in nursing homes. From the studies, we recorded population characteristics, how diabetes was diagnosed (by doctor or self-reported), domain and definition of disability, and risk estimates for disability. We calculated pooled estimates by disability type and type of risk estimate (odds ratio [OR] or risk ratio [RR]). Results Our systematic review returned 3224 results, from which 26 studies were included in our meta-analyses. Diabetes increased the risk of mobility disability (15 studies; OR 1·71, 95% CI 1·53–1·91; RR 1·51, 95% CI 1·38–1·64), of IADL disability (ten studies; OR 1·65, 95% CI 1·55–1·74), and of ADL disability (16 studies; OR 1·82, 95% CI 1·63–2·04; RR 1·82, 95% CI 1·40–2·36). Interpretation Diabetes is associated with a strong increase in the risk of physical disability. Efforts to promote healthy ageing should account for this risk through prevention and management of diabetes. Funding Monash University, Baker IDI Bright Sparks Foundation, Australian Postgraduate Award, VicHealth, National Health and Medical Research Council, Australian Research Council, Victorian Government.

Objective To develop and recalibrate an Australian 5-year cardiovascular disease (CVD) mortality risk score to produce contemporary predictions of risk. Methods Data were pooled from six Australian cohort studies (n = 54,829), with baseline data collected between 1989 and 2003. Participants included were aged 40–74 years and free of CVD at baseline. Variables were harmonised across studies and missing data were imputed using multiple imputation. Cox proportional hazards models were used to estimate the risk of CVD mortality associated with factors mutually independently predictive (p

BACKGROUND: Observational studies examining associations between hypertension and cancer are inconsistent. We explored the association of hypertension, graded hypertension and antihypertensive treatment with cancer incidence and mortality. METHOD: Eighty-six thousand five hundred and ninety-three participants from the Australian and New Zealand Diabetes and Cancer Collaboration were linked to the National Death Index and Australian Cancer Database. Cox proportional hazards models estimated hazard ratios and 95% confidence intervals (95% CI) for the association of treated and untreated hypertension with cancer incidence and mortality. RESULTS: Over a median follow-up of 15.1 years, 12 070 incident and 4350 fatal cancers were identified. Untreated and treated hypertension, compared with normotension, were associated with an increased risk for cancer incidence [hazard ratio 1.06, 95% CI (1.00-1.11) and 1.09 (1.02-1.16) respectively], and cancer mortality (1.07, 0.98-1.18) and (1.15, 1.03-1.28), respectively. When compared with untreated hypertension, treated hypertension did not have a significantly greater risk for cancer incidence (1.03, 0.97-1.10) or mortality (1.07, 0.97-1.19). A significant dose-response relationship was observed between graded hypertension and cancer incidence and mortality; Ptrend = 0.053 and Ptrend = 0.001, respectively. When stratified by treatment status, these relationships remained significant in untreated, but not in treated, hypertension. CONCLUSION: Hypertension, both treated and untreated, is associated with a modest increased risk for cancer incidence and mortality. Similar risks in treated and untreated hypertension suggest that the increased cancer risk is not explained by the use of antihypertensive treatment.