Glucose, blood pressure and cholesterol levels and their relationships to clinical outcomes in type 2 diabetes: a retrospective cohort study

Kontopantelis, Evangelos; Springate, David A.; Reeves, David; Ashcroft, Darren M.; Rutter, Martin K.; Buchan, Iain; Doran, Tim

doi:10.1007/s00125-014-3473-8

Cited by 68 publications

(60 citation statements)

References 37 publications

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“…Other studies revealed a non-linear (U-or J-shaped) relationship [31,32]. The present findings confirm to a great extent the recent results from Kontopantelis et al [33]. They showed, within a retrospective cohort study of more than 246,000 patients after adjustment for several important confounders, that the relationship between HbA 1c levels and coronary and stroke mortality was positive curvilinear related (U-shaped).…”

Section: Discussionsupporting

confidence: 91%

Association of the average rate of change in HbA1c with severe adverse events: a longitudinal evaluation of audit data from the Bavarian Disease Management Program for patients with type 2 diabetes mellitus

et al. 2015

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Aims/hypothesis In patients with type 2 diabetes mellitus, the effects of HbA 1c variability on macrovascular events remain uncertain. The present investigation evaluates the association of HbA 1c variability with non-fatal cardiovascular events, emergency admissions and episodes of severe hypoglycaemia in a cohort of patients newly started on insulin therapy. Methods HbA 1c variability was defined as the rate of change in values between observations. The medical records of 406,356 patients enrolled in a disease management programme for type 2 diabetes mellitus were analysed to identify a cohort of 13,777 patients with observed transition to insulin therapy. The cohort was observed for a period of at least 5 years. Cox regression models were applied to quantify the association of HbA 1c variability with the events of interest. Results The models reveal a significant non-linear association between HbA 1c variability and the risk of experiencing myocardial infarction, stroke and hypoglycaemia. The lowest risk is seen with a variability of approximately 0.5% (5.5 mmol/ mol) per quarter. Using Cox models to predict survival curves for the cohort with hypothetical HbA 1c variability of 0.5% (5.5 mmol/mol) and 1.5% (16.4 mmol/mol) per quarter, the proportion experiencing myocardial infarction within 2 years increases significantly from 1% to 10%. The proportion experiencing stroke increases from 1% to 29%, hypoglycaemia from 2% to 24% and the risk of emergency admission from 2% to 21%. Conclusions/interpretation In patients newly started on insulin therapy, rapid and higher HbA 1c variability is associated with an increased risk of myocardial infarction, stroke, severe hypoglycaemia and emergency admission.

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Section: Discussionsupporting

confidence: 91%

Association of the average rate of change in HbA1c with severe adverse events: a longitudinal evaluation of audit data from the Bavarian Disease Management Program for patients with type 2 diabetes mellitus

et al. 2015

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“…For example, clinical trial findings indicate that intensive glucose control is associated with increased mortality, 51 especially risk of cardiovascular death in younger patients, 52 while observational studies have generally demonstrated U-shaped relationships between levels of HbA 1c in diabetic patients and death. [53][54][55] Similar U-shaped relationships have been observed for other biometric measurements, including blood pressure and total cholesterol levels. 55 56 These non-linear patterns might suggest that target values (sich as ≤7.5 mm Hg for HbA 1c in 2011-12) are suboptimal measures of high quality of care and that target ranges might be more suitable.…”

Section: Resultssupporting

confidence: 70%

Investigating the relationship between quality of primary care and premature mortality in England: a spatial whole-population study

Kontopantelis

Springate

Ashworth

et al. 2015

BMJ

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Objectives To quantify the relationship between a national primary care pay-for-performance programme, the UK's Quality and Outcomes Framework (QOF), and all-cause and cause-specific premature mortality linked closely with conditions included in the framework.Design Longitudinal spatial study, at the level of the "lower layer super output area" (LSOA).Setting 32482 LSOAs (neighbourhoods of 1500 people on average), covering the whole population of England (approximately 53.5 million), from 2007 to 2012.Participants 8647 English general practices participating in the QOF for at least one year of the study period, including over 99% of patients registered with primary care.Intervention National pay-for-performance programme incentivising performance on over 100 quality-of-care indicators.Main outcome measures All-cause and cause-specific mortality rates for six chronic conditions: diabetes, heart failure, hypertension, ischaemic heart disease, stroke, and chronic kidney disease. We used multiple linear regressions to investigate the relationship between spatially estimated recorded quality of care and mortality.Results All-cause and cause-specific mortality rates declined over the study period. Higher mortality was associated with greater area deprivation, urban location, and higher proportion of a non-white population. In general, there was no significant relationship between practice performance on quality indicators included in the QOF and all-cause or cause-specific mortality rates in the practice locality. ConclusionsHigher reported achievement of activities incentivised under a major, nationwide pay-for-performance programme did not seem to result in reduced incidence of premature death in the population. IntroductionPrimary care has enormous potential to improve population health outcomes-including mortality from common chronic conditions-through early intervention in the disease process 1 2 and coordinated provision of care. Effective primary care is associated with reduced morbidity, increased longevity, and more equitable health outcomes, 3 4 but quality of primary care varies widely between providers.5 6 Traditional physician payment systems have facilitated this variation, with fee-for-service systems potentially incentivising over-investigation and over-treatment, and capitation systems potentially incentivising under-utilisation. Neither approach directly rewards high quality care or investment in quality improvement. [7][8][9] In order to improve patient outcomes, policymakers worldwide have attempted to link remuneration for providers to quality of care through pay-for-performance programmes. Multiple programmes have been implemented across a range of settings, but clear evidence for improved patient outcomes is yet to emerge. [10][11][12] In the United Kingdom a national primary care incentive scheme was introduced in 2004. The Quality and Outcomes Framework (QOF), one of largest pay-for-performance programmes in the world, links up to 25% of family practitioners' income to performance on o...

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“…Although there is a risk of unmeasured confounding (eg, multimorbidity not captured by the QOF conditions), it does appear that refusal of QOF investigations and treatments is linked to poorer outcomes. However, previous investigations have questioned the effectiveness of some QOF indicators 36 and have failed to identify a link between performance on QOF indicators and mortality. 12 Therefore, although informed dissent under the QOF might have no direct effect on survival, it might be a proxy for non-adherence with the advice and recommendations of health professionals generally, or of other risk-prone or unhealthy behaviours.…”

Section: Resultsmentioning

confidence: 99%

Associations between exemption and survival outcomes in the UK's primary care pay-for-performance programme: a retrospective cohort study

et al. 2015

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ObjectivesThe UK's Quality and Outcomes Framework permits practices to exempt patients from financially-incentivised performance targets. To better understand the determinants and consequences of being exempted from the framework, we investigated the associations between exception reporting, patient characteristics and mortality. We also quantified the proportion of exempted patients that met quality targets for a tracer condition (diabetes).DesignRetrospective longitudinal study, using individual patient data from the Clinical Practice Research Datalink.Setting644 general practices, 2006/7 to 2011/12.ParticipantsPatients registered with study practices for at least one year over the study period, with at least one condition of interest (2 460 341 in total).Main outcome measuresException reporting rates by reason (clinical contraindication, patient dissent); all-cause mortality in year following exemption. Analyses with logistic and Cox proportional-hazards regressions, respectively.ResultsThe odds of being exempted increased with age, deprivation and multimorbidity. Men were more likely to be exempted but this was largely attributable to higher prevalence of conditions with high exemption rates. Modest associations remained, with women more likely to be exempted due to clinical contraindication (OR 0.90, 99% CI 0.88 to 0.92) and men more likely to be exempted due to informed dissent (OR 1.08, 99% CI 1.06 to 1.10). More deprived areas (both for practice location and patient residence) were non-linearly associated with higher exception rates, after controlling for comorbidities and other covariates, with stronger associations for clinical contraindication. Compared with patients with a single condition, odds ratios for patients with two, three, or four or more conditions were respectively 4.28 (99% CI 4.18 to 4.38), 16.32 (99% CI 15.82 to 16.83) and 68.69 (99% CI 66.12 to 71.37) for contraindication, and 2.68 (99% CI 2.63 to 2.74), 4.02 (99% CI 3.91 to 4.13) and 5.17 (99% CI 5.00 to 5.35) for informed dissent. Exempted patients had a higher adjusted risk of death in the following year than non-exempted patients, regardless of whether this exemption was for contraindication (hazard ratio 1.37, 99% CI 1.33 to 1.40) or for informed dissent (1.20, 99% CI 1.17 to 1.24). On average, quality standards were met for 48% of exempted patients in the diabetes domain, but there was wide variation across indicators (ranging from 8 to 80%).ConclusionsOlder, multimorbid and more deprived patients are more likely to be exempted from the scheme. Exception reported patients are more likely to die in the following year, whether they are exempted by the practice for a contraindication or by themselves through informed dissent. Further research is needed to understand the relationship between exception reporting and patient outcomes.

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Glucose, blood pressure and cholesterol levels and their relationships to clinical outcomes in type 2 diabetes: a retrospective cohort study

Cited by 68 publications

References 37 publications

Association of the average rate of change in HbA1c with severe adverse events: a longitudinal evaluation of audit data from the Bavarian Disease Management Program for patients with type 2 diabetes mellitus

Association of the average rate of change in HbA1c with severe adverse events: a longitudinal evaluation of audit data from the Bavarian Disease Management Program for patients with type 2 diabetes mellitus

Investigating the relationship between quality of primary care and premature mortality in England: a spatial whole-population study

Associations between exemption and survival outcomes in the UK's primary care pay-for-performance programme: a retrospective cohort study

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