Cumulative Risk of End-Stage Renal Disease Among Patients With Type 2 Diabetes: A Nationwide Inception Cohort Study.

OBJECTIVE: To estimate long-term cumulative risk of end-stage renal disease (ESRD) after diagnosis of type 2 diabetes. RESEARCH DESIGN AND METHODS: This nationwide population-based inception cohort study included 421,429 patients with type 2 diabetes diagnosed in 1990-2011; patients were followed until the end of 2013. Data linkage between several national health care registers in Finland, covering 100% of the population, enabled the inclusion of almost all inhabitants who started taking diabetes medication or were hospitalized for diabetes. Cumulative risk of ESRD and hazard ratios [HR] for ESRD and death were estimated according to age, sex, and time period of diabetes diagnosis. RESULTS: Among 421,429 patients with type 2 diabetes, 1,516 developed ESRD and 150,524 died during 3,458,797 patient-years of follow-up. Cumulative risk of ESRD was 0.29% at 10 years and 0.74% at 20 years from diagnosis of diabetes. Risk was higher among men than among women (HR 1.93 [95% CI 1.72-2.16]), decreased with older age at diagnosis (HR 0.70 [95% CI 0.60-0.81] for age 60-69 vs. 40-49 years), and was lower for those diagnosed in 2000-2011 than in 1990-1994 (HR 0.72 [95% CI 0.63-0.81]). Patients diagnosed with diabetes in 2000-2011 had lower risk of death during follow-up than those diagnosed in 1990-1994 (HR 0.64 [95% CI 0.63-0.65]). CONCLUSIONS: Cumulative risk of ESRD is minimal among patients with type 2 diabetes compared with their risk of death. Patients diagnosed with diabetes at an older age have a lower risk of ESRD due to higher competing mortality.

Type 2 diabetic patients on renal replacement therapy: Probability to receive renal transplantation and survival after transplantation.

BACKGROUND: Type 2 diabetic (T2DM) patients on renal replacement therapy (RRT) seldom receive a kidney transplant, which is partly due to age and comorbidities. Adjusting for case mix, we investigated whether T2DM patients have equal opportunity for renal transplantation compared to other patients on dialysis, and whether survival after transplantation is comparable. METHODS: Patients who entered RRT in Finland in 2000-2010 (n = 5419) were identified from the Finnish Registry for Kidney Diseases and followed until the end of 2012. Of these, 20% had T2DM, 14% type 1 diabetes (T1DM) and 66% other than diabetes as the cause of ESRD. Uni-/multivariate survival analysis techniques were employed to assess the probability of kidney transplantation after the start of dialysis and survival after transplantation. RESULTS: T2DM patients had a relative probability of renal transplantation of 0.18 (95% CI 0.15-0.22, P<0.001) compared to T1DM patients: this increased to 0.51 (95% CI 0.36-0.72, P<0.001) after adjustment for case mix (age, gender, laboratory values and comorbidities). When T2DM patients were compared to non-diabetic patients, the corresponding relative probabilities were 0.25 (95% CI 0.20-0.30, P<0.001) and 0.59 (95% CI 0.43-0.83, P = 0.002). After renal transplantation when adjusted for age and gender, relative risk of death was 1.25 (95% CI 0.64-2.44, P = 0.518) for T1DM patients and 0.72 (0.43-1.22, P = 0.227) for other patients compared to T2DM patients. CONCLUSIONS: T2DM patients had a considerably lower probability of receiving a kidney transplant, which could not be fully explained by differences in the patient characteristics. Survival within 5 years after transplantation is comparably good in T2DM patients.

An observational study of how patients are identified before medication administrations in medical and surgical wards.

The aims of this study were to clarify how a patient's identity was verified before the administration of medication in medical and surgical wards in a hospital, as well as to study the association between patient identification and the registered nurse's work experience, observed interruptions, and distractions. The study material was collected during April and May 2012 in two surgical and two medical wards in one university hospital in Finland, using a direct, structured observation method. A total of 32 registered nurses were observed while they administered 1058 medications to 122 patients. Patients were not identified at all in 66.8% (n = 707) of medication administrations. Patient identifications were made more often by nurses with shorter work experience in the nursing profession or in the wards (4 years or less), or if distractions existed during medication administration. According to the results, patient identification was not adequately conducted. There is a need for education and change in the culture of medication processes and nursing practice.

Patient-specific risk factors of adverse drug events in adult inpatients - evidence detected using the Global Trigger Tool method.

AIMS AND OBJECTIVES: To identify the prevalence, preventability, and severity of adverse drug events in randomly selected adult hospital inpatients, and to study the association between adverse drug events and patient-specific factors. BACKGROUND: Adverse drug events represent one of the major concerns in patient safety. DESIGN: A retrospective record review. METHODS: The study was conducted in an 800-bed university hospital in Finland within a 12-month period. Retrospective reviews of randomly selected discharged patients' (n = 463) records using the Global Trigger Tool method were undertaken. The prevalence, preventability, and severity of adverse drug events were studied, and the association between patient-specific factors and adverse drug events were examined using a binary logistic regression model and Pearson's chi-squared tests. RESULTS: A total of 180 adverse drug events were detected in 125 (27%) patients, of which 74 (41·1%) were preventable, and 94·4% caused temporary harm. An abnormal level of potassium in the blood was the most frequent adverse drug event (n = 37). The risk of adverse drug events increased with the length of hospital stay and the increased number of drugs patients used. The patients with coronary diseases (n = 130) had a 2·5 times higher risk of experiencing adverse drug events. In addition, the risk of adverse drug events during hospitalisation increased together with the co-morbidity of patients. CONCLUSIONS: Adverse drug events were experienced by a quarter of inpatients, while severe adverse drug events were rare. The risk of adverse drug events increased with patients' prolonged hospital stay, polypharmacy, and morbidity. In addition, information of the usefulness of the Global Trigger tool can be used for future development of the method. RELEVANCE TO CLINICAL PRACTICE: Patient-specific risk factors were identified using the Global Trigger Tool method revealing that more efficient monitoring of inpatients with these risk factors may be profitable for decreasing adverse drug events.

The factors associated with medication errors in adult medical and surgical inpatients: a direct observation approach with medication record reviews.

INTRODUCTION: Observing real situations in clinical practice can provide undetected information regarding problems in the medication process. AIMS: The aims of this study were to describe the frequency, types, and severity of medication errors in medical and surgical inpatients as well as to study the relationship between medication errors and associating factors. METHODS: A cross-sectional study using direct observations and medication record reviews was conducted to assess how 32 registered nurses administered 1058 medications to 122 inpatients in four medical and surgical wards at a university hospital in Finland between April and May 2012. Observations were recorded using a structured observation form and patients' medication record reviews (n = 122) before and after the observations were conducted. A multiprofessional team analysed and classified all of the detected errors and assessed their severity. A logistic regression was used to analyse the factors (work environment, team, person-specific, patient-specific or medication-related) associated with medication errors. RESULTS: At least one error was found in 22.2% (235/1058) of administered medications, 63.4% of which were medication administration errors and 18.3% of which were documentation errors. Of the medication administration errors, 59.1% involved an incorrect administration technique. 3.4% of errors caused harm to patients. Statistically significant factors that increased the risk of medication errors included every other weekday, except Sunday; morning shifts; increased rushes; nurses asking for help; and increased number of medications that patients used. Factors that decreased the risk of errors included administering medications through an oral route, double-checking the drugs, and additional people in the medication room at the same time. CONCLUSION: Medication errors in inpatient care are frequent, and improvements to increase safety are vital. More attention to medication administration techniques, administration instructions and attitudes toward safety are needed to prevent problems.

Effect of vascular comorbidities on survival of type 2 diabetes patients on renal replacement therapy.

BACKGROUND: Atherosclerosis is an important predictor of mortality in patients with end-stage renal disease. The aim of this study was to determine how various vascular comorbidities such as coronary heart disease (CHD), peripheral vascular disease (PVD) or cerebrovascular disease (CeVD) affect survival of type 2 diabetic patients on renal replacement therapy (RRT). METHODS: Patients who entered RRT because of type 2 diabetes in 2000-2008 (n = 877) were identified within the Finnish Registry for Kidney Diseases. The patients were followed up until death or end of follow-up. Survival probabilities were calculated using Kaplan-Meier curves. Multivariate modeling was performed using Cox regression. RESULTS: 41% of the patients had CHD, 27% PVD and 16% CeVD at the start of RRT. Patients with PVD had a 1.9-fold (95% CI 1.6-2.3) risk of death compared to those without PVD when adjusting for age and gender, while patients with CHD had a 1.5-fold (95% CI 1.2-1.8) and those with CeVD a 1.4-fold (95% CI 1.1-1.8) risk compared to those without these diseases. The hazard ratio (HR) for death was highest in patients with the combination of PVD and either CHD (HR 2.8, 95% CI 2.1-3.8) or CeVD (HR 2.9, 95% CI 1.6-5.2) as compared to patients without any vascular comorbidities. CONCLUSION: PVD is the vascular comorbidity that increases risk of death the most among patients with type 2 diabetes starting RRT. Prevention of PVD in this patient group would merit further studies.

Improved survival of type 2 diabetic patients on renal replacement therapy in Finland.

BACKGROUND: Survival of type 2 diabetes mellitus patients on maintenance dialysis therapy is poor mainly due to cardiovascular events. The aim was to examine whether survival of type 2 diabetes patients on renal replacement therapy (RRT) in Finland has improved during 1995-2005. METHODS: Patients who entered RRT because of type 2 diabetes mellitus in 1995-99 (n = 314) and 2000-05 (n = 583) were identified within the Finnish Registry for Kidney Diseases. The two cohorts were followed up from start of RRT until death or end of follow-up on 31 December 2006. Survival probabilities and probabilities of receiving a kidney transplant were calculated using Kaplan-Meier curves. Multivariate modelling was performed using Cox regression. RESULTS: Patients who entered RRT in 2000-05 had lower risk of dying than those who entered in 1995-99; hazard ratio (HR) was 0.76 (95% CI 0.65-0.89) and 0.74 (95% CI 0.63-0.87) with adjustment for age and gender. The decreased risk of death was most obvious in age groups 55-64 (HR 0.67, 95% CI 0.49-0.92) and 65-74 years (HR 0.69, 95% CI 0.56-0.87). Adjustment for albumin in addition to age and gender only slightly weakened the effect of study periods (HR 0.83, 95% CI 0.69-1.01). The patients in 2000-05 were more obese, had lower total and LDL cholesterol and higher HDL cholesterol and albumin concentration in serum than patients in 1995-99. Patients' probability to receive a kidney transplant was low in both groups. CONCLUSIONS: Survival of type 2 diabetes patients on RRT improved during the time period 1995-2005 in Finland while the probability of receiving a kidney transplant remained low and unchanged.

Discontinuation of dialysis treatment: experience of a single dialysis centre.

OBJECTIVE: Discontinuation of dialysis is a common cause of death in end-stage renal disease (ESRD) patients in the USA and UK, but is less common in the rest of Europe and in Japan. The aim of this study was to describe the discontinuation pattern in a single dialysis unit in eastern Finland. MATERIAL AND METHODS: We retrospectively analysed the case history and cause of death of 146 dialysis patients in whom dialysis treatment was started between 1992 and 2001 and who had died by March 2003. We compared patients who died after withdrawal from dialysis and those who continued dialysis until death. RESULTS: In 53 patients (36.3%) dialysis treatment was discontinued before death (withdrawal group). In the rest of the patients (control group; n=93) dialysis was continued until death. The patients in the withdrawal group were older (median 69 vs 65 years at the onset of ESRD), more often institutionalized before death (49% vs 11.8%) and more often had dementia diagnosed before death (20.8% vs 2.2%) than those in the control group. They were also less rehabilitated before death (54.7% vs 76.7%) and their treatment more often lasted for <3 months (20.8% vs 7.6%). The patients in the withdrawal group died less often of cardiac disease (11.3% vs 39.8%), whereas kidney disease was the commonest cause of death (41.5 vs 19.4%). The commonest reason for discontinuation of dialysis was severe medical illness (86.5%). In most cases the nephrologist or the renal team raised the issue of stopping dialysis. Nearly 70% of patients were incompetent at the time of the decision. Patient refusal to stop dialysis was uncommon. CONCLUSIONS: Stopping dialysis before death is a common practice in our unit. Dialysis was mostly discontinued in severely ill patients who were near the end of their life. The nephrologist or the renal team decided to stop treatment. Our results should encourage renal teams to raise the issue of stopping dialysis when a patient's illness has become terminal. More studies and discussion of this difficult field are needed.