Oral glucose tolerance test and HbA1c for diagnosis of diabetes in patients undergoing coronary angiography: [corrected] the Silent Diabetes Study.

AIMS/HYPOTHESIS: The primary aim of this study was to compare the results of HbA(1c) measurements with those of an OGTT for early diagnosis of 'silent diabetes' in patients with coronary artery disease (CAD) undergoing angiography without prediagnosed diabetes. A secondary aim was to investigate the correlation between the extent of CAD and the glycaemic status of the patient. METHODS: Data from 1,015 patients admitted for acute (n = 149) or elective (n = 866) coronary angiography were analysed. Patients with known diabetes were excluded from the study. Using the OGTT results, patients were classified as having normal glucose tolerance (NGT), impaired fasting glucose (IFG), impaired glucose tolerance (IGT) or diabetes. According to the results of the HbA(1c) measurements, patients were classified into three groups: normal (HbA(1c) <5.7% [<39 mmol/mol]), borderline (HbA(1c) 5.7-6.4% [39-47 mmol/mol]) and diabetes (HbA(1c) ≥6.5% [≥48 mmol/mol]). RESULTS: Based on the OGTT, 513 patients (51%) were classified with NGT, 10 (1%) with IFG, 349 (34%) with IGT and 149 (14%) were diagnosed with diabetes. According to HbA(1c) measurements, 588 patients (58%) were classified as normal, 385 (38%) as borderline and 42 (4%) were diagnosed with diabetes. The proportion of patients with IGT and diabetes increased with the extent of CAD (IGT ρ = 0.14, p < 0.001, diabetes ρ = 0.09, p = 0.01). No differences in HbA(1c) were seen among the groups with different extents of CAD (p = 0.652). CONCLUSIONS/INTERPRETATION: An OGTT should be performed routinely for diagnosis of diabetes in patients with CAD undergoing coronary angiography, since HbA(1c) measurement alone appears to miss a substantial proportion of patients with silent diabetes. A limitation of the study is that the OGTT was not performed before the angiography.

[Analysis of the quality of health care for patients with type 2 diabetes enrolled in statutory or private health plans]. / Analyse der Versorgungsqualität bei Typ-2-Diabetes bei gesetzlich und privat versicherten Patienten.

BACKGROUND AND OBJECTIVE: Worldwide the quality of care of patients with type 2 diabetes has been investigated only by analysing within cross-sectional studies. But the quality of care in relation to statutory or private health plans in not known. It was the aim of this study to ascertain retrospectively, how in the course of time from first diagnosis the quality of medical care of patients with type 2 diabetes differed depending on the type of health insurance of the individual patient. METHODS AND PATIENTS: As part of the ROSSO study (a German retrospective epidemiological cohort study), data on all patients diagnosed with type 2 diabetes between 1.1.1995 and 31.12.1999 had been recorded. They had been collected from 192 randomly selected general practitioner or internal medicine specialist practices. RESULTS: The data of 3268 patients diagnosed with type 2 diabetes were recorded. The mean observation period was 6.5 years. The mean age of this patients at the time of diagnosis of diabetes was 62.4 +/- 9.6 years, 49 % being male. The portion of patients visiting their chosen practice at least 3 - 4 times in a given year was about 70 - 80 %. Documentation of HbA (1c) or blood pressure as requested in the guideline was presented in 20 - 50 % of patient files with no differences between enrolled in a statutory or private health plans. Even when cholesterol or blood pressure levels were greatly elevated 20 - 50 % of patients had been prescribed no adequate drug treatment. Only 20 % of the patients had been described platelet aggregation inhibitors during the first years after myocardial infarction or stroke. CONCLUSION: The quality of care in general practitioner of specialist internal medicine practices failed to meet the guidelines for patients with type 2 diabetes. There were no differences that depended on whether the patients had been enrolled in a statutory or private health plan.

Epidemiology of complications and total treatment costs from diagnosis of Type 2 diabetes in Germany (ROSSO 4).

OBJECTIVE: To determine the occurrence of complications and treatment costs in the first 6 years from diagnosis of Type 2 diabetes in the primary care level. DESIGN: The German multi-centre, retrospective epidemiological cohort study ROSSO observed patients from diagnosis in 1995-1999 until the end of 2003 or loss to follow-up. SETTING: 192 randomly contacted primary care practices and all patient records of newly diagnosed type 2 diabetes patients. PARTICIPANTS: All 3,142 patients insured in a public health insurance plan. MAIN OUTCOME MEASURES: Diabetes-related complications were documented from patient files. Treatment costs were attributed using the doctor's tariff, hospital DRGs and medication price lists for Germany. RESULTS: At diagnosis, already 22.4% of patients presented with CHD, 15.4% with CHF, 5.8% with pAOD, 3.1% with stroke and 3.9% with AMI, but less than 0.5% with documented microvascular complications. 7.4% of patients were diagnosed with prior depression and, 5.0% with polyneuropathy. Within a mean of 6.5 years of follow-up 114 patients (3.6%) died. The cumulated occurrence of AMI and stroke rose without a lag phase almost linearly from diagnosis reaching 6.7% for AMI and 7.7% for stroke. The total number of strokes was significantly higher than AMI (181 strokes vs. 109 AMI; p

Self-monitoring of blood glucose in type 2 diabetes and long-term outcome: an epidemiological cohort study.

AIMS/HYPOTHESIS: The aim of this study was to obtain epidemiological data on self-monitoring of blood glucose (SMBG) in type 2 diabetes and to investigate the relationship of SMBG with disease-related morbidity and mortality. METHODS: The German multicentre Retrolective Study 'Self-monitoring of Blood Glucose and Outcome in Patients with Type 2 Diabetes' (ROSSO) followed 3,268 patients from diagnosis of type 2 diabetes between 1995 and 1999 until the end of 2003. Endpoints were diabetes-related morbidity (non-fatal myocardial infarction, stroke, foot amputation, blindness or haemodialysis) and all-cause mortality. SMBG was defined as self-measurement of blood glucose for at least 1 year. RESULTS: During a mean follow-up period of 6.5 years, 1,479 patients (45.3%) began SMBG prior to an endpoint and an additional 64 patients started SMBG after a non-fatal endpoint. Interestingly, many patients used SMBG while being treated with diet or oral hypoglycaemic drugs (808 of 2,515, 32%). At baseline, the SMBG cohort had higher mean fasting blood glucose levels than the non-SMBG cohort (p<0.001), suggesting that insufficient metabolic control was one reason for initiating SMBG. This was associated with a higher rate of microvascular endpoints. However, the total rate of non-fatal events, micro- and macrovascular, was lower in the SMBG group than in the non-SMBG group (7.2 vs 10.4%, p=0.002). A similar difference was found for the rate of fatal events (2.7 vs 4.6%, p=0.004). Cox regression analysis identified SMBG as an independent predictor of morbidity and mortality, with adjusted hazard ratios of 0.68 (95% CI 0.51-0.91, p=0.009) and 0.49 (95% CI 0.31-0.78, p=0.003), respectively. A better outcome for both endpoints was also observed in the SMBG cohort when only those patients who were not receiving insulin were analysed. CONCLUSIONS/INTERPRETATION: SMBG was associated with decreased diabetes-related morbidity and all-cause mortality in type 2 diabetes, and this association remained in a subgroup of patients who were not receiving insulin therapy. SMBG may be associated with a healthier lifestyle and/or better disease management.