Factors Associated With Nonattendance in a Nationwide Screening Program for Diabetic Retinopathy: A Register-Based Cohort Study.

OBJECTIVE: The aim of the study was to identify factors associated with nonattendance in a Danish nationwide screening program for diabetic retinopathy among people with type 2 diabetes. RESEARCH DESIGN AND METHODS: A retrospective observational study linking individual-level register data was performed. First, we compared characteristics of 156,878 people with type 2 diabetes divided into attenders and never-attenders on the basis of their screening history over a 6-year period. Second, we assessed 230,173 screening intervals within the same 6-year period. Mixed-effects models were used to investigate the effect of sociodemographic and health-related factors on the likelihood of having a nonattender interval (i.e., failing to attend screening within the recommended interval). RESULTS: A total of 42,068 (26.8%) people were identified as never-attenders, having no registered eye screening over a 6-year period. Compared with attenders, never-attenders were more frequently divorced/widowed, lived in the Capital Region of Denmark, and had poorer health. A total of 62,381 (27.1%) screening intervals were identified as nonattender intervals. Both sociodemographic and health-related factors were significantly associated with the likelihood of having a nonattender interval. The largest odds ratios for nonattendance were seen for mental illness, nonwestern descent, divorce, comorbidity, and place of residence. CONCLUSIONS: Our findings suggest that never- and nonattendance of screening for diabetic retinopathy are more common among people who are divorced/widowed and of poorer health. Additionally, nonattendance is more frequent among people of nonwestern decent. These population subgroups may benefit from targeted interventions aimed at increasing participation in diabetic retinopathy screening.

National study of the prevalence of gestational diabetes mellitus among Danish women from 2004 to 2012.

AIMS: The prevalence of gestational diabetes mellitus (GDM) is increasing worldwide. We studied the prevalence of GDM from 2004 to 2012 in Danish women aged 15-49 years using registries with records of the diagnosis of GDM at delivery. METHODS: We conducted a national register-based study of 12,538 women with a diagnosis of GDM during a pregnancy leading to a live birth in the period 2004-2012. The diagnosis of GDM was taken from the National Patient Registry and combined with the total number of births at the national level from Statistics Denmark. Prevalence estimates were reported as crude and age-standardized using Danish and international data for women aged 15-49 years. RESULTS: A total of 566,083 live births was registered in Denmark from 2004 to 2012. The age-standardized prevalence of GDM increased from 1.7% (1095/63,465) of the total births in 2004 to 2.9% (1721/56,894) of the total births in 2012. During the period 2004-2012, the age-stratified prevalence increased from 1.1 to 1.8% among women aged 15-24 years, from 1.5 to 2.6% among women aged 25-34 years and from 2.9 to 4.7% among women aged 35-49 years. The prevalence was higher among immigrants and their descendants than in native Danish women (4.06 and 2.09% in 2007 vs. 4.51 and 2.72% in 2012, respectively). CONCLUSIONS: The prevalence of GDM in Denmark has increased across all age groups. Although the prevalence is low on a global scale, attention should be paid to this development by preventive health services.

The Danish Adult Diabetes Registry.

AIM OF THE DATABASE: The aim of the Danish Adult Diabetes Registry (DADR) is to provide data from both the primary health care sector (general practice [GP]) and the secondary sector (specialized outpatient clinics) to assess the quality of treatment given to patients with diabetes. The indicators represent process and outcome indicators selected from the literature. STUDY POPULATION: The total diabetes population in Denmark is estimated to be ~300,000 adult diabetes patients. Approximately 10% have type 1 diabetes, which is managed mainly in the secondary sector, and 90% have type 2 diabetes with the majority (80%) being treated in primary health care. In 2014, DADR included data from a total of 70,826 patients. MAIN VARIABLES: The following variables are assessed: date of analysis as well as the outcome for hemoglobin A1c, blood pressure, lipids, urinary albumin-creatinine ratio, smoking status, glucose-, blood pressure-, and lipid-lowering treatment (yes/no), insulin pump treatment (yes/no), and date of last eye and foot examination. DESCRIPTIVE DATA: In 2014, the annual report included data regarding over 38,000 patients from outpatient clinics, which is assumed to have included almost all patients in this setting, and >32,000 from GPs, reflecting improved but still limited coverage from this setting. The annual results are published in a compiled report of Danish Diabetes Care, which included DADR, data from the pediatric diabetes database, and the national ophthalmological diabetes database. The annual report is published, which included data on national, regional, and local level (individual outpatient clinics and corresponding GPs). This allows a comprehensive overview of diabetes care in Denmark. CONCLUSION: The database covers an increasing fraction of patients with diabetes in Denmark, and the structure for full coverage is in place. Annual reporting has helped to ensure focus on the quality of diabetes treatment in the primary and secondary health care. Furthermore, it is an important resource for Danish register-based diabetes research.

Relationship of HbA1c variability, absolute changes in HbA1c, and all-cause mortality in type 2 diabetes: a Danish population-based prospective observational study.

OBJECTIVE: We assessed the relationship of mortality with glycated hemoglobin (HbA1c) variability and with absolute change in HbA1c. DESIGN: A population-based prospective observational study with a median follow-up time of 6 years. METHODS: Based on a validated algorithm, 11 205 Danish individuals with type 2 diabetes during 2001-2006 were identified from public data files, with at least three HbA1c measurements: one index measure, one closing measure 22-26 months later, and one measurement in-between. Medium index HbA1c was 7.3%, median age was 63.9 years, and 48% were women. HbA1c variability was defined as the mean absolute residual around the line connecting index value with closing value. Cox proportional hazard models with restricted cubic splines were used, with all-cause mortality as the outcome. RESULTS: Variability between 0 and 0.5 HbA1c percentage point was not associated with mortality, but for index HbA1c ≤8% (64 mmol/mol), a variability above 0.5 was associated with increased mortality (HR of 1 HbA1c percentage point variability was 1.3 (95% CI 1.1 to 1.5) for index HbA1c 6.6-7.4%). For index HbA1c≤8%, mortality increased when HbA1c declined, but was stable when HbA1c rose. For index HbA1c>8%, change in HbA1c was associated with mortality, with the lowest mortality for greatest decline (HR=0.9 (95% CI 0.80 to 0.98) for a 2-percentage point decrease). CONCLUSIONS: For individuals with an index HbA1c below 8%, both high HbA1c variability and a decline in HbA1c were associated with increased mortality. For individuals with index HbA1c above 8%, change in HbA1c was associated with mortality, whereas variability was not.

Self-management support to people with type 2 diabetes - a comparative study of Kaiser Permanente and the Danish Healthcare System.

BACKGROUND: Self-management support is considered to be an essential part of diabetes care. However, the implementation of self-management support within healthcare settings has appeared to be challenging and there is increased interest in "real world" best practice examples to guide policy efforts. In order to explore how different approaches to diabetes care and differences in management structure influence the provision of SMS we selected two healthcare systems that have shown to be comparable in terms of budget, benefits and entitlements. We compared the extent of SMS provided and the self-management behaviors of people living with diabetes in Kaiser Permanente (KP) and the Danish Healthcare System (DHS). METHODS: Self-administered questionnaires were used to collect data from a random sample of 2,536 individuals with DM from KP and the DHS in 2006-2007 to compare the level of SMS provided in the two systems and identify disparities associated with educational attainment. The response rates were 75 % in the DHS and 56 % in KP. After adjusting for gender, age, educational level, and HbA1c level, multiple linear regression analyses determined the level of SMS provided and identified disparities associated with educational attainment. RESULTS: Receipt of SMS varied substantially between the two systems. More people with diabetes in KP reported receiving all types of SMS and use of SMS tools compared to the DHS (p < .0001). Less than half of all respondents reported taking diabetes medication as prescribed and following national guidelines for exercise. CONCLUSIONS: Despite better SMS support in KP compared to the DHS, self-management remains an under-supported area of care for people receiving care for diabetes in the two health systems. Our study thereby suggests opportunity for improvements especially within the Danish healthcare system and systems adopting similar SMS support strategies.

Something is amiss in Denmark: a comparison of preventable hospitalisations and readmissions for chronic medical conditions in the Danish Healthcare system and Kaiser Permanente.

BACKGROUND: As many other European healthcare systems the Danish healthcare system (DHS) has targeted chronic condition care in its reform efforts. Benchmarking is a valuable tool to identify areas for improvement. Prior work indicates that chronic care coordination is poor in the DHS, especially in comparison with care in Kaiser Permanente (KP), an integrated delivery system based in the United States. We investigated population rates of hospitalisation and readmission rates for ambulatory care sensitive, chronic medical conditions in the two systems. METHODS: Using a historical cohort study design, age and gender adjusted population rates of hospitalisations for angina, heart failure, chronic obstructive pulmonary disease, and hypertension, plus rates of 30-day readmission and mortality were investigated for all individuals aged 65+ in the DHS and KP. RESULTS: DHS had substantially higher rates of hospitalisations, readmissions, and mean lengths of stay per hospitalisation, than KP had. For example, the adjusted angina hospitalisation rates in 2007 for the DHS and KP respectively were 1.01/100 persons (95%CI: 0.98-1.03) vs. 0.11/100 persons (95%CI: 0.10-0.13/100 persons); 21.6% vs. 9.9% readmission within 30 days (OR = 2.53; 95% CI: 1.84-3.47); and mean length of stay was 2.52 vs. 1.80 hospital days. Mortality up through 30 days post-discharge was not consistently different in the two systems. CONCLUSIONS: There are substantial differences between the DHS and KP in the rates of preventable hospitalisations and subsequent readmissions associated with chronic conditions, which suggest much opportunity for improvement within the Danish healthcare system. Reductions in hospitalisations also could improve patient welfare and free considerable resources for use towards preventing disease exacerbations. These conclusions may also apply for similar public systems such as the US Medicare system, the NHS and other systems striving to improve the integration of care for persons with chronic conditions.

The prevalence of retinopathy in an unselected population of type 2 diabetes patients from Arhus County, Denmark.

PURPOSE: To determine the prevalence of diabetic retinopathy and the causes of visual impairment in an unselected population of type 2 diabetes patients, and to describe the risk factors for developing diabetic retinopathy in this population. METHODS: A total of 10 851 type 2 diabetes patients were identified in the county of Arhus. A representative sample of 378 patients underwent a routine ocular examination, including fundus photography. Blood pressure and serum haemoglobin A1c, total cholesterol, high density lipoprotein cholesterol, triglyceride and apolipoprotein a were measured. RESULTS: The prevalence of diabetic retinopathy in the type 2 diabetes population was 31.5%. In all, 2.9% had proliferative diabetic retinopathy and 5.3% had clinically significant macular oedema. Of the latter, 8/20 (40%) were newly identified and had not yet been laser-treated. There was a positive correlation between severity of retinopathy and duration of diabetes, HbA(1c), systolic blood pressure and treatment with insulin. None of the patients had social blindness (visual acuity < 0.1), but 15/378 (4.0%) had developed visual impairment (VA < 0.3). CONCLUSION: The prevalence of diabetic retinopathy and visual impairment in this unselected type 2 diabetes population was lower than anticipated from the existing literature, and causes other than diabetic retinopathy contributed significantly to the occurrence of visual loss. A substantial number of the patients with vision-threatening diabetic maculopathy had not been referred for timely photocoagulation treatment.