Cost-effectiveness of an innovative four-year post-discharge programme for elderly patients--prospective follow-up of hospital and nursing home use in project elderly and randomized controls.

The cost-effectiveness of a post-discharge programme on the use of hospital care and the continuity of care was assessed in an elderly cohort (n = 204) discharged from the city hospital. The participation rate was 97.6%, and the patients were aged 75 years or over and lived alone. The randomized controls (n = 204) received standard aftercare. During the follow-up the costs of university hospital care decreased by 52% in the intervention group and by 24% in the control group per patient year, compared with the costs in the year preceding the project. This happened despite the higher morbidity in the intervention group in terms of fractures and the use of university hospital care in the year preceding the project. There was also a tendency in the intervention group for the previous non-users of university hospital care to remain non-users during the follow-up. The costs of city hospital care increased by 16% and 5%, and of all hospital care by 1.3% and 0.2%, respectively. There were no differences in admissions to permanent care in the nursing homes. The intervention group did not make their first contact with the hospitals or permanent care in nursing homes earlier than the control group during the follow-up. The co-operation between hospital and domiciliary care and voluntary workers was well-suited to the innovative care of the elderly people.

Hyperinsulinaemia in hypertensive subjects: validity of a test for the detection of insulin resistance in clinical practice.

OBJECTIVES: To determine the prevalence of hyperinsulinaemia in non-diabetic hypertensive subjects and to investigate the validity of a simple test for the detection of insulin resistance/hyperinsulinaemia. The test consisted of five markers: (1) obesity (body-mass index, BMI > or =30 kg/m2); (2) central adiposity (waist-to-hip ratio, WHR > or =1.00 in men and > or =0.88 in women); (3) hypertriglyceridaemia (> or =1.70 mmol/l); (4) low high-density lipoprotein (HDL) cholesterol (<1.00 mmol/l in men and <1.20 mmol/l in women); and (5) impaired glucose tolerance according to the WHO criteria. The test was defined to be positive for subjects who had simultaneously at least two of the five markers. DESIGN AND SETTING: A community-based screening programme for hypertension carried out at Pieksämäki District Health Centre, and the Community Health Centre of the City of Tampere, Finland. SUBJECTS: The 161 hypertensives who were detected by screening all subjects aged 36, 41, 46 and 51 years (n = 1148) in Pieksämäki town, and a randomly selected normotensive control group of 177 men and women aged 40 and 45 years in the City of Tampere. MAIN OUTCOME MEASURES: Hyperinsulinaemia defined by using two different cut-off points of the fasting plasma insulin (> or =13.0 mU/l and > or =18.0 mU/l). RESULTS: Hyperinsulinaemia > or =13.0 mU/l was present in 45% of hypertensive men and in 25% of hypertensive women. The sex difference was statistically significant (P < 0.01). The corresponding rates of hyperinsulinaemia > or =18.0 mU/l were 18% and 16%. The sensitivity of the test for hyperinsulinaemia > or =13.0 mU/l was 77% and specificity 73% in men, and 100% and 70% in women. The corresponding figures for hyperinsulinaemia > or =18.0 mU/l were 94% and 60% in men, and 100% and 63% in women. CONCLUSION: Our results suggest that hyperinsulinaemia/insulin resistance in hypertensives becomes identifiable by using simple measurements of BMI, WHR, serum triglycerides and HDL cholesterol as well as the oral glucose tolerance test as means.

Obesity type and clustering of insulin resistance-associated cardiovascular risk factors in middle-aged men and women.

OBJECTIVE: To examine different clusterings of the insulin resistance-associated cardiovascular risk factors with respect to different types of obesity. DESIGN: A screening programme for obesity (body mass index; BMI> or =30 kg/m2) and abdominal adiposity (waist-to-hip ratio; WHR > or = 1.00 in men and > or = 0.88 in women). SETTINGS: Pieksämäki District Health Centre and the Community Health Centre of the City of Tampere, Finland. SUBJECTS: All volunteers were either aged 36, 41, 46 or 51 y (n=1148) and living in the town of Pieksämäki, with a control population of 162 subjects in the City of Tampere. MAIN OUTCOME MEASURES: Different clusterings of: 1) hypertension (a systolic blood pressure > or = 160 mmHg and/or a diastolic blood pressure > or = 95 mmHg or concurrent drug treatment for hypertension); 2) hypertriglyceridaemia > or = 1.70 mmol/l; 3) a low level of high-density-lipoprotein (HDL) cholesterol; < 1.00 mmol/l in men, < 1.20 mmol/l in women; 4) abnormal glucose metabolism (impaired glucose tolerance or non-insulin-dependent diabetes) and 5) hyperinsulinaemia with a fasting plasma insulin > or = 13.0 mU/l. RESULTS: The prevalence of a cluster consisting of dyslipidaemia (hypertriglyceridaemia and/or low HDL-cholesterol) and insulin resistance (abnormal glucose metabolism and/or hyperinsulinaemia) was found to be 4% in the control subjects, 18% in the abdominal adipose subjects (WHR > or = 1.00 in men and > or = 0.88 in women with a BMI < 30 kg/m2), 28% in the 'pure' obese subjects (BMI> or = 30 kg/m2 with WHR < 1.00 in men and < 0.88 in women), and 46% in the central obese subjects (subjects showing both 'pure' obesity and abdominal adiposity). The prevalence rates of the other clusterings of abnormalities varied similarly according to the type of obesity. CONCLUSION: Clusterings of insulin resistance-associated abnormalities were related to the type of obesity in both middle-aged men and middle-aged women.

Metabolic syndrome' in a middle-aged Finnish population.

OBJECTIVE: To investigate methods for the detection of different clusterings of the insulin-resistant abnormalities consistent with the concept of the 'metabolic syndrome' in clinical practice, and to research the occurrence of these clusters in a middle-aged Finnish population. METHODS: We studied a random sample of 207 middle-aged subjects in the city of Tampere, and all 1148 subjects of four middle-aged age groups in Pieksamaki town, in central Finland. Clusterings of the following eight markers of insulin resistance were recorded as the main outcome measures: 1) at least one first-degree relative with non-insulin-dependent diabetes (NIDDM); 2) obesity: body mass index (BMI) > or = 30 kg/m2; 3) central adiposity: waist-to-hip ratio (WHR) > or = 1.00 in men and > or = 0.88 in women; 4) hypertension: systolic blood pressure > or = 160 mmHg or diastolic blood pressure > or = 95 mmHg, or receiving drug treatment for hypertension; 5) hypertriglyceridaemia > or = 1.70 mmol/l; 6) low high-density lipoprotein (HDL) cholesterol: < 1.0 mmol/l in men and < 1.20 mmol/l in women; 7) abnormal glucose metabolism according to WHO criteria and 8) hyperinsulinaemia: fasting plasma insulin > or = 13.0 mU/l. RESULTS: The metabolic syndrome, defined as a clustering of dyslipidaemia (hypertriglyceridaemia, low HDL cholesterol, or both) and insulin resistance (abnormal glucose tolerance, hyperinsulinaemia, or both) was present in 17% of men and in 8% of women; this sex difference was statistically significant (P< .001). The syndrome was detectable with a sensitivity of 96% and a specificity of 55% by the combined four markers of insulin resistance (NIDDM in a close relative, obesity, central adiposity and hypertension). CONCLUSION: In clinical practice, the metabolic syndrome can be detected during normal clinical examination. The occurrence of the syndrome is already high by middle age.

Hyperinsulinemia and clustering of cardiovascular risk factors in middle-aged hypertensive Finnish men and women.

OBJECTIVE: To examine the relationship between hyperinsulinemia and clusters of cardiovascular risk factors in middle-aged hypertensive patients. DESIGN: A population-based study. SETTING: Pieksämäki District Health Center, and the Community health Center of the city of Tampere, in central Finland. SUBJECTS: Hypertensive men and women aged 36, 41, 46, and 51 years (n = 18) in the town of Pieksämäki, and a normotensive control population of 177 subjects aged 40 and 45 years in the city of Tampere. MAIN OUTCOME MEASURES: Clusters of obesity (body mass index > 30.0 kg/m2), abdominal adiposity (waist:hip ratio > 1.00 for men and > 0.88 for women), hypertriglyceridemia (> 1.70 mmol/l), a low level of high-density lipoprotein cholesterol (< 1.0 mmol/l in men and < 1.20 mmol/l in women) and abnormal glucose metabolism (impaired glucose tolerance or noninsulin-dependent diabetes as defined by World Health Organization criteria) according to statistical quartiles of the fasting plasma insulin concentration. RESULTS: Among the hypertensives, there was a 2.0- to 3.6-fold higher risk of having a clustering of the insulin-resistance associated cardiovascular risk factors compared with that of the normotensives. Among the hypertensive subjects in the highest quartile of fasting plasma insulin there was a six- to 12-fold increase in risk associated with having two or more insulin resistance-associated cardiovascular risk factors compared with the subjects in the lowest quartile. There was a positive correlation between a high number of ascertained risk factors and high levels of fasting plasma insulin. CONCLUSION: In clinical practice, knowledge of the close relationship between risk-factor cluster status and fasting plasma insulin levels offers a tool to evaluate the occurrence of hyperinsulinemia in middle-aged hypertensive men and women.