ResearchPad - health-services-research Default RSS Feed en-us © 2020 Newgen KnowledgeWorks <![CDATA[Glycated hemoglobin (HbA1c) as diagnostic criteria for diabetes: the optimal cut-off points values for the Pakistani population; a study from second National Diabetes Survey of Pakistan (NDSP) 2016–2017]]> Glycated hemoglobin (HbA1c) cut-off values as diagnostic tool in diabetes and prediabetes with its concordance to oral glucose tolerance test (OGTT) in Pakistani population.MethodologyData for this substudy was obtained from second National Diabetes Survey of Pakistan (NDSP) 2016–2017. With this survey, 10 834 individuals were recruited and after excluding known subjects with diabetes, 6836 participants fulfilled inclusion criteria for this study. Demographic, anthropometric and biochemical parameters were obtained. OGTT was used as standard diagnostic tool to screen population and HbA1c for optimal cut-off values. Participants were categorized into normal glucose tolerance (NGT), newly diagnosed diabetes (NDD) and prediabetes.ResultsOut of 6836 participants, 4690 (68.6%) had NGT, 1333 (19.5%) had prediabetes and 813 (11.9%) had NDD by OGTT criteria with median (IQR) age of 40 (31–50) years. Optimal HbA1c cut-off point for identification of diabetes and prediabetes was observed as 5.7% ((AUC (95% CI)=0.776 (0.757 to 0.795), p<0.0001)) and 5.1% ((AUC (95% CI)=0.607 (0.590 to 0.624), p<0.0001)), respectively. However, out of 68.6% NGT subjects identified through OGTT, 24.1% and 9.3% participants were found to have prediabetes and NDD, respectively by using HbA1c criteria. By using both OGTT and HbA1c criteria, only 7.9% and 7.3% were observed as prediabetes and diabetes, respectively.ConclusionFindings from second NDSP demonstrated disagreement between findings of OGTT and HbA1c as diagnostic tool for Pakistani population. As compared with international guidelines, HbA1c threshold for prediabetes and NDD were lower in this part of world. HbA1c as diagnostic tool might require ethnic or regional-based modification in cut-off points, validated by relevant community-based epidemiological surveys. ]]> <![CDATA[Low-value injury care in the adult orthopaedic trauma population: a protocol for a rapid review]]> Orthopaedic injuries affect almost 90% of trauma patients. A previous scoping review and expert consultation survey identified 15 potential low-value intra-hospital practices in the adult orthopaedic trauma population. Limiting the frequency of such practices could reduce adverse events, improve clinical outcomes and free up resources. The aim of this study is to synthesise the evidence on intra-hospital practices for orthopaedic injuries, previously identified as potentially of low value.Methods and analysisWe will search Medline, Excerpta Medica Database (EMBASE), the Cochrane Central Register of Controlled Trials and Epistemonikos to identify systematic reviews, randomised controlled trials (RCTs), quasi-RCTs, cohort studies and case–control studies that evaluate selected practices according to a priori PICOS statements (Population–Intervention–Comparator–Outcome–Study design). We will evaluate the methodological quality for systematic reviews using the Measurement Tool to Assess Systematic Reviews version 2 (AMSTAR-2). Risk of bias in original studies will be evaluated with the Cochrane revised tool for RCTs (RoB2) and with the risk of bias in non-randomised studies of interventions (ROBINS-I) tool. If for a given practice, more than two original studies on our primary outcome are identified, we will conduct meta-analysis using a random effects model and assess heterogeneity using the I2 index. We will assess credibility of evidence (I–IV) based on statistical significance, sample size, heterogeneity and bias as per published criteria.Ethics and disseminationEthics approval is not required as original data will not be collected. Knowledge users from three level I trauma centres are involved in the design and conduct of the study in accordance with an integrated knowledge translation approach. Findings related to the rapid review will be available in May 2020. They will be presented to key stakeholders to inform discussions and raise awareness on low-value injury care. In addition, results will be disseminated in a peer-reviewed journal, at national and international scientific meetings and to healthcare associations. ]]> <![CDATA[Use of healthcare services and assistive devices among centenarians: results of the cross-sectional, international 5-COOP study]]> To measure the use of healthcare services and assistive devices by centenarians in five countries.DesignCross-sectional study using a survey questionnaire.SettingCommunity-dwelling and institutionalised centenarians living in Japan, France, Switzerland, Sweden and Denmark.Participants1253 participants aged 100 or in their 100th year of life, of whom 1004 (80.1%) were female and 596 (47.6%) lived in institutions.Main outcome measuresRecent use of medical visits, nursing care at home, home-delivered meals, acute care hospital stays overnight, professional assessments such as sight tests, mobility aids and other assistive devices. A set of national healthcare system indicators was collected to help interpret differences between countries.ResultsThere was considerable variability in the healthcare services and assistive devices used by centenarians depending on their country and whether they were community-dwelling or institutionalised. In contrast to the relatively homogeneous rates of hospitalisation in the past year (around 20%), community-dwelling centenarians reported widely ranging rates of medical visits in the past 3 months (at least one visit, from 32.2% in Japan to 86.6% in France). The proportion of community-dwellers using a mobility device to get around indoors (either a walking aid or a wheelchair) ranged from 48.3% in Japan to 79.2% in Sweden. Participants living in institutions and reporting the use of a mobility device ranged from 78.6% in Japan to 98.2% in Denmark.ConclusionsOur findings suggest major differences in care received by centenarians across countries. Some may result from the characteristics of national healthcare systems, especially types of healthcare insurance coverage and the amounts of specific resources available. However, unexplored factors also seem to be at stake and may be partly related to personal health and cultural differences. ]]> <![CDATA[FINDRISC in Latin America: a systematic review of diagnosis and prognosis models]]> This review aimed to assess whether the FINDRISC, a risk score for type 2 diabetes mellitus (T2DM), has been externally validated in Latin America and the Caribbean (LAC). We conducted a systematic review following the CHARMS (CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies) framework. Reports were included if they validated or re-estimated the FINDRISC in population-based samples, health facilities or administrative data. Reports were excluded if they only studied patients or at-risk individuals. The search was conducted in Medline, Embase, Global Health, Scopus and LILACS. Risk of bias was assessed with the PROBAST (Prediction model Risk of Bias ASsessment Tool) tool. From 1582 titles and abstracts, 4 (n=7502) reports were included for qualitative summary. All reports were from South America; there were slightly more women, and the mean age ranged from 29.5 to 49.7 years. Undiagnosed T2DM prevalence ranged from 2.6% to 5.1%. None of the studies conducted an independent external validation of the FINDRISC; conversely, they used the same (or very similar) predictors to fit a new model. None of the studies reported calibration metrics. The area under the receiver operating curve was consistently above 65.0%. All studies had high risk of bias. There has not been any external validation of the FINDRISC model in LAC. Selected reports re-estimated the FINDRISC, although they have several methodological limitations. There is a need for big data to develop—or improve—T2DM diagnostic and prognostic models in LAC. This could benefit T2DM screening and early diagnosis.

<![CDATA[Variability in estimated glomerular filtration rate and the incidence of type 2 diabetes: a nationwide population-based study]]> Variability in estimated glomerular filtration rate (eGFR) has been associated with adverse outcomes in patients with diabetes or chronic kidney disease (CKD). However, no previous study has explored the relationship between eGFR variability and type 2 diabetes incidence.Research design and methodsIn this nationwide, longitudinal, cohort study, we investigated the association between eGFR variability and type 2 diabetes risk using the Korean National Health Insurance Service datasets from 2002 to 2017. eGFR variability was calculated using the variability independent of the mean (eGFR-VIM), coefficient of variation (eGFR-CV), standard deviation (eGFR-SD) and average real variability (eGFR-ARV).ResultsWithin 7 673 905.58 person-years of follow-up (mean follow-up: 3.19 years; n=2 402 668), 11 981 cases of incident type 2 diabetes were reported. The HRs and 95% CIs for incident type 2 diabetes increased according to advance in quartiles of eGFR-VIM (HR (95% CI): Q2, 1.068 (1.009 to 1.130); Q3, 1.077 (1.018 to 1.138); Q4, 1.203 (1.139 to 1.270)) even after adjusting for confounding factors including mean eGFR and mean fasting plasma glucose levels. The subgroup analyses according to risk factors as well as analyses using eGFR-CV, eGFR-SD and eGFR-ARV showed consistent results. The association between increased eGFR variability and type 2 diabetes risk was more prominent in men, individuals with dyslipidemia and those with CKD as shown in the subgroup analysis (p for interaction <0.001).ConclusionsIncreased eGFR variability may be an independent predictor of type 2 diabetes and might be useful for risk stratification of individuals without diabetes. ]]> <![CDATA[Association of fasting plasma glucose variability with gestational diabetes mellitus: a nationwide population-based cohort study]]> Long-term glycemic variability has recently been recognized as another risk factor for future adverse health outcomes. We aimed to evaluate the risk of gestational diabetes mellitus (GDM) according to the prepregnancy long-term fasting plasma glucose (FPG) variability.Research design and methodsA total of 164 053 women who delivered their first baby between January 1, 2012 and December 31, 2015, were selected from the Korean National Health Insurance data. All women underwent at least three national health screening examinations, and the last examination should be conducted within 2 years before their first delivery. GDM was defined as the presence of more than four times of claim of GDM (International Classification of Disease, 10th Revision (ICD-10) O24.4 and O24.9) or prescription of insulin under the ICD-code of GDM. FPG variability was assessed by variability independent of the mean (FPG-VIM), coefficient of variation, SD, and average successive variability.ResultsAmong the 164 053 women, GDM developed in 6627 (4.04%). Those in the higher quartiles of FPG-VIM showed a stepwise increased risk of GDM. In fully adjusted model, the ORs for GDM was 1.22 (95% CI 1.14 to 1.31) in women with the highest FPG-VIM quartile compared with those in the lowest quartile. The risk for GDM requiring insulin therapy was 48% increase in women in the highest quartile of FPG-VIM compared with those in the lowest quartile, while that for GDM not requiring insulin therapy was 19% increase. The association between high FPG variability and the risk of GDM was intensified in the obese and aged more than 35 years women.ConclusionsIncreased FPG variability in the prepregnancy state is associated with the risk of GDM independent of confounding factors. Therefore, prepregnancy FPG variability might be a surrogate marker of the risk of GDM. ]]> <![CDATA[Shared genetic architecture and casual relationship between leptin levels and type 2 diabetes: large-scale cross-trait meta-analysis and Mendelian randomization analysis]]> We aimed to estimate genetic correlation, identify shared loci and test causality between leptin levels and type 2 diabetes (T2D).Research design and methodsOur study consists of three parts. First, we calculated the genetic correlation of leptin levels and T2D or glycemic traits by using linkage disequilibrium score regression analysis. Second, we conducted a large-scale genome-wide cross-trait meta-analysis using cross-phenotype association to identify shared loci between trait pairs that showed significant genetic correlations in the first part. In the end, we carried out a bidirectional MR analysis to find out whether there is a causal relationship between leptin levels and T2D or glycemic traits.ResultsWe found positive genetic correlations between leptin levels and T2D (Rg=0.3165, p=0.0227), fasting insulin (FI) (Rg=0.517, p=0.0076), homeostasis model assessment-insulin resistance (HOMA-IR) (Rg=0.4785, p=0.0196), as well as surrogate estimates of β-cell function (HOMA-β) (Rg=0.4456, p=0.0214). We identified 12 shared loci between leptin levels and T2D, 1 locus between leptin levels and FI, 1 locus between leptin levels and HOMA-IR, and 1 locus between leptin levels and HOMA-β. We newly identified eight loci that did not achieve genome-wide significance in trait-specific genome-wide association studies. These shared genes were enriched in pancreas, thyroid gland, skeletal muscle, placenta, liver and cerebral cortex. In addition, we found that 1-SD increase in HOMA-IR was causally associated with a 0.329 ng/mL increase in leptin levels (β=0.329, p=0.001).ConclusionsOur results have shown the shared genetic architecture between leptin levels and T2D and found causality of HOMA-IR on leptin levels, shedding light on the molecular mechanisms underlying the association between leptin levels and T2D. ]]> <![CDATA[Association between pre-diabetes and microvascular and macrovascular disease in newly diagnosed type 2 diabetes]]> The associated risk of vascular disease following diagnosis of type 2 diabetes in people previously identified as having pre-diabetes in real-world settings is unknown. We examined the presence of microvascular and macrovascular disease in individuals with newly diagnosed type 2 diabetes by glycemic status within 3 years before diagnosis.Research design and methodsWe identified 159 736 individuals with newly diagnosed type 2 diabetes from the UK Clinical Practice Research Datalink database in England between 2004 and 2017. We used logistic regression models to compare presence of microvascular (retinopathy and nephropathy) and macrovascular (acute coronary syndrome, cerebrovascular and peripheral arterial disease) disease at the time of type 2 diabetes diagnosis by prior glycemic status.ResultsHalf of the study population (49.9%) had at least one vascular disease, over one-third (37.4%) had microvascular disease, and almost a quarter (23.5%) had a diagnosed macrovascular disease at the time of type 2 diabetes diagnosis.Compared with individuals with glycemic values within the normal range, those detected with pre-diabetes before the diagnosis had 76% and 14% increased odds of retinopathy and nephropathy (retinopathy: adjusted OR (AOR) 1.76, 95% CI 1.69 to 1.85; nephropathy: AOR 1.14, 95% CI 1.10 to 1.19), and 7% higher odds of the diagnosis of acute coronary syndrome (OR 1.07, 95% CI 1.03 to 1.12) in fully adjusted models at time of diabetes diagnosis.ConclusionsMicrovascular and macrovascular diseases are detected in 37%–24% of people with newly diagnosed type 2 diabetes. Pre-diabetes before diagnosis of type 2 diabetes is associated with increased odds of microvascular disease and acute coronary syndrome. Detection of pre-diabetes might represent an opportunity for reducing the burden of microvascular and macrovascular disease through heightened attention to screening for vascular complications. ]]> <![CDATA[Development and validation of an early pregnancy risk score for the prediction of gestational diabetes mellitus in Chinese pregnant women]]> To develop and validate a set of risk scores for the prediction of gestational diabetes mellitus (GDM) before the 15th gestational week using an established population-based prospective cohort.MethodsFrom October 2010 to August 2012, 19 331 eligible pregnant women were registered in the three-tiered antenatal care network in Tianjin, China, to receive their antenatal care and a two-step GDM screening. The whole dataset was randomly divided into a training dataset (for development of the risk score) and a test dataset (for validation of performance of the risk score). Logistic regression was performed to obtain coefficients of selected predictors for GDM in the training dataset. Calibration was estimated using Hosmer-Lemeshow test, while discrimination was checked using area under the receiver operating characteristic curve (AUC) in the test dataset.ResultsIn the training dataset (total=12 887, GDM=979 or 7.6%), two risk scores were developed, one only including predictors collected at the first antenatal care visit for early prediction of GDM, like maternal age, body mass index, height, family history of diabetes, systolic blood pressure, and alanine aminotransferase; and the other also including predictors collected during pregnancy, that is, at the time of GDM screening, like physical activity, sitting time at home, passive smoking, and weight gain, for maximum performance. In the test dataset (total=6444, GDM=506 or 7.9%), the calibrations of both risk scores were acceptable (both p for Hosmer-Lemeshow test >0.25). The AUCs of the first and second risk scores were 0.710 (95% CI: 0.680 to 0.741) and 0.712 (95% CI: 0.682 to 0.743), respectively (p for difference: 0.9273).ConclusionBoth developed risk scores had adequate performance for the prediction of GDM in Chinese pregnant women in Tianjin, China. Further validations are needed to evaluate their performance in other populations and using different methods to identify GDM cases. ]]> <![CDATA[Conditions, pathogenesis, and progression of diabetic kidney disease and early decliner in Japan]]> Glomerular filtration rate (GFR) decreases without or prior to the development of albuminuria in many patients with diabetes. Therefore, albuminuria and/or a low GFR in patients with diabetes is referred to as diabetic kidney disease (DKD). A certain proportion of patients with diabetes show a rapid progressive decline in renal function in a unidirectional manner and are termed early decliners. This study aimed to elucidate the prevalence of DKD and early decliners and clarify their risk factors.Research design and methodsThis combination cross-sectional and cohort study included 2385 patients with diabetes from 15 hospitals. We defined DKD as a urinary albumin to creatinine ratio (ACR) ≥30 mg/gCr and/or estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m². We classified patients into four groups based on the presence or absence of albuminuria and a decrease in eGFR to reveal the risk factors for DKD. We also performed a trajectory analysis and specified the prevalence and risk factors of early decliners with sequential eGFR data of 1955 patients in five facilities.ResultsOf our cohort, 52% had DKD. Above all, 12% with a low eGFR but no albuminuria had no traditional risk factors, such as elevated glycated hemoglobin, elevated blood pressure, or diabetic retinopathy in contrast to patients with albuminuria but normal eGFR. Additionally, 14% of our patients were early decliners. Older age, higher basal eGFR, higher ACR, and higher systolic blood pressure were significantly associated with early decliners.ConclusionsThe prevalence of DKD in this cohort was larger than ever reported. By testing eGFR yearly and identifying risk factors in the early phase of diabetes, we can identify patients at high risk of developing end-stage renal disease. ]]> <![CDATA[High prevalence of impaired awareness of hypoglycemia and severe hypoglycemia among people with insulin-treated type 2 diabetes: The Dutch Diabetes Pearl Cohort]]> People with type 2 diabetes on insulin are at risk for hypoglycemia. Recurrent hypoglycemia can cause impaired awareness of hypoglycemia (IAH), and increase the risk for severe hypoglycemia. The aim of this study was to assess the prevalence and determinants of self-reported IAH and severe hypoglycemia in a Dutch nationwide cohort of people with insulin-treated type 2 diabetes.Research design and methodsObservational study of The Dutch Diabetes Pearl, a cohort of people with type 2 diabetes treated in primary, secondary and tertiary diabetes care centers. The presence of IAH and the occurrence of severe hypoglycemia in the past year, defined as an event requiring external help to recover, were assessed using the validated Dutch version of the Clarke questionnaire. In addition, clinical variables were collected including age, diabetes duration, hemoglobin A1c, ethnicity and education.Results2350 people with type 2 diabetes on insulin were included: 59.1% men, mean age 61.1±10.4 years, mean diabetes duration 14.8±9.2 years and 79.5% on basal-bolus therapy. A total of 229 patients (9.7%) were classified as having IAH and 742 patients (31.6%) reported severe hypoglycemia. Increased odds for IAH were found with complex insulin regimens and lower odds with having a partner and body mass index ≥30 kg/m2. Severe hypoglycemia was associated with complex insulin regimens, non-Caucasian ethnicity and use of psychoactive drugs, and inversely with metformin use.ConclusionsIn this nationwide cohort, almost one out of ten people with type 2 diabetes on insulin had IAH and >30% had a history of severe hypoglycemia in the past year. ]]> <![CDATA[Association between the triglyceride to high-density lipoprotein cholesterol ratio and the risk of type 2 diabetes mellitus among Chinese elderly: the Beijing Longitudinal Study of Aging]]> Time-dependent covariates are generally available as longitudinal data were collected periodically in the cohort study. To examine whether time-dependent triglyceride to high-density lipoprotein cholesterol (TG/HDL-C) ratio could predict the future risk of type 2 diabetes mellitus (T2DM) and assess its potential impact on the risk of T2DM incidence.Research design and methodsThis study enrolled 1460 participants without T2DM aged 55 or above in 1992 in the Beijing Longitudinal Study of Aging during 25 years. The questionnaire data were collected in nine surveys from 1992 to 2017. Physical examination and blood laboratory tests including TG and HDL-C concentrations were measured in five surveys. Incident T2DM cases were confirmed via a self-reported history of T2DM or the fasting plasma glucose level.Results119 new cases of T2DM were identified. In the Cox regression analysis with time-dependent TG/HDL-C ratios and covariates, the adjusted hazard ratios (95% confidence interval) of T2DM incidence were 1.90 (1.12 to 3.23), 2.75 (1.58 to 4.80) and 2.84 (1.69 to 4.77), respectively, for those with TG/HDL-C ratios (both TG and HDL-C were expressed in millimole per liter) in the ranges of 0.87–1.30, 1.31–1.74 and ≥1.75, compared with individuals with TG/HDL-C ratios <0.87. The similar results of subdistribution hazard ratios were obtained by performing the Fine-Gray model with time-dependent TG/HDL-C ratios. This positive association and the statistically significant trend with increased risk of T2DM incidence in the three categories of elevated TG/HDL-C ratio was confirmed by multiple sensitivity analyses. Furthermore, the T2DM discriminatory power of TG/HDL-C ratio combining with other risk factors was moderately high.ConclusionsWe found that time-dependent TG/HDL-C ratios were positively associated with the risk of T2DM risk. The elevated TG/HDL-C ratios increased the future risk of T2DM incidence. Lowering the TG/HDL-C ratio could assist in the prevention of diabetes for older adults. ]]> <![CDATA[Effectiveness of a clinic-based randomized controlled intervention for type 2 diabetes management: an innovative model of intensified diabetes management in Mainland China (C-IDM study)]]> Highly efficient diabetes management programs are needed for tackling diabetes in China. This study aimed to assess the effectiveness of a clinic-based intensified diabetes management model (C-IDM) in Mainland China.Research design and methodsA 2-year clinic-based randomized controlled trial was conducted among patients with type 2 diabetes in Nanjing, China. The C-IDM intervention components comprised four domains (disease targeting management, express referral channel, expert visit, patients’ self-management) and an integrated running system (disease control centers, general hospitals and local clinics). Control group participants received their usual care, while intervention participants received both the C-IDM package and the usual services. The primary outcome variable was change of hemoglobin A1c (HbA1c). Mixed-effects models were used to compute effect estimates and 95% CI with consideration of both individual and cluster-level confounders.ResultsOverall, 1095 of 1143 participants were assessed at study completion. The mean change in HbA1c was significantly greater in the intervention group than in the control group (mean difference (MD)=−0.57, 95% CI −0.79 to –0.36). Similar results were observed for change in body mass index (MD=−0.29, 95% CI −0.49 to –0.10). Participants in the intervention group were more likely to achieve normal HbA1c and body weight compared with their counterparts in control group after adjusting for potentially confounding variables (adjusted OR=1.94, 95% CI 1.35 to 2.81 and 1.79, 95% CI 1.13 to 2.85, respectively).ConclusionsThe C-IDM model is feasible and effective in large-scale management of patients with type 2 diabetes in China. It has public health implications for tackling the burden of diabetes in China.Trial registration numberChiCTR-IOR-15006019. ]]> <![CDATA[Evidence-based quality indicators for primary healthcare in association with the risk of hospitalisation: a population-based cohort study in Switzerland]]> The quality of ambulatory care in Switzerland is widely unknown. Therefore, this study aimed to evaluate the recently proposed quality indicators (QIs) based on a nationwide healthcare claims database and determine their association with the risk of subsequent hospitalisation at patient-level.DesignRetrospective cohort study.SettingInpatient and outpatient claims data of a large health insurance in Switzerland covering all regions and population strata.Participants520 693 patients continuously insured during 2015 and 2016.MeasuresA total of 24 QIs were obtained by adapting the existing instruments to the Swiss national context and measuring at patient-level. The association between each QI and hospitalisation in the subsequent year was assessed using multiple logistic regression models.ResultsThe proportion of patients with good adherence to QIs was high for the secondary prevention of diabetes and myocardial infarction (glycated haemoglobin (HbA1c) control, 89%; aspirin use, 94%) but relatively low for polypharmacy (53%) or using potentially inappropriate medications (PIMs) in the elderly (PIM, 33%). Diabetes-related indicators such as the HbA1c control were significantly associated with a lower risk of hospitalisation (OR, 0.87; 95% CI, 0.80 to 0.95), whereas the occurrence of polypharmacy and PIM increased the risk of hospitalisation in the following year (OR, 1.57/1.08; 95% CI, 1.51 to 1.64/1.05 to 1.12).ConclusionsThis is the first study to evaluate the recently presented QIs in Switzerland using nationwide real-life data. Our study suggests that the quality of healthcare, as measured by these QIs, varied. The majority of QIs, in particular QIs reflecting chronic care and medication use, are considered beneficial markers of healthcare quality as they were associated with reduced risk of hospitalisation in the subsequent year. Results from this large practical test on real-life data show the feasibility of these QIs and are beneficial in selecting the appropriate QIs for healthcare implementation in general practice. ]]> <![CDATA[Factors influencing the early initiation of breast feeding in public primary healthcare facilities in Northeast Nigeria: a mixed-method study]]> The early initiation of breast feeding is a high-impact intervention that gives newborns a better chance of survival. We assess the barriers and facilitators influencing the practice of early breast feeding of newborns in public primary healthcare facilities (PHCs) in Northeast Nigeria, to influence the planning of programmes targeted at improving newborn care in the region.MethodWe used an explanatory mixed-method approach. We conducted case observation of childbirths and newborn care for the quantitative arm, and interviewed mothers and birth attendants 1 hour after childbirth for the qualitative arm. The analysis for the quantitative arm was done with SPSS V.23. For the qualitative arm, we transcribed the audio files, coded the texts and categorised them using thematic analysis.ResultWe observed 393 and 27 mothers for the quantitative and qualitative arms of the study, respectively. The quantitative arm shows that 39% of mothers did not breastfeed their newborns within 1 hour of birth. The qualitative arm shows that 37% of mothers did not breastfeed within 1 hour of birth. Themes that describe the barriers to early breast feeding in public PHCs are: birth attendants’ unwillingness or inability to accommodate mothers’ safe traditional practices, ineffective rooming-in practices, staff shortages, lack of privacy in the lying-in ward and poor implementation of visiting-hour policy in public PHCs. The pregnant women denied safe traditional birth practices like chanting, praying or reading religious books during delivery are five times more likely not to breastfeed newborns within the first hour of birth (relative risk=4.5, 95% CI 1.2–17.1) compared with pregnant women allowed these practices.ConclusionStakeholders must increase their focus on improving breastfeeding practices in public PHCs. Instituting policies that protect mothers’ privacy and finding innovative ways to accommodate and promote safe traditional practices in the intrapartum and postpartum period in PHCs will improve the early breast feeding of newborns in these PHCs. ]]> <![CDATA[Results from NEXT-D: the association of a pre-diabetes-specific health plan and rates of incident diabetes among a national sample of working-age adults]]> Pre-diabetes affects one-third of adults in the USA and a subset will progress to type 2 diabetes. Our objective was to determine whether a disease-specific health plan, known as the Diabetes Health Plan (DHP), designed to improve care for persons with pre-diabetes and diabetes also led to lower rates of incident diabetes among adults with pre-diabetes.MethodsWe examined eligibility and claims data from a large payer who offered the DHP to a national sample of employers. We included adult employees and dependents who were continuously covered by the DHP over a 4-year study window. The primary outcome was incident diabetes. We conducted propensity score matching at the employer level to find comparable control employer groups offering standard plans. Using an adjusted logistic regression model at the individual level, we tested the association between DHP employer group status and incident diabetes diagnosis during the 3 years of postbaseline follow-up.FindingsOur analysis included data from 11 965 continuously enrolled adults with pre-diabetes (n=1538 from nine employers offering DHP; n=10 427 from 105 control employers offering standard plans). DHP employees and covered dependents with pre-diabetes had an 8% lower absolute predicted probability of incident diabetes compared with individuals from employer groups offering standard benefit plans (29% predicted probability of incident diabetes for DHP vs 37% for controls, p<0.001).ConclusionsA pre-diabetes-specific health benefit design was associated with lower rates of incident diabetes and represents an area of needed future study. ]]> <![CDATA[Prevalence of diagnosed diabetes in American Indian and Alaska Native adults, 2006–2017]]> The objective of this study was to examine recent trends in diagnosed diabetes prevalence for American Indian and Alaska Native (AI/AN) adults aged 18 years and older in the Indian Health Service (IHS) active clinical population.Research design and methodsData were extracted from the IHS National Data Warehouse for AI/AN adults for each fiscal year from 2006 (n=729 470) through 2017 (n=1 034 814). The prevalence of diagnosed diabetes for each year and the annual percentage change were estimated for adults overall, as well as by sex, age group, and geographic region.ResultsAfter increasing significantly from 2006 to 2013, diabetes prevalence for AI/AN adults in the IHS active clinical population decreased significantly from 2013 to 2017. Prevalence was 14.4% (95% CI 13.9% to 15.0%) in 2006; 15.4% (95% CI 14.8% to 16.0%) in 2013; and 14.6% (95% CI 14.1% to 15.2%) in 2017. Trends for men and women were similar to the overall population, as were those for all age groups. For all geographic regions, prevalence either decreased significantly or leveled off in recent years.ConclusionsDiabetes prevalence in AI/AN adults in the IHS active clinical population has decreased significantly since 2013. While these results cannot be generalized to all AI/AN adults in the USA, this study documents the first known decrease in diabetes prevalence for AI/AN people. ]]> <![CDATA[Effective diabetes complication management is a step toward a carbon-efficient planet: an economic modeling study]]> The management of diabetes-related complications accounts for a large share of total carbon dioxide equivalent (CO2e) emissions. We assessed whether improving diabetes control in people with type 2 diabetes reduces CO2e emissions, compared with those with unchanging glycemic control.MethodsUsing the IQVIA Core Diabetes Model, we estimated the impact of maintaining glycated hemoglobin (HbA1c) at 7% (53 mmol/mol) or reducing it by 1% (11 mmol/mol) on total CO2e/patient and CO2e/life-year (LY). Two different cohorts were investigated: those on first-line medical therapy (cohort 1) and those on third-line therapy (cohort 2). CO2e was estimated using cost inputs converted to carbon inputs using the UK National Health Service’s carbon intensity factor. The model was run over a 50-year time horizon, discounting total costs and quality adjusted life years (QALYs) up to 5% and CO2e at 0%.ResultsMaintaining HbA1c at 7% (53 mmol/mol) reduced total CO2e/patient by 18% (1546 kgCO2e/patient) vs 13% (937 kgCO2e/patient) in cohorts 1 and 2, respectively, and led to a reduction in CO2e/LY gain of 15%–20%. Reducing HbA1c by 1% (11 mmol/mol) caused a 12% (cohort 1) and 9% (cohort 2) reduction in CO2e/patient with a CO2e/LY gain reduction of 11%–14%.ConclusionsWhen comparing people with untreated diabetes, maintaining glycemic control at 7% (53 mmol/mol) on a single agent or improving HbA1c by 1% (11 mmol/mol) by the addition of more glucose-lowering treatment was associated with a reduction in carbon emissions. ]]> <![CDATA[Tissue inhibitor matrix metalloproteinase 1 and risk of type 2 diabetes in a Chinese population]]> The non-invasive enhanced liver fibrosis (ELF) score—comprising tissue inhibitor of matrix metalloproteinases-1 (TIMP1), hyaluronic acid (HA) and amino-terminal propeptide of type III procollagen (PIIINP)—has been shown to accurately predict fibrosis stages among patients with non-alcoholic fatty liver disease (NAFLD). However, no study has examined whether the ELF score or its components would also be predictive of type 2 diabetes, which commonly coexists and shares the same pathogenic abnormalities with NAFLD. Therefore, we prospectively investigated their associations with type 2 diabetes risks for the first time.Research design and methodsThe ELF score was measured among 254 type 2 diabetes cases and 254 age-matched and sex-matched controls nested within the prospective Singapore Chinese Health Study. Cases had hemoglobin A1c (HbA1c) levels <6.5% at blood collection (1999–2004) and reported to have diabetes during follow-up II (2006–2010). Controls had HbA1c levels <6.0% at blood-taking and remained free of diabetes at follow-up II. Multivariable conditional logistic regression models were used to assess the ELF-diabetes association.ResultsHigher TIMP1 levels were associated with increased type 2 diabetes risk, and the OR comparing the highest versus lowest quartiles was 2.56 (95% CI 1.23 to 5.34; p trend=0.035). However, ELF score, PIIINP and HA were not significantly associated with type 2 diabetes risks.ConclusionsHigher TIMP1 levels, but not ELF score, PIIIMP and HA, were associated with increased type 2 diabetes risk in Chinese adults. Our results suggested that elevated TIMP1 levels may contribute to the type 2 diabetes development through pathways other than liver fibrosis. ]]> <![CDATA[Collaborating with healthcare providers to understand their perspectives on a hospital-to-home warning signs intervention for rural transitional care: protocol of a multimethod descriptive study]]> This study builds on our prior research, which identified that older rural patients and families (1) view preparation for detecting and responding to worsening health conditions as their most pressing unmet transitional care (TC) need and (2) perceive an evidence-based intervention, preparing them to detect and respond to warning signs of worsening health conditions, as highly likely to meet this need. Yet, what healthcare providers need to implement a warning signs intervention in rural TC is unclear. The objectives of this study are (1) to examine healthcare providers’ perspectives on the acceptability of a warning signs intervention and (2) to identify barriers and facilitators to healthcare providers’ provision of the intervention in rural communities.Methods and analysisThis multimethod descriptive study uses a community-based, participatory research approach. We will examine healthcare providers’ perspectives on a warning signs intervention. A purposive, criterion-based sample of healthcare providers stratified by professional designation (three strata: nurses, physicians and allied healthcare professionals) in two regions (Southwestern and Northeastern Ontario, Canada) will (1) rate the acceptability of the intervention and (2) participate in small (n=4–6 healthcare providers), semistructured telephone focus group discussions on barriers and facilitators to delivering the intervention in rural communities. Two to three focus groups per stratum will be held in each region for a total of 12–18 focus groups. Data will be analysed using conventional qualitative content analysis and descriptive statistics.Ethics and disseminationEthics approval was obtained from the Office of Research Ethics at York University and the Health Sciences North Research Ethics Board. Findings will be communicated through plain language summary and policy briefs, press releases, manuscripts and conferences. ]]>