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Rinnakkaistallenteet Terveystieteiden tiedekunta
2019
Maintenance of good glycaemic control is challenging - A cohort study of type
2 diabetes patient in North Karelia Finland
Nazu, NA
Wiley
Tieteelliset aikakauslehtiartikkelit
© John Wiley & Sons Ltd All rights reserved
http://dx.doi.org/10.1111/ijcp.13313
https://erepo.uef.fi/handle/123456789/7539
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Original PaperMaintenance of good glycaemic control is challenging – A cohort study of type 2 diabetes patient in North Karelia Finland.
Nazma Akter Nazu1,3, Jaana Lindström1,3, Päivi Rautiainen4, Hilkka Tirkkonen4, Katja Wikström2,3, Teppo Repo5, Tiina Laatikainen2,3,4
1 Department of Public Health, University of Helsinki, Helsinki, Finland
2 Institute of Public Health and Clinical Nutrition, University of Eastern Finland. Kuopio, Finland.
3 Department of Public Health Solutions, National Institute for Health and Welfare, Helsinki, Finland.
4 Joint municipal authority for North Karelia social and health services (Siun sote), Joensuu, Finland
5 Department of Geographical and Historical Studies, University of Eastern Finland. Joensuu, Finland
Corresponding author:
Nazma Akter Nazu
Department of Public Health, University of Helsinki PO BOX 63, 00014 University of Helsinki
e-mail: nazma.a.nazu@helsinki.fi DISCLOSURES: None
ABSTRACT
Aims: This study assessed type 2 diabetes treatment outcomes and process indicators using a comprehensive type 2 diabetes patient cohort in North Karelia, Finland, from 2011 to 2016.
Methods: Data from all diagnosed type 2 diabetes patients (n = 8,429) living in North Karelia was collated retrospectively from regional electronic patient records. We assessed whether HbA1c and LDL were measured and managed as recommended.
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Results: The HbA1c measurement rate improved (78% vs. 89%) during 2011–12 and 2015–
16, but a gradual deterioration in glycaemic control (HbA1c < 7.0% or 53 mmol/mol) was observed among both females (75% vs. 67%) and males (72% vs. 64%). The LDL measurement rate initially improved from the baseline. LDL control (< 2.5 mmol/l) improved among both females (52% vs. 59%) and males (58% vs. 66%). A gender difference was observed in the achievement of the treatment target for LDL, with females showing worse control.
Conclusions: LDL control in type 2 diabetes patients has improved, but the existence of gender disparities needs further attention. Maintaining appropriate HbA1c control among type 2 diabetes patients over time appears to be difficult. Active follow-up and tailored treatment have the potential to improve the quality of care. Electronic patient records could be more efficiently used to improve the quality of care and to support decision-making.
Keywords: Type 2 diabetes; Cohort study; Quality of Care; Glycaemic control; Low-density lipoprotein; Process indicator.
What’s Known
Complications related to type 2 diabetes can be prevented by improving the quality of diabetes care.
Maintaining appropriate HbA1c control in long term is challenging.
Follow-up information on quality of diabetes care is available only from few countries.
What’s new
The maintenance of good glycemic control is still challenging but has clearly improved in Finland.
Information from administrative data sources such as electronic patient records should be better utilised to support the development of treatment processes.
1 INTRODUCTION
The main concern of type 2 diabetes is the development of complications arising from it.
Type 2 diabetes patients are at risk of developing serious microvascular and macrovascular conditions, which subsequently reduce patients’ quality of life [1]. However, evidence suggests that complications related to type 2 diabetes can be prevented or postponed by improving the quality of diabetes care [2]. Guidelines have been developed to support healthcare professionals involved in the treatment of diabetes, both nationally and
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internationally. The purpose of the guidelines is to guarantee equally good quality diabetes care to all diabetes patients [3, 4].
A survey on diabetes care in different European countries established a divergence in quality.
Stone et al. assessed the levels of adherence to type 2 diabetes management guidelines in eight European countries—Belgium, France, Germany, Italy, Ireland, Sweden, the Netherlands, and the United Kingdom. The study reported that in the previous 12 months, in the sample of 7,597 patients, Glycated haemoglobin (HbA1c) was recorded for 97.6% of them, and 53.6% achieved the recommended HbA1c outcome (HbA1c < 7%, 53 mmol/mol).
Low-density lipoprotein (LDL) was measured for 82% of the patients, among which 55%
achieved the target LDL outcome (LDL < 2.6 mmol/l). They also observed significant variation between the highest and lowest scoring countries for both process and outcomes.
The follow-up rate for HbA1c varied from 94.7% to 99.3% and for LDL 63.5% to 96.3%.
Regarding the outcomes, the proportion of those achieving the target varied from 35.7% to 70.5% for HbA1c and from 30.7% to 76.9% for LDL [5]. In the Scottish diabetes survey, the proportion of type 2 diabetes patient achieving glycaemic control was 58.6% in 2016 [6]. In Sweden, the outcomes of diabetes care are regularly followed using the data from the national diabetes register. The latest figures from the 2016 report show that 51.5% of the type 2 diabetes patients achieved the treatment target of HbA1c (˂6.9 or 52mmol/mol), and 54.7%
achieved the LDL target (< 2.5 mmol/l) [7].
In Finland, no national diabetes register exists, and data on outcomes of type 2 diabetes care are available only from a few separate evaluations. In 1993, the outcome of type 2 diabetes care was measured among 3,195 adults, and data were collected from 51 health centers randomly selected from different provinces in Finland. The study found that the median HbA1c level was 8.4% in 1993. HbA1c levels were not satisfactory compared with the recommended level of HbA1c. This study did not provide any information about the other cardiovascular risk factors, i.e. LDL cholesterol level, blood pressure, etc. [8]. Later, the Development Programme for the Prevention and Care of Diabetes in Finland (DEHKO) investigated the treatment outcome related to type 2 diabetes in 2000–2001. It bridged the gap in the prior study and included blood pressure and LDL cholesterol measurements along with the HbA1c level. The study reported that glycaemic control had considerably improved.
The HbA1c median was 7.6%, and the median LDL cholesterol was 3.1 mmol/l [9]. The assessment was repeated by DEHKO in 2009–2010. The study reported that the median HbA1c was 6.7% and the median LDL cholesterol level was 2.4 mmol/l, showing a
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significant improvement in the treatment outcome of diabetes care [10]. More recently, outcomes of type 2 diabetes care have only been reported from Eastern Finland, North Karelia, where the regional electronic patient records enable easy retrieval of treatment data.
The study by Tirkkonen et al. showed that HbA1c was measured among 83% and LDL cholesterol among 75.1% of type 2 diabetes patients during the period 2011–12 in North Karelia. The recommended treatment outcome of HbA1c (< 7%, 53 mmol/mol) was achieved by 71.5% and the LDL target (< 2.5 mmol/l) by only 54.6% of the patients [11].
As type 2 diabetes is a progressive disease characterized by beta cell failure, a deterioration in HbA1c levels is often observed over time despite continuous lifestyle and pharmacological interventions [12–15]. Several studies have reported deterioration rates and calculated
‘coefficients of failure’ for patients on a certain treatment [16, 17]. It has been shown that there is an increased loss of glycaemic control, especially in patients on monotherapy [15].
To maintain good glycaemic control and to avoid complications, active follow-up of patients, efficient support for weight management and other healthy lifestyles, and continuous tailoring of glucose-lowering therapies are needed [18].
In the ideal situation, health professionals should be able to continuously follow up the outcomes of care among their patient population. Because of the challenges related to current patient record systems, these possibilities are scarce in many countries. In North Karelia, the joint regional database of electronic patient records has provided a unique opportunity for register-based analyses since 2011. The aim of this study is to provide long-term follow-up data on type 2 diabetes treatment outcomes and process indicators until the end of the year 2016, covering the entire type 2 diabetes patient cohort in North Karelia.
2 METHODS
2.1 Study design & setting
The study was designed to investigate the changes in the treatment outcome of type 2 diabetes in the same cohort over the period of 2011–16 by collating the data retrospectively.
We included data on all individuals with a confirmed diagnosis of type 2 diabetes (based on ICD-10 code E11) living in North Karelia, a region in eastern Finland consisting of 13 municipalities. A common electronic patient database system (Mediatri) was established by all the municipalities of North Karelia. The database has been in full use since the beginning of 2011 and includes data both from primary and specialized care. The data used in this study
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was extracted from the Mediatri database for the years 2011–16; it included patients’ age, gender, place of residence, other permanent diagnoses, and key laboratory markers. The ethics approval for the study was received on 13th November 2012 from the ethics committee of the Northern Savonia Hospital District.
2.2 Participants
At first, all patients with a diagnosis of type 2 diabetes from any visit to a health care center were identified from the database and checked by a group of physicians that they were not mixed up with type 1 diabetics. There were a total of 10,197 individuals identified as having type 2 diabetes (based on ICD-10 code E11) in the North Karelia region who were alive at the end of 2012. We followed up the same cohort instead of including new cases. After excluding those who died during the follow-up (2013–14: n = 903 and 2015–16: n = 858), there were 8,436 type 2 diabetes patients available for the follow-up at the end of 2016.
Among the living individuals, we included only those aged 20 or older at baseline, ending up with a total of 8,429 type 2 diabetes patients.
2.3 Variables
Two process and two intermediate outcome measures of quality of care were defined based on internationally accepted quality of care measurement indicators [19]. According to current Finnish care guidelines, the HbA1c level of type 2 diabetes patients should be monitored at least every 6–12 months, and the LDL level should be monitored at least once every 1-3 years [18]. Therefore, as a process of care indicators, we assessed whether the HbA1c and LDL were measured on a regular basis during the periods of 2011–12, 2013–14, and 2015–
16.
The outcome of care was assessed by the achievement of the target level of HbA1c (< 7% or 53 mmol/mol) and LDL (< 2.5 mmol/l) recommended by the current Finnish care guidelines among those whose HbA1c or LDL was measured in all observation periods (2011–12, 2013–14, and 2015–16). For those having any cardiovascular disease (CVD) along with type 2 diabetes, the treatment target of LDL according to the guideline is 1.8 mmol/l, and a separate analysis was performed for this subgroup. CVDs considered were coronary heart
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disease (ICD 10 code I20-I25), cerebrovascular disease (ICD 10 code I60-I69), peripheral arterial disease (ICD 10 code G60-G64), hypertension (ICD 10 code I10) and dyslipidemia (ICD 10 code E78). To make sure there was sufficient time for the treatment take effect, we included patients who had measurements for HbA1c and LDL at least three months and one month, respectively, after the diagnosis of type 2 diabetes. Altogether 5,779 patients met the criteria for the HbA1c measurement and 5,289 for the LDL measurement. For descriptive analyses, the values were categorized as HbA1c < 7, 7-8.9 and ≥ 9% (< 53 mmol/mol, 53-74 mmol/l, ≥ 75 mmol/mol) and LDL as < 2.5 mmol/l and ≥ 2.5 mmol/l.
To describe the treatment outcomes by age, they were categorized into four groups ranging from age 20 to age 80 or older. There were reasonably few young patients, especially patients under 50 years old, so the categories used were 20-49, 50-69, 70-79, and 80 or over. All analyses were run separately for men and women.
2.4 Biochemical methods
HbA1c and LDL samples were analyzed in the eastern Finland laboratory. The turbidimetric inhibition immunoanalysis method (TINIA) was considered for analyzing the HbA1c samples, and the photometric direct enzymatic method was used to analyze the LDL samples.
All the values were standardized to International Federation of Clinical Chemistry (IFCC) units.
2.5 Statistical method
We used IBM SPSS Statistics for Windows v. 25, for statistical analysis. The Chi-square test was performed to observe the differences in the HbA1c or LDL measurement rate and management by age group and gender in years 2011–12, 2013–14, and 2015–16. After that, an age-standardized univariate ANOVA was carried out to examine the gender difference. To observe the difference in the measurement rate and management of HbA1c and LDL between the years (2011–12 vs. 2013–14) and (2011–12 vs. 2015–16), a one-sample t-test was performed among females and males separately. The mean difference in the measurement rate and management of HbA1c and LDL between the years were calculated, and the observed difference was compared to zero. A statistically significant result designated that the difference differs from zero. The level of statistical significance was set to P < 0.05 for all statistical analysis.
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3 RESULTS
3.1 Population characteristics
The study population comprised a total of 8,429 individuals with type 2 diabetes. Of the patients, 53% (n = 4,476) were male and 47% (n = 3,953) were female. Most of the patients (54%, n = 4,555) were within the age group of 50-69. The mean age was 66 (SD ±11). The youngest and oldest patients were 21 and 98, respectively.
3.2 Process indicators
An increase in the measurement rate of HbA1c was observed during the follow-up of the cohort compared with the baseline (78% vs. 88% vs. 89% in 2011–12, 2013–14, and 2015–
16, respectively). Improvement in the measurement rate of HbA1c was observed among both females and males. There was no gender difference in the measurement rate. However, there were significant differences in the measurement rate of HbA1c between the age groups during all observation periods (P < 0.001). Younger females and males were poorly monitored compared with the older patients (Table 1).
The LDL measurement rate also improved from the baseline (2011–12) during the follow-up but remained steady after 2013–14 (75% vs. 85% vs. 85% in 2011–12, 2013–14, and 2015–
16, respectively). LDL levels were checked equally both among females and males during the follow-up. Significant differences in the measurement of LDL were observed both in females and males between the age groups during all observation periods. In 2011–12, younger females (20-49) showed a poor measurement rate, but it improved by the period 2015–16. On the other hand, younger males (20-49) showed a poor measurement rate throughout the follow-up (Table 2).
3.3 Outcome indicators
Achievement of the recommended level of HbA1c (< 7%, 53 mmol/mol) declined gradually both among females (75% vs. 68% vs. 67%) and males (72% vs. 66% vs. 64%) throughout the follow-up. This deterioration of treatment outcome occurred in all age groups. Running a subgroup analysis including same-aged patients for each observation period did not change the result. HbA1c < 7% (53mmol/mol) was observed in 74%, 64%, and 66% in 2011–12, 2013–14, and 2015–16, respectively, indicating that the deterioration of the treatment outcome is not caused only by aging of the cohort.
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A gender difference in treatment outcome that was observed during 2011–12 (P = 0.014), disappeared during the follow-up. Differences in the achievement of the recommended level of HbA1c (< 7%, 53 mmol/mol) were observed between the age groups both among females and males. Elderly females showed poorer achievement of HbA1c levels compared with younger females. In contrast, the poorest control among males was observed among the young males (Table 3).
A significant improvement was observed in the achievement of the recommended level of LDL (< 2.5 mmol/l), both among females (52% vs. 54% vs. 59%) and males (58% vs. 62%
vs. 66%) throughout the follow-up. Males demonstrated better LDL control compared with females in all observation periods. Differences in LDL management was observed between the age groups both among females and males. The younger age group demonstrated the poorest LDL control (Table 4).
Those having CVD were analyzed separately to observe whether they achieved the recommended LDL level of < 1.8 mmol/l. A similar trend of improvement in LDL control was observed among the type 2 diabetes patients with CVD (19% vs. 23% vs. 28% in 2011–
12, 2013–14, and 2015–16, respectively). Achievement of the recommended level of LDL was poorest among females compared with males (15% vs. 22%, 18% vs. 26%, and 22% vs.
32% in 2011–12, 2013–14, and 2015–16, respectively) throughout the follow-up (Supplementary Table 1).
The mean HbA1c worsened both among females from 6.6% (49 mmol/mol) to 6.9%
(52 mmol/mol) and males from 6.7% (50 mmol/mol) to 7.0% (53 mmol/mol) in 2011–12, 2013–14, and 2015–16, respectively (Figure 1).
4 DISCUSSION
This study comprised all type 2 diabetes patients in the North Karelia region and evaluated the treatment outcome of a patient cohort which was followed up for 6 years. Our key findings were improvement in the HbA1c measurement rate but a gradual deterioration in glycaemic control. On the other hand, the screening of LDL was increased initially from the baseline but then remained steady. A clear trend of improvement in LDL control was observed among the cohort during the follow-up. Females and males were equally monitored,
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and there was no difference in the achievement of the recommended level of outcome indicators, except for better LDL control in males.
A study in Spain evaluating the quality of type 2 diabetes care in primary care settings observed significant improvement in the HbA1c measurement rate (51.7% vs. 88.9%) during a fifteen-year follow-up [20]. The National Diabetes Audit (NDA) in England and Wales also showed a similar trend of improvement (93.1% vs. 95.0% from 2011–12 to 2015–16) [21]. It seems that in our study region, type 2 diabetes patients are more often screened for HbA1c values (89% in 2015–16; Table 1) than in Spain, but less often when compared with England and Wales. Furthermore, LDL cholesterol monitoring was also found to increase largely during the follow-up period of 2011–12 to 2013–14 and remain stable afterward. NDA also showed improvement in the LDL measurement rate (92.1% vs. 92.7% from 2011–12 to 2015–16) [21]. Although the improvement in the measurement rate was small in NDA, it is in general much better compared with our study region (85% in 2015–16; Table 2).
One of the interesting findings of our study was a significant improvement in monitoring of patients (both HbA1c and LDL measurement rate) during the follow-up period of 2011–12 to 2013–14. The introduction of an electronic recording system (ERS) for patient data in the North Karelia region might partly explain the large increase in the measurement rate. It has been observed in prior studies that ERS has the potential to improve the process of care indicators [22]. The fundamental abilities of ERS for improving quality of care was described in the Institute of Medicine report [22, 23]. ERSs are able to provide information about diagnosed patients with diabetes and identify the patients who are monitored and who achieve the treatment targets. This information helps guide the physicians to send reminders to patients who are due for screening tests and take special care of those who failed to achieve the treatment target, thus improving the care [23].
We found that overall 65% of the patients achieved the recommended level of HbA1c (< 7%, 53mmol/mol) during the follow-up period of 2015–16 (Table 3). Achievement of the treatment target of type 2 diabetes in Scotland and Sweden was 58.6% and 51.5%, respectively, in 2016. The used cut-off point for the treatment target in Scotland was higher (HbA1c < 7.5%, 58 mmol/mol) and in Sweden a little lower (HbA1c < 6.9%, 52 mmol/mol) than the one used in our study (HbA1c < 7%, 53mmol/mol) following the current Finnish care guidelines [6, 7, 18]. However, if we consider the treatment target of Scotland and
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Sweden, achievement in the recommended level of HbA1c in the North Karelia region is still better than in either of these countries.
It was observed earlier that an improvement in process indicators does not always ensure an improvement in outcome indicators [24, 25]. We also observed a deterioration in HbA1c control throughout the follow-up, despite the improvement in HbA1c monitoring of the type 2 diabetes patients. Our result is in line with the Swedish study, which also observed deterioration in HbA1c control among the whole Swedish national diabetes register population [26]. The deterioration in HbA1c has been linked with many factors, for instance, aging, duration of disease, and severity of disease [27-29]. In our study, a subgroup analysis of HbA1c control among same-aged patients throughout the follow-up showed no effect of aging in HbA1c deterioration. Type 2 diabetes is a progressive disease, and β-cell dysfunction is found to be the key reason for this progression. The gradual loss of β-cell function and reduction in β-cell mass is found to be responsible for the deterioration of glycaemic control [12], even with the treatment [30]. This most likely explains the observed deterioration in the HbA1c control in our study. Another possible explanation is the new treatment recommendation following the publication of the results from the ACCORD [31]
and ADVANCE [32] trials. The new guidelines recommend more individualized strategies in treatment, focusing on intensive control among newly diagnosed patients and less strict control of patients who are at high risk [26]. We assessed the mean glycaemic deterioration in our study, which was 0.08 HbA1c %/year. Compared with the study using the UKPDS patient data (0.47 HbA1c %/year) and a study by Donnelly et al. (0.12 HbA1c %/year), the observed rate of deterioration was lower in our study, which is a positive indication of good glycaemic control of the patients [16, 17].
A significant improvement in LDL management was observed in our study. Overall 63%
patients achieved the recommended level of LDL (< 2.5 mmol/l) in 2015–16 (Table 4).
Compared to the results of Sweden’s national diabetes register, the achievement of the recommended level of LDL in our study was found to be higher than in Sweden, where 54.7% achieved the LDL target < 2.5 mmol/l [7]. On the other hand, the National Diabetes Survey in Canada reported a higher achievement (74.8%) in the treatment target of LDL ≤ 2.5 mmol/l among type 2 diabetes patients in a primary care setting compared with our study result [33]. Diabetic patients have a higher risk of developing cardiovascular disease, and good LDL control has the potential to reduce the risk of macrovascular complications [34].
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Therefore, following the current guidelines, the pharmacological treatment of dyslipidemia along with diabetes should be considered even more often [18].
Another important finding of our study was that males showed more improvement in the management of LDL than females and in overall better control. This indicates that females are still neglected in LDL control and thus at higher risk of developing CVD. Gender disparity in the achievement of the target level of LDL has been observed in many prior studies [35–37]. In Finland, the historical mortality rate due to cardiovascular disease was far higher among men than among women [38], which may have influenced the more intensive treatment of men for the reduction of cardiovascular risk factors, especially LDL cholesterol.
In addition, poor adherence to medication and differences in pharmacodynamics and pharmacokinetics may also contribute to the worse achievement of the target LDL level among females [35].
A subgroup analysis of type 2 diabetes patients with CVD also showed improvement in LDL control throughout the follow-up. Only 22% of females and 32% of males achieved the treatment target of < 1.8 mmol/l in 2015–16 (Supplementary Table 1), which however is higher than in the EUROASPIRE 4 study (17% of females and 22% of males achieved LDL
< 1.8 mmol/l) [39]. The achievement of target levels among CVD patients still has room for improvement.
The major strength of this study is that it included all the diagnosed patients with type 2 diabetes in North Karelia. We have managed to avoid selection bias by using data from patient registers. In addition, all the municipalities of North Karelia use the same regional laboratory and the same standardized methods for HbA1c and LDL measurements, guaranteeing the comparability of laboratory data. The data used in our study were collected directly from the electronic patient record system of the region; thus, it was possible to avoid non-responsiveness of the patients and missing data of laboratory investigations and to ensure the comparability of the results between patients in different municipalities.
We also have some limitations in our study. We have included all diagnosed patients of type 2 diabetes, but there still might be some undiagnosed patients in the region. We have some missing information on those who used only private health care services or who did not use the service at all during the follow-up period. Another important limitation of our study is that we do not have accurate information on the age of onset of diabetes among the cohort, as not all the information from earlier patient recording systems was transferred to the new
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system when it was established. Therefore, we were not able to adjust the deterioration of the HbA1c level with the duration of disease.
5 CONCLUSION
It can be concluded that during the follow-up of the patient cohort with type 2 diabetes, there have been improvements in the process of care in the study region. Although the overall LDL cholesterol control has improved, there still are gender disparities that need further attention.
Upholding appropriate HbA1c control among type 2 diabetes patients over time appears to be difficult because of the progressive nature of the disease and gradual β-cell deterioration.
However, active follow-up and effectively tailored treatment strategies may reduce the progression of β-cell failure and improve glycaemic control. The electronic patient recording system provides good possibilities for data-driven decision-making and quality improvement.
AUTHOR CONTRIBUTIONS:
NN, JL and TL planned the study design. TR compiled the data. NN carried out the statistical analyses. All authors participated in the interpretation of the data and NN drafted the manuscript. KW, PR and HT contributed to critical revision of the work. All authors read and approved the final version of the manuscript.
ACKNOWLEDGEMENTS:
This study was partly funded by the Research Committee of the Kuopio University Hospital Catchment Area for the State Research Funding (project QCARE, Joensuu, Finland) and the Strategic Research Council at the Academy of Finland (project IMPRO, 312703, 312704).
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Accepted Article
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Accepted Article
Table-1: Proportion (%) of patients with HbA1c measurement (2011-12, 2013-14 and 2015- 16) by age group and gender.
Gender Age
group
Total n
HbA1c Measured 2011-12
%
2013-14
%
2015-16
%
Female 20-49 277 70 83 82
50-69 1814 77 89 89
70-79 1125 84 92 93
≥ 80 737 83 91 88
Total 3953 79 90 90
Male 20-49 387 68 82 78
50-69 2741 74 85 87
70-79 1014 84 93 92
≥ 80 334 84 90 90
Total 4476 76 87 88
Total 20-49 664 69 82 80
50-69 4555 75 87 88
70-79 2139 84 93 93
≥ 80 1071 83 91 89
Total 8429 78 88 89
Differences in the rate of HbA1c measurements between age groups in 2011-12: Females (P
< 0.001), Males (P < 0.001), Total (P < 0.001), 2013-14: Females (P < 0.001), Males (P <
0.001), Total (P < 0.001), 2015-16: Females (P < 0.001), Males (P < 0.001), Total (P <
0.001); Chi squaretest
Age adjusted gender difference in HbA1c measurement rate in 2011-12 (P = 0.155), 2013-14 (P = 0.057) and 2015-16 (P = 0.244); Univariate analysis of variance
Difference in HbA1c measurement rate in 2011-12 vs 2013-14 (Females P = 0.005, Males P
= 0.008), 2011-12 vs 2015-16 (Females P = 0.010, Males P = 0.010); One sample t-test
Accepted Article
Table-2: Proportion (%) of patients with LDL measurement (2011-12, 2013-14 and 2015-16) by age group and gender.
Gender Age
group
Total n
LDL Measured 2011-12
%
2013-14
%
2015-16
%
Female 20-49 277 66 80 81
50-69 1814 76 87 88
70-79 1125 81 88 87
≥ 80 737 71 75 70
Total 3953 76 85 84
Male 20-49 387 66 79 76
50-69 2741 73 84 85
70-79 1014 81 91 89
≥ 80 334 79 82 81
Total 4476 75 85 85
Total 20-49 664 66 80 78
50-69 4555 74 85 86
70-79 2139 81 89 88
≥ 80 1071 74 77 74
Total 8429 75 85 85
Differences in the rate of LDL measurements between age groups in 2011-12: Females (P <
0.001), Males (P < 0.001), Total (P < 0.001), 2013-14: Females (P < 0.001), Males (P <
0.001), Total (P < 0.001), 2015-16: Females (P < 0.001), Males (P < 0.001), Total (P <
0.001); Chi squaretest
Age adjusted gender difference in LDL measurement rate in 2011-12 (P = 0.843), 2013-14 (P
= 0.230) and 2015-16 (P = 0.169); Univariate analysis of variance
Difference in LDL measurement rate in 2011-12 vs 2013-14 (Females P = 0.025, Males P = 0.022), 2011-12 vs 2015-16 (Females P = 0.116, Males P = 0.031); One sample t-test
Accepted Article
Table-3: HbA1c levels (2011-12, 2013-14 and 2015-16) by age group and gender among those whose HbA1c was measured in all observation periods.
Gende r
Age grou p
Tota l n
< 7%
(< 53 mmol/mol)
7-8.9%
(53 – 74 mmol/mol)
≥ 9%
(≥ 75 mmol/mol) 2011-
12
%
2013- 14
%
2015- 16
%
2011- 12
%
2013- 14
%
2015- 16
%
2011- 12
%
2013- 14
%
2015- 16
% Femal
e
20- 49
159 74 67 65 18 25 27 8 8 8
50- 69
123 9
77 70 70 18 24 22 5 7 7
70- 79
859 75 68 66 21 26 27 4 6 7
≥ 80 528 71 62 62 25 31 30 4 7 9
Total 278 5
75 68 67 20 26 26 5 7 8
Male 20- 49
220 63 54 51 22 35 35 15 11 15
50- 69
175 6
73 67 64 22 27 29 6 7 6
70- 79
775 76 70 67 21 26 28 3 4 5
≥ 80 243 69 61 58 26 31 34 5 8 9
Total 299 4
72 66 64 22 27 30 6 7 7
Total 20- 49
379 68 59 57 20 31 32 12 10 12
50- 69
299 5
75 68 67 20 26 26 5 7 7
70- 79
163 4
75 69 66 21 26 27 3 5 6
≥ 80 771 70 62 60 25 31 31 5 7 9
Total 577 9
74 67 65 21 27 28 5 7 7
Differences in the rate of HbA1c management between age groups in 2011-12: Females (P = 0.008), Males (P < 0.001), Total (P < 0.001), 2013-14: Females (P = 0.047), Males (P <
0.001), Total (P < 0.001), 2015-16: Females (P = 0.023), Males (P < 0.001), Total (P <
0.001); Chi square test
Age adjusted gender difference in HbA1c management in 2011-12 (P = 0.014), 2013-14 (P = 0.458) and 2015-16 (P = 0.158); Univariate analysis of variance.
Difference in HbA1c management in 2011-12 vs 2013-14 (Females P < 0.001, Males P = 0.003), 2011-12 vs 2015-16 (Females P = 0.001, Males P = 0.003); One sample t-test
Accepted Article
Table-4: LDL levels (2011-12, 2013-14 and 2015-16) by age group and gender among those whose LDL was measured in all observation periods.
Gender Age group Total n
< 2.5 mmol/l ≥ 2.5 mmol/l 2011-12
%
2013-14
%
2015-16
%
2011-12
%
2013-14
%
2015-16
%
Female 20-49 150 41 43 46 59 57 54
50-69 1191 49 53 58 51 48 42
70-79 780 56 58 63 44 42 37
≥ 80 365 54 56 61 46 44 39
Total 2486 52 54 59 48 46 41
Male 20-49 201 43 51 53 57 49 47
50-69 1695 55 59 63 45 41 37
70-79 714 66 68 73 34 33 27
≥ 80 193 69 73 75 31 27 25
Total 2803 58 62 66 42 38 34
Total 20-49 351 42 48 50 58 52 50
50-69 2886 52 57 61 48 44 39
70-79 1494 61 62 68 39 38 32
≥ 80 558 59 62 66 41 38 34
Total 5289 55 58 63 45 42 37
Differences in the rate of LDL management between age groups in 2011-12: Females (P = 0.001), Males (P< 0.001), Total (P < 0.001), 2013-14: Females (P = 0.005), Males (P <
0.001), Total (P < 0.001), 2015-16: Females (P = 0.001), Males (P < 0.001), Total (P <
0.001); Chi square test
Age adjusted gender difference in LDL management in 2011-12 (P < 0.001), 2013-14 (P <
0.001) and 2015-16 (P < 0.001); Univariate analysis of variance.
Difference in LDL management in 2011-12 vs 2013-14 (Females P = 0.019, Males P = 0.044), 2011-12 vs 2015-16 (Females P = 0.004, Males P = 0.004); One sample t-test
