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 Treatment of cardiovascular risk factors in type 2 diabetes: time trends and clinical practice
Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Family Medicine.
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Objectives

Patients with type 2 diabetes are at much greater risk of developing cardiovascular diseases (CVD), including coronary heart disease (CHD), compared to non-diabetics. The lowering of glucose, blood pressure, and plasma lipid levels has been shown to reduce CHD risk, and treatment goals for these risk factors are now part of clinical practice guidelines. However, the incidence and outcome of CHD in diabetic patients does not show the same favourable trend as in the general population. Thus, the overall aim of the thesis was to investigate how the treatment goals for CVD risk factors contained in the national guidelines for diabetes care were reflected in clinical practice, and to explore factors that might influence the remaining high incidence of CHD in the type 2 diabetes population.

Research designs and results

I. The effectiveness of the introduction of treatment goals for dyslipidaemia was evaluated in a retrospective observational population-based cross-sectional study of 971 diabetic patients participating in the Västerbotten Intervention Programme (VIP) 1995–2004. There was a stronger trend of decrease in cholesterol levels among patients with diabetes compared to the non-diabetic population in 2000–2004. Increased use of lipid-lowering agents influenced the trend in diabetic patients, even though only 25.3% received lipid-lowering treatment after the introduction of the new guidelines.

II. The experiences of general practitioners relating to treatment practice for type 2 diabetes with specific focus on the prevention of cardiovascular disease were explored in a focus group study. The overall theme was ‘dilemmas’ in GPs’ treatment practice for patients with type 2 diabetes. Five main dilemma categories were identified. First, GPs were hesitant about labelling a person who feels healthy as ill. Second, as regards communicating a diabetes diagnosis and its consequences, GPs were unsure as to whether patients should be frightened or comforted. Third, GPs experienced uncertainty in their role: should they take responsibility for the care or not? Fourth, GPs expressed concern over a conflict between lifestyle changes and drug treatment. Fifth, the GPs described difficulties when attempting to translate science into reality.

III. Screening for microvascular and coronary heart disease according to national guidelines was evaluated in a cross-sectional study of 201 screening-detected patients with type 2 diabetes 1.5±0.7 years after diagnosis. A larger proportion of diabetic patients was screened for nephropathy and retinopathy than for CHD. Twenty-three percent of the patients had minor or major ECG abnormalities, but ECG findings seemed to have little or no impact on CHD prevention using lipid-lowering medication and ASA. A clinical history of CHD correlated with a larger proportion of patients receiving secondary prevention.

IV. Time trends relating to the achievement of treatment goals and 10-year CHD risk at three years of diabetes duration were studied in 19,382 patients with type 2 diabetes without CHD, who were reported by primary health care sources in the National Diabetes Register in 2003–2008. National treatment goals for glycaemia, blood pressure, total cholesterol, and LDL cholesterol were achieved in 78.4%, 65.5%, 55.6%, and 61.0%, respectively, of the diabetic patients in 2008 following a trend of improved results in 2003–2008. Absolute 10-year risk of CHD increased between year of diagnosis and follow up in a studied subgroup while modifiable risk decreased.

Conclusions

The introduction of treatment goals for dyslipidemia in Swedish national guidelines in 1999 were reflected in lowered cholesterol levels in people with type 2 diabetes. Since the introduction of the guidelines, an increasing number of diabetic patients are treated in accordance with guidelines. A remaining microvascular focus on the patients together with the revealed dilemmas within the GP’s consultation with diabetic patients might negatively influence the remaining high incidence of CHD in the type 2 diabetes population. Lipid levels, blood pressure and smoking are targets for further improvements.

Place, publisher, year, edition, pages
Umeå: Umeå university , 2010. , 86 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1326
Keyword [en]
diabetes mellitus, cardiovascular disease, effectiveness, epidemiology, guideline adherence, primary health care, risk factor
Identifiers
URN: urn:nbn:se:umu:diva-30686ISBN: 978-91-7264-939-2 (print)OAI: oai:DiVA.org:umu-30686DiVA: diva2:285727
Public defence
2010-02-05, Sal B, 9 tr, Tandläkarhögskolan, NUS, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Note
KappaAvailable from: 2010-01-18 Created: 2010-01-12 Last updated: 2010-01-18Bibliographically approved
List of papers
1. Guidelines improve general trend of lowered cholesterol levels in type 2 diabetes patients in spite of low adherence
Open this publication in new window or tab >>Guidelines improve general trend of lowered cholesterol levels in type 2 diabetes patients in spite of low adherence
2008 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, Vol. 36, no 1, 69-75 p.Article in journal (Refereed) Published
Place, publisher, year, edition, pages
SAGE, 2008
Identifiers
urn:nbn:se:umu:diva-10170 (URN)10.1177/1403494807085374 (DOI)
Available from: 2010-01-14 Created: 2008-06-25 Last updated: 2015-04-29Bibliographically approved
2. ‘Aiming for the stars’—GPs’ dilemmas in the prevention of cardiovascular disease in type 2 diabetes patients: focus group interviews
Open this publication in new window or tab >>‘Aiming for the stars’—GPs’ dilemmas in the prevention of cardiovascular disease in type 2 diabetes patients: focus group interviews
2009 (English)In: Family Practice, ISSN 0263-2136, E-ISSN 1460-2229, no 26, 109-114 p.Article in journal (Refereed) Published
Abstract [en]

Background

Studies have revealed low adherence to guidelines for treatment of diabetes and cardiovascular risk factors.

Objective

To explore general practitioners’ experiences regarding treatment practice in type 2 diabetes with specific focus on the prevention of cardiovascular disease.

Methods

Fourteen experienced general practitioners from nine health care centres with group practices were interviewed in focus groups. The interviews were digitally recorded, transcribed verbatim and analysed by qualitative content analysis.

Results

The overall theme was “dilemmas” in GPs´ treatment practice for type 2 diabetes patients. Five main dilemma categories were identified. First, the GPs were hesitant about labelling someone who feels healthy as ill. Secondly, regarding communicating a diabetes diagnosis and its consequences; should the patient be frightened or comforted? Thirdly, the GPs experienced uncertainty in their role; were they to take responsibility for the care or not? Fourthly, the GPs expressed a conflict between lifestyle changes and drug treatment. Fifthly, the GPs described difficulties in integrating science into reality.

Conclusions

The five dilemmas in the general practitioners’ approach to diabetes patients and the treatment of their cardiovascular risk were related to the GPs´ professional role and communication with the patient. To consider these dilemmas in educational efforts is probably essential to achieve improved diabetes care and guideline adherence. 

Place, publisher, year, edition, pages
Oxford: Oxford University Press, 2009
Keyword
Diabetes mellitus, family physicians, focus group interview, guideline adherence, primary health care
National Category
Family Medicine
Research subject
Family Medicine
Identifiers
urn:nbn:se:umu:diva-30621 (URN)
Available from: 2010-01-14 Created: 2010-01-09 Last updated: 2017-12-12Bibliographically approved
3. Is there an appropriate focus on coronary heart disease in patients with newly diagnosed type 2 diabetes?
Open this publication in new window or tab >>Is there an appropriate focus on coronary heart disease in patients with newly diagnosed type 2 diabetes?
(English)Article in journal (Other academic) Submitted
Keyword
Diabetes Mellitus, Coronary Heart Disease, Diabetic Retinopathy, Diabetic Nephropathy, Guideline Adherence
Identifiers
urn:nbn:se:umu:diva-30684 (URN)
Available from: 2010-01-12 Created: 2010-01-12 Last updated: 2010-01-18Bibliographically approved
4. Time trends in absolute and modifiable CHD risk in type 2 diabetes patients in the Swedish national diabetes register (NDR) 2003–2008
Open this publication in new window or tab >>Time trends in absolute and modifiable CHD risk in type 2 diabetes patients in the Swedish national diabetes register (NDR) 2003–2008
Show others...
2012 (English)In: Diabetic Medicine, ISSN 0742-3071, E-ISSN 1464-5491, Vol. 29, no 2, 198-206 p.Article in journal (Other academic) Published
Abstract [en]

Aims: The aim was to evaluate treatment goal achievements early in the course of Type 2 diabetes, and their effect on 10-year risk of coronary heart disease in patients receiving usual care.

Methods: Assessment of risk factor control 3 years after diagnosis in patients with Type 2 diabetes with no previous coronary heart disease included from the Swedish National Diabetes Register; a total of 19 382 patients (mean age 58 years) in cross-sectional surveys from 2003 to 2008, and a subgroup of 4293 patients followed individually from year of diagnosis to follow-up after a mean 2.6 years. Estimation of absolute 10-year risk of coronary heart disease using the UK Prospective Diabetes Study risk engine, and modifiable 10-year risk defined as percentage excess risk above patients with normal risk factor values.

Results: Treatment goals for HbA1c, blood pressure, total and LDL cholesterol were achieved in 78.4, 65.5, 55.6% and 61.0%, respectively, in the cross-sectional survey in 2008, following a trend of generally improved control. In the individually followed patients in the subgroup, mean absolute 10-year coronary heart disease risk increased from 13.7% (men/women 16.9/9.5%) to 14.2 (men/women 17.6/9.6%) (P < 0.001) from year of diagnosis to follow-up after 2.6 years, while mean modifiable risk decreased from 37.7% (men/women 28.6/49.9%) to 19.1% (13.2/26.9%) (P < 0.001 in all).

Conclusions: A high achievement of treatment goals and a low mean modifiable 10-year coronary heart disease risk was found at the 3-year follow-up, both in the cross-sectional survey in 2008 and in patients individually followed since diagnosis. This indicates the feasibility and significance of early multifactorial risk factor treatment.

Place, publisher, year, edition, pages
Malde, USA: Wiley-Blackwell, 2012
Keyword
blood pressure, diabetes mellitus, dyslipidaemia, HbA1c, myocardial infarction
National Category
Endocrinology and Diabetes
Identifiers
urn:nbn:se:umu:diva-30685 (URN)10.1111/j.1464-5491.2011.03425.x (DOI)
Available from: 2010-01-12 Created: 2010-01-12 Last updated: 2017-12-12Bibliographically approved

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