Control of Glycemia and Cardiovascular Risk Factors in Pts with Type 2 Diabetes in Primary Care.pdf

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Control of Glycemia and CardiovascularRisk Factors in Patients With Type 2Diabetes in Primary Care in

Catalonia (Spain)IRENEVINAGRE, MD1

MANELMATA-CASES, MD2,3

EDUARD HERMOSILLA, BSC3

ROSA MORROS, MD3,4

FRANCESC F INA, MD3,5

MAGDALENA ROSELL, MD3

CONXA CASTELL, MD, PHD6

JOSEPFRANCH-NADAL, MD, PHD3,7

BONAVENTURA BOLBAR, MD, MPH3,4

DIDAC MAURICIO, MD, PHD8,9

OBJECTIVEdThe objective of this study was to analyze the clinical characteristics and levelsof glycemic and cardiovascular risk factor control in patients with type 2 diabetes that are inprimary health care centers in Catalonia (Spain).

RESEARCH DESIGN AND METHODSdThis was a cross-sectional study of a total pop-

ulation of 3,755,038 individuals aged 3190 years at the end of 2009. Clinical data were obtainedretrospectively from electronic clinical records.

RESULTSdA total of 286,791 patients with type 2 diabetes were identied (7.6%). Fifty-fourpercent were men, mean (SD) age was 68.2 (11.4) years, and mean duration of disease was 6.5 (5.1)years. The mean (SD) A1C value was 7.15 (1.5)%, and 56% of the patients had A1C values #7%.The mean (SD) blood pressure (BP) values were 137.2 (13.8)/76.4 (8.3) mmHg, mean total cho-lesterol concentration was 192 (38.6) mg/dL, mean HDL cholesterol concentration was 49.3 (13.2)mg/dL, mean LDL cholesterol (LDL-C) concentration was 112.5 (32.4) mg/dL, and mean BMI was29.6(5)kg/m2. Thirty-one percent of thepatientshad BP values#130/80 mmHg, 37.9% had LDL-Cvalues #100 mg/dL, and 45.4% had BMI values #30 kg/m2. Twenty-two percent were managedexclusively with lifestyle changes. Regarding medicated diabetic patients, 46.9, 22.9, and 2.8% wereprescribed one, two, or three antidiabetic drugs, respectively, and 23.4% received insulin therapy.

CONCLUSIONSdThe results from this study indicate a similar or improved control of

glycemia, lipids, and BP in patients with type 2 diabetes when compared with previous studiesperformed in Spain and elsewhere.

Diabetes Care35:774779, 2012

Type 2 diabetes is a chronic diseasewith a prevalence of 13.8% in peopleover 18, with up to 6% of the pop-

ulation remaining undiagnosed, accordingto a recent Spanish study (1). Becausediabetic patients have a higher risk of

developing microvascular disease and atwo- to fourfold higher risk of developingmacrovascular disease than the generalpopulation, type 2 diabetes is consideredto be among the top conditions with thegreatest health and economic impact (2).

Many studies have shown that the occur-rence of these complications dependslargely on the degree of glycemic controland intensive control of cardiovascularrisk factors (CVRFs) (35).

In the last few decades, a consensustoward the implementation of a multi-disciplinary approach to prevention andcontrol of patients with type 2 diabetes inprimary care has been reached. Since1993, the Spanish Group of Study of Di-

abetes in Primary Health Care(Gedaps) haspublished up-to-date guidelines with themain recommendations for diagnos is,control, and treatment of diabetes. TheCatalan Health Institute has subsequentlyincorporated these recommendations intoits own guidelines (6). Current targets in-clude an A1C value #7%, blood pressure(BP) values#130/80mmHg, a total choles-terol (TC) value #200 mg/dL, and an LDLcholesterol (LDL-C) value#100mg/dL(7).

Despitescienticevidenceandthepub-lication of international (8,9) and national

guidelines (6,7), adequate control of thesepatients health remains beset with chal-lenges. A number of observational studiesperformed in Spain (1014) and elsewhere(1522) have shown that there is a gap be-tween recommendations and daily clinicalpractice. Several studies have indicated thatonly 79% of diabetic patients achieve op-timal control of all CVRFs (11,13,23). Thecurrent generalization of electronic clinicalrecords systems in Spain allowed us to ac-cess the data of the entire diabetic popula-tion registered in the public health caresystem for our study, unlike previous stud-ies that were based on population samples.The analyses of these data more accuratelyreect the actual control of patients withtype 2 diabetes in our setting. Previouspublications on population registers inother countries have indicated the rele-vance of these types of data (1522). Con-sequently, this cross-sectional studyaimed to determine the clinical featuresand the glycemic and CVRF control of pa-tients with type 2 diabetes in primary carecenters of the Catalan Health Institute inCatalonia (Spain).

c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c

From the 1Department of Endocrinology and Nutrition, Diabetes Unit, Hospital Clinic, University of Barcelona,

Barcelona, Spain; 2Primary Care Center La Mina, Gerencia d Ambit d Atencio P rimaria Barcelona Ciutat,Institut Catala de la Salut, Barcelona, Spain; the 3Institut Universitari dInvestigacio en Atencio Primaria

Jordi Gol, Barcelona, Spain; the 4Universitat Autnoma de Barcelona, Barcelona, Spain; the 5TechnicalOfce,Institut Catalade la Salut, Barcelona, Spain; the6PublicHealth ManagementAgency, Department ofHealth, Generalitat de Catalunya, Barcelona, Spain; 7Primary Care Center Raval, Gerencia dAmbitdAtencio Primaria Barcelona Ciutat, Institut Catala de la Salut, Barcelona, Spain; the 8Department of En-docrinology and Nutrition, Hospital Universitari Arnau de Vilanova, Lleida, Spain; and the9Department ofEndocrinology, Institut de Recerca Biomedica de Lleida, University of Lleida, Lleida, Spain.

Corresponding author: Didac Mauricio,[email protected] 31 August 2011 and accepted 27 December 2011.DOI: 10.2337/dc11-1679This article contains Supplementary Data online at http://care.diabetesjournals.org/lookup/suppl/doi:10

.2337/dc11-1679/-/DC1. 2012 by the American Diabetes Association. Readers may use this article as long as the work is properly

cited,theuse iseducationaland notforprot,and the workis notaltered.See http://creativecommons.org/licenses/by-nc-nd/3.0/for details.

774 DIABETESCARE, VOLUME35, APRIL2012 care.diabetesjournals.org

E p i d e m i o l o g y / H e a l t h S e r v i c e s R e s e a r c h

O R I G I N A L A R T I C L E
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RESEARCH DESIGN ANDMETHODSdA cross-sectional studythat included all patients with type 2 dia-betes treated at the Catalan Health Institutewas conducted in Catalonia, a Mediterra-nean region in northeastern Spain. Catalo-nia has a public health system in whichprimary care is organized in primary care

centers. Every citizen is registered with anindividual general practitioner (GP) and anurse in one of these centers. The mainhealth provider in the region is the CatalanHealth Institute, a publicly funded healthcare system that operates 279 health carecenters with .3,500 GPs and 5.8 millionpatients (80% of the regions population).

All GPs in the Catalan Health Institute usethe same specic software called ECAP torecord clinical information of their pa-tients. Prescribed medication is sold in pri-vate pharmacies and registered in a generaldatabase (CatSalut database).

Health care and all diagnostic proce-dures are free of charge to patients. Mostpatients pay40% of thecost of medications,which is free for retired, severely ill, orhandicapped people. Antidiabetic drugsare almost completely free of charge. Stripsfor blood glucose monitoring are providedfree of charge according to local guidelines.

On average, 70% of patients contac-ted their primary care team in a given year,although this rate varied accordingto socio-economic status. Over three consecutiveyears, thisgure rose to an average of 85%

of patients.The source of information used in this

study is the SIDIAP, a computerized data-basecontaining anonymized patient recordsfor the 5.8 million people registered witha GP in the Catalan Health Institute. TheSIDIAP includes data from ECAP (demo-graphics, consultations with GPs, diagno-ses, clinical variables, prescriptions, andreferrals), laboratory test results, and medi-cations obtained from the pharmacists(provided by the CatSalut database). TheSIDIAP contains all data entered into theECAP database since it was rst introducedin some practices in 1998. In 2005, thesystem was generalized and used systemati-cally in every Catalan Health Institute prac-tice. Data on laboratory test results andmedications sold were available beginningin 2005. Since the SIDIAP database wasestablished, differentstudies haveassessedthe validity of its information. This studyalso contributes to its validation.

All patients aged 3190 years with adiagnosis of type 2 diabetes (InternationalClassication of Diseases 10 [ICD-10] co-des E11 and E14) before 1 July 2009 were

included. All variables registered at theend of 2009 were collected. The followingdata were available for each patient: age;sex; number of visits with the primary careteam (physician or nurse) in theprevious12months; time since diagnosis; and A1C val-ues, using the last value of the previous 15months. Values expressed in Japan Diabetes

Society/Japan Society of Clinical Chemistry(JDS/JSCC) units were converted to the Na-tional Glycohemoglobin StandardizationProgram/Diabetes Control and Compli-cations Trial (NGSP/DCCT) units usingthe NGSP equation (24).

Data pertaining to chronic complica-tions werealso available, including diabeticretinopathy (ICD-10 codes E11.3 andH36.0), diabetic nephropathy (using themost recent value of albumin/creatinineratio of the study period), and impairedrenal function (using the last recordedvalueof the estimated glomerularltrationrate [GFR] with the MDRD [modicationof diet in renal disease] formula in the last15 months). In addition, data were availablefor coronary artery disease (ICD-10 codesI20, I21, I22, I23, and I24), stroke (codesI63, I64, G45, and G46), peripheral arterydisease (code I73.9), and heart failure (codeI50). Information on other CVRFs wasavailable, such as BMI, using the most re-cent weight value of the last 24 months;blood lipids (TC, LDL-C, and HDL cho-lesterol [HDL-C]), using the most recentvalue of the last 15 months; BP (systolic

and diastolic BP with the mean value ofthe last 12 months); and smoking status,according to the last condition registered.CVRF diagnostic criteria were hypertension(ICD-10 code I10) or BP $140/90 mmHg,TC$250 mg/dL, triglycerides (TGs)$150mg/dL, BMI $30 kg/m2, and a current orformer smoking habit.

To assess the degree of control, weused the current local guideline targets:

A1C value #7%, BP#130/80 mmHg, TC#200 mg/dL, and LDL-C #100 mg/dLfor secondary prevention and LDL-C#130 mg/dL for primary prevention (7).Furthermore,we assessed thesame variablesaccording to the pay-for-performancethresholds established by our institution:

A1C ,8%, BP #140/90 mmHg, and anLDL-C #100 mg/dL; however, this LDL-Cthresholdwasusedforsecondary-preventionpatients.

At thisstage, we alsocollected basic dataon glucose-lowering medication. For thispurpose, drug treatment data for 2009were obtained from the CatSalut prescrip-tion drug pharmacy invoice database. Sub-

jects were considered to have received

antidiabetic medication when they hadpurchased from the pharmacy sufcientmedication to cover at least 80% of thetotal theoretical minimum dose neededduring the study period. Patients wereconsidered to be untreated if they had notpurchased any drugs. Patients who did notmeet the criteria described above, such as

those on sporadic treatment or those af-fected by potential invoicing errors, wereconsidered unclassiable. SupplementaryTable 1describes the minimum dose usedand thepercentage ofunclassiable dia-betic patients for each antidiabetic drug(,5% of all patients).

We labeled the patient as undergoingdouble or triple antidiabetic therapy when1) thecriteriafor continuous treatmentweremet for each of the components and

2) either a combination or a xed-dosecombination of two or three antidiabeticdrugswasgivenat least for2 months, accord-ing to the prescription drug pharmacyinvoices. This study was approved by theEthics Committee of the Primary HealthCareUniversity Research Institute Jordi Gol.

AnalysisWe estimated the prevalence of type 2diabetes stratied by age for binomialevents. Means with SDs and proportionswere calculated for all variables (clinicalcharacteristics, diabetes-related complica-tions, treatment,and therapeutic goals). Wealways provide the value over the total

number of patients, excluding those withmissing values. The Pearson x2 test wasused to compare categorical data accordingto sex and age (,65 vs. $65 years), and anunpairedStudent t test wasused to comparecontinuous variables. All statistical analyseswere conducted according to the complete-case principle. A two-tailed value ofP,0.05 was considered statistically signicant.Statistical calculations were performedusing Stata Statistical Software Release 11(StataCorp, LP, College Station, TX).

RESULTSdOf a total population of3,755,038 individuals between ages 31 and90 years, 286,791 people were diagnosedwith type 2 diabetes, which correspondsto a prevalence of 7.6%. The prevalence in-creases to 22.4% in patients.70yearsofage. Fifty-four percent of the patients weremen. Clinical and laboratory characteris-tics are summarized in Table 1.

During 2009, 96% of patients withtype 2 diabetes consulted their GP, andblood tests, which included A1C measure-ments, wereperformed on 75% of patients.The mean (SD)A1C value was 7.15 (1.5)%.

care.diabetesjournals.org DIABETESCARE, VOLUME35, APRIL2012 775

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Fifty-sixpercent of the patientsachievedtheoptimal A1C target (#7%), a result morefrequently observed in patients .65 yearsof age (P, 0.001). Eighty-ve percent ofthe patients had at least one BP measure-ment during the study period. Of these pa-tients, 65% had a systolic BP measurement,140 mmHg, and 36.2% were ,130mmHg, whereas 92.5% had a diastolic BPmeasurement ,90 mmHg, with up to69.5% of the patients ,80 mmHg. Totalcholesterol was measured in 77.3% of pa-tients,andoverall,women hadhigher valuesthan men. Ninety-three percent had TC

values ,250 mg/dL, and 61.3% had values,200 mg/dL. HDL-C values were .40mg/dL in 79.04% of men and .50 mg/dLin 70.1% of women. TG values were,200mg/dL in 79.7% of patients with type 2diabetes, with a mean value of 156.2 mg/dL.Obesity was more frequent in women,whereas smoking was more frequent inmen (P, 0.005 for both comparisons).The control of target CVRFs is summarizedin Table 2. The complete set of data for allthree main control criteria (A1C, LDL-C,and BP) was available for 179,915 (63%) pa-tients.Of thepatients onprimaryprevention,

only 12.9% had met all targets (A1C#7%,BP #130/80 mmHg, and LDL-C ,130mg/dL), whereas in patients on secondaryprevention, this number was similar at12.1% (A1C #7%, BP #130/80 mmHg,and LDL-C ,100 mg/dL).

Chronic complications of the patientswith type 2 diabetes are shown in Table 3.Diabetic retinopathy, impaired renal func-tion (but not albuminuria), and ischemicheart disease were more frequent in womenthaninmen(P,0.001 forallcomparisons).

With regard to antidiabetic treatment,we analyzed only those patients considered

Table 1dClinical characteristics of the study population

Total = 286,791

Men

(n= 153,987)

Women

(n= 132,804)

Age (years) 68.2 (11.4) 66.4 (11.3) 70.3 (11.1)

Diabetes duration (years) 6.5 (5.1) 6.2 (4.8) 6.9 (5.3)

A1C (%) (n= 214,867; women = 102,063) 7.15 (1.46) 7.16 (1.48) 7.14 (1.44)

Hypertension (%) 77.8 76.3 79.9Systolic BP (mmHg) (n= 243,092; women = 114,606) 137.2 (13.8) 136.9 (13.6) 137.5 (14.0)

Diastolic BP (mmHg) (n= 242,942; women = 114,548) 76.4 (8.3) 76.6 (8.5) 76.2 (8.1)

TGs (mg/dL) (n= 195,285, women = 91,627) 156.2 (104.9) 158.5 (117.3) 153.5 (88.7)

TC (mg/dL) (n= 221,623; women = 105,249) 192.0 (38.6) 186.2 (38.2) 198.4 (38.0)

HDL-C (mg/dL) (n= 176,021; women = 83,666) 49.3 (13.2) 46.2 (12.3) 52.7 (13.4)

LDL-C (mg/dL) (n= 199,586; women = 95,426) 112.5 (32.4) 109.7 (32.2) 115.6 (32.3)

Obesity (%) (n= 202,451; women = 94,777) 45.4 39 52.7

BMI (kg/m2) (n= 202,451; women = 94,777) 29.6 (5.0) 28.8 (4.3) 30.5 (5.6)

Smoking habit (%) (n= 218,068; women = 96,716)

Current smoker 15.4 24.0 6.0

Ex-smoker 18.7 30.9 5.3

Data are mean (SD) or percent. Where indicated, the n value denotes the number of study subjects with available data. All comparisons between men andwomen showed a signicant difference,P, 0.005.

Table 2dResults of individual or combined (primary and secondary cardiovascular prevention) treatment goals achieved for the totalpopulation and also stratied according to sex and age

Total Men Women

Age ,65

years

Age $65

years

A1C #7% (n= 214,867; women = 102,063; $65 years = 139,161) 56.1 55.8 56.5 51.8 58.5

A1C #8% 79.6 79.1 80.1 74.2 82.5

A1C .10% 5 5.2 4.7 8 3.3

BP #130/80 mmHg (n= 242,842; women = 114,493; $65 years = 159,838) 31.7 32.0 31.4 33.3 30.9

BP #140/90 mmHg 63.5 63.5 63.1 66.6 61.9

TC ,200 mg/dL (n= 221,623; women = 91,627; $65 years = 126,014) 61.3 67.3 54.6 55.4 63.4

LDL-C ,100 mg/dL (n= 199,586; women = 95,426; $65 years = 130,529) 37.9 41.3 34.2 32.8 40.6

LDL-C ,130 mg/dL 72.4 75.2 69.4 67.2 75.2

TGs ,150 mg/dL (n= 195,285; women = 91,627; $65 years = 126,014) 39.6 38.8 40.4 47.2 35.4

BMI ,30 kg/m2 (n= 202,451; women = 94,777; $65 years = 130,851) 45.4 39.0 52.7 51.5 42.1

Nonsmoker (n= 195,632; women = 96,716; $65 years = 138,247) 65.9 45.1 88.8 51.2 73.7

Primary prevention: A1C #7%, BP #130/80 mmHg, and LDL-C

,130 mg/dL (n= 145,605; women = 71,246; $65 years = 91,689) 12.9 13.3 12.7 12.2 13.3

Secondary prevention: A1C #7%, BP #130/80 mmHg, and LDL-C

,100 mg/dL (n= 34,310; women = 12,200; $65 years = 27,386) 12.1 13.3 9.9 11.9 12.1

Dara are percentages. The primary and secondary prevention treatment goals were dened according to the local guidelines. The percentages are from the studysubjects with available data for each variable. All variables showed signicant differences between sex (P, 0.005) and age groups (P, 0.001).


Control of type 2 diabetes in Spain


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to be taking continuous medication.Twenty-two percent of all patients studiedwere managed by lifestyle measures. Mostmedicated patients were prescribed oral anti-diabetic treatments: 46.9, 22.9, and 2.8%were taking one, two, and three antidi-abetic drugs, respectively. A total of 23.4%of the patients on continuous antidiabeticdrug therapy received insulin, ;10% asmonotherapy, whereas 13.4% combinedinsulin with oral agents.

CONCLUSIONSdIn Spain, where thecurrent prevalence of diabetes is 13.8% (ofwhich 6% corresponds to unknown diabe-tes) (1), type 2 diabetic patients are mainlytreated by the primary care public healthsystem. In recent years, several studieshaveanalyzed the characteristics and degreeof control of patients with type 2 diabetes inour country, but these studies were charac-terized by great differences in methods andsample size (2,1014,23,25). The majorstrengthof our studyisthe inclusion of everypatient with type 2 diabetes from a totalpopulation database of 3,755,038 peopleover age 30. With data from 286,791 di-abetic patients and a prevalence of diabetesof 7.6%, this is the largest study ever un-dertaken in Europe. The observed preva-lence of type 2 diabetes is close to thereported prevalence of 7.8% for known di-abetes in the Spanish population (1), eventhough our study analyzed only type 2 di-abetes in people .30, with the main pur-pose to avoid the inclusion of patients withtype 1 diabetes. Although we did not haveaccess to the data of every patient in

Catalonia, we considered this prevalenceto be a precise estimate because the CatalanHealth Institute provides health care to80% of the Catalan population (7 millionpatients in 2009). Moreover, 96% of thepatients with type 2 diabetes had contactedthe health care system at least once duringthe year of study. The frequent use andquality of this registry make the SIDIAPan ideal reference database for surveillanceof the prevalence and risk factor control of

type 2 diabetes in our region. With regardto methodology, the accuracy of the resultsis strengthened by the existing link be-tween primary care clinical records andprescriptions obtained from the pharmacydatabase, thus reducing the possible gapbetween physician prescription and patientadherence.

Study subject characteristics, such asmean age and degree of obesity, weresimilar to previously published data fromother Spanish studies (3450% patientswere obese), though we found a slightlyhigher proportion of men and a slightlyshorter duration of the disease (6.5 years).This could have been the result of the com-puterization of clinical records that tookplace between 2000 and 2004 at our insti-tution, which required active registrationof the date of diagnosis by the health careprofessional. The registration in some casescould have been set by default as the date oftherst visit.

Likewise,thedegreeof glycemic control,as measured by the mean A1C at a cutoffof 7.15%, is comparable to that of otherstudies that have found values between 6.8

and 7.3%. However, the proportion of pa-tients with good control (56.1% with A1C#7%) was lower than in other Spanishstudies, most likely because of the previouslack of standardization of A1C measure-ment. The lack of A1C standardization af-fects the proportion of patients with goodcontrol. In fact, the Japanese kit (JDS/JSCC

method) yields lower values of A1C thanthe DCCT kit, and standardization has ledto a slight increase in the A1C values (6.85vs. 7.15%) and a decreasein the percentageof patients with A1C #7% (65 vs. 56.1%).

We considered this difference to be themain reason for the differences observedbetween Spanish studies and those in othercountries, such as the U.S., where DCCTvalues were more widely used. Indeed, inthe American study of Saaddine et al. (16),carried out between 1988 and 2002, only42.3% of patients had A1C values #7%,whereas in 2005, a study in Italy showedthat 59.9% of patients had A1C values#7% (19), a result very similar to ours.This relatively good result can be explainedby early diagnosis and treatment aimed atachieving the control targets. The imple-mentation of a target-based managementsystem for chronic diseases includes nan-cial incentives for Catalan Health Instituteprofessionals, who receive an annualnan-cial incentive based on the percentage ofpatients that achieve glycemic (55% with

A1C ,8%), hypertension (55% with BP,140/90 mmHg), and lipid control

(40% with LDL-C ,100 mg/dL) duringthe previous year.

In our current study, 79.6% of thepatients had A1C values #8%, a resultabove the proposed target. The effect ofpay for performance on quality in primarycare was recently evaluated in England(20). In that study, the proportion of pa-tients who achieved the target A1C value(#7.5%) increased from 59.1 to 66.7%,the proportion that achieved the target BP(#145/85 mmHg) increased from 70.9 to80.2%, and the proportion that achievedthe target TC value (#5 mmol/L) increasedfrom 72.6 to 83.6%.

According to the data published bythe Gedaps group in Catalonia, glycemiccontrol has improved progressively, asdemonstrated by A1C values that initiallyaveraged 7.7% in 1993 and later reached6.8% in 2007 (14). Because A1C values inthe Gedaps study were not standardizedto DCCT values, the 2007 result was ac-tually similar to our result, which was6.85% before standardization. Compara-ble positive trends have been observed incertain American Health Maintenance

Table 3dPrevalence of diabetes-related micro- and macroangiopathic complications, asassessed by ICD code records and laboratory data

Total = 286,791

Men

(n= 153,987)

Women

(n= 132,804)

Retinopathy (%) 5.8 5.6 6.1

Impaired renal function (%) (n= 174,571;

women = 82,440)GFR: 3059 mL/min 18.6 14.5 23.9

GFR: 1530 mL/min 1.2 0.9 1.5

GFR,15 mL/min 0.2 0.3 0.2

Albuminuria (%) (n= 171,063;

women = 80,983)

Microalbuminuria 14.9 18.4 11.1

Macroalbuminuria 1.8 2.4 1.2

Ischemic heart disease (%) 11.3 14.3 7.8

Cerebral vascular disease (%) 6.5 7.1 5.9

Peripheral vascular disease (%) 2.9 4.2 1.5

Where indicated, the n value denotes the number of study subjects with available data. GFR was assessedusing the MDRD formula. Micro- and macroalbuminuria were dened as an albumin/creatinine ratio of30300 and .300 mg/g, respectively. All comparisons between men and women showed a signicant

difference, P, 0.001.




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Organizations, such as Kaiser Permanente,where the mean A1C value decreased from8.3% in 1994 to 6.9% in 2003, and themean LDL-C value decreased from 132mg/dL in 1995 to 97 mg/dL in 2003 (22).The average LDL-C concentration in ourstudy was 112.5 mg/dL, and 37.9% ofpatients had LDL-C #100 mg/dL.

The mean values of BP control weresimilar to those observed in the Gedapsstudy in 2007 (137/77 mmHg and 66%ofpatients with BP #140/90 mmHg) (14),better than those published in otherSpanish studies (10,12,25). However,the American Behavioral Risk Factor Sur-veillance System (BRFSS) study (70.3% ofpatients with systolic BP ,140 mmHg)(16) and the British pay-for-performancestudy (80.2% with BP #145/85 mmHg)(20) achieved better control values thanthose observed in our study.

The results regarding chronic compli-cations, such as macroangiopathy, are sim-ilar to those observed in other Spanishstudies (14), whereas microvascular com-plications were probably underreported.

We considered the impaired renal functionvalues (MDRD ,60 mL/min, 20%) reliablebecause they have been calculated by theMDRD formula, though this prevalence isslightlylowerthan that of other studies (14).

In general, the percentage of patientson pharmacological treatment (78%) washigherthan that of other studies (15,17,18),even when only patientswho were receiv-

ing continuous treatment with antidiabeticdrugs wereconsidered. Most patients receiv-ing medication were managed with oralantidiabetic treatment (72.6%), whereas23.4% were treated either with insulinalone or insulin combined with oral agents.

The current study has several limita-tions. The main limitation of this cross-sectional study is the missing data for asignicant proportion of the patients stud-ied. In some instances, the data were notrecorded by the health care professionals,but in other cases, the heterogeneity of thevariables recorded in the different centersprecluded their use in the analysis. Al-though the data are consistent with pre-viousndings, there is still a risk of bias inthe results of this study, as underdiagnosisof type 2 diabetes or other associated con-ditions and underrecording of data mayhave occurred. These are common limi-tations of current primary-care, electronic-record databases and justify additionalvalidation studies using external databases,the development of internal control algo-rithms, and thecomparison of the results toother, similar studies. The present results

are comparable to those of previous publi-cations. There is a need for further improve-ment of the quality of the data obtained instudies such as ours to strengthen theirvalidity. Finally, some relevant diabeticpatientoriented outcomes, such as themortality and quality of life, could not beaddressed in this study. However, a future

study on cardiovascular morbidity andmortality in this population is warranted.

The availability of the data on real-lifeclinical practice at the primary care levelmay have important implications for dia-betes care. The information obtainedshould allow the current clinical practiceto be assessed in terms of the outcomes ofthe process and the results of diabetes care.This possibility has several implicationsthat should ultimately lead to improvedpatient care, including monitoring of dia-betes indicators, identication of practiceissues to be improved, potential introduc-tion of changes in the health care plans,identication of appropriate targets for pay-for-performance incentives, and alloca-tion of resources for this type of registryas a tool to aid decisions to improve dia-betes care.

In conclusion, the results of this study,with regardto A1Cvalue, dyslipidemia, andBP control in patients with type 2 diabetesaresimilar to those reported in other studiesconducted in Spain and elsewhere. Theseresults may be explained by early detectionand adequate treatment by primary care

professionals, which is enhanced by thetarget-based management system thatincludesnancial incentives. The informa-tion provided by the current study mightlead to the implementation of strategies toimprove clinical care of type 2 diabeticpatients. However, further improvement isnecessary, and the SIDIAP database mightbe an optimal surveillance reference sys-tem for the prevalence and control ofthe disease. The impact of late compli-cations in patients with type 2 diabetesdeserves further analysis. To reduce theburden of this disease, policies that pro-mote the optimal management of thiscondition and associated CVRFs shouldbe implemented.

AcknowledgmentsdThe Catalan DiabetesAssociation, the Catalan Health Department,and part of an unrestricted grant provided bysano-aventis Spain supported this study, aswell as the Network of Preventive Activitiesand HealthPromotion in Primary Care (redIAPP)granted by the Instituto de Salud Carlos III(RD06/0018). No other potential conicts ofinterest relevant to this article were reported.

I.V., M.M.-C., and R.M. wrote the manu-script and contributed to discussion. E.H. andF.F. researched the data and contributed todiscussion. M.R. and C.C. contributed to dis-cussion. J.F.-N., B.B., and D.M. designed andconducted the study, reviewed and editedthe manuscript, and contributed to discussion.D.M. is the guarantor of this work and, as such,had full access to all the data in the study and

takes responsibility for the integrity of the dataand the accuracy of the data analysis.

This study was possible thanks to the com-mitment of physicians and nurses working inthe Catalan Health Institute to provide optimalcare to patients with diabetes.

References1. Soriguer F, Goday A, Bosch-Comas A,

et al. Prevalence of diabetes mellitus andimpaired glucose regulation in Spain: theDiabetes Study. Diabetologia 2011;55:8893

2. Mata M, Antoanzas J, Tafalla M, Sanz P.The cost of type 2 diabetes in Spain: theCODE-2 study. Gac Sanit 2002;16:511520 [in Spanish]

3. American Diabetes Association. Implica-tions of the United Kingdom ProspectiveDiabetes Study. Diabetes Care 2002;25:S28S32

4. Holman RR, Paul SK, Bethel MA, MatthewsDR, Neil HAW. 10-year follow-up of inten-sive glucose control in type 2 diabetes.N Engl J Med 2008;359:15771589

5. Gaede P, Lund-Andersen H, Parving HH,Pedersen O. Effect of a multifactorial in-tervention on mortality in type 2 diabetes.N Engl J Med 2008;358:580591

6. Abordatge de la diabetes mellitus tipus 2[article online], 2009. Available from http://www.gencat.cat/ics/professionals/guies/docs/guia_diabetis.pdf. Accessed11 August2011

7. Cano JF, Franch J, Mata M; Grup dEstudide laDiabetesa lAtenci Primria de Salut(GEDAPS). Gua Para el Tratamiento de laDiabetes Tipo 2 en Atencin Primaria. Madrid,Harcourt Ed, 2004.

8. American Diabetes Association. Standardsof medical care in diabetesd2010. DiabetesCare 2010;33:S11S61

9. IDF Clinical Guidelines Task Force. Global

Guideline for Type 2 Diabetes: recommen-dations for standard, comprehensive, andminimal care.Diabet Med 2006;23:579593

10. Benito-Lpez P, Garca-Mayor R, Puig-Domingo M, et al.; MIDIA. Pathologicalcharacteristics of patients with diabetesmellitus type 2, in Spanish primary care.Rev Clin Esp 2004;204:1824 [in Spanish]

11. ArroyoJ,BadaX,delaCalleH,etal.;Grupopro-Star. Management of type 2 diabeticpatients in primary care in Spain. Med Clin(Barc) 2005;125:166172 [in Spanish]

12. Orozco-Beltrn D, Gil-Guillen VF, Quirce F,et al.; Collaborative Diabetes Study Investiga-tors. Control of diabetes and cardiovascular


Control of type 2 diabetes in Spain
http://www.gencat.cat/ics/professionals/guies/docs/guia_diabetis.pdfhttp://www.gencat.cat/ics/professionals/guies/docs/guia_diabetis.pdfhttp://www.gencat.cat/ics/professionals/guies/docs/guia_diabetis.pdfhttp://www.gencat.cat/ics/professionals/guies/docs/guia_diabetis.pdfhttp://www.gencat.cat/ics/professionals/guies/docs/guia_diabetis.pdfhttp://www.gencat.cat/ics/professionals/guies/docs/guia_diabetis.pdf


6/6

risk factors in patients with type 2 di-abetes in primary care. The gap betweenguidelines and reality in Spain. Int J ClinPract 2007;61:909915

13. Franch Nadal J, Artola Menndez S, DiezEspino J, Mata Cases M; en representacinde la Red de Grupos de Estudio de la Di-abetes en Atencin Primaria de la Salud.The evolution of quality care indicators of

patients with type 2 diabetes in the Spanishprimary care (1996-2007). The RedGEDAPSquality of care program . Med Clin (Barc)2010;135:600607 [in Spanish]

14. Mata-Cases M, Benito-Badorrey B, Roura-Olmeda P, Coll de Tuero G, Pepi-VilaubJM, Franch-Nadal J; Gedaps (Primary careGroup for the study of Diabetes) of theCatalan Society of Family & CommunityMedicine.Fifteen yearsof improvement inprocess and outcome indicators in themanagement of type 2 diabetes mellitus inprimary care centers in Catalonia, Spain(Abstract). Diabetologia 2010;53:407S

15. Rothe U, Mller G, Schwarz PE, et al.

Evaluation of a diabetes management sys-tem based on practice guidelines, integratedcare, and continuous quality managementin a Federal State of Germany: a population-based approach to health care research.Diabetes Care 2008;31:863868

16. Saaddine JB, Cadwell B, Gregg EW, et al.Improvements in diabetes processes ofcare and intermediate outcomes: UnitedStates, 1988-2002. Ann Intern Med 2006;144:465474

17. Eliasson B, Cederholm J, Nilsson P,Gudbjrnsdttir S; Steering Committeeof the Swedish National Diabetes Regis-ter. The gap between guidelines and

reality: type 2 diabetes in a National Di-abetes Register 1996-2003. Diabet Med2005;22:14201426

18. Cooper JG, Claudi T, Jenum AK, et al.Quality of care for patients with type 2diabetes in primary care in Norway is im-proving: results of cross-sectional surveys of33 general practices in 1995 and 2005.Diabetes Care 2009;32:8183

19. Club Diabete Sicili@. Five-year impactof a continuous quality improvement ef-fort implemented by a network of diabetesoutpatient clinics. Diabetes Care 2008;31:5762

20. Vaghela P, Ashworth M, Schoeld P,

Gulliford MC. Population intermediateoutcomes of diabetes under pay-for-performanceincentivesin England from2004to 2008. Diabetes Care 2009;32:427429

21. Morris AD, Boyle DI, MacAlpine R, et al.;DARTS/MEMO Collaboration. The diabetes

audit and research in Tayside Scotland(DARTS) study: electronic record linkageto create a diabetes register. BMJ 1997;315:524528

22. Sperl-Hillen JM, OConnor PJ. Factorsdriving diabetes care improvement in alarge medical group: tenyears of progress.Am J Manag Care 2005;11(Suppl.):S177S185

23. De la Calle H, Costa A, Dez-Espino J,Franch J, Goday A. Evaluation on thecompliance of the metabolic controlaims in outpatients with type 2 diabetesmellitus in Spain. The TranSTAR study.Med Clin (Barc) 2003;120:446450 [inSpanish]

24. Hoelzel W, Weycamp C, Jeppson JO,et al.; IFCC Working Group on HbA1cStandardization. IFCC reference sys-tem for measurement of hemoglobinA1c in hum an blo od and the Nat ion alStandarization Schemes in the UnitedStates, Japan and Sweden: a method-comparison study. Clin Chem 2004;

50:16617425. Liebl A, Mata M, Eschwge E; CODE-2

Advisory Board. Evaluation of risk factorsfor development of complications in TypeII diabetes in Europe. Diabetologia 2002;45:S23S28



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