Abstract Objective The aim of this study was to describe the utilization of diabetes education centres by people not diagnosed with diabetes mellitus in real-world clinical care in Ontario. Methods ...Using population-level health administrative databases and registries, all people in Ontario, Canada, who attended a diabetes self-management education centre in 2006 were identified. The proportion of attendees without diagnosed diabetes at the time of their visit was determined, they were stratified by centre and health region, and their utilization of diabetes education centres was characterized. They were then followed up until 2010 for incident diabetes. Results Of 117 660 adults attending a diabetes education centre, 19 920 (16.9%) did not have diagnosed diabetes. There was a marked variation in the proportion of attendees without diagnosed diabetes between health regions and between individual centres. More attendees did not have diagnosed diabetes at centres based in community health centres (47.5%) or First Nations communities (22.1%) than those based in hospitals (13.9%) or other community settings (13.0%). Only 2741 attendees (13.8%) without diabetes attended group education classes; most attended individual counselling sessions. Diabetes incidence during follow up was 11.2 cases per 100 person years. Conclusions One in 6 people receiving care at a diabetes education centre in Ontario did not have diabetes, and the significant regional variations could represent inappropriate overuse or underuse. Although education and counselling for patients at risk for diabetes is clinically important, the volume of such persons served at Ontario diabetes education centres may detract from the centres' core function of supporting and managing patients already diagnosed with diabetes.
Ursodeoxycholic acid (UDCA) is a safe and effective treatment for patients with primary biliary cirrhosis (PBC), but the cost of this drug has raised concerns regarding cost‐effectiveness. The aim of ...our study was to determine the cost‐effectiveness of UDCA in PBC. We compared the costs and outcomes of managing PBC patients with and without UDCA. From two previously published trials, the effectiveness of UDCA was determined by comparing the annual reduction in the development of ascites, varices, variceal bleeding, encephalopathy, liver transplantation, and death between the treatment groups. Average annual costs for each of these events were estimated based on literature and institutional data. Approximately twice as many major events occurred in the placebo group compared with the UDCA group. The relative risk (RR) of liver transplantation (1.95; 95% CI: 1.14‐3.68) and development of esophageal varices (3.11; 95% CI: 1.57‐10.65) were significantly higher in the placebo group compared with the UDCA group. There were no significant increases in the RR of ascites, variceal bleeding, encephalopathy, or death between the two groups. Based on the estimated annual cost of managing these events and the annual costs of UDCA ($2,500), there was an annual cost savings per patient of $1,372. Compared with the placebo group, patients receiving UDCA had a lower incidence of major complications and lower medical care costs.
ABSTRACT OBJECTIVE: To describe the quality of diabetes care delivered by academic endocrinologists practicing at 4 teaching hospitals affiliated with a single medical school. METHODS: Up to 30 ...patients who first saw an endocrinologist for an ambulatory consultation for diabetes between January 2004 and December 2005 were randomly selected for chart review. Process and intermediate measures of quality of care were abstracted. RESULTS: There were 417 patient charts available for analysis. Quality of care was generally high, with 61% of patients achieving a glycated hemoglobin of ≤ 7.0%, 77% achieving blood pressure ≤ 130/80 mm Hg and 73% achieving a low-density lipoprotein cholesterol level of ≤ 2.5 mmol/L. More than 80% of patients had had eye examinations, microalbuminuria screening and foot examinations. There were no significant differences in quality between hospitals. CONCLUSIONS: The quality of diabetes care delivered by academic endocrinologists in this setting was high and approached the "ideal" levels of care recommended by practice guidelines. Compared to past studies in both the primary and specialist care settings, the results show that high-quality care can be delivered in routine academic clinical practice without having previously instituted a specific quality improvement program.
We investigated symptoms suggestive of swallowing problems in patients with primary biliary cirrhosis, some of whom displayed features of sicca complex. A prospective study of 95 consecutive patients ...with primary biliary cirrhosis was conducted at a single teaching hospital using a questionnaire administered over the telephone. Some symptoms of sicca complex (dry mouth and/or dry eyes) were found in 65 patients (68.4%). Subjective xerostomia alone was present in 45 patients (47.4%). The questionnaire revealed an increase in incidence of dysphagia in xerostomia subjects, affecting 21 of 45 patients, compared with 6 of 50 non-xerostomia patients. Multivariate logistic regression analysis showed that confounding factors such as age, obesity, cigarette smoking, and medications associated with a dry mouth could not explain these findings. Twenty-eight patients complained of hoarseness, 23 of coughing, and 14 of wheezing, all of which were significantly more frequent than in the 50 patients without xerostomia. Heartburn affected 17 xerostomia patients and 15 non-xerostomia patients, indicating no difference in frequency between these two groups, even after age, obesity, cigarette smoking, and medications associated with heartburn were considered in the multivariate analysis. Acid regurgitation, nausea, and vomiting were also similar in frequency between patients with and without xerostomia. Swallowing problems, manifested primarily as dysphagia, are common in primary biliary cirrhosis patients who have subjective xerostomia.
Background & Aims: Hepatic osteodystrophy is a complication of primary biliary cirrhosis (PBC). Allelic polymorphisms of the vitamin D receptor (VDR) gene are related to bone mineral density (BMD) in ...normal cohorts and those with primary osteoporosis. We sought to establish the prevalence of reduced bone mass in PBC, correlate BMD with VDR gene polymorphisms, and identify risk factors for the development of hepatic osteodystrophy.
Methods: Seventy-two female patients with PBC were evaluated prospectively. Clinical information, BMD assessment, disease severity, and osteoporosis risk factors were documented, and multivariate regression modeling was performed.
Results: Twenty-four percent of the patients were osteoporotic at the lumbar spine and 32% at the femur. Severe bone loss (z score <−2.0) occurs 4 times more frequently in patients with PBC compared with controls. Body weight (
P = 0.003) and postmenopausal status (
P = 0.012) correlated independently with BMD. VDR genotype (
P = 0.01) correlated with lower BMD at the spine only.
Conclusions: Osteoporosis is a common complication of PBC. VDR genotype predicts lower BMD in patients with PBC. Studies are warranted to investigate the mechanism(s) by which VDR as well as other candidate genes may contribute to the development of hepatic osteodystrophy in PBC.
GASTROENTEROLOGY 2000;118:145-151
Retrospective studies have reported that subtypes of antimitochondrial antibodies (AMAs) discriminate between a benign and a progressive course in patients with primary biliary cirrhosis (PBC). Four ...AMA profiles (A-D) were defined: profiles A and B associated with a benign course and C and D with a progressive course. We aimed to confirm whether AMA profiles predict prognosis in a large sample of North American patients with PBC.
Stored pretreatment sera from patients with PBC from two centers were tested for AMA profiles using standard techniques. Proportions of patients in each profile group reaching the endpoints of liver transplantation or death from liver disease were compared. Kaplan-Meier curves were constructed comparing AMA profiles.
All 472 patients studied had AMA positive, biopsy-confirmed PBC. Mean age at diagnosis was 53 yr, 90% were female, mean follow-up was 7.6 yr (range = 0.5-23), and 51% received ursodeoxycholic acid for >6 months. Profile A was not detected; 16.7% had profile B; 51.1%, profile C; and 32.2%, profile D. Duration of follow-up was comparable among the different profile groups. The proportions of patients reaching endpoints of death from liver disease or transplantation did not differ among the AMA profiles. No difference in the Kaplan-Meier curves between the different profile groups was observed (p > 0.05).
AMA profiles do not predict prognosis in patients with PBC.
OBJECTIVE: The Métis are a distinct Aboriginal people in Canada with a unique history, culture, and language. This study examined diabetes prevalence and care in the Métis of Ontario. RESEARCH DESIGN ...AND METHODS: The 14,480 people in the citizenship registry of the Métis Nation of Ontario were linked with provincial health care databases to determine diabetes prevalence and processes of care. Rates were compared between the Métis and the general Ontario population. RESULTS: The age/sex standardized prevalence of diabetes for the Métis was 11.2%, nearly 25% higher than that of the general Ontario population. Métis were more likely to be hospitalized (12.7 vs. 10.7%) or require emergency room visits (36.1 vs. 27.7%). CONCLUSIONS: Métis people have an increased burden of diabetes that puts them at risk for complications and morbidity. Ensuring adequate access to and quality of care for diabetes is essential to maintain the health of the Métis people.
Antinuclear antibodies (ANA) staining nuclear dot structures predominantly occur in primary biliary cirrhosis (PBC) patients and recognize the Sp100 and promyelocytic leukemia protein (PML). From ...retrospective analysis of sera from a clinically well-defined Canadian series of 170 PBC patients included into a 24-month therapeutic trial of ursodeoxycholic acid (UDCA), we report the prevalence of these ANA and their dynamics in the course of the disease. Using an enzyme-linked immunosorbent assay (ELISA), anti-Sp100 autoantibodies were shown in 35 (21%) patients. Thirty-three patients (19%) had autoantibodies against PML as determined by indirect immunostaining of cells overexpressing PML. Altogether, anti-nuclear dot autoantibodies were present in 25% of the 170 PBC patients. Their occurrence correlated with an unfavorable disease course, because these patients progressed significantly more frequently from early stages (I/II) to late stages (III/IV) within the 24-month observation period (P < .05). During the course of the disease, the autoantibody levels against the Sp100 full-length protein remained nearly constant in all 35 positive patients. However, 9 patients showed remarkable changes in Sp100 epitope recognition as revealed by ELISA and immunoblotting. When the occurrence of these changes and the treatment of the patients were compared retrospectively, it became evident that 8 of the 9 patients had received UDCA (42% of all Sp100-positive patients treated with UDCA). These findings indicate subtle changes of the Sp100 epitope recognition pattern during the natural course of the disease and its induction or acceleration by UDCA treatment. This implies that UDCA can modulate immunoglobulin (Ig) expression not only quantitatively, but also qualitatively. (Hepatology 1997 Nov;26(5):1123-30)
Background/Aims
: An association of Class II HLA-DR8 antigen is reported in patients with serum antimitochondrial antibodies (AMA)-positive primary biliary cirrhosis (PBC); no information exists as ...to an association with AMA-negative PBC. We compared the frequency of HLA Class II genes in AMA-positive and AMA-negative PBC patients and healthy controls.
Methods
: Genomic DNA was extracted from the blood of 154 AMA-positive and 26 AMA-negative Caucasian PBC patients and from 216 healthy Caucasian controls and tested for the alleles at two HLA Class II loci, DR
β1 and DQ
β1.
Results
: Higher allele frequencies of HLA-DR
β1*08 and DQ
β1*04 were found in the AMA-positive PBC patients versus controls (14.9% vs. 6.5%, odds ratio (OR)=3.3, global
P
=0.03 and 14.4% vs. 6.5%, OR=2.6, global
P
=0.002). All patients positive for DR
β1*0801 were positive for the DQ
β1*0402 allele, delta score=22 for AMA-positive patients, 11 for controls. In AMA-negative PBC, the frequency of DR
β1*08 and DQ
β1*04 was 0%, significantly different from the AMA-positive patients (
P
=0.05,
P
=0.05).
Conclusions
: AMA response may identify a group of PBC patients with a distinctive expression of the disease with the response associated with a gene(s) in the class II region of the major histocompatibility complex on the short arm of chromosome 6.
OBJECTIVE: To examine whether quality of diabetes care is equitable for South Asian and Chinese patients in an urban Canadian setting. RESEARCH DESIGN AND METHODS: Process and intermediate measures ...of quality of care were compared between 246 South Asians, 170 Chinese, and 431 patients from the general population with type 2 diabetes selected from 45 family physicians’ practices. RESULTS: A total of 61% of Chinese achieved A1C ≤7.0% versus 45% of South Asians and 49% of the general population (P < 0.05). They were also more likely to achieve LDL cholesterol ≤2.0 mmol/L, while South Asians were more likely to achieve blood pressure ≤130/80. There was only one significant process of care deficiency: fewer foot examinations among South Asians (34 vs. 49% for the general population, P < 0.01). CONCLUSIONS: Quality of diabetes care in a Canadian urban setting was equitable, with ethnic minorities somewhat more likely to achieve recommended targets than the general population.
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