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Groupe de recherche PRIMUS
Time to Insulin Initiation in Diabetic Patients: A Quebec Population-Based Analysis
Present by: Shabnam Asghari M.D. Ph.D.
Epidemiologist, PRIMUS research group
Research team
Alain Vanasse MD, PhD, FCMF Professor in the Department of Family Medicine and Director of the PRIMUS
Research Group
Shabnam Asghari MD, PhD Researcher, PRIMUS Research Group
Josiane Courteau PhD Researcher, PRIMUS Research Group
Catherine Drouin PhD(C) PhD candidate, PRIMUS Research Group
André C. Carpentier MD Professor in the Department of Medicine
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Miracle of Insulin
Before insulin was discovered in 1921, everyone with type 1 diabetes died within weeks to years of its onset
Background
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Insulin initiation
• All adults and children with type 1 diabetes begin the use of insulin as their first medication.
• The number of adults beginning insulin therapy has increased in recent years (Davis ,2006).
Background
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Early Initiation of Insulin for Adults
Early initiation of insulin is a marker of type 1 diabetes in adults
Time to insulin initiation cannot be used in defining latent autoimmune diabetes in adults (Brophy, 2008)
Background
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Previous studies
• There are wide variations in practice among the multidisciplinary team
and • There is little published regarding the
insulin initiation in patients with type 2 diabetes.(Davis RE ,2006; Yeap B,2007)
Background
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Why early initiation of insulin
• The link between hyperglycemia and increased overall mortality
• Improvement in glycemic control
• Reduce and delay the onset of diabetic complications.
(Davis, RE. ,2006; Liebl, A. , 2007; Meneghini,L., 2008)
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Background
Why delay
• Delays in initiating insulin may come from both physician and patient barriers. (Haque,M. ,2005; Oliveria,S.A. 2007)
• Time to insulin treatment is dependent on local clinical judgment and not on the disease process. (Brophy,S. 2008)
Background
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Study objective
To measure, describe and compare “time to insulin” initiation in incident cases of diabetes
by age and gender
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Outcome: Time from diabetes diagnosis to insulin initiation
Measure of time : Days
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Methodology
Data Sources
• Hospital discharge registry (MedEcho)
• Death registry (MSSS)
• Beneficiary registry (RAMQ)
• Pharmacological registry (RAMQ)
Methodology
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Study Population
An exhaustive cohort of incident cases of diabetes aged 20 years and older in 1995
Methodology
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Diabetes case definition
• Diabetes cases Two physician claims with a diagnosis of
diabetes (ICD-9 Code 250) or one hospital discharge (Canadian National Diabetes Surveillance
System’s case definition for administrative data). • Incident cases of diabetes A diabetes case using NDSS with a one
ICD code 250 for a 5 year clearance period (Asghari S et al,2008).
Methodology
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Study Design
An exhaustive retrospective cohort of diabetes cases for 1995 in the
province of Quebec were followed-up until the date of insulin initiation,
death or December 31, 2004, whichever occurred first.
Methodology
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Eligibility Criteria
Inclusion criteria• New cases of diabetes
(by NDSS+ one ICD code 250 for a 5 year clearance period)
• ≥ 20 years old• Living in the province
of Quebec • Covered by the public
drug insurance
Exclusion criteria
• Gestational diabetes
Methodology
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Other variables
• Age
• Gender
Methodology
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Statistical Analysis
The Kaplan-Meier method was used to estimate time from diabetes diagnosis to insulin initiation and to compare ‘survival
curves’.
Methodology
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Results
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Results
A total of 17,828 patients met the selection criteria (mean age: 68.9 years ± 12.0;
female: 54.5%).
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• Overall, 13.7% (N=2444) (mean age: 63.7; 95% CI: 63.2-64.3) claimed at least one prescription of insulin during the follow-up period.
• 1 out of 3 began insulin in the first year.
Results
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No significant difference between gender
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Time to insulin curves differ significantly between age groups.
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15%
Discussion
More than 86% of diabetic patients had no insulin initiation during the ten-year follow-up.
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Discussion
Younger patients (20-39 years) were more likely to initiate early insulin therapy.
Although a recent study revealed that time to insulin cannot be used in defining
diabetes types. The result of this large scale study suggests that insulin was
initiated early for younger adults which are more prone to have type 1 diabetes.
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More studies are needed to confirm the hypothesis of using early insulin initiation as a marker of type 1 diabetes in adults
in a medico-administrative database. We also suggest another study to find PPV and NPV of early insulin initiation using
patient records and medico-administrative data
Suggestion
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Research team
Alain Vanasse MD, PhD, FCMF Professor in the Department of Family Medicine and Director of the PRIMUS
Research Group
Shabnam Asghari MD, PhD Researcher, PRIMUS Research Group
Josiane Courteau PhD Researcher, PRIMUS Research Group
Catherine Drouin PhD(C) PhD candidate, PRIMUS Research Group
André C. Carpentier MD Professor in the Department of Medicine
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??• Groupe de recherche PRIMUS http://pages.usherbrooke.ca/primus
• Alain.Vanasse@USherbrooke.ca
• CHUS,3001-12e Avenue Nord, Sherbrooke Québec, Canada ,J1H 5N4
• Telephone : 819- 820-6868, poste 15130
Fax: 819- 564-5424
Contact
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