Hikmayani, Nur Hafidha; (2020) Quality of care in incident type 2 diabetes and initial presentation of vascular complications: Prospective cohort study using linked electronic health records from CALIBER research platform. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Background. Numbers of new cases of type 2 diabetes (T2D) are increasing rapidly. Early and continuing intervention after T2D presentation is crucial for best possible outcomes, ensuring that the existing high burden of T2D will not be aggravated. Identification of patterns of continuous care and predictors for meeting key targets for T2D management can improve quality of care. Glycaemic control is particularly important for primary prevention of vascular complications but its relationship with contemporary cardiovascular diseases (CVDs) has been less explored. More importantly, long-term glycaemic control can be assessed from routine monitoring, potentially providing new insight into T2D management to prevent vascular complications. Linked electronic health records are invaluable data resources for investigating these issues. Objective. To examine the quality of care in an incident T2D cohort through assessment of temporal trends of care, predictors of glycaemic, blood pressure and lipid control, and associations of short-term and long-term glycaemic control with chronic vascular complications. Methods. The data source for studies in this thesis was CALIBER which links electronic health records from primary care, hospitalisation, myocardial infarction and mortality registries. Patients newly diagnosed with T2D between 1998 and 2010 were followed-up until a censoring administrative date or initial occurrence of vascular complications. Trends in receipt of care and attainment of glycaemic, blood pressure and total cholesterol targets were examined. Predictors for meeting the targets were explored using multinomial logistic regressions. Association of early glycaemic control with a range of specific cardiovascular complications were investigated using Cox regressions. A longitudinal metric for glycaemic control was developed by quantifying time spent at target during follow-up and was tested for its association with cardiovascular and microvascular outcomes using mixed logistic regressions. Results. A total of 52,379 incident T2D patients were identified with a median follow-up of over 4 years. Positive trends were observed for blood pressure and total cholesterol control, but not for glycaemic control, whilst attainment of HbA1c and blood pressure targets over time consistently fell short. Older age at diagnosis was an important predictor for meeting the key targets. In 36,149 patients free from prior CVD, early glycaemic and blood pressure control was associated with lower risk for heart failure and peripheral arterial disease, whereas cholesterol control with myocardial infarction and transient ischaemic attack. Shorter duration at glycaemic target was associated with higher risk of major adverse cardiovascular events, cardiovascular death and diabetic retinopathy. Conclusions. This thesis highlights missed opportunities and inequality in T2D care. Both short-term and long-term glycaemic control are important for reducing risk of vascular complications. Limitations and implications of the findings for clinical practice and research were discussed.

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