Defining the Health Needs of Patients with Type II Diabetes

An approach based on a case cohort study

George Karystianis

School of Computer Science

2

Motivation

● Complex health problem related with various diseases.

● Comprehend the diabetic needs from different health

perspectives.

● Improve the quality of the provided health care.

3

AimsTo perform a preliminary analysis in a case cohort study:

● To observe the incidence of Type II diabetes.

●To understand the relation between diabetes, depression, CVDs, hypertension.

● To discover markers for the onset of diabetes or progression states.

● To examine the extent of polypharmacy.

4

Objectives

● To suggest a relation between diabetes and

depression, cardiovascular diseases, hypertension.

● To discover the number of diabetic patients, the

number and the type of prescribed medications.

● To find any diseases before and after the diabetes

onset.

5

Diabetes (1)

● Diabetes Mellitus.

● Production of excessive sweet urine (“glycosuria”).

● Syndrome of disordered metabolism.

● Hereditary and environmental factors.

● Elevated levels of blood sugar (glucose).

● Controlled mainly by the hormone insulin.

6

Insulin (1)

● Hormone.

● Produced from the β-cells in the isles of pancreas.

● Uptake of glucose from the blood to cells.

● Glucose the conversion product between carbohydrates.

7

Insulin (2)

Pangreas InsulinIsles of

Langerlans

β-cells

Food Glucose

Uptake glucose

Cells Liver,Muscle cells

Glucose used as fuel

Storage

Bloodcirculation

Limited insulinproduction

Storaged glucosere-enters

blood stream

Low glucose levels

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Diabetes (2)

DIABETES

TYPE I

TYPE II

Genetic Inheritance

&Environmental

triggers

Sedentary Lifestyle

&Obesity

Lack of insulin

Insulin resistance

Risk factors Complications

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Diabetes Type I

Symptoms

Increased thristWeight loss

Increased appetiteFrequent urination

Weakness

Cure

CausesEnvironmental

factors

10

Diabetes Type II

● Worldwide problem.

● Part of the metabolic syndrome.

● Reduced insulin sensitivity or (rarely) decreased insulin secretion.

● High insulin levels in the blood (hyperglycemia).

11

Diagnosis

WHO criteria:● fasting plasma glucose level >= 126mg/dL (7.0mmol/L), ● plasma glucose >= 200mg/dL (11.1mmol/L) two hours

after a 75g oral glucose load, ● a glucose tolerance test, symptoms of hyperglycemia

and casual plasma glucose >= 200mg/dL (11.1mmol/L). ● Fuzzy diabetes classification in children.

12

Risk factors

Obesity

Genetic factor

Lack ofexercise

Unhealthy diet

Socioeconomicalstatus

Sedentary lifestyle

Sex

Insulin resistance

Type II

13

Symptoms

Leg pain

Slow healing

Frequent urination

Itching skin

Blurred vision

Excessive thirst

Dry mouth

Symptoms

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Treatment

Oral antidiabetic medications

Prevention

Glibenclamide Metformin

Delay

LifestyleinterventionsHealthy dietPhysical

activity

No definitivecure

Golden standard treatment

Cure

Official guidelines

Losingweight

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Impaired Glucose Tolerance (IGT)Impaired Fasting Glucose (IFG)

IFGIGT

High risk groups for diabetes onset

plasma glucose >= 140 mg/dL (7.8mmol/L)

2hs after a 75g oral glucose load

fasting glucose levels from 110 to 125mg/dL

(6.1mmol/L – 7mmol/L).

PreventionLifestyle interventions

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Example

Figure 1: Reduction in risk of progressing from IGT to diabetes as a result of changes in intensive lifestyle [Paul Zimmet et al 2001].

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Complications

AcuteChronic

HyperglycemiaHypersmolar state

Hypoglycemia

Diabetic foot

Carotid arterystenosis Diabetic

KetoacidosisDiabetic

nephropathy

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Diabetes and depression

● Evidence about depression and Type II. ● 121 million depressed people worldwide. ● Risk factor for onset or progression state. ● Treatment for depression led to an earlier diagnosis.● 37% increased risk of Type II.

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Diabetes and cardiovascular diseases

● Myocardial infarction, coronary heart disease, stroke related strongly.

● Limited studies – Susceptible diabetics in major CV events.

● Cause of death.

● Treatment of diabetic patients as non-diabetic patients with CV events?

● Study in Finland - treating diabetics as non diabetic.

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Diabetes and hypertension

● One of the most important CVD risk factors.

● Complex relationship with diabetes.

● 1 billion people worldwide.

● Antihypertensive medications increasing risk of diabetes onset ?

●Study in U.S disproving it but still not clear.

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Polypharmacy

● Successful treatment of a disease group through multiple medications.

● Probably necessary against chronic conditions.

● Adverse drug events.

● Multiple prescribers, existence of different therapies, psychological factors, adverse drug events.

● Decrease in health care quality, high medical costs, therapy duplication, adverse drug events.

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Overview of the methodology

Case cohort Study

2003-06QueriesServer

Total

Disease

Medication

Per year200420052006

Diagrams

Conclusions

Returned results

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Research methods (1) First part.

● Use of diabetes diagnosis/drug read codes for queries.● Definition of the diabetic population with the best result

query.● Discover the incidence of Type II in total with the query.● Apply of diagnosis/drug read code queries for the

diseases of interest.● Selection of queries with the best results.

QUERIES ABOUT DIABETES TYPE II READ CODES (DIAGNOSIS AND READ CODES)

Diagnosed as diabetic Type II C10F.%

Metformin f4%

Glibenclamide (glyburide) f33%

Sulfunylureas f3%

Metformin and sulfonylureas f4% and f3%

Rosiglitazone ft4%

Pioglitazone ft5%

Metformin and rosiglitazone f4% and ft4%

Metformin and pioglitazone f4% and ft5%

Metformin and pioglitazone ft4% and f3A%

Rosiglitazone and glimepiride ft7%

Metformin and repaglinide f4% and ft3%

Metformin and nateglinide f4% and ft6%

Repaglinide ft3%

Nateglinide ft6%

Metformin but not short-acting insulin and not medium/long lasting insulin

f4% not f1% and not f2%

Long lasting insulin f2%

Short lasting insulin f1%

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Research methods (2)

Query with the best returned results:

Individuals diagnosed as diabetic Type II (C10F.%) or individuals prescribed with the drug Metformin (f4%) or

with any other drug belonging to the sulfonylureas group (f3%).

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DISEASE READ CODE

Coronary heart disease G340.

Myocardial infarction G30..

Stroke G66%

Hypertension (essential) G20..

Hypertensive disease G2…

Depressed or symptoms of depression or neurotic depression

or depression

1B17. or 1B1U. or Eu341 or Eu32z

DRUG READ CODE DISEASE

ACE inhibitors bi% common for stroke, myocardial infarction, hypertension, coronary heart disease

Statins bx% common for stroke, myocardial infarction,coronary heart

disease

Aspirin bu2% common for stroke, myocardial infarction,coronary heart

disease

Beta Blockers bd% common for myocardial infarction,hypertension, coronary heart disease

Nitrates bl1% or bl2% or bl3% common for myocardial infarction, coronary heart

isease

Clopidogrel bu5% common for stroke, myocardial infarction

Thrombolytic agents bs% or br% common for stroke, myocardial infarction

ACE inhibitors and Diuretics (thiazide group)

bi% & b2% hypertension

ACE inhibitors and angiotensin 2 receptor

antagonists

bi% & bk% hypertension

Angiotensin 2 receptor antagonists

bk% hypertension

Alpha blockers bh% hypertension

All Diuretics groups b3% or b2% or b4% or b9% or b5%

hypertension

Diuretics (Thiazide group) b2% hypertension

SSRI antidepressants da% depression

Tricyclic antidepressants d7% depression

Diseases diagnosis read codes

Medications read codes

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Research methods (3)

Second part.● Same methodology to be used for every year.

Third part.● Same methodology for the years 2004-06.● Discover the diabetic group in each year.● Search about diseases before and after the onset.● Examination as markers or as progression states.

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Data

● Case cohort study from health patient records.● Hospitals, health communities, GPs.● Salford, Manchester, U.K.● Approximately 20.000 health records.

Patient ID RubricGP codeRead CodeDate

Record clinical Summary

information

Recorded date

of medical procedures

Distinction between patients

Pseudonymized id for GPs

distinction

Free text describing the

meaning of RC

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Read Codes● Standardization of medical data recording. ● Developed within disease areas (chapters). ● Individuality, limit the amount of written stuff, help

communication between IT systems. ● Max length: five characters.

Example:

          G30..    Acute Myocardial Infarction

          G30y.  Other Acute Myocardial Infarction

          G30y2  Acute Septal Infarction

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Quality Control

● Duplicate entries, wrong diagnosis/drug treatment.

● Different codes.

● Queries with only distinct patient id.

● Exclusion of a number of cases due to bad recording or wrong code.

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Ethical considerations

● Anonymous data.

● Protection of confidentiality and availability.● limited access to a server.

● Written letter approval from ethics committee of University of Manchester.

●(Yeah!)

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Results (1)

● Diabetes an epidemic.● Number of diabetics increasing through the years. ● More related to depression, hypertensive group.● Hypertensive group had the biggest incidence.● Steady rise in depression. ● Limited number of CV diseases. ● Decline through the years, especially those of

coronary heart disease.

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2003-2006 diseases in total

0

500

1000

1500

2000

2500

3000

1

Number of patients with other diseases besides diabetes Type II

myocardial infarctionstrokeHypertensive diseaseshypertensioncoronary heart diseasedepression

Figure 1: Overview of the diabetic patients’ numbers with other diseases based on diagnosis read codes for all the years (2003-06).

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2003-2006 prescribed drugs in total

0

1000

2000

3000

4000

5000

6000

1Drugs

Number of drug prescriptions in diabetic patients in total

ACE inhibitors

s tatins

aspirin

beta blockers

nitrates

throm bolytic agents-clot busting drugs(anticoagulant or parental anticoagulant)clopidogrel

SSRI depressants

tricyclic antidepressants

ACE inhibitors and diuretics (thiazide group)

ACE inhibitors and angiotens in 2 receptorantagonis tsangiontens in 2 receptor antagonis ts

alpha blockers

diuretics (thiazide group)

diuretics

Figure 1: Overview of prescribed drugs in diabetic patients for all the years (2003-06).

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Progression of diabetes rates from 2003-06

0

1000

2000

3000

4000

5000

6000

7000

2003 2004 2005 2006

Progression of diabetes Type II from 2003 to 2006

diabetes

Figure 1: Overview of diabetic patients through the years 2003-6 based on the diagnosis read code for diabetes Type II (C10F.%) and the read codes for the prescribed oral antidiabetic drugs such as the sulfolynurea group (f3%) and metformin (f4%).

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Diseases per yearOverview of the progression for patients with diseases besides

diabetes through the years 2003-06

0

100

200

300

400

500

600

700

800

2003 2004 2005 2006

Years

Num

ber

of p

atie

nts myocardial infarction

strokeHypertensive diseaseshypertensioncoronary heart diseasedepression

Figure 1: Progression of diseases in diabetic patients through the years 2003-2006 based on diagnosis codes.

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Prescribed medications per yearDrug prescriptions in diabetic patients through the years 2003-6

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

2003 2004 2005 2006

Years

Nu

mb

er

of

pre

scri

pti

on

s

ACE inhibitors

statins

aspirin

beta blockers

nitrates

thrombolytic agents-clot busting drugs(anticoagulant or parental anticoagulant)clopidogrel

SSRI depressants

tricyclic antidepressants

ACE inhibitors and diuretics (thiazidegroup)ACE inhibitors and angiotensin 2receptor antagonistsangiontensin 2 receptor antagonists

alpha blockers

diuretics (thiazide group)

diuretics

Figure 1: Progression of the drug prescriptions in diabetic patients though the years 2003-2006 based on drug read codes.

37

Results (2)

● Low increase before the onset.● Least possible to be considered as a

marker for diabetes. ● Coronary heart disease possible no

existing association.

● Escalation of rates before the onset -

possible marker.● Early treatment may lead to early

diabetes diagnosis.

● Prevalent disease group.● Increased before onset - possible marker.

Depression

Hypertensive group

CVDs

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Results (3)

Depression

Hypertensive group

CVDs

● Limited rates after the onset.● Rise of myocardial infarction.-possible

complication (highest rates). ● Highest prescriptions. ● Stroke and coronary heart low rates.

● Stable rates tended to increase. ● High prescriptions after the onset. ● More as a marker and less as a

complication.

● Large decrease. ● Among the most prescribed drugs.● More as a marker.

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Disease cases before and after the onset of Type II

Number of diabetic patients with diseases developed a year before and after their diabetes onset

0

50

100

150

200

250

300

350

400

450

500

a year before year of onset a year after

Num

ber o

f pat

ient

s

DepressionHypertensive diseasehypertensionMyocardial infarctionCoronary heart diseaseStroke

Figure 1: Figure presenting the number of diabetic patients with other diseases one year before, during and after their classification as diabetic based on diagnosis read codes.

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Prescribed medications before and after the onset of Type II

Number of medications prescribed on diabetic patients a year before and after their diabetes onset

0

200

400

600

800

1000

1200

1400

1600

a year before year of onset a year after

Nu

mb

er

of

pre

scri

pti

on

s

thrombolytic agents-clot busting drugs(anticoagulant or parental anticoagulant)clopidogrel

nitrates

ace inhibitors

aspirin

statins

beta blockers

SSRI antidepressants

tricyclic antidepressants

diuretics

angiotensin receptor II antagonists

alpha blockers

Diuretics thiazide group

ACE inhibitors and diuretics (thiazidegroup)ACE inhibitors and angiotensin receptor IIantagonists

Figure 1: Diagram of the prescribed medications in diabetic patients for one year before their classification as diabetic, for the year diagnosed with diabetes and for one year their diabetes onset based on medication read codes.

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Conclusions (1)

● Diabetes related depression or hypertension rather

CVDs. ● Escalation of depression rates yearly.● Hypertensive diseases possible marker.● Myocardial infarction slow increase.● Stroke, coronary heart disease no possible pattern.● Application of polypharmacy.

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Conclusions (2)

● Large population research aiming depression and

hypertensive diseases. ● Recording of diagnosis and prescribed medications. ● Careful implementation of polypharmacy.● Review and evaluation of patient’s drug list. ● Creation of detailed diabetic guidelines.● Diabetes a part of an underlying disease.● Aggressive treatment.

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