Abstract
This cross-sectional study aimed to investigate the quality of care of diabetes in Shanghai, China. A total of 173 235 patients with type 2 diabetes in 2017 were included in the analysis. Profiles of risk factors and intermediate outcomes were determined. The patients had a mean age of 66.43 ± 8.12 (standard deviation (SD)) years and a mean diabetes duration of 7.95 ± 5.53 (SD) years. The percentage of patients who achieved the target level for HbA1c (< 7.0%) was 48.6%. Patients who achieved the target levels for blood pressure (BP) < 130/80 mmHg and low-density lipoprotein-cholesterol (LDL-c) < 2.6 mmol/L reached 17.5% and 34.0%, respectively. A total of 3.8% achieved all three target levels, and the value increased to 6.8% with an adaptation of the BP target level (< 140/90 mmHg) for those over 65 years. Multivariable analysis identified the factors associated with a great likelihood of achieving all three target levels: male, young age, short diabetes duration, low body mass index, macrovascular complications, no microvascular complications, prescribed with lipid-lowering medication, and no prescription of antihypertensive medication. In conclusion, nearly 50% and one-third of the patients with diabetes met the target levels for HbA1c and LDL-c, respectively, with a low percentage achieving the BP target level. The percentage of patients who achieved all three target levels needs significant improvement.
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References
International Diabetes Federation. IDF Diabetes Atlas, 9th ed. Brussels, Belgium: International Diabetes Federation. 2019. http://www.diabetesatlas.org (accessed April 26, 2021)
Pan XR, Yang WY, Li GW, Liu J; National Diabetes Prevention and Control Cooperative Group. Prevalence of diabetes and its risk factors in China, 1994. Diabetes Care 1997; 20(11): 1664–1669
Yang W, Lu J, Weng J, Jia W, Ji L, Xiao J, Shan Z, Liu J, Tian H, Ji Q, Zhu D, Ge J, Lin L, Chen L, Guo X, Zhao Z, Li Q, Zhou Z, Shan G, He J; China National Diabetes and Metabolic Disorders Study Group. Prevalence of diabetes among men and women in China. N Engl J Med 2010; 362(12): 1090–1101
Wang L, Gao P, Zhang M, Huang Z, Zhang D, Deng Q, Li Y, Zhao Z, Qin X, Jin D, Zhou M, Tang X, Hu Y, Wang L. Prevalence and ethnic pattern of diabetes and prediabetes in China in 2013. JAMA 2017; 317(24): 2515–2523
Li Y, Teng D, Shi X, Qin G, Qin Y, Quan H, Shi B, Sun H, Ba J, Chen B, Du J, He L, Lai X, Li Y, Chi H, Liao E, Liu C, Liu L, Tang X, Tong N, Wang G, Zhang JA, Wang Y, Xue Y, Yan L, Yang J, Yang L, Yao Y, Ye Z, Zhang Q, Zhang L, Zhu J, Zhu M, Ning G, Mu Y, Zhao J, Teng W, Shan Z. Prevalence of diabetes recorded in mainland China using 2018 diagnostic criteria from the American Diabetes Association: national cross sectional study. BMJ 2020; 369: m997
World Health Organization. Global action plan for the prevention and control of noncommunicable diseases 2013–2020. Geneva: World Health Organization. 2013. https://apps.who.int/iris/handle/10665/94384 (accessed April 26, 2021)
United Nations. Sustainable development goals. 2015. https://sustainabledevelopment.un.org/sdg3. (accessed April 26, 2021)
Meng Q, Mills A, Wang L, Han Q. What can we learn from China’s health system reform? BMJ 2019; 365: l2349
Yuan B, Balabanova D, Gao J, Tang S, Guo Y. Strengthening public health services to achieve universal health coverage in China. BMJ 2019; 365: l2358
Jia W, Weng J, Zhu D, Ji L, Lu J, Zhou Z, Zou D, Guo L, Ji Q, Chen L, Chen L, Dou J, Guo X, Kuang H, Li L, Li Q, Li X, Liu J, Ran X, Shi L, Song G, Xiao X, Yang L, Zhao Z; Chinese Diabetes Society. Standards of medical care for type 2 diabetes in China 2019. Diabetes Metab Res Rev 2019; 35(6): e3158
American Diabetes Association. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Medical Care in Diabetes-2021. Diabetes Care 2021; 44(Suppl 1): S40–S52
Cholesterol Treatment Trialists’ (CTT) Collaboration; Baigent C, Blackwell L, Emberson J, Holland LE, Reith C, Bhala N, Peto R, Barnes EH, Keech A, Simes J, Collins R. Efficacy and safety of more intensive lowering of LDL cholesterol: a meta-analysis of data from 170,000 participants in 26 randomised trials. Lancet 2010; 376 (9753): 1670–1681
Ji L, Hu D, Pan C, Weng J, Huo Y, Ma C, Mu Y, Hao C, Ji Q, Ran X, Su B, Zhuo H, Fox KA, Weber M, Zhang D; CCMR Advisory Board; CCMR-3B STUDY Investigators. Primacy of the 3B approach to control risk factors for cardiovascular disease in type 2 diabetes patients. Am J Med 2013; 126(10): 925.e11–925.e22
Ruan Y, Yan QH, Xu JY, Yang QD, Yao HH, Li R, Shi Y. Epidemiology of diabetes in adults aged 35 and older from Shanghai, China. Biomed Environ Sci 2016; 29(6): 408–116
Liu Y, Wu X, Cai C, Tang PY, Coufal MM, Qian Y, Luu SL, Fisher EB, Jia W. Peer support in Shanghai’s Commitment to diabetes and chronic disease self-management: program development, program expansion, and policy. Transl Behav Med 2020; 10(1): 13–24
Scanlon PH, Malhotra R, Greenwood RH, Aldington SJ, Foy C, Flatman M, Downes S. Comparison of two reference standards in validating two field mydriatic digital photography as a method of screening for diabetic retinopathy. Br J Ophthalmol 2003; 87(10): 1258–1263
World Health Organization. Prevention of blindness from diabetes mellitus: report of a WHO consultation in Geneva, Switzerland. 2006. https://www.who.int/diabetes/publications/prevention_diabetes2006/en/ (accessed March 10, 2020)
Writing Group of 2018 Chinese Guidelines for the Management of Hypertension, Chinese Hypertension League, Chinese Society of Cardiology, Chinese Medical Doctor Association Hypertension Committee, Hypertension Branch of China International Exchange and Promotive Association for Medical and Health Care, Hypertension Branch of Chinese Geriatric Medical Association. 2018 Chinese guidelines for the management of hypertension. Chin J Cardiovas Med 2019; 24: 24–56
Bao Y, Lu J, Wang C, Yang M, Li H, Zhang X, Zhu J, Lu H, Jia W, Xiang K. Optimal waist circumference cutoffs for abdominal obesity in Chinese. Atherosclerosis 2008; 201(2): 378–384
Wong TY, Sun J, Kawasaki R, Ruamviboonsuk P, Gupta N, Lansingh VC, Maia M, Mathenge W, Moreker S, Muqit MMK, Resnikoff S, Verdaguer J, Zhao P, Ferris F, Aiello LP, Taylor HR. Guidelines on diabetic eye care: the International Council of Ophthalmology Recommendations for Screening, Follow-up, Referral, and Treatment Based on Resource Settings. Ophthalmology 2018; 125(10): 1608–1622
Wilson PW, D’Agostino RB, Parise H, Sullivan L, Meigs JB. Metabolic syndrome as a precursor of cardiovascular disease and type 2 diabetes mellitus. Circulation 2005; 112(20): 3066–3072
Kanaya AM, Adler N, Moffet HH, Liu J, Schillinger D, Adams A, Ahmed AT, Karter AJ. Heterogeneity of diabetes outcomes among asians and pacific islanders in the US: the diabetes study of northern california (DISTANCE). Diabetes Care 2011; 34(4): 930–937
Selvin E, Steffes MW, Zhu H, Matsushita K, Wagenknecht L, Pankow J, Coresh J, Brancati FL. Glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults. N Engl J Med 2010; 362(9): 800–811
Kosiborod M, Gomes MB, Nicolucci A, Pocock S, Rathmann W, Shestakova MV, Watada H, Shimomura I, Chen H, Cid-Ruzafa J, Fenici P, Hammar N, Surmont F, Tang F, Khunti K; DISCOVER investigators. Vascular complications in patients with type 2 diabetes: prevalence and associated factors in 38 countries (the DISCOVER study program). Cardiovasc Diabetol 2018; 17(1): 150
Rawshani A, Rawshani A, Franzén S, Eliasson B, Svensson AM, Miftaraj M, McGuire DK, Sattar N, Rosengren A, Gudbjörnsdottir S. Mortality and cardiovascular disease in type 1 and type 2 diabetes. N Engl J Med 2017; 376(15): 1407–1418
Gaede P, Vedel P, Larsen N, Jensen GV, Parving HH, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 2003; 348(5): 383–393
Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med 2008; 358(6): 580–591
Bakke Å, Tran AT, Dalen I, Cooper JG, Løvaas KF, Jenum AK, Berg TJ, Madsen TV, Nøkleby K, Gjelsvik B, Claudi T, Skeie S, Carlsen S, Sandberg S, Thue G. Population, general practitioner and practice characteristics are associated with screening procedures for microvascular complications in type 2 diabetes care in Norway. Diabet Med 2019; 36(11): 1431–1443
Seo DH, Kang S, Lee YH, Ha JY, Park JS, Lee BW, Kang ES, Ahn CW, Cha BS. Current management of type 2 diabetes mellitus in primary care clinics in Korea. Endocrinol Metab (Seoul) 2019; 34 (3): 282–290
Ali MK, Bullard KM, Saaddine JB, Cowie CC, Imperatore G, Gregg EW. Achievement of goals in U.S. diabetes care, 1999–2010. N Engl J Med 2013; 368(17): 1613–1624
Stone MA, Charpentier G, Doggen K, Kuss O, Lindblad U, Kellner C, Nolan J, Pazderska A, Rutten G, Trento M, Khunti K; GUIDANCE Study Group. Quality of care of people with type 2 diabetes in eight European countries: findings from the Guideline Adherence to Enhance Care (GUIDANCE) study. Diabetes Care 2013; 36(9): 2628–2638
Luk AOY, Hui EMT, Sin MC, Yeung CY, Chow WS, Ho AYY, Hung HF, Kan E, Ng CM, So WY, Yeung CK, Chan KS, Chan KW, Chan PF, Siu SC, Tiu SC, Yeung VTF, Chan JCN, Chan FWK, Cheung C, Cheung NT, Ho ST, Lam KSL, Yu LWL, Chao D, Lau IT. Declining trends of cardiovascular-renal complications and mortality in type 2 diabetes: the Hong Kong Diabetes Database. Diabetes Care 2017; 40(7): 928–935
De Cosmo S, Viazzi F, Pacilli A, Giorda C, Ceriello A, Gentile S, Russo G, Rossi MC, Nicolucci A, Guida P, Di Bartolo P, Pontremoli R; AMD-Annals Study Group. Achievement of therapeutic targets in patients with diabetes and chronic kidney disease: insights from the Associazione Medici Diabetologi Annals initiative. Nephrol Dial Transplant 2015; 30(9): 1526–1533
Kar D, Gillies C, Zaccardi F, Webb D, Seidu S, Tesfaye S, Davies M, Khunti K. Relationship of cardiometabolic parameters in non-smokers, current smokers, and quitters in diabetes: a systematic review and meta-analysis. Cardiovasc Diabetol 2016; 15(1): 158
Alomari MA, Khabour OF, Alzoubi KH, Shqair DM, Eissenberg T. Central and peripheral cardiovascular changes immediately after waterpipe smoking. Inhal Toxicol 2014; 26(10): 579–587
Cryer PE, Haymond MW, Santiago JV, Shah SD. Norepinephrine and epinephrine release and adrenergic mediation of smoking-associated hemodynamic and metabolic events. N Engl J Med 1976; 295(11): 573–577
Narkiewicz K, van de Borne PJ, Hausberg M, Cooley RL, Winniford MD, Davison DE, Somers VK. Cigarette smoking increases sympathetic outflow in humans. Circulation 1998; 98(6): 528–534
Waeber B, Schaller MD, Nussberger J, Bussien JP, Hofbauer KG, Brunner HR. Skin blood flow and cigarette smoking: the role of vasopressin. Clin Exp Hypertens A 1984; 6(10–11): 2003–2006
Li G, Wang H, Wang K, Wang W, Dong F, Qian Y, Gong H, Hui C, Xu G, Li Y, Pan L, Zhang B, Shan G. The association between smoking and blood pressure in men: a cross-sectional study. BMC Public Health 2017; 17(1): 797
Gordon T, Kannel WB, Dawber TR, McGee D. Changes associated with quitting cigarette smoking: the Framingham Study. Am Heart J 1975; 90(3): 322–328
Green MS, Harari G. A prospective study ofthe effects ofchanges in smoking habits on blood count, serum lipids and lipoproteins, body weight and blood pressure in occupationally active men. The Israeli CORDIS Study. J Clin Epidemiol 1995; 48(9): 1159–1166
Seltzer CC. Effect of smoking on blood pressure. Am Heart J 1974; 87(5): 558–564
Lee DH, Ha MH, Kim JR, Jacobs DR Jr. Effects of smoking cessation on changes in blood pressure and incidence of hypertension: a 4-year follow-up study. Hypertension 2001; 37(2): 194–198
Rawshani A, Rawshani A, Franzén S, Sattar N, Eliasson B, Svensson AM, Zethelius B, Miftaraj M, McGuire DK, Rosengren A, Gudbjörnsdottir S. Risk factors, mortality, and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med 2018; 379(7): 633–644
Fagard RH. Smoking amplifies cardiovascular risk in patients with hypertension and diabetes. Diabetes Care 2009; 32 (Suppl 2): S429–S431
Acknowledgements
We thank all the study participants for their contributions and appreciate the contributions made by all 240 CHCs of 16 districts and the Shanghai Municipal Government for funding support. This project was supported by the Shanghai Municipal Government Grants Award (No. GWIV-3), the Shanghai Health Policy Grant (No. 2019HP49), the Shanghai Health Commission Grant (No. 20194Y0141), the Shanghai Jiao Tong University Grant (No. CHDI-2018-A-05), the Shanghai Public Health Youth Award (No. GWV-10.2-YQ24), and the Three-Year Action Program of Shanghai Municipality for Strengthening the Construction of Public Health System (No. GWV-10.1-XK05).
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Chun Cai, Yuexing Liu, Yanyun Li, Yan Shi, Haidong Zou, Yuqian Bao, Yun Shen, Xin Cui, Chen Fu, Weiping Jia, and the SIM Study Group declare that they have no conflicts of interest. All procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients for being included in the study.
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Effectiveness of quality of care for patients with type 2 diabetes in China: findings from the Shanghai Integration Model (SIM)
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Cai, C., Liu, Y., Li, Y. et al. Effectiveness of quality of care for patients with type 2 diabetes in China: findings from the Shanghai Integration Model (SIM). Front. Med. 16, 126–138 (2022). https://doi.org/10.1007/s11684-021-0897-7
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DOI: https://doi.org/10.1007/s11684-021-0897-7