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Is the Rule of Halves framework relevant for diabetes care in Copenhagen today? A register-based cross-sectional study
  1. Astrid Ledgaard Holm1,
  2. Gregers Stig Andersen2,
  3. Marit E Jørgensen2,3,
  4. Finn Diderichsen1
  1. 1 Department of Public Health, University of Copenhagen, Copenhagen, Denmark
  2. 2 Clinical Epidemiology Research Group, Steno Diabetes Center Copenhagen, Gentofte, Denmark
  3. 3 National Institute of Public Health, Southern Denmark University, Odense, Denmark
  1. Correspondence to Dr Finn Diderichsen; fidi{at}


Objective The study aimed at analysing whether the ‘Rule of Halves’ framework applies for diabetes care in the Danish healthcare system with high levels of accessibility and equity. The Rule of Halves states that only one-half of people with a particular chronic condition are diagnosed; one-half of those diagnosed get treatment, and one-half of treated achieve desired therapeutic goals.

Design The analysis is cross sectional based on available surveys, register data and clinical databases covering the adult population in Copenhagen. We analysed five levels of prevention and care including behavioural risk factors and biomarkers, prevalence of diagnosed and undiagnosed diabetes as well as how many received care according to guidelines and achieved relevant outcomes.

Setting The study population is Copenhagen City with a population of 550 000 with 21 500 prevalent cases of diabetes. While the registers used cover the whole population, the surveys include 750 cases and the biobank data 365 cases.

Outcome measures Outcome measures are for each level of analysis: the prevalence of high-risk individuals, prevalence of undiagnosed and diagnosed diabetes, proportion receiving treatment and proportion achieving quality and treatment targets.

Results We found that the ‘Rule of Halves’ framework raises relevant questions on how diabetes care works in a specific population, but the actual proportions found in Copenhagen are far from halves. Our analyses showed that 74% are diagnosed and among those who are 90% are receiving care. 40%–60% have achieved target levels of treatment in terms of HbA1c level and lipid levels. 80% have received eye and foot examinations in the last 2 years. 11% have retinopathy and 25% have macrovascular complications.

Conclusion Copenhagen is doing much better than halves, when it comes to diagnosis and providing treatment, whereas the Rule of Halves still prevails when it comes to treatment targets. There is thus still room for improvement.

  • general diabetes
  • epidemiology
  • quality in healthcare

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  • Contributors ALH, FD and GSA conceptualised and designed the study. ALH and GSA have analysed registers and surveys and made the calculations. ALH made the first draft and FD, GSA and MEJ have contributed significantly to the revisions of the manuscript. All authors have approved the submission of this version of the manuscript.

  • Funding This study was conducted as part of the global mapping of urban diabetes challenges for the cities involved in the Cities Changing Diabetes programme initiated by Novo Nordisk. Novo Nordisk has partly financed the study.

  • Disclaimer Novo Nordisk has not been involved in the design, analyses or reporting of the study.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval The ethics protection committee of Copenhagen has approved the Copenhagen Midlife Biobank used in this study (H-A-2008-12-6). The public registers and survey data used are not subject to ethical approval according to Danish law. All data materials are registered with the Danish data protection agency (Datatilsynet).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The study is based on linked public registers and surveys. Accessible from Statistics Denmark with special permissions.

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