Elsevier

Diabetes & Metabolism

Volume 37, Issue 2, April 2011, Pages 152-161
Diabetes & Metabolism

Original article
Trends in the quality of care for elderly people with type 2 diabetes: The need for improvements in safety and quality (the 2001 and 2007 ENTRED Surveys)Évolution de 2001 à 2007 de la qualité des soins reçue par les personnes âgées atteintes de diabète de type 2 (études Entred) : renforcer sécurité et qualité

https://doi.org/10.1016/j.diabet.2011.02.001Get rights and content

Abstract

Aim

This study aimed to characterize the sociodemographic data, health status, quality of care and 6-year trends in elderly people with type 2 diabetes.

Methods

This study used two French cross-sectional representative surveys of adults of all ages with all types of diabetes (Entred 2001 and 2007), which combined medical claims, and patient and medical provider questionnaires. The 2007 data in patients with type 2 diabetes aged 65 years or over (n = 1766) were described and compared with the 2001 data (n = 1801).

Results

Since 2001, obesity has increased (35% in 2007; +7 points since 2001) while written nutritional advice was less often provided (59%; −6 points). Mean HbA1c (7.1%; −0.2%), blood pressure (135/76 mmHg; −4/−3 mmHg) and LDL cholesterol (1.04 g/L; −0.21 g/L) declined, while the use of medication increased: at least two OHAs, 34% (+4 points); OHA(s) and insulin combined, 10% (+4 points); antihypertensive treatment, 83% (+4 points); and statins 48% (+26 points). Severe hypoglycaemia remained frequent (10% had an event at least once a year). The overall prevalence of complications increased. Renal complications were not monitored carefully enough (missing value for albuminuria: 42%; −4.5 points), and 46% of those with a glomerular filtration rate less than 60 mL/min/1.73 m2 were taking metformin.

Conclusion

Elderly people with type 2 diabetes are receiving better quality of care and have better control of cardiovascular risk factors than before. However, improvement is still required, in particular by performing better screening for complications. In this patient population, it is important to carefully monitor the risks for hypoglycaemia, hypotension, malnutrition and contraindications related to renal function.

Résumé

Objectif

Décrire les caractéristiques socioéconomiques, l’état de santé, la qualité des soins reçue par les personnes âgées atteintes d’un diabète de type 2, et leurs évolutions (2001–2007).

Méthodes

Nous avons utilisé deux études représentatives des personnes diabétiques de tout type et de tout âge (Entred 2001 et 2007) combinant consommation médicale, questionnaires médecins et patients. Nous décrivons les données de 2007 des personnes de 65 ans et plus, diabétiques de type 2, et les comparons aux données de 2001 (n = 1801 en 2001 et n = 1766 en 2007).

Résultats

Depuis 2001, l’obésité a augmenté (35 % en 2007 ; +7 pts depuis 2001) tandis que des conseils diététiques écrits ont été moins fréquemment fournis (59 % ; −6 pts). Les moyennes d’HbA1c (7,1 % ; −0,2%), de pression artérielle (135/76 mmHg ; −4/−3 mmHg) et de LDL cholestérol (1,04 g/L ; −0,21 g/L) ont diminué, alors que les traitements médicamenteux étaient plus fréquents : 34 % (+4 pts) avec deux ou plus antidiabétiques oraux (ADO), 10 % (+4 pts) avec ADO + insuline, antihypertenseurs 83 % (+4 pts), statines 48 % (+26 pts). Les hypoglycémies sévères restaient fréquentes dans l’année (10 %). La prévalence des complications s’est accrue. Les complications rénales n’étaient pas suffisamment dépistées (albuminurie manquante : 42 %, −4,5 pts) ; 46 % des personnes avec une filtration glomérulaire inférieure à 60 mL/min par 1,73 m2 étaient traitées par metformine.

Conclusions

La qualité des soins et le contrôle des facteurs de risque cardiovasculaire des personnes âgées diabétiques de type 2 se sont améliorés. Néanmoins, des progrès sont encore nécessaires, en particulier pour mieux dépister les complications. Il est nécessaire dans cette population de surveiller attentivement le risque d’hypoglycémie, d’hypotension, de malnutrition et les contre-indications liées à la fonction rénale.

Introduction

The World Health Organization (WHO) predicts an epidemic of diabetes in most countries linked to both changes in lifestyle and ageing of the population [1]. In France, the prevalence of diabetes was estimated at 4.4% in 2009 based on pharmaceutical treatments. The prevalence increased with age to 14.2% in those aged 65–74 years, peaking at 19.7% in men and 14.2% in women aged 75–79 years [2]. More than half of those with diabetes were aged 65 years or above, corresponding to at least one million people in France [3]. From 2001 to 2005, the prevalence of diabetes increased by 3.1 points in men aged 70–79 years and 3.8 points in men aged 80–89 years, and by 0.7 points and 3.0 points, respectively, in women in those age groups [4].

Elderly patients with diabetes are at increased risk of diabetes complications, loss of cognitive function and mobility and, consequently, of dependency [5]. The increasing number of older individuals with diabetes will, therefore, lead to a greater public health burden [6], [7]. Adequate management and active monitoring of this population with comprehensive gerontological assessment may reduce this growing burden [8].

Cross-sectional surveys of adults (all ages) with diabetes (the Échantillon national témoin représentatif des personnes diabétiques, or Entred, surveys) were performed in France in 2001 and 2007 to monitor the health status of patients with diabetes. Results have been published for all age ranges elsewhere [9]. The present analysis used the 2001 and 2007 French surveys, and focused on the growing population of elderly people (≥ 65 years old) with type 2 diabetes, whose status is often already frail, to assess 6-year trends in sociodemographic characteristics, risk factors, diabetes complications and quality of care.

Section snippets

Population

The 2007 Entred source population included all adults who claimed reimbursements for at least three oral hypoglycaemic agents (OHAs) or insulin between August 2006 and July 2007 from the two major French health insurance systems—Caisse nationale d’assurance maladie des travailleurs salariés (CNAMTS, which covers 70% of the population of France) and Régime des salariés indépendants (RSI, covering 5% of the population)—which together cover all active and retired employees or self-employed workers

Participants in the 2001 and 2007 Entred surveys, all ages and diabetes types

Response rates to both the PQ and CPQ increased significantly between 2001 and 2007 (PQ: 44% in 2007; +11 points since 2001; CPQ: 56%; +9 points since 2001) (Table 1). Compared with non-responders, responders to the 2007 PQ were younger, more likely to be male and benefited more often from a waiver of co-payment due to diabetes or another chronic disease. Overall, both PQ responders and patients whose care providers responded to the CPQ were more likely to receive better care than

Discussion

The present analysis documented substantial decreases in mean HbA1c, BP and LDLc in elderly people with diabetes over 6 years, while the use of medication sharply increased. However, although the aim of such medication is to stop or delay the appearance of diabetes complications, there was also an increase in the prevalence of complications, insufficient screening for most complications and an increasing risk of side effects.

Conclusion

The quality of care delivered to elderly people with type 2 diabetes has dramatically increased since 2001, and their cardiovascular risk profile has improved significantly, which may improve their life expectancy and perhaps their quality of life. Specific improvements, however, are still required, such as better screening and treatment for diabetes complications, especially with regard to eyesight, podiatric risk and renal function, even in the elderly with a recent diabetes diagnosis. Some

Disclosure of interest

E. Eschwège has received consultant’ fees from Astra-Zeneca, GlaxoSmithKline, Novartis, Novo Nordisk, Sanofi Aventis, Merck-Lipha, Mayoly-Spingler.

I. Bourdel-Marchasson: support of teaching book: Novartis, Roche diagnostic, Servier Laboratories; and speaker's bureau and teaching engagement: Novo Nordisk.

P. Lecomte: support of teaching book: Novartis, Roche diagnostic, Servier Laboratories.

A. Fagot-Campagna received an honorarium in 2009 and 2010 from Servier to give a lecture on a course on the

Acknowledgments

We thank all of the patients with diabetes and all of their care providers who participated in this study. The 2007 study was financially supported by the Institut de veille sanitaire as part of its public health missions, Institut national de la prévention et de l’éducation pour la santé, Régime général de l’assurance maladie, Régime des salariés indépendants and Haute Autorité de santé.

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