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Predictors of 5-year mortality of 1,323 patients newly diagnosed with clinical
type 2 diabetes in general practiceWith special emphasis on self-rated health
Niels de Fine OlivariusVolkert Siersma
Anni B. S. NielsenLars J. Hansen
Lotte RosenvingeCarl Erik Mogensen
Important predictors of mortality in type 2 diabetic patients
• Age• Sex• Blood glucose level• Blood pressure• Lipids• Urinary albumin excretion• Smoking• Cardiovascular disease
Self-rated general health (SRH)
Question to patients:"In general, how would you rate your health at present?" Excellent Good Fair Poor Very poor
Implications of SRH
In the general population SRH predicts both future morbidity such as ischaemic heart disease and mortality independently of
established risk indicators,
but evidence of this is scarce for people with diabetes
Aim of the study
To investigate the contribution to 5-year all-cause and cardiovascular mortality of the
characteristics found at the more or less acute state at diabetes diagnosis.
In particular, we evaluated the possible independent effect of SRH on mortality.
Flow
cha
rtInclusion criteria:1) Diabetes mellitus diagnosed from 1 March 1989 to 28 February 19922) Whole blood or plasma glucose concentration ≥ 7.0/8.0 mmol/l
measured at a major laboratory3) Age 40 years or older
Eligible patients, n=1,543
Primary exclusions:Severe somatic disease, n=50Severe mental illness, n=50Declined to consent, n=62
Analysed, n=1,323
Secondary exclusions:Steroid treatment at diagnosis, n=46Non-white ethnicity, n=12
Available patient sample, n=1,381
Outcome variables
From the Danish National Death Register:• All-cause mortality• Cardiovascular mortality
Median observation time: 5.2 yearsNumber of deaths: 298
Baseline predictor variables
SexAgeLiving aloneEducationDiagnostic plasma glucoseFasting triglycerideTotal cholesterolUrinary albuminBody mass index
Resting heart rateSystolic blood pressurePhysical activitySmokingSelf-rated healthCardiovascular diseaseDiabetic retinopathyPeripheral neuropathyCancer (former or present)
Statistical analysisPredictors of 5-year mortality
The influence on all-cause and cardiovascular mortality of patient characteristics measured at diabetes diagnosis was investigated in Cox proportional hazard models. In these models the death intensity was represented as a function of patient age, multiplicatively affected by the characteristics.
Predictors of 5-year mortalityCox regression analyses
* p<0.05 ** p<0.01 *** p<0.001
Estimated life expectancy according to predictors at diagnosis. Men only
Values are median life expectancy according to baseline characteristics calculated from a Cox model which includes all baseline characteristics. The other faxtors in the model are kept fixed.
Implications 1 – the easy part
In newly diagnosed diabetic patients: be attentive to patients who are/have
- Relatively young- Inactive- Cardiovascular disease- (Micro)albuminuria
What does SRH measure?
SRH ≈ A personal estimation of longevity?… taking into account
- Current and previous health
- Symptom perception
- Personal resources
- Physical functioning
- Health behaviour
- Comparison with age peers
- Familial disposition
The SRH hypothesis
SRH primarily carries risk information which cannot be uncovered by
present-day technology, and
this information has to a considerable degree a biological basis
A question from a colleague
Non-excellent SRH Increased mortality
“Does it mean that GPs can concentrate on making the patients feel content and happy about their lives and not worry so much about blood glucose, blood pressure and
lipids”
?
Implications 2 - SRH
This finding could motivate general practitioners and practice nurses to discuss perceptions of health with newly diagnosed diabetic patients and be attentive to patients with
suboptimal health ratings
Non-excellent SRH Increased mortality
The problem of frailty
Frailty ≈ Heterogeneity among our patients in their susceptibility to dying
Undiagnosed or even unascertainable conditions may have contributed to precipitate the diabetes diagnosis,
and these conditions may be associated with both poor SRH or low physical activity and high risk of death.
Approaching heterogeneity
• Sub-group analysis of "healthy" patients (n=696) without CVD, diabetic retinopathy, peripheral neuropathy, cancer and proteinuria
• Analysis of deaths occurring within 3 years of diabetes diagnosis (n=153) and after this time (n=145)
• Analyses excluding deaths occurring within 6 months of diabetes diagnosis (n=25)
Predictors of 5-year all-cause mortalityCox regression analysis
Bold: p<0.05
The excess mortality of type 2 diabetic patients
Prop
ortio
n of
sur
vivo
rs
Years since diabetes diagnosis
80+ years
60-79 years
40-59 years
The Danishpopulation
Patients withnewly diagnoseddiabetes
Men