Fang Zhao's research while affiliated with The George Institute for Global Health and other places

To assess the association between insulin regimens and health-related quality of life (HRQoL) after the introduction of basal insulin (BI) among people with type 2 diabetes in real-world clinical settings. 16,339 registered people with diabetes who had inadequate glycaemic control by oral agents initiated BI (either single BI or Basal-bolus) and completed a 6-month follow-up from 209 hospitals were included in the analyses. At the end of the follow-up, the switches of insulin regimens, change of HRQoL (EQ-5D-3L) and their associations were assessed. Initial insulin regimens of single BI and of basal-bolus (BI included Glargine, Detemir, and Neutral Protamine Hagedorn) accounted for 75.6% and 24.4%, respectively. At 6 months, regimens used were BI alone (65.2%), basal-bolus (10.4%), and premixed (6.4%), whereas 17.9% stopped all insulin therapy. The visual analogue scale score increased by 5.46 ( P < .001), and the index value increased slightly by 0.02 ( P < .001). Univariate analysis showed that people with diabetes taking basal-bolus regimen had the greatest improvement on HRQoL in all dimensions, especially in the reduction of the percentage of Pain/Discomfort (by 10.03%) and Anxiety/Depression (by 11.21%). In multivariable analysis, single BI or premixed insulin at 6 months was associated with more improvement of visual analogue scale score compared with stopping all insulin. Improved HRQoL was observed after initiating BI in people with type 2 diabetes . If the same achievement on HbA1c control can be guaranteed, single BI is preferred to other regimens from the viewpoint of HRQoL. Basal-bolus has the most significant potential to increase HRQoL, however, the people with diabetes characteristics differ from those initiating BI alone. Further longitudinal cohort study with a longer study period might be necessary to evaluate the certain effect.

Aims/introduction: To estimate the prevalence, and patient clinical and demographic profile, as well as risk factors associated with obstructive sleep apnea syndrome (OSAS) in hospitalized patients with type 2 diabetes mellitus in Beijing, China. Materials and methods: Hospitalized adult patients with type 2 diabetes mellitus were consecutively screened and invited for an overnight polysomnography from four hospitals in Beijing, China, from May 2016 to February 2017. We used the American Academy of Sleep Medicine 2012 polysomnography recording techniques and scoring criteria to identify the type of apnea and the severity of OSAS. The χ2 -test was used to evaluate differences between groups regarding the prevalence, and demographic and other clinical parameters. Results: A total of 735 patients were found eligible for the study, of whom 309 patients completed the overnight polysomnography. The mean age of the patients was 58.2 ± 10.9 years, and most (67.3%) were men. The prevalence of overall (apnea hypopnea index ≥5/h), moderate-to-severe (apnea hypopnea index ≥15/h) and severe (apnea hypopnea index ≥30/h) OSAS was 66.3% (95% confidence interval 60.8-71.6%), 35.6% (95% confidence interval 30.3-41.2%) and 16.5% (95% confidence interval 12.5-21.1%), respectively. Central and mixed apnea contributed 12% to all sleep-disordered breathing. With the aggravation of OSAS, the combined prevalence for central, mixed and obstructive apnea increased from 57% to 70%. We found OSAS to be associated with older age, obesity, self-reported snoring and apnea, and diabetes complications. Conclusions: Guidelines on screening and treatment of OSAS among hospitalized patients with diabetes are needed to direct the routine practice for diabetes endocrinologists for optimal clinical care of such patients.

Introduction: To evaluate insulin injection knowledge, attitudes, and practices of nurses across China in order to provide reference for the formulation of a national unified standard of insulin injection practice and the targeted implementation of standardized training on insulin injection for nurses. Methods: We enrolled nurses who worked and injected insulin at grassroot hospitals including community health service centers and township clinics, secondary and tertiary care hospitals across China between July 28, 2019 and August 30, 2019. A nurse insulin injection knowledge, attitude, and practice questionnaire was used to evaluate the knowledge, attitude, and practice level of nurses. Results: A total of 223,368 nurses were included in the study. The mean knowledge score was 13.70 ± 3.30 and 35.19% had a poor knowledge score. The mean attitude score was 17.18 ± 2.69 for the study nurses; merely 3.15% had a poor attitude score. The mean practice score of the study population was 83.03 ± 8.16 and only 0.88% had a poor practice score. Pearson correlation analysis showed significant correlation between the knowledge score and the attitude score (r = 0.29; P < 0.001), the knowledge score and the practice score (r = 0.27; P < 0.001), and between the attitude score and the practice score (r = 0.56; P < 0.001). A multivariate analysis revealed that nurses with higher knowledge scores were also more likely to have higher attitude scores and practice scores, and nurses with higher attitude scores were also more likely to have higher practice scores. Conclusion: Chinese nurses have a good attitude and behavior towards insulin injection, while their knowledge of insulin injection is insufficient. It is also revealed that knowledge of insulin injection can directly or indirectly affect insulin injection behavior through attitude, indicating that hospitals should formulate unified insulin injection norms and regularly organize relevant training and assessment so as to improve nurses' knowledge, attitude, and behavior of insulin injection.

Background: The number of patients with diabetes has been increasing rapidly according to a 2014 report by the International Diabetes Federation. Diabetes has become one of the most challenging public health problems, and there will be an estimated 143 million patients with diabetes in China by 2035. This puts considerable pressure on nurses who specialize in the care of patients with diabetes in China and increases related social and financial burdens. Clinical practice has proven that strengthening the core competencies of nurses and establishing an evaluation system of core competencies improve both healthcare quality and patient quality of life. However, no core-competence system framework currently addresses the unique characteristics of nurses in China. Purposes: The purpose of this study was to construct a core-competence system framework for primary nurse specialists in diabetes care. Methods: A brainstorming approach was conducted that worked to conceptualize the core competencies of nurse specialists in diabetes care in China. Next, a study group organized this information and conducted a seminar; 50 experts and patients with diabetes were invited to develop the first draft of the framework. Afterward, the 50 experts were selected to participate in the Delphi survey. Most indicators were retained after a three-round Delphi process, and the superiority chart was used to determine the weights of the six dimensions. Results: Forty-seven experts completed the consultation. The experts' rate of response ranged from 94% to 100%, the authority coefficient was .91, and the Kendall's coefficients of concordance in Grades 1-3 were .793, .418, and .542, respectively. An increasingly detailed, three-grade system framework was developed, including six first-grade indicators (diabetes professional knowledge, diabetes-related knowledge, communication skills and health education ability, specialized skills, clinical judgment, and specialty development capacity), 23 second-grade indicators, and 87 third-grade indicators. The weights of the six first-grade indicators were .221, .149, .192, .209, .160, and .069, respectively. Conclusions: The core-competence system framework includes six core competencies, which represent the main characteristics of primary nurse specialists in diabetes care who are highly recommended by experts. It is important to keep in mind that this is only a theoretical framework and thus must be further tested in clinical practice settings in China.This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective To estimate the prevalence and incidence of needlestick injuries associated with insulin injection among nurses working in hospitals in China and to quantify the direct healthcare costs associated with insulin injection-related needlestick injuries. Methods We conducted a large online survey among hospital nurses from 31 provinces, municipal cities, and autonomous regions in China from October 2016 to February 2017. The survey covered a wide range of questions, including geographical location, years of experience, insulin injection practice, number of insulin injection-related needlestick injuries in the past 12 months, interventions for needlestick injuries, and treatment costs. We developed a cost estimate model and categorized costs into two major components: infection prevention and treatment of infections. Results We received a total of 10,447 questionnaires, of which 9873 were complete and validated. 39.1% of the nurses reported at least one needlestick injury while administering diabetic injections at some point in the past. The incidence of needlestick injuries involving injection pens was 139.5 per 1000 nurses per year and, with adjustment for exposure, 10.2 needlestick injuries per 100,000 injections. Among the respondents, 3.2% reported of having hepatitis B virus infection and 0.9% having hepatitis C virus infection as a result of needlestick injuries. The total costs of one insulin injection-related needlestick injury was estimated to range from ¥1,884 - ¥2,389. Conclusions Insulin injection-related needlestick injuries were common in nurses working in hospitals in China and imposed a significant economic burden. More resources should be allocated for preventive efforts for needlestick injuries, including adoption of injection devices with advanced safety features.

Introduction: This study evaluates an insulin dose titration model and factors that impact insulin dose adjustment in Chinese adults with type-2 diabetes, who receive basal insulin in real-world settings. Material and methods: A total of 19,894 patients from the ORBIT study were included. These patients were divided into four groups, according to the type of insulin dose adjustment: no insulin titration (group A), self-titration (group B), physician-led insulin titration (group C), and combined physician and patient-led insulin titration (group D). Data were collected and compared at baseline and after six months of treatment. Results: A total of 12,865 patients completed the visits and were included in the analysis. Among these patients, 3187 (24.8%), 1971 (15.3%), 5165 (40.1%), and 2542 (19.8%) patients were included in groups A, B, C, and D, respectively. The multivariate logistic regression analysis revealed that the duration of diabetes, body mass index, microvascular complications, inpatient days, HbA1C level, and self-monitoring of blood glucose (SMBG) were positively correlated with insulin titration in group B, C, and D, compared with group A. The number of inpatient days and outpatient visits were positively correlated with dose adjustment for physician-led titration, while this was negatively correlated for self-titration. Self-titration encouraged by physicians and home blood glucose monitoring were positively correlated with self-titration and the combined physician and patient-led titration. Conclusions: High HbA1C level, SMBG, long disease duration, microvascular complications, and the encouragement of physicians while initiating insulin use prompt patients to perform dose adjustments in real-world settings.

Background: We aimed to determine the clinical characteristics of type 2 diabetes patients on basal insulin therapy with inadequate glucose control due to discordance between glycated hemoglobin (HbA1c) and fasting plasma glucose (FPG) in the real world. Methods: This was a retrospective analysis of data from the ORBIT study in China. Clinical characteristics of patients with discordance between HbA1c and FPG at baseline and at the end of 6 months of follow-up were analyzed using multinomial logistic regression in 4 study groups devided by HbA1c and FPG. Results: Overall, of 6721 patients initiated on basal insulin, 853 achieved HbA1c<7% but FPG≥7mmol/L (group 2), while 997 had FPG<7mmol/L but HbA1c≥7% (group 3) at the end of follow-up. Patients in group 3 had a longer duration of type 2 diabetes compared with those in group 2 (7.22±5.30 vs. 6.00±4.80 years, p<0.05). Patients on glargine (32.90%) or detemir (36.88%) treatment accounted for a higher proportion of patients with both HbA1c and FPG controlled than those on NPH therapy (23.45%; p<0.05). Per the multinomial logistic analysis, higher frequency of self-monitoring of blood glucose(SMBG) and use of glargine or detemir therapy were significantly inversely associated with risk of discordance between HbA1c and FPG, while dose of insulin was a risk factor for discordance at the end of follow-up (all p<0.05). Conclusions: Patients treated with insulin analogs (glargine or detemir), instead of NPH, and with more frequent SMBG are more likely to exhibit concordance between HbA1c and FPG.

Background: The Observational Registry of Basal Insulin Treatment (ORBIT) study evaluated the safety of basal insulin (BI) in real-world settings in China. Methods: We analyzed 9002 patients with type 2 diabetes (T2D) inadequately controlled with oral hypoglycemic agents from 8 geographic regions and 2 hospital tiers in China who initiated and maintained BI treatment. Body weight and hypoglycemic episodes were recorded at baseline and 3 and 6 months. Serious adverse events (SAEs) were recorded at 3 and 6 months. Results: Age, gender, inpatient/outpatient status, body mass index, glycated hemoglobin (HbA1c) at baseline and at the end of study, T2D duration, microvascular complications, BI type, combination with insulin secretagogues, self-monitoring of blood glucose frequency, and insulin dosage, all predicted hypoglycemia. BI use generally did not induce significant weight gain (0.02 kg); weight gain with insulin detemir (-0.30 kg) was less than that with neutral protamine Hagedorn (NPH) insulin (0.20 kg) or insulin glargine (0.05 kg). Overall, general hypoglycemia incidence (5.6% vs. 7.7%) and annual event rate (1.6 vs. 1.8) were similar before and after BI initiation, whereas a slight decrease was noted in severe hypoglycemia incidence (0.6%-0.3%) and frequency (0.05-0.03 events/patient-year). The general hypoglycemia rate was lowest with insulin glargine, whereas there was no significant difference in severe hypoglycemia among the three BI groups. Overall, 3.5% of patients had at least one SAE during the study. Most SAEs were found to be unrelated to BI treatment. Conclusions: Real-world BI use, particularly insulin detemir and glargine, was associated with only slight weight gain and low hypoglycemia risk in patients with T2D in China.

Background: Obstructive sleep apnea (OSA) is prevalent in patients with type 2 diabetes, but the influence of OSA on diabetes complications is not clear. We aimed to investigate the association of OSA with chronic diabetes complications in Chinese patients with type 2 diabetes. Subjects and methods: In total, 880 hospitalized patients were enrolled in a multicenter, cross-sectional study that involved 12 hospitals from six cities in the People's Republic of China. Overnight sleep monitoring with a portable monitor was used to record respiratory parameters, including the apnea-hypopnea index (AHI), the oxygen desaturation index (ODI), the oxygen saturation (SPO2), and the cumulative time of SPO2 below 90% or 85% (CT90% and CT85%, respectively). Chronic diabetes complications were recorded from medical charts. Results: CT90% was independently associated with diabetic nephropathy (DN) after adjusting for age, sex, diabetes duration, glycosylated hemoglobin, body mass index, hypertension, and the use of angiotensin converting enzyme inhibitor/angiotensin receptor blocker drugs within 1 week. The associated parameters increased from two (the average SPO2 and CT90%) to three (ODI, the lowest SPO2, and CT85%) when the severity of DN increased from microalbuminuria to renal insufficiency. The estimated glomerular filtration rate was independently correlated with ODI (β = -0.172, P = 0.029) and the lowest SPO2 (β = 0.354, P = 0.004) after adjustments. The lowest SPO2 was associated with proliferative diabetic retinopathy by univariate logistic regression but was not significant in multivariate regression after adjustment. Conclusions: Parameters of nocturnal hypoxemia are associated with DN and renal function of patients with type 2 diabetes. The parameters of hypoxemia may more sensitively reflect the association of OSA and diabetic microvascular complications than AHI.

Background The prevalence of type 2 diabetes in China is increasing rapidly. Appropriate management of glycemia, blood pressure, and dyslipidemia in his population is a major public health concern.Objective We assessed glycated hemoglobin A1c (HbA1c), blood pressure (BP), and LDL cholesterol (LDL-c), the ABCs of good management in a large sample of patients with type 2 diabetes in China and attempted to identify factors that correlated with achievement of ABCs goals.MethodA nationwide survey was conducted in 50 medical centers across China from April to July of 2010. Baseline information on demographics, medical history HbA1c, BP and LDL cholesterol levels were measured in 5961 patients with type 2 diabetes.ResultsMean age, body mass index (BMI), and HbA1c were 59.50 ±1.25 years, 24.49± 4.10 kg/m2, and 8.27±2.23 % respectively. With respect to generally accepted ABC treatment goals, 35.2% of the participants had HbA1c <7%, 35.5% had BP<140/80 mmHg, and 45.1% had LDL-c<100 mg/dl. The proportion of patients met all three targets was only 5.4%. Smoking, higher BMI and insulin use were the strongest determinants of failing to meet ABC targets.Conclusion The percentage of Chinese patients with type 2 diabetes in our sample who met recommended targets met achieving for HbA1c, BP and LDL-c was low. The percentage of patients at target was lower among those who smokes, had higher BMI, and use insulin.