Mikko Honkasalo’s research while affiliated with Helsinki University Central Hospital and other places

The aim of this study was to evaluate whether patients with type 2 diabetes (T2D) who had stopped attending their diabetes treatment system (referred to as “lost to follow-up”, LTF) but who succeeded in improving their glycaemic control after returning to the diabetes treatment system had changes in their diabetes medication when compared with similar patients who did not show improvement. “LTFs” who had baseline haemoglobin A1 c (HbA1 c) ≥53 mmol/mol and succeeded in reducing HbA1 c ≥ 6 mmol/mol during a 12–30 month follow-up period after adhering again to their diabetes treatment system were compared with “LTFs” who had an unsatisfactory change in HbA1 c or with “LTFs” who maintained good glycaemic control throughout the 12–30 month follow-up period. Unsatisfactory change in HbA1 c was determined as HbA1 c ≥ 53 mmol/mol and change <6 mmol/mol after the 12–30 month follow-up period in their diabetes treatment system or HbA1 c < 53 mmol/mol when returning to the diabetes treatment system but ≥53 mmol/mol at the end of the 12–30 month follow-up period. “LTFs” with improvement in glycaemic control used a higher number of different anti-hyperglycaemic agents (P < 0.001) and their dosages of metformin increased (P < 0.05) when compared with “LTFs” without improvement or “LTFs” with satisfactory glycaemic control. Cholesterol-, LDL-cholesterol- and triglyceride-concentrations decreased during the 12–30 month follow-up period (P < 0.05) in “LTFs” with improved glycaemic control, but not in the other groups. “LTFs” with T2D who had poor glycaemic control seemed to require an increase in their anti-diabetic medication when attempting to improve their glycaemic control.

Aim: Previous study findings have shown that more frequent contacts with the diabetes care team predict better diabetes control. It is unknown whether this is true also for previous dropouts with type 2 diabetes (T2D). The aim of this study was to evaluate if those previous dropouts with T2D who succeeded to improve their glycaemic control had more frequent contacts with health care professionals in the public primary diabetes health care system than those dropouts who did not show improvement. Methods: In this "real life" retrospective cohort study, we identified 115 dropouts with T2D who were contacted by trained diabetes nurses and who returned to a public T2D-care system. Those previous dropouts who had baseline haemoglobin A1c ≥53mmol/mol (7%) and had a reduction in HbA1c≥6mmol/mol (0.5%) during the follow-up were compared with those with unsatisfactory change in HbA1c (baseline HbA1c≥53mmol/mol and change <6mmol/mol, or HbA1c<53mmol/mol at the baseline measurement but above that in the end of the study period) or with those who remained at good glycaemic control over the study period. Trained diabetes nurses collected quantitative data from the patient records about visits and contacts during the follow-up. Results: Previous dropouts showing improvement had more visits to the diabetes nurse (p=0.003) and other nurses (p<0.001) than those with no improvement or those with satisfactory glycaemic control. Telephone calls not focusing on diabetes (p<0.001) were also more frequent among previous dropouts with improvement than among the others. Conclusions: Especially previous dropouts with T2D who had poor glycaemic control, may benefit from more frequent contacts including visits and telephone calls. Recalling dropouts does not seem to lead to overuse of the T2D care-system by those recalled patients whose glycaemic control does not require special care.

Introduction Although primarily utilized in type 1 diabetes, continuous subcutaneous insulin infusion (CSII) represents a useful treatment alternative for patients with type 2 diabetes who are unable to achieve good glycemic control despite optimization of multiple daily injections (MDI). The aim of the analysis reported here was to investigate the long-term cost-effectiveness of CSII versus MDI in type 2 diabetes patients with poor glycemic control in Finland. Methods The IQVIA CORE Diabetes Model was used to make long-term projections of the clinical and economic outcomes associated with CSII use in type 2 diabetes, based on clinical input data from the OpT2mise trial, which showed that CSII was associated with a 1.1% decrease in glycated hemoglobin (HbA1c) in patients with poor glycemic control at baseline. The analysis was performed from a societal perspective and the time horizon was that of patient lifetimes. Future costs and clinical outcomes were discounted at 3% per annum. Results Continuous subcutaneous insulin infusion was associated with a gain in quality-adjusted life expectancy of 0.32 quality-adjusted life-years (QALYs) compared with MDI (8.15 vs. 7.83 QALYs, respectively), as well as higher mean lifetime costs, resulting in an incremental cost-effectiveness ratio of Euro (EUR) 47,834 per QALY gained for CSII versus MDI. The higher treatment costs in the CSII group were partly mitigated by a 15% reduction in diabetes-related complication costs. Sensitivity analyses demonstrated that CSII was most cost-effective in patients with the highest baseline HbA1c values. Conclusion In Finland, CSII is likely to represent a cost-effective treatment alternative for patients with type 2 diabetes with poor glycemic control despite optimization of MDI. In such patients, CSII is associated with improved clinical outcomes relative to MDI, with the higher acquisition costs partly offset by a lower lifetime incidence and cost of diabetes-related complications. Funding Medtronic International Sàrl.

Purpose: The aim of this study was to evaluate the effect of an individual intervention given by health care professionals to dropouts with type 2 diabetes (T2D) on their metabolic profile. Materials/methods: In 2010, we identified 356 T2D dropouts in Vantaa Health Centre, Finland. At the baseline visit the participants' status was assessed including laboratory tests. Diabetes counseling was given, and drug treatment was enhanced when needed. The follow-up visit was performed 13 to 30 months later including the same assessments as performed at the baseline visit. The dropouts who attended the follow-up visit formed the study group. One third (n=115) of the dropouts participated in the follow-up visit. Results: The study participants (mean age 61.4 years) were older than the non-participants (mean age 58.5 years) (p=0.009). After the intervention the proportion of participants with hemoglobin A1c≥9% (75mmol/mol) decreased from 15.5% to 5.2% (p=0.004). Improvements were also observed in general in hemoglobin A1c, from 6.6% (49mmol/mol) to 6.3% (45mmol/mol) (p=0.001), in total cholesterol, from 4.9mmol/l to 4.5mmol/l (p=0.011), in low-density lipoprotein cholesterol, from 2.9mmol/l to 2.6mmol/l (p=0.015) and in diastolic blood pressure, from 90mmHg to 84mmHg (p=0.001). Conclusions: Dropouts with T2D were difficult to bring back to the public health care system, especially men under the age of 60 years. Dropouts who participated in the intervention showed improvements in several metabolic outcomes.

Objective: To characterize dropouts from type-2 diabetes (T2D) care in communal primary health care. Design: An observational study. Setting: In a Finnish city, patients with T2D who had not contacted the public primary health care system during the past 12 months were identified with a computer based search and contacted by a trained diabetes nurse. Subjects: Dropouts from T2D treatment. Main outcome measures: Demographic factors, laboratory parameters, examinations, medications, and comorbidities. Results: Of the patients with T2D, 10% (n = 356) were dropouts and 60% of them were men. Median HbA1c was 6.5 (QR for 25% and 75%: 6.0, 7.7) %, (45 [42,61] mmol/mol). Of the dropouts, 14% had HbA1c ≥ 9.0% (75 mmol/mol), and these patients were younger than the other dropouts (mean age 54.4 [SD 10.8] years vs. 60.6 [9.4] years, p < 0.001). Median low-density lipoprotein (LDL) cholesterol level was 2.8 (QR 2.1, 3.4) mmol/l. Median systolic blood pressure (BP) was 142 (QR 130, 160) mm Hg. Median diastolic BP was 86 (78, 94) mm Hg. Of the dropouts, 83% had comorbidities and 62% were prescribed metformin as a treatment. Conclusions: Ten percent of T2D patients were dropouts of whom those with a poor glycaemic control were younger than the other dropouts. BP and LDL cholesterol concentrations were non-optimal among the majority of the dropouts. Metformin was prescribed less frequently to the dropouts than is usual for T2D patients. The comorbidities were equally common among the dropouts as among the other T2D patients. KEY POINTS Which kinds of patients are dropouts from type-2 diabetes care is not known. • One-tenth of the patients with T2D were dropouts and they generally had good glycaemic control. • Blood pressure and LDL cholesterol concentrations were non-optimal among the majority of the dropouts. • Fourteen percent of these dropouts had HbA1c > 9% (75 mmol/mol) and they were more often younger than the other dropouts.