Groupe de recherche PRIMUS

Time to Insulin Initiation in Diabetic Patients: A Quebec Population-Based Analysis

Present by: Shabnam Asghari M.D. Ph.D.

   Epidemiologist, PRIMUS research group

Research team

Alain Vanasse MD, PhD, FCMF  Professor in the Department of Family Medicine and Director of the PRIMUS

Research Group

Shabnam Asghari MD, PhD Researcher, PRIMUS Research Group

Josiane Courteau  PhD Researcher, PRIMUS Research Group

Catherine Drouin PhD(C) PhD candidate, PRIMUS Research Group

André C. Carpentier MD Professor in the Department of  Medicine

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Miracle of Insulin

Before insulin was discovered in 1921, everyone with type 1 diabetes died within weeks to years of its onset

Background

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Insulin initiation

• All adults and children with type 1 diabetes begin the use of insulin as their first medication.

• The number of adults beginning insulin therapy has increased in recent years (Davis ,2006).

Background

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Early Initiation of Insulin for Adults

Early initiation of insulin is a marker of type 1 diabetes in adults

Time to insulin initiation cannot be used in defining latent autoimmune diabetes in adults (Brophy, 2008)

Background

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Previous studies

• There are wide variations in practice among the multidisciplinary team

and • There is little published regarding the

insulin initiation in patients with type 2 diabetes.(Davis RE ,2006; Yeap B,2007)

Background

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Why early initiation of insulin

• The link between hyperglycemia and increased overall mortality

• Improvement in glycemic control

• Reduce and delay the onset of diabetic complications.

(Davis, RE. ,2006; Liebl, A. , 2007; Meneghini,L., 2008)

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Background

Why delay

• Delays in initiating insulin may come from both physician and patient barriers. (Haque,M. ,2005; Oliveria,S.A. 2007)

• Time to insulin treatment is dependent on local clinical judgment and not on the disease process. (Brophy,S. 2008)

Background

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Study objective

To measure, describe and compare “time to insulin” initiation in incident cases of diabetes

by age and gender

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Outcome: Time from diabetes diagnosis to insulin initiation

Measure of time : Days

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Methodology

Data Sources

• Hospital discharge registry (MedEcho)

• Death registry (MSSS)

• Beneficiary registry (RAMQ)

• Pharmacological registry (RAMQ)

Methodology

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Study Population

An exhaustive cohort of incident cases of diabetes aged 20 years and older in 1995

Methodology

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Diabetes case definition

• Diabetes cases Two physician claims with a diagnosis of

diabetes (ICD-9 Code 250) or one hospital discharge (Canadian National Diabetes Surveillance

System’s case definition for administrative data). • Incident cases of diabetes A diabetes case using NDSS with a one

ICD code 250 for a 5 year clearance period (Asghari S et al,2008).

Methodology

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Study Design

An exhaustive retrospective cohort of diabetes cases for 1995 in the

province of Quebec were followed-up until the date of insulin initiation,

death or December 31, 2004, whichever occurred first.

Methodology

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Eligibility Criteria

Inclusion criteria• New cases of diabetes

(by NDSS+ one ICD code 250 for a 5 year clearance period)

• ≥ 20 years old• Living in the province

of Quebec • Covered by the public

drug insurance

Exclusion criteria

• Gestational diabetes

Methodology

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Other variables

• Age

• Gender

Methodology

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Statistical Analysis

The Kaplan-Meier method was used to estimate time from diabetes diagnosis to insulin initiation and to compare ‘survival

curves’.

Methodology

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Results

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Results

A total of 17,828 patients met the selection criteria (mean age: 68.9 years ± 12.0;

female: 54.5%).

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• Overall, 13.7% (N=2444) (mean age: 63.7; 95% CI: 63.2-64.3) claimed at least one prescription of insulin during the follow-up period.

• 1 out of 3 began insulin in the first year.

Results

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No significant difference between gender

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Time to insulin curves differ significantly between age groups.

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15%

Discussion

More than 86% of diabetic patients had no insulin initiation during the ten-year follow-up.

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Discussion

Younger patients (20-39 years) were more likely to initiate early insulin therapy.

Although a recent study revealed that time to insulin cannot be used in defining

diabetes types. The result of this large scale study suggests that insulin was

initiated early for younger adults which are more prone to have type 1 diabetes.

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More studies are needed to confirm the hypothesis of using early insulin initiation as a marker of type 1 diabetes in adults

in a medico-administrative database. We also suggest another study to find PPV and NPV of early insulin initiation using

patient records and medico-administrative data

Suggestion

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Research team

Alain Vanasse MD, PhD, FCMF  Professor in the Department of Family Medicine and Director of the PRIMUS

Research Group

Shabnam Asghari MD, PhD Researcher, PRIMUS Research Group

Josiane Courteau  PhD Researcher, PRIMUS Research Group

Catherine Drouin PhD(C) PhD candidate, PRIMUS Research Group

André C. Carpentier MD Professor in the Department of  Medicine

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??• Groupe de recherche PRIMUS http://pages.usherbrooke.ca/primus

• Alain.Vanasse@USherbrooke.ca  

• CHUS,3001-12e Avenue Nord, Sherbrooke Québec, Canada ,J1H 5N4

• Telephone :  819- 820-6868, poste 15130

Fax: 819- 564-5424

Contact

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