Groupe de recherche PRIMUS

1. Groupe de recherche PRIMUS

2. Time to Insulin Initiation in Diabetic Patients: A Quebec Population-Based Analysis Present by: Shabnam Asghari M.D. Ph.D.    Epidemiologist, PRIMUS research group

3. 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 27

4. Background Miracle of Insulin Before insulin was discovered in 1921, everyone with type 1 diabetes died within weeks to years of its onset 4

5. Background 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). 5

6. Background 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) 6

7. Background 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) 7

8. Background 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) 8

9. 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) 9

10. Study objective To measure, describe and compare “time to insulin” initiation in incident cases of diabetes by age and gender 10

11. Methodology Outcome: Time from diabetes diagnosis to insulin initiation Measure of time : Days 11

12. Methodology Data Sources • Hospital discharge registry (MedEcho) • Death registry (MSSS) • Beneficiary registry (RAMQ) • Pharmacological registry (RAMQ) 12

13. Methodology Study Population An exhaustive cohort of incident cases of diabetes aged 20 years and older in 1995 13

14. Methodology 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). 14

15. Methodology 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. 15

16. 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 Eligibility Criteria 16

17. Methodology Other variables • Age • Gender 17

18. Methodology Statistical Analysis The Kaplan-Meier method was used to estimate time from diabetes diagnosis to insulin initiation and to compare ‘survival curves’. 18

19. Results 19

20. Results A total of17,828 patients met the selection criteria (mean age: 68.9 years ± 12.0; female: 54.5%). 20

21. Results • 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. 21

22. No significant difference between gender 22

24. 15% Time to insulin curves differ significantly between age groups. 23

26. Discussion More than 86% of diabetic patients had no insulin initiation during the ten-year follow-up. 24

27. 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. 25

28. Suggestion 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 26

29. 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 27

30. Contact ? • 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 28