This document describes a case cohort study examining the health needs of patients with type 2 diabetes. The study aimed to observe the incidence of type 2 diabetes, understand relationships between diabetes and other conditions like depression and cardiovascular disease, and discover markers for diabetes onset or progression. The results showed an increasing number of diabetics between 2003-2006, with most having hypertension or depression. Depression and hypertension rates increased before diabetes onset, suggesting they may be markers. Myocardial infarction rates also increased after onset, indicating it may be a complication.

1. Defining the Health Needs of
Patients with Type II Diabetes
An approach based on a case cohort study
George Karystianis
School of Computer Science

2. 2
Motivation
● Complex health problem related with various diseases.
● Comprehend the diabetic needs from different health
perspectives.
● Improve the quality of the provided health care.

3. 3
Aims
To perform a preliminary analysis in a case cohort study:
● To observe the incidence of Type II diabetes.
●To understand the relation between diabetes, depression,
CVDs, hypertension.
● To discover markers for the onset of diabetes or progression
states.
● To examine the extent of polypharmacy.

4. 4
Objectives
● To suggest a relation between diabetes and
depression, cardiovascular diseases, hypertension.
● To discover the number of diabetic patients, the
number and the type of prescribed medications.
● To find any diseases before and after the diabetes
onset.

5. 5
Diabetes (1)
● Diabetes Mellitus.
● Production of excessive sweet urine (“glycosuria”).
● Syndrome of disordered metabolism.
● Hereditary and environmental factors.
● Elevated levels of blood sugar (glucose).
● Controlled mainly by the hormone insulin.

6. 6
Insulin (1)
● Hormone.
● Produced from the β-cells in the isles of pancreas.
● Uptake of glucose from the blood to cells.
● Glucose the conversion product between
carbohydrates.

7. 7
Insulin (2)
Pangreas Insulin
Isles of
Langerlans
β-cells
Food Glucose
Uptake glucose
Cells
Liver,
Muscle cells
Glucose used as
fuel
Storage
Blood
circulation
Limited insulin
production
Storaged glucose
re-enters
blood stream
Low glucose
levels

8. 8
Diabetes (2)
DIABETES
TYPE I
TYPE II
Genetic
Inheritance
&
Environmental
triggers
Sedentary
Lifestyle
&
Obesity
Lack of
insulin
Insulin
resistance
Risk factors Complications

9. 9
Diabetes Type I
Symptoms
Increased thrist
Weight loss
Increased appetite
Frequent urination
Weakness
Cure
Causes
Environmental
factors

10. 10
Diabetes Type II
● Worldwide problem.
● Part of the metabolic syndrome.
● Reduced insulin sensitivity or (rarely) decreased insulin
secretion.
● High insulin levels in the blood (hyperglycemia).

11. 11
Diagnosis
WHO criteria:
● fasting plasma glucose level >= 126mg/dL (7.0mmol/L),
● plasma glucose >= 200mg/dL (11.1mmol/L) two hours
after a 75g oral glucose load,
● a glucose tolerance test, symptoms of hyperglycemia
and casual plasma glucose >= 200mg/dL (11.1mmol/L).
● Fuzzy diabetes classification in children.

12. 12
Risk factors
Obesity
Genetic factor
Lack of
exercise
Unhealthy diet
Socioeconomical
status
Sedentary
lifestyle
Sex
Insulin
resistance
Type II

13. 13
Symptoms
Leg pain
Slow healing
Frequent
urination
Itching skin
Blurred vision
Excessive thirst
Dry mouth
Symptoms

14. 14
Treatment
Oral antidiabetic
medications
Prevention
Glibenclamide
Metformin
Delay
Lifestyle
interventionsHealthy diet
Physical
activity
No definitive
cure
Golden standard
treatment
Cure
Official guidelines
Losing
weight

15. 15
Impaired Glucose Tolerance (IGT)
Impaired Fasting Glucose (IFG)
IFGIGT
High risk groups for diabetes onset
plasma glucose >=
140 mg/dL (7.8mmol/L)
2hs after a
75g oral glucose load
fasting glucose levels
from 110 to 125mg/dL
(6.1mmol/L – 7mmol/L).
Prevention
Lifestyle interventions

16. 16
Example
Figure 1: Reduction in risk of progressing from IGT to diabetes as a result of changes in intensive
lifestyle [Paul Zimmet et al 2001].

17. 17
Complications
AcuteChronic
Hyperglycemia
Hypersmolar state
Hypoglycemia
Diabetic foot
Carotid artery
stenosis Diabetic
Ketoacidosis
Diabetic
nephropathy

18. 18
Diabetes and depression
● Evidence about depression and Type II.
● 121 million depressed people worldwide.
● Risk factor for onset or progression state.
● Treatment for depression led to an earlier diagnosis.
● 37% increased risk of Type II.

19. 19
Diabetes and cardiovascular
diseases
● Myocardial infarction, coronary heart disease, stroke
related strongly.
● Limited studies – Susceptible diabetics in major CV
events.
● Cause of death.
● Treatment of diabetic patients as non-diabetic patients
with CV events?
● Study in Finland - treating diabetics as non diabetic.

20. 20
Diabetes and hypertension
● One of the most important CVD risk factors.
● Complex relationship with diabetes.
● 1 billion people worldwide.
● Antihypertensive medications increasing risk of
diabetes onset ?
●Study in U.S disproving it but still not clear.

21. 21
Polypharmacy
● Successful treatment of a disease group through
multiple medications.
● Probably necessary against chronic conditions.
● Adverse drug events.
● Multiple prescribers, existence of different therapies,
psychological factors, adverse drug events.
● Decrease in health care quality, high medical costs,
therapy duplication, adverse drug events.

22. 22
Overview of the methodology
Case cohort
Study
2003-06
QueriesServer
Total
Disease
Medication
Per year
2004
2005
2006
Diagrams
Conclusions
Returned results

23. 23
Research methods (1)
First part.
● Use of diabetes diagnosis/drug read codes for queries.
● Definition of the diabetic population with the best result
query.
● Discover the incidence of Type II in total with the query.
● Apply of diagnosis/drug read code queries for the
diseases of interest.
● Selection of queries with the best results.
QUERIES ABOUT DIABETES TYPE II READ CODES (DIAGNOSIS AND READ CODES)
Diagnosed as diabetic Type II C10F.%
Metformin f4%
Glibenclamide (glyburide) f33%
Sulfunylureas f3%
Metformin and sulfonylureas f4% and f3%
Rosiglitazone ft4%
Pioglitazone ft5%
Metformin and rosiglitazone f4% and ft4%
Metformin and pioglitazone f4% and ft5%
Metformin and pioglitazone ft4% and f3A%
Rosiglitazone and glimepiride ft7%
Metformin and repaglinide f4% and ft3%
Metformin and nateglinide f4% and ft6%
Repaglinide ft3%
Nateglinide ft6%
Metformin but not short-acting insulin and not
medium/long lasting insulin
f4% not f1% and not f2%
Long lasting insulin f2%
Short lasting insulin f1%

24. 24
Research methods (2)
Query with the best returned results:
Individuals diagnosed as diabetic Type II (C10F.%) or
individuals prescribed with the drug Metformin (f4%) or
with any other drug belonging to the sulfonylureas group
(f3%).

25. 25
DISEASE READ CODE
Coronary heart disease G340.
Myocardial infarction G30..
Stroke G66%
Hypertension (essential) G20..
Hypertensive disease G2…
Depressed or symptoms of
depression or neurotic depression
or depression
1B17. or 1B1U.
or Eu341 or Eu32z
DRUG READ CODE DISEASE
ACE inhibitors bi% common for stroke, myocardial
infarction, hypertension,
coronary heart disease
Statins bx% common for stroke, myocardial
infarction,coronary heart
disease
Aspirin bu2% common for stroke, myocardial
infarction,coronary heart
disease
Beta Blockers bd% common for myocardial
infarction,hypertension,
coronary heart disease
Nitrates bl1% or bl2% or bl3% common for myocardial
infarction, coronary heart
isease
Clopidogrel bu5% common for stroke, myocardial
infarction
Thrombolytic agents bs% or br% common for stroke, myocardial
infarction
ACE inhibitors and
Diuretics (thiazide group)
bi% & b2% hypertension
ACE inhibitors and
angiotensin 2 receptor
antagonists
bi% & bk% hypertension
Angiotensin 2 receptor
antagonists
bk% hypertension
Alpha blockers bh% hypertension
All Diuretics groups b3% or b2% or b4% or b9%
or b5%
hypertension
Diuretics (Thiazide group) b2% hypertension
SSRI antidepressants da% depression
Tricyclic antidepressants d7% depression
Diseases diagnosis read codes
Medications read codes

26. 26
Research methods (3)
Second part.
● Same methodology to be used for every year.
Third part.
● Same methodology for the years 2004-06.
● Discover the diabetic group in each year.
● Search about diseases before and after the onset.
● Examination as markers or as progression states.

27. 27
Data
● Case cohort study from health patient records.
● Hospitals, health communities, GPs.
● Salford, Manchester, U.K.
● Approximately 20.000 health records.
Patient ID RubricGP codeRead CodeDate
Record clinical
Summary
information
Recorded
date
of medical
procedures
Distinction
between
patients
Pseudonymized
id for
GPs
distinction
Free text
describing the
meaning
of RC

28. 28
Read Codes
● Standardization of medical data recording.
● Developed within disease areas (chapters).
● Individuality, limit the amount of written stuff, help
communication between IT systems.
● Max length: five characters.
Example:
G30.. Acute Myocardial Infarction
G30y. Other Acute Myocardial Infarction
G30y2 Acute Septal Infarction

29. 29
Quality Control
● Duplicate entries, wrong diagnosis/drug treatment.
● Different codes.
● Queries with only distinct patient id.
● Exclusion of a number of cases due to bad recording
or wrong code.

30. 30
Ethical considerations
● Anonymous data.
● Protection of confidentiality and availability.
● limited access to a server.
● Written letter approval from ethics committee of
University of Manchester.
●(Yeah!)

31. 31
Results (1)
● Diabetes an epidemic.
● Number of diabetics increasing through the years.
● More related to depression, hypertensive group.
● Hypertensive group had the biggest incidence.
● Steady rise in depression.
● Limited number of CV diseases.
● Decline through the years, especially those of
coronary heart disease.

32. 32
2003-2006 diseases in total
0
500
1000
1500
2000
2500
3000
1
Number of patients with other diseases besides diabetes Type II
myocardial infarction
stroke
Hypertensive diseases
hypertension
coronary heart disease
depression
Figure 1: Overview of the diabetic patients’ numbers with other diseases based on diagnosis read codes
for all the years (2003-06).

33. 33
2003-2006 prescribed drugs in total
0
1000
2000
3000
4000
5000
6000
1
Drugs
Number of drug prescriptions in diabetic patients in total
ACE inhibitors
statins
aspirin
beta blockers
nitrates
throm bolytic agents-clot busting drugs
(anticoagulant or parental anticoagulant)
clopidogrel
SSRI depressants
tricyclic antidepressants
ACE inhibitors and diuretics (thiazide group)
ACE inhibitors and angiotensin 2 receptor
antagonists
angiontensin 2 receptor antagonists
alpha blockers
diuretics (thiazide group)
diuretics
Figure 1: Overview of prescribed drugs in diabetic patients for all the years (2003-06).

34. 34
Progression of diabetes rates from
2003-06
0
1000
2000
3000
4000
5000
6000
7000
2003 2004 2005 2006
Progression of diabetes Type II from 2003 to 2006
diabetes
Figure 1: Overview of diabetic patients through the years 2003-6 based on the diagnosis read code for
diabetes Type II (C10F.%) and the read codes for the prescribed oral antidiabetic drugs such as the
sulfolynurea group (f3%) and metformin (f4%).

35. 35
Diseases per year
Overview of the progression for patients with diseases besides
diabetes through the years 2003-06
0
100
200
300
400
500
600
700
800
2003 2004 2005 2006
Years
Numberofpatients
myocardial infarction
stroke
Hypertensive diseases
hypertension
coronary heart disease
depression
Figure 1: Progression of diseases in diabetic patients through the years 2003-2006 based on diagnosis
codes.

36. 36
Prescribed medications per year
Drug prescriptions in diabetic patients through the years 2003-6
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
2003 2004 2005 2006
Years
Numberofprescriptions
ACE inhibitors
statins
aspirin
beta blockers
nitrates
thrombolytic agents-clot busting drugs
(anticoagulant or parental anticoagulant)
clopidogrel
SSRI depressants
tricyclic antidepressants
ACE inhibitors and diuretics (thiazide
group)
ACE inhibitors and angiotensin 2
receptor antagonists
angiontensin 2 receptor antagonists
alpha blockers
diuretics (thiazide group)
diuretics
Figure 1: Progression of the drug prescriptions in diabetic patients though the years 2003-2006 based on
drug read codes.

37. 37
Results (2)
● Low increase before the onset.
● Least possible to be considered as a
marker for diabetes.
● Coronary heart disease possible no
existing association.
● Escalation of rates before the onset -
possible marker.
● Early treatment may lead to early
diabetes diagnosis.
● Prevalent disease group.
● Increased before onset - possible marker.
Depression
Hypertensive
group
CVDs

38. 38
Results (3)
Depression
Hypertensive
group
CVDs
● Limited rates after the onset.
● Rise of myocardial infarction.-possible
complication (highest rates).
● Highest prescriptions.
● Stroke and coronary heart low rates.
● Stable rates tended to increase.
● High prescriptions after the onset.
● More as a marker and less as a
complication.
● Large decrease.
● Among the most prescribed drugs.
● More as a marker.

39. 39
Disease cases before and after the
onset of Type II
Number of diabetic patients with diseases developed a year before and after their
diabetes onset
0
50
100
150
200
250
300
350
400
450
500
a year before year of onset a year after
Numberofpatients
Depression
Hypertensive disease
hypertension
Myocardial infarction
Coronary heart disease
Stroke
Figure 1: Figure presenting the number of diabetic patients with other diseases one year before, during
and after their classification as diabetic based on diagnosis read codes.

40. 40
Prescribed medications before and
after the onset of Type II
Number of medications prescribed on diabetic patients a year before and
after their diabetes onset
0
200
400
600
800
1000
1200
1400
1600
a year before year of onset a year after
Numberofprescriptions
thrombolytic agents-clot busting drugs
(anticoagulant or parental anticoagulant)
clopidogrel
nitrates
ace inhibitors
aspirin
statins
beta blockers
SSRI antidepressants
tricyclic antidepressants
diuretics
angiotensin receptor II antagonists
alpha blockers
Diuretics thiazide group
ACE inhibitors and diuretics (thiazide
group)
ACE inhibitors and angiotensin receptor II
antagonists
Figure 1: Diagram of the prescribed medications in diabetic patients for one year before their
classification as diabetic, for the year diagnosed with diabetes and for one year their diabetes onset
based on medication read codes.

41. 41
Conclusions (1)
● Diabetes related depression or hypertension rather
CVDs.
● Escalation of depression rates yearly.
● Hypertensive diseases possible marker.
● Myocardial infarction slow increase.
● Stroke, coronary heart disease no possible pattern.
● Application of polypharmacy.

42. 42
Conclusions (2)
● Large population research aiming depression and
hypertensive diseases.
● Recording of diagnosis and prescribed medications.
● Careful implementation of polypharmacy.
● Review and evaluation of patient’s drug list.
● Creation of detailed diabetic guidelines.
● Diabetes a part of an underlying disease.
● Aggressive treatment.

43. 43
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