Multimorbidity, mortality, and HbA1c in type 2 diabetes: a cohort study with UK and Taiwanese cohorts

Chiang, J. I. et al. (2020) Multimorbidity, mortality, and HbA1c in type 2 diabetes: a cohort study with UK and Taiwanese cohorts. PLoS Medicine, 17(5), e1003094. (doi: 10.1371/journal.pmed.1003094)

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Background: There is emerging interest in multimorbidity in type 2 diabetes (T2D), which can be either concordant (T2D related) or discordant (unrelated), as a way of understanding the burden of disease in T2D. Current diabetes guidelines acknowledge the complex nature of multimorbidity, the management of which should be based on the patient’s individual clinical needs and comorbidities. However, although associations between multimorbidity, glycated haemoglobin (HbA1c), and mortality in people with T2D have been studied to some extent, significant gaps remain, particularly regarding different patterns of multimorbidity, including concordant and discordant conditions. This study explores associations between multimorbidity (total condition counts/concordant/discordant/different combinations of conditions), baseline HbA1c, and all-cause mortality in T2D. Methods and findings: We studied two longitudinal cohorts of people with T2D using the UK Biobank (n = 20,569) and the Taiwan National Diabetes Care Management Program (NDCMP) (n = 59,657). The number of conditions in addition to T2D was used to quantify total multimorbidity, concordant, and discordant counts, and the effects of different combinations of conditions were also studied. Outcomes of interest were baseline HbA1c and all-cause mortality. For the UK Biobank and Taiwan NDCMP, mean (SD) ages were 60.2 (6.8) years and 60.8 (11.3) years; 7,579 (36.8%) and 31,339 (52.5%) were female; body mass index (BMI) medians (IQR) were 30.8 (27.7, 34.8) kg/m2 and 25.6 (23.5, 28.7) kg/m2; and 2,197 (10.8%) and 9,423 (15.8) were current smokers, respectively. Increasing total and discordant multimorbidity counts were associated with lower HbA1c and increased mortality in both datasets. In Taiwan NDCMP, for those with four or more additional conditions compared with T2D only, the mean difference (95% CI) in HbA1c was −0.82% (−0.88, −0.76) p < 0.001. In UK Biobank, hazard ratios (HRs) (95% CI) for all-cause mortality in people with T2D and one, two, three, and four or more additional conditions compared with those without comorbidity were 1.20 (0.91–1.56) p < 0.001, 1.75 (1.35–2.27) p < 0.001, 2.17 (1.67–2.81) p < 0.001, and 3.14 (2.43–4.03) p < 0.001, respectively. Both concordant/discordant conditions were significantly associated with mortality; however, HRs were largest for concordant conditions. Those with four or more concordant conditions had >5 times the mortality (5.83 [4.28–7.93] p <0.001). HRs for NDCMP were similar to those from UK Biobank for all multimorbidity counts. For those with two conditions in addition to T2D, cardiovascular diseases featured in 18 of the top 20 combinations most highly associated with mortality in UK Biobank and 12 of the top combinations in the Taiwan NDCMP. In UK Biobank, a combination of coronary heart disease and heart failure in addition to T2D had the largest effect size on mortality, with a HR (95% CI) of 4.37 (3.59–5.32) p < 0.001, whereas in the Taiwan NDCMP, a combination of painful conditions and alcohol problems had the largest effect size on mortality, with an HR (95% CI) of 4.02 (3.08–5.23) p < 0.001. One limitation to note is that we were unable to model for changes in multimorbidity during our study period. Conclusions: Multimorbidity patterns associated with the highest mortality differed between UK Biobank (a population predominantly comprising people of European descent) and the Taiwan NDCMP, a predominantly ethnic Chinese population. Future research should explore the mechanisms underpinning the observed relationship between increasing multimorbidity count and reduced HbA1c alongside increased mortality in people with T2D and further examine the implications of different patterns of multimorbidity across different ethnic groups. Better understanding of these issues, especially effects of condition type, will enable more effective personalisation of care.

Item Type:Articles
Glasgow Author(s) Enlighten ID:Nicholl, Dr Barbara and Chiang, Mr Jason and Jani, Dr Bhautesh and Mair, Professor Frances and Hanlon, Dr Peter
Creator Roles:
Chiang, J. I.Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing – original draft, Writing – review and editing
Hanlon, P.Conceptualization, Formal analysis, Methodology, Writing – review and editing
Jani, B. D.Conceptualization, Data curation, Formal analysis, Methodology, Writing – review and editing
Nicholl, B. I.Conceptualization, Data curation, Investigation, Methodology, Writing – review and editing
Mair, F. S.Conceptualization, Investigation, Methodology, Supervision, Writing – review and editing
Authors: Chiang, J. I., Hanlon, P., Li, T.-C., Jani, B. D., Manski-Nankervis, J.-A., Furler, J., Lin, C.-C., Yang, S.-Y., Nicholl, B. I., Thuraisingam, S., and Mair, F. S.
College/School:College of Medical Veterinary and Life Sciences > Institute of Health and Wellbeing > General Practice and Primary Care
Journal Name:PLoS Medicine
Publisher:Public Library of Science
ISSN (Online):1549-1676
Copyright Holders:Copyright © 2020 Chiang et al.
First Published:First published in PLoS Medicine 17(5): e1003094
Publisher Policy:Reproduced under a Creative Commons License

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