Clinical routines for diabetes screening and treatment in cardiac rehabilitation improves detection and treatment of diabetes mellitus in patients with myocardial infarction
Authors: Sharad B , Magnusson M , Ogmundsdottir Michelsen H , Jujic A , Lidin M , Mellbin L , Shaat N , Wallert J , Hagstrom E , Leosdottir M 
Published: October 2022

Abstract

Background
Patients with myocardial infarction (MI) have a high prevalence of diabetes mellitus (DM). Prognosis in patients with MI and DM is substantially worse than for those without DM. An unacceptably high proportion of patients with DM remain both undiagnosed and undertreated despite follow-up at cardiac rehabilitation (CR) centres.

Purpose
Using nationwide survey and registry data to investigate associations of clinical routines for DM screening and treatment at CR centres in Sweden with detection and treatment of DM at one-year post-MI.

Methods
Data on CR clinical routines were derived from the Perfect-CR survey, evaluating structures and follow-up processes at CR centres in Sweden (n=78). The response rate was 100% and missing data was minimal. Clinical routines for DM screening and treatment during CR (exposures) included the following: 1) laboratory assessments of fasting glucose and/or HbA1c as a part of initial patient assessment by a nurse, 2) routine use of oral glucose tolerance test (OGTT), 3) joint case rounds with diabetologists, and 4) whether diabetes medication is adjusted by cardiologists. Patient baseline and outcome data was derived from the national quality registry SWEDEHEART (n=7549). Primary outcome was DM incidence at one-year post-MI. Secondary outcome was the proportion of patients receiving diabetes medication other than insulin (secondary outcome). The association between exposures (for each clinical routine and cumulatively [0–4 work routines]) and outcomes was estimated using unadjusted and adjusted logistic regression, adjusting for relevant covariates.

Results
Number (%) of CR centres applying each of the clinical routines is shown in Table 1. The most common routine applied was fasting glucose and/or HbA1c being routinely evaluated at initial patient assessment (n=48 (62%)), while the least common was CR centres having joint case rounds with diabetologists (n=7 (9%)). Twenty (26%) CR centres did not apply any of the clinical routines while 7 (9%) centres applied 3 or 4 routines. Unadjusted and adjusted odds ratios (OR) with 95% confidence intervals (CI) for incident DM are shown in Figure 1. Compared to not applying any routines, 1) applying one or more routines was positively associated higher DM incidence at one-year post-MI (p for trend in unadjusted and adjusted models &lt;0.001. Figure 1), and 2) at centres where all four working routines were applied, the odds for patients being treated with diabetes medication was significantly higher (crude OR 2.37 [1.80–3.13], adjusted OR 1.78 [1.19–2.66]).

Conclusion
Applying structured clinical routines for DM screening and treatment within CR can improve detection and treatment of DM in patients with MI

Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): The current study was supported by The Swedish Research Council for Health, Working Life and Welfare (FORTE, grant number 2019-00365); The Swedish Heart and Lung Association (grant number 20190431); The Swedish Heart and Lung Patient Organization; The Swedish Cardiology Society; The faculty of Medicine, Lund University, Sweden; Astra Zeneca; and Amgen.