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

5. 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 5

6. 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 6

7. 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 7

8. 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 Background

9. 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 9

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

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

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

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

14. 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 14

15. 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 15

16. 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 16

17. Other variables Age Gender Methodology 17

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

19. Results 19

20. Results A total of 17,828 patients met the selection criteria (mean age: 68.9 years ± 12.0; female: 54.5%). 20

21. 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 21

22. No significant difference between gender 22

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

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. 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 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. ? ? 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 28