The COVID-19 pandemic disrupted primary care delivery and may have exacerbated disparities in chronic disease management, particularly for diabetes mellitus. This study sought to investigate how living in areas with low access to primary care providers (PCP) affected the delivery of diabetes care during the pandemic. This is a retrospective longitudinal study using the Panel 24 of the Medical Expenditure Panel Survey data merged with the 2019 County Health Rankings data to classify areas by PCP availability (low vs. high). Dependent variables included measures of care processes (e.g., number of HbA1c tests), quality (e.g., diet modification) and outcomes (e.g., eye complications). Multivariable models were adjusted for demographics, insurance status and COVID-19 diagnosis. HbA1c testing, foot examinations and retinal examinations decreased during the pandemic for both groups, with much more pronounced declines in low PCP density areas. The largest change occurred in the frequency of attending group classes, dropping nearly 80% in low PCP areas. Individuals in low PCP areas were more likely to initiate oral diabetes medications (as opposed to insulin) compared with those in high PCP areas (0.84% vs. 0.28%, p = 0.015). Older age was associated with new diabetes (HR = 1.05) and new kidney disease (HR = 1.04), but less likely to start diet modification (HR = 0.99). Being female (HR = 0.69) and non-Hispanic whites (HR = 0.60) were associated with a lower likelihood of diabetes incidents. These findings highlight the importance of preparing public health responses for future events that limit access to routine care, particularly for individuals with or at risk of diabetes. Strengthening both in-person and virtual primary care services is critical to reducing gaps in chronic disease management and to supporting ongoing PCP follow-up.
Diabetes is a major health concern in Malaysia, yet no comprehensive review has assessed the quality of care for these patients. This study aims to systematically review published evidence on type 2 diabetes mellitus (T2DM) management in Malaysian primary health care (PHC), focusing on the achievement of glycated haemoglobin (HbA1c), blood pressure (BP), and LDL-cholesterol (LDL-C) targets (ABC control). A scoping review was conducted, involving a comprehensive search of four databases (PubMed, Embase, Scopus, and MyMedR) and grey literature for publications up to December 2024. Studies were included if they reported on at least one ABC indicator among the general adult T2DM population in Malaysian PHC settings. The scoping review followed the Joanna Briggs Institute (JBI) methodology and PRISMA-ScR guidelines. EndNote was used for deduplication, and Rayyan was utilised for the screening process. Data were extracted and synthesised narratively. A total of 109 publications were included. Publications increased post-2010 but remained geographically concentrated in urban states. Large-scale studies heavily relied on the National Diabetes Registry. HbA1c was the most reported indicator. Findings revealed no evidence of improvement in HbA1c and BP control over two decades; achievement rates were 30-45% for HbA1c (<7.0%) and 20-50% for combined BP target (<130/80 mmHg). Conversely, LDL-C control (≤2.6 mmol/L) showed a modest improvement, with achievement rates rising from approximately 30% to 50% over a decade. Despite a substantial increase in research, the HbA1c and BP control for T2DM in Malaysian PHC has remained static and suboptimal, highlighting a persistent gap between clinical guidelines and real-world outcomes. The modest improvement in LDL-C suggests that progress is achievable. These findings underscore the need for a balanced policy focus on all three ABC indicators, strategies to overcome systemic barriers, and continued investment in the national registry to guide evidence-based improvements in diabetes care.
To evaluate primary care providers' attitudes and practices regarding albuminuria testing in patients with type 2 diabetes in the United States. Using a web-based opt-in panel of providers (Porter Novelli DocStyles survey, Fall 2024), we conducted a cross-sectional study to assess attitudes toward albuminuria testing, adherence to guidelines, and reported barriers. Associations were estimated using multivariable Poisson regression. Among 1236 providers who see at least one patient with diabetes weekly, 90.0% supported albuminuria testing and 83.3% agreed that annual testing helps with diabetes prognosis. Adherence to recommended urine testing-defined as correct test type, concurrent urine creatinine measurement, and recommended testing frequency-ranged from 52% to 68%. Lower adherence was associated with inpatient practice, being a nurse practitioner or physician assistant, lack of a urinalysis reminder system, perceived guideline ambiguity or time constraints, and lower diabetes patient volume. Despite most providers supporting urine testing for patients with diabetes, significant gaps between knowledge and practice were identified. Clinical decision support tools and clearer recommendations may help close the gaps between the guideline recommendations and practice.
Older patients with chronic kidney disease (CKD) often experience relatively slow kidney function decline, suggesting that, despite meeting referral criteria, primary care management may be appropriate. We assessed guideline recommended CKD management in patients with CKD stage 4-5 across primary and nephrology care. Population-based study using routine healthcare data from primary care and hospitals, including patients ≥ 65 years with incident or prevalent eGFR <30 ml/min/1.73m2 between 2015 and 2024. Guideline adherence was evaluated using thirteen quality indicators, calculated as the proportion of patients fulfilling these indicators or the proportion of follow-up time covered by adherent care. Of 1969 patients (mean age 81.8 years, median eGFR 25 ml/min/1.73m2), 61.2% were managed in primary care. These patients were older and were more often considered frail. In primary care, monitoring covered 82.5% of follow-up time for kidney function, 47.8% for albuminuria, 76.6% for blood pressure, 85.6% for haemoglobin, 50.9% for LDL-cholesterol and 68.3% for HbA1c among patients with diabetes. Corresponding estimates in nephrology care were 86.8%, 65.2%, 84.4%, 97.5%, 68.3% and 84.9%, respectively. Monitoring of metabolic complications, which falls beyond primary care guidelines, was 28.4%-79.2% in primary care and 73.6%-97.8% in nephrology care. RAAS inhibitors were prescribed in 56.9% (primary care) and 84.4% (nephrology care); SGLT2 inhibitors in 4.3% and 10.1%, and NSAIDs in both settings < 7%. Guideline adherence did not vary by socio-economic status or country of origin. In primary care, adherence was higher in patients with diabetes. The majority of older patients with CKD stage 4-5 are managed in primary care. Guideline adherence varied across care settings, which served substantially different patient populations. Higher adherence in patients with diabetes, typically enrolled in structured disease management programs, suggests that embedding similar structured approaches may enhance adherence to CKD guideline in primary care.
 With the increasing burden of non-communicable chronic diseases, it is important to empower people to self-manage their conditions. This study aimed to explore the support that persons living with chronic disease require to self-manage their conditions at a Primary Health Care (PHC) facility in the Victor-Khanye subdistrict, Delmas, Mpumalanga.  Individual in-depth interviews were conducted with 14 adult participants who collected their monthly medication for diabetes, human immunodeficiency virus or hypertension. Data were analysed manually using thematic analysis.  Three themes were identified: (1) individual self-management; (2) support enhancing for self-management; and (3) barriers to self-management. The study highlights that self-management requires a combination of individual beliefs, capabilities, education, access to healthcare resources, financial assistance, emotional support from family and friends, and community support. While knowledge is crucial for empowering individuals to manage their diseases effectively, challenges such as financial constraints and a lack of specific self-management support provided by healthcare workers hinder many from fully implementing self-management strategies.  Persons living with chronic disease require comprehensive care that extends beyond healthcare and includes emotional, social and financial support. Effective self-management requires access to tailored education and community support networks that allow people to take an active role in their health.Contribution: Understanding the support persons living with chronic diseases require for effective self-management is critical for improving health outcomes, enhancing quality of life and promoting sustainable healthcare systems.
Social determinants of health (SDOH) screenings have identified disproportionate inequities in Hispanic populations that increase diabetes risk, yet they rarely lead to interventions. Churches are trusted community hubs with the potential to address health needs; however, partnerships with Hispanic churches remain largely unexplored. To assess the feasibility of a church-based, community health worker (CHW)-led program to identify and address SDOH inequities in a Hispanic community. Pilot quasi-experimental feasibility study PARTICIPANTS: Forty-seven Hispanic adults, predominantly women (74.5%), with a mean age of 51 years INTERVENTIONS: Five church congregants obtained CHW state certification (160-h course) and received training in teaching skills, diabetes self-management, and SDOH. With ongoing mentoring, CHWs led a 6-month diabetes prevention and self-management program with monthly in-person education and weekly mHealth coaching focused on addressing SDOH inequities in the healthcare access and quality domain. Feasibility was assessed across eight pre-established variables (integration, expansion, demand, implementation, limited efficacy, acceptability, practicality, and adaptation), including CHWs' ability to address SDOH inequities such as insurance coverage, established medical home, primary care utilization, eye exams, medication access, and glucose monitoring. CHWs completed 97.3% of planned weekly mHealth contacts, identified and addressed 92.8% of participant concerns, and conducted all in-person education sessions per protocol. Healthcare access improved significantly: insurance coverage/clinic eligibility (66.0 to 85.1%; p = 0.025), established medical home (61.7 to 91.5%; p < 0.0001), time since last primary care visit (16.2 to 1.4 months; p = 0.017), and annual eye exams (25.0 to 64.3%; p < 0.0001). On a 5-point Likert scale, participants increased access to medications (Δ = 0.54; p = 0.03), medical care (Δ = 0.67; p = 0.012), and a primary care provider (Δ = 0.79; p = 0.009). Among participants with diabetes, glucose monitoring increased from 0.5 to 1.4 times daily (p = 0.017). Findings support the feasibility of partnering with Hispanic churches to both identify and address healthcare access SDOH inequities.
Given around 50% of people with heart failure have a degree of iron deficiency, guidelines recommend screening. It is uncertain to what extent this is done in primary care and whether testing is equitable. To report the proportion of people with incident heart failure who undergo a ferritin test within 12 months. Retrospective primary care cohort study using Clinical Practice Research Datalink Aurum data, between 2016 and 2021. We report the proportion of adults with an incident diagnosis of heart failure who received a ferritin test within 12 months. Multivariable logistic regression was used to examine the odds of testing based on key demographic covariates and co-morbidities. Among 105 749 individuals with an incident diagnosis of heart failure (mean age 71.6 years, SD 14.3), only 35 688 (33.7%) received a ferritin test within the subsequent year. Increasing age (odds ratio 1.25 per 10-year increase, 95% CI: 1.24-1.27), female sex (male sex OR 0.86, 0.84-0.89) and Asian ethnicity (OR 1.70, 1.59-1.80) were all associated with increased odds of testing as were diagnoses of coeliac disease (OR 1.86, 1.58-2.21), type 1 diabetes (OR 1.82, 1.51-2.19) and cirrhosis (OR 1.64, 1.43-1.87). There was geographic variation in testing, even in adjusted analyses. In a large primary care dataset, two thirds of people with incident heart failure did not receive a ferritin test for iron deficiency within a year of diagnosis demonstrating a gap in current practice and an opportunity for improvements in service delivery.
As a critical preclinical stage of type 2 diabetes (T2D), prediabetes necessitates urgent lifestyle interventions to halt disease progression. Despite robust evidence supporting the efficacy of exercise in improving glycemic control, exercise adherence remains suboptimal among individuals with prediabetes. This review aimed to identify barriers and facilitators to exercise adherence in individuals with prediabetes while also extracting evidence-based behavior change techniques (BCTs) that may enhance physical activity maintenance. Mixed-methods systematic review. A comprehensive literature search was performed in 10 databases from inception to November 2024. Guided by the JBI Manual for Evidence Synthesis, a convergent integrated approach was used to map barriers and facilitators to the Behavior Change Wheel (BCW) and Theoretical Domains Framework (TDF). TDF domains were ranked by frequency across studies, while adherence-promoting interventions were mapped to BCW intervention functions and BCTs. Barriers were systematically linked to BCW intervention functions and BCTs to guide implementation design. A total of 36 studies were included, consisting of 9 qualitative studies, 24 quantitative studies (15 randomized controlled trials, 5 cross-sectional studies, and 4 quasi-experimental studies), and 3 mixed-methods studies. The synthesis identified "lack of time," "lack of appropriate exercise equipment or venues," and "health-related physical limitations" as predominant barriers. Conversely, "perceived health benefits," "social support," and "tools or methods to help with exercise adherence" emerged as key facilitators. These factors were mapped to five primary TDF domains: reinforcement, environmental context and resources, behavioral regulation, social influences, and skills. Furthermore, seven intervention functions derived from the BCW were linked to 21 BCTs. This review highlights multifaceted determinants of exercise adherence in individuals with prediabetes and identifies theory-informed strategies to address barriers to adherence. Determinants supported more consistently across studies may provide a stronger basis for intervention development, whereas less frequently reported findings should be interpreted more cautiously. PROSPERO CRD42024605588. What helps or stops people with prediabetes from exercising, and how can we support them? Prediabetes is a condition where blood sugar levels are higher than normal but not yet high enough to be called type 2 diabetes. Exercising is one of the best ways to stop prediabetes from getting worse. However, many people find it hard to stick to an exercise routine. In this study, we looked at existing research to find out what stops people with prediabetes from exercising (barriers) and what helps them keep going (facilitators). We found that the biggest hurdles are a lack of time, not having the right equipment or places to exercise, and physical health problems. On the other hand, understanding the health benefits, getting support from friends and family, and using helpful tools make people more likely to exercise. To help people overcome these hurdles, we suggest creating personalized exercise plans. These plans should include specific techniques like setting clear goals, making action plans, and building social support. By using these simple strategies, doctors and nurses can better help people with prediabetes stay active, which may help reduce their risk of developing type 2 diabetes.
Continuous glucose monitoring (CGM) offers real-time and longitudinal insights into glycemic patterns, time in range, and hypoglycemia. Adopting CGMs into practice can improve clinical outcomes while strengthening patient engagement and enabling data-driven care across routine visits and population health programs. Despite strong evidence of benefit, CGM remains underused in primary care, where most patients with diabetes mellitus are managed. Barriers include limited familiarity with CGM technology, interpretation, workflow, documentation and billing, and patient access and education. The purpose of this clinical review was to help equip primary care clinicians with a concise, family medicine-focused framework for adopting CGM, including technology overview, patient selection and education, practical interpretation of standardized reports, team-based workflow, documentation, and reimbursement.
To quantify the incidence of gestational diabetes mellitus in England, determine inequalities in diagnoses and pregnancy outcomes, and assess the indirect effects of the covid-19 pandemic. Contemporary, cross sectional observational study. Primary and secondary care data from NHS England, based on the Hospital Episode Statistics Admitted Patient Care dataset, 1 January 2018 to 31 December 2022. 2 314 365 women, aged 16-50 years, who gave birth to 2 758 170 babies in 184 hospitals. Rates of gestational diabetes, infants born small for gestational age or large for gestational age, and emergency caesarean births, summarised yearly and monthly, based on socioeconomic deprivation and ethnic group. Diagnoses of gestational diabetes increased from about 8% in 2018 to >12% in 2022. The increase was greatest for individuals from non-white ethnic groups (23% for Asian women) or those living in deprivation (14%). Mothers from these backgrounds were also at greater risk of adverse pregnancy outcomes, such as emergency caesarean birth (odds ratio for black mothers 1.36, 95% confidence interval 1.34 to 1.38), preterm birth (odds ratio for deprived mothers 1.29, 1.27 to 1.31), or having an infant small for gestational age (odds ratio for Asian mothers 2.42, 2.39 to 2.45). Also, a diagnosis of gestational diabetes for these women was associated with an increase in the odds of preterm birth. Changes to screening methodology for gestational diabetes during the covid-19 pandemic had no significant effect on the number of diagnoses. The study found that one in eight mothers in England had a diagnosis of gestational diabetes, and that profound health inequalities exist in their outcomes. Strategies are urgently needed to provide and improve care for this high risk group, given the implications of gestational diabetes on the short and long term health outcomes for mothers and babies.
Remote patient monitoring (RPM), including self-measured blood pressure monitoring with clinician review and telehealth-supported feedback, can support hypertension management. However, RPM use and related care continuity after switching from Medicare fee-for-service (FFS) to Medicare Advantage (MA) remain unclear. To compare RPM adoption, clinician continuity, and hypertension-related acute care utilization among beneficiaries who remained in Medicare FFS vs switched to MA plans, categorized as value-based contract (VBC) proxy or non-VBC. This cohort study with an observational difference-in-differences design with propensity score matching used data from 2016 to 2022 Medicare enrollment, FFS claims, and MA encounter data. Beneficiaries were aged 65 years or older with prevalent diagnosed hypertension in 2018 and continuous enrollment in Parts A and B in 2018. Treated groups switched from FFS to MA in January 2019 and remained enrolled through 2022; comparators remained in FFS. Follow-up extended from January 1, 2019, through December 31, 2022. Data analysis was conducted from April to July 2025. Switching from Medicare FFS to MA-VBC proxy or MA non-VBC in 2019. The primary outcome was annual RPM adoption during hypertension-related visits; secondary outcomes included clinician loss without replacement, clinician switching or substitution, and hypertension-related emergency department (ED) visits and hospitalizations. Matched samples included 281 620 beneficiaries, with 46 833 MA-VBC proxy plan switchers and 46 833 FFS comparators (27 920 [59.6%] aged 71 years or older and 27 685 female [59.1%] in each group) and 93 977 MA non-VBC switchers and 93 977 FFS comparators (67 188 [71.5%] aged 71 years or older; 53 122 female [56.5%] in each group). Common comorbidities included diabetes, chronic kidney disease, and heart failure. Switching to MA was associated with lower RPM adoption in 2022 (MA-VBC proxy: odds ratio [OR], 0.55; 95% CI, 0.42-0.72; -0.63 percentage points; non-VBC: OR, 0.73; 95% CI, 0.54-0.99; -0.52 percentage points), greater clinician loss without replacement (MA-VBC proxy: OR, 1.27; 95% CI, 1.23-1.32; 3.41 percentage points; MA non-VBC: OR, 1.09; 95% CI, 1.06-1.12; 0.83 percentage points), and higher hypertension-related hospitalizations (MA-VBC proxy: OR, 1.75; 95% CI, 1.48-2.06; MA non-VBC: OR, 1.94; 95% CI 1.71-2.19; 1.56 percentage points in both comparisons). Event-study analyses showed postswitch divergence through 2022. In this cohort study of older Medicare beneficiaries with hypertension, switching from FFS to MA was associated with lower RPM adoption, greater clinician discontinuity, and higher hypertension-related acute care use. These findings suggest that continuity safeguards and clearer payment or quality incentives during MA transitions may support remote monitoring and clinician follow-up for hypertension.
The high prevalence of hearing impairment in older adults and the scarcity of diagnostic resources in primary health care (PHC) highlight the need for solutions based on artificial intelligence. This study aimed to develop and evaluate a decision tree model to prioritize hearing examinations in this population. An observational study was conducted using 60 clinical profiles. The decision tree model was developed in R, using the Recursive Partitioning and Regression Trees (rpart) package after data preprocessing that included cleaning, dichotomization, and multiple imputations by chained equations (MICE). The algorithm was trained on 70% of the sample and tested on the remaining 30%. Its performance was evaluated using standard metrics. The model achieved satisfactory performance with good accuracy, sensitivity, and specificity. The area under the curve (AUC) was 0.825, outperforming a classic logistic regression model (AUC 0.700). Based on the model's key predictors, which include the presence of tinnitus, not having a partner, female sex, hypertension and/or diabetes, and age ≥ 65 years, a user-friendly, interactive web-based dashboard was developed for clinical use. The decision tree model is a promising tool that demonstrates technical viability for prioritizing hearing loss screening. While further large-scale external validation is required, it serves as a foundational step for integrating AI-driven prioritization in primary health care.
Pacific peoples experience significant health inequities. National health data often aggregate diverse Pacific communities into a single category, potentially masking important differences in social-context health needs between subgroups. This study aimed to describe the epidemiology and health indicators of Pacific Peoples enrolled at Pegasus Health Primary Health Organisation (PHO), Waitaha Canterbury, Aotearoa New Zealand (NZ), from the five largest ethnic subgroups: Samoan, Tongan, Cook Islands Māori, Niuean, and Fijian peoples. This cross-sectional study used anonymised administrative data from Pegasus Health PHO, NZ. All enrolled patients with Pacific ethnicity recorded at any level were identified (n = 14,209). Demographic characteristics, socioeconomic deprivation, smoking status, and diabetes diagnoses were analysed by ethnicity using descriptive statistics. Samoan patients comprised 52.8% of Pacific peoples enrolled (n = 7,498), followed by Fijian (18.4%), Tongan (14.3%), Cook Islands Māori (11.2%), and Niuean (3.4%). The population was predominantly young (mean age ranged from 27 to 32 years). Socioeconomic deprivation varied substantially: 33% of Samoan and 25% of Tongan patients lived in the most deprived areas (quintile 5), compared to 17% of Fijians who lived in quintile 5. Smoking prevalence ranged from 7.2% (Fijian) to 13.1% (Cook Islands Māori). Diabetes ranged from 5.5% (Cook Islands Māori) to 9.3% (Samoans). Substantial heterogeneity exists across Pacific subgroups in Canterbury regarding demographics, socioeconomic circumstances, and key health indicators. Disaggregated ethnicity data reveal distinct patterns that are obscured when Pacific peoples are treated as a single homogeneous group. This has important implications for targeting health services and designing interventions to achieve health equity.
Diabetes-related knowledge, attitudes, and practices (KAP) and associated clinical outcomes, including diabetic retinopathy (DR), have not been adequately examined across patient demographics in Trinidad and Tobago (T&T), which this study examined. A total of 194 patients with diabetes (age = 59.56 ± 12.9 years, diabetes duration = 14.29 ± 11.2 years; 59.3% females) attending various eye clinics were recruited via convenience sampling. KAP was assessed using a validated questionnaire. Data on duration of diabetes/treatment, height/weight, blood pressure, fasting blood glucose (FBG) level, and DR status and severity were obtained from recent medical records. Associations between independent (age, gender, education level, employment status) and dependent variables (KAP, clinical data) were explored. Of the total participants, 43.8% (85/194) were employed, 82.0% (159/194) had above primary-level education, 51.0% (99/194) were 60 years or older, 49.5% (96/194) reported doing regular physical activity, 60.6% (117/194) would be less concerned at forgetting diabetes medication, and 36.1% (70/194) were unaware that diabetic eye exam differed from basic eye test for spectacles. Females were less willing to discuss their diabetes openly, along with younger participants. DR status/severity was recorded for 78.3% (152/194) using Early Treatment Diabetic Retinopathy Study classification; 42.8% had DR, and 5.7% had sight-threatening DR (moderate non-proliferative DR or worse, and/or the presence of diabetic macular edema). FBG (OR = 1.04, 95% CI: 1.01-1.07, p = 0.006) and lower (below secondary) level of education (OR = 8.3, 95% CI = 1.53-44.7, p = 0.014) predicted DR presence independently. Notable gaps in diabetes-related KAP were observed. Women/younger participants were less willing to discuss their diabetes openly. More women knew the importance of physical activity than men. Elevated FBG and lower education levels were independently associated with DR. Our findings support the need for demographically targeted education interventions for diabetic patients attending eye clinics in T&T.
Type 2 diabetes mellitus (T2DM) is a major modifiable risk factor for accelerated brain ageing, cognitive decline, and dementia. However, sustainable lifestyle interventions targeting cognitive health in at-risk older adult populations remain limited. This mixed-methods study evaluated the effects of a 12-week technology-blended Intensive Aerobic and Resistance Exercise Program (IAREP) on cognitive risk and related health outcomes among middle-aged and older adults with T2DM in a primary care setting in Singapore. Participants were recruited from a community polyclinic and allocated to either the intervention or usual care group. The intervention integrated face-to-face, Zoom-based, and video-recorded home exercise sessions to support accessibility and adherence. Quantitative outcomes included cognitive impairment risk, physical function, metabolic and inflammatory markers, physical activity, and self-care maintenance. Qualitative focus group discussions explored participant experiences following programme completion. Fifty-three participants completed the study (mean age 66.7 years). Compared with usual care, the intervention group demonstrated significant reductions in predicted risk of cognitive impairment (F(1,51)=4.9, p = 0.031, η²ₚ=0.088), improvements in physical function (F(1,51)=10.6, p = 0.002, η²ₚ=0.172), and higher physical activity levels (F(1,51)=8.3, p = 0.006, η²ₚ=0.140). Self-care maintenance also improved significantly (F(1,51)=4.5, p = 0.040, η²ₚ=0.081). Adherence was high (88.9%). Qualitative findings highlighted enhanced motivation, social connectedness, and perceived cognitive and physical well-being. These findings support technology-blended exercise might be a feasible and scalable strategy for cognitive risk reduction and brain health promotion among middle-aged and older adults with T2DM, with potential translational relevance for dementia prevention in primary care and community settings.
Cost analysis of autonomous artificial intelligence (AI)-based screening of diabetic retinopathy (DR) for adults with diabetes at a primary care clinic. This study provides a comparative cost analysis of actual results using AI-based DR screening with counterfactual results based on all patients going through the physician-based referral system. A cost analysis is conducted using cost data from published sources, provincial billing codes, statistical sources, and patient characteristics from a clinical study to compare autonomous AI-based screening for DR versus physician-based screening. Costs considered include direct costs of operating the AI system, physician fees, and indirect costs to patient time. Along with total cost comparisons, a cost per DR case detected is estimated and a sensitivity analysis based on variations in AI costs is provided. Over the study period, 202 participants were screened for DR using autonomous AI. The majority (93.6%, n=189) of AI-based DR screening exams were completed successfully. The AI-based scenario results in total direct costs of $C7919.04 and indirect costs of $C5728.80, resulting in total costs of $C13 647.84 per 100 patients. The traditional physician-based approach results in total direct costs of $C8240 and indirect costs of $C19 998.09, resulting in total costs of $C28 238.09 for 100 patients. When costs are converted to costs per unit outcome, the total cost per diagnosed DR case is $C620.36 for the AI-based approach and $C1283.55 for the physician-based approach; the AI-based cost per diagnosed case was 52% lower. Given the lower cost per diagnosed case of the AI-based approach, there are advantages to the implementation of AI-based screening for DR.
Sleep disturbances, particularly insomnia, are increasingly recognized as behavioral determinants of type 2 diabetes (T2DM). However, their contribution to validated diabetes risk scores beyond traditional sociodemographic and lifestyle factors remains insufficiently explored. To examine the association between insomnia severity, sociodemographic variables, lifestyle habits, and estimated T2DM risk using three validated non-invasive risk assessment scales. A cross-sectional study was conducted among 84,898 Spanish workers aged 18-69 years undergoing occupational health evaluations (2021-2024). Sociodemographic and behavioral data were collected through standardized questionnaires, including adherence to the Mediterranean diet (MEDAS-14), physical activity (IPAQ-SF), and smoking status. Insomnia was assessed using the Insomnia Severity Index (ISI). Diabetes risk was estimated using three validated non-invasive risk-assessment tools: the Finnish Diabetes Risk Score, the QDScore/QDiabetes, and the Trinidad Risk Assessment Questionnaire for Type 2 Diabetes Mellitus. As these instruments were developed and validated in different populations, comparisons of absolute risk categories across scales should be interpreted with caution. Multivariable logistic regression models adjusted for age, sex, social class, smoking, diet, and physical activity were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). Severe insomnia was associated with approximately 2.1-2.6-fold higher odds of high estimated diabetes risk across all three scales in the pooled analyses, with significant trends across categories of insomnia severity (all P for trend <0.001). This association persisted across sex and activity strata. Adding ISI modestly improved model discrimination (ΔAUC ≈ +0.015; P≤0.003) and reclassification (continuous net reclassification improvement [NRI], 6.5%-8.1%). Insomnia severity was independently associated with higher estimated risk of T2DM beyond measured sociodemographic and lifestyle determinants. Incorporating sleep health-via brief tools such as the ISI-into diabetes risk assessment could enhance early prevention strategies in clinical and occupational settings.
Athletes with diabetes increasingly participate in endurance running, benefiting from physiological adaptations and technological advances like continuous glucose monitoring (CGM) for glycemic control. So far, no comprehensive review summarizing the current knowledge has been performed. To identify the prevalence of long-distance runners with diabetes, their performance, methods used for blood glucose monitoring and glycemic control. PubMed, Medline Ovid, Scopus, SPORTDiscus, Cochrane databases, CINAHL, and Web of Science were systematically searched until April 2024 using key terms related to long-distance running and diabetes. An updated search applying the identical strategy was conducted on May 3rd, 2026, to capture subsequently published literature. This study included original research articles, case reports, and case studies published in English or German in peer-reviewed journals, utilizing both quantitative and qualitative methodologies. Eligibility criteria encompassed runners with a confirmed diagnosis of diabetes mellitus, irrespective of type, who participated in endurance events of at least half-marathon distance, including half-marathons, marathons, ultra-marathons, and other ultra-endurance competitions. Patients with prediabetic state, gestational diabetes, or after pancreatic islet-cell transplantation were excluded. For quality assessment, we used the Joanna Briggs Institute of Analytical Cross-Sectional Studies or the Joanna Briggs Institute of Analytical Case Report critical appraisal tool. A total of 656 studies were identified, with 22 meeting the inclusion criteria, comprising 99 runners with diabetes (99.0% Type 1, 1.0% Type 2 diabetes mellitus). Among them, 50.0% used CGM, 27.2% had an insulin pump, 63.6% administered insulin via multiple daily injections, and the method of insulin application was not specified in 7.0% of runners. The weighted mean HbA1c was 7.4% (95% CI 6.9-8.1). Time-in-range varied by race distance: 40-100% for half-marathoners, 51.6% for marathoners, and 47-73% for ultra-marathoners. No cases of symptomatic hypoglycemia were observed during the races. However, asymptomatic late-onset hypoglycemia (occurring 6-15 h post-exercise) was reported in 27 runners. The most common insulin adjustment strategy before competitive races was a 50-80% reduction of basal insulin. Despite limited research, evidence suggests that with proper preparation and multidisciplinary support, athletes with diabetes can safely participate in endurance events, including ultra-marathons, while maintaining stable glycemic control. PROSPERO-CRD42024539281.
Annual Diabetes Reviews (ADRs) are a key Ministry of Health initiative designed to ensure comprehensive annual assessment for people with diabetes in Aotearoa New Zealand. Although national guidance outlines core components, the consistency with which ADRs are delivered across primary care remains unclear. This study aims to assess the structure, components, and delivery of ADRs in general practices, identifying gaps and opportunities for improving diabetes care. A National cross-sectional survey was conducted among a 10% random sample (n = 85) of Foundation Standard-certified practices. Practices were invited via email and phone, yielding a 40% response rate (n = 34). Data were collected through an anonymized online or phone survey covering ADR structure, provider roles, and recall systems. Of the 34 participating practices, 32 (94%) conducted ADRs. Nurses were the primary providers (91%), other providers included GPs, healthcare assistants, pharmacists, and Māori health workers. All practices included blood pressure checks, foot examinations, and retinal screening, whereas mental health assessment (56%) and contraception counselling (28%) were less common. Electronic recall systems were used by 94% of practices, though strategies varied. Most practices have established processes for delivering ADRs, but implementation of key elements remains inconsistent. The proportion of patients receiving a comprehensive ADR is unclear. Further research involving medical record reviews across sociodemographic groups and qualitative studies of patient and whānau experiences could improve ADR processes.
 Diabetic retinopathy (DR) is a major cause of avoidable vision loss, yet public awareness is low, hindering early detection and treatment. Many people living with diabetes are unaware of their risk for DR and the need for screening.  To assess the knowledge, attitudes and practices of people living with diabetes regarding DR prevention.  Ten primary health care clinics in the Maruleng sub-district in Limpopo province of South Africa.  A cross-sectional study utilised a self-reported questionnaire with yes/no questions to measure knowledge and practices, and attitudes were assessed with a 5-point Likert scale. Scores above the median for knowledge, attitudes and practices were indicative of good knowledge and practices and positive attitudes.  Almost two-thirds of participants (n = 255; 65.6%) were female. Approximately 268 participants (61.2%) knew that uncontrolled high blood sugar can lead to DR. The majority (n = 355; 86.1%) showed positive attitudes towards their eye health, while 216 (55.8%) had good practices towards DR prevention. Higher education and duration of diabetes were associated with good knowledge (adjusted odds ratio [AOR]: 2.2; 95% confidence interval [CI]: 1.3-3.9; p  0.05) and (AOR: 1.9; 95% CI: 1.2-2.9; p  0.05), respectively, while good knowledge about diabetic eye complications was associated with positive attitudes (AOR: 2.0; 95% CI: 1.3-3.1; p  0.05). Patients diagnosed with diabetes mellitus for more than five years were more likely to attend regular eye exams (AOR: 2.3; 95% CI: 1.5-3.6; p  0.05).  Although participants had high median scores for knowledge and attitudes, important deficiencies were noted that could hinder effective DR screening.Contribution: These findings provide the baseline evidence on the need for ongoing patient education in primary care to enhance DR prevention.