title: Effect of early intensive multifactorial therapy compared with routine care on self-reported health status, general well-being, diabetes-specific quality of life and treatment satisfaction in screen-detected type 2 diabetes mellitus patients (ADDITION-Europe): a cluster-randomised trial.
abstract: OBJECTIVE
  The study aimed to examine the effects of intensive treatment (IT) vs routine care (RC) on patient-reported outcomes after 5 years in screen-detected diabetic patients.
  
  
  METHODS
  In a pragmatic, cluster-randomised, parallel-group trial, 343 general practices in Denmark, Cambridge and Leicester (UK) and the Netherlands were randomised to screening for type 2 diabetes mellitus plus IT of multiple risk factors in people 40-69 years without known diabetes (n = 1,678 patients) or screening plus RC (n = 1,379 patients). Practices were randomised in a 1:1 ratio according to a computer-generated list. Diabetes mellitus was diagnosed according to WHO criteria. Exclusions were: life expectancy <1 year, housebound, pregnant or lactating, or psychological or psychiatric problems. Treatment targets for IT were: HbA1c<7.0% (53 mmol/mol), BP ≤135/85 mmHg, cholesterol <5 mmol/l in the absence of a history of coronary heart disease and <4.5 mmol/l in patients with cardiovascular (CV) disease; prescription of aspirin to people taking antihypertensive medication and, in cases of CV disease or BP >120/80 mmHg, ACE inhibitors were recommended. After 2003, the treatment algorithm recommended statins to all patients with cholesterol of ≥3.5 mmol/l. Outcome measures were: health status (Euroqol 5 Dimensions [EQ-5D]) at baseline and at follow-up; and health status (36-item Short Form Health Survey [SF-36] and Euroquol Visual Analogue Scale [EQ-VAS]), well-being (12-item Short Form of the Well-Being Questionnaire), diabetes-specific quality of life (Audit of Diabetes-Dependent Quality of Life) and satisfaction with diabetes treatment (Diabetes Treatment Satisfaction Questionnaire) at follow-up. At baseline, standardised self-report questionnaires were used to collect information. Questionnaires were completed at the same health assessment visit as the anthropometric and biochemical measurements. The patients and the staff assessing the outcomes were unaware of the group assignments. Participants were followed for a mean of 5.7 years. Outcome data were available for 1,250 participants in the intensive treatment group (74%) and 967 participants in the routine care group (70%). The estimated differences in means from the four centres were pooled using random effects meta-analysis. Baseline EQ-5D level was used as a covariate in all analyses.
  
  
  RESULTS
  EQ-5D values did not change between diagnosis and follow-up, with a median (interquartile range) of 0.85 (0.73-1.00) at baseline and 0.85 (0.73-1.00) at 5 year follow-up. Health status, well-being, diabetes-specific quality of life and treatment satisfaction did not differ between the intensive treatment and routine care groups. There was some heterogeneity between centres (I2being between 13% [SF-36 physical functioning] and 73% [EQ-VAS]).
  
  
  CONCLUSIONS
  There were no differences in health status, well-being, quality of life and treatment satisfaction between screen-detected type 2 diabetes mellitus patients receiving intensive treatment and those receiving routine care. These results suggest that intensive treatment does not adversely affect patient-reported outcomes.
  
  
  BACKGROUND
  ClinicalTrials.gov NCT00237549 FUNDING: ADDITION-Denmark was supported by the National Health Services, the Danish Council for Strategic Research, the Danish Research Foundation for General Practice, Novo Nordisk Foundation, the Danish Centre for Evaluation and Health Technology Assessment, the Diabetes Fund of the National Board of Health, the Danish Medical Research Council and the Aarhus University Research Foundation. In addition, unrestricted grants from pharmaceutical companies were received. ADDITION-Cambridge was supported by the Wellcome Trust, the Medical Research Council, the NIHR Health Technology Assessment Programme, National Health Service R&D support funding and the National Institute for Health Research. SJG received support from the Department of Health NIHR grant funding scheme. ADDITION-Leicester was supported by Department of Health, the NIHR Health Technology Assessment Programme, National Health Service R&D support funding and the National Institute for Health Research. ADDITION-Netherlands was supported by unrestricted grants from Novo Nordisk, Glaxo Smith Kline and Merck, and by the Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht.
authors: Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, the Netherlands.
authors: Maureen
authors: M
authors: Van den Donk
authors: Simon J
authors: SJ
authors: Griffin
authors: Rebecca K
authors: RK
authors: Stellato
authors: Rebecca K
authors: RK
authors: Simmons
authors: Annelli
authors: A
authors: Sandbæk
authors: Torsten
authors: T
authors: Lauritzen
authors: Kamlesh
authors: K
authors: Khunti
authors: Melanie J
authors: MJ
authors: Davies
authors: Knut
authors: K
authors: Borch-Johnsen
authors: Nicholas J
authors: NJ
authors: Wareham
authors: Guy E H M
authors: GE
authors: Rutten
references: Qual Life Res. 2010 May;19(4):509-13
references: 20155327
references: Diabet Med. 2011 Nov;28(11):1416-24
references: 21679235
references: Diabet Med. 2010 Apr;27(4):442-50
references: 20536517
references: Lancet. 2003 Jun 14;361(9374):2005-16
references: 12814710
references: Lancet. 2008 May 10;371(9624):1563-4
references: 18468532
references: Diabetes Care. 1999 Jul;22(7):1125-36
references: 10388978
references: Med Care. 1992 Jun;30(6):473-83
references: 1593914
references: Diabetes Care. 1999 Dec;22(12):2004-10
references: 10587834
references: BMC Public Health. 2009 May 12;9:136
references: 19435491
references: Qual Life Res. 1999;8(1-2):79-91
references: 10457741
references: J Clin Epidemiol. 2006 Oct;59(10):1087-91
references: 16980149
references: N Engl J Med. 2008 Feb 7;358(6):580-91
references: 18256393
references: Med Care. 1997 Nov;35(11):1095-108
references: 9366889
references: Br J Gen Pract. 2009 Jan;59(558):43-8
references: 19105915
references: Psychol Med. 2000 Mar;30(2):455-62
references: 10824665
references: BMJ. 2013 Jan 28;346:f167
references: 23358487
references: Diabetes Care. 2002 Mar;25(3):458-63
references: 11874930
references: Int J Obes Relat Metab Disord. 2000 Sep;24 Suppl 3:S6-11
references: 11063279
references: Diabetes Care. 2011 Apr;34(4):807-12
references: 21346183
references: N Engl J Med. 2003 Jan 30;348(5):383-93
references: 12556541
references: Diabet Med. 2012 Apr;29(4):531-40
references: 21913966
references: Health Policy. 1996 Jul;37(1):53-72
references: 10158943
references: Lancet. 2011 Jul 9;378(9786):156-67
references: 21705063
references: Diabet Med. 2005 Oct;22(10):1379-85
references: 16176200
references: Diabetologia. 2008 Jul;51(7):1127-34
references: 18443762
references: Trials. 2010 Feb 19;11:16
references: 20170482
references: BMJ. 2008 Mar 1;336(7642):491-5
references: 18276664