title: Insulin pump therapy, multiple daily injections, and cardiovascular mortality in 18,168 people with type 1 diabetes: observational study.
abstract: OBJECTIVE
  To investigate the long term effects of continuous subcutaneous insulin infusion (insulin pump therapy) on cardiovascular diseases and mortality in people with type 1 diabetes.
  
  
  METHODS
  Observational study.
  
  
  METHODS
  Swedish National Diabetes Register, Sweden 2005-12.
  
  
  METHODS
  18,168 people with type 1 diabetes, 2441 using insulin pump therapy and 15,727 using multiple daily insulin injections.
  
  
  METHODS
  Cox regression analysis was used to estimate hazard ratios for the outcomes, with stratification of propensity scores including clinical characteristics, risk factors for cardiovascular disease, treatments, and previous diseases.
  
  
  RESULTS
  Follow-up was for a mean of 6.8 years until December 2012, with 114,135 person years. With multiple daily injections as reference, the adjusted hazard ratios for insulin pump treatment were significantly lower: 0.55 (95% confidence interval 0.36 to 0.83) for fatal coronary heart disease, 0.58 (0.40 to 0.85) for fatal cardiovascular disease (coronary heart disease or stroke), and 0.73 (0.58 to 0.92) for all cause mortality. Hazard ratios were lower, but not significantly so, for fatal or non-fatal coronary heart disease and fatal or non-fatal cardiovascular disease. Unadjusted absolute differences were 3.0 events of fatal coronary heart disease per 1000 person years; corresponding figures were 3.3 for fatal cardiovascular disease and 5.7 for all cause mortality. When lower body mass index and previous cardiovascular diseases were excluded, results of subgroup analyses were similar to the results from complete data. A sensitivity analysis of unmeasured confounders in all individuals showed that an unmeasured confounders with hazard ratio of 1.3 would have to be present in >80% of the individuals treated with multiple daily injections versus not presence in those treated with pump therapy to invalidate the significantly lower hazard ratios for fatal cardiovascular disease. Data on patient education and frequency of blood glucose monitoring were missing, which might have influenced the observed association.
  
  
  CONCLUSIONS
  Among people with type 1 diabetes use of insulin pump therapy is associated with lower cardiovascular mortality than treatment with multiple daily insulin injections.
authors.affiliation: Department of Endocrinology, Aarhus University Hospital, Aarhus Denmark isabelle.steineck@iname.com.
authors.forename: Isabelle
authors.initials: I
authors.lastname: Steineck
authors.affiliation: Department of Public Health and Caring Sciences/Family and Preventive Medicine, Uppsala University, Uppsala, Sweden.
authors.forename: Jan
authors.initials: J
authors.lastname: Cederholm
authors.affiliation: Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden.
authors.forename: Björn
authors.initials: B
authors.lastname: Eliasson
authors.affiliation: National Diabetes Register, Centre of Registers, Gothenburg, Sweden.
authors.forename: Araz
authors.initials: A
authors.lastname: Rawshani
authors.affiliation: Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden.
authors.forename: Katarina
authors.initials: K
authors.lastname: Eeg-Olofsson
authors.affiliation: National Diabetes Register, Centre of Registers, Gothenburg, Sweden.
authors.forename: Ann-Marie
authors.initials: AM
authors.lastname: Svensson
authors.affiliation: Department of Public Health and Caring Sciences/Geriatrics, Uppsala University, Uppsala, Sweden Medical Products Agency, Uppsala, Sweden.
authors.forename: Björn
authors.initials: B
authors.lastname: Zethelius
authors.affiliation: National Diabetes Register, Centre of Registers, Gothenburg, Sweden.
authors.forename: Tarik
authors.initials: T
authors.lastname: Avdic
authors.affiliation: Department of Clinical Science, Lund University, Lund, Sweden.
authors.forename: Mona
authors.initials: M
authors.lastname: Landin-Olsson
authors.affiliation: Faculty of Health Sciences and Medicine, Örebro University, Örebro, Sweden.
authors.forename: Johan
authors.initials: J
authors.lastname: Jendle
authors.affiliation: Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden National Diabetes Register, Centre of Registers, Gothenburg, Sweden.
authors.forename: Soffia
authors.initials: S
authors.lastname: Gudbjörnsdóttir
mesh_terms: D001794:Blood Pressure; D002318:Cardiovascular Diseases / Q000097:blood / Q000401:mortality / Q000517:prevention & control*; D003922:Diabetes Mellitus, Type 1 / Q000097:blood / Q000188:drug therapy* / Q000401:mortality; D003925:Diabetic Angiopathies / Q000097:blood / Q000401:mortality / Q000517:prevention & control*; D018450:Disease Progression; D005500:Follow-Up Studies; D006442:Glycated Hemoglobin / Q000187:drug effects; D006801:Humans; D007004:Hypoglycemic Agents / Q000008:administration & dosage*; D007267:Injections; D007328:Insulin / Q000008:administration & dosage*; D007332:Insulin Infusion Systems; D010353:Patient Education as Topic; D012042:Registries; D012307:Risk Factors; D013548:Sweden / Q000453:epidemiology
chemical_list: D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; D007328:Insulin; C517652:hemoglobin A1c protein, human