title: Does training of general practitioners for intensive treatment of people with screen-detected diabetes have a spillover effect on mortality and cardiovascular morbidity in 'at risk' individuals with normoglycaemia? Results from the ADDITION-Denmark cluster-randomised controlled trial.
abstract: Within a trial of intensive treatment of people with screen-detected diabetes, we aimed to assess a potential spillover effect of the trial intervention on incident cardiovascular disease (CVD) and all-cause mortality among people who screened positive on a diabetes risk questionnaire but who were normoglycaemic.
  
  
  
  In the Anglo-Danish-Dutch Study of Intensive Treatment In People with Screen-Detected Diabetes in Primary Care (ADDITION)-Denmark trial, 175 general practices were cluster-randomised into: (1) screening plus routine care of individuals with screen-detected diabetes (control group); or (2) screening plus training and support in intensive multifactorial treatment of individuals with screen-detected diabetes (intervention group). We identified all individuals who screened positive on a diabetes risk questionnaire in ADDITION-Denmark but were normoglycaemic following biochemical testing for use in this secondary analysis. After a median 8.9 years follow-up, we used data from national registers to compare rates of first CVD events and all-cause mortality in individuals in the routine care group with those in the intensive treatment group.
  
  
  
  In total, 21,513 individuals screened positive for high risk of diabetes but were normoglycaemic on biochemical testing in ADDITION-Denmark practices between 2001 and 2006 (10,289 in the routine care group and 11,224 in the intensive treatment group). During 9 years of follow-up, there were 3784 first CVD events and 1748 deaths. The incidence of CVD was lower among the intensive treatment group compared with the routine care group (HR 0.92 [95% CI 0.85, 0.99]). This association was stronger among individuals at highest CVD risk (heart SCORE ≥ 10; HR 0.85 [95% CI 0.75, 0.96]). There was no difference in mortality between the two treatment groups (HR 1.02 [95% CI 0.92, 1.14]).
  
  
  
  Training of general practitioners to provide target-driven intensive management of blood glucose levels and other cardiovascular risk factors showed some evidence of a spillover effect on the risk of CVD over a 9 year period among individuals at high risk of diabetes. The effect was particularly pronounced among those at highest risk of CVD. There was no effect on mortality.
  
  
  
  ClinicalTrials.gov NCT00237549.
authors.affiliation: MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge, UK. rks34@cam.ac.uk.|Department of Public Health, Aarhus University, Building 1260, Bartholins Allé 2, DK-8000, Aarhus C, Denmark. rks34@cam.ac.uk.|Danish Diabetes Academy, Odense, Denmark. rks34@cam.ac.uk.|Aarhus Institute of Advanced Studies, Aarhus University, Aarhus, Denmark. rks34@cam.ac.uk.
authors.forename: Rebecca K
authors.initials: RK
authors.lastname: Simmons
authors.affiliation: Department of Public Health, Aarhus University, Building 1260, Bartholins Allé 2, DK-8000, Aarhus C, Denmark.
authors.forename: Niels H
authors.initials: NH
authors.lastname: Bruun
authors.affiliation: Department of Public Health, Aarhus University, Building 1260, Bartholins Allé 2, DK-8000, Aarhus C, Denmark.|Danish Diabetes Academy, Odense, Denmark.
authors.forename: Daniel R
authors.initials: DR
authors.lastname: Witte
authors.affiliation: Holbæk Hospital, Holbæk, Denmark.
authors.forename: Knut
authors.initials: K
authors.lastname: Borch-Johnsen
authors.affiliation: Steno Diabetes Center Copenhagen, Gentofte, Denmark.|National Institute of Public Health, Southern Denmark University, Copenhagen, Denmark.
authors.forename: Marit E
authors.initials: ME
authors.lastname: Jørgensen
authors.affiliation: Department of Public Health, Aarhus University, Building 1260, Bartholins Allé 2, DK-8000, Aarhus C, Denmark.
authors.forename: Annelli
authors.initials: A
authors.lastname: Sandbæk
authors.affiliation: Department of Public Health, Aarhus University, Building 1260, Bartholins Allé 2, DK-8000, Aarhus C, Denmark. tl@ph.au.dk.
authors.forename: Torsten
authors.initials: T
authors.lastname: Lauritzen
mesh_terms: D000328:Adult; D000368:Aged; D001786:Blood Glucose / Q000378:metabolism; D002318:Cardiovascular Diseases / Q000097:blood / Q000401:mortality*; D003924:Diabetes Mellitus, Type 2 / Q000175:diagnosis* / Q000401:mortality*; D005260:Female; D058005:General Practitioners / Q000706:statistics & numerical data*; D006801:Humans; D015994:Incidence; D008297:Male; D008403:Mass Screening; D008875:Middle Aged; D016032:Randomized Controlled Trials as Topic; D012307:Risk Factors; D011795:Surveys and Questionnaires
chemical_list: D001786:Blood Glucose
keywords: Cardiovascular disease; Diabetes; High risk; Intensive treatment; Normoglycaemic; Routine care; Screening; Spillover; Trial