SA JOURNAL OF DIABETES & VASCULAR DISEASE RESEARCH ARTICLE VOLUME 21 NUMBER 1 • November 2024 23 and Nutrition Examination Survey (NHANES) with yearly clinical reminders for diabetes care and enhanced patient education.7 The simultaneous control of ABC risk factors has been projected to prevent 38% of CAD events over 10 years.15 Depression related to long-term control of HbA1c and LDL-C levels and SBP in patients with T2DM has been well studied in the USA. Heckbert et al.16 reported that MDD was associated with slightly higher average HbA1c levels, and no difference in average SBP or LDL-C levels during follow up in patients with T2DM. However, the study by Katon et al.17 showed patients with T2DM and MDD, with or without evidence of heart disease, had a higher number of CVD risk factors. A recent study in Ghana conducted in a tertiary public healthcare facility reported no independent association of MDD with poor glycaemic control in the T2DM + MDD patients.18 In SA, the national prevalence of adults with T2DM is 12.7%19 and with MDD is 9.7%.2 However, the national co-prevalence of MDD in patients with T2DM is yet to be enumerated. Private managed healthcare individuals in SA have a high incidence of T2DM with all the CV sequelae, in addition to having MDD overlapping as a most frequent co-morbidity.3 T2DM is a significant contributor to disease burden and together with MDD may have a negative effect on the CV outcomes of T2DM;20 hence this study examined the ABC control achieved in individuals with T2DM + MDD. Emerging evidence demonstrates shared mechanisms between non-communicable diseases (NCD) such as MDD and T2DM and between MDD and atherosclerotic cardiovascular disease (ASCVD) are attributed predominantly due to the immunometabolic pathways.21-24 MDD has been attributed to high levels of proinflammatory cytokines,25,26 which over a length of time can lead to elevated BP and blood glucose levels, abdominal obesity and dyslipidaemia,27 known as traditional risk factors for T2DM, ASCVD and other related disorders.28 Statins [3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors] have been demonstrated to be effective in both primary and secondary prevention of ASCVD.11 This effect is largely dependent on the extent to which LDL-C level is lowered and not by the type of statin used.11,29,30 The main cause of death in MDD remains ASCVD,31 where statins have proven to have therapeutic benefits.32 The combination of a selective serotonin reuptake inhibitor (SSRI) and a statin has been associated with lower risk for psychiatric hospitalisations due to depression, compared to the use of SSRI alone.33 This study aimed to assess the CVD risk and the attainment of control of the triad ABC guideline in individuals with T2DM with and without co-morbid MDD in a South African privately managed healthcare environment. Methods This cross-sectional, retrospective, descriptive study was conducted in a private managed healthcare organisation in SA. We utilised an integrated database of electronic health records (EHR), laboratory data, and the medical, hospital and pharmacy administrative claims data of members with T2DM and MDD of a South African managed healthcare organisation in the year 2019. The EHR of study members registered with the medical scheme was linked to the administrative claims system, which together provided processed data of membership, healthcare and claims. The database included patient-level demographics and clinical characteristics such as illnesses, hospital events, diagnosis and follow-up BP readings, HbA1c levels and lipogram reports. Medications claimed by the study subjects were extracted from the administrative system claims database. The data set included patients enrolled as members of a health insurance scheme. Of the 47 380 registered beneficiaries on the scheme in 2019, 879 adults (18 years and older) with a registered diagnosis of T2DM were included if: (1) their latest HbA1c value was recorded on the healthcare system in 2019, and (2) they had a pharmacy claim of oral and/or injectable hypoglycaemic agents, or insulin claimed sequentially for over six months. The diagnosis of T2DM was identified according to the International Classification of Diseases and Related Health Problems, 10th revision (ICD10).34 Diagnosis codes E11.0 (T2DM with hyperosmolarity), E11.1 (T2DM with ketoacidosis), E11.2 (T2DM with renal complications), E11.3 (T2DM with ophthalmic complications), E11.4 (T2DM with neurological complications), E11.5 (T2DM with peripheral circulatory complications), E11.6 (T2DM with other specified complications), E11.7 (T2DM with multiple complications), E11.8 (T2DM with unspecified complications) to E11.9 (T2DM without complications) were used to classify patients having T2DM as stated by the practitioner. From these 879 patients with T2DM, two groups were identified: T2DM + MDD: those registered with a diagnosis of MDD and claiming antidepressants over six months (n = 223), and T2DM – MDD: those without a diagnosis of MDD or claiming for antidepressants (n = 656). The third group, the MDD control group (n = 332), was selected from the beneficiaries as being diagnosed with MDD and claiming antidepressant usage without any history of T2DM. The diagnosis of MDD was identified with ICD10 codes F32.2 (MDD, single episode, severe without psychotic features) to F33.9 (MDD, recurrent, unspecified). The ICD10 codes were obtained from the Council of Medical Schemes Prescribed Minimum Benefit ICD10 coded list.35 Patients with no available clinical data for HbA 1c and LDL-C level, and SBP were excluded from this study. Glycaemic, BP and lipid level indices were defined and characterised with reference to the 2017 Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA) guidelines.6 Using medical record review, the schemes hospitalisation management database, ICD10 diagnostic code and current procedural terminology, 4th edition (CPT-4) procedure code data, physician-diagnosed, documented major macrovascular hospitalisations were identified. Major macrovascular hospitalisations were identified as the presence of a diagnosis or an event of a CAD (unstable angina, angiogram, angina pectoris, atherosclerotic heart disease), congestive heart failure, atrial fibrillation, stroke, transient cerebral ischaemic attack, embolism and thrombosis of arteries or other specified veins, and peripheral vascular disease; or procedures such as coronary revascularisation (acute transmural myocardial infarction percutaneous procedures, coronary artery bypass, angioplasty, percutaneous transluminal coronary angioplasty, bare metal or balloon or drug-eluting, pacemaker insertion and cardioversion). Using the administrative medicines claims data that were categorised according to anatomical therapeutic chemical (ATC) classification,36 individuals claiming hypoglycaemic agents were identified as using A10B (blood glucose-lowering drugs excluding insulins), which are the older oral agents (metformin, glibenclamide,
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