Canagliflozin and renal outcomes in type 2 diabetes and nephropathy

BACKGROUND Type 2 diabetes mellitus is the leading cause of kidney failure worldwide, but few effective long-term treatments are available. In cardiovascular trials of inhibitors of sodium–glucose cotransporter 2 (SGLT2), exploratory results have suggested that such drugs may improve renal outcomes in patients with type 2 diabetes. METHODS In this double-blind, randomized trial, we assigned patients with type 2 diabetes and albuminuric chronic kidney disease to receive canagliflozin, an oral SGLT2 inhibitor, at a dose of 100 mg daily or placebo. All the patients had an estimated glomerular filtration rate (GFR) of 30 to <90 ml per minute per 1.73 m2 of body-surface area and albuminuria (ratio of albumin [mg] to creatinine [g], >300 to 5000) and were treated with renin–angiotensin system blockade. The primary outcome was a composite of end-stage kidney disease (dialysis, transplantation, or a sustained estimated GFR of <15 ml per minute per 1.73 m2), a doubling of the serum creatinine level, or death from renal or cardiovascular causes. Prespecified secondary outcomes were tested hierarchically. RESULTS The trial was stopped early after a planned interim analysis on the recommendation of the data and safety monitoring committee. At that time, 4401 patients had undergone randomization, with a median follow-up of 2.62 years. The relative risk of the primary outcome was 30% lower in the canagliflozin group than in the placebo group, with event rates of 43.2 and 61.2 per 1000 patient-years, respectively (hazard ratio, 0.70; 95% confidence interval [CI], 0.59 to 0.82; P=0.00001). The relative risk of the renal-specific composite of end-stage kidney disease, a doubling of the creatinine level, or death from renal causes was lower by 34% (hazard ratio, 0.66; 95% CI, 0.53 to 0.81; P<0.001), and the relative risk of end-stage kidney disease was lower by 32% (hazard ratio, 0.68; 95% CI, 0.54 to 0.86; P=0.002). The canagliflozin group also had a lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80; 95% CI, 0.67 to 0.95; P=0.01) and hospitalization for heart failure (hazard ratio, 0.61; 95% CI, 0.47 to 0.80; P<0.001). There were no significant differences in rates of amputation or fracture. CONCLUSIONS In patients with type 2 diabetes and kidney disease, the risk of kidney failure and cardiovascular events was lower in the canagliflozin group than in the placebo group at a median follow-up of 2.62 years

Patient Perception of remote, digital NHS healthcare during the COVID-19 pandemic: a UK-wide survey (Preprint)

BACKGROUND During the early spring of 2020, the use of remote healthcare services in the UK saw a dramatic increase in usage as services transitioned away from face-to-face delivery due to the risk of contracting COVID-19. While by far the largest shift was to telephone access which has been studied in recent years pre-COVID (Campbell, 2014), we wanted to determine the impact on patients of any shift to digital access (via an online consultation using a webcam, laptop, mobile phone application). We therefore commissioned a UK-wide representative survey of patient use and attitudes towards digital remote healthcare during the peak of the 2020 COVID-19 Pandemic in the UK. This report predominantly focuses on primary care as it accounts for 300 million NHS patient contacts each year. OBJECTIVE To rapidly assess patient attitudes towards the use of digital healthcare methods during the COVID-19 pandemic via a representative UK-wide survey. METHODS 2,138 survey responses were analysed against the respondents’ protected characteristics, social status, working status, location (UK region), social media usage and number of children (if any) in their household. Inferential statistics were used to compare these variables and survey responses. The survey consisted of three questions. 2,129 free text responses were thematically analysed from the survey, using an inductive, rapid coding method. RESULTS Initially, 14 themes arose from the data. These were collapsed into 7 parent themes with a smaller number of subtopics. These themes represent patient concern and experience of digital, remote healthcare, (1) Remote healthcare is a lesser service, (2) Useful but only for certain conditions, (3) No preference between face-to-face and remote healthcare. (4) Ease of Access to remote healthcare, (5) Speed of Access to Remote Healthcare. (6) Safety Concerns and Remote Healthcare, and (7) Remote healthcare is better than face-to-face. In summary, current patient perception of remote healthcare is that it is a lesser service, compared to face-to-face delivery. Quantitative results indicate 26% of respondents had used a digital, remote consultation. Users were more likely to be females and in a higher social grade. The largest correlation (Cramer’s V 0.51) between variables was across patients who did not see the benefits of digital, remote consultation but who were willing to use it for safety reasons due to the COVID-19 pandemic. CONCLUSIONS Patient preference for using digital, remote healthcare comes with a series of caveats that practitioners and commissioners should be aware of as the active engagement of patients in remote working appears to be more complex than simple measures of technical ability. The survey data intimates issues around willingness, trust, user-preference and more basic behavioural traits that may not have been factored into the delivery of digital care so far. In short, capacity to act is not well equated to willingness or free will of individuals, least of all acceptance of digital, remote healthcare in any universal form. Our data indicates the need for a psychology-based understanding of the frictions and enablers to remote healthcare, rather than a more narrow assessment of technical capacity if we are to drive behaviour change and help shape effective policy. CLINICALTRIAL n/a </sec