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Background Type 2 diabetes mellitus patients with an acute coronary event (ACE) experience decreased quality of life and increased distress. According to the American Diabetes Association, discharge from the hospital is a time of increased distress for all patients. Tailored support specific to diabetes is scarce in that period. We developed an intervention based on Bandura's Social Cognitive Theory, Leventhal's Common Sense Model, and results of focus groups. The aim of this study is to evaluate the effectiveness of the intervention to reduce distress in type 2 diabetes patients who experienced a first ACE. Methods Randomised controlled trial. Two hundred patients are recruited in thirteen hospitals. A diabetes nurse visits the patients in the intervention group (n = 100) at home within three weeks after discharge from hospital, and again after two weeks and two months. The control group (n = 100) receives a consultation by telephone. The primary outcome is diabetesrelated distress, measured with the Problem Areas in Diabetes (PAID) questionnaire. Secondary outcomes are well-being, health status, anxiety, depression, HbA1c, blood pressure and lipids. Mediating variables are self-management, self-efficacy and illness representations. Outcomes are measured with questionnaires directly after discharge from hospital and five months later. Biomedical variables are obtained from the records from the primary care physician and the hospital. Differences between groups in change over time are analysed according to the intention-to-treat principle. The Holm-Bonferroni correction is used to adjust for multiplicity. Discussion Type 2 diabetes patients who experience a first ACE need tailored support after discharge from the hospital. This trial will provide evidence on the effectiveness of a supportive intervention in reducing distress in these patients. [ABSTRACT FROM AUTHOR]

Background. Early detection and appropriate treatment of metabolic syndrome (MetS) can modify cardiometabolic risk factors and prevent cardiovascular disease. Optimal screening outcomes require follow-up management of MetS. Objective. To investigate the natural course of events in the first year after positive screening for MetS in primary care with regard to follow-up behavior, medication prescription and lifestyle changes. Methods. Screening of 1721 apparently healthy primary care patients (20–70 years old) detected 473 new MetS cases. These people were asked to contact their general practice for subsequent advice and treatment. Data about follow-up behavior of the screening participants and prescription of cardiovascular medication were collected from the electronic medical file, and changes in lifestyle were collected by the practice nurse. Results. Of the 424 participants with screen-detected MetS for whom data about follow-up were available, 306 (72.2%) spontaneously contacted the practice. Antihypertensive, lipid-lowering and blood glucose-lowering medications were prescribed in 21.5%, 21.2% and 1.9% of the participants, respectively. Half of the participants for whom data about self-reported lifestyle changes were available reported to have increased their physical activity; 16.9% of the smokers quit smoking. Average weight loss was 2.1kg. Conclusions. Screening for MetS followed by the advice to contact the general practice for lifestyle counseling and treatment had a substantial spontaneous follow-up. Although the changes in physical activity, weight loss and smoking abstinence are promising, further research will have to demonstrate whether they are sustainable. [ABSTRACT FROM PUBLISHER]

Background: Type 2 diabetes patients have a decreased health-related quality of life compared to healthy persons, especially regarding physical functioning and well-being. Health-related quality of life is even lower in type 2 diabetes patients when other diseases co-exist. In contrast to earlier studies, we assessed the associations between the number and type of comorbidities and health status in well-controlled type 2 diabetes patients, in whom treatment goals for HbA1c, blood pressure and cholesterol had been reached. Approximately one in five type 2 diabetes patients belongs to this group. Methods: Cross-sectional analysis was performed in 2086 well-controlled (HbA1c ≤58 mmol/mol, systolic blood pressure ≤145 mmHg, total cholesterol ≤5.2 mmol/l and not using insulin) type 2 diabetes patients in general practice. Both number and type (cardiovascular and non-cardiovascular) of comorbidities were determined for each patient. Health status was assessed with the questionnaires Short Form-36 (SF-36) and EuroQol (EQ). The SF-36 generates eight dimensions of health and a Physical and Mental Component Score (PCS and MCS), scale: 0-100. The EQ consists of two parts: EQ-5D and EQ Visual Analogue Scale. Multivariable linear regression analysis was used to assess if number and type of comorbidities were associated with health status. Results: Well-controlled type 2 diabetes patients with comorbidities had a much lower health status, with a decrease ranging from -1.5 for the MCS to -26.3 for role limitations due to physical problems, compared to those without. Health status decreased when the number of comorbidities increased, except for mental health, role limitations due to emotional problems, MCS and both EQ measures. In patients with both cardiovascular and non-cardiovascular comorbidity, physical functioning, role limitations due to physical problems and PCS were significantly lower than in patients with only cardiovascular comorbidity. Physical functioning was also lower compared to patients with only non-cardiovascular comorbidity. Conclusions: Even acceptable values of HbA1c, blood pressure and cholesterol in type 2 diabetes patients are not necessarily related with a good health status. We have shown that comorbidities have a large impact on health status. Physicians may take into account patient's health status and integrate the impact of comorbidities into diabetes care. [ABSTRACT FROM AUTHOR]

Background: Early detection and treatment of the metabolic syndrome may prevent diabetes and cardiovascular disease. Our aim was to assess remission of the metabolic syndrome and its determinants after a population based screening without predefined intervention in the Netherlands. Methods: In 2006 we detected 406 metabolic syndrome cases (The National Cholesterol Education Program's Adult Treatment Panel III (NCEP ATP III) definition) among apparently healthy individuals with an increased waist circumference. They received usual care in a primary care setting. After three years metabolic syndrome status was re-measured. We evaluated which baseline determinants were independently associated with remission. Results: The remission rate among the 194 participants was 53%. Baseline determinants independently associated with a remission were the presence of more than three metabolic syndrome components (OR 0.46) and higher levels of waist circumference (OR 0.91), blood pressure (OR 0.98) and fasting glucose (OR 0.60). Conclusions: In a population with screen-detected metabolic syndrome receiving usual care, more than half of the participants achieved a remission after three years. This positive result after a relatively simple strategy provides a solid basis for a nation-wide implementation. Not so much socio-demographic variables but a higher number and level of the metabolic syndrome components were predictors of a lower chance of remission. In such cases, primary care physicians should be extra alert. [ABSTRACT FROM AUTHOR]

Objective: To assess opinions and their determinants of patients with type 2 diabetes about responsibility for managing their diabetes, setting treatment targets and willingness taking medication. Methods: Questionnaire survey carried out in general practices and outpatient clinics across the Netherlands. Outcomes: opinions about responsibility, targets and medication. Multinomial logistic regression analysis. Results: Data of 994 consecutive persons were analysed (mean age 65 years; 54% males). Of these 62% agreed to take responsibility for their diabetes. In the opinion of 89% the setting of targets should be by or in cooperation with their physician or nurse and 40% were willing to take tablets until all targets were attained. Patients who perceived dysfunction by barriers to activity did not agree to take responsibility (OR 3.68; 1.65–8.19). Patients with complications preferred to set targets in cooperation with their physician or nurse (OR 1.98; 1.03–3.80). Males were more willing to take tablets until all targets were attained (OR 1.62; 1.17–2.25). Conclusion: Not all patients want to take responsibility for their diabetes or taking all necessary tablets, especially those with barriers to activity or complications. Practice implications: Doctors and nurses should ask for patients’ opinions about responsibility and treatment goals before starting education. [Copyright &y& Elsevier]

Background. Women with diabetes have an increased risk of urinary tract infections (UTIs), especially recurrences. [ABSTRACT FROM PUBLISHER]

To examine the effects of a multi-factorial, intensified treatment on self-reported health status, treatment satisfaction, and diabetes-related distress in screen-detected type 2 diabetes patients. Cluster-randomised controlled trial; A total of 498 screen-detected type 2 diabetes patients from 79 general practices were assigned to intensified ( n = 255) or routine treatment according to Dutch guidelines ( n = 243). At baseline and after 3 years, patients completed the Short Form-36 and the European Quality of Life-5 Dimensions questionnaires. After 4.5 years, patients completed the Diabetes Treatment Satisfaction Questionnaire and the Problem Areas In Diabetes scale. We analysed the effects of intensified treatment on self-rated health status, treatment satisfaction, and diabetes-related distress, using random effects models to account for clustering at practice level. Three to 5 years after type 2 diabetes was detected by screening, there were no differences between intensified and routine treatment in self-reported health status, treatment satisfaction, and diabetes-related distress. Multi-factorial, intensified treatment did not influence self-rated health status, treatment satisfaction, and distress in screen-detected type 2 diabetes patients. Therefore, health care professionals do not have to fear negative effects of an intensified treatment on these psychological outcomes. [ABSTRACT FROM AUTHOR]

Objective. To investigate whether the yield of population-based diabetes screening is influenced by characteristics of the general practitioner (GP) and the practice. Design. Cross-sectional study. Setting. Seventy-nine general practices in the south-western region of the Netherlands. Subjects. From 2002 to 2004, 56 978 people were screened for diabetes. GPs completed a questionnaire containing items on the GP (age, gender, employment, special interest in diabetes, providing insulin therapy) and the practice (setting, location, number of patients from ethnic minority groups, specific diabetes clinic, involvement of practice assistant, practice nurse or diabetes nurse in diabetes care). Main outcome measures. The ratio screen-detected diabetic patients/known diabetic patients per practice (SDM/KDM) and the number of detected diabetic patients per practice adjusted for practice size and age distribution (SDM per standardized practice). Results. The yield of screening per practice varied widely. Higher age of the GP (regression coefficient 0.20; 95% confidence interval, CI 0.07-0.34), urban location (-4.60; 95% CI -6.41 to -2.78) and involvement of the practice assistant (2.27; 95% CI 0.49-4.06) were independently associated with SDM/KDM. Using the other outcome variable, results were similar. Additionally, cooperation with a diabetes nurse was associated with a lower yield. Conclusion. A lower yield of screening, reflecting a lower prevalence of undiagnosed diabetes, was found in practices of younger GPs and in urban practices. A lower yield was not associated with an appropriate practice organization regarding diabetes care nor with a specialty of the GP in diabetes. The wide variation in the yield of screening stresses the importance of a screening programme in each general practice. [ABSTRACT FROM AUTHOR]

OBJECTIVE -- The aim of this study was to assess the short-term effects of an educational program on (determinants of) self-reported health-seeking behavior for infections of the urinary tract (UTIs) and lower respiratory tract (LRTIs) in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS -- In a randomized controlled trial, 1,124 patients with type 2 diabetes aged between 44 and 85 years participated. The intervention consisted of a multifaceted educational program with an interactive meeting, a leaflet, a Web site, and a consultation with the diabetes care provider. The program focused on the needs of patients, apparent from a prior focus group and questionnaire study. The primary outcome measure was an indicator of health-seeking behavior for UTIs and LRTIs, defined as the proportion of participants with a positive score on at least seven of nine determinants, six from the Health Belief Model and the additional three domains of knowledge, need for information, and intention. The primary outcome was measured with questionnaires at baseline and after 5 months. RESULTS -- Complete outcome data were available for 468 intervention group patients and 472 control group patients. In all, 68% of the intervention group patients attended the meeting. At baseline, 28% of the participants from the intervention group had a positive score on seven of the nine determinants, compared with 27% from the control group. After the educational program, these percentages were 53 and 32%, respectively (P < 0.001). CONCLUSIONS -- Our educational program positively influenced determinants of health-seeking behavior for common infections in patients with type 2 diabetes. [ABSTRACT FROM AUTHOR]

OBJECTIVE--The Diabetes Care Protocol combines task delegation (a practice nurse), computerized decision support, and feedback every 3 months. We studied the effect of the Diabetes Care Protocol on AIC and cardiovascular risk factors in type 2 diabetic patients in primary care. RESEARCH DESIGN AND METHODS -- In a cluster randomized trial, mean changes in cardiovascular risk factors between the intervention and control groups after 1 year were calculated by generalized linear models. RESULTS -- Throughout the Netherlands, 26 intervention practices included 1,699 patients and 29 control practices 1,692 patients. The difference in A1C change was not significant, whereas total cholesterol, LDL cholesterol, and blood pressure improved significantly more in the intervention group. The 10-year coronary heart disease risk estimate of the UK Prospective Diabetes Study improved 1.4% more in the intervention group. CONCLUSIONS -- Delegation of routine diabetes care to a practice nurse combined with computerized decision support and feedback did not improve A1C but reduced cardiovascular risk in type 2 diabetes patients. [ABSTRACT FROM AUTHOR]

Objective: A patient Web portal allows patients to access their personal health record through the Internet. It may improve diabetes outcomes, but the adoption is unsatisfactory. We examined the differences between patients with and without a login in order to optimize its use. Patients and Methods: A survey was conducted among patients from 62 general practices and one outpatient clinic that all use a diabetes Web portal. Between November 2011 and March 2012 questionnaires were sent to 1,500 patients with and 3,000 patients without a login. Patient groups were stratified according to type of diabetes. Demographic and diabetes-related variables were analyzed with multivariable regression analysis. Results: The total response rate was 67%. Fewer than 50% of the patients did request a login. Among 128 patients with type 1 diabetes mellitus, those with a login (89.8%) were younger and more frequently treated by an internist. In 1,262 patients with type 2 diabetes mellitus, fewer patients had a log-in (41.0%), and the likelihood of having a login was independently associated with younger age, male gender, higher educational level, treatment by an internist, longer duration of diabetes, and polypharmacy (all P < 0.001). Conclusions: Patients with type 1 diabetes request a login more frequently than patients with type 2 diabetes, and patients with a login are strikingly different than patients without. The healthcare provider seems to play an important role in patients' Web utilization. Simply promoting use of electronic healthcare methods does not make sense. It is important to address disparities between patient groups to optimize the use of a Web portal. [ABSTRACT FROM AUTHOR]

Background: Patient's satisfaction with monitoring frequency is of interest when implementing six-monthly monitoring for well-controlled type 2 diabetes patients. Here we want to determine the satisfaction of well-controlled type 2 diabetes patients with either three-monthly or six-monthly diabetes monitoring and their future preference. Methods: Survey among 2215 well-controlled type 2 diabetes patients (not using insulin, HbA1c ≤58 mmol/mol, systolic blood pressure ≤145 mmHg and total cholesterol ≤5.2 mmol/l) who participated in the EFFIMODI study, a randomised controlled patient-preference equivalence trial. At baseline, participants were asked whether they had a strong preference for three-monthly or six-monthly monitoring or not. If not, they were randomised to either three-monthly or six-monthly monitoring, while the others were monitored according to their preference. After eighteen months, all participants were asked whether they were satisfied with the monitoring frequency and about their future preference. Patient characteristics associated with satisfaction were also examined. Results: Most patients (70.8%) would like to continue their monitoring frequency. Patients from the preference groups were more often satisfied than randomised patients (92.7% and 88.1%, respectively) and patients monitored three-monthly were more often satisfied than patients monitored six-monthly (93.5% and 88.5%, respectively). Higher age, better physical health, less diabetes-related distress, higher diabetes treatment satisfaction and less perceived hyper- and hypoglycaemias were associated with a higher monitoring satisfaction. Conclusions: Most well-controlled type 2 diabetes patients were satisfied with their monitoring frequency and would like to continue it. Although the satisfaction for three-monthly monitoring was slightly higher, the satisfaction with six-monthly monitoring was still rather high (88.5%). [ABSTRACT FROM AUTHOR]

Background: Scientific evidence for the frequency of monitoring of type 2 diabetes patients is lacking. If threemonthly control in general practice could be reduced to six-monthly control in some patients, this would on the one hand reduce the use of medical services including involvement of practice nurses, and thus reduce costs, and on the other hand alleviate the burden of people with type 2 diabetes. The goal of this study is to make primary diabetes care as efficient as possible for patients and health care providers. Therefore, we want to determine whether six-monthly monitoring of well-controlled type 2 diabetes patients in primary care leads to equivalent cardiometabolic control compared to the generally recommended three-monthly monitoring. Methods and design: The study is a randomised controlled patient-preference equivalence trial. Participants are asked if they prefer three-monthly (usual care) or six-monthly diabetes monitoring. If they do not have a preference, they are randomised to a three-monthly or six-monthly monitoring group. Patients are eligible for the study if they are between 40 and 80 years old, diagnosed with type 2 diabetes more than one year ago, treated by a general practitioner, not on insulin treatment, and with HbA1c ≤7.5%, systolic blood pressure ≤145 mmHg and total cholesterol ≤5.2 mmol/l. The intervention group (six-monthly monitoring) will receive the same treatment with the same treatment targets as the control group (three-monthly monitoring). The intervention period will last one and a half year. After the intervention, the three-monthly and six-monthly monitoring groups are compared on equivalence of cardiometabolic control. Secondary outcome measures are HbA1c, blood pressure, cholesterol level, Body Mass Index, smoking behaviour, physical activity, loss of work due to illness, health status, diabetes-specific distress, satisfaction with treatment and adherence to medications. We will use intention-to-treat analysis with repeated measures. For outcomes that have only baseline and final measurements, we will use ANCOVA. Depending on the results, a cost-minimisation analysis or an incremental cost-effectiveness analysis will be done. Discussion: This study will provide valuable information on the most efficient control frequency of well-controlled type 2 diabetes patients in primary care. [ABSTRACT FROM AUTHOR]

OBJECTIVE -- Type 2 diabetes is known to be associated with decrements in memory and executive functions and information-processing speed. It is less clear, however, at which stage of diabetes these cognitive decrements develop and how they progress over time. In this study, we investigated cognitive functioning of patients with recent screen-detected type 2 diabetes, thus providing insight into the nature and severity of cognitive decrements in the early stage of the disease. Possible risk factors were also addressed. RESEARCH DESIGN AND METHODS-- Included in this study were 183 diabetic patients from a previously established study cohort and 69 control subjects. A full neuropsychological assessment, addressing six cognitive domains, was made for each participant. Raw test scores were standardized into z scores per domain and compared between the groups. Possible risk factors for cognitive decrements were examined with multivariate linear regression. RESULTS-- Relative to scores for the control group, mean z scores were between 0.01 and 0.2 lower in the diabetic group across all domains, but after adjustment for differences in IQ between patients and control subjects, only memory performance was significantly reduced (mean difference -0.15 [95% CI -0.28 to -0.03]). A history of macrovascular disease and current smoking were significant determinants of slower information-processing speed in patients with diabetes. CONCLUSIONS -- This study shows that modest cognitive decrements are already present at the early stage of type 2 diabetes. A history of macrovascular disease and smoking are significant risk factors for some early decrements. [ABSTRACT FROM AUTHOR]

Abstract: Aims: Erectile dysfunction (ED) prevalence is usually based on questionnaires, too elaborate for daily practice. The single question for ED prevalence is unknown. Literature reports an independent association between ED and both cardiovascular disease (CVD) and diabetes. Whether routinely asking men with Type 2 diabetes (DM2) about ED identifies those at elevated risk for CVD is unknown. We assessed cardiovascular risk of DM2 men with ED. Design and Methods: This was a cross-sectional study in primary care. During annual check-up, the practice nurse asked 1823 DM2 men: “Do you have erection problems? Yes/no.” ED prevalence rate was calculated. Age, medication, and other known factors associated with ED and/or CVD were used in univariate analysis (odds ratio [OR], Student''s t test, and Mann–Whitney test). This revealed confounding variables used in the multivariable analysis. The association between ED and history of cardiovascular disease (HCVD) was assessed by logistic regression analysis. In patients with no HCVD, we assessed the association between ED and 10-year United Kingdom Prospective Diabetes Study (UKPDS) coronary heart disease risk by linear regression analysis. Results: The prevalence of ED in DM2 patients was 41.3%. There was no independent association between ED and HCVD [adjusted OR, 1.2 (95% CI, 0.9–1.5)]. The 10-year UKPDS CHD risk difference between men with and without ED was 5.9% (95% CI, 3.2–8.7), but after adjustment for age, this association disappeared [adjusted risk difference, 0.6% (95% CI, −1.5 to 2.7)]. Conclusion: The ED prevalence rate assessed by a single question was comparable to that assessed by questionnaires. ED neither did independently relate to patients'' cardiovascular history nor to cardiovascular risk. [Copyright &y& Elsevier]

Abstract: Objectives: To determine the feasibility of population-based screening for metabolic syndrome (MetS) in primary care with self-measurement of waist circumference (WC) as first step, and the prevalence of MetS in a Dutch city. Methods: A survey of 14,000 people on the list of primary care physicians in the city of IJsselstein. All adults between 20 and 70 years on July 1st, 2006 were asked to measure their WC using a mailed tape measure. Participants with a high WC (>88/102 cm for women/men) were invited for assessment of other factors defining MetS. For patients already known with cardiovascular risk factors, these data were collected from medical records. Results: 11,862 subjects were invited, of whom 6843 (58%) measured their WC. 2004 had a WC>88/102 cm and 1721 participated in all examinations. In 473 MetS was detected. The sensitivity of the screening was 77%, the negative predictive value 96%. The prevalence of MetS, including patients known with cardiovascular risk factors, was 15.5%. Conclusions: A primary care physician-driven population screening with self-measurement of WC can identify adults with MetS. The estimated prevalence of MetS is 15.5%. This procedure creates possibilities for targeted screening, prevention and treatment of people who are at increased cardiovascular risk. [Copyright &y& Elsevier]

Background: Foot pain is a common problem for people aged 50 and over and occurs more often in women than in men. About 60% of the foot problems are forefoot problems and slightly more than half of these patients seek medical help, mainly in the form of podiatric care. Podiatric treatment of forefoot problems is known to be heterogeneous. The aims of the present study are to describe the podiatric treatment of patients with forefoot pain and to evaluate the podiatric examination and treatment using an expert panel. Method: We invited twenty-five randomly selected subjects with forefoot problems who had received podiatric treatment in a pragmatic randomised clinical trial to participate in an analysis of their treatment by an expert panel. The panel retrospectively established the cause of the foot problem as well as the therapeutic goals and evaluated the treatment. These findings were compared to those reported by the treating podiatrist. Results: Two fundamentally different approaches were found in approach of podiatric examination; a functional approach (n =13) and a non-functional approach (n =12). In nine cases the expert panel agreed with the cause recorded by the podiatrist. In five other cases the expert panel concluded that the treatment of the podiatrist was not consistent with the cause of the problem recorded by the podiatrist. Of the 10 patients for whom the podiatrist had recorded to have given shoe advice, only two were able to recollect the proper advice. Three patients did not remember receiving advice at all. Conclusion: In this study almost half of the podiatrists worked according to a non-functional approach where the other half (like the expert panel) chose a functional strategy that analyses the underlying problem. Fundamental differences in treatment plans and thus heterogeneous treatments could be a consequence. [ABSTRACT FROM AUTHOR]

Abstract: Aim: To examine the relation of performance on the self-administered Test Your Memory test (TYM) and the Mini-Mental State Examination (MMSE) with a comprehensive neuropsychological assessment in a population sample including people with modest cognitive decrements. Methods: Eighty-six participants (aged 56–77years), without known cognitive dysfunction, performed a neuropsychological assessment including MMSE, and were asked to fill out the TYM. The relation between both the TYM and the MMSE and a neuropsychological assessment was examined by means of correlation analyses, area under the ROC curves for discriminating between a “normal” and “modest decrements”(≥1SD below the sample mean) group, and Bland–Altman plots. Results: Correlation with the full neuropsychological assessment was significantly stronger for the TYM than the MMSE (r =0.78 versus r =0.55; Steiger's Z =2.66, p <0.01). The TYM showed an area under the ROC-curve of 0.88 (95% CI 0.80 to 0.97) for differentiating between “normal” and “modest decrements” compared with 0.71 (0.53 to 0.90) for the MMSE. Bland–Altman plots showed limits of agreement for the TYM of −1.10 to 1.10 and for the MMSE of −1.39 to 1.38. Conclusions: The TYM showed good correlation with a neuropsychological assessment, performed better in discriminating between variations of cognition and showed more agreement with a neuropsychological assessment than the MMSE. [Copyright &y& Elsevier]

Background: Worldwide, the organisation of diabetes care is changing. As a result general practices and diabetes teams in hospitals are becoming part of new organisations in which multidisciplinary care programs are implemented. In the Netherlands, 97 diabetes care groups and 104 outpatient clinics are working with a diabetes care program. Both types of organisations aim to improve the quality of diabetes care. Therefore, it is essential to understand the comprehensive elements needed for optimal quality management at organisational level. This study aims to assess the current level of diabetes quality management in both care groups and outpatient clinics and its improvement after providing feedback on their quality management system and tailored support. Methods/design: This study is a before-after study with a one-year follow-up comparing the levels of quality management before and after an intervention to improve diabetes quality management. To assess the status of quality management, online questionnaires were developed based on current literature. They consist of six domains: organisation of care, multidisciplinary teamwork, patient centeredness, performance management, quality improvement policy and management strategies. Based on the questionnaires, respondents will receive feedback on their score in a radar diagram and an elucidating table. They will also be granted access to an online toolbox with instruments that proved to be effective in quality of care improvement and with practical examples. If requested, personal support in implementing these tools will be available. After one year quality management will be measured again using the same questionnaire. Discussion: This study will reveal a nationwide picture of quality management in diabetes care groups and outpatient clinics in the Netherlands and evaluate the effect of offering tailored support. The operationalisation of quality management on organisational level may be of interest for other countries as well. [ABSTRACT FROM AUTHOR]

Summary: Type 2 diabetes (T2DM) is associated both with cognitive decrements and depressive symptoms. Since depression in itself has been associated with cognitive decrements we aimed to investigate the influence of depressive symptoms on the relation between T2DM and cognitive functioning. Data were derived from three independent studies on cognitive functioning in patients with T2DM (n =366) and controls without diabetes (n =204), two with longitudinal and one with only cross-sectional assessments. Depressive symptoms were measured with self-report inventories (CES-D or BDI-II). The composite z-score of the domains memory, information-processing speed, and attention and executive function was the primary cognitive outcome measure. Mixed linear regression analyses were used in a stepped approach to compare cognitive functioning between (1) patients with T2DM and controls (cross-sectionally and longitudinally), (2) participants with and without depressive symptoms, separately for patients and controls, and (3) patients and controls after adjustment for depressive symptoms. In addition the mediating effect of depressive symptoms was assessed with a bootstrapping technique. Depressive symptoms were present in 11% of the patients with T2DM and in 7% of controls (p =0.15). Cognitive performance in patients with T2DM was worse than in controls (overall difference composite z-score −0.13). However, T2DM was not associated with accelerated cognitive decline over three years of follow-up relative to controls. Controls with depressive symptoms performed worse than those without depressive symptoms, although not statistically significant. Performance in patients with T2DM with and without depressive symptoms was similar. Adjustment for depressive symptoms and estimation of the mediating effect showed that the difference between patients and controls was not mediated by depressive symptoms. In conclusion, the modest cognitive decrements that are associated with T2DM are not due to the presence of mild depressive symptoms. [Copyright &y& Elsevier]

Objective. To describe the relationship between comorbidity (absolute number as well as the presence of specific comorbidities) and pain, physical functioning and mental health status of participants with early symptomatic OA of the hip or knee.Methods. In the Netherlands, a prospective 10-year follow-up study was initiated by the Dutch Arthritis Association in participants with early symptomatic OA of the hip or knee: CHECK (Cohort Hip and Cohort Knee), which consists of 1002 individuals. At baseline, linear regression analysis was used to determine the influence of comorbidity on the outcome variables: Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain, WOMAC physical functioning, Medical Outcomes Study Short Form 36 (SF-36) Physical Component Summary and Mental Component Summary.Results. Of 979 subjects, 67% reported one or more comorbidities. After controlling for age, gender, social status and severity of radiographic OA (Kellgren and Lawrence score), back disorders have the largest effect on WOMAC pain and physical functioning, and one of the largest effects on physical status of SF-36, besides obesity. Mental status was negatively influenced by the additional presence of duodenal ulcer, thyroid disease, and migraine or chronic headache.Conclusion. In early stage of OA, the presence of additional problems in the musculoskeletal system and of obesity have a negative effect on pain and physical health status. Also mental status is affected in early symptomatic OA by the presence of specific comorbidities. Comorbidity should be assessed and treated to improve the burden of illness in patients with early symptomatic OA. [ABSTRACT FROM PUBLISHER]

Abstract: Aim: To assess whether an intensive multifactorial treatment can reduce cognitive decrements and cognitive decline in screen-detected type 2 diabetes. Methods: The multinational ADDITION-study, a cluster-randomized parallel group trial in patients with screen-detected type 2 diabetes, compared the effectiveness of intensive multifactorial treatment (IT; lifestyle advice and strict regulation of metabolic parameters) with routine care (RC) on cardiovascular outcome. In The Netherlands randomization was stratified according to practice organization. Allocation was concealed from patients. The present study assessed the effect of IT on cognition through two neuropsychological assessments (NPA) on two occasions. The assessments took place three and six years after the start of the intervention. Non-diabetic controls served as reference group. The first NPA was performed in 183 patients (IT: 97; RC: 86) and 69 controls. The second NPA was performed in 135 patients (IT: 71; RC: 64) and 55 controls. Primary outcome was a composite score, including the domains memory, information-processing speed and attention and executive function. Comparisons between the treatment groups were performed with multi-level analyses. Results: The first NPA showed no differences between the treatment groups (mean difference composite z-score: 0.00; 95%-CI −0.16 to 0.16; IT vs RC). Over the next three years cognitive decline in the diabetic groups was within the range of the reference group and did not differ between the treatment arms (difference decline between diabetic groups −0.12; −0.24 to 0.01; IT vs RC). Conclusions: Six years of IT in screen-detected type 2 diabetes had no benefit on cognitive functioning over RC. [Copyright &y& Elsevier]

Background: Foot problems in general and forefoot problems in particular can lead to a decrease in mobility and a higher risk of falling. Forefoot problems increase with age and are more common in women than in men. Around 20% of people over 65 suffer from non-traumatic foot problems and 60% of these problems are localised in the forefoot. Little is known about the best way to treat forefoot problems in older people. The aim of this study is to compare the effects of two common modes of treatment in the Netherlands: shoe advice and podiatric treatment. This paper describes the design of this study. Methods: The study is designed as a pragmatic randomised clinical trial (RCT) with 2 parallel intervention groups. People aged 50 years and over who have visited their general practitioner (GP) with non traumatic pain in the forefoot in the preceding year and those who will visit their GP during the recruitment period with a similar complaint will be recruited for this study. Participants must be able to walk unaided for 7 metres and be able to fill in questionnaires. Exclusion criteria are: rheumatoid arthritis, neuropathy of the foot or pain caused by skin problems (e.g. warts, eczema). Inclusion and exclusion criteria will be assessed by a screening questionnaire and baseline assessment. Those consenting to participation will be randomly assigned to either a group receiving a standardised shoe advice leaflet (n = 100) or a group receiving podiatric treatment (n = 100). Primary outcomes will be the severity of forefoot pain (0-10 on a numerical rating scale) and foot function (Foot Function 5-pts Index and Manchester Foot Pain and Disability Index). Treatment adherence, social participation and quality of life will be the secondary outcomes. All outcomes will be obtained through self-administered questionnaires at the start of the study and after 3, 6, 9 and 12 months. Data will be analysed according to the "intention-to-treat" principle using multilevel level analysis. Discussion: Strength of this study is the comparison between two common primary care treatments for forefoot problems, ensuring a high external validity of this trial. Trial registration: Netherlands Trial Register (NTR): NTR2212 [ABSTRACT FROM AUTHOR]

OBJECTIVE -- The objective of this study was to investigate how time since diagnosis and treatment intensity influence psychological outcomes in patients with screen-detected type 2 diabetes. RESEARCH DESIGN AND METHODS -- A 2 x 2 factorial cross-sectional design was used to examine psychological outcomes in 196 patients with screen-detected diabetes diagnosed 3-33 months previously who were receiving usual care or intensive multifactoral pharmacological treatment. Outcomes included anxiety, depression, diabetes-related distress, perceived seriousness and vulnerability, self-efficacy, and self-care. Multivariate analysis was used to examine variations in outcomes based on time since diagnosis (<1 vs. 2-3 years) and treatment intensity. RESULTS -- Most patients reported little distress, low perceived seriousness and vulnerability, high self-efficacy, and low self-care, but outcomes varied considerably across conditions. Time effects were found for perceived vulnerability, which increases significantly with time since diagnosis. Time x treatment interactions were found for anxiety, diabetes-related distress, and self-efficacy; notably, intensively treated patients showed more distress and less self-efficacy in the 1st year, and usual-care patients reported more distress and less self-efficacy 2-3 years after diagnosis. CONCLUSIONS -- Screen-detected patients generally do not experience much difficulty with their condition in the first few years, but early and intensive treatment can influence patients' psychological outcomes, leading to relatively more anxiety and less self-efficacy in the 1st year after diagnosis but not necessarily improving self-care. This suggests that intensive treatments confront patients with their diabetes earlier on whereas milder treatments may delay confrontation. This finding should be taken into account in the development and timing of psychological interventions for patients with newly diagnosed diabetes. [ABSTRACT FROM AUTHOR]

Objective: The Diabetes Care Protocol combines task delegation (a practice nurse), computerized decision support, and feedback every 3 months. We studied the effect of the Diabetes Care Protocol on A1C and cardiovascular risk factors in type 2 diabetic patients in primary care.Research Design and Methods: In a cluster randomized trial, mean changes in cardiovascular risk factors between the intervention and control groups after 1 year were calculated by generalized linear models.Results: Throughout the Netherlands, 26 intervention practices included 1,699 patients and 29 control practices 1,692 patients. The difference in A1C change was not significant, whereas total cholesterol, LDL cholesterol, and blood pressure improved significantly more in the intervention group. The 10-year coronary heart disease risk estimate of the UK Prospective Diabetes Study improved 1.4% more in the intervention group.Conclusions: Delegation of routine diabetes care to a practice nurse combined with computerized decision support and feedback did not improve A1C but reduced cardiovascular risk in type 2 diabetes patients. [ABSTRACT FROM AUTHOR]

Background: Worldwide, the organisation of diabetes care is changing. As a result general practices and diabetes teams in hospitals are becoming part of new organisations in which multidisciplinary care programs are implemented. In the Netherlands, 97 diabetes care groups and 104 outpatient clinics are working with a diabetes care program. Both types of organisations aim to improve the quality of diabetes care. Therefore, it is essential to understand the comprehensive elements needed for optimal quality management at organisational level. This study aims to assess the current level of diabetes quality management in both care groups and outpatient clinics and its improvement after providing feedback on their quality management system and tailored support.Methods/design: This study is a before-after study with a one-year follow-up comparing the levels of quality management before and after an intervention to improve diabetes quality management. To assess the status of quality management, online questionnaires were developed based on current literature. They consist of six domains: organisation of care, multidisciplinary teamwork, patient centeredness, performance management, quality improvement policy and management strategies. Based on the questionnaires, respondents will receive feedback on their score in a radar diagram and an elucidating table. They will also be granted access to an online toolbox with instruments that proved to be effective in quality of care improvement and with practical examples. If requested, personal support in implementing these tools will be available. After one year quality management will be measured again using the same questionnaire.Discussion: This study will reveal a nationwide picture of quality management in diabetes care groups and outpatient clinics in the Netherlands and evaluate the effect of offering tailored support. The operationalisation of quality management on organisational level may be of interest for other countries as well. [ABSTRACT FROM AUTHOR]