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1 april 2010, Contains fulltext : 89166.pdf (publisher's version ) (Closed access), AIMS: To evaluate the effectiveness of a two-arm quality improvement program (QIP) to support general practice with limited tradition in chronic care on type 2 diabetes patient outcomes. METHODS: During 18 months, we performed a cluster randomized trial with randomization of General Practices. The usual QIP (UQIP: 53 GPs, 918 patients) merged standard interventions including evidence-based treatment protocol, annual benchmarking, postgraduate education, case-coaching for GPs and patient education. The advanced QIP (AQIP: 67 GPs, 1577 patients) introduced additional interventions focussing on intensified follow-up, shared care and patient behavioural changes. Main outcomes were HbA1c, systolic blood pressure (SBP), and low density lipoprotein cholesterol (LDL-C), analyzed by generalized estimating equations and linear mixed models. RESULTS: In UQIP, endpoints improved significantly after intervention: HbA1c -0.4%, 95% CI [-0.4; -0. 3]; SBP -3mmHg, 95% CI [-4; -1]; LDL-C -13mg/dl, 95% CI [-15; -11]. In AQIP, there were no significant additional improvements in outcomes: HbA1c -0.4%, 95% CI [-0.4; -0.3]; SBP -4mmHg, 95% CI [-5; -2]; LDL-C -14mg/dl, 95% CI [-15; -11]. CONCLUSIONS: A multifaceted program merging standard interventions in support of general practice induced significant improvements in the quality of diabetes care. Intensified follow-up in AQIP with focus on shared care and patient behaviour changes did not yield additional benefit.

1 juli 2010, Contains fulltext : 89159.pdf (publisher's version ) (Closed access), BACKGROUND: Because many patients in usual care reach the diabetes treatment goals, it may be more efficacious to focus quality improvement efforts on those general practice populations requiring additional support. We therefore developed a tool based on a composite end point considering blood pressure, lipids, and glycaemia. METHODS: We created an aggregated z(A)-score, calculated as the average of 3 z-scores testing whether the mean practice values of hemoglobin A1c, low density lipoprotein cholesterol, and systolic blood pressure are significantly higher than the corresponding ADA-target (respectively 7%, 100 mg/dL, and 130 mm Hg). This score was used with 100 general practitioners who participated in a Quality Improvement Program. We defined the cut-off value (COV) to determine "Practices Requiring Support" (z(A)

Contains fulltext : 80009.pdf (publisher's version ) (Closed access), OBJECTIVES: The aim of this study is to make an inventory of the changes that are needed to make an interactive computer based training program (ICBT) with a specific educational content, acceptable to professional communities with different linguistic,cultural and health care backgrounds in different European countries. METHODS: Existing educational software, written in two languages was reviewed by GPs and primary care professionals in three different countries. Reviewers worked through the program using a structured critical reading grid. RESULTS: A 'simple' translation of the program is not sufficient. Minor changes are needed to take account of linguistic differences and medical semantics. Major changes are needed in respect of the existing clinical guidelines in every country related to differences in the existing health care systems. CONCLUSIONS: ICTB programs cannot easily be used in different countries and cultures. The development of a structured educational program needs collaboration between educationalists, domain experts, information technology advisers and software engineers. Simple validation of the content by local expert groups will not guarantee the program's exportability. It is essential to involve different national expert groups at every phase of the development process in order to disseminate it in other countries.

Contains fulltext : 81044.pdf (publisher's version ) (Closed access), OBJECTIVE: To picture the profile of type 2 diabetic patients in Belgium and to study the quality of care in the primary care setting, with regard, to multi-factorial approach of the disease. METHODS: Observational study of all known DM2-patients registered by 120 volunteer general practitioners. Quality of care was evaluated by the achievement of three major treatment targets: HbA1c<7%; Systolic Blood Pressure

Objective: To picture the profile of type 2 diabetic patients in Belgium and to study the quality of care in the primary care setting, with regard, to multi-factorial approach of the disease. Methods: Observational study of all known DM2-patients registered by 120 volunteer general practitioners. Quality of care was evaluated by the achievement of three major treatment targets: HbA1c<7%: Systolic Blood Pressure <= 130 mmHg; LDL-Cholesterol <100 mg/dl (ADA 2003). Multivariate analysis was performed. Results: 2495 DM2-patients were included with a mean age of 68 +/- 12 years and 51% being women. One fifth of the patients had microvascular complications and 27% had macrovascular complications. Sixty-eight percent received oral anti-diabetic drugs and 19% were on insulin. Satisfactory glycaemic control (HbA1c < 7%) was achieved in 54% of the patients, with however glucose control deteriorating with disease progression despite more intensive hypoglycaemic treatment. Systolic blood pressure targets were reached in 50%. Statin use was present in 39% and LDL levels <100 mg/dl were reached in 42%. 59% of insulin treated patients were followed LIP in shared care with specialised diabetes centres. These patients obtained lower values for HbA1c (7.5 +/- 1.2% vs. 7.8 +/- 1.5%, p=0.038) and LDL-C (90 +/- 34 vs. 111 +/- 37, p<0.001) compared to insulin-treated patients only followed up in primary care. Conclusion: Overall metabolic control in type 2 diabetic patients in primary care in Belgium was acceptable for glucose control, but major room for improvement exists especially for statin use and blood pressure control. Clinical inertia is present and the presence of more structured care in specialised diabetes centres, focusing on therapeutic guidelines, may explain the better overall metabolic control in Patients followed up in shared care with these centres.

The aim of this study is to make an inventory of the changes that are needed to make an interactive computer based training program (ICBT) with a specific educational content, acceptable to professional communities with different linguistic,cultural and health care backgrounds in different European countries.

Contains fulltext : 80136.pdf (publisher's version ) (Open Access), BACKGROUND: Type 2 diabetes mellitus is a complex, progressive disease which requires a variety of quality improvement strategies. Limited information is available on the feasibility and effectiveness of interdisciplinary diabetes care teams (IDCT) operating on the interface between primary and specialty care. A first study hypothesis was that the implementation of an IDCT is feasible in a health care setting with limited tradition in shared care. A second hypothesis was that patients who make use of an IDCT would have significantly better outcomes compared to non-users of the IDCT after an 18-month intervention period. A third hypothesis was that patients who used the IDCT in an Advanced quality Improvement Program (AQIP) would have significantly better outcomes compared to users of a Usual Quality Improvement Program (UQIP). METHODS: This investigation comprised a two-arm cluster randomized trial conducted in a primary care setting in Belgium. Primary care physicians (PCPs, n = 120) and their patients with type 2 diabetes mellitus (n = 2495) were included and subjects were randomly assigned to the intervention arms. The IDCT acted as a cornerstone to both the intervention arms, but the number, type and intensity of IDCT related interventions varied depending upon the intervention arm. RESULTS: Final registration included 67 PCPs and 1577 patients in the AQIP and 53 PCPs and 918 patients in the UQIP. 84% of the PCPs made use of the IDCT. The expected participation rate in patients (30%) was not attained, with 12,5% of the patients using the IDCT. When comparing users and non-users of the IDCT (irrespective of the intervention arm) and after 18 months of intervention the use of the IDCT was significantly associated with improvements in HbA1c, LDL-cholesterol, an increase in statins and anti-platelet therapy as well as the number of targets that were reached. When comparing users of the IDCT in the two intervention arms no significant differences were noted, except f

Contains fulltext : 69746.pdf (publisher's version ) (Closed access)

Contains fulltext : 70617.pdf (publisher's version ) (Open Access), BACKGROUND: Most quality improvement programs in diabetes care incorporate aspects of clinician education, performance feedback, patient education, care management, and diabetes care teams to support primary care physicians. Few studies have applied all of these dimensions to address clinical inertia. AIM: To evaluate interventions to improve adherence to evidence-based guidelines for diabetes and reduce clinical inertia in primary care physicians. DESIGN: Two-arm cluster randomized controlled trial. PARTICIPANTS: Primary care physicians in Belgium. INTERVENTIONS: Primary care physicians will be randomly allocated to 'Usual' (UQIP) or 'Advanced' (AQIP) Quality Improvement Programs. Physicians in the UQIP will receive interventions addressing the main physician, patient, and office system factors that contribute to clinical inertia. Physicians in the AQIP will receive additional interventions that focus on sustainable behavior changes in patients and providers. OUTCOMES: Primary endpoints are the proportions of patients within targets for three clinical outcomes: 1) glycosylated hemoglobin < 7%; 2) systolic blood pressure differences

Microbial biofilms were massively developing on the surfaces and within the painting layers of mural paintings of a parish church in Lower Saxony, which were exposed and restored in the end of 1970s. The causes of the heavy infections remained unclear. Within the frame of an European research project (ENV4-CT98-0705) these microbial infections were documented and analyzed. By scanning electron microscopy (SEM) and dissecting microscope analysis of mural painting fragments it was shown that the main biofilm formers were microscopic fungi with strong pigment development. Thirty-two fungal and 139 heterotrophic bacterial isolates were obtained by cultivation methods. Most of the fungi (32 isolates) were characterized by morphological methods and nutritional physiology (BIOLOG system) and identified as Acremonium, Aspergillus, Cladosporium, Fusarium and other imperfect fungal genera among which several melanized Mycelia sterilia, Representative bacterial strains were analyzed by 16S rDNA sequencing, the majority of bacteria belonged to the genera Arthrobacter, Bacillus and Bacillus-related genera. Isolated strains (both fungal and bacterial) belong to spore formers and thus could have been potentially stimulated to grow only by the transfer to the growth medium. The results of SEM analysis, cultivation experiments and visualization of microbial activity, confirm the hypothesis that the current microbial community is inactive and represent a stagnant microbial community developed after drastic environmental changes caused by an unfortunate conservation treatment. © 2003 Elsevier Ltd. All rights reserved.