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Objective: The introduction of bundled payment for diabetes care in the Netherlands led to the origination of care groups. This study explored to what extent variation in health care costs per patient can be attributed to the performance of care groups. Furthermore, the commonly applied simple mean aggregation was compared with the more advanced generalized linear mixed model (GLMM) to benchmark health care costs per patient between care groups., Data Source: Dutch 2009 nationwide insurance claims data of diabetes type 2 patients (104,544 patients, 50 care groups)., Study Design: Both a simple mean aggregation and a GLMM approach was applied to rank care groups, using two different health care costs variables: total treatment health care costs and diabetes-specific specialist care costs per diabetes patient., Principal Findings: Care groups varied slightly in the first and mainly in the second indicator. Care group variation was not explained by composition. Although the ranking methods were correlated, some care groups' rank positions differed, with consequences on the top-10 and the low-10 positions., Conclusions: Differences between care groups exist when an appropriate indicator and a sophisticated aggregation technique is used. Currently applied benchmarking may have unfair consequences for some care groups., (© Health Research and Educational Trust.)

Objective: To study the prevalence, impact and dose-response relationship of comorbid chronic conditions on quality of life of type 2 diabetes patients., Research Design and Methods: Cross-sectional data of 1676 type 2 diabetes patients, aged 31-96 years, and treated in primary care, were analyzed. Quality of life (QoL) was measured using the mental component summary (MCS) and the physical component summary (PCS) scores of the Short Form-12. Diagnosis of type 2 diabetes was obtained from medical records and comorbidities from self-reports., Results: Only 361 (21.5%) of the patients reported no comorbidities. Diabetes patients with comorbidities showed significantly lower mean difference in PCS [-8.5; 95% confidence interval (CI) -9.8 to -7.3] and MCS scores (-1.9; 95% CI -3.0 to -0.9), compared to diabetes patients without. Additional adjustments did not substantially change these associations. Both MCS and PCS scores decrease significantly with the number of comorbid conditions, yet most pronounced regarding physical QoL. Comorbidities that reduced physical QoL most significantly were retinopathy, heart diseases, atherosclerosis in abdomen or legs, lung diseases, incontinence, back, neck and shoulder disorder, osteoarthritis and chronic rheumatoid arthritis, using the backwards stepwise regression procedure., Conclusion: Comorbidities are highly prevalent among type 2 diabetes patients and have a negative impact on the patient's QoL. A strong dose-response relationship between comorbidities and physical QoL was found. Reduced physical QoL is mainly determined by musculoskeletal and cardiovascular disorders.

Aims: To test a simulation model, the MICADO model, for estimating the long-term effects of interventions in people with and without diabetes., Methods: The MICADO model includes micro- and macrovascular diseases in relation to their risk factors. The strengths of this model are its population scope and the possibility to assess parameter uncertainty using probabilistic sensitivity analyses. Outcomes include incidence and prevalence of complications, quality of life, costs and cost-effectiveness. We externally validated MICADO's estimates of micro- and macrovascular complications in a Dutch cohort with diabetes (n = 498,400) by comparing these estimates with national and international empirical data., Results: For the annual number of people undergoing amputations, MICADO's estimate was 592 (95% interquantile range 291-842), which compared well with the registered number of people with diabetes-related amputations in the Netherlands (728). The incidence of end-stage renal disease estimated using the MICADO model was 247 people (95% interquartile range 120-363), which was also similar to the registered incidence in the Netherlands (277 people). MICADO performed well in the validation of macrovascular outcomes of population-based cohorts, while it had more difficulty in reflecting a highly selected trial population., Conclusions: Validation by comparison with independent empirical data showed that the MICADO model simulates the natural course of diabetes and its micro- and macrovascular complications well. As a population-based model, MICADO can be applied for projections as well as scenario analyses to evaluate the long-term (cost-)effectiveness of population-level interventions targeting diabetes and its complications in the Netherlands or similar countries., (© 2015 The Authors. Diabetic Medicine © 2015 Diabetes UK.)

Objectives: To enhance the quality of diabetes care in the Netherlands, so-called care groups with three to 250 general practitioners emerged to organise and coordinate diabetes care. This introduced a new quality management level in addition to the quality management of separate general practices. We hypothesised that this new level of quality management might be associated with the aggregate performance indicators on the patient level. Therefore, we aimed to explore the association between quality management at the care group level and its aggregate performance indicators., Design: A cross-sectional study., Setting: All Dutch care groups (n=97)., Participants: 23 care groups provided aggregate register-based performance indicators of all their practices as well as data on quality management measured with a questionnaire filled out by 1 or 2 of their quality managers., Primary Outcomes: The association between quality management, overall and in 6 domains ('organisation of care', 'multidisciplinary teamwork', 'patient centredness', 'performance management', 'quality improvement policy' and 'management strategies') on the one hand and 3 process indicators (the percentages of patients with at least 1 measurement of glycated haemoglobin, lipid profile and systolic blood pressure), and 3 intermediate outcome indicators (the percentages of patients with glycated haemoglobin below 53 mmol/mol (7%); low-density lipoprotein cholesterol below 2.5 mmol/L; and systolic blood pressure below 140 mm Hg) by weighted univariable linear regression., Results: The domain 'management strategies' was significantly associated with the percentage of patients with a glycated haemoglobin <53 mmol/mol (β 0.28 (0.09; 0.46) p=0.01) after correction for multiple testing. The other domains as well as overall quality management were not associated with aggregate process or outcome indicators., Conclusions: This first exploratory study on quality management showed weak or no associations between quality management of diabetes care groups and their performance. It remains uncertain whether this second layer on quality management adds to better quality of care., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: To assess the change in level of diabetes quality management in primary care groups and outpatient clinics after feedback and tailored support., Research Design and Methods: This before-and-after study with a 1-year follow-up surveyed quality managers on six domains of quality management. Questionnaires measured organization of care, multidisciplinary teamwork, patient centeredness, performance results, quality improvement policy, and management strategies (score range 0-100%). Based on the scores, responders received feedback and a benchmark and were granted access to a toolbox of quality improvement instruments. If requested, additional support in improving quality management was available, consisting of an elucidating phone call or a visit from an experienced consultant. After 1 year, the level of quality management was measured again., Results: Of the initially 60 participating care groups, 51 completed the study. The total quality management score improved from 59.8% (95% CI 57.0-62.6%) to 65.1% (62.8-67.5%; P < 0.0001). The same applied to all six domains. The feedback and benchmark improved the total quality management score (P = 0.001). Of the 44 participating outpatient clinics, 28 completed the study. Their total score changed from 65.7% (CI 60.3-71.1%) to 67.3% (CI 62.9-71.7%; P = 0.30). Only the results in the domain multidisciplinary teamwork improved (P = 0.001)., Conclusions: Measuring quality management and providing feedback and a benchmark improves the level of quality management in care groups but not in outpatient clinics. The questionnaires might also be a useful asset for other diabetes care groups, such as Accountable Care Organizations., (© 2015 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.)

Background: In recent years, most Dutch general practitioners started working under the umbrella of diabetes care groups, responsible for the organisation and coordination of diabetes care. The quality management of these new organisations receives growing interest, although its association with quality of diabetes care is yet unclear. The best way to measure quality management is unknown and it has not yet been studied at the level of outpatient clinics or care groups. We aimed to assess quality management of type 2 diabetes care in care groups and outpatient clinics., Results: Quality management was measured with online questionnaires, containing six domains (see below). They were divided into 28 subdomains, with 59 (care groups) and 57 (outpatient clinics) questions respectively. The mean score of the domains reflects the overall score (0-100%) of an organisation. Two quality managers of all Dutch care groups and outpatient clinics were invited to fill out the questionnaire.Sixty care groups (response rate 61.9%) showed a mean score of 59.6% (CI 57.1-62.1%). The average score in 52 outpatient clinics (response rate 50.0%) was 61.9% (CI 57.5-66.8%).Mean scores on the six domains for care groups and outpatient clinics respectively were: 'organisation of care' 71.9% (CI 68.8-74.9%), 76.8% (CI 72.8-80.7%); 'multidisciplinary teamwork' 67.1% (CI 62.4-71.9%), 71.5% (CI 65.3-77.8%); 'patient centeredness' 46.7% (CI 42.6-50.7%), 62.5% (CI 57.7-67.2%); 'performance management' 63.3% (CI 61.2-65.3%), 50.9% (CI 44.2-57.5%); 'quality improvement policy' 52.6% (CI 49.2-56.1%), 50.9% (CI 44.6-57.3%); and 'management strategies' 56.0% (CI 51.4-60.7%), 59.0% (CI 52.8-65.2%). On subdomains, care groups scored highest on 'care program' (83.3%) and 'measured outcomes' (98.3%) and lowest on 'patient safety' (15.1%) and 'patient involvement' (17.7%). Outpatient clinics scored high on the presence of a 'diabetic foot team' (81.6%) and the support in 'self-management' (81.0%) and low on 'patient involvement' (26.8%) and 'inspection of medical file' (28.0%)., Conclusions: This nationwide assessment reveals that the level of quality management in diabetes care varies between several subdomains in both diabetes care groups and outpatient clinics.

Background: The increasing prevalence of diabetes is associated with increased health care use and costs. Innovations to improve the quality of care, manage the increasing demand for health care and control the growth of health care costs are needed. The aim of this study is to evaluate the care process and costs of managed, protocolized and usual care for type 2 diabetes patients from a societal perspective., Methods: In two distinct regions of the Netherlands, both managed and protocolized diabetes care were implemented. Managed care was characterized by centralized organization, coordination, responsibility and centralized annual assessment. Protocolized care had a partly centralized organizational structure. Usual care was characterized by a decentralized organizational structure. Using a quasi-experimental control group pretest-posttest design, the care process (guideline adherence) and costs were compared between managed (n = 253), protocolized (n = 197), and usual care (n = 333). We made a distinction between direct health care costs, direct non-health care costs and indirect costs. Multivariate regression models were used to estimate differences in costs adjusted for confounding factors. Because of the skewed distribution of the costs, bootstrapping methods (5000 replications) with a bias-corrected and accelerated approach were used to estimate 95% confidence intervals (CI) around the differences in costs., Results: Compared to usual and protocolized care, in managed care more patients were treated according to diabetes guidelines. Secondary health care use was higher in patients under usual care compared to managed and protocolized care. Compared to usual care, direct costs were significantly lower in managed care (€-1.181 (95% CI: -2.597 to -334)) while indirect costs were higher (€ 758 (95% CI: -353 to 2.701), although not significant. Direct, indirect and total costs were lower in protocolized care compared to usual care (though not significantly)., Conclusions: Compared to usual care, managed care was significantly associated with better process in terms of diabetes care, fewer secondary care consultations and lower health care costs. The same trends were seen for protocolized care, however they were not statistically significant., Trial Registration: Current Controlled trials: ISRCTN66124817.

Objective: To investigate risk of a recurrent cardiovascular event and its predictors in a population-based cohort., Research Design and Methods: Participants of the Hoorn Study who had experienced a first cardiovascular event after baseline (n = 336) were followed with respect to a recurrent event. Absolute risk of a recurrent event was calculated for individuals with normal glucose metabolism, intermediate hyperglycemia, and type 2 diabetes. Cox regression models were used to investigate which variables, measured before the first vascular event, predicted a recurrent event using the stepwise backward procedure., Results: During a median follow-up of 4.1 years, 44% (n = 148) of the population developed a recurrent vascular event. The rate of recurrent events per 100 person-years was 7.2 (95% CI 5.8-8.7) in individuals with normal glucose metabolism, compared with 9.8 (6.6-14.0) in individuals with intermediate hyperglycemia and 12.5 (8.5-17.6) in individuals with type 2 diabetes. Higher age (hazard ratio 1.02 [95% CI 1.00-1.04]), male sex (1.56 [1.08-2.25]), waist circumference (1.02 [1.02-1.03]), higher systolic blood pressure (1.01 [1.01-1.02]), higher HbA1c (%, 1.13 [0.97-1.31]/ mmol/mol, 1.01 [1.00-1.03]), and family history of myocardial infarction (1.38 [0.96-2.00]) predicted a recurrent cardiovascular event., Conclusions: Individuals with type 2 diabetes, but not individuals with intermediate hyperglycemia, are at increased risk for a recurrent vascular event compared with individuals with normal glucose metabolism. In people with a history of cardiovascular disease, people at increased risk of a recurrent event can be identified based on the patient's risk profile before the first event.

Background: Despite the favorable effects of behavior change interventions on diabetes risk, lifestyle modification is a complicated process. In this study we therefore investigated opportunities for refining a lifestyle intervention for type 2 diabetes prevention, based on participant perceptions of behavior change progress., Methods: A 30 month intervention was performed in Dutch primary care among high-risk individuals (FINDRISC-score ≥ 13) and was compared to usual care. Participant perceptions of behavior change progress for losing weight, dietary modification, and increasing physical activity were assessed after18 months with questionnaires. Based on the response, participants were categorized as 'planners', 'initiators' or 'achievers' and frequencies were evaluated in both study groups. Furthermore, participants reported on barriers for lifestyle change., Results: In both groups, around 80% of all participants (intervention: N = 370; usual care: N = 322) planned change. Except for reducing fat intake (p = 0.08), the number of initiators was significantly higher in the intervention group than in usual care. The percentage of achievers was high for the dietary and exercise objectives (intervention: 81-95%; usual care: 83-93%), but was lower for losing weight (intervention: 67%; usual care: 62%). Important motivational barriers were 'I already meet the standards' and 'I'm satisfied with my current behavior'. Temptation to snack, product taste and lack of time were important volitional barriers., Conclusions: The results suggest that the intervention supports participants to bridge the gap between motivation and action. Several opportunities for intervention refinement are however revealed, including more stringent criteria for participant inclusion, tools for (self)-monitoring of health, emphasis on the 'small-step-approach', and more attention for stimulus control., Trial Registration: Netherlands Trial Register: NTR1082.

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.

Aims: Depression and anxiety are relatively common in patients with diabetes, but it is unclear whether migrant patients with diabetes are at increased risk for emotional distress. We determined levels of emotional distress in patients with diabetes with a Turkish, Moroccan or Dutch ethnic background and compare distress levels with healthy control subjects. Among patients with diabetes, we examined demographic and clinical correlates of higher levels of emotional distress., Methods: Cross-sectional data were collected within the framework of the population-based Amsterdam Health Monitor Survey. Adult participants were interviewed to assess demographics, presence of chronic disease(s) and ethnic background. Emotional distress was determined with the Kessler psychological distress scale. Blood was drawn to determine HbA(1c) , glucose, HDL and total cholesterol. Anthropometrics and blood pressure were assessed during a medical examination., Results: The total sample comprised of 1736 participants. The prevalence of emotional distress was significantly higher in participants with diabetes (31%) compared with healthy participants (19%). Increased levels of emotional distress were reported by 38% of the Turkish, 35% of the native Dutch and 29% of the Moroccan patients with diabetes. Among patients with diabetes, the presence of two or more co-morbid chronic diseases was most strongly associated with higher levels of emotional distress, whereas glycaemic control, cholesterol, blood pressure or waist circumference were not., Conclusions: Emotional distress affects approximately one third of adult patients with diabetes living in Amsterdam. Having multiple co-morbid diseases seems related to more emotional distress among these patients, while ethnicity and diabetes-related characteristics are not., (© 2012 The Authors. Diabetic Medicine © 2012 Diabetes UK.)

Background: As in clinical practice resources may be limited compared to experimental settings, translation of evidence-based lifestyle interventions into daily life settings is challenging. In this study we therefore evaluated the implementation of the APHRODITE lifestyle intervention for the prevention of type 2 diabetes in Dutch primary care. Based on this evaluation we discuss opportunities for refining intervention delivery., Methods: A 2.5-year intervention was performed in 14 general practices in the Netherlands among individuals at high risk for type 2 diabetes (FINDRISC-score ≥ 13) (n = 479) and was compared to usual care (n = 446). Intervention consisted of individual lifestyle counselling by nurse practitioners (n = 24) and GPs (n = 48) and group-consultations. Drop-out and attendance were registered during the programme. After the intervention, satisfaction with the programme and perceived implementation barriers were assessed with questionnaires., Results: Drop-out was modest (intervention: 14.6 %; usual care: 13.2 %) and attendance at individual consultations was high (intervention: 80-97 %; usual care: 86-94 %). Providers were confident about diabetes prevention by lifestyle intervention in primary care. Participants were more satisfied with counselling from nurse practitioners than from GPs. A major part of the GPs reported low self-efficacy regarding dietary guidance. Lack of counselling time (60 %), participant motivation (12 %), and financial reimbursement (11 %) were regarded by providers as important barriers for intervention implementation., Conclusions: High participant compliance and a positive attitude of providers make primary care a suitable setting for diabetes prevention by lifestyle counselling. Results support a role for the nurse practitioner as the key player in guiding lifestyle modification. Further research is needed on strategies that could increase cost-effectiveness, such as more stringent criteria for participant inclusion, group-counselling, more tailor-made counselling and integration of screening and / or interventions for different disorders.

Aims: To determine the effectiveness of a 2.5-year lifestyle intervention for Type 2 diabetes prevention in Dutch general practice compared with usual care., Methods: A randomized controlled trial of 925 individuals at high risk for Type 2 diabetes (FINDRISC-score ≥ 13) in 14 general practices in the Netherlands. Intervention consisted of lifestyle counselling from the nurse practitioner and the general practitioner. Usual care consisted of oral and written information at the start of the study. Study groups were compared over 2.5 years regarding changes in clinical and lifestyle measures., Results: Both groups showed modest changes in body weight, glucose concentrations, physical activity and dietary intake [weight: intervention group, -0.8 (5.1) kg, usual care group, -0.4 (4.7) kg, (P=0.69); fasting plasma glucose: intervention group, -0.17 (0.4) mmol/l, usual care group, -0.10 (0.5) mmol/l, (P=0.10)]. Differences between groups were significant only for total physical activity and fibre intake. In the intervention group, self-efficacy was significantly higher in individuals successful at losing weight compared with unsuccessful individuals. No significant differences in participant weight loss were found between general practitioners and nurse practitioners with different levels of motivation or self-efficacy., Conclusions: Diabetes risk factors could significantly be reduced by lifestyle counselling in Dutch primary care. However, intervention effects above the effects attributable to usual care were modest. Higher participant self-efficacy seemed to facilitate weight loss. Lack of motivation or self-efficacy of professionals did not negatively influence participant guidance., (© 2012 The Authors. Diabetic Medicine © 2012 Diabetes UK.)

Background: More than half of the patients with type 2 diabetes (T2DM) patients are diagnosed with one or more comorbid disorders. They can participate in several single-disease oriented disease management programs, which may lead to fragmented care because these programs are not well prepared for coordinating care between programs. Comorbid patients are therefore at risk for suboptimal treatment, unsafe care, inefficient use of health care services and unnecessary costs. Case management is a possible model to counteract fragmented care for comorbid patients. It includes evidence-based optimal care, but is tailored to the individual patients' preferences.The objective of this study is to examine the effectiveness of a case management program, in addition to a diabetes management program, on the quality of care for comorbid T2DM patients., Methods/design: The study is a randomized controlled trial among patients with T2DM and at least one comorbid chronic disease (N=230), who already participate in a diabetes management program. Randomization will take place at the level of the patients in general practices. Trained practice nurses (case managers) will apply a case management program in addition to the diabetes management program. The case management intervention is based on the Guided Care model and includes six elements; assessing health care needs, planning care, create access to other care providers and community resources, monitoring, coordinating care and recording of all relevant information. Patients in the control group will continue their participation in the diabetes management program and receive care-as-usual from their general practitioner and other care providers., Discussion: We expect that the case management program, which includes better structured care based on scientific evidence and adjusted to the patients' needs and priorities, will improve the quality of care coordination from both the patients' and caregivers' perspective and will result in less consumption of health care services., Trial Registration: Netherlands Trial Register (NTR): NTR1847.

Objective: To test the hypothesis that type 2 diabetes is associated with greater decline in cognitive function in middle-aged individuals., Research Design and Methods: In the Dutch prospective Doetinchem Cohort Study, cognitive functioning was measured twice within a 5-year time interval in 2,613 men and women. Participants were aged 43-70 years at baseline (1995-2002), and no one had a history of stroke. Change in scores on global cognitive function as well as on specific cognitive function domains (memory, speed of cognitive processes, and cognitive flexibility) were compared for respondents with and without type 2 diabetes (verified by the general practitioner or random plasma glucose levels >or=11.1 mmol/l)., Results: At the 5-year follow-up, the decline in global cognitive function in diabetic patients was 2.6 times greater than that in individuals without diabetes. For individuals aged >or=60 years, patients with incident and prevalent diabetes showed a 2.5 and 3.6 times greater decline, respectively, in cognitive flexibility than individuals without diabetes. For most cognitive domains, the magnitude of cognitive decline in patients with incident diabetes was intermediate between that of individuals without diabetes and that of patients with diabetes at baseline., Conclusions: Middle-aged individuals with type 2 diabetes showed a greater decline in cognitive function than middle-aged individuals without diabetes.

The impact of weight change on diabetes incidence remains unclear. To clarify the role of weight change as a risk factor for diabetes, the authors assessed the association between weight change and diabetes incidence conditional upon either initial or attained body mass index (BMI). They used 7,837 observations available from repeated measurements of 4,259 participants (men and women aged 20-59 years) in the Dutch population-based Doetinchem Cohort Study (1987-2007) to analyze the association between 5-year weight change and diabetes incidence (n = 124) in the subsequent 5 years. When adjusted for initial BMI, 5-year weight change was a significant risk factor for diabetes (odds ratio = 1.08, 95% confidence interval: 1.04, 1.13 per kilogram of weight change). However, no significant association was found between weight change and diabetes if the association was adjusted for attained BMI (odds ratio = 0.99, 95% confidence interval: 0.94, 1.04 per kilogram of weight change). Results suggest that weight change is associated with diabetes incidence because, conditional upon initial BMI, weight change determines attained BMI. This finding implies that lifestyle interventions can contribute to diabetes prevention because they affect attained BMI. Weight change appears to have no effect on diabetes incidence beyond its effect on attained BMI.

Objective: To estimate the number of people with diagnosed diabetes mellitus in the Netherlands in 2007 using a new method; to describe trends in the past; to predict the situation in 2025., Design: Model calculations., Methods: Based on five general practice records (Nijmegen Continuous Morbidity Registration [CMR], Netherlands Information Network of General Practice [LINH], Limburg Family Practice Registration Network [RNH-Limburg], Registration Network University Family Practices, Leiden and its environs [RNUH-LEO], and the transition project) the prevalence and incidence of diagnosed diabetes in the Netherlands in 2007 was estimated. Trends in the prevalence of diagnosed diabetes were estimated from the five records over the period 2000-2007. The prevalence of diagnosed diabetes in 2025 was estimated using the Dutch Chronic Diseases Model, which takes into account demographic developments and a further increase in obesity in the Netherlands in the future., Results: In 2007, 740,000 persons (95% CI: 665,000-824,000) with diabetes were undergoing care. The incidence of new diabetes during 2007 was 71,000 (95% CI: 57,000-90,000). The prevalence of diagnosed diabetes increased by almost 80% in 2000-2007. The model projection resulted in an estimate of 1.3 million people with diagnosed diabetes in 2025, i.e. 8% of the Dutch population. There is a high level of uncertainty about these estimates., Conclusion: The increase in the number of diabetes patients in 2025 has consequences for care and will require measures to be taken in coming years in the areas of prevalence and care organisation.

Objective: In the current study we explore the long-term health benefits and cost-effectiveness of both a community-based lifestyle program for the general population (community intervention) and an intensive lifestyle intervention for obese adults, implemented in a health care setting (health care intervention)., Research Design and Methods: Short-term intervention effects on BMI and physical activity were estimated from the international literature. The National Institute for Public Health and the Environment Chronic Diseases Model was used to project lifetime health effects and effects on health care costs for minimum and maximum estimates of short-term intervention effects. Cost-effectiveness was evaluated from a health care perspective and included intervention costs and related and unrelated medical costs. Effects and costs were discounted at 1.5 and 4.0% annually., Results: One new case of diabetes per 20 years was prevented for every 7-30 participants in the health care intervention and for every 300-1,500 adults in the community intervention. Intervention costs needed to prevent one new case of diabetes (per 20 years) were lower for the community intervention (2,000-9,000 euros) than for the health care intervention (5,000-21,000 euros). The cost-effectiveness ratios were 3,100-3,900 euros per quality-adjusted life-year (QALY) for the community intervention and 3,900-5,500 euros per QALY for the health care intervention., Conclusions: Health care interventions for high-risk groups and community-based lifestyle interventions targeted to the general population (low risk) are both cost-effective ways of curbing the growing burden of diabetes.

A systematic review of the literature was conducted to give an overview of economic evaluations of preventive interventions in type 2 diabetes mellitus. The interventions were sorted by type of preventive intervention (primary, secondary or tertiary) and by category (e.g. education, medication for hypertension). Several databases were searched for studies published between January 1990 and May 2004 on the three types of preventive intervention. For each study selected, inclusion of specific components from a standardised list of items, including quality, was recorded in a database. Summary tables were generated based on the database.A number of conclusions were drawn from this review. The most important was that strict blood pressure control was a more cost-effective intervention than less strict control, as shown by six studies reporting cost savings to very low costs per life-year gained. Primary and secondary prevention of type 2 diabetes were also highly cost effective, but these results were based on very few studies. Medications to reduce weight and hyperglycaemia together were cost effective compared with conventional interventions. Finally, the separate results regarding medications to reduce weight, hyperglycaemia and hypercholesterolaemia varied enormously, thus no conclusion could be drawn and further economic analysis is required.

A consistent estimate of the prevalence, mortality and incidence of diabetes mellitus type II in the Netherlands was obtained by combining data from several sources using statistical and modelling techniques. In the Netherlands, the prevalence of diabetes in the age-group 30-74 years is 2.7-3.2%. The prevalence increases with age: for men by 7% per year of age and for women by almost 8% per year of age. This age-related increase will give rise to a 36% increase in the prevalence of diabetes in the period 1993-2010. Diabetic patients account for 12% of the total mortality in men and 18% in women; in 2.5% and 5% of the cases respectively, diabetes is the cause of mortality. If this excess mortality could be eliminated then the life expectancy for men with diabetes would increase by 4.7 years at the age of 45 and for women the corresponding increase would be 6.3 years. The estimated incidence per year increases from 8 per 10,000 men (7 for women) in the age group 40-44 years to 80 per 10,000 men (86 for women) in the age group 75-79 years.

Diabetes mellitus type II is a major clinical and public health problem and is therefore a candidate for several primary and secondary preventive strategies. Further research on the effects and side effects of both types of prevention is required before it is possible to accurately determine which prevention strategy is most suitable. Research into primary prevention should not only focus on the effect of the strategy on diabetes itself, but also on its complications. With respect to diabetic screening, it is advisable to investigate the cost-effectiveness of several screening strategies. As opportunistic screening is becoming the predominant current practice, a cost-effectiveness study of screening strategies should be started in the short term due to increasing difficulties in selecting a control group.

Our goal was to estimate non-insulin-dependent diabetes mellitus incidence in the Netherlands in the absence of equivocal empirical data. Incidence can be expressed as a function of age, sex, prevalence, and mortality. We obtained prevalence data from a study that pooled existing prevalence estimates. We calculated diabetes-related mortality using relative risks on all-cause mortality. Sensitivity for the rate of excess mortality was determined using the 95% confidence intervals (95% CI) of the relative risks. The estimated incidence increases exponentially with age, with a doubling time of 10 years for men and 9 years for women. The rate increases from 8.1 per 10,000 (95% CI = 7.7-8.8) for men ages 40-44 years and 7.0 (95% CI = 6.8-8.0) for women to 79.7 per 10,000 (95% CI = 69.5-90.9) for men ages 75-79 years and 85.8 (95% CI = 80.6-91.0) for women. When empirical estimates of incidence are largely lacking, the methodology described offers a useful alternative, in particular for the assessment of potential intervention effects.

The authors carried out a study to investigate the association between different indicators of physical activity and the prevalence of impaired glucose tolerance (IGT) and newly diagnosed diabetes (nDM) in a population-based cohort of elderly men and women in the Netherlands. A sample of participants of the Rotterdam Study (n = 1,016) aged 55-75 years who were not known to have diabetes mellitus underwent an oral glucose tolerance test. Physical activity was assessed by means of a self-administered questionnaire and expressed as time spent on activities per week. Associations with the prevalence of IGT and nDM were assessed by logistic regression analysis after adjustment for age, body mass index, waist-hip ratio, family history of diabetes, and smoking. A total of 745 subjects had normal glucose tolerance, 153 IGT, and 118 nDM. The total amount of time spent on physical activity decreased with increasing glucose intolerance. Adjusted for main confounders, vigorous activities such as bicycling (men: odds ratio (OR) = 0.26, 95% confidence interval (CI) 0.14-0.49; women: OR = 0.37, 95% CI 0.18-0.78) and sports (men: OR = 0.28, 95% CI 0.11-0.74) showed an inverse association with the presence of nDM. For IGT, the associations pointed in the same direction but did not reach statistical significance. These results indicate that physical inactivity and glucose intolerance are associated among older adults similar to the way they are associated among middle-aged adults.