Search

Abstract 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.

Aims: To assess the planned diabetes care for the coming year and its associated factors in patients with Type 2 diabetes who have a person-centered annual consultation. Methods: Implementation study of a new consultation model in 47 general practices (primary care) and 6 outpatient clinics (secondary care); 1200 patients from primary and 166 from secondary care participated. Data collection took place between November 2015 and February 2017. Outcomes: preferred monitoring frequency; referral to other health care provider(s); medication change. One measurement at the end of the consultation. We performed logistic regression analyses. Differences between primary and secondary care were analyzed. Results: Many patients arranged a monitoring frequency <4 times per year (general practices 19.5%, outpatient clinics 40%, p < .001). Type of provider (physician/nurse, OR 3.83, p < .001), baseline HbA1c (OR 1.02, p = .017), glucose lowering medication; and setting treatment goals (OR .65, p = .048) were associated with the chosen frequency. Independently associated with a referral were age (OR .99, p = .039), baseline glucose lowering medication and patients’ goal setting (OR 1.52, p = .016). Medication change was associated with type of provider, baseline HbA1c, blood glucose lowering medication, quality of life (OR .80, p = .037) and setting treatment goals (OR 2.64, p = .001). Conclusions: Not only disease but also person related factors, especially setting treatment goals, are independently associated with planned care use in person-centered diabetes care. [ABSTRACT FROM AUTHOR]

Aims: Information and communications technology (ICT) could support care organisations to cope with the increasing number of patients with diabetes mellitus. We aimed to aid diabetes care providers in allocating patients to the preferred treatment setting (hospital outpatient clinic or primary care practice), by using the Electronic Medical Record (EMR). Methods: A cluster randomised controlled trial. Physicians in primary and secondary care practices of the intervention group received an advisory message in the EMR during diabetes consultations if patients were treated in the ‘incorrect’ setting according to national management guidelines. Primary outcome: the proportion of patients that shifted to the correct treatment setting at one year follow-up. Results: 47 (38 primary care and 9 internist) practices and 2778 patients were included. At baseline, 1197 (43.1%) patients were in the correct treatment setting (intervention 599; control 598). Advice most often (68.4%) regarded a consultation with the internist. After one year 12.4% of the patients in the intervention and 10.6% in the control group (p = 0.30) had shifted to the correct setting. Main reasons for not following advice were: 1. physician’s preference to consider other treatment options; 2. patients’ preferences. Conclusions: We could not find evidence that using the EMR to send consultation-linked advice to physicians resulted in a shift in patients. Physicians will not follow the advice, at least partly due to patients’ preferences. [ABSTRACT FROM AUTHOR]

Given that there are indications of overtreatment in older patients with type 2 diabetes in both the United States and Europe, we assessed the level of personalized diabetes treatment for older patients in primary care, focusing on overtreatment. Based on Dutch guidelines individuals aged ≥70 years were classified into 3 glycated haemoglobin (HbA1c) treatment target groups: 7% (53 mmol/mol), 7.5% (58 mmol/mol) and 8% (64 mmol/mol). In our cohort of 1002 patients (n = 319 aged ≥70 years), the 165 patients with HbA1c targets >7% had more micro‐ and macrovascular complications, more often used ≥5 medicines and were more often frail compared with those with an HbA1c target ≤7%. Of these 165 patients, 64 (38.8%) were overtreated; that is, 20% of all people aged ≥70 years. The majority of overtreated people were frail and used ≥5 medicines. Hypoglycaemia occurred in 20.3% of these patients and almost 30% reported accidents involving falls. Personalized treatment in older people with type 2 diabetes is not common practice. A substantial number of older people are overtreated, with probable harmful consequences. To prevent overtreatment, definition of lower HbA1c limits might be helpful. [ABSTRACT FROM AUTHOR]

Background: Despite the wealth of research devoted to the performance of individual cognitive tests for diagnosing cognitive impairment (including mild cognitive impairment and dementia), it can be difficult for general practitioners to choose the most appropriate test for a patient with cognitive complaints in daily practice. In this paper we present a diagnostic algorithm for the evaluation of cognitive complaints in primary care. The rationale behind this algorithm is that the likelihood of cognitive impairment -which can be determined after history taking and an informant interview- should determine which cognitive test is most suitable. Methods: We distinguished three likelihoods of cognitive impairment: not likely, possible or likely. We selected cognitive tests based on pre-defined required test features for each of these three situations and a review of the literature. We incorporated the cognitive tests in a practical diagnostic algorithm. Results: Based on the available literature, in patients with complaints but where cognitive impairment is considered to be unlikely the clock-drawing test can be used to rule out cognitive impairment. When cognitive impairment is possible the Montreal cognitive assessment can be used to rule out cognitive impairment or to make cognitive impairment more likely. When cognitive impairment is likely the Mini-Mental State Examination can be used to confirm the presence of cognitive impairment. Conclusions: We propose a diagnostic algorithm to increase the efficiency of ruling out or diagnosing cognitive impairment in primary care. Further study is needed to validate and evaluate this stepwise diagnostic algorithm. [ABSTRACT FROM AUTHOR]

Background: The worldwide epidemic of type 2 diabetes (T2DM) underlines the need for diabetes prevention strategies. In this study the feasibility and effectiveness of a nurse led lifestyle program for subjects with impaired fasting glucose (IFG) is assessed. Methods: A cluster randomized clinical trial in 26 primary care practices in the Netherlands included 366 participants older than 45 years with newly diagnosed IFG and motivated to change their lifestyle (intervention group, n = 197; usual care group, n = 169). The one-year intervention, consisting of four to five individual nurse-led consultations, was directed at improving physical activity and dietary habits. The primary outcome measure was body mass index (BMI). Linear and logistic multilevel analyses and a process evaluation were performed. Results: Both groups showed small reductions in BMI at 1 and 2 years, but differences between groups were not significant. At both 1 and 2-year follow-up the number of participants physically active for at least 30 minutes at least five days a week was significantly improved in the intervention group compared to the usual care group (intervention group vs. usual care group: OR1year = 3.53; 95 % CI = 1.69-7.37 and OR2years = 1.97; 95 % CI = 1.22-3.20, respectively). The total drop-out rate was 24 %. Process evaluation revealed that participants in the intervention group received fewer consultations than advised, while some practice nurses and participants considered the RM protocol too intensive. Conclusions: This relatively simple lifestyle program in subjects with IFG resulted in a significant improvement in reported physical activity, but not in BMI. Despite its simplicity, some participants still considered the intervention too intensive. This viewpoint could be related to poor motivation and an absence of disease burden due to IFG, such that participants do not feel a need for behavioural change. Although the intervention provided some benefit, its wider use cannot be advised. Trial registration: Current Controlled Trials ISRCTN41209683, date of registration 16/10/2013h . [ABSTRACT FROM AUTHOR]

Background. Secondary prevention is efficient in reducing morbidity and mortality after a myocardial infarction (MI). However, both short-term and long-term mortality after MI remains relativity high in type 2 diabetes patients. Objective. To evaluate repeat prescriptions of secondary prevention medication (anti-thrombotic agent, beta-blocker and statin) in type 2 diabetes patients with a previous MI. Methods. Data of 1009 type 2 diabetes patients with a previous MI were extracted from the Julius General Practitioners’ Network database. The proportion of patients with recent repeat prescriptions of guideline-based medication was determined. Furthermore, repeat prescriptions was determined 6 months, 1 year, 2 years and 5 years after MI. Generalized linear models were used to examine changes over time. Multivariate logistic regression analysis was used to analyse the association between patient characteristics and prescription. Results. Only 46% of all type 2 diabetes patients with a previous MI had a recent repeat prescription for all three medicines. An increase in prescription over time was found for statins (P = 0.001). Older aged people [odds ratio (OR): 0.99, 95% confidence interval (CI): 0.98–1.00] were less likely to receive the combination of all three. Conclusion. A substantial proportion of type 2 diabetes patients with a previous MI did not receive guideline-based secondary prevention. Prescription rates were quite stable over time. This study confirms the need for a different approach to achieve an improvement of secondary prevention in type 2 diabetes patient with a previous MI. GPs can play an important role in this respect by being extra alert that prescription occurs according to the guidelines. [ABSTRACT FROM AUTHOR]

Background Many programmes to detect and prevent cardiovascular disease (CVD) have been performed, but the optimal strategy is not yet clear. Aim To present a systematic review of cardiometabolic screening programmes performed among apparently healthy people (not yet known to have CVD, diabetes, or cardiometabolic risk factors) and mixed populations (apparently healthy people and people diagnosed with risk factor or disease) to define the optimal screening strategy. Design and setting Systematic review of studies performed in primary care in Western countries. Method MEDLINE, Embase, and CINAHL databases were searched for studies screening for increased cardiometabolic risk. Exclusion criteria were studies designed to assess prevalence of risk factors without follow-up or treatment; without involving a GP; when fewer than two risk factors were considered as the primary outcome; and studies constrained to ethnic minorities. Results The search strategy yielded 11 445 hits; 26 met the inclusion criteria. Five studies (1995-2012) were conducted in apparently healthy populations: three used a stepwise method. Response rates varied from 24% to 79%. Twenty-one studies (1967-2012) were performed in mixed populations; one used a stepwise method. Response rates varied from 50% to 75%. Prevalence rates could not be compared because of heterogeneity of used thresholds and eligible populations. Observed time trends were a shift from mixed to apparently healthy populations, increasing use of risk scores, and increasing use of stepwise screening methods. Conclusion The optimal screening strategy in primary care is likely stepwise, in apparently healthy people, with the use of risk scores. Increasing public awareness and actively involving GPs might facilitate screening efficiency and uptake. [ABSTRACT FROM AUTHOR]

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: 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]