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Aims: To examine experiences of primary care providers with six-monthly diabetes monitoring of well-controlled patients., Methods: This study was part of the EFFIMODI study, examining whether six-monthly monitoring of well-controlled (HbA1c ≤58 mmol/mol, systolic blood pressure ≤145 mmHg and total cholesterol ≤5.2 mmol/l) type 2 diabetes patients results in equivalent cardiometabolic control compared to three-monthly monitoring. Primary care providers completed a questionnaire about their experiences with six-monthly diabetes monitoring, whether they want to continue six-monthly monitoring and for which type of patients six-monthly monitoring is sufficient., Results: Of 163 questionnaires, 157 (96.3%) were completed and returned. Only 14 (8.9%) primary care providers were negative about the six-monthly monitoring and 102 (65.0%) would like to continue six-monthly monitoring. Primary care providers disagreed about patients' ability to determine their own monitoring frequency and whether six-monthly monitoring was suitable for all well-controlled type 2 diabetes patients. Practical concerns emerged such as the inability to declare healthcare costs and the unsuitability of electronic health record systems., Conclusions: Almost two out of three primary care providers would like to continue six-monthly monitoring of well-controlled type 2 diabetes patients. However, some diabetes care providers should be convinced and some practical concerns should be solved., (Copyright © 2013 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.)

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.

Purpose: Computerized decision support systems (CDSSs) are often part of a multifaceted intervention to improve diabetes care. We reviewed the effects of CDSSs alone or in combination with other supportive tools in primary care for type 2 diabetes mellitus (T2DM)., Materials and Methods: A systematic literature search was conducted for January 1990-July 2011 in PubMed, Embase, and the Cochrane Database and by consulting reference lists. Randomized controlled trials (RCTs) in general practice were selected if the interventions consisted of a CDSS alone or combined with a reminder system and/or feedback on performance and/or case management. The intervention had to be compared with usual care. Two pairs of reviewers independently abstracted all available data. The data were categorized by process of care and patient outcome measures., Results: Twenty RCTs met inclusion criteria. In 14 studies a CDSS was combined with another intervention. Two studies were left out of the analysis because of low quality. Four studies with a CDSS alone and four studies with a CDSS and reminders showed improvements of the process of care. CDSS with feedback on performance with or without reminders improved the process of care (one study) and patient outcome (two studies). CDSS with case management improved patient outcome (two studies). CDSS with reminders, feedback on performance, and case management improved both patient outcome and the process of care (two studies)., Conclusions: CDSSs used by healthcare providers in primary T2DM care are effective in improving the process of care; adding feedback on performance and/or case management may also improve patient outcome.

Background: Scientific evidence for the frequency of monitoring of type 2 diabetes patients is lacking. If three-monthly 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 < or = 7.5%, systolic blood pressure < or = 145 mmHg and total cholesterol < or = 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.

Background: European studies on quality of diabetes care in an unselected primary care diabetes population are scarce., Research Question: To test the feasibility of the set-up and logistics of a cross-sectional EUropean study on Care and Complications in patients with type 2 diabetes (T2DM) in Primary Care (EUCCLID) in 12 European countries., Method: One rural and one urban practice from each country participated. The central coordinating centre randomly selected five patients from each practice. Patient characteristics were assessed including medical history, anthropometric measures, quality indicators, UKPDS-risk engine, psychological and general well-being., Results: We included 103 participants from 22 GPs in 11 countries. Central data and laboratory samples were successfully collected. Of the participants 54% were female, mean age was 66 years and mean duration of diabetes was 9.6 years. Besides, 18% were using insulin, 31% had a history of cardiovascular disease, mean HbA1c was 7.1% (range 6.6-8.0), mean systolic blood pressure was 133.7 mmHg (range 126.1-144.4) and mean total cholesterol was 4.9 mmol/l (range 4.0-6.2)., Conclusion: A European study on care and complications in a random selection of people with T2DM is feasible. There are large differences in indicators of metabolic control and wellbeing between countries., ((c) 2010 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.)

Aim: Because Dutch health care organisations did want to establish well-defined diabetes shared care groups, we investigated the organisation of insulin therapy in general practice in the Netherlands and assessed factors that were associated with providing insulin therapy in type 2 diabetes (DM2) patients., Methods: Questionnaire to half of the Dutch general practitioners (GPs) (n=3848). We compared GPs who both start insulin treatment and monitor the dosages with those who always refer patients requiring insulin therapy or only monitor insulin dosages., Results: Total response was 42% (n=1621). 67% of the GPs start insulin therapy in patients with DM2, especially male GPs and those above the age of 40, as well as GPs working in a health centre and those working together with a practice nurse. GPs working in urban regions less often start insulin. The most often mentioned barriers for starting and/or monitoring insulin therapy are lack of knowledge of insulin therapy, lack of time and insufficient financial incentives., Conclusion: This nation-wide overview shows that insulin therapy is no longer a secondary care based activity. However, there is still need to enlarge the practice staff and to overcome the perceived skills deficit.

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.

Aim: To determine the acceptability of an educational leaflet regarding the prevention and treatment of infections of the lower respiratory tract (LRTIs) and urinary tract (UTIs) and to determine the effects of the leaflet on knowledge and attitude of DM2 patients in primary care., Method: In a randomized controlled intervention trial 200 DM2 patients enlisted in two practices, one urban and one rural, from the Utrecht general practitioners Research Network (HNU) were selected. Per practice, 50 patients were randomly assigned to the intervention group and 50 to the control group. The intervention was a leaflet on diabetes and LRTIs and UTIs based on the results of focus group interviews. The leaflet was sent to the patients homes. The outcome measures were acceptability of the leaflet and differences in knowledge and attitude, measured by a questionnaire., Results: The mean age was 68 years and 55% was male. There were no substantial differences in characteristics between the two groups. Among the intervention group, the leaflet was appreciated as understandable (100%) and inviting (79%). Compared to the control group, specific knowledge and attitude did not substantially differ. Patients in the intervention group had a slightly more positive attitude about 'being attentive to signs indicating pneumonia' (median difference, 1 point; p=.003) and they also answered 'UTI is mostly caused by a bacteria' more often correctly (risk difference, 18%; 95% CI, 4-33%, p=.016)., Conclusion: A leaflet on prevention and treatment of LRTIs and UTIs is considered acceptable among DM2 patients, but a multi-faceted educational approach may be needed to improve health behavioral determinants.

Aim: The EUCCLID study aims to compare the quality of type 2 diabetes (DM2) care and the prevalence of complications in primary care DM2 patients in Europe., Design: A cross-sectional survey consisting of three parallel studies: (1) study on actual clinical practice; (2) study on patient's perspective of diabetes care; (3) study on general practitioner's perspective of diabetes care., Methods: Patients will be randomly selected from a list of all patients known to the participating GPs with DM2 for whom the GP is the main diabetes care provider. Exclusion criteria will include people with type 1 diabetes mellitus, diabetes of pregnancy, serious mental illness, unable to complete a questionnaire in national language or unable to give written informed consent. Approximately 12,000 patients will be included. Participants will have a detailed medical history and anthropometric measurements, blood and urine will be collected and questionnaires will be taken. Endpoints will include quality indicators of clinical DM2 care, prevalence of diabetic complications, knowledge, attitudes, barriers and behaviour affecting good control in DM2 patients, quality of life and patients' satisfaction with diabetes care. We will also determine primary care physician's attitudes, behaviour and perception of barriers to deliver effective diabetes care.

Background A growing body of evidence suggests that earlier diagnosis and treatment of diabetes may be beneficial; however, definitive evidence is lacking. Aim To evaluate the effectiveness of an intensified multifactorial treatment on cardiovascular risk factors in patients with screen-detected type 2 diabetes. Design of study Randomised controlled trial. Setting Seventy-nine general practices in the southwestern region of the Netherlands. Method In this randomised trial, patients diagnosed with diabetes by screen-detection were assigned to intensified (n = 255) or routine treatment (n = 243), and followed over 1 year. Intensified treatment consisted of pharmacological treatment combined with lifestyle education to achieve haemoglobin A1c (HbA1c) <7.0% blood pressure <135/85 mmHg and cholesterol <5.0 mmol/l (4.5 mmo/l if cardiovascular disease was present). Health-related quality of life (HRQoL) was assessed using the Short Form (SF)-36. Analyses were performed using generalised estimating equations models. Results Changes in body mass index were 0.2 (routine care) versus - 1.4 kg/m² (intensified treatment), P<0.001; systolic blood pressure -19 versus -33 mmHg, P<0.001; diastolic blood pressure -7 versus -12 mmHg, P<0.001; HbA1c -0.9% versus -1.1%, P = 0.03; cholesterol -0.5 versus -1.2 mmol/l, P<0.001; high-density liboprotein cholesterol 0.1 versus 0.1 mmol/l, P = 0.26; low-density lipoprotein cholesterol -0.5 versus -1.0 mmol/l, P<0.001; triglycerides -0.3 versus -0.4 mmol/l, P = 0.71. No difference in HRQoL between the two groups was reported. Conclusion Intensified multifactorial treatment of patients with screen-detected diabetes in general practice reduces cardiovascular risk factor levels significantly without worsening HRQoL. [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]

Background Patients with diabetes have an elevated risk of developing complicated lower respiratory tract infections (LRTIs). However, up until now, GPs have not had the tools to assess individual risks. Aim To assess the applicability of an existing prediction rule for complicated LRTI among patients with diabetes. Design of study Retrospective cohort study. Setting The Utrecht GP Research Network. Method An existing rule that was used estimates the risk of 30-day hospitalisation or death following an episode of LRTI. Predictors were exacerbation of chronic obstructive pulmonary disease, or pneumonia, increasing age, head failure, number of hospitalisations in the previous year, use of antibiotics in the previous month, diabetes medication, and prednisone use. Discriminative capacity of the rule was estimated in patients with diabetes. Other potential predictors from the original study were examined, to test for a potentially improved model. Results Of 445 episodes of LRTI in patients with diabetes, 68 had an outcome of hospitalisation or death within 30 days of diagnosis of LRTI (15.3%). Results showed good reliability of the model (goodness of fit test P = 0.16) and discriminative properties (area under the receiver operating characteristic curve: 0.79, 95% confidence interval = 0.73 to 0.86). No other predictors could be added. Patients with a lower-risk assignment (score ≤ 2) had a probability of 5.2%, and those with higher risks (score ≥7) had a probability of 36.6% for the composite endpoint of hospitalisation or death within 30 days of diagnosis of LRTI. Conclusion The use of a prediction rule may help GPs to assess the risk of hospitalisation or death in patients with diabetes who have an episode of LRTI. [ABSTRACT FROM AUTHOR]

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]