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Aim: To evaluate if, one year after notification of possible overtreatment, diabetes care providers de-intensified glucose-lowering medications and to gain insight into the opinions and beliefs of both care providers and patients regarding de-intensification. Methods: Mixed methods using routine care data from five health-care centres in the Netherlands. Patient characteristics and medication prescription of patients, previously identified as possibly over-treated, were extracted from patients' medical records. Opinions of care providers were obtained through interviews. Patients received questionnaires about their diabetes treatment and were asked to participate in focus groups. Results: A total of 64 elderly patients with type 2 diabetes were previously identified as possibly over-treated and included; 57.8% male, median age 75 years (IQR=72–82), median diabetes duration 12 years (IQR=8–18). De-intensification was implemented in more than half (n=36) of them. Care providers preferred person-centred care above just setting general HbA1c target values, considering patient characteristics (such as comorbidity) and patient's preference. Patients valued glucose levels as most important in determining their treatment. Both patients and care providers felt that de-intensification should occur gradually. Conclusion: Treatment had been de-intensified in more than half of the patients (56.3%). Insight in reasons for not de-intensifying elderly patients is important since treatment for them can be "person-centred care". De-intensification is an iterative and time-intensive process. [ABSTRACT FROM AUTHOR]

Objective About 20% of patients with type 2 diabetes achieve all their treatment targets. Shared decision making ( SDM) using a support aid based on the 5-years results of the ADDITION study on multifactorial treatment, could increase this proportion. Research design and methods Cluster-randomized trial in 35 former ADDITION primary care practices. Practices were randomized to SDM or care as usual (1:1). Both ADDITION and non- ADDITION type 2 diabetes patients, 60-80 years, known with diabetes for 8-12 years, were included. In the intervention group, patients were presented evidence about the relationship between treatment intensity and cardiovascular events. They chose intensive or less intensive treatment and prioritized their targets. After 1 year priorities could be rearranged. Follow-up: 24 months. Intention-to-treat analysis. Main outcome measure: proportion of patients that achieved all three treatment targets. Results At baseline 26.4% in the SDM group (n=72) had already achieved all three treatment goals ( CG: 23.5%, n=81). In the SDM group 44 patients chose intensive treatment, 25 continued their former less intensive treatment and three people switched from the more to the less intensive protocol. After 24 months 31.8% of the patients in the SDM group achieved all three treatment targets ( CG: 25.3%), RR 1.26 (95% CI 0.81-1.95). Mean systolic blood pressure decreased in the SDM group (−5.4 mm Hg, P<.01), mean HbA1c and total cholesterol did not change. Conclusions Despite an already high baseline level of diabetes care, we found strong indications that SDM on both intensity of treatment and prioritizing treatment goals further improved outcomes. [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: Levels of high-sensitivity C-reactive protein (hs-CRP) and adiponectin, reflecting chronic inflammation, are associated with cardiovascular disease in type 2 diabetes. The long-term effects of multifactorial therapy in type 2 diabetes patients on CRP and adiponectin are unknown.Methods: The ADDITION-NL study is a randomized clinical trial among screen-detected type 2 diabetes patients, randomized to intensive treatment (HbA1c <7.0% (53 mmol/mol), blood pressure ≤135/85 mmHg, total cholesterol ≤3.5 mmol/L) or routine care. Hs-CRP and adiponectin were measured before and 1, 2 and 6 years after inclusion. We analysed the effectiveness of the intervention on hs-CRP and adiponectin levels using a mixed effects model, taking into account practice, baseline levels and different medications.Results: A total of 424 patients were included (intensive care n = 235; routine care n = 189). Both groups were well matched. Body mass index, systolic blood pressure, total cholesterol and HbA1c improved significantly more in the intensive care group compared to routine care group. Levels of hs-CRP decreased significantly in both treatment groups over time. Mean hs-CRP in the routine care group was 24% higher (p = 0.0027) than in the intensive treatment group during follow-up. After an initial increase the adiponectin values levelled off to nearly baseline values in both groups. The difference between the two groups after 6 years was 0.44 µg/mL (p = 0.27).Conclusions: Intensified multifactorial treatment in type 2 diabetes results in an enhanced decrease in hs-CRP. Whether this is clinically meaningful remains uncertain. The link to adiponectin seems to be more complex. [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]

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]

OBJECTIVES:Stressful events during early life have been suggested to play an important role in the development of the irritable bowel syndrome (IBS). In this study, we evaluate whether an exposure to severe wartime conditions during gestation and in early life are associated with an increased prevalence of IBS.METHODS:We assessed the prevalence of IBS using the Rome II questionnaire among 816 men and women (aged 58±1 years) who were born as term singletons in Wilhelmina Gasthuis, Amsterdam, The Netherlands around the time of World War II.RESULTS:Of a total of 816 participants, 9.6% (n=78, 52F) met the criteria for IBS. Exposure to severe wartime conditions in utero was not associated with the prevalence of IBS in adulthood (8.3%). Early-life exposure to severe wartime conditions was associated with an increased prevalence of IBS. The prevalence of IBS among individuals exposed up to 0.5 years of age, 1 year of age, and 1.5 years of age was 8.1%, 12.5%, and 15.3%, respectively. The increased IBS prevalence was not associated with an increased stress response.CONCLUSIONS:Our data indicate that exposure to severe wartime conditions in early life is associated with an increased risk of developing IBS. To what extent this is attributable to the stressful environment of war, to severe undernutrition, or to the increased prevalence of infectious diseases is, however, unclear. [ABSTRACT FROM AUTHOR]

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]

Focuses on a study which estimated the health-related quality of life and treatment satisfaction for patients with type 2 diabetes in the Netherlands. Research design and methods; Results; Conclusions.

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]

Aims: Short-term weight loss may lead to remission of type 2 diabetes but the effect of maintained weight loss on cardiovascular disease (CVD) is unknown. We quantified the associations between changes in weight 5 years following a diagnosis of diabetes, and incident CVD events and mortality up to 10 years after diagnosis., Materials and Methods: Observational analysis of the ADDITION-Europe trial of 2730 adults with screen-detected type 2 diabetes from the UK, Denmark and the Netherlands. We defined weight change based on the maintenance at 5 years of weight loss achieved during the year after diabetes diagnosis, and as 5-year overall change in weight. Incident CVD events (n = 229) and all-cause mortality (n = 225) from 5 to 10 years follow-up were ascertained from medical records., Results: Gaining >2% weight during the year after diabetes diagnosis was associated with higher hazard of all-cause mortality versus maintaining weight [hazard ratio (95% confidence interval): 3.18 (1.30-7.82)]. Losing ≥5% weight 1 year after diagnosis was also associated with mortality, whether or not weight loss was maintained at 5 years: 2.47 (0.99-6.21) and 2.72 (1.17-6.30), respectively. Losing ≥10% weight over 5 years was associated with mortality among those with body mass index <30 kg/m 2 [4.62 (1.87-11.42)]. Associations with CVD incidence were inconclusive., Conclusions: Both weight loss and weight gain after screen-detected diabetes diagnosis were associated with higher mortality, but not CVD events, particularly among participants without obesity. The clinical implications of weight loss following a diagnosis of diabetes probably depend on its magnitude and timing, and may differ by body mass index status. Personalization of weight loss advice and support may be warranted., (© 2020 John Wiley & Sons Ltd.)

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., Competing Interests: The authors have declared that no competing interests exist.

Background: Achalasia patients with longstanding disease are considered to be at risk for developing esophageal cancer. Endoscopic screening is not standardized and detection of dysplastic lesions is difficult, for which Lugol chromoendoscopy could be helpful. Aim was to evaluate the efficacy of screening for esophageal dysplasia and carcinoma in patients with longstanding achalasia using Lugol chromoendoscopy., Methods: In this cohort study achalasia patients underwent three-annual screening by Lugol chromoendoscopy between January 2000 and March 2016. Patients with low-grade dysplasia (LGD) underwent yearly screening, patients with high-grade dysplasia (HGD) or carcinoma were treated., Results: In total, 230 achalasia patients (144 male, median age 52 years (IQR 43-63) at first endoscopy) were included. Three patients (1.3%, 2 male, age 68 years (range 50-87)) developed esophageal squamous cell carcinoma (ESCC), without LGD at the preceding screening. Incidence rate for ESCC was 63 (95% CI 13-183) per 100 000 persons-years. LGD was observed in 4 patients (1.7%, 2 male, age 64 years (range 57-73)), without progression to HGD/ESCC during a follow-up of 9 (IQR 7-14) years. ESCC/LGD was diagnosed 30 (IQR 14-36) years after onset of symptoms and 22 (IQR 4-13) years after diagnosis. Lugol chromoendoscopy tripled the detection rate of suspected lesions (111 lesions white light versus 329 lesions Lugol), but only 8% was histopathological confirmed ESCC or LGD., Conclusion: Achalasia patients with longstanding disease (>20 years) have an increased risk to develop esophageal dysplasia and carcinoma. Endoscopic screening using white light and Lugol chromoendoscopy does not accurately identify precursor lesions for ESCC and therefore cannot be systematically recommended.

In the Netherlands so-called Diabetes Care Groups organize the primary diabetes care centrally with delegation to different health care providers. A training course for general practitioners who would like to become experts in diabetology in the primary care setting meets the need to guide the quality management processes in these care groups., (Copyright © 2013 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.)

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., (© The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aims: Despite diabetes patients' efforts to control their disease, many of them are confronted with an acute coronary event. This may evoke depressive feelings and self-management may be complicated. According to the American Diabetes Association, the transition from hospital to home after an acute coronary event (ACE) is a high-risk time for diabetes patients; it should be improved. Before developing an intervention for diabetes patients with an ACE in the period after discharge from hospital, we want to gain a detailed understanding of patients' views, perceptions and feelings in this respect., Methods: Qualitative design. Two semi-structured focus groups were conducted with 14 T2DM patients (71% male, aged 61-77 years) with a recent ACE. One focus group with partners (67% male, aged 64-75 years) was held. All interviews were transcribed verbatim and analyzed by two independent researchers., Results: Patients believed that coping with an ACE differs between patients with and without T2DM. They had problems with physical exercise, sexuality and pharmacotherapy. Patients and partners were neither satisfied with the amount of information, especially on the combination of T2DM and ACE, nor with the support offered by healthcare professionals after discharge. Participants would appreciate tailored self-management support after discharge from hospital., Conclusions: Patients with T2DM and their partners lack tailored support after a first ACE. Our findings underpin the ADA recommendations to improve the transition from hospital to home. The results of our study will help to determine the exact content of a self-management support program delivered at home to help this specific group of patients to cope with both conditions., (Copyright © 2013 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.)

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 present article presents the protocol for a randomised controlled trial to test the effectiveness of a group-based self-management support programme for recently diagnosed type 2 diabetes mellitus (T2DM) patients (one to three years post-diagnosis) and their partners. The course aims to support T2DM patients and their partners in successfully integrating diabetes care into their daily lives and hereby enhance self-management and diabetes-specific health-related quality of life. The content of the course is based on the Common-Sense Model of Self-Regulation (CSM). Furthermore, principles from the Social Cognitive Theory (SCT) and social support theories are integrated., Methods/design: We aim to recruit 160 recently diagnosed T2DM patients and their partners from general practices in six different regions in the Netherlands. Patients need to be diagnosed with T2DM for one to three years and have to experience some degree of diabetes-related difficulties, as measured with a three-item screener. Participating patients and their partners are randomly allocated to the intervention or control condition. Participants in the intervention condition receive three monthly group sessions and a booster session three months later. Participants in the control condition receive a single information meeting. Data will be collected at baseline (T0), directly after the programme (T1) and six months post-programme (T2), including: self-management, diabetes-specific health-related quality of life, illness perceptions, attitudes, social support and empowerment. A three-level multilevel model will be used to compare change-scores between the conditions (intervention/control) on each outcome., Discussion: Our study will be the first to determine whether a group-based support programme based on the CSM is effective in enhancing self-management and diabetes-specific health-related quality of life in recently diagnosed T2DM patients. The important role of patients' partners in effective diabetes care is also acknowledged in the study., Trial Registration: Netherlands National Trial Register (NTR) NTR3302.

Background: People with central obesity have an increased risk for developing the metabolic syndrome, type 2 diabetes and cardiovascular disease. However, a substantial part of obese individuals have no other cardiovascular risk factors, besides their obesity. High sensitivity C-reactive protein (hs-CRP), a marker of systemic inflammation and a predictor of type 2 diabetes and cardiovascular disease, is associated with the metabolic syndrome and its separate components. We evaluated the use of hs-CRP to discriminate between centrally obese people with and without the metabolic syndrome., Methods: 1165 people with central obesity but without any previous diagnosis of hypertension, dyslipidemia, diabetes or cardiovascular disease, aged 20-70 years, underwent a physical examination and laboratory assays to determine the presence of the metabolic syndrome (NCEP ATP III criteria). Multivariable linear regression analyses were performed to assess which metabolic syndrome components were independently associated with hs-CRP. A ROC curve was drawn and the area under the curve was calculated to evaluate whether hs-CRP was capable to predict the presence of the metabolic syndrome., Results: Median hs-CRP levels were significantly higher in individuals with central obesity with the metabolic syndrome (n = 417; 35.8%) compared to individuals with central obesity without the metabolic syndrome (2.2 mg/L (IQR 1.2-4.0) versus 1.7 mg/L (IQR 1.0-3.4); p < 0.001). Median hs-CRP levels increased with an increasing number of metabolic syndrome components present. In multivariable linear regression analyses, waist circumference and triglycerides were the only components that were independently associated with hs-CRP after adjusting for smoking, gender, alcohol consumption and the other metabolic syndrome components. The area under the ROC curve was 0.57 (95%-CI 0.53-0.60)., Conclusions: Hs-CRP has limited capacity to predict the presence of the metabolic syndrome in a population with central obesity.

We have previously developed and validated a prognostic model to predict the risk for unfavorable outcome in Dutch adults with bacterial meningitis. The aim of the current study was to validate this model in adults with bacterial meningitis from two developing countries, Vietnam and Malawi. Demographic and clinical characteristics of Vietnamese (n = 426), Malawian patients (n = 465) differed substantially from those of Dutch patients (n = 696). The Dutch model underestimated the risk of poor outcome in both Malawi and Vietnam. The discrimination of the original model (c-statistic [c] 0.84; 95% confidence interval 0.81 to 0.86) fell considerably when re-estimated in the Vietnam cohort (c = 0.70) or in the Malawian cohort (c = 0.68). Our validation study shows that new prognostic models have to be developed for these countries in a sufficiently large series of unselected patients.

Increased production of matrix metalloproteinases (MMPs) plays an important role in tissue damage in inflammatory bowel disease (IBD). Genetically encoded variation between individuals in MMP production may therefore contribute to disease onset, type, or severity. We undertook an extensive candidate gene single nucleotide polymorphism (SNP) study of MMP-1, -2, -3, -7, -8, -9, -10, -12, -13, and -14 and tissue inhibitor of metalloproteinases (TIMPs)-1, -3, and -4 in ulcerative colitis (UC). We identified tagging SNPs across these genes, and genotyped these SNPs in a Caucasian New Zealand dataset consisting of 419 UC patients and 907 controls. SNPs in a number of MMP genes were associated with UC. After correcting for multiple testing SNPs in MMP-3, MMP-8, MMP-10, and MMP-14 remained significant in their associations with UC. In a second study, using samples from a Dutch cohort, most of the significant findings in the New Zealand cohort were not replicated. However, data from an international meta-analysis provide some support for the initial findings. In conclusion, this study provides preliminary evidence to suggest that genetic variation in the MMPs may play a role in interindividual differences in UC susceptibility and clinical outcome. Further studies are needed in other cohorts to determine the robustness of these observations in different populations., (Copyright © 2011 American Society for Histocompatibility and Immunogenetics. Published by Elsevier Inc. All rights reserved.)

Background: Intensive treatment of multiple cardiovascular risk factors can halve mortality among people with established type 2 diabetes. We investigated the effect of early multifactorial treatment after diagnosis by screening., Methods: In a pragmatic, cluster-randomised, parallel-group trial done in Denmark, the Netherlands, and the UK, 343 general practices were randomly assigned screening of registered patients aged 40-69 years without known diabetes followed by routine care of diabetes or screening followed by intensive treatment of multiple risk factors. The primary endpoint was first cardiovascular event, including cardiovascular mortality and morbidity, revascularisation, and non-traumatic amputation within 5 years. Patients and staff assessing outcomes were unaware of the practice's study group assignment. Analysis was done by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00237549., Findings: Primary endpoint data were available for 3055 (99·9%) of 3057 screen-detected patients. The mean age was 60·3 (SD 6·9) years and the mean duration of follow-up was 5·3 (SD 1·6) years. Improvements in cardiovascular risk factors (HbA(1c) and cholesterol concentrations and blood pressure) were slightly but significantly better in the intensive treatment group. The incidence of first cardiovascular event was 7·2% (13·5 per 1000 person-years) in the intensive treatment group and 8·5% (15·9 per 1000 person-years) in the routine care group (hazard ratio 0·83, 95% CI 0·65-1·05), and of all-cause mortality 6·2% (11·6 per 1000 person-years) and 6·7% (12·5 per 1000 person-years; 0·91, 0·69-1·21), respectively., Interpretation: An intervention to promote early intensive management of patients with type 2 diabetes was associated with a small, non-significant reduction in the incidence of cardiovascular events and death., Funding: National Health Service Denmark, Danish Council for Strategic Research, Danish Research Foundation for General Practice, Danish Centre for Evaluation and Health Technology Assessment, Danish National Board of Health, Danish Medical Research Council, Aarhus University Research Foundation, Wellcome Trust, UK Medical Research Council, UK NIHR Health Technology Assessment Programme, UK National Health Service R&D, UK National Institute for Health Research, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, Novo Nordisk, Astra, Pfizer, GlaxoSmithKline, Servier, HemoCue, Merck., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

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 © 2010. Published by Elsevier Ireland Ltd.)

Aim: To explore the knowledge, and health beliefs of patients with type 2 diabetes mellitus (T2DM) regarding management of infections of the urinary tract (UTIs) and lower respiratory tract (LRTIs)., Methods: Three semi-structured focus groups with 23 patients with T2DM were conducted and analyzed., Results: Only a few patients mentioned specific preventive measures for UTIs and LRTIs, like not smoking and taking enough fluids (n=3). Making a nuisance of oneself, denying the seriousness of the disease and fear of insulin therapy were barriers to health-seeking behaviour. Some people did not complete the course of antibiotics (n=2) or forgot to take the tablets, especially when tablets had to be taken more than once a day (n=4)., Conclusion: Our results showed that patients with T2DM lack knowledge and realistic health beliefs about common infections such as UTIs and LRTIs. Health education should aim to help patients with T2DM to interpret symptoms of infections correctly in order to take the appropriate action such as taking preventive measures or taking antibiotics. Identifying patients at high risk of a complicated infection may target education towards those who need it most., (Copyright © 2010 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.)

Background: Women with diabetes have an increased risk of urinary tract infections (UTIs), especially recurrences. Aim. To investigate diabetes characteristics associated with the risk of recurrent lower UTIs and the antibiotic prescription pattern., Methods: In an exploratory retrospective study involving 7063 women aged>or=30 years, we studied the incidence of recurrent UTI (relapses and reinfection) in women with (n=340) and without diabetes (n=6618). Multivariable logistic regression and multilevel multinomial logistic analyses were used to determine the adjusted associations between diabetes characteristics and recurrent UTI [odds ratio (OR); 95% confidence interval (CI)] and the influence of diabetes on the pattern of antibiotic prescriptions for UTI, respectively., Results: Relapses and reinfections were reported in 7.1% and 15.9% of women with diabetes versus 2.0% and 4.1% of women without diabetes. There was an independent higher risk of recurrent UTI in women with diabetes compared with women without diabetes (OR 2.0; 95% CI 1.4-2.9). Women taking oral blood glucose-lowering medication (OR 2.1; 95% CI 1.2-3.5) or insulin (OR 3.0; 95% CI 1.7-5.1) or who had had diabetes for >or=5 years (OR 2.9; 95% CI 1.9-4.4) or who had retinopathy (OR 4.1; 95% CI 1.9-9.1) were at risk of recurrent UTI. The pattern of antibiotic prescriptions for UTI was not influenced by diabetes., Conclusions: Women with diabetes>or=5 years or with glucose-lowering medication or with retinopathy have an increased risk of recurrent UTI. Diabetes itself does not seem to influence the antibiotic prescription pattern. Research focusing on effective antibiotic treatment of UTI in women at risk of recurrence is needed and may help limit the development of antibiotic resistance.

Background & Aims: Transient lower esophageal sphincter relaxations (TLESRs) are a major mechanism behind reflux. This study assessed the effects of lesogaberan (AZD3355), a novel gamma-aminobutyric acid type B receptor agonist, on reflux and lower esophageal sphincter (LES) function when used as add-on treatment in patients with reflux symptoms despite proton pump inhibitor (PPI) treatment., Methods: In this randomized, double-blind, placebo-controlled, crossover study, patients received lesogaberan (65 mg) or placebo twice on day 1 (morning/evening) and once on day 2 (morning), in addition to existing PPI treatment. Patients consumed a standardized meal 45-60 minutes after morning doses. Ambulatory impedance-pH monitoring was conducted for 24 hours after the first dose on day 1. Stationary manometry and impedance-pH monitoring was conducted for 4 hours after the third dose on day 2., Results: Of 27 randomized patients, 21 were included in the per-protocol efficacy analysis. During the 24 hours after treatment start, lesogaberan reduced the mean number of reflux events by approximately 35% compared with placebo. During the 3 postprandial hours on day 2, lesogaberan reduced the geometric mean number of TLESRs by 25% and increased geometric mean LES pressure by 28% compared with placebo. The most common adverse events were headache (placebo: 11/27 patients; lesogaberan: 8/25 patients) and paresthesia (transient; placebo: 3/27 patients; lesogaberan: 5/25 patients)., Conclusions: In patients with reflux symptoms despite PPI treatment, lesogaberan decreased the number of TLESRs and reflux episodes, and increased LES pressure compared with placebo. These findings support further evaluation of lesogaberan as an add-on treatment in patients partially responding to PPIs., (Copyright (c) 2010 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Purpose: 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., Methods: 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., Results: 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., Conclusions: 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.

Objective: The Diabetes Care Protocol (DCP), a multifaceted computerized decision support diabetes management intervention, reduces cardiovascular risk of type 2 diabetic patients. We performed a cost-effectiveness analysis of DCP from a Dutch health care perspective., Research Design and Methods: A cluster randomized trial provided data of DCP versus usual care. The 1-year follow-up patient data were extrapolated using a modified Dutch microsimulation diabetes model, computing individual lifetime health-related costs, and health effects. Incremental costs and effectiveness (quality-adjusted life-years [QALYs]) were estimated using multivariate generalized estimating equations to correct for practice-level clustering and confounding. Incremental cost-effectiveness ratios (ICERs) were calculated and cost-effectiveness acceptability curves were created. Stroke costs were calculated separately. Subgroup analyses examined patients with and without cardiovascular disease (CVD+ or CVD- patients, respectively)., Results: Excluding stroke, DCP patients lived longer (0.14 life-years, P = NS), experienced more QALYs (0.037, P = NS), and incurred higher total costs (euro 1,415, P = NS), resulting in an ICER of euro 38,243 per QALY gained. The likelihood of cost-effectiveness given a willingness-to-pay threshold of euro 20,000 per QALY gained is 30%. DCP had a more favorable effect on CVD+ patients (ICER = euro 14,814) than for CVD- patients (ICER = euro 121,285). Coronary heart disease costs were reduced (euro-587, P < 0.05)., Conclusions: DCP reduces cardiovascular risk, resulting in only a slight improvement in QALYs, lower CVD costs, but higher total costs, with a high cost-effectiveness ratio. Cost-effective care can be achieved by focusing on cardiovascular risk factors in type 2 diabetic patients with a history of CVD.

Background and Aims: Non-adherence is considered a major barrier to better outcomes of diabetes care. A relationship has been established between polypharmacy and patients' adherence. This study aims to investigate the occurrence of polypharmacy and non-adherence in general practice, their mutual relationship and the association between adherence and the intermediate outcomes of diabetes care., Materials and Methods: We used the baseline and follow-up data of a randomised controlled trial (RCT) that compared usual care with care in accordance with a locally adapted national guideline. This study took place in the Netherlands and involved 30 general practices and 1283 patients. We obtained a complete medication profile of all participants and calculated the number of prescribed drugs and the adherence indices (AI) for oral blood glucose, blood pressure and cholesterol lowering drugs. Patients with an adherence index < 0.8 were considered non-adherent. Clustering at practice level and case-mix were taken into account., Results: Approximately 80% of the participating patients demonstrated an adherence index >or= 0.8 for oral blood glucose, blood pressure and cholesterol lowering drugs. In the intervention group, increase of drug prescriptions exceeded that of controls (1.1 +/- 2.0 vs. 0.6 +/- 1.5, p < 0.001, adjusted p < 0.05). There was evidence of an inverse relationship between the number of drugs that had been prescribed during the last 6 months of the study and patients' adherence to blood pressure lowering medications (adjusted OR 0.84, 95%CI 0.78-0.91). After one year, HbA1c and total cholesterol levels were significantly lower in adherent patients., Conclusion: During the intervention the mean number of drug prescriptions increased in both the study groups. This did not result in a lower adherence to blood glucose and cholesterol lowering medications. Given the relationship between the number of medications and patients' adherence to blood pressure lowering drugs, it may be wise to discuss adherence before prescribing multiple drug regimens., ((c) 2009 John Wiley & Sons, Ltd.)

Background: People with non-diabetic hyperglycaemia might be at risk of lacking adequate control for cardiovascular risk factors. Our aim was to determine the extent of health care utilization and provision in primary care and to evaluate the risk of cardiovascular disease in persons with an elevated risk score in a stepwise diabetes screening programme., Methods: A total of 56,978 non-diabetic patients, aged 50-70 years, from 79 practices in the Netherlands were invited to participate in a screening programme starting with a questionnaire. Those with an elevated score, underwent further glucose testing. Screened participants with type 2 diabetes (n = 64), impaired glucose tolerance (IGT) (n = 62), impaired fasting glucose (IFG) (n = 86), and normal glucose tolerance (NGT) (n = 142) were compared after three years regarding use of medication, care provider encounters and occurrence of CVD., Results: In all glucose regulation categories cardiovascular medication was prescribed more frequently during follow-up with the strongest increase in diabetic patients. Number of practice visits was higher in diabetic patients compared to those in the other categories. Glucose, lipids, and blood pressure were measured most frequently in diabetic patients. Numbers of cardiovascular events in participants with NGT, IFG, IGT and diabetes were 16.7, 32.6, 17.3 and 15.7 per 1,000 person-years (non significant), respectively., Conclusion: After three years of follow-up, screened non-diabetic participants with an elevated risk score had cardiovascular event rates comparable with diabetic patients. Screened non-diabetic persons are at risk of lacking optimal control for cardiovascular risk factors while screen-detected diabetic patients were controlled adequately.

Aims: To investigate if patients' perceptions of their diabetes status is related to blood glucose self-monitoring (SMBG) behaviour, independent of self-reported disease severity., Methods: The setting of this study was a cross-sectional study among 1561 patients, 18 years or older, who filled at least two prescriptions for any glucose lowering drug between March 2002 and 2003 in the Netherlands. Using a 30-item self-administered questionnaire, data on self-monitoring behaviour (frequency of test strip use and objective of self-monitoring), perceived diabetes status and disease severity were gathered. Type 1 diabetes mellitus patients were excluded. We used logistic regression to calculate odds ratios (OR) and their 95% confidence intervals (CI)., Results: About 54% of the patients (n=841) returned evaluable questionnaires. After exclusion of 97 type 1 diabetes mellitus patients, 744 type 2 diabetes mellitus patients were included. Practising SMBG was more common among patients who rated their diabetes status as poorly or moderately controlled compared to those who rated it (very) well-controlled (OR 1.93; 95% CI: 1.20-3.12). A better perceived diabetes status was more likely in those who performed SMBG infrequently compared to those who performed SMBG frequently (p-value for trend=0.001). Self-reported factors of disease severity and personalized objectives did not affect these associations considerably., Conclusions: Among type 2 diabetes mellitus patients, SMBG behaviour is associated with patients' perceptions of diabetes status, irrespective of the self-reported disease severity.

Background: Reducing cardiovascular risk in patients with diabetes mellitus type 2 (DM2) is important in diabetes care. However, treating patients according to clinical guidelines appears to be difficult. Delegating routine tasks to a practice nurse combined with computerized decision support systems (CDSS) may be helpful. The objective was to study the effectiveness of practice nurse-managed CDSS for diabetes care on improving cardiovascular risk factors in DM2 patients., Methods: In 113 primary care practices (n = 7,893 DM2 patients) across the Netherlands, the diabetes care protocol (DCP) was assessed in a before-after study, lasting 1 year. All practices implemented DCP, which is characterized by delegation of routine tasks in diabetes care to a practice nurse, software that supports diabetes management, medical decisions, and benchmarking (CDSS). All DM2 patients treated by their primary care physician were asked to attend the program. Primary outcome was the percentage of patients achieving treatment targets: hemoglobin A1c (HbA1c)

Aims: To determine cardiovascular risk of screen detected subjects with type 2 diabetes (T2DM), impaired glucose tolerance (IGT) and impaired fasting glucose (IFG). To examine whether BMI is an effect modifier regarding the relation between level of glucose regulation and cardiovascular risk factors., Methods: From 2002 to 2003, 29,251 persons, aged 50-70 years, participated in a population-based diabetes screening programme. Diagnosis was based on the 1999 WHO criteria. Characteristics were assessed of 285 subjects with T2DM, 175 with IGT and 218 with IFG., Results: IFG did not resemble IGT and T2DM regarding weight and blood pressure. BMI (kg/m2) was 27.3+/-4.4, 29.5+/-5.7, 30.7+/-5.6 in IFG, IGT, DM, respectively; systolic blood pressure (mmHg) 150+/-25, 161+/-24, 162+/-23; diastolic blood pressure (mmHg) 84+/-12, 89+/-12, 90+/-11. The poorer the glycaemic control, the worse levels of BMI, blood pressure and lipids. When BMI was higher, cardiovascular risk factors were more adverse, especially in subjects with diabetes., Conclusions: Subjects with IFG had lower blood pressure and weight than subjects with IGT and T2DM suggesting IFG is a condition with less risk to develop cardiovascular diseases. Effect modification by BMI was found.

Objective: To evaluate maternal serum screening for trisomy 21 (MSS) in Flanders between 1992 and 2002., Study Design: Data of a large database on the results of MSS, nuchal translucency (NT) and pregnancy outcome were analysed retrospectively., Results: Despite an excellent performance of second trimester MSS at a maternal age > or = 35 years (94.4% detection rate (DR) of trisomy 21 at a false positive rate (FPR) of 22.4%), the proportion of patients above 35 years of age in the study population was significantly lower than in the Flemish general pregnant population (5.5% versus 8.9%, P < 0.001). In the population screened by MSS and NT, the DR of second trimester MSS at a 5% FPR was 44.4%, which was lower than 66.6% in the population screened by MSS without NT. When nine trisomy 21-affected pregnancies were compared to 3265 normal pregnancies, the mean NT-MoM values were not significantly different (1.16 +/- 0.89 versus 1.00 +/- 0.46, P > 0.05). Both the findings comply to a sequential screening practice where second trimester MSS is only performed after a normal measurement of NT in the first trimester., Conclusion: In Flanders, the uptake of second trimester maternal serum screening is low in women aged 35 years or more. Its screening performance decreased after the introduction of sequential screening.

The work situation and fatigue-related complaints of employees with diabetes (N = 141) were compared with "healthy" employees (N = 8946) and employees with other chronic diseases (N = 1883). Baseline data from a Dutch Cohort Study on Fatigue at Work were used to test differences in background variables, work characteristics, lifestyle factors, and fatigue-related complaints. Odds ratios were calculated for prolonged fatigue, the need for recovery, burnout, and psychological distress. Results showed that employees with diabetes work more daytime hours and work less overtime than the other groups. If they have no comorbidity, they are no more likely to report fatigue-related complaints than "healthy" employees, except for a depressed mood. Comorbidity (the presence of one or more additional chronic diseases) is associated with increased fatigue-related complaints. Therefore, this group will need special attention from professionals.

Background: The quality of recording of clinical data in diabetes care in general practices is very variable. It has been suggested that better recording leads to improved glycaemic control., Objectives: The purpose of this study was to assess the completeness of recording by GPs of data from type 2 diabetes patients; to compare recorded and missing data; and to investigate the association between completeness and glycaemic control., Methods: A cross-sectional survey was carried out in 52 general practices. Medical records were scrutinized for the presence of 11 variables. Examining patients through an active approach completed incomplete records. We compared recorded and unrecorded items. Completeness of recording was determined at both patient and practice levels., Results: Fifty-two general practices with 1641 type 2 diabetes patients cared for by the GP participated. The frequency of absence of any particular item ranged from 20 to 70%. Weight, systolic blood pressure and HbA(1c) were slightly lower in patients with those items missing on their files, and more such patients were non-smokers (P < 0.05). The percentage of patients with unrecorded variables that exceeded target values ranged from 39 to 75. Neither at practice level nor at patient level was any association between the completeness of the data recording and HbA(1c) found., Conclusion: Records often were incomplete, which hampers a systematic approach to care of diabetic patients. However, the lack of association between completeness of data recording and control of glycaemia indicates that improved recording is not a valid indicator of good quality of care.

Objective: To determine the incidence of foot ulceration and lower limb amputation in type 2 diabetic patients in primary health care., Research Design and Methods: Data on type 2 diabetes were collected by the Nijmegen Monitoring Project between 1993 and 1998 as part of a study of chronic diseases. The records of all patients recorded as having diabetic foot problems and those who died, moved to a nursing home, or were under specialist care were included. The annual incidence of foot ulceration was defined as the number of type 2 diabetic patients per patient-year who developed a new foot ulcer. Incidence of lower limb amputation was similarly defined. Additional information was collected on treatment of foot ulcers., Results: The study population of type 2 diabetic patients increased from 511 patient-years in 1993 to 665 in 1998. The annual incidence of foot ulceration varied between 1.2 and 3.0% (mean 2.1) per year; 25% of the patients had recurrent episodes. The annual incidence of lower limb amputation varied between 0.5 and 0.8% (mean 0.6). Ten of the 15 amputees died, and 12 of 52 (23%) patients with ulceration had a subsequent amputation or a previous history of amputation. In 35 of the 73 (48%) episodes of ulceration, only the family physician provided treatment. Patients with foot problems were older and had more cardiovascular disease, retinopathy, and absent peripheral pulses., Conclusions: The incidence of foot ulceration and lower limb amputation in type 2 diabetes is low; nevertheless, recurrence rates of ulceration and risk of amputation are high, with high mortality.