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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]

Objective: We assessed both from a patient and provider perspective the usefulness and added value of a consultation model that facilitates person-centered diabetes care.Research Design and Methods: The model consists of 1) inventory of disease and patient-related factors; 2) setting personal goals; 3) choosing treatment; and 4) determination of required care. It was implemented in 47 general practices and 6 hospital outpatient clinics. Providers were trained, and patients were recommended to prepare their visit. All filled out a questionnaire after every consultation. Differences between primary and secondary care practices and between physician-led and nurse-led consultations were analyzed.Results: Seventy-four physicians and thirty-one nurses participated, reporting on 1,366 consultations with type 2 diabetes patients. According to providers, the model was applicable in 72.4% (nurses 79.3% vs. physicians 68.5%, P < 0.001). Physicians more often had a consultation time <25 min (80.4% vs. 56.9%, P < 0.001). According to providers, two of three patients spoke more than half of the consultation time (outpatient clinics 75.2% vs. general practices 66.6%, P = 0.002; nurses 73.2% vs. physicians 64.4%, P = 0.001). Providers stated that person-related factors often determined treatment goals. Almost all patients (94.4%) reported that they made shared decisions; they felt more involved than before (with physicians 45.1% vs. with nurses 33.6%, P < 0.001) and rated the consultation 8.6 of 10. After physician-led consultations, 52.5% reported that the consultation was better than before (nurse visit 33.7%, P < 0.001).Conclusions: A consultation model to facilitate person-centered care seems well applicable and results in more patient involvement, including shared decision making, and is appreciated by a substantial number of patients. [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: Illness perceptions involve the personal beliefs that patients have about their illness and may influence health behaviours considerably. Since an instrument to measure these perceptions for Malay population in Malaysia is lacking, we translated and examined the psychometric properties of the Malay version of the Brief Illness Perception Questionnaire (MBIPQ) in adult patients with type 2 diabetes mellitus.Methods: The MBIPQ has nine items, all use a 0-10 response scale, except the ninth item about causal factors, which is an open-ended item. A standard procedure was used to translate and adapt the English BIPQ into Malay language. Construct validity was examined comparing item scores and scores on the Diabetes Management Self-Efficacy Scale, the Morisky Medication Adherence Scale, the World Health Organization Quality of Life-brief, the 9-item Patient Health Questionnaire, the 17-item Diabetes Distress Scale, HbA1c and the presence of complications. In addition, 2-week and 4-week test-retest reliability were studied.Results: A total of 312 patients completed the MBIPQ. Out of this, 97 and 215 patients completed the 2- or 4-weeks test-retest reliability questionnaire, respectively. Moderate inter-items correlations were observed between illness perception dimensions (r = -0.31 to 0.53). MBIPQ items showed the expected correlations with self-efficacy (r = 0.35), medication adherence (r = 0.29), quality of life (r = -0.17 to 0.31) and depressive symptoms (r = -0.18 to 0.21). People with severe diabetes-related distress also were more concern (t-test = 4.01, p < 0.001) and experienced lower personal control (t-test = 2.07, p = 0.031). People with any diabetes-related complication perceived the consequences as more serious (t-test = 2.04, p = 0.044). The 2-week and 4-week test-retest reliabilities varied between ICCagreement 0.39 to 0.70 and 0.58 to 0.78, respectively.Conclusions: The psychometric properties of items in the MBIPQ are moderate. The MBIPQ showed good cross-cultural validity and moderate construct validity. Test-retest reliability was moderate. Despite the moderate psychometric properties, the MBIPQ may be useful in clinical practice as it is a useful instrument to elicit and communicate on patient's personal thoughts and feelings. Future research is needed to establish its responsiveness and predictive validity.Trial Registration: ClinicalTrials.gov NCT02730754 registered on March 29, 2016; NCT02730078 registered on March 29, 2016. [ABSTRACT FROM AUTHOR]

Background: Type 2 diabetes mellitus (T2DM) patients experience many psychosocial problems related to their diabetes. These often lead to emotional disorders such as distress, stress, anxiety and depression, resulting in decreased self-care, quality of life and disease control. The purpose of the current study is to evaluate the effectiveness of a brief value-based emotion-focused educational programme in adults with T2DM on diabetes-related distress (DRD), depressive symptoms, illness perceptions, quality of life, diabetes self-efficacy, self-care and clinical outcomes. Methods: A cluster randomised controlled trial will be conducted in 10 public health clinics in Malaysia, all providing diabetes care according to national clinical practice guidelines. Patients' inclusion criteria: Malay, ≥ 18 years with T2DM for at least 2 years, on regular follow-up with one of three biomarkers HbA1c, systolic blood pressure and LDL-cholesterol sub-optimally controlled, and with a mean 17-item Diabetes Distress Scale (DDS-17) score ≥ 3. The intervention consists of four sessions and one booster over a period of 4 months that provide information and skills to assist patients in having proper perceptions of their T2DM including an understanding of the treatment targets, understanding and managing their emotions and goal-setting. The comparator is an attention-control group with three meetings over a similar period. With an estimated intra-cluster correlation coefficient p of 0.015, a cluster size of 20 and 20% non-completion, the trial will need to enroll 198 patients. Primary outcome: the between groups difference in proportion of patients achieving a mean DDS-17 score < 3 (non-significant distress) at 6 months post-intervention. Secondary outcomes will be the differences in the above mentioned variables between groups. Discussion: We hypothesize that primary and secondary outcomes will improve significantly after the intervention compared to the comparator group. The results of this study can contribute to better care for T2DM patients with DRD. Trial registration: ClinicalTrials.gov NCT02730078. Registered on 29 March 2016, last updated on 4 January 2017. [ABSTRACT FROM AUTHOR]

Aims: To compare the proportion of cardiometabolic well-controlled type 2 diabetes mellitus (T2DM) patients according to a clearly defined, simple personalised approach, versus the 'one-size-fits-all' approach.Methods: Observational study using routine data of primary care type 2 diabetes patients in the Netherlands. The proportions of patients that reach the targets for HbA1c, systolic blood pressure and low-density lipoprotein cholesterol in the two different approaches were compared.Results: Of the 890 patients (54.7% men, mean age 62.7 years), 31.8% were well-controlled according to the individualised approach and 24.8% according to the 'one-size-fits-all' approach. For specific subgroups personalising the treatment led to a 5.2%, 27.3% and 45.6% increase of patients achieving low-density lipoprotein cholesterol, HbA1c and systolic blood pressure goals respectively.Conclusions: A clearly defined and relatively simple personalised approach leads to a higher proportion of T2DM patients considered as cardiometabolic well-controlled. This approach may especially be beneficial for patients aged ≥70 years on more than metformin monotherapy (HbA1c) and for patients aged ≥80 years (SBP). Precisely these patients are suggested not to benefit from stricter HbA1c or SBP targets, whereas they may experience more adverse effects (e.g. hypoglycaemia, postural hypotension) when a stricter target value is pursued. [ABSTRACT FROM AUTHOR]

Aims: To determine whether US and European participants in the Liraglutide Effect and Action in Diabetes: Evaluation of cardiovascular outcome Results (LEADER) trial differ regarding risk factors for cardiovascular mortality and morbidity. Methods: Baseline data, stratified for prior cardiovascular disease (CVD), were compared using multivariable logistic regression analysis to establish whether region is an independent determinant of achieved targets for glycated hemoglobin (HbA1c), blood pressure (BP), and low-density lipoprotein (LDL)-cholesterol. Results: Independent of CVD history, US participants were more often of non-White origin and had a longer history of type 2 diabetes, higher body weight, and higher baseline HbA1c. They had substantially lower systolic and diastolic BP, and a marginally lower LDL-cholesterol level. Fewer US participants were diagnosed with left ventricular dysfunction. In the largest group of patients, those with prior CVD and the highest cardiovascular risk, US participants were more often female, had a higher waist circumference, and had a decreased estimated glomerular filtration rate, but less frequently prior myocardial infarction or angina pectoris. Conclusions: There were baseline differences between US and European participants. These differences may result from variation in regional targets for cardiovascular risk factor management, and should be considered in the analysis and reporting of the trial results. [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]

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

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

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. [ABSTRACT FROM AUTHOR]