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Background: The evidence gained from effective self-management interventions is often criticised for the ambiguity of its active components, and consequently the obstruction of their implementation into daily practice. Our aim is to report how an intervention development model aids the careful selection of active components in an intervention for people with dysglycaemia. Methods: The first three phases of the UK Medical Research Council's model for developing complex interventions in primary care were used to develop a self-management intervention targeting people with screen-detected dysglycaemia. In the preclinical phase, the expected needs of the target group were assessed by review of empirical literature and theories. In phase I, a preliminary intervention was modelled and in phase II, the preliminary intervention was pilot tested. Results: In the preclinical phase the achievement of health-related action competence was defined as the overall intervention goal and four learning objectives were identified: motivation, informed decision-making, action experience and social involvement. In Phase I, the educational activities were defined and the pedagogical tools tested. In phase II, the intervention was tested in two different primary healthcare settings and adjusted accordingly. The 18- hour intervention "Ready to Act" ran for 3 months and consisted of two motivational one-to-one sessions conducted by nurses and eight group meetings conducted by multidisciplinary teams. Conclusions: An intervention aimed at health-related action competence was successfully developed for people with screen-detected dysglycaemia. The systematic and transparent developmental process is expected to facilitate future clinical research. The MRC model provides the necessary steps to inform intervention development but should be prioritised according to existing evidence in order to save time

Objective. In people with screen-detected type 2 diabetes in primary care, (1) to assess adherence to guidelines, recommending consultation with the GP every three months and treatment initiation with an ACE inhibitor or an angiotensin-II receptor antagonist when systolic BP was > 120 mmHg and/or diastolic BP was > 80 mmHg, and (2) to identify predictors for adherence. Design. Prospective follow-up of a fixed cohort of patients. Setting. Fifty-four Danish general practices. Subjects and main outcome measures. A total of 361 people with screen-detected type 2 diabetes were followed up for 410 days to assess planned consultations with their GP and recording of BP. Some 226 people, with BP recorded above guideline threshold(s) and where treatment was not already initiated, were followed for up to 410 days to monitor prescription redemption. Results. At 3, 6, 9 and 12 months 80%, 77%, 74%, and 73% of the cohort attended a consultation. A total of 89% of the cohort attended two of the four planned consultations. The probability of redeemed prescriptions for an ACE inhibitor or an angiotensin-II receptor antagonist according to the guideline during the first year following diagnosis was 51%. High initial BP was associated with prescription redemption. No other analysed individual or organisational characteristics were found to be associated with treatment initiation. Conclusion. The consultation attendance was reasonably high, and treatment initiation with an ACE inhibitor or an angiotensin-II receptor antagonist according to the guideline was found in half of the cases. High initial BP increased the probability of treatment initiation.

Objective: We evaluated association of variants in the sterol regulatory element-binding factor 1 gene (SREBF1) with type 2 diabetes. Due to the previous inconclusive quantitative trait associations, we also did studies of intermediate quantitative phenotypes. Research design and methods: We genotyped four variants in SREBF1 in the population-based Inter99 cohort (n=6,070), the Danish ADDITION study (n=8,662) and in additional type 2 diabetic patients (n=1,002). The case-control studies involved 2,980 type 2 diabetic patients and 4,522 glucose-tolerant subjects. Results: The minor alleles of the rs2297508, rs11868035 and rs1889018 (linkage disequilibrium R(2)=0.6-0.8) associated with a modestly increased risk of type 2 diabetes (rs2297508: OR 1.17 [95% CI 1.05-1.30], P=0.003) which was confirmed in meta-analyses of all published studies (rs2297508 G-allele: OR 1.08 [1.03-1.14] per allele, P=0.001). The diabetes-associated alleles also associated strongly with a higher plasma-glucose at 30 and 120 minutes and serum-insulin at 120 minutes during an OGTT (all P Udgivelsesdato: 2008-Feb-25

We evaluated variations in glucose measurements and the reproducibility of glucose tolerance classification in a high-risk screening setting in general practice. Screening for diabetes was performed in persons aged 40-69 years. Based on capillary fasting (FBG) and 2-h blood glucose (2hBG) individuals with impaired fasting glycaemia (IFG), impaired glucose tolerance (IGT) and diabetes had a second test done after 14 days. Intra-individual coefficients of variation (CV) were estimated in each glucose tolerance class using the approximation CV(2)(x)=var(ln(x)). Bland-Altman plots with limits of agreement were made. In the total population, the CV(intra) was 7.9% and 13.8% for FBG and 2hBG, respectively. Limits of agreement ranged from -1.15 to 1.67mmol/l for FBG and from - 2.62 to 3.27mmol/l for 2hBG. One individual with IFG and 22.5% with IGT had diabetes at the second test, 76.1% with diabetes had this diagnosis confirmed, and about 30% with IFG and IGT had normal glucose tolerance at the second test. The expected values of repeated capillary blood glucose measurements were about+/-1 and+/-3mmol/l for FBG and 2hBG, respectively. Yet, 70% of high-risk prediabetic individuals were persistently classified with abnormal glucose regulation; diabetes was confirmed in 76% of the cases. Udgivelsesdato: 2007-Dec-12

Udgivelsesdato: 2006-Jun BACKGROUND: Motivational interviewing has been shown to be broadly usable in a scientific setting in the management of behavioural problems and diseases. However, data concerning implementation and aspects regarding the use of motivational interviewing in general practice is missing. AIM:To evaluate GPs' conception of motivational interviewing in terms of methods, adherence to and aspects of its use in general practice after a course. STUDY DESIGN: In a randomised controlled trial concerning intensive treatment of newly diagnosed patients with type 2 diabetes detected by screening, the GPs were randomised to a course in motivational interviewing or not. The study also included a third group of GPs outside the randomised controlled trial, who had 2 years previously received a similar course in motivational interviewing. SETTING: General practice in Denmark. METHOD: The intervention consisted of a 1.5-day residential course in motivational interviewing with 0.5-day follow-ups, twice during the first year. Questionnaire data from GPs were obtained. RESULTS: We obtained a 100% response-rate from the GPs in all three groups. The GPs trained in motivational interviewing adhered statistically significantly more to the methods than did the control group. More than 95% of the GPs receiving the course stated that they had used the specific methods in general practice. CONCLUSION: A course in motivational interviewing seems to influence GPs professional behaviour. Based on self-reported questionnaires, this study shows that the GPs after a course in motivational interviewing seemed to change their professional behaviour in daily practice using motivational interviewing compared with the control group. GPs evaluated motivational interviewing to be more effective than 'traditional advice giving'. Furthermore, GPs stated that the method was not more time consuming than 'traditional advice giving'.

Udgivelsesdato: August

Udgivelsesdato: 2007-Feb AIM: To answer: (1) Do we have effective treatments to improve prognosis for those identified at risk of Type-2 diabetes? (2) Will prevention be cost-effective? METHODS: A systematic search was done in PubMed using the following search strategy: "diabetes AND prevention AND (IFG OR IGT)". Restrictions were: "English, Meta-Analysis, Randomized Controlled Trial, Review, Humans". RESULTS: Few randomised controlled preventive trials were found. Almost all were done in research settings in people with high risk of developing Type-2 diabetes. It seems possible to either delay or prevent Type-2 diabetes through lifestyle interventions and medication. Cost-utility analyses are few in number and come to very different conclusions as to whether health policy should promote prevention of Type-2 diabetes. CONCLUSION: Intervention studies using lifestyle counselling and drug therapy in research settings illustrate promising results with lowering of the incidence of Type-2 diabetes, meaning that Type-2 diabetes can be delayed or prevented. It is, however, questionable whether these interventions are cost-effective. We need studies in routine clinical settings evaluating morbidity, mortality and cost-effectiveness as primary outcomes. While waiting for these studies to prove cost-effective, patients with pre-diabetes should be treated according to their 10-year risk of cardiovascular disease following present guidelines.

Aim: To assess the predicative value of clinical judgement of endoscopic diagnosis in the dyspeptic patients among General Practitioners (GPs) Methods: 32 general practices included 233 patients with dyspepsia without alarm symptoms. All patients had an endoscopy performed within 2 weeks. Dyspepsia definition: Epigastric pain/discomfort with/without symptom of reflux. The study was conducted in the County of Aarhus, Denmark. Outcome measures: The GPs clinical judgement of endoscopic diagnosis, endoscopic diagnosis. Results: According to the GPs clinical judgments 36% had functional dyspepsia, 24% had ulcer, 40% had reflux/oesophagitis and 0.4% had malignant disease. The endoscopy revealed that 74% had functional dyspepsia, 7% had ulcer, 18 % had oesophagitis and 1.3% had malignant disease. The predicative values of the GPs clinical judgement were 80 % (67/84) for functional dyspepsia, 11% (6/55) for ulcer, 25% (23/93) for oesophagitis, 0% (0/1) for malignant disease and 30% (44/149) for all organic lesions (ulcer, oesophagitis or malignancy). The sensitivity of the GPs clinical judgement was 39 % (67/172 for functional dyspepsia, 38% (6/16) for ulcer, 55% (23/42) for oesophagitis, 0% (0/3) for malignant disease and 72% (44/61) for all organic lesions. The GPs assessed organic lesion three times more common than revealed by endoscopy, but even then ¼ of the organic lesion was overlooked. Concerning reflux/oesophagitis both predicative value and sensitivity was even lower despite reflux should be the easiest organic dyspeptic lesion to asses clinical. Conclusion: Clinical judgement of endoscopic diagnosis in the dyspeptic patients by GPs does not satisfactorily predict endoscopic verified diagnosis. -- page break -- The General Practitioners clinical judgementEndoscopic diagnosisPredicative value of clinical judgementSensitivity of clinical judgementFunctional dyspepsia36 % (84)74 % (172)80 % (67/84)39 % (67/172)Ulcer24 % (55)7 % (16)11 % (6/55)38 % (6/16)Oesophagitis40 % (93)18 % (42)25 % (23/93)55 % (23/42)Malignancy0.4 (1)1.3 % (3)0 % (0/1)0 % (0/3)All organic lesion (ulcer, oesophagitis or malignancy)74% (149)26 % (61)30 % (44/149)72% (44/61) Endoscopic diagnosisFunctional dyspepsiaNo functional dyspepsia Clinical judgementFunctional dyspepsia6717No functional dyspepsia10544 Total17261 Endoscopic diagnosisUlcerNo ulcer Clinical judgementUlcer649No ulcer10168 Total16217 Endoscopic diagnosisOesophagitisNo oesophagitis Clinical judgementOesophagitis2370No oesophagitis19121 Total42191 Endoscopic diagnosisOrganic lesionNo organic lesion Clinical judgementOrganic lesion44105No organic lesion1767 Total61172

Udgivelsesdato: 22. juni

Udgivelsesdato: Januar

OBJECTIVE - To examine the correlates of patient and provider attitudes toward insulin therapy. RESEARCH DESIGN AND METHODS - Data are from surveys of patients with type 2 diabetes not taking insulin (n = 2,061) and diabetes care providers (nurses = 1,109; physicians = 2,681) in 13 countries in Asia, Australia, Europe, and North America. Multiple regression analysis is used to identify correlates of attitudes toward insulin therapy among patients, physicians, and nurses. RESULTS - Patient and provider attitudes differ significantly across countries, controlling for individual characteristics. Patients rate the clinical efficacy of insulin as low and would blame themselves if they had to start insulin therapy. Self-blame is significantly lower among those who have better diet and exercise adherence and less diabetes-related distress. Patients who are not managing their diabetes well (poor perceived control, more complications, and diabetes-related distress) are significantly more likely to see insulin therapy as potentially beneficial. Most nurses and general practitioners (50-55%) delay insulin therapy until absolutely necessary, but specialists and opinion leaders are less likely to do so. Delay of insulin therapy is significantly less likely when physicians and nurses see their patients as more adherent to medication or appointment regimens, view insulin as more efficacious, and when they are less likely to delay oral diabetes medications. CONCLUSIONS - Patient and provider resistance to insulin therapy is substantial, and for providers it is part of a larger pattern of reluctance to prescribe blood glucose-lowering medication. Interventions to facilitate timely initiation of insulin therapy will need to address factors associated with this resistance.

Udgivelsesdato: Januar

Background: Decision analyses conclude that empirical anti-secretory therapy is more cost-effective than endoscopy for managing patients with dyspepsia however RCTs including economic evaluation come to diverging results Aim: to compare the cost-effectiveness of two strategies for management of dyspepsia in primary care 1) endoscopy and 2) empirical proton pump inhibition (PPI) therapy. MethodsA prospective RCT designed to include prospective collection of economic resource data was conducted in general practice from June 2000 to August 2002, Aarhus County, Denmark. 368 patients with dyspepsia were randomly assigned to treatment with omeprazol 40 mg for two weeks (n: 184) or endoscopy (n: 184). Main outcome measures: days free of dyspeptic symptoms and proportion of patients symptomatic after one year. Cost were estimated from patients' and GPs' questionnaire and from medical records. ResultsThe incremental cost effectiveness (CE) ratio for one day free of dyspeptic symptoms using the endoscopy strategy was €/day 300 compared with the PPI strategy. The incremental CE ratio for one patient free of dyspeptic symptoms after one year using the endoscopy strategy was € 13,600 based on the patients' evaluation. The PPI strategy was both cheaper and more effective when reflux was the predominant symptom. ConclusionEndoscopy was associated with a small, non-significant improvement in patients' health status compared with empirical PPI, but it was the more costly of the two strategies. The empirical PPI strategy was hence the more cost-effective strategy for managing patients with dyspepsia in general practice especially if reflux was the predominant symptom.

Title: Clinical Efficacy of Proton Pump Inhibitor versus Prompt Endoscopy for Management of People with Dyspepsia: A Randomized Clinical Trial in General Practice. Purpose: To compare the clinical efficacy of two strategies for management of dyspepsia in general practice in a RCT design. Setting: June 2000 to August 2002, 41 GPs, Aarhus County, Denmark Methods: 368 people with dyspepsia (epigastric pain/discomfort, no alarm symptoms) were randomly assigned to treatment with omeprazol 40 mg/day for two weeks (PPI group, n:185) or endoscopy (endoscopy group, n:183). Due to migration, cancer, or death 25 were excluded.Outcome measures: Dyspeptic symptoms after 1 year and endoscopies in PPI group (GPs and patients' questionnaires). Use of PPI, sick leaves, visit to GPs and patients' satisfaction (patients' questionnaires).Results: We found no base line difference in age, symptoms, and use of PPI between the groups. The questionnaire response rates after 1 year were 91.3% for GPs and 86.9% for patients. After 1 year the GPs assessed whether the patients primary symptom at inclusion had improved, and 75.6% in the PPI group and 83.6% in the endoscopy group had improvement in their dyspeptic symptoms (2; P: 0.08). Pain/discomfort was the primary symptom at inclusion in 63.7% of the cases, and 74.1% in the PPI group, and after 1 year 85.7% in the endoscopy group had improvement in their pain/discomfort symptoms (2; P: 0.03). After 1 year the patients assessed whether they had of upper GI symptom regardless of the primary symptom at inclusion. The patients assessed 23.6% in the PPI group and 20.1% in the endoscopy group were free of symptoms after 1 year (2; P: 0.47). When pain/discomfort was the primary symptom at inclusion 20.4% in the PPI group and 35.4% in the endoscopy group were free of symptoms after 1 year (2; P: 0.05). The patients reported 31.8% in the PPI group and 42.6% in the endoscopy group used PPI after 1 year (2; P: 0.08). In the PPI group 35.7% had secondary endoscopy performed. We found no differences between the two strategies in respect to sick leaves, dyspeptic contacts to GP or patients' satisfaction. Conclusions: Prompt endoscopy was superior to proton pump inhibitor concerning symptom improvement in management of dyspepsia in general practice when pain/discomfort was the primary symptom. There were no differences between the two strategies in respect to sick leaves, dyspeptic contacts to GP or patients' satisfaction. Table1GPs and patients assessment of dyspeptic symptoms after 1 year. 20 of the GPs and 40 of the patients assessed other primary symptom than reflux or pain/discomfort at inclusion. All value in percentages. Chi-square used for all p-values Primary symptom at inclusionAll N(GP): 310N(pat): 298Pain/discomfortn(GP): 206n (pat): 154Reflux n(GP):84 n(pat):104PPIEndoscopyPPPIEndoscopyPPPIEndoscopyPGPs after 1 yearDyspepticsymptoms improved74.185.70.0479.277.10.9375.683.60.08Patientsafter 1 yearNo dyspepticsymptoms20.833.80.0717.914.60.6520.1 23.60.47

Er vi tilbageholdende med at initiere insulinbehandling? Hos type 2-diabetikere vil det være et rationelt tiltag, når der ikke længere kan opnås en acceptabel glykæmisk kontrol med livsstilsændringer og perorale antidiabetika.