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Background: Sex differences in clinical outcomes have been observed for patients with type 2 diabetes mellitus (T2DM). These could be related to sex disparities in treatment.Objectives: To determine whether there are sex disparities in medication prescribing amongst patients with T2DM.Methods: A cohort study was conducted using the Groningen Initiative to ANalyze Type 2 diabetes Treatment (GIANTT) database, which includes data from primary care patients with T2DM from the north of the Netherlands. Data on demographics, physical examinations, laboratory measurements and prescribing were extracted. A set of validated prescribing quality indicators assessing the prevalence, start, intensification and safety of glucose-, lipid-, blood pressure- and albuminuria-lowering medication was applied for the calendar year 2019. Univariate logistic regression analyses were conducted.Results: We included 10,456 patients (47% females). Females were less often treated with metformin (81.7% vs. 86.5%; OR 0.70, 95% CI 0.61–0.80), and were less often prescribed a renin-angiotensin-aldosterone inhibitor (RAAS-i) when treated with multiple blood pressure-lowering medicines (81.9% vs. 89.3%; OR 0.55, 95% CI 0.46–0.64) or when having albuminuria (74.7% vs. 82.1%; OR 0.64, 95% CI 0.49–0.85) than males. Statin treatment was less frequently started (19.7% vs. 24.7%; OR 0.75, 95% CI 0.58–0.96) and prescribed (58.7% vs. 63.9%; OR 0.80, 95% CI 0.73–0.89) in females. There were no differences in starting and intensifying glucose-, blood pressure- and albuminuria-lowering medication.Conclusions: Sex disparities in medication prescribing amongst T2DM patients were seen, including less starting with statins and potential undertreatment with RAAS-i in females. Such disparities may partly explain higher excess risks for cardiovascular and renal complications associated with diabetes observed in females.

Introduction There is a consensus that the incidence, prevalence, progression and severity of periodontal disease (PD) are higher in individuals with diabetes mellitus (DM). Moreover, DM and PD appear to have a bi-directional relationship. Individuals with DM, who also suffer from PD, exhibit more difficulties to stabilize metabolic control and develop other diabetes complications more frequently. Interestingly, for individuals with DM type 2 and PD, intensive periodontal treatment demonstrated to improve glycemic control. Therefore, we hypothesized that periodontal treatment may lead to lower diabetes-related healthcare costs, and aimed to study this in a Dutch population of individuals with DM. Methods For this purpose, a large data-based retrospective study was undertaken using claims data of a health insurance company. Data from adults’ health insurance policies with additional dental coverage continuously from 2012 to 2018 were extracted. Individuals who received at least one diabetes-related claim reimbursed in 2012 were included in this study. Taking account of unobserved heterogeneity, a series of panel data regression models with patient-level fixed effects were estimated to assess the potential impact of periodontal treatment on diabetes-related healthcare costs. Results A total of 39,758 individuals with DM (age range 18-19 years; 45% females) were included in the final analyses. The median diabetes-related healthcare costs in 2012 were €42.74 per quarter of a year (interquartile range €12.45 - €277.03), including diagnoses, treatment, medication, and hospitalization costs. The fixed effect models showed €10.84 [95%CI €-14.86; €-6.83] lower diabetes-related healthcare costs per quarter of a year following periodontal treatment compared to no periodontal treatment. These results held robust across different model specifications which examined potential influences of severity of periodontal treatment and different time spells after periodontal treatment. Discussions PD may be seen as the sixth complication of DM, and should therefore receive the appropriate attention in DM patients. It has been shown before that periodontal treatment may have a beneficial effect on HbA1c levels. The results of this study are in line with a previously published study that showed a financial benefit from periodontal treatment in newly-diagnosed diabetes. Conclusions This study showed that individuals with DM had lower diabetes-related healthcare costs following periodontal treatment. This implies that periodontal treatment in DM patients may offer a financial benefit, besides the clinical one. Lessons learned Periodontal treatment may be financially beneficial in individuals with DM. Limitations This study was performed using only claims data of a health insurance company. Clinical data were unavailable, hence the severity of PD and DM and the need for periodontal treatment could not be determined. This may have influenced the study results. Suggestions for further research The results of this study must be verified in observational clinical studies in which individuals who have DM or are diagnosed with DM are followed over several years to see whether PD develops and if they are treated, what the effects will be both clinically and financially.

Contains fulltext : 218135.pdf (Publisher’s version ) (Open Access) OBJECTIVES: People following a vegetarian diet could be more prone to oral health problems than people following a nonvegetarian diet. The aim of this systematic review was to examine the possible impacts of following a vegetarian diet on dental hard tissues, focusing on caries development, dental erosion and number of natural teeth. METHODS: PubMed, EMBASE, Web of Science and CINAHL were searched systematically up until 17 April 2019. Original studies comparing dental health (exclusively focusing on dental hard tissues) in vegetarians and nonvegetarians were selected. Study characteristics and outcome data were extracted, and the quality of the studies was assessed using the Newcastle-Ottawa Scale. When a dental health characteristic was reported in three or more papers in a comparable way, a meta-analysis was performed. RESULTS: Twenty-one papers reporting on 18 studies were included in this review. In meta-analyses, the vegetarian diet was associated with a higher risk for dental erosion (odds ratio: 2.40 [95% confidence interval: 1.24, 4.66]; P = .009) and a lower decayed, missing and filled teeth (DMFT) score (mean difference: -0.15 [95% confidence interval: -0.29, -0.02]; P = .023), although the quality of most included studies was poor and the findings for DMFT score became insignificant when only studies on adults were included in the meta-analysis. A meta-analysis for the other dental characteristics was not possible due to the limited number of eligible studies. There was inconsistent evidence for a link between following a vegetarian diet and dental caries or the number of natural teeth. CONCLUSIONS: Within the limitations of the present study, the findings suggest that following a vegetarian diet may be associated with a greater risk of dental erosion.

Periodontitis has been considered the sixth complication of diabetes. The aim of this study was to assess the impact of periodontal treatment on diabetes-related healthcare costs in patients with diabetes. Data on 41,598 adults (45.7% female) with at least 1 insurance claim in 2012 for diabetes-related treatment were included in the analysis. The impact of periodontal treatment on diabetes-related healthcare costs was analysed by means of fixed effect models for panel data. The median diabetes-related healthcare costs per patient in 2012, including costs for diagnosis, treatment, medication, and hospitalisation, were €38.45 per quarter (interquartile range €11.52 - €263.14). The fixed effects models showed a reduced expenditure on diabetes-related costs of €12.03 [95%CI €-15.77; €-8.29] per quarter following periodontal treatment. These results support the relevance and necessity of good periodontal care for patients with diabetes.Parodontitis wordt beschouwd als de zesde complicatie van diabetes. Het doel van dit onderzoek was de impact van parodontale behandeling op diabetesgerelateerde zorgkosten bij diabetespatiënten te beoordelen. Vanuit een database van grootschalige verzekeringsdata werden data van 41.598 volwassenen (45,7% vrouwen) met ten minste 1 diabetesgerelateerde behandelingsclaim in 2012 opgenomen in de analyse. De impact van parodontale behandeling op de diabetesgerelateerde zorgkosten werd geanalyseerd door middel van fixed effects-modellen voor paneldata. De mediane diabetesgerelateerde zorgkosten inclusief kosten voor diagnose, behandeling, medicatie en ziekenhuisopnamen bedroegen € 38,45 (interkwartielafstand € 11,52-€ 263,14) per kwartaal in 2012 per patiënt. Het fixed effects-model liet een verminderde uitgave aan diabetesgerelateerde kosten per kwartaal zien van € 12,03 [95% betrouwbaarheidsinterval -€ 15,77; -€ 8,29)] na parodontale behandeling. Deze resultaten onderbouwen de relevantie en behoefte aan goede parodontale zorg bij patiënten met diabetes.

Contains fulltext : 232775.pdf (Publisher’s version ) (Open Access) The present scoping review has the objective of providing an overview of meta-research in dentistry. A search of the PubMed database was performed for the period 11 October 2014 to 10 October 2019. Study selection and data extraction were performed independently by one author; prior to this, a random sample of 10% of the retrieved titles and abstracts were independently screened by two authors, achieving agreement of >80% on eligibility for initial inclusion, corresponding to good agreement. The following information was extracted from the full text of each article: meta-research area of interest; study design; type of studies evaluated in the meta-research; type of methodology used in assessment of the primary research; conflicts of interest reported; sponsorships reported; dental discipline; journal of publication; country of the first author; number of citations; and impact factor. A total of 7800 documents were initially retrieved. After analysis of the title/abstract and the full text of each article, and a snowballing procedure, 155 meta-research studies were identified and included. The 'methods' and 'reporting' meta-research areas were the most prevalent, with 73 (47%) and 61 (40%) studies, respectively. General dentistry, and orthodontics and dentofacial orthopaedics were the dental specialties with the greatest number/proportion of included studies with 45 (29%) and 28 (18%) studies, respectively. These findings may help to prioritize future meta-research in dentistry, consequently avoiding unnessecary investigations, and increasing the value of oral and dental research.

© 2020 The Authors. International Dental Journal published by John Wiley & Sons Ltd on behalf of World Dental FederationObjectives: Quality measures offer opportunities for evaluation and improvement of the quality of oral health care. This study describes the development of a core set of oral health care quality measures for adults in the Netherlands, which can be used in dental practice. Materials and methods: A comprehensive two-stage approach was used, consisting of: (1) identification of an initial set of measures based on appraised literature; and (2) a four-round modified RAND/UCLA Appropriateness Method to establish measures that are relevant, appropriate and important to oral health care. Measures were rated anonymously on a nine-point Likert scale, ranging from 1 (lowest rating) to 9 (highest rating), followed by a group discussion to reach consensus. Multiple key stakeholder groups in the Dutch oral health care field were involved in the Delphi rounds, including dental professionals, scientists and representatives from Dutch oral health care organisations. Results: The study resulted in a core set of 13 oral health care quality measures. The measures cover domains related to oral disease outcomes, oral treatment and preventive services, patient experiences, patient safety, and organisational aspects of oral health care. In addition, the study led to the identification of 49 structural aspects of oral health care that are important to measure. Discussion: To our knowledge, this is the first study combining appraised literature from a systematic review and a rigorous multi-stage procedure with extensive stakeholder involvement to develop a core set of oral health care quality measures. In the next phase, the measures will be tested on feasibility, reliability, and will be piloted and implemented in practice.

IntroductionPeriodontitis has been considered a sixth complication of diabetes. The aim of this study was to assess the impact of periodontal treatment on diabetes-related healthcare costs in patients with diabetes.Research design and methodsA retrospective analysis was done, exploiting unique and large-scale claims data of a Dutch health insurance company. Data were extracted for a cohort of adults who had been continuously insured with additional dental coverage for the years 2012–2018. Individuals with at least one diabetes-related treatment claim in 2012 were included for analysis. A series of panel data regression models with patient-level fixed effects were estimated to assess the impact of periodontal treatment on diabetes-related healthcare costs.ResultsA total of 41 598 individuals with diabetes (age range 18–100 years; 45.7% female) were included in the final analyses. The median diabetes-related healthcare costs per patient in 2012 were €38.45 per quarter (IQR €11.52–€263.14), including diagnoses, treatment, medication and hospitalization costs. The fixed effect models showed €12.03 (95% CI −€15.77 to −€8.29) lower diabetes-related healthcare costs per quarter of a year following periodontal treatment compared with no periodontal treatment.ConclusionsPeriodontitis, a possible complication of diabetes, should receive appropriate attention in diabetes management. The findings of this study provide corroborative evidence for reduced economic burdens due to periodontal treatment in patients with diabetes.

Introduction There is conflicting evidence for the effect of clinical decision support systems (CDSS) for improving health care. While there have been success stories, other studies have highlighted potential pitfalls for CDSS. It is also uncertain whether and how a CDSS could improve integration of health care. This abstract reports the development and evaluation of a CDSS to improve integration of primary diabetes and periodontal healthcare. Methods The CDSS was developed using focus group and individual discussions with general practitioners (GPs) and dentists. These resulted in decision trees which acted as the basic structure for the CDSS. After the development, a case vignette study was conducted to evaluate the impact of the CDSS on decision making. Two sets of vignettes were developed, one set for GPs (n=200) and one set for dentists (n=200). Each participant was presented three different vignettes, with one chosen at random to include support from the CDSS. Logistic regression analysis was performed to assess the influence of the CDSS on the recommended decisions. Results The CDSS was developed for both GPs and dentists. Based on risk scores for diabetes and periodontitis, the CDSS gives tailored information, warnings and recommendations to the healthcare providers. The case vignette study showed that if assisted by the CDSS the GPs more often provided information on common risk factors for chronic conditions and dental problems (OR 3.3) and GDPS more often provided information regarding the bi-directional relationship between periodontitis and diabetes (OR 1.6). Both groups were also more likely to refer to each other when the CDSS was activated (GP OR 4.1; GDP OR 4.3). GDPs were also more likely to ask for a patient's HbA1c value when prompted by the CDSS (OR 3.2) Discussions A CDSS for cooperation between primary and dental healthcare might provide innovative and novel possibilities to improve integration of healthcare through more awareness and better informed decision making. Conclusions We have developed a CDSS to raise awareness among general practitioners and dentists about the bi-directional link between diabetes and periodontitis and to promote integration of primary diabetes and periodontal healthcare. Lessons learned The vignette study suggested that the CDSS will help to raise awareness among healthcare providers and facilitates intersectoral cooperation. The CDSS may act as a blue-print for further oral-systemic interaction and integration. Limitations The decision trees and CDSS were developed using expert opinions from healthcare providers due to a lack of clinical guidelines for patients suffering from both conditions. These opinions may not be generally representative. The participants in the case vignette study are not a representative sample for GPs and GDPs in Germany, so the results cannot be generalized. Suggestions for future research The CDSS could be improved by integration of electronic dental and general health records. For the time being, the necessary information needed by the CDSS can be reported by the patients during the visit. Future research may focus on implementation of this CDSS and exploration of other oral-systemic interactions for which this DSS might be extendable.

Introduction People around the world are increasingly affected by multimorbidity, where conditions in different medical specialties can correlate in complex ways. This increases the relevance of multidisciplinary integrated care pathways. Modern software solutions provide vast opportunities to enhance information exchange between patients and various healthcare professionals, thereby improving patient-centered and inter-professional care. This paper describes the development and validation of a mobile patient application which exploits Patient Reported Outcomes to enhance patient-centered medical-dental integration with a focus on integrated management of periodontitis and diabetes. Methods This study was part of a multidisciplinary project for enhancement of medical-dental integration. The Intervention Mapping Protocol was supplemented by the RAND/UCLA Appropriateness Method, including literature reviews, focus group discussions and a Delphi panel in cooperation with various stakeholders. A mobile application was developed in close collaboration with patients, physicians and dentists. The usability of the application’s core components was validated in two medical and two dental practices using the System Usability Scale (SUS). Results 39 questions were identified to provide relevant patient-reported information which can be collected via a mobile application to enhance integrated management of periodontitis and diabetes. Usability testing of the application’s core components (14 questions) among 137 participants in medical and dental practices indicated a good SUS score of 77.88 (±12.17). Discussion The systematically developed mobile application offers the potential to provide physicians and dentists with treatment-relevant information to enhance medical-dental integration, thereby reducing the workload of medical staff, improving the quality of routinely collected data, and enabling automated data processing. This unique, novel, and validated approach can serve as an open framework for the development and evaluation of interdisciplinary healthcare software.

Introduction: There is a growing body of evidence for associations between oral and other chronic non-communicable diseases. Early recognition and diagnosis can be important in treating these diseases and better integration of primary and dental care could improve patient care. With the Dent@Prevent project, we aim to develop an electronic decision support system (DSS) and interactive mobile application to promote better collaboration between general practitioners (GPs) and dentists. Methods: A mixed-methods approach, including a systematic literature review, routine data analysis, focus groups with GPs and dentists and a Delphi-method with GPs, dentists and patients, is used to acquire information to develop the interactive mobile application that assesses patient-reported measures and the DSS that supports GP and dentist decision-making in an evidence-oriented way. Both the mobile application and DSS will be piloted to validate the use of these products. Results Findings: from the systematic literature review yielded a primary focus for the mobile application and DSS on links between diabetes and periodontitis. From the focus groups with dentists and GPs it appeared that GPs are generally less aware of interactions between oral and non-communicable diseases than dentists. Furthermore, several intervention points and integration of care processes were discussed as a basis for the DSS. The developed mobile application includes patient-reported measures for diabetes and periodontitis risks, as well as measures of patient experiences and perceptions towards the integration of care. The DSS is being designed to support the GP and dentist to recognize respectively an increased risk for periodontitis in their diabetes patients and an increased risk for diabetes in their patients with periodontitis, and to care for their patients accordingly. Discussions and conclusions: Electronic decision support systems for integration of primary and dental care might provide innovative and novel possibilities to improve integration of care through better informed decision making, including at the health policy level. Lessons learned: Clinicians may be unaware of interactions between oral and non-communicable diseases, which may reduce the chance for early recognition of disease in both sectors of care. Limitations: The Delphi-method was used to determine the content of the mobile application with regards to measures of patient experiences and perceptions. It was performed with an anonymized panel including dentists, GPs and patients. Because of this anonymity, the characteristics such as gender and age of the panel are unknown. Furthermore, because of limited scientific evidence on integrated care for diabetes patients with periodontitis, several development steps of the DSS depend on expert opinions from clinicians which may not be generally representative. Finally, the DSS we are developing is a pilot version but this seems a sensible approach towards stepwise creation of the DSS. Suggestions for future research: The mobile application and DSS have to be tested and validated in real-life settings before implementation in actual practice. Once the mobile application and DSS have been validated, the system can be evaluated to assess the efficiency of the intervention to promote integrated health under day-to-day practice conditions.

Introduction: Several chronic non-communicable diseases share common risk factors.Integration of care is important to ensure the best quality and efficiency of care for patients with multiple conditions. Patients’ perceptions are important for assessing the integration of care. For example,oral and general health are closely related. However, oral and general healthcare often take place in a disintegrated manner. This study aimed to develop a short and simple survey to assess integration of oral and general healthcare through patient perceptions. In addition, the survey was intended to be developed such that it can easily be implemented as an add-on to other surveys. Methods: A literature search was performed to develop a conceptual framework and set of questions for the Intersectoral Care Reported by Patients (ICRP) survey. Thereafter, a modified Delphi-method was used to further elaborate the survey. A panel consisting of seven international experts assessed the survey in three rounds. The experts were based in the United States, Germany, and the Netherlands and had different professional backgrounds including general practice and dentistry. During two interactive discussion rounds and one online round of voting, the framework and the questions were assessed, adapted, and prioritized by the experts. During the online round, the experts were asked to rate the necessity of each question and rank the questions based on importance for inclusion in the ICRP survey. Results: The co-creative development process yielded thirteen questions for inclusion in the ICRP survey. These questions focus on five domains: patients’ wishes, expectations and awareness regarding communication between healthcare providers; patients’ perception of healthcare providers’ knowledge; healthcare provider-patient communication about health status; utilization of healthcare; and self-rated health. Discussion and conclusions: We developed a short, easy-to-understand survey to assess integration of oral and general healthcare as perceived by patients. The survey provides opportunities for usage in research and as a tool in feedback systems for healthcare providers. Lessons learned: During the first group discussion, there were many suggestions for questions, including many differently formatted questions for the same concept. By asking the experts to rate the necessity and rank the questions during the online round, we were able to determine which questions were deemed most apt and relevant for inclusion in the ICRP survey. Limitations: The panel included seven experts, although not all experts were able to participate in all rounds of group conversations. This was solved through individual discussion with some of the experts. Although patients were not involved in the development of the survey, they will soon be involved in usability and understandability testing and piloting of the survey. Suggestions for future research: The survey’s understandability will be assessed by patients. Furthermore, the survey will be tested for usability in real-life practice settings. In order to compare different countries, the survey will be translated to other languages such as Dutch and German.