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The prevalence of end-stage kidney disease (ESKD) continuously increases worldwide. The increasing prevalence parallels the growth in the number of people with diabetes, which is the leading cause of ESKD. Early diagnosis of chronic kidney disease (CKD) in patients with diabetes and appropriate intervention is important to delay the progression of kidney function decline and prevent ESKD. Rate of CKD progression and response to treatment varies among patients with diabetes, highlighting the need to tailor individual treatment. In this review, we describe recent advances and areas for future studies with respect to precision medicine in diabetic kidney disease (DKD). DKD is a multi-factorial disease that is subject in part to genetic heritability, but is also influenced by various exogenous mediators, such as environmental or dietary factors. Genetic testing so far has limited utility to facilitate early diagnosis, classify progression or evaluate response to therapy. Various biomarker-based approaches are currently explored to identify patients at high risk of ESKD and to facilitate decision-making for targeted therapy. These studies have led to discovery and validation of a couple of inflammatory proteins such as circulating tumour necrosis factor receptors, which are strong predictors of kidney disease progression. Moreover, risk and drug-response scores based on multiple biomarkers are developed to predict kidney disease progression and long-term drug efficacy. These findings, if implemented in clinical practice, will pave the way to move from a one-size-fits-all to a one-fit-for-everyone approach. [ABSTRACT FROM AUTHOR]

Background: Anticholinergic and sedative medications are frequently prescribed to older individuals. These medications are associated with short-term cognitive and physical impairment, but less is known about long-term associations. We therefore examined whether over 20 years cumulative exposure to these medications was related to poorer cognitive and physical functioning.Methods: Older adult participants of the Longitudinal Aging Study Amsterdam (LASA) were followed from 1992 to 2012. On seven measurement occasions, cumulative exposure to anticholinergic and sedative medications was quantified with the drug burden index (DBI), a linear additive pharmacological dose-response model. Cognitive functioning was assessed with the Mini-Mental State Examination (MMSE), Alphabet Coding Task (ACT, three trials), Auditory Verbal Learning Test (AVLT, learning and retention condition), and Raven Colored Progressive Matrices (RCPM, two trials). Physical functioning was assessed with the Walking Test (WT), Cardigan Test (CT), Chair Stands Test (CST), Balance Test (BT), and self-reported Functional Independence (FI). Data were analyzed with linear mixed models adjusted for age, education, sex, living with a partner, BMI, depressive symptoms, comorbidities (cardiovascular disease, diabetes, cancer, COPD, osteoarthritis, CNS diseases), and prescribed medications.Results: Longitudinal associations were found of the DBI with poorer cognitive functioning (less items correct on the three ACT trials, AVLT learning condition, and the two RCPM trials) and with poorer physical functioning (longer completion time on the CT, CST, and lower self-reported FI).Conclusions: This longitudinal analysis of data collected over 20 years, showed that higher long-term cumulative exposure to anticholinergic and sedative medications was associated with poorer cognitive and physical functioning. [ABSTRACT FROM AUTHOR]

Background. Quality assessment is a key element for improving the quality of care. Currently, a comprehensive indicator set for measuring the quality of medication treatment in patients with chronic kidney disease (CKD) is lacking. Our aim was to develop and validate a set of prescribing quality indicators (PQIs) for CKD care, and to test the feasibility of applying this set in practice. Methods. Potential indicators were based on clinical practice guidelines and evaluated using the RAND/UCLA Appropriateness Method. This is a structured process in which an expert panel assesses the validity of the indicators. Feasibility was tested in a Dutch primary care database including >4500 diabetes patients with CKD. Results. An initial list of 22 PQIs was assessed by 12 experts. After changing 10 PQIs, adding 2 and rejecting 8, a final list of 16 indicators was accepted by the expert panel as valid. These PQIs focused on the treatment of hypertension, albuminuria, mineral and bone disorder, statin prescribing and possible unsafe medication. The indicators were successfully applied to measure treatment quality in the primary care database, but for some indicators the number of eligible patients was too small for reliable calculation. Results showed that there was room for improvement in the treatment quality of this population. Conclusions. We developed a set of 16 PQIs for measuring the quality of treatment in CKD patients, which had sufficient content and face validity as well as operational feasibility. These PQIs can be used to point out priority areas for improvement. [ABSTRACT FROM AUTHOR]

The funding section was missing text that read 'The work leading to this received funding from the European Unions's Horizon 2020 research and innovation programme under the Marie Sklodowska-Curie grant agreement No. 754425'. When this paper first published, there was text missing from the funding section. [Extracted from the article]

Background Failure of diagnosing and treatment of albuminuria play a role in morbidity and mortality in type 2 diabetes (T2DM). We evaluated guideline adherence and factors associated with albuminuria screening and treatment in T2DM patients in primary care. Methods Guidelines recommend annual measurement of albuminuria and, if increased, treatment with renin–angiotensin–aldosterone system (RAAS) blockers. We performed a cohort study of T2DM patients managed by 182 Dutch general practitioners (GPs; Groningen Initiative to Analyse Type 2 diabetes Treatment database), and evaluated guideline adherence in the years 2007–2009. We assessed whether demographic, clinical, organizational or provider factors determined guideline adherence with multilevel analyses. Results Data were available for 14 120 T2DM patients [47.6% male, mean age 67.3 ± 11.7 years, median diabetes duration 6 (IQR: 3–10) years]. The albumin–creatinine ratio (ACR) was measured in 45.2% in 2007, 57.4% in 2008 and 56.8% in 2009. Only 23.7% of all patients were measured every year and 21.4% were never measured. The ACR was more often measured in patients <75 years, with a previous ACR measurement, using anti-diabetic medication, and receiving additional care by a diabetes support facility. RAAS treatment was prescribed to 78.4% of patients with prevalent micro/macroalbuminuria, 66.5% with incident micro/macroalbuminuria, 59.3% with normoalbuminuria and 52.1% of those without ACR measurements. In those not treated with RAAS blockers, it was initiated in 14.3, 12.3, 3.0 and 2.3%, respectively. The presence of micro/macroalbuminuria, higher blood pressure, incidence of cardiovascular events and treatment with antihypertensive medication were the determinants of RAAS-treatment initiation. Conclusions Guideline implementation regarding the management of albuminuria in T2DM patients in primary care should be further improved. [ABSTRACT FROM PUBLISHER]

OBJECTIVE: This study evaluated a computerized method for extracting numeric clinical measurements related to diabetes care from free text in electronic patient records (EPR) of general practitioners. DESIGN AND MEASUREMENTS: Accuracy of this number-oriented approach was compared to manual chart abstraction. Audits measured performance in clinical practice for two commonly used electronic record systems. RESULTS: Numeric measurements embedded within free text of the EPRs constituted 80% of relevant measurements. For 11 of 13 clinical measurements, the study extraction method was 94%-100% sensitive with a positive predictive value (PPV) of 85%-100%. Post-processing increased sensitivity several points and improved PPV to 100%. Application in clinical practice involved processing times averaging 7.8 minutes per 100 patients to extract all relevant data. CONCLUSION: The study method converted numeric clinical information to structured data with high accuracy, and enabled research and quality of care assessments for practices lacking structured data entry. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to explore and compare treatment decisions and the influence of specific patient characteristics on asthma management in five European countries, and to relate this to existing guidelines.Methods: Using the technique of clinical judgement analysis, doctors in The Netherlands, Norway, Germany, Sweden and the Slovak Republic (40-100 doctors per country) were presented with sets of written simulated cases on asthma treatment. Patient characteristics were varied to determine their influence on the doctors' decisions. Decisions indicating over- and under-prescribing in relation to a gold standard derived from guidelines were also determined.Results: Doctors in The Netherlands prescribed more oral steroid courses and fewer antibiotics than doctors in Norway and Sweden, whereas doctors in Germany and the Slovak Republic prescribed the least oral steroids and the most antibiotics. Partially, this variation could be explained by differences in the underlying propensity to prescribe, but differences in the use of patient characteristics also contributed to the variation. Norwegian doctors were most inclined to increase the maintenance treatment of inhaled corticosteroids, which could best be explained by their relatively high focus on the patient's peak expiratory flow value. Compared with the gold standard, there was 25-56% under-prescribing of oral steroids, and 21-45% over-prescribing of antibiotics.Conclusions: The variation in treatment of asthma patients between doctors in different countries may, in part, be attributed to variations in the underlying propensity to prescribe, and in part to different use of clinical patient characteristics. These findings can be used in tailoring educational programmes to improve treatment practices. [ABSTRACT FROM AUTHOR]

Background: Non-adherence to recommendations for treatment of uncomplicated urinary tract infections (UTI) is common, but the reasons are not sufficiently understood.Objectives: We aimed to assess and compare the influence of specific patient characteristics on GPs' treatment decisions for UTI in four European countries.Methods: GPs in The Netherlands, Norway, Sweden and Germany were presented 18-26 case vignettes of UTI. Linear regression models were used to determine which patient characteristics predicted non-optimal decisions.Results: Adherence to national recommendations varied both within and between countries, but there were remarkable similarities in the case characteristics predicting non-optimal decisions: a history of UTI and the patient's age were strongly related to prescription of second-choice antibiotics and longer treatment courses.Conclusion: In all countries many GPs were reluctant to follow the recommendations in UTI cases that they might perceive as being more complicated. [ABSTRACT FROM AUTHOR]

The feasibility of studying the decision-making process of physicians with the ‘thinking aloud’ method was tested in a study of 33 physicians. On 2 occasions 3 months apart the study subjects were asked for their management of 2 duplicate sets of 5 patients. On 1 occasion they either had to think aloud when making their decision, or they had to give a retrospective report of their decision-making process. The verbalized thoughts and retrospective reports were analysed to search for different decision-making strategies. In 2 relatively simple cases (women with urinary tract infections), the thinking aloud method showed a decision process with little deliberation about the treatment, suggesting the use of rules-of-thumb or routine behaviour. Thinking aloud during more complex cases (stomach and reflux complaints) showed more comparative and absolute evaluations of possible management and treatment options. This differentiation in strategies did not emerge from the retrospective reports. The inconsistency in the repeated treatment choices was about 27/. Thinking aloud did not significantly increase this inconsistency. It is concluded that thinking aloud is a useful method of analysing treatment decisions. [ABSTRACT FROM PUBLISHER]