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Wermeling PR, Gorter KJ, Stellato RK, de Wit GA, Beulens JW, Rutten GE. Is zesmaandelijkse controle bij type-2-diabetes haalbaar? Huisarts Wet 2015;58(9):462-7. De invloed vergelijken van zesmaandelijkse versus driemaandelijkse controles op de cardiometabole regulatie bij goed gereguleerde patienten met diabetes mellitus type 2 (DM2) in de eerste lijn. Een gerandomiseerd patient-voorkeuronderzoek bij 233 huisartsen en 2215 patienten met een follow-upduur van achttien maanden. Wij includeerden patienten die tussen de 40 en 80 jaar oud waren, minstens een jaar bekend waren met DM2, behandeld werden door hun huisarts, geen insuline kregen voorgeschreven en het afgelopen jaar een goede cardiometabole regulatie hadden (HbA1c ≤ 58 mmol/mol, systolische bloeddruk ≤ 145 mmHg en totaal cholesterol ≤ 5,2 mmol/l). Patienten zonder sterke voorkeur voor de controlefrequentie werden gerandomiseerd naar driemaandelijkse of zesmaandelijkse controles. Primaire uitkomstmaat was het percentage patienten dat een goede regulatie behield. Als maat voor gelijkwaardigheid namen wij een 95%-betrouwbaarheidsinterval (95%-BI) van maximaal –5% tot 5% voor het verschil in het percentage goed reguleerde deelnemers. Secundaire uitkomstmaten waren de afzonderlijke streefwaarden voor HbA1c, systolische bloeddruk en totaal cholesterol, BMI, roken, lichamelijke activiteit, gezondheidstoestand, diabetesgerelateerde zorgen, patienttevredenheid, ervaren hyper- en hypoglykemieen en medicatie. In de driemaandelijkse groep bleef 69,5% onder goede cardiometabole regulatie, in de zesmaandelijkse groep 69,8% (verschil 0,3%; 95%-BI –6,2% tot 6,7%). Dit 95-BI was groter dan het vooraf gepostuleerde gelijkwaardigheidsbereik, dus het blijft onzeker of beide controlefrequenties daadwerkelijk gelijkwaardig zijn. Op de meeste secundaire uitkomstmaten bleken de driemaandelijkse en de zesmaandelijkse frequentie gelijkwaardig. Alleen voor systolische bloeddruk, lichamelijke activiteit en het gebruik van bloeddrukverlagers vielen de betrouwbaarheidsintervallen buiten het gelijkwaardigheidbereik. DM2-patienten die een goede cardiometabole regulatie hebben en die geen voorkeur hebben voor een bepaalde controlefrequentie, hoeven niet per se iedere drie maanden op controle bij de huisarts. Wel is het zaak, vooral de bloeddruk goed te monitoren.

Objective: A patient Web portal allows patients to access their personal health record through the Internet. It may improve diabetes outcomes, but the adoption is unsatisfactory. We examined the differences between patients with and without a login in order to optimize its use. Patients and Methods: A survey was conducted among patients from 62 general practices and one outpatient clinic that all use a diabetes Web portal. Between November 2011 and March 2012 questionnaires were sent to 1,500 patients with and 3,000 patients without a login. Patient groups were stratified according to type of diabetes. Demographic and diabetes-related variables were analyzed with multivariable regression analysis. Results: The total response rate was 67%. Fewer than 50% of the patients did request a login. Among 128 patients with type 1 diabetes mellitus, those with a login (89.8%) were younger and more frequently treated by an internist. In 1,262 patients with type 2 diabetes mellitus, fewer patients had a log-in (41.0%), and the likelihood of having a login was independently associated with younger age, male gender, higher educational level, treatment by an internist, longer duration of diabetes, and polypharmacy (all P

Objective: There is a lack of data on the progression from a healthy obese phenotype toward an unhealthy obese phenotype and the development of metabolic syndrome (MetS). Our aim was to assess the development of MetS 3 years after screening in centrally obese individuals with a healthy obese phenotype and to evaluate the usefulness of repeated screening. Design and Methods: Eighty-eight individuals (mean age 47 years, 88% female) with central obesity as their only MetS component (ATP III criteria) at baseline screening were re-evaluated for MetS status after 3 years. Results: At follow-up, the cardiometabolic risk profile in centrally obese individuals with a healthy phenotype showed a tendency toward deterioration. Thirty-two percent developed at least one additional MetS component, 7% had developed MetS. Nobody had developed type 2 diabetes. An increased triglyceride level (n = 16) and an increased blood pressure (n = 18) were the components most often present at follow-up. The people developing additional MetS components had a lower education level compared with the group that preserved the healthy centrally obese phenotype (80 vs. 71% lower educated, P = 0.35). They also had slightly worse baseline levels of the risk factors. Conclusion: The number of centrally obese individuals developing an unhealthy phenotype in this relatively short follow-up period emphasizes the need for a regular surveillance of cardiometabolic parameters in centrally obese individuals. However, it is questionable whether a repeated screening for type 2 diabetes every 3 years, as recommended by the American Diabetes Association, in this category of patients is appropriate.

Background It is unclear whether people with type 2 diabetes mellitus on insulin monotherapy who do not achieve adequate glycaemic control should continue insulin as monotherapy or can benefit from adding oral glucose-lowering agents to the insulin therapy. Objectives To assess the effects of insulin monotherapy compared with the addition of oral glucose-lowering agents to insulin monotherapy for people with type 2 diabetes already on insulin therapy and inadequate glycaemic control. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and reference lists of articles. The date of the last search was November 2015 for all databases. Selection criteria Randomised controlled clinical trials of at least two months' duration comparing insulin monotherapy with combinations of insulin with one or more oral glucose-lowering agent in people with type 2 diabetes. Data collection and analysis Two review authors independently selected trials, assessed risk of bias, extracted data and evaluated overall quality of the evidence using GRADE. We summarised data statistically if they were available, sufficiently similar and of sufficient quality. We performed statistical analyses according to the statistical guidelines in the Cochrane Handbook for Systematic Reviews of Interventions. Main results We included 37 trials with 40 treatment comparisons involving 3227 participants. The duration of the interventions ranged from 2 to 12 months for parallel trials and two to four months for cross-over trials. The majority of trials had an unclear risk of bias in several risk of bias domains. Fourteen trials showed a high risk of bias, mainly for performance and detection bias. Insulin monotherapy, including once-daily long-acting, once-daily intermediate-acting, twice-daily premixed insulin, and basal-bolus regimens (multiple injections), was compared to insulin in combination with sulphonylureas (17 comparisons: glibenclamide = 11, glipizide = 2, tolazamide = 2, gliclazide = 1, glimepiride = 1), metformin (11 comparisons), pioglitazone (four comparisons), alpha-glucosidase inhibitors (four comparisons: acarbose = 3, miglitol = 1), dipeptidyl peptidase-4 inhibitors (DPP-4 inhibitors) (three comparisons: vildagliptin = 1, sitagliptin = 1, saxagliptin = 1) and the combination of metformin and glimepiride (one comparison). No trials assessed all-cause mortality, diabetes-related morbidity or health-related quality of life. Only one trial assessed patients' treatment satisfaction and showed no substantial differences between the addition of either glimepiride or metformin and glimepiride to insulin compared with insulin monotherapy. Insulin-sulphonylurea combination therapy (CT) compared with insulin monotherapy (IM) showed a MD in glycosylated haemoglobin A1c (HbA1c) of -1% (95% confidence interval (CI) -1.6 to -0.5); P < 0.01; 316 participants; 9 trials; low-quality evidence. Insulin-metformin CT compared with IM showed a MD in HbA1c of -0.9% (95% CI -1.2 to -0.5); P < 0.01; 698 participants; 9 trials; low-quality evidence. We could not pool the results of adding pioglitazone to insulin. Insulin combined with alpha-glucosidase inhibitors compared with IM showed a MD in HbA1c of -0.4% (95% CI -0.5 to -0.2); P < 0.01; 448 participants; 3 trials; low-quality evidence). Insulin combined with DPP-4 inhibitors compared with IM showed a MD in HbA1c of -0.4% (95% CI -0.5 to -0.4); P < 0.01; 265 participants; 2 trials; low quality evidence. In most trials the participants with CT needed less insulin, whereas insulin requirements increased or remained stable in participants with IM. We did not perform a meta-analysis for hypoglycaemic events because the included studies used different definitions.. In most trials the insulin-sulphonylurea combination resulted in a higher number of mild episodes of hypoglycaemia, compared to the IM group (range: 2.2 to 6.1 episodes per participant in CT versus 2.0 to 2.6 episodes per participant in IM; low-quality evidence). Pioglitazone CT also resulted in more mild to moderate hypoglycaemic episodes compared with IM (range 15 to 90 episodes versus 9 to 75 episodes, respectively; low-quality evidence. The trials that reported hypoglycaemic episodes in the other combinations found comparable numbers of mild to moderate hypoglycaemic events (low-quality evidence). The addition of sulphonylureas resulted in an additional weight gain of 0.4 kg to 1.9 kg versus -0.8 kg to 2.1 kg in the IM group (220 participants; 7 trials; low-quality evidence). Pioglitazone CT caused more weight gain compared to IM: MD 3.8 kg (95% CI 3.0 to 4.6); P < 0.01; 288 participants; 2 trials; low-quality evidence. Metformin CT was associated with weight loss: MD -2.1 kg (95% CI -3.2 to -1.1), P < 0.01; 615 participants; 7 trials; low-quality evidence). DPP-4 inhibitors CT showed weight gain of -0.7 to 1.3 kg versus 0.6 to 1.1 kg in the IM group (362 participants; 2 trials; low-quality evidence). Alpha-glucosidase CT compared to IM showed a MD of -0.5 kg (95% CI -1.2 to 0.3); P = 0.26; 241 participants; 2 trials; low-quality evidence. Users of metformin CT (range 7% to 67% versus 5% to 16%), and alpha-glucosidase inhibitors CT (14% to 75% versus 4% to 35%) experienced more gastro-intestinal adverse effects compared to participants on IM. Two trials reported a higher frequency of oedema with the use of pioglitazone CT (range: 16% to 18% versus 4% to 7% IM). Authors' conclusions The addition of all oral glucose-lowering agents in people with type 2 diabetes and inadequate glycaemic control who are on insulin therapy has positive effects on glycaemic control and insulin requirements. The addition of sulphonylureas results in more hypoglycaemic events. Additional weight gain can only be avoided by adding metformin to insulin. Other well-known adverse effects of oral glucose-lowering agents have to be taken into account when prescribing oral glucose-lowering agents in addition to insulin therapy.

Background Early detection and appropriate treatment of metabolic syndrome (MetS) can modify cardiometabolic risk factors and prevent cardiovascular disease. Optimal screening outcomes require follow-up management of MetS. Objective To investigate the natural course of events in the first year after positive screening for MetS in primary care with regard to follow-up behavior, medication prescription and lifestyle changes. Methods Screening of 1721 apparently healthy primary care patients (20-70 years old) detected 473 new MetS cases. These people were asked to contact their general practice for subsequent advice and treatment. Data about follow-up behavior of the screening participants and prescription of cardiovascular medication were collected from the electronic medical file, and changes in lifestyle were collected by the practice nurse. Results Of the 424 participants with screen-detected MetS for whom data about follow-up were available, 306 (72.2%) spontaneously contacted the practice. Antihypertensive, lipid-lowering and blood glucose-lowering medications were prescribed in 21.5%, 21.2% and 1.9% of the participants, respectively. Half of the participants for whom data about self-reported lifestyle changes were available reported to have increased their physical activity; 16.9% of the smokers quit smoking. Average weight loss was 2.1kg. Conclusions Screening for MetS followed by the advice to contact the general practice for lifestyle counseling and treatment had a substantial spontaneous follow-up. Although the changes in physical activity, weight loss and smoking abstinence are promising, further research will have to demonstrate whether they are sustainable.

S Van Avendonk MJP, Gorter KJ, Van den Donk M, Van Haeften TW, Rutten GEHM. SU-derivaten bij starten insuline: toch maar stoppen? Huisarts Wet 2012;55(4):152-8.

Gorter KJ, Tuytel GH, De Leeuw RRJ, Rutten GEHM. Huisarts of ketenzorg: wat wilde de diabetespatient? Huisarts Wet 2011;54(5):238–43.

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 LATIs. 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. (C) 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 >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 >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 >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.

A picture of a human figure (manikin) on which pain can be indicated can be used to measure musculoskeletal pain in self administered or web-based questionnaires. In this paper we present an analysis of the agreement between pain reported on a manikin and pain reported using written questions as assessed in the follow-up questionnaire of the Dutch population-based Musculoskeletal Conditions and Consequences Cohort (DMC(3)-study). Both a manikin and extensive questions on pain were included and the agreement between the two measures was studied for nine pain locations. For a similar pain definition - pain lasting at least a week - the manikin gave slightly higher prevalences than the written questions. Around three quarter of those who reported pain on the written questionnaire also indicated pain on the manikin on the same anatomical location. There were no differences in the percentage of agreement by sex, age group or level of education, except for a lower percentage of agreement of the manikin among the elderly for pain in the lower extremities, neck and shoulder and among the lower level of education group for neck pain. Almost 6% of the participants reported pain according to the questions only and more than 10% (especially men) reported pain on the manikin only. We concluded that a manikin gives similar findings on prevalence of pain as written questions and could therefore be a good alternative for written questions only.

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 (€1,415, P = NS), resulting in an ICER of €38,243 per QALY gained. The likelihood of cost-effectiveness given a willingness-to-pay threshold of €20,000 per QALY gained is 30%. DCP had a more favorable effect on CVD+ patients (ICER = €14,814) than for CVD− patients (ICER = €121,285). Coronary heart disease costs were reduced (€−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.

Janssen P, Gorter K, Stolk R, Rutten G. Screening op diabetes mellitus type 2 in de huisartsenpraktijk. Tijdschr praktijkonderst 2009;4:126-31.

van Bruggen R, Gorter K, Stolk R, Klungel O and Rutten G. Clinical inertia in general practice: widespread and related to the outcome of diabetes care. Family Practice 2009; 26: 428–436. Background and aims. Clinical inertia is considered a major barrier to better care. We assessed its prevalence, predictors and associations with the intermediate outcomes of diabetes care. Materials and methods. Baseline and follow-up data of a Dutch randomized controlled trial on the implementation of a locally adapted guideline were used. The study involved 30 general practices and 1283 patients. Treatment targets differed between study groups [HbA1c < 8.0% and blood pressure (BP) < 140/85% versus HbA1c < 8.5% and BP < 150/85]. Clinical inertia was defined as the failure to intensify therapy when indicated. A complete medication profile of all participating patients was obtained. Results. In the intervention and control group, the percentages of patients with poor diabetes or lipid control who did not receive treatment intensification were 45% and 90%, approximately. More control group patients with BP levels above target were confronted with inertia (72.7% versus 63.3%, P < 0.05). In poorly controlled hypertensive patients, inertia was associated with the height of systolic BP at baseline [adjusted odds ratio (OR) 0.98, 95% confidence interval (CI) 0.98–0.99] and the frequency of BP control (adjusted OR 0.89, 95% CI 0.81–0.99). If a practice nurse managed these patients, clinical inertia was less common (adjusted OR 0.12, 95% CI 0.02–0.91). In both study groups, cholesterol decreased significantly more in patients who received proper treatment intensification. Conclusion. GPs were more inclined to control blood glucose levels than BP or cholesterol levels. Inertia in response to poorly controlled high BP was less common if nurses assisted GPs.

Aims Erectile dysfunction (ED) prevalence is usually based on questionnaires, too elaborate for daily practice. The single question for ED prevalence is unknown. Literature reports an independent association between ED and both cardiovascular disease (CVD) and diabetes. Whether routinely asking men with Type 2 diabetes (DM2) about ED identifies those at elevated risk for CVD is unknown. We assessed cardiovascular risk of DM2 men with ED. Design and Methods This was a cross-sectional study in primary care. During annual check-up, the practice nurse asked 1823 DM2 men: "Do you have erection problems? Yes/no." ED prevalence rate was calculated. Age, medication, and other known factors associated with ED and/or CVD were used in univariate analysis (odds ratio [OR], Student's t test, and Mann–Whitney test). This revealed confounding variables used in the multivariable analysis. The association between ED and history of cardiovascular disease (HCVD) was assessed by logistic regression analysis. In patients with no HCVD, we assessed the association between ED and 10-year United Kingdom Prospective Diabetes Study (UKPDS) coronary heart disease risk by linear regression analysis. Results The prevalence of ED in DM2 patients was 41.3%. There was no independent association between ED and HCVD [adjusted OR, 1.2 (95% CI, 0.9–1.5)]. The 10-year UKPDS CHD risk difference between men with and without ED was 5.9% (95% CI, 3.2–8.7), but after adjustment for age, this association disappeared [adjusted risk difference, 0.6% (95% CI, −1.5 to 2.7)]. Conclusion The ED prevalence rate assessed by a single question was comparable to that assessed by questionnaires. ED neither did independently relate to patients' cardiovascular history nor to cardiovascular risk.

OBJECTIVE Type 2 diabetes is known to be associated with decrements in memory and executive functions and information-processing speed. It is less clear, however, at which stage of diabetes these cognitive decrements develop and how they progress over time. In this study, we investigated cognitive functioning of patients with recent screen-detected type 2 diabetes, thus providing insight into the nature and severity of cognitive decrements in the early stage of the disease. Possible risk factors were also addressed. RESEARCH DESIGN AND METHODS Included in this study were 183 diabetic patients from a previously established study cohort and 69 control subjects. A full neuropsychological assessment, addressing six cognitive domains, was made for each participant. Raw test scores were standardized into z scores per domain and compared between the groups. Possible risk factors for cognitive decrements were examined with multivariate linear regression. RESULTS Relative to scores for the control group, mean z scores were between 0.01 and 0.2 lower in the diabetic group across all domains, but after adjustment for differences in IQ between patients and control subjects, only memory performance was significantly reduced (mean difference −0.15 [95% CI −0.28 to −0.03]). A history of macrovascular disease and current smoking were significant determinants of slower information-processing speed in patients with diabetes. CONCLUSIONS This study shows that modest cognitive decrements are already present at the early stage of type 2 diabetes. A history of macrovascular disease and smoking are significant risk factors for some early decrements.

Objectives To determine the feasibility of population-based screening for metabolic syndrome (MetS) in primary care with self-measurement of waist circumference (WC) as first step, and the prevalence of MetS in a Dutch city. Methods A survey of 14,000 people on the list of primary care physicians in the city of IJsselstein. All adults between 20 and 70 years on July 1st, 2006 were asked to measure their WC using a mailed tape measure. Participants with a high WC (> 88/102 cm for women/men) were invited for assessment of other factors defining MetS. For patients already known with cardiovascular risk factors, these data were collected from medical records. Results 11,862 subjects were invited, of whom 6843 (58%) measured their WC. 2004 had a WC > 88/102 cm and 1721 participated in all examinations. In 473 MetS was detected. The sensitivity of the screening was 77%, the negative predictive value 96%. The prevalence of MetS, including patients known with cardiovascular risk factors, was 15.5%. Conclusions A primary care physician-driven population screening with self-measurement of WC can identify adults with MetS. The estimated prevalence of MetS is 15.5%. This procedure creates possibilities for targeted screening, prevention and treatment of people who are at increased cardiovascular risk.

Aim Because Dutch health care organisations did want to establish well-defined diabetes shared care groups, we investigated the organisation of insulin therapy in general practice in the Netherlands and assessed factors that were associated with providing insulin therapy in type 2 diabetes (DM2) patients. Methods Questionnaire to half of the Dutch general practitioners (GPs) ( n =3848). We compared GPs who both start insulin treatment and monitor the dosages with those who always refer patients requiring insulin therapy or only monitor insulin dosages. Results Total response was 42% ( n =1621). 67% of the GPs start insulin therapy in patients with DM2, especially male GPs and those above the age of 40, as well as GPs working in a health centre and those working together with a practice nurse. GPs working in urban regions less often start insulin. The most often mentioned barriers for starting and/or monitoring insulin therapy are lack of knowledge of insulin therapy, lack of time and insufficient financial incentives. Conclusion This nation-wide overview shows that insulin therapy is no longer a secondary care based activity. However, there is still need to enlarge the practice staff and to overcome the perceived skills deficit.

Objective:To describe the osteoarthritis study population of CHECK (Cohort Hip and Cohort Knee) in comparison with relevant selections of the study population of the Osteoarthritis Initiative (OAI) based on clinical status and radiographic parameters.Methods:In The Netherlands a prospective 10-year follow-up study was initiated by the Dutch Arthritis Association on participants with early osteoarthritis-related complaints of hip and/or knee: CHECK. In parallel in the USA an observational 4-year follow-up study, the OAI, was started by the National Institutes of Health, on patients with or at risk of symptomatic knee osteoarthritis. For comparison with CHECK, the entire cohort and a subgroup of individuals excluding those with exclusively hip pain were compared with relevant subpopulations of the OAI.Results:At baseline, CHECK included 1002 participants with in general similar characteristics as described for the OAI. However, significantly fewer individuals in CHECK had radiographic knee osteoarthritis at baseline when compared with the OAI (pConclusion:Although both cohorts focus on the early phase of osteoarthritis, they differ significantly with respect to structural (radiographic) and clinical (health status) characteristics, CHECK expectedly representing participants in an even earlier phase of disease.

In diabetes care, knowledge about what is achievable in primary and secondary care is important. There is a need for an objective method to assess the quality of care in different settings. A quality-of-care summary score has been developed based on process and outcome measures. An adapted version of this score was used to evaluate diabetes management in different settings.To evaluate the quality of diabetes management in primary and secondary care in a defined geographic region in the Netherlands, using a quality score.Cross-sectional study.Thirty general practices in the Netherlands.A study of 2042 patients with type 2 diabetes (1640 primary care and 402 secondary care) was conducted. Quality of diabetes management was assessed by a score of process and outcome indicators (range 0-40). Clustering at practice level and differences in patient characteristics (case mix) were taken into account.At the outpatient clinic, patients were younger (mean age 64.1 years, standard deviation (SD)=12.5 years, versus mean age 67.1 years, SD=11.7, P0.001), had more diabetes-related complications (macrovascular: 39.7% versus 24.3%, P0.001; and microvascular: 25.9% versus 7.3%, P0.001), and lower quality-of-life scores (EuroQol-5D: mean=0.60, SD=0.29, versus mean=0.80, SD=0.21, P0.001). After adjusting for case mix and clustering, there was a weak association between the setting of treatment and haemoglobin A1c (primary care: mean 7.1%, SD=1.1, versus secondary care: mean 7.6%, SD=1.2, P0.016), and between setting and systolic blood pressure (primary: mean 145.7 mmHg, SD=19.2, versus secondary care: 147.77 mmHg, SD 21.0, P0.035). Quality-of-care summary scores in primary and secondary care differed significantly, with a higher score in primary care (mean 19.6, SD=8.5 versus, mean 18.1, SD=8.7, P0.01). However, after adjusting for case mix and clustering, this difference lost significance.GPs and internists are treating different categories of patients with type 2 diabetes. However, overall quality of diabetes management in primary and secondary care is equal. There is much room for improvement. Future guidelines may differentiate between different categories of patients.

OBJECTIVE—The aim of this study was to assess the short-term effects of an educational program on (determinants of) self-reported health-seeking behavior for infections of the urinary tract (UTIs) and lower respiratory tract (LRTIs) in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS—In a randomized controlled trial, 1,124 patients with type 2 diabetes aged between 44 and 85 years participated. The intervention consisted of a multifaceted educational program with an interactive meeting, a leaflet, a Web site, and a consultation with the diabetes care provider. The program focused on the needs of patients, apparent from a prior focus group and questionnaire study. The primary outcome measure was an indicator of health-seeking behavior for UTIs and LRTIs, defined as the proportion of participants with a positive score on at least seven of nine determinants, six from the Health Belief Model and the additional three domains of knowledge, need for information, and intention. The primary outcome was measured with questionnaires at baseline and after 5 months. RESULTS—Complete outcome data were available for 468 intervention group patients and 472 control group patients. In all, 68% of the intervention group patients attended the meeting. At baseline, 28% of the participants from the intervention group had a positive score on seven of the nine determinants, compared with 27% from the control group. After the educational program, these percentages were 53 and 32%, respectively (P < 0.001). CONCLUSIONS—Our educational program positively influenced determinants of health-seeking behavior for common infections in patients with type 2 diabetes.

Purpose Anecdotal evidence suggests that antidepressants (ADs) may complicate glycaemic control. The objective of this longitudinal study was to investigate the influence of ADs on glycaemic control within diabetes patients. Methods From the pharmacy registry database PHARMO, we selected insulin users who did not use oral antidiabetics. The study population comprised: 133 patients with at least 12 months insulin use before and 6 months during an AD episode, including 56 patients with an additional 6 months of insulin use after the AD episode; 180 patients with 24 months insulin use without an AD episode. Glycaemic control was measured as the amount of insulin used, which was calculated intra-individually in 3-month periods. We stratified for selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs). Results Mean age (s.d.) of the subjects was 53.9 (19) years; 46.9% were men. Overall, the amount of insulin used did not change during or after AD use. No-AD users showed an increase of 16% in amount of insulin used over a period of 2 years (p

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.

This study investigated whether the association between depression and diabetes was influenced by the presence of chronic somatic disease. To distinguish between depression and other psychosocial complaints, we studied the onset of diabetes in antidepressant (AD) users and benzodiazepine (BD) users, respectively. From the PHARMO database, which includes complete drug prescription data, we identified subjects using (i) no ADs and no BDs; (ii) AD but no BD; (iii) BD but no AD; and (iv) AD and BD. A total of 60 516 individuals (age: 45.5+/-17 years; 42.1% men) were followed from their first prescription for AD or BD until end of registration or a first prescription for antidiabetic drugs. The crude incidence rate in AD but no BD users was not increased compared with no AD and no BD users. After adjustment for age, sex and chronic diseases, the hazard ratios (95% confidence interval) were 1.05 (0.88-1.26) for AD but no BD users, 1.21 (1.02-1.43) for BD but no AD users and 1.37 (1.12-1.68) for AD and BD users compared with no AD and no BD users. We did not find an increased risk of diabetes in individuals using ADs. The association between BD use and diabetes was partly explained by chronic somatic comorbidity.

Aim The EUCCLID study aims to compare the quality of type 2 diabetes (DM2) care and the prevalence of complications in primary care DM2 patients in Europe. Design A cross-sectional survey consisting of three parallel studies: (1) study on actual clinical practice; (2) study on patient's perspective of diabetes care; (3) study on general practitioner's perspective of diabetes care. Methods Patients will be randomly selected from a list of all patients known to the participating GPs with DM2 for whom the GP is the main diabetes care provider. Exclusion criteria will include people with type 1 diabetes mellitus, diabetes of pregnancy, serious mental illness, unable to complete a questionnaire in national language or unable to give written informed consent. Approximately 12,000 patients will be included. Participants will have a detailed medical history and anthropometric measurements, blood and urine will be collected and questionnaires will be taken. Endpoints will include quality indicators of clinical DM2 care, prevalence of diabetic complications, knowledge, attitudes, barriers and behaviour affecting good control in DM2 patients, quality of life and patients' satisfaction with diabetes care. We will also determine primary care physician's attitudes, behaviour and perception of barriers to deliver effective diabetes care.

Aim To determine the acceptability of an educational leaflet regarding the prevention and treatment of infections of the lower respiratory tract (LRTIs) and urinary tract (UTIs) and to determine the effects of the leaflet on knowledge and attitude of DM2 patients in primary care. Method In a randomized controlled intervention trial 200 DM2 patients enlisted in two practices, one urban and one rural, from the Utrecht general practitioners Research Network (HNU) were selected. Per practice, 50 patients were randomly assigned to the intervention group and 50 to the control group. The intervention was a leaflet on diabetes and LRTIs and UTIs based on the results of focus group interviews. The leaflet was sent to the patients homes. The outcome measures were acceptability of the leaflet and differences in knowledge and attitude, measured by a questionnaire. Results The mean age was 68 years and 55% was male. There were no substantial differences in characteristics between the two groups. Among the intervention group, the leaflet was appreciated as understandable (100%) and inviting (79%). Compared to the control group, specific knowledge and attitude did not substantially differ. Patients in the intervention group had a slightly more positive attitude about ‘being attentive to signs indicating pneumonia' (median difference, 1 point; p =.003) and they also answered ‘UTI is mostly caused by a bacteria' more often correctly (risk difference, 18%; 95% CI, 4–33%, p =.016). Conclusion A leaflet on prevention and treatment of LRTIs and UTIs is considered acceptable among DM2 patients, but a multi-faceted educational approach may be needed to improve health behavioral determinants.

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/m 2 ) 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.

Background Type 2 diabetes is an important, chronic condition notorious for its costly and disabling complications. Nowadays, enhanced cooperation is expected to improve the quality of diabetes care and reduce risks for chronically ill patients. It is, however, questionable whether this assumption is evidence based. Methods Using a structured literature search, we selected systematic reviews, randomised controlled trials (RCTs) and other effect evaluations regarding the sharing and allocation of diabetes care. Results We selected 22 studies to include in this review. The process of care improved in all studies investigating this quality aspect. HbA1c improved in seven reviews and in five other studies. All included reviews and four RCTs were unable to demonstrate a positive effect on blood pressure. Total cholesterol improved in two reviews and five other studies. Conclusions The sharing and allocation of diabetes care leads to significant reduction in HbA1c and improves the process of care. However, this improvement has not as yet led to better cardiovascular risk management. For a number of reasons, a truly accurate estimation of the results of shared and allocated diabetes care within the Dutch diabetes care system is not possible.

To investigate if disturbed glucose homeostasis or known diagnosis of diabetes was associated with depressive symptoms. The reason for the increased prevalence of depression in patients with Type 2 diabetes mellitus (DM2) is unknown.Within the Utrecht Health Project, an ongoing longitudinal study among inhabitants of a residential area of a large city in The Netherlands, 4747 subjects (age: 39.4 +/- 12.5 years) were classified into four mutually exclusive categories: normal fasting plasma glucose (FPG) (5.6 mmol/l), impaired FPG (or =5.6 and7.0 mmol/l), undiagnosed DM2 (FPGor =7.0 mmol/l), and diagnosed DM2. Presence of depressive symptoms was defined as a score ofor =25 on the depression subscale of the Symptom Check List (SCL-90) or self-reported use of antidepressants.Diagnosed DM2 was associated with an increased risk of depressive symptoms (odds ratio (OR) = 1.69; 95% confidence interval (CI) 1.06-2.72) after adjustment for demographic and lifestyle variables. Additional adjustment for number of chronic diseases reduced the OR to 1.36 (95% CI 0.83-2.23). Impaired fasting glucose and undiagnosed DM2 were not associated with depressive symptoms.Our findings suggest that disturbed glucose homeostasis is not associated with depressive symptoms. The increased prevalence of depressive symptoms among patients with diagnosed DM2 suggests that depressive symptoms might be a consequence of the burden of diabetes. The number of chronic diseases seems to explain part of the association between DM2 and depressive symptoms.

OBJECTIVE—The objective of this study was to investigate how time since diagnosis and treatment intensity influence psychological outcomes in patients with screen-detected type 2 diabetes.RESEARCH DESIGN AND METHODS—A 2 × 2 factorial cross-sectional design was used to examine psychological outcomes in 196 patients with screen-detected diabetes diagnosed 3–33 months previously who were receiving usual care or intensive multifactorial pharmacological treatment. Outcomes included anxiety, depression, diabetes-related distress, perceived seriousness and vulnerability, self-efficacy, and self-care. Multivariate analysis was used to examine variations in outcomes based on time since diagnosis (RESULTS—Most patients reported little distress, low perceived seriousness and vulnerability, high self-efficacy, and low self-care, but outcomes varied considerably across conditions. Time effects were found for perceived vulnerability, which increases significantly with time since diagnosis. Time × treatment interactions were found for anxiety, diabetes-related distress, and self-efficacy; notably, intensively treated patients showed more distress and less self-efficacy in the 1st year, and usual-care patients reported more distress and less self-efficacy 2–3 years after diagnosis.CONCLUSIONS—Screen-detected patients generally do not experience much difficulty with their condition in the first few years, but early and intensive treatment can influence patients’ psychological outcomes, leading to relatively more anxiety and less self-efficacy in the 1st year after diagnosis but not necessarily improving self-care. This suggests that intensive treatments confront patients with their diabetes earlier on whereas milder treatments may delay confrontation. This finding should be taken into account in the development and timing of psychological interventions for patients with newly diagnosed diabetes.

Gorter KJ. Alledaagse voetproblemen: de behandeling. Huisarts Wet 2003;46(7):392-5. Veel mensen bezoeken hun huisarts voor alledaagse voetproblemen. De meeste problemen ontstaan door mechanische overbelasting; rust, geduld en goede schoenen zijn dan belangrijke interventies. De meeste behandelingen zijn niet gebaseerd op wetenschappelijk bewijs, maar op praktische ervaring of consensus. Voor veel voetproblemen kan de huisarts een gerichte behandeling geven. Indien het dan niet lukt het probleem voldoende op te lossen, kan veelal een verwijzing binnen de eerste lijn volstaan. In algemene zin bepaalt de ‘vervormbaarheid’ van de voet naar wie de huisarts moet verwijzen. Een patient met een soepele en corrigeerbare voet kan in eerste instantie naar een podotherapeut worden verwezen; een patient met een structureel afwijkende en niet-corrigeerbare voet zal meer baat hebben bij een orthopedisch schoentechnicus. In zeldzame gevallen is verwijzing naar een medisch specialist aangewezen.

Aim To investigate effectiveness and cost-effectiveness of 6-monthly monitoring compared with 3-monthly monitoring of well-controlled type 2 diabetes patients in primary care. Methods A pragmatic randomised controlled patient-preference equivalence trial was performed. From April 2009 to August 2010, 2215 patients from 233 general practitioners across the Netherlands were included. Patients were eligible if between 40- and 80-years-old, diagnosed with type 2 diabetes for more than a year, treated by their general practitioner, not on insulin treatment and well-controlled during the last year (HbA1c ≤58 mmol/mol, systolic blood pressure ≤145 mmHg and total cholesterol ≤5.2 mmol/l). Patients without a strong preference for their monitoring frequency were randomised to 3-monthly or 6-monthly monitoring. Follow-up was 18 months. The primary outcome is the percentage of patients remaining under: HbA1c ≤58 mmol/mol, systolic blood pressure ≤145 mmHg and total cholesterol ≤5.2 mmol/l. Equivalence was assumed if the two-sided 95% confidence interval (CI) was between −5 and 5%. Cost-effectiveness was determined using a cost-minimisation analysis. Results In the 3-monthly group 69.5% remained under good cardiometabolic control, versus 69.8% in the 6-monthly group (difference: 0.3%; 95%CI: −6.2–6.7%). All secondary outcomes were equivalent for 3-monthly and 6-monthly monitoring, except the systolic blood pressure target, physical activity and antihypertensive drug use. Six-monthly monitoring was €387 (£333) cheaper per patient compared to 3-monthly monitoring during the study period. Conclusions Patients with good cardiometabolic control and without preference for their monitoring frequency can visit the primary care physician less often. The cost-savings can be considerable.

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 A1C 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.

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 61–77years) with a recent ACE. One focus group with partners (67% male, aged 64–75years) 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.

Background Type 2 diabetes mellitus patients with an acute coronary event (ACE) experience decreased quality of life and increased distress. According to the American Diabetes Association, discharge from the hospital is a time of increased distress for all patients. Tailored support specific to diabetes is scarce in that period. We developed an intervention based on Bandura’s Social Cognitive Theory, Leventhal’s Common Sense Model, and results of focus groups. The aim of this study is to evaluate the effectiveness of the intervention to reduce distress in type 2 diabetes patients who experienced a first ACE. Methods Randomised controlled trial. Two hundred patients are recruited in thirteen hospitals. A diabetes nurse visits the patients in the intervention group (n = 100) at home within three weeks after discharge from hospital, and again after two weeks and two months. The control group (n = 100) receives a consultation by telephone. The primary outcome is diabetes-related distress, measured with the Problem Areas in Diabetes (PAID) questionnaire. Secondary outcomes are well-being, health status, anxiety, depression, HbA1c, blood pressure and lipids. Mediating variables are self-management, self-efficacy and illness representations. Outcomes are measured with questionnaires directly after discharge from hospital and five months later. Biomedical variables are obtained from the records from the primary care physician and the hospital. Differences between groups in change over time are analysed according to the intention-to-treat principle. The Holm-Bonferroni correction is used to adjust for multiplicity. Discussion Type 2 diabetes patients who experience a first ACE need tailored support after discharge from the hospital. This trial will provide evidence on the effectiveness of a supportive intervention in reducing distress in these patients. Trial registration NCT01801631

Aims To examine experiences of primary care providers with six-monthly diabetes monitoring of well-controlled patients. Methods This study was part of the EFFIMODI study, examining whether six-monthly monitoring of well-controlled (HbA1c ≤58 mmol/mol, systolic blood pressure ≤145 mmHg and total cholesterol ≤5.2 mmol/l) type 2 diabetes patients results in equivalent cardiometabolic control compared to three-monthly monitoring. Primary care providers completed a questionnaire about their experiences with six-monthly diabetes monitoring, whether they want to continue six-monthly monitoring and for which type of patients six-monthly monitoring is sufficient. Results Of 163 questionnaires, 157 (96.3%) were completed and returned. Only 14 (8.9%) primary care providers were negative about the six-monthly monitoring and 102 (65.0%) would like to continue six-monthly monitoring. Primary care providers disagreed about patients’ ability to determine their own monitoring frequency and whether six-monthly monitoring was suitable for all well-controlled type 2 diabetes patients. Practical concerns emerged such as the inability to declare healthcare costs and the unsuitability of electronic health record systems. Conclusions Almost two out of three primary care providers would like to continue six-monthly monitoring of well-controlled type 2 diabetes patients. However, some diabetes care providers should be convinced and some practical concerns should be solved.

Background Foot pain is a common problem for people aged 50 and over and occurs more often in women than in men. About 60% of the foot problems are forefoot problems and slightly more than half of these patients seek medical help, mainly in the form of podiatric care. Podiatric treatment of forefoot problems is known to be heterogeneous. The aims of the present study are to describe the podiatric treatment of patients with forefoot pain and to evaluate the podiatric examination and treatment using an expert panel. Method We invited twenty-five randomly selected subjects with forefoot problems who had received podiatric treatment in a pragmatic randomised clinical trial to participate in an analysis of their treatment by an expert panel. The panel retrospectively established the cause of the foot problem as well as the therapeutic goals and evaluated the treatment. These findings were compared to those reported by the treating podiatrist. Results Two fundamentally different approaches were found in approach of podiatric examination; a functional approach (n =13) and a non-functional approach (n =12). In nine cases the expert panel agreed with the cause recorded by the podiatrist. In five other cases the expert panel concluded that the treatment of the podiatrist was not consistent with the cause of the problem recorded by the podiatrist. Of the 10 patients for whom the podiatrist had recorded to have given shoe advice, only two were able to recollect the proper advice. Three patients did not remember receiving advice at all. Conclusion In this study almost half of the podiatrists worked according to a non-functional approach where the other half (like the expert panel) chose a functional strategy that analyses the underlying problem. Fundamental differences in treatment plans and thus heterogeneous treatments could be a consequence.

Diabetes mellitus is a progressive disorder of glucose metabolism. It is estimated that about 285 million people between the ages of 20 and 79 years had diabetes worldwide in 2010, or 5% of the adult population. Type 2 diabetes may occur with obesity, hypertension, and dyslipidaemia (the metabolic syndrome), which are powerful predictors of cardiovascular disease. Without adequate blood-glucose-lowering treatment, blood glucose levels may rise progressively over time in people with type 2 diabetes. Microvascular and macrovascular complications may develop.We conducted a systematic review and aimed to answer the following clinical question: What are the effects of blood-glucose-lowering medications in adults with type 2 diabetes? We searched: Medline, Embase, The Cochrane Library, and other important databases up to February 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).We found 194 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.In this systematic review we present information relating to the effectiveness and safety of the following interventions: alpha-glucosidase inhibitors (AGIs), combination treatment (single, double, and triple), dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) analogues, insulins (including conventional [human] and analogue, different regimens, different length of action), meglitinides, metformin, sulphonylureas, and thiazolidinediones.

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.

SummaryType 2 diabetes (T2DM) is associated both with cognitive decrements and depressive symptoms. Since depression in itself has been associated with cognitive decrements we aimed to investigate the influence of depressive symptoms on the relation between T2DM and cognitive functioning.Data were derived from three independent studies on cognitive functioning in patients with T2DM (n=366) and controls without diabetes (n=204), two with longitudinal and one with only cross-sectional assessments. Depressive symptoms were measured with self-report inventories (CES-D or BDI-II). The composite z-score of the domains memory, information-processing speed, and attention and executive function was the primary cognitive outcome measure. Mixed linear regression analyses were used in a stepped approach to compare cognitive functioning between (1) patients with T2DM and controls (cross-sectionally and longitudinally), (2) participants with and without depressive symptoms, separately for patients and controls, and (3) patients and controls after adjustment for depressive symptoms. In addition the mediating effect of depressive symptoms was assessed with a bootstrapping technique.Depressive symptoms were present in 11% of the patients with T2DM and in 7% of controls (p=0.15). Cognitive performance in patients with T2DM was worse than in controls (overall difference composite z-score −0.13). However, T2DM was not associated with accelerated cognitive decline over three years of follow-up relative to controls. Controls with depressive symptoms performed worse than those without depressive symptoms, although not statistically significant. Performance in patients with T2DM with and without depressive symptoms was similar. Adjustment for depressive symptoms and estimation of the mediating effect showed that the difference between patients and controls was not mediated by depressive symptoms.In conclusion, the modest cognitive decrements that are associated with T2DM are not due to the presence of mild depressive symptoms.

Computerized decision support systems (CDSSs) are often part of a multifaceted intervention to improve diabetes care. We reviewed the effects of CDSSs alone or in combination with other supportive tools in primary care for type 2 diabetes mellitus (T2DM).A systematic literature search was conducted for January 1990-July 2011 in PubMed, Embase, and the Cochrane Database and by consulting reference lists. Randomized controlled trials (RCTs) in general practice were selected if the interventions consisted of a CDSS alone or combined with a reminder system and/or feedback on performance and/or case management. The intervention had to be compared with usual care. Two pairs of reviewers independently abstracted all available data. The data were categorized by process of care and patient outcome measures.Twenty RCTs met inclusion criteria. In 14 studies a CDSS was combined with another intervention. Two studies were left out of the analysis because of low quality. Four studies with a CDSS alone and four studies with a CDSS and reminders showed improvements of the process of care. CDSS with feedback on performance with or without reminders improved the process of care (one study) and patient outcome (two studies). CDSS with case management improved patient outcome (two studies). CDSS with reminders, feedback on performance, and case management improved both patient outcome and the process of care (two studies).CDSSs used by healthcare providers in primary T2DM care are effective in improving the process of care; adding feedback on performance and/or case management may also improve patient outcome.

Objective. To describe the relationship between comorbidity (absolute number as well as the presence of specific comorbidities) and pain, physical functioning and mental health status of participants with early symptomatic OA of the hip or knee. Methods. In the Netherlands, a prospective 10-year follow-up study was initiated by the Dutch Arthritis Association in participants with early symptomatic OA of the hip or knee: CHECK (Cohort Hip and Cohort Knee), which consists of 1002 individuals. At baseline, linear regression analysis was used to determine the influence of comorbidity on the outcome variables: Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain, WOMAC physical functioning, Medical Outcomes Study Short Form 36 (SF-36) Physical Component Summary and Mental Component Summary. Results. Of 979 subjects, 67% reported one or more comorbidities. After controlling for age, gender, social status and severity of radiographic OA (Kellgren and Lawrence score), back disorders have the largest effect on WOMAC pain and physical functioning, and one of the largest effects on physical status of SF-36, besides obesity. Mental status was negatively influenced by the additional presence of duodenal ulcer, thyroid disease, and migraine or chronic headache. Conclusion. In early stage of OA, the presence of additional problems in the musculoskeletal system and of obesity have a negative effect on pain and physical health status. Also mental status is affected in early symptomatic OA by the presence of specific comorbidities. Comorbidity should be assessed and treated to improve the burden of illness in patients with early symptomatic OA.

Aims To investigate the impact of the UKPDS risk engine on management of CHD risk in T2DM patients. Methods Observational study among 139 GPs. Data from 933 consecutive patients treated with a maximum of two oral glucose lowering drugs, collected at baseline and after twelve months. GPs estimated the CHD risk themselves and afterwards they calculated this with the UKPDS risk engine. Under- and overestimation were defined as a difference >5 percentage points difference between both calculations. The impact of the UKPDS risk engine was assessed by measuring differences in medication adjustments between the over-, under- and accurately estimated group. Results In 42.0% the GP accurately estimated the CHD risk, in 32.4% the risk was underestimated and in 25.6% overestimated. Mean difference between the estimated (18.7%) and calculated (19.1%) 10 years CHD risk was −0.36% (95% CI −1.24 to 0.52). Male gender, current smoking and total cholesterol level were associated with underestimation. Patients with an subjectively underestimated CHD risk received significantly more medication adjustments. Their UKPDS 10 year CHD risk did not increase during the follow-up period, contrary to the other two groups of patients. Conclusions The UKPDS risk engine may be of added value for risk management in T2DM.

Accumulation of advanced glycation end products (AGEs) is enhanced by chronic hyperglycemia and oxidative stress and this process may contribute to the pathogenesis of vascular disease. Skin autofluorescence (AF), a measure of accumulation of AGEs in skin collagen, is associated with vascular disease in patients with diabetes. Because central obesity enhances oxidative stress people with central obesity might already have increased accumulation of AGEs before diabetes or cardiovascular disease become manifest. To test this hypothesis, we compared the distribution of skin AF and its association with clinical and biochemical parameters in individuals with and without central obesity. Skin AF was measured by a validated AGE Reader in 816 persons with and 431 persons without central obesity, aged 20–70 y. Mean skin AF increased with age and smoking and was higher in centrally obese individuals compared with non-obese individuals (p = 0.001, after adjustment for age and smoking p = 0.13). Mean skin AF in the subgroups without central obesity and without other risk factors (n = 106), central obesity without other risk factors (n = 74) and central obesity with other risk factors (n = 742) was 1.63 ± 0.37, 1.74 ± 0.44 and 1.87 ± 0.43 AU, respectively (p for trend < 0.001, after adjustment for age and smoking p for trend = 0.12). In the group with central obesity age, current smoking, alcohol consumption, waist circumference, creatinine clearance and hs-CRP were independently associated with skin AF (R2 = 29.4%). Waist circumference hardly contributed to the explained variance. The relationship between waist circumference and skin AF is not as obvious as we hypothesized.

Objective To describe the preferences and the associated patients’ characteristics of well-controlled type 2 diabetes patients for the diabetes monitoring frequency in primary care. Methods Cross-sectional study with 233 participating general practitioners across the Netherlands. Eligible patients were between 40 and 80 years, diagnosed with type 2 diabetes for more than 1 year not on insulin, and with glycated hemoglobin (A1C) ≤7.5%, systolic blood pressure ≤145 mm Hg and total cholesterol ≤5.2 mmol/L. Participants were asked whether they had a preference for 3-monthly or 6-monthly monitoring or no preference. Results From 2215 patients, 747 patients (33.7%) preferred 3-monthly and 677 (30.6%) 6-monthly monitoring by either the general practitioner or the practice nurse. The former group consisted of less smokers, felt less healthy, reported more diabetes-related distress, had the highest reported frequency of hyperglycemic episodes and used more oral blood glucose lowering drugs compared to the other patients. Those preferring 6-monthly monitoring were least satisfied with diabetes treatment, reported the lowest frequency of hyperglycemic episodes and used less oral blood glucose lowering drugs compared to the other patients. Conclusion A preference for more frequent monitoring was associated with a worse disease status, whereas a preference for less frequent monitoring tended to be associated with the opposite. Patients seem to have logical preferences that need to be accounted for in diabetes care.

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.

Background Foot problems in general and forefoot problems in particular can lead to a decrease in mobility and a higher risk of falling. Forefoot problems increase with age and are more common in women than in men. Around 20% of people over 65 suffer from non-traumatic foot problems and 60% of these problems are localised in the forefoot. Little is known about the best way to treat forefoot problems in older people. The aim of this study is to compare the effects of two common modes of treatment in the Netherlands: shoe advice and podiatric treatment. This paper describes the design of this study. Methods The study is designed as a pragmatic randomised clinical trial (RCT) with 2 parallel intervention groups. People aged 50 years and over who have visited their general practitioner (GP) with non traumatic pain in the forefoot in the preceding year and those who will visit their GP during the recruitment period with a similar complaint will be recruited for this study. Participants must be able to walk unaided for 7 metres and be able to fill in questionnaires. Exclusion criteria are: rheumatoid arthritis, neuropathy of the foot or pain caused by skin problems (e.g. warts, eczema). Inclusion and exclusion criteria will be assessed by a screening questionnaire and baseline assessment. Those consenting to participation will be randomly assigned to either a group receiving a standardised shoe advice leaflet (n = 100) or a group receiving podiatric treatment (n = 100). Primary outcomes will be the severity of forefoot pain (0-10 on a numerical rating scale) and foot function (Foot Function 5-pts Index and Manchester Foot Pain and Disability Index). Treatment adherence, social participation and quality of life will be the secondary outcomes. All outcomes will be obtained through self-administered questionnaires at the start of the study and after 3, 6, 9 and 12 months. Data will be analysed according to the "intention-to-treat" principle using multilevel level analysis. Discussion Strength of this study is the comparison between two common primary care treatments for forefoot problems, ensuring a high external validity of this trial. Trial registration Netherlands Trial Register (NTR): NTR2212

To determine the factors associated with the type of health care chosen by elderly people suffering from non-traumatic foot complaints.Cross-sectional mailed survey.Population-based random sample of 7200 people agedor = 65 years in The Netherlands.1130 peopleor = 65 years with non-traumatic foot complaints for 4 weeks or more.Use of non-(para)medical care (i.e. no care at all, self-care and chiropodial care) versus (para)medical care (i.e. care given by paramedical personnel, general practitioners and medical specialists).Six of every 10 respondents sought (para)medical care, half of these visited the GP. Factors associated with the use of (para)medical care were foot-related limitations (adj OR 3.18; 95% CI 2.26-4.46), painful feet (adj OR 1.55; 1.09-2.23), and foot osteoarthritis (adj OR 1.88; 1.32-2.68). (Para)medical care was sought less often than non-(para)medical care for forefoot complaints (adj OR 0.56; 0.41-0.76).Elderly people with non-traumatic foot complaints did not seem to underreport their problems to (para)medical care providers. Furthermore, they appeared to select the appropriate type of care. Future studies will have to assess the effectiveness of the care provided.

Background Scientific evidence for the frequency of monitoring of type 2 diabetes patients is lacking. If three-monthly control in general practice could be reduced to six-monthly control in some patients, this would on the one hand reduce the use of medical services including involvement of practice nurses, and thus reduce costs, and on the other hand alleviate the burden of people with type 2 diabetes. The goal of this study is to make primary diabetes care as efficient as possible for patients and health care providers. Therefore, we want to determine whether six-monthly monitoring of well-controlled type 2 diabetes patients in primary care leads to equivalent cardiometabolic control compared to the generally recommended three-monthly monitoring. Methods and design The study is a randomised controlled patient-preference equivalence trial. Participants are asked if they prefer three-monthly (usual care) or six-monthly diabetes monitoring. If they do not have a preference, they are randomised to a three-monthly or six-monthly monitoring group. Patients are eligible for the study if they are between 40 and 80 years old, diagnosed with type 2 diabetes more than one year ago, treated by a general practitioner, not on insulin treatment, and with HbA1c ≤7.5%, systolic blood pressure ≤145 mmHg and total cholesterol ≤5.2 mmol/l. The intervention group (six-monthly monitoring) will receive the same treatment with the same treatment targets as the control group (three-monthly monitoring). The intervention period will last one and a half year. After the intervention, the three-monthly and six-monthly monitoring groups are compared on equivalence of cardiometabolic control. Secondary outcome measures are HbA1c, blood pressure, cholesterol level, Body Mass Index, smoking behaviour, physical activity, loss of work due to illness, health status, diabetes-specific distress, satisfaction with treatment and adherence to medications. We will use intention-to-treat analysis with repeated measures. For outcomes that have only baseline and final measurements, we will use ANCOVA. Depending on the results, a cost-minimisation analysis or an incremental cost-effectiveness analysis will be done. Discussion This study will provide valuable information on the most efficient control frequency of well-controlled type 2 diabetes patients in primary care. Trial registration Current Controlled Trials ISRCTN93201802

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.