Challenges in preventing cardiovascular complications in type 2 diabetes in primary care

Can diabetes management be safely transferred to practice nurses in a primary care setting? A randomised controlled trial

AIMS AND OBJECTIVES

To determine whether the management of type 2 diabetes mellitus in a primary care setting can be safely transferred to practice nurses.

BACKGROUND

Because of the increasing prevalence of type 2 diabetes mellitus and the burden of caring for individual patients, the demand type 2 diabetes mellitus patients place on primary health care resources has become overwhelming.

DESIGN

Randomised controlled trial.

METHODS

The patients in the intervention group were cared for by practice nurses who treated glucose levels, blood pressure and lipid profile according to a specified protocol. The control group received conventional care from a general practitioner. The primary outcome measure was the mean decrease seen in glycated haemoglobin (HbA1c) levels at the end of the follow-up period (14 months).

RESULTS

A total of 230 patients was randomised with 206 completing the study. The between-group differences with respect to reduction in HbA1c, blood pressure and lipid profile were not significant. Blood pressure decreased significantly in both groups; 7.4/3.2 mm Hg in the intervention group and 5.6/1.0 mm Hg in the control group. In both groups, more patients met the target values goals for lipid profile compared to baseline. In the intervention group, there was some deterioration in the health-related quality of life and an increase in diabetes-related symptoms. Patients being treated by a practice nurse were more satisfied with their treatment than those being treated by a general practitioner.

CONCLUSION

Practice nurses achieved results, which were comparable to those achieved by a general practitioner with respect to clinical parameters with better patient satisfaction.

RELEVANCE TO CLINICAL PRACTICE

This study shows that diabetes management in primary care can be safely transferred to practice nurses.

Cross-sectional versus sequential quality indicators of risk factor management in patients with type 2 diabetes

BACKGROUND

The fairness of quality assessment methods is under debate. Quality indicators incorporating the longitudinal nature of care have been advocated but their usefulness in comparison to more commonly used cross-sectional measures is not clear.

AIMS

To compare cross-sectional and sequential quality indicators for risk factor management in patients with type 2 diabetes.

METHODS

The study population consisted of 1912 patients who received diabetes care from one of 40 general practitioners in The Netherlands. Clinical outcomes, prescriptions, and demographic data were collected from electronic medical records. Quality was assessed for glycemic, blood pressure, and lipid control using indicators focusing on clinical outcomes, and treatment in relation to outcomes. Indicator results were compared with a reference method based on national guidelines for general practice.

RESULTS

According to the reference method, 76% of the patients received management as recommended for glycemic control, 58% for blood pressure control, and 67% for lipid control. Cross-sectional indicators looking at patients adequately controlled gave estimates that were 10-25% lower than the reference method. Estimates from indicators focusing on uncontrolled patients receiving treatment were 10-40% higher than the reference method for blood pressure and glycemic control. Sequential indicators focusing on improvement in clinical outcomes or assessing treatment modifications in response to poor control gave results closer to the reference method.

CONCLUSIONS

Sequential indicators are valuable for estimating quality of risk factor management in patients with diabetes. Such indicators may provide a more accurate and fair judgment than currently used cross-sectional indicators.

The impact of new insights and revised practice guidelines on prescribing drugs in the treatment of Type 2 diabetes mellitus

AIMS

The aim of this study was to investigate the impact of new insights and revised guidelines on initial and follow-up treatment with antihyperglycaemic drugs over the period 1998-2003.

METHODS

The InterAction Database (IADB), which contains pharmacy dispensing data from 53 community pharmacies in the Northern and Eastern part of the Netherlands, was used in this study. Prevalence and incidence rates of oral antihyperglycaemic drug use were calculated for each year. Follow-up treatment was compared for two cohorts of initial users of oral antihyperglycaemic drugs, starting treatment either 1 year before or 1 year after guideline revision.

RESULTS

The prevalence and incidence rate of oral antihyperglycaemic drug use increased over the study period from 1.8% to 2.4% (P < 0.001) and 0.3% to 0.4% (P = 0.04). The proportion of metformin as initial treatment increased rapidly in the observation period from 14% to 50% (P < 0.001). Initial users of metformin in 2000 received additional treatment with a sulphonylurea in the follow-up period less often compared with those who started metformin in 1998 (46%vs. 60%, P < 0.004). In contrast, initial users of sulphonylurea in 2000 received additional treatment with metformin more often compared with those who started a sulphonylurea in 1998 (42%vs. 36%, P < 0.008). The new drugs, thiazolidinediones and meglitinides, were seldom used as initial treatment.

CONCLUSIONS

New insights and the revision of the practice guideline were followed by a significant increase in both initial and follow-up treatment with metformin among patients with Type 2 diabetes mellitus.

Metabolic (glycaemic, lipidic) and blood pressure control in 101 type 2 diabetic patients on first admission to diabetes centres

The aim of our study was to analyse the quality of metabolic and blood pressure control in a cohort of 101 patients with type 2 diabetes (54 males; 47 females), previously followed in primary care settings and admitted for the first time to the diabetes centres of Saint-Luc (n=66) or Mont-Godinne (n=35) University Hospitals. Age and (known) duration of diabetes were 64 +/-12 and 6 +/- 7 years (mean +/- SD), respectively. Body mass index was 31 +/- 7 kg/m2. Systolic and diastolic blood pressures were 140 +/-12 and 81 +/-11 mmHg. Homeostasis model assessment (HOMA) showed insulin sensitivity at 63 +/-32% and P-cell function at 49 +/- 44% (n=34). Forty-seven percent of patients received either diet alone or combined with an oral antidiabetic monotherapy. Seven-teen percent of all patients were on insulin monotherapy or associated with oral drugs. HbAlc was 9.0 +/- 2.3%, with 22% of patients within HbAlc targets of < or = 7%. Only a subset of patients reached international targets of care in terms of blood pressure and lipidic profile, despite antihypertensive and lipid-lowering agents in 62% and 36% of patients, respectively. Forty-five percent of individuals had at least one diabetes-related long-term complication. In view of this unsatisfactory control, our results suggest that "anti-diabetic" treatment should be intensified earlier in primary care settings.