Type 2 Diabetes in Primary Care in Belgium: Need for Structured Shared Care

 

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Abstract

Objective: To picture the profile of type 2 diabetic patients in Belgium and to study the quality of care in the primary care setting, with regard, to multi-factorial approach of the disease.

Methods: Observational study of all known DM2-patients registered by 120 volunteer general practitioners. Quality of care was evaluated by the achievement of three major treatment targets: HbA1c<7%; Systolic Blood Pressure ≤130 mmHg; LDL-Cholesterol<100 mg/dl (ADA 2003). Multivariate analysis was performed.

Results: 2495 DM2-patients were included with a mean age of 68±12 years and 51% being women. One fifth of the patients had microvascular complications and 27% had macrovascular complications. Sixty-eight percent received oral anti-diabetic drugs and 19% were on insulin. Satisfactory glycaemic control (HbA1c<7%) was achieved in 54% of the patients, with however glucose control deteriorating with disease progression despite more intensive hypoglycaemic treatment. Systolic blood pressure targets were reached in 50%. Statin use was present in 39% and LDL levels<100 mg/dl were reached in 42%. 59% of insulin treated patients were followed up in shared care with specialised diabetes centres. These patients obtained lower values for HbA1c (7.5±1.2% vs. 7.8±1.5%, p=0.038) and LDL-C (90±34 vs. 111±37, p<0.001) compared to insulin-treated patients only followed up in primary care.

Conclusion: Overall metabolic control in type 2 diabetic patients in primary care in Belgium was acceptable for glucose control, but major room for improvement exists especially for statin use and blood pressure control. Clinical inertia is present and the presence of more structured care in specialised diabetes centres, focusing on therapeutic guidelines, may explain the better overall metabolic control in patients followed up in shared care with these centres.

References

• 1 WHO . Diabetes Mellitus fact sheet n 138. 1999; 
  PubMed
• 2 ▪ ▪. Standards of medical care for patients with diabetes mellitus.  Diabetes Care. 2003;  26 33S-50
  CrossrefPubMedGoogle Scholar
• 3 ▪ ▪. Diabetes Atlas. Third Edition. International Diabetes Federation (IDF) 2006
• 4 ▪ ▪. Standards of medical care in diabetes – 2007.  Diabetes Care. 2007;  30 ((Suppl 1)) S4-S41
  CrossrefPubMedGoogle Scholar
• 5 Ryden L, Standl E, Bartnik M. et al . Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: executive summary. The Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European Association for the Study of Diabetes (EASD).  Eur Heart J. 2007;  28 88-136
  PubMedGoogle Scholar
• 6 Kvamme OJ, Olesen F, Samuelson M. Improving the interface between primary and secondary care: a statement from the European Working Party on Quality in Family Practice (EQuiP).  Qual Health Care. 2001;  10 33-39
  CrossrefPubMedGoogle Scholar
• 7 Smith SM, Allwright S, O'Dowd T. Effectiveness of shared care across the interface between primary and specialty care in chronic disease management.  Cochrane Database Syst Rev. 2007;  CD004910
  PubMedGoogle Scholar
• 8 Mathieu C, Nobels F, Peeters G. et al . Quality and organisation of type 2 Diabetes care. KCE, Belgian Health Care Knowledge Centrum.  KCE reports 27A. 2006;  , Brussels
  PubMedGoogle Scholar
• 9 Shah BR, Hux JE, Laupacis A. et al . Deficiencies in the quality of diabetes care: comparing specialist with generalist care misses the point.  J Gen Intern Med. 2007;  22 275-279
  CrossrefPubMedGoogle Scholar
• 10 Bourgeuil Y, Marek A, Mousquès J. Médecine de groupe en soins primaires dans six pays européens, en Ontario et au Québec: quels enseignements pour la France?.  Questions d'économie de la Santé. 2007;  127
  PubMedGoogle Scholar
• 11 Debacker N, Mathieu C, Nobels F. et al .Initiatief voor Kwaliteitsbevordering en Epidemiologie bij Diabetes IKED. Rapport Resultaten 2005–2006 2007
• 12 De Backer G, Ambrosioni E, Borch-Johnsen K. et al . European guidelines on cardiovascular disease prevention in clinical practice: third joint task force of European and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of eight societies and by invited experts).  Eur J Cardiovasc Prev Rehabil. 2003;  10 S1-S10
  PubMedGoogle Scholar
• 13 Resnick HE, Foster GL, Bardsley J. et al . Achievement of American Diabetes Association clinical practice recommendations among U.S. adults with diabetes, 1999–2002: the National Health and Nutrition Examination Survey.  Diabetes Care. 2006;  29 531-537
  CrossrefPubMedGoogle Scholar
• 14 Wan Q, Harris MF, Jayasinghe UW. et al . Quality of diabetes care and coronary heart disease absolute risk in patients with type 2 diabetes mellitus in Australian general practice.  Qual Saf Health Care. 2006;  15 131-135
  CrossrefPubMedGoogle Scholar
• 15 Rothenbacher D, Ruter G, Saam S. et al . Management of patients with type 2 diabetes Results in 12 practices of general practitioners.  Dtsch Med Wochenschr. 2002;  127 1183-1187
  Article in Thieme ConnectPubMedGoogle Scholar
• 16 Yurgin N, Secnik K, Lage MJ. Antidiabetic prescriptions and glycemic control in German patients with type 2 diabetes mellitus: a retrospective database study.  Clin Ther. 2007;  29 316-325
  CrossrefPubMedGoogle Scholar
• 17 De Berardis G, Pellegrini F, Franciosi M. et al . Quality of care and outcomes in type 2 diabetic patients: a comparison between general practice and diabetes clinics.  Diabetes Care. 2004;  27 398-406
  CrossrefPubMedGoogle Scholar
• 18 O’Connor R, Houghton F, Saunders J. et al . Diabetes mellitus in Irish general practice: level of care as reflected by HbA1c values.  Eur J Gen Pract. 2006;  12 58-65
  PubMedGoogle Scholar
• 19 Polonsky WH, Fisher L, Guzman S. et al . Psychological insulin resistance in patients with type 2 diabetes: the scope of the problem.  Diabetes Care. 2005;  28 2543-2545
  CrossrefPubMedGoogle Scholar
• 20 Peyrot M, Rubin RR, Lauritzen T. et al . Resistance to insulin therapy among patients and providers: results of the cross-national diabetes attitudes, wishes, and needs (DAWN) study.  Diabetes Care. 2005;  28 2673-2679
  CrossrefPubMedGoogle Scholar
• 21 Knight K, Badamgarav E, Henning JM. et al . A systematic review of diabetes disease management programs.  Am J Manag Care. 2005;  11 242-250
  PubMedGoogle Scholar
• 22 Renders CM, Valk GD, Griffin SJ. et al . Interventions to improve the management of diabetes in primary care, outpatient, and community settings: a systematic review.  Diabetes Care. 2001;  24 1821-1833
  CrossrefPubMedGoogle Scholar
• 23 Shojania KG, Ranji SR, MacDonald KM. et al . Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis.  JAMA. 2006;  296 427-440
  CrossrefPubMedGoogle Scholar
• 24 Nutting PA, Dickinson WP, Dickinson LM. et al . Use of chronic care model elements is associated with higher-quality care for diabetes.  Ann Fam Med. 2007;  5 14-20
  CrossrefPubMedGoogle Scholar
• 25 Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials.  Diabetes Care. 2001;  24 561-587
  CrossrefPubMedGoogle Scholar
• 26 Ellis SE, Speroff T, Dittus RS. et al . Diabetes patient education: a meta-analysis and meta-regression.  Patient Educ Couns. 2004;  52 97-105
  CrossrefPubMedGoogle Scholar
• 27 Huang ES. Appropriate application of evidence to the care of elderly patients with diabetes.  Curr Diabetes Rev. 2007;  3 260-263
  PubMedGoogle Scholar
• 28 European Union Geriatric Medicine Society . Clinical Guidelines for Type 2 Diabetes Mellitus, European Diabetes Working Party for Older People. 2004; 
  PubMed
• 29 Luck T, Riedel-Heller SG, Kaduszkiewicz H. et al . Mild cognitive impairment in general practice: age-specific prevalence and correlate results from the German study on ageing, cognition and dementia in primary care patients (AgeCoDe).  Dement Geriatr Cogn Disord. 2007;  24 307-316
  CrossrefPubMedGoogle Scholar
• 30 Roberts RO, Geda YE, Knopman DS. et al . Association of duration and severity of diabetes mellitus with mild cognitive impairment.  Arch Neurol. 2008;  65 1066-1073
  CrossrefPubMedGoogle Scholar
• 31 European Union Geriatric Medicine Society . Clinical Guidelines for type 2 doabetes Mellitus, European Daibetes Working Party for Older People. 2004; 
  PubMed
• 32 Botelho RJ, Dudrak R. Home assessment of adherence to long-term medication in the elderly.  J Fam Pract. 1992;  35 61-65
  PubMedGoogle Scholar
• 33 Anderson RJ, Kirk LM. Methods of improving patient compliance in chronic disease states.  Arch Intern Med. 1982;  142 1673-1675
  CrossrefPubMedGoogle Scholar
• 34 Okuno J, Yanagi H, Tomura S. Is cognitive impairment a risk factor for poor compliance among Japanese elderly in the community?.  Eur J Clin Pharmacol. 2001;  57 589-594
  CrossrefPubMedGoogle Scholar
• 35 Boyd CM, Darer J, Boult C. et al . Clinical Practice Guidelines and Quality of Care for Older Patients With Multiple Comorbid Diseases: Implications for Pay for Performance.  JAMA. 2005;  294 716-724
  CrossrefPubMedGoogle Scholar
• 36 Hader C, Beischer W, Braun A. et al . Diagnosis, treatment and follow up of diabetes mellitus in elderly.  Europ J Geriatr. 2006;  8 1-57
  PubMedGoogle Scholar
• 37 Brown AF, Mangione CM, Saliba D. et al . Guidelines for improving the care of the older person with diabetes mellitus.  J Am Geriatr Soc. 2003;  51 S265-S280
  PubMedGoogle Scholar
• 38 Bonds DE, Kurashige EM, Bergenstal R. et al . Severe hypoglycemia monitoring and risk management procedures in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial.  Am J Cardiol. 2007;  99 80i-89i
  PubMedGoogle Scholar
• 39 Mathieu C, Bollaerts K. Antihyperglycaemic therapy in elderly patients with type 2 diabetes: potential role of incretin mimetics and DPP-4 inhibitors.  Int J Clin Pract Suppl. 2007;  1 29-37
  PubMedGoogle Scholar
• 40 MacAlister FA, Majumdar SR, Eurich DT. et al . The effect of specialist care within the first year on subsequent outcomes in 24,232 adults with new-onset diabetes mellitus: population-based cohort study.  Qual Saf Health Care. 2007;  16 6-11
  CrossrefPubMedGoogle Scholar

Correspondence

Dr. G. Goderis

Department of General Practice (Academisch Centrum voor Huisartsgeneeskunde)

Catholic University Leuven

Kapucijnenvoer 33/J Bus 7001

3000 Leuven

Belgium

Phone: +32/16/33 74 68

Fax: +32/16/33 74 80

Email: geert.goderis@skynet.be