Prescribing quality indicators of type 2 diabetes mellitus ambulatory care.

BACKGROUND: Existing performance indicators for assessing quality of care in type 2 diabetes mellitus (T2DM) focus mostly on registration of measurements and clinical outcomes, and not on quality of prescribing. OBJECTIVE: To develop a set of valid prescribing quality indicators (PQI) for internal use in T2DM, and assess the operational validity of the PQI using electronic medical records. METHODS: Potential PQI for hypertension, hyperglycaemia, dyslipidaemia and antiplatelet treatment in T2DM were based on clinical guidelines, and assessed on face and content validity in an expert panel followed by a panel of GPs and diabetologists. Analysis of ratings was performed using the RAND/UCLA Appropriateness Method. The operational validity of selected indicators was assessed in a dataset of 3214 T2DM patients registered with 70 GPs. RESULTS: Out of 31 potential prescribing indicators, the expert panel considered 18 indicators as sufficiently valid, of which 14 indicators remained valid after assessment by the panel of GPs and diabetologists. Of these 14 indicators, one could not be calculated because of an absence of eligible patients. For the remaining indicators, outcomes varied from 10% for timely prescribing of insulin to 96% for prescribing of any antihyperglycemic medication in patients with elevated HbA1c levels. CONCLUSIONS: This study provides a set of face- and content-valid PQI for pharmacological management of patients with T2DM. While outcomes of some PQI were limited to patients with registration of clinical values, the selected PQI had good operational validity to be used in practice for assessment of prescribing quality.

[Summary of the practice guideline 'Diabetes mellitus type 2' (second revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Diabetes mellitus type 2' (tweede herziening) van het Nederlands Huisartsen Genootschap.

The practice guideline 'Diabetes mellitus type 2' (second revision) addresses the diagnosis, treatment and management of adults with diabetes mellitus type 2 in general practice. The aim of management is the prevention and treatment of diabetes-related symptoms and complications such as cardiovascular disease, nephro-, retino- and neuropathy. The general practitioner gives the patient education and lifestyle advice and repeats this regularly. In addition, the general practitioner and the patient strive to achieve good glycaemic control. The agent of first choice in the medicinal treatment of all type 2 diabetic patients is metformin. This is continued even after the addition of a sulphonylurea derivative or insulin. This represents a change compared to the previous version of the practice guideline. The indications for thiazolidinediones are limited. To reduce the cardiovascular risk, it is advised to aim at a systolic blood pressure below 140 mmHg. It is also recommended that each patient be prescribed a statin, unless the patient belongs to a subgroup in which the indication for cholesterol lowering therapy is weak or the patient refuses it. Compared to the former guideline, more emphasis is placed on the prevention of nephropathy. The general practitioner is advised to calculate the creatinine clearance yearly and to test for relevant albuminuria in each patient with a life expectancy of 10 years or more. If microalbuminuria is present, the patient is prescribed an angiotensin converting enzyme (ACE) inhibitor, even if the blood pressure is not elevated. The detection of patients with a high risk of diabetic ulcer is also given more emphasis.

Alpha-glucosidase inhibitors for people with impaired glucose tolerance or impaired fasting blood glucose.

BACKGROUND: Alpha-glucosidase inhibitors (AGIs) reduce blood glucose levels and may thus prevent type 2 diabetes and cardiovascular disease in patients with impaired glucose tolerance. These possible effects, and the effects on quality of life, plasma lipids and body weight, have never been investigated in a systematic literature review and meta-analysis. OBJECTIVES: To assess the effects of alpha-glucosidase inhibitors in patients with impaired glucose tolerance (IGT) or impaired fasting blood glucose (IFBG), or both. SEARCH STRATEGY: We searched The Cochrane Library (Clinical Trials database, formerly known as CENTRAL), PUBMED, EMBASE, Web of Science, LILACS, databases of ongoing trials, reference lists of relevant reviews, and we contacted experts and manufacturers. Date of last search was February 2006. SELECTION CRITERIA: Randomised controlled trials of at least one-year duration in patients with IGT or IFBG, or both, comparing AGI monotherapy with any other intervention. DATA COLLECTION AND ANALYSIS: Two reviewers read all abstracts, assessed quality and extracted data independently. Discrepancies were resolved by consensus or by the judgement of a third reviewer. MAIN RESULTS: We included five trials (2360 participants), all investigating acarbose, that included patients with IGT or patients 'at increased risk for diabetes' (n = 1). Study duration was one, three (n = 2), five and six years. One study was at low risk of bias and four studies at high risk of bias. Except for the outcome incidence of type 2 diabetes in acarbose versus no treatment (two studies), meta-analyses were not possible. Data from the study at low risk of bias suggests that acarbose decreases the occurrence of type 2 diabetes (NNT = 10), cardiovascular events (NNT = 50, based on 47 events, study not initially powered for this outcome), post-load blood glucose (-0.6 mmol/L, 95% CI -1.0 to -0.3) and body mass index (0.3 kg/m(2), 95% CI -0.1 to -0.5). No statistically significant effects were observed on mortality, other morbidity, glycated haemoglobin, fasting blood glucose, lipids and blood pressure. The effects on the incidence of type 2 diabetes were confirmed in two studies at high risk of bias (OR 0.2, 95% CI 0.1 to 0.6). Adverse effects were mostly of gastro-intestinal origin (OR 3.5, 95% CI 2.7 to 4.4). AUTHORS' CONCLUSIONS: There is evidence that acarbose reduces the incidence of type 2 diabetes in patients with IGT. However, it is unclear whether this should be seen as prevention, delay or masking of diabetes. Acarbose may prevent the occurrence of cardiovascular events, but this finding needs to be confirmed in more studies.

[Methods of collecting urine for the determination of microalbuminuria: time for consensus]. / Methoden van urineverzameling voor het bepalen van microalbuminurie: tijd voor consensus.

In daily practice, collecting urine for the determination of microalbuminuria may take place in various ways and several different procedures are often used side by side in one institution. Ideally, the collection of urine should be as simple as possible for the patient, without losing diagnostic value. Having considered the pros and cons of the various procedures, we recommend measurement of the albumin-creatinine ratio in the 1st morning urine for both diagnosis and follow-up. This ratio is reported in gram of albumin per mol of creatinine and sex-dependent cut-off values must be used when interpreting the results: there is microalbuminuria above 2.5 g/mol for men and above 3.5 g/mol for women. If microalbuminuria is detected, the investigation should be repeated at least twice in a period of a few months in order to establish the degree of microalbuminuria.

Risk factors for development of impaired renal function in Type 2 diabetes mellitus patients in primary care.

AIMS: To evaluate risk factors for the development of an impaired renal function, defined as a glomerular filtration rate (GFR) by Cockcroft-Gault formula < 50.5 ml/min, in primary care patients with Type 2 diabetes mellitus. METHODS: A case-control study of Type 2 diabetes mellitus patients with impaired renal function and age, sex and practice matched controls with Type 2 diabetes mellitus without impaired renal function in 10 Dutch family practices performing the Nijmegen Monitoring Project. Main outcome measure was the independent risk factors of impaired renal function. RESULTS: Eighty-seven individuals with impaired renal function were identified. The point prevalence of impaired renal function in the sample population on 31 March 2001 was 87/873 (10.0%; 95% confidence interval 7.0-15.1%). Of 87 cases, 23 (26.5%; 17.3-30.9%) were found to have impaired renal function at diagnosis. Conditional multiple logistic regression analysis revealed the following independent risk factors for the development of impaired renal function: duration of diabetes > or = 8 years (adjusted odds ratio 5.6 (2.5-12.5); P < 0.001), glomerular filtration rate by Cockcroft-Gault formula 50.5-80.5 ml/min at diagnosis [3.5 (1.5-8.1); P < 0.01] and existing macrovascular complications at diagnosis [2.6 (1.1-6.3); P < 0.01]. CONCLUSION: Duration of diabetes > or = 8 years, mild renal impairment at the time of diagnosis and existing macrovascular complications at the time of diagnosis are independent risk factors for the development of impaired renal function in white patients with Type 2 diabetes mellitus.