Would you like to be a general practitioner? Baseline findings of a longitudinal survey among Danish medical trainees.

BACKGROUND: Recruiting and securing primary care physician workforce has been the center of international attention for decades. In Denmark, the number of general practitioners has decreased by 8.5% since 2013. However, a rising population age and increasing prevalence of chronic diseases and multimorbidity place an even greater future need for general practitioners in Denmark. The choice of general practice as specialty has been associated with a range of both intrinsic and extrinsic factors, however, few studies have examined the recruitment potential that lies within medical trainees' who are undecided about general practice specialization. The aim of this study was, therefore, to explore how medical trainees who are undecided about general practice specialization (GP-positive/undecided) differ from medical trainees who are either committed (GP-committed) or not committed to a general practice career (GP-non-committed) regarding factors related to future work life. METHODS: The present study concerns baseline findings from a longitudinal survey study. An online questionnaire was e-mailed to a national cohort of medical trainees during their transition from under- to postgraduate education. The associations between orientations towards general practice specialization and work-related factors and potential influencing factors, respectively, were analyzed using uni- and multivariable modified Poisson regression models. RESULTS: Of 1,188 invited participants, 461 filled out key study variables concerning specialty preferences and rejections, corresponding to a response rate of 38.8%. We found significant positive associations between GP-positive/undecided orientation and valuing a good work/life balance and the opportunity to organize own working hours when compared to GP-non-committed respondents. Compared to the GP-committed orientations, the GP-positive/undecided orientation was associated with a positive attitude towards technology, working shift hours, and an openness towards several career paths. Across all orientations, undergraduate exposure to the specialties was found to be highly influential on the specialty preferences. CONCLUSION: GP-positive/undecided medical trainees value autonomy over their working hours more than the GP-non-committed, but less than the GP-committed. However, the GP-positive/undecided respondents present more openness to different career opportunities and the use of technology in daily work. We suggest using this knowledge in the planning of recruitment strategies aiming to increase interest in general practice specialization.

Medical trainees' speciality considerations at their transition from under- to postgraduate education: a descriptive, cross-sectional study.

PURPOSE: This paper aims to provide knowledge on medical trainees' considerations about specialisation as they move from undergraduate to postgraduate medical education; especially their interest in general practice compared to other specialities. METHOD: We developed and content-validated a questionnaire to examine medical trainees' speciality considerations and conducted a descriptive, cross-sectional study. All medical trainees initiating their internship in Denmark in 2022 (N = 1,188) were invited to participate in the study. Medical specialities were categorised as hospital service specialities, internal medicine specialities, primary care, psychiatry specialities and surgery and emergency specialities. Descriptive statistics were used to describe the cohort and examine the participants' speciality considerations by assigning them to one of the following three orientations: committed, undecided or non-committed to a speciality. RESULTS: The response rate was 38.8% (n = 461), and participants' mean age was 27.4 years with a majority of females (68.1%). Nearly 25% of the participants had general practice as speciality preference, and only 13.9% had excluded general practice for future specialisation. Overall, around half of the participants had general practice as a first, second or third preference for specialisation. CONCLUSION: Danish medical trainees show considerable interest in general practice at the time of their transition from undergraduate to postgraduate education. However, to meet future demands on the primary care, further recruitment of general practitioners is still needed. This knowledge of the specialities' recruitment potential will likely be of interest to medical educators and healthcare planners alike.

Effects of DPP-4 inhibitors, GLP-1 receptor agonists, SGLT-2 inhibitors and sulphonylureas on mortality, cardiovascular and renal outcomes in type 2 diabetes: A network meta-analyses-driven approach.

AIMS: The aim of our meta-analyses was to compare the effects of glucose-lowering drugs on mortality, cardiovascular and renal endpoints for a range of type 2 diabetes (T2D) subgroups defined by their specific cardiovascular risk profile. METHODS: Meta-analyses comparing drugs within the classes of GLP-1RAs and SGLT-2 inhibitors were performed and compared to sulphonylureas and DPP-4 inhibitors with available cardiovascular outcome trials. The comparison between the different classes of glucose-lowering drugs included analyses of T2D populations with low risk and high risk for cardiovascular disease including populations with established cardiovascular disease and/or kidney disease. Outcomes included mortality, major cardiovascular adverse events (MACE), hospitalisation for heart failure (HHF) and a composite renal endpoint as applied in the underlying clinical trials. RESULTS: SGLT-2 inhibitors and GLP-1RAs showed beneficial effects on mortality and MACE compared to the classes of DPP-4 inhibitors and sulphonylureas. SGLT-2 inhibitors were shown to be the most effective treatment in terms of HHF and kidney disease. Metformin was used as background therapy for the vast majority of participants in all included studies. Overall, the absolute effects of SGLT-2 inhibitors and GLP-1RAs on these important outcomes were evident for patients with established or at high risk for cardiovascular disease but limited for the low-risk subgroup. CONCLUSIONS: The findings from our analyses substantiate the relevance of treatment with SGLT-2 inhibitors or GLP-1RAs as an add-on to metformin in patients with T2D and a high risk for cardiovascular disease, and furthermore, support the recommendation for SGLT-2 inhibitor treatment in patients with T2D and heart failure or established kidney disease.

Effect of an electronic reminder of follow-up screening after pregnancy complicated by gestational diabetes mellitus: a randomized controlled trial.

AIM: To determine the effectiveness of despatching an electronic reminder of participation in screening for gestational diabetes. The reminder was sent to the women 1-8 years after delivery. METHODS: A registry-based, randomized controlled trial in the North Denmark Region among women with gestational diabetes. Randomization was made, which included seven groups stratified by the child's birth year (2012-2018). The intervention group received standard care supplemented by an electronic reminder through a secure nationwide email system (n = 731), while the control group received only standard care (n = 732). The primary outcome was based on blood testing for diabetes (OGTT, HbA1c or fasting P-glucose). RESULTS: A total of 471 (32.1%) women participated in screening. The primary outcome was experienced by 257 women (35.1%) in the intervention group and 214 women (29.2%) in the control group. The effect of the reminder seemed to increase with recipient's age, non-western origin, urban dwelling, and multiparity. Of those who participated in follow-up screening, 56 (3.8%) were diagnosed with type 2 diabetes. CONCLUSION: Electronic reminders, based on the principles of informed choice and patient-centred care, to women have been shown to support life-long participation in follow-up screening. Attempts to further stimulation of coverage could however be considered. TRAIL REGISTRATION: ISRCTN registry (22/04/2022, ISRCTN23558707).

The pathway and characteristics of patients with non-specific symptoms of cancer: a systematic review.

BACKGROUND: Non-specific symptoms are common and often sign of a non-serious disease. Because of this, patients with non-specific symptoms of cancer (NSSC) present a challenge for general practitioners (GP). Studies describing characteristics of patients with NSSC have been done after fast-track pathways were created to diagnose and treat patients with NSSC. This study reviews characteristics of patients with NSSC and their patient pathways. MATERIALS AND METHODS: Database searches of Embase, Cochrane, PubMed, Cinahl and Web of Science were performed. Search terms used were cancer, patient pathway, and NSSC with their synonyms. The flow diagram Preferring Reporting Items for Systematic Review was applied to the systematic search. The Newcastle-Ottawa Assessment Scale (NOS) was used to compare the quality of the included studies. RESULTS: Twelve studies met the inclusion criterias. All studies were considered to be of high methodological quality. Patient Pathway: 11-35% of patients were diagnosed with cancer. Median number of days through diagnostic process was 7-10. PATIENT CHARACTERISTICS: The most prevalent cancers included hematological-(14-30%), gastrointestinal-(13-23%) and lung cancers (13%). Rheumatological, musculoskeletal and gastrointestinal diseases were among the most common non-malignant diseases diagnosed. Weight loss, fatigue, pain and loss of appetite were the most common symptoms. Cardiovascular diseases, lung diseases, diabetes and previous diagnosed cancer were the most common comorbidities. Mean age of included patients was 60-72 years. CONCLUSION: Limited number of studies were found and they lacked sufficient heterogenic data to conduct a metaanalysis. Symptoms, diagnoses, age and gender were described with some heterogenic results. Further studies should be conducted to gather broader knowledge about patients with NSSC.

Danish GPs' and practice nurses' management of acute sore throat and adherence to guidelines.

BACKGROUND: Sore throat is a frequent presentation of acute respiratory tract infections in general practice. Though these infections are often harmless and self-limiting, antibiotics are frequently prescribed. In Denmark, practice nurses manage an increasing part of patients with acute minor illnesses. OBJECTIVES: We aimed (i) to investigate Danish practice nurses' and GPs' management of patients presenting with a sore throat and (ii) to explore to what extent management is according to current Danish guidelines. METHODS: A cross-sectional study was conducted during winter 2017, involving GPs and practice nurses in Danish general practices. Patients with a sore throat were registered according to the Audit Project Odense method. RESULTS: A total of 44 practices participated with the registration of 1503 patients presenting with a sore throat. Most patients had a strep A test performed, especially when managed by a practice nurse (84.6% versus 61.8%, χ2 = 90.1, P < 0.05). In total, 40.6% of performed strep A tests were not according to guideline recommendations. Antibiotics were prescribed for about one-third of patients, regardless whether managed by a practice nurse or a GP (χ2 = 0.33, P = 0.57). However, 32.4% of these prescriptions were not in line with Danish guidelines. CONCLUSION: Patients with acute sore throat were managed similarly by GPs and practice nurses, apart from a higher use of strep A tests in patients seen by practice nurses. Importantly, this study demonstrated that there is still room for improvement of the management of these patients in Danish general practice.

Cervical screening in Denmark - a success followed by stagnation.

INTRODUCTION: Despite an intensive screening activity, the incidence of cervical cancer in Denmark has remained stable for the last 15 years, while regional differences have increased. To search for explanations, we investigated possible weaknesses in the screening program. MATERIAL AND METHODS: Data on the screen-targeted women were retrieved from Statistics Denmark. Data on screening activity were retrieved from the annual reports from 2009 to 2015 on quality of cervical screening. Coverage was calculated as proportion of screen-targeted women with at least one cytology sample within recommended time intervals. Insufficient follow-up was calculated as proportion of abnormal and unsatisfactory samples not followed up within recommended time intervals. Diagnostic distribution was calculated for samples with a satisfactory cytology diagnosis. RESULTS: Coverage remained stable at 75%-76% during the study period. Annually, approximately 100,000 women are screened before they are eligible for invitation, and 600,000 invitations and reminders are issued resulting in screening of 200,000 women. In 2009, 21% of abnormal and unsatisfactory samples were not followed up within the recommended time interval; a proportion that had decreased to 15% in 2015. Overall, 11% of satisfactory samples with a cytology diagnosis were abnormal, but with surprising variation from 6% to 15% across regions. DISCUSSION: The success of a screening program depends first of all on coverage and timely follow-up of abnormal findings. Our analysis indicated that the currently high incidence of cervical cancer in Denmark may partly be due to low screening coverage. Also worrisome is a high proportion of non-timely follow-up of abnormal findings. Innovative ways to improve coverage and follow-up are urgently needed.

Person-centred medicine in the care home setting: development of a complex intervention.

BACKGROUND: Person-centred medicine is recommended in the care of older patients. Yet, involvement of care home residents and relatives in medication processes remains limited in routine care. Therefore, we aimed to develop a complex intervention focusing on resident and relative involvement and interprofessional communication to support person-centred medicine in the care home setting. METHODS: The development took place from October 2021 to March 2022 in the Municipality of Aarhus, Denmark. The study followed the Medical Research Council guidance on complex intervention development using a combination of theoretical, evidence-based, and partnership approaches. The patient involvement tool, the PREparation of Patients for Active Involvement in medication Review (PREPAIR), was included in a preliminary intervention model. Study activities included developing programme theory, engaging stakeholders, and exploring key uncertainties through interviews, co-producing workshops, and testing with end-users to develop the intervention and an implementation strategy. The Consolidated Framework for Implementation Research and the Interprofessional Shared Decision Making Model were used. Data were analysed using a rapid analysis approach. RESULTS: Before the workshops, six residents and four relatives were interviewed. Based on their feedback, PREPAIR was modified to the PREPAIR care home to fit the care home population. In total, ten persons participated in the co-producing workshops, including health care professionals and municipal managerial and quality improvement staff. The developed intervention prototype was tested for three residents and subsequently refined to the final intervention, including two fixed components (PREPAIR care home and an interprofessional medication communication template) delivered in a flexible three-stage workflow. Additionally, a multi-component implementation strategy was formed. In line with the developed programme theory, the intervention supported health care professionals´ awareness about resident and relative involvement. It provided a structure for involvement, empowered the residents to speak, and brought new insights through dialogue, thereby supporting involvement in medication-related decisions. The final intervention was perceived to be relevant, acceptable, and feasible in the care home setting. CONCLUSION: Our results indicate that the final intervention may be a viable approach to facilitate person-centred medicine through resident and relative involvement. This will be further explored in a planned feasibility study.

Safe Medication in Nursing Home Residents Through the Development and Evaluation of an Intervention (SAME): Protocol for a Fully Integrated Mixed Methods Study With a Cocreative Approach.

BACKGROUND: Medication safety is increasingly challenging patient safety in growing aging populations. Developing positive patient safety cultures is acknowledged as a primary goal to improve patient safety, but evidence on the interventions to do so is inconclusive. Nursing home residents are often cognitively and physically impaired and are therefore highly reliant on frontline health care providers. Thus, interventions to improve medication safety of nursing home residents through patient safety culture among providers are needed. Using cocreative partnerships, integrating knowledge of residents and their relatives, and ensuring managerial support could be beneficial. OBJECTIVE: The primary aim of the Safe Medication of Nursing Home Residents Through Development and Evaluation of an Intervention (SAME) study is to improve medication safety for nursing home residents through developing an intervention by gaining experiential knowledge of patient safety culture in cocreative partnerships, integrating knowledge of residents and their relatives, and ensuring managerial support. METHODS: The fully integrated mixed method study will be conducted using an integrated knowledge translation approach. Patient safety culture within nursing homes will first be explored through qualitative focus groups (stage 1) including nursing home residents, their relatives, and frontline health care providers. This will inform the development of an intervention in a multidisciplinary panel (stage 2) including cocreators representing the medication management process across the health care system. Evaluation of the intervention will be done in a randomized controlled trial set at nursing homes (stage 3). The primary outcome will be changes in the mean scale score of an adapted version of the Danish "Safety Attitudes Questionnaire" (SAQ-DK) for use in nursing homes. Patient safety-related outcomes will be collected through Danish health registers to assess safety issues and effects, including medication, contacts to health care, diagnoses, and mortality. Finally, a mixed methods analysis on patient safety culture in nursing homes will be done (stage 4), integrating qualitative data (stage 1) and quantitative data (stage 3) to comprehensively understand patient safety culture as a key to medication safety. RESULTS: The SAME study is ongoing. Focus groups were carried out from April 2021 to September 2021 and the workshop in September 2021. Baseline SAQ-DK data were collected in January 2022 with expected follow-up in January 2023. Final data analysis is expected in spring 2024. CONCLUSIONS: The SAME study will help not only to generate evidence on interventions to improve medication safety of nursing home residents through patient safety culture but also to give insight into possible impacts of using cocreativity to guide the development. Thus, findings will address multiple gaps in evidence to guide future patient safety improvement efforts within primary care settings of political and scientific scope. TRIAL REGISTRATION: ClinicalTrials.gov NCT04990986; https://clinicaltrials.gov/ct2/show/NCT04990986. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/43538.

Follow-up after gestational diabetes: a qualitative study of perspectives from general practices.

BACKGROUND: Women whose pregnancies are complicated by gestational diabetes mellitus (GDM) are approximately eight times more likely to develop type 2 diabetes mellitus (T2DM). Although regular participation in follow-up screening increases the chance of early detection of diabetes, participation rates are often suboptimal. A better understanding of general practice as a key contextual setting for screening could help inform the development and adoption of, for example, electronic reminder interventions to support women's participation. AIM: To explore the perspectives of GPs and relevant staff members engaged in early detection of diabetes after gestational diabetes in order to identify barriers to and facilitators of follow-up screening. DESIGN & SETTING: A qualitative interview study undertaken in general practices in the North Denmark Region. METHOD: Based on a purposive sample strategy, 18 semi-structured interviews of 12 GPs and six staff members, who were either nurses or midwives, were analysed using a reflexive thematic analytical approach. RESULTS: The following three main themes were formulated: (1) challenges of addressing women's risk; (2) prioritisation of early detection of diabetes; and (3) system influence on clinical procedures. CONCLUSION: Follow-up screening was facilitated by knowledge of guidelines. Professional collaboration and adaptation support were found to lead to successful implementation of guidelines in general practice. Supporting GPs and their staff's reflection and discussion of ways to engage in communication and decisionmaking processes with women is, however, important; it was found to create an important barrier to follow-up screening. Overall, the findings can help inform the future development of interventions to increase uptake.

The National Diabetes Register.

INTRODUCTION: A National Diabetes Register was established in the National Board of Health in 2006 following a pilot study showing the feasibility of doing so based on existing registers. CONTENT: The register contains data of birth, date of inclusion, and date of death as well as information on the criteria met for inclusion. VALIDITY AND COVERAGE: The register is more than 90% complete when compared to records of general practitioners, and it covers the entire Danish population. CONCLUSION: The register is a source of demographic information for the diabetes population in itself, but also a source of linkable information for studies of diabetes as outcome and as determinant.

A qualitative study on dyad practice in a clinical setting.

INTRODUCTION: General practice in Denmark is at risk of experiencing an educational capacity problem in which the quality of medical students' clinical stays is compromised due to reduced tutor capacity. Dyad practice, in which students work and acquire competencies in pairs, is known from simulation and ultrasound training to be as effective with regard to learning outcome as single practice despite reduced hands-on time. This study aimed to explore the experience of dyad practice during a group of medical students' first clinical stay in general practice. METHODS: A focus group interview was conducted with eight medical students who had attended clinical stays in general practice in four dyads. Individual semi-structured interviews were held with three general practitioners who tutored the medical students during the clinical stays. Data were transcribed by the interviewer and analysed using systematic text condensation. RESULTS: Both the medical students and general practitioners described how dyad practice enhanced the students' self-reflection and introduced new learning experiences. Furthermore, the medical students experienced shared memory with their peer and a broader overview before, during and after the consultation with the patient. CONCLUSIONS: Dyad practice was experienced by both medical students and general practitioners as suitable for medical students' first-time clinical stay in general practice. Dyad practice may thus reduce the capacity problems with regard to medical education in general practice. FUNDING: This study was funded in part by the PLU Foundation. TRIAL REGISTRATION: not relevant.

Clinical and biochemical characteristics of postpancreatitis diabetes mellitus: A cross-sectional study from the Danish nationwide DD2 cohort.

BACKGROUND: Postpancreatitis diabetes mellitus (PPDM) is a common metabolic sequalae of acute and chronic pancreatitis. We conducted a cross-sectional study to examine the proportion of PPDM among patients clinically diagnosed with type 2 diabetes (T2D) in Denmark and their clinical and biochemical characteristics. METHODS: We identified all past diagnoses of pancreatitis among patients in the Danish Centre for Strategic Research in Type 2 Diabetes (DD2) cohort through linkage with national health registries. Using International Classification of Diseases, Tenth Revision codes we categorized patients as PPDM and further divided them into acute/chronic subtypes (PPDM-A and PPDM-C). We assessed PPDM prevalence and examined associations with clinical and biochemical parameters using log binomial or Poisson regression to calculate age-/sex-adjusted prevalence ratios (aPRs). RESULTS: Among 5564 patients with a clinical diagnosis of T2D, 78 (1.4%) had PPDM. Compared to T2D, PPDM patients were more often underweight or normal weight (body mass index ≤25.0 kg/m2 : aPR 2.3; 95% confidence interval [CI]: 1.6-3.2) and had lower waist-to-hip ratio (≤0.95/≤0.80 in men/women: aPRs 1.8; 95% CI: 1.2-2.7). PPDM patients had lower plasma amylase levels (<17 U/L: aPRs 2.2; 95% CI: 1.1-4.3), higher insulin sensitivity (homeostatic model assessment 2S [HOMA2S] >63: aPR 2.0; 95% CI: 1.2-3.2) and tended to have worse glycaemic control (HbA1c ≥8.0%: aPRs 1.4; 95% CI: 0.8-2.4). PPDM-A was largely indistinguishable from T2D, whereas PPDM-C had impaired insulin secretion, higher insulin sensitivity, and worse glycemic control. CONCLUSIONS: The proportion of PPDM among patients with clinically diagnosed T2D is ~1.5% in an everyday clinical care setting. Glucose metabolism of PPDM-A is largely indistinguishable from T2D, whereas PPDM-C differs in relation to insulin secretion and sensitivity.

Identification of Important Factors Affecting Use of Digital Individualised Coaching and Treatment of Type 2 Diabetes in General Practice: A Qualitative Feasibility Study.

Most type 2 diabetes patients are treated in general practice and there is a need of developing and implementing efficient lifestyle interventions. eHealth interventions have shown to be effective in promoting a healthy lifestyle. The purpose of this study was to test the feasibility, including the identification of factors of importance, when offering digital lifestyle coaching to type 2 diabetes patients in general practice. We conducted a qualitative feasibility study with focus group interviews in four general practices. We identified two overall themes and four subthemes: (1) the distribution of roles and lifestyle interventions in general practice (subthemes: external and internal distribution of roles) and (2) the pros and cons for digital lifestyle interventions in general practice (subthemes: access to real life data and change in daily routines). We conclude that for digital lifestyle coaching to be feasible in a general practice setting, it was of great importance that the general practitioners and practice nurses knew the role and content of the intervention. In general, there was a positive attitude in the general practice setting towards referring type 2 diabetes patients to digital lifestyle intervention if it was easy to refer the patients and if easily understandable and accessible feedback was implemented into the electronic health record. It was important that the digital lifestyle intervention was flexible and offered healthcare providers in general practice an opportunity to follow the type 2 diabetes patient closely.

Albuminuria and Risk of Cardiovascular Events and Mortality in a General Population of Patients with Type 2 Diabetes Without Cardiovascular Disease: A Danish Cohort Study.

BACKGROUND: Albuminuria level is associated with cardiovascular events and mortality in patients with diabetes. However, little is known about the association between albuminuria level in diabetes patients without overt cardiovascular disease. We aimed to examine the association between albuminuria level and the risk of ischemic stroke, myocardial infarction, and all-cause mortality in patients with type 2 diabetes without overt cardiovascular disease. METHODS: We linked Danish nationwide registries to identify patients with type 2 diabetes without cardiovascular disease from May 2005 through June 2015. Patients were followed for the outcomes ischemic stroke, myocardial infarction, and all-cause mortality until December 31, 2015. Albuminuria level was based on 2 consecutive measurements of the urinary albumin excretion rate or albumin-to-creatinine ratio. Associations between albuminuria level and incidence of cardiovascular disease and mortality were evaluated with Cox proportional hazard regression. RESULTS: The study population consisted of 69,532 patients with type 2 diabetes without cardiovascular disease. When comparing patients with microalbuminuria to patients with normoalbuminuria, in an analysis adjusted for cardiovascular risk factors, we found hazard ratios of 1.28 (95% confidence interval [CI], 1.07-1.52), 1.34 (95% CI, 1.10-1.62), and 1.48 (95% CI, 1.36-1.61) for ischemic stroke, myocardial infarction, and all-cause mortality, respectively. For macroalbuminuria, the hazard ratios were 1.81 (95% CI, 1.46-2.23), 1.99 (95% CI, 1.59-2.48), and 1.83 (95% CI, 1.64-2.04). Similar results were found after adjusting for concomitant medication. CONCLUSIONS: This study showed that albuminuria level is associated with higher risk of incident ischemic stroke, myocardial infarction, and all-cause mortality in Type 2 diabetes patients without overt cardiovascular disease.

Risk of diabetic complications and subsequent mortality among individuals with schizophrenia and diabetes - a population-based register study.

BACKGROUND: Individuals with schizophrenia often develop diabetes, but little is known about their risk of diabetic complications. We aimed to study incidence of registered diabetic complications and subsequent mortality in individuals with schizophrenia and diabetes compared to individuals with diabetes only. METHODS: We conducted a cohort study using nationwide registers and followed all individuals in the entire Danish population diagnosed with diabetes from 1997 to 2017. Incidence rate ratios (IRR) of diabetic complications, all-cause and cause-specific mortality rate ratios (MRR) were estimated by Cox regression comparing individuals diagnosed with schizophrenia and diabetes to individuals diagnosed only with diabetes. RESULTS: In a cohort of 239,118 individuals with diagnosed diabetes, the incidence of any diabetic complication was similar in females with schizophrenia and diabetes compared to females with diabetes only; IRR = 0.93 (95%CI: 0.84-1.02), and significantly lower in males; IRR = 0.85 (95%CI: 0.78-0.92). The all-cause mortality for individuals with a diagnosis of a diabetic complication was higher in individuals with schizophrenia and diabetes than in those with diabetes only; MRR = 1.92 (95%CI: 1.65-2.23) for females and MRR = 1.69 (95%CI: 1.49-1.92) for males. Among those without diabetic complications, schizophrenia was also associated with a higher mortality. CONCLUSIONS: Individuals with schizophrenia and diabetes had similar or lower rates of diabetic complications, compared to those with diabetes only. Among those with diabetic complications, schizophrenia was associated with higher mortality. Similar, among those without diabetic complications, schizophrenia was also associated with higher mortality. Hence, diabetic complications do not seem to explain the excess mortality seen in individuals with schizophrenia.

The effect of feedback to general practitioners on quality of care for people with type 2 diabetes. A systematic review of the literature.

BACKGROUND: There have been numerous efforts to improve and assure the quality of treatment and follow-up of people with Type 2 diabetes (PT2D) in general practice. Facilitated by the increasing usability and validity of guidelines, indicators and databases, feedback on diabetes care is a promising tool in this aspect. Our goal was to assess the effect of feedback to general practitioners (GPs) on the quality of care for PT2D based on the available literature. METHODS: Systematic review searches were conducted using October 2008 updates of Medline (Pubmed), Cochrane library and Embase databases. Additional searches in reference lists and related articles were conducted. Papers were included if published in English, performed as randomized controlled trials, studying diabetes, having general practice as setting and using feedback to GPs on diabetes care. The papers were assessed according to predefined criteria. RESULTS: Ten studies complied with the inclusion criteria. Feedback improved the care for PT2D, particularly process outcomes such as foot exams, eye exams and Hba1c measurements. Clinical outcomes like lowering of blood pressure, Hba1c and cholesterol levels were seen in few studies. Many process and outcome measures did not improve, while none deteriorated. Meta analysis was unfeasible due to heterogeneity of the studies included. Two studies used electronic feedback. CONCLUSION: Based on this review, feedback seems a promising tool for quality improvement in diabetes care, but more research is needed, especially of electronic feedback.

Glycemic Status and Thromboembolic Risk in Patients With Atrial Fibrillation and Type 2 Diabetes Mellitus: A Danish Cohort Study.

Background Diabetes mellitus is associated with increased risk of stroke in patients with atrial fibrillation, and differences in glycemic status may affect this risk. We aimed to examine the effect of glycemic status evaluated by hemoglobin A1c (HbA1c) on the risk of thromboembolism among patients with atrial fibrillation and type 2 diabetes mellitus. Methods In this cohort study, we used data from Danish registries to identify patients with type 2 diabetes mellitus and incident nonvalvular atrial fibrillation in the period of May 1, 2005, through December 31, 2015. On the basis of the most recent HbA1c measurement before an incident atrial fibrillation diagnosis, patients were divided into the categories: HbA1c ≤48 mmol/mol, HbA1c=49-58 mmol/mol, and HbA1c >58 mmol/mol. Cox regression analysis was used to estimate hazard ratios for the outcome thromboembolism. Results The study population included 5386 patients with incident nonvalvular atrial fibrillation and type 2 diabetes mellitus. Compared with patients with HbA1c ≤48 mmol/mol, we observed a higher risk of thromboembolism among patients with HbA1c=49-58 mmol/mol (hazard ratio, 1.49; 95% CI, 1.09-2.05) and HbA1c >58 mmol/mol (hazard ratio, 1.59; 95% CI, 1.13-2.22) after adjusting for confounding factors. When stratified on diabetes mellitus duration, similar results were found among patients with diabetes mellitus duration of <10 years. Contrastingly, in patients with diabetes mellitus duration of ≥10 years, higher HbA1c levels were not associated with a higher risk of thromboembolism. Conclusions In patients with incident atrial fibrillation and type 2 diabetes mellitus, increasing levels of HbA1c were associated with a higher risk of thromboembolism. However, no association was found among patients with diabetes mellitus duration ≥10 years.

A follow-up study of the occurrence and consequences of HbA1c measurements in an unselected cohort of non-pharmacologically treated patients with Type 2 diabetes.

OBJECTIVES: To describe the occurrence of HbA1c measurements among non-pharmacologically treated diabetes patients, and to evaluate whether poor blood glucose regulation (HbA1c >8%) prompted intensification of treatment. METHOD: Data from the National Health Service Registry, the Regional Laboratory Database and the Danish National Hospital Registry were collected from 2002 to 2004 to identify and describe all Type 2 diabetic patients above 40 years of age in a background population of nearly 660,000 citizens in Aarhus County, corresponding to 12% of the total Danish population. RESULTS: A total of 1989 had at least one HbA1c measurement, whereas 484 (20%) had no HbA1c measurement at all in 2003. Most patients had an HbA1c of less than 8%, and for 820 (41%) HbA1c was less than 6.5%, but for 316 (16%) patients, the first HbA1c measurement in 2003 was above 8%. After 6 months, patients with HbA1c above 8% had a higher probability of initiating pharmacological treatment (M; 0.64; 95% CI 0.58-0.70) (F; 0.68; 95% CI 0.58-0.77) than patients with HbA1c below 8% (M; 0.12; 95% CI 0.10-0.14) (F; 0.11; 95% CI 0.09-0.14). CONCLUSION: This study indicates that poor blood glucose regulation (HbA1c >8%) prompted a shift from non-pharmacological treatment to pharmacological treatment for most patients. However, a substantial group of patients are either not monitored on a regular basis or, if monitored, their elevated measurements of HbA1c do not prompt initiation of pharmacological treatment.

[Combination therapy of thyroxine and triiodothyronine in hypothyroid patients].

Decreased quality of life is described more often in hypothyroid patients, who are treated with a synthetic form of thyroxine (L-T4), than in euthyroid controls. A combination of L-T4 and a synthetic form of triiodothyronine (L-T3) has been suggested; however, previous meta-analyses on unselected patients did not find any effect. Recent studies demonstrate, that the overall hypothalamic-pituitary-thyroid-tissue homeostasis could be more complex than previously suggested. Polymorphisms in deiodinase and thyroid hormone transporter genes could theoretically explain, why a minor subgroup of hypothyroid patients seem to have an effect of L-T4/L-T3 combination therapy.