Introduction of diabetes passports involving both patients and professionals to improve hospital outpatient diabetes care.

AIM: To investigate whether a comprehensive strategy involving both patients and professionals, with the introduction of a diabetes passport as a key component, improves diabetes care. METHODS: The first 150 consecutive patients who visited their internist for a diabetes check up at the internal medicine outpatient departments at each of nine Dutch general hospitals were included in this 1 year clustered, randomised, controlled trial. Health care professionals attended an educational meeting about the use and dissemination of the diabetes passport which is a patient held record. They also received aggregated feedback on baseline data and personal feedback. Educational meetings were also organised for patients. Patient files were used in conjunction with questionnaires to determine adherence rates. Data were analysed using multilevel regression analysis. RESULTS: Small but significant changes were found in mean HbA1c levels. In the intervention group, positive health changes for patients were found (-0.3%) when compared to those in the control group (+0.2%). Diastolic blood pressure improved slightly, but no changes were found in systolic blood pressure or cholesterol. Improvements were found with regard to levels of examination of patients' feet and in patient education. CONCLUSIONS: Efforts to improve professional practice involving both professionals and patients led to small improvements in HbA1c and diastolic blood pressure levels. Further study is needed to establish whether a better structured health care delivery, operating in a more supportive environment can enhance these effects.

Perceived barriers to the implementation of diabetes guidelines in hospitals in The Netherlands.

OBJECTIVE: To determine the organisational and personal barriers to the implementation of diabetes guidelines in hospitals in The Netherlands and relate them to structural factors of diabetes care. METHOD: In a written survey internists specialised (or with a specific interest) in diabetes in all general hospitals in The Netherlands (n = 120) were asked to indicate the perceived organisational and personal barriers to adherence to the diabetes guidelines. In the same questionnaire their activities related to diabetes care and the working hours of the additional personnel involved were measured. RESULTS: There was at least one specialised diabetes nurse employed in all hospitals, although the extent of the appointment varied widely from 0.2 to 6.9 full-time equivalent (average 1.5). In most hospitals (90%) a diabetes care team had been established, while podiatrists were working in only 72% of the hospitals. Furthermore, 65-80% of the hospitals organised special consultation hours for diabetic patients, had a protocol for diabetes treatment, or patient held administration booklets. The most frequently mentioned barriers to the implementation of diabetes guidelines were high workload, no adequate financial compensation, and a shortage of necessary personnel. CONCLUSION: A number of preconditions for structured diabetes care, like the presence of a diabetes team and a specialised diabetes nurse, were in place. However, large differences between the hospitals in the organisation of diabetes care and the availability of staff, together with the related perceived barriers to the implementation of the guidelines showed that there are still many opportunities for improvements.

[Left ventricular hypertrophy; differences in the diagnostic and prognostic value of electrocardiography and echocardiography]. / Linkerventrikelhypertrofie; verschillen in diagnostische en prognostische waarde van elektrocardiografie en echocardiografie.

OBJECTIVE: To compare the electrocardiogram (ECG) and the echocardiogram for demonstration of left ventricular hypertrophy (LVH) and the prognostic values of these methods. DESIGN: Literature study. SETTING: Department of General Practice, Social and Nursing Home Medicine, R.C. University of Nijmegen, the Netherlands. METHOD: Using articles retrieved by means of a search action in Medline (1962-January 1996), a study was made of the differences between determination of LVH by ECG and by echocardiography with regard to the sensitivities and specificities for measuring anatomical LVH, and their predictive values concerning cardiovascular morbidity and mortality. RESULTS: The sensitivity of echocardiography for the prediction of anatomical LVH (88-93%) exceeded that of ECG (21-54%), while both methods had a high specificity (77-97%). ECG-LVH seemed a better predictor of cardiovascular complications than echo-LVH. CONCLUSION: Echocardiography is the better instrument for screening for LVH, but ECG should keep its place in the diagnostics of LVH in view of its high predictive value for morbidity and mortality and its availability to primary health care. In regard to LVH, echocardiography measures only morphological disorders, while ECG also detects functional disorders.

Patient-centred and professional-directed implementation strategies for diabetes guidelines: a cluster-randomized trial-based cost-effectiveness analysis.

AIMS: Economic evaluations of diabetes interventions do not usually include analyses on effects and cost of implementation strategies. This leads to optimistic cost-effectiveness estimates. This study reports empirical findings on the cost-effectiveness of two implementation strategies compared with usual hospital outpatient care. It includes both patient-related and intervention-related cost. PATIENTS AND METHODS: In a clustered-randomized controlled trial design, 13 Dutch general hospitals were randomly assigned to a control group, a professional-directed or a patient-centred implementation programme. Professionals received feedback on baseline data, education and reminders. Patients in the patient-centred group received education and diabetes passports. A validated probabilistic Dutch diabetes model and the UKPDS risk engine are used to compute lifetime disease outcomes and cost in the three groups, including uncertainties. RESULTS: Glycated haemoglobin (HbA(1c)) at 1 year (the measure used to predict diabetes outcome changes over a lifetime) decreased by 0.2% in the professional-change group and by 0.3% in the patient-centred group, while it increased by 0.2% in the control group. Costs of primary implementation were < 5 Euro per head in both groups, but average lifetime costs of improved care and longer life expectancy rose by 9389 Euro and 9620 Euro, respectively. Life expectancy improved by 0.34 and 0.63 years, and quality-adjusted life years (QALY) by 0.29 and 0.59. Accordingly, the incremental cost per QALY was 32 218 Euro for professional-change care and 16 353 for patient-centred care compared with control, and 881 Euro for patient-centred vs. professional-change care. Uncertainties are presented in acceptability curves: above 65 Euro per annum the patient-directed strategy is most likely the optimum choice. CONCLUSION: Both guideline implementation strategies in secondary care are cost-effective compared with current care, by Dutch standards, for these patients. Additional annual costs per patient using patient passports are low. This analysis supports patient involvement in diabetes in the Netherlands, and probably also in other Western European settings.

Patients and nurses determine variation in adherence to guidelines at Dutch hospitals more than internists or settings.

AIMS: To measure adherence to recently developed diabetes guidelines at Dutch hospital outpatient clinics and distinguish determinants for variations in care on hospital, internist and patient levels. METHODS: Thirteen general hospitals with 58 internists recruited 1950 diabetic patients. Data were extracted from medical files (n = 1915) and from patient questionnaires (n = 1465). Multilevel logistic regression analysis was performed to explain differences in adherence rates to the guidelines. RESULTS: Adherence to process measures was high, except for the examination of feet, calculation of the body mass index and patient education activities (the mean of 12 process measures was 64%). Adherence to intermediate outcome indicators was moderate. The mean percentage of patients with HbA(1c) < 7.0% was 23%. Adherence variation on a hospital level was very small (0.6-7.9%), on an internist level moderate (0.4-18.8%) and on a patient level high (74.4-98.8%). Adherence to all process measures and most of the intermediate outcome indicators was highest in the patients seen by a diabetes specialist nurse. DISCUSSION: More focus on patient involvement in diabetic care and the contribution of diabetes specialist nurses may be important factors in improving the quality of diabetes care.