The STAP-study: The (cost) effectiveness of custom made orthotic insoles in the treatment for plantar fasciopathy in general practice and sports medicine: design of a randomized controlled trial.

BACKGROUND: Plantar fasciopathy is a common cause of foot pain, accounting for 11 to 15% of all foot symptoms requiring professional care in adults. Although many patients have complete resolution of symptoms within 12 months, many patients wish to reduce this period as much as possible. Orthotic devices are a frequently applied option of treatment in daily practice, despite a lack of evidence on the effectiveness. Therefore, the objective is to study the (cost)-effectiveness of custom made insoles by a podiatrist, compared to placebo insoles and usual care in patients with plantar fasciopathy in general practice and sports medicine clinics. METHOD/DESIGN: This study is a multi-center three-armed participant and assessor-blinded randomized controlled trial with 6-months follow-up. Patients with plantar fasciopathy, with a minimum duration of complaints of 2 weeks and aged between 18 and 65, who visit their general practitioner or sport physician are eligible for inclusion. A total of 185 patients will be randomized into three parallel groups. One group will receive usual care by the general practitioner or sports physician alone, one group will be referred to a podiatrist and will receive a custom made insole, and one group will be referred to a podiatrist and will receive a placebo insole. The primary outcome will be the change from baseline to 12 weeks follow-up in pain severity at rest and during activity on a 0-10 numerical rating scale (NRS). Secondary outcomes include foot function (according to the Foot Function Index) at 6, 12 and 26 weeks, recovery (7-point Likert) at 6, 12 and 26 weeks, pain at rest and during activity (NRS) at 6 and 26 weeks and cost-effectiveness of the intervention at 26-weeks. Measurements will take place at baseline and at, 2, 4, 6, 12 and 26 weeks of follow-up. DISCUSSION: The treatment of plantar fasciopathy is a challenge for health care professionals. Orthotic devices are frequently applied, despite a lack of evidence of the effectiveness on patient reported outcome. The results of this randomized controlled trial will improve the evidence base for treating this troublesome condition in daily practice. TRIAL REGISTRATION: Dutch Trial Registration: NTR5346 . Date of registration: August 5(th) 2015.

Effectiveness and cost-effectiveness of 3-monthly versus 6-monthly monitoring of well-controlled type 2 diabetes patients: a pragmatic randomised controlled patient-preference equivalence trial in primary care (EFFIMODI study).

AIM: To investigate effectiveness and cost-effectiveness of 6-monthly monitoring compared with 3-monthly monitoring of well-controlled type 2 diabetes patients in primary care. METHODS: A pragmatic randomised controlled patient-preference equivalence trial was performed. From April 2009 to August 2010, 2215 patients from 233 general practitioners across the Netherlands were included. Patients were eligible if between 40- and 80-years-old, diagnosed with type 2 diabetes for more than a year, treated by their general practitioner, not on insulin treatment and well-controlled during the last year (HbA1c ≤ 58 mmol/mol, systolic blood pressure ≤ 145 mmHg and total cholesterol ≤ 5.2 mmol/l). Patients without a strong preference for their monitoring frequency were randomised to 3-monthly or 6-monthly monitoring. Follow-up was 18 months. The primary outcome is the percentage of patients remaining under: HbA1c ≤ 58 mmol/mol, systolic blood pressure ≤ 145 mmHg and total cholesterol ≤ 5.2 mmol/l. Equivalence was assumed if the two-sided 95% confidence interval (CI) was between -5 and 5%. Cost-effectiveness was determined using a cost-minimisation analysis. RESULTS: In the 3-monthly group 69.5% remained under good cardiometabolic control, versus 69.8% in the 6-monthly group (difference: 0.3%; 95%CI: -6.2-6.7%). All secondary outcomes were equivalent for 3-monthly and 6-monthly monitoring, except the systolic blood pressure target, physical activity and antihypertensive drug use. Six-monthly monitoring was €387 (£333) cheaper per patient compared to 3-monthly monitoring during the study period. CONCLUSIONS: Patients with good cardiometabolic control and without preference for their monitoring frequency can visit the primary care physician less often. The cost-savings can be considerable.

Effectiveness of peer-led self-management coaching for patients recently diagnosed with Type 2 diabetes mellitus in primary care: a randomized controlled trial.

AIMS: To study the effectiveness of a peer-led self-management coaching intervention in recently diagnosed patients with Type 2 diabetes. METHODS: Randomized controlled trial of recently diagnosed patients with Type 2 diabetes from 54 participating general practices. The intervention group received three home visits by an experienced peer (expert patient) who adhered to the recommended treatment and lifestyle guidelines. Together with their expert patient, participants set feasible goals and these were evaluated in the next visit. Participants in the control group received care as usual. At baseline, 3 months and 6 months post-intervention, participants completed a questionnaire measuring changes in self-efficacy, coping, physical activity, dietary habits, psychological well-being, depressive symptoms and diabetes related distress. RESULTS: In total, 327 patients were eligible for inclusion in the study of which 133 consented to participate. In participating patients, self-efficacy, coping and saturated fat intake improved significantly over time. Analyses of participants with low self-efficacy at baseline (25th percentile: 44) revealed a significant time × group difference, F = 3.71; P = 0.03. Participants who reported low psychological well-being at baseline increased substantially throughout the study (F = 23.84; P < 0.01) but no significant time × group differences were found. CONCLUSIONS: A peer-led self-management coaching programme for recently diagnosed patients with Type 2 diabetes improved self-efficacy of patients experiencing low self-efficacy shortly after diagnosis.

Diabetes Care Protocol: effects on patient-important outcomes. A cluster randomized, non-inferiority trial in primary care.

AIMS: The Diabetes Care Protocol (DCP) combines task delegation, intensification of diabetes treatment and feedback. It reduces cardiovascular risk in Type 2 diabetes (T2DM) patients. This study determines the effects of DCP on patient-important outcomes. METHODS: A cluster randomized, non-inferiority trial, by self-administered questionnaires in 55 Dutch primary care practices: 26 practices DCP (1699 patients), 26 usual care (1692 patients). T2DM patients treated by their general practitioner were included. Main outcome was the 1-year between-group difference in Diabetes Health Profile (DHP-18) total score. SECONDARY OUTCOMES: DHP-18 subscales, general perceived health [Medical Outcomes Study 36-Items Short Form Health Survey (SF-36), Euroqol 5 Dimensions (EQ-5D) and Euroqol visual analogue scale (EQ-VAS)], treatment satisfaction (Diabetes Treatment Satisfaction Questionnaire; DTSQ status) and psychosocial self-efficacy (Diabetes Empowerment Scale Short Form; DES-SF). Per protocol (PP) and intention-to-treat (ITT) analyses were performed: non-inferiority margin Delta=-2%. At baseline 2333 questionnaires were returned and 1437 1 year thereafter. RESULTS: Comparing DCP with usual care, DHP-18 total score was non-inferior: PP -0.88 (95% CI -1.94 to 0.12), ITT -0.439 (95% CI -1.01 to 0.08), SF-36 'health change' improved: PP 3.51 (95% CI 1.23 to 5.82), ITT 1.91 (95% CI 0.62 to 3.23), SF-36 'social functioning' was inconclusive: PP-1.57 (95% CI-4.3 to 0.72), ITT-1.031 (95% CI-2.52 to -0.25). Other DHP and SF-36 scores were inconsistent or non-inferior. DHP-18 'disinhibited eating' was significantly worse in PP analyses. For EQ-5D/EQ-VAS, DTSQ and DES-SF, no significant between-group differences were found. CONCLUSION: DCP does not seem to influence health status negatively, therefore diabetes care providers should not shrink from intensified treatment. However, they should take possible detrimental effects on 'social functioning' and 'disinhibited eating' into account.

Preferences and opinions of patients with Type 2 diabetes on education and self-care: a cross-sectional survey.

OBJECTIVE: To assess the preferences of patients with Type 2 diabetes regarding self-care activities and diabetes education. RESEARCH DESIGN AND METHODS: Questionnaire survey carried out in general practices and outpatient clinics across the Netherlands. OUTCOMES: preferred setting for education, preferred educator, and preferred and most burdensome self-care activity. Multinomial logistic regression analysis assessed associations between outcomes and patient characteristics, preferences and opinions. RESULTS: Data of 994 consecutive individuals were analysed (mean 65 years; 54% male; 97% Caucasian; 21% low education level; 80% primary care). Of these, 19% thought they had poor to average glycaemic control, 61% thought they were over-weight and 32% thought they took too little exercise. Eighty per cent of respondents preferred diabetes education during regular diabetes check-ups. Patients taking insulin preferred education to be given by nurses [odds ratio (OR) 2.45; 95% confidence interval (CI) 1.21-4.96]. Individuals who thought their health to be poor/average preferred education to be given by doctors (OR 1.65; 95% CI 1.08-2.53). Physical exercise was the preferred self-care activity of those who thought they took too little exercise (OR 1.97; 95% CI 1.32-2.93) but was preferred less by patients with mobility problems (OR 0.65; 95% CI 0.43-0.97). Patients with eating disinhibition reported keeping to a healthy diet (OR 4.63; 3.00-7.16) and taking medication (OR 1.66; 95% CI 1.09-2.52) as the most burdensome self-care activities. Age was not an independent determinant of any preference. CONCLUSIONS: When providing education for patients with newly diagnosed Type 2 diabetes, healthcare providers should consider making a tailored education plan, irrespective of the patient's age.

CHECK (Cohort Hip and Cohort Knee): similarities and differences with the Osteoarthritis Initiative.

OBJECTIVE: To describe the osteoarthritis study population of CHECK (Cohort Hip and Cohort Knee) in comparison with relevant selections of the study population of the Osteoarthritis Initiative (OAI) based on clinical status and radiographic parameters. METHODS: In The Netherlands a prospective 10-year follow-up study was initiated by the Dutch Arthritis Association on participants with early osteoarthritis-related complaints of hip and/or knee: CHECK. In parallel in the USA an observational 4-year follow-up study, the OAI, was started by the National Institutes of Health, on patients with or at risk of symptomatic knee osteoarthritis. For comparison with CHECK, the entire cohort and a subgroup of individuals excluding those with exclusively hip pain were compared with relevant subpopulations of the OAI. RESULTS: At baseline, CHECK included 1002 participants with in general similar characteristics as described for the OAI. However, significantly fewer individuals in CHECK had radiographic knee osteoarthritis at baseline when compared with the OAI (p<0.001). In contrast, at baseline, the CHECK cohort reported higher scores on pain, stiffness and functional disability (Western Ontario and McMaster osteoarthritis index) when compared with the OAI (all p<0.001). These differences were supported by physical health status in contrast to mental health (Short Form 36/12) was at baseline significantly worse for the CHECK participants (p<0.001). CONCLUSION: Although both cohorts focus on the early phase of osteoarthritis, they differ significantly with respect to structural (radiographic) and clinical (health status) characteristics, CHECK expectedly representing participants in an even earlier phase of disease.

Influence of antidepressants on glycaemic control in patients with diabetes mellitus.

PURPOSE: Anecdotal evidence suggests that antidepressants (ADs) may complicate glycaemic control. The objective of this longitudinal study was to investigate the influence of ADs on glycaemic control within diabetes patients. METHODS: From the pharmacy registry database PHARMO, we selected insulin users who did not use oral antidiabetics. The study population comprised: 133 patients with at least 12 months insulin use before and 6 months during an AD episode, including 56 patients with an additional 6 months of insulin use after the AD episode; 180 patients with 24 months insulin use without an AD episode. Glycaemic control was measured as the amount of insulin used, which was calculated intra-individually in 3-month periods. We stratified for selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs). RESULTS: Mean age (s.d.) of the subjects was 53.9 (19) years; 46.9% were men. Overall, the amount of insulin used did not change during or after AD use. No-AD users showed an increase of 16% in amount of insulin used over a period of 2 years (p < 0.001). SSRI users showed a decrease of 13% in amount of insulin used during the AD episode (p = 0.029), while no change was seen in TCA users. Notable was the large intra- and interindividual variation in amount of insulin used across all groups. CONCLUSIONS: Overall, AD use did not influence glycaemic control in diabetes patients. The tendency for a difference between SSRIs and TCAs is suggestive for a pharmacologic effect of ADs rather than a general effect of depression on glycaemic control.

[Increased risk of infection in patients with diabetes mellitus type 1 or 2]. / Toegenomen risico op infecties bij patiënten met diabetes mellitus type 1 of 2.

OBJECTIVE: To determine the risk of common infections in patients with diabetes mellitus type 1 (DM1) or type 2 (DM2). DESIGN: Prospective controlled study. METHODS: In a 12-month prospective cohort study as part of the Second Dutch National Survey of General Practice, 705 adult DM1 and 6,712 DM2 patients were compared with 18,911 control patients who had hypertension without diabetes. Outcome measures were medically-attended episodes of infections of the respiratory tract, urinary tract, skin and mucous membranes. Multivariate and multinomial logistic regression analysis was applied to determine independent risks of infections and their recurrence in patients with diabetes compared to controls. RESULTS: Upper respiratory-tract infections were as common in diabetes patients as in controls. Diabetes patients had a higher risk of lower respiratory-tract infections (DM2: odds ratio (OR): 1.30; 95% CI: 1.11-1.52), urinary-tract infections (DM1: OR: 1.56; 95% CI: 1.13-2.15; DM2: OR: 1.21; 95% CI: 1.07-1.38), bacterial skin or mucous-membrane infections (DM1: OR: 1.48; 95% CI: 1.01-2.15; DM2: OR: 1.32; 95% CI: 1.13-1.55) and mycotic skin or mucous-membrane infections (DM2: OR: 1.41; 95% CI: 1.24-1.61). The risk of recurrence of these common infections was seen to be increased. CONCLUSIONS: Patients with type-1 and type-2 diabetes are at increased risk of lower respiratory-tract infections, urinary-tract infections and skin or mucous-membrane infections.

Increased risk of common infections in patients with type 1 and type 2 diabetes mellitus.

BACKGROUND: Clinical data on the association of diabetes mellitus with common infections are virtually lacking, not conclusive, and often biased. We intended to determine the relative risks of common infections in patients with type 1 and type 2 diabetes mellitus (DM1 and DM2, respectively). METHODS: In a 12-month prospective cohort study conducted as part of the Second Dutch National Survey of General Practice, we compared 705 adult patients who had DM1 and 6712 adult patients who had DM2 with 18,911 control patients who had hypertension without diabetes. Outcome measures were medically attended episodes of infection of the respiratory tract, urinary tract, and skin and mucous membranes. We applied multivariable and polytomous logistic regression analysis to determine independent risks of infections and their recurrences in patients with diabetes, compared with control patients. RESULTS: Upper respiratory infections were equally common among patients with diabetes and control patients. Patients with diabetes had a greater risk of lower respiratory tract infection (for patients with DM1: adjusted odds ratio [AOR], 1.42 [95% confidence interval {CI}, 0.96-2.08]; for patients with DM2: AOR, 1.32 [95% CI, 1.13-1.53]), urinary tract infection (for patients with DM1: AOR, 1.96 [95% CI, 1.49-2.58]; for patients with DM2: AOR, 1.24 [95% CI, 1.10-1.39]), bacterial skin and mucous membrane infection (for patients with DM1: AOR, 1.59 [95% CI, 1.12-2.24]; for patients with DM2: AOR, 1.33 [95% CI, 1.15-1.54]), and mycotic skin and mucous membrane infection (for patients with DM1: AOR, 1.34 [95% CI, 0.97-1.84]; for patients with DM2: AOR, 1.44 [95% CI, 1.27-1.63]). Risks increased with recurrences of common infections. CONCLUSIONS: Patients with DM1 and DM2 are at increased risk for lower respiratory tract infection, urinary tract infection, and skin and mucous membrane infection. Studies are warranted into management of such infections in patients with diabetes.

Nontraumatic foot complaints in older people. A population-based survey of risk factors, mobility, and well-being.

In a population-based cross-sectional survey conducted in the Netherlands of 7,200 people aged 65 years and older (with a response rate of 79%), 20% of the respondents were found to have nontraumatic foot complaints of more than 4 weeks' duration, often involving the forefoot. Female sex, joint disease, and multimorbidity were found to be risk factors for the presence of foot complaints; older age and obesity were not. Respondents with these complaints had limited mobility and poor perceived well-being.

[Summary of the Dutch College of General Practitioners' "Gout" Standard]. / Samenvatting van de standaard 'Jicht' van het Nederlands Huisartsen Genootschap.

The typical form of acute gout can be clinically diagnosed. The term 'complicated gout' is used if there are more than three acute attacks of gout per year, tophi or urate stones in the urinary tracts. In the case of recurrent probable acute gout, a diagnostic fine needle aspirate from the joint during an attack is indicated. First choice treatment of acute gout consists of NSAIDs. Colchicine is the second choice treatment and the third choice treatment consists of corticosteroids. Excessive alcohol use should be limited. Treatment of chronic gout depends on the uric acid excretion in the 24-hour urine. If the level of excretion is too low, the first choice should be benzbromarone, and if the uric acid output is too high, allopurinol should be the treatment of first choice. Increased fluid intake is recommended; maintenance treatment with colchicine is not advised. Consultation with or referral to a rheumatologist is indicated in the case of doubt about the diagnosis of 'acute gout' or 'complicated gout', or (suspected) bacterial arthritis and insufficient treatment effect.

[Improvement of glycemic regulation without exogenous insulin in 40% of poorly regulated patients with type 2 diabetes mellitus; a study in 18 family practices]. / Verbetering van glykemische regulering zonder exogeen insuline bij 40% van slecht ingestelde patiënten met diabetes mellitus type 2; een onderzoek in 18 huisartspraktijken.

OBJECTIVE: To determine the possibility of improving glycaemic control in poorly regulated patients with type 2 diabetes mellitus (DM 2) through maximization of oral medication by the general practitioner followed by education and instruction in self-regulation by the diabetes nurse, as required. DESIGN: Explorative, descriptive, prospective cohort study. METHOD: 24 general practitioners selected all known patients with DM 2 and poor glycaemic control (HbA1c value > or = 8% and/or fasting blood glucose > 8 mmol/l), and maximized oral blood glucose lowering drugs if possible. When the HbA1c level remained > or = 8%, patients were referred to the diabetes nurse. RESULTS: In a population of 735 patients with DM 2 treated by the general practitioner, 146 patients were poorly regulated. Out of 112 patients with sub-maximal therapy, 50 achieved an HbA1c < 8% after adjustment of oral therapy. Of the 60 poorly regulated patients on maximum therapy, 39 were referred to the diabetes nurse. Nine of these patients subsequently achieved an HbA1c level < 8%. CONCLUSION: In 40% (50 + 9/146) of the poorly regulated patients with DM 2, improvement of glycaemic control could be achieved through optimization of oral therapy by the general practitioner and diabetes nurse, without exogen administered insulin.

Development of metabolic syndrome components in adults with a healthy obese phenotype: a 3-year follow-up.

OBJECTIVE: There is a lack of data on the progression from a healthy obese phenotype toward an unhealthy obese phenotype and the development of metabolic syndrome (MetS). Our aim was to assess the development of MetS 3 years after screening in centrally obese individuals with a healthy obese phenotype and to evaluate the usefulness of repeated screening. DESIGN AND METHODS: Eighty-eight individuals (mean age 47 years, 88% female) with central obesity as their only MetS component (ATP III criteria) at baseline screening were re-evaluated for MetS status after 3 years. RESULTS: At follow-up, the cardiometabolic risk profile in centrally obese individuals with a healthy phenotype showed a tendency toward deterioration. Thirty-two percent developed at least one additional MetS component, 7% had developed MetS. Nobody had developed type 2 diabetes. An increased triglyceride level (n = 16) and an increased blood pressure (n = 18) were the components most often present at follow-up. The people developing additional MetS components had a lower education level compared with the group that preserved the healthy centrally obese phenotype (80 vs. 71% lower educated, P = 0.35). They also had slightly worse baseline levels of the risk factors. CONCLUSION: The number of centrally obese individuals developing an unhealthy phenotype in this relatively short follow-up period emphasizes the need for a regular surveillance of cardiometabolic parameters in centrally obese individuals. However, it is questionable whether a repeated screening for type 2 diabetes every 3 years, as recommended by the American Diabetes Association, in this category of patients is appropriate.

Incidence and antibiotic prescription rates for common infections in patients with diabetes in primary care over the years 1995 to 2003.

OBJECTIVE: To assess changes in incidence and in antibiotic prescription rates for infections of the lower respiratory tract (LRTI) and urinary tract (UTI) in patients with diabetes (DM) over the years 1995 to 2003. METHODS: This was a retrospective cohort study as part of the University Medical Center Utrecht General Practitioners Research Network. We included patients with DM aged > or = 45 years. We assessed incidence and antibiotic prescription rates for LRTI and UTI. Incidence rates were calculated as episodes per 1000 person-years. Antibiotic prescription rates were calculated per 100 episodes of LRTI and UTI. RESULTS: The study population increased over the years 1995 to 2003. The male-to-female ratio and mean age of the study population remained constant over these years. The incidence rate for LRTI remained stable (13%; p=0.442), and for UTI the incidence rate increased by 40% (p=0.037). Antibiotic prescription rates increased in LRTI by 60% (p<0.001) and in cystitis by 15% (p=0.029). CONCLUSIONS: Incidence rates for UTI and antibiotic prescription rates for LRTI in diabetes have increased over the years 1995 to 2003. In particular, attention should be paid to the increasing use of antibiotics in DM patients with LRTI.

A clinical prediction rule for urinary tract infections in patients with type 2 diabetes mellitus in primary care.

We aimed to develop a prediction rule for urinary tract infections (UTIs) in patients with type 2 diabetes mellitus (DM2). A 12-month prospective cohort study was conducted in patients with DM2 aged > or = 45 years to predict the occurrence of recurrent UTIs in women and lower UTIs in men. Predictors for recurrent UTI in women (n=81, 2%) and lower UTIs in men (n=93, 3%) were age, number of general practitioner (GP) visits, urinary incontinence, cerebrovascular disease or dementia. In women, renal disease was an additional predictor. The optimism [corrected] corrected area under the receiver-operating curve (AUC) was 0.79 (95% CI 0.74-0.83) for women and 0.75 (95% CI 0.70-0.80) for men. Using a cut-off score of 4, women with a lower risk assignment had a probability of 0.3% for the outcome. For a cut-off score of 6, women with a higher risk assignment had a probability of 5.8%. For men these figures were 0.8 and 7.1 for a cut-off score of 2 and 4, respectively. Simple variables can be used for the risk stratification of patients.

Low yield of population-based screening for Type 2 diabetes in the Netherlands: the ADDITION Netherlands study.

BACKGROUND: About 10 years ago, it was estimated that half of all people with diabetes were unrecognized. Since then, according to the national guidelines, case finding for diabetes in general practice has become common in the Netherlands, resulting in a substantial increase of the prevalence of known diabetes. Nevertheless, the need for population-based screening is advocated, especially by the national federation of diabetes patients. OBJECTIVE: To evaluate the efficiency of population-based screening for Type 2 diabetes. METHODS: From 2002 to 2004, we performed a four-step screening procedure [questionnaire, random glucose measurement, fasting glucose measurement and oral glucose tolerance test (OGTT)] and a three-step procedure (without random glucose measurement) in 79 general practices in the southwestern region of the Netherlands. RESULTS: A total of 56 978 non-diabetic subjects, aged 50-70 years, were asked to complete the questionnaire. Those with a score above threshold underwent further glucose testing. Eventually, 586 participants (1.0%) were diagnosed with Type 2 diabetes (in four-step procedure 285 subjects and in three-step procedure 301). Impaired glucose regulation was assessed in 1011 participants (1.8%). Dropout rate in the screening programme among participants who should undergo an OGTT was 23.4%. The risk score was higher if glucose metabolism was more disturbed. CONCLUSION: In the Netherlands, the yield of population-based screening is low. The dropout among high-risk individuals was high. Given the decreasing prevalence of undiagnosed diabetes and the possibility of opportunistic screening on a continuous basis, opportunistic screening for diabetes might be more appropriate than population-based screening. Further research on this topic is needed.

Shared and delegated systems are not quick remedies for improving diabetes care: a systematic review.

BACKGROUND: Type 2 diabetes is an important, chronic condition notorious for its costly and disabling complications. Nowadays, enhanced cooperation is expected to improve the quality of diabetes care and reduce risks for chronically ill patients. It is, however, questionable whether this assumption is evidence based. METHODS: Using a structured literature search, we selected systematic reviews, randomised controlled trials (RCTs) and other effect evaluations regarding the sharing and allocation of diabetes care. RESULTS: We selected 22 studies to include in this review. The process of care improved in all studies investigating this quality aspect. HbA1c improved in seven reviews and in five other studies. All included reviews and four RCTs were unable to demonstrate a positive effect on blood pressure. Total cholesterol improved in two reviews and five other studies. CONCLUSIONS: The sharing and allocation of diabetes care leads to significant reduction in HbA1c and improves the process of care. However, this improvement has not as yet led to better cardiovascular risk management. For a number of reasons, a truly accurate estimation of the results of shared and allocated diabetes care within the Dutch diabetes care system is not possible.