A risk score including body mass index, glycated haemoglobin and triglycerides predicts future glycaemic control in people with type 2 diabetes.

AIM: To identify, predict and validate distinct glycaemic trajectories among patients with newly diagnosed type 2 diabetes treated in primary care, as a first step towards more effective patient-centred care. METHODS: We conducted a retrospective study in two cohorts, using routinely collected individual patient data from primary care practices obtained from two large Dutch diabetes patient registries. Participants included adult patients newly diagnosed with type 2 diabetes between January 2006 and December 2014 (development cohort, n = 10 528; validation cohort, n = 3777). Latent growth mixture modelling identified distinct glycaemic 5-year trajectories. Machine learning models were built to predict the trajectories using easily obtainable patient characteristics in daily clinical practice. RESULTS: Three different glycaemic trajectories were identified: (1) stable, adequate glycaemic control (76.5% of patients); (2) improved glycaemic control (21.3% of patients); and (3) deteriorated glycaemic control (2.2% of patients). Similar trajectories could be discerned in the validation cohort. Body mass index and glycated haemoglobin and triglyceride levels were the most important predictors of trajectory membership. The predictive model, trained on the development cohort, had a receiver-operating characteristic area under the curve of 0.96 in the validation cohort, indicating excellent accuracy. CONCLUSIONS: The developed model can effectively explain heterogeneity in future glycaemic response of patients with type 2 diabetes. It can therefore be used in clinical practice as a quick and easy tool to provide tailored diabetes care.

Gender differences in the evaluation of care for patients with type 2 diabetes: a cross-sectional study (ZODIAC-52).

BACKGROUND: Little is known about the association between patient-related factors and patients' evaluation of care. Aim was to investigate which patient-related factors are associated with patients' evaluation of care in men and women with type 2 diabetes (T2D) in primary care. METHODS: This cross-sectional study included 1102 patients with T2D from 52 general practices. We measured patients' evaluation with the EUROPEP questionnaire and collected demographic, clinical and psychological data from questionnaires and health records. Stepwise linear regression analyses were used. RESULTS: The location where the questionnaire was completed (at home or at the general practice) was associated with all outcomes in men and women. Next to this, in men, explanatory factors for the care provider EUROPEP subscale were use of insulin, having some problems with T2D self-care and coffee consumption (R2 8.4%); coffee consumption was associated with the general practice subscale (R2 4.0%). In women, well-being, quality of life, following a general diet, and use of oral glucose-lowering drugs were associated with the care provider subscale (R2 16.8%). For the general practice subscale, well-being and age were explanatory factors (R2 9.4%). CONCLUSIONS: Only a few factors were found to be associated with patients' evaluation of care for men and women with T2D. Taken together, these factors explained only a small part of the variance of the EUROPEP scores. This explained variance was largely attributable to the location where the questionnaire was completed. We therefore advise to be aware of the possible consequences of filing-out questionnaires about patients' evaluation of care at the general practice. TRIAL REGISTRATION: NCT01570140 (Clinicaltrials.gov). Registered 29 March 2012.

High-sensitive troponin T is associated with all-cause and cardiovascular mortality in stable outpatients with type 2 diabetes (ZODIAC-37).

BACKGROUND: We aimed to investigate whether high-sensitive cardiac troponin T (hs-cTnT) is associated with all-cause and cardiovascular mortality in stable type 2 diabetes (T2D) outpatients treated in primary care. METHODS: Cardiac troponin T was measured with a high-sensitive assay at baseline in patients with T2D participating in the observational ZODIAC study. Cox proportional hazards models were used to investigate the relationship between hs-cTnT and mortality with adjustment for selected confounders. Risk prediction capabilities of hs-cTnT were assessed with Harrell C statistics. RESULTS: Complete baseline data were available for 1,133 patients. During median follow-up of 11 (7-14) years, 513 (45%) patients died, of which 218 (42%) died of cardiovascular causes. Of the patients with undetectable hs-cTnT levels (<3 ng/L), only 23% died, compared with 58% with low detectable levels (3-14 ng/L) and 84% with raised levels (≥14 ng/L). Natural log hs-cTnT was significantly associated with all-cause mortality (hazard ratio 1.30, 95% CI 1.19-1.42) and cardiovascular mortality (hazard ratio 1.33, 95% CI 1.15-1.53), independent of potential confounders. The Harrell C statistic for the crude model of hs-cTnT was 0.72 (95% CI 0.70-0.75) for all-cause mortality and 0.74 (95% CI 0.71-0.77) for cardiovascular mortality. CONCLUSIONS: Higher levels of hs-cTnT are associated with mortality in stable outpatients with T2D. The high crude Harrell C values and the excellent prognosis of patients with undetectable levels illustrate the strength of hs-cTnT as a potential marker for mortality.

Validation of the howRu and howRwe questionnaires at the individual patient level.

BACKGROUND: The howRu and howRwe are new short questionnaires which are meant to measure health-related quality of life and patient experience. However, validation at the individual patient level has not yet taken place. We aimed to investigate the validity of both questionnaires at the individual patient level. METHODS: In this prospective validation study, patients were asked to complete both questionnaires and comment on their answers in a semi-structured in-depth interview. Based on the transcribed interviews, a panel of 45 general practitioners and 45 patients filled out the questionnaires as they thought the patients had completed them. The questionnaires were considered valid instruments when a reliable and acceptable level of agreement was reached between the patient's score and the score of a review panel, defined as a concordance correlation coefficient (CCC) of ≥0.70. Bland-Altman plots were also made. RESULTS: Ninety patients were included. The CCC of the howRu total score of the review panel and patients was 0.80 (95 % CI 0.73 to 0.86). Bland-Altman plots showed a mean difference of -0.96 and the limits of agreement ranged from -2.87 to 0.95. The CCC of the howRwe total score was 0.57 (95 % CI 0.42 to 0.69). The mean difference on the Bland-Altman plots was -0.54 and the limits of agreement ranged from -3.59 to 2.52. CONCLUSIONS: The howRu seems to be a valid questionnaire for measuring health-related quality of life at the individual patient level. We do not advice to use the tested version of the howRwe questionnaire for assessing patient experience at the individual patient level. TRIAL REGISTRATION: The study was registered at clinicaltrials.gov NCT01830803 . Registration date: 5 April 2013.

Design of the e-Vita diabetes mellitus study: effects and use of an interactive online care platform in patients with type 2 diabetes (e-VitaDM-1/ZODIAC-40).

UNLABELLED: Trial registration: NCT01570140. BACKGROUND: Due to ongoing rise in need for care for people with chronic diseases and lagging increase in number of care providers, alternative forms of care provision and self-management support are needed. Empowering patients through an online care platform could help to improve patients' self-management and reduce the burden on the healthcare system. METHODS: Access to laboratory results and educational modules on diabetes will be offered through a platform for subjects with type 2 diabetes mellitus treated in primary care. Differences in socio-demographic and clinical characteristics between subjects expressing interest vs. disinterest to use the platform will be explored. Platform usage will be tracked and compared. Patient satisfaction and quality of life will be measured by validated questionnaires and economic analyses will be performed. DISCUSSION: This study is designed to assess the feasibility of use of an online platform in routine primary healthcare for subjects with type 2 diabetes mellitus in the Netherlands, and to study effects of use of the platform on treatment satisfaction, quality of life and clinical parameters. Although providing access to a online platform is not a novel intervention, usage and effects have not yet been studied in this patient population.

Type 2 diabetes seems not to be a risk factor for the carpal tunnel syndrome: a case control study.

BACKGROUND: Previous studies have shown that the carpal tunnel syndrome seems to occur more frequently in patients with diabetes mellitus and might be associated with the duration of diabetes mellitus, microvascular complications and degree of glycaemic control. Primary aim was to determine if type 2 diabetes can be identified as a risk factor for carpal tunnel syndrome after adjusting for possible confounders. Furthermore, the influence of duration of diabetes mellitus, microvascular complications and glycaemic control on the development of carpal tunnel syndrome was investigated. METHODS: Retrospective, case-control study using data from electronic patient charts from the Isala (Zwolle, the Netherlands). All patients diagnosed with carpal tunnel syndrome in the period from January 2011 to July 2012 were included and compared with a control group of herniated nucleus pulposus patients. RESULTS: A total of 997 patients with carpal tunnel syndrome and 594 controls were included. Prevalence of type 2 diabetes was 11.5% in the carpal tunnel syndrome group versus 7.2% in the control group (Odds Ratio 1.67 (95% confidence interval 1.16-2.41)). In multivariate analyses adjusting for gender, age and body mass index, type 2 diabetes was not associated with carpal tunnel syndrome (OR 0.99 (95% CI 0.66-1.47)). No differences in duration of diabetes mellitus, microvascular complications or glycaemic control between groups were detected. CONCLUSION: Although type 2 diabetes was more frequently diagnosed among patients with carpal tunnel syndrome, it could not be identified as an independent risk factor.

Web-based self-management with and without coaching for type 2 diabetes patients in primary care: design of a randomized controlled trial.

BACKGROUND: Self-management is recognized as the cornerstone of overall diabetes management. Web-based self-management programs have the potential of supporting type 2 diabetes patients with managing their diabetes and reducing the workload for the care provider, where the addition of online coaching could improve patient motivation and reduce program attrition. This study aims to test the hypothesis that a web-based self-management program with coaching will prove more effective on improving patient self-management behavior and clinical outcome measures than a web-based self-management program without coaching. METHODS: The effects of a web-based self-management program with and without coaching will be tested with a nested randomized controlled trial within a healthcare group in the Netherlands. In one year 220 type 2 diabetes patients will be randomized into an intervention group (n = 110) or a control group (n = 110). The control group will receive only the online self-management program. The intervention group will receive the online self-management program and additional online coaching. Participants will be followed for one year, with follow-up measurements at 6 and 12 months. DISCUSSION: The intervention being tested is set to support type 2 diabetes patients with their diabetes self-management and is expected to have beneficial effects on self-care activities, well being and clinical outcomes. When proven effective this self-management support program could be offered to other health care groups and their type 2 diabetes patients in the Netherlands. TRIAL REGISTRATION: Nederlands Trial Register NTR4064.

Hypomagnesaemia and its determinants in a contemporary primary care cohort of persons with type 2 diabetes.

AIMS: Among persons with type 2 diabetes mellitus (T2DM) hypomagnesaemia has been reported in 14-48% of patients. This may be of significance given the emerging associations of hypomagnesaemia with glucometabolic disturbances and possibly even complications. We assessed the prevalence of hypomagnesaemia and its determinants, in a well-defined cohort of persons with T2DM treated in primary care. METHODS: Observational cohort study among persons with T2DM treated in primary care in the Northeast of the Netherlands. Magnesium was measured using a colorimetric endpoint assay (Roche). Hypomagnesaemia was defined as a serum magnesium level <0.70 mmol/L. Pearson correlations were performed to correlate variables with serum magnesium. Next, a stepwise backward regression model was made. RESULTS: Data of 929 persons (55% male) with a mean age of 65 (± 10) years, diabetes duration 6.5 [3.0-10.1] years, and HbA1c concentration 6.7 (± 0.7)% (50 (± 9) mmol/mol) were analysed. Serum magnesium was 0.79 (± 0.08) mmol/L. The percentage of persons with magnesium deficiency was 9.6%. Age, diabetes duration, BMI, HbA1c, use of metformin, sulfonylurea derivatives, and DPP4 inhibitors were negatively associated with magnesium concentrations. In contrast, LDL cholesterol and serum creatinine were positively associated serum magnesium. CONCLUSIONS: Hypomagnesaemia was present in 9.6% of T2DM patients treated in primary care. This percentage is remarkably lower than reported previously, possibly due to the unselected nature of our population. Concerning T2DM-related factors, only BMI, HbA1c and the use of metformin, sulfonylurea derivatives and DPP4 inhibitors correlated negatively with magnesium concentrations.

Serum free thiols in type 2 diabetes mellitus: A prospective study.

AIMS: Oxidative stress is a driver in the development of type 2 diabetes (T2DM) complications. As thiols (R-SH) are oxidized by reactive oxygen and sulfur species, circulating concentrations may directly reflect systemic redox status. We hypothesized that high serum R-SH concentrations are a reflection of a favourable redox status and may therefore positively associate with disease status. METHODS: R-SH were measured in serum of 943 T2DM outpatients (55% males, 65 years and HbA1c of 6.7% (50 mmol/mol)) with a follow-up period of 1.2 years. RESULTS: In the highest R-SH tertile patients were younger, more often men, had less microvascular complications, lower HbA1c and were more often treated nutritionally or with oral glucose-lowering drugs. Age- and sex adjusted hazard ratios for developing micro-, macro- or any complication plus death were 0.994, 0.992 and 0.993: even after adjustment for potential confounders. The Harrell's C statistic to predict microvascular complications or any complication plus death was higher in the models with R-SH than in those without R-SH. CONCLUSIONS: Although R-SH concentrations were associated with a favourable disease status, it did not add to the predictive capacity for long-term complications. Based on the current data R-SH seems unsuitable as a prognostic marker in T2DM.

Is guideline-adherent prescribing associated with quality of life in patients with type 2 diabetes?

BACKGROUND: Guideline-adherent prescribing for treatment of multiple risk factors in type 2 diabetes (T2D) patients is expected to improve clinical outcomes. However, the relationship to Health-Related Quality of Life (HRQoL) is not straightforward since guideline-adherent prescribing can increase medication burden. OBJECTIVES: To test whether guideline-adherent prescribing and disease-specific medication burden are associated with HRQoL in patients with T2D. METHODS: Cross-sectional study including 1,044 T2D patients from the e-VitaDM/ZODIAC study in 2012 in the Netherlands. Data from the diabetes visit, such as laboratory and physical examinations and prescribed medication, and from two HRQoL questionnaires, the EuroQol 5 Dimensions 3 Levels (EQ5D-3L) and the World Health Organization Well-Being Index (WHO-5) were collected. Twenty indicators assessing prescribing of recommended glucose lowering drugs, statins, antihypertensives and renin-angiotensin-aldosterone system (RAAS)-inhibitors and potentially inappropriate drugs from a validated diabetes indicator set were included. Disease-specific medication burden was assessed using a modified version of the Medication Regimen Complexity Index (MRCI). Associations were tested with regression models, adjusting for age, gender, diabetes duration, comorbidity, body mass index and smoking. RESULTS: The mean MRCI was 7.1, the median EQ5D-3L-score was 0.86 and the mean WHO-5 score was 72. Seven indicators included too few patients and were excluded from the analysis. The remaining thirteen indicators focusing on recommended start, intensification, current and preferred use of glucose lowering drugs, statins, antihypertensives, RAAS inhibitors, and on inappropriate prescribing of glibenclamide and dual RAAS blockade were not significantly associated with HRQoL. Finally, also the MRCI was not associated with HRQoL. CONCLUSIONS: We found no evidence for associations between guideline-adherent prescribing or disease-specific medication burden and HRQoL in T2D patients. This gives no rise to refrain from prescribing intensive treatment in T2D patients as recommended, but the interpretation of these results is limited by the cross-sectional study design and the selection of patients included in some indicators.

Association between body mass index and obesity-related cancer risk in men and women with type 2 diabetes in primary care in the Netherlands: a cohort study (ZODIAC-56).

OBJECTIVE: To investigate the relationship between body mass index (BMI) and obesity-related cancers in men and women with type 2 diabetes (T2D). DESIGN: Observational cohort study. SETTING: Primary care. PARTICIPANTS: A total of 52 044 patients with T2D who participated in the ZODIAC (Zwolle Outpatient Diabetes project Integrating Available Care) study between 1998 and 2012 was included (49% women). A dataset of these patients was linked to available information of the Netherlands Cancer Registry to obtain data on cancer incidents. PRIMARY OUTCOME MEASURES: Analyses were performed for the total group of obesity-related cancers and for non-sex-specific and sex-specific obesity-related cancers (in men: advanced prostate cancer, in women: ovarian, endometrial and postmenopausal breast cancer). RESULTS: The median follow-up period in all analyses was 3.1 (1.7-5.0) years in men and 3.1 (1.7-5.1) in women. During follow-up, 689 men and 914 women were diagnosed with an obesity-related cancer. In men, BMI was associated with a higher risk of the total group of obesity-related cancers and non-sex-specific obesity-related cancers (HR (per 5 kg/m2 increase) 1.12 (95% CI 1.02 to 1.23) and HR 1.18 (95% CI 1.06 to 1.31)). No association was found with prostate cancer. In women, an association between BMI and all obesity-related cancers combined and sex-specific obesity-related cancers was present (HR 1.15 (95% CI 1.08 to 1.22) and HR 1.22 (95% CI 1.14 to 1.32)). No association with non-sex-specific cancers was found in women. CONCLUSIONS: BMI is associated with obesity-related cancers in men with T2D, except with advanced prostate cancer. The results of this study provide reason to reconsider the classification of advanced prostate cancer as an obesity-related cancer, at least in T2D. In women, BMI is associated with the total group of obesity-related cancers and with sex-specific obesity-related cancers.

Sex differences in obesity related cancer incidence in relation to type 2 diabetes diagnosis (ZODIAC-49).

BACKGROUND: Diabetes and obesity seem to be partly overlapping risk factors for the development of obesity-related cancer (mainly breast, prostate and colorectal cancer) in patients with type 2 diabetes (T2DM). In the general population, women have a lower risk for obesity-related cancer compared to men. Previous studies involving cardiovascular disease have shown that T2DM eliminates a female advantage of lower CVD risk in the general population compared to men. It is unclear whether the same could be true for obesity-related cancer. This study aimed to this investigate obesity-related cancer incidence in women and men known with T2DM as compared to the Dutch general population. METHODS: This study included 69,583 patients with T2DM selected from a prospective primary care cohort, which was linked to the Dutch National Cancer Registry to obtain cancer specific data. Obesity-related cancers included liver, kidney, colorectal, gallbladder, pancreas, ovarian, endometrial, advanced prostate cancer, post-menopausal breast cancer and oesophageal adenocarcinoma. Primary outcome was sex-stratified, age and year of cancer diagnosis adjusted standardized incidence ratios (SIRs) for three time periods: 5 years before, the year after diagnosis and the next 4 years after T2DM diagnosis. The Dutch general population was used as reference group. RESULTS: Women with T2DM were at an increased risk for obesity-related cancer compared to women in the general population already 5 years before diabetes diagnosis (SIR 1.77; 95%CI: 1.63-1.91). In both men and women, there was a peak in obesity-related cancer incidence following diabetes diagnosis (SIR: 1.38; 95%CI 1.11-1.64 and SIR: 2.21; 95%CI 1.94-2.30, respectively). From the second to the fifth year after diabetes diagnosis the obesity-related cancer incidence was higher in women compared to women in the general population (SIR: 2.12; 95%CI 1.94-2.30). CONCLUSIONS: Women with T2DM seem to have a substantially higher obesity-related cancer risk. As opposed to men, in women this risk was already increased years before diabetes diagnosis. These results could imply that a relative advantage of women in the general population with regard to cancer risk is lost in women with T2DM.

Sex differences in survival of patients with type 2 diabetes in primary care (ZODIAC-50).

OBJECTIVE: To investigate sex differences in survival of primary care treated patients with type 2 diabetes (T2D) in the Netherlands. SETTING: Primary care. PARTICIPANTS: A total of 1815 patients who participated in a prospective observational cohort study (Zwolle Outpatient Diabetes Project Integrating Available Care (ZODIAC)) were included of which 56% was female. Inclusion took place in 1998, 1999 and 2001. Vital status was assessed in 2013. MAIN OUTCOME MEASURE: Relative survival of men and women with T2D. The relative survival rate was expressed as the ratio of observed survival of patients divided by the survival of the general population in the Netherlands with comparable age. RESULTS: After 14 years, 888 (49%) patients had died. The relative survival rate was 0.88 (0.81-0.94) for men and 0.82 (0.76-0.87) for women with T2D after 14 years (p value for difference between sexes=0.169). In patients without a history of cardiovascular diseases (CVD), the relative survival was 0.99 (0.94-1.05) in men and 0.92 (0.87-0.97) in women (p value for difference between sexes=0.046). CONCLUSIONS: The survival of men and women with T2D was 12% and 18% lower, respectively, after 14 years of follow-up compared with men and women in the general population. This corresponds to a decrease in median survival of 2.2 and 3.5 years in men and women, respectively. Only for patients with T2D without a history of CVD, a significantly lower relative survival in women compared with men with T2D was found.

Lifestyle and emotional well-being in men and women with type 2 diabetes (e-VitaDM-4; ZODIAC-48).

BACKGROUND: Whether lifestyle is associated with well-being in patients with type 2 diabetes (T2D) is largely unknown. Uncovering and clarifying associations between these constructs may lead to new strategies for improving both. OBJECTIVES: The aim was to investigate the relationship between lifestyle and well-being, focussing on gender differences. METHODS: This cross-sectional study included 1085 patients with T2D that participated in the e-Vita part of the Zwolle outpatient diabetes project integrating available care (ZODIAC) study. Patients were included from May 2012 until September 2014 from 52 general practices. Emotional well-being was assessed with the World Health Organization-5 well-being index (WHO-5). Lifestyle information on body mass index, smoking, physical activity and alcohol use was extracted from self-reported questionnaires. Multiple linear regression analyses were used. RESULTS: After adjustment for other lifestyle factors, physical activity, smoking and drinking 22-35 alcohol consumptions per week were associated with the WHO-5 score in men and physical activity and smoking were associated with the WHO-5 score in women. In the fully adjusted analyses for the total study population, physical activity and smoking were still associated with the WHO-5 score (b = 1.1, P < .001 and b =-3.1, P = .018, respectively). In the fully adjusted analyses stratified to gender only physical activity was associated with the WHO-5 score (in men: b =0.8, P = .006, in women: b = 1.4, P = .001). CONCLUSION: This study shows a negative, non-clinically relevant association between smoking and emotional well-being in the total population with T2D and a positive, non-clinically relevant association between physical activity and emotional well-being in both men and women with T2D.

Orthostatic changes in blood pressure and mortality in a nursing home population.

OBJECTIVE: Hypertension, orthostatic hypotension and orthostatic hypertension (OHT) are highly prevalent in old age. The associations in the very elderly and frail patients between blood pressure, and especially orthostatic changes in blood pressure, and mortality are unclear. We aimed to investigate the relationships between orthostatic changes in blood pressure, blood pressure and mortality in nursing home residents. DESIGN AND METHODS: A prospective observational cohort study. Cox proportional hazard modelling was used to investigate the relation between orthostatic hypotension, OHT, the various blood pressure variables and mortality with adjustment for confounders. In the case of significant associations in the models, risk prediction capabilities were assessed with Harrell's C statistics and the proportion of explained variance (R). RESULTS: Two hundred and ninety patients with a mean age of 80.8 (SD 9.9) years participated in this study. The overall mortality risk increased by 17% [95% confidence interval (CI): 2-34%] for every 10-mmHg increase in DBP. Adding DBP did not change Harrell's C values and increased R with 0.03 or less. Only in patients at the psychogeriatric department, orthostatic hypotension was associated with an increased all-cause mortality risk [hazard ratio (HR) 1.71 (95% CI: 1.08-2.71%)]. The HR of OHT in this patient group was 0.61 (95% CI: 0.32-1.19%). CONCLUSION: DBP was related to all-cause mortality in a nursing home population. Orthostatic hypotension was related to all-cause mortality in the most frail group of nursing home patients. The predictive capabilities of both DBP and orthostatic hypotension are rather small with respect to mortality. A beneficial effect of OHT could not be excluded on the basis of the width of the CI.

Demographical, Clinical, and Psychological Characteristics of Users and Nonusers of an Online Platform for T2DM Patients (e-VitaDM-3/ZODIAC-44).

BACKGROUND: Online platforms offer opportunities for support in changing lifestyle and taking responsibility for one's health, but engaging patients with type 2 diabetes is challenging. Previous studies have shown that patients interested in platforms were more often male, younger, and higher educated. This study aims to investigate differences in clinical and psychological characteristics between users and nonusers of a newly developed platform. METHODS: A prospective study started in the Drenthe region of Netherlands. Participants in the study concerning quality of care and quality of life were additionally invited to use the platform. RESULTS: 633 patients were registered after they opted for platform use. Of these patients, 361 (57.0%) never logged on, 184 (29.1%) were labeled "curious" users, and 88 (13.9%) were identified as "active" users. Users had lower HbA1c levels and more often hypertension compared to nonusers, and reported higher quality of life, better well-being, lower diabetes-related distress, and better medication adherence. DISCUSSION: Platform use was associated with more favorable clinical and psychological characteristics relative to nonuse. Those with greater severity of disease, lower mood, and progression of disease used the platform the least. Other approaches need to be developed to reach these patients. Furthermore, improving the platform could also help to reach them. This trial is registered with Clinicaltrials.gov NCT01570140.

Patient Activation in Type 2 Diabetes: Does It Differ between Men and Women?

Background. Aim was to investigate whether the degree of patient activation of patients with type 2 diabetes (T2D) is different between men and women. Furthermore, we investigated which factors are associated with patient activation in men and women. Methods. This cross-sectional study included 1615 patients with T2D from general practices. Patient activation was measured with the Patient Activation Measure (PAM) questionnaire. Multivariate linear regression analyses were used to investigate the association between gender and patient activation. Stratified analyses according to gender were performed to investigate which factors are associated with patient activation. Results. No association between gender and PAM score was found after adjustment for all selected confounders (p = 0.094). In men, lower age (p = 0.001), a higher WHO-5 score (p < 0.001), and a lower BMI (p = 0.013) were associated with a higher PAM score. In women, a higher WHO-5 score (p < 0.017) and the absence of macrovascular complications (p < 0.031) were associated with a higher PAM score. Conclusion. There is no difference in the degree of patient activation of men and women with T2D. Age, well-being, and BMI were found to be associated with patient activation in men, whereas well-being and macrovascular complications were found to be associated with patient activation in women.

Sex Differences in the Quality of Diabetes Care in the Netherlands (ZODIAC-45).

OBJECTIVE: Our aim was to investigate whether trends in quality of diabetes care differ between sexes in the Netherlands from 1998 till 2013. RESEARCH DESIGN AND METHODS: In this prospective observational cohort study quality of care was measured using process and outcome measures in patients with type 2 diabetes in primary care. Trend and absolute differences between sexes were investigated for patients <75 years. Subgroup analyses were performed in patients ≥75 years. 10-year mortality risk was assessed with the Globorisk risk equation in patients without cardiovascular diseases <75 years. RESULTS: The number of patients increased from 2,644 in 1998 to 62,230 in 2013. In 1998, 51% of the men and 60% of the women <75 years had an HbA1c >53 mmol/mol; this decreased to approximately 29% in both sexes in 2013. Patients having a systolic blood pressure >140 mmHg decreased from 70% to 42%, and from 80% to 40% in men and women <75 years, respectively. In patients ≥75 years it decreased from 72% to 50% in men and 85% to 56% in women. Obesity increased in both sexes, whereas smoking in men and women declined in patients <75 years (men: 34% to 22%; women: 22% to 18%). The number of patients with a mortality risk >20% over 10 years decreased from 15% to 3% in men and from 18% to 3% in women. CONCLUSIONS: Quality of diabetes care has improved considerably in the period 1998-2013 in both sexes. Possibly relevant trend differences between sexes were observed for HbA1c, systolic blood pressure, BMI and smoking. The predicted mortality risk decreased over time in both sexes. Except for BMI in both age groups and systolic blood pressure in patients ≥75 years, no evident poorer risk factor control in women compared to men was found at the end of the study period.

Frailty and the relationship between blood pressure and mortality in elderly patients with type 2 diabetes (Zwolle Outpatient Diabetes project Integrating Available Care-34).

OBJECTIVE: We aimed to investigate whether adjustment for frailty influences the relationship of blood pressure with mortality in elderly patients with type 2 diabetes mellitus (T2DM). METHODS: Patients aged 60 years and older (n = 858) were selected from a prospective observational cohort study of primary care patients with T2DM. Frailty was defined as a score less than 80 on the subscale 'physical functioning' of the RAND-36 questionnaire. After median follow-up for 14 years, multivariate Cox regression analyses were performed to evaluate the association between blood pressure and (cardiovascular) mortality. Analyses were performed in strata according to the frailty level ('physical functioning' score <80 and ≥80) and were repeated for patients older than 75 years. RESULTS: Frailty was highly prevalent in our study population; 629 out of 858 patients (73%) fulfilled the criterion. For patients aged at least 60 years, the hazard ratios (95% confidence interval) of a 10 mmHg increase in SBP and DBP for cardiovascular mortality in nonfrail patients were 1.38 (1.15-1.68%) and 1.60 (1.07-2.37%), respectively. No relationship was observed for frail patients. For the oldest frail elderly, the hazard ratios of SBP and DBP for all-cause mortality were 0.92 (0.87-0.98%) and 0.83 (0.73-0.93%), respectively. For the oldest nonfrail elderly, a positive relationship between SBP and all-cause mortality was observed. CONCLUSIONS: Frailty modifies the relationship between blood pressure and mortality in elderly patients with T2DM. Higher blood pressure was related to increased cardiovascular mortality in nonfrail patients, even in the oldest elderly, and to lower all-cause mortality in frail patients.

Differences Between Patients With Type 2 Diabetes Mellitus Interested and Uninterested in the Use of a Patient Platform (e-VitaDM-2/ZODIAC-41).

The prevalence of type 2 diabetes mellitus (T2DM) is rising in the Netherlands, and health care's workload will increase. e-Health applications may increase patients' participation in their care and could help reducing workload. To explore potential users, differences in patients interested and uninterested in e-Health are characterized. A prospective cohort study was initiated in the Drenthe region of the Netherlands. This study included inviting T2DM patients to use e-Health (the e-Vita platform). Patients were offered access to clinical data, laboratory results, educational modules, and a self-management support program. Data were obtained from health record systems of general practices and questionnaires. Out of 2674 patients, 1378 (51.5%) participated in the study. Of the 1378 patients, 974 (70.7%) were interested in e-Health. Of 974, 405 (41.6%) were registered for e-Health. Interested patients were more often male, were younger, had shorter T2DM duration, and were higher educated. Of 405, 110 (27.2%) used the e-Health. No differences were found between users and nonusers of e-Health. Patients interested in e-Health were more often male, were younger, had shorter T2DM duration, and were more often higher educated. However, even in this interested group, the actual participation rate remained low. Together with characteristics and attitudes of caregivers and T2DM patients, the look and content of the e-Health platform strategies that increase interest and participation need to be developed.