Association between quality management and performance indicators in Dutch diabetes care groups: a cross-sectional study.

OBJECTIVES: To enhance the quality of diabetes care in the Netherlands, so-called care groups with three to 250 general practitioners emerged to organise and coordinate diabetes care. This introduced a new quality management level in addition to the quality management of separate general practices. We hypothesised that this new level of quality management might be associated with the aggregate performance indicators on the patient level. Therefore, we aimed to explore the association between quality management at the care group level and its aggregate performance indicators. DESIGN: A cross-sectional study. SETTING: All Dutch care groups (n=97). PARTICIPANTS: 23 care groups provided aggregate register-based performance indicators of all their practices as well as data on quality management measured with a questionnaire filled out by 1 or 2 of their quality managers. PRIMARY OUTCOMES: The association between quality management, overall and in 6 domains ('organisation of care', 'multidisciplinary teamwork', 'patient centredness', 'performance management', 'quality improvement policy' and 'management strategies') on the one hand and 3 process indicators (the percentages of patients with at least 1 measurement of glycated haemoglobin, lipid profile and systolic blood pressure), and 3 intermediate outcome indicators (the percentages of patients with glycated haemoglobin below 53 mmol/mol (7%); low-density lipoprotein cholesterol below 2.5 mmol/L; and systolic blood pressure below 140 mm Hg) by weighted univariable linear regression. RESULTS: The domain 'management strategies' was significantly associated with the percentage of patients with a glycated haemoglobin <53 mmol/mol (ß 0.28 (0.09; 0.46) p=0.01) after correction for multiple testing. The other domains as well as overall quality management were not associated with aggregate process or outcome indicators. CONCLUSIONS: This first exploratory study on quality management showed weak or no associations between quality management of diabetes care groups and their performance. It remains uncertain whether this second layer on quality management adds to better quality of care.

Beta-blockers and depression in elderly hypertension patients in primary care.

BACKGROUND AND OBJECTIVES: Previous findings regarding a possible association between beta-blocker use and depression are mixed. To our knowledge there have been no studies investigating the association of beta-blockers with depression in primary care hypertension patients without previous myocardial infarction. The aim of this study was to determine the relation between lipophilic beta-blocker use and depression in elderly primary care patients with hypertension. METHODS: This was a cross-sectional study in primary care practices located in the South of The Netherlands. Primary care hypertension patients without previous myocardial infarction or heart failure (n=573), aged between 60 and 85 years (mean age=70±6.6), were included. All patients underwent a structured interview that included a self-report questionnaire to assess depression (PHQ-9), which was divided in four groups (PHQ-9 score of 0, 1--3, 4--8, 9 or higher). RESULTS: A PHQ-9 score of 0 was more prevalent in non-beta-blocker users versus lipophilic beta-blocker users (46% versus 35%), a PHQ-9 score of 4--8 was less prevalent in non-beta-blocker users as compared with lipophilic beta-blocker users (14% versus 25%). A chi-squared test showed that lipophilic beta-blocker users as compared to non-beta-blockers users were more likely to be in a higher depression category. Ordinal regression showed a significant relationship between use of lipophilic beta-blockers and depression (OR=1.60, 95% CI=1.08--2.36) when adjusting for potential confounders. CONCLUSIONS: Our findings show that primary care hypertension patients who use a lipophilic beta-blocker are more likely to have higher depression scores than those who do not use a lipophilic beta-blocker.

Testing the effectiveness of a self-efficacy based exercise intervention for inactive people with type 2 diabetes mellitus: design of a controlled clinical trial.

BACKGROUND: Sufficient exercise is important for people with Type 2 Diabetes Mellitus (T2DM), as it can prevent future health problems. Despite, it is estimated that only 30-40% of people with T2DM are sufficiently active. One of the psychosocial constructs that is believed to influence physical activity behaviour, is exercise self-efficacy. The goal of this study is to evaluate a patient-tailored exercise intervention for people with T2DM that takes exercise self-efficacy into account. METHODS/DESIGN: This study is conducted as a non-randomized controlled clinical trial. Patients are eligible when they are diagnosed with T2DM, exercise less than advised in the ADA guideline of 150 min/week of moderate-intensity aerobic physical activity, have an BMI >25 and are between 18 and 80 years old. Recruitment takes place at a Primary care organization of general practitioners and practice nurses in the south of the Netherlands.Participants are allocated to three groups: An advice intervention -for participants with a high exercise self-efficacy score- in which participants receive a patient-tailored exercise intervention, an intensive intervention -for participants with a low exercise self-efficacy score- in which participants receive a patient-tailored exercise intervention accomplished by a group based intervention, and a control group in which participants receive regular Dutch diabetes care. The primary outcome measure of this study is physical activity. Secondary outcome measures are health status, (symptoms of) depression, exercise self-efficacy, Body Mass Index (BMI), blood pressure and glycemic control. DISCUSSION: We aimed to design an intervention that can be implemented in Primary care, but also to design an easy accessible program. This study is innovative as it is -to our best knowledge- the first study that takes level of exercise self-efficacy of people with T2DM into account by means of giving extra support to those with the lowest exercise self-efficacy. If the program succeeds in increasing the amount of physical activity it can be implemented in regular primary care. TRIAL REGISTRATION: Dutch Trial Register NTR2734.

Depression after low-energy fracture in older women predicts future falls: a prospective observational study.

BACKGROUND: Falls are one of the main causes of fractures in elderly people and after a recent fracture, the risk of another fall is increased, resulting in subsequent fracture. Therefore, risk factors for future falls should be determined. We prospectively investigated the relationship between depression and the incidence of falls in post-menopausal women after a low-energy fracture. METHODS: At baseline, 181 women aged 60 years and older who presented with a recent low-energy fracture were evaluated at the fracture and osteoporosis outpatient clinics of two hospitals. As well as clinical evaluation and bone mineral density tests, the presence of depression (measured using the Edinburgh Depression Scale, EDS, depression cut-off > 11) and risk factors for falling were assessed. During two years of follow-up, the incidence of falls was registered annually by means of detailed questionnaires and interviews. RESULTS: Seventy-nine (44%) of the women sustained at least one fall during follow-up. Of these, 28% (n = 22) suffered from depression at baseline compared to 10% (n = 10) of the 102 women who did not sustain a fall during follow-up (Χ(2) = 8.76, df = 1, p = .003). Multiple logistic regression showed that the presence of depression and co-morbidity at baseline were independently related to falls (OR = 4.13, 95% CI = 1.58-10.80; OR = 2.25, 95% CI = 1.11-4.56, respectively) during follow-up. CONCLUSIONS: The presence of depression in women aged 60 years and older with recent low-energy fractures is an important risk factor for future falls. We propose that clinicians treating patients with recent low-energy fractures should anticipate not only on skeletal-related risk factors for fractures, but also on fall-related risk factors including depression.

Validation of the Dutch guidelines for dual X-ray absorptiometry measurement.

BACKGROUND: In Europe, a case-finding strategy for osteoporosis is recommended above widespread population-based screening. However, no universally accepted policy currently exists. In 2005, the Dutch College of General Practitioners published guidelines for GPs to select patients for dual energy X-ray absorptiometry (DXA). AIM: To evaluate the sensitivity, specificity, and predictive value of the Dutch guidelines to select participants with osteoporosis for DXA. DESIGN OF STUDY: Cross-sectional. SETTING: A total of 345 females aged over 50 years (mean age = 62 years, standard deviation [SD] = 8.3) and 99 males over 65 years of age (mean age = 72 years, SD = 5.2) of a Dutch general practice. METHOD: Calculation of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the Dutch case-finding instrument for selecting patients with osteoporosis for DXA measurement. RESULTS: Sensitivity was 19.5%, specificity 85.6%, PPV 18.6%, and NPV 86.6%. CONCLUSION: The Dutch guidelines are unreliable in detecting people at risk for osteoporosis.