Variation in the achievement of HbA1c , blood pressure and LDL cholesterol targets in type 2 diabetes in general practice and characteristics associated with risk factor control.

AIMS: To identify population, general practitioner, and practice characteristics associated with the achievement of HbA1c , blood pressure and LDL cholesterol targets, and to describe variation in the achievement of risk factor control. METHODS: We conducted a cross-sectional survey of 9342 people with type 2 diabetes, 281 general practitioners and 77 general practices in Norway. Missing values (7.4%) were imputed using multiple imputation by chained equations. We used three-level logistic regression with the achievement of HbA1c , blood pressure and LDL cholesterol targets as dependent variables, and factors related to population, general practitioners, and practices as independent variables. RESULTS: Treatment targets were achieved for HbA1c in 64%, blood pressure in 50%, and LDL cholesterol in 52% of people with type 2 diabetes, and 17% met all three targets. There was substantial heterogeneity in target achievement among general practitioners and among practices; the estimated proportion of a GPs diabetes population at target was 55-73% (10-90 percentiles) for HbA1c , 36-63% for blood pressure, and 47-57% for LDL cholesterol targets. The models explained 11%, 5% and 14%, respectively, of the total variation in the achievement of HbA1c , blood pressure and LDL cholesterol targets. Use among general practitioners of a structured diabetes form was associated with 23% higher odds of achieving the HbA1c target (odds ratio 1.23, 95% confidence interval (CI) 1.02-1.47) and 17% higher odds of achieving the LDL cholesterol target (odds ratio 1.17, 95% CI 1.01-1.35). CONCLUSIONS: Clinical diabetes management is difficult, and few people meet all three risk factor control targets. The proportion of people reaching target varied among general practitioners and practices. Several population, general practitioner and practice characteristics only explained a small part of the total variation. The use of a structured diabetes form is recommended.

Population, general practitioner and practice characteristics are associated with screening procedures for microvascular complications in Type 2 diabetes care in Norway.

AIMS: To assess population, general practitioner (GP) and practice characteristics associated with the performance of microvascular screening procedures and to propose strategies to improve Type 2 diabetes care. METHODS: A cross-sectional survey in Norway (281 GPs from 77 practices) identified 8246 people with a Type 2 diabetes duration of 1 year or more. We used multilevel regression models with either the recording of at least two of three recommended screening procedures (albuminuria, monofilament, eye examination) or each procedure separately as dependent variable (yes/no), and characteristics related to the person with diabetes, GP or practice as independent variables. RESULTS: The performance of recommended screening procedures was recorded in the following percentages: albuminuria 31.5%, monofilament 27.5% and eye examination 60.0%. There was substantial heterogeneity between practices, and between GPs within practices for all procedures. Compared with people aged 60-69 years, those aged < 50 years were less likely to have an albuminuria test performed [odds ratio (OR) 0.75, 95% CI 0.61 to 0.93] and eye examination (OR 0.79, 95% CI 0.66 to 0.95). People with macrovascular disease had fewer screening procedures recorded (OR 0.68, 95% CI 0.59 to 0.78). Use of an electronic diabetes form was associated with improved screening  (OR 2.65, 95% CI 1.86 to 3.78). GPs with high workload recorded fewer procedures (OR 0.59, 95% CI 0.39 to 0.90). CONCLUSIONS: Performance of screening procedures was suboptimal overall, and in people who should be prioritized. Performance varied substantially between GPs and practices. The use of a structured diabetes form should be mandatory.

Clinical reappraisal of SHORT syndrome with PIK3R1 mutations: toward recommendation for molecular testing and management.

SHORT syndrome has historically been defined by its acronym: short stature (S), hyperextensibility of joints and/or inguinal hernia (H), ocular depression (O), Rieger abnormality (R) and teething delay (T). More recently several research groups have identified PIK3R1 mutations as responsible for SHORT syndrome. Knowledge of the molecular etiology of SHORT syndrome has permitted a reassessment of the clinical phenotype. The detailed phenotypes of 32 individuals with SHORT syndrome and PIK3R1 mutation, including eight newly ascertained individuals, were studied to fully define the syndrome and the indications for PIK3R1 testing. The major features described in the SHORT acronym were not universally seen and only half (52%) had four or more of the classic features. The commonly observed clinical features of SHORT syndrome seen in the cohort included intrauterine growth restriction (IUGR) <10th percentile, postnatal growth restriction, lipoatrophy and the characteristic facial gestalt. Anterior chamber defects and insulin resistance or diabetes were also observed but were not as prevalent. The less specific, or minor features of SHORT syndrome include teething delay, thin wrinkled skin, speech delay, sensorineural deafness, hyperextensibility of joints and inguinal hernia. Given the high risk of diabetes mellitus, regular monitoring of glucose metabolism is warranted. An echocardiogram, ophthalmological and hearing assessments are also recommended.

Comparison of urinary albumin excretion rate in overnight urine and albumin creatinine ratio in spot urine in diabetic patients in general practice.

OBJECTIVE: To evaluate whether measurement of albumin creatinine ratio (ACR) on a spot urine specimen can replace a timed overnight collection of urine albumin excretion rate (UAER) in patients with diabetes in primary care. DESIGN: Patients with diabetes attending Rønvik Health Centre were asked to bring a timed overnight collection of urine for measurement of UAER. They were also asked to void a urine specimen for measurement of albumin creatinine ratio. SETTING: Primary health care. SUBJECTS: One-hundred-and-six persons with diabetes (47 women, 59 men) aged 13 to 78 years. RESULTS: The sensitivity and specificity of ACR with cut-off values of 2.5 mg/mmol for men and 3.5 mg/mmol for women compared to UAER with cut-off value of 20 mg/24 h was 90%. CONCLUSIONS: Spot urine ACR analysed on a DCA 2000 can replace a timed (overnight) collection of urine and measurement of UAER when diabetic patients are reviewed in general practice. This simplifies procedures for the patient as a timed urine collection is no longer necessary. Another advantage is that the results are available after 7 min.

[Prevention of cardiovascular disease in type 2 diabetes]. / Forebygging av hjerte- og karsykdom ved type 2-diabetes.

BACKGROUND: Patients with type 2 diabetes have a high risk of morbidity and premature mortality from cardiovascular disease. Epidemiological studies show that many of the risk factors are the same as in non-diabetic subjects. At present there are sufficient data in the literature to recommend prophylactic measures to be initiated in diabetic patients. MATERIAL AND METHODS: We review major studies relevant for prophylactic measures against cardiovascular disease in patients with type 2 diabetes, and suggest Norwegian recommendations. RESULTS: All patients should be advised to adhere to a healthy life style including an appropriate diet, physical exercise and no smoking. Treatment of hyperglycaemia is primarily indicated in order to improve quality of life and reduce the risk of microvascular complications, as it still remains to be proven if glucose lowering therapy may protect against macrovascular disease. Pharmacological prophylactic therapy with acetylsalicylic acid, anti-hypertensive agents and lipid lowering drugs are indicated in high-risk patients. IMPLICATIONS: Several pharmacological and non-pharmacological interventions may protect type 2 diabetic patients from premature cardiovascular morbidity and mortality. Anti-hypertensive treatment may protect diabetic patients both from microvascular and macrovascular disease and premature death.

[Is treatment of diabetes too complicated for general practitioners?]. / Er diabetesbehandling for vanskelig for allmennpraktikeren alene?

The prevalence of type 2 diabetes is increasing rapidly. In order to reduce the morbidity and mortality of type 2 diabetes, it is important to treat both hyperglycaemia and risk factors for cardiovascular disease. This means that diabetes care is becoming increasingly comprehensive and complicated. Studies in Norway show that diabetes care in general practice could be improved. The primary care system needs more resources and better organisation to be able to meet the demands for improved quality and more comprehensive care. We suggest more active use of nurses and other health care professionals, as well as changes in the remuneration system for general practitioners. Remuneration for an annual review of patients with diabetes will stimulate quality improvement work. The division of work between primary health care and hospital clinics should be clarified.

[New diagnostic criteria for diabetes mellitus--why?]. / Nye diagnostiske kriterier for diabetes mellitus--hvorfor?

In 1997, the diagnostic criteria for diabetes mellitus were changed in the USA; the WHO has also proposed changes in its criteria. The main difference from the previous set of WHo criteria is a lowering of the cut-off level of fasting plasma glucose to > or = 7.0 mmol/l. This article discusses the implications of new diagnostic criteria and recommends that the level of fasting plasma glucose for diagnosing diabetes is decreased to > or = 7.0 mmol/l in Norway as well.

Cardiovascular disease and risk factors in persons with type 2 diabetes diagnosed in a large population screening: the Nord-Trøndelag Diabetes Study, Norway.

OBJECTIVE: To study cardiovascular status and risk factors in persons with newly diagnosed type 2 diabetes and controls in a large population. DESIGN: Case-control study. SETTING: Population screening. SUBJECTS: The screening of 74 499 individuals (88.1%), aged 20 years and older, in Nord-Trøndelag County, Norway, during 1984-86 detected 428 persons with undiagnosed diabetes according to the 1980 WHO criteria, of whom 205 attended a clinical follow-up examination assessing cardiovascular status and risk factors. METHODS: For each of 205 cases, one control person matched by age and sex underwent the same clinical examination. Lipids, body mass index, waist/hip ratio, blood pressure, pulse rate, blood pressure medication, kidney function, cardiovascular disease, family history and lifestyle were recorded. RESULTS: At the screening prior to the diagnosis of diabetes, those with diabetes reported poorer general health, less physical activity, more siblings with diabetes and more frequent use of antihypertensive medication. They had higher body mass index, systolic and diastolic blood pressure and pulse rate compared with controls. At the clinical evaluation, diabetics had higher urine albumin levels, increased waist/hip ratio, and higher total cholesterol/HDL cholesterol ratios than the controls. They also reported a greater incidence of angina pectoris and had more ECG changes. CONCLUSIONS: Diabetics presented with more cardiovascular risk factors, angina pectoris and ECG changes than the controls, and they had an established metabolic syndrome more often than controls. These results suggest that prevention of cardiovascular disease in diabetics requires earlier diagnosis of the diabetes.

Rapid changes in the prevalence of obesity and known diabetes in an adult Norwegian population. The Nord-Trøndelag Health Surveys: 1984-1986 and 1995-1997.

OBJECTIVE: To determine whether changes in mean BMI and the prevalence of obesity in a total adult population during a short (11-year) period were associated with changes in the prevalence of diabetes. RESEARCH DESIGN AND METHODS: This study involved cross-sectional surveys of all inhabitants aged > or = 20 years of the county of Nord-Trøndelag from 1984 to 1986 (n = 85,100) and from 1995 to 1997 (n = 92,434). Attendance rates were 88.1 and 71.3%, respectively, and 90.0% in an additional survey of people aged 13-19 years from 1995 to 1997 (n = 9,593). Main outcome measures were age-specific mean BMI for the diabetic and nondiabetic subgroups and the prevalence of obesity and diabetes. For comparison, mean BMIs from 18 of 19 Norwegian counties for the group aged 40-42 years were examined. RESULTS: Mean BMI increased from 27.2 to 29.0 kg/m2 in the diabetic population and from 25.1 to 26.3 kg/m2 in the nondiabetic population. The BMI distribution curve shifted to the right, but homogeneity was also reduced. A comparison with other Norwegian counties indicated that this increase occurred during the last 6 years between the surveys. The prevalence of obesity (BMI > or = 30 kg/m2) increased from 7.5 to 14% in nondiabetic men and from 13 to 18% in nondiabetic women. The increase was particularly great in men aged < 60 years and in women aged < 50 years. The overall prevalence of known diabetes increased between the two surveys (from 2.9 to 3.2%) but only in men. The largest increase was observed in the corresponding younger sex and age-groups. CONCLUSIONS: A substantial increase in mean BMI and the prevalence of obesity occurred in the younger age-groups at the same time as an increase in the prevalence of diabetes. A greater increase in diabetes prevalence in this ethnically stable Western European population may follow if effective primary preventive strategies are not undertaken.

[Efficient learning with data from own practice--experiences from the SATS-project]. / Effektiv laering med data fra egen praksis--erfaringer fra SATS-prosjektet.

Between 1995 and 1998 the Norwegian Medical Association carried out a project to develop and assess a quality improvement tool for use in general practice (SATS). This method combines self-directed learning, documentation of practice and peer group support. SATS defined performance indicators for registration of practice by means of computerised patient records. Groups of four to ten general practitioners used their own consultation data as a basis for learning cycles. The practice evaluation indicates significant improvement in clinical work. Participating doctors found that having their own recorded data examined in a supportive peer environment was a major force for change. They reported satisfaction with the method, and expressed an interest in trying out new topics. However, the project demonstrated the need for simplification of terminology, further development of group process methods and computer software. There is also a need for strong local support of peer review groups.

Insulin treatment for poorly regulated diabetic patients in general practice. Better regulation and symptom relief?

OBJECTIVE: To study the relationship between symptoms, metabolic control and insulin treatment in diabetes mellitus. DESIGN: A cross-sectional questionnaire study of diabetic patients, and a 1-year follow-up study of poorly regulated patients prescribed insulin. Regulation criteria were predefined and the patients acted as their own controls. SETTING: Five primary care practices in Nordland county, Norway. PATIENTS: 111 patients in the cross-sectional study, with 18 of them participating in the follow-up study. MAIN OUTCOME MEASURES: Symptom scores and sum scores, based on five general symptoms--dizziness, depression, fatigue, thirst and dry mouth--and on two urinary symptoms--urinary frequency and urination during the night. RESULTS: Poorly regulated diabetic patients had a higher sum score for general symptoms than better regulated patients (6.1 vs. 4.2, p = 0.078 with Wilcoxon two-sample rank sum test). With parametric analysis, the difference was significant, and remained so when adjusted for age and sex. Females reported more symptoms than males. Symptom relief with insulin was not statistically significant; however, there was a slight but consistent tendency towards less symptoms with better regulation. There was no correlation with HbA1 values at any time during the follow-up study. Only one patient wanted to stop taking insulin after 1 year. CONCLUSION: Better metabolic control and better general well-being seem to be achieved in many cases when poorly regulated patients with type 2 diabetes mellitus begin insulin treatment. The general practitioner should be cautious in promising relief of specific symptoms.

[Diabetic care in Norwegian general practice. A report of current status from Salten and some regions in Rogaland]. / Diabetesomsorg i norsk allmennpraksis. En tilstandsrapport fra Salten og deler av Rogaland.

Few published data are available on the quality of diabetic care in Norway. This applies both to general practice and to hospital clinics. We reviewed the notes of 1,876 diabetic patients who were registered with general practitioners in Salten and Rogaland to assess the quality of care with reference to the Norwegian College of General Practitioners' guidelines for diabetic care. 89% of patients were classified as having type-2 diabetes. Hospital clinics were responsible for the care of 93 patients. Analysis of the results showed that during the last 12 months Hb A1c and blood pressure had been measured in 84 and in 86% of those patients under the care of their general practitioner. Some inspection of the foot had been carried out in 45% of the patients, and 37% of the patients had been referred to an ophthalmologist. Guideline targets for glycaemic control had been achieved in 46% of patients younger than 70 years of age (Hb A1c < 7.5%), and in 82% of patients older than 69 years of age (Hb A1c < 9%). Diabetic patients on insulin therapy had the worst glycaemic control. The study shows that the quality of diabetic care is not optimal, examination of the foot, referral for eye examination and glycaemic control of diabetic patients on insulin therapy are examples of areas where improvement is needed.

[Quality development in family practice--development and use of health indicators]. / Kvalitetsutvikling i allmennpraksis--utvikling og bruk av indikatorsett.

In 1995 the Norwegian general practitioners' associations embarked upon a three-year project to assess a new model for improving the quality of primary health care. Indicators are proposed for assessing quality and setting standards in local practice. Software has been developed to simplify collection of data and production of reports from computerized medical records. Peer groups of 5-10 practitioners discuss results, agree on local standards and plan improvements. General practitioners who participate in a cycle of quality improvement will be awarded credits for recertification as specialists in general practice. The initial topics are: care of diabetics, use of laboratory tests, management of sore throat, and management of migraine. This national project will be evaluated both in terms of improvement in the quality of care, and of the views of the participating practitioners.

[Quality assurance of cooperation/distribution of work between primary health care and other health services. Using care for diabetics as a basis]. / Kvalitetssikring av samhandling/arbeidsfordeling mellom primaerhelsetjenesten og annenlinjetjenesten. Utgangspunkt er tatt i diabetikeromsorgen.

Chronic illnesses account for an increasing share of the work load of the health services, implying that health personnel have to face a number of different complex problems. Many of these concern co-operation between the various professionals and levels of the health services, and distribution of the load of work. How well this co-operation works will have a decisive effect on the quality of the treatment. These problems are discussed using care of diabetes patients as an example. It is important to achieve medical consensus at different levels. The authors suggest ways of establishing co-operation within the medical profession, specifically defining responsibility, ensuring good and frequent communication with patients, and promoting patient participation. The article also describes concrete solutions and includes a check list for quality assessment.

[Diagnosis of type 2 diabetes in general practice]. / Diagnostikk av type 2-diabetes i allmennpraksis.

Among 285 patients seen in general practice, all over the age of 40, 11 (4%) new cases of non-insulin-dependent diabetes mellitus was diagnosed. 12 patients (4%) were found to have impaired glucose tolerance. Measurement of glucose levels in unstandardized blood samples is a suitable method of screening for non-insulin-dependent diabetes in general practice. In order to reduce the number of oral glucose tolerance tests we suggest a modification of WHO guidelines.