Health problems associated with irritable bowel syndrome: analysis of a primary care registry.

BACKGROUND: Associations between irritable bowel syndrome and other health problems have been described, but comprehensive reports are missing, especially in primary care. AIMS: To investigate which health problems are associated with irritable bowel syndrome, how they cluster together and when they are typically diagnosed relative to irritable bowel syndrome. METHODS: We used Intego, a general practice registry in Flanders, Belgium. Patients with an irritable bowel syndrome diagnosis (n = 13 701) were matched with controls without gastrointestinal diagnosis and controls with organic gastrointestinal disease. Long-term prevalences of 680 symptoms and diagnoses were compared between patients and controls. Results were summarised using functional enrichment analysis and visualised in a network and we calculated incidence rate ratios in the 10 years before and after the irritable bowel syndrome diagnosis for the network's key components. RESULTS: Various symptoms and infections, but not neoplasms, were enriched in irritable bowel syndrome patients compared to both control groups. We characterised the comorbidities of irritable bowel syndrome as psychosocial health problems, urogenital symptoms and infections, musculoskeletal symptoms and other somatic symptoms. These had a uniform incidence in the years around the irritable bowel syndrome diagnosis, and did not structurally precede or follow irritable bowel syndrome. CONCLUSIONS: Irritable bowel syndrome shares long-term associations with psychosocial health problems, urogenital symptoms and infections, musculoskeletal symptoms and other somatic symptoms in primary care. Clinicians are encouraged to take comorbidities into account when diagnosing and managing irritable bowel syndrome, as this may have important treatment implications.

Patient and provider acceptance of telecoaching in type 2 diabetes: a mixed-method study embedded in a randomised clinical trial.

BACKGROUND: Despite advances in diagnosis and treatment of type 2 diabetes, suboptimal metabolic control persists. Patient education in diabetes has been proved to enhance self-efficacy and guideline-driven treatment, however many people with type 2 diabetes do not have access to or do not participate in self-management support programmes. Tele-education and telecoaching have the potential to improve accessibility and efficiency of care, but there is a slow uptake in Europe. Patient and provider acceptance in a local context is an important pre-condition for implementation. The aim of the study was to explore the perceptions of patients, nurses and general practitioners (GPs) regarding telecoaching in type 2 diabetes. METHODS: Mixed-method study embedded in a clinical trial, in which a nurse-led target-driven telecoaching programme consisting of 5 monthly telephone sessions of +/- 30 min was offered to 287 people with type 2 diabetes in Belgian primary care. Intervention attendance and satisfaction about the programme were analysed along with qualitative data obtained during post-trial semi-structured interviews with a purposive sample of patients, general practitioners (GPs) and nurses. The perceptions of patients and care providers about the intervention were coded and the themes interpreted as barriers or facilitators for adoption. RESULTS: Of 252 patients available for a follow-up analysis, 97.5 % reported being satisfied. Interviews were held with 16 patients, 17 general practitioners (GPs) and all nurses involved (n = 6). Themes associated with adoption facilitation were: 1) improved diabetes control; 2) need for more tailored patient education programmes offered from the moment of diagnosis; 3) comfort and flexibility; 4) evidence-based nature of the programme; 5) established cooperation between GPs and diabetes educators; and 6) efficiency gains. Most potential barriers were derived from the provider views: 1) poor patient motivation and suboptimal compliance with "faceless" advice; 2) GPs' reluctance in the area of patient referral and information sharing; 3) lack of legal, organisational and financial framework for telecare. CONCLUSIONS: Nurse-led telecoaching of people with type 2 diabetes was well-accepted by patients and providers, with providers being in general more critical in their reflections. With increasing patient demand for mobile and remote services in healthcare, the findings of this study should support professionals involved in healthcare policy and innovation. TRIAL REGISTRATION: NCT01612520 , registered prior to recruitment on 4th June 2012.

Optimizing diabetes control in people with Type 2 diabetes through nurse-led telecoaching.

AIMS: To study the effect of a target-driven telecoaching intervention on HbA1c and other modifiable risk factors in people with Type 2 diabetes. METHODS: We conducted a randomized controlled trial in patients receiving hypoglycaemic agents. The primary outcome was HbA1c level at 6 months in the entire sample and in a subgroup with HbA1c levels ≥ 53 mmol/mol (7%) at baseline. Secondary outcomes were HbA1c at 18 months; total cholesterol, LDL, HDL, triglycerides, blood pressure, BMI and proportion of people who had achieved guideline-recommended targets at 6 and 18 months. RESULTS: A total of 287 participants were randomized to telecoaching and 287 to usual care. The mean (sd) baseline HbA1c level was 53 (11) mmol/mol [7.0 (1.0)%] overall and 63 (10) mmol/mol [7.9 (0.9)%] in the elevated HbA1c subgroup. At 6 months, the between-group differences in favour of telecoaching were: HbA1c -2 (95% CI -4; -1) mmol/mol [-0.2 (95% CI -0.3;-0.1)%; P=0.003] overall and -4 (95% CI -7; -2) mmol/mol [-0.4 (95% CI -0.7; -0.2)%; P=0.001] in the elevated HbA1c subgroup; BMI -0.4 kg/m(2) (95% CI -0.6; -0.1; P=0.003); total cholesterol -6 mg/dl (95% CI -11; -1, P=0.012). The proportion of participants on target for the composite of HbA1c , LDL and blood pressure increased by 8.9% in the intervention group and decreased by 1.3% in the control group (P=0.011). At 18 months, the difference in HbA1c was: -2 (95% CI -3;-0) mmol/mol [-0.2 (95% CI -0.3; -0.0)%; P=0.046] overall and -4 (-7; -1) mmol/mol [-0.4 (95% CI -0.7; -0.1)%; P=0.023] in the elevated HbA1c subgroup. CONCLUSION: Nurse-led telecoaching improved glycaemic control, total cholesterol levels and BMI in people with Type 2 diabetes. Twelve months after the intervention completion, there were sustained improvements in glycaemic control.

Public Health Triangulation to inform decision-making in Belgium.

We assessed the impact of a nation-wide ambulatory care complex intervention (the "care trajectory program") on quality of care in Belgium. We used the three-step public health triangulation method described in this paper and data from four different data sources: a national reimbursement database, an electronic patient record-based general practitioner network, the Belgian general practitioner sentinel network, and a new national registry for care trajectory patients. By applying our method and using the available evidence, we identified key findings that have been accepted by experts and stakeholders. We also produced timely recommendations for the decision-making process, four years after the start of the care trajectory program.

EPR-based, quality-related process parameters: a nationwide assessment.

The aim of the study was to determine whether or not primary care EPR-based data can be used to measure specific process parameters that can then, in turn, be used to assess the quality of care provided to chronic patients. We analysed data from a large research network that collects data from all Belgian GP practices through both manual and automatic extraction procedures. We built a number of quality-related process parameters and observed the concordance of our results with two external databases: a nationwide reimbursement database and a regional EPR-based network. We found that only the automatic data extraction method was suitable for building process parameters. The current research network may lead to an underestimation of the quality of care processes. We suggested ways to improve this network.

Type 2 diabetes in primary care in belgium: need for structured shared care.

OBJECTIVE: To picture the profile of type 2 diabetic patients in Belgium and to study the quality of care in the primary care setting, with regard, to multi-factorial approach of the disease. METHODS: Observational study of all known DM2-patients registered by 120 volunteer general practitioners. Quality of care was evaluated by the achievement of three major treatment targets: HbA1c<7%; Systolic Blood Pressure

Cardiovascular prevention in type 2 diabetic patients: review of efficacious treatments.

BACKGROUND: Type 2 diabetes (t2DM) is a chronic and complex metabolic condition requiring continuing medical care in order to reduce the risk of long-term complications. Macrovascular complications cause about 65% of deaths in subjects with t2DM and are responsible for severe co-morbidity. Many studies have addressed cardiovascular (CV) risk reduction in t2DM subjects. OBJECTIVES: To summarise the evidence concerning the impact of lifestyle and of medical interventions in t2DM patients on CV risk (myocardial infarction, stroke, CV death, or a combination of these). METHODS: We successively reviewed the recent guidelines addressing CV prevention in t2DM and searched the Cochrane Controlled Trials Register (CCTR), Medline & Embase to find systematic reviews and original articles on CV events in t2DM patients. We selected original studies which included solely t2DM patients or a large t2DM subgroup (n>100), tested lifestyle habits or drug treatments, and analysed CV endpoints. Their design had to be a randomised controlled trial for drug interventions, and a prospective cohort for lifestyle habits. MAIN STUDIES: We found 4 major guidelines focusing on CV prevention in t2DM patients, all released in 2003, and 10 reviews and meta-analyses: one dealing with dietary intervention, three with blood pressure lowering, one with ACE-inhibitors, one (with update) with platelet-inhibitors , three with cholesterol-inhibitors and one that dealt with both cholesterol-inhibition and blood pressure lowering. We included cohort studies on cigarette smoking (1), physical exercise (3) and weight control (1), as well as randomised trials on treatment of glycaemia (1), lipidaemia (13), blood pressure (12) and platelet aggregation (4). We also included one open randomised trial dealing with a multifactorial treatment. CONCLUSIONS: Global CV risk management in t2DM should aim at changes in lifestyle habits and daily use of multiple drugs. Treatment should be long-term and target-driven with intensified interventions aimed at all validated targets. Lifestyle approach is of primary importance. Five targets are supported by strong clinical evidence (Table 4): reduction of blood pressure and of LDL-Cholesterol to normal values, and the use of three types of drugs which inhibit, respectively, platelet aggregation, angiotensin pathway and cholesterol synthesis.