Care of general practice patients preceding and following a suicide attempt: observational study in Flemish general practices.

OBJECTIVES: First, to examine general practitioner (GP) knowledge about the care (needs) of their patients; second, to examine the quality of GP follow-up care; third, to examine the transmission of patient care information from hospitals/emergency services (ES) to GPs. SETTING: 105 general practices from the representative Belgian Network of Sentinel General Practices (SGP) in Flanders, the largest region of Belgium, during 2013-2016. PARTICIPANTS: 245 suicide attempts by regular patients. OUTCOMES MEASURES: Ten care-related measures, including three indicators of quality of follow-up care, were based on data reported by the SGP on structured forms at baseline and at two follow-up points in time. RESULTS: As for GP knowledge, 10.5% of SGP failed to report whether suicidal risk was noticed in patients seen in the month preceding the attempt; 9.0% whether there were previous attempts; 22.5% whether the patient was receiving mental health treatment at follow-up and 22.0% whether suicidal behaviour was repeated at follow-up. Relatively more patients≥65 years had no suicide risk evaluation (OR 3.54; 95% CI 1.11 to 11.26). As for quality of follow-up care, there was a GP-patient contact following 90.5% of the attempts, follow-up appointments were planned following 43.4% of the attempts and there was a GP contact with patient proxies following 62.8% of the attempts. Patient age ≥65 years (OR 4.09; 95% CI 1.79 to 9.33), a recent GP-patient contact preceding the attempt (OR 1.97; 95% CI 1.13 to 3.43), depression of patient (OR 1.96; 95% CI 1.14 to 3.37) and a suburban SGP area (OR 2.34; 95% CI 1.13 to 4.82) were determinants of an increased quality of care sum. GPs received patient care information from a hospital (ES) for 67.8% of eligible attempts, with SGP practice location being a determinant. CONCLUSIONS: GPs are highly involved in the care of suicide attempters but there is room for improvement, also in informational continuity from hospital (ES) to GPs.

General Practice Care for Patients with Rare Diseases in Belgium. A Cross-Sectional Survey.

There are almost no studies about rare diseases in general practice. This study examined care characteristics of active rare disease patients in the Belgian Network of Sentinel General Practices (SGP) and the importance of rare diseases in general practice by its caseload, general practitioner (GP)⁻patient encounter frequency and nationwide prevalence. The SGP reported data about: (i) the number of active rare disease patients in 2015; and (ii) characteristics of one to three most recently seen patients. Rare diseases were matched against Orphanet (www.orpha.net). GP encounter frequency and patients' age were compared to the total general practice population. Details from 121 active patients (median age: 44, interquartile range (IQR) 24⁻60) showed that for 36.9% the GP had been the first caregiver for the rare disease and for 35.8% the GP established a diagnostic referral. GPs rated their knowledge about their patients' disease as moderate and used Orphanet for 14.9% of patients. Any active rare disease patients (median: 1, IQR 0⁻2) were reported by 66 of 111 SGP. Compared to the total general practice population, the mean GP encounter frequency was higher (7.3; 95% confidence intervals (CI) 6.1⁻8.5 versus 5.4; 95% CI 5.4⁻5.4). The prevalence of rare diseases in the Belgian general practice population was estimated at 12.0 (95% CI 10.3⁻13.9) per 10,000. This study acknowledges the important role of GPs in rare disease care. Knowledge and use of Orphanet by GPs could be improved.

General practice patients treated for substance use problems: a cross-national observational study in Belgium.

BACKGROUND: General Practitioners (GPs) are well placed to care for patients with (chronic) substance use problems. This pilot was carried out to study the feasibility and usefulness of a continuous surveillance of substance use problems among general practice patients. The objectives were (i) to describe variables with missing values exceeding 1% and whether patients were reported without substance-related problems; (ii) the profile and the magnitude of the patient population that is treated for substance use problems. METHODS: Observational study by the Belgian Network of Sentinel General Practices (SGP) in 2013. Baseline (at the first encounter) and 7-month follow-up data were reported of all patients treated for substance use problems. Two main measurements were type of substance use and patient status at follow-up. Multiple logistic regression analysis was used to examine patient status at follow-up. RESULTS: Of 479 patients, 47.2% had problems with alcohol alone, 20.3% with prescription drugs, 16.7% with illicit drugs other than heroin or methadone and 15.9% with heroin or methadone. Problems with alcohol alone were more prevalent in Flanders (53.0%; 95% confidence interval (CI) 46.8-59.1%) than in Wallonia-Brussels (39.8%; 95% CI 33.1-46.8%), while problems with heroin or methadone were more prevalent in Wallonia-Brussels (27.0%; 95% CI 21.1-33.5%) than in Flanders (7.1%; 95% CI 4.3-10.9%). At follow-up, 32.8% of the patients had dropped out, 29.0% had discontinued GP treatment and 38.2% had continued GP treatment. Overall, 32.4% of 479 patients had continued GP treatment for substance use problems during the study period. In Wallonia-Brussels, this proportion was higher (42.7%; 95% CI 35.9-49.6%) than in Flanders (24.3%; 95% CI 19.2-29.8%). CONCLUSIONS: A continuous surveillance of the general practice population treated for substance use problems seems to be feasible and useful. The latter is suggested by the specific profile and the relative magnitude of the population. Inter-regional health system differences should be taken into account to estimate the epidemiology of substance use problems among general practice patients.

Clinical action measures improve the reliability of feedback on quality of care in diabetes centres: a retrospective cohort study.

BACKGROUND: Assessment of quality of care using classical threshold measures (TM) is open to debate. Measures that take into account the clinician's actions and the longitudinal nature of chronic care are more reliable, although their major limitation is that they require more sophisticated electronic health records. We created a clinical action measure (CAM) for the control of LDL and non-HDL cholesterol from low-complexity data, and investigated how quality of care in individual diabetes centres based on the CAM is related to that based on the classical TM. METHODS: Data was used from 3421 diabetes patients treated in 95 centres, collected in two consecutive retrospective data collections. Patients met the TM when their index value was below target. Patients met the CAM when their index value was below target or above target but for whom treatment initiation or intensification, or possible contraindication, was indicated. RESULTS: Based on the TM, 60-70 % of the patients received good care. This percentage increased significantly using the CAM (+5 %, p < 0.001). At the centre level, the CAM was associated with a higher median score, and a change in position among centres ('poor', 'good' or 'excellent' performer) for 5-10 % of the centres. CONCLUSIONS: Judging quality of diabetes care of a centre based on a TM may be misleading. Low-complexity data available from a quality improvement initiative can be used to construct a more fair and feasible measure of quality of care.

Results of the Belgian Sentinel Network of General Practitioners on the Involvement of Therapists in Stroke Rehabilitation.

This study examines which therapists are involved in the rehabilitation of stroke survivors in Belgium at different points in time. A nationwide registration of stroke patients was provided by 199 and 189 family physicians working in sentinel practices for the years 2009 and 2010 respectively. 326 patients who were diagnosed with stroke were included. Patients with paralysis/paresis received significant more physiotherapy after one month (63%) compared to non-paralysed patients (38%) (P = 0.005). Residing in a nursing home was associated with higher proportions of patients receiving physiotherapy, both after one (P = 0.003) and six (P = 0.002) months. 31% of patients with aphasia were treated by a speech and language therapist after one month, which decreased after six months to 20%. After six months, the patients in a nursing home received significant more often speech and language therapy (P = 0.004), compared to patients living at home. The proportion of patients receiving stroke rehabilitation services provided by physiotherapists, speech/language therapists and occupational therapists is rather low, especially 6 months after the critical event.

Trends from the surveillance of suicidal behaviour by the Belgian Network of Sentinel General Practices over two decades: a retrospective observational study.

OBJECTIVES: First, we describe trends in characteristics of suicidal events using new (2011-2012) and previous (1993-1995, 2000-2001 and 2007-2008) data reported by the Belgian Network of Sentinel General Practices (SGP); second, we examine patient age-related trends in on-site attendance of sentinel general practitioners (GPs) as first professional caregivers following suicidal behaviour; third, we investigate the accuracy of suicide incidence estimates derived from the SGP data. DESIGN: Retrospective observational study. SETTING: General practices from the nationwide representative Belgian Network of SGP. OUTCOME MEASURES: Patient gender and age, suicide methods, whether the patient was new, whether the GP was the first caregiver on-site, and the outcome of the suicidal behaviour (fatal or not) were recorded on standard registration forms. The accuracy of suicide incidence estimates was tested against suicide mortality data. RESULTS: Over the four time periods, 1671 suicidal events were reported: 275 suicides, 1287 suicide attempts and 109 events of suicidal behaviour of unknown outcome. In 2011-2012, sentinel GPs' on-site attendance following the suicidal behaviour of patients <65 years had continued to decrease (from 71% in 1993-1995 to 58% in 2000-2001, 39% in 2007-2008 and 25% in 2011-2012). In 2011-2012, it had also decreased steeply in the population ≥65 years (from 70% in 1993-1995, 76% in 2000-2001 and 79% in 2007-2008 to 35% in 2011-2012). No significant differences were found between the SGP-based suicide incidence estimates for 2011-2012 and the available suicide mortality rates for people <65 and ≥65 years. CONCLUSIONS: GPs' on-site attendance as first professional caregivers following suicidal behaviour continues to decline since 2011-2012 also in the population ≥65 years. Unawareness of patients' suicidal behaviour endangers both care for surviving patients and the completeness of SGP surveillance data. Yet, the incidence of suicide for 2011-2012 was estimated accurately by the SGP.

Does the Belgian diabetes type 2 care trajectory improve quality of care for diabetes patients?

BACKGROUND: The Belgian care trajectory (CT) for diabetes mellitus type 2 (T2DM), implemented in September 2009, aims at providing integrated, evidence-based, multidisciplinary patient- centred care, based on the chronic care model. The research project ACHIL (Ambulatory Care Health Information Laboratory) studied the adherence of CT patients, in the early phases of CT programme implementation, with CT obligations, their uptake of incentives for self-management, whether the CT programme was targeting the appropriate group of patients, how care processes for these patients evolved over time and whether CT start led to better quality in the processes and outcomes of care. METHODS: This observational study took place in the period 2006-2011 and covered T2DM patients who started a CT between 01/09/2009 and 31/12/2011. Four data sources were used: outcome data, from electronic patient records (EPRs) on all CT patients, provided by general practitioners (GPs); reimbursement process data on all CT patients and clinically comparable patients; and data from a sample of CT patients and clinically comparable patients from an EPR-based regional GP network and a paper-based national GP network, respectively. Through multilevel analysis of cross-sectional and longitudinal data, the effect of CT inclusion on processes and outcome was estimated, controlling for potential confounders. RESULTS: By the end of 2011, data on 18,250 CT patients had been collected. Approximately 50 % of these CT patients had received reimbursement for a glucometer and nearly 60 % had had at least one encounter with a diabetes educator. The CT programme recruited T2DM patients who had been difficult to control in the past. In the years prior to CT start, there had been a gradual improvement in the follow up of these patients. Moreover, compared to non-CT patients, the proportion of CT patients adhering to the recommended frequency for monitoring of parameters, such as HbA1c, increased significantly around CT start. Some data sources, albeit not all, suggested there had been an improvement in certain outcomes, such as HbA1c, after CT inclusion. CONCLUSIONS: According to this study, CT enrolment is associated with better quality of care processes compared to non-CT patients. This improvement was found in several of the data sources used in this study. However, results on outcome parameters remain inconclusive.

Care trajectories are associated with quality improvement in the treatment of patients with uncontrolled type 2 diabetes: A registry based cohort study.

AIMS: To analyse whether care trajectories (CT) were associated with increased prevalence of parenteral hypoglycemic treatment (PHT=insulin or GLP-1 analogues), statin therapy or RAAS-inhibition. Introduced in 2009 in Belgium, CTs target patients with type 2 diabetes mellitus (T2DM), in need for or with PHT. METHODS: Retrospective study based on a registry with 97 general practitioners. The evolution in treatment since 2006 was compared between patients with vs. without a CT, using longitudinal logistic regression. RESULTS: Comparing patients with (N=271) vs. without a CT (N=4424), we noted significant differences (p<0.05) in diabetes duration (10.1 vs. 7.3 years), HbA1c (7.5 vs. 6.9%), LDL-C (85 vs. 98mg/dl), microvascular complications (26 vs. 16%). Moreover, in 2006, parenteral treatment (OR 52.1), statins (OR 4.1) and RAAS-inhibition (OR 9.6) were significantly more prevalent (p<0.001). Between 2006 and 2011, the prevalence rose in both groups regarding all three treatments, but rose significantly faster (p<0.05) after 2009 in the CT-group. CONCLUSIONS: Patients enrolled in a CT differ from other patients even before the start of this initiative with more intense hypoglycemic and cardiovascular treatment. Yet, they presented higher HbA1c-levels and more complications. Enrolment in a CT is associated with additional treatment intensification.

Early stages of building a rare disease registry, methods and 2010 data from the Belgian Neuromuscular Disease Registry (BNMDR).

The Belgian Neuromuscular Disease Registry, commissioned in 2008, aims to collect data to improve knowledge on neuromuscular diseases and enhance quality health services for neuromuscular disease patients. This paper presents a clear outline of the strategy to launch a global national registry. All patients diagnosed with one of the predefined 62 neuromuscular disease groups and living in Belgium may be included in the yearly updated Registry. Basic core data is harvested through a newly designed web application by the six accredited neuromuscular reference centres. In 2010, 3,424 patients with a neuromuscular disorder were registered. The most prevalent disease group in the Registry is Hereditary Motor and Sensory Neuropathy, as similarly stated by other studies, albeit the prevalence in Belgium is five times lower: 6.5 per 100,000 in the north of Belgium, versus 17.0-41.0 per 100,000 in other areas of Europe. Very few patients were captured in the south of the country. With the aim to collect valuable epidemiological data, the registry targets to gather high quality data, that the sample to be representative of the population and that it be complete. The past 5 years of building the registry have improved its quality, albeit the consistent gap in data from the south of the country prevails, influencing the estimated prevalence of these diseases. To this day, the true burden of neuromuscular diseases in Belgium is not known but actions have been undertaken to address these issues.

Place of residence after a stroke: results of the registration by the Belgian Sentinel Network of general practitioners.

BACKGROUND: Stroke is a major health problem worldwide. The health consequences for the survivors are not to be underestimated. The increased care needs after a stroke result often in a change of residence or an institutionalisation. The aim of the study is to provide an overview in the changes of the place of residence in the first year after stroke. METHODS: A nationwide observational registration by 199 and 189 family physicians (respectively in 2009 and 2010) working in sentinel practices. All cerebrovascular events that occurred in 2009 and 2010 were recorded. Follow-up was provided 1, 6 and 12 month(s) after the initial registration. RESULTS: In total 326 patients were diagnosed with a stroke and 87% were hospitalized. At the time of the event 83% of the patients lived at home and one year after the event 80% did (p = 0.366). Older age (p = 0.008), originally living in a nursing home (p = 0.009) and speech problems (p = 0.003) and incontinence (p = 0.017) were the most important determinants for institutionalisation in a nursing home after one year. CONCLUSION: There is a high proportion of the Belgian stroke survivors that can return home after the initial hospitalization. Mainly older patients with severe disabilities did not return to their home.

What determines inclusion in the early phase of the type 2 diabetes care trajectory in Belgium?

BACKGROUND: In 2009, the Belgian National Institute of Health and Disability Insurance established a care trajectory (CT) for a subgroup of type 2 diabetes mellitus patients (T2DM) based on Wagner's chronic care model. The goal of this CT is to optimise the quality of care using an integrated multidisciplinary approach. This study aims to identify patient-related factors associated with inclusion in a CT and to determine the most frequent reasons for non-inclusion. METHODS: In 2010, the Belgian Sentinel Network of General Practices conducted a prevalence study of type 2 diabetes. The surveillance study carried out by this nationwide, representative network collected unique information about eligibility for the CT, inclusion in the CT and reasons for non-inclusion. Based on the official inclusion and exclusion criteria, we first identified a group of eligible patients. Within this group, we then calculated the proportion of patients included in a CT as well as the prevalence of reasons for non-inclusion as reported by GPs. Furthermore, bivariate associations between patient-level parameters and inclusion were analysed. Finally, any patient-level parameters found to be statistically significant were included in a multivariate logistic regression model. RESULTS: The 2010 study recorded 4600 Belgian type 2 diabetes patients. According to the official criteria, 589 patients were eligible for inclusion in a CT T2DM. By the end of August 2011, 95 patients had been included in a CT T2DM. Our findings reveal that the younger the eligible patient was, the more likely he or she was to be included in a CT. Patients living in Flanders were more likely to be included in the CT than were patients living in Wallonia. Motivated patients with specific plans to change their diets were also more likely to be included in a CT. The two most frequently reported reasons for non-inclusion were participation in another diabetes care programme and the timing of this surveillance study (inclusion will take place in the near future). CONCLUSIONS: Eligible diabetes patients who were admitted to a CT T2DM during the early phases of CT implementation were mainly found to be those who are able to make progress in their disease trajectories. In the future, more attention could be paid to also include more high-risk patients.

Belgian primary care EPR: assessment of nationwide routine data extraction.

Starting in 2009, the first ever Belgian nationwide data collection network using routine data extracted from primary care EPR (upload method) has been built from scratch. The network also uses a manual web-based data collection method. This paper compares these two methods by analysing missing and most recent values for certain parameters. We collected data from 4954 practices, pertaining to 29,180 patients. Mean values for the most recent parameters were similar regardless of which data collection method was used. Many missing recent values (>46%) were found for all of the parameters when using the upload method. It seems that, in Belgium, uploading routine data from primary care EPR on a large scale is suitable and allows the collection of chronological retrospective data. However, the method still requires major, carefully controlled improvements.

Falls among older general practice patients: a 2-year nationwide surveillance study.

BACKGROUND: Falling among older persons is a multifactorial health condition needing multifactorial care. Several targeted preventive interventions and their coordination are considered to be general practitioner (GP)-specific tasks. OBJECTIVES: To estimate the incidence of falls among older non-institutionalized general practice patients in Belgium (2009-10) and to describe the main characteristics of falls, fallers and fall risks; factors associated with multiple fall risks and the co-occurrence of fall risks; patient status 3 months later and care delivery. METHODS: A 2-year nationwide cross-sectional study based on data collected by the Belgian network of Sentinel General Practices on all non-institutionalized persons aged ≥65 years consulting their GP for new fall-related injuries. RESULTS: Baseline data were collected on 1503 persons and valid follow-up data were available on 715 persons (79%). The yearly incidence of older persons with fall-related injuries was estimated at 2.5% of the older general practice population; 39% of patients had also received hospital care, physician-specialist or nursing home care. A multifactorial risk profile was observed in 59% and associated with increasing age, recurrent falling, falling at home and during lower level activity. The clustering of frailty-specific fall risks was higher than expected by chance. At follow-up, 46% of at-risk patients had received physical therapy, 47% were using assistive devices, and medication had been reviewed in 28% of patients taking psychopharmacy and 17% of patients with polypharmacy. CONCLUSIONS: Our study shows a high burden of care for fall-related injuries in older general practice patients and provides baseline data for its future monitoring.

Implementation of a quality improvement initiative in Belgian diabetic foot clinics: feasibility and initial results.

BACKGROUND: This article aims to describe the implementation and initial results of an audit-feedback quality improvement initiative in Belgian diabetic foot clinics. METHODS: Using self-developed software and questionnaires, diabetic foot clinics collected data in 2005, 2008 and 2011, covering characteristics, history and ulcer severity, management and outcome of the first 52 patients presenting with a Wagner grade ≥ 2 diabetic foot ulcer or acute neuropathic osteoarthropathy that year. Quality improvement was encouraged by meetings and by anonymous benchmarking of diabetic foot clinics. RESULTS: The first audit-feedback cycle was a pilot study. Subsequent audits, with a modified methodology, had increasing rates of participation and data completeness. Over 85% of diabetic foot clinics participated and 3372 unique patients were sampled between 2005 and 2011 (3312 with a diabetic foot ulcer and 111 with acute neuropathic osteoarthropathy). Median age was 70 years, median diabetes duration was 14 years and 64% were men. Of all diabetic foot ulcers, 51% were plantar and 29% were both ischaemic and deeply infected. Ulcer healing rate at 6 months significantly increased from 49% to 54% between 2008 and 2011. Management of diabetic foot ulcers varied between diabetic foot clinics: 88% of plantar mid-foot ulcers were off-loaded (P10-P90: 64-100%), and 42% of ischaemic limbs were revascularized (P10-P90: 22-69%) in 2011. CONCLUSIONS: A unique, nationwide quality improvement initiative was established among diabetic foot clinics, covering ulcer healing, lower limb amputation and many other aspects of diabetic foot care. Data completeness increased, thanks in part to questionnaire revision. Benchmarking remains challenging, given the many possible indicators and limited sample size. The optimized questionnaire allows future quality of care monitoring in diabetic foot clinics.

Availability of informal caregivers in surviving stroke patients in Belgium.

OBJECTIVE: To quantify the availability of informal caregivers in surviving stroke patients residing at home in Belgium. METHODS: National estimates on the availability of informal caregivers were made using data from a nationwide observational registration of family physicians working in sentinel practices and a nationwide administrative database for reimbursement of hospitals in Belgium. RESULTS: A total of 189 Belgian family physicians (FPs) from 141 practices participated in the study and recorded 326 patients (144 men and 182 women) with stroke. These FPs reach 1.5% of the Belgian population. After 1 month, 71% of the male and 75% of the female stroke survivors received support from family caregivers (p = 0.547). After 6 months, the percentage of male patients who received support from family caregivers decreased to 60% compared with 75% in female (p = 0.038). Of all patients with stroke admitted to Belgian hospitals during the reference year 2009 (n = 16.437), 8.997 returned home. Based on the findings from the sentinel practices, it is estimated that a mean of 73% (n = 6.568) and 67.5% (n = 6.073) of surviving patients with stroke can rely on informal caregivers in their home setting after one and 6 months, respectively. CONCLUSIONS: A vast majority of surviving stroke patients in Belgium can rely on informal caregivers in their home setting, but their availability rapidly decreases 6 months after the event. These findings underline the importance of proactive health policy making in stroke care taking into account the potentially decreasing number of available informal caregivers in the decades to come.

Routinely-collected general practice data from the electronic patient record and general practitioner active electronic questioning method: a comparative study.

The numerous existing primary care-based research networks currently use various data collection methods. In this paper, we compared routine data extracted from general practitioners' (GPs') electronic patient records (EPRs) and GPs' answers to an electronic questionnaire. We investigated for 10,307 Belgian patients 10 healthcare conditions using clinical and biological parameters (cholesterol, blood pressure, and body mass index), diagnoses (hypertension, diabetes, and personal past cardiovascular event(s)), and drug prescriptions (antidiabetic drugs, aspirin, statins, and antihypertensive drugs). We found a relatively fair agreement (Kappa≥0.40) between the two data collection methods for 7 healthcare conditions, but no agreement for the biological parameters. When EPR data was used and compared with the questioning method, the prevalence of diagnoses and drug prescriptions was relatively lower and the prevalence of clinical and biological parameters was relatively higher (all missing data excluded) in the EPR data than in the data collected using the questioning method. Using EPR data, we calculated an acceptable proxy for the prevalence as observed using the questioning method. The comparison of the two data collection methods was a worthwhile approach, in that it could highlight potential ways to improve both care quality and information systems.

Nationwide continuous monitoring of end-of-life care via representative networks of general practitioners in Europe.

BACKGROUND: Although end-of-life care has become an issue of great clinical and public health concern in Europe and beyond, we lack population-based nationwide data that monitor and compare the circumstances of dying and care received in the final months of life in different countries. The European Sentinel GP Networks Monitoring End of Life Care (EURO SENTIMELC) study was designed to describe and compare the last months of life of patients dying in different European countries. We aim to describe how representative GP networks in the EURO SENTIMELC study operate to monitor end of life care in a country, to describe used methodology, research procedures, representativity and characteristics of the population reached using this methodology. METHODS: Nationwide representative Networks of General Practitioners (GPs)--ie epidemiological surveillance systems representative of all GPs in a country or large region of a country--in Belgium, The Netherlands, Italy and Spain continuously registered every deceased patient (>18 year) in their practice, using weekly standardized registration forms, during two consecutive years (2009-2010). RESULTS: A total of 6858 deaths were registered of which two thirds died non-suddenly (from 62% in The Netherlands to 69% in Spain), representative for the GP populations in the participating countries. Of all non-sudden deaths, between 32% and 44% of deaths were aged 85 or older; between 46% and 54% were female, and between 23% and 49% died at home. Cancer was cause of death in 37% to 53% of non-sudden death cases in the four participating countries. CONCLUSION: Via the EURO SENTI-MELC methodology, we can build a descriptive epidemiological database on end-of-life care provision in several EU countries, measuring across setting and diseases. The data can serve as baseline measurement to compare and monitor end-of-life care over time. The use of representative GP networks for end-of-life care monitoring has huge potential in Europe where several of these networks are operational.

Global quality indicators for primary care Electronic Patient Records.

Electronic Patient Records can be interfaced with medical decision support systems and quality of care assessment tools. An easy way of measuring the quality of EPR data is therefore essential. This study identified a number of global quality indicators (tracers) that could be easily calculated and validated them by correlating them with the Sensitivity and Positive Predictive Value (PPV) of data extracted from the EPR. Sensitivity and PPV of automatically extracted data were calculated using a gold standard constructed using answers to questions GPs were asked at the end of each contact with a patient. These properties were measured for extracted diagnoses, drug prescriptions, and certain parameters. Tracers were defined as drug-disease pairs (e.g. insulin-diabetes) with the assumption that if the patient is taking the drug, then the patient is suffering from the disease. Four tracers were identified that could be used for the ResoPrim primary care research database, which includes data from 43 practices, 10,307 patients, and 13,372 contacts. Moderately positive correlations were found between the 4 tracers and between the tracers and the sensitivity of automatically extracted diagnoses. For some purposes, these results may support the potential use of tracers for monitoring the quality of information systems such as EPRs.

Cardiovascular risk factors and complications associated with albuminuria and impaired renal function in insulin-treated diabetes.

AIMS: To establish the association between albuminuria and cardiovascular risk factors as well as micro- and macrovascular complications in type 1 and insulin-treated type 2 diabetes, both in the presence and in the absence of reduced estimated glomerular filtration rate (eGFR). METHODS: Cross-sectional study including 7640 insulin-treated diabetic patients (33% type 1) treated in specialist diabetes centers. Albuminuria was defined as ≥30 mg/g, 20 mg/L, 20 µg/min or 30 mg/24 h. Reduced eGFR was defined as <60 mL/min/1.73 m(2) (CKD-EPI equations). RESULTS: Albuminuria, reduced eGFR or a combination was more prevalent in type 2 (21.5%, 15.9% and 16.5%) than in type 1 diabetes (16.1%, 4.7% and 4.0%, all P < 0.001 vs. type 2). Albuminuria was associated with poorer control of blood pressure, blood lipids and glycemia as well as higher prevalence of retinopathy and macrovascular disease, regardless of preserved/reduced eGFR or diabetes type. Reduced eGFR was associated with higher prevalence of micro- and macrovascular complications especially in type 2 diabetes. Combined presence of albuminuria and reduced eGFR was associated with the worst cardiovascular outcomes. CONCLUSIONS: Albuminuria and impaired renal function are prevalent in type 1 and insulin-treated type 2 diabetes. Albuminuria, but also normoalbuminuric renal impairment, is associated with micro- and macrovascular complications.