Sex disparities in medication prescribing amongst patients with type 2 diabetes mellitus managed in primary care.

BACKGROUND: Sex differences in clinical outcomes have been observed for patients with type 2 diabetes mellitus (T2DM). These could be related to sex disparities in treatment. OBJECTIVES: To determine whether there are sex disparities in medication prescribing amongst patients with T2DM. METHODS: A cohort study was conducted using the Groningen Initiative to ANalyze Type 2 diabetes Treatment (GIANTT) database, which includes data from primary care patients with T2DM from the north of the Netherlands. Data on demographics, physical examinations, laboratory measurements and prescribing were extracted. A set of validated prescribing quality indicators assessing the prevalence, start, intensification and safety of glucose-, lipid-, blood pressure- and albuminuria-lowering medication was applied for the calendar year 2019. Univariate logistic regression analyses were conducted. RESULTS: We included 10,456 patients (47% females). Females were less often treated with metformin (81.7% vs. 86.5%; OR 0.70, 95% CI 0.61-0.80), and were less often prescribed a renin-angiotensin-aldosterone inhibitor (RAAS-i) when treated with multiple blood pressure-lowering medicines (81.9% vs. 89.3%; OR 0.55, 95% CI 0.46-0.64) or when having albuminuria (74.7% vs. 82.1%; OR 0.64, 95% CI 0.49-0.85) than males. Statin treatment was less frequently started (19.7% vs. 24.7%; OR 0.75, 95% CI 0.58-0.96) and prescribed (58.7% vs. 63.9%; OR 0.80, 95% CI 0.73-0.89) in females. There were no differences in starting and intensifying glucose-, blood pressure- and albuminuria-lowering medication. CONCLUSIONS: Sex disparities in medication prescribing amongst T2DM patients were seen, including less starting with statins and potential undertreatment with RAAS-i in females. Such disparities may partly explain higher excess risks for cardiovascular and renal complications associated with diabetes observed in females.

Evaluation of a Digital Decision Support System to Integrate Type 2 Diabetes Mellitus and Periodontitis Care: Case-Vignette Study in Simulated Environments.

BACKGROUND: As highlighted by the recent World Health Organization Oral Health Resolution, there is an urgent need to better integrate primary and oral health care. Despite evidence and guidelines substantiating the relevance of integrating type 2 diabetes mellitus (T2DM) and periodontitis care, the fragmentation of primary and oral health care persists. OBJECTIVE: This paper reports on the evaluation of a prototype digital decision support system (DSS) that was developed to enhance the integration of T2DM and periodontitis care. METHODS: The effects of the prototype DSS were assessed in web-based simulated environments, using 2 different sets of case vignettes in combination with evaluation surveys among 202 general dental practitioners (GDPs) and 206 general practitioners (GPs). Each participant evaluated 3 vignettes, one of which, chosen at random, was assisted by the DSS. Logistic regression analyses were conducted at the participant and case levels. RESULTS: Under DSS assistance, GPs had 8.3 (95% CI 4.32-16.03) times higher odds of recommending a GDP visit. There was no significant impact of DSS assistance on GP advice about common risk factors for T2DM and periodontal disease. GDPs had 4.3 (95% CI 2.08-9.04) times higher odds of recommending a GP visit, 1.6 (95% CI 1.03-2.33) times higher odds of giving advice on disease correlations, and 3.2 (95% CI 1.63-6.35) times higher odds of asking patients about their glycated hemoglobin value. CONCLUSIONS: The findings of this study provide a proof of concept for a digital DSS to integrate T2DM and periodontal care. Future updating and testing is warranted to continuously enhance the functionalities of the DSS in terms of interoperability with various types of data sources and diagnostic devices; incorporation of other (oral) health dimensions; application in various settings, including via telemedicine; and further customization of end-user interfaces.

Meta-research publications in dentistry: a review.

The present scoping review has the objective of providing an overview of meta-research in dentistry. A search of the PubMed database was performed for the period 11 October 2014 to 10 October 2019. Study selection and data extraction were performed independently by one author; prior to this, a random sample of 10% of the retrieved titles and abstracts were independently screened by two authors, achieving agreement of >80% on eligibility for initial inclusion, corresponding to good agreement. The following information was extracted from the full text of each article: meta-research area of interest; study design; type of studies evaluated in the meta-research; type of methodology used in assessment of the primary research; conflicts of interest reported; sponsorships reported; dental discipline; journal of publication; country of the first author; number of citations; and impact factor. A total of 7800 documents were initially retrieved. After analysis of the title/abstract and the full text of each article, and a snowballing procedure, 155 meta-research studies were identified and included. The 'methods' and 'reporting' meta-research areas were the most prevalent, with 73 (47%) and 61 (40%) studies, respectively. General dentistry, and orthodontics and dentofacial orthopaedics were the dental specialties with the greatest number/proportion of included studies with 45 (29%) and 28 (18%) studies, respectively. These findings may help to prioritize future meta-research in dentistry, consequently avoiding unnessecary investigations, and increasing the value of oral and dental research.

Development and validation of prescribing quality indicators for patients with type 2 diabetes.

AIM: Quality indicators are used to measure whether healthcare professionals act according to guidelines, but few indicators focus on the quality of pharmacotherapy for diabetes. The aim of this study was to develop and validate a set of prescribing quality indicators (PQIs) for type 2 diabetes in primary care, and to apply this set in practice. To take into account the stepwise treatment of chronic disease, clinical action indicators were specifically considered. METHODS: Potential PQIs were derived from clinical practice guidelines and evaluated using the RAND/UCLA Appropriateness Method, a modified Delphi panel. Thereafter, the feasibility of calculating the PQIs was tested in two large Dutch primary care databases including >80 000 diabetes patients in 2012. RESULTS: 32 PQIs focusing on treatment with glucose, lipid, blood pressure and albuminuria lowering drugs, and on vaccination, medication safety and adherence were assessed by ten experts. After the Delphi panel, the final list of twenty PQIs was tested for feasibility. All PQIs definitions were feasible for measuring the quality of medication treatment using these databases. Indicator scores ranged from 18.8% to 90.8% for PQIs focusing on current medication use, clinical action and medication choice, and from 2.1% to 37.2% for PQIs focusing on medication safety. DISCUSSION AND CONCLUSIONS: Twenty PQIs focusing on treatment with glucose, lipid, blood pressure and albuminuria lowering drugs, and on medication safety in type 2 diabetes were developed, considered valid and operationally feasible. Results showed room for improvement, especially in initiation and intensification of treatment as measured with clinical action indicators.

Development and initial validation of prescribing quality indicators for patients with chronic kidney disease.

BACKGROUND: Quality assessment is a key element for improving the quality of care. Currently, a comprehensive indicator set for measuring the quality of medication treatment in patients with chronic kidney disease (CKD) is lacking. Our aim was to develop and validate a set of prescribing quality indicators (PQIs) for CKD care, and to test the feasibility of applying this set in practice. METHODS: Potential indicators were based on clinical practice guidelines and evaluated using the RAND/UCLA Appropriateness Method. This is a structured process in which an expert panel assesses the validity of the indicators. Feasibility was tested in a Dutch primary care database including >4500 diabetes patients with CKD. RESULTS: An initial list of 22 PQIs was assessed by 12 experts. After changing 10 PQIs, adding 2 and rejecting 8, a final list of 16 indicators was accepted by the expert panel as valid. These PQIs focused on the treatment of hypertension, albuminuria, mineral and bone disorder, statin prescribing and possible unsafe medication. The indicators were successfully applied to measure treatment quality in the primary care database, but for some indicators the number of eligible patients was too small for reliable calculation. Results showed that there was room for improvement in the treatment quality of this population. CONCLUSIONS: We developed a set of 16 PQIs for measuring the quality of treatment in CKD patients, which had sufficient content and face validity as well as operational feasibility. These PQIs can be used to point out priority areas for improvement.

Process quality indicators for chronic kidney disease risk management: a systematic literature review.

BACKGROUND AND OBJECTIVES: Quality indicators (QIs) can be used for measuring the quality of actions of healthcare providers. This systematic review gives an overview of such QIs measuring processes of care for chronic kidney disease (CKD), and identifies the QIs that have content, face, operational and/or predictive validity. METHODS: PubMed and Embase were searched using a strategy combining the terms "quality of care," "quality indicators" and "chronic kidney disease". Papers were included if they focused on developing, testing or applying QIs for assessing the quality of care in adult patients with CKD not on renal replacement therapy. RESULTS: Two hundred and seventy-three QIs from thirty-one papers were extracted, including QIs on adequate monitoring of kidney function and vascular risk factors, on indicated treatment, drug safety, adherence and referral to a specialist. The QIs that were considered content, face and operational valid focused on monitoring of glomerular filtration rate, albumin-creatinine ratio, lipid levels and blood pressure, the use of non-steroidal anti-inflammatory drugs, nitrofurantoin and biphosphonates in patients with CKD, and QIs on monitoring haemoglobin and treatment with angiotensin-converting-enzyme-inhibitors/angiotensin-receptor-II-blockers in patients with CKD and comorbidities. No QIs were tested for predictive validity. In addition, only two QIs focused on diet and no other QIs focused on lifestyle management. CONCLUSIONS: Based on this review, sufficiently validated QIs can be selected for measuring the quality of CKD care. This review provides insight in QIs that need further validation, and in areas of care where QIs are still lacking.

Development and evaluation of a mobile patient application to enhance medical-dental integration for the treatment of periodontitis and diabetes.

INTRODUCTION: People around the world are increasingly affected by multimorbidity, where conditions in different medical specialties can correlate in complex ways. This increases the relevance of multidisciplinary integrated care pathways. Modern software solutions provide vast opportunities to enhance information exchange between patients and various healthcare professionals, thereby improving patient-centered and inter-professional care. This paper describes the development and validation of a mobile patient application which exploits Patient Reported Outcomes to enhance patient-centered medical-dental integration with a focus on integrated management of periodontitis and diabetes. METHODS: This study was part of a multidisciplinary project for enhancement of medical-dental integration. The Intervention Mapping Protocol was supplemented by the RAND/UCLA Appropriateness Method, including literature reviews, focus group discussions and a Delphi panel in cooperation with various stakeholders. A mobile application was developed in close collaboration with patients, physicians and dentists. The usability of the application's core components was validated in two medical and two dental practices using the System Usability Scale (SUS). RESULTS: 39 questions were identified to provide relevant patient-reported information which can be collected via a mobile application to enhance integrated management of periodontitis and diabetes. Usability testing of the application's core components (14 questions) among 137 participants in medical and dental practices indicated a good SUS score of 77.88 (±12.17). DISCUSSION: The systematically developed mobile application offers the potential to provide physicians and dentists with treatment-relevant information to enhance medical-dental integration, thereby reducing the workload of medical staff, improving the quality of routinely collected data, and enabling automated data processing. This unique, novel, and validated approach can serve as an open framework for the development and evaluation of interdisciplinary healthcare software.

Vegetarian diet and its possible influence on dental health: A systematic literature review.

OBJECTIVES: People following a vegetarian diet could be more prone to oral health problems than people following a nonvegetarian diet. The aim of this systematic review was to examine the possible impacts of following a vegetarian diet on dental hard tissues, focusing on caries development, dental erosion and number of natural teeth. METHODS: PubMed, EMBASE, Web of Science and CINAHL were searched systematically up until 17 April 2019. Original studies comparing dental health (exclusively focusing on dental hard tissues) in vegetarians and nonvegetarians were selected. Study characteristics and outcome data were extracted, and the quality of the studies was assessed using the Newcastle-Ottawa Scale. When a dental health characteristic was reported in three or more papers in a comparable way, a meta-analysis was performed. RESULTS: Twenty-one papers reporting on 18 studies were included in this review. In meta-analyses, the vegetarian diet was associated with a higher risk for dental erosion (odds ratio: 2.40 [95% confidence interval: 1.24, 4.66]; P = .009) and a lower decayed, missing and filled teeth (DMFT) score (mean difference: -0.15 [95% confidence interval: -0.29, -0.02]; P = .023), although the quality of most included studies was poor and the findings for DMFT score became insignificant when only studies on adults were included in the meta-analysis. A meta-analysis for the other dental characteristics was not possible due to the limited number of eligible studies. There was inconsistent evidence for a link between following a vegetarian diet and dental caries or the number of natural teeth. CONCLUSIONS: Within the limitations of the present study, the findings suggest that following a vegetarian diet may be associated with a greater risk of dental erosion.

Effect of periodontal treatment on diabetes-related healthcare costs: a retrospective study.

INTRODUCTION: Periodontitis has been considered a sixth complication of diabetes. The aim of this study was to assess the impact of periodontal treatment on diabetes-related healthcare costs in patients with diabetes. RESEARCH DESIGN AND METHODS: A retrospective analysis was done, exploiting unique and large-scale claims data of a Dutch health insurance company. Data were extracted for a cohort of adults who had been continuously insured with additional dental coverage for the years 2012-2018. Individuals with at least one diabetes-related treatment claim in 2012 were included for analysis. A series of panel data regression models with patient-level fixed effects were estimated to assess the impact of periodontal treatment on diabetes-related healthcare costs. RESULTS: A total of 41 598 individuals with diabetes (age range 18-100 years; 45.7% female) were included in the final analyses. The median diabetes-related healthcare costs per patient in 2012 were €38.45 per quarter (IQR €11.52-€263.14), including diagnoses, treatment, medication and hospitalization costs. The fixed effect models showed €12.03 (95% CI -€15.77 to -€8.29) lower diabetes-related healthcare costs per quarter of a year following periodontal treatment compared with no periodontal treatment. CONCLUSIONS: Periodontitis, a possible complication of diabetes, should receive appropriate attention in diabetes management. The findings of this study provide corroborative evidence for reduced economic burdens due to periodontal treatment in patients with diabetes.

Dutch oral health care quality measures: a modified Delphi study.

OBJECTIVES: Quality measures offer opportunities for evaluation and improvement of the quality of oral health care. This study describes the development of a core set of oral health care quality measures for adults in the Netherlands, which can be used in dental practice. MATERIALS AND METHODS: A comprehensive two-stage approach was used, consisting of: (1) identification of an initial set of measures based on appraised literature; and (2) a four-round modified RAND/UCLA Appropriateness Method to establish measures that are relevant, appropriate and important to oral health care. Measures were rated anonymously on a nine-point Likert scale, ranging from 1 (lowest rating) to 9 (highest rating), followed by a group discussion to reach consensus. Multiple key stakeholder groups in the Dutch oral health care field were involved in the Delphi rounds, including dental professionals, scientists and representatives from Dutch oral health care organisations. RESULTS: The study resulted in a core set of 13 oral health care quality measures. The measures cover domains related to oral disease outcomes, oral treatment and preventive services, patient experiences, patient safety, and organisational aspects of oral health care. In addition, the study led to the identification of 49 structural aspects of oral health care that are important to measure. DISCUSSION: To our knowledge, this is the first study combining appraised literature from a systematic review and a rigorous multi-stage procedure with extensive stakeholder involvement to develop a core set of oral health care quality measures. In the next phase, the measures will be tested on feasibility, reliability, and will be piloted and implemented in practice.

Prescribing quality in secondary care patients with different stages of chronic kidney disease: a retrospective study in the Netherlands.

OBJECTIVES: Insight in the prescribing quality for patients with chronic kidney disease (CKD) in secondary care is limited. The aim of this study is to assess the prescribing quality in secondary care patients with CKD stages 3-5 and possible differences in quality between CKD stages. DESIGN: This was a retrospective cohort study. SETTING: Data were collected at two university (n=569 and n=845) and one non-university nephrology outpatient clinic (n=1718) in the Netherlands. PARTICIPANTS: Between March 2015 and August 2016, data were collected from patients with stages 3a-5 CKD seen at the clinics. Blood pressure measurements, laboratory measurements and prescription data were extracted from medical records. For each prescribing quality indicator, patients with incomplete data required for calculation were excluded. OUTCOME MEASURES: Potentially appropriate prescribing of antihypertensives, renin-angiotensin-aldosterone system (RAAS) inhibitors, statins, phosphate binders and potentially inappropriate prescribing according to prevailing guidelines was assessed using prescribing quality indicators. Χ2 or Fisher's exact tests were used to test for differences in prescribing quality. RESULTS: RAAS inhibitors alone or in combination with diuretics (57% or 52%, respectively) and statins (42%) were prescribed less often than phosphate binders (72%) or antihypertensives (94%) when indicated. Active vitamin D was relatively often prescribed when potentially not indicated (19%). Patients with high CKD stages were less likely to receive RAAS inhibitors but more likely to receive statins when indicated than stage 3 CKD patients. They also received more active vitamin D and erythropoietin-stimulating agents when potentially not indicated. CONCLUSIONS: Priority areas for improvement of prescribing in CKD outpatients include potential underprescribing of RAAS inhibitors and statins, and potential overprescribing of active vitamin D. CKD stage should be taken into account when assessing prescribing quality.

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.