Diabetic Patients In General Practice Research Articles

Insulin treatment for diabetes

The first use of insulin in 1922 began a new era in the management and survival of patients with type 1 diabetes. Before 1922, patients with this condition were placed on a starvation diet and survived only a few months. Nearly a century later, insulin remains the dominant treatment for type 1 diabetes, is used in gestational diabetes and increasingly in type 2 diabetes. This article focuses on insulin treatment for adult diabetic patients in general practice. It will explore the effect of insulin and the role it has in diabetes, the preparations available, recommended regimens and some challenges with insulin treatment.

How pragmatic are the randomised trials used in recommendations for control of glycosylated haemoglobin levels in type 2 diabetic patients in general practice: an application of the PRECIS II tool

BackgroundRecommendations for good clinical practice have been reported to be difficult to apply in real life by primary care clinicians. This could be because the clinical trials at the origin of the guidelines are based on explanatory trials, conducted under ideal conditions not reflecting the reality of primary care, rather than pragmatic trials conducted under real-life conditions. The objective of this study was to evaluate how pragmatic are the clinical trials used to build the French High Authority of Health’s recommendations on the management of type II diabetes.MethodsTrials from the 2013 Cochrane meta-analysis that led to the 2013 French High Authority of Health’s recommendations on the management of type II diabetes were selected. Each trial was analysed by applying the PRECIS-2 tool to evaluate whether the trial was pragmatic or explanatory, according to the nine domains of PRECIS-2. Each domain was scored between 1 (very explanatory) and 5 (very pragmatic) by two blinded researchers, and consensus was reached with a third researcher in case of discrepancy. Median scores were calculated for each of the nine domains.ResultsTwenty-three articles were analysed. Eight out of nine domains – namely eligibility, recruitment, setting, organisation, flexibility of delivery, flexibility of adherence, follow-up, and primary outcome – had a median score of less than 3, indicating a more explanatory design. Only the primary analysis domain had a score indicating a more pragmatic approach (median score of 4). In more than 25% of the articles, data to score the domains of recruitment, flexibility of delivery, flexibility of adherence, and primary analysis were missing.ConclusionsTrials used to build French recommendations for good clinical practice for the management of type 2 diabetes in primary care were more explanatory than pragmatic. Policy-makers should encourage the funding of pragmatic trials to evaluate the different strategies proposed for managing the patient’s treatment according to HbA1C levels and give clinicians feasible recommendations.

An audit investigating the management of diabetic patients in general practice, in relation to periodontal health

Research has found a close relationship between the disease progression of diabetes and periodontitis. The aim of this audit is to determine the compliance of general dental practitioners (GDPs) with recommendations from the Delivering Better Oral Health toolkit (2014) for the management of diabetic patients. The final section of this article discusses the factors that affect the prognosis of immediate natural tooth bridges. Providing information on prognosis is an important part of the consent process; this includes patient factors and clinician factors. CPD/Clinical Relevance: There is evidence of a bi-directional relationship between diabetes and periodontitis.

Call for Applications and Nominations for Editor in Chief of the NCMJ

BACKGROUND: Audit of diabetic care is becoming common in general practice. Most of this audit is concerned with structure and process; outcome audit is much more difficult to achieve. AIM: To determine whether the structure of general practice diabetic care influenced the process or outcome and whether efficiency of process predicted improved outcome. METHOD: Cross-sectional survey, by questionnaire and review of notes, among general practices in the East Dorset district, involving diabetic patients identified from general practitioner (GP) disease registers or from a hospital diabetic register. The main outcome measures were the proportion of process and outcome measurements, related to selected structure criteria and the proportion of outcome measurements, related to appropriate process measurements. All associations were tested using the practice as the unit of analysis. RESULTS: Practices with a detailed diabetic register showed a positive association with a higher proportion of some process, but no outcome, measurements compared to those practices without such a registrar. A high proportion of process measurements did not correlate with improved outcome. CONCLUSION: Assessment of the follow-up of diabetic patients in general practice by measurement of the structure or process of care does not allow the prediction of an improved outcome for those patients when summarized on a practice basis. There is no shortcut to the collection of data on outcome as a measure of the benefit of follow-up for diabetic patients.

Prevalence of macrovascular disease amongst type 2 diabetic patients detected by targeted screening and patients newly diagnosed in general practice: the Hoorn Screening Study.

Screening for type 2 diabetes has been recommended and targeted screening might be an efficient way to screen. The aim was to investigate whether diabetic patients identified by a targeted screening procedure differ from newly diagnosed diabetic patients in general practice with regard to the prevalence of macrovascular complications. Cross-sectional population-based study. Population study, primary care. Diabetic patients identified by a population-based targeted screening procedure (SDM patients), consisting of a screening questionnaire and a fasting capillary glucose measurement followed by diagnostic testing, were compared with newly diagnosed diabetic patients in general practice (GPDM patients). Ischaemic heart disease and prior myocardial infarction were assessed by ECG recording. Peripheral arterial disease was assessed by the ankle-arm index. Intima-media thickness of the right common carotid artery was measured with ultrasound. A total of 195 SDM patients and 60 GPDM patients participated in the medical examination. The prevalence of MI was 13.3% (95% CI 9.3-18.8%) and 3.4% (1.0-11.7%) in SDM patients and GPDM patients respectively. The prevalence of ischaemic heart disease was 39.5% (95% CI 32.9-46.5%) in SDM patients and 24.1% (15.0-36.5%) in GPDM patients. The prevalence of peripheral arterial disease was similar in both groups: 10.6% (95% CI 6.9-15.9%) and 10.2% (4.7-20.5%) respectively. Mean intima-media thickness was 0.85 mm (+/-0.17) in SDM patients and 0.90 mm (+/-0.20) in GPDM patients. The difference in intima-media thickness was not statistically significant. Targeted screening identified patients with a prevalence of macrovascular complications similar to that of patients detected in general practice, but with a lower degree of hyperglycaemia.

Patient characteristics do not predict poor glycaemic control in type 2 diabetes patients treated in primary care.

Many diabetic patients in general practice do not achieve good glycaemic control. The aim of this study was to assess which characteristics of type 2 diabetes patients treated in primary care predict poor glycaemic control (HbA1c > or = 7%). Data were collected from the medical records. 1641 patients were included who had mean HbA1c 7.1(SD 1.7)% , and 42% had HbA1c > or = 7%. On univariate analysis younger age; longer duration of diabetes; higher levels of blood glucose at diagnosis; most recent fasting blood glucose (FBG), total cholesterol, and triglyceride; higher body mass index (BMI); treatment with oral hypoglycaemic agents (OHA); treatment with insulin; more GP-visits for diabetes in the last year; and lower educational level were associated with poor control. Both in multiple linear regression and in multiple logistic regression higher levels of FBG (odds ratio (OR): = 1.6, 95% confidence interval (CI): 1.49, 1.70), treatment with OHA (OR: 2.1, 95% CI: 1.41, 3.04), treatment with insulin (OR: 7.2, 95% CI: 4.18, 12.52), lower educational level (OR: 1.26, 95% CI: 1.01, 1.56) were independently associated with poor levels of HbA1c. When FBG levels were excluded from the model, higher blood glucose at diagnosis, higher values for triglyceride and total cholesterol, and younger age predicted poor glycaemic control, but these variables explained only 15% of the variation in HbA1c. In conclusion prediction of poor glycaemic control from patient characteristics in diabetic patients in general practice is hardly possible. FBG appeared to be a strong predictor of HbA1c, which underlines the usefulness of this simple test in daily diabetes care. The worse metabolic control in those treated with either OHA or insulin suggests that current treatment regimes might be not sufficiently applied to reach the targets of care. Providers of diabetes care should be attentive to patients with lower educational level.

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.

Metabolic control and morbidity of type 2 diabetic patients in a general practice network.

Glycaemic control and the prevalence of modifiable cardiovascular risk factors, and micro- and macrovascular morbidity was examined in 637 Type 2 diabetic patients in general practice, of whom 405 consented to undergo a more extensive examination. In these 405 patients, HbA1c was > or = 7% in 56.6%, and hypertension and dyslipidaemia were found in 59.8% and 46.5% of the patients, respectively. The level of cardiovascular risk factors was acceptable, according to the European guidelines, in the following proportions of patients: BMI 45.0%; total cholesterol 69.1%; HDL-cholesterol 68.1%; triglycerides 67.8%; current blood pressure 89.8%; and smoking 21.0%. Retinopathy was present in 12.5% and microalbuminuria in 27.0% of the patients. In all 637 patients, the prevalence of angina pectoris was 17.7%, of myocardial infarction 11.4% and of congestive heart failure 10.7%. The care for Type 2 diabetic patients needs improvement and should focus on cardiovascular risk factors as much as on glycaemic control.

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.

Evaluation of a Structured Teaching and Treatment Programme for Type 2 Diabetes in General Practice in a Rural Area of Austria

The efficacy of a treatment and teaching programme for non-insulin-treated Type 2 diabetic patients in general practice was evaluated in a prospective, controlled study. In a rural area in southern Austria, 53 patients from seven general practices participated in a structured programme (intervention group) and 55 patients from seven general practices without the programme served as the control group. After 6 months the weight reduction in the intervention group was 2.6 kg (1.6-3.7 kg, p < 0.001) and the difference in HbA1c between the groups was 0.92% (0.23-1.61%, p < 0.01) at follow-up. Systolic (-16.6 mmHg) and diastolic (-11.1 mmHg) blood pressure, serum triglycerides (-0.63 mmol I-1), and serum cholesterol (-0.40 mmol I-1) were reduced significantly in the intervention group (p < 0.006). The number of patients with callus formation and poor nail care decreased significantly after participating in the teaching programme (p < 0.001). In the control group no reduction in body weight, metabolic control or in risk factors for diabetic foot complications were observed. Calculated health care costs per patient and year decreased in the intervention group (-33 pounds) and increased in the control group (+ 30 pounds) mainly due to changes in prescription of oral hypoglycaemic agents in both groups. This programme may be an efficient and helpful model to increase overall quality of diabetes care according to the St Vincent Declaration.

Diabetic patients who do not have diabetes: investigation of register of diabetic patients in general practice.

The care of patients with non-insulin dependent diabetes mellitus is often considered the responsibility of general practitioners.*RF 1-3* Organising such care usually entails setting up a diabetic register, standardising care,4 and then performing an audit.5 While auditing our diabetic care we noted that some patients' serial glycated haemoglobin (HbA1) concentrations were all normal or nearly so. We decided to investigate whether these patients actually had diabetes. Our practice serves an isolated community of 8770 patients. A diabetic register was established in 1983. Although no formal criteria were used for entry, most patients had results from a blood glucose test (random, fasting, or postprandial) or an oral glucose tolerance test. A written management protocol was agreed in 1987; this included checking HbA1 concentrations in all patients every three months. An audit of diabetic care was performed in October 1992. Patients with normal or near normal serial HbA1 concentrations were noted and their records examined. Those with no clear clinical evidence of diabetes …