Abstract
The central aim of this thesis is to investigate the effectiveness of the current management of type 2 diabetes patients with unsatisfactory glycaemic control (HbA1c > 7%) treated in primary care. In chapter 1 we outline the present role of primary care in type 2 diabetes against the background of
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important developments in diabetes care during the past decades. Evidence-based practice guidelines and shared-care projects did facilitate a more structural approach of diabetes care. Nevertheless, evaluations showed considerable numbers of patients being insufficiently reviewed or treated, resulting in less optimal outcomes of care. The studies in this thesis were conducted in sixty general practices in the Utrecht region between July 1999 and February 2003, and covered the following themes: monitoring of clinical data and outcome of care (chapter 2); predictors of poor glycaemic control (chapter 3); nurse facilitators and oral hypoglycaemic agent therapy (chapter 4); patient self-management education by a diabetes nurse (chapter 6); and insulin treatment (chapter 6 and 7).
The medical records of the patients appeared to be often incomplete. However, we found no association between completeness of data recording and control of glycaemia. This suggests that more careful data recording does not automatically result in better control of patients. Besides, abnormal values collected with recurrent reviews should be followed more rigorously by efforts to initiate glucose lowering treatment. A simple flowchart and relatively little support by trained facilitators resulted after a mean of three consultations per patient over 14 weeks a clinically significant reduction in HbA1c, while the number of patients with poor control (HbA1c > 8.5%) decreased with sixty percent. This result was attained by adjusting oral medication according to the level of the fasting blood glucose, together with a rigorous appointment policy. In the education study the educational programme has proven to be a powerful instrument in patients (mean age 60 years) with poor glycaemic control despite maximal treatment with oral agents. For a majority of patients the urgency of a transfer to insulin therapy had disappeared. Therefore, this type of education can be delivered at least to all patients in this stage of diabetes, but should not be offered without regular reinforcements integrated into standard diabetes care. The results of the insulin study as well as the systematic review showed that bedtime NPH insulin in addition to the existing maximal oral is a simple, effective, and well tolerated first choice approach in uncontrolled type 2 diabetes patients.
This thesis supplies considerable evidence that actual shortcomings in care could be tackled if providers of diabetes care adopt a more “outcome oriented” approach. Although the objective was targeted on glycaemic control, this attitude might also be effective in other risk factors for cardiovascular complications. Since diabetes care is complex and time-consuming we believe that the general practitioner should retain a central position in the care for these patients. However, this position can only be sustained if the care is well organised and in the presence of sufficient specialised support.
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