Barriers and facilitators to evidence based care of type 2 diabetes patients: experiences of general practitioners participating to a quality improvement program

Objective To evaluate the barriers and facilitators to high-quality diabetes care as experienced by general practitioners (GPs) who participated in an 18-month quality improvement program (QIP). This QIP was implemented to promote compliance with international guidelines. Methods Twenty out of the 120 participating GPs in the QIP underwent semi-structured interviews that focused on three questions: 'Which changes did you implement or did you observe in the quality of diabetes care during your participation in the QIP?' 'According to your experience, what induced these changes?' and 'What difficulties did you experience in making the changes?' Results Most GPs reported that enhanced knowledge, improved motivation, and a greater sense of responsibility were the key factors that led to greater compliance with diabetes care guidelines and consequent improvements in diabetes care. Other factors were improved communication with patients and consulting specialists and reliance on diabetes nurse educators. Some GPs were reluctant to collaborate with specialists, and especially with diabetes educators and dieticians. Others blamed poor compliance with the guidelines on lack of time. Most interviewees reported that a considerable minority of patients were unwilling to change their lifestyles. Conclusion Qualitative research nested in an experimental trial may clarify the improvements that a QIP may bring about in a general practice, provide insight into GPs' approach to diabetes care and reveal the program's limits. Implementation of a QIP encounters an array of cognitive, motivational, and relational obstacles that are embedded in a patient-healthcare provider relationshipGeert Goderis, Liesbeth Borgermans, Chantal Mathieu, Carine Van Den Broeke, Karen Hannes, Jan Heyrman and Richard Gro

Malnutrition in older patients with type 2 diabetes is associated with increased frailty

INTRODUCTION. Type 2 diabetes may be associated with malnutrition. This study explored the relationship between this association and frailty features in older patients. METHODS. Cross-sectional study among 172 older diabetic patients (83±4 years; sex ratio 1:1) admitted in a Belgian teaching hospital (2012-2013). Included patients had old age (≥75 years), type 2 diabetes mellitus, risk of functional decline (ISAR≥2) and comprehensive geriatric assessment including a short mini-nutritional assessment (MNA-SF, range 0-14). We compared the patients with malnutrition (MNA-SF ≤ 7/14) to those without malnutrition, using appropriate statistics (chi² and t-tests). RESULTS. The 44 diabetic patients with malnutrition (MNA-SF 5.8±1.6) - as compared to the 128 ones without malnutrition (MNA-SF 10.7±1.7) - were similar in age, gender, co-morbidities (e.g. hypertension 78%, ischaemic disease 62%, grade IV-V renal failure 22%) and common geriatric syndromes (e.g. multiple falls 49%, chronic pain 34%, visual impairment 33%, cognitive decline 32%). Diabetic patients with malnutrition more frequently presented with HbA1c 3/6: 54vs.34%), nursing home residency (36vs.10%) and high risk of functional decline (ISAR ≥ 4: 70vs.46%). Their mortality rate in January 2014 was also higher (34vs.19%, p=0.05). CONCLUSIONS. Malnutrition was present in 1 in 4 older patients with diabetes mellitus. This subgroup of patients with diabetes and malnutrition deserves increased medical attention, as it shows higher prevalence of inappropriately low HbA1c, as well as higher risk of functional decline and mortality

Aspirin Misuse At Home According To START And STOPP In Frail Older Persons

Background. Aspirin misuse is concerned by three and six criteria of the START and STOPP lists, which help detecting inappropriate prescribing in older people. This study described aspirin misuse and aspirin-related hospital admissions in this population. Methods. Data were collected upon acute hospital admission in frail older persons (≥75 years; ISAR≥2/6). Using the START and STOPP criteria, a pharmacist and a geriatrician independently detected events of prescribing omission (PO) and inappropriate medication (IM) concerning drugs at home, and determined whether the hospital admission was related to PO or IM. Results. In 302 frail older persons (84±5 years; ♀63%), 77 of the 362 PO were aspirin underuse (lack of aspirin in patients in secondary cardiovascular (CV) prevention and sinus rhythm, n=41; with diabetes and coexisting CV risk factor, n=33; or with chronic atrial fibrillation and contraindicated warfarin, n=3), while 35 of the 210 detected IM were aspirin overuse (dose>150mg/d, n=25; aspirin in primary CV prevention, n=7; aspirin and peptic ulcer disease history without gastric protection, n=2; aspirin and warfarin without gastric protection, n=1). Overall, 82 hospital admissions were related to inappropriate prescribing, of which 8 were linked to aspirin misuse (aspirin underuse and admission for myocardial ischaemia in secondary CV prevention, n=6; aspirin overuse and admissions for haemorrhage, n=2). Conclusions. Aspirin misuse at home was detected in about one third of these frail older persons and accounted for 10% of the hospital admissions related to inappropriate prescribing. Clinicians should remember when to consider and to avoid aspirin in this frail populatio

Easy-to-use clinical criteria for screening malnutrition in older patients with type 2 diabetes mellitus.

INTRODUCTION. In the daily practice, the mini-nutritional assessment short form (MNA-SF) is not systematically performed in geriatric inpatients. This study aimed at identifying some easy-to-use and effective clinical criteria for screening malnutrition in geriatric patients with diabetes. METHODS. Cross-sectional study in 172 older diabetic patients (83±4 years) admitted in a Belgian academic hospital. We compared the patients with malnutrition (MNA-SF≤7/14) to those without malnutrition in terms of the five MNA-SF items (see below) and mid-arm circumference (MAC), using χ2 and t-tests. RESULTS. The 44 diabetic patients with malnutrition (26%), as compared to the 128 without malnutrition, were similar in age and gender but presented smaller MAC (25.2±3 vs. 28.6±4 cm, n=151, p<0.001). MAC<27 cm (median value) was more frequent in patients with malnutrition (68vs.32%, p<0.001) and offered fair screening characteristics (sensitivity 68%, specificity 67%). Comparing the MNA-SF items in patients with and without malnutrition, we observed differences in mobility problems (scores: 0.84vs.1.25; ∆=0.41), neuropsychological troubles (1.02vs.1.48; ∆=0.46), body mass index (1.41vs.2.68; ∆=1.27, n=121) and in reports of weight loss (0.82vs.2.13; ∆=1.31), psychological stress/acute disease (1.09vs.1.69; ∆=0.60) and food intake decline (0.59vs.1.46; ∆=0.87) over the past 3 months. CONCLUSIONS. The largest score differences in MNA-SF items between the two groups were body mass index (missing data in 30%), food intake decline or weight loss over the previous three months. Any of these three criteria or MAC<27 cm should prompt further nutritional assessment in settings where MNA-SF is not systematic

Insulin sensitivity and secretion in older patients differ according to age at diabetes diagnosis.

INTRODUCTION. Little is known on insulin sensitivity and secretion in older patients with type 2 diabetes mellitus (DM2), a heterogeneous group of patients. METHODS. Cross-sectional study of 210 consecutive older (≥75 years) patients followed for DM2 at the outpatient diabetes clinic of an academic hospital. DM2 was classified as habitual-onset diabetes (HODM2) when diagnosed <65 years or elderly-onset diabetes (EODM2) when diagnosed ≥65 years. Insulin sensitivity and β-cell function were assessed by HOMA modeling. Statistical significance (p<0.05) of differences was assessed using Student’s t-test, Welch’s test or Fisher’s Exact test. RESULTS. Patients with EODM2 (n=88; 82.6±5 years), as compared to HODM2 (n=122; 81.2±6 years), had a shorter history of DM2 (10±5vs.26±10 years). Both groups were not different in terms of cardio-vascular risk factors and DM2-related complications, except at the micro-vascular level (EODM2vs.HODM2: 45vs.72%). Concerning metabolic profile, EODM2 significantly differed from HODM2 in 4 anthropometric and metabolic characteristics: lower BMI (26.6vs.28.2 kg/m2), lower prevalence of obesity (18vs.27%), higher insulin sensitivity (66vs.53%) and higher residual β-cell secretion (68vs.52%). Although HbA1c was similar in both groups (7.31vs.7.62%), HbA1c <7% was more frequently observed in EODM2 patients than in HODM2 ones (49vs.37%). EODM2 patients, as compared to HODM2 ones, received significantly less intensive anti-diabetic regimens, specifically oral ones (bi- or tri-therapies: 28%vs.59%) and insulin (32vs.66%, p<0.001) at a lower mean daily dosage (0.47vs.0.57 IU/kg). CONCLUSION. EODM2 patients had specific metabolic features and differ from HODM2 ones. Thereby, because of their higher risk of hypoglycemia, EODM2 patients should be treated with lighter glucose-lowering therapy