Many patients with diabetes do not achieve target values. One of the reasons for this is clinical inertia. The correct explanation of clinical inertia requires a conjunction of patient with physician ...and health care system factors. Our aim was to determine the rate of clinical inertia in treating diabetes in primary care and association of patient, physician, and health care setting factors with clinical inertia.
This was a national, multicenter, observational, cross-sectional study in primary care in Croatia. Each family physician (FP) provided professional data and collected clinical data on 15-25 type 2 diabetes (T2DM) patients. Clinical inertia was defined as a consultation in which treatment change based on glycated hemoglobin (HbA1c) levels was indicated but did not occur.
A total of 449 FPs (response rate 89.8%) collected data on 10275 patients. Mean clinical inertia per FP was 55.6% (SD ±26.17) of consultations. All of the FPs were clinically inert with some patients, and 9% of the FPs were clinically inert with all patients. The main factors associated with clinical inertia were: higher percentage of HbA1c, oral anti-diabetic drug initiated by diabetologist, increased postprandial glycemia and total cholesterol, physical inactivity of patient, and administration of drugs other than oral antidiabetics.
Clinical inertia in treating patients with T2DM is a serious problem. Patients with worse glycemic control and those whose therapy was initiated by a diabetologist experience more clinical inertia. More research on causes of clinical inertia in treating patients with T2DM should be conducted to help achieve more effective diabetes control.
To assess lifestyle habits and self-reported stress levels among type 2 diabetes mellitus (T2DM) patients and their association with hemoglobin A1c (HbA1c) in general practitioners' (GP) offices in ...Croatia.
449 GPs from all Croatian regions from 2008 to 2010 consecutively recruited up to 20-25 participants diagnosed with T2DM at least 3 years prior to the study, aged ≥40 years, and scheduled for diabetes control check-ups. The recruitment period lasted six months. Lifestyle habits and self-reported stress were assessed using the questionnaire from the Croatian Adult Health Survey.
The study included 10285 patients with T2DM with mean (±standard deviation) age of 65.7±10.05 years (48.1% men). Mean HbA1c level was 7.57±1.58%. 79% of participants reported insufficient physical activity, 24% reported inappropriate dietary patterns, 56% reported current alcohol consumption, 19% were current smokers, and 85% reported at least medium level of stress. Multivariate analysis showed that having received advice to stop drinking alcohol, inadequate physical activity, consumption of milk and dairy products, adding extra salt, and high level of stress were significantly associated with increased HbA1c (P < 0.05).
Poor glycemic control was more frequent in patients who had several "unhealthy" lifestyle habits. These results suggest that diabetes patients in Croatia require more specific recommendations on diet, smoking cessation, exercise, and stress control.
Objective To the authors' knowledge, there are few valid data that describe the prevalence of comorbidity in type 2 diabetes mellitus (T2DM) patients seen in family practice. This study aimed to ...investigate the prevalence of comorbidities and their association with elevated (≥ 7.0%) haemoglobin A1c (HbA1c) using a large sample of T2DM patients from primary care practices. Design A cross-sectional study in which multivariate logistic regression was applied to explore the association of comorbidities with elevated HbA1c. Setting Primary care practices in Croatia. Subjects Altogether, 10 264 patients with diabetes in 449 practices. Main outcome measures Comorbidities and elevated HbA1c. Results In total 7979 (77.7%) participants had comorbidity. The mean number of comorbidities was 1.6 (SD 1.28). Diseases of the circulatory system were the most common (7157, 69.7%), followed by endocrine and metabolic diseases (3093, 30.1%), and diseases of the musculoskeletal system and connective tissue (1437, 14.0%). After adjustment for age and sex, the number of comorbidities was significantly associated with HbA1c. The higher the number of comorbidities, the lower the HbA1c. The prevalence of physicians' inertia was statistically significantly and negatively associated with the number of comorbidities (Mann-Whitney U test, Z = -12.34; p < 0.001; r = -0.12). Conclusion There is a high prevalence of comorbidity among T2DM patients in primary care. A negative association of number of comorbidities and HbA1c is probably moderated by physicians' inertia in treatment of T2DM strictly according to guidelines.
Key points
There is a high prevalence of comorbidity among T2DM patients in primary care.
Patients with breast cancer, obese patients, and those with dyslipidaemia and ischaemic heart disease were more likely to have increased HbA1c.
The higher the number of comorbidities, the lower the HbA1c.
This study compared the association between the 3 definitions of metabolic syndrome (MetS) suggested by the World Health Organization (WHO), National Cholesterol Education Programme (NCEP ATP III), ...and International Diabetes Federation (IDF), and the risk of cardiovascular diseases (CVD) and shows the prevalence and characteristics of persons with MetS in continental vs. coastal regions and rural vs. urban residence in Croatia.
A prospective multicenter study was conducted on 3245 participants≥40 years, who visited general practices from May to July 2008 for any reason. This was a cross-sectional study of the Cardiovascular Risk and Intervention Study in Croatia-family medicine project (ISRCTN31857696).
All analyzed MetS definitions showed an association with CVD, but the strongest was shown by NCEP ATP III; coronary disease OR 2.48 (95% CI 1.80-3.82), cerebrovascular disease OR 2.14 (1.19-3.86), and peripheral artery disease OR 1.55 (1.04-2.32), especially for age and male sex. According to the NCEP ATP III (IDF), the prevalence was 38.7% (45.9%) 15.9% (18.6%) in men, and 22.7% (27.3%) in women, and 28.4% (33.9%) in the continental region, 10.2% (10.9%) in the coastal region, 26.2% (31.5%) in urban areas, and 12.4% (14.4%) in rural areas. Older age, male sex, and residence in the continental area were positively associated with MetS diagnosis according to NCEP ATP III, and current smoking and Mediterranean diet adherence have protective effects.
The NCEP ATP III definition seems to provide the strongest association with CVD and should therefore be preferred for use in this population.
The optimal intensity and duration of the intervention to achieve sustained risk reduction in patients at high and very high cardiovascular (CV) risk still need to be established. The aim of this ...study was to evaluate the impact of general practitioner's (GP's) systematic and planned intervention on total CV risk reduction and a change in individual CV risk factors.
This was a cluster-randomized trial (ISRCTN31857696) including 64 practices and 3245 patients aged ≥40. The participating GPs and their examinees were randomized into an intervention or to a control group (standard care). Intervention group practitioners followed up their examinees during 1, 3, 6, 12, and 18 months. The main outcome measures were change in proportion of patients with low, moderate, high, and very high CV risk, and change in individual CV risk factors from the first to the second registration.
The proportion of patients with very high CV risk was lower in the intervention group, the same as of patients with high blood pressure, total and LDL cholesterol, and increased intake of alcohol. The mean systolic (-1.49 mmHg) and diastolic (-1.57 mmHg) blood pressure, triglycerides (-0.18 mmol/L), body mass index (-0.22), and waist (-0.4 cm) and hip circumference (-1.08 cm) was reduced significantly in the intervention group. There was no additional impact in the intervention group of other tested CV risk factors.
Systematic and planned GP's intervention in CVD prevention reduces the number of patients with very high total CV risk and influences a change in lifestyle habits.
The association between hyperuricemia, hypertension, and diabetes has been proved to have strong association with the risk for cardiovascular diseases, but it is not clear whether hyperuricemia is ...related to the early stages of hypertension and diabetes. Therefore, in this study we investigated the association between hyperuricemia, prediabetes, and prehypertension in Croatian adults, as well as that between purine-rich diet and hyperuricemia, prediabetes, or prehypertension.
A stratified random representative sample of 64 general practitioners (GP) was selected. Each GP systematically chose participants aged ≥ 40 year (up to 55 subjects) . Recruitment occurred between May and September 2008. The medical history, anthropometric, and laboratory measures were obtained for each participant.
59 physicians agreed to participate and recruited 2485 subjects (response rate 77%; average age (± standard deviation) 59.2 ± 10.6; 61.9% women. In bivariate analysis we found a positive association between hyperuricemia and prediabetes (OR 1.66, 95% CI 1.09-2.53), but not for prehypertension (OR 1.68, 95% CI 0.76-3.72). After controlling for known confounders for cardiovascular disease (age, gender, body mass index, alcohol intake, diet, physical activity, waist to hip ratio, total cholesterol, low density lipoprotein, high density lipoprotein, and triglycerides), in multivariate analysis HU ceased to be an independent predictor(OR 1.33, CI 0.98-1.82, p = 0.069) for PreDM. An association between purine-rich food and hyperuricemia was found (p<0.001) and also for prediabetes (p=0.002), but not for prehypertension (p=0.41). The prevalence of hyperuricemia was 10.7% (15.4% male, 7.8% female), 32.5% for prediabetes (35.4% male, 30.8% female), and 26.6% for prehypertension (27.2% male, 26.2% female).
Hyperuricemia seems to be associated with prediabetes but not with prehypertension. Both, hyperuricemia and prediabetes were associated with purine-rich food and patients need to be advised on appropriate diet.
Current Controlled Trials ISRCTN31857696.
Abstract The purpose of the study was to compare the effectiveness of programmed and intensified intervention on lifestyle changes, including physical activity, cigarette smoking, alcohol consumption ...and diet, in patients aged ≥65 with the usual care of general practitioners (GP). In this multicenter randomized controlled trial, 738 patients aged ≥65 were randomly assigned to receive intensified intervention ( N = 371) or usual care ( N = 367) of a GP for lifestyle changes, with 18-month follow-up. The main outcome measures were physical activity, smoking, alcohol consumption and diet. The study was conducted in 59 general practices in Croatia between May 2008 and May 2010. The patients’ mean age was 72.3 ± 5.2 years. Significant diet correction was achieved after 18-month follow-up in the intervention group, comparing to controls. More patients followed strictly Mediterranean diet and consumed healthy foods more frequently. There was no significant difference between the groups in physical activity, tobacco smoking and alcohol consumption or diet after the intervention. In conclusion, an 18-month intensified GP's intervention had limited effect on lifestyle habits. GP intervention managed to change dietary habits in elderly population, which is encouraging since elderly population is very resistant regarding lifestyle habit changes. Clinical trial registration number. ISRCTN31857696.
To compare the distribution of cardiovascular disease (CVD) factors between continental and Mediterranean areas and urban and rural areas of Croatia, as well as to investigate the differences in ...achieving treatment goals by the general practitioners (GP) in different settings.
A multicenter prospective study was performed on 2467 participants of both sexes ≥40 years old, who visited for any reason 59 general practices covering the whole area of Croatia (May-July 2008). The study was a part of the Cardiovascular Risk and Intervention Study in Croatia-family medicine (CRISIC-fm) study. Patients were interviewed using a 140-item questionnaire on socio-demographics and CVD risk factors. We measured body mass index (BMI) and waist circumference and determined biochemical variables including blood pressure, total, high-density lipoprotein-, and low-density lipoprotein-cholesterol, triglycerides, glycemia, and uric acid.
Participants from continental rural areas had significantly higher systolic and diastolic blood pressure (P<0.001), obesity (P=0.001), increased waist circumference (P<0.001), and more intense physical activity (P=0.020). Participants from coastal rural areas had higher HDL-cholesterol, participants from continental rural and coastal urban areas had higher LDL-cholesterol, and participants from rural continental had significantly higher BMI and waist circumference.
Prevalence of CVD risk factors in Croatian population is high. Greater burden of risk factors in continental region and rural areas may be partly explained by lifestyle differences.
Iako je učestalost astme u porastu, pogotovo u djece, astma je danas nedovoljno dijagnosticirana, ali i nedovoljno dobro i neadekvatno liječena bolest. Najveći broj bolesnika zbrinjava i prati ...liječnik obiteljske medicine (LOM). Prema smjernicama Global Initiative For Asthma (GINA) iz 2006. liječenje se određuje prema stupnju kontrole bolesti, umjesto dosad preporučene klasifikacije prema težini bolesti. Temelj liječenja trajne astme, bilo kojeg stupnja u odraslih i djece su inhalacijski kortikosteroidi (ICS) u monoterapiji, a dugodjelujući β2-agonist (LABA), montelukast (LTRA) ili teofilin su dodatna terapija ako se s ICS ne postigne zadovoljavajuća kontrola bolesti. Fiksne kombinacije (ICS + LABA) mogu se rabiti u liječenju samo umjerene i teške trajne astme, ne i kod blage astme, ili kada se s ICS u monoterapiji ne postigne kontrola bolesti. Postoji neopravdani trend sve većeg propisivanja fiksnih kombinacija. Iako postoje jasne smjernice profesionalnih i nacionalnih stručnih drštava, javlja se razmimoilaženje između smjernica i prakse.
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