Epidemiology of Diabetes Mellitus in German General Practitioners' Consultation - Results of the SESAM 2-study

Saxon Epidemiological Study in General Practice-6 (SESAM-6): protocol of a cross-sectional study

INTRODUCTION

General practitioners (GPs) are mostly the first point of contact for patients with health problems in Germany. There is only a limited epidemiological overview data that describe the GP consultation hours based on other than billing data. Therefore, the aim of Saxon Epidemiological Study in General Practice-6 (SESAM-6) is to examine the frequency of reasons for encounter, prevalence of long-term diagnosed diseases and diagnostic and therapeutic decisions in general practice. This knowledge is fundamental to identify the healthcare needs and to develop strategies to improve the GP care. The results of the study will be incorporated into the undergraduate, postgraduate and continuing medical education for GP.

METHODS AND ANALYSIS

This cross-sectional study SESAM-6 is conducted in general practices in the state of Saxony, Germany. The study design is based on previous SESAM studies. Participating physicians are assigned to 1 week per quarter (over a survey period of 12 months) in which every fifth doctor-patient contact is recorded for one-half of the day (morning or afternoon). To facilitate valid statements, a minimum of 50 GP is required to document a total of at least 2500 doctor-patient contacts. Univariable, multivariable and subgroup analyses as well as comparisons to the previous SESAM data sets will be conducted.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of the Technical University of Dresden in March 2023 (SR-EK-7502023). Participation in the study is voluntary and will not be remunerated. The study results will be published in peer-reviewed scientific journals, preferably with open access. They will also be disseminated at scientific and public symposia, congresses and conferences. A final report will be published to summarise the central results and provided to all study participants and the public.

Helicobacter pylori infection and increased diabetes prevalence were the risks of colorectal adenoma for adults: A systematic review and meta-analysis (PRISMA-compliant article)

BACKGROUND

Helicobacter pylori infection and hyperglycemia are associated with an increased risk of colorectal neoplasm, and may have a synergistic effect in combination. However, these 2 factors that affect colorectal neoplasm remain controversial. We aimed to carry out a meta-analysis to evaluate the study population diabetes prevalence rate and H pylori infection rate with colorectal adenoma risk for adults.

METHODS

We conducted systemic research through English databases for medical reports. We also recorded the diabetes prevalence and H pylori infection prevalence in each study. We classified these studies into 4 subgroups as their background population diabetes prevalence <6% (Group 1); between 6% and 8% (Group 2); between 8% and 10% (Group 3), and more than 10% (Group 4). The random-effects model had used to calculate pooled prevalence estimates with 95% confidence interval (CI).

RESULTS

Twenty-seven studies were finally eligible for meta-analysis. The random-effects model of the meta-analysis was chosen, showing pooled odds ratio (OR) equal to 1.51 (95% CI 1.39-1.63). The subgroup meta-analyses showed in Group 1 the H pylori infection associated colorectal adenoma risk OR was 1.24 (95% CI 0.86-1.78). As the diabetes rate exceed 6%, the H pylori infection became the more significant increased risk of colorectal adenoma (Group 2: OR 2.16 (95% CI 1.61-2.91); Group 3: OR 1.40 (95% CI 1.24-1.57); and Group 4: OR 1.52 (95% CI 1.46-1.57)).

CONCLUSIONS

The results of this meta-analysis showed elevated diabetes prevalence combined H pylori infection increasing the risks of colorectal adenoma in the adult population.

Headache in General Practice: Frequency, Management, and Results of Encounter

Objective. Headache is a common reason for consulting the general practitioner. The goal of the investigation was to characterize the headache consultation rates, the associated symptoms, the frequency of diagnostic and therapeutic procedures, and the results of the encounter of patients with headache. Methods. Cross-sectional data were collected from randomly selected patients during the German SESAM 2 study and compared with unpublished but publicly available data from the Dutch Transition Project. Results. Headache accounts for up to five percent of all general practice consultations. Women consult the general practitioner for headache twice as often as men. Physical examination and drug prescription are the most frequent procedures. Most of the patients suffer from primary headache; secondary headache is due to upper respiratory tract infections or problems of the spinal column. Dangerous courses occur in very rare cases. Conclusion. This work confirms the findings of earlier studies regarding the management of patients that consult the general practitioner for headache. It broadens the preexisting database since cross-sectional data regarding headache in general practice was rarely published.

[Prevalence and temporal trend of known diabetes mellitus: results of the German Health Interview and Examination Survey for Adults (DEGS1)]

The first wave of the "German Health Interview and Examination Survey for Adults" (DEGS1, 2008-2011) allows for up-to-date, representative prevalence estimates of known diabetes amongst the 18- to 79-year-old resident population of Germany. Temporal trends can be shown by comparing the survey findings with those of the "German National Health Interview and Examination Survey 1998" (GNHIES98). The definition of known diabetes was based on self-reports in physician-administered interviews that asked respondents if they had ever been diagnosed with diabetes by a doctor or were on anti-diabetic medication. Overall, diabetes had been diagnosed in 7.2 % of the adults (7.4 % of the women; 7.0 % of the men). The prevalence increased substantially with advancing age and was higher in persons of low than of high socioeconomic status. Prevalence varied depending on the type of health insurance held and was highest amongst those insured with AOK health insurance funds. In comparison with GNHIES98, there was a 38 % increase in prevalence, of which approximately one third is to be attributed to demographic ageing. In the context of other nationwide studies, the results indicate a figure of at least 4.6 million 18- to 79-year-olds having been diagnosed with diabetes at some point. Planned analyses of undiagnosed diabetes will contribute to the interpretation of the observed increase in the prevalence of known diabetes. An English full-text version of this article is available at SpringerLink as supplemental.

Knee pain as the reason for encounter in general practice

Objective. Currently, an overview of the management of knee pain in general practitioner's offices is not available. The main concern of this study was to evaluate the consultation prevalence of knee pain, accompanying symptoms, the frequency of diagnostic and therapeutic procedures, and results of encounters of patients suffering from knee pain. Methods. For the SESAM 2 study cross-sectional data was collected from randomly selected patients during one year and compared with publicly available data from the Dutch Transition Project. Results. Overall, 127 out of 8,877 (1.4%) patients of the SESAM 2 study and 6,754 out of 149,238 (4.5%) patients of the Dutch Transition Project consulted for knee pain. Drug prescription, follow-up consultation, giving doctor's advice, and referral to a specialist or physiotherapist were the most frequent procedures. Osteoarthritis of the knee and other musculoskeletal diseases were the most frequent results of encounter. Overweight, age, gender, and other musculoskeletal diseases were found to be significantly associated with knee pain. Conclusion. Knee pain in general practice settings is mainly associated with chronic problems. Dangerous outcomes (as suspected fracture or thrombosis) are rare. Further research is needed in order to reduce the influence knee pain has on daily living.

The effect of nurse-led diabetes self-management education on glycosylated hemoglobin and cardiovascular risk factors: a meta-analysis

PURPOSE

The purpose of this meta-analysis was to determine the effect of nurse-led diabetes self-management education (DSME) on blood glucose control and cardiovascular risk factors.

METHODS

The electronic databases PubMed and ISIS Knowledge were searched for relevant randomized controlled studies published between 1999 and 2009. Effect size was calculated for change in A1C, blood pressure, and lipid levels using both fixed- and random-effects models. Subgroup analyses were performed on patient age, gender, diabetes type, baseline A1C, length of follow-up, and study setting.

RESULTS

A total of 34 randomized controlled trials with a combined cohort size of 5993 patients was identified. Mean patient age was 52.8 years, 47% were male, and mean A1C at baseline was 8.5%. Mean change in A1C was a reduction by -0.70% for nurse-led DSME versus -0.21% with usual care (UC). This corresponded to an effect size of 0.506, using a random-effects model for nurse-led DSME versus UC. Effect size was significantly associated with patient age older than 65 years and with duration of follow-up. Nurse-led DSME was also associated with improvements in cardiovascular risk factors, particularly among male patients, among those with good glycemic control, and in studies conducted in the United States.

CONCLUSIONS

Nurse-led DSME is associated with improved glycemic control, demonstrating that programs are most effective among seniors and with follow-up periods of 1 to 6 months. Future programs tailored to the needs of patients younger than 65 years may improve the impact of DSME on blood glucose.

Dyspnea as the reason for encounter in general practice

Background

Dyspnea is a common reason for consulting a physician. Data from the primary care setting on the epidemiology, management, and underlying causes of dyspnea have seldomly been published. The present study is aimed to explore the consultation prevalence of dyspnea, frequency of diagnostic and therapeutic procedures, accompanying symptoms and results of encounter or diagnoses of patients with dyspnea in a day-to-day primary care setting.

Methods

Cross-sectional data were collected from randomly selected patients during the SESAM 2 study (October 1, 1999 to September 30, 2000). Unpublished but publicly available data from the Dutch Transition Project were also analysed.

Results

One (n = 93; SESAM 2) and 3.9% (n = 7,855; Transition Project) of the patients consulted the practioner for dyspnea. The male to female ratio was almost 1 : 1. Half of the patients sought medical advice for not previously known dyspnea (Transition Project). Dyspnea occurs more frequently among small children (0 to 4 years) and elderly adults (> 64 years of age). Nearly all patients received a physical examination. Many causes were examined with the help of electrocardiograms but spirometry and laboratory tests were also used. Drug prescription was the most frequent (79.6%) therapeutic procedure. Acute bronchitis was the most common diagnosis. Dyspnea was significantly associated to cough, dysphagia, abnormal sputum, airway pain, sweating, and thoracic pain. There was also a significant association to chronic obstructive pulmonary disease.

Conclusions

Dyspnea is a common reason for seeking medical advice. Emergency cases (e.g. myocardial infarction) are rarely present in the general practitioner’s consultation. The majority of underlying causes are respiratory tract infections and exacerbated, previously known chronic diseases.

Keywords

Dyspnea; General practice; Primary care; Reason for encounter

Pruritus as reason for encounter in general practice

Background

Pruritus is a common reason for consulting the general practitioner. Data from a primary care setting have seldom been published. The goal of the recent investigation was to characterize the consultation prevalence of pruritus, frequency of diagnostic and therapeutic procedures, accompanying symptoms and results of encounter or diagnoses of patients with pruritus.

Methods

Cross-sectional data were collected from randomly selected patients during the SESAM 2 study and compared with unpublished but publicly available data from the Dutch Transition Project and the published Australian BEACH study data.

Results

Overall 64 of the 8,877 patients from the SESAM 2 study consulted a physician for pruritus. The male to female ratio was 1.0 : 1.3. Pruritus was more frequent in children and people aged over 75 years. Physical examination was performed in all patients. Further diagnostic measures were seldom necessary. Drugs were prescribed in 84% of the cases. Allergic contact eczema and infectious diseases of the skin were the most frequent results of encounter or diagnoses. Medical adverse effects and allergic reactions should be considered as causes of pruritus. We found no significant association to systemic diseases.

Conclusions

In a primary care setting, pruritus occurs regularly. It is associated to (infectious) skin diseases. Acute dangerous courses are rare.

Keywords

Pruritus; Itch; General practice; Primary care; Reason for encounter

Inadequate diabetic care: global figures cry for preventive measures and personalized treatment

Diabetes mellitus (DM) is a lifelong progressive disease. Currently there are more than 285 million DM-affected people worldwide. Globally the prevalence of diabetes continues to rise and is more pronounced in countries with large populations such as China, India and USA. Driving forces behind the epidemic are obesity, aging of the population and longer life expency. Prospective, the majority of diabetic population will be in their six to eight decades of life with the implication of more females than males. Severe micro- and macrovascular complications associated with diabetes lead to a highly increased morbidity and mortality. Therefore, DM is projected to be one of the leading health problems of 21st centuary. Urgent measures are required to reduce the diabetic burden. Thus advanced predictive diagnostic tools and personalized treatment strategies in (pre)diabetic care are critical and should exert beneficial impact on public health.

The conjunctival bacterial pattern of diabetics undergoing cataract surgery

PURPOSE

To ascertain the conjunctival bacterial pattern of diabetics undergoing cataract operation to reduce the risk of postoperative endophthalmitis (PE).

METHODS

An observational retrospective study of the conjunctival bacteria of consecutive patients undergoing cataract surgery from July 2005 to November 2008. Records of patients having eye surgical prophylaxis in the 6 months before the culture and those patients having cataract operation combined with other surgical procedures were excluded. Aerobic and microaerobic cultures were carried out. Dade-Behring panels were used for bacterial identification. The database containing the isolated bacteria was linked to another Access database containing demographic and clinical data such as diabetes presence and baseline blood glucose and creatinine levels. The conjunctival bacteria of diabetics were compared with those of the non-diabetics. Epidat 3.1 program was used for statistical calculations.

RESULTS

From 5922 selected patients, 1325 (22.37%) knew they were diabetics (higher prevalence than expected). Among self-reported non-diabetics, 900 (15.2%) could be 'unknown' diabetics; another 274 had an impaired renal function; and 3423 non-diabetics joined the control group. Diabetics have a significantly higher prevalence of Staphylococcus aureus, Enterococci, certain Streptococci, and Klebsiella sp. than non-diabetics. Diabetics and non-diabetics having a blood creatinine level above 105.2 mumol/l had an increased conjunctival bacterial prevalence; these groups had a higher mean age and men predominated.

CONCLUSIONS

Diabetics have a conjunctival flora pattern whose increased bacteria are a predominant cause of many diabetic infections. An abnormally high blood creatinine level is an indicator of increased conjunctival colonisation in diabetics and non-diabetics.

Three- and four-digit ICD-10 is not a reliable classification system in primary care

OBJECTIVE

The International Classification of Diseases 10th revision (ICD-10) is a standard international diagnostic classification for medical diagnoses. Reliable diagnostic coding is of high medical and epidemiological importance. Coding diagnoses with ICD-10 is the basis of reimbursement in some healthcare systems.

DESIGN

The ICD-10 coding of each case was performed by two raters to investigate the inter-rater agreement. The degree of agreement was assessed using Cohen's kappa. Kappa was divided into two groups: Kappa > or = 0.61 meaning high or satisfactory and kappa < or = 0.6 (incl. < or = 0.000 and 0.000*) meaning low or unsatisfactory.

SUBJECTS

Cross-sectional data were collected from 8877 randomly selected patients. The 209 participating general practitioners used a standardized data collection form. The first of the reasons for encounter was taken into account on new and chronic managed problems.

RESULTS

Kappa values were satisfactory on the chapter level with on average 0.685 (chronic managed problems) and 0.675 (new managed problems). Kappa was unsatisfactory when the three-digit level was used (0.428) and lower for terminal codes (four-digit level) at 0.199 on average (chronic managed problems). For new managed problems the kappa values were at 0.384 (three-digit level) and 0.166 (four-digit level) on average.

CONCLUSION

The ICD-10 is reliable for coding managed problems on the chapter level. Further refinement of ICD-10 with three- and four-digit codes leads to significant coding uncertainties. There is no reliable coding scheme that meets the demands of general practice. The use of coded data for healthcare reimbursement requires a simplification of ICD-10 to provide a realistic picture of morbidity.