The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)
To investigate the effect of glycosylated hemoglobin, age, sex, hypertension, body mass index, waist-hip ratio, serum lipid levels, and smoking on the incidence of retinopathy in persons with normal and abnormal glucose metabolism.The incidence of retinopathy was determined in 233 individuals, aged 50 to 74 years, by ophthalmoscopy and fundus photography at baseline and after an average follow-up of 9.4 years. Relative risks for retinopathy, estimated by odds ratios, were calculated for tertiles of cardiovascular risk factors at baseline. Logistic regression analysis was used, without and with adjustment for age, sex, hypertension, and glucose metabolism.The cumulative incidences of retinopathy among individuals with normal, impaired, and diabetic glucose metabolism were 7.3%, 13.6%, and 17.5%, respectively. Adjusted odds ratios for retinopathy were 2.36 (95% confidence interval, 1.02-5.49) for hypertension and 3.29 (95% confidence interval, 1.11-9.72) and 8.67 (95% confidence interval, 1.85-40.60) for the highest tertiles of glycosylated hemoglobin level and waist-hip ratio, respectively. No consistent or statistically significant associations with retinopathy were present for age, sex, body mass index, smoking, and serum levels of triglycerides and total, high-density lipoprotein, and non-high-density lipoprotein cholesterol (P>.05 for all).Glycemia, hypertension, and abdominal obesity are determinants for retinopathy in a general population.
Abstract Purpose To increase the efficiency of retinal image grading, algorithms for automated grading have been developed, such as the IDx‐DR 2.0 device. We aimed to determine the ability of this device, incorporated in clinical work flow, to detect retinopathy in persons with type 2 diabetes. Methods Retinal images of persons treated by the Hoorn Diabetes Care System (DCS) were graded by the IDx‐DR device and independently by three retinal specialists using the International Clinical Diabetic Retinopathy severity scale (ICDR) and EURODIAB criteria. Agreement between specialists was calculated. Results of the IDx‐DR device and experts were compared using sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), distinguishing between referable diabetic retinopathy (RDR) and vision‐threatening retinopathy (VTDR). Area under the receiver operating characteristic curve (AUC) was calculated. Results Of the included 1415 persons, 898 (63.5%) had images of sufficient quality according to the experts and the IDx‐DR device. Referable diabetic retinopathy (RDR) was diagnosed in 22 persons (2.4%) using EURODIAB and 73 persons (8.1%) using ICDR classification. Specific intergrader agreement ranged from 40% to 61%. Sensitivity, specificity, PPV and NPV of IDx‐DR to detect RDR were 91% (95% CI: 0.69–0.98), 84% (95% CI: 0.81–0.86), 12% (95% CI: 0.08–0.18) and 100% (95% CI: 0.99–1.00; EURODIAB) and 68% (95% CI: 0.56–0.79), 86% (95% CI: 0.84–0.88), 30% (95% CI: 0.24–0.38) and 97% (95% CI: 0.95–0.98; ICDR). The AUC was 0.94 (95% CI: 0.88–1.00; EURODIAB) and 0.87 (95% CI: 0.83–0.92; ICDR). For detection of VTDR, sensitivity was lower and specificity was higher compared to RDR. AUC's were comparable. Conclusion Automated grading using the IDx‐DR device for RDR detection is a valid method and can be used in primary care, decreasing the demand on ophthalmologists.
OBJECTIVE—To study potential risk factors for retinopathy in diabetic and nondiabetic individuals. RESEARCH DESIGN AND METHODS—The Hoorn Study is a population-based study including 2,484 50- to 74-year-old Caucasians. A subsample of 626 individuals stratified by age, sex, and glucose tolerance underwent extensive measurements during 1989–1992, including ophthalmologic examination and two-field 45-degree fundus photography. The prevalence of (diabetic) retinopathy was assessed among individuals with normal glucose metabolism (NGM) and impaired glucose metabolism (IGM) and individuals with newly diagnosed diabetes mellitus (NDM) and known diabetes mellitus (KDM) (new World Health Organization 1999 criteria). RESULTS—The prevalence of retinopathy was 9% in NGM, 11% in IGM, 13% in NDM, and 34% in KDM. Retinopathy worse than minimal nonproliferative diabetic retinopathy was present in 8% in KDM and 0–2% in other glucose categories. The prevalence of retinopathy was positively associated with elevated blood pressure, BMI, cholesterol, and triglyceride serum levels in all glucose categories. The age-, sex-, and glucose metabolism category–adjusted odds ratios were 1.5 (95% CI 1.2–1.9), 1.3 (1.0–1.7), and 1.3 (1.0–1.6) per SD increase of systolic blood pressure, BMI, and total cholesterol concentration, respectively, and 1.2 (1.0–1.5) per 50% increase of triglyceride level. Elevated blood pressure and plasma total and LDL cholesterol levels showed associations with retinal hard exudates. CONCLUSIONS—Retinopathy is a multifactorial microvascular complication, which, apart from hyperglycemia, is associated with blood pressure, lipid concentrations, and BMI.
In 2010, a national integrated health care standard for (childhood) obesity was published and disseminated in the Netherlands. The aim of this study is to gain insight into the needs of health care providers and the barriers they face in terms of implementing this integrated health care standard. A mixed-methods approach was applied using focus groups, semi-structured, face-to-face interviews and an e-mail-based internet survey. The study's participants included: general practitioners (GPs) (focus groups); health care providers in different professions (face-to-face interviews) and health care providers, including GPs; youth health care workers; pediatricians; dieticians; psychologists and physiotherapists (survey). First, the transcripts from the focus groups were analyzed thematically. The themes identified in this process were then used to analyze the interviews. The results of the analysis of the qualitative data were used to construct the statements used in the e-mail-based internet survey. Responses to items were measured on a 5-point Likert scale and were categorized into three outcomes: 'agree' or 'important' (response categories 1 and 2), 'disagree' or 'not important'. Twenty-seven of the GPs that were invited (51 %) participated in four focus groups. Seven of the nine health care professionals that were invited (78 %) participated in the interviews and 222 questionnaires (17 %) were returned and included in the analysis. The following key barriers were identified with regard to the implementation of the integrated health care standard: reluctance to raise the subject; perceived lack of motivation and knowledge on the part of the parents; previous negative experiences with lifestyle programs; financial constraints and the lack of a structured multidisciplinary approach. The main needs identified were: increased knowledge and awareness on the part of both health care providers and parents/children; a social map of effective intervention; structural funding; task rearrangements; a central care coordinator and structural information feedback from the health care providers involved. The integrated health care standard stipulate that the care of overweight or obese children be provided using an integrated approach. The barriers and needs identified in this study can be used to define strategies to improve the implementation of the integrated health care standard pertaining to overweight and obese children in the Netherlands.
Objective The objective of this study was to evaluate the cost-effectiveness of a Multidisciplinary Integrated Care (MIC) model compared to Usual Care (UC) in Dutch residential homes. Methods The economic evaluation was conducted from a societal perspective alongside a 6 month, clustered, randomized controlled trial involving 10 Dutch residential homes. Outcome measures included a quality of care weighted sum score, functional health (COOP WONCA) and Quality Adjusted Life-Years (QALY). Missing cost and effect data were imputed using multiple imputation. Bootstrapping was used to analyze differences in costs and cost-effectiveness. Results The quality of care sum score in MIC was significantly higher than in UC. The other primary outcomes showed no significant differences between the MIC and UC. The costs of providing MIC were approximately €225 per patient. Total costs were €2,061 in the MIC group and €1,656 for the UC group (mean difference €405, 95% −13; 826). The probability that the MIC was cost-effective in comparison with UC was 0.95 or more for ceiling ratios larger than €129 regarding patient related quality of care. Cost-effectiveness planes showed that the MIC model was not cost-effective compared to UC for the other outcomes. Interpretation Clinical effect differences between the groups were small but quality of care was significantly improved in the MIC group. Short term costs for MIC were higher. Future studies should focus on longer term economic and clinical effects. Trial Registration Controlled-Trials.com ISRCTN11076857
Abstract Background: Hypertriglyceridemia is a cardiovascular risk factor. Apolipoprotein C-III (apoC-III) is an important determinant of the catabolic rate of triglyceride-rich lipoproteins. The aim of this study was to investigate the prognostic value of plasma apoC-III concentrations for cardiovascular mortality. Methods: We performed this prospective study in 2244 subjects (ages 49–77 years) who participated in the Hoorn Study. During a mean follow-up of 15 years, 504 individuals died: 231 of cardiovascular disease, 180 of cancer, and 93 of other causes. Cardiovascular disease risk factors and plasma apoC-III concentrations were measured at baseline. Results: The age- and sex-adjusted plasma apoC-III concentration was prospectively associated with cardiovascular mortality (P < 0.001). After adjustment for traditional risk factors, including fasting triglycerides, the hazard ratio (95% CI) for cardiovascular death between the highest and the lowest quartile of apoC-III was 1.85 (1.02–3.38). High concentrations of apoC-III did not appear to be associated with noncardiovascular mortality. Conclusions: In this general population cohort, a high apoC-III concentration in plasma, independently of fasting triglycerides and other traditional risk factors, predicts cardiovascular mortality.
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