Tailored support for type 2 diabetes patients after an acute coronary event : The Diacourse-ACE study

Aims: The aims of this thesis were to define the clinical profile and difficulties encountered by type 2 diabetes patients with a first acute coronary event (ACE), to develop and evaluate a tailored supportive intervention for type 2 diabetes patients with a first ACE and to examine diabetes-related distress and self-management over the course of diabetes. Methods: Data of 563 patients with a first myocardial infarction (MI), of which 77 had type 2 diabetes, were analysed to explore differences in clinical profile between patients with and without diabetes. Data of 1,009 diabetes patients with a previous MI were extracted from the Julius General Practitioners’ Network database to determine prescription of secondary prevention medication. Focus groups were conducted with fourteen type 2 diabetes patients with a first ACE and three partners to examine which difficulties they encountered after discharge. 201 patients participated in a randomised controlled trial to study the effectiveness of a tailored supportive intervention to reduce diabetes-related distress, and improve health status and well-being. The intervention consisted of three home visit by a diabetes nurse, during which patients (and their partners) had the opportunity to discuss problems they experienced in the period after hospital discharge. Diabetes-related distress and self-management over the course of illness was examined in 590 participants from 3 different cohorts of type 2 diabetes patients. Results: The clinical profile of patients with type 2 diabetes hospitalised with their first MI differed from their counterparts without diabetes; diabetes patients were older and had lower cholesterol. Regarding secondary preventive medication it was found that only 46% of the type 2 diabetes with a MI had recent prescriptions of secondary preventive medication according to the guidelines. Type 2 diabetes patients with an ACE experienced difficulties with physical activity, sexuality and pharmacotherapy after hospital discharge and were in need of tailored support. Type 2 diabetes patients reported low levels of diabetes-related distress after an ACE. Health status was less favourable but improved by the intervention. The intervention was also effective in increasing perceived controllability of the diabetes and the ACE and improving perceived understanding of the diabetes. Most type 2 diabetes patients experienced their ACE not as complication of the diabetes, but as another, additional disease (comorbidity). In general, type 2 diabetes patients with a longer diabetes durations experience higher levels of diabetes-related distress and this was associated with microvascular complications and the use of insulin Conclusions: Type 2 diabetes patients are a unique group of ACE patients for whom the usual follow-up care is not sufficient. Tailored support can help type 2 diabetes patients in the period after hospital discharge after a first ACE, especially to improve their self-reported health. Health-care providers should explicitly pay attention to diabetes in the period after an ACE, since understanding of the diabetes plays an important role in improving the patient's health status. Furthermore, topics such as health status, self-management and illness perceptions should be monitored over the course of illness, especially when changes occur in the health situation of the patient.