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Making sense of a myocardial infarction in relation to changing lifestyle in the five months following the event
Brust, M.; Gebhardt, W.A.; Bruggen, S. van; Janssen, V.; Numans, M.E.; Kiefte-de Jong, J.C. 2023
Making sense of a myocardial infarction in relation to changing lifestyle in the five months following the event: an interpretative phenomenological analysis
Article / Letter to editor
open access
AbstractObjectivePrevious research has shown that experiencing an acute cardiac event, such as a myocardial infarction (MI), can lead to lifestyle changes. This study aimed to explore the potential... Show moreAbstractObjectivePrevious research has shown that experiencing an acute cardiac event, such as a myocardial infarction (MI), can lead to lifestyle changes. This study aimed to explore the potential of a MI as a ‘teachable moment’ (TM) for positive lifestyle changes and to identify psychosocial sensemaking processes that facilitate or hinder the presence of a TM.MethodWe conducted semi-structured interviews with 14 patients who suffered their first MI and were hospitalized in a larger Dutch city. Participants were interviewed twice, respectively one and five months after their hospitalization. They were encouraged to explain how they experienced their MI and how this had affected their lifestyle. We used an Interpretative Phenomenological Analysis approach to the data collection and analysis.FindingsThe participants varied in their willingness to adopt a healthy lifestyle due to their MI. Most participants experienced their event as a TM for changing specific health behaviors, for example facilitated by reflecting on self-concept or social roles and by constructing and comprehending a personal narrative of their MI. Some participants struggled to follow through on their intentions to change their behavior, for example because of a negative attitude towards a healthy behavior or because they perceived it as incongruent to their identity. Only three participants maintained most former health behaviors, for example because they failed to acknowledge their MI as severe or because of earlier life events that elicited more blunted cognitive responses.ConclusionCardiac patients may experience a TM, which is the consequence of interrelated processes of psychosocial sensemaking. As this does not occur at a singular time point, we suggest using the term ‘teachable window’ rather than ‘moment’. Given these findings, there is a window of opportunity to provide continuous psychosocial and lifestyle support during and after hospitalization for acute cardiac events. Show less
Making sense of a myocardial infarction in relation to changing lifestyle in the five months following the event
Brust, M.; Gebhardt, W.A.; Bruggen, S. van; Janssen, V.; Numans, M.E.; Jong, J.C.K.D. 2023
Making sense of a myocardial infarction in relation to changing lifestyle in the five months following the event: an interpretative phenomenological analysis
Article / Letter to editor
open access
ObjectivePrevious research has shown that experiencing an acute cardiac event, such as a myocardial infarction (MI), can lead to lifestyle changes. This study aimed to explore the potential of a MI... Show more

ObjectivePrevious research has shown that experiencing an acute cardiac event, such as a myocardial infarction (MI), can lead to lifestyle changes. This study aimed to explore the potential of a MI as a ‘teachable moment’ (TM) for positive lifestyle changes and to identify psychosocial sensemaking processes that facilitate or hinder the presence of a TM.MethodWe conducted semi-structured interviews with 14 patients who suffered their first MI and were hospitalized in a larger Dutch city. Participants were interviewed twice, respectively one and five months after their hospitalization. They were encouraged to explain how they experienced their MI and how this had affected their lifestyle. We used an Interpretative Phenomenological Analysis approach to the data collection and analysis.FindingsThe participants varied in their willingness to adopt a healthy lifestyle due to their MI. Most participants experienced their event as a TM for changing specific health behaviors, for example facilitated by reflecting on self-concept or social roles and by constructing and comprehending a personal narrative of their MI. Some participants struggled to follow through on their intentions to change their behavior, for example because of a negative attitude towards a healthy behavior or because they perceived it as incongruent to their identity. Only three participants maintained most former health behaviors, for example because they failed to acknowledge their MI as severe or because of earlier life events that elicited more blunted cognitive responses.ConclusionCardiac patients may experience a TM, which is the consequence of interrelated processes of psychosocial sensemaking. As this does not occur at a singular time point, we suggest using the term ‘teachable window’ rather than ‘moment’. Given these findings, there is a window of opportunity to provide continuous psychosocial and lifestyle support during and after hospitalization for acute cardiac events.

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Making sense of a myocardial infarction in relation to changing lifestyle in the five months following the event
Brust, M.; Gebhardt, W.A.; Bruggen, S. van; Janssen, V.; Numans, M.E.; Kiefte-de Jong, J.C. 2023
Making sense of a myocardial infarction in relation to changing lifestyle in the five months following the event: an interpretative phenomenological analysis
Article / Letter to editor
open access
The impact of the covid-19 pandemic on diabetes care
Grondelle, S.E. van; Bruggen, S. van; Rauh, S.P.; Zwan, M. van der; Cebrian, A.; Seidu, S.; ... ; Vos, R.C. 2023
The impact of the covid-19 pandemic on diabetes care: the perspective of healthcare providers across Europe
Article / Letter to editor
open access
AimsCovid-19 caused changes on the delivery of diabetes care. This study aimed to explore perceptions of healthcare providers across Europe concerning 1) the impact of covid-19 on delivery of... Show moreAimsCovid-19 caused changes on the delivery of diabetes care. This study aimed to explore perceptions of healthcare providers across Europe concerning 1) the impact of covid-19 on delivery of diabetes care; 2) impact of changes in diabetes care on experienced workload; 3) experiences with video consultation in diabetes care.MethodsCross-sectional survey among healthcare providers in the Netherlands, United Kingdom, Turkey, Ukraine and Sweden, with a focus on primary care.ResultsThe survey was completed by 180 healthcare providers. During the COVID-19 pandemic 57.1% of respondents provided less diabetes care and 72.8% observed a negative impact on people with diabetes. More than half of respondents (61.9%) expressed worries to some extent about getting overloaded by work. Although the vast majority considered their work meaningful (85.6%). Almost half of healthcare providers (49.4%) thought that after the pandemic video-consultation could be blended with face-to-face contact.ConclusionsLess diabetes care was delivered and a negative impact on people with diabetes was observed by healthcare providers. Despite healthcare providers’ feeling overloaded, mental wellbeing seemed unaffected. Video consultations were seen as having potential. Given the remaining covid-19 risks and from the interest of proactive management of people with diabetes, these findings urge for further exploration of incorporating video consultation in diabetes care. Show less
Opinions on hypertension care and therapy adherence at the healthcare provider and healthcare system level
Grondelle, S.E. van; Bruggen, S. van; Meijer, J.; Duin, E. van; Bots, M.L.; Rutten, G.; ... ; Vos, R.C. 2022
Opinions on hypertension care and therapy adherence at the healthcare provider and healthcare system level: a qualitative study in the Hague, Netherlands
Article / Letter to editor
open access
Objectives: Hypertension is a common cause of cardiovascular morbidity and mortality. Although hypertension can be effectively controlled by blood pressure-lowering drugs, uncontrolled blood... Show moreObjectives: Hypertension is a common cause of cardiovascular morbidity and mortality. Although hypertension can be effectively controlled by blood pressure-lowering drugs, uncontrolled blood pressure is common despite use of these medications. One explanation is therapy non-adherence. Therapy non-adherence can be addressed at the individual level, the level of the healthcare provider and at the healthcare system level. Since the latter two levels are often overlooked, we wished to explore facilitators and barriers on each of these levels in relation to hypertension care for people with hypertension, with a specific focus on therapy adherence. Design: Qualitative study using focus groups of healthcare providers. Data were analysed using the theoretical domains framework (TDF) and the behaviour change wheel. Setting and participants: Participants were from a highly urbanised city environment (the Hague, Netherlands), and included nine primary care physicians, six practice nurses and five secondary care physicians involved in hypertension care. Results: Nine domains on the TDF were found to be relevant at the healthcare provider level ('knowledge', 'physical, cognitive and interpersonal skills', 'memory, attention and decision processes', 'professional, social role and identity', 'optimism', 'beliefs about consequences', 'intention', 'emotion' and 'social influences') and two domains ('resources' and 'goals') were found to be relevant at the system level. Facilitators for these domains were good interpersonal skills, paying attention to behavioural factors such as medication use, and the belief that treatment improves health outcomes. Barriers were related to time, interdisciplinary collaboration, technical and financial issues, availability of blood pressure devices and education of people with hypertension. Conclusions: This study highlighted a need for better collaboration between primary and secondary care, for more team-based care including pharmacists and social workers, tools to improve interpersonal skills and more time for patient-healthcare provider communication. Show less
Opinions on hypertension care and therapy adherence at the healthcare provider and healthcare system level
Grondelle, S.E. van; Bruggen, S. van; Meijer, J.; Duin, E. van; Bots, M.L.; Rutten, G.; ... ; Vos, R.C. 2022
Opinions on hypertension care and therapy adherence at the healthcare provider and healthcare system level: a qualitative study in the Hague, Netherlands
Article / Letter to editor
open access
Objectives Hypertension is a common cause of cardiovascular morbidity and mortality. Although hypertension can be effectively controlled by blood pressure-lowering drugs, uncontrolled blood... Show moreObjectives Hypertension is a common cause of cardiovascular morbidity and mortality. Although hypertension can be effectively controlled by blood pressure-lowering drugs, uncontrolled blood pressure is common despite use of these medications. One explanation is therapy non-adherence. Therapy non-adherence can be addressed at the individual level, the level of the healthcare provider and at the healthcare system level. Since the latter two levels are often overlooked, we wished to explore facilitators and barriers on each of these levels in relation to hypertension care for people with hypertension, with a specific focus on therapy adherence.Design Qualitative study using focus groups of healthcare providers. Data were analysed using the theoretical domains framework (TDF) and the behaviour change wheel.Setting and participants Participants were from a highly urbanised city environment (the Hague, Netherlands), and included nine primary care physicians, six practice nurses and five secondary care physicians involved in hypertension care.Results Nine domains on the TDF were found to be relevant at the healthcare provider level (‘knowledge’, ‘physical, cognitive and interpersonal skills’, ‘memory, attention and decision processes’, ‘professional, social role and identity’, ‘optimism’, ‘beliefs about consequences’, ‘intention’, ‘emotion’ and ‘social influences’) and two domains (‘resources’ and ‘goals’) were found to be relevant at the system level. Facilitators for these domains were good interpersonal skills, paying attention to behavioural factors such as medication use, and the belief that treatment improves health outcomes. Barriers were related to time, interdisciplinary collaboration, technical and financial issues, availability of blood pressure devices and education of people with hypertension.Conclusions This study highlighted a need for better collaboration between primary and secondary care, for more team-based care including pharmacists and social workers, tools to improve interpersonal skills and more time for patient–healthcare provider communication. Show less
Socioeconomic status is not associated with delivery of care in people with diabetes but does modify HbA1c levels
Bruggen, S. van; Kasteleyn, M.J.; Bonten, T.N.; Chavannes, N.H.; Numans, M.E.; Rauh, S.P. 2021
Socioeconomic status is not associated with delivery of care in people with diabetes but does modify HbA1c levels: an observational cohort study (ELZHA-cohort 1).
Article / Letter to editor
open access
BackgroundStructured primary diabetes care within a collectively supported setting is associated with better monitoring of biomedical and lifestyle-related target indicators among people with type... Show moreBackgroundStructured primary diabetes care within a collectively supported setting is associated with better monitoring of biomedical and lifestyle-related target indicators among people with type 2 diabetes and with better HbA1c levels. Whether socioeconomic status affects delivery of care in terms of monitoring and its association with HbA1c levels within this approach, is unclear. This study aims to understand whether, within a structured care approach, 1) socioeconomic categories differ concerning diabetes monitoring as recommended; 2) socioeconomic status modifies the association between monitoring as recommended and HbA1c.MethodsObservational real-life cohort study with primary care registry data from general practitioners within diverse socioeconomic areas, who are supported with implementation of structured diabetes care. People with type 2 diabetes mellitus were offered quarterly diabetes consultations. 'Monitoring as recommended' by professional guidelines implied minimally one annual registration of HbA1c, systolic blood pressure, LDL, BMI, smoking behaviour and physical activity. Regarding socioeconomic status, deprived, advantageous urban and advantageous suburban categories were compared to the intermediate category concerning 1) recommended monitoring; 2) association between recommended monitoring and HbA1c.ResultsAim 1 (n=13,601 people): Compared to the intermediate socioeconomic category, no significant differences in odds of being monitored as recommended were found in the deprived (OR 0.45 (95%CI 0.19-1.08)), advantageous-urban (OR 1.27 (95%CI 0.46-3.54)) and advantageous- suburban (OR 2.32 (95%CI 0.88-6.08)) categories. Aim 2 (n=11,164 people): People with recommended monitoring had significantly lower HbA1c levels than incompletely-monitored people (-2.4 (95%CI -2.9;-1.8)mmol/mol). SES modified monitoring-related HbA1c differences, which were significantly higher in the deprived (-3.3 (95%CI -4.3;-2.4)mmol/mol) than the intermediate category (-1.3 (95%CI -2.2;-0.4)mmol/mol). Conclusions Within a structured diabetes care setting, socioeconomic status is not associated with recommended monitoring. Socioeconomic differences in the association between recommended monitoring and HbA1c levels advocate further exploration of practice and patient-related factors contributing to appropriate monitoring and for care adjustment to population needs. Show less
Experiences with tailoring of primary diabetes care in well-organised general practices
Bruggen, S. van; Kasteleyn, M.J.; Rauh, S.P.; Meijer, J.S.; Busch, K.J.G.; Numans, M.E.; Chavannes, N.H. 2021
Experiences with tailoring of primary diabetes care in well-organised general practices: a mixed-methods study
Article / Letter to editor
open access
Background Dutch standard diabetes care is generally protocol-driven. However, considering that general practices wish to tailor diabetes care to individual patients and encourage self-management,... Show moreBackground Dutch standard diabetes care is generally protocol-driven. However, considering that general practices wish to tailor diabetes care to individual patients and encourage self-management, particularly in light of current COVID-19 related constraints, protocols and other barriers may hinder implementation. The impact of dispensing with protocol and implementation of self-management interventions on patient monitoring and experiences are not known. This study aims to evaluate tailoring of care by understanding experiences of well-organised practices 1) when dispensing with protocol; 2) determining the key conditions for successful implementation of self-management interventions; and furthermore exploring patients' experiences regarding dispensing with protocol and self-management interventions. Methods in this mixed-methods prospective study, practices (n = 49) were invited to participate if they met protocol-related quality targets, and their adult patients with well-controlled type 2 diabetes were invited if they had received protocol-based diabetes care for a minimum of 1 year. For practices, study participation consisted of the opportunity to deliver protocol-free diabetes care, with selection and implementation of self-management interventions. For patients, study participation provided exposure to protocol-free diabetes care and self-management interventions. Qualitative outcomes (practices: 5 focus groups, 2 individual interviews) included experiences of dispensing with protocol and the implementation process of self-management interventions, operationalised as implementation fidelity. Quantitative outcomes (patients: routine registry data, surveys) consisted of diabetes monitoring completeness, satisfaction, wellbeing and health status at baseline and follow-up (24 months). Results Qualitative: In participating practices ( = 4), dispensing with protocol encouraged reflection on tailored care and selection of various self-management interventions nA focus on patient preferences, team collaboration and intervention feasibility was associated with high implementation fidelity Quantitative: In patients ( = 126), likelihood of complete monitoring decreased significantly after two years (OR 0.2 (95% CI 0.1-0.5), < 0.001) npSatisfaction decreased slightly (- 1.6 (95% CI -2.6;-0.6), = 0.001) pNon-significant declines were found in wellbeing (- 1.3 (95% CI -5.4; 2.9), p = 0.55) and health status (- 3.0 (95% CI -7.1; 1.2), p = 0.16). Conclusions To tailor diabetes care to individual patients within well-organised practices, we recommend dispensing with protocol while maintaining one structural annual monitoring consultation, combined with the well-supported implementation of feasible self-management interventions. Interventions should be selected and delivered with the involvement of patients and should involve population preferences and solid team collaborations. Show less
From protocol to personalised care
Bruggen, S. van 2021
From protocol to personalised care: improving and tailoring diabetes management in general practice
Doctoral Thesis
open access
2023-03-23T00:00:00Z; 2023-03-23T00:00:00Z
To improve primary diabetes care in the Netherlands, in 2007 a ‘care group’ system is initiated. We first studied the association between adherence to a structured diabetes protocol and patient... Show moreTo improve primary diabetes care in the Netherlands, in 2007 a ‘care group’ system is initiated. We first studied the association between adherence to a structured diabetes protocol and patient outcomes. We then investigated what practices actually require when seeking to adjust care to patient needs. With that aim in mind, we explored the effect of dispensing with protocol and the key conditions for successful implementation of self-management interventions. Finally, we measured patient outcomes with regard to treatment satisfaction, quality of life and monitoring.A structured care protocol has added value for people with diabetes; the proportion of people having recommended monitoring increases sharply. Practices likely undergo an intensive learning process when they join a care group and appear to reach the same as experienced practice within a year. When comparing the HbA1 levels of people with recommended and incomplete monitoring, we found that the HbA1c levels in people with recommended monitoring are significantly circa 2 mmol/mol lower compared to incomplete monitoring. In other words, recommended monitoring is far more than merely an administrative procedure; it actually reflects better real-world HbA1c levels. Differences in HbA1c level between people with recommended versus incomplete monitoring were greater in vulnerable populations, to the extent of approximately 3 mmol/mol, whereas a circa 1 mmol/mol difference was found in the intermediate category. In other words, within a care group setting people in the deprived category derive the most benefit from recommended monitoring.Protocol-free care provided room for reflection concerning ‘tailored care’; varying self-management interventions were chosen Our study revealed three key conditions for successful implementation of self-management interventions. Considering that patient satisfaction and monitoring decreased, this thesis ends with a roadmap consisting of several recommendations to improve and tailor diabetes care in general practice. Show less
Socioeconomic status is not associated with the delivery of care in people with diabetes but does modify HbA1c levels
Bruggen, S. van; Kasteleyn, M.J.; Bonten, T.N.; Chavannes, N.H.; Numans, M.E.; Rauh, S.P. 2021
Socioeconomic status is not associated with the delivery of care in people with diabetes but does modify HbA1c levels: an observational cohort study (Elzha-cohort 1)
Article / Letter to editor
open access
Background Structured primary diabetes care within a collectively supported setting is associated with better monitoring of biomedical and lifestyle-related target indicators amongst people with... Show moreBackground Structured primary diabetes care within a collectively supported setting is associated with better monitoring of biomedical and lifestyle-related target indicators amongst people with type 2 diabetes and with better HbA1c levels. Whether socioeconomic status affects the delivery of care in terms of monitoring and its association with HbA1c levels within this approach, is unclear. This study aims to understand whether, within a structured care approach, (1) socioeconomic categories differ concerning diabetes monitoring as recommended; (2) socioeconomic status modifies the association between monitoring as recommended and HbA1c.Methods Observational real-life cohort study with primary care registry data from general practitioners within diverse socioeconomic areas, who are supported with the implementation of structured diabetes care. People with type 2 diabetes mellitus were offered quarterly diabetes consultations. "Monitoring as recommended" by professional guidelines implied minimally one annual registration of HbA1c, systolic blood pressure, LDL, BMI, smoking behaviour and physical activity. Regarding socioeconomic status, deprived, advantageous urban and advantageous suburban categories were compared to the intermediate category concerning (a) recommended monitoring; (b) association between recommended monitoring and HbA1c.Results Aim 1 (n = 13 601 people): Compared to the intermediate socioeconomic category, no significant differences in odds of being monitored as recommended were found in the deprived (OR 0.45 (95% CI 0.19-1.08)), advantageous urban (OR 1.27 (95% CI 0.46-3.54)) and advantageous suburban (OR 2.32 (95% CI 0.88-6.08)) categories. Aim 2 (n = 11 164 people): People with recommended monitoring had significantly lower HbA1c levels than incompletely monitored people (-2.4 (95% CI -2.9; -1.8) mmol/mol). SES modified monitoring-related HbA1c differences, which were significantly higher in the deprived (-3.3 (95% CI -4.3; -2.4) mmol/mol) than the intermediate category (-1.3 (95% CI -2.2; -0.4) mmol/mol).Conclusions Within a structured diabetes care setting, socioeconomic status is not associated with recommended monitoring. Socioeconomic differences in the association between recommended monitoring and HbA1c levels advocate further exploration of practice and patient-related factors contributing to appropriate monitoring and for care adjustment to population needs. Show less
Association between GP participation in a primary care group and monitoring of biomedical and lifestyle target indicators in people with type 2 diabetes
Bruggen, S. van; Rauh, S.P.; Bonten, T.N.; Chavannes, N.H.; Numans, M.E.; Kasteleyn, M.J. 2020
Association between GP participation in a primary care group and monitoring of biomedical and lifestyle target indicators in people with type 2 diabetes: a cohort study (ELZHA cohort-1)
Article / Letter to editor
open access
Objective Whether care group participation by general practitioners improves delivery of diabetes care is unknown. Using 'monitoring of biomedical and lifestyle target indicators as recommended by... Show moreObjective Whether care group participation by general practitioners improves delivery of diabetes care is unknown. Using 'monitoring of biomedical and lifestyle target indicators as recommended by professional guidelines' as an operationalisation for quality of care, we explored whether (1) in new practices monitoring as recommended improved a year after initial care group participation (aim 1); (2) new practices and experienced practices differed regarding monitoring (aim 2).Design Observational, real-life cohort study.Setting Primary care registry data from Eerstelijns Zorggroep Haaglanden (ELZHA) care group.Participants Aim 1: From six new practices (n=538 people with diabetes) that joined care group ELZHA in January 2014, two practices (n=211 people) were excluded because of missing baseline data; four practices (n=182 people) were included. Aim 2: From all six new practices (n=538 people), 295 individuals were included. From 145 experienced practices (n=21 465 people), 13 744 individuals were included.Exposure Care group participation includes support by staff nurses on protocolised diabetes care implementation and availability of a system providing individual monitoring information. 'Monitoring as recommended' represented minimally one annual registration of each biomedical (HbA1c, systolic blood pressure, low-density lipoprotein) and lifestyle-related target indicator (body mass index, smoking behaviour, physical exercise).Primary outcome measures Aim 1: In new practices, odds of people being monitored as recommended in 2014 were compared with baseline (2013). Aim 2: Odds of monitoring as recommended in new and experienced practices in 2014 were compared.Results Aim 1: After 1-year care group participation, odds of being monitored as recommended increased threefold (OR 3.00, 95% CI 1.84 to 4.88, p<0.001). Aim 2: Compared with new practices, no significant differences in the odds of monitoring as recommended were found in experienced practices (OR 1.21, 95% CI 0.18 to 8.37, p=0.844).Conclusions We observed a sharp increase concerning biomedical and lifestyle monitoring as recommended after 1-year care group participation, and subsequently no significant difference between new and experienced practices-indicating that providing diabetes care within a collective approach rapidly improves registration of care. Show less
Association between full monitoring of biomedical and lifestyle target indicators and HbA(1c) level in primary type 2 diabetes care: an observational cohort study (ELZHA-cohort 1)
Bruggen, S. van; Rauh, S.P.; Kasteleyn, M.J.; Bonten, T.N.; Chavannes, N.H.; Numans, M.E. 2019
Association between full monitoring of biomedical and lifestyle target indicators and HbA(1c) level in primary type 2 diabetes care: an observational cohort study (ELZHA-cohort 1)
Article / Letter to editor
metadata only
Association between full monitoring of biomedical and lifestyle target indicators and HbA1c level in primary type 2 diabetes care: an observational cohort study (ELZHA-cohort 1)
Bruggen, S. van; Rauh, S.P.; Kasteleyn, M.J.; Bonten, T.N.; Chavannes, N.H.; Numans, M.E. 2019
Association between full monitoring of biomedical and lifestyle target indicators and HbA1c level in primary type 2 diabetes care: an observational cohort study (ELZHA-cohort 1)
Article / Letter to editor
metadata only
Objective Management of type 2 diabetes mellitus (T2DM) requires frequent patient monitoring. Within a collective care group setting, doubts on the clinical effects of registration are a barrier... Show more Objective Management of type 2 diabetes mellitus (T2DM) requires frequent patient monitoring. Within a collective care group setting, doubts on the clinical effects of registration are a barrier for full adoption of T2DM registration in general practice. We explored whether full monitoring of physiological, biomedical and lifestyle-related target indicators within a care group approach is associated with lower HbA1c levels. Design Observational, real-life cohort study Setting Primary care data registry from the EerstelijnsZorggroepHaaglanden care group. Exposure The care group provides general practitioners collectively with organisational support to facilitate structured T2DM primary care. Patients are offered quarterly medical and lifestyle-related consultation. Main outcome measure Full monitoring of each target indicator in patients with T2DM, which includes minimally one measure of HbA1c level, systolic blood pressure, LDL, BMI, smoking behaviour and physical exercise between January and December 2014; otherwise, patients were defined as ´incompletely monitored´. HbA1c levels of 8,137 fully-monitored and 3,958 incompletely-monitored patients were compared, adjusted for the confounders diabetes duration, age and gender. Since recommended HbA1c values depend on age, medication use and diabetes duration, analyses were stratified into three HbA1c profile groups. Linear multilevel analyses enabled adjustment for general practice. Results Compared to incompletely-monitored patients, fully-monitored patients had significantly lower HbA1c levels [95%CI] in the first (-2.03 [-2.53;-1.52]mmol/mol) (-0.19% [-0.23%;-0.14%]), second (-3.36 [-5.28;-1.43]mmol/mol) (-0.31% [-0.48%;-0.13%]) and third HbA1c profile group (-1.89 [-3.76;-0.01]mmol/mol) (-0.17% [-0.34%;0.00%]). Conclusions/interpretation This study shows that in a care group setting, fully-monitored patients had significantly lower HbA1c levels compared with incompletely-monitored patients. Since this difference might have considerable clinical impact in terms of T2DM-related risks, this might help general practices in care group settings to overcome barriers on adequate registration and thus improve structured T2DM primary care. From population health management perspective, we recommend a systematic approach to adjust the structured care protocol for incompletely-monitored subgroups. Show less