Diabetes Care (diabetes + care)

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Distribution within Medical Sciences

Selected Abstracts

Measuring the Quality of Diabetes Care Using Administrative Data: Is There Bias?

Nancy L. Keating
Objectives. Health care organizations often measure processes of care using only administrative data. We assessed whether measuring processes of diabetes care using administrative data without medical record data is likely to underdetect compliance with accepted standards for certain groups of patients. Data Sources/Study Setting. Assessment of quality indicators during 1998 using administrative and medical records data for a cohort of 1,335 diabetic patients enrolled in three Minnesota health plans. Study Design. Cross-sectional retrospective study assessing hemoglobin A1c testing, LDL cholesterol testing, and retinopathy screening from the two data sources. Analyses examined whether patient or clinic characteristics were associated with underdetection of quality indicators when administrative data were not supplemented with medical record data. Data Collection/Extraction Methods. The health plans provided administrative data, and trained abstractors collected medical records data. Principal Findings. Quality indicators that would be identified if administrative data were supplemented with medical records data are often not identified using administrative data alone. In adjusted analyses, older patients were more likely to have hemoglobin A1c testing underdetected in administrative data (compared to patients <45 years, OR 2.95, 95 percent CI 1.09 to 7.96 for patients 65 to 74 years, and OR 4.20, 95 percent CI 1.81 to 9.77 for patients 75 years and older). Black patients were more likely than white patients to have retinopathy screening underdetected using administrative data (2.57, 95 percent CI 1.16 to 5.70). Patients in different health plans also differed in the likelihood of having quality indicators underdetected. Conclusions. Diabetes quality indicators may be underdetected more frequently for elderly and black patients and the physicians, clinics, and plans who care for such patients when quality measurement is based on administrative data alone. This suggests that providers who care for such patients may be disproportionately affected by public release of such data or by its use in determining the magnitude of financial incentives. [source]

Prolonged use of continuous glucose monitors in children with type 1 diabetes on continuous subcutaneous insulin infusion or intensive multiple-daily injection therapy

Diabetes Research in Children Network (DirecNet) Study Group
Objective:, For continuous glucose sensors to improve the treatment of children with type 1 diabetes (T1D), they must be accurate, comfortable to wear, and easy to use. We conducted a pilot study of the FreeStyle NavigatorÔ Continuous Glucose Monitoring System (Abbott Diabetes Care) to examine the feasibility of daily use of a continuous glucose monitor (CGM) in an extended ambulatory setting. Methods:, Following a 13-wk trial of daily Navigator use, 45 children with T1D [10.7 ± 3.7 yr, range 4.6,17.6, 24 using insulin pumps; continuous subcutaneous insulin infusion (CSII) and 21 using glargine-based multiple daily injections (MDI)] used the Navigator for an additional 13 wk. Results:, Navigator use was initially slightly higher in the CSII users than in the MDI users but declined similarly in both groups by 22,26 wk. After 26 wk, 11 (46%) of 24 CSII users and 7 (33%) of 21 MDI users were using the CGM at least 5 d a week. No baseline demographic or clinical factors were predictive of the amount of sensor use at 26 wk. However, Navigator use during weeks 1,13 and scores on a CGM satisfaction survey at 13 wk were predictive of use in weeks 22,26. Conclusions:, CGM was generally well-tolerated in children with T1D for more than 6 months, and early acceptance of CGM was predictive of extended use of the device. Although many subjects and parents found CGM valuable, the declining usage over time underscores the need to develop new technologies and strategies to increase acceptance, effectiveness, and long-term use of these devices in youth with T1D. [source]

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PRESCRIBER, Issue 6 2008
Article first published online: 24 APR 200
Government responds to NICE report The Government has published its response to the Health Select Committee's report into NICE, broadly arguing that the Committee's recommendations are either already being dealt with or are not appropriate. The Committee recommended appraisals for all new drugs, shorter, rapid appraisals to coincide with their launch, and improved mechanisms for setting drug prices. The Government says its negotiations on the PPRS preclude a detailed response but suggests a rapid system may not be transparent or legally robust. It is exploring how high-cost drugs can be brought within the payment-by-results tariff. While defending NICE's reliance on QALYs, the Government accepts the need to explore how wider economic factors can be considered. As for the threshold cost per QALY by which NICE defines cost effectiveness, it says this is being validated scientifically and NICE will continue to determine the threshold. More topically, the Committee criticised the quality of clinical trial data available to NICE. The Government sees no need to compel pharmaceutical companies to disclose information and says NICE is already becoming more involved with research programmes. All clinical trials must be registered (confidentially) with the EU and the Government believes mandatory registration in the UK would be ineffective and illegal. Prescription charge up again from April The Government has raised the prescription charge by 25p to £7.10 per item with effect from 1 April. Prescription prepayment certificates will cost £27.85 for three months and £102.50 for 12 months. The increase, below the annual rate of inflation for the 10th successive year, will be levied on the 12 per cent of prescriptions that are liable for the charge: 5 per cent via prepayment certificates and 7 per cent from other prescriptions. The charge will generate £435 million in England in 2008/09; this excludes money from prescriptions written by dispensing doctors, which is retained by the PCT. Following criticism of the charge by the Health Select Committee, the Government says it has reviewed the charge and is now consulting on ,cost-neutral' options. MHRA safety update The MHRA warns of possible dose errors associated with Boots Medisure Domiciliary Dosage System in its latest issue of Drug Safety Update (2008;1:issue 8). One case has been reported in which incomplete sealing allowed tablets to mix between compartments. No other cases are known and the MHRA says no harm was reported but the risk is serious. The system should be carefully sealed and inspected visually and physically. The MHRA reaffirms its plans to reclassify all pseudoephedrine and ephedrine products to prescription-only status in 2009 if the new restrictions on sales do not reduce misuse. Other topics in this month's Update include revised indications for oral ketoconazole (Nizoral), restricting its use to selected conditions unresponsive to topical therapy; reformulation of the injectable antibiotic Tazocin (piperacillin plus tazobactum); the risk of peripheral neuropathy associated with pegylated interferon and telbivudine (Sebivo) in the treatment of hepatitis B; and serious adverse events associated with modafinil (Provigil). First oral anticoagulant since warfarin In January this year the EMEA issued a positive opinion to recommend marketing authorisation of the oral, fixed-dose, direct thrombin inhibitor dabigatran etexilate (Pradaxa) for the primary prevention of venous thromboembolism (VTE) in adult patients that have undergone elective knee or hip replacement surgery. Marketing authorisation for the EU (including the UK) is expected from the European Commission in the next few weeks, making dabigatran the first oral anticoagulant since warfarin was introduced in 1954. Dabigatran etexilate has been shown to be as safe and effective as enoxaparin (Clexane) with a similar adverse event profile in the noninferiority phase III RENOVATE (Lancet 2007;370: 949-56) and RE-MODEL (J Throm Haemost 2007;5:217885) trials, which investigated the efficacy and safety of dabigatran compared to enoxaparin in reducing the risk of VTE after total hip and knee surgery respectively. Dabigatran has the practical advantage over low-molecular-weight heparin of oral postoperative administration and no risk of heparin-induced thrombocytopenia and, unlike warfarin, does not require monitoring or dose titration. Risk scale predicts anticholinergic effects US investigators have developed a scale for predicting the risk of anticholinergic side-effects from older patients' medicines (Arch Intern Med 2008;168: 508-13). The scale assigns a score from 1 (low) to 3 (high) for the risk of anticholinergic effects such as dry mouth, constipation and dizziness associated with commonly prescribed medicines. Checking the scale retrospectively in older patients in residential care, a higher score was associated with a 30 per cent increased risk of side-effects after adjustment for age and number of medicines. When this was repeated prospectively in a primary-care cohort, the increased risk was 90 per cent. HRT cancer risk persists The latest analysis of the Women's Health Initiative (WHI) trial of HRT shows that the small increase in the risk of cancer persists for up to three years after stopping treatment (J Am Med Assoc 2008;299:1036-45). WHI was stopped after 5.6 years' follow-up when it became clear the risks of HRT outweighed its benefits. This follow-up after a further three years (mean 2.4) involved 15 730 women. The annual risk of cardiovascular events was similar for HRT (1.97 per cent) and placebo (1.91 per cent). Cancers were more common among women who had taken HRT (1.56 vs 1.26 per cent), in particular breast cancer (0.42 vs 0.33 per cent). All-cause mortality was higher, but not statistically significantly so, with HRT (1.20 vs 1.06 per cent). Tight glycaemic control may increase falls Maintaining HbA1C at or below 6 per cent with insulin is associated with an increased risk of falls, a US study suggests (Diabetes Care 2008;31:391-6). The Health, Aging and Composition study involved 446 older people with type 2 diabetes (mean age 74) followed up for approximately five years. The incidence of falls ranged from 22 to 30 per cent annually. Comparing subgroups with HbA1C of ,6 per cent and >8 per cent, an increased risk of falls was associated with insulin use (odds ratio 4.4) but not oral hypoglycaemic drugs. Copyright © 2008 Wiley Interface Ltd [source]

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PRESCRIBER, Issue 6 2007
Article first published online: 8 JUN 200
Initial macrolide better for pneumonia? An observational study has suggested that initial treatment with a macrolide antibiotic (such as erythromycin) may be more effective than a fluoroquinolone (like ciprofloxacin) or tetracycline as initial treatment for community acquired pneumonia and bacteraemia (Chest 2007;131:466-73). The US review of 2209 hospital episodes found that macrolide therapy was associated with a 40 per cent lower risk of death during hospital stay or within 30 days and of hospital readmission within 30 days of discharge. By contrast, no such benefit was apparent with fluoroquinolones or tetracycline. Two-year safety data for inhaled insulin Compared with sc insulin, inhaled insulin (Exubera) is associated with a small early decrease in lung function in the first three months of therapy but no further difference for up to two years (Diabetes Care 2007;30: 579-85). The comparative trial found that FEV1 declined at a mean rate of 0.051 litres per year with inhaled insulin and 0.034 litres per year with sc insulin, but there was no significant difference in the rates of decline after three months. Inhaled insulin was associated with a higher incidence of cough (37.6 vs 13.1 per cent) but a lower incidence of severe hypoglycaemic events (2.8 vs 4.1 events per 100 subject- months) and mean weight gain was 1.25kg less. Fracture risk warning with rosiglitazone GlaxoSmithKline has warned US prescribers that rosiglitazone may be associated with an increased risk of fractures. The company says information for prescribers in Europe will follow shortly. The warning comes from the ADOPT study (N Engl J Med 2006;355:2427-43), which found a significantly higher incidence of fractures of the humerus, hand and foot among women taking rosiglitazone (9.3 per cent) than with metformin (5.1 per cent) or glibenclamide (3.5 per cent). There was no difference in fracture incidence among men. The company recommends that fracture risk should be considered for women taking or about to take rosiglitazone. Oral treatment for grass pollen allergy A new treatment for allergic rhinitis due to grass pollen allergy has been introduced by ALK-Abelló. Grazax is a sublingual tablet containing a stan-dardised dose of allergen from the pollen of timothy grass. Treatment should be initiated by a specialist four months before the onset of the allergy season and continued throughout the season. Adverse effects include oral and ear pruritus, nasopharyngitis and mouth oedema. A month's treatment at the recommended dose of one tablet daily costs £67.50. Frequent analgesics linked with hypertension Men who take analgesics regularly have an increased frequency of hypertension, a US study has shown (Arch Intern Med 2007;167:394-9). The US Health Professionals Follow-Up study evaluated the use of NSAIDs, paracetamol and aspirin in 16 031 men with normal blood pressure and followed them up for four years. Compared with those who did not report analgesic use, the risk of hypertension was increased by 38 per cent for NSAID use, 34 per cent for paracetamol and 26 per cent for aspirin, all for for six or seven days a week. Similar risks were found when anal- gesic use was determined according to the number of tablets taken. The authors acknowledge the increased risk is modest, but point out that the implications may nonetheless be important because analgesics are widely used. Multiples do most pharmacist MURs Uptake of medicines use reviews (MURs) by pharmacists was modest in 2005 and most reviews were carried out by pharmacy chains rather than independent contractors, a new study has shown (Pharm J 2007;278:218-23). The survey of PCTs and SHAs in England and Wales found that, although 38 per cent of community pharmacies claimed payments for the service, 84 per cent of MURs were carried out by pharmacy chains. Uptake was low, amounting to only 7 per cent of the maximum possible number of MURs. Patients see information needs differently There is a mismatch in the perceptions of patients and health professionals about the purpose of written information about medicines, a systematic review has concluded (Health Technol Assess 2007;11:1-178). Some health professionals believe the main purpose of information is to promote compliance, whereas patients want information to help them make decisions about their treatment, including not taking it. In particular, patients want information on adverse effects, but health professionals have reservations about providing it. Aspirin for all women over 65? All women over 65 should take low-dose aspirin if the benefits are likely to outweigh the risk of adverse effects, according to new guidelines from the American Heart Association on preventing cardiovascular disease in women (published online 19 Feb 2007;doi: 10.1161/circulationaha.107.181546). The guidelines have moved away from the long-established Framingham model of risk assessment to categorising three levels of risk: high (heart disease or other relevant disease present), at risk (at least one risk factor) and optimal (healthy lifestyle, no risk factors). Low-dose aspirin is recommended for all women at high risk, for women aged 65 or over when reducing the risk of MI or ischaemic stroke outweighs the risk of adverse effects, and for younger women when reducing the risk of ischaemic stroke outweighs that of toxicity. Combination inhaler therapy Combining an inhaled long-acting bronchodilator with a steroid reduces COPD exacerbations but not all-cause mortality, a three-year trial has shown (N Engl J Med 2007;356:775-89). However, inhaled steroids appear to increase the risk of pneumonia. The TORCH trial randomised 6112 patients (FEV1<60 per cent predicted) to treatment with salmeterol 50µg plus fluticasone 500µg (Seretide) twice daily, salmeterol (Serevent) or fluticasone (Flixotide) as monotherapy, or placebo. All-cause mortality rates were 12.6, 13.5, 16.0 and 15.2 per cent respectively; the risk of death was 17 per cent lower with combined therapy, but the difference did not reach statistical significance. The combination reduced the incidence of exacerbations by 25 per cent and improved health status and FEV1. Use of fluticasone was not associated with more ocular or bone disorders, but there was an increased incidence of pneumonia among users (19.6 per cent with combined therapy and 18.3 per cent with fluticasone vs 12.3 per cent with placebo). Seretide is currently licensed in the UK for use in patients with FEV1 <50 per cent predicted. Tamoxifen long- term benefits Women with breast cancer who take tamoxifen for five to eight years continue to have a lower risk of recurrence for 10-20 years, long-term follow-up of two blinded trials has shown (J Nat Cancer Inst 2007; 99:258-60, 272-90). The frequency of adverse effects was markedly reduced when treatment ended, changing the balance of risk and benefit. Copyright © 2007 Wiley Interface Ltd [source]

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PRESCRIBER, Issue 5 2007
Article first published online: 16 MAY 200
OFT wants PPRS reform The Office of Fair Trading (www.oft.gov.uk) says reform of the Pharmaceutical Price Regulatory Scheme (PPRS) would allow the NHS to re- invest £500 million in drugs it needs. Its investigation of the 50- year-old PPRS concludes that the scheme does not reflect the therapeutic value of drugs and, while providing a financial safety net for the industry, it mitigates against innovation. The OFT believes drugs should be priced according to their therapeutic value based on their cost effectiveness. Analyses would be fast- tracked for new drugs or, if there are insufficient data, a risk-sharing scheme should be adopted. The ABPI insists that its medicines offer the NHS value for money and believes the OFT's proposal for drug- by-drug pricing would delay access to new medicines. Switching saves money and is problem free Switching to cheaper alternatives within a drug class does not affect the quality of care and offers substantial savings, say UK researchers (Int J Clin Pract 2007;61:15-23). They switched selected patients from atorvastatin (Lipitor) to simvastatin and from losartan (Cozaar) to candesartan (Amias). Exclusion criteria included previous unsuccessful use, poor control of lipids or blood pressure, contraindications and potential drug interactions. In 70 patients switched to simvastatin, there was no change in mean total cholesterol after four months; one patient reverted to atorvastatin due to adverse effects. Of 115 switched to candesartan, seven reverted to losartan; in the remainder, blood pressure was slightly reduced after four months. The switch was not associated with adverse effects. Savings for the year 2005/06 were estimated at £12 716 for statins and £13 374 for antihypertensive drugs. Scotland gets donepezil for mild to moderate AD The Scottish Medicines Consortium (www.scottish medicines.org.uk) has approved the use of orodispersible donepezil (Aricept Evess) for the treatment of mild to moderate Alzheimer's disease in NHS Scotland. The decision conflicts with NICE advice that the drug is not appropriate for patients with mild disease. The SMC has not approved rimonabant (Acomplia) as adjunctive treatment for obese patients. Adherence threatens anticoagulation Patients find it difficult to adhere to anticoagulant treatment ,significantly impairing the quality of anticoagulation, US investigators have shown (Arch Intern Med 2007;167:229-35). Using electronic containers to monitor dose adherence over 32 weeks in 136 patients, they found that 92 per cent opened the container at least once too often or too little and one-third missed 20 per cent of scheduled openings. Patients with less than 20 per cent adherence were twice as likely to be undercoagulated compared with adherent patients. Those with overadherence were overcoagulated. Hypo risk greatest with glibenclamide Glibenclamide is associated with a significantly greater risk of hypoglycaemic events than other secretagogues, a new systematic review has concluded (Diabetes Care 2007;30:389-94). The review of 21 randomised trials found that the risk of experiencing at least one hypoglycaemic event was 52 per cent greater with glibenclamide compared with other secretagogues and 83 per cent greater than with other sulphonylureas. In three comparative trials with insulin, there was no significant difference in the risk of hypoglycaemia (though this could not be excluded) but only insulin was associated with weight gain. Glibenclamide was not associated with significantly increased risks of cardiovascular events, weight gain or death. Few major hypoglycaemic events were reported in these trials. Drug groups implicated in ADR admissions Four classes of drugs account for half of hospital admissions for adverse reactions, according to a new systematic review (Br J Clin Pharmacol 2007;63:136-47). Antiplatelet agents (16 per cent of admissions), diuretics (16 per cent), NSAIDs (11 per cent) and anticoagulants (8 per cent) were implicated in drug- related admissions according to a review of nine studies. Analysis of five studies also showed that adherence problems were associated with one-third of drug-related admissions. The authors suggest that focussing resources in these areas could substantially reduce admissions. Value of pharmacist MUR questioned Pharmacist medicines use review (MUR) for older patients does not reduce hospital readmission and is not cost effective by current standards, according to a study from Norfolk (Pharmacoeconomics 2007;25:171-80). A total of 872 patients aged over 80 who had been admitted as an emergency and discharged taking two or more drugs were randomised to MUR by a pharmacist or usual care. The pharmacist visited twice, providing education, removing out-of-date drugs and checking for adverse effects, interactions and the need for compliance aids. After six months, the admissions rate was not reduced among patients who received MUR and quality of life was not significantly improved. The estimated cost per QALY gained was £54 454 , above the conventional threshold for cost effectiveness of £30 000. MHRA review of LABAs The MHRA has clarified which aspects of long-acting beta-agonists (LABAs) are being addressed in its current review. This full review of salmeterol (Serevent) and formoterol, following advice issued in December last year, will consider recent research, whether the two agents differ significantly, dose-response relationships, the effect of concurrent treatment with inhaled steroid and how they are used in practice. Manufacturers have been asked to provide data by the end of March. Interventions for weight gain in schizophrenia There is not enough evidence to support the use of drugs to reduce weight gain associated with schizophrenia, a new Cochrane review has found (Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD005148. DOI: 10.1002/14651858. CD005148.pub2). Noting a lack of adequate trials, the review found that cognitive/behavioural interventions effectively prevented weight gain by a mean of 3.4kg and reduced established weight gain by a mean of 1.7kg. Drugs prevented weight gain by about 1.2kg. Switching anti-TNFs An analysis of a UK rheumatoid arthritis (RA) registry has shown that patients who stop treatment with their first anti-TNF agent should be switched to a second (Arthr Rheum 2007;56:13-20). Every UK patient with RA who receives an anti-TNF agent is included in the British Society for Rheumatology Biologics Register. Analysis of this database identified 6739 patients who started treatment, of whom 841 stopped within 15 months due to lack of efficacy and 1023 due to toxicity. Of these, 503 and 353 respectively were switched to another anti- TNF agent. Overall, 73 per cent of patients remained on their second drug by the end of follow-up, but patients were two to three times more likely to stop their second treatment for the same reason they discontinued their first. Copyright © 2007 Wiley Interface Ltd [source]

The State of Diabetes Care Provided to Medicare Beneficiaries Living in Rural America

Joseph P. Weingarten Jr PhD
ABSTRACT:,Context: Diabetes poses a growing health burden in the United States, but much of the research to date has been at the state and local level. Purpose: To present a national profile of diabetes care provided to Medicare beneficiaries living in urban, semirural, and rural communities. Methods: Medicare beneficiaries with diabetes aged 18-75 were identified from Part A and Part B claims data from 1999 to 2001. A composite of 3 diabetes care indicators was assessed (annual hemoglobin A1c test, biennial lipid profile, and biennial eye examination). Findings: Over 77% had a hemoglobin A1c test, 74% a lipid profile, and 69% an eye examination. Patterns of care were considerably different across the urban-rural continuum at the state, Census division, and regional levels. States in the northern and eastern portions of the country had higher indicator rates for rural than for urban residents. States in the South had much lower rates for rural residents than their urban counterparts. Despite these within-state differences, across-state comparisons found that several states tended to have low indicator rates in every level of the urban-rural continuum. A common feature of these states was the relatively high concentration of nonwhite beneficiaries. For example, southern states had much higher concentrations of nonwhite beneficiaries relative to other areas in the country and demonstrated low rates in every level of the urban-rural continuum. Conclusions: Urban-rural quality of care differences may be a function not just of geography but also of the presence of a large nonwhite population. [source]

Diabetes care in childhood and adolescence

P. R. Betts
Abstract The presentation of diabetes in young people has changed significantly over recent years. Not only has there been a rising incidence of Type 1 diabetes, especially in young children, but also there is an increasing recognition of Type 2 diabetes. Young people are also increasingly being diagnosed with genetic defects of B-cell function and with diabetes in association with cystic fibrosis and other chronic diseases. There have also been significant changes in the pattern of paediatric diabetes care. This is increasingly being provided by a specialized paediatric multidisciplinary team in each health district working to agreed national standards. Despite improvements, diabetes control is still suboptimal with a high incidence of complications being reported in young adults. The challenge over the next few years is the provision of a uniform, equitable and first class paediatric service throughout the UK together with the introduction of new approaches to care, aiming to improve individual diabetic control and reduce long-term complications. Increased collaboration with adult colleagues is needed to enable the transition of care in adolescence to a service that young adults perceive to meet their needs, encourage their attendance and improve their diabetes control and quality of life. A national paediatric diabetes register together with regular audit will encourage these objectives. [source]

Adaptation and negotiation as an approach to care in paediatric diabetes specialist nursing practice: a critical review

,,Considerable attention has been given to diabetes care in children. However, nursing practice may be guided by biomedical models. ,,Diabetes care in children should focus on family-centred approaches arguably based in the community. ,,Psychosocial constructs have an important role in the development of self-management of chronic illness in children. ,,Paediatric diabetes nurse specialists are pivotal in facilitating family-centred care based on personal models of child and family interventions. [source]

Effectiveness of staged diabetes management on the quality of diabetes care in Mexico

J Rodriguez-Saldana MD
Abstract The aim of this study was to investigate the effectiveness of staged diabetes management, a structured programme developed by the International Diabetes Center in Minneapolis, USA, on the quality of outpatient diabetes care at the primary level in Mexico. A prospective study was conducted in patients treated at outpatient diabetes clinics established in public health centres in 2001,2007 in Hidalgo, Mexico. Diabetes care was provided by multidisciplinary teams which included general physicians and nurses as a minimum. Organisational arrangements were made to reduce waiting times, avoid rotation of staff, and provide adequate time for baseline and follow-up visits. Process and outcomes indicators of quality of diabetes care included body mass index, blood pressure, fasting/casual blood glucose, lipoprotein measurement, haemoglobin A1c, and foot examination. Analysis of 4393 patients showed increases in the percentage of recorded process indicators of quality of diabetes care between baseline and the fifth visit: body mass index 85.5 vs 95.9%; blood pressure measurement 74.4 vs 95.6%; HbA1c 12.9 vs 17.7%; total cholesterol 18.3 vs 55.9%; and foot examination 19.1 vs 94.9%. Significant differences were noted by a decrease in fasting blood glucose (185.75±79.01 vs 162.89±72.53mg/dl, p<0.001), and a 3.6 percentage point decrease in HbA1c (12.05±4.47 vs 8.45±1.89%, p<0.001). These results suggest that it is possible to improve the quality of diabetes care at the primary level; this can be done through the implementation of a programme that integrates: changes in the structure and in the process of care, customised clinical guidelines, and a standardised system of information that enables measuring clinical results with very limited resources. Copyright © 2010 John Wiley & Sons. [source]

Diabetes care in Brazil: now and in the future

HC Pedrosa MD Professor of Medicine
Abstract Brazil, like many other developing countries, faces the dual problem of an increasing burden of chronic disease together with many communicable diseases. The organisation of diabetes care and the provision of drugs have improved considerably over the last 20 years, and the Brazilian Diabetes Society has had a major role in these improvements. However, many people remain unaware that they have diabetes and some diagnosed patients receive no treatment. Copyright © 2004 John Wiley & Sons, Ltd. [source]

Heart Failure and Diabetes: Collateral Benefit of Chronic Disease Management

Molly G. Ware MD
To test the hypothesis that a focus on heart failure (HF) care may be associated with inadequate diabetes care, the authors screened 78 patients (aged 64±11 years; 69% male) with diabetes enrolled in an HF disease management program for diabetes care as recommended by the American Diabetes Association (ADA). Ninety-five percent of patients had hemoglobin A1c levels measured within 12 months, and 71% monitored their glucose at least once daily. Most patients received counseling regarding diabetic diet and exercise, and approximately 80% reported receiving regular eye and foot examinations. Mean hemoglobin A1c level was 7.8±1.9%. There was no relationship between hemoglobin A1c levels and New York Heart Association class or history of HF hospitalizations. Contrary to the authors' hypothesis, patients in an HF disease management program demonstrated levels of diabetic care close to ADA goals. "Collateral benefit" of HF disease management may contribute to improved patient outcomes in diabetic patients with HF. [source]

Integrating educational and technological interventions to improve pregnancy outcomes in women with diabetes

Helen R. MurphyArticle first published online: 5 NOV 200
A gap currently exists between our expectations of tight blood glucose control and the reality of safely achieving it before and during pregnancy. Technological and pharmaceutical advances will not in isolation prevent poor pregnancy outcomes without recognising the social, cultural and behavioural context of the women living with diabetes. Neither will behavioural and/or educational programmes completely overcome the fundamentally disordered metabolic pathways and physiological challenges of pregnancy. Improved integration of the technological, behavioural and educational aspects of diabetes care will pave the way for truly personalized, interdisciplinary diabetes management and ultimately improved pregnancy outcomes for women with diabetes and their infants. [source]

Glycemic risk factors of diabetic vascular complications: the role of glycemic variability

Francesco Zaccardi
Abstract Achieving adequate targets relatively to all risk factors is considered a standard of care for patients with diabetes mellitus. To date, current guidelines underline the importance of the ,glucose triad' (post-prandial glucose, fasting plasma glucose and glycated haemoglobin) as the three glycemic factors that should be controlled in diabetes care; however, several literature data show that optimizing glycemic control needs achieving a control of glycemic variations. The objective of the present work is reviewing biological and clinical data supporting the role of glycemic variability, its measurement and relationship with the three other well-known glycemic risk factors and evidencing the areas that need further investigation. At last, we propose a simple model that summarizes the ,glucose triad' plus the ,new' risk factor glycemic variability (the ,Pyramid of the Risk'). Copyright © 2009 John Wiley & Sons, Ltd. [source]

Diabetes trends in Europe

Philippe Passa
Abstract Estimates and projections suggest an epidemic expansion of diabetes incidence and prevalence in Europe. To evaluate trends in type 1 and type 2 diabetes in seven European countries (Finland, Denmark, the UK, Germany, France, Spain, and Italy), a variety of information is available, including population-based studies on small or large cohorts of subjects representative of the general population in a particular country, European co-operative studies, and sales figures for insulin and oral hypoglycemic agents that allow extrapolation of the number of pharmacologically treated diabetic patients. The incidence of type 1 diabetes in young people is increasing in most European countries, as is its prevalence in all age groups. Type 2 diabetes is the major contributor to the epidemic rise in diabetes. From 1995 to 1999, the prevalence of type 2 diabetes increased considerably, particularly in the UK, Germany, and France. Costs of ambulatory and in-hospital diabetic care (including antidiabetic, antihypertensive, and hypolipidemic agents) have increased even more rapidly than has the number of affected patients. Diabetes trends in Europe are alarming; health care professionals involved in diabetes care must be made aware of these detrimental trends, and health care delivery to patients with diabetes must be improved. Copyright © 2002 John Wiley & Sons, Ltd. [source]

Insulin therapy in Europe

Werner A. Scherbaum
Abstract The prevalence of type 1 diabetes is rising in all European countries, particularly in Scandinavia and the UK. Insulin therapy in Europe is strongly influenced by the results of the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS), both of which showed the importance of tight metabolic control in patients with diabetes. The importance of tight glycemic control is also emphasized in the Saint Vincent Declaration, which established 5-year goals for antidiabetic therapy in Europe. Insulin therapy in Europe has been significantly improved over the past 10,years, owing to a number of developments. These include increased use of intensive insulin therapy in patients with type 1 diabetes; the development of new insulin analogs, including insulin glargine for injection therapy and short-acting agents that are particularly suitable for use in pumpsand the establishment of comprehensive and standardized treatment goals and guidelines. Nevertheless, important obstacles must still be overcome to optimize therapy for patients with diabetes and reduce the long-term complications of this disease. These obstacles include low public awareness of diabetes and its symptoms, training of physicians as well as patients that is often insufficient to ensure adherence to professional guidelines for diabetes care, and limitations in communication among professional care providers. Copyright © 2002 John Wiley & Sons, Ltd. [source]

Continuous glucose monitoring in managing diabetes in children

Phyllis W. Speiser
Abstract Continuous glucose monitoring (CGM) devices have now been added to the repertoire of technological devices useful in the management of patients with diabetes. In this issue, Schiaffini and colleagues confirm and extend published data describing the benefits of CGM in diabetic children. Specifically, such monitoring enables clinicians to detect occult hypoglycemia not otherwise discernable with intermittent testing of blood glucose. Although results of monitoring are not yet available in real time, the data can be used to adjust insulin regimens to allow more effective glycemic control. This is especially important in the pediatric population for whom strict glycemic control has traditionally been limited owing to concerns about the negative effects of hypoglycemia on the developing central nervous system. Additionally, postprandial hyperglycemia can be more readily detected and controlled. CGM provides new and important informaton not necessarily provided by measurement of HbA1c, and will likely prove an indispensable adjunct to diabetes care. Finally, this procedure has potential applications in the diagnosis and management of patients with other metabolic disorders. Copyright © 2002 John Wiley & Sons, Ltd. [source]

The Diabetes UK Mozambique Twinning Programme.

Results of improvements in diabetes care in Mozambique: a reassessment 6 years later using the Rapid Assessment Protocol for Insulin Access
Diabet. Med. 27, 855,861 (2010) Abstract Objective, To assess improvements in diabetes care in Mozambique between 2003 and 2009 following the implementation of the Diabetes UK Twinning Programme. Methods, As in 2003, a Rapid Assessment Protocol was implemented from August to September 2009 in order to assess the improvements in diabetes care and impact of the Diabetes UK Twinning Programme. One hundred and eighty-four interviews were carried out at different levels of the health system in different areas of Mozambique. Results, The Diabetes UK Twinning Programme in Mozambique allowed the development of the first comprehensive non-communicable disease plan in sub-Saharan Africa. The other main improvements include a strengthening of the diabetes association with an 8-fold increase in membership, 265 health workers trained in diabetes care in all provinces, the development of patient education materials inspired by some Diabetes UK tools and the expansion of public awareness, particularly from events associated with World Diabetes Day. Conclusions, Much progress has been made in Mozambique with regard to diabetes and non-communicable diseases. Besides the direct impact of specific activities supported by Diabetes UK, this project allowed for ,collateral' benefits in the overall provision of diabetes care. As diabetes and non-communicable diseases have a low profile on the global health agenda, twinning partnerships based on rigorous needs assessment have the capacity to make significant improvements in diabetes care at a relatively low level of investment. Moreover, this study suggests that the tool used might be of value in assessing progress in health system strengthening as well as in conducting the initial needs assessment. [source]

Are clinical practical guidelines (CPGs) useful for health services and health workforce planning?

A critique of diabetes CPGs
Diabet. Med. 27, 570,577 (2010) Abstract Aims, Chronic disease management is increasingly informed by clinical practice guidelines (CPGs). However, their implementation requires not only knowledge of guideline content by clinicians and practice processes that support implementation, but also a health workforce with the capacity to deliver care consistent with CPGs. This has a health services planning as well as a health workforce dimension. However, it is not known whether CPGs are described in a way that can inform health services and health workforce planning and potentially drive better quality care. This study aimed to ascertain whether CPGs are useful for health service and health workforce planning. Methods, This question was explored taking diabetes mellitus as a case study. A systematic search of Medline, EMBASE, CINAHL and Scopus was carried out to identify all CPGs relating to the management of diabetes mellitus in the primary healthcare setting. The search was limited to guidelines published in the English language between 2003 and 2009. The quality of guidelines was assessed against a subset of criteria set by the Appraisal of Guidelines for Research and Evaluation (AGREE) collaboration. Results, Seventy-five diabetes-related CPGs were identified, of which 27 met the inclusion criteria. In terms of quality, many guidelines adopted evidence-based recommendations for diabetes care (59%) and most were endorsed by national authorities (70%). With regards to coverage of 17 identified subpopulations, guidelines were generally selective in the populations they covered. Whilst many provided adequate coverage of common complications and comorbidities, approaches to management for those with reduced capacity for effective diabetes self-care were largely absent, except for indigenous populations. Conclusions, Clinical practice guidelines are potentially useful for health services and health workforce planning, but would be more valuable for this purpose if they contained more detail about care protocols and specific skills and competencies, especially for subpopulations who would be expected to have reduced capacity for effective self-care. If service planning ignores these subgroups that tend to require more resource-intensive management, underprovision of services is likely. [source]

Association of British Clinical Diabetologists (ABCD) and Diabetes-UK survey of specialist diabetes services in the UK, 2006.


Abstract Aims To identify the views and working practices of consultant diabetologists in the UK in 2006,2007, the current provision of specialist services, and to examine changes since 2000. Methods All 592 UK consultant diabetologists were invited to participate in an on-line survey. Quantitative and qualitative analyses of responses were undertaken. A composite ,well-resourced service score' was calculated. In addition to an analysis of all respondents, a sub-analysis was undertaken, comparing localities represented both in 2006/2007 and in 2000. Results In 2006/2007, a 49% response rate was achieved, representing 50% of acute National Health Service Trusts. Staffing levels had improved, but remained below recommendations made in 2000. Ten percent of specialist services were still provided by single-handed consultants, especially in Northern Ireland (in 50% of responses, P = 0.001 vs. other nations). Antenatal, joint adult,paediatric and ophthalmology sub-specialist diabetes services and availability of biochemical tests had improved since 2000, but access to psychology services had declined. Almost 90% of consultants had no clinical engagement in providing community diabetes services. The ,well-resourced service score' had not improved since 2000. There was continued evidence of disparity in resources between the nations (lowest in Wales and Northern Ireland, P = 0.007), between regions in England (lowest in the East Midlands and the Eastern regions, P = 0.028), and in centres with a single-handed consultant service (P = 0.001). Job satisfaction correlated with well-resourced service score (P = 0.001). The main concerns and threats to specialist services were deficiencies in psychology access, inadequate staffing, lack of progress in commissioning, and the detrimental impact of central policy on specialist services. Conclusions There are continued disparities in specialist service provision. Without effective commissioning and adequate specialist team staffing, integrated diabetes care will remain unattainable in many regions, regardless of reconfigurations and alternative service models. [source]

Quality of diabetes care in patients with schizophrenia and bipolar disorder: cross-sectional study

S. Whyte
Abstract Aims To determine whether patients with severe mental illness receive poorer health care for diabetes than patients without. Methods This population-based cross-sectional survey used electronic general practice records from 481 UK general practices contributing to the QRESEARCH database. The records of 11 043 patients with diabetes, drawn from a database population of over 9 million patients, were extracted. Unadjusted and adjusted odds ratios were calculated using unconditional logistic regression for each of 17 quality indicators for diabetes care from the new General Medical Services contract for general practitioners. Results The presence of severe mental illness did not reduce the quality of care received; the only significant difference between groups showed that such patients were more likely to have glycated haemoglobin < 7.5%[adjusted odds ratio = 1.45 (99% confidence interval 1.20,1.76)]. Increasing age was associated with better care [adjusted odds ratios from 1.06 (1.02,1.11) to 1.61 (1.52,1.70)], but other confounding variables had no consistent effect across indicators. Overall, performance against government targets was good. Conclusions The hypothesis of poorer diabetes care for those with severe mental illness is disproved, perhaps surprisingly, in the light of other recent UK studies showing inequalities in care for the mentally ill. The study does not reveal who is providing this good care (general practitioners, psychiatrists or diabetologists) or take account of the estimated 600 000 people in the UK with undiagnosed diabetes. [source]

Physical activity consultation for people with Type 2 diabetes.

Evidence, guidelines
Abstract Physical activity is an important, but often underused, therapeutic strategy within diabetes care. To date, little is known about the best way to promote physical activity in diabetes care. Physical activity consultation is an intervention designed to promote physical activity behaviour change. This article provides guidelines on how to conduct a physical activity consultation with people who have Type 2 diabetes, and reviews the evidence surrounding the effectiveness of this intervention in this population. The trans-theoretical model is the underlying theory of behaviour change for the physical activity consultation intervention. The review identifies research which supports the use of this model for understanding physical activity behaviour in people with Type 2 diabetes. The review outlines a number of modifiable variables associated with physical activity behaviour change in this population. How each of these variables is addressed within the guidelines for conducting a physical activity consultation is identified. Finally, limited but consistent research highlights the effectiveness of physical activity consultation for promoting physical activity in people with Type 2 diabetes. [source]

Near patient testing for glycated haemoglobin in people with Type 2 diabetes mellitus managed in primary care: acceptability and satisfaction

M. A. Stone
Abstract Aims To assess the acceptability of and satisfaction with near patient testing for glycated haemoglobin in primary care in patients and health professionals. Methods A questionnaire survey and qualitative study were nested within a randomized controlled trial conducted in eight general practices in Leicester-shire, UK. Satisfaction with diabetes care was compared in the intervention group (near patient test) and in the control subjects (usual laboratory test), using the Diabetes Clinic Satisfaction Questionnaire. Semistructured interviews were conducted with a purposive sample of patients and healthcare professionals and analysed using thematic coding and framework charting. Results Questionnaire data for 344 patients were analysed and interviews were conducted with 15 patients and 11 health professionals. Interviews indicated that the near patient test was highly acceptable to patients and staff and confirmed that there may be potential benefits such as time saving, reduced anxiety and impact on patient management and job satisfaction. However, both the survey and the interviews identified high pre-existing levels of satisfaction with diabetes care in both intervention and control group patients and survey results failed to confirm increased patient satisfaction as a result of rapid testing. Limited patient understanding of glycated haemoglobin testing was noted. Conclusions We were unable to confirm actual rather than potential advantages of the near patient test. Widespread adoption in primary care cannot be recommended without further evidence of benefit. [source]

Diabetes service provision: a qualitative study of the experiences and views of Pakistani and Indian patients with Type 2 diabetes

J. Lawton
Abstract Aims To explore Pakistani and Indian patients' experiences of, and views about, diabetes services in order to inform the development of culturally sensitive services. Design Qualitative, interview study involving 23 Pakistani and nine Indian patients with Type 2 diabetes recruited from general practices and the local community in Edinburgh, Scotland. Data collection and analysis occurred concurrently and recruitment continued until no new themes emerged from the interviews. Results Respondents expressed gratitude for the availability of free diabetes services in Britain, as they were used to having to pay to access health care on the Indian subcontinent. Most looked to services for the prompt detection and treatment of complications, rather than the provision of advice about managing their condition. As respondents attached importance to receiving physical examinations, they could be disappointed when these were not offered by health-care professionals. They disliked relying on interpreters and identified a need for bilingual professionals with whom they could discuss their diabetes care directly. Conclusions Gratitude for free services in Britain may instil a sense of indebtedness which makes it difficult for Pakistanis and Indians to be critical of their diabetes care. Health-care professionals may need to describe their roles carefully, and explain how different diabetes services fit together, to avoid Pakistani and Indian patients perceiving treatment as unsatisfactory. Whilst linkworker schemes may meet patients' need to receive culturally sensitive information in their first language, work is needed to assess their effectiveness and sustainability. [source]

Role of habit in adherence to medical treatment

G. Reach
Abstract This paper presents an analysis, from a philosophical point of view, of three psychological models describing how one adopts a health behaviour. More specifically, this analysis makes it possible to explain the role of habit in therapeutic adherence. By clarifying the notions of intention and decision, this novel analysis may be useful for understanding the dynamics of diabetes care. [source]

Persistent poor glycaemic control in adult Type 1 diabetes.

A closer look at the problem
Abstract Around 25% of the adult Type 1 diabetes population is in persistent poor glycaemic control and thus at increased risk of developing microvascular complications. We here discuss correlates of long-standing poor glycaemic control and review the efficacy of clinical strategies designed to overcome persistent poor control. Only a few studies have identified determinants and correlates of long-standing poor glycaemic control in Type 1 diabetes. There is some evidence implicating genetic factors, as well as lower economic status, and psychological factors, including lack of motivation, emotional distress, depression and eating disorders. Ways of improving glycaemic control include strategies to enable self-management, e.g. motivational strategies, coping-orientated education, psychosocial therapies, and/or intensifying insulin injection therapy plus continuous subcutaneous insulin infusion. Long-standing poor glycaemic control appears to be a heterogeneous and complex phenomenon, for which there is no simple, single solution. Comprehensive psycho-medical assessment in diabetes care may prove useful in tailoring interventions. Further research is warranted, to increase our understanding how psychosocial and biomedical factors, separately and in interaction, determine poor outcomes in Type 1 diabetes. [source]

Reversible cognitive deterioration after a single episode of severe hypoglycaemia: a case report

T. Kubiak
Abstract A case of a male 34-year-old Type 1 diabetic patient who experienced a prolonged severe hypoglycaemic episode is presented. After the hypoglycaemic event, the patient suffered from moderate to severe neuropsychological impairments. On the basis of neuropsychological assessment results, diabetes therapy was modified (less complex insulin regimen, fixed insulin doses and fixed carbohydrate distribution). At a follow-up examination (3 months), presumable complete recovery of cognitive function was observed. This case demonstrates the possible detrimental neuropsychological effects of severe hypoglycaemia, that, in this case, turned out to be reversible. It highlights the clinical implications of impaired cognitive function on self-care and self-management abilities and the usefulness of neuropsychological testing in clinical diabetes care. [source]

A pilot randomized trial in primary care to investigate and improve knowledge, awareness and self-management among South Asians with diabetes in Manchester

A. Vyas
Abstract Aims To investigate whether a secondary,primary care partnership education package could improve understanding of diabetes care among South Asians. Methods In a pilot randomized controlled trial, in the setting of eight general practices randomized to intervention or control, patients were invited to four or more rotating visits per year by one of a diabetes specialist nurse, dietician or chiropodist working with general practice staff. Participants were from lists of South Asian patients with known Type 2 diabetes in each (general) practice. Results Patients and practice scores at baseline and 1-year follow-up, from an interview using a questionnaire on knowledge, awareness and self-management of diabetes. Responses were developed into educational packages used during intervention. Of the 411 patients listed at baseline only 211 were traced for interview (refusal only 4%). Mean age was 55.4 years, age of diabetes onset 47.1 years. Fourteen percent were employed and 35% were able to communicate in English fluently. Only 118 could be traced and interviewed at 1 year, although there was no significant difference in demography between those who completed the study and those who did not. Despite a mean of four visits/patient, intervention had no impact on scores for diabetes knowledge, or awareness [score change 0.14, 95% confidence interval (CI) ,0.20, 0.49] or self-management (,0.05, 95% CI ,0.48, 0.39) between baseline and 1 year. Conclusions This form of secondary/primary care support did not transfer information effectively, and we suspect similar problems would arise in other similar communities. Different methods of clinician/patient information exchange need to be developed for diabetes in this South Asian group. [source]

Diabetes care in childhood and adolescence

P. R. Betts
Abstract The presentation of diabetes in young people has changed significantly over recent years. Not only has there been a rising incidence of Type 1 diabetes, especially in young children, but also there is an increasing recognition of Type 2 diabetes. Young people are also increasingly being diagnosed with genetic defects of B-cell function and with diabetes in association with cystic fibrosis and other chronic diseases. There have also been significant changes in the pattern of paediatric diabetes care. This is increasingly being provided by a specialized paediatric multidisciplinary team in each health district working to agreed national standards. Despite improvements, diabetes control is still suboptimal with a high incidence of complications being reported in young adults. The challenge over the next few years is the provision of a uniform, equitable and first class paediatric service throughout the UK together with the introduction of new approaches to care, aiming to improve individual diabetic control and reduce long-term complications. Increased collaboration with adult colleagues is needed to enable the transition of care in adolescence to a service that young adults perceive to meet their needs, encourage their attendance and improve their diabetes control and quality of life. A national paediatric diabetes register together with regular audit will encourage these objectives. [source]

In-patient management of diabetes mellitus and patient satisfaction

A. Bhattacharyya
Abstract Aims To devise a system for assessing in-patient glycaemic control and care satisfaction in diabetic patients admitted to hospital for reasons other than their diabetes. Methods Consecutive January to March 2001 case-notes were reviewed. Admissions with acute metabolic complications, acute myocardial infarction and pregestational or gestational diabetes were excluded. Glycaemic control, frequency of blood monitoring and management of hyperglycaemia were recorded. The diabetes treatment satisfaction questionnaire was used to assess preadmission satisfaction with care. Post-admission a 12-stem questionnaire was used to assess satisfaction with in-patient diabetes management. Results Hypoglycaemia was common. Although none developed a hyperglycaemic emergency, high blood glucose was prevalent and, frequently, persistent hyperglycaemia or recurrent hypoglycaemia was not acted on appropriately. The overall score for in-patient satisfaction with treatment was fair (4.1 ± 1.8 on a six-point scale; 6 = very satisfied and 1 = very dissatisfied). Scores were higher among patients on surgical wards than on medical wards (P = 0.008), but satisfaction did not vary when patients were stratified according to sex, age and mode of treatment. Conclusion Current systems are not achieving satisfactory in-patient glycaemic control and there is poor satisfaction with medical in-patient diabetes care. Following changes intended to produce improvements, this assessment system can be used recurrently to monitor in-patient care and satisfaction. [source]

Self-monitoring in Type 2 diabetes mellitus: a meta-analysis

S. Coster
SUMMARY Aims Self-monitoring of blood or urine glucose is widely used by subjects with Type 2 diabetes mellitus. This study evaluated the effectiveness of the technique at improving blood glucose control through a systematic review and meta-analysis. Methods Randomized controlled trials were identified that compared the effects of blood or urine glucose monitoring with no self-monitoring, or blood glucose self-monitoring with urine glucose self-monitoring, on glycated haemoglobin as primary outcome in Type 2 diabetes. Results , Eight reports were identified. These were rated for quality and data were abstracted. The mean (sd) quality score was 15.0 (1.69) on a scale ranging from 0 to 28. No study had sufficient power to detect differences in glycated haemoglobin (GHb) of less than 0.5%. One study was excluded because it was a cluster randomized trial of a complex intervention and one because fructosamine was used as the outcome measure. A meta-analysis was performed using data from four studies that compared blood or urine monitoring with no regular monitoring. The estimated reduction in GHb from monitoring was ,0.25% (95% confidence interval ,0.61 to 0.10%). Three studies that compared blood glucose monitoring with urine glucose monitoring were also combined. The estimated reduction in GHb from monitoring blood glucose rather than urine glucose was ,0.03% (,0.52 to 0.47%). Conclusions The results do not provide evidence for clinical effectiveness of an item of care with appreciable costs. Further work is needed to evaluate self-monitoring so that resources for diabetes care can be used more efficiently. [source]