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Researchers examine ways to improve diabetes care in different health care settings

Diabetes affects 10 million patients and costs over $100 billion annually. Complications of diabetes, which range from poor wound healing and cardiovascular disease to kidney and eye damage, can be delayed by reducing hyperglycemia or high levels of blood sugar that arise from lack of insulin to metabolize it. Structured treatment programs, which typically include patient education, use of nurse case managers, and stepped-care rules to guide drug management, have been shown to improve glycemic control. However, despite recommendations for national standards of care, management of the disease often falls short of these standards. Four new studies supported by the Agency for Healthcare Research and Quality examine ways to improve diabetes management in different health care settings.

The first study shows that failure to intensify therapy for black patients with diabetes, who are at risk for persistent hyperglycemia despite treatment, may contribute to their poor outcomes. The second study finds that physician assistant students need to improve their understanding of when to intensify insulin therapy. The third study identifies barriers to improving care for individuals treated for diabetes at community health centers. The fourth study describes four interactive technologies that may improve self-management of diabetes.

Cook, C.B., Lyles, R.H., El-Kebbi, I., and others. (2001, February). "The potentially poor response to outpatient diabetes care in urban African-Americans." (AHRQ grant HS09722). Diabetes Care 24(2), pp. 209-215.

The usual basis for defining diabetes program success is lowering a patient's blood sugar (HbA1c) level to 7 percent or less. However, some individuals are more responsive to treatment than others. Less responsive patients with diabetes, who show little reduction in blood sugar levels, are at greater risk for complications of diabetes such as eye and kidney disease. These researchers studied urban black patients with type 2 (adult-onset) diabetes who were managed in an outpatient diabetes clinic. Patients who had diabetes longer, had a higher initial blood sugar level, and had greater body mass index were at significantly increased risk of poor treatment response (persistent hyperglycemia) compared with similar patients who did not have these characteristics.

All black patients treated at the clinic were managed with diet, sulfonylureas (oral medication to lower blood glucose levels), and insulin. Patients were characterized as responders, intermediate responders, or poor responders according to their HbA1c level after 1 year of care. Most patients had diabetes for a mean of 5 years, were in their 50s, and were overweight. Overall, the mean HbA1c level fell from 9.6 to 8.1 percent after 1 year. Mean HbA1c levels fell from 8.8 to 6.2 percent in responders and from 9.5 to 7.9 percent in intermediate responders. However, in poor responders, the average HbA1c level was 10.8 initially and 10.9 percent 1 year later.

Although doses of oral medication and insulin were significantly higher among poor responders at most visits, the acceleration of insulin therapy did not occur until late in the followup period. This suggests that in addition to the patient characteristics identified, insufficient intensification of therapy may have been a factor underlying the failure to achieve glycemic goals in this group of patients. The authors note that clinical diabetes programs need to devise methods to identify patients who are at risk for persistent hyperglycemia and thus might benefit from intensified therapy.

Fisk, D.M., Hayes, R.P., Barnes, C.S., and Cook, C.B. (2001, January). "Physician assistant students and diabetes: Evaluation of attitudes and beliefs." (AHRQ grant HS09722). Diabetes Educator 27(1), pp. 111-118.

Growing numbers of physician assistants are taking principal responsibility for patient care, including diabetes management. However, physician assistant students need a better understanding of when to intensify therapy for their patients with diabetes, concludes this study. The researchers used the Diabetes Attitude Scale to survey three currently enrolled classes of physician assistant students as to their attitudes about type 2 (adult-onset) diabetes and at what level of hyperglycemia students would intensify diabetes therapy.

Most students agreed that diabetes is a serious disease, providers should receive instruction in diabetes management, tight glucose control is important, diabetes does have an impact on patients' lives, and patients should be the primary decisionmakers regarding the daily self-care of their diabetes. However, many students did not understand at what point they should start or increase medications to reach recommended blood sugar levels. The American Diabetes Association target for fasting plasma glucose (FPG) is less than 120 mg/dL and an HbA1c of less than 7 percent, with intensification of therapy suggested for an FPG of more than 140 mg/dL or an HbA1c of more than 8 percent.

Yet, nearly 64 percent of the first-year students did not know at what level of FPG they would start or increase medications. Also, 84 percent of the first-year students could not state an HbA1c level that would prompt drug intervention. Fewer second- and third-year students responded "don't know," but the wide distribution of values they reported to start or increase medications suggests that even they may be unfamiliar with current clinical targets. Future instruction of physician assistant students should focus on how to achieve glucose goals.

Chin, M.H., Cook, S., Jin, L., and others. (2001, February). "Barriers to providing diabetes care in community health centers." (AHRQ grant HS10479). Diabetes Care 24(2), pp. 268-274.

Financially disadvantaged people with diabetes often rely on a safety net system of care, which in many cases is the community health center (CHC). Researchers in this study identified the barriers to improving diabetes care in CHCs that typically serve vulnerable patients and have limited resources. The researchers surveyed 389 health providers and administrators at 42 Midwestern CHCs about the barriers they faced in delivering diabetes care. More than 25 percent of providers and administrators agreed that significant barriers to care included patients' inability to afford home blood glucose monitoring, HbA1c testing, dilated eye examination (to detect changes in the eye associated with diabetes), and special diets; lack of accessibility to an ophthalmologist; forgetting to order eye examinations and to examine patients' feet; time required to teach home blood glucose monitoring; and language or cultural barriers.

Overall, providers and administrators rated access to care, affordability of care, and sufficient appointment time as mild to moderate barriers to quality diabetes treatment at CHCs. Providers were more confident in their ability to instruct patients on diet and exercise than on their ability to help them make changes in these areas. On the other hand, providers perceived that patients were significantly less likely than providers to believe that key processes of care were important.

The researchers conclude that improvement in diabetes care at CHCs probably requires a multifaceted approach emphasizing patient education, improved training of providers in how to effect behavioral change, and enhanced delivery systems that improve the affordability, accessibility, and efficiency of care.

Glasgow, R.E., and Bull, S.S. (2001, May). "Making a difference with interactive technology: Considerations in using and evaluating computerized aids for diabetes self-management education." (AHRQ grant HS10123). Diabetes Spectrum 14(2), pp. 99-106.

Self-management activities—including taking medication, eating properly, exercising regularly, and self-monitoring of blood glucose levels (SMBG)—are considered central to good diabetes control. These researchers describe the potential or actual impact of four interactive technologies (IT) on the self-management of diabetes: hand-held SMBG devices, automated telephone disease management (ATDM), CD-ROM technology, and Internet interaction. Hand-held SMBG devices automatically record time, date, glucose level, and other data related to self-management (for example, calorie intake and exercise level) and allow for transfer of data directly to health care providers. In addition, SMBG devices can present feedback in a variety of ways, including average blood glucose for specified intervals or frequency distributions of levels within preset ranges.

In ATDM, patients are called at specified intervals (for example, the weekly) by the automated system. A familiar voice (for example, the clinic nurse) offers the patient opportunities to touch the telephone keypad in response to prompts to discuss self-care activities or hear self-care tips.

CD-ROM technology allows for the display of video and other large multimedia files and for very complex programming algorithms. For example, one study developed an easy-to-use CD-ROM program with touch screen capability allowing patients to obtain immediate, personalized feedback on their barriers to healthy eating and to engage in diabetes self-management goal-setting and problem-solving to improve dietary behavior and serum cholesterol.

Use of the Internet for diabetes self-management is perhaps the IT with the greatest potential. It adds a new dimension for health promotion via online support groups, interactions with health experts, access to decisionmaking aids, and participation in health care. The researchers emphasize the importance of having a set of standards to apply to these evolving technologies to help distinguish actual IT advances from ineffective or misguided applications.

Current IT offers advantages of speed, availability, consistency, and tailoring in performing routine tasks and activities that have been programmed. However, these technologies are more limited in their ability to deal with novel situations that have not been anticipated. Thus, the intent of IT should not be to replace health care professionals but to inform both patients and providers to make their interactions more productive.

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