Self-monitoring of blood glucose: language and financial barriers in a managed care population with diabetes

When is social support important? The association of family support and professional support with specific diabetes self-management behaviors

BACKGROUND

Social support is associated with better diabetes self-management behavior (SMB), yet interventions to increase family and friend support (FF support) have had inconsistent effects on SMB.

OBJECTIVE

To test whether FF support differentially affects specific SMBs and compare the influence of support from health professionals and psychological factors on specific SMBs to that of FF support.

DESIGN

Cross-sectional survey of people with diabetes recruited for a self-management intervention

PARTICIPANTS AND SETTING

One hundred sixty-four African-American and Latino adults with diabetes living in inner-city Detroit

MEASUREMENTS AND MAIN RESULTS

For every unit increase in FF support for glucose monitoring, the adjusted odds ratio (AOR) of completing testing as recommended was 1.77 (95% CI 1.21-2.58). FF support was not associated with four other SMBs (taking medicines, following a meal plan, physical activity, checking feet). Support from non-physician health professionals was associated with checking feet [AOR 1.72 (1.07-2.78)] and meal plan adherence [AOR = 1.61 (1.11-2.34)]. Diabetes self-efficacy was associated with testing sugar, meal plan adherence, and checking feet. Additional analyses suggested that self-efficacy was mediating the effect of FF support on diet and checking feet, but not the FF support effect on glucose monitoring.

CONCLUSIONS

The association between FF support and SMB performance was stronger for glucose monitoring than for other SMBs. Professional support and diabetes self-efficacy were each independently associated with performance of different SMBs. SMB interventions may need to differentially emphasize FF support, self-efficacy, or professional support depending on the SMB targeted for improvement.

Self-Monitoring of Blood Glucose (SMBG) in insulin- and non-insulin-using adults with diabetes: consensus recommendations for improving SMBG accuracy, utilization, and research

Current clinical guidelines for diabetes care encourage self-monitoring of blood glucose (SMBG) to improve glycemic control. Specific protocols remain variable, however, particularly among non-insulin-using patients. This is due in part to efficacy studies that neglect to consider (1) the performance of monitoring equipment under real-world conditions, (2) whether or how patients have been taught to take action on test results, and (3) the physiological, behavioral, and social circumstances in which SMBG is carried out. As such, a multidisciplinary group of specialists, including several endocrinologists, a health psychologist, a diabetes nurse practitioner, and a patient advocate (the Panel), discuss within this review article how the potential of SMBG might be fully realized in today's healthcare environment. The resulting recommendations cover technological, clinical, behavioral, and research considerations with the aim of achieving short- and long-term benefits, ranging from fewer hypoglycemic episodes to lower complication-related costs. The panel also made suggestions for designing future studies that increase the ability to discern optimal models of SMBG utilization for individuals with diabetes who may, or may not, use insulin.

Self-care practices of Malaysian adults with diabetes and sub-optimal glycaemic control

OBJECTIVE

To investigate the self-care practices of Malaysian adults with diabetes and sub-optimal glycaemic control.

METHODS

Using a one-to-one interviewing approach, data were collected from 126 diabetic adults from four settings. A 75-item questionnaire was used to assess diabetes-related knowledge and self-care practices regarding, diet, medication, physical activity and self-monitoring of blood glucose (SMBG).

RESULTS

Most subjects had received advice on the importance of self-care in the management of their diabetes and recognised its importance. Sixty-seven subjects (53%) scored below 50% in their diabetes-related knowledge. Subjects who consumed more meals per day (80%), or who did not include their regular sweetened food intakes in their daily meal plan (80%), or who were inactive in daily life (54%), had higher mean fasting blood glucose levels (p=0.04). Subjects with medication non-adherence (46%) also tended to have higher fasting blood glucose levels. Only 15% of the subjects practiced SMBG. Predictors of knowledge deficit and poor self-care were low level of education (p = <0.01), older subjects (p=0.04) and Type 2 diabetes subjects on oral anti-hyperglycaemic medication (p = <0.01).

CONCLUSION

There were diabetes-related knowledge deficits and inadequate self-care practices among the majority of diabetic patients with sub-optimal glycaemic control.

PRACTICE IMPLICATIONS

This study should contribute to the development of effective education strategies to promote health for adults with sub-optimal diabetes control.

The relationship between type of drug therapy and blood glucose self-monitoring test strips claimed by beneficiaries of the Seniors' Pharmacare Program in Nova Scotia, Canada

BACKGROUND

The healthcare expenditure on self-monitoring of blood glucose (SMBG) test strips under the Nova Scotia Seniors' Pharmacare Program (NSSPP) has increased significantly in recent years. The objective of this study was to identify the frequency and cost of claims for blood glucose monitoring test strips by NSSPP beneficiaries in the fiscal year 2005/06 and to explore the variation in the use of test strips by type of treatment, age and sex.

METHODS

Retrospective analysis was conducted using pharmacy administrative claims data for NSSPP beneficiaries. Study subjects were aged > or = 65 years on October 1, 2004, received SMBG test strips in the 110 days prior to April 1, 2005, and were alive throughout the twelve month study period. Subjects were categorized into four groups: insulin only, oral antihyperglycemic agents (OAA) only, both OAA and insulin; and no reimbursed diabetes medications. Statistical analysis was performed to identify differences in expenditure by medication group and in frequency of SMBG test strips claimed by medication group, age, and sex.

RESULTS

Of 13,564 included beneficiaries, 13.2% were categorized as insulin only, 53.5% OAA only, 7.2% both OAA and insulin, and 26.0% no reimbursed diabetes medications. Over half (58.7%) were femle. The insulin only category had the highest mean (+/- SD) number of SMBG test strips claimed per day (2.0 +/- 1.5) with a mean annual total cost of $615 +/- $441/beneficiary. Beneficiaries aged 80 years and above claimed fewer test strips than beneficiaries below 80 years.

CONCLUSION

This population based study shows that in Nova Scotia the SMBG test strips claimed by the majority of seniors were within Canadian guidelines. However, a small proportion of beneficiaries claimed for SMBG test strips infrequently or too frequently, which suggests areas for improvement. The provincial drug plan covers the majority of the costs of test strip utilization, suggesting that the majority of test strips claimed did not exceed the maximum allowable cost (MAC) established in the program's MAC policy. Drug insurance programs need to work with healthcare providers to determine if patients are using test strips optimally; and to determine their impact on patient outcomes. In addition, they need to determine the cost-effectiveness of their SMBG test strip reimbursement policies.

Quality of care for first-degree relatives of type 2 diabetes patients diagnosed with diabetes at a screening program one year after diagnosis

AIMS

Diabetes screening is an effective tool for diagnosing patients who are unaware of their diabetes and for providing them with optimal treatment. The quality of care and treatment of diabetic patients diagnosed at a screening program during one year in Isfahan, a centrally located Iranian city, was assessed.

METHODS

In a prospective study, 1640 first-degree relatives of diabetic patients (aged 35-55) were screened for diabetes mellitus at Isfahan Endocrine and Metabolism Research Center during 2003-2004. All patients diagnosed with diabetes during screening were selected and their height, weight, blood pressure, fasting plasma glucose, lipids and HbA1c were recorded at the time of diagnosis and one year later. The values at the time of screening were subsequently compared with those collected one year later.

RESULTS

Eighty-three subjects (5.06%) were diagnosed with diabetes during screening. Of these patients, 78.3% were dyslipidemic and 45% were hypertensive. One year after diagnosis, 77.1% of patients were receiving treatment for hyperglycemia. However, only 49.2% of dyslipidemic and 45% of hypertensive patients were being treated for these conditions. Body mass index, fasting plasma glucose, lipids and HbA1c had improved one year after diagnosis, but no significant improvement was observed in blood pressure.

CONCLUSIONS

The evaluation of the quality of care for newly diagnosed diabetic patients revealed that more attention should be paid to glycemic control and reducing cardiovascular risk factors, in particular hypertension.

Development and piloting of an acceptability questionnaire for continuous glucose monitoring devices

BACKGROUND

User acceptability of new health technologies is important in determining their widespread use and adoption. The aim of this current study was twofold: first, to investigate the acceptability of two continuous glucose monitoring devices for people with diabetes; and second, to develop a valid questionnaire measure to assess the acceptability of continuous glucose monitoring devices.

METHODS

Semi-structured interviews were conducted with six people with diabetes who had previously used the GlucoWatchBiographer (Animas Corp., West Chester, PA) or the CGMS continuous glucose monitoring system (Medtronic MiniMed, Northridge, CA) in order to increase understanding of the issues relating to acceptability of, and satisfaction with, the devices. Interview transcripts were analyzed qualitatively using framework analysis. These analyses, together with consultation with researchers and health professionals in the field, provided the foundation for development of a questionnaire measure that was piloted with 19 individuals.

RESULTS

Six broad themes were elicited from the framework analysis: interference with daily activities; reliability and accuracy of the devices; practicality and ease of use; improvements in glycemic control; side effects; and self-consciousness and disclosure. Piloting of the questionnaire arising from this analysis demonstrated face validity. Further psychometric testing of the questionnaire will be conducted as part of a randomized controlled trial evaluating the clinical efficacy and cost-effectiveness of the CGMS and GlucoWatch G2 Biographer.

CONCLUSIONS

Ultimately it is the user's preferences and his or her assessment of acceptability that will determine uptake and use of continuous glucose monitoring devices. It is therefore essential to consider and evaluate this alongside clinical efficacy and cost-effectiveness.

Differences in quality of diabetes care between Jews and Arabs in Jerusalem

AIMS

To evaluate whether differences exist in the quality of diabetes care delivered to the Arab and Jewish populations in Jerusalem.

METHODS

A cross-sectional study was conducted in West Jerusalem's 4 major hospitals. Participants were patients with type 2 diabetes mellitus, 45 to 75 years of age, who were insured by Israel's largest health maintenance organization (HMO) and admitted to an emergency room (ER) between May and June 2004 for any medical cause. Hospital files were reviewed, patients were interviewed, and computerized data were retrieved from the HMO's database.

RESULTS

Arab patients received less nutritional counseling (odds ratio [OR] = 0.46; 95% CI = 0.24-0.85; P = .013), fewer recommendations about and less support in performing physical activities (OR = 0.42; 95% CI = 0.24-0.74; P = .003), and less guidance in performing self foot examinations (OR = 0.55; 95% CI = 0.32-0.96; P = .035).

CONCLUSIONS

Arab patients in Jerusalem receive lower quality diabetes care compared with Jewish residents.

The relationship between alcohol consumption and glycemic control among patients with diabetes: the Kaiser Permanente Northern California Diabetes Registry

BACKGROUND

Alcohol consumption is a common behavior. Little is known about the relationship between alcohol consumption and glycemic control among people with diabetes.

OBJECTIVE

To evaluate the association between alcohol consumption and glycemic control.

DESIGN

Survey follow-up study, 1994-1997, among Kaiser Permanente Northern California members.

PATIENTS

38,564 adult diabetes patients.

MEASUREMENTS

Self-reported alcohol consumption, and hemoglobin A1C (A1C), assessed within 1 year of survey date. Linear regression of A1C by alcohol consumption was performed, adjusted for sociodemographic variables, clinical variables, and diabetes disease severity. Least squares means estimates were derived.

RESULTS

In multivariate-adjusted models, A1C values were 8.88 (lifetime abstainers), 8.79 (former drinkers), 8.90 (<0.1 drink/day), 8.71 (0.1-0.9 drink/day), 8.51 (1-1.9 drinks/day), 8.39 (2-2.9 drinks/day), and 8.47 (>/=3 drinks/day). Alcohol consumption was linearly (p < 0.001) and inversely (p = 0.001) associated with A1C among diabetes patients.

CONCLUSIONS

Alcohol consumption is inversely associated with glycemic control among diabetes patients. This supports current clinical guidelines for moderate levels of alcohol consumption among diabetes patients. As glycemic control affects incidence of complications of diabetes, the lower A1C levels associated with moderate alcohol consumption may translate into lower risk for complications.

Patient factors associated with attrition from a self-management education programme

OBJECTIVE

To examine utilization patterns of diabetes self-management training (DSME) and identify patient factors associated with attrition from these services at an ambulatory diabetes education centre (DEC).

METHODS

A retrospective medical chart review of first time visits (536) to the centre between 1 August 2000 and 31 July 2001 was conducted for patients with type 2 diabetes. Descriptive analyses were conducted to examine utilization patterns over a 1-year period. Multivariable logistic regression was used to identify patient factors associated with attrition from DSME and non-use of group education among new patients.

RESULTS

Almost 50% of new patients withdrew prematurely from recommended DSME services over the 1-year period, and only 24.8% attended group education. Patient variables such as being older than 65 years of age, primarily speaking English, or working full or part-time were associated with attrition from DSME and non-use of group education when compared with middle aged, non-English-speaking, and non-working patients.

CONCLUSIONS

High DSME attrition rates indicate that retention needs to become a focus of programme policy, planning and evaluation to improve programme effectiveness. DSME tailored to the cultural and linguistic characteristics of the community, and convenient and accessible to working and older patients will potentially increase retention in and accessibility to these services.

Racial differences in long-term self-monitoring practice among newly drug-treated diabetes patients in an HMO

BACKGROUND

One approach to improving outcomes for minority diabetics may be through better self-care. However, minority patients may encounter barriers to better self-care even within settings where variations in quality of care and insurance are minimized.

OBJECTIVE

The objective of the study was to evaluate racial differences in long-term glucose self-monitoring and adherence rates in an HMO using evidence-based guidelines for self-monitoring.

DESIGN

Retrospective cohort study using 10 years (1/1/1993-12/31/2002) of electronic medical record data was used.

PATIENTS

Patients were 1,732 insured adult diabetics of black or white race newly initiated on hypoglycemic therapy in a large multi-specialty care group practice.

MEASUREMENTS

Outcomes include incidence and prevalence of glucose self-monitoring, intensity of use, and rate of adherence to national recommended standards.

RESULTS

We found no evidence of racial differences in adjusted initiation rates of glucose self-monitoring among insulin-treated patients, but found lower rates of initiation among black patients living in low-income areas. Intensity of glucose self-monitoring remained lower among blacks than whites throughout follow-up [IRR for insulin = 0.41 (0.27-0.62); IRR for oral hypoglycemic = 0.75 (0.63, 0.90)], with both groups monitoring well below recommended standards. Among insulin-treated patients, <1% of blacks and <10% of whites were self-monitoring 3 times per day; 36% of whites and 10% of blacks were self-monitoring at least once per day.

CONCLUSIONS

Adherence to glucose self-monitoring standards was low, particularly among blacks, and racial differences in self-monitoring persisted within a health system providing equal access to services for diabetes patients. Early and continued emphasis on adherence among black diabetics may be necessary to reduce racial differences in long-term glucose self-monitoring.

Patterns of blood glucose monitoring in relation to glycemic control among patients with type 2 diabetes in the UK

AIMS

The objectives of this study were to compare patterns of blood glucose monitoring among patients with type 2 diabetes initiating therapy with insulin or oral medication and to examine the relationship between the quantity of prescribed monitoring strips and glycemic control.

METHODS

Data were obtained from the UK General Practice Research Database. Patients were eligible if they were identified as having type 2 diabetes, initiated therapy with insulin or an oral agent, and had 12-month postinitiation data. Differences in patient characteristics and number of test strips prescribed between the insulin (n=347) and oral cohorts (n=2436) were examined. Multivariate regressions examined the relationship between quantity of monitoring and glycemic control for a subset of patients (insulin, n=245; oral, n=1795) with available glycosylated hemoglobin (HbA1c) data.

RESULTS

During the 12-month postinitiation period, patients using insulin were prescribed approximately twice as many test strips compared with those patients using oral medication (149 vs. 78, P<.0001). Multivariate regressions revealed that individuals who initiated insulin therapy and were prescribed enough test strips to test at least once per day in the 6 months prior to the HbA1c test date had, on average, a 0.65% lower HbA1c value (P=.02) compared with individuals who were prescribed fewer test strips.

CONCLUSIONS

Results indicate significant differences in the prescription of blood glucose monitoring strips, with patients initiated on insulin prescribed almost twice as many test strips compared with patients initiated on orals. The greater number of blood glucose test strips prescribed was associated with lower HbA1c values for insulin patients.

Coping and psychosocial adaptation to Type 2 diabetes in older Blacks born in the Southern US and the Caribbean

Older Black men and women (n = 212) with Type 2 diabetes completed questionnaires. Spearman's rho correlation indicated that confrontive coping strategies supported effective psychosocial adaptation for persons originally from Haiti and Jamaica, while emotive coping strategies were related to ineffective psychosocial adaptation for persons originally from Barbados and to increased psychological distress for all participants. Women used more palliative coping; no gender differences were observed for psychosocial adaptation. Health care orientation, extended family relationships, and psychological distress domains distinguished Blacks born in Haiti from Blacks born in Barbados and Jamaica, the Southern US and Jamaica, and the Southern US, Barbados, and Jamaica. Findings from this study may aid in the development of interventions focused on improving diabetes self-management for older Blacks.

Racial/ethnic differences in multiple self-care behaviors in adults with diabetes

OBJECTIVE

To assess racial/ethnic differences in multiple diabetes self-care behaviors.

DESIGN

Cross-sectional study.

PARTICIPANTS

21,459 participants with diabetes in the 2003 Behavioral Risk Factor Surveillance survey.

MEASUREMENTS

The study assessed self-care behaviors including physical activity, fruits/vegetables consumption, glucose testing, and foot examination, as well as a composite of the 4 self-care behaviors across racial/ethnic groups. Multiple logistic regression was used to assess the independent association between race/ethnicity, the composite variable, and each self-care behavior controlling for covariates. STATA was used for statistical analysis.

RESULTS

Overall, 6% engaged in all 4 self-care behaviors, with a range of 5% in non-insulin users to 8% in insulin users. Blacks were less likely to exercise (OR 0.63, 95% CI 0.51, 0.79), while Hispanics and "others" were not significantly different from whites. Hispanics (OR 0.64, 95% CI 0.49, 0.82) and others (OR 0.69, 95% CI 0.49, 0.96) were less likely to do home glucose testing, while blacks were not significantly different from whites. Blacks (OR 1.42, 95% CI 1.12, 1.80) were more likely to do home foot examinations, while Hispanics and others were not significantly different from whites. Blacks (OR 0.56, 95% CI 0.36, 0.87) were less likely to engage in all 4 behaviors, while Hispanics and others were not significantly different from whites. There were no significant racial/ethnic differences in fruit and vegetable consumption.

CONCLUSIONS

Few patients engage in multiple self-care behaviors at recommended levels, and there are significant racial/ethnic differences in physical activity, dietary, and foot care behaviors among adults with diabetes.

Self-reported medication and lifestyle adherence in Hungarian patients with Type 2 diabetes

BACKGROUND

Type 2 diabetes is a complex disorder that requires the patient to pay constant attention to diet, physical activity, glucose monitoring and medication.

OBJECTIVE

To evaluate the medication, lifestyle adherence and factors associated to these in Type 2 diabetes in Hungarian patients.

SETTING

Fourteen community pharmacies in Hungary between March and May 2004.

METHOD

A questionnaire was given to every tenth Type 2 diabetic patient who presented to one of the 14 pharmacies included in this study with a prescription for oral antidiabetics, oral antidiabetics and insulin or exclusively insulin. For the latter two groups, the prerequisite for inclusion in the study was also that their diabetes had developed after the age of 35 and that at some in their treatment regimen they had taken only oral antidiabetics. These latter two criteria were controlled in the patient's general practitioners' (GP) database. General and diabetes-related data were collected in the questionnaire, and the adherence and lifestyle of the participant were assessed. An adapted and validated Hungarian version of the EQ-5D (EuroQol Group, 1993) quality-of-life questionnaire was also included. Descriptive and chi(2) test statistical methods and two sample t-test were used. A significance level of P<0.05 was considered to be significant.

MAIN OUTCOME MEASURE

Patient self-reported adherence to diet, physical activity, self monitoring of blood glucose, purchasing of drug(s), drug regimen, association of demographic factors, treatment, lifestyle and quality of life on adherence.

RESULTS

Of the 220 questionnaires distributed to diabetic patients, 151 were returned, of which 142 were evaluated (nine did not satisfy the above-mentioned inclusion criteria). With respect to the factors assessed, sub-optimal adherence was assessed for: diet (76.8%), physical activity (33.8%), self-monitoring of blood glucose (81%), drug purchasing (20.4%) and drug taking (52.1%). Smokers comprised 14.8% of the respondents, while 8.5% were heavy drinkers. Fewer than five meals a day were eaten by 46.5% of the patients, and about 43.6% of the patients did not self-monitor blood glucose. The results indicate few significant associations between at least one of the four main areas of adherence (diet, physical activity, purchasing of drug(s), drug regimen) and body mass index, GP consultation frequency, quality-of-life parameters and EQ-5D index.

CONCLUSION

The adherence of Hungarian Type 2 diabetics in some areas does not reach optimal levels, especially for diet, self-monitoring, drug purchasing and adherence to drug taking.

Effects of physician specialty on use of antidiabetes drugs, process and outcomes of diabetes care in a medical center

BACKGROUND/PURPOSE

Physician characteristics might determine the quality of diabetes care. This study evaluated the effects of physician specialty on the use of antidiabetes drugs, process and outcomes of diabetes care.

METHODS

In 2002, 12,023 diabetes patients visited outpatient clinics more than four times at National Taiwan University Hospital. One-tenth of the patients were randomly sampled out. A retrospective chart review was conducted for those who were regularly cared for by endocrinologists (EN), other specialists in internal medicine (IM) and family medicine (FM) physicians. The use of antidiabetes drugs was assessed. Effects of physician specialty on the process or outcome indicators were analyzed by logistic or linear regression, accordingly.

RESULTS

A total of 875 diabetes patients (477 men, 398 women) with a mean age of 62.3 +/- 12.7 years were recruited. EN patients had the highest rate of being prescribed insulin, metformin or nonsulfonylurea insulin secretagogues, and the lowest rate of being given sulfonylureas. EN patients showed a significantly better adherence to glucose checkup, glycosylated hemoglobin A1C measures and urinalysis than IM patients. EN patients also showed better adherence to glucose checkup and urinalysis than FM patients. EN patients had the lowest mean fasting plasma glucose (FPG) and lowest mean postprandial plasma glucose (PPG). The difference in PPG between EN and IM patients and the difference in FPG between EN and FM patients were persistently significant following adjustment by patient and physician characteristics.

CONCLUSION

The use of antidiabetes drugs differed among patients cared for by EN, internists or generalists. Physician specialty had significant effects on the process and outcomes of diabetes care.

Differences in self-management behaviors and use of preventive services among diabetes management enrollees by race and ethnicity

We assessed the degree that managed care organization (MCO) enrollees used preventive services and engaged in diabetes self-management behaviors by race/ethnicity. A 40-item selfadministered survey was mailed to 19,483 diabetic MCO enrollees. The survey measured use of eight preventive services and engagement in four self-management behaviors among enrollees who self-identified as black, white, or Hispanic. Of the 6,035 surveys analyzed, 4,623 respondents (76.6%) were white, 984 (16.3%) were black, and 428 (7.0%) were Hispanic. Black and Hispanic respondents reported more healthcare visits (mean of 7.0 and 6.5, respectively) in the past year compared to whites (mean, 5.7; p < 0.0001). However, compared to whites, blacks had significantly lower utilization of five of the eight preventive services measured, and Hispanics had significantly lower utilization of seven of the eight preventive services (p < 0.005). With regard to self-management behaviors, blacks were significantly less likely than whites to monitor their diet (65.9% vs. 73.7%, p < 0.0001), exercise (46.4% vs. 52.8%; p = 0.0004) and not smoke (85.1% vs. 89.3%; p = 0.0002); while Hispanics were less likely to monitor their diet (67.3% vs. 73.7%, p = 0.0051). All racial/ethnic groups had low levels of selfmanagement behaviors. Further research is warranted to identify why disparities remain in settings where services are universally available, and to find practical ways to eliminate disparities in a group with routine healthcare encounters.

The influence of glucose self-monitoring on glycaemic control in patients with diabetes mellitus in Sudan

OBJECTIVE

To investigate the influence of self-monitoring of glucose on the glycaemic control in Sudanese diabetic subjects.

SUBJECTS AND METHODS

A group of 193 consecutive type 2 and type 1 diabetic subjects (95 men, 98 women) were studied. In 104 subjects with type 2 diabetes fasting blood glucose was measured using a glucose meter and blood was obtained for serum glucose measurement in the laboratory. In the remaining 89 diabetic subjects random blood glucose was measured using the same glucose meter and a whole blood sample was drawn for laboratory assessment of HbA1c. Data on self-monitoring and other clinical and personal characteristics were recorded.

RESULTS

More than 75% of either type 1 and type 2 diabetic patients never self-monitored blood or urine glucose. In type 2 diabetic subjects self-monitoring of blood or urine glucose was not related to glycaemic control. In type 1 diabetic subjects, however, self-monitoring of blood glucose was significantly associated with better glycaemic control, as assessed by HbA1c (P=0.02) and blood glucose at clinic visits (P< or =0.0001), and similar associations were found for urine glucose self-monitoring (P=0.04 and 0.02) respectively. Neither glycaemic control nor glucose self-monitoring was associated with education level.

CONCLUSIONS

Self-monitoring of blood glucose was not found to be associated to better glycaemic control in Sudanese subjects with type 2 diabetes. In contrast, self-monitoring of both blood and urine glucose was significantly associated with glycaemic control in subjects with type 1 diabetes. Self-monitoring of urine glucose could be useful where measurement of blood glucose is not available or affordable.

Time to pharmacotherapy change in response to elevated HbA1c test results

OBJECTIVE

This study describes the clinical management of type 2 diabetes among a cohort of patients receiving oral antidiabetic monotherapy.

STUDY DESIGN AND SETTING

A retrospective study was conducted within an integrated Midwestern health system that included all individuals receiving oral antidiabetic monotherapy during the period June 1, 1999 to November 30, 2002 (n = 9335). Among patients with elevated hemoglobin A(1c) (HbA(1c)) test result(s), Kaplan-Meier estimates of median time until pharmacotherapy change were calculated.

RESULTS

Among the 8068 patients who had > or = 1 HbA(1c) measurement during the study period, 21.4% were at goal (i.e. HbA(1c) < 7%). Among patients with at least one elevated test result (> or = 7%), the median time to pharmacotherapy change following an HbA(1c) test result of between 7-10% was just over 1 year (372 days, 95% confidence interval [CI] 358-393 days) and 160 days for patients with HbA(1c) > 10%. Among patients with at least two elevated tests, the median time to pharmacotherapy change was 275 days from the second test result of between 7-10%, and 70 days among patients with a second HbA(1c) > 10%. The median time between HbA(1c) testing was 166 days overall, and 154 days among patients with at least one elevated result.

CONCLUSION

Despite the known benefits of glycemic control among patients with diabetes, the time between elevated HbA(1c) results and pharmacotherapy change exceeds 12 months for those with HbA(1c) test results between 7-10% and 9 months for those with results over 10%.

Longitudinal study of new and prevalent use of self-monitoring of blood glucose

OBJECTIVE

We sought to assess longitudinal association between self-monitoring of blood glucose (SMBG) and glycemic control in diabetic patients from an integrated health plan (Kaiser Permanente Northern California).

RESEARCH DESIGN AND METHODS

Longitudinal analyses of glycemic control among 1) 16,091 patients initiating SMBG (new-user cohort) and 2) 15,347 ongoing users of SMBG (prevalent-user cohort). SMBG frequency was based on pharmacy use (number of blood glucose test strips dispensed), and glycemic control was based on HbA(1c) (A1C). In the new-user cohort, ANCOVA models (pre- and posttest design) were used to assess the effect of initiating SMBG. In the prevalent-user cohort, repeated-measure, mixed-effects models with random-intercept and time-dependent covariates were used to assess changes in SMBG and A1C. All models were stratified by therapy (no medications, oral agents only, or insulin) and adjusted for baseline A1C, sociodemographics, insulin injection frequency, comorbidity index, medication adherence, smoking status, health care use, and provider specialty.

RESULTS

Greater SMBG practice frequency among new users was associated with a graded decrease in A1C (relative to nonusers) regardless of diabetes therapy (P < 0.0001). Changes in SMBG frequency among prevalent users were associated with an inverse graded change in A1C only among pharmacologically treated patients (P < 0.0001).

CONCLUSIONS

These observational findings are consistent with short-term benefits of initiating SMBG practice for all patients but continuing benefits only for pharmacologically treated patients. Differences in effectiveness between new versus prevalent users of SMBG have implications for guideline development and interpretation of observational outcomes data.

A systematic review of interventions to improve diabetes care in socially disadvantaged populations

OBJECTIVE

To identify and synthesize evidence about the effectiveness of patient, provider, and health system interventions to improve diabetes care among socially disadvantaged populations.

RESEARCH DESIGN AND METHODS

Studies that were included targeted interventions toward socially disadvantaged adults with type 1 or type 2 diabetes; were conducted in industrialized countries; were measured outcomes of self-management, provider management, or clinical outcomes; and were randomized controlled trials, controlled trials, or before-and-after studies with a contemporaneous control group. Seven databases were searched for articles published in any language between January 1986 and December 2004. Twenty-six intervention features were identified and analyzed in terms of their association with successful or unsuccessful interventions.

RESULTS

Eleven of 17 studies that met inclusion criteria had positive results. Features that appeared to have the most consistent positive effects included cultural tailoring of the intervention, community educators or lay people leading the intervention, one-on-one interventions with individualized assessment and reassessment, incorporating treatment algorithms, focusing on behavior-related tasks, providing feedback, and high-intensity interventions (>10 contact times) delivered over a long duration (>or=6 months). Interventions that were consistently associated with the largest negative outcomes included those that used mainly didactic teaching or that focused only on diabetes knowledge.

CONCLUSIONS

This systematic review provides evidence for the effectiveness of interventions to improve diabetes care among socially disadvantaged populations and identifies key intervention features that may predict success. These types of interventions would require additional resources for needs assessment, leader training, community and family outreach, and follow-up.

Alcohol consumption is inversely associated with adherence to diabetes self-care behaviours

AIMS

Our aim was to examine the associations of alcohol consumption with six diabetes self-care behaviours.

METHODS

We determined levels of alcohol consumption and examined associations between alcohol consumption and six self-care behaviours in 65 996 adults with diabetes who received care through Kaiser Permanente Northern California and who responded to a 1994-1997 survey. Adherence with recommendations for self monitoring of blood glucose, HbA1c testing, and diabetes medications were determined from electronic records; smoking and use of diet and exercise to treat diabetes were self reported. Multiple logistic regression models were used to determine the associations between alcohol consumption (average number of drinks/day in the past year) and the probability of adherence to each self-care behaviour.

RESULTS

Current alcohol consumption was reported by 50.8% of adults with diabetes. In adjusted models, we observed a gradient of increasing risk for poor adherence to diabetes self-care behaviours with increasing alcohol consumption, starting with those who consume even one drink a day. Former drinkers had the greatest compliance with each self-care behaviour, except for current smoking.

CONCLUSIONS

Alcohol consumption is a marker for poorer adherence to diabetes self-care behaviours. These findings highlight the importance of routine assessment of alcohol intake in people with diabetes, particularly as half of adults with diabetes consume alcohol. Given extant evidence that moderate alcohol intake may have cardiovascular benefits for patients with diabetes, examination of the trade-offs between cardiovascular benefits vs. potential risk of lower adherence with self-care behaviours deserves study.

Racial differences in impact of coverage on diabetes self-monitoring in a health maintenance organization

BACKGROUND

Insurance coverage of patient self-management devices like self-monitoring blood glucose (SMBG) equipment may help to reduce race-related barriers to effective care.

OBJECTIVES

We examined whether providing free home glucose monitors had greater impacts on self-monitoring among black versus white patients with diabetes.

RESEARCH DESIGN

Using electronic medical record data (1992-1996), we used longitudinal survival analysis to examine racial differences in rates of initiation of SMBG after coverage and rates of discontinuation of SMBG 18 months after initiation. We used piecewise Cox models to compare relative rates of SMBG initiation between black and white patients before and after the policy.

SUBJECTS

The study cohort included 2275 continuously enrolled adult patients with diabetes in a large, staff model HMO. Multivariate models were restricted to patients using oral therapy.

RESULTS

Controlling for time-dependent and fixed effects, black patients were as likely to initiate SMBG as white patients before the policy (hazard ratio 1.14; 95% confidence interval 0.86-1.50) but more likely after the policy (hazard ratio 1.33; 95% confidence interval 1.01-1.76). Among postpolicy SMBG initiators, black patients were consistently at higher risk of SMBG discontinuation than white patients over time (P < 0.05). By the end of follow-up, discontinuation rates were 78% among black patients and 64% among white patients.

CONCLUSIONS

The policy is effective in triggering additional diabetes patients to self-manage, particularly black patients. However, persistence after initiation of monitoring is short-lived. Although our results show the potential of such policies to narrow racial gaps in self-management among racial minority groups, further interventions may be needed to promote long-term adherence.

Racial and ethnic disparities in the control of cardiovascular disease risk factors in Southwest American veterans with type 2 diabetes: the Diabetes Outcomes in Veterans Study

Background

Racial/ethnic disparities in cardiovascular disease complications have been observed in diabetic patients. We examined the association between race/ethnicity and cardiovascular disease risk factor control in a large cohort of insulin-treated veterans with type 2 diabetes.

Methods

We conducted a cross-sectional observational study at 3 Veterans Affairs Medical Centers in the American Southwest. Using electronic pharmacy databases, we randomly selected 338 veterans with insulin-treated type 2 diabetes. We collected medical record and patient survey data on diabetes control and management, cardiovascular disease risk factors, comorbidity, demographics, socioeconomic factors, psychological status, and health behaviors. We used analysis of variance and multivariate linear regression to determine the effect of race/ethnicity on glycemic control, insulin treatment intensity, lipid levels, and blood pressure control.

Results

The study cohort was comprised of 72 (21.3%) Hispanic subjects (H), 35 (10.4%) African Americans (AA), and 226 (67%) non-Hispanic whites (NHW). The mean (SD) hemoglobin A1c differed significantly by race/ethnicity: NHW 7.86 (1.4)%, H 8.16 (1.6)%, AA 8.84 (2.9)%, p = 0.05. The multivariate-adjusted A1c was significantly higher for AA (+0.93%, p = 0.002) compared to NHW. Insulin doses (unit/day) also differed significantly: NHW 70.6 (48.8), H 58.4 (32.6), and AA 53.1 (36.2), p < 0.01. Multivariate-adjusted insulin doses were significantly lower for AA (-17.8 units/day, p = 0.01) and H (-10.5 units/day, p = 0.04) compared to NHW. Decrements in insulin doses were even greater among minority patients with poorly controlled diabetes (A1c ≥ 8%). The disparities in glycemic control and insulin treatment intensity could not be explained by differences in age, body mass index, oral hypoglycemic medications, socioeconomic barriers, attitudes about diabetes care, diabetes knowledge, depression, cognitive dysfunction, or social support. We found no significant racial/ethnic differences in lipid or blood pressure control.

Conclusion

In our cohort, insulin-treated minority veterans, particularly AA, had poorer glycemic control and received lower doses of insulin than NHW. However, we found no differences for control of other cardiovascular disease risk factors. The diabetes treatment disparity could be due to provider behaviors and/or patient behaviors or preferences. Further research with larger sample sizes and more geographically diverse populations are needed to confirm our findings.

Role of self-monitoring of blood glucose in glycemic control

OBJECTIVE

To examine the role of self-monitoring of blood glucose (SMBG) in the management of diabetes mellitus.

METHODS

Current trends and published evidence are reviewed.

RESULTS

Despite the widespread evidence that lowering glycemic levels reduces the risks of complications in patients with diabetes, little improvement in glycemic control has been noted among patients in the United States and Europe in recent years. Although SMBG has been widely used, considerable controversy surrounds its role in achieving glycemic control. The high cost of test strips has made considerations regarding appropriate recommendations for SMBG a priority, especially in light of the current climate of health-care cost-containment. Existing clinical recommendations lack specific guidance to patients and clinicians regarding SMBG practice intensity and frequency, particularly for those patients not treated with insulin. Previous studies of the association between SMBG and glycemic control often found weak and conflicting results.

CONCLUSION

A reexamination of the role of SMBG is needed, with special attention to the unique needs of patients using different diabetes treatments, within special clinical subpopulations, and during initiation of SMBG versus its ongoing use. Further understanding of the intensity and frequency of SMBG needed to reflect the variability in glycemic patterns would facilitate more specific guideline development. Educational programs that focus on teaching patients the recommended SMBG practice, specific glycemic targets, and appropriate responses to various blood glucose readings would be beneficial. Continuing medical education programs for health-care providers should suggest ways to analyze patient SMBG records to tailor medication regimens. For transfer or communication of SMBG reports to the clinical staff, a standardized format that extracts key data elements and allows quick review by health-care providers would be useful. Because the practice of SMBG is expensive, the cost-effectiveness of SMBG needs to be carefully assessed.

Regional influences on the dispensing of glucose test strips in Dutch community pharmacies

BACKGROUND

Pharmacy practice guidelines promote the role of community pharmacies in self-monitoring of blood glucose. However, variations between Dutch pharmacies exist in the proportion of patients to whom test strips are dispensed.

OBJECTIVE

To assess whether variations between community pharmacies in dispensing of blood glucose test strips can be explained by differences in patient characteristics and the region in which the pharmacy is located.

SETTING

PHARMO-Record Linkage System containing drug dispensing histories from 40 community pharmacies of about 450,000 patients in the Netherlands.

METHOD

We performed a retrospective cohort study. Data on prescription of all drugs and medical aids between 1991 and 2001 were extracted for all new users of antidiabetic drugs. Patients were excluded if the dispensing history did not allow classification of the type of diabetes or if the dispensing pharmacy could not be determined. The data were analysed using a Cox proportional hazard model.

MAIN OUTCOME MEASURE

Time to first test strips dispensed.

RESULTS

We identified 8,233 starters of antidiabetic drugs. During a median follow-up of 2.1 years, 20% of the patients were dispensed test strips at least once. Community pharmacy was significantly associated with the dispensing of test strips after adjustment for patient characteristics. This association was less apparent when stratified for the geographical location of the pharmacy.

CONCLUSION

Community pharmacy is an independent determinant of the start of use of test strips. Differences in dispensing of test strips between pharmacies are dependent on geographical region. This suggests that implementing practice guidelines for diabetes care in community pharmacy requires different approaches in different regions.

Is self-efficacy associated with diabetes self-management across race/ethnicity and health literacy?

OBJECTIVE

Although prior research demonstrated that improving diabetes self-efficacy can improve self-management behavior, little is known about the applicability of this research across race/ethnicity and health literacy levels. We examined the relationship between diabetes self-efficacy and self-management behavior in an urban, diverse, low-income population with a high prevalence of limited health literacy.

RESEARCH DESIGN AND METHODS

We administered an oral questionnaire in Spanish and English to patients with type 2 diabetes at two primary care clinics at a public hospital. We measured self-efficacy, health literacy, and self-management behaviors using established instruments. We performed multivariate regressions to explore the associations between self-efficacy and self-management, adjusting for clinical and demographic factors. We tested for interactions between self-efficacy, race/ethnicity, and health literacy on self-management.

RESULTS

The study participants were ethnically diverse (18% Asian/Pacific Islander, 25% African American, 42% Latino/a, and 15% white), and 52% had limited health literacy (short version of the Test of Functional Health Literacy in Adults score <23). Diabetes self-efficacy was associated with four of the five self-management domains (P < 0.01). After adjustment, with each 10% increase in self-efficacy score, patients were more likely to report optimal diet (0.14 day more per week), exercise (0.09 day more per week), self-monitoring of blood glucose (odds ratio 1.16), and foot care (1.22), but not medication adherence (1.10, P = 0.40). The associations between self-efficacy and self-management were consistent across race/ethnicity and health literacy levels.

CONCLUSIONS

Self-efficacy was associated with self-management behaviors in this vulnerable population, across both race/ethnicity and health literacy levels. However, the magnitude of the associations suggests that, among diverse populations, further study of the determinants of and barriers to self-management is warranted. Policy efforts should be focused on expanding the reach of self-management interventions to include ethnically diverse populations across the spectrum of health literacy.

The need for more research on language barriers in health care: a proposed research agenda

Many U.S. residents who speak little English may face language barriers when seeking health care. This article describes what is currently known about language barriers in health care and outlines a research agenda based on mismatches between the current state of knowledge of language barriers and what health care stakeholders need to know. Three broad areas needing more research are discussed: the ways in which language barriers affect health and health care, the efficacy of linguistic access service interventions, and the costs of language barriers and efforts to overcome them. In each of these areas, we outline specific research questions and recommendations.

Race, ethnicity, socioeconomic position, and quality of care for adults with diabetes enrolled in managed care: the Translating Research Into Action for Diabetes (TRIAD) study

OBJECTIVE

To examine racial/ethnic and socioeconomic variation in diabetes care in managed-care settings.

RESEARCH DESIGN AND METHODS

We studied 7,456 adults enrolled in health plans participating in the Translating Research Into Action for Diabetes study, a six-center cohort study of diabetes in managed care. Cross-sectional analyses using hierarchical regression models assessed processes of care (HbA(1c) [A1C], lipid, and proteinuria assessment; foot and dilated eye examinations; use or advice to use aspirin; and influenza vaccination) and intermediate health outcomes (A1C, LDL, and blood pressure control).

RESULTS

Most quality indicators and intermediate outcomes were comparable across race/ethnicity and socioeconomic position (SEP). Latinos and Asians/Pacific Islanders had similar or better processes and intermediate outcomes than whites with the exception of slightly higher A1C levels. Compared with whites, African Americans had lower rates of A1C and LDL measurement and influenza vaccination, higher rates of foot and dilated eye examinations, and the poorest blood pressure and lipid control. The main SEP difference was lower rates of dilated eye examinations among poorer and less educated individuals. In almost all instances, racial/ethnic minorities or low SEP participants with poor glycemic, blood pressure, and lipid control received similar or more appropriate intensification of therapy relative to whites or those with higher SEP.

CONCLUSIONS

In these managed-care settings, minority race/ethnicity was not consistently associated with worse processes or outcomes, and not all differences favored whites. The only notable SEP disparity was in rates of dilated eye examinations. Social disparities in health may be reduced in managed-care settings.

Self-management in African American women with diabetes

PURPOSE

This study describes demographic and medical characteristics, self-efficacy, locus of control, self-management defined by functional status, hemoglobin HbA1c outcomes, and the relationships among these variables based on age group differences (25-44 years, 45-64 years, and 65-84 years) in African American women with type 2 diabetes.

METHODS

Subjects (n = 75) in community medical practices were interviewed to complete a demographic and medical form, the Diabetes Self-efficacy Outcomes Expectancy Questionnaire (DSEQ), the Diabetes Locus of Control Scale, and the Medical Outcomes-Short Form 36 (SF-36). A venous blood sample was taken following the interview. Data were analyzed for the total sample and separately for age groups.

RESULTS

Scores on the self efficacy (DSEQ) and the locus of control (LOC) were above average for all 3 groups. Significant correlations were found among subscales of the LOC, SF-36, and HbA1c. HbA1c scores were abnormally high across groups. Significant group differences were found in duration of diabetes and number of medications used.

CONCLUSIONS

Despite high levels of internal locus of control and self-efficacy and scores indicating good mental, physical, emotional, and social health, self-management among the women was inadequate, as indicated by abnormally high HbA1c levels.

The role of self-monitoring of blood glucose in the care of people with diabetes: report of a global consensus conference

Self-monitoring of blood glucose (SMBG) is an underutilized but integral part of disease management for patients with both type 1 and type 2 diabetes. Guidelines on the recommended frequency and timing of SMBG vary among international diabetes associations, and patients are often unaware of actions they should take in response to SMBG. results. In response to this, a global consensus conference of recognized diabetes experts convened to clarify the role of SMBG as a tool to help optimize glycemic control (e.g., complementing information provided by hemoglobin A1c, detecting postprandial excursions, identifying glucose patterns, and providing patients feedback on lifestyle and medications) while minimizing hypoglycemia and maintaining quality of life. The consensus panel also sought to reinforce the importance of appropriate and systematic patient and provider response to the collected SMBG data. A set of 16 consensus statements was approved by the panel. This article presents the 16 statements together with some brief rationale for their inclusion.

Strategies for improving glycemic control: effective use of glucose monitoring

Despite the increasing prevalence of diabetes, improved understanding of the disease, and a variety of new medications, glycemic control does not appear to be improving. Self-monitoring of blood glucose (SMBG) is one strategy for improving glycemic control; however, patient adherence is suboptimal and proper education and follow-up are crucial. Patients need to understand why they are being asked to self-test, what their glycemic targets are, and what they should do based on the results of self-monitoring. Patients also must be taught proper technique and must be given specific recommendations regarding frequency and timing for self-monitoring. Situations in which SMBG is essential or should be more frequent include self-adjustment of insulin doses, changes in medications, lack of awareness of hypoglycemia, gestational diabetes, illness, or when hemoglobin A1c (HbA1c) values are above target. SMBG should include postprandial monitoring to identify glycemic excursions after meals, to indicate the need for lifestyle adjustments, and to provide patient feedback on dietary choices.

Invasiveness as a barrier to self-monitoring of blood glucose in diabetes

BACKGROUND

This study investigated the degree to which the invasive characteristic of glucose monitoring is a barrier to self-monitoring of blood glucose (SMBG).

METHODS

A paper-and-pencil Measure of Invasiveness as a reason for Skipping SMBG (MISS) was created and administered to 339 people with diabetes. The correlations between MISS scores and actual SMBG frequency, percent adherence to SMBG recommendations, SMBG anxiety, SMBG burden, and knowledge of the importance of glycemic control for avoiding diabetes complications were each explored.

RESULTS

On a scale of 0-28, the average MISS score was M = 4.3 (SD = 5.4, range 0-28). Fully 63% (nearly two-thirds) of respondents reported skipping SMBG because of the invasiveness of the procedure. MISS scores were negatively related to percent adherence to healthcare provider SMBG recommendations as measured by memory function of automated meters (Spearman's r= -0.47, P < 0.01). MISS scores were also negatively related to absolute SMBG frequency regardless of SMBG recommendations (Spearman's r= -0.11, P < 0.05). Correlation between the MISS and SMBG anxiety was significant (Spearman's r = 0.50, P < 0.01). With highly anxious participants deleted, the magnitude of the correlation was attenuated, but persisted (Spearman's r = 0.28, P < 0.01), suggesting that invasiveness is associated with SMBG anxiety even among patients without a blood or injection phobia. MISS scores were also correlated with the degree to which patients find routine and non-routine SMBG checks a burden (routine r = 0.38, P < 0.01; non-routine r = 0.45, P < 0.01). Results of Mann-Whitney U tests indicated higher MISS scores among participants with less knowledge about the importance of glycemic control in the development of diabetes vascular complications.

CONCLUSIONS

Invasiveness is a common and serious barrier to SMBG. These findings suggest that people with diabetes would perform SMBG more frequently and have improved quality of life with non-invasive SMBG.

Pioglitazone initiation and subsequent hospitalization for congestive heart failure

AIMS

Thiazolidinediones (TZD) have been associated with an expansion in plasma volume and the development of peripheral oedema. A recent study reported an association between the use of TZDs and development of congestive heart failure (CHF). The objective of this study was to determine if short-term use of pioglitazone, a TZD, is associated with increased risk of admission to hospital because of CHF in a well-characterized, community-based cohort of Type 2 diabetic patients without prevalent CHF.

METHODS

A cohort study of all patients in the Kaiser Permanente Medical Care Program with Type 2 diabetes (Kaiser Permanente Northern California Diabetes Registry) who initiated any diabetes pharmacotherapy (n = 23 440) between October 1999 and November 2001. Only patients initiating single new therapies ('new users') were included to reduce confounding and create mutually exclusive exposure groups. We constructed Cox proportional hazards models (with sulphonylureas initiators specified as the reference group) to evaluate the impact of initiating new diabetes therapies on time-to-incident admission to hospital because of CHF, defined by primary hospital discharge diagnosis.

RESULTS

Patients initiated pioglitazone (15.2%), sulphonylureas (25.3%), metformin (50.9%), and insulin (8.6%) alone, or as additions to pre-existing or maintained therapies. Three hundred and twenty admissions for CHF were observed during the follow-up (mean 10.2 months) after drug initiation. Relative to patients initiating sulphonylureas, there were no significant increases in the incidence of hospitalization for CHF in those initiating pioglitazone [hazard ratio (HR) = 1.28; 95% confidence interval (CI): 0.85-1.92] after adjusting for demographic, behavioural and clinical factors. There was a significantly higher incidence among those initiating insulin (HR = 1.56; 95% CI: 1.00-2.45) and lower incidence among those initiating metformin (HR = 0.70; 95% CI: 0.49-0.99).

CONCLUSIONS

This study of patients with Type 2 diabetes failed to find evidence that short-term pioglitazone use was associated with an elevated risk of hospitalization for CHF relative to the standard, first-line diabetes therapy.

Population-based assessment of diabetes care and self-management among Puerto Rican adults in New York City

PURPOSE

The purpose of this study was to assess the status of diabetes medical care and self-management among adult Puerto Ricans in New York City.

METHODS

A random-digit-dialing telephone survey with a dual-frame sampling design was employed to obtain a probability sample of adult Puerto Ricans with diagnosed diabetes (n = 606). Demographic characteristics, health status, and indicators of diabetes medical care and self-management were collected using the standard Behavioral Risk Factor Surveillance System (BRFSS) questionnaire. A statewide sample of adults with diagnosed diabetes (n = 232) was obtained from the BRFSS for comparison.

RESULTS

Compared to New York State adults, Puerto Ricans were significantly less likely to receive annual A1C testing (72.7% vs 84.9%), cholesterol testing (67.5% vs 87.2%), blood-pressure-lowering medication (82.4% vs 91.9%), and pneumococcal vaccination (19.3% vs 28.5%, among those aged 18 to 64 years). Puerto Ricans were also less likely to take aspirin every day or every other day to prevent cardiovascular complications (30.6% vs 40.7%). Puerto Ricans were younger and more likely to have lower educational attainment and lower income than New York State adults, but they were not significantly disadvantaged in access to health care indicated by rates of health insurance coverage, having a particular place for medical care, and frequencies of seeing a provider for diabetes.

CONCLUSIONS

These findings support the need to introduce culturally sensitive and linguistically appropriate diabetes education programs for Puerto Ricans and continue system-based diabetes care quality improvement efforts in the areas of prevention and control of cardiovascular complications, adult immunization, and A1C testing.

Self-monitoring of blood glucose in non-insulin-treated diabetic patients: a longitudinal evaluation of its impact on metabolic control

AIMS

In the framework of a nationwide outcomes research programme, we assessed the impact of self-monitoring of blood glucose (SMBG) on metabolic control over 3 years in patients with Type 2 diabetes mellitus (DM2) not treated with insulin.

METHODS

The study involved 1896 patients who completed, at 6-month intervals for 3 years, a questionnaire investigating SMBG practice. Clinical information was collected by participating clinicians at the same time intervals. The predictive value of SMBG frequency on long-term metabolic control was estimated using multilevel analysis. The impact of SMBG on metabolic control was also evaluated in distinct and homogeneous subgroups of patients showing different likelihood of performing SMBG, identified using a tree-growing technique (RECPAM).

RESULTS

Overall, 22% of the patients were on diet alone and 78% were treated with oral agents; 41% practiced SMBG > or = 1/week (10.3% > or = 1/day). The analysis of metabolic control according to the frequency of SMBG failed to show any significant impact of this practice on HbA1c levels over 3 years. Similarly, changes in SMBG frequency during the study were not related to significant changes in HbA1c levels. RECPAM analysis led to the identification of eight classes, characterized by substantial differences in the likelihood of performing SMBG with a frequency of at least 1/week. Nevertheless, in none of the RECPAM classes identified, did SMBG predict a better metabolic control over 3 years of follow-up. In those RECPAM classes indicating that SMBG was mainly performed to avoid hypoglycaemic episodes, SMBG was associated with a decrease in the frequency of hypoglycaemic episodes during the study.

CONCLUSIONS

In a large sample of non-insulin-treated Type 2 diabetic patients, the performance and frequency of SMBG did not predict better metabolic control over 3 years. We could not identify any specific subgroups of patients for whom SMBG practice was associated with lower HbA1c levels during the study.

Photocoagulation for diabetic retinopathy: determinants of patient satisfaction and the patient−provider relationship

PURPOSE

To assess satisfaction with photocoagulation treatment in diabetes patients and to investigate how it relates to patient-related characteristics and patients' visual ability. Further, to observe the interaction between physician and patient and suggest ways to improve the patient-provider relationship and, thereby, treatment satisfaction.

METHODS

This open longitudinal study included 123 diabetes patients undergoing first photocoagulation treatment for diabetic maculopathy or proliferative retinopathy. The Diabetes Treatment Satisfaction Questionnaire (DTSQ) was completed by all patients. Communication, scheduling and adherence scores were defined for each physician-patient pair. Outcome measures were: the patient's overall satisfaction with laser treatment; the patient's degree of satisfaction in relation to visual results; communication, scheduling and adherence scores, and visual acuity results.

RESULTS

The level of satisfaction after initial photocoagulation treatment was high; 46.4% of patients with proliferative retinopathy and 53.1% with maculopathy scored 31 or higher. Although 69.5% of all patients reported that their expectations of treatment corresponded to their final 9-month visual results, only 8.7% of these patients reported an improvement in visual acuity after 9 months. The number of unwanted actions performed by the patients during treatment were significantly related to the number of unclear instructions given by the physician (Fisher's exact test P < 0.01).

CONCLUSIONS

A high level of satisfaction was observed, despite the minimal improvements in visual acuity. Attempts to further improve patient satisfaction might focus on improved education of patients on the possible benefits of laser treatment, greater care in communicating information during treatment, additional nursing support, and additional clerical time to communicate with patients before each appointment.

Diabetes-related comorbidities in Asian Americans: results of a national health survey

OBJECTIVE

The aim of this study was to compare the prevalence of diabetes-related comorbidities in Asian Americans to the prevalence in other racial and ethnic groups in the United States using data from the 2001 Behavioral Risk Factor Surveillance System (BRFSS).

METHODS

The BRFSS is a population-based telephone survey of the health status and health behaviors of 212,510 Americans aged > or = 18 years in all 50 states, Guam, Puerto Rico, and the U.S. Virgin Islands. In 2001, participants included 196 Asian Americans, 1138 African Americans, 1276 Hispanics, 294 Native Americans, 71 Pacific Islanders, and 7799 non-Hispanic Whites with a self-reported physician diagnosis of diabetes. Comorbidity was determined by self-report. Odds ratios (OR) were adjusted for age, sex, body mass index (BMI) or height and weight, duration of diabetes, smoking, and health-insurance status.

RESULTS

The adjusted prevalences of hypercholesterolemia and retinopathy were similar across groups. Relative to Asian Americans, only African Americans were more likely to report hypertension [adjusted OR=2.1, 95% confidence interval (CI)=1.0-4.2, P<.05]. Higher odds of current or past foot ulceration was observed for Hispanics (adjusted OR=2.8, 95% CI=1.2-6.9), Native Americans (adjusted OR=4.2, 95% CI=1.4-12.8), and Pacific Islanders (adjusted OR=7.4, 95% CI=1.3-41.2) compared with Asian Americans.

CONCLUSIONS

Among Americans with diabetes, Asian Americans have a prevalence of hypertension, hypercholesterolemia, retinopathy, and foot ulceration that is similar to that in Whites. Asian Americans had a significantly lower prevalence of hypertension than African Americans did and a lower prevalence of foot ulceration than Hispanics, Native Americans, and Pacific Islanders did.

Individuals with type 2 diabetes and depressive symptoms exhibited lower adherence with self-care

OBJECTIVE

Our study aimed to determine whether depressive symptoms are associated with poor self-care behaviors among patients with type 2 diabetes.

METHODS

Study subjects were 168 patients with diabetes, aged >30 years, who had a diabetes history of 1-15 years. Using a self-reported questionnaire, we evaluated diabetes self-care behaviors and depressive symptoms. Self-care behaviors were evaluated in five categories: medication taking, self-monitoring of blood glucose (SMBG), diet, exercise, and participation in patient education programs. Depressive symptoms were evaluated using the Centers for Epidemiologic Studies-Depression (CES-D) scales. Multiple logistic regression analyses were used to determine the association between self-care behaviors and depressive symptoms.

RESULTS

Higher depressive-symptom scores were associated with poor self-care behaviors, significantly with poor participation in education programs (odds ratio OR=1.21, 95% confidence interval CI=1.06-1.38) and poor diet (OR=1.11, 95% CI=1.01-1.22), and marginally with poor medication taking (OR=1.14, 95% CI=1.00-1.31). Depressive symptoms were not significantly associated with either SMBG or exercise.

CONCLUSIONS

These data suggest that the evaluation and control of depressive symptoms among diabetic patients would improve their adherence to self-care behaviors.