A controlled evaluation of a national continuing medical education programme designed to improve family physicians' implementation of diabetes-specific clinical practice guidelines

Metabolic labeling unveils alterations in the turnover of HDL-associated proteins during diabetes progression in mice

Several aspects of diabetes pathophysiology and complications result from hyperglycemia-induced alterations in the structure and function of plasma proteins. Furthermore, insulin has a significant influence on protein metabolism by affecting both the synthesis and degradation of proteins in various tissues. To understand the role of progressive hyperglycemia on plasma proteins, in this study, we measured the turnover rates of high-density lipoprotein (HDL)-associated proteins in control (chow diet), prediabetic [a high-fat diet (HFD) for 8 wk] or diabetic [HFD for 8 wk with low-dose streptozotocin (HFD + STZ) in weeks 5-8 of HFD] C57BL/6J mice using heavy water (2H2O)-based metabolic labeling approach. Compared with control mice, HFD and HFD + STZ mice showed elevations of fasting plasma glucose levels in the prediabetic and diabetic range, respectively. Furthermore, the HFD and HFD + STZ mice showed increased hepatic triglyceride (TG) levels, total plasma cholesterol, and plasma TGs. The kinetics of 40 proteins were quantified using the proteome dynamics method, which revealed an increase in the fractional synthesis rate (FSR) of HDL-associated proteins in the prediabetic mice compared with control mice, and a decrease in FSR in the diabetic mice. The pathway analysis revealed that proteins with altered turnover rates were involved in acute-phase response, lipid metabolism, and coagulation. In conclusion, prediabetes and diabetes have distinct effects on the turnover rates of HDL proteins. These findings suggest that an early dysregulation of the HDL proteome dynamics can provide mechanistic insights into the changes in protein levels in these conditions.NEW & NOTEWORTHY This study is the first to examine the role of gradual hyperglycemia during diabetes disease progression on HDL-associated protein dynamics in the prediabetes and diabetic mice. Our results show that the fractional synthesis rate of HDL-associated proteins increased in the prediabetic mice whereas it decreased in the diabetic mice compared with control mice. These kinetic changes can help to elucidate the mechanism of altered protein levels and HDL dysfunction during diabetes disease progression.

Does Continuing Medical Education (CME) Activity Contribute to Learning Gain: An Objective Evaluation

Continuing medical education (CME) and work-shops go a long way to update and refresh medical education of the medical practitioners and help them to stay updated about latest advances in the medical field which helps them to impart latest and better treatment to the patients. This article aims at reporting the evaluation of the effectiveness of the learning in terms of knowledge gained immediately after the workshop and to objectively quantify the knowledge gain from the CME program. Pre- and post-CME survey of knowledge by the way of multiple choice question questionnaire was used to assess the efficacy of the CME and the learning gain of the participants. 42 participants were included in the assessment of the gain in knowledge after the CME. An increase of 17.9% in the scores of the participants was seen at the end of the CME, with a learning gain of 38%. Educational activity like CME can improve the knowledge base of the intended participants. Further research is required to evaluate if education delivered in a short workshop of this nature is retained for any length of time and if it results in any change in practice that affects health outcomes.

Continuing Medical Education: A Cross Sectional Study on a Developing Country's Perspective

To determine the attitude of general practitioners towards continuing medical education (CME) and reasons motivating or hindering them from attending CME procedures, we conducted a cross-sectional survey from November 2013 to April 2014 in Karachi. Three hundred general practitioners who possessed a medical license for practice in Pakistan filled a pre-designed questionnaire consisting of questions pertaining to attitudes towards CME. Data was entered and analyzed using SPSS v16.0. 70.3% (n = 211) of the participants were males. Mean age was 47.75 ± 9.47 years. Only 67.33% knew about CME and only 52% had attended a CME session. Reasons for attending CME procedures reported were: need for updating knowledge, skills and competencies (67.30%), opportunity to meet colleagues (18.58%) and presenting scientific papers (8.97%). Mean Likert score was 1.67 (±0.667) for those who thought CME is worthwhile and 1.44 (±0.686) for those who consider their clinical duties as the major hurdle in attending CME procedures. Most common cause for not attending CME was lack of knowledge (32.66%) followed by time constraint (24%). Most physicians were not sufficiently informed about the potential benefits of CME and had never attended a CME session. Most common reason for attending CME procedures reported was need for updating knowledge, skills and competencies while reasons hindering physicians from attending CME were lack of knowledge and time constraint.

Type 2 diabetes continuing medical education for general practitioners: what works? A systematic review

AIMS

To perform a systematic review of studies that have assessed the effectiveness of interventions designed to improve healthcare professionals' care of patients with diabetes and to assess the effects of educational interventions targeted at general practitioners' diabetes management.

METHODS

A computer search was conducted using the Cochrane Library, PubMed, Ovid MEDLINE, Scopus, EMBASE, Informit, Google scholar and ERIC from the earliest date of each database up until 2013. A supplementary review of reference lists from each article obtained was also carried out. Measured changes in general practitioners' satisfaction, knowledge, practice behaviours and patient outcomes were recorded.

RESULTS

Thirteen out of 1255 studies met the eligibility criteria, but none was specifically conducted in rural or remote areas. Ten studies were randomized trials. Fewer than half of the studies (5/13, 38.5%) reported a significant improvement in at least one of the following outcome categories: satisfaction with the programme, knowledge and practice behaviour. There was little evidence of the impact of general practitioner educational interventions on patient outcomes. Of the five studies that examined patient outcomes, only one reported a positive impact: a reduction in patient HbA1c levels.

CONCLUSIONS

Few studies examined the effectiveness of general practitioner Type 2 diabetes education in improving general practitioner satisfaction, knowledge, practices and/or patient outcomes. Evidence to support the effectiveness of education is partial and weak. To determine effective strategies for general practitioner education related to Type 2 diabetes, further well designed studies, accompanied by valid and reliable evaluation methods, are needed.

Performance assessment through pre- and post-training evaluation of continuing medical education courses in prevention and management of cardio-vascular diseases in primary health care facilities of Armenia

To assess the difference of pre- and post-training performance evaluation of continuing medical education (CME) courses in cardio-vascular diseases (CVD) management among physicians at primary health care facilities of Armenian regions we conducted an evaluation survey. 212 medical records were surveyed on assessment of performance before and after the training courses through a self-employed structured questionnaire. Analysis of survey revealed statistically significant differences (p < 0.05) in a number of variables: threefold increased recording of lipids and body mass index (p = 0.001); moderate increased recording of comorbidities and aspirin prescription (p < 0.012); eightfold increased recording of dyslipidemia management plan, twofold increased recording for CVD management plan and fivefold increased recording for CVD absolute risk (p = 0.000). Missing records of electrocardiography and urine/creatinine analyses decreased statistically significantly (p < 0.05). Statistically significant decrease was observed in prescription of thiazides and angiotensin receptor blockers/angiotensin converting enzyme inhibitors (p < 0.005), while prescription of statins and statins with diet for dyslipidemia management showed increased recording (p < 0.05). Similarly, we observed increased records for counseling of rehabilitation physical activity (p = 0.006). In this survey most differences in pre- and post-evaluation of performance assessment may be explained by improved and interactive training modes, more advanced methods of demonstration of modeling. Current findings may serve a basis for future planning of CME courses for physicians of remote areas facing challenges in upgrading their knowledge, as well as expand the experience of performance assessment along with evaluation of knowledge scores.

The value of training in communication skills for continuing medical education

OBJECTIVE

Question arises as to what extent communication skills are considered in continuing medical education (CME).

METHODS

Analysis for CME-courses in communication skills in the area of the Chamber of Physicians North Rhine (ÄkNo), Germany. Supply Arm(A): CME events (n = 19,320) certified in 2007 were evaluated. Demand Arm(B): course participation of 850 family physicians in the period 2002-2007 was analyzed (n = 37,724). Tests were calculated to the level 0.05 using Mann-Whitney U-test.

RESULTS

(A) 388 (2.0%) events were concerned with the topic communications. 59.3% involved active cooperation of the participants. 0.5% events devoted more than 50% of their duration to the topic communication. Proportions in the subjects of internal medicine, general medicine and pediatrics amounted to 0.2%. (B) 803 (2.1%) events with a focus on communication were identified. Women took part in significantly more events than men (p<0.002) and selected more interactive courses.

CONCLUSION

Content on communication training was small. Increasing experience does not automatically improve communication skills but an extent of deliberate praxis seems to be necessary and must be sought and developed.

PRACTICE IMPLICATIONS

Communication skills are still insufficiently provided in CME-courses and should be more directed to focus as treatment strategies and scientifically investigated for outcome improvements.

Evaluation of an online interactive Diabetes Needs Assessment Tool (DNAT) versus online self-directed learning: a randomised controlled trial

BACKGROUND

Methods for the dissemination, understanding and implementation of clinical guidelines need to be examined for their effectiveness to help doctors integrate guidelines into practice. The objective of this randomised controlled trial was to evaluate the effectiveness of an interactive online Diabetes Needs Assessment Tool (DNAT) (which constructs an e-learning curriculum based on individually identified knowledge gaps), compared with self-directed e-learning of diabetes guidelines.

METHODS

Health professionals were randomised to a 4-month learning period and either given access to diabetes learning modules alone (control group) or DNAT plus learning modules (intervention group). Participants completed knowledge tests before and after learning (primary outcome), and surveys to assess the acceptability of the learning and changes to clinical practice (secondary outcomes).

RESULTS

Sixty four percent (677/1054) of participants completed both knowledge tests. The proportion of nurses (5.4%) was too small for meaningful analysis so they were excluded. For the 650 doctors completing both tests, mean (SD) knowledge scores increased from 47.4% (12.6) to 66.8% (11.5) [intervention group (n = 321, 64%)] and 47.3% (12.9) to 67.8% (10.8) [control group (n = 329, 66%)], (ANCOVA p = 0.186). Both groups were satisfied with the usability and usefulness of the learning materials. Seventy seven percent (218/284) of the intervention group reported combining the DNAT with the recommended reading materials was "very useful"/"useful". The majority in both groups (184/287, 64.1% intervention group and 206/299, 68.9% control group) [95% CI for the difference (-2.8 to 12.4)] reported integrating the learning into their clinical practice.

CONCLUSIONS

Both groups experienced a similar and significant improvement in knowledge. The learning materials were acceptable and participants incorporated the acquired knowledge into practice.

TRIAL REGISTRATION

ISRCTN: ISRCTN67215088.

Evaluation of an online Diabetes Needs Assessment Tool (DNAT) for health professionals: a randomised controlled trial

Background

Continuous medical education is traditionally reliant to a large extent on self-directed learning based on individuals' perceived learning priorities. Evidence suggests that this ability to self-assess is limited, and more so in the least competent. Therefore, it may be of benefit to utilise some form of external assessment for this purpose. Many diabetes educational programmes have been introduced, but few have been assessed for their benefit in a systematic manner. As diabetes is an increasingly prevalent disease, methods for the dissemination and understanding of clinical guidelines need to be explored for their effectiveness. This paper describes the study design of a randomised controlled trial to evaluate the effectiveness of using an interactive online Diabetes Needs Assessment Tool (DNAT), that builds a learning curriculum based on identified knowledge gaps, compared with conventional self-directed learning. The study assesses the effect of these interventions on health professionals' knowledge of diabetes management, evaluates the acceptability of this process of learning and self-reported changes in clinical practice as a result of this novel educational process.

Methods

Following a baseline assessment, participants will be randomised to undergo a 4-month learning period where they will either be given access to the diabetes learning modules alone (control group) or a Diabetes Needs Assessment Tool (DNAT) plus the diabetes learning modules (intervention group). On completion of the DNAT, a personalised learning report will be created for each participant identifying needs alongside individualised recommendations of the most appropriate learning modules to meet those requirements. All participants will complete a Diabetes Knowledge Test before and immediately after the allocated learning and the primary outcome will be the state of knowledge at 4 months. Learners will also be surveyed immediately after the learning period to assess the acceptability of the learning formats and the perceived usefulness and usability of the materials. After a further month, all learners will receive a series of questions to evaluate self-reported changes in clinical practice as a result of this educational experience and asked to include specific examples of any changes in their diabetes care practice.

Trial registration

Current Controlled Trials ISRCTN67215088

[The effectiveness of CME -- quality improvement through differentiated advanced medical education research]

Continuing medical education (CME) increasingly focuses on measurable patient outcomes. Nevertheless, international data on this issue are insufficient, and in Germany the measurable effects of CME in terms of its efficacy and utility for patient care have hardly been subjected to scientific examination. Advanced medical education as a continuation of university education is always based on scientific standards and research-oriented learning. Advanced medical training in Germany therefore requires the implementation of a kind of learning and teaching research that should be geared toward individual training needs, personal motivation and the outcomes of medical care. In addition, the definition of educational goals and the advancement of CME in terms of continuing professional development (CPD) should be considered an important component for a reevaluation of CME.

Continuing medical education effect on practice performance: effectiveness of continuing medical education: American College of Chest Physicians Evidence-Based Educational Guidelines

BACKGROUND

There has been sizable debate and widespread skepticism about the effect of continuing medical education (CME) on the performance of physicians in the practice setting. This portion of the review was undertaken to examine that effect.

METHODS

The guideline panel used data from a comprehensive review of the effectiveness of CME developed by The Johns Hopkins Evidence-based Practice Center, focusing on the effect of CME on clinical performance.

RESULTS

The review found 105 studies, which evaluated the impact of CME on short- and long-term physician practice performance. Nearly 60% met objectives relative to changing clinical performance in prescribing; screening; counseling about smoking cessation, diet, and sexual practices; guideline adherence; and other topics. Single live and multiple media appeared to be generally positive in their effect, print media much less so. Multiple educational techniques were more successful at changing provider performance than single techniques. The amount or frequency of exposure to CME activities appeared to have little effect on behavior change.

CONCLUSIONS

Overall, CME, especially using live or multiple media and multiple educational techniques, is generally effective in changing physician performance. More research, however, is needed that focuses on the specific types of media and educational techniques that lead to the greatest improvements in performance.

Integrating primary care and early intervention in psychosis services: a general practitioner perspective

AIMS

Earlier detection and treatment of psychosis is associated with improved health outcomes. While the role of specialist services to facilitate early diagnosis and treatment has been extensively described internationally, little data on their impact on general practice has been reported. A new specialist service for psychosis - the 'Dublin East Treatment and Early Care Team (DETECT)'- has recently been established. This study aimed to describe general practitioners' (GPs) attitudes towards working within the catchment area of an early intervention service.

METHODS

A purposive sample of GPs practising in DETECT's catchment area was identified from the Irish Medical Directory and invited to participate in a semi-structured interview. The sampling parameters were solo/practice and area of practice. Participants were provided with information regarding the new service and a range of educational material. Each interview was reviewed by two researchers who identified dominant themes. The study was approved by the Research Ethics Committee of the Irish College of GPs.

RESULTS

16 GPs were interviewed. The DETECT early intervention model was identified as reducing the challenges of managing psychosis in primary care including the practical difficulties of accessing psychiatric assessment and the pervasive effect of stigma. Participants viewed communication between primary and specialist care as essential to the success of early intervention services.

CONCLUSIONS

General Practice has an important role in early detection of psychosis and accessing timely psychiatric evaluations of suspected psychosis. Increasing awareness among GPs and ensuring the early intervention model is responsive to primary care can support this role.

The reported validity and reliability of methods for evaluating continuing medical education: a systematic review

PURPOSE

To appraise the reported validity and reliability of evaluation methods used in high-quality trials of continuing medical education (CME).

METHOD

The authors conducted a systematic review (1981 to February 2006) by hand-searching key journals and searching electronic databases. Eligible articles studied CME effectiveness using randomized controlled trials or historic/concurrent comparison designs, were conducted in the United States or Canada, were written in English, and involved at least 15 physicians. Sequential double review was conducted for data abstraction, using a traditional approach to validity and reliability.

RESULTS

Of 136 eligible articles, 47 (34.6%) reported the validity or reliability of at least one evaluation method, for a total of 62 methods; 31 methods were drawn from previous sources. The most common targeted outcome was practice behavior (21 methods). Validity was reported for 31 evaluation methods, including content (16), concurrent criterion (8), predictive criterion (1), and construct (5) validity. Reliability was reported for 44 evaluation methods, including internal consistency (20), interrater (16), intrarater (2), equivalence (4), and test-retest (5) reliability. When reported, statistical tests yielded modest evidence of validity and reliability. Translated to the contemporary classification approach, our data indicate that reporting about internal structure validity exceeded reporting about other categories of validity evidence.

CONCLUSIONS

The evidence for CME effectiveness is limited by weaknesses in the reported validity and reliability of evaluation methods. Educators should devote more attention to the development and reporting of high-quality CME evaluation methods and to emerging guidelines for establishing the validity of CME evaluation methods.

A meta-analysis of continuing medical education effectiveness

INTRODUCTION

We undertook a meta-analysis of the Continuing Medical Education (CME) outcome literature to examine the effect of moderator variables on physician knowledge, performance, and patient outcomes.

METHODS

A literature search of MEDLINE and ERIC was conducted for randomized controlled trials and experimental design studies of CME outcomes in which physicians were a major group. CME moderator variables included the types of intervention, the types and number of participants, time, and the number of intervention sessions held over time.

RESULTS

Thirty-one studies met the eligibility criteria, generating 61 interventions. The overall sample-size weighted effect size for all 61 interventions was r = 0.28 (0.18). The analysis of CME moderator variables showed that active and mixed methods had medium effect sizes (r = 0.33 [0.33], r = 0.33 [0.26], respectively), and passive methods had a small effect size (r = 0.20 [0.16], confidence interval 0.15, 0.26). There was a positive correlation between the effect size and the length of the interventions (r = 0.33) and between multiple interventions over time (r = 0.36). There was a negative correlation between the effect size and programs that involved multiple disciplines (r = -0.18) and the number of participants (r = -0.13). The correlation between the effect size and the length of time for outcome assessment was negative (r = -0.31).

DISCUSSION

The meta-analysis suggests that the effect size of CME on physician knowledge is a medium one; however, the effect size is small for physician performance and patient outcome. The examination of moderator variables shows there is a larger effect size when the interventions are interactive, use multiple methods, and are designed for a small group of physicians from a single discipline.

Impact of a general practitioner educational intervention on osteoarthritis treatment in an elderly population

PURPOSE

We examined whether a continuing medical education intervention increased general practitioners' ability to select the proper pharmacological treatment for patients with osteoarthritis.

SUBJECTS AND METHODS

Eight towns in Quebec, Canada were randomly allocated to one of four intervention options, workshop and decision tree, workshop, decision tree, or no intervention. All general practitioners practicing in each town were eligible to participate. We evaluated all dispensed prescriptions for either a cyclooxygenase (COX)-2 inhibitor, nonselective nonsteroidal anti-inflammatory drug or acetaminophen written by eligible general practitioners between May 2000 and June 2001 to elderly patients suffering from osteoarthritis. We used a multi-level Bayesian hierarchical model to assess the impact of the interventions on prescription adequacy.

RESULTS

We analyzed 5318 dispensed prescriptions written by 249 general practitioners in the five-month preintervention period and 4610 dispensed prescriptions written by the same physicians in the five-month postintervention period. A score of zero or one was given to every prescription, with one indicating prescription adequacy according to guidelines provided during the interventions. Bayesian hierarchical models showed some improvement in scores in the post- versus preintervention periods in all four groups. The probability of an improvement in the towns allocated the workshop and decision tree over the control was 94%, compared with 74% in the workshop group and 55% in the decision tree group.

CONCLUSION

An interactive approach offered by peers and complemented by easy to use guidelines may enhance the general practitioner's ability to manage osteoarthritis patients.

Guidelines for the management of hepatitis C in general practice: a semi-qualitative interview survey of GPs’ views regarding content and implementation

BACKGROUND

Hepatitis C is a common infection among people who attend GPs for methadone maintenance treatment.

AIM

To determine the views of GPs towards clinical guidelines for the management of hepatitis C among current or former injecting drug users in advance of their implementation.

METHODS

A purposive sample of 14 GPs (10% of the total prescribing methadone at the time the guidelines were developed) was invited to review a pre-publication draft of the guidelines and interviewed regarding content, presentation, perceived barriers to implementation and suggested interventions to facilitate effective implementation of the guidelines.

RESULTS

GPs indicated the guidelines were useful but suggested aspects of presentation should be clarified. Organisational issues were identified as the principal barriers to effective implementation, with the provision of additional nursing support the principal intervention suggested to facilitate implementation.

CONCLUSIONS

Interviewing intended recipients may be an important step in ensuring clinical practice guidelines are effectively implemented.

Teleconferenced educational detailing: diabetes education for primary care physicians

INTRODUCTION

Formal didactic continuing medical education (CME) is relatively ineffective for changing physician behaviour. Diabetes mellitus is an increasingly prevalent disease, and interventions to improve adherence to clinical practice guidelines (CPGs) are needed.

METHODS

A stratified, cluster-randomized, controlled trial design was used to evaluate the effects of a teleconferenced educational detailing (TED) CME on glycemic control (hemoglobin [Hb] A1c) and family physician adherence to national diabetes guidelines. TED employed sequential, small-group, case-based education using CPGs delivered by a diabetes specialist. Medical record audit data from baseline through the end of a 12-month postintervention period were compared for the control and intervention groups. Satisfaction with the intervention was evaluated.

RESULTS

Sixty-one physicians provided 660 medical records. The intervention did not affect mean Hb A1c levels but did significantly (p = .04) alter the distribution of patients by category of glycemic control, with fewer in the intervention group in inadequate control (15.8% versus 23.9%). More patients took insulin (alone or with oral agents) in the intervention group (21.2% versus 12.0%, p = .03), and more took oral agents only in the control group (89.0% versus 82.9%, p = .005). More patients in the intervention group had documentation of body mass index (7.8% versus 1.9%, p < .02), eye exam (12.1% versus 5.1%, p = .02), and treatment plan (43.5% versus 23.6%, p = .01) and used a flow sheet (14.6% versus 7.7%, p < .03). Although there was general satisfaction with the teleconferencing format, specialist educators found the format more challenging than the family physicians.

DISCUSSION

CME delivered by teleconference was feasible, well attended, well received by participants, and improved some key diabetes management practices and outcomes.

Effective control of hypertension: a project of the Hungarian society of hypertension, baseline data

The aim of the project is to assess the quality and improve the preventive and curative practices at the primary care level in Hungary. A total of 50 general practitionaires were selected on a voluntary basis in Budapest, Hungary, and from them, 30 were randomized to the intervention (I) group and 20 to the reference (R) group. The members in the I group have been trained for the official hypertension guideline and their everyday work is monitored. Those in the R group have only been monitored to measure the efficacy of the training. In all, 10% from the known hypertensive persons (N=10,799) and 5% of the remaining (nonhypertensive) patients (N=60,341) were selected randomly from the GP's computer files and invited for screening investigation performed by trained medical students. They measured the blood pressure of patients, assessed the cardiovascular risk status and the quality of education of patients by standardized questionnaires. In total, 4083 patients were invited, but only 39.2% attended the screening visit. The prevalence of undetected hypertension was 34.6%. This prevalence was significantly higher in the older (>60 years: 46.8%) than in the younger (<50 years: 20.8%, P<0.0001) age group and it was higher in men (41.5%) than in women (30.1%, P<0.001). The proportion of H patients on drug treatment was 85.3% and the frequency of patients under effective blood pressure control (eg<140/90 mmHg) was 27.8%. Counselling to patients for a healthier lifestyle (exercise, smoking, alcohol consumption, diet) was very rare. In conclusion, our data represent the primary care of Budapest and may not be relevant to the whole country. As a consequence of this study, education of primary care physicians and patients is a must for further improvement of hypertension care.

Medical nutrition therapy for the prevention and treatment of unintentional weight loss in residential healthcare facilities

OBJECTIVES

To identify the rate of unintentional weight loss (UWL) in adults following their admission into residential healthcare facilities, assess the effectiveness of a new medical nutrition therapy (MNT) protocol for the prevention and treatment of UWL, and describe nutrition assessment and intervention activities of dietitians.

DESIGN

Prospective intervention study in which volunteer dietitians were randomly assigned to usual nutrition care (UC) or MNT protocol care (MNT-PC) groups. Dietitians recruited newly admitted residents and tracked their weights for up to 6 months using standardized weighing procedures. Data on weight outcomes and nutrition care activities were abstracted from medical records and compared between study groups. Subjects/settings Thirty-one dietitians from 29 facilities completed the field test (16 MNT-PC, 13 UC). Medical record data were available for 394 residents (223 MNT-PC, 171 UC), and complete weight trend data were available for 364 residents (200 MNT-PC, 164 UC).

INTERVENTION

The new MNT protocol for UWL in residential facilities emphasized assessment; intervention (including weighing frequency); communication with staff, medical doctor, family, and resident; and reassessment. Main outcome measures Rate of UWL and weight status 90 days after admission and weight status 90 days after identification of UWL. Statistical analyses Chi;(2), Independent t test, analysis of variance, and multiple regression using the general linear model.

RESULTS

Fourteen of 364 residents (4%) were admitted with significant preexisting weight loss, which was successfully treated in eight residents during the first 90 days. Substantial unintentional weight loss (>or=5% in any 30 days) developed in 78 residents (21%). MNT-PC dietitians were more likely to identify UWL. When UWL was identified, and, after providing nutrition care to these residents for an additional 90 days, 32 of 61 residents (52%) maintained or gained weight. Dietitians in UC and MNT-PC groups were equally successful in treating preexisting or postadmission unintentional weight loss when it was identified. Differences were found in nutrition care activities. MNT-PC dietitians reported more nutrition assessment activities, whereas UC dietitians reported more intervention activities. Conclusions/applications Nutrition care protocols with standardized weighing procedures can increase the identification of UWL in the residential healthcare environment. Improved identification supports the additional assessment activities used by MNT-PC dietitians. Similar outcomes for UC and MNT-PC groups when UWL was identified indicate that usual nutrition care was already a high standard of care for intervention.

Identifying older diabetic patients at risk of poor glycemic control

BACKGROUND

Optimal glycemic control prevents the onset of diabetes complications. Identifying diabetic patients at risk of poor glycemic control could help promoting dedicated interventions. The purpose of this study was to identify predictors of poor short-term and long-term glycemic control in older diabetic in-patients.

METHODS

A total of 1354 older diabetic in-patients consecutively enrolled in a multicenter study formed the training population (retrospective arm); 264 patients consecutively admitted to a ward of general medicine formed the testing population (prospective arm). Glycated hemoglobin (HbA1c) was measured on admission and one year after the discharge in the testing population. Independent correlates of a discharge glycemia > or = 140 mg/dl in the training population were assessed by logistic regression analysis and a clinical prediction rule was developed. The ability of the prediction rule and that of admission HbA1c to predict discharge glycemia > or = 140 mg/dl and HbA1c > 7% one year after discharge was assessed in the testing population.

RESULTS

Selected admission variables (diastolic arterial pressure < 80 mmHg, glycemia = 143-218 mg/dl, glycemia > 218 mg/dl, history of insulinic or combined hypoglycemic therapy, Charlson's index > 2) were combined to obtain a score predicting a discharge fasting glycemia > or = 140 mg/dl in the training population. A modified score was obtained by adding 1 if admission HbA1c exceeded 7.8%. The modified score was the best predictor of both discharge glycemia > or = 140 mg/dl (sensitivity = 79%, specificity = 63%) and 1 year HbA1c > 7% (sensitivity = 72%, specificity = 71%) in the testing population.

CONCLUSION

A simple clinical prediction rule might help identify older diabetic in-patients at risk of both short and long term poor glycemic control.