Individualised treatment goals in diabetes care

Physician reasons for nonpharmacologic treatment of hyperglycemia in older patients newly diagnosed with type 2 diabetes mellitus

INTRODUCTION

To identify reasons why primary care physicians (PCPs) do not treat older patients newly diagnosed with type 2 diabetes mellitus (T2DM) with antihyperglycemic agents following diagnosis.

METHODS

US PCPs were surveyed via the internet regarding their reasons for not treating patients aged >65 years diagnosed with T2DM and had not yet initiated antihyperglycemic therapy for ≥6 months after diagnosis. PCPs were requested to provide relevant clinical information for untreated older patients and select applicable reasons for not initiating treatment from a list of 35 possibilities, grouped into five categories.

RESULTS

A total of 508 PCPs completed the online survey and provided complete clinical data for 770 patients. The reasons provided by the first-ranked physician for not initiating antihyperglycemic therapy were related to diet and exercise (57.5%); mild hyperglycemia (23.8%); patient's concerns (13.4%); concerns about antihyperglycemic agents (3.0%); and comorbidities and polypharmacy (2.3%). The "diet and exercise" category was the most common first-ranked non-treatment reason, regardless of recent hemoglobin A(1c) (HbA(1c)) stratum. Reasons within the "patient's concerns," "concerns related to antihyperglycemic agents," and "comorbidities and polypharmacy" categories tended to be selected more often as first-ranked reasons by physicians for patients with higher HbA(1c) values. Of the 158 patients whose physicians planned to initiate antihyperglycemic therapy within the next month, 54.4% already had a most recent HbA(1c) value above their physician-stated threshold for treatment initiation.

CONCLUSION

In the PCPs studied, there was a tendency to select appropriate reasons for non-treatment with antihyperglycemic agents given their patients' glycemic status. However, there was inertia related to the initiation of pharmacological therapy in some older patients with newly diagnosed T2DM. Important factors included physicians' perceptions of "mild" hyperglycemia and the HbA(1c) threshold for using antihyperglycemic agents.

The dilemma of patient responsibility for lifestyle change: perceptions among primary care physicians and nurses

OBJECTIVE

To explore physicians' and nurses' views on patient and professional roles in the management of lifestyle-related diseases and their risk factors.

DESIGN

A questionnaire study with a focus on adult obesity, dyslipidemia, high blood pressure, type 2 diabetes, and smoking.

SETTING

Healthcare centres in Päijät-Häme hospital district, Finland.

SUBJECTS

Physicians and nurses working in primary healthcare (n =220).

MAIN OUTCOME MEASURES

Perceptions of barriers to treatment of lifestyle-related conditions, perceptions of patients' responsibilities in self-care, experiences of awkwardness in intervening in obesity and smoking, perceptions of rushed schedules, and perceptions of health professionals' roles and own competence in lifestyle counselling.

RESULTS

A majority agreed that a major barrier to the treatment of lifestyle-related conditions is patients' unwillingness to change their habits. Patients' insufficient knowledge was considered as such a barrier less often. Self-care was actively encouraged. Although a majority of both physicians and nurses agreed that providing information, and motivating and supporting patients in lifestyle change are part of their tasks, only slightly more than one half estimated that they have sufficient skills in lifestyle counselling. Among nurses, those with less professional experience more often reported having sufficient skills than those with more experience. Two-thirds of the respondents reported that they had been able to help many patients to change their lifestyles into healthier ones.

CONCLUSIONS

The primary care professionals experienced a dilemma in patients' role in the treatment of lifestyle-related diseases: the patient was recognized as central in disease management but also, if reluctant to change, a major potential barrier to treatment.

Self-monitoring of blood glucose and glycaemic control in type 2 diabetes

OBJECTIVE

Previous studies have shown inconsistent results with regard to whether or not self-monitoring of blood glucose (SMBG) is related to better glycaemic control in type 2 diabetes. The aim of this study was to explore the use of SMBG and its association with glycaemic control in patients with type 2 diabetes in primary care.

DESIGN

A cross-sectional observational study was conducted in 2003 at 18 primary health care centres in Sweden, in which all known patients with diabetes were surveyed. The study included 6495 patients with type 2 diabetes. A sample of 896 patients was selected for further exploration of data from medical records. A telephone interview was performed with all patients in this group using SMBG (533 patients).

RESULTS

There were no differences in HbA1c levels between users (6.9%) and non-users (6.8%) of SMBG in patients treated with insulin or in patients treated with oral agents (6.3% in both groups). In patients treated with diet only, users of SMBG had higher levels of HbA1c compared with non-users (5.5% vs. 5.4%, p =0.002). Comparing medical records between users and non-users of SMBG showed no differences in diabetes-related complications in any treatment category group.

CONCLUSION

The use of SMBG was not associated with improved glycaemic control in any therapy category of patients with type 2 diabetes in primary care. The absence of difference in glycaemic control between users and non-users of SMBG could not be explained by differences in comorbidity between users and non-users of SMBG.

Abdominal obesity and insulin resistance in patients with type 2 diabetes in a Swedish community. Skaraborg hypertension and diabetes project

OBJECTIVE

To explore the association between abdominal obesity and insulin resistance in patients with type 2 diabetes.

DESIGN

A cross-sectional observational study.

SETTING

Primary care in Skara, Sweden.

SUBJECTS

A total of 198 men and 186 women with type 2 diabetes who consecutively completed an annual check-up in 1992-1993.

MAIN OUTCOME MEASURES

Abdominal obesity was defined according to criteria for the metabolic syndrome using the waist circumference (WC): > 102 cm for men and > 88 cm for women. Insulin resistance was estimated using the Homeostasis Model Assessment (HOMA), and was dichotomized by the 75th percentile (IR).

RESULTS

Abdominal obesity was found in 66 men (33%), and in 106 women (57%). Pearson's correlation coefficients between components of the metabolic syndrome and IR were statistically significant for WC, waist-hip ratio, serum triglycerides, and HDL cholesterol, and were higher for WC (0.40) than for waist-hip ratio (0.23) in both genders (p < 0.001). The association between WC and IR was challenged by successively entering other components of the metabolic syndrome into the model in a logistic regression. In the final model, adjusting for differences in age, systolic blood pressure, HbA1c, serum triglycerides, HDL cholesterol, and microalbuminuria, the association remained statistically significant both in men (OR 8.6, 95% CI 3.0-25.2, p < 0.001), and in women (OR 5.6, 95% CI 1.7-18.1, p = 0.004).

CONCLUSIONS

WC provides a feasible measure for insulin resistance in the vast majority of subjects with type 2 diabetes. It is convenient and less expensive than direct means and could be used as a proxy for insulin resistance in population studies.

Dietary and physical activity counselling on type 2 diabetes and impaired glucose tolerance by physicians and nurses in primary healthcare in Finland

OBJECTIVE

To investigate the initiation of dietary and physical activity counselling and the arguments used when discussing physical activity and the type and consumption of dietary fats, during nurse-patient and physician-patient diabetic lifestyle counselling.

DESIGN AND SUBJECTS

This study is a part of a larger follow-up research project focusing on diabetes counselling. The data include 129 videotaped counselling sessions between 17 patients and their physicians and nurses. Content analysis was carried out by identifying the verbal comments and reactions of participants concerning both physical activity and the type and consumption of dietary fats.

RESULTS

The physicians and nurses spent little time on dietary and physical activity counselling. The counselling sessions consisted mainly of short questions with minimal feedback from either party. The beginning of the sessions concentrated on blood cholesterol levels and the extent of physical activity. The health professionals failed to emphasize the roles of reduced dietary fats and increased physical activity in substituting for or supplementing diabetes care. Although the patients communicated the factors that encouraged or discouraged physical activity the subject was generally not pursued by the health professionals.

CONCLUSION

Within primary care there is a need for methods that would facilitate the discussion of health behaviour changes. In healthcare settings, education and training are required to develop the communication skills of health professionals in all aspects of preventive medicine.

Inadequate treatment of dyslipidemia in people with type 2 diabetes: quality assessment of diabetes care in a Danish County

OBJECTIVE

This study aims to describe the routine monitoring of lipids and the use of lipid-lowering medicine in people with type 2 diabetes in the period 2000-2002.

MATERIAL AND METHODS

Data from the National Health Service Registry, the Regional laboratory database and the Danish National Hospital Registry have been used for identification and description of known diabetes in a background population of 649,177 citizens in the County of Aarhus, corresponding to 12% of the total Danish population. All data were collected for the period 1 January 2000 to 31 December 2002.

RESULTS

A total of 14,644 people with type 2 diabetes were identified, 52% of whom were men. The mean age was 64 years and the mean duration of diabetes was 7 years. A total of 61% had a minimum of one measurement of total cholesterol in 2000 compared with 64% in 2002. Some 71% of the patients in 2000 compared with 66% in 2002 had a total cholesterol concentration above 5.0 mmol/l. The proportion of people with type 2 diabetes treated with a lipid-lowering drug increased from 15% in 2000 to 24% in 2002. For those who were treated with lipid-lowering medication 33% in 2000 and 42% in 2002 reached currently recommended targets of total cholesterol concentrations.

CONCLUSIONS

The results of this study provide a realistic picture of the monitoring of cholesterol as part of diabetes care and found a tendency to increased adherence to guidelines. Even so, it seems as if more patients with diabetes could benefit from treatment with lipid-lowering medication.

Diabetes care today: not everyone should have intensive multipharmacological treatment

The uncritical promotion of intensive multipharmacological treatment for type 2 diabetic patients is an example of simplistic communication of research results. The effect, practicability and safety of pharmacological treatment is greater for high than for low levels of blood glucose and other risk factors. The large number of poorly controlled diabetic patients is a further argument for concentrating the treatment effort on those patients at highest risk. A pragmatic risk balance sheet can be used to decide when to start treatment even at relatively low levels of risk factors. We need such a framework in which we can individualise goal-setting and treatment.