Social deprivation and diabetic kidney disease: A European view

There is a large body of literature demonstrating a social gradient in health and increasing evidence of an association between social deprivation and diabetes complications. Diabetic kidney disease (DKD) increases mortality in people with diabetes. Socioeconomic deprivation is increasingly recognized as a modifier of risk factors for kidney disease but also an independent risk factor itself for kidney disease. This may not be truly appreciated by clinicians and warrants further attention and exploration. In this review we explore the literature to date from Europe on the relationship between social deprivation and DKD. The majority of the studies showed at least an association with microalbuminuria, an early marker of DKD, while many showed an association with overt nephropathy. This was seen across many countries in Europe using a variety of different measures of deprivation. We reviewed and considered the mechanisms by which deprivation may lead to DKD. Health related behaviors such as smoking and suboptimal control of risk factors such as hypertension, hyperglycemia and elevated body mass index (BMI) accounts for some but not all of the association. Poorer access to healthcare, health literacy, and stress are also discussed as potential mediators of the association. Addressing deprivation is difficult but starting points include targeted interventions for people living in deprived circumstances, equitable roll out of diabetes technology, and flexible outpatient clinic arrangements including virtual and community-based care.

The Person's Care Requires a Sex and Gender Approach

There is an urgent need to optimize pharmacology therapy with a consideration of high interindividual variability and economic costs. A sex-gender approach (which considers men, women, and people of diverse gender identities) and the assessment of differences in sex and gender promote global health, avoiding systematic errors that generate results with low validity. Care for people should consider the single individual and his or her past and present life experiences, as well as his or her relationship with care providers. Therefore, intersectoral and interdisciplinary studies are urgently required. It is desirable to create teams made up of men and women to meet the needs of both. Finally, it is also necessary to build an alliance among regulatory and ethic authorities, statistics, informatics, the healthcare system and providers, researchers, the pharmaceutical and diagnostic industries, decision makers, and patients to overcome the gender gap in medicine and to take real care of a person in an appropriate manner.

Characteristic of FINDRISC Score and Association with Diabetes Development in 6-Year Follow-Up in PURE Poland Cohort Study

Purpose

The aim of the study was to assess if FINDRISC score was associated with diabetes development after 6 years of observation.

Methods

Polish cohort is a part of global PURE study. Hereby analysis presents data from baseline (2007–2010) and 6-year follow-up (2013–2016) and was conducted on 1090 participants (702 women) from urban and rural areas in Lower Silesia region (Poland) without diabetes at the baseline and with complete data throughout course of the study.

Results

At the baseline, women had significantly higher FINDRISC score than men (10.43 vs 8.91; p=0.000) and participants from rural areas had higher score than from urban areas (10.97 vs 9.33; p=0.000). At the baseline, 25.87% of the participants had low risk of diabetes according to FINDRISC score, 38.90% had slightly elevated risk, 16.79% moderate risk, 16.42% high risk and 2.02% very high risk. Participants, who were healthy at baseline, but developed diabetes after 6 years of observation had significantly higher FINDRISC, than those who did not (13.39 vs 9.36; p=0.000). In 6-year follow-up, diabetes was diagnosed in 2.8% of participants, who were ascertained to “low risk” according to FINDRISC score in baseline; in 9.9% of participants of “slightly elevated risk”, 17.5% of participants of “moderate risk”, 26.8% in participants of “high risk” and 50.0% of participants of “very high risk”.

Conclusions

Results of PURE Poland cohort study indicates that higher FINDRISC score at the baseline was associated with higher risk of diabetes development during 6 years of observation.

Influencing Indicators and Spatial Variation of Diabetes Mellitus Prevalence in Shandong, China: A Framework for Using Data-Driven and Spatial Methods

To control and prevent the risk of diabetes, diabetes studies have identified the need to better understand and evaluate the associations between influencing indicators and the prevalence of diabetes. One constraint has been that influencing indicators have been selected mainly based on subjective judgment and tested using traditional statistical modeling methods. We proposed a framework new to diabetes studies using data-driven and spatial methods to identify the most significant influential determinants of diabetes automatically and estimated their relationships. We used data from diabetes mellitus patients' health insurance records in Shandong province, China, and collected influencing indicators of diabetes prevalence at the county level in the sociodemographic, economic, education, and geographical environment domains. We specified a framework to identify automatically the most influential determinants of diabetes, and then established the relationship between these selected influencing indicators and diabetes prevalence. Our autocorrelation results showed that the diabetes prevalence in 12 Shandong cities was significantly clustered (Moran's I = 0.328, p < 0.01). In total, 17 significant influencing indicators were selected by executing binary linear regressions and lasso regressions. The spatial error regressions in different subgroups were subject to different diabetes indicators. Some positive indicators existed significantly like per capita fruit production and other indicators correlated with diabetes prevalence negatively like the proportion of green space. Diabetes prevalence was mainly subjected to the joint effects of influencing indicators. This framework can help public health officials to inform the implementation of improved treatment and policies to attenuate diabetes diseases.

Diabetic Pneumopathy-A New Diabetes-Associated Complication: Mechanisms, Consequences and Treatment Considerations

Patients with diabetes are over-represented among the total cases reported with "idiopathic" pulmonary fibrosis (IPF). This raises the question, whether this is an association only or whether diabetes itself can cause pulmonary fibrosis. Recent studies in mouse models of type 1 and type 2 diabetes demonstrated that diabetes causes pulmonary fibrosis. Both types of diabetes trigger a cascade, starting with increased DNA damage, an impaired DNA repair, and leading to persistent DNA damage signaling. This response, in turn, induces senescence, a senescence-associated-secretory phenotype (SASP), marked by the release of pro-inflammatory cytokines and growth factors, finally resulting in fibrosis. Restoring DNA repair drives fibrosis into remission, thus proving causality. These data can be translated clinically to patients with type 2 diabetes, characterized by long-term diabetes and albuminuria. Hence there are several arguments, to substitute the term "idiopathic" pulmonary fibrosis (IPF) in patients with diabetes (and exclusion of other causes of lung diseases) by the term "diabetes-induced pulmonary fibrosis" (DiPF). However, future studies are required to establish this term and to study whether patients with diabetes respond to the established therapies similar to non-diabetic patients.

Educational inequalities in the prevalence and outcomes of diabetes in the Emilian Longitudinal Study

BACKGROUND AND AIM

Studies carried out in Italy in the last decades reported an effect modification in the association between socioeconomic position and diabetes outcomes, and the disease integrated care approach has been suggested as an explanatory factor. Whether this is true in Emilia-Romagna region in recent years is unknown and the aim of this study is to describe the role of educational level both on diabetes prevalence and health outcomes among the adult population with and without diabetes enrolled in the Emilian Longitudinal Study.

METHODS AND RESULTS

Inequalities in diabetes prevalence were evaluated through standardised estimates and prevalence ratios by educational level and inequalities in outcomes through standardised hospitalisation and mortality ratios and rate ratios by educational level. The lower the education the greater the diabetes prevalence; such differences were larger among women and younger age groups. Diabetes conferred a higher risk of hospitalisation and mortality; those outcomes also presented a social gradient with the less educated bearing the higher risk. However, educational differences were slightly stronger among the disease-free subjects, especially in the case of mortality. In both genders, inequalities tended to disappear with age.

CONCLUSION

This study confirms that diabetes increases the risk of unfavourable outcomes, but does not increase social inequalities in outcomes as might be expected. Similarly to what has been previously shown, it is likely that the protective effect of diabetes on the negative health effects of the low social position is attributable to the disease integrated care approach.

Comorbidity prevalence among cancer patients: a population-based cohort study of four cancers

BACKGROUND

The presence of comorbidity affects the care of cancer patients, many of whom are living with multiple comorbidities. The prevalence of cancer comorbidity, beyond summary metrics, is not well known. This study aims to estimate the prevalence of comorbid conditions among cancer patients in England, and describe the association between cancer comorbidity and socio-economic position, using population-based electronic health records.

METHODS

We linked England cancer registry records of patients diagnosed with cancer of the colon, rectum, lung or Hodgkin lymphoma between 2009 and 2013, with hospital admissions records. A comorbidity was any one of fourteen specific conditions, diagnosed during hospital admission up to 6 years prior to cancer diagnosis. We calculated the crude and age-sex adjusted prevalence of each condition, the frequency of multiple comorbidity combinations, and used logistic regression and multinomial logistic regression to estimate the adjusted odds of having each condition and the probability of having each condition as a single or one of multiple comorbidities, respectively, by cancer type.

RESULTS

Comorbidity was most prevalent in patients with lung cancer and least prevalent in Hodgkin lymphoma patients. Up to two-thirds of patients within each of the four cancer patient cohorts we studied had at least one comorbidity, and around half of the comorbid patients had multiple comorbidities. Our study highlighted common comorbid conditions among the cancer patient cohorts. In all four cohorts, the odds of having a comorbidity and the probability of multiple comorbidity were consistently highest in the most deprived cancer patients.

CONCLUSIONS

Cancer healthcare guidelines may need to consider prominent comorbid conditions, particularly to benefit the prognosis of the most deprived patients who carry the greater burden of comorbidity. Insight into patterns of cancer comorbidity may inform further research into the influence of specific comorbidities on socio-economic inequalities in receipt of cancer treatment and in short-term mortality.

The health care reform in Portugal: Outcomes from both the New Public Management and the economic crisis

The Portuguese health system concentrates most of its activity in a National Health Service, created in 1979 to promote universal and general access. The National Health Service should ensure equity, efficiency, and quality of all health care delivered services. This study assesses the impact of health care policies between 2002 and 2017, focusing on 3 timeframes: the adoption and adaptation of New Public Management principles to the health care sector (2002 to 2010), the economic and financial crisis period (2011-2015), and the postcrisis recovery period (2016-2017). The current study evaluates the main policy measures in the health sector, presenting their impacts in terms of access, efficiency, accountability, and costs over those 3 economic periods. It was verified that not all the measures implemented by the successive governments obtained the desired outcomes, generating even costs increase, apart from the austerity period in which health expenditure showed a significant reduction because of the financial constraints.

Socioeconomic status is associated with global diabetes prevalence

The incidence of diabetes is increasing globally. We investigated the relationship between diabetes prevalence and patient socioeconomic status across multiple countries. We searched PubMed to identify population-based surveys reporting diabetes prevalence between 1990 and May 2016. Search results were filtered, and Human Development Index (HDI) values from the United Nations Development Programme were used to assess socioeconomic status for a given nation. Our analysis included 45 national surveys from 32 countries. Diabetes prevalence was positively correlated with national HDI (r = 0.421 P = 0.041) in developing countries, and negatively correlated with HDI (r = −0.442 P = 0.045) in developed countries. Diabetes prevalence trends were the same in women and men, although men were associated with increased diabetes risk in developed countries (r = 0.459 P = 0.048). Thus, diabetes prevalence rises with increasing HDI in developing countries, and this is reversed in developed countries. Ours is the first study to investigate the relationship between diabetes and socioeconomic status at global level using HDI values. These results will aid in evaluating global diabetes prevalence and risk with respect to patient socioeconomic status, and will be useful in the development of policies that help reduce disease incidence.

Prevalence of and secular trends in diagnosed diabetes in Italy: 1980-2013

BACKGROUND AND AIMS

The aim of this research was to examine the prevalence of diabetes in Italy over a 34-year period.

METHODS AND RESULTS

Self-reported diabetes was assessed in eight health interview surveys of representative samples of Italian population aged 20 years and over. Crude and standardised prevalence were calculated by age, sex, educational level and area of residence. Logistic models were fitted to calculate the contribution of age and BMI to the trend in prevalence. In 2013 nearly 3.4 million Italians had a diagnosis of diabetes, more than twice as many as in 1980. The crude prevalence of diabetes in men rose from 3.3% in 1980 to 7.1% in 2013 (+115%), and from 4.7% to 6.8% in women (+45%). The prevalence was almost stable during the eighties, and started to rise from the beginning of the nineties. One third of the increase in men and two thirds in women is due to the ageing of the population, since the age-standardised prevalence increased by 79% in men and 14% in women. The prevalence of overweight and obesity increased less steeply than diabetes, and their contribution to the trend in diabetes is less relevant than age. Prevalence rose more in the elderly, in low-educated men, and in high-educated women.

CONCLUSION

Given that the ageing population plays a considerable role in explaining the trend, and that the number of people in the oldest age groups will continue to grow, the rise in the number of individuals with diabetes will represent a severe challenge for the national health system.

Air pollution and occurrence of type 2 diabetes in a large cohort study

The few cohort studies that have investigated the association between exposure to air pollution and occurrence of diabetes have reported conflicting results. We aimed to evaluate the association of long-term exposure to particulate matter (PM), nitrogen oxides (NO_x) and ozone (O₃), with baseline prevalence and incidence of type 2 diabetes in a large administrative cohort in Rome, Italy. A total of 1,425,580 subjects aged 35+years (January 1st, 2008) were assessed and followed for six years. We estimated PM₁₀, PM_2.5-10, PM_2.5, NO₂, and NO_x exposures at residence using land use regression models, and summer O₃ exposure using dispersion modeling. To estimate the association between air pollutant exposures and prevalence and incidence of diabetes, we used logistic and Cox regression models, considering individual, environmental (noise and green areas), and contextual characteristics. We identified 106,387 prevalent cases at baseline and 65,955 incident cases during the follow-up period. We found positive associations between nitrogen oxides exposures and prevalence of diabetes with odds ratios (ORs) up to 1.010 (95% CI: 1.002, 1.017) and 1.015 (1.009, 1.021) for NO₂ and NOx, respectively, per fixed increases (per 10μg/m³ and 20μg/m³, respectively). We also found some evidence of an association between NOx and O₃ and incidence of diabetes, with hazard ratios (HRs) of 1.011 (95%CI: 1.003-1.019) and 1.015 (1.002-1.027) per 20 and 10μg/m³ increases, respectively. The association with O₃ with incident diabetes was stronger in women than in men and among those aged <50years. In sum, long-term exposure to nitrogen oxides was associated with prevalent diabetes while NOx and O₃ exposures were associated with incident diabetes.

Health inequalities and the impact on the prevalence of cardiovascular risk factors and chronic complications in Argentina: a study on national risk factors surveys

BACKGROUND

In Argentina, there is evidence of health inequalities, measured both at the general level and also using income as a parameter of social status. However, few studies address the issue of health equality in chronic diseases such as cardiovascular risk factors.

OBJECTIVE

To describe health inequalities, using cardiovascular risk factors as a tracer for chronic diseases in different areas of the country and over time. In addition, we aim to identify differences in the quality of care provided to people with cardiovascular risk factors, between 2005 and 2009.

METHODS

This is an observational study, which used descriptive and quantitative methods. Data from the National Risk Factors Survey from 2005 and 2009 in the cohorts who have chronic diseases (hypertension, diabetes, dyslipidemia and overweight/obesity) were analyzed to assess associations between health status and several demographic, epidemiological and socioeconomic variables. Additionally, clinical and metabolic characteristics of people with diabetes and other cardiovascular risks factors were analyzed in 2005 and 2009 using the database Quality of Diabetes Care (QUALIDIAB).

RESULTS

Cardiovascular risk factors are more frequent in people with lower socioeconomic status, regardless of the indicator. The inequalities detected showed the worst indicators in strata with lower education and income, with the same results both nationwide and separated by region. This inequalities were more pronounced in 2009, and their magnitude changed by region and cardiovascular risk factor. From 2005 to 2009, body mass index, blood glucose and HbA1c value increased. In contrast, both systolic blood pressure and triglycerides decreased, with no significant changes in total cholesterol and diastolic blood pressure.

CONCLUSION

Cardiovascular risk factors present inequalities attributed to social status manifesting at both national and regional levels.

Socioeconomic status and type 2 diabetes complications among young adult patients in Japan

Objective

To assess the relationship between socioeconomic status (SES) and complications of type 2 diabetes among young adults in Japan.

Design

A cross-sectional study.

Setting

Outpatient wards of 96 member hospitals and clinics of the Japan Federation of Democratic Medical Institutions.

Participants

A total of 782 outpatients with type 2 diabetes (525 males, 257 females), aged 20–40 years as of March 31, 2012. After excluding 110 participants whose retinopathy diagnosis was in question, 672 participants were analyzed.

Measurements

We examined the relations between SES (educational level, income, type of public healthcare insurance, and employment status) and diabetes complications (retinopathy and nephropathy) using a multivariate logistic regression analysis.

Results

The prevalence of type 2 diabetic retinopathy was 23.2%, while that of nephropathy was 8.9%. The odds of having retinopathy were higher among junior high school graduates (OR 1.91, 95% CI 1.09–3.34), patients receiving public assistance (OR 2.19, 95% CI 1.20–3.95), and patients with irregular (OR 1.72, 95% CI 1.03–2.86) or no employment (OR 2.23, 95% CI 1.36–3.68), compared to those with a higher SES, even after covariate adjustment (e.g., age, gender, body mass index). Similarly, the odds of having nephropathy were higher among patients with middle (OR 3.61, 95% CI 1.69–8.27) or low income levels (OR 2.53, 95% CI 1.11–6.07), even after covariate adjustment.

Conclusions

Low SES was associated with a greater likelihood of type 2 diabetes complications in young adults. These findings suggest the necessity of health policies that mitigate socioeconomic disparity and thereby reduce the prevalence of diabetic complications.

Neighbourhood immigration, health care utilization and outcomes in patients with diabetes living in the Montreal metropolitan area (Canada): a population health perspective

BACKGROUND

Understanding health care utilization by neighbourhood is essential for optimal allocation of resources, but links between neighbourhood immigration and health have rarely been explored. Our objective was to understand how immigrant composition of neighbourhoods relates to health outcomes and health care utilization of individuals living with diabetes.

METHODS

This is a secondary analysis of administrative data using a retrospective cohort of 111,556 patients living with diabetes without previous cardiovascular diseases (CVD) and living in the metropolitan region of Montreal (Canada). A score for immigration was calculated at the neighbourhood level using a principal component analysis with six neighbourhood-level variables (% of people with maternal language other than French or English, % of people who do not speak French or English, % of immigrants with different times since immigration (<5 years, 5-10 years, 10-15 years, 15-25 years)). Dependent variables were all-cause death, all-cause hospitalization, CVD event (death or hospitalization), frequent use of emergency departments, frequent use of general practitioner care, frequent use of specialist care, and purchase of at least one antidiabetic drug. For each of these variables, adjusted odds ratios were estimated using a multilevel logistic regression.

RESULTS

Compared to patients with diabetes living in neighbourhoods with low immigration scores, those living in neighbourhoods with high immigration scores were less likely to die, to suffer a CVD event, to frequently visit general practitioners, but more likely to visit emergency departments or a specialist and to use an antidiabetic drug. These differences remained after controlling for patient-level variables such as age, sex, and comorbidities, as well as for neighbourhood attributes like material and social deprivation or living in the urban core.

CONCLUSIONS

In this study, patients with diabetes living in neighbourhoods with high immigration scores had different health outcomes and health care utilizations compared to those living in neighbourhoods with low immigration scores. Although we cannot disentangle the individual versus the area-based effect of immigration, these results may have an important impact for health care planning.

Area deprivation and the prevalence of type 2 diabetes and obesity: analysis at the municipality level in Germany

Background

The objective of this study was to analyse the association between area deprivation at municipality level and the prevalence of type 2 diabetes (T2D) and obesity across Germany, controlling for individual socioeconomic status (SES).

Methods

The analyses are based on a large survey conducted in 2006. Information was included from 39,908 adults aged 20 years or above. Area deprivation was assessed using the German Index of Multiple Deprivation (GIMD) at municipality level. About 4,700 municipalities could be included and assigned to a deprivation quintile. Individual SES was assessed by income and educational level. Multilevel logistic models were used to control for individual SES and other potential confounders such as age, sex and physical activity.

Results

We found a positive association of area deprivation with T2D and obesity. Controlling for all individual-level variables, the odds ratios for municipalities in the most deprived quintile were significantly increased for T2D (OR 1.35; 95% CI 1.12–1.64) as well as for obesity (OR 1.14; 95% CI 1.02–1.26). Further analyses showed that these associations were relatively similar for both men and women.

Conclusions

Based on a nationwide dataset, we were able to show that area deprivation at municipality level is significantly associated with the prevalence of T2D and obesity. It will be important to focus preventive efforts on very deprived municipalities.

Comparison of direct costs of type 2 diabetes care: different care models with different outcomes

BACKGROUNDS AND AIMS

To compare direct costs of four different care models and health outcomes in adults with type 2 diabetes.

METHODS AND RESULTS

We used multiple independent data sources to identify 25,570 adults with type 2 diabetes residing in Turin, Italy, as of 1 July 2003. Data extracted from administrative data databases were used to create four care models ranging in organization from highly structured care (integrated primary and specialist care) to progressively less structured care (unstructured care). Regression analyses, adjusted for main confounders, were applied to examine the differences between the models in direct costs, mortality, and diabetes-related hospitalizations rates over a 4-year period. In patients managed according to the unstructured care model (i.e., usual care by a primary care provider and without strict guidelines adherence), excess of all-cause mortality was 84% and 4-year direct cost was 8% higher than in those managed according to the highly structured care model. Cost ratio analysis revealed that the major cost driver in the unstructured care model was hospital admissions, which were 31% higher than the rate calculated for the more structured care models. In contrast, spending on prescription medications and specialist consultations was higher in the highly structured care model.

CONCLUSION

A diabetes care model that integrates primary and specialty care, together with practices that adhere to guideline recommendations, was associated with a reduction in all-cause mortality and hospitalizations, as compared with less structured models, without increasing direct health costs.

Area level deprivation is an independent determinant of prevalent type 2 diabetes and obesity at the national level in Germany. Results from the National Telephone Health Interview Surveys 'German Health Update' GEDA 2009 and 2010

Objective

There is increasing evidence that prevention programmes for type 2 diabetes mellitus (T2DM) and obesity need to consider individual and regional risk factors. Our objective is to assess the independent association of area level deprivation with T2DM and obesity controlling for individual risk factors in a large study covering the whole of Germany.

Methods

We combined data from two consecutive waves of the national health interview survey ‘GEDA’ conducted by the Robert Koch Institute in 2009 and 2010. Data collection was based on computer-assisted telephone interviews. After exclusion of participants <30 years of age and those with missing responses, we included n = 33,690 participants in our analyses. The outcome variables were the 12-month prevalence of known T2DM and the prevalence of obesity (BMI ≥30 kg/m²). We also controlled for age, sex, BMI, smoking, sport, living with a partner and education. Area level deprivation of the districts was defined by the German Index of Multiple Deprivation. Logistic multilevel regression models were performed using the software SAS 9.2.

Results

Of all men and women living in the most deprived areas, 8.6% had T2DM and 16.9% were obese (least deprived areas: 5.8% for T2DM and 13.7% for obesity). For women, higher area level deprivation and lower educational level were both independently associated with higher T2DM and obesity prevalence [highest area level deprivation: OR 1.28 (95% CI: 1.05–1.55) for T2DM and OR 1.28 (95% CI: 1.10–1.49) for obesity]. For men, a similar association was only found for obesity [OR 1.20 (95% CI: 1.02–1.41)], but not for T2DM.

Conclusion

Area level deprivation is an independent, important determinant of T2DM and obesity prevalence in Germany. Identifying and targeting specific area-based risk factors should be considered an essential public health issue relevant to increasing the effectiveness of diabetes and obesity prevention.

The association between resilience and diabetic neuropathy by socioeconomic position: cross-sectional findings from the KORA-Age study

We investigated whether older adults with diabetes mellitus and lower resilience have an increased risk of diabetic neuropathy as compared to older adults with higher resilience, and whether this association varies by socioeconomic position. In total, 3942 individuals took part in a health survey in Augsburg, Germany, in 2008-2010 (KORA-Age study). We found that among participants with low socioeconomic position, those with higher resilience had a lower probability of suffering from neuropathy as compared to participants with lower resilience (absolute risk reduction = 10%). Adjusted odds ratio with 95% confidence intervals for the outcome diabetic neuropathy also showed that lower resilience scores had an independent effect in increasing the risk of diabetic neuropathy among elderly individuals with a low socioeconomic position (odds ratio: 1.83; confidence interval: 1.09-3.08). Health-promoting strategies focussing on resilience should be further explored.

Reward-based, task-setting education strategy on glycemic control and self-management for low-income outpatients with type 2 diabetes

AIMS/INTRODUCTION

The purpose of the study was to determine the feasibility and effect of a reward-based, task-setting strategy for low-income outpatients with type 2 diabetes.

MATERIALS AND METHODS

Indigent diabetes outpatients without glucometers were eligible to participate in this trial. A total of 132 cases were randomly recruited. Participants in group B used glucometers for self-monitoring at no cost. Group A participants could keep the glucometers only if the glycosylated hemoglobin level declined compared with the baseline visit; for those not achieving a reduction in the glycosylated hemoglobin level, the glucometers would have to be returned. Group C served as the control group without self-monitoring setout. Diabetes education was provided to all groups. Metabolic indices and self-management were evaluated after 6 months of follow up.

RESULTS

Group A had a significant decline in the glycosylated hemoglobin level (-0.97%) and medical costs (-159 yuan) compared with the baseline visit, whereas groups B and C had a decrease in the glycosylated hemoglobin levels alone (-0.62 and -0.57%, respectively). The body mass index did not change significantly in any group. There was a statistical difference in the glycosylated hemoglobin level of group A compared with groups B and C. Self-management in group A improved the outcome relative to groups B and C.

CONCLUSIONS

This preliminary evidence suggests that the program is feasible, acceptable for improving patient self-management, and cost-effective in reducing the glycosylated hemoglobin level and medical costs.