The relationship between physicians' self-reported target fasting blood glucose levels and metabolic control in type 2 diabetes. The QuED Study Group--quality of care and outcomes in type 2 diabetes

Efficacy and Safety of Basal Insulin-Based Treatment Versus Twice-Daily Premixed Insulin After Short-Term Intensive Insulin Therapy in Patients with Type 2 Diabetes Mellitus in China: Study Protocol for a Randomized Controlled Trial (BEYOND V)

INTRODUCTION

Many Chinese patients who are uncontrolled by oral antidiabetic drugs (OADs) receive short-term intensive insulin therapy (IIT) in hospital to rapidly relieve glucose-associated toxicity and to preserve/improve β-cell function. However, evidence for optimizing insulin algorithms for maintenance treatment after IIT is lacking. This study will compare the efficacy and safety of basal insulin-based treatment versus twice-daily premixed insulin in type 2 diabetes mellitus (T2DM) patients after short-term in-hospital IIT.

METHODS

This 26-week randomized, multicenter, positive-controlled, open-label, parallel-group study will enroll approximately 400 male and female patients aged 18-70 years with poorly-controlled T2DM (HbA1c > 7.5%) despite treatment with metformin plus at least one other OAD for 8 or more weeks. During a run-in period of 7-10 days, patients will be treated in-hospital with IIT comprising insulin glargine (Lantus^®) once daily and insulin glulisine (Apidra^®) three times daily; both regimens will be titrated daily to achieve the glycemic goal. Eligible patients will then be randomized in a 1:1 ratio to insulin glargine plus OADs or twice-daily premixed insulin (NovoLog^® Mix 70/30) for 24 weeks, with metformin maintained throughout the study in both treatment groups. The primary endpoint is HbA1c change from baseline to week 24. Secondary endpoints include assessment of fasting plasma glucose, total daily insulin dose, hypoglycemia incidence, body weight change, adverse events, and patient satisfaction.

DISCUSSION

Given the current lack of clinical data, this study will provide evidence supporting safe and effective glycemic control using basal insulin glargine-based therapy plus OADs compared with twice-daily premixed insulin in Chinese patients with T2DM after short-term IIT. This will assist physicians by providing a wider choice of treatments.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT03359837 (registered on 2 December 2017).

Patient and General Practitioner characteristics influencing the management of non-insulin-treated diabetes mellitus: A cross-sectional study in Italy

AIMS

We assessed the influence of patient and General Practitioner (GP) characteristics on the adherence to process of care indicators for non-insulin-treated type 2 diabetes management in the Veneto Region (northeastern Italy).

METHODS

Among non-insulin-treated diabetic patients aged 18-84years identified by multiple information sources, we assessed the measurement of glycated hemoglobin, microalbumin, and lipids through the year 2013. Patients' variables included gender, age, citizenship, and the attendance to Diabetes Clinics, while GP characteristics were gender, age and an attitude score derived from a questionnaire. The influence of patient and GP variables were investigated through multilevel regression with the execution of two HbA1c tests in 2013 as the outcome.

RESULTS

Out of 139,935 study subjects, more than 70% had at least one HbA1c test in 2013; this percentage decreased to about 40% for two HbA1c examinations. 67% of patients had an assessment of lipid profile, while 45% underwent a microalbumin test. These percentages were lower for immigrant patients and increased with age until the 65-74years age class. Patients attending Diabetes Clinics were usually better monitored than those who did not. In this latter group, female gender (risk ratio 1.08, 1.02-1.14), younger age (risk ratio 1.15, 1.06-1.25) and high attitude score of GPs (risk ratio 1.20, 1.13-1.27) were associated with a better management.

CONCLUSIONS

Both patient and GP variables influence the adherence to process of care indicators. The implementation of effective strategies of disease management at the primary care level may improve the control of glycemic and cardiovascular risk factors.

Fears and concerns of Iranian diabetic women: A phenomenological study

This study explored the fears and concerns of 19 Iranian diabetic women using a phenomenological approach. Semistructured individual interviews were conducted; each interview was transcribed verbatim and analyzed simultaneously using Van Manen's method. Data analysis resulted in the emergence of two main themes: (1) "a vague and uncertain future" with sub-themes of "fears of dependency," "loneliness," "disease complications," and "children's future"; and (2) "changing lifestyles" with sub-themes of "dietary restrictions" and "insulin injection." Psychological concerns are common in Iranian diabetic women. These concerns can contribute to poor disease self-management. Thus, it is hoped that identifying these concerns can lead to better management of these issues and a better outcome in diabetic patients.

Trauma healthcare providers' knowledge of alcohol abuse

BACKGROUND

Brief alcohol interventions for patients in trauma settings have demonstrated significant reductions in drinking behaviors, injury related risk behaviors, and subsequent arrests for driving while intoxicated. However, although a number of surveys have examined the knowledge and attitudes of trauma center personnel regarding alcohol problems, the knowledge and attitudes toward alcohol misuse, screening, and intervention services among various trauma care personnel within an individual trauma center have not been investigated. The purpose of this study was to examine provider knowledge and attitudes related to screening and brief intervention for alcohol problems in a single Level-I trauma center.

METHODS

A cross-sectional online survey was administered to employees of a Level-I trauma center with a screening and brief intervention program. Surveys were solicited from hospital staff responsible for the care of trauma patients. Topics covered in the survey included alcoholism, brief interventions in trauma centers, and motivational interviewing.

RESULTS

Most trauma care staff members surveyed were white and held BS/BA degrees or Associates' degrees in nursing. The average years of professional practice were 8.6 years. Staff's attitudes regarding those who misuse alcohol was somewhat neutral, showing a weak understanding of the etiology of alcoholism and the effectiveness of brief intervention and referral for treatment. Staff members also struggled to correctly identify the components of brief interventions.

CONCLUSIONS

This limited knowledge and the neutral attitudes regarding alcohol problems may indirectly influence metrics of program success. Trauma care staff will benefit from additional training regarding alcohol problems and brief interventions.

Association of doctor specialty with diabetic patient risk of hospitalization due to diabetic ketoacidosis: a national population-based study in Taiwan

OBJECTIVES

Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus, and its risks can be largely reduced by adequate and high-quality ambulatory diabetic care. The aim of this study is to assess the risk and frequency of developing DKA in relation to the specialty of doctors who provide diabetes cares.

METHODS

In searching for possible episodes of hospitalization due to DKA (ICD-9-CM: 250.1), we used a prospective cohort design in which 500,867 diabetic patients identified in the 1997 National Health Insurance (NHI) ambulatory care data set of Taiwan were linked to the 1997-2006 NHI inpatient claims data. The study subjects were categorized into four groups according to doctor specialty. A logistic regression model was used to assess the risk and frequency of DKA admission in relation to doctor's specialty.

RESULTS

Compared with the patients routinely cared by endocrinologists, those not consistently cared by endocrinologists had significantly increased odds ratios (ORs) of DKA admission, ranging between 1.51 and 2.12. Moreover, the adjusted OR of the higher DKA admission frequency (≥ 0.133 times/person-year) for the patients not regularly cared by endocrinologists was also significantly increased, between 4.45 and 6.93.

CONCLUSIONS

Doctor specialty significantly influenced the risk and frequency of DKA admission in diabetes patients in Taiwan. Local health care administrators and policy makers should therefore consider promoting the quality of diabetes care provided by non-endocrinologists.

Target setting in intensive insulin management is associated with metabolic control: the Hvidoere childhood diabetes study group centre differences study 2005

OBJECTIVE

To evaluate glycaemic targets set by diabetes teams, their perception by adolescents and parents, and their influence on metabolic control.

METHODS

Clinical data and questionnaires were completed by adolescents, parents/carers and diabetes teams in 21 international centres. HbA1c was measured centrally.

RESULTS

A total of 2062 adolescents completed questionnaires (age 14.4 +/- 2.3 yr; diabetes duration 6.1 +/- 3.5 yr). Mean HbA 1c = 8.2 +/- 1.4% with significant differences between centres (F = 12.3; p < 0.001) range from 7.4 to 9.1%. There was a significant correlation between parent (r = 0.20) and adolescent (r = 0.21) reports of their perceived ideal HbA1c and their actual HbA1c result (p < 0.001), and a stronger association between parents' (r = 0.39) and adolescents' (r = 0.4) reports of the HbA1c they would be happy with and their actual HbA1c result. There were significant differences between centres on parent and adolescent reports of ideal and happy with HbA1c (8.1 < F > 17.4;p < 0.001). A lower target HbA1c and greater consistency between members of teams within centres were associated with lower centre HbA1c (F = 16.0; df = 15; p < 0.001).

CONCLUSIONS

Clear and consistent setting of glycaemic targets by diabetes teams is strongly associated with HbA1c outcome in adolescents. Target setting appears to play a significant role in explaining the differences in metabolic outcomes between centres.

Clinical and socio-economic correlates of quality of life and treatment satisfaction in patients with type 2 diabetes

BACKGROUND AND AIM

The aim of the present study was to assess health-related quality of life (HRQOL) and treatment satisfaction in a large, ambulatory based sample of patients with type 2 diabetes. In particular, we evaluated a large array of socio-economic, clinical, and management-related factors, to investigate the extent to which they correlate with physical and psychological well-being, and with treatment satisfaction.

METHODS AND RESULTS

Patients were requested to fill in a questionnaire including the SF-36 Health Survey (SF-36), the WHO-Well Being Questionnaire (WBQ), and the WHO-Diabetes Treatment Satisfaction Questionnaire (DTSQ). The analyses were based on multivariate analyses, adjusted for patient clinical and socio-demographic characteristics. The study involved 2499 patients, enrolled in 203 diabetes outpatient clinics. Female gender and diabetes complications were associated with worse physical and psychological well-being, while socioeconomic variables were mainly related to general well-being. The perceived frequency of hyperglycemic episodes was negatively associated with all the dimensions explored. Treatment satisfaction was inversely related to female gender, insulin treatment, perceived frequency of hyperglycemic episodes and diabetes complications. Blood glucose self-monitoring, and among patients treated with insulin, self-management of insulin doses and the use of pen for insulin injections, were associated with higher levels of satisfaction. Finally, higher levels of satisfaction were associated with a better perception of physical and psychological well-being.

CONCLUSIONS

Health related quality of life and treatment satisfaction are associated with each other and are both affected by a complex interplay between clinical and socio-economic variables. Some negative aspects, mainly associated with insulin treatment and poor perceived metabolic control, can be attenuated by a deeper involvement of the patients in the management of the disease.

Family physician and endocrinologist coordination as the basis for diabetes care in clinical practice

BACKGROUND

To estimate the proportion of diabetic patients (DPts) with peripheral vascular disease treated at a primary health care site after an endocrinologist-based intervention, who meet ATP III and Steno targets of metabolic control, as well as to compare the outcome with the results of the patients treated by endocrinologists.

METHODS

A controlled, prospective over 30-months period study was conducted in area 7 of Madrid. One hundred twenty six eligible diabetic patients diagnosed as having peripheral vascular disease between January 2003 and June 2004 were included in the study. After a treatment period of three months by the Diabetes team at St Carlos Hospital, 63 patients were randomly assigned to continue their follow up by diabetes team (Group A) and other 63 to be treated by the family physicians (FP) at primary care level with continuous diabetes team coordination (Group B). 57 DPts from Group A and 59 from Group B, completed the 30 months follow-up period. At baseline both groups were similar in age, weight, time from diagnosis and metabolic control. The main outcomes of this study were the proportion of patients meeting ATP III and Steno goals for HbA1c (%), Cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, blood pressure, albumine-to-creatinine excretion ratio (ACR), body mass index (BMI), waist circumference (WC), anti-aggregation treatment and smoking status.

RESULTS

At the end of the follow up, no differences were found between the groups. More than 37% of diabetic patients assigned to be treated by FP achieved a HbA1c < 6.5%, more than 50% a ACR < 30 mg/g, and more than 80% reached low risk values for cholesterol, LDL cholesterol, triglycerides, diastolic blood pressure and were anti-aggregated, and 12% remained smokers. In contrast, less than 45% achieved a systolic blood pressure < 130 mm Hg, less than 12% had a BMI < 25 Kg.m-2 (versus 23% in group A; p < 0.05) and 49%/30% (men/women) had a waist circumference of low risk.

CONCLUSION

Improvements in metabolic control among diabetic patients with peripheral vascular disease treated at a primary health care setting is possible, reaching similar results to the patients treated at a specialized level. Despite such an improvement, body weight control remains more than poor in both levels, mainly at primary care level. General practitioner and endocrinologist coordination care may be important to enhance diabetes management in primary care settings.

TRIAL REGISTRATION

Clinical Trial number ISRCTN75037597.

Point of care testing to improve glycemic control

PURPOSE

The purpose of this paper is to pilot-test the feasibility and impact of protocol-driven point-of-care HbAlc testing on levels of glycemic control and on rates of diabetic regimen intensification in an urban community health center serving low-income patients.

DESIGN/METHODOLOGY/APPROACH

The paper suggests a primary care process re-design, using point of care finger-stick HbA1c testing under a standing order protocol that provided test results to the provider at patient visit.

FINDINGS

The paper finds that the protocol was well received by both nurses and physicians. HbA1c testing rates increased from 73.6 percent to 86.8 percent (p = 0.40, n = 106). For the 69 patients who had both pre- and post-intervention results, HbAlc levels decreased significantly from 8.55 to 7.84 (p = 0.004, n = 69). At baseline, the health center as a system was relatively ineffective in responding to elevated HbA1c levels. An opportunity to intensify, i.e. a face-to-face visit with lab results available, occurred for only 68.6 percent of elevated HbAlc levels before the intervention, vs. 100 percent post-intervention (p < 0.001). Only 28.6 percent of patients with HbAlc levels >8.0 had their regimens intensified in the pre-intervention phase, compared with 53.8 percent in the post-intervention phase (p = 0.03).

RESEARCH LIMITATIONS/IMPLICATIONS

This was a pilot-study in one urban health center. Larger group-randomized controlled trials are needed.

PRACTICAL IMPLICATIONS

The health center's performance as a system, improved significantly as a way of intensifying diabetic regimens thereby achieving improved glycemic control.

ORIGINALITY/VALUE

This intervention is feasible, replicable and scalable and does not rely on changing physician behaviors to improve primary care diabetic outcomes.

Quality of diabetes care predicts the development of cardiovascular events: results of the QuED study

BACKGROUND AND AIM

In the context of the QuED Study we assessed whether a quality of care summary score was able to predict the development of cardiovascular (CV) events in patients with type 2 diabetes.

METHODS AND RESULTS

The score was calculated using process and intermediate outcome indicators (HbA1c), blood pressure, low-density lipoprotein cholesterol, microalbuminuria) and ranged from 0 to 40. Overall, 3235 patients were enrolled, of whom 492 developed a CV event after a median follow-up of 5 years. The incidence rate (per 1000 person-years) of CV events was 62.4 in patients with a score < or =10, 54.8 in those with a score between 15 and 20, and 39.8 in those with a score >20. In adjusted multilevel regression models, the risk to develop a CV event was 89% greater in patients with a score of < or =10 (rate ratio [RR]=1.89; 95% confidence interval [CI] 1.43-2.50) and 43% higher in those with a score between 10 and 20 (RR=1.43; 95% CI 1.14-1.79), as compared to those with a score >20. A difference between centers of 5 points in the mean quality score was associated with a difference of 16% in CV event risk (RR=0.84; 95% CI 0.72-0.98).

CONCLUSION

Our study documented for the first time a close relationship between a score of quality of diabetes care and long-term outcomes.

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.

Family doctors' knowledge and self-reported care of type 2 diabetes patients in comparison to the clinical practice guideline: cross-sectional study

Background

It is widely believed that providing doctors with guidelines will lead to more effective clinical practice and better patient care. However, different studies have shown contradictory results in quality improvement as a result of guideline implementation. The aim of this study was to compare family doctors' knowledge and self-reported care of type 2 diabetes patients with recommendation standards of the clinical practice guideline.

Methods

In April 2003 a survey was conducted among family doctors in Estonia. The structured questionnaire focused on the knowledge and self-reported behavior of doctors regarding the guideline of type 2 diabetes. The demographic and professional data of the respondents was also provided.

Results

Of the 354 questionnaires distributed, 163 were returned for a response rate of 46%. Seventy-six percent of the responded doctors stated that they had a copy of the guideline available while 24% reported that they did not. Eighty-three percent of the doctors considered it applicable and 79% reported using it in daily practice. The doctors tended to start treatment with medications and were satisfied with treatment outcomes at higher fasting blood glucose levels than the levels recommended in the guideline. Doctors' self-reported performance of the tests and examinations named in the guideline, which should be performed within a certain time limit, varied from overuse to underuse. Blood pressure, serum creatinine, eye examination and checking patients' ability to manage their diabetes were the best-followed items while glycosylated hemoglobin and weight reduction were the most poorly followed. Doctors' behavior was not related to the fact of whether they had the guideline available, whether they considered it applicable, or whether they actually used it.

Conclusion

Doctors' knowledge and self-reported behavior in patient follow-up of type 2 diabetes is very variable and is not related to the reported availability or usage of the guideline. Practice guidelines may be a useful source of information but they should not be overestimated.

Efficacy of intensive multitherapy for patients with type 2 diabetes mellitus: a randomized controlled trial

BACKGROUND

National guidelines for managing diabetes set standards for care. We sought to determine whether a 1-year intensive multitherapy program resulted in greater goal attainment than usual care among patients with poorly controlled type 2 diabetes mellitus.

METHODS

We identified patients with poorly controlled type 2 diabetes receiving outpatient care in the community or at our hospital. Patients 30-70 years of age with a hemoglobin A1c concentration of 8% or greater were randomly assigned to receive intensive multitherapy (n = 36) or usual care (n = 36).

RESULTS

The average hemoglobin A1c concentration at entry was 9.1% (standard deviation [SD] 1%) in the intensive therapy group and 9.3% (SD 1%) in the usual therapy group. By 12 months, a higher proportion of patients in the intensive therapy group than in the control group had achieved Canadian Diabetes Association (CDA) goals for hemoglobin A(1c) concentrations (goal < or = 7.0%: 35% v. 8%), diastolic blood pressure (goal < 80 mm Hg: 64% v. 37%), low-density lipoprotein cholesterol (LDL-C) levels (goal < 2.5 mmol/L: 53% v. 20%) and triglyceride levels (goal < 1.5 mmol/L: 44% v. 14%). There were no significant differences between the 2 groups in attaining the targets for fasting plasma glucose levels, systolic blood pressure or total cholesterol:high-density lipoprotein cholesterol ratio. None of the patients reached all CDA treatment goals. By 18 months, differences in goal attainment were no longer evident between the 2 groups, except for LDL-C levels. Quality of life, as measured by a specific questionnaire, increased in both groups, with a greater increase in the intensive therapy group (13% [SD 10%] v. 6% [SD 13%], p < 0.003).

INTERPRETATION

Intensive multitherapy for patients with poorly controlled type 2 diabetes is successful in helping patients meet most of the goals set by a national diabetes association. However, 6 months after intensive therapy stopped and patients returned to usual care, the benefits had vanished.

Are Type 2 diabetic patients offered adequate foot care? The role of physician and patient characteristics

In the context of a nationwide outcomes research program on Type 2 diabetes, we investigated physician and patient practices related to foot care. Patients filled in a questionnaire investigating whether they had received information about foot care, how often they had had their feet examined in the last year, and how often they usually checked their feet. Analyses were adjusted for patient case-mix and physician-level clustering. Overall, 3564 patients were recruited by 125 diabetes outpatient clinics (DOCs) and 103 general practitioners (GPs), of whom 6.8% suffered form lower limb complications. The presence of foot complications was correlated with insulin treatment, cigarette smoking, low levels of school education, and the presence of other diabetic complications. More than 50% of the patients reported that they had not had their feet examined by their physician and 28% referred that they had not received foot education. Patients with lower levels of school education and income, as well as overweight individuals, were less likely to receive foot education. Physicians tended to perform foot examination more often in males, low-income patients, those with foot complications, and those treated with insulin, but not in patients with the highest risk of foot complications, that is, those with diabetic neuropathy or peripheral vascular disease (PVD). GPs tended to perform foot examination less frequently than diabetologists do. Foot self-examination was not performed by 33% of the patients. Those individuals who had received foot education or had had their feet examined were more likely to check their feet regularly. A substantial proportion of Type 2 diabetic patients is not offered adequate foot care, even in the presence of major risk factors for lower limb complications. Patient knowledge and practices are strongly related to physicians' attitudes.

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.

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.

General practitioner attitudes to the care of people with epilepsy: an examination of clustering within practices and prediction of patient-rated quality of care

BACKGROUND

There is wide variation in the quality of care provided by primary care practices to individuals with chronic illnesses. Individual doctor attitudes and interest have been demonstrated to influence patient outcomes in some instances. Given the trend towards larger practices and part-time working, continuity of care is likely to fall and thus practice-based rather than individual general practitioner attributes and attitudes are likely to become increasingly important. The aim in this paper was to examine the extent to which individual general practitioner (G.P.) attitudes to the care of people with epilepsy cluster within practices and predict patient-rated quality of care.

METHODS

The sample consisted of 1255 people with active epilepsy (a recent seizure or on anti-convulsant medication for epilepsy) and 199 GPs from 82 general practices. Measures of GP attitudes (a 17-item GP attitudes questionnaire) and patient-rated quality of epilepsy care were obtained. 1210 individuals completed initial questionnaires and 975 patients filled in final questionnaires one year later. Responses were achieved from 64 practices (83% of total) and 115 GPs (60% of total).

RESULTS

2 main factors were found to underlie GP attitudes to the care of people with epilepsy and these demonstrated clustering within practices "epilepsy viewed as a primary care responsibility" (Eigenvalue 3.98, intra-class correlation coefficient (ICC) 0.40), and "medication skills"(Eigenvalue 2.74, ICC 0.35). GP-rated scores on "epilepsy care being a primary care responsibility" were a significant predictor of patient-rated quality of GP care (p = 0.031). Other contributory factors were seizure frequency (p = 0.044), and patient-rated "shared decision making" (p = 0.022).

CONCLUSION

Specific general practitioner attitudes to the care of people with epilepsy cluster within practices and are significantly associated with patient-rated quality of epilepsy care. It is important to take these findings into consideration when planning primary care interventions to ensure people with epilepsy receive the benefits of available medical and surgical expertise.

Impact of physicians' beliefs and practices on cholesterol levels in patients with type 2 diabetes: a longitudinal assessment

BACKGROUND

Clinical trials demonstrate significant benefit from cholesterol management for patients with type 2 diabetes. The aim of this work was to explore the correlates of lipid management in patients with type 2 diabetes, including the subjective beliefs of physicians, setting of care, and patient-related factors.

METHODS

This longitudinal outcomes research study involved 2359 patients with type 2 diabetes recruited by 111 general practitioners and 214 physicians practicing in diabetes clinics. Physicians' beliefs were assessed through a questionnaire administered when the study started in 1998. Main outcome measures were total cholesterol (TC) and LDL cholesterol (LDL-C) levels over 3 years and the proportion of patients treated with lipid-lowering drugs (LLDs).

RESULTS

Less than one-third of the physicians (27%) stated that they routinely started pharmacologic therapy for TC values > or =200 mg/dL (more aggressive), whereas 46% considered a TC level > or =240 mg/dL as the threshold for the initiation of treatment (less aggressive). During 3 years of observation, mean TC and LDL-C levels decreased from 215 +/- 40 mg/dL to 203 +/- 37 mg/dL and from 135 +/- 36 mg/dL to 126 +/- 35 mg/dL respectively, while the proportion of patients treated with LLDs increased from 13.2% to 24.6%; in particular, among individuals cared for by the more aggressive physicians, 30.0% were taking LLDs after 3 years, while only 17.7% of those followed by the less aggressive physicians and 18.1% of those followed by >1 physician were being treated with LLDs. Multilevel analysis showed that physicians' beliefs were an independent predictor of TC levels over the 3-year period. In patients treated with LLDs, TC levels decreased on average by 14%, and LDL-C levels decreased by 20%.

CONCLUSION

Our data show that physicians' beliefs in more aggressive management strategies will result in better mean TC values over a 3-year period.

Correlates of satisfaction for the relationship with their physician in type 2 diabetic patients

In the context of an Italian nation-wide outcomes research program on type 2 diabetes, we investigated the contribution of both patient and setting-related factors to patient satisfaction with their relationship with their physicians. The level of patient satisfaction was measured using the American Board of Internal Medicine (ABIM) 14 patient satisfaction questionnaire. The main results were obtained using multilevel analysis, a statistical technique that takes into account the clustered nature of our data. Overall, 3563 patients were recruited by 101 diabetologists and 103 general practitioners (GPs). Information on patients' satisfaction was available for 2515 patients (71% of the whole sample). Patients' satisfaction was related to patient characteristics and attitudes, but not with physician's sex, age, speciality, and setting of care. In particular, patients who were less likely to delegate to physicians responsibility for diabetes management and those perceiving a lower degree of involvement in disease management showed lower levels of satisfaction. Lower satisfaction scores were also related to lower levels of school education, more severe clinical conditions, and lower psychological adaptation to diabetes. However, patients reporting higher levels of diabetes related worries and more frequent encounters with health care providers showed higher levels of satisfaction. In conclusion, patient satisfaction with physicians' humanness and communication skills is strongly related to personal characteristics, attitudes, expectations, and perceived health. In deciding the best decision-making approach to adopt in individual patients, it is of primary importance to measure how the patient perceives and engages in relationships.

Individualised treatment goals in diabetes care

OBJECTIVES

To examine 1) patients' characteristics according to the treatment goal chosen at diabetes diagnosis, and 2) the association between individualised goals for glycated haemoglobin (HbA1c), blood pressure (BP) and lipids, and the risk factor level subsequently achieved.

DESIGN

Follow-up study embedded in a multifaceted intervention study directed at doctors encouraging individualised goal-setting in newly diagnosed diabetic patients aged > or = 40 years.

SETTING

General practice.

SUBJECTS

In all, 243 general practitioners and 674 patients participated.

MAIN OUTCOME MEASURES

Risk factors for diabetic complications.

RESULTS

Relatively young age, low diagnostic plasma glucose, low BMI, a moderate or high level of physical activity and normoalbuminuria were associated with a treatment goal of good control at diagnosis. After 5 years, median HbA1c was 8.2%, 8.6% and 8.0% in patients with a goal of good, acceptable and poor control, respectively. Patients with a goal of good control versus those with a goal of acceptable control had a lower HbA1c level in a regression analysis adjusted for age, sex, HbA1c at diagnosis, BMI, total cholesterol, fasting triglycerides, BP, physical activity, smoking status and diabetes duration. We found no association between goals and the level of BP and lipids.

CONCLUSION

Doctors tend to pursue normoglycaemia in relatively young patients with low blood glucose, low BMI, high activity level and normoalbuminuria. Patients for whom a goal of normoglycaemia was chosen at diagnosis achieved favourable glycaemic control at 5-year follow-up. Whether doctors choosing the goals were good at predicting future glycaemic control, or whether goal-setting is an important motivational factor in achieving optimal glycaemic control needs to be explored.

The assessment and management of antipsychotic-associated metabolic disturbances from a psychiatric perspective

OBJECTIVE

To review the available data on the management of antipsychotic-associated metabolic disturbances from a psychiatric perspective.

METHOD

A literature search was initially conducted using the key words followed by a search of relevant articles, including conference abstracts.

RESULTS

The investigation and management of metabolic disturbances in psychiatric patients poses particular problems. Given that this population is at high risk, early identification and prevention are particularly important.

CONCLUSION

Strategies for the management of metabolic disturbances in psychiatric patients are primarily based on treatments used in the general population, but their effectiveness in psychiatric populations is anecdotal. In view of the high levels of untreated medical comorbidity in psychiatric patients and the potential exacerbation through antipsychotic use in this high-risk population, specific outcome research in this population is needed. Further, referral for specialist management is recommended.

Quality of care and outcomes in type 2 diabetic patients: a comparison between general practice and diabetes clinics

OBJECTIVE

The role of general practice and diabetes clinics in the management of diabetes is still a matter of debate. Methodological flaws in previous studies may have led to inaccurate conclusions when comparing the care provided in these different settings. We compared the care provided to type 2 diabetic patients attending diabetes outpatient clinics (DOCs) or being treated by a general practitioner (GP) using appropriate statistical methods to adjust for patient case mix and physician-level clustering.

RESEARCH DESIGN AND METHODS

We prospectively evaluated the process and intermediate outcome measures over 2 years in a sample of 3,437 patients recruited by 212 physicians with different specialties practicing in 125 DOCs and 103 general practice offices. Process measures included frequency of HbA(1c), lipids, microalbuminuria, and serum creatinine measurements and frequency of foot and eye examinations. Outcome measures included HbA(1c), blood pressure, and total and LDL cholesterol levels.

RESULTS

Differences for most process measures were statistically significantly in favor of DOCs. The differences were more marked for patients who were always treated by the same physician within a DOC and if that physician had a specialty in diabetology. Less consistent differences in process measures were detected when patients followed by GPs were compared with those followed by physicians with a specialty other than diabetology. As for the outcomes considered, patients attending DOCs attained better total cholesterol levels, whereas no major differences emerged in terms of metabolic control and blood pressure levels between DOCs and GPs. Physicians' specialties were not independently related to patient outcomes.

CONCLUSIONS

Being followed always by the same physician in a DOC, particularly if the physician had a specialty in diabetes, ensured better quality of care in terms of process measures. In the short term, care provided by DOCs was also associated with better intermediate outcome measures, such as total cholesterol levels.

Secondary prevention of coronary artery disease in high-risk diabetic patients

BACKGROUND AND AIM

To compare guideline implementation and the actual delivery of secondary prevention for coronary artery disease in the cohort of Italian diabetic patients enrolled in the DAI study.

METHODS AND RESULTS

The DAI study is a multicentre cohort study of the prevalence and incidence of macroangiopathic events among 19,570 type 2 diabetic patients attending 201 Diabetic Care Units. For this study, we selected 1,475 subjects with a history of myocardial infarction, coronary artery bypass graft or percutaneous transluminal coronary angioplasty at enrollment. Only 25% of the coronary patients in secondary prevention were receiving lipid-lowering drugs, and 20% were receiving beta-blockers. None of the patients in 54/185 Diabetic Care Units were on statins, and none in 82/185 Units were on beta-blockers. Multivariate analysis showed a positive correlation between the number of treatments and the taking of statins, and a negative correlation with age.

CONCLUSION

Our data highlight a gap between the therapeutic guidelines and actual treatment, with wide variability in the delivery of secondary prevention across Units. The out-of-pocket cost of medication, daily treatment burden and geographic area can be ruled out as possible explanatory factors. Physicians' prescription attitudes may be a possible reason.

The association between three different measures of health status and satisfaction among patients with diabetes

Studies suggest that health status influences patient satisfaction, but little work has examined the influence of different measures of health status on satisfaction. The authors examined whether the association between health status and satisfaction varied for different measures of health status among 2000 diabetic patients receiving care across 25 Veterans Affairs facilities. Health status was measured using (1) the diabetes-related components of the Total Illness Burden Index (DM TIBI), a measure of diabetes severity and comorbidities; (2) the Short Form 36 (SF-36) Physical Function Index (PFI10); and (3) the SF-36 general health perceptions question (SF-1). Satisfaction was measured both by a 5-item scale on satisfaction with patient-provider communication and by a single item on overall diabetes care satisfaction. In adjusted models, worse health on all three health status measures correlated with lower satisfaction, but the DM TIBI explained more of the variation in satisfaction than either the PFI10 or SF-1. Moreover, when the DM TIBI was added to the model containing PFI10, PFI10 was no longer significantly associated with satisfaction. In this diabetes population, health status appears to have a substantial impact on patient satisfaction, and this effect is considerably greater for diabetes severity than for physical functioning.

Comparison of patients' and healthcare professionals' beliefs about and attitudes towards Type 2 diabetes

AIMS

To compare patients' and healthcare professionals' beliefs and attitudes towards diabetes.

METHODS

One hundred and four healthcare professionals (nurses, dieticians, general practitioners) and 100 of their patients with Type 2 diabetes completed the Diabetes Attitude Scale, 3rd version (DAS-3). Healthcare professionals also answered questions about their provision of diabetes care.

RESULTS

Healthcare professionals viewed Type 2 diabetes as more serious than their patients. Most of the healthcare professionals considered diabetes harder to treat than other chronic conditions and felt that they did not have adequate time and resources to treat their diabetes patients effectively.

CONCLUSIONS

This study suggests that an important part of forming collaborative alliances with patients is to recognize the distinction between practitioner and patient perspectives in Type 2 diabetes.

The Diabcare-Asia 1998 study--outcomes on control and complications in type 1 and type 2 diabetic patients

The aim of this study was to describe the glycaemic and metabolic control and diabetes-related complications in type 1 and type 2 Asian patients.

METHODS

Data of diabetes patients from 230 diabetes centres in 12 Asian regions were collected on a retrospective-prospective basis through review of medical records, interview and laboratory assessments. Analysis of glycated haemoglobin (HbA1c) was carried out in central laboratories appointed by Bio-Rad. The data collection case record forms were scanned electronically.

RESULTS

22177 patients with valid data made up the analysis population. Among patents with type 1 and type 2 diabetes, there was a higher proportion of women than men (53% vs. 47% for type 1 patients and 56% vs. 44% for type 2 diabetes). Hypertension (61%) and overweight (40% with BMI > or = 25 kg/m2 were common in type 2 patients. Dyslipidaemia was also present in at least half of both types of patients. Control of glycaemia (mean HbA,1c and fasting blood glucose [FBG]) was poor in type 1 (9.9 +/- 2.5%; 10.2 +/- 5.2 mmol/l) and type 2 patients (8.5 +/- 2.0%; 8.9 +/- 3.4 mmol/l). Glycaemia in the majority of both types of patients fell short of those stipulated by various guidelines. In type 2 patients, glycaemia deteriorated (HbA1c > 7.5%, FBG > or = 7.0 mmol/l) with duration of diabetes > 7 years. Both types of diabetes appear to share a similar high prevalence of complications of cataract, retinopathy and neuropathy, although the prevalence of cataract (27%) and neuropathy (35%) was higher in type 2 diabetes. Screening for microalbuminuria was not common.

CONCLUSIONS

The Inadequate metabolic and hypertension control, especially in type 2 patients, needs to be addressed.