Effectiveness and cost-benefit analysis of intensive treatment and teaching programmes for type 1 (insulin-dependent) diabetes mellitus in Moscow--blood glucose versus urine glucose self-monitoring

[History of patient education for chronic diseases (with diabetes mellitus as an example): from an idea to the branch of modern medicine]

The article describes the history of the formation of therapeutic education as one of the most essential components of the treatment of chronic diseases, in particular diabetes. The varieties and methods of programs for patients existing in the Russian Federation are considered in detail.

Health economic evaluation of structured education programs for patients with diabetes: a systematic review

Background

Diabetes structured education programs have been demonstrated to effectively improve glycemic control and self-management behaviors. However, evidence on the health economic evaluation of these programs is limited.

Objectives

To systematically review the health economic evaluation of structured education programs for patients with type 1 and type 2 diabetes mellitus.

Methods

The English databases PUBMED, WEB OF SCIENCE, OVID, COCHRANE LIBRARY, EMBASE, and EBSCO, along with the Chinese databases CNKI, WANFANG, VIP, and SINOMED, were searched from their inception to September 2024. The quality of the literature was assessed using the CHEERS 2022 checklist. A descriptive analysis was performed on the studies included in the review, with all currencies converted to international dollars. An incremental cost-effectiveness ratio of less than one times the per capita GDP was considered highly cost-effective, while a ratio between one and three times the per capita GDP was considered cost-effective.

Results

A total of 28 studies from upper-middle-income and high-income countries were included. The average quality score of the included studies was 18.6, indicating a moderate level of reporting quality. Among these, eleven studies demonstrated that diabetes structured education programs were highly cost-effective and twelve were found to be cost-effective. In contrast, three studies were deemed not cost-effective, and two studies provided uncertain results. The ranges of the incremental cost-effectiveness ratios for short-term, medium-term, and long-term studies were - 520.60 to 65,167.00 dollars, -24,952.22 to 14,465.00 dollars, and -874.00 to 236,991.67 dollars, respectively.

Conclusion

This study confirms the cost-effectiveness of structured education programs for diabetes and highlights their importance for patients with type 2 diabetes who have HbA1c levels exceeding 7% and are receiving non-insulin therapy. Additionally, the potential advantages of incorporating telecommunication technologies into structured diabetes education were emphasized. These findings offer valuable insights and guidance for decision-making in diabetes management and clinical practice, contributing to the optimization of medical resource allocation and the improvement of health status and quality of life for patients.

Pharmacoeconomic Aspects of Diabetes Mellitus: Outcomes and Analysis of Health Benefits Approach

Pharmacoeconomics is an important tool for investigating and restructuring healthcare policies. In India, recent statistical studies have shown that the number of diabetic patients is rapidly increasing in the rural, middle and upper-class settings. The aim of this review is to call attention towards the need to carry out pharmacoeconomic studies for diabetes mellitus and highlight the outcome of these studies on healthcare. A well-structured literature search from PubMed, Embase, Springer, ScienceDirect, and Cochrane was done. Studies that evaluated the cost-effectiveness of various anti-diabetic agents for type 2 diabetes were eligible for inclusion in the analysis and review. Two independent reviewers sequentially assessed the titles, abstracts, and full articles to select studies that met the predetermined inclusion and exclusion criteria for data abstraction. Any discrepancies between the reviewers were resolved through consensus. By employing search terms such as pharmacoeconomics, diabetes mellitus, cost-effective analysis, cost minimization analysis, cost-utility analysis, and cost-benefit analysis, a total of 194 papers were gathered. Out of these, 110 papers were selected as they aligned with the defined search criteria and underwent the removal of duplicate entries. This review outlined four basic pharmacoeconomic studies carried out on diabetes mellitus. It gave a direction that early detection, patient counseling, personalized medication, appropriate screening intervals, and early start of pharmacotherapy proved to be a cost-effective as well as health benefits approach.

What are the characteristics of the best type 1 diabetes patient education programmes (from diagnosis to long-term care), do they improve outcomes and what is required to make them more effective?

The last 20 years have witnessed a marked change in approaches to the management of type 1 diabetes in the UK. This is exemplified by National Institute of Health and Care Excellence (NICE) guidance which acknowledges that reaching and maintaining target glucose depends on people with type 1 diabetes effectively implementing flexible intensive insulin therapy. The guidance emphasizes that successful self-management requires the acquisition of complex skills and is best achieved by participation in high-quality structured education. Controlled trials and other research have shown that programmes teaching self-management can lower glucose levels while reducing hypoglycaemia, improve psychological outcomes and are highly cost-effective. An important principle of successful programmes is therapeutic education in which learning becomes a partnership between the professional and the person with diabetes who learns to fit diabetes into his/her everyday life. Other recommended elements of programmes include a written curriculum, group teaching by a professional multidisciplinary team and quality assurance. Yet many participants struggle post-course to implement and maintain skills, and overall HbA_1c levels, particularly in the UK, remain far from target. Recent studies have identified the barriers to sustained effective self-management and concluded that even high-quality programmes generally lack critical components. These include incorporating evidence from behaviour change research, exploiting the promise of new technologies in reducing the burden of self-management, and providing structured professional support once people have completed the training. Studies are currently underway to evaluate structured training courses which have added these elements and examine whether they can lower glucose to levels closer to target without impairing quality of life.

Assessment of Alimentación Normal con Ajuste de Insulina (ANAIS), a Spanish version of the DAFNE programme, in people with Type 1 diabetes: a randomized controlled parallel trial

AIM

To evaluate the effects of Alimentación Normal con Ajuste de Insulina (ANAIS), a group-based, therapeutic education programme for Type 1 diabetes based on a flexible insulin regimen adjusted to the individual's food intake.

METHODS

Participants with Type 1 diabetes and HbA_1c levels of 53-86 mmol/mol (7-10%) were recruited from outpatient clinics at a tertiary care centre. They were randomized (using opaque, sealed envelopes, with a 2:1 treatment allocation ratio) to attend the training course immediately (immediate ANAIS; intervention group) or a year later (delayed ANAIS; control group). The main outcome was HbA_1c level at 1 year. Secondary outcomes included lipid levels, weight, hypoglycaemic events, insulin dose, treatment satisfaction, self-perceived dietary freedom, quality of life and participant-defined goals.

RESULTS

A total of 48 participants were assigned to the intervention group and 32 to the control group. Twelve months after completing the training, adjusted HbA_1c was not significantly different in the intervention group [64 ± 1.3 vs 68 ± 1.6 mmol/mol (8.0 ±0.1% vs 8.4 ±0.1%); P=0.081]. Treatment satisfaction was significantly higher in the intervention group, but no differences were found in hypoglycaemic events, weight, insulin dose or changes in dietary freedom. At 1 year after the intervention, 72% of the participants (vs 33% in the control group; P=0.046) reported exceeding their expectations regarding achievement of their main personal goal.

CONCLUSION

Promoting dietary freedom and empowering people with Type 1 diabetes through structured education programmes, such as ANAIS, improves treatment satisfaction and self-defined goals. No significant improvement in HbA_1c level was achieved.

Adequate Structured Inpatient Diabetes Intervention in People With Type 1 Diabetes Improves Metabolic Control and Frequency of Hypoglycaemia

OBJECTIVE

Several studies evaluated inpatient diabetes teaching and treatment programmes (DTTP) in diabetes type 1 (DM1) many years ago, but in these studies insulin treatment was not yet intensified before the DTTP. Today, most patients are already on intensified insulin treatment before entering a DTTP. The aim of this trial was to evaluate the outcome one year after participation in an inpatient intervention including a DTTP in a longitudinal study.

METHODS

109 patients participated in an inpatient intervention in 2014. All individuals were invited to participate in an outpatient follow-up visit after one year.

RESULTS

Ninety participants (52.2% female, age 48.0 y, diabetes duration 19.1 y, 31.1% CSII, HbA1c 7.9% / 63.3 mmol/mol) were followed-up after 1.2±0.3 y [1 died, 18 declined / were not available]. 83 / 90 individuals participated to optimise diabetes therapy, 7 / 90 had newly-diagnosed DM1. In the optimisation group, HbA1c decreased by 0.4% (p=0.009) without change of insulin dose (54 IU/day before and after) or BMI (26 kg/m² before and after). In people with baseline HbA1c ≥7.5% (n=26 / 83), HbA1c decreased by 0.9%. The frequency of severe hypoglycaemia decreased from 0.22 to 0.05 events / year (p=0.045). In people with frequent non severe hypoglycaemia (n=8), events decreased from 4.5±2.0 to 2.8±0.9 / week (p=0.358). Systolic (-6.5 mmHg, p=0.035) and diastolic (-3.4 mmHg, p=0.003) blood pressure improved without change of number of antihypertensive medication (1.9±2.1 vs. 1.8±2.0, p=0.288).

CONCLUSIONS

In people with DM1, metabolic control improved after the inpatient intervention without increasing insulin dosage or BMI. The inpatient intervention remains effective to substantially improve metabolic control under the present circumstances of care.

The role of structured education in the management of hypoglycaemia

The role of intensive glycaemic control in preventing microvascular disease in diabetes is well established. Iatrogenic hypoglycaemia is, however, a major barrier to effective treatment. Hypoglycaemia is associated with a significant level of morbidity and, despite pharmacological and technological therapeutic advances, reported rates of severe hypoglycaemia in clinical practice have not fallen over the last 20 years. This suggests that human factors are of major relevance and that ensuring the effective self-management of diabetes is an important strategy for the reduction of hypoglycaemic risk. Most of the evidence for the impact of this strategy on hypoglycaemia risk is confined to adults with type 1 diabetes although, in this review, we also cite studies that have specifically addressed this in type 2 diabetes. There are relatively few adequately powered RCTs that have rigorously evaluated the effectiveness of structured education and training programmes on hypoglycaemia; however, the available data suggest a subsequent reduction in severe hypoglycaemia rates of around 50%, a rate reduction that is comparable with that observed following technological interventions. Furthermore, longitudinal observational cohorts support these data, showing similar reductions in rates of hypoglycaemia following structured education. Those who continue to experience recurrent hypoglycaemia and impaired awareness of hypoglycaemia despite education and training in diabetes self-management may benefit from technological interventions and/or interventions that specifically address psychological factors that contribute to hypoglycaemia risk; however, there is urgent need for further research in this area. In the meantime, structured education for effective self-management of diabetes should be part of routine therapy for all those with type 1 diabetes.

Recent Updates on Type 1 Diabetes Mellitus Management for Clinicians

Type 1 diabetes mellitus (T1DM) is a chronic autoimmune condition that requires life-long administration of insulin. Optimal management of T1DM entails a good knowledge and understanding of this condition both by the physician and the patient. Recent introduction of novel insulin preparations, technological advances in insulin delivery and glucose monitoring, such as continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring and improved understanding of the detrimental effects of hypoglycaemia and hyperglycaemia offer new opportunities and perspectives in T1DM management. Evidence from clinical trials suggests an important role of structured patient education. Our efforts should be aimed at improved metabolic control with concomitant reduction of hypoglycaemia. Despite recent advances, these goals are not easy to achieve and can put significant pressure on people with T1DM. The approach of physicians should therefore be maximally supportive. In this review, we provide an overview of the recent advances in T1DM management focusing on novel insulin preparations, ways of insulin administration and glucose monitoring and the role of metformin or sodium-glucose co-transporter 2 inhibitors in T1DM management. We then discuss our current understanding of the effects of hypoglycaemia on human body and strategies aimed at mitigating the risks associated with hypoglycaemia.

Metabolic control and hypoglycaemia in people with type 2 diabetes on conventional or intensified insulin therapy: a 22 year retrospective single centre survey

BACKGROUND

Multiple insulin injection therapy can easily be adapted to the patient's needs. Therefore, it is supposed that more intensive insulin therapy is associated with better metabolic control and less hypoglycaemia compared with a conventional insulin strategy in patients with type 2 diabetes.

METHODS

HbA1c and incidence of non-severe and severe hypoglycaemia were analysed with regard to the strategy of insulin therapy [multiple insulin injection therapy with preprandial insulin with or without basal insulin or conventional insulin therapy with twice-daily premix insulin] from 20 943 visits of 1417 people treated with insulin with type 2 diabetes in a university outpatient department for endocrinology and metabolic diseases over a period of 22 years.

RESULTS

Multiple insulin injection therapy was used in 13 896 (66.4%) of all 20 942 visits. Compared with conventional insulin therapy, these patients were younger (62.0 vs 68.7 years; p < 0.001), had a slightly longer diabetes duration (16.5 vs 15.8 years; p < 0.001) and higher body mass index (32.8 vs 30.9 kg/m(2) ; p < 0.001), a higher insulin dose (76.4 vs 46.5 IU/day; p < 0.001), more frequent blood glucose monitorings/week (24.2 vs 14.8; p < 0.001), a slightly lower HbA1c [7.7 (61.2) vs 7.9% (62.9 mmol/mol); p < 0.001] but more non-severe hypoglycaemic incidences per week (0.3 vs 0.2; p = 0.01). Episodes of severe hypoglycaemia were rare and comparable (0.01/patient/year) with both insulin therapy strategies.

CONCLUSIONS

Multiple insulin injection therapy and conventional insulin therapy yielded comparable metabolic control with HbA1c below 8% (63.9 mmol/mol), but multiple insulin injection therapy is associated with higher body mass index and higher incidence of non-severe hypoglycaemia. Copyright © 2016 John Wiley & Sons, Ltd.

Prospective analysis of principles and frequency of self-adjustment of insulin dose in people with diabetes type 1 before and after participation in a diabetes treatment and teaching programme

OBJECTIVE

Insulin dose self-adjustment is an essential part of intensified insulin therapy - nowadays the routine treatment of type 1 diabetes (DM1). The aim of this study was to evaluate principles and frequency of insulin dose self-adjustments in people with DM1 before and one year after participating in a structured diabetes treatment and teaching programme (DTTP) and to determine to which extent the patients followed the way they had been trained.

METHODS

72 people with DM1 were interviewed before participation in our inpatient (32/72) or outpatient (40/72) DTTP. Sixty-six participants (91.7%) were followed up after one year. The number of adaptations of the insulin dose by the patients was recorded from 28days of the patients' diary. The ability to find the correct dose was tested using five different examples.

RESULTS

Metabolic control improved significantly after one year (7.9±1.0 to 7.5±0.8%, p=0.004). The participants performed 86.0±37.1 insulin dosage adaptations per 28days before the DTTP. After one year the frequency increased significantly to 99.1±30.7 per 28days (p=0.011). Before the DTTP, 42 of 72 patients (58.3%) adjusted their insulin dose to correct high blood glucose levels by adjustment rules (factor for correction or correction scheme) and 20 of 72 people (27.8%) by personal experience/feeling. One year after the DTTP, 73% (48/66) used adjustment rules.

CONCLUSIONS

After participating in an structured education programme, patients adjusted their insulin dosage more frequently. Metabolic control improved despite the fact that many patients did not strictly apply the rules they had been trained for.

A randomised, controlled trial of self-monitoring of blood glucose in patients with type 2 diabetes receiving conventional insulin treatment

AIMS/HYPOTHESIS

We evaluated whether self-monitoring of blood glucose (SMBG) leads to better glycaemic control (HbA(1c)) in patients with type 2 diabetes on conventional insulin regimens.

METHODS

Patients with type 2 diabetes on a conventional insulin regimen (basal or premixed insulin with or without additional oral glucose-lowering agents) were recruited at study centres led by members of the German Diabetes Association. In a randomised, prospective, open 2 × 2 factorial design, the once-weekly performance of four-point glucose profiles (SMBG +; n = 151 patients) was compared with no SMBG (SMBG -; n = 149), and the measuring and transmitting of HbA1c results to the study centres (HbA(1c) +; n = 158, of these 82 SMBG - and 76 SMBG +) was compared with HbA1c measurement without disclosure of results (HbA(1c) -; n = 142, of these 67 SMBG - and 75 SMBG +). Randomised allocation was carried out by a central office, using sequentially numbered, sealed envelopes. The primary endpoint was the reduction of HbA(1c) compared with baseline after 12 months. Secondary analyses were of therapy intensification in response to higher blood or urinary glucose or HbA(1c). Participants and caregivers were not blinded as to the allocation of interventions, whereas the laboratory determining HbA(1c) remained blinded.

RESULTS

Patient characteristics were balanced across groups. A total of 56 patients dropped out. In completers, HbA(1c) was reduced in the SMBG + group from 7.3% to 7.0%, i.e. by 0.3% (0.1%, 0.5%) vs SMBG - from 7.3% to 7.0% and 0.3% (0.2%, 0.5%), respectively, the difference being 0.0% (-0.2%, 0.2%) (p = 0.93). The disclosure of HbA(1c) results had no significant influence, with a difference of 0.1% (-0.1%, 0.4%) (p = 0.28). Values above are mean (95% CI). The ORs for therapy intensification significantly rose as the following increased: proportions of urine samples testing positive for glucose, HbA1c concentrations, and fasting or postprandial glucose concentrations. No important adverse events were associated with the interventions.

CONCLUSIONS/INTERPRETATION

SMBG profiles once weekly or the disclosure of HbA(1c) results did not improve glycaemic control in patients with type 2 diabetes on conventional insulin treatment, although indicators of hyperglycaemia increased the likelihood of therapy intensification. Greater intensification may be necessary to impact on glycaemic control.

TRIAL REGISTRATION

www.clinicaltrials.gov (registration code NCT00688363) FUNDING: Deutsche Diabetes-Gesellschaft, Deutsche Diabetes-Stiftung, Bayer Vital GmbH.

Evaluation of a treatment and teaching refresher programme for the optimization of intensified insulin therapy in type 1 diabetes

OBJECTIVE

Evaluation of an ambulatory diabetes teaching and treatment refresher programme (DTTP) for the optimization of intensified insulin therapy in patients with type 1 diabetes (refresher course).

METHODS

85 outpatients took part in this prospective multicentre trial. Metabolic and psychosocial data were analyzed at baseline (V1), 6 weeks (V2) and 12 months after DTTP (V3).

RESULTS

In patients with baseline HbA1c>7% (88%), HbA1c decreased by 0.36% (p=0.004). The percentage of patients with HbA1c≤7% increased from 21.3 to 34.9% and with HbA1c above 10% decreased from 6.6 to 1.6% at V3. The incidence of hypoglycaemia decreased significantly: non severe hypoglycaemia from 3.31 to 1.39 episodes/pat/week (p=0.001) and severe hypoglycaemia from 0.16 to 0.03 episodes/pat/year (p=0.02). The treatment satisfaction increased by +10 of maximal ±18 points. The negative influence of diabetes on quality of life decreased from -1.93 to -1.69 points (p=0.031).

CONCLUSION

In a group of patients with moderately controlled diabetes type 1 who were already treated with intensified insulin therapy, metabolic control, treatment satisfaction and quality of life were improved after participation in an ambulatory DTTP without increasing insulin dosage, number of injections or insulin species.

PRACTICE IMPLICATIONS

This DTTP is effective for the optimization of intensified insulin therapy.

Glycaemic control and weight 7 years after Dose Adjustment For Normal Eating (DAFNE) structured education in Type 1 diabetes

AIMS

The provision of structured education is increasingly prevalent in the management of Type 1 diabetes. There are little long-term follow-up data from such programmes. We have assessed HbA(1c) and weight over a 7-year period following the Dose Adjustment For Normal Eating (DAFNE) structured education course.

METHODS

We obtained annual HbA(1c) and weight data in 111 patients who attended the initial series of DAFNE courses in our centre from June 2002 to end 2003 and in a matched group of 111 patients with Type 1 diabetes of similar age and duration of diabetes seen over the same period who had not undergone structured education.

RESULTS

With DAFNE structured education, the mean (± sd) HbA(1c) fell from 71 ± 12 mmol/mol (8.6 ± 1.1%) at baseline to 65 ± 12 mmol/mol (8.1 ± 1.1%) at year 1, with a subsequent rise to 67 ± 13 mmol/mol (8.3 ± 1.2%) at year 7 (P = 0.0048 vs. baseline). In the comparator group, the baseline HbA(1c) level was 70 ± 14 mmol/mol (8.5 ± 1.3%) and remained approximately constant during 7 years of follow-up. Weight increased by 2.4 ± 6.0 and 2.8 ± 6.6 kg in the DAFNE and comparator group, respectively, during follow-up (not significant).

CONCLUSIONS

DAFNE structured education is associated with an improvement in glycaemic control at 1 year, and there remains a persistent and clinically relevant reduction in HbA(1c) of 3 mmol/mol (0.3%) after 7 years. The improvement in glycaemic control after DAFNE is achieved without excess weight gain.

Assessment of metabolic control among patients in a capillary glucose self-monitoring program

OBJECTIVE: To assess the metabolic control of diabetes mellitus patients registered in a capillary glucose self-monitoring program at home. METHODS: In this longitudinal retrospective study, 97 subjects at four health institutions in a Brazilian city were followed during 37 months between 2005 and 2008. The health files were analyzed of patients selected to register the evolution of variables related to capillary glucose self-monitoring at home and metabolic control of diabetes mellitus. RESULTS: During the assessment, both mean and monthly percentages of capillary blood glucose measurements at home decreased from 34.1 (65.1%) to 33.6 (64.8%), respectively (p <0.001). Mean HbA1c levels dropped from 9.20% to 7.94% (p<0.001). HDL cholesterol decreased from 51 mg/dl to 47 mg/dl (p=0.001). CONCLUSION: Patients' metabolic control improved, characterized by a significant reduction in HbA1C.

Long-term biomedical and psychosocial outcomes following DAFNE (Dose Adjustment For Normal Eating) structured education to promote intensive insulin therapy in adults with sub-optimally controlled Type 1 diabetes

AIMS

To explore long-term outcomes of participation in a Dose Adjustment For Normal Eating (DAFNE) training course, which provided one-off exposure to structured education in intensive insulin therapy to people with established Type 1 diabetes.

METHODS

A cohort design follow-up of original trial participants at a mean of 44 months (range: 37-51 months) in hospital diabetes clinics in three English health districts. 104 (74%) original participants provided biomedical data; 88 (63%) completed questionnaires including the ADDQoL, measuring impact of diabetes on quality of life (QoL).

RESULTS

At 44 months, mean improvement in HbA(1c) from baseline was 0.36% (9.32+/-1.1% to 8.96+/-1.2%, p<0.01) remaining significant but deteriorated from 12 months (p<0.05). Improvements in QoL seen at 12 months were sustained at 44 (e.g. impact of diabetes on dietary freedom: -1.78+/-2.33 at 44 months versus -4.27+/-2.94, baseline, p<0.0001; versus 1.80+/-2.32 at 12 months, ns). Similar results were obtained using last observation carried forward for patients not supplying follow-up data.

CONCLUSIONS

The impact of a single DAFNE course on glycaemic control remains apparent in the long term, although further interventions will be required to achieve recommended HbA(1c). In contrast, improvements in QoL and other patient-reported outcomes are well maintained over approximately 4 years.

On what evidence-base do we recommend self-monitoring of blood glucose?

Self-monitoring of blood glucose (SMBG) has been considered one major breakthrough in diabetes therapy because, for the first time, patients were able to determine their blood glucose levels during daily life. It seems obvious that this must be of advantage to disease management and clinical outcome, but it has become a nightmare for those trying to provide evidence. Randomised controlled trials have yielded inconsistent results on a benefit of SMBG-based treatment strategies not only in type 2 but - surprisingly - also in type 1 and gestational diabetes. Despite this, SMBG is being considered indispensible in intensive insulin treatment, but is being debated for other clinical settings. When considering the non-RCT based reasons for recommending SMBG in type 1 and gestational diabetes it becomes apparent that the same reasons also apply to type 2 diabetes.

Frequency and motives of blood glucose self-monitoring in type 1 diabetes

AIMS

Recommendations for self-monitoring of blood glucose (SMBG) from the DCCT have not been implemented with the same rigour as recommendations for intensifying insulin therapy. We assessed the frequency of and motives for SMBG and compared SMBG behaviour with clinical, behavioural and demographic characteristics.

METHODS

Cross-sectional Danish-British multicentre survey of 1076 consecutive patients with type 1 diabetes, who completed a detailed questionnaire on SMBG and related issues. The key variables were test frequency and motive.

RESULTS

SMBG was performed daily by 39% of the patients and less than weekly by 24%. Sixty-seven percent reported to perform routine testing, while the remaining 33% only tested when hypo- or hyperglycaemia was suspected. Age, gender, and level of diabetes-related concern were associated with test pattern. Reported frequencies of mild and severe hypoglycaemia and awareness of hypoglycaemia were independently associated with testing behaviour, whereas the presence of late diabetic complications was not. Lower HbA1c was associated with more frequent testing.

CONCLUSION

Patient compliance regarding SMBG is limited. Thus, almost two thirds of the patients do not perform daily SMBG and one third do not perform routine tests.

Self blood glucose monitoring in type 2 diabetes. A financial impact analysis based on UK primary care

BACKGROUND

UK consensus guidelines recommend limited use of self-monitoring of blood glucose (SMBG) in patients with type 2 diabetes using diet and exercise, metformin and/or a glitazone. This analysis quantifies the usage of and costs associated with SMBG in type 2 diabetes according to treatment regimen.

METHODS

Prevalence data for diabetes were assessed using UK Quality and Outcomes Framework returns for 2006/2007. Data on current SMBG prescribing expenditure were extracted from UK Prescription Pricing Agency Data for 2007. Prescribing data were extracted from the records of 40,651 patients with diabetes on the IMS Disease Analyzer (MediPlus) database. These were combined to arrive at mean usage and expenditure data per patient, broken down by treatment type. The analysis assumes that it is appropriate to use patients' treatment regimen alone to compare the frequency of SMBG in clinical practice with the frequency recommended in treatment guidelines; it does not take into account other valid reasons for SMBG.

RESULTS

Mean national expenditure on SMBG was 73.64 pound sterling per patient per year. Estimated mean weekly test strip usage by treatment was 2.5 (diet), 2.6 (glitazone monotherapy), 3.1 (metformin monotherapy) and 3.5 (sulphonylurea monotherapy). Combination oral therapy ranged from 3.3 to 4.1. Mean annual expenditure in patients with an identified treatment type was 62.06 pound sterling per patient, ranging from 9.83 pound sterling for diet-treated patients to 37.87 pound sterling for those on triple therapy, with insulin-treated patients incurring costs 3-5 times higher.

CONCLUSIONS

Based on the assumptions that the treatment regimen is the sole factor in determining the appropriate level of SMBG frequency, this study demonstrates that the use of SMBG exceeds current guidelines in certain treatment groups. The study estimates that the potential savings of up to 17 million pound sterling could be made each year if guidelines were followed more closely. There is a need for further research into SMBG use in patients with type 2 diabetes.

Flexible, intensive insulin therapy and dietary freedom in adolescents and young adults with Type 1 diabetes: a prospective implementation study

AIMS

To assess the outcome of a Diabetes Treatment and Teaching Programme (DTTP) on glycated haemoglobin (HbA1c), severe hypoglycaemia (SH) and severe ketoacidosis (SKA) in adolescents and young adults with Type 1 diabetes.

METHODS

Quality-assurance project with assessment of participants 1 year after participation in a DTTP (5-day inpatient course, groups < or = 10 patients, fixed curriculum of education/training, introduction of dietary freedom). Before-after analyses of participants aged 12-15, 15-18, 18-21 and 21-24 years. Main outcome measures were HbA1c, SH and SKA.

RESULTS

For the 1592 participants, aged 12 to 24 years, mean age at enrolment was 19 +/- 3 years, mean duration of diabetes was 7.3 +/- 5.4 (range 0.3-24) years, mean baseline HbA1c declined from 8.8 +/- 2.3% to 8.1 +/- 2.0%. The incidence of SH was 0.31 vs. 0.11 events/patient/year; the incidence of SKA 0.17 vs. 0.07 events/patient/year. In mixed effects models taking into account effects of centres, age and diabetes duration, the mean difference was -0.64%[P < 0.001, 95% confidence interval (CI) -0.79 to -0.5] for HbA1c, -0.2 events/patient/year (P < 0.0001, 95% CI -0.28 to -0.12) for SH and -0.1 events/patient/year (P < 0.0001, 95% CI -0.14 to -0.06) for SKA.

CONCLUSIONS

Adolescents and young adults with Type 1 diabetes benefit from participation in a standard DTTP for flexible, intensive insulin therapy and dietary freedom.

Meta-analysis does not allow appraisal of complex interventions in diabetes and hypertension self-management: a methodological review

Common methodologies used in systematic reviews do not allow adequate appraisal of complex interventions. The aim of the present study was to describe and critically appraise current methods of systematic reviews on complex interventions, using diabetes and hypertension patient education as examples. PubMed, the Cumulative Index to Nursing and Allied Health (CINAHL), the Cochrane Library and Health Technology Assessment databases were searched. Systematic reviews focusing on diabetes or hypertension patient education were included. Authors were contacted. Two investigators independently evaluated the reviews. The available evidence of three patient education programmes of diabetes and hypertension self-management implemented in Germany was used as a reference. We included 14 reviews; 12 reviews mentioned that the included education programmes were multidimensional. Reviews on comparable topics identified different publications of the same programme. Identical programmes were classified differently within and between reviews. Education programmes were dissected to analyse effects of single components. Different components of identical programmes were used. Interdependencies between components were not explored. Six reviews performed meta-analysis across programmes with heterogeneous educational or organisational approaches. The complexity of efficacy measures was disregarded: e.g. HbA(1c) was used as an isolated outcome variable without considering treatment goals, effects on hypoglycaemia, body weight or quality of life. Our results indicate that methods of current systematic reviews are not fully equipped to appraise patient education and self-management programmes. Since these are complex and heterogeneous interventions, consideration of aggregated evidence is necessary.

Análise dos ajustes insulinoterápicos realizados a partir de dois esquemas de monitorização domiciliar em pacientes com diabetes mellitus do tipo 1

OBJETIVOS: Identificar a freqüência e magnitude nos ajustes das doses de insulina a partir de dois esquemas de monitorização domiciliar sangüíneo e urinário em pacientes com diabetes mellitus do tipo1 e avaliar a efetividade dos ajustes no controle metabólico. MÉTODOS: Amostra de 25 pacientes dividida em dois grupos. Osdo Grupo A realizaram monitorização domiciliar da glicemia capilar e osdo Grupo B, monitorização domiciliar da glicosúria, conforme esquemas preconizados. Estes esquemas possibilitaram construção de perfis e de ajustes insulinoterápicos. RESULTADOS: Houve 204 possibilidades de ajustes no Grupo A e 87 no Grupo B. Com relação às doses de insulina NPH matutina, no Grupo A foram implementados 95 (46,57%)ajustes e no Grupo B 30 (34,48%) (p= 0,03715). Os ajustes nas doses de insulina regular feitas antes do jantar também foram maiores no Grupo A ,22 (10,84%)do que no Grupo B, 3 (3,45%) (p=0,02852). O Grupo A, apresentou-se com melhor controle metabólico (HbA1c=10,17%) quando comparado ao Grupo B (HbA1c=12,31%). CONCLUSÕES: A monitorização domiciliar da glicemia, possibilitou maior número de ajustes, maior número de aplicações e melhor controle metabólico.

Flexible intensive insulin therapy in adults with type 1 diabetes and high risk for severe hypoglycemia and diabetic ketoacidosis

OBJECTIVE

Diabetes treatment and teaching programs (DTTPs) for type 1 diabetes, which teach flexible intensive insulin therapy to enable dietary freedom, have proven to be safe and effective in routine care. This study evaluates DTTP outcomes in patients at high risk for severe hypoglycemia and severe ketoacidosis.

RESEARCH DESIGN AND METHODS

There were 96 diabetes centers that participated between 1992 and 2004. A total of 9,583 routine-care patients with type 1 diabetes were examined before and 1 year after a DTTP. History of repeated severe hypoglycemia/severe ketoacidosis was an indication for DTTP participation. Before-after analyses were performed for subgroups of patients with three or more episodes of severe hypoglycemia or two or more episodes of severe ketoacidosis during the year before a DTTP. Main outcome measures were GHb, severe hypoglycemia, severe ketoacidosis, and hospitalization.

RESULTS

A total of 341 participants had three or more episodes of severe hypoglycemia the year before a DTTP. Mean baseline GHb was 7.4 vs. 7.2% after the DTTP, incidence of severe hypoglycemia was 6.1 vs. 1.4 events x patient(-1) x year(-1), and hospitalization was 8.6 vs. 3.9 days x patient(-1) x year(-1). In mixed-effects models taking effects of centers and diabetes duration into account, mean difference was -0.3% (95% CI -0.5 to -0.1%; P = 0.0006) for GHb and -4.7 events x patient(-1) x year(-1) (-5.4 to -4; P < 0.0001) for severe hypoglycemia. A total of 95 patients had two or more episodes of severe ketoacidosis. GHb was 9.4% at baseline versus 8.7% after DTTP; incidence of severe ketoacidosis was 3.3 vs. 0.6 events x patient(-1) x year(-1), and hospitalization was 19.4 vs. 10.2 days x patient(-1) x year(-1). In linear models with diabetes duration as the fixed effect, the adjusted mean difference was -2.7 events x patient(-1) x year(-1) (95% CI -3.3 to -2.1; P < 0.0001) for severe ketoacidosis and -8.1 days (-12.9 to -3.2; P = 0.0014) for hospitalization.

CONCLUSIONS

Patients at high risk for severe hypoglycemia or severe ketoacidosis may benefit from participation in a standard DTTP for intensive insulin therapy and dietary freedom.

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

OBJECTIVE

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

SUBJECTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Cost-effectiveness of interventions to support self-care: A systematic review

Objectives: Interventions to support patient self-care of their condition aim to improve patient health and reduce health service costs. Consequently, they have attracted considerable policy interest. There is some evidence of clinical effectiveness but less attention has been paid to whether these interventions are cost-effective. This study examines the quality and quantity of existing evidence of the cost-effectiveness.

Methods: A systematic review was carried out to assess the extent and quality of economic evaluations of self-care support interventions. Thirty-nine economic evaluations were assessed against a quality checklist developed to reflect the special features of these interventions.

Results: The majority of the studies claimed that self-care support interventions were cost-effective or cost saving. The overall quality of economic evaluations was poor because of flaws in study designs, especially a narrow definition of relevant costs and short follow-up periods.

Conclusions: The current evidence base does not support any general conclusion that self-care support interventions are cost-effective, but ongoing trials may provide clearer evidence.

Glycaemic control and severe hypoglycaemia following training in flexible, intensive insulin therapy to enable dietary freedom in people with type 1 diabetes: a prospective implementation study

AIMS/HYPOTHESIS

The aim of this study was to evaluate the implementation of a course teaching flexible, intensive insulin therapy on glycaemic control and severe hypoglycaemia in routine care.

METHODS

This is a continuous quality-assurance project involving hospital diabetes centres. Every third year each centre re-examines 50 consecutive patients (evaluation sample) 1 year after participation in the course. Ninety-six diabetes centres in Germany participated and 9,583 patients with type 1 diabetes (190 evaluation samples) were re-examined between 1992 and 2004. The intervention was a 5-day inpatient course for groups of up to ten patients with a fixed curriculum of education and training for dietary flexibility and insulin adjustment. The main outcome measures were HbA1c and severe hypoglycaemia.

RESULTS

Mean baseline HbA1c was 8.1%, and had decreased to 7.3% at follow-up; incidence of severe hypoglycaemia was 0.37 events per patient per year prior to intervention and 0.14 after intervention. In mixed-effects models adjusted for effects of centres, age and diabetes duration, the mean difference was -0.7% (95% CI -0.9 to -0.6%, p<0.0001) for HbA1c and -0.21 events per patient per year (95% CI -0.32 to -0.11, p=0.0001) for severe hypoglycaemia, with similar results for evaluation samples, with a maximum of 10% of patients lost to follow-up. Before intervention, the incidence of severe hypoglycaemia was three-fold higher in the lowest quartile than in the highest quartile of HbA1c, whereas the risk was comparable across the range of HbA1c values after intervention.

CONCLUSIONS/INTERPRETATION

Implemented as part of a continuous quality-assurance programme the self-management programme is effective and safe in routine care. Improvement of glycaemic control can be achieved without increasing the risk of severe hypoglycaemia.

[Evaluation of 2 home monitoring schemes in patients with type 1 diabetes mellitus]

The goal of this study was to evaluate the effectiveness of two monitoring schemes(blood and urine) in the metabolic control of type 1 diabetic patients, in biweekly therapeutic adjustments, along 6 months of participation in the educational groups. A sample of 34 patients was divided in two groups. The interventions proposed to group A were daily blood glucose monitoring, during three consecutive days for each period (before breakfast, before lunch, before dinner and before bed) and biweekly in the dawn. For the other group B was proposed daily urine glucose monitoring, during three consecutive days for each period (before breakfast, before lunch, before dinner and before bed). These schemes were used to construct glycemic profile and to determine the therapeutic adjustments. The results evidenced that there was no significant statistical difference in the metabolic control after proposed intervention in each group. In spite of this, the monitoring facilitated the educational process and the considerations about the use of more intensive monitoring schemes.

Information technology and home glucose clamping

Persons with diabetes are responsible for the day-to-day control of their glycemia. To assist patients in discharging this responsibility and help them achieve and sustain improvements in self-blood glucose control, we developed information technology capable of executing algorithms for "clamping glucose" at home. Algorithms for laboratory glucose clamping were translated and adapted for use by patients. The procedures were supported by a central computer and registry. Interaction with the algorithms from home required the patient to handle only a touch-tone telephone, which accessed voice response hardware in the central computer. Patients reported self-measured blood glucose levels or hypoglycemia symptoms together with dietary changes, planned exercise, stress, illness or other lifestyle events. In response, they received self-management instructions and dosing decision support. Metabolic end points were measured. System beta testing in active patients was for 1 year. Patients (n = 142) used the algorithms for their daily self-management, accumulating 1,651 patient-months of follow-up. Almost 100,000 telephone calls were received. Patients benefited. Prevalence of diabetes related crises (hyperglycemia > 400 mg/dL, hypoglycemia < 50 mg/dL or symptoms without measurement) fell approximately twofold (p < 0.05) and glycated hemoglobin levels fell 1.3% (p < 0.001), while body weight was stable. Providers benefited from the timely receipt of standardized reports to monitor the progress of their patients. Earlier intervention was possible. Information technology facilitated home glucose clamping whereby patients with diabetes received timely assistance, advice and decision support for crucial self-control of blood glucose levels. This empowered patients to achieve independence and improve diabetes self-management.

Evaluation of a holistic treatment and teaching programme for patients with Type 1 diabetes who failed to achieve their therapeutic goals under intensified insulin therapy

AIMS

To evaluate a treatment and teaching programme including psychosocial modules for patients with Type 1 diabetes mellitus on intensified insulin therapy who failed to achieve their treatment goals despite participation in standard programmes.

METHODS

The 5-day inpatient programme comprises small groups of 4-6 patients, focusing on individual needs and problems. Beyond the teaching lessons (most topics are deliberately chosen by the patients), the programme provides intensive group discussions and offers individual counselling concerning motivational aspects, psychosocial problems and coping strategies. Of the first consecutive 83 participants, 76 were re-examined after 17.5 +/- 5.5 months (range 9-31 months).

RESULTS

At follow-up, HbA1c was not improved compared to baseline (8.0 +/- 1.3% vs. 8.1 +/- 1.5%). However, the incidence of severe hypoglycaemia per patient/year (glucose i.v., glucagon injection) was substantially decreased: 0.62 +/- 1.5 episodes at baseline compared to 0.16 +/- 0.9 at follow-up (P < 0.001). Twenty-six per cent of the patients at baseline, and 4% at re-examination had experienced at least one episode of severe hypoglycaemia during the preceding year (P < 0.001). Sick leave days per patient/year decreased from 17.0 +/- 38.5-7.7 +/- 13.6 days (P < 0.05). Patients improved their perceptions of self-efficacy, their relationship to doctors and felt less externally controlled (P < 0.001). The majority of patients perceived an improved competence regarding diet (80.6%) and adaptation of insulin dosage (82.4%), an improved knowledge (82.2%), and a renewed motivation for the treatment (84.5%). Treatment success was significantly associated with baseline HbA1c, stability of motivation, frequency of blood glucose self-monitoring, control beliefs and change in subsequent outpatient care.

CONCLUSIONS

The programme improved glycaemic control mainly as a result of a substantial reduction in the incidence of severe hypoglycaemia. Patients with persistent poor glycaemic control may benefit from structured follow-up care focusing on motivational aspects of self-management and psychosocial support.

Quality of self-care in patients on replacement therapy with hydrocortisone

OBJECTIVES

To assess the quality of self-care in patients receiving replacement therapy with hydrocortisone for primary or secondary adrenal insufficiency.

DESIGN

A questionnaire-based survey.

SETTING

The outpatient Clinic of Endocrinology at the University Hospital in Herlev, Denmark.

SUBJECTS

Ninety-seven patients identified from the case reports of the clinic. All patients had received repeated oral information about hydrocortisone treatment and dose adjustments. Eighty-four (87%) patients completed the questionnaire.

MAIN OUTCOME MEASURES

Ability to act appropriately in case of physical stress, possession of a 'Steroid warning card', number and nature of episodes of physical stress during the past year and self-experienced level of information was recorded.

RESULTS

Thirty-nine (46%) of the patients were not sufficiently skilled in coping with physical stress. This was more prominent in the elderly patients. Seventeen (20%) did not possess a 'steroid warning card'. Thirty-seven (44%) had experienced at least one febrile episode and 24 (29%) had been admitted to hospital during the past year. Fifty (60%) felt themselves to be well informed, but this did not correlate with the ability to act appropriately.

CONCLUSIONS

The study shows the need for continuous education of patients with adrenal insufficiency. Oral instructions should be supplemented with written information or a more detailed and structured education.

Methodologic principles of cost analyses in the nursing, medical, and health services literature, 1990-1996

BACKGROUND

Cost analyses are needed to inform resource decisions. Oftentimes, however cost-benefit analysis (CBA), cost-effectiveness analysis (CEA), cost-minimization analysis (CMA), and cost-utility analysis (CUA) are performed using untested techniques and adhering to a variety of questionable principles.

OBJECTIVES

To analyze, compare, and present a set of useful principles for the main types and methods of cost analyses through a synthesis of current information in the published literature.

METHODS

The area of interest included all reports of cost research published as full articles in professional journals from January 1990 to August 1996 in the nursing, medical, and health services fields. In all, 88 sampled articles met the criteria for inclusion. A four-page data collection guide with 28 items grouped as demographics, cost-analysis types, methods, and principles was designed for the review. Incremental testing for interrater reliability using the kappa statistic for two raters was performed. Sampling, process-oriented, construct, and correlational validity were assessed.

RESULTS

The 88 articles included 4 from nursing, 59 from medical, and 25 from health services journals. Of these articles, 45 (51%) reported CBA, 36 (41%) CEA, 2 CMA, 4 CUA, and 1 both CBA and CEA. Three nursing studies were authored only by nurses. Three fourths of the medical and four fifths of the health services publications had interdisciplinary authorship. Existing databases were the primary source of data in 61 (69%) publications. Adherence to six main methodologic principles was apparent in 19 (22%) articles. None of the nursing studies adhered to all six principles, whereas 16% of the health services and 25% of the medical studies did.

CONCLUSIONS

Funded cost analyses of nursing interventions that adhere to the six known methodologic principles are needed to inform policy-level health care decisions. Because of the complexity of cost analysis methodology, including sensitivity analysis, future interdisciplinary efforts using existing databases may prove most effective. The six methodologic principles presented in this article can be useful for future nursing education and cost-analysis research designed to control cost and increase the quality of health care.

The JEVIN trial: a population-based survey on the quality of diabetes care in Germany: 1994/1995 compared to 1989/1990

Since 1990 in most Eastern European countries health care systems have been decentralized or are undergoing the processes of decentralization. Increasingly, diabetic patients are no longer treated by diabetologists but by non-specialized physicians. During the same period structured treatment and teaching programmes have been introduced and health care is increasingly influenced by the St. Vincent declaration. To show the effect of these changes on the quality of diabetes care 90% (n = 244) of all insulin-treated diabetic patients aged 16 to 60 years and living in the city of Jena (100247 inhabitants) were studied in 1994/1995. The results were compared with the baseline examination of 1989/1990 (n = 190). HbA1c (HbA1c/mean normal) in IDDM patients under specialized care was similar in 1994/1995 (1.54 +/- 0.27, n = 47) to 1989/1990 (1.52 +/- 0.31, n = 131, p = 0.0018), but higher under non-specialized care (1.71 +/- 0.38, n = 80, p = 0.0087). In the total group of NIDDM patients there was no significant change in HbA1c (1994/1995: 1.75 +/- 0.4, n = 117, vs 1989/1990: 1.78 +/- 0.4, n = 59, p = 0.67), but with a tendency to higher HbA1c under non-specialized (1.81 +/- 0.4, n = 79) compared to specialized care (1.66 +/- 0.39, n = 38, p = 0.06). Incidence of severe hypoglycaemia (IDDM 0.13; NIDDM 0.04), ketoacidosis (0.02; 0.01) and the prevalence of nephropathy (21%; 35%) and neuropathy (24%; 38%) remained unchanged in comparison to 1989/1990, whereas there was an increase in the prevalence of diabetic retinopathy. Specialized care is mandatory for patients with IDDM.

Cost-benefit analyses in the health-care literature: don't judge a study by its label

OBJECTIVES

To assess whether health-care related economic evaluations labeled as "cost benefit analyses" (CBA) meet a contemporary definition of CBA methodology and to assess the prevalence of methods used for assigning monetary units to health outcomes.

DATA SOURCES

Medline, Current Contents, and HSTAR databases and reference lists of review articles, 1991-1995.

STUDY SELECTION

Economic analyses labeled as CBAs were included. Agreement on study selection was assessed. STUDY EVALUATION: CBA studies were classified according to standard definitions of economic analytical techniques. For those valuing health outcomes in monetary units (bona fide CBAs), the method of valuation was classified.

RESULTS

53% of 95 studies were reclassified as cost comparisons because health outcomes were not appraised. Among the 32% considered bona fide CBAs, the human capital approach was employed to value health states in monetary units in 70%. Contingent valuation methods were employed infrequently (13%).

CONCLUSIONS

Studies labeled as CBAs in the health-care literature often offer only partial program evaluation. Decisions based only on resource costs are unlikely to improve efficiency in resource allocation. Among bona fide CBAs, the human capital approach was most commonly used to valuing health, despite its limitations. The results of health-care related CBAs should be interpreted with extreme caution.

Renal threshold for glucose in non-insulin-dependent diabetic patients

Measurement of glycosuria is still widely used for home monitoring of glycaemia control in non-insulin-dependent diabetes (NIDDM). This method has been criticized because the renal threshold for glucose (RTglu) varies between subjects. In order to evaluate the validity of RTglu by measuring corresponding measurements of blood and urine glucose in NIDDM patients, we studied the blood/urine glucose relationship in 24 NIDDM patients. RTglu estimated from 75 contemporary blood and urine glucose concentrations measured at home by each patient (h-RTglu) was compared with RTglu measured by a hyperglycaemic glucose clamp (c-RTglu). H-RTglu and c-RTglu, being 7.6 mmol/1 (range 5.5-12.4) and 10.3 mmol/1 (6.2-12.3) respectively (P < 0.005), were weakly correlated (R(S) = 0.35, P = 0.15). In conclusion, c-RTglu varies two-fold between NIDDM patients. RTglu detected by home monitored urine and blood glucose determinations underestimates the true RTglu, probably due to the splay phenomenon. However, the method for detection of RTglu used by us seems of clinical relevance, since it reflects the individual blood glucose level at which glucose is detectable in the urine.

Long-term efficacy of a 5-day structured teaching and treatment programme for intensified conventional insulin therapy and risk for severe hypoglycemia

In the DCCT, intensification of insulin therapy led to a threefold increase in the risk of severe hypoglycemia (defined as the need for third party assistance). The reasons for this strong exponential relationship appears to be unclear to date. The present trial, a long-term evaluation of a 5-day structured teaching and treatment programme (5-DTTP) for intensified conventional insulin therapy (ICT), was performed to elucidate factors determining HbA1c and the incidence of severe hypoglycemia. A total of 71 patients were examined at baseline and 45.5 +/- 4.2 months following participation in a 5-DTTP. Comparing the data at follow-up examination with baseline measurements. HbA1c improved (8.52 +/- 2.29% vs. 8.0 +/- 1.43%, P = 0.04), the frequency of daily insulin injections (3.1 +/- 1.6 vs. 4.8 +/- 0.8, P < 0.001) and weekly blood-glucose self-tests (5.2 +/- 8.9 vs. 25.5 +/- 9.6, P < 0.001) increased, and the incidence of severe hypoglycemia (glucose i.v., glucagon injection) remained stable (0.18 vs. 0.17, P = 0.99). But, comparing the 21 patients who suffered from severe hypoglycemia during the follow-up period with the 50 patients without hypoglycemia, no differences between the two groups were found with respect to metabolic control (7.70 +/- 1.48% vs. 8.21 +/- 1.43%, P = 0.17), quality of life or treatment satisfaction. However differences arose with respect to diabetes knowledge. In the group of 21 patients with severe hypoglycemia we identified certain crucial gaps in diabetes knowledge: insulin self-adjustment; dietary aspects; hypo- and hyperglycemia. Performing multiple regression analysis, strong correlations were found between HbA1c and diabetes knowledge (r = -0.58. P = 0.002 for 50 patients without hypoglycemia and r = -0.63, P = 0.05 for 21 patients with hypoglycemia). In the total group, the most important factors determining HbA1c, were diabetes knowledge (r = -0.055, P = 0.007) and daily insulin dosage/kg body weight (r = 2.13, P = 0.0008, R2 = 0.26). Intervention like education of patients on a continuous basis and modifications of the DTTP's with more information and training in the recognition and treatment of hypoglycemic episodes seems to be essential to prevent hypoglycemia and to improve the efficacy of DTTP's over longer periods of time.

Diabetes intervention in the information age

Sustained improvement in blood glucose control is the only treatment outcome which will reduce or eliminate the long term complications of diabetes mellitus. We have designed and evaluated an electronic information system which facilitates this task. The system is voice-interactive, physician directed and affords, to remote patients, 24 h access via touch-tone telephone. Accordingly, patients access the system each day to report self-measured blood glucose levels or hypoglycaemic symptoms together with dietary changes, planned exercise, stress, illness or other lifestyle events. In turn they receive immediate advice with respect to medication dosing changes, and other pertinent feedback. Preliminary system beta-testing for safety and efficacy was performed for one year in an open study of 204 patients derived from two independent, health-care environments. Among the two testing centres, over 60,000 telephone cells were received by the computer systems during the start-up year. Safety and efficacy expectations were met. In addition, prevalence of diabetes related crises (hyperglycaemia or hypoglycaemia) fell approximately 3-fold. Glycated haemoglobin fell significantly (1.0-1.3%) in patients actively using the system. In control groups of patients not actively using the system, there were no improvements in metabolic control while body weights were stable in all groups. The new system was safe and effective in our hands and empowered our health professionals to provide improved diabetes care.

Liberalized diet in patients with type 1 diabetes

OBJECTIVE

To document that strict dietary regimen are not necessary in the context of intensified insulin therapy.

DESIGN

German multicentre, prospective cohort study; 6 years follow-up.

SETTING

Ambulatory examination using a mobile ambulance.

SUBJECTS

A total of 636 type 1 diabetic patients (age 33 +/- 7 years, diabetes duration 15 +/- 7 years; mean +/- SD), who had participated in a structured, 5-day, in-patient, group treatment and teaching programme for intensification of insulin therapy and liberalization of the diabetes diet 6 years prior to follow-up.

MAIN OUTCOME MEASURES

Relations between the extent to which patients practise a liberalized diet, the degree of metabolic control (HbA1c, severe hypoglycaemia, body mass index, cholesterol), and the patients' perceived burden through dietary treatment.

RESULTS

In the total patient group, HbA1c was 7.9 +/- 1.6%, and the incidence of severe hypoglycaemia was 0.17 cases per patient during the preceding year; 31% patients injected insulin < or = 3 times per day, 58% 4-7 times per day, and 11% used insulin pump therapy. Only 11% patients reported following a meal plan, whereas 89% continually changed timing and amount of carbohydrate intake; only 5% had the same number of meals every day, whereas as many as 20% varied the number of meals per day by four or more; 53% skipped main meals; 85% habitually consumed sugar or sugar containing foods. Patients with a higher degree of diet liberalization injected insulin or used an insulin pump therapy more frequently, and perceived their dietary treatment to be less burdensome. No clinically significant associations were found between the extent of diet liberalization and metabolic control.

CONCLUSIONS

Under the conditions where type 1 diabetic patients have the opportunity to participate in an intensified insulin treatment and teaching programme, liberalization of the diabetes diet is not associated with adverse effects on glycaemic control, but is associated with less perceived burden through dietary treatment.

Implementation of intensified insulin therapy: a European perspective

The Diabetes Education Study Group (DESG) of the European Association for the Study of Diabetes (EASD) was founded in 1979 with its major goal to make effective patient training an integral part of any diabetes therapy. Within the DESG, a number of models for structured diabetes treatment and teaching programmes were developed. Concerning the care of persons with Type 1 diabetes, substantial emphasis was placed upon the 5-day in-patient treatment and teaching programme for groups of 6 to 10 patients as originally introduced at the University of Geneva and further developed for general use at the University of Düsseldorf. During the early 1980s, this programme was based upon intensified insulin therapy including a stepwise liberalization of previously rigid rules for nutrition and life schedules. In several European centres the programme was continuously evaluated and shown to be effective as documented by significant reductions of glycated haemoglobin values, episodes of ketoacidosis, hospitalizations, and sick-day leaves. In contrast to the Diabetes Control and Complications Trial (DCCT) the improvement of glycated haemoglobin values was not associated with an increased risk of severe hypoglycaemia. Possible reasons for this favourable outcome are discussed. During recent years the 5-day treatment and teaching programme for Type 1 diabetes has been translated into the general health care system of Germany without any loss of its efficacy. In addition, in various other European countries, model centres of diabetes care have implemented the 5-day programme, and for a number of these centres, its efficacy to improve the overall quality of diabetes care has been published or presented at meetings.