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

The poor quality of diabetes care in a cluster randomized community survey from Delhi (DEDICOM-II): A crisis, an opportunity

AIMS

To evaluate the quality of care in known diabetes patients of Delhi.

METHODS

A cross-sectional survey was conducted using a two-stage cluster design. In all, 30 of 150 wards were chosen in Stage 1 (using a random computer-generated seed value and then selecting wards at a predefined sampling interval; Probability Proportionate to Size-Systematic) and one colony from each ward was selected randomly in Stage 2. The selected areas were surveyed house-to-house in one-of-four random directions to recruit a minimum of 25 subjects (known diabetes ≥1 year; 35-65 years of age) per area. Data were collected by interview, blood sampling and from medical records by specifically trained research staff.

RESULTS

A total of 843 subjects (of 1315 eligible) were enrolled from 11,490 houses. For the intermediate outcome measures, an estimated 33.5% (95% CI 27.3-40.2) had an HbA_1c value >10%, 67.2% (95% CI 62.8-71.4) had an LDL cholesterol level >100 mg/dl and 57.3% (95% CI 50.4-63.9) had BP levels >140/90 mmHg. For the processes of care in the last 1 year, 25.6% (95% CI 19.7-32.6) of the patients had an HbA_1c (A1c) estimation and 2.4% (95% CI 1.1-4.9) had a dilated eye examination and 4.1% (95% CI 2.6-6.2) had foot examination. Diabetes self-management education was provided to only 11.3% (95% CI 8.6-14.7) while nutrition counselling was provided to 56.0% (95% CI 51.7-60.2).

CONCLUSIONS

The glycaemic control, lipid control and BP management of known diabetes patients in Delhi are unacceptably poor and a wide gap exists between practice recommendations and delivery of diabetes care in Delhi.

Technology in Diabetes Treatment: Update and Future

Worldwide the number of people with diabetes mellitus is increasing. There are estimations that diabetes is one of the leading causes of death. The most important goals for the treatment of diabetes are self-management of the disease and an optimal quality of diabetes control. In the therapy new technologies, like real-time continuous interstitial glucose monitoring, continuous subcutaneous insulin infusion (CSII), electronic tools for the monitoring of therapeutic approaches, automated bolus calculators for insulin and electronic tools for education and information of patients, have become widespread and play important roles. All these efforts are related to the interaction between patients, caregivers, scientists or researchers and industry. The presentation of different aspects of new technological approaches in the present article should give more information about different technologies. However, because of the rather quickly appearance of new technologies, the presentation can only be a spotlight. Further studies are mandatory to analyze the effects and long-term benefits of each technology and electronic device.

ENDO ECHO IMPROVES PRIMARY CARE PROVIDER AND COMMUNITY HEALTH WORKER SELF-EFFICACY IN COMPLEX DIABETES MANAGEMENT IN MEDICALLY UNDERSERVED COMMUNITIES

OBJECTIVE

To determine whether participation in a multidisciplinary telementorship model of healthcare delivery improves primary care provider (PCP) and community health worker (CHW) confidence in managing patients with complex diabetes in medically underserved regions.

METHODS

We applied a well-established healthcare delivery model, Project ECHO (Extension for Community Healthcare Outcomes), to the management of complex diabetes (Endo ECHO) in medically underserved communities. A multidisciplinary team at Project ECHO connected with PCPs and CHWs at 10 health centers across New Mexico for weekly videoconferencing virtual clinics. Participating PCPs and CHWs presented de-identified patients and received best practice guidance and mentor-ship from Project ECHO specialists and network peers. A robust curriculum was developed around clinical practice guidelines and presented by weekly didactics over the ECHO network. After 2 years of participation in Endo ECHO, PCPs and CHWs completed self-efficacy surveys comparing confidence in complex diabetes management to baseline.

RESULTS

PCPs and CHWs in rural New Mexico reported significant improvement in self-efficacy in all measures of complex diabetes management, including PCP ability to serve as a local resource for other healthcare providers seeking assistance in diabetes care. Overall self-efficacy improved by 130% in CHWs ( P<.0001) and by 60% in PCPs ( P<.0001), with an overall large Cohen's effect size.

CONCLUSION

Among PCPs and CHWS in rural, medically underserved communities, participation in Endo ECHO for 2 years significantly improved confidence in complex diabetes management. Application of the ECHO model to complex diabetes care may be useful in resource-poor communities with limited access to diabetes specialist services.

ABBREVIATIONS

CHW = community health worker; CME = Continuing Medical Education; ECHO = Extension for Community Healthcare Outcomes; FQHC = federally qualified health center; PCP = primary care provider.

Implementing the Chronic Care Model for Improvements in Diabetes Care and Education in a Rural Primary Care Practice

Purpose

The purpose of this pilot study was to determine the impact of implementing elements of the chronic care model (CCM; decision support, self-management, and delivery system redesign) on providers' diabetes care practices and patient outcomes in a rural practice setting.

Methods

In this pilot study, 104 patients with type 2 diabetes and 6 providers in a rural primary care practice were involved in an intervention that included a certified diabetes educator (CDE) who educated and supported providers on diabetes management and adherence to the American Diabetes Association (ADA) Standards of Care over the year of the project. The CDE also provided diabetes self-management education (DSME) at the office site for 29 of the 104 patients who received their care in the practice. The following variables were evaluated: provider perceived barriers to care and adherence to ADA standards of care and patient A1C, blood pressure, cholesterol, knowledge, and empowerment levels.

Results

Provider adherence to ADA Standards of Care increased significantly across all process measures. Patients who received DSME at point of service in the primary care practice setting gained improvements in knowledge, empowerment, A1C, and high-density lipoprotein cholesterol levels.

Conclusions

Implementing systems to support decision support, selfmanagement education, and delivery system redesign has a positive influence on practices and patient outcomes in outlying rural communities.

Taking Telemedicine to the Next Level in Diabetes Population Management: a Review of the Endo ECHO Model

Worldwide increases in diabetes prevalence in the face of limited medical resources have prompted international interest in innovative healthcare delivery models. Project ECHO (Extension for Community Healthcare Outcomes) is a "telementoring" program which has been shown to increase capacity for complex disease management in medically underserved regions. In contrast to a traditional telemedicine model which might connect a specialist with one patient, the ECHO model allows for multiple patients to benefit simultaneously by building new expertise. We recently applied the ECHO model to improve health outcomes of patients with complex diabetes (Endo ECHO) living in rural New Mexico. We describe the design of the Endo ECHO intervention and a 4-year, prospective program evaluation assessing health outcomes, utilization patterns, and cost-effectiveness. The Endo ECHO evaluation will demonstrate whether and to what extent this intervention improves outcomes for patients with complex diabetes living in rural New Mexico, and will serve as proof-of-concept for academic medical centers wishing to replicate the model in underserved regions around the world.

Quality of diabetes care in family medicine practices in eastern Bosnia and Herzegovina

OBJECTIVES

In the present study, the audit of medical files of patients with diabetes, followed in family medicine practices in the eastern region of Bosnia and Herzegovina (BiH), was carried out in order to investigate the frequency of the use of screening tests for early diagnosis of diabetes complications.

METHODS

The audit was conducted in 32 family medicine practices from 12 primary health care centers in the eastern part of BiH over one-year period (March 2010 to March 2011). A specially established audit team randomly selected medical files of 20 patients with diabetes from the Diabetes Registry administered by each family medicine team database. Screening tests assessed are selected according to the ADA guidelines.

RESULTS

Frequency of the individual screening test varied between 99%, found for at least one blood pressure measurement, and 3.8% for ABI measurement. When the frequency of optimal use of screening was analyzed, only 1% of patients received all recommended screening tests.

CONCLUSION

The frequency of the use of screening tests for chronic diabetes complications was found to be low in the eastern part of Bosnia and Herzegovina. Multivariate linear regression analysis showed that longer duration of diabetes and a larger number of diabetics per practice were associated with a smaller number of screening tests, but specialists in family medicine provided a higher number of screening tests compared to other physicians.

Provider and systems factors in diabetes quality of care

A gap exists in knowledge and the observed frequency with which patients with diabetes actually receive treatment for optimal cardiovascular risk reduction. Many interventions to improve quality of care have been targeted at the health systems level and provider organizations. Changes in several domains of care and investment in quality by organizational leaders are needed to make long-lasting improvements. In the studies reviewed, the most effective strategies often have multiple components, whereas the use of one single strategy, such as reminders only or an educational intervention, is less effective. More studies are needed to examine the effect of several care management strategies simultaneously, such as use of clinical information systems, provider financial incentives, and organizational model on processes of care and outcomes.

Glycemic control and type 1 diabetes: the differential impact of model of care and income

OBJECTIVE

To examine the effect of model of care (specialist care vs. shared care), and income, on glycemic control in a sample of young people with type 1 diabetes.

METHODS

A total of 158 children and young people with type 1 diabetes, aged 8-19 yr, and their families, were recruited independent of their source of care as part of a longitudinal, cross-sectional exploratory study. At enrollment, participants completed a series of questionnaires and underwent a structured interview to gather data regarding the type of specialist and healthcare services attended, as well as demographic, healthcare, and self-care information. Capillary sample was taken for HbA1c determination.

RESULTS

The mean HbA1c for the group as a whole was 8.6 ± 1.4%. There was no effect for model of care on glycemic control. However, young people living in households with a family income of less than AUS$83,000 (US$73,500) per year had a significantly higher mean HbA1c than their counterparts reporting a higher household income (8.8 ± 1.4% vs. 8.3 ± 1.1%; p = 0.019).

CONCLUSION

Although no differences were found with respect to the short-term impact of specialist vs. shared care, it is evident that more support is required to improve glycemic control in this sample of young people where the mean level of HbA1c was significantly higher than target. Further research is also indicated to determine the relationship between glycemic control and socioeconomic status.

[Metabolic control in patients with type-1 and type-2 diabetes mellitus receiving ambulatory care from general practitioners: results of a cross-sectional trial performed in the German federal states of Thuringia and West Pomerania]

Up to the present moment there has been a large controversy over the metabolic control in patients with type-1 and type-2 diabetes mellitus receiving ambulatory treatment from general practitioners. Hence this trial aimed to assess the parameters of treatment quality in patients under ambulatory care in two German regions.

PATIENTS AND METHODS

A total of 2,242 patients from 25 general practitioners' care units were assessed from October 1998 to September 1999.

RESULTS

The mean age of the patients was 67.5 +/- 13.1, and the mean diabetes duration was 8.8 +/- 7.5 years. 26.1% of the patients were treated without using anti-diabetic drugs, and 44.2% took oral anti-diabetic medications. 20.0% received insulin alone and 9.5% a combination therapy of insulin and oral anti-diabetic agents. The mean HbA1c of 6.9 +/- 1.5 was comparable in Thuringia and West Pomerania. It was measured in 68.4% of the patients. Blood pressure values were documented in 98.8%. A total of 31.6% of patients took part in structured diabetes treatment and teaching programmes. In Thuringia the percentage of patients under specialized diabetes care was 3.6%; in West Pomerania it was significantly lower (18%, p<0.001).

CONCLUSION

The quality of treatment and metabolic control in patients with type-1- and type-2 diabetes mellitus receiving ambulatory care from general practitioners is much better than is commonly assumed. However, as indicated by the relatively low frequency of HbA1c measurements, the treatment quality is far from reaching the requirements of national guideline recommendations.

Do specialized centers and specialists produce better outcomes for patients with chronic diseases than primary care generalists? A systematic review

PURPOSE

Although specialized centers are generally accepted for treatment of relatively uncommon diseases, such as cystic fibrosis, statements regarding the amount of expertise or minimum number of patients treated are increasingly included in guidelines for the treatment of other chronic diseases such as rheumatoid arthritis and diabetes mellitus.

DATA SOURCES

Medline and Embase from 1987 through March 2008 were searched.

STUDY SELECTION

Studies reporting the effect of treatment in a specialized or high-volume center or by subspecialists on a clinically relevant outcome. Data extraction Two reviewers extracted the data independently and assessed the methodological quality.

RESULTS OF DATA SYNTHESIS

We included 22 articles. Two randomized-controlled trials and a quasi-experimental study compared the effect of outpatient team care with traditional outpatient care for patients with rheumatoid arthritis. These studies showed no difference or were inconsistent. Studies on the outcomes of care for diabetic patients (5 prospective or historical cohort studies and 10 retrospective cohort studies) were generally of poor quality. Studies comparing the subspecialist care with the care provided by general internists or primary care providers produced inconsistent results. Similar inconsistency and poor quality were found for three observational studies on cystic fibrosis.

CONCLUSION

The available literature suggests that among patients with rheumatoid arthritis, diabetes mellitus or cystic fibrosis, outcomes are not superior in specialized centers or with subspecialists compared with other forms of chronic illness care.

[Prevalence of diabetic retinopathy. Check-up program of a public health insurance company in Germany 2002-2004]

OBJECTIVES

Population based studies have reported a prevalence of diabetic retinopathy (DR) at the time of diagnosis in up to 30% of the patients. In the context of a general diabetes check-up program (so called "Diabetes-TUV"), the prevalence of diabetic retinopathy in Germany was examined in all diabetes patients insured in a public health insurance company.

METHODS

Patients were screened in the offices of 181 ophthalmologists according to a standardized protocol formulated by Prof. Kroll, Marburg. A total of 6,500 sheets were analysed out of which 14.5% were multiply documented. The latest protocols of 5,596 patients were evaluated; the mean age was 64.7 years with an average duration of diabetes of 10.2 years.

RESULTS

Some 86.3% of the eyes examined had no DR, in 3.1% no evaluation was possible. Of the patients checked, 10.6% had DR. Mild/moderate DR was reported in 8.3%, severe non-proliferative DR in 1.7% and proliferative DR in 0.5%. Macular edema was reported in 0.85% of cases, vitreous hemorrhage in 0.2%. There was 0.1% iris neovascularisation and 0.1% retinal detachment. Visual impairment due to cataract or secondary cataract was found in 25.2% of patients with an 8.3% pseudophakia rate.

CONCLUSION

Documentation of the eye examination in the diabetes check-up program was good. The 10.6% prevalence of DR in Germany, even after long standing diabetes, seems to be lower than in earlier population based studies in the US or UK. The data reported here could be an indication of better diabetes care in Germany. However, not all patients were examined with dilated pupils, and in the case of severe changes, the ophthalmologist might have decided not to fill in the report form and to have chosen another form of communication.

Cross-sectional analysis of adult diabetes type 1 and type 2 patients with diabetic microvascular complications from a German retrospective observational study

OBJECTIVE

To obtain epidemiological data on the prevalence of predefined stages of diabetic microvascular complications from a representative cross-section of patients with existing microvascular complications of type 1 or type 2 diabetes in Germany.

RESEARCH DESIGN AND METHODS

A cross-sectional, retrospective study of medical records of 705 type 1 and 1910 type 2 adult diabetic patients with a diagnosis of retinopathy and/or peripheral neuropathy and/or nephropathy before 2002 and treated in 2002 in Germany.

RESULTS

Of 376 patients with type 1 diabetes having retinopathy, 59.3% had mild or moderate non-proliferative retinopathy without macular oedema, 27.1% had macular oedema, and 13.6% had severe retinopathy without macular oedema. In 862 patients with type 2 diabetes, the distribution of retinopathy/maculopathy classes was 56.8%, 35.5%, and 7.7%, respectively. Of 381 type 1 diabetes patients with observed peripheral neuropathy, 81.4% had sensorimotor neuropathy, 8.9% had diabetic foot conditions, and 9.7% had lower extremity amputations because of diabetes. In 1005 patients with type 2 diabetes, the distribution of neuropathy classes was 78.2%, 12.1%, and 9.7%, respectively. The proportions of patients with renal insufficiency in type 1 and type 2 diabetes groups were 15.3% versus 13.5%, respectively.

CONCLUSIONS

The study suggests that there are considerable proportions of patients with progressive stages of microvascular complications related to type 1 and type 2 diabetes in Germany. This underlines the importance of improvement of optimal quality of care and frequent screening for preventing late diabetic microvascular complications and the necessity of effective intervention strategies to tackle this major public health problem.

Deficiencies in the quality of diabetes care: comparing specialist with generalist care misses the point

The quality of diabetes care delivered to patients falls below the expectations of practice guidelines and clinical trial evidence. Studies in many jurisdictions with varying health care systems have shown that recommended processes of care occur less often than they should; hence, outcomes of care are inadequate. Many studies comparing care between specialists and generalists have found that specialists are more likely to implement processes of care. However, this provides little insight into improving quality of care, as the difference between specialists and generalists in these studies is small compared to the overall deficiency in quality. Therefore, future research should instead focus on ways to implement high quality care, regardless of specialty. To date, few methodologically rigorous studies have uncovered interventions that can improve quality of care. The development of such interventions to help all physicians implement better quality care could greatly benefit people with diabetes.

Quality of diabetes care in the middle- and high-income group populace: the Delhi Diabetes Community (DEDICOM) survey

OBJECTIVE

We sought to evaluate the quality of care in known diabetic patients from the middle- and high-income group populace of Delhi.

RESEARCH DESIGN AND METHODS

A cross-sectional survey was conducted using a probability proportionate to size (systematic), two-stage cluster design. Thirty areas were selected for a house-to-house survey to recruit a minimum of 25 subjects (known diabetes >/= 1 year; aged 35-65 years) per area. Data were collected by interview, by blood sampling, and from medical records.

RESULTS

A total of 819 subjects (of 1,153 eligible) were enrolled from 20,666 houses. In total, 13.0% (95% CI 9.6-17.3) of the patients had an HbA(1c) (A1C) estimation and 16.2% (13.5-19.4) had a dilated eye examination in the last year, 32.1% (27.5-36.6) had serum cholesterol estimation in the last year, and 17.5% (14.2-21.5) were taking aspirin. An estimated 42.0% (37.7-46.2) had an A1C value >8%, 40.6% (36.5-44.7) had an LDL cholesterol level >130 mg/dl, and 63.2% (59.6-66.6) had blood pressure levels >140/90 mmHg.

CONCLUSIONS

A wide gap exists between practice recommendations and delivery of diabetes care in Delhi.

Cost-effectiveness of rosiglitazone oral combination for the treatment of type 2 diabetes in Germany

AIMS/HYPOTHESIS

To assess the cost-effectiveness of rosiglitazone in combination with other oral agents for the treatment of overweight and obese patients with type 2 diabetes in Germany.

METHODS

The Diabetes Decision Analysis of Cost--type 2 model was adapted for clinical practice and healthcare financing rules in Germany. The model was calibrated using Cost of Diabetes in Europe Type 2 study data and national statistics. The perspective is that of the sickness funds, and includes all hospital inpatient, ambulatory, rehabilitation, and diabetes therapy, other medications, and sickness leave. The model simulates lifetime treatment histories and associated health outcomes and costs for age and sex-matched cohorts of 1000 overweight and obese patients. The measures of effectiveness used in the analysis were life-years and quality adjusted life-years (QALYs).

RESULTS

The combination therapy of rosiglitazone with metformin or sulfonylurea produces better glycaemic control than conventional care of metformin with sulfonylurea and insulin in most patients, extends the viability of oral therapy before requiring insulin, and typically leads to lifetime cost increases across all treatment types. The improvements in glycaemic control lead to survival gains and reductions in morbidity, because of the reduced risk of developing or progressing to later stages of complications. Improvements in morbidity and mortality generate additional QALYs. Costs and health outcomes combine to yield favourable incremental cost-effectiveness ratios, which fall below international 'willingness-to-pay' thresholds in the medium term.

CONCLUSION

The model predicts that rosiglitazone in combination with other oral agents is a cost-effective intervention for the treatment of normal weight, overweight and obese patients with type 2 diabetes when compared with conventional care in Germany.

Prevalence of diabetes complications 6 years after diagnosis in an incident cohort of childhood diabetes

AIMS

To examine the prevalence of early diabetes complications 6 years after diagnosis of diabetes. The hypothesis that initial contact with a multidisciplinary team would be associated with a reduced risk of microvascular complications was tested in this cohort.

METHODS

Participants were recruited from an incident cohort of children aged < 15 years diagnosed between 1990 and 1992 in NSW, Australia. Initial management at a teaching hospital was documented at case notification. At 6 years, health care questionnaires and complications were assessed: retinopathy by 7-field stereoscopic retinal photography and elevated albumin excretion rate (AER) defined as the median of three overnight urine collections > or = 7.5 microg/min. Case attainment was 58% (209/361) with participants younger than non-participants and more likely living in an urban than rural location.

RESULTS

Retinopathy was present in 24%, median AER > or = 7.5 microg/min in 18%, and median AER > or = 20 microg/min in 2%. In multivariate analysis, initial management at a teaching hospital or consultation with all three allied health professionals combined with pubertal staging and cholesterol or HbA1c were all determinants of risk for retinopathy.

CONCLUSIONS

Early retinopathy and elevated AER are common in children 6 years after diagnosis. Initial allied health contact and management at a teaching hospital were associated with a reduced risk of microvascular complications in this cohort.

Long-term prognosis of patients after kidney transplantation: a comparison of those with or without diabetes mellitus

BACKGROUND

Compared with non-diabetic subjects, patients with type 2 diabetes and end-stage renal disease (ESRD) have seldom been selected for renal transplantation. It was the aim of this study to compare the long-term prognoses of the two groups of patients after transplantation and to identify factors associated with allograft rejection.

METHODS

In a retrospective analysis, we studied all 333 consecutive patients who received a kidney transplant at our centre since 1992. Mean follow-up in 302 out of 333 patients (91%) was 3.3+/-1.5 (0.1-11.7) years. At the time of transplantation, diabetes mellitus (type 1, n=3; type 2, n=46) was known in 49 patients.

RESULTS

Patients with diabetes mellitus were older [patients without diabetes (n=253) vs patients with diabetes (n=49), 52.2+/-12.6 vs 58.8+/-13.1 years, respectively; P=0.002], but they had very good diabetes control [haemoglobin A1c (HbA1c) of patients with diabetes 6.3+/-0.9% vs those without diabetes 5.2+/-1.0%, P=0.03]. Even during their follow-up, patients with diabetes showed a tendency to further improvement (HbA1c for patients with diabetes 5.7+/-0.9% vs those without diabetes 5.5+/-0.9%, P=0.30). At the end of follow-up also, there were no differences between the groups with respect to blood pressure control (patients with diabetes 135.3+/-28.2/79.6+/-17.2 mmHg vs patients without diabetes 130.9+/-28.7/78.8+/-17.1 mmHg, P=0.33/0.78) and renal function (creatinine, 142.9+/-61.6 vs 151.8+/-68.2 micromol/l, P=0.38; glomerular filtration rate, 63.1+/-23.3 vs 59.1+/-24.0 ml/min/1.73 m(2), respectively, P=0.30). In total, 26 patients had acute transplant rejections [eight patients with diabetes (prevalence 16.3%) vs 18 patients without diabeteses (prevalence 7.1%), P=0.11]. In multivariate analysis, the most important parameter associated with the incidence of transplant rejections was the preceding fasting blood glucose (R2=0.044, beta=0.21, P=0.009). All other parameters included in the model (body mass index, time since transplantation, diabetes duration, immunosuppressive therapy, HbA1c and HLA mismatch) revealed no associations.

CONCLUSIONS

Following kidney transplantation, the prevalence of rejections in patients with diabetes mellitus is slightly but not significantly higher than in non-diabetic subjects. One of the most important risk factors seems to be fasting blood glucose. Hence, following renal transplantation, treatment strategies should focus not only on optimal immunosuppressive therapy and HLA matching, good HbA1c and blood pressure control, but also on maintaining near-normal fasting blood glucose levels.

Hyperglycaemic crises and lactic acidosis in diabetes mellitus

Diabetic ketoacidosis, hyperglycaemic hyperosmolar state, and lactic acidosis represent three of the most serious acute complications of diabetes. There have been some advances in our understanding of the pathogenesis of these conditions over the last three decades, together with more uniform agreement on their treatment and innovations in technology. Accordingly their incidence, morbidity, and mortality are decreasing, but at rates that fall short of our aspirations. Hyperglycaemic crises in particular remain an important cause of morbidity and mortality in diabetic populations around the world. In this article, understanding of these conditions and advances in their management, and the available guidelines for their treatment, are reviewed. As far as is possible, the recommendations are based on clear published evidence; failing that, what is considered to be a common sense synthesis of consensus guidelines and recommendations is provided.

Impact on mortality and incidence of end-stage renal disease of education and treatment at a diabetes center among patients with type 1 diabetes: comparison of two subgroups in the Japanese DERI cohort

The aim of this study was to compare mortality and incidence of end-stage renal disease (ESRD) in patients with type 1 (insulin-dependent) diabetes who had attended a diabetes center with those who had not. The cohort consisted of a total of 1430 patients diagnosed with Type 1 diabetes at 18 years or younger, and between 1965 and 1979. This population-based cohort in Japan was subdivided into two groups: patients who had visited a large diabetes center in Tokyo (n=162) and those who had not (n=1212). Mortality and incidence of ESRD were compared between the two subgroups as of January 1, 1990. Crude mortality was 1.95 per 1000 person-years (95% CI: 0.49-5.06) for those who had visited the center and 6.05 (4.86-7.41) for those who had not. A multivariate Cox proportional hazard model showed that the patients who had visited the center were three times less likely to die (hazard ratio: 0.31, 95% CI: 0.10-0.98) than those who had not. Crude incidence of ESRD was 1.32 (0.22-4.09) and 5.86 (4.65-7.26) for those who had visited the center and for those who had not, respectively. After adjusting for covariates, the patients who had visited the center were five times less likely to develop ESRD (hazard ratio: 0.19, 0.05-0.78) than those who had not. Education and treatment of type 1 diabetes with an integrated management system under specialists and a multidisciplinary team appears to be associated with a better prognosis.

Use of Telemedicine in Periodic Screening of Diabetic Retinopathy

Telemedicine was used for taking ocular fundus images of diabetic patients, which were subsequently sent by electronic mail to experienced ophthalmologists at a university hospital. The ophthalmologists provided reports on the patients to the internists. The objective of the study was to evaluate the effectiveness of this telemedicine system. A total of 279 diabetic patients were admitted to the Third Department of Internal Medicine of Yokohama City University Hospital, School of Medicine, for blood sugar control or for education on lifestyle between April, 1999, and October, 2000. The subjects did not have eye disease nor diabetic retinopathy when evaluated by an ophthalmologist (at either Yokohama City University Hospital or other facility) within 3 months before enrollment in the study. After dilation of the pupil, fundus images were taken of each eye from four angles using a nonmydriatic fundus camera. The images were transmitted by electronic mail to the Division of Ophthalmology of Tokyo University Branch Hospital along with other patient information. The ophthalmologists there evaluated the images on the screen according to Fukuda's classification of diabetic retinopathy. They sent ophthalmologic reports to the internists at the Third Department of Internal Medicine of Yokohama City University Hospital, School of Medicine, and recommended whether the patient should be seen by his/her regular ophthalmologist earlier than the next scheduled visit. Fundus images were obtained at the time of admission, at 1, 3, and 6 months after discharge, and at every 6 months thereafter. Out of the images of 1170 eyes obtained at various time points from the 279 patients, 1076 (92.0%) were successfully evaluated by the ophthalmologists at the University of Tokyo, while 60 (5.1%) could not be evaluated and there was a communication problem for the images of 34 eyes. The ophthalmologists determined that 5 eyes of 3 patients required further evaluation by the patient's regular ophthalmologist based on the images transferred by telemedicine. No patient dropped out during the study period.

Continuous subcutaneous insulin infusion in patients with diabetes mellitus

During the last quarter of a century continuous subcutaneous insulin infusion (CSII) with external portable insulin pumps has been increasingly used in selected type 1 diabetic subjects and also in some patients with type 2 diabetes mellitus. The treatment of diabetes mellitus with insulin pumps has become more and more popular and accepted by diabetic patients as well as by medical professionals worldwide. Published trials have shown that, in most patients, mean blood glucose concentration and glycated hemoglobin (HbA1c) percentages are either slightly lower or similar on CSII versus an optimized therapy with multiple daily insulin injections. Hypoglycemic episodes seem to be less frequent and ketoacidoses occur at a comparable rate to that during intensive injection therapy. Moreover, nocturnal glycemic control can be improved with insulin pumps, and automatic basal rate changes help to minimize a prebreakfast blood glucose increase (often called 'the dawn phenomenon'). For many patients, CSII provides greater flexibility in timing of meals with the result of better quality of life and higher treatment satisfaction. However, despite these promising data, and although many patients with diabetes mellitus with well-defined clinical problems are likely to benefit substantially from CSII, either in respect to glycemic control, acute complications or quality of life and treatment satisfaction, we are still far away from reaching'dream diabetes management', the fully automatic closed-loop system. Presently, the most difficult problem concerns not the design of an 'optimal' insulin pump, but rather the development of a system which is able to provide continuous and reliable blood glucose monitoring. Hence, because this problem has not been solved with maximum satisfaction, the development of a feedback-controlled 'artificial pancreas' is one of the main goals in diabetes management in the new millennium.

Improvement in quality of diabetes control and concentrations of AGE-products in patients with type 1 and insulin-treated type 2 diabetes mellitus studied over a period of 10 years (JEVIN)

Advanced glycation end (AGE)-products, a complex and heterogeneous group of compounds, have been implicated in diabetes-related long-term complications. Up to the present, only few data exist about serum levels of the AGE-proteins N- epsilon -carboxymethyllysine (CML) and pentosidine in selection-free populations of patients with type 1 and insulin-treated type 2 diabetes mellitus. In the present 10-year, population-based trial of patients with insulin-treated diabetes mellitus, serum CML and pentosidine levels were examined in correlation to the patients' quality of diabetes control and the prevalence of diabetes-related long-term complications. Jena's St. Vincent Trial (JEVIN) was started in 1989/1990. At this time, a centralised diabetes care system existed. After the baseline examination of 190 patients (83% of the target population) with insulin-treated diabetes mellitus, follow-up examinations were performed in 1994/1995 and 1999/2000. In 1994/1995, the CML concentration in patients with type 1/type 2 diabetes mellitus was 1096.47+/-405.50/1136.43+/-405.24 ng/ml. In 1999/2000, it was significantly lower (727.49+/-342.91 ng/ml, P=.033/743.76+/-312.47 ng/ml, P<.0001). The same tendency showed the AGE-protein pentosidine (type 1: 1994/1995 203.18+/-118.88 vs. 1999/2000 156.59+/-104.84 pmol/ml [P=.029], type 2: 1994/1995 189.72+/-67.66 vs. 1999/2000 151.54+/-127.73 pmol/ml [P=.020]). Parallel to the decrease in the mean concentration of the AGE-products CML and pentosidine mean HbA1c improved and the prevalence of diabetic long-term complications (retino-, neuro-, and nephropathy) remained comparable 1999/2000-1989/1990. Comparing the data of 1999/2000 with those from 1994/1995, there was not only a substantial improvement in patients' quality of diabetes control but also a decrease in the concentration of AGE-products. In patients with diabetes mellitus, the AGE-products seem to be mainly influenced by the quality of diabetes control. However, the most important parameter reflecting the risk for development and progression of diabetes-related long-term complications seems not to be the AGE-products, but patients' HbA1c.

The Improving Primary Care of African Americans with Diabetes (IPCAAD) project: rationale and design

African Americans have an increased burden of both diabetes and diabetes complications. Since many patients have high glucose levels novel interventions are needed, especially for urban patients with limited resources. In the Grady Diabetes Clinic in Atlanta, a stepped care strategy improves metabolic control. However, most diabetes patients do not receive specialized care. We will attempt to translate diabetes clinic approaches to the primary care setting by implementing a novel partnership between specialists and generalists. We hypothesize that endocrinologist-supported strategies aimed at providers will result in effective diabetes management in primary care sites, and the Improving Primary Care of African Americans with Diabetes project will test this hypothesis in a major randomized, controlled trial involving over 2000 patients. Physicians in Grady Medical Clinic units will receive (1) usual care, (2) computerized reminders that recommend individualized changes in therapy and/or (3) directed discussion by endocrinologists providing feedback on performance. We will measure outcomes related to both microvascular disease (HbA1c, which reflects average glucose levels over an approximately 2-month period) and macrovascular disease (blood pressure and lipids) and assess provider performance as well. We will compare two readily generalizable program interventions that should delineate approaches effective in a primary care setting as needed to improve care and prevent complications in urban African Americans with type 2 diabetes.

Influence of health care providers on the development of diabetes complications: long-term follow-up from the Pittsburgh Epidemiology of Diabetes Complications Study

OBJECTIVE

To quantify total diabetes care received (generalist or specialist) from diagnosis onward and its association with the incidence of diabetes complications in a representative cohort of patients with type 1 diabetes.

RESEARCH DESIGN AND METHODS

A total of 429 subjects from the Pittsburgh Epidemiology of Diabetes Complications Study, a prospective follow-up study of childhood-onset type 1 diabetic subjects first seen between 1986 and 1988 (mean age 28 years, mean duration 19 years), followed biennially for up to 10 years were studied. Specialist care was defined as care received from a board-certified endocrinologist, diabetologist, or diabetes clinic and quantified as the percent of diabetes duration spent in specialist care.

RESULTS

There was a significant trend for a higher incidence of neuropathy, overt nephropathy, and coronary artery disease with lower use of specialist care. Multivariate analyses controlling for diabetes duration, demographic characteristics, health care practices, and physiological risk factors demonstrated that higher past use of specialist care was found to be significantly protective against the development of overt nephropathy (risk ratio 0.43, 95% CI 0.21-0.88) and neuropathy (0.54, 0.35-0.83) and weakly protective against coronary artery disease (0.65, 0.37-1.1).

CONCLUSIONS

A higher proportion of diabetes duration spent in specialist care may result in delayed development of certain diabetes complications independent of other risk factors. This study thus supports the concept that the benefits of specialist care should be available to all patients with type 1 diabetes.

Screening for people with diabetes mellitus for poor blood glucose control in an ophthalmological laser clinic

PURPOSE

The study was performed to test the effect of a structured intervention in diabetic patients with poor glycaemic control in an ophthalmological department.

PATIENTS AND METHODS

All the patients attending the ophthalmological out-patient department with the need for laser therapy due to diabetic retinopathy were investigated from January to March 1998 (Type 1: n=20, Type 2: n=144). If an HbA(1c)-level higher than 9.0% was found the patient was informed within 1 week and a standardised letter was sent to the primary care physician and the local ophthalmologist. Over the first 3 months of 1999 the effect was evaluated.

RESULTS

HbA(1c) values higher than 9.0% were found in eight/20 of the patients (40%) with Type 1 diabetes and in 61/144 of the patients (54%) with Type 2 diabetes. In 55% this new information in the context of the need for laser therapy resulted in the acceptance of a structured intervention by the patient. This led to an improvement of the HbA(1c) in the people with Type 1 diabetes.

CONCLUSION

Patients with poor blood glucose control can be identified in an ophthalmological department. The need for laser therapy can be used to motivate the patients for a significant improvement of the quality of blood glucose control.

GAD autoantibodies in a selection-free population of insulin-treated diabetic patients: indicator of a high prevalence of LADA?

Up to the present only few data have been available concerning the prevalence of diabetes-specific autoantibodies (anti-GAD, ICA, IAA, IA-2) in unselected populations, in particular in type 2 diabetic patients. Hence, the aim of the present study was to determine the prevalence of anti-GAD in a selection-free population of insulin-treated diabetic patients. Accordingly, 90% of all the insulin-treated diabetic patients (type 1, n=127, type 2, n=117) aged 16-60 years and living in the city of Jena (100242 inhabitants) were examined. In order to test sera for anti-GAD, serum samples were taken in 75% of type 1 (n=95) and in 80% of insulin-treated type 2 diabetic (n=94) patients.

RESULTS

In the group of type 1 diabetic patients 55% of the patients tested were positive for anti-GAD. But, interestingly, in the type 2 group, a total of 21% patients were positive. With respect to this high percentage of anti-GAD positive type 2 diabetic patients it must be suggested that the frequency of patients with latent autoimmune diabetes mellitus in adults (LADA) was underestimated in the past.

Therapeutic plasma exchange and cyclosporine in the treatment of systemic lupus erythematosus

Despite treatment with intensive immunosuppressive drug regimens, often the prognosis of patients suffering from systemic lupus erythematosus (SLE) is poor. Side effects such as infections and malignant tumors often occur. In the present trial, 21 patients (4 male and 17 female, aged 37.9 +/- 12.8 years) suffering from SLE for 9.4 +/- 2.6 years, were treated for 2.3 +/- 1.8 years with drug regimens of corticosteroids, azathioprine and/or cyclophosphamide. Then, over a period of up to 8 years, in addition to conventional therapies, especially in active stages of the disease with extremely high concentrations of anti-DNA-, antinuclear antibodies and circulating immunocomplexes, therapeutic plasma exchange (TPE) sessions were carried out depending on symptomatology. In addition patients received 2.5 +/- 0.6 mg cyclosporine/kg body weight/day. Compared to previous treatment modalities, clinical symptoms improved more quickly and more effectively (p = 0.046). After 5 to 48 (17.5 +/- 13.8) months, cyclosporine was established as a monotherapy for 8 of 21 patients. In the other cases, corticosteroids, azathioprine and cyclophosphamide were reduced by 40 to 100%. No severe side effects were seen. In acute stages of SLE and in forms with persistently high antibody levels, the addition of TPE sessions and cyclosporine as the basic immunosuppressive drug is usually very effective with regard to improving clinical symptomatology.

Prevalence of sexual disorders in a selection-free diabetic population (JEVIN)

There is an extensive literature on sexual disorders among diabetic patients, but a shortage of studies on their prevalence in selection-free populations. In the present trial (JEVIN), 90% of all insulin-treated diabetic patients (IDDM/NIDDM, n = 127/117) aged 16-60 years and living in the city of Jena (100247 inhabitants) were studied. Each subject underwent a structured interview followed by a clinical and laboratory examination. The prevalence of sexual disorders was 32% in IDDM and 46% in NIDDM male patients. Patients with sexual disorders were older (IDDM 47.5 +/- 9.8 vs. 37.7 +/- 11.6, P = 0.0004; NIDDM 53.4 +/- 4.3 vs. 49.5 +/- 8.2 years, P = 0.04) and had longer diabetes duration (IDDM 23.1 +/- 13.8 vs. 13.5 +/- 11.1, P = 0.001; NIDDM 12.4 +/- 7.5 vs. 8.4 +/- 5.8 years, P = 0.03) than patients without sexual disorders. There were no significant differences (P < 0.05) between the groups as regards HbA1c, body-mass index and insulin dose/kg body weight. The prevalence of diabetes long-term complications in men with versus men without sexual disorders (IDDM/NIDDM): retinopathy, 65/53% vs. 50/18% (P = 0.34/0.03); neuropathy, 58/48% vs. 9/34% (P = 0.001/0.47); nephropathy, 65/50% vs. 12/36% (P = 0.001/0.45). In addition, all the patients completed standardized questionnaires according to Bradley et al. and Lewis et al. to assess quality of life and treatment satisfaction, and one question concerning sexual disorders. The quality of life of IDDM patients with sexual disorders was lower than that of patients without sexual disorders (42.2 +/- 11.4 vs. 54.2 +/- 8.5, P = 0.0005), but there were no differences (P < 0.05) in NIDDM patients. In women, the prevalence of sexual disorders was 18/42% in IDDM and NIDDM. Comparing these data with the literature and with reports from healthy controls, mostly there is clearly an underestimation of the prevalence of sexual disorders in diabetic populations. Physicians must make more efforts to detect and treat sexual disorders, which may result in an improvement of patients' quality of life.

Cardiovascular risk profile of type 2 diabetic patients cared for by general practitioners or at a diabetes clinic: a population-based study

The aims of this study were to compare the cardiovascular risk profiles of patients with type 2 diabetes mellitus cared for by general practitioners and those regularly attending a diabetes center. Out of an Italian population-based cohort of 1967 diabetic patients, 1574 (80%) were investigated. Patients exclusively cared for by general practitioners (23.8%) were older and showed lower prevalence of hypertension (79.0% vs 85.9%, P < 0.001), poor blood glucose control (HbA1c >8.0, 33.4% vs 47.9%, P < 0.001) and coronary heart disease (18.1% vs 22.3%, P = 0.003), and lower plasma fibrinogen (3.5 +/- 0.8 vs 3.7 +/- 0.9 g/L, P < 0.001). In logistic regression analysis, they had significantly lower ORs for HbA1c >8.8% (OR 0.67, 95% CI 0.45-0.99), hypertension (OR 0.53, 95% CI 0.36-0.78), fibrinogen >4.1 g/L (OR 0.50, 95% CI 0.32-0.77), smoking (OR 0.60, 95% Cl 0.36-1.00), and coronary heart disease (OR 0.65, 95% CI 0.45-0.93), after adjustment for age, sex, duration of diabetes, BMI, and antidiabetic treatment. Patients regularly cared for at a diabetes clinic had a higher cardiovascular risk profile, suggesting selective referral to the clinics of patients with more difficult management and/or severity of the disease. These findings have implications in the interpretation of morbidity and mortality clinic-based studies.

[Quality of care of patients with diabetes mellitus living in a rural area of Germany]

PATIENTS AND METHOD

In a population based study the quality of diabetes care of insulin-treated diabetic patients aged 16 to 60 years and living in a rural area was studied. The parameters of metabolic control as well as the incidence of acute complications (severe hypoglycemia with the need of glucose or glucagon injection, ketoacidosis with hospital admission) were assessed by examination and with a standardized questionnaire in 81% of the target population (type-1/type-2-diabetic patients: n = 25/33). Also, in all the patients diabetic long-term complications (retinopathy, nephropathy, amputations of the lower extremities) were examined. 76% of the patients with type-1-diabetes and 91% of the patients with type-2-diabetes mellitus completed standardized questionnaires to assess quality of life and treatment satisfaction.

RESULTS

In type-1-diabetic patients HbA1c was 9.38 +/- 1.6%. In type-2-diabetic patients it was 9.53 +/- 1.91%. None of the patients examined was regularly treated by a specialized physician/diabetologist. The goal of metabolic control, a HbA1c value below 7.2%, was reached only by 4% of the patients with type-1-and 12% of the patients with type-2-diabetes mellitus. In multivariate analysis the most important factor associated with HbA1c was in type-1-diabetic patients female sex (R-squared = 0.17, c = 0.38, p = 0.059); in patients with type-2-diabetes mellitus it was the number of insulin injections per day (R-squared = 0.37, c = 0.19, p = 0.0096). All other factors investigated in the model (diabetes duration, insulin dosage/kg body weight, frequency of blood- or urine-glucose self-monitoring/week, body mass index, educational level) showed no significant associations. Quality of life and treatment satisfaction of the patients were good and comparable to other trials.

CONCLUSION

Out of other studies there is evidence for better metabolic control in patients regularly treated by specialized physicians/diabetologists and in patients who participated in structured treatment and teaching programs. These features must be the main goals of treatment for all patients with diabetes mellitus.