[Population-based study of diabetic retinopathy in Wolfsburg]

INTRODUCTION

Since November 1997 the complete documentation of an ophthalmological examination of diabetics has been annually subsidized by the Volkswagen Corporation Health Maintenance Organization (VW-HMO).

METHODS

The results of an annual ophthalmological examination were recorded in a standardised history sheet developed by the Initiative Group for Early Detection of Diabetic Eye Diseases. These data included visual acuity, intraocular pressure, lens status and a description of fundus abnormalities.

RESULTS

Within 26 months ophthalmological examinations of 2,801 patients were completed which represented 4.5% of all VW-HMO insured patients. On average, patients suffered from diabetes for 9.6 years (SD +/- 8.3), artificial intraocular lenses were present in 357 eyes (6.4%) and 1,216 eyes (12.0%) were diagnosed with cataract or posterior capsule opacification impairing visual acuity. Out of 263 patients younger than 40 years old, 18.8% had a mild or moderate and 3.3% a severe non-proliferative diabetic retinopathy (NPDR). A proliferative diabetic retinopathy (PDR) was found in 2.2% of the younger patients. Of 2,228 patients aged 40 years and older, 11.9% had a mild or moderate and 2.6% a severe NPDR. In 0.9% of this group PDR was diagnosed.

CONCLUSIONS

An annual ophthalmological screening based on a survey sheet of the Initiative Group was successfully introduced. For the first time a population-based evaluation on the prevalence of diabetic retinopathy was carried out for inhabitants of a German city. The prevalence of PDR was found to be lower than previously published in comparable studied.

Predictors of mortality and end-stage diabetic complications in patients with Type 1 diabetes mellitus on intensified insulin therapy

AIMS

To assess predictors of mortality and end-stage diabetic complications in patients with Type 1 diabetes mellitus on intensified insulin therapy.

METHODS

A cohort of 3,674 patients (insulin treatment before age 31) who had participated in a 5-day in-patient group treatment and teaching programme for intensification of insulin therapy between 9/1978 and 12/1994 were reassessed after 10 +/- 3 (mean +/- SD) years.

RESULTS

Vital status and data on blindness, amputations, and renal replacement therapy were documented for 97% patients; 7% patients had died, 1.3% had become blind, 2% had amputations and 4.6% started renal replacement therapy. Using the Cox proportional hazards model, the following risk factors of mortality as assessed at baseline were identified: nephropathy (at least macroproteinuria), hazard ratio 3.8 (95% confidence interval 2.6-5.6); smoking, 1.9 (1.4-2.6); diabetes duration, 1.5 (1.2-1.8) for a difference of 10 years; serum cholesterol, 1.1 (1.0-1.2) for a difference of 1 mmol/l; lower social status, 1.4 (1.1-1.8) for a difference of 1 out of 3 levels; age, 1.3 (1.1-1.6) for a difference of 10 years; male sex, 1.4 (1.1-1.9); systolic blood pressure, 1.1 (1-1.2) for a difference of 10 mmHg. For the combined endpoint - blindness or amputations or renal replacement therapy - predictors were: nephropathy, foot complications, HbA1c, smoking, cholesterol, systolic blood pressure, retinopathy, hypertension, and social status.

CONCLUSION

In Type 1 diabetic patients who start intensified insulin therapy, nephropathy remains the strongest predictor of mortality and end-stage complications. Glycosylated haemoglobin is a risk factor of end-stage complications but not of mortality. Conventional risk factors comparable to the general population, particularly smoking become operative as predictors of both mortality and end-stage complications.

[Self-treatment instruction of patients with type 1 diabetes. Report from hospitals belonging to Working Group for Structured Diabetes Therapy (ASD) in Germany 1998]

AIM

Intensified insulin therapy is the therapy of choice for patients with diabetes Type I. Intensified insulin therapy includes an basis-bolus insulin injection regimen or continuous subcutaneous insulin infusion, several times daily blood glucose self-monitoring, self-adaptation of insulin dosages by the patients themselves and a far-reaching liberalization of nutrition. The patients learn self management of diabetes therapy in a structured treatment and teaching program. The effectivity of this program is evaluated in the routine care.

PATIENTS AND METHOD

A peer-review quality circle was formed as an official working group of the German Diabetes Association based on the formation of a working group (Arbeitsgemeinschaft für Strukturierte Diabetestherapie [ASD]) of presently 135 general internal medicine departments from city, country and university hospitals throughout the country. The group attempted to document and to improve the quality of structure and process of Type-I diabetes care in its participating institutions by a system of peer supervision. Systematic follow-up examinations of 50 consecutive Type-I diabetic patients 12 to 15 months after participation in the program confirm the outcome quality. The working group meets every year to discuss the results non anonymously. A PC-system (DIQUAL) was developed for collecting, checking and pooling of the outcome data.

RESULTS

From 1992 a representative sample of 6.555 patients with Type-I diabetes was examined. At the first time in 1998 the outcome results of 1.789 patients were analyzed depending on the therapeutic goals. In patients with a high initial HbA1c (> or = 8%) an improvement from 9.8 to 8.0% was reached going together with a reduction of severe hypoglycemia from 0.23 to 0.13/patient/year. In patients with an acceptable initial HbA1c (< 8%) the frequency of severe hypoglycemia could be reduced from 0.65 to 0.24/patient/year without any deterioration in metabolic control. Furthermore the incidence of ketoacidosis with hospitalization and the inpatient days were reduced significantly.

CONCLUSION

A substantial improvement of HbA1c and reduction of acute complications, especially of severe hypoglycemia in patients with Type-I diabetes were reached by participation in a structured teaching and treatment programme in clinical routine care.

[Preventive care for early detection of diabetes mellitus complications: a model project in Wolfsburg]

In the city of Wolfsburg, an annual screening to detect diabetic complications was introduced. In this model, project internists and general practitioners were remunerated for the documentation of diabetic complications. Ophthalmologists were remunerated for the documentation of screening for diabetic eye disease. The patients received a copy of the results. 1,563 patients (2.57% of 60,800 persons insured by the Volkswagen health insurance in the city) received ophthalmologic examination. 1,554 patients (2.6%) were examined by internists and general practitioners (58 practices). Out of 2,879 eyes examined in no retinopathy was detected 80.9%. In 14.1%, mild or moderate retinopathy was observed as well as 3.3% severe non-proliferative retinopathy and 1.3% proliferative retinopathy. 32 amputations were documented. Three of them were not related to diabetes. 32 patients had diabetic foot ulcers (75% males). The implementation of screening for diabetic complications was very successful. Based on the results, an evidence based disease management programme can be started focussing especially on improved tertiary prevention of diabetic complications.

Rationale for the use of insulin therapy alone as the pharmacological treatment of type 2 diabetes

Before any treatment of type 2 diabetes in accordance with the principles of evidence-based medicine can be generally recommended, the considerable disease heterogeneity must be taken into account, and randomized controlled intervention trials directed to cardiovascular and microangiopathic organ damage end points must be performed for the various subgroups of patients. Until then, it appears prudent to treat the typical Caucasian type 2 diabetic patient primarily by nondrug therapies, and if they fail to achieve the patient's individual treatment goals, then insulin treatment should be initiated. Treatment of type 2 diabetic patients with insulin alone, aimed at the patient's individual therapeutic goals, is effective and safe when conducted as an integral part of specific and structured treatment and teaching programs. Insulin treatment can be safely used to achieve near-normal HbA1c levels (< 7.0-7.5%) if prevention of diabetic microangiopathy is indicated, or to maintain HbA1c levels < 8.5-9.0% if catabolic symptoms due to insulin deficiency are to be prevented.

Intensified treatment and education of type 1 diabetes as clinical routine. A nationwide quality-circle experience in Germany. ASD (the Working Group on Structured Diabetes Therapy of the German Diabetes Association)

This contribution describes the nationwide implementation of an intensive treatment and education program for type 1 diabetic patients in the clinical routine of the German health care system. Based on the formation of a working group (Arbeitsgemeinschaft Strukturierte Diabetestherapie [ASD]) of presently 57 general internal medicine departments, mainly from secondary and tertiary care levels in city and country hospitals throughout the country, a peer-review quality circle was formed as an official working group of the German Diabetes Association. The participating institutions performed a structured program of intensive treatment and education in all type 1 diabetic patients referred to them on a routine basis. The program includes multiple daily insulin injections or continuous subcutaneous insulin infusion, several times daily blood glucose self-monitoring and self-adaptation of insulin dosages and other aspects of treatment by the patients, and a far-reaching liberalization of the nutrition regimen. The group has attempted to document and to improve the quality of the structure and process of type 1 diabetes care in its participating institutions by a system of peer supervision. Furthermore, all member institutions volunteered to collect outcome data based on systematic 1-1.3 years' follow-up examinations of consecutive type 1 diabetic patients. For the 1997 evaluation of 1,103 type 1 diabetic patients, significant decreases of GHb levels and of incidence rates of severe hypoglycemia (from 0.35 to 0.16 cases per patient-year) and ketoacidosis (from 0.08 to 0.02 cases per patient-year) are presented. The ASD quality circle represents a model to improve principal aspects of type 1 diabetes care on a nationwide basis.

[Diabetology in the German medical system in 1998]

In 1990, instruction of diabetic patients was not recognised by health insurance providers in Germany, and a practitioner received no remuneration for training patients. Moreover, no physicians specialised in diabetology were recognised by health insurance providers. Specialised diabetology was performed exclusively in hospitals. Physicians conducting their practice in offices and interested in caring for diabetic patients were in a rather difficult situation. In 1991, remuneration was provided for the first time in Germany for therapeutic training of Type 2 (non-insulin-dependent) diabetic patients. Health insurance providers paid physicians DM 60 per patient for 4 class sessions. Since 1993, physicians in the Brandenburg region have been receiving DM 250 per patient for 5 class sessions (thus DM 1,000 for a group of 4 patients) to provide therapeutic training for Type 2 diabetic patients on conventional insulin therapy. This programme has been assessed in two reported studies: one showing that this ambulatory programme is as efficient as training in a hospital and the other evaluating the setting up the Brandenburg programme. However, the number of patients receiving training in medical offices has remained inadequate (around 250,000 patients in total). In 1997/98, in order to improve this situation, a health insurance group, the VdAK/AEV (representing nearly half of the insured persons in Germany), raised fees for physicians from DM 60 to 200 per patient for the training of diabetic patients. Moreover, a book for patients (the "passport for diabetic persons" provided by the German Association of Diabetology) is distributed to patients during the training courses and reimbursed by the insurers. Within a few years in nearly all regions of Germany, diabetologists practising in medical offices have succeeded in obtaining special contracts for performance of ambulatory diabetology. This development began in East Germany but has now spread to most regions of West Germany. In 1998, an annual examination for diabetic patients was established for preventive purposes. Thus, remuneration is related to precise disease documentation (feet, nephropathy, retinopathy). This model is currently being evaluated in Wolfsburg for all diabetic patients covered by the insurers of Volkswagen AG. The first results expected in 1999 will be useful in extending this preventive examination to other regions of Germany.

Social status and the quality of care for adult people with type I (insulin-dependent) diabetes mellitus--a population-based study

The objective of this study was to assess the degree of diabetes care and education achieved for Type I (insulin-dependent) diabetes mellitus at the community level in relation to social status and to elucidate potential pathways that mediate any social class gradient. A population-based sample of 684 adults with Type I diabetes (41% women, mean +/- SD age 36 +/- 11, diabetes duration 18 +/- 11 years) in the district of North-Rhine (9.5 million inhabitants), Germany, were examined in their homes using a mobile ambulance.

RESULTS

HbA1c (normal 4.3-6.1%) 8.0 +/- 1.5%, incidence of severe hypoglycaemia (injection of glucose or glucagon) 0.21 cases per patient-year; 62% of patients had participated in a structured group treatment and teaching programme for intensification of insulin therapy; 70% used 3 or more insulin injections per day, 9% were on continuous subcutaneous insulin infusion; 91% reported to have had measurements of HbA1c during the preceding year, and 80% to have had an examination of the retina by an ophthalmologist. Care was insufficient with respect to the quality of blood pressure control (70% of patients on antihypertensive drugs had blood pressure values > or = 160/95 mmHg), patient awareness of proteinuria/albuminuria (27% of patients had not heard about it) and prevention of foot complications (only 42% with a diabetes duration over 10 years had remembered to have a foot examination during the preceding 12 months). There was a pronounced social gradient with respect to micro- and macrovascular complications (prevalence of overt nephropathy 7 vs 20% for highest vs lowest quintiles of social class [OR 3.5, 95% CI 1.6-7.5, p = 0.002]) and diabetes-specific quality of life. HbA1c, blood pressure and smoking accounted for part of the association between social class and microvascular complications. The social class gradient was not due to inequality to access to health services, but to lower acceptance among low social class patients of preventive and health maintaining behaviour. In conclusion, achieved standards of care are high with respect to the implementation of intensified treatment regimens, the level of patient education achieved, treatment control and eye care, whereas areas for improvement are blood pressure control and preventive measures for foot care. A substantial social gradient in diabetes care persists despite equal access of patients to health services.

Should insulin therapy in type 2 diabetic patients be started on an out- or inpatient basis? Results of a prospective controlled trial using the same treatment and teaching programme in ambulatory care and a university hospital

The aim of this study was to determine whether Type 2 diabetic patients should be hospitalised to start insulin therapy. The same structured diabetes treatment and teaching programme (DTTP) was used in outpatients in 10 private practices after postgraduate training of physicians and teaching staff as well as in the Diabetes Department of the University Hospital of Jena, Germany. Seventy-two consecutive Type 2 diabetic patients (ambulatory group) participated in the outpatient DTTP. After one year, 70 patients were re-evaluated and compared with 70 other patients (matched pairs) who were referred to the University Hospital of Jena to start insulin treatment and participated in the same programme during hospitalisation. Initially there were no significant differences between the groups for age, gender, HbA1c, body mass index (BMI), and the time since diagnosis of diabetes. HbA1c (mean normal value 5%) decreased in both groups within the 12 months of follow-up (ambulatory group from 10.3 +/- 2.2 to 8.1 +/- 1.7, p < 0.0001; inpatient group from 10.4 +/- 1.6 to 8.4 +/- 1.7, P = 0.0001). At follow-up there were no significant differences between the groups concerning insulin dosage, HbA1c, severe hypoglycaemia, BMI, and hospitalisation. In combination with a DTTP, the initiation of insulin therapy on an ambulatory basis was as safe and effective as in the inpatient programme. Cost-benefit analysis demonstrated substantial savings in direct costs in the ambulatory programme.

[Cost effectiveness and evaluation of a structured therapy and education program for insulin-treated type II diabetic patients in Bradenburg]

The aim of the study was to evaluate the practicability and efficacy of a structured treatment and teaching programme (STTP) for Type II diabetic outpatients on conventional insulin treatment after introducing a remuneration for physicians. Reimbursement policy was introduced in the state of Brandenburg, Germany, in July 1993. Between August 1993 and February 1994, 108 practices in Brandenburg participated in a postgraduate seminar, which is a prerequisite for remuneration. Within the first year 10% of the target group of physicians participated in the seminars. A standardised interview was performed with 103 physicians. Twenty of the practices who had performed STTP were visited in order to collect data on all the patients who had participated in the programme. The seminar and the programme were well accepted. An improvement of HbA1c levels was observed in patients (n = 54) who had started insulin treatment (9.7 +/- 1.6% of total Hb before, 8.2 +/- 1.3% of total Hb after the programme) and in those (n = 189) who were already being treated with insulin before the STTP (9.6 +/- 2.5% of total Hb before, 8.1 +/- 1.4% of total Hb after the programme). The results of the study demonstrate the efficacy and practicability of an STTP for Type II diabetic patients on conventional insulin therapy in ambulatory health care.

Cigarette smoking and progression of retinopathy and nephropathy in type 1 diabetes

The objective of the present study was to analyse the association between cigarette smoking and progression of retinopathy and nephropathy, respectively, in a prospective multicentre study including 636 people with Type 1 diabetes: 81% of the original cohort of consecutively referred patients, aged 15 to 40 years and free of severe late diabetic complications. At baseline, all patients had participated in a 5-day in-patient group treatment and teaching programme for intensification of insulin therapy. Patients were examined at recruitment, and after 1, 2, 3 and 6 years including assessment of smoking status, blood pressure, metabolic control, and degree of nephropathy. Degree of retinopathy was assessed by ophthalmoscopy or fundus photography at baseline and after 6 years. Several logistic regression analyses were performed by describing the responses retinopathy and nephropathy, respectively, either as progression yes/no or as actual status at the 6-year follow-up and by using different measures for smoking. Adjustments for important covariables were made. While significant associations between smoking, and retinopathy and nephropathy respectively, were found, the relations were variable depending on the statistical model used. The results show that the real associations between smoking and retinopathy and nephropathy are complex and that more emphasis should be put on the complete description of the response variables and the statistical models used in clinical and epidemiological research.

Health care for persons with non-insulin-dependent diabetes mellitus. The German experience

A structured treatment and education program for patients with non-insulin-dependent diabetes mellitus (NIDDM) who are not taking insulin was developed, evaluated, and implemented at the primary health care level throughout Germany. The program is based on the definition of individual and pragmatic therapeutic goals for each patient, primarily using nondrug treatment, which includes systematic glycosuria self-monitoring by the patients and four structured sessions of group education held in a general practitioner's office. After documentation of the program's efficacy in a randomized, controlled trial and several pilot projects, the program has been officially incorporated into the general German health care scheme and includes payment to practicing physicians for each patient treated. More than 12,500 primary health care physicians have participated in special 2-day postgraduate courses given by diabetologists; these courses are a precondition to participating in the program. As part of the primary health care scheme, the NIDDM program will be continuously monitored for quality control and efficiency. Currently, similar structured treatment and education programs targeted to primary health care physicians are being introduced for both insulin-treated NIDDM and arterial hypertension.

[Structured public health quality circle on the topic of diabetes management in general practice]

The efficacy of quality circles has not yet been evaluated in controlled studies in Germany. The Central Research Institute for Ambulatory Health Care in Germany conducted a prospective controlled trial in order to evaluate the effects of structured quality circles on the process of quality ambulatory care for diabetic patients. Following a training for moderators (two for each quality circle) two quality circles undertook five sessions. In a representative random sample (25 diabetic patients per practice), the quality of diabetes care was evaluated before and after participation in the quality circles and was compared to the results of a control group without peer review. The participation in a quality circle resulted in a significant and relevant improvement of the quality concerning the detection of diabetes related complications.

[The graduate education project in the new federal German lands "Diabetics--Management in General Practice"]

Supported by the federal ministry of health, the Central Research Institute for Ambulatory Health Care in Germany organised postgraduate courses with the topic "How to take care of diabetic patients" in cooperation with the society of panel physicians. Contents and media of the postgraduate course were developed with the help of experts, a formative evaluation of the curriculum was carried out. In a consensus- and preparatory meeting, diabetologists discussed the medical objectives with experts and were trained under the guidance of educationalists (microteaching with video-monitoring aiming at improving teaching behaviour). Later on, 1315 physicians participated in 38 postgraduate courses. The experiences of this project can provide useful informations how to structure postgraduate medical education.

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.

Predictors of glycaemic control in type 1 diabetic patients after participation in an intensified treatment and teaching programme

The aim of the study was to identify predictors of long-term glycaemic control in Type 1 diabetic patients after participation in an intensified insulin treatment and teaching programme. The study population consisted of 697 Type 1 diabetic patients (mean age 26 +/- 7 (SD) years, duration of diabetes 8 +/- 7 years) who participated in the same structured intensified insulin treatment and teaching programme in 10 hospitals and who were re-examined after 1, 2, and 3 years. Multiple and logistic regression analyses were performed including a set of demographic, disease-related, social, and psychosocial variables as potential predictors. As dependent variables the average HbA1 values during the 3-year follow-up period and a composite variable (average HbA1 values/frequency of severe hypoglycaemia)--dividing patients into three groups with good, moderate or poor metabolic control--were considered. Regression analysis of average HbA1 values revealed significance (p < 0.05) for seven independent predictors in descending order: smoking, age at onset of diabetes, frequency of home blood glucose monitoring, socioeconomic status, diabetes-related knowledge, perceived coping abilities, and sex (R2 (percentage of variation explained by the model) = 17%). In a second regression model, HbA1 values before the intervention programme were added to the model and achieved the highest standardized regression coefficient (0.38), increasing R2 to 29%. In the logistic regression models considering both HbA1 and severe hypoglycaemia as a composite dependent variable, diabetes-related knowledge, HbA1 values before the intervention, smoking, perceived coping abilities, age at onset of diabetes, and C-peptide levels were the strongest predictors of glycaemic control. In conclusion, the relationship between demographic, disease-related, psychosocial, and social variables and metabolic control is complex. Therefore, simplistic concepts of linear causality should be abandoned. In addition to HbA1 values before the intervention, smoking, diabetes-related knowledge, home blood glucose monitoring, age at onset of diabetes, perceived coping abilities and C-peptide levels were the most significant and consistent predictors of glycaemic control.

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

In a prospective controlled trial the effects of a 5-day in-patient treatment and teaching programme for Type 1 (insulin-dependent) diabetes mellitus on metabolic control and health care costs were studied in Moscow. Two different intervention programmes were compared, one based upon urine glucose self-monitoring (UGSM, n = 61) and one using blood glucose self-monitoring (BGSM, n = 60). Follow-up was 2 years. A control group (n = 60) continued the standard treatment of the Moscow diabetes centre and was followed-up for 1 year. Costs and benefits with respect to hospitalizations and lost productivity (according to average wage) were measured in November 1992 rubles (Rb.), with respect to imported drugs and test strips in 1992 German marks (DM). In the intervention groups there were significant decreases of HbA1 values [UGSM: 12.5% before, 9.4% after 1 year, 9.2% after 2 years (p < 0.0001); BGSM: 12.6% before, 9.3% after 1 year, 9.2% after 2 years (p < 0.0001) compared to no change in the control group (12.2% before, 12.3% after 1 year)], and of the frequency of ketoacidosis. The frequency of severe hypoglycaemia was comparable between the UGSM (10 cases during 2 years), BGSM (10 cases during 2 years), and the control group (8 cases during 1 year).(ABSTRACT TRUNCATED AT 250 WORDS)

[Cost-benefit analysis of education programs and of treatment in type 2 diabetes]

Structured teaching and treatment programmes for Type-II non insulin dependent diabetic patients have been proved in several studies to be cost effective. K. Davidson in Atlanta described the considerable decrease of health care costs after the introduction of his programme. Recently a similar programme was introduced into the German health care system and physicians in private practice are remunerated for providing the programme. Until now more than 10,000 physicians have participated in postgraduate courses, which are the prerequisite to be remunerated. The evaluation of the programme including a cost benefit analysis demonstrated the financial benefits of the programme even in a short time. The methods of nation-wide multiplication of the programme and its contents are summarised in this article. The principles of the treatment strategy follows the objectives which have been published already in 1875 by A. Bouchardat: Urine testing, hypocaloric diet and exercise.

Effective and safe translation of intensified insulin therapy to general internal medicine departments

Up to now all published experience with intensified insulin therapy has originated from specialized diabetes centres. However, even in diabetes centres and under research conditions intensification of insulin therapy may substantially increase the risk of severe hypoglycaemia. The aim of the present study was to demonstrate the feasibility of effectively and safely transferring intensified insulin therapy based upon a 5-day in-patient treatment and teaching programme from a University diabetes centre to non-specialized general hospitals. A total of nine general hospitals were recruited; the University diabetes centre served as a reference centre. From each general hospital a nurse and a dietitian were trained as diabetes educators, and a diabetes unit with about 10 beds was organized within each department of internal medicine. A total of 697 consecutively admitted Type 1 (insulin-dependent) diabetic patients (age 26 +/- 7 years, duration of diabetes 8 +/- 7 years) who participated in the programme either in one of the general hospitals (n = 579) or in the reference centre (n = 118) were re-examined after 1, 2 and 3 years. Insulin therapy was intensified to a similar extent in the reference centre and the general hospitals; at the 3-year follow-up about 80% of the patients injected insulin at least three times daily or used continuous subcutaneous insulin infusion (10%), and about 70% reported measuring blood glucose levels more than twice per day. HbA1 levels were lowered (p < 0.0001) to comparable levels, i.e. from 10.6% (reference centre) and 9.9% (general hospital), respectively, at baseline to 9.4% and 9.3%, respectively, at the 3-year follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of a structured treatment and teaching programme on hypertension in general practice

OBJECTIVE

Evaluation of a structured hypertension treatment and teaching programme in general practice.

DESIGN

Prospective controlled trial; follow-up period 18 months.

SETTING

10 primary health care practices. PRACTICES AND PATIENTS: From each practice 20 patients (30 to 60 years old, mean of the last two blood pressure measurements at or above 160 and/or 95 mmHg) were randomly selected; in 5 practices these patients were to participate in the treatment and teaching programme; in the remaining 5 practices hypertension care was continued without the availability of such a programme (controls).

INTERVENTION

Structured treatment and teaching programme based upon four group sessions for patients mainly conducted by paramedical personnel.

MAIN OUTCOME MEASURES

Blood pressure, body weight, prescription of antihypertensive drugs - as documented in the patient's records.

MAIN RESULTS

Of the 100 control patients 26 and of the 100 intervention patients 14 were lost to observation; 46 patients had agreed to participate in the programme. The mean number of prescribed antihypertensive agents per patient decreased in the intervention group (1.8 +/- 1.3 at baseline, vs 1.2 +/- 1.2 at follow-up) compared to the control group (1.6 +/- 1.3 vs 1.8 +/- 1.6); difference 0.8 (95% CI 0.4 to 1.1), p < 0.0001. In the control group 9% and in the intervention group 33% of patients had documented reductions of body weight (p < 0.0001). Blood pressure decreased in the intervention group (162 +/- 14/100 +/- 7 mmHg at baseline, vs 154 +/- 16/95 +/- 9 mmHg at follow-up) compared to the control group (161 +/- 13/98 +/- 7 mmHg vs 158 +/- 18/96 +/- 11 mmHg); differences for systolic blood pressure 5 (95% CI 0 to 10) mmHg, p = 0.071; for diastolic blood pressure 4 (1 to 7) mmHg, p = 0.018.

CONCLUSIONS

The introduction of a structured hypertension treatment and teaching programme in general practice may lead to significant improvements of hypertension care.

Evaluation of a structured treatment and teaching programme on non-insulin-dependent diabetes

A structured treatment and teaching programme for non-insulin-treated non-insulin-dependent (type 2) diabetes was evaluated prospectively in general practice. The four group sessions were mainly conducted by paramedical personnel. 65 patients from five general practices were assessed at the start of the programme and 50 (mean age 65 years, diabetes duration 7 years) completed the 1 year follow-up (intervention group). The control group consisted of 49 patients (mean age 63 years, diabetes duration 7 years) from three other general practices without the programme. In the intervention group the percentage of patients receiving sulfonylureas fell from 68% at the start of the study to 38% after 1 year (mean difference 30%, 95% confidence interval [CI] 16-44%); the mean weight loss was 2.7 kg (95% CI 1.6-3.8 kg), and non-fasting triglycerides were reduced by 0.77 mmol/1 (95% CI 0.35-1.19 mmol/l); and glycosylated haemoglobin remained unchanged (7.1% of total haemoglobin). In the control group none of these indices was changed during the study year, and 10% of patients started insulin treatment. The structured treatment and teaching programme improved the overall quality of patient care in elderly non-insulin-dependent diabetic patients treated by general practitioners.

Uncontrolled hypertension in type 1 diabetes: assessment of patients' desires about treatment and improvement of blood pressure control by a structured treatment and teaching programme

Control of arterial blood pressure at near-normal levels is of importance for the prognosis of patients with Type 1 (insulin-dependent) diabetes mellitus. In non-diabetic populations patient compliance to antihypertensive therapy is frequently poor, especially in young people. Thirty-seven consecutive eligible patients with longstanding Type 1 diabetes and persistently uncontrolled hypertension were questioned about their preferences regarding hypertension treatment. Throughout they expressed a strong desire for more information about hypertension and for active participation in monitoring of blood pressure and therapeutic decision-making. In addition, they showed considerable reluctance to accept a pharmacological intervention. Therefore, in order to improve blood pressure control, the patients participated in a structured outpatient hypertension treatment and teaching programme for groups of about 6 patients consisting of four teaching sessions at weekly intervals. The programme comprised home-monitoring of blood pressure and involvement of the patients in treatment decision-making. In 34 patients who had a complete follow-up examination after an average of 16 months, mean sitting arterial pressure had decreased from 111 to 101 mmHg (p less than 0.001) and 53% of the patients were below 140/90 mmHg. The number and dosage of prescribed antihypertensive agents remained unchanged by the intervention. Sodium intake was not reduced during the study, but pulse rate decreased significantly in patients treated with beta-adrenergic blockers and serum uric acid rose in patients on diuretic therapy, suggesting increased adherence of the patients to prescribed antihypertensive drug therapy. In 34 comparable Type 1 diabetic patients who were not subjected to a hypertension treatment and teaching programme mean arterial blood pressure remained unchanged during a 12-month period.

Evaluation of an intensified insulin treatment and teaching programme as routine management of type 1 (insulin-dependent) diabetes. The Bucharest-Düsseldorf Study

It has been questioned whether aiming at near-normoglycaemia by intensified insulin treatment regimens is feasible and safe for the majority of patients with insulin-dependent diabetes. In this study, intensified insulin injection therapy (including blood glucose self-monitoring and multiple insulin injections) based upon a 5-day inpatient group teaching programme was evaluated in Type 1 (insulin-dependent) diabetes mellitus in the centralised health care system of Bucharest. One hundred patients (group A, initial HbA1 12.5%) were followed for 1 year on their standard therapy (individual teaching, no metabolic self-monitoring), and thereafter for 1 year on intensified therapy. Another 100 patients (group B, HbA1 12.3%) were followed for 2 years on intensified therapy. A third 100 patients (group C, HbA1 11.7%) were assigned to a basic 4-day inpatient group teaching programme with conventional insulin therapy (including self-monitoring of glucosuria and acetonuria) and followed for 1 year. Mean HbA1 remained unchanged after standard treatment (group A: 12.8% at 12 months), but decreased during intensified therapy (group A: 10.1% at 24 months; group B: 9.3% at 12 months, 9.5% at 24 months; p less than 0.0001). In group C, no change was found compared to standard treatment (i.e. group A at 12 months). Incidence rates of ketoacidosis were 0.16 episodes per patient per year during standard treatment, 0.01 during intensified treatment (p less than 0.01) and 0.04 in group C (p less than 0.025). Hospitalisation rates were reduced by 60% during intensified therapy and by 40% in group C. Frequency of severe hypoglycaemia was not significantly different between the three treatment regimens. Thus, under the condition that insulin treatment is based upon a structured and comprehensive training of the patient, intensified insulin injection therapy performed as routine treatment of Type 1 diabetes significantly lowers HbA1 levels without increasing the risk of severe hypoglycaemia.

Incidence and management of severe hypoglycemia in 434 adults with insulin-dependent diabetes mellitus

The risk of severe hypoglycemia associated with the particular therapeutic approach of two University hospitals was assessed in 96% of all patients with insulin-dependent diabetes mellitus (IDDM) who had been admitted during a period of almost 3 yr to the diabetic wards of two hospitals and who participated in a structured teaching and treatment program. During a mean follow-up period of 18 mo, 10% of the conventionally treated patients (N = 384; age 30 +/- 13 yr; duration of diabetes 12 +/- 9 yr) and 9% of the CSII-treated patients (N = 50, age 28 +/- 7 yr, duration of diabetes 13 +/- 7 yr, total follow-up period 1093 patient-mo) experienced at least one severe hypoglycemic episode per year, and a total of 123 severe hypoglycemic episodes occurred. In a subgroup of 169 conventionally treated patients, mean glycosylated hemoglobin values decreased from 10.5 +/- 1.9% before participation in the program to 9.2 +/- 2.0% (P less than 0.001) 18 +/- 4 mo thereafter. For the CSII-treated patients, glycosylated hemoglobin values were 9.7 +/- 1.9% before initiation of pump therapy and remained at the upper normal range from 3 mo thereafter throughout the study. There was no relationship between glycosylated hemoglobin levels and the occurrence of severe hypoglycemic episodes. Fifty-three severe hypoglycemic episodes were treated with glucagon injections by the patients' relatives (all but one effectively), 30 were managed by assisting physicians, and 44 led to hospitalization. Thus, successful attempts to improve glycosylated hemoglobin values in an unselected group of patients with IDDM were not associated with an unduly high risk of severe hypoglycemia when compared with the scarce data from the literature.

Bicentric evaluation of a teaching and treatment programme for type 1 (insulin-dependent) diabetic patients: improvement of metabolic control and other measures of diabetes care for up to 22 months

In two hospitals an identical diabetes teaching and treatment programme (in-patient, Monday to Friday, group teaching) was set up. Seventy-eight consecutive, conventionally treated Type 1 diabetic patients (duration of diabetes 10 +/- 6 years), referred during a certain period, were reinvestigated after 1 year, and again (for assessment of metabolic control only) 22 months after the teaching and treatment programme. Initially, mean glycosylated haemoglobin was 2.6%, after one year 1.0%, and after 22 months 1.5% above the upper limit of the normal range (p less than 0.001). Hospital admissions were reduced from a mean of 10 to a median of 1 day per patient per year (p less than 0.001). The long-term quality of diabetes care achieved by the diabetes teaching and treatment programme was unrelated to intelligence quotient, diabetes duration, or diabetes-related knowledge. Patients with normal levels of glycosylated haemoglobin on follow-up (33% of all patients) had particularly good compliance rates, and significantly lower initial values of glycosylated haemoglobin than patients with glycosylated haemoglobin levels greater than or equal to 10%. The data indicate that the diabetes teaching and treatment programme resulted in a substantial long-term improvement of metabolic control and a striking reduction of hospital admissions. The study substantiates the feasibility of applying this teaching and treatment programme on a large scale to other hospitals, so as to improve the quality of diabetes care and decrease health care costs.

[Evaluation of education of the diabetic. Quality control in diabetes therapy]

Any successful treatment of type-I diabetic patients has to be based upon a detailed education of the diabetic patient in order to enable him to selfmanage his disease as much as possible. The goals of diabetes-therapy (i.e. near-normalization of glycaemia in order to prevent diabetic microangiopathy at as high a quality of life as possible) can only be achieved by actively involving the patient in his/her therapy. Thus patient education becomes the cornerstone of modern diabetes-care. The evaluation of diabetes-education has--eventually--be based upon an assessment of the quality of metabolic control. A number of studies have proven that effective diabetes-education programmes can substantially improve long-term metabolic control and the incidence of acute complications in type I diabetic patients. At present, it appears that the most efficient way to improve the overall quality of diabetes-care is to improve diabetes-education delivered to the patients.

Obesity and hypertension: cardiovascular response of weight reduction

There is a close epidemiological association between obesity and blood pressure for all age groups, although not every obese individual becomes hypertensive. In populations without age-related increases in body weight, an elevation of blood pressure with age is not seen. Treatment of obesity by weight loss decreases blood pressure substantially; however, in a minority of patients blood pressure does not fall with weight loss. Blood pressure generally decreases before normal weight is achieved. Blood pressure after weight loss remains reduced as long as there is no marked regain of body weight. Salt intake reduction does not appear to explain why weight reduction lowers blood pressure. Reduced levels of plasma renin activity, serum aldosterone levels, catecholamine levels, and serum insulin levels may be involved in the blood pressure lowering associated with weight loss. Since the risk to the hypertensive patient is not only determined by the blood pressure, an overall treatment that aims at reduction of all risk factors is advocated. Some risk factors, e.g., glucose intolerance, may be normalized only when desirable weight is achieved. Thus, in any obese hypertensive patient with other risk factors, normalization of excess body weight appears to be the first the most important step of any rational therapeutic strategy.

[Raised plasma glucagon levels in obesity (author's transl)]

Plasma glucagon levels were measured in 129 grossly obese patients with 77 +/- 29% excess weight according to Broca. A significantly raised basal glucagon level (179 +/- 7 pg/ml) was found when compared with normal weight controls (109 +/- 7 pg/ml). Weight reduction of 9.1 +/- 3.8 kg with reduction of glucose-stimulated hyperinsulinaemia from 97 +/- 12 microU/ml to 62 +/- 6 microU/ml had no influence on hyperglucagonaemia. A subgroup of obese patients with hypertriglyceridaemia (270 +/- 24 mg/dl) and glucose intolerance had particularly high plasma glucagon levels (198 +/- 12 pg/ml). It seems that these patients have a resistance to glucagon in addition to a marked insulin resistance.

Absorption kinetics and biologic effects of subcutaneously injected insulin preparations

This paper describes systematic studies on the absorption kinetics of exogenous insulin from its subcutaneous tissue depot in 52 male nonobese volunteers (age 20-30 yr). Five experimental protocols were used: effect of changing injection site, effect of temperature change and local massage, effect of aprotinin and human serum, effect of mixing regular insulin with long-acting insulin preparations, and effect of temperature change, muscular exercise, and local massage on the absorption of long-acting insulin preparations. The fastest absorption of insulin occurred at the abdominal injection. Absorption after arm injection was faster than after thigh injection. A hot bath and local massage dramatically increased serum insulin levels in the first 90 min after injection; in contrast, a cold bath delayed absorption substantially. Both aprotinin and the subjects' own blood serum mixed with insulin caused a marked acceleration of the insulin absorption process. Absorption kinetics of two neutral regular insulins (Actrapid and Leo Regular) were virtually identical. Mixing Actrapid with Monotard caused higher serum insulin levels than the mixture of Leo Regular with NPH. A time lag of 5 min between the mixing of Actrapid and Monotard and the injection caused a delayed rise of serum insulin levels; in contrast, this delay could not be observed when Leo Regular and NPH were mixed. Volunteers performed bicycle exercise, applied a hot water bottle to the injection site, or rubbed the injection site 2 1/2 h after injection of long-acting insulin. Accelerated absorption of insulin was only observed after local massage of the injection site of Monotard, Leo NPH, and Mixtard. Local heat had no effect. Exercise caused only an increased absorption of insulin after the Mixtard injection but not after Monotard or NPH injection. These findings have clinical significance and should not be without potential benefit in the attempt to improve metabolic control in insulin-treated diabetic patients.

Cardiovascular risk factors and HDL-cholesterol levels in obesity

In 1332 patients with different degrees of obesity (344 men, mean age 36 +/- 13 years, Broca Index 1.46 +/- 0.23; 988 women, mean age 37 +/- 13 years, Broca Index 1.67 +/- 0.30), cardiovascular risk factors (RF), serum HDL-cholesterol, and insulin levels were investigated. The most frequent RF was diastolic hypertension (68 per cent), followed by systolic hypertension (56 per cent), glucose intolerance (55 per cent), hypertriglyceridemia (31 per cent), hyperuricemia (19 per cent) and hypercholesterolemia (18 per cent). Only 9.4 per cent of the patients were without RF, and these patients were younger and less obese than patients with RF. Compared with controls, HDL-cholesterol levels were decreased in obese patients, however, the negative linear correlation between relative body weight and HDL-cholesterol levels was only significant in women, not in men. HDL-cholesterol levels were higher in women than in men. Serum insulin levels were correlated positively with relative body weight and negatively with age. Partial correlation analysis revealed a stronger influence of age than body weight on blood pressure, serum levels of total cholesterol, LDL-cholesterol, triglycerides and blood glucose levels. Uric acid levels correlated positively, and HDL-cholesterol levels negatively with relative body weight alone and not with age. On the basis of prevalence of RF, low serum HDL-cholesterol and high insulin levels, obese patients must be considered at high risk with respect to the development of cardiovascular disease.

Epidemiology of obesity and hypertension

Based on the reviewed literature and the data from the düsseldorf Obesity Study there is a close association between obesity and hypertension. This association is found in adults, adolescents and children. Hypertension is the most frequent cardiovascular risk factor in obesity. The black population shows higher blood pressure levels than the white population within the same relative weight. Prospectively investigated normotensive obese subjects are more likely to develop hypertension than normal weight subjects. In Western population there is also an association between hypertension and age. This is not seen in tribal populations, where after the age of 20 years body weight does not increase, suggesting body weight to be an important factor for the regulation of blood pressure. Present epidemiological evidence strongly calls for detailed prospective studies of obesity and hypertension, in order to define particularly hypertension-prone obesity subtypes.

[Blood-sugar self control. A means for the diabetic of controlling his metabolic management. Quality control of a battery-run pocket size reflectometer (glucose-meter)]

Home blood glucose monitoring by diabetic patients has recently been advocated as an effective means to improve metabolic control. The Glucocheck apparatus, a pocket-size battery-driven reflectance-meter (in Germany commercially available under the name Glucose-meter), has been evaluated for accuracy and practicability. In 450 blood glucose measurements, the variance between the values obtained using the Glucocheck apparatus and routine clinical laboratory procedures was +/- 11.7%. Especially in the low range of blood glucose concentrations, the Glucocheck method was very reliable. The quantitative precision of the Glucocheck method depends, however, quite considerably on the ability of the patient to use the apparatus correctly. In order to profit from Glucocheck in clinical practice, particular efforts to educate the patients in its use are necessary.

Analysis of T-lymphocyte subpopulations in juvenile-onset diabetics

In juvenile-onset diabetics (JOB) subpopulations of T-lymphocytes in the peripheral blood have been analysed by the E-rosetting technique. We determined the number of 'low', 'intermediate' and 'high affinity' ('active') rosette forming T-cells by the use of three different lymphocyte:sheep red blood cell ratios in the assay. When comparing the percentage and absolute number of peripheral T-cells between twenty well controlled JODs and twenty normal persons a slight reduction was found in diabetics. Of the three T-lymphocyte subpopulations only active rosette forming cells appeared to be affected. We conclude that minor differences exist in number and characteristics of peripheral blood T-cells between well controlled JODs and normal persons.

[Behavior modification and obesity (author's transl)]

Good results were obtained treating 49 obese patients with an elaborated selfcontrol behavior modification program. This program was an addition to the normal program of the obesity clinic of the 2. Medizinische Klinik der Universität Düsseldorf. The normal program contains some principles of behavior modification but less accentuated. After the initial 12 weeks of controlled training patients tried to reduce weight further decreasing external control. Only few patients were able to loose additional pounds during this period of 8 weeks. At the end of the initial 12 weeks patients had asked for another control before the vacational season, but only 10 out of 49 appeared at the control sessions 9 months after the program's start. If an additional behavior modification program is considered for incorporation into an already existing weight reduction clinic, additional costs and expected results have to be checked. Durative success of behavior modification techniques in weight loss programs has still to be submitted to proof.