Diabetes-related Care Research Articles

Mortality, Health Outcomes, and Body Mass Index in the Overweight Range

Health hazards of obesity have been recognized for centuries, appearing, for example, in writings attributed to Hippocrates. From the later decades of the 20th century through the present, there have been numerous epidemiological studies of the relationship between excess weight and the total, or all-cause, mortality rate,1 a critical cumulative measure of the public health impact of any health condition. Using body mass index (BMI), an indicator of relative weight for height (weight [kg]/height [m]2) and a frequently used surrogate for assessment of excess body fat, these studies have found linear, U-shaped, or J-shaped relationships between total mortality and BMI. That is, in some studies, both the thin and the obese were more likely to die than those in between. There is, however, always a point at which increasing BMI is associated with increasing mortality risk, but the BMI at which this occurs varies across studies and populations.2 Currently,3 overweight in adults is defined as a BMI of 25.0 to <30.0 kg/m2 and obesity as a BMI of ≥30.0 kg/m2 (Table 1). A number of studies have found no significant relationship between BMI in the overweight range and mortality rate4 and have shown the nadir of mortality risk to be in the overweight range. In particular, commentaries in both the lay press5–7 and scientific literature2,8,9 subsequent to recent reports from National Health and Nutrition Examination Surveys (NHANES)10,11 have highlighted the confusion and controversy regarding this issue. Some have interpreted the recent data to mean that overweight is not detrimental to health and is not in itself a public health concern and that drawing attention to the need for weight loss in this range will have negative effects on the health and well-being of the general population.8 Others have argued …

A Systematic Review of Research on Culturally Relevant Issues for Hispanics With Diabetes

The purpose of this review is to provide a description of current research on culturally relevant issues among Hispanics subgroups with diabetes throughout the United States. A search of 2655 abstracts was conducted using Medline, PubMed, and Psychlit. Sixty articles were identified, and 33 were reviewed. Most studies focused on Mexican Americans, and little is known about the unique and shared health beliefs of different Hispanics subgroups within the United States. Personal models of illness varied across groups and were influenced by levels of acculturation. Definitions and treatments for susto varied considerably: Puerto Ricans did not identify it as a cause of diabetes. Patients' thoughts about God and diabetes differed, and little is known about how these thoughts affect diabetes self-management. There is also limited research on Hispanics' use of curanderos (folk healers) for diabetes-related care, and only some participants reported using alternative treatments in conjunction with standard medical care. There is limited evidence that fatalistic thinking is unique to Hispanic culture, and its relationship to diabetes self-management remains unclear. More research is needed to determine how cultural factors influence Hispanics' approaches to diabetes self-management. Clinicians and educators would benefit from exploring cultural belief systems with patients, as they may enhance the patient-provider relationship and serve as tools in identifying appropriate treatment strategies.

Incremental Cost Savings 6 Months Following Initiation of Insulin Glargine in a Medicaid Fee-For-Service Sample

This study assessed the role of insulin glargine use on the short-term costs of diabetes care from a state Medicaid fee-for-service reimbursement perspective. A retrospective claims analysis was performed for 20% of Medicaid recipients in California (Medi-Cal) between November 2000 and September 2002. Each patient with continuous enrollment at least 6 months before and after the insulin glargine index date was matched with 2 reference patients by age, gender, diabetes diagnosis, and enrollment dates. Costs were calculated for emergency department, inpatient, outpatient, and pharmacy claims paid, and changes from baseline were determined. Incremental cost savings were estimated from baseline cost in the insulin glargine group multiplied by the difference in percentage of changes from baseline. Of the 1018 insulin glargine users, 267 satisfied inclusion criteria and were matched to 534 reference patients. Baseline treatment costs were 2.7-fold higher in the insulin glargine group. Absolute cost reductions in the insulin glargine and reference groups were 185 dollars and 72 dollars per patient, respectively. Incremental cost savings were 69 dollars per insulin glargine user, including more than 200 dollars in incremental savings for inpatient claims. Hypoglycemia decreased from 9.5% to 3.8% of inpatient claims in the insulin glargine group but remained 1.1% throughout in the reference group. Insulin glargine use was associated with reduced inpatient hypoglycemia-related claims paid and short-term reductions in the inpatient and total costs of diabetes-related care. Additional studies are warranted to assess the influence of insulin glargine on diabetes-related costs.

Primary and Specialty Medical Care Among Ethnically Diverse, Older Rural Adults With Type 2 Diabetes: The ELDER Diabetes Study

Residents in rural communities in the United States, especially ethnic minority group members, have limited access to primary and specialty health care that is critical for diabetes management. This study examines primary and specialty medical care utilization among a rural, ethnically diverse, older adult population with diabetes. Data were drawn from a cross-sectional face-to-face survey of randomly selected African American (n=220), Native American (n=181), and white (n=297) Medicare beneficiaries > or =65 years old with diabetes in 2 rural counties in central North Carolina. Participants were asked about utilization of a primary care doctor and of specialists (nutritionist, diabetes specialist, eye doctor, bladder specialist, kidney specialist, heart specialist, foot specialist) in the past year. Virtually all respondents (99.0%) reported having a primary care doctor and seeing that doctor in the past year. About 42% reported seeing a doctor for diabetes-related care. On average, participants reported seeing 2 specialists in the past year, and 54% reported i seeing >1 specialist. Few reported seeing a diabetes specialist (5.7%), nutritionist (10.9%), or kidney specialist (17.5%). African Americans were more likely than others to report seeing a foot specialist (P < .01), while men were more likely than women to have seen bladder specialist (P = .02), kidney specialist (P = .001), and heart specialist (P = .004), after adjusting for potential confounders. Predictors of the number of specialists seen include gender, education, poverty status, diabetes medication use, and self-rated health. These data indicate low utilization of specialty diabetes care providers across ethnic groups and reflect the importance of primary care providers in diabetes care in rural areas.

The association of patient trust and self-care among patients with diabetes mellitus.

BackgroundDiabetes requires significant alterations to lifestyle and completion of self management tasks to obtain good control of disease. The objective of this study was to determine if patient trust is associated with reduced difficulty and hassles in altering lifestyle and completing self care tasks.MethodsA cross-sectional telephone survey and medical record review was performed to measure patient trust and difficulty in completing diabetes tasks among 320 medically underserved patients attending diabetes programs in rural North Carolina, USA. Diabetes tasks were measured three ways: perceived hassles of diabetic care activities, difficulty in completing diabetes-related care activities, and a global assessment of overall ability to complete diabetes care activities. The association of patient trust with self-management was examined after controlling for patient demographics, physical functioning, mental health and co-morbidities.ResultsLevel of patient trust was high (median 22, possible max 25). Higher trust levels were associated with lower levels of hassles (p = 0.006) and lower difficulty in completing care activities (p = 0.001). Patients with higher trust had better global assessments of overall ability to complete diabetes care activities (p < 0.0001).ConclusionHigher patient trust in physicians is associated with reduced difficulty in completing disease specific tasks by patients. Further studies are needed to determine the causal relationship of this association, the effect of trust on other outcomes, and the potential modifiability of trust

PDB9: COST-EFFECTIVENESS ANALYSIS OF A MULTIDISCIPLINARY DIABETES CARE CLINIC

OBJECTIVES: Diabetes affects more than 15.7 million people in the United States, resulting in an estimated annual cost of $98 billion (1997). With numerous complications, including heart disease, retinopathy, nephropathy, and neuropathy, contributing to the direct and indirect costs of diabetes, control is vital. A cost-effectiveness analysis was performed to compare health care resource utilization related to diabetes care incurred by health plan patients. METHODS: Subjects were enrolled in the Diabetes Care Clinic (DCC) for at least one year and were members of the health plan for one year prior to enrollment. Pharmacy and medical claims data from 1997–2000 were analyzed to identify diabetes-related charges incurred one year pre- and post-enrollment in the DCC. Charges were used to estimate costs and were adjusted to year 2000 dollars at a rate of inflation of 3%. Using the electronic medical record and clinic charts, hemoglobin A1c (HgbA1c), cholesterol profile, microalbuminuria, and blood pressure were evaluated. RESULTS: 23 diabetic patients met the inclusion criteria. These patients were mostly Type 2 diabetics (91%), female (65%), and Caucasian (70%). The mean age was 58 years. A preliminary analysis of the data indicated that the average HgbA1c decreased from 10.3 to 8.5, with 9 patients attaining glycemic control (defined as HgbA1c < 8.0) after one year of enrollment. Additionally, average blood pressure decreased from 152/80 to 136/73. The average annual cost per patient for diabetes-related care was $3,090 pre-enrollment and $4,760 post-enrollment. A marginal cost-effectiveness ratio, in terms of cost to number of patients attaining glycemic control, was calculated. The added cost for glycemic control of one patient was $186. CONCLUSIONS: An analysis of short-term outcomes demonstrated the cost-effectiveness of a diabetes care clinic. By maintaining tight glycemic and blood pressure control, diabetic complications can be reduced with significant savings to the health plan.

Geographic variation in mortality among individuals with youth-onset diabetes mellitus across the world. DERI Mortality Study Group. Diabetes Epidemiology Research International.

The aim of this study was to evaluate the geographic variation in mortality among individuals with youth-onset insulin-dependent diabetes mellitus (IDDM) across the world. The study was based on the currently available IDDM incidence and mortality data. Mortality data for diabetes in the 0-24 year age group were obtained from the World Health Organization (WHO) statistics. The mortality rates were adjusted for the frequency of occurrence of IDDM and dividing the mortality rates by the IDDM incidence rates which were obtained from the WHO DiaMond project. There was a more than 10-fold geographic variation in mortality between the developed countries and Eastern European populations. The areas with the highest mortality rates were located in Japan, Eastern Europe and Russia. The areas having the best outcome associated with IDDM were Northern Europe, Central Europe, and Canada. An ecological study demonstrated a relationship between the incidence-adjusted mortality (estimated case-fatality) with IDDM incidence itself (Spearman's correlation coefficient = 0.45) as well as infant mortality and life expectancy at birth. These data demonstrated the possibility of an enormous geographic variation in mortality of youth-onset diabetic patients even in developed countries. It is important to note that these excess deaths are potentially preventable. The ecological study also suggested that the mortality differences may be in part related to overall and diabetes related care.

The care of older persons with diabetes mellitus: families and primary care physicians.

To determine the extent to which family members participate in the day-to-day management of diabetes mellitus in older persons, and in older diabetics' medical encounters, and to identify patient and family member characteristics associated with this participation. A longitudinal observational study, with baseline data being reported herein. Three primary care practice settings in Seattle, Washington, Boston, Massachusetts, and Indianapolis, Indiana. Family members of patients 70 years of age or older participating in the Patient Outcomes Research Team (PORT) Study of type II diabetics. The two dependent variables represent, respectively, the extent of family members' assistance with diabetes-related care and participation in older diabetics' medical encounters. The 357 family members enrolled were older (mean age = 66.3 years), were mostly women (76.2%), and were usually the spouses of diabetic patients (71.3%). Between 22% and 50% of family members reported helping with various aspects of diabetes care; 35.6% of family members participated regularly in their diabetic patients' medical encounters. A multiple linear regression model relating family assistance with diabetes-related care to patient and family member characteristics included four variables: patients' physical function, and the family member's relationship to the patient, assistance with basic activities of daily living (ADLs), and understanding of diabetes management issues (all P < .05). A multiple logistic regression model relating family member participation in the medical encounter to patient and family member characteristics also included four variables: patient age and physical function, and family member assistance with instrumental activities of daily living (IADLs) and with diabetes-related care (all P < .05). The family members studied frequently assisted older diabetics with diabetes-specific care; more than one-third were regular participants in older diabetics' medical encounters. Family member involvement in the day-to-day management of diabetes and in the medical encounter was more likely when patients were functionally disabled. Health care systems and physicians need to educate their older patients, and involved family members when patients are frail, about diabetes-related care issues and support them in their roles in the management of diabetes as well as other chronic diseases.

Exploring the concept of health among adolescents with diabetes using photography

The purpose of this study was to explore and describe the concept of health among adolescents with diabetes. Photography was used to facilitate communication. Participants were given Polaroid cameras with instructions to take pictures illustrating health. They were then asked to explain in writing how their pictures demonstrated the concept. The participants produced 46 pictures and 53 descriptive expressions, which were analyzed for content. Health was described as energy, positive feelings, absence of illness, strength, activity, fitness, mental ability, and relationships. There were also descriptions of what one does to be healthy, which included eating nutritious food, exercising, engaging in diabetes-related care, sleeping, studying, relaxing, maintaining hygiene, and obtaining shelter.

Diabetes Care in Schools: Benefits and Pitfalls of Public Law 94-142

The implementation of the Education for All Handicapped Children Act of 1975 (Pub L No. 94-142) has brought significant changes in educational services for health-impaired children. Health-related services are one of many important services available to children under Pub L No. 94-142. For some children with IDDM, specific diabetes-related care is essential for continued progress in school. However, barriers exist that impede access to related health support services, including lack of agreement about the applicability for Pub L No. 94-142 to children with IDDM, lack of consensus as to who should provide services, and concern about liability of school personnel. This paper describes those barriers and suggests approaches to overcome them. One such approach is an Indiana State legislative amendment that provides schools with immunity from civil liability for diabetes-related care.