Staged Diabetes Management Research Articles

Lack of association between anemia and renal disease progression in Chinese patients with type 2 diabetes.

Anemia has a close interaction with renal dysfunction in diabetes patients. More proof is still awaited on the relationship between anemia and the progression of renal disease in this population. In the present longitudinal study, 1,645 Chinese type2 diabetes patients without end-stage renal disease were included in the analysis in Nanjing, China, during January 2006 and December 2012. All patients were managed by staged diabetes management protocol, and clinical parameters were collected at each visit. The end-point of progression of renal disease was evaluated during the follow up. Cox regression analysis was used to estimate the risk of anemia on renal disease progression. On recruitment, 350 (21.3%) patients had anemia, which was more common among those with older ages, longer diabetes duration, lower estimated glomerular filtration rate or more albuminura. On median follow up of 49months (range 28-62months), 37 patients (2.2%) developed the defined renal end-point. Compared with those without anemia, patients with anemia had a higher risk of renal disease progression. However, multivariate analysis showed that anemia lost its statistical significance once estimated glomerular filtration rate was added into the model. Although the incidence of renal disease progression markedly increased by anemia status in patients of estimated glomerular filtration rate <60mL/min/1.73m(2), anemia was still not an independent risk factor for renal disease progression in this subgroup. Anemia was a common finding in Chinese type2 diabetes patients. Anemia was a risk factor for renal disease progression, but lost its significance once baseline renal function was adjusted.

Efficacy of a staged diabetes management programme in achieving glycaemic goal in a low socio‐economic Hispanic population

AbstractThe aim of this study was to identify the efficacy of a staged diabetes management (SDM) clinic serving a low socio‐economic Hispanic population in achieving glycaemic goal.We analysed prospectively collected data from patients discharged from the clinic in 2008 with an admission HbA1c &gt;8% (64mmol/mol) and &gt;one clinic visit. Adjusted odds ratios (AOR) were determined for factors significantly associated with glycaemic goal achievement.Both those patients who achieved the clinic HbA1c goal of ≤8% (n=277) and those who did not (n=209) had a clinically significant decrease in HbA1c (‐3.13±1.80, ‐1.08±1.78). After adjustment, the following were associated with failure to achieve goal: higher admission HbA1c (%) 11.0±1.8 vs 10.3±1.7, AOR (95% CI) 1.22 (1.08, 1.37), p=0.0016; higher admission insulin (IU/kg/day) 0.56±0.58 vs 0.26±0.41, AOR 2.08 (1.09, 4.00), p=0.026; greater increase in insulin (IU/kg/day) 0.23±0.46 vs 0.09±0.32, AOR 2.38 (1.15, 5.00), p=0.02; and a longer stay (days) 229±110 vs 172±84, AOR 1.007 (1.003, 1.012), p=0.0008.In this SDM clinic, most patients achieved significant reduction in HbA1c. The study identified factors associated with a lower likelihood of achieving goal thereby demonstrating the value of review of the response to an SDM protocol in indicating areas for further improvement. Copyright © 2010 John Wiley &amp; Sons.

Effectiveness of staged diabetes management on the quality of diabetes care in Mexico

AbstractThe aim of this study was to investigate the effectiveness of staged diabetes management, a structured programme developed by the International Diabetes Center in Minneapolis, USA, on the quality of outpatient diabetes care at the primary level in Mexico.A prospective study was conducted in patients treated at outpatient diabetes clinics established in public health centres in 2001–2007 in Hidalgo, Mexico. Diabetes care was provided by multidisciplinary teams which included general physicians and nurses as a minimum. Organisational arrangements were made to reduce waiting times, avoid rotation of staff, and provide adequate time for baseline and follow‐up visits. Process and outcomes indicators of quality of diabetes care included body mass index, blood pressure, fasting/casual blood glucose, lipoprotein measurement, haemoglobin A1c, and foot examination.Analysis of 4393 patients showed increases in the percentage of recorded process indicators of quality of diabetes care between baseline and the fifth visit: body mass index 85.5 vs 95.9%; blood pressure measurement 74.4 vs 95.6%; HbA1c 12.9 vs 17.7%; total cholesterol 18.3 vs 55.9%; and foot examination 19.1 vs 94.9%. Significant differences were noted by a decrease in fasting blood glucose (185.75±79.01 vs 162.89±72.53mg/dl, p&lt;0.001), and a 3.6 percentage point decrease in HbA1c (12.05±4.47 vs 8.45±1.89%, p&lt;0.001).These results suggest that it is possible to improve the quality of diabetes care at the primary level; this can be done through the implementation of a programme that integrates: changes in the structure and in the process of care, customised clinical guidelines, and a standardised system of information that enables measuring clinical results with very limited resources. Copyright © 2010 John Wiley &amp; Sons.

Quality of diabetes care in India, China, Brazil, Mexico and Russia

AbstractEmploying US national standards, baseline data for type 2 diabetes were collected in India, China, Brazil, Mexico and Russia prior to Staged Diabetes Management implementation.In all, 5507 patients (India 2778, China 489, Brazil 1106, Mexico 925, and Russia 209) were evaluated. No site sample met the US standard for HbA1c or blood pressure. China, India and Mexico achieved criteria for LDL ≥ 130 mg/dL. Post‐programme data from Russian sites showed significant improvement in HbA1c (p &lt; 0.00001). In Brazil a trend toward improvement in blood pressure and blood glucose was also noted.Assessing current diabetes care employing US national criteria can serve as a benchmark for interventions to improve diabetes care. Collecting follow‐up data measures programme impact and identifies areas requiring further intervention. Copyright ©2009 John Wiley &amp; Sons.

Implementation of a systematic approach to diabetes in primary care in Bahia, Brazil improves metabolic outcomes: PRODIBA—Programa de Interiorização da Assistência ao Diabetes na Bahia (Project for Dissemination of Diabetes Care in the State of Bahia)

Staged Diabetes Management (SDM) improves glycaemic control and reduces diabetes-related complications in primary care. An 18-month randomized controlled cohort study was conducted in two municipalities in the state of Bahia, Brazil, involving 100 patients with Type 2 diabetes in each municipality. In one municipality, healthcare professionals were trained to use SDM customized protocols for clinical decisions and, in the other municipality, no protocols for diabetes care were implemented. We hypothesized that, in the municipality with SDM trained professionals, patients would have better outcomes, including a fall in glycated haemoglobin (HbA(1c)). Improvements in some metabolic parameters were observed in the SDM group, including a 22% decrease in mean random glucose, a significant 15% decrease in mean HbA(1c), a 6% decrease in systolic blood pressure and an 11% decrease in diastolic blood pressure. There were no differences in body mass index and lipid profile. SDM customized algorithms are effective, practical and easy to use in primary healthcare teams with very limited resources.

Staged Diabetes Management: improving clinical outcomes in Russia

Staged Diabetes Management: improving clinical outcomes in Russia

Staged diabetes management ISSSTE: The First National Diabetes Program in Mexico

Staged diabetes management ISSSTE: The First National Diabetes Program in Mexico

Partners in Advancing Care and Education Solutions Study: Impact on Processes and Outcomes of Diabetes Care

This study evaluated a comprehensive approach to clinical care, Staged Diabetes Management, and a curriculum to facilitate optimum self-care, Type 2 Diabetes BASICS. The goal was to meet the Diabetes Physician Recognition Program (DFRP) and Education Recognition Program (ERP) criteria. Baseline chart audits were used to identify areas for improvement. Multiple methods were employed to train clinicians and staff and address organizational issues. Improvements in care were supported through consultation and repeated measurements and incentives. Eight centers completed training and submitted final data. None of the centers met DPRP recognition criteria at baseline; 3 centers already had ERP certification. After completing the program, all centers received DPRP and ERP certification. The greatest improvements occurred in documentation of eye and foot examinations. The Partners in Advancing Care and Education Solutions Study, or PACES, program was associated with significant improvements in diabetes care in diverse settings. Focusing on process deficiencies led to significant improvements, and spillover improvements were apparent in the outcome indicators.

Staged diabetes management according to individual patient insulin resistance and β‐cell function ameliorates glycaemic control in type 2 diabetes mellitus

The current consensus algorithm for management of type 2 diabetes is based on the fasting glucose concentration and glycated haemoglobin A(1c) (HbA(1c)) level. We applied a new therapeutic strategy by assessing insulin secretion and insulin resistance, in addition to glucose concentrations in individual patients. We enrolled 193 patients with type 2 diabetes. The patients were assigned to one of six groups according to insulin secretion measured by the serum fasting C-peptide concentration and insulin resistance measured by an insulin tolerance test (ITT). The two groups were treated differently: 108 patients were treated using a new staged diabetes management (SDM) strategy and 85 patients continued with conventional therapy. We compared metabolic variables in the two groups at baseline and 12 months after enrollment. In patients treated with the SDM strategy, fasting glucose concentration decreased from 9.8 +/- 2.1 to 8.2 +/- 1.7 mmol/l (P < 0.001). Postprandial 2-h glucose concentration decreased from 14.19 +/- 3.34 to 12.27 +/- 3.24 mmol/l (P < 0.001). HbA(1c) level decreased from 8.37 +/- 1.42% to 7.72 +/- 1.39% (P < 0.001). About 43% of the new SDM group achieved an HbA(1c) of < 7.0% compared with 25% of patients in the conventional treatment group. The new SDM strategy, based on individual data on insulin resistance and insulin secretion, may provide valuable clinical benefits in non-obese Korean patients with type 2 diabetes.

Progress of the patients with diabetes mellitus who were managed with the staged diabetes management framework

OBJECTIVE: To describe the progress of patients with diabetes mellitus seen by health care team members who followed the Staged Diabetes Management framework. METHODS: This descriptive, prospective, and longitudinal study was conducted in a period of 12 months. The sample consisted of 54 patients with diabetes mellitus. Data were collected in three occasions through interviews: P0 - at beginning of the study; P6 - in six months; and, P12 - at the end of the study. RESULTS: There was an increase in adherence to diet from 61.1% in the P0 to 92.6% in the P12, in adherence to physical activities from 57.4% in the P0 to 66,7% in the P12, and in the use of medication. CONCLUSION: The use of the SDM framework among this sample of patients with diabetes promoted better adherence to diet, physical activities, and the use of medication.

Internet Diabetic Patient Management Using a Short Messaging Service Automatically Produced by a Knowledge Matrix System

Lifelong strict self-care is essential in the management of diabetes, along with easy access to the health care system (1–3). However, there is an evident limitation in fulfilling these conditions in the current health care system, which is oriented toward outpatient care (4–7). Thus, various strategies have been designed to improve the quality and efficiency of treating diabetic patients. Wireless technology is a worldwide communication system that allows a person to contact others anywhere at any time. Therefore, doctor-patient communication becomes possible anywhere with the use of this system (8). Currently, in civilized countries, nearly all adults and adolescences have their own cellular phones and use short message services (SMSs) in their daily lives. Moreover, numerous people are using ultra-fast Internet services at work or in the home. We designed an Internet-based diabetic patient management system using SMS that was automatically produced by a knowledge matrix. Subsequently, we compared biochemical profiles and clinical status between diabetic patients who used our system for 12 weeks and those who received the conventional outpatient management over the same time period. We developed a knowledge matrix containing information on proper diet and exercise for diabetic patients based on the Korea Staged Diabetes Management Guideline (Table 1). Moreover, with the technical assistance from ISU UBCare, we created a Web site program (http://yds.healthkorea.net) that was used to formulate appropriate messages through an automated algorithm. We also designed a device that had the dual function of a glucometer and a pedometer. By connecting this device to the …

Satisfaction of diabetes patients under follow-up in a diabetes education program

This study aimed to describe the satisfaction of diabetes patients, using the information received and the care offered after the implementation of the health educational program called Staged Diabetes Management (SDM), in April 2005, at a University Research and Extension Center in Ribeirão Preto - SP. Patient satisfaction was assessed through a satisfaction questionnaire, applied to 54 diabetes patients who participated in the program during 12 months. The patients reported that the information received during the program attended their needs; of the 54 patients, 59.3% mentioned information related to nutrition; 33.3% mentioned medicines and 31.5% glucose control. Related to the assessment of care, 81.5% of the patients considered it excellent. We concluded that the patient satisfaction evaluation was a valuable feedback to evaluate the program implemented by the multiprofessional team.

Response to comment on: Davidson MB (2007) The dilemma of self-monitoring of blood glucose. Diabetologia 50:497–499

To the Editor: After several long discussions at meetings concerning self-monitoring of blood glucose (SMBG) in diabetic patients not taking insulin, A. J. Karter and I agree to disagree. I will respond briefly to the points raised in his letter [1]. As stated in my Commentary [2], observational studies can be compromised by self-selection and issues of confounding. Although a few of them have shown a benefit of SMBG in terms of glycaemic control, most have not [3]. Regarding the ‘select’ randomised clinical trials (RCTs), five of the nine did not find an association, and serious design flaws in the remaining four invalidated (in my view) the conclusion that SMBG per se was responsible for the lowered glycaemia. Although the two meta-analyses found overall changes in HbA1c of −0.3% [4] and −0.4% [5] in those that performed SMBG, the authors stated that the methodological quality of the studies was limited [4] and that there was either a moderate or high risk of bias in the studies reviewed [5]. The reference [6] citing the importance of behavioural interventions deals mainly with the untranslatability of positive, tightly controlled efficacy trials into messier, realworld effectiveness studies. One problem with this argument is that, to date, the efficacy trials of SMBG in diabetic patients not taking insulin have produced negative results. Based on the overwhelming evidence that lowering glycaemia ameliorates the microvascular complications of diabetes, we first need to demonstrate this outcome before dealing with the valid issues that impede its translation. I do agree that SMBG values have no direct effect on glycaemia [1]; appropriate action leading to better control based on these results is necessary. However, as pointed out previously [2], immediate actions in patients not taking insulin are limited and longer term behavioural changes have, for the most part, not materialised. The two references cited to imply that performing SMBG may enhance the ability of patients to make appropriate behavioural decisions [7, 8] may not be particularly germane. In one [7], which included patients who did and did not take insulin, changes in HbA1c were −0.13% in those performing SMBG after receiving intensive instruction, −0.04% in those performing SMBG after receiving standard instruction, and +0.04% in those receiving standard care with no new instruction in SMBG at the start of the study. Significantly more patients in the first group than in the other two groups saw improvements in their HbA1c level. However, as Gertrude Stein is alleged to have said, ‘A difference to be different must make a difference.’ That would certainly not seem to be the case here since this difference would not lead to any change in patient outcomes. In the second study the intervention patients were taught how to use the internet and uploaded their SMBG values at their convenience while the control patients simply visited the outpatient department every 3 months (as did the intervention group) [8]. Most patients were not taking insulin. Regarding the point raised about intensive nurse case management [1], the 40 intervention patients in this study were serviced by three endocrinologists (a professor and two clinical instructors), a nurse and a dietitian. The two clinical instructors logged on to the system daily and sent appropriate recommendations every 2 weeks (based on the Staged Diabetes Management Protocols, with any changes in medication cleared by the professor). Approximately half of the patients logged on to the system more Diabetologia (2007) 50:1567–1568 DOI 10.1007/s00125-007-0691-3

Staged Diabetes Management, 2nd Edition

Staged Diabetes Management, 2nd Edition

Staged Diabetes Management

Staged Diabetes Management

Improving glycaemic control of patients with Type 2 diabetes in a primary care setting: a French application of the Staged Diabetes Management programme

To assess the impact of a French adaptation of the Staged Diabetes Management (SDM) programme on glycaemic control of people with Type 2 diabetes in primary care. Secondary endpoints were blood pressure, blood lipids, healthcare costs and quality of life. Prospective, randomized controlled study, of 1 years' duration. General practitioners (GPs) were recruited in four separate districts of a French region. They enrolled consecutive patients with Type 2 diabetes. GPs in the intervention group were educated in the SDM programme. GPs in the control group were asked to provide usual care. Healthcare costs were collected by medical departments of the Health Insurance systems. Quality of life was assessed with the Duke Health Profile. Three hundred and forty patients enrolled by 57 GPs completed the study, 192 in the intervention group and 148 in the control group. Patients in the intervention group were managed more adequately in accordance with the guidelines (P < 0.05 for nine out of 10 items). HbA(1c) decreased by 0.31% in the intervention group and increased by 0.56% in the control group, resulting in a difference of 0.87% by the end of the study (P = 0.001). Blood pressure and blood lipids did not differ between groups. Occurrence of major complications was low and identical in both groups. Incremental costs during the study in the intervention group were 35 euros per patient per month, and this was not significantly different in comparison with the control group. Quality of life was not affected by the intervention. Educating GPs in the French adaptation of the SDM programme improves glycaemic control in a primary care setting, without significantly increasing healthcare costs.

A multifaceted intervention in support of diabetes treatment guidelines: a cont trial

Objective: in an academic family practice clinic, we performed a controlled trial of a multifaceted intervention versus usual care for managing diabetes. Providers received didactic training and computerized compliance feedback to support staged diabetes management, an evidenced-based approach to diabetes care. Research design and methods: one firm of the clinic practice received the intervention, the other served as the control group during a 14-month baseline period and a 14-month study period. HbA1c was the principal outcome measure. Results: there was a significant 0.71% difference in change in HbA1c values between the intervention and control firms (P=0.02). The subgroup with the greatest improvement in HbA1c was those subjects who started the intervention with a HbA1c above 8%. The overall improvement in glycemic control could not be explained by differences in visit frequency or the aggressiveness of drug therapy. There were no changes in healthcare utilization or costs between the two firms. Conclusion: in an academic family practice clinic, a multifaceted intervention in support of diabetes treatment guidelines modestly improved glycemic control without incurring additional costs. The improvement was mostly due to mitigation of the natural deterioration in control usually seen. Further efforts are required to involve all patients in co-managing their diabetes.

Enfoque multidisciplinar ao paciente diabético: avaliação do impacto do "staged diabetes management" em um sistema de saúde privado

Estudo realizado para avaliar o impacto do Staged Diabetes Management (SDM) na melhora do controle glicêmico, perfil lipídico e pressão arterial, e a satisfação dos pacientes com este modelo de atendimento. Desde 1998, o SDM, guia prático desenvolvido pelo International Diabetes Center (Minneapolis, MN, EUA), tem sido utilizado como modelo para o treinamento de profissionais da saúde e algoritmo de atendimento aos pacientes no Centro de Diabetes do hospital privado Nossa Senhora das Graças, Curitiba, PR. A equipe multiprofissional inclui endocrinologistas, nutricionistas, enfermeiras e assistente social. Foram avaliados 78 pacientes que completaram um ano de seguimento; 27 pacientes com diabetes tipo 1 e 51 com diabetes tipo 2. Em um ano a hemoglobina glicosilada diminuiu de 8,06%±2,25 para 7,49%±2,0 (p= 0,045). Não houve mudança significativa no perfil lipídico e nos níveis de pressão arterial; 80% dos pacientes estavam satisfeitos com este atendimento. Estes resultados mostram que, usando o SDM, houve melhora na qualidade de atendimento ao paciente diabético.

Staged diabetes management: a systematic evidence-based approach to the prevention and treatment of diabetes and its co-morbidities

Staged diabetes management: a systematic evidence-based approach to the prevention and treatment of diabetes and its co-morbidities

Improved care for diabetes in underserved populations.

Diabetes mellitus (DM) is a common chronic health condition among the adult population in the United States. DM is more prevalent and complications higher in Latinos, possibly due to inadequate medical and self-care as well as inaccurate culture-bound beliefs. Project Dulce is a nurse-managed DM educational and treatment program designed to measure the effect on clinical outcomes, adherence to American Diabetes Association and American Heart Association standards of care, and cultural beliefs in 210 high risk (HbA1c > 9.5%) and 346 lower risk (HbA1c < 9.5%) indigent Latinos with DM. All patients were given a 12-week culturally sensitive educational program. Nurse manager/certified diabetes educators working together with primary care providers treated high-risk patients using protocols from Staged Diabetes Management. Physical exam and biochemical markers of DM were followed. Pre- and post-program questionnaires measured changes in diabetes knowledge, cultural beliefs practices, treatment satisfaction, and health locus of control. Chart reviews of Latinos with diabetes (n = 311) not enrolled in Project Dulce provided the case controls. After 1 year, the high-risk group showed significant improvements in HbA1c (11.5% to 8.3%, p < 0.0001), total cholesterol (219 to 181 mg/dL, p < 0.00001), SBP (129 to 122 mmHg, p < 0.03), and DBP (79 to 75 mmHg, p < 0.006). Pre- and post-test evaluations showed improved diabetes knowledge (p = .024), treatment satisfaction (p = .001) and internal locus of control (p = 0.04), and fewer inaccurate culture-bound beliefs (p = 0.001). Compliance was 100% in the high-risk group in obtaining HbAlc, lipids, urine microalbumin, and foot exams and 47% in obtaining eye exams, while the case controls had 28%, 46%, 31%, 14%, and 6% respectively. Mean TC and LDL values improved in Project Dulce patients compared to case controls (181 vs 221 Img/dL, p < 0.0001 and 99 vs 1241 mg/dL, p < 0.0004). Patients enrolled in Project Dulce had significantly improved clinical outcomes, adherence to standards of care, and culture bound beliefs. Nurse managed diabetes management programs that are culturally sensitive may decrease the incidence of complications of diabetes and improve health outcomes.