Preventive-care practices among persons with diabetes--United States, 1995 and 2001

Effective interventions are available to persons with diabetes that can prevent or delay the development of serious health complications such as lower limb amputation, blindness, kidney failure, and cardiovascular disease. However, the use of preventive-care practices is lower than recommended, and the national health objectives for 2010 aim to improve care for all persons with diabetes. To assess progress toward meeting these goals, CDC analyzed data on selected diabetes-related preventive-care practices, including influenza and pneumococcal vaccination coverage, from the Behavioral Risk Factor Surveillance System (BRFSS) from 1995 and 2001. This report presents the findings of these analyses, which indicate that levels of preventive-care practices among persons with diabetes in the United States increased from 1995 to 2001. Further efforts are needed to improve care among persons with diabetes, reduce the burden of diabetes-related complications, and achieve the national health objectives, including continued surveillance of diabetes-related preventive-care practices and collaboration with community-based organizations, health-care providers, public health officials, and persons with diabetes.     

The impact of formal diabetes education on the preventive health practices and behaviors of persons with type 2 diabetes

BACKGROUND: Diabetes-related morbidity and mortality are primarily attributable to complications such as heart disease, stroke, lower extremity amputation, kidney disease, blindness, and visual impairment, many of which potentially can be delayed or prevented. METHODS: We examined the association of diabetes self-management education (DSME) with preventive health practices and behaviors among 22,682 persons with type 2 diabetes using data from the 2001 and 2002 Behavioral Risk Factor Surveillance System (BRFSS). BRFSS is an ongoing, state-based, random-digit-dialed telephone survey of noninstitutionalized adults aged > or = 18 years. RESULTS: Approximately 48% of all adults with type 2 diabetes had never attended a DSME course. Among both diabetic persons who used insulin and those who did not, persons who received DSME were significantly more likely than those who had not received training to be physically active, to have received an annual dilated eye exam and flu vaccine, to have received a pneumococcal vaccine, to have checked their blood sugar daily, and to have had a physician or other health professional check their feet for sores or irritations and their hemoglobin A1C level in the past year. CONCLUSIONS: These data indicate the importance of DSME in the promotion of health practices that could prevent or delay potential diabetes complications among persons with type 2 diabetes.     

Review of the performance of methods to identify diabetes cases among vital statistics, administrative, and survey data

PURPOSE: The ability to identify prevalent cases of diagnosed diabetes is crucial to monitoring preventative care practices and health outcomes among persons with diagnosed diabetes. METHODS: We conducted a comprehensive literature review to assess and summarize the validity of various strategies for identifying individuals with diagnosed diabetes and to examine the factors influencing the validity of these strategies. RESULTS: We found that studies using either administrative data or survey data were both adequately sensitive (i.e., identified the majority of cases of diagnosed diabetes) and highly specific (i.e., did not identify the individuals as having diabetes if they did not). In contrast, studies based on cause-of-death data from death certificates were not sensitive, failing to identify about 60% of decedents with diabetes and in most of these studies, researchers did not report specificity or positive predictive value. CONCLUSIONS: Surveillance is critical for tracking trends in diabetes and targeting diabetes prevention efforts. Several approaches can provide valuable data, although each has limitations. By understanding the limitations of the data, investigators will be able to estimate diabetes prevalence and improve surveillance of diabetes in the population.     

Community diabetes educational intervention at the primary care level]

OBJECTIVE: To offer an educational alternative on diabetes, with the participation of patients with type 2 diabetes, their family members, and health care providers, adapted to local conditions and to these person's felt needs. METHODS: Focused on the primary-care level, this program was carried out in the health area of El Guarco, which is in the province of Cartago, Costa Rica. The first stage of the project included a qualitative study of the knowledge and practices of both patients and health care providers, looking at diabetes prevention and control and the local availability of foods. Based on those results, an educational methodology was developed, educational manuals were written, and courses for health care providers, patients, and patients' families were implemented. Other strategies were developed to make the effort sustainable. RESULTS: We found that patients did not associate family history or obesity with diabetes and that those persons were also confused about the symptoms of diabetes. Patients also received inconsistent nutrition messages from health care providers. Using the diabetes education manual as a base, the providers increased their knowledge of diabetes prevention, treatment, and education by an average of 85%. The diabetic patients who received educational training (mean age, 57.0 years, with a standard deviation of 8.9 years; 92% women) improved their glycemic control. Blood glucose levels decreased from 189 +/- 79 mg/dL (average and standard deviation) to 157 +/- 48 mg/dL (P < 0.05), and glycosylated hemoglobin (HbA1c) went from 11.3% +/- 2.4% to 9.7% +/- 2.3% (P = 0.05). There were no significant changes in body weight or lipid profile, except for triglycerides, which declined (P < 0.05). CONCLUSIONS: This educational program was successfully incorporated into the regular activities of the El Guarco-area health centers. The primary-care level is ideal for carrying out educational programs for diabetes treatment and early detection that are directed at patients, their families, and health care providers.     

Diabetes-related preventive-care practices--Guam, 2001-2003

Persons with diabetes are at risk for serious complications, such as blindness, kidney failure, nontraumatic lower-extremity amputations, and cardiovascular disease. Preventive-care practices have been determined effective in reducing both the incidence and progression of diabetes-specific complications. Despite the benefits of these practices, their level of use has been lower than recommended in the United States. To emphasize the importance of preventive-care practices, national health objectives for 2010 for persons with diabetes, include the following targets: have an annual dilated eye examination (75%; objective 5-13), have an annual foot examination (75%; objective 5-14), perform self-monitoring of blood glucose (SMBG) at least once daily (60%; objective 5-17), and have a glycated hemoglobin (HbA1c) measurement at least twice per year (65%; objective 5-12 [revised]). In the U.S. territory of Guam (2004 population: 166,090), no previous population-based assessment of the use of diabetes-related preventive-care practices has been conducted. For this report, data from the 2001-2003 Guam Behavioral Risk Factor Surveillance System (BRFSS) were analyzed to determine the prevalence of preventive-care practices among persons with diabetes in Guam, which is the southernmost and largest of the Marianas Islands, located approximately 3,300 miles west of Hawaii and 1,550 miles south of Japan. Results of the analysis indicated that Guam residents with diabetes remain below the national targets for 2010 for four preventive-care practices, most notably SMBG. The preventive care programs and surveillance activities of the Guam Diabetes Prevention and Control Program (DPCP) should be continued, with emphasis on SMBG recommendations, to prevent poor health outcomes in persons with diabetes and achieve the national health objectives.     

The effect of underreporting on the apparent incidence and epidemiology of acute viral hepatitis

To determine if passively reported cases of acute viral hepatitis are representative of the affected population, an active surveillance system was set up that identified all persons in Pierce County, Washington, who had been diagnosed by a physician as having acute viral hepatitis in the period March 1 through August 31, 1984. In this county, this was part of an ongoing epidemiologic study of viral hepatitis that had previously included some stimulation of reporting. The active surveillance system covered all primary sources of medical care, including all private physicians who were most likely to see persons with hepatitis. Secondary sources, those that did not provide direct medical care but might be aware of new cases, were also surveyed. The results of active surveillance showed that passive reporting was about 65% complete in Pierce County. No change occurred in the number of hepatitis A cases reported, but hepatitis B cases increased by 50%, and non-A, non-B hepatitis cases increased by 138%. Most of the increase was a result of enhanced reporting from private physicians. The two risk groups most affected by underreporting were homosexual men with hepatitis B and blood transfusion recipients with non-A, non-B hepatitis. During active surveillance, the proportion of persons with hepatitis B who reported homosexual activity was 52% compared with 20% from passive surveillance. Transfusion recipients represented 24% of the non-A, non-B hepatitis reported from active surveillance compared with 9% reported from passive surveillance. Although Pierce County may not be representative of all counties in the United States, persons responsible for public health prevention programs should recognize that data acquired through passive surveillance may not accurately reflect the magnitude of the risk for specific populations or the amount of disease that can be prevented.     

The control of hypertension in persons with diabetes: a public health approach

Coexistent diabetes and hypertension affect an estimated 2.5 million persons in the United States. Hypertension occurs approximately twice as frequently in persons with diabetes as without and contributes to most of the chronic complications of diabetes, including coronary artery disease, stroke, lower extremity amputations, renal failure and, perhaps, to diabetic retinopathy and blindness. The proportions of complications in the diabetic population attributable to hypertension range from 35 to 75 percent. Hypertension in the diabetic population increases with age and is particularly associated with obesity and nephropathy. Limited data suggest the control of hypertension in the diabetic population may be better than in the general population, perhaps due to greater contact that persons with diabetes have with the health care system. Yet, in approximately half, hypertension is not controlled. Control strategies for hypertension in the diabetic population must take into account the higher frequency of hypertension, increased risks for adverse sequelae from the coexistent conditions, more complicated clinical management, and the greater contact with the health care system experienced by persons with diabetes. Community programs to improve hypertension control in the diabetic population may target a subset of the diabetic population and should tailor strategies to meet the needs of the target population. Hypertension control in the diabetic population must be addressed at multiple levels in the health care system, including improved detection, evaluation, and treatment of hypertension; improved adherence to antihypertensive therapy and long-term followup; provision of quality professional education and patient education and support; and systematic health care monitoring and program evaluation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Guidelines vs practice in the delivery of diabetes nutrition care

The American Dietetic Association and the American Diabetes Association have published recommendations for the nutrition care of people with diabetes. However, the frequency of this care is rarely documented. As part of a study of diabetes care and education practices, the Michigan Diabetes Research and Training Center collected extensive data from 440 randomly selected adults who receive diabetes care from community physicians. These data provided a basis for comparison between diabetes nutrition care as recommended and as delivered in typical American communities. In this population (mean AGE = 61 years; 54% women), 89% (393) had non-insulin-dependent diabetes mellitus (NIDDM). Of these, 152 were managed with insulin (NIDDM/I) and 241 were not managed with insulin (NIDDM/NI). Most of the NIDDM/NI group was overweight (71%) and had elevated levels of glycated hemoglobin (62%) and serum cholesterol (53%). Yet they were significantly less likely than those with NIDDM/I to see a dietitian. The most frequently reported reason for not seeing a dietitian was that a physician had not referred them (53%). More than 90% of those with NIDDM/I or NIDDM/NI who were referred to a dietitian saw one. Because this population was from randomly selected communities, physicians, and patients, the results are probably generalizable to other regions of the United States. This study shows that in community practice, insulin use is the primary marker of the need for nutrition intervention, and the lack of physician referred to a dietitian is an important barrier to people receiving recommended diabetes nutrition care.     

Accommodating type 2 diabetes in the Chinese American family

In this interpretive study, the authors aimed to describe family responses to type 2 diabetes in Chinese Americans as reported by persons with diabetes (PWD) and spouses. Twenty participants representing 16 families completed multiple group interviews. The authors elicited positive and difficult diabetes care narratives and conducted narrative and thematic analysis of transcribed interview texts. Accommodation, the key family response, comprised the enactment of social concerns and practices to balance quality of life for individuals and families with quality of diabetes care. PWDs' accommodation included negotiating disease disclosure, protecting the family's meals, and maintaining ease in family relations despite diabetes symptoms. Accommodation by family members included developing shared diabetes care practices and indirect approaches to disagreements about diabetes management.     

Surveillance of adverse events following immunization against pandemic influenza in Slovenia in season 2009/10

The results of Slovenian surveillance system of AEFI which was in place for the early detection and investigation of rare adverse events were analysed. The reports about AEFI obtained from physicians, and self-assessment questionnaires from vaccinated persons showed predominantly non-serious and expected side effects. Nine reports (3%) included serious AEFI. No deaths consequent to vaccination were reported. A total of 1170 AEFI were reported by physicians and 1030 by self-assessment. Overall, the most commonly reported AEFI either by physicians or persons were local site reactions (37.3% and 50.5%), tiredness (11.9% and 6.8%) and fever or malaise (10.8% and 6.3%). More than 100,000 people were vaccinated with pandemic vaccines in Slovenia. The type and the frequency of AEFI detected through Slovenian AEFI surveillance system are comparable to the results from other surveillance systems. The benefit-risk balance for the pandemic vaccines used in Slovenia remains positive.     

Inequalities in provision of systematic care for patients with diabetes

BACKGROUND: GPs are now playing a greater role in the care of people with diabetes; however, the level of performance in primary care is variable. Practices with a recall system and diabetes mini-clinic have been shown to achieve better outcome of care of patients with diabetes. Systematic care also requires effective community-based diabetes services and access to primary care diabetes teams including dieticians, chiropodists, and optometrists and ophthalmologists. OBJECTIVES: The aims of this study were to determine how services for people with diabetes are organized in primary care and whether there are inequalities in systematic care of people with diabetes. METHODS: A piloted postal questionnaire was sent to all 327 general practices in three health authorities in England serving a population of >2 million people. The three health authorities provided practice-based routine data relating to all general practices. RESULTS: A total of 264 (80.7%) practices replied; 236 (89.4%) employed a diabetes recall system and 196 (74.2%) reviewed their patients in a diabetes mini-clinic. Multiple regression showed that having a recall system was associated independently with a GP [odds ratio (OR) 6.2; 95% confidence interval (CI) 2.6-14.9] or a practice nurse (OR 3.5; 1.4-8.7) with an interest in diabetes. Having a diabetes mini-clinic was associated independently with a GP with an interest in diabetes (OR 4.1; 2.1-7.8), a practice nurse having attended a diabetes course (OR 2.8, 1.3-6.2), practices with more partners (OR 1.2 per additional partner; 1.0-1.4) and fundholding practices (OR 2.6; 1.2-5.5). One hundred and sixteen (43.9%) practices had a chiropodist present in the practice, and 90 (34.1%) had a practice-based dietician. A chiropodist and a dietician were significantly more likely to be attached in training practices and in less deprived areas. A practice-based dietician was significantly associated with larger practices. CONCLUSIONS: Providing high quality primary care is essential to meeting the government's agenda of reducing inequalities. This study shows high levels of structured diabetes care which are not related to deprivation. However, practices in more deprived areas still lag behind practices in more affluent areas in terms of access to members of the diabetes team. To improve care of people with diabetes in primary care, deficiencies and inequalities highlighted in our survey must be addressed. The results of this survey will be valuable to primary care groups and organizations responsible for commissioning diabetes services.     

Underreporting of diabetes on death certificates, King County, Washington.

We estimated the reporting of diabetes on death certificates for persons known to have diabetes. Surveillance of 19 hospitals and two paramedic emergency medical services during 12 months in Seattle and King County, Washington, ascertained acute ischemic heart disease events for persons with diabetes and yielded 1235 persons with suspected ischemic heart disease. Mortality was 23.6%, and 41% of death certificates listed diabetes. The reporting of diabetes on the death certificate was not random, and it varied by patient and physician characteristics. Diabetes is strongly linked to fatal ischemic heart disease, but its importance is underrepresented by death certificates for some subgroups.     

Evaluation of practices and knowledge among primary health care professionals in relation to child development surveillance

In the present study, the practices and knowledge of 40 physicians and 40 nurses from municipal health care units (UMS) and 40 physicians and 40 nurses from the Family Health Program (FHP) in Belém, Pará State, Brazil, all of whom working in primary health care, were evaluated in relation to child development surveillance. Measures of knowledge of child development showed an average of 63.7% correct answers for UMS physicians, 57.3% for FHP physicians, 62.1% for FHP nurses, and 54.3% for UMS nurses. Only 21.8% of mothers attending appointments mentioned that the health care professional had asked about their children s development, 27.6% of mothers reported that the health care professional had asked about or observed the child s development, and 14.4% mothers reported having received instructions on how to stimulate their children s development. According to this study, primary health care physicians and nurses in the municipality of Belém showed gaps in their knowledge of child development. Child development surveillance is not being conducted satisfactorily in primary health care in the municipality of Belém. It is thus necessary to raise the awareness of health care professionals concerning the problem and provide them with appropriate training.     

Preferences, Beliefs, and Self-Management of Diabetes

Objective. To assess relationships between self-assessed control over life events, subjective beliefs about longevity, time and risk preference, and other factors on use of recommended care for diabetes mellitus (DM), self-assessed control of diabetes, general health, and laboratory measures of HbA1c levels.
Data Sources. Health and Retirement Study (HRS) and 2003 HRS Diabetes Study (HRS-DS).
Study Design. We used logit and ordered logit analyses to assess use of recommended care, and subjective and objective measures of health outcomes.
Data Collection. Secondary analysis of HRS and HRS-DS data.
Principal Findings. Individuals with higher self-assessed control over life events and higher subjective probabilities of living 10 years engaged in more recommended DM care practices and had better self-assessed DM control and general health. However, these beliefs did not influence HbA1c levels. More highly educated and cognitively able persons were more likely to follow care recommendations. There were differences by race/ethnicity in health outcomes, but not in health investment among Hispanics.
Conclusions. Individuals' beliefs about control over life events and longevity influenced health investment and subjective health outcomes, although these beliefs did not translate into differences in HbA1c levels. Hispanics may realize lower returns on health investments, at least for diabetes care.     

Managing and treating risk and uncertainty for health: a case study of diabetes among First Nation's people in Ontario, Canada

'Risk' has become a key concept for understanding health care policies that are focused on prevention. Intervention no longer depends on the presence of an illness but rather an individual's risk of developing an illness. Through 'risk factors' individuals are subject to medical examination and surveillance to determine the real presence of danger, based on this abstract notion of risk. This paper explores 'risk' and its consequences for medical intervention by focusing on biomedical practices surrounding diabetes care among First Nations on Manitoulin Island, Ontario. The first section explores the process of diagnosing diabetes. The second section outlines the treatment regimens resulting from membership in this category. The theme linking these two processes is that both diagnosis and management of diabetes depend on inclusion into categories of 'risk'. Practices surrounding diagnosis focus on a population described 'at risk' for diabetes. First Nation's people. Similarly, practices surrounding management of diabetes focus on a population 'at risk' for secondary complications, referring to individuals with diabetes. As the following discussion outlines, it is through the quantitative assessment of risk that scientific uncertainty is translated into definitive therapy and the need for constant surveillance.     

Trends in care practices and outcomes among Medicare beneficiaries with diabetes

BACKGROUND: While diabetes is a major issue for the aging U.S. population, few studies have described the recent trends in both preventive care practices and complications among the Medicare population with diabetes. Using the Medicare Quality Monitoring System (MQMS), this 2004 study describes these trends from 1992 to 2001 and how these rates vary across demographic subgroups. METHODS: Outcomes include age- and gender-adjusted rates of 15 indicators associated with diabetes care from 1992 to 2001, the absolute change in rates from 1992 to 2001, and 2001 rates by demographic subgroups. The data were cross-sectional samples of Medicare beneficiaries with diabetes from 1992 to 2001 from the Medicare 5% Standard Analytic Files. RESULTS: Use of preventive care practices rose from 1992 to 2001: 45 percentage points for HbA1c tests, 51 for lipid tests, 8 for eye exams, and 38 for self-monitoring of glucose levels (all p<0.05). Rates for short-term and some long-term complications of diabetes (e.g., lower-extremity amputations and cardiovascular conditions) fell from 1992 to 2001 (p<0.05). However, rates of other long-term complications such as nephropathy, blindness, and retinopathy rose during the period (p<0.05). Nonwhites and beneficiaries aged <65 and >85 exhibited consistently higher complication rates and lower use of preventive services. CONCLUSIONS: The Medicare program has seen some significant improvement in preventive care practices and significant declines in lower-limb amputations and cardiovascular conditions. However, rates for other long-term complications have increased, with evidence of subgroup disparities. The MQMS results provide an early warning for policymakers to focus on the diabetes care provided to some vulnerable subgroups.     

Therapeutic itinerary of the family and adolescent with type I mellitus diabetes

This is a qualitative assistential convergent study. Its main objective is to understand the therapeutic itinerary of adolescents with type 1 mellitus diabetes, as well as that of their families. The sample was composed of adolescents, between 15 and 25 years old, involved with a health institution in Florianópolis through the Health Care model that includes professional, family, and popular subsystems. Data were obtained through in-depth interviews and field observation of 20 people (relatives and adolescents with diabetes). The data analysis included data codification and categorization. Two categories were constructed: Decisions and negotiations about health, care and treatment; and the journey through the three subsystems of health care. The study permitted to understand that the treatment and care within the professional subsystem are not the only ones available. There are different practices in health performed from the evaluation each family makes, of what they believe adequate for their adolescent with diabetes.     

Developing an automated speech-recognition telephone diabetes intervention.

OBJECTIVE: Many patients do not receive guideline-recommended care for diabetes and other chronic conditions. Automated speech-recognition telephone outreach to supplement in-person physician-patient communication may enhance patient care for chronic illness. We conducted this study to inform the development of an automated telephone outreach intervention for improving diabetes care among members of a large, not-for-profit health plan. DESIGN: In-depth telephone interviews with qualitative analysis. SETTING: participants Individuals with diabetes (n=36) enrolled in a large regional health plan in the USA. Main outcome measure Patients' opinions about automated speech-recognition telephone technology. RESULTS: Patients who were recently diagnosed with diabetes and some with diabetes for a decade or more expressed basic informational needs. While most would prefer to speak with a live person rather than a computer-recorded voice, many felt that the automated system could successfully supplement the information they receive from their physicians and could serve as an integral part of their care. Patients suggested that such a system could provide specific dietary advice, information about diabetes and its self-care, a call-in menu of information topics, reminders about laboratory test results and appointments, tracking of personal laboratory results and feedback about their self-monitoring. CONCLUSIONS: While some patients expressed negative attitudes toward automated speech recognition telephone systems generally, most felt that a variety of functions of such a system could be beneficial to their diabetes care. In-depth interviews resulted in substantive input from health plan members for the design of an automated telephone outreach system to supplement in-person physician-patient communication in this population.     

Quality of diabetes care in family medicine practices: influence of nurse-practitioners and physician's assistants

PURPOSE The aim of this study was to assess whether the quality of diabetes care differs among practices employing nurse-practitioners (NPs), physician’s assistants (PAs), or neither, and which practice attributes contribute to any differences in care.METHODS This cross-sectional study of 46 family medicine practices from New Jersey and Pennsylvania measured adherence to American Diabetes Association diabetes guidelines via chart audits of 846 patients with diabetes. Practice characteristics were identified by staff surveys. Hierarchical models determined differences between practices with and without NPs or PAs.RESULTS Compared with practices employing PAs, practices employing NPs were more likely to measure hemoglobin A_1c levels (66% vs 33%), lipid levels (80% vs 58%), and urinary microalbumin levels (32% vs 6%); to have treated for high lipid levels (77% vs 56%); and to have patients attain lipid targets (54% vs 37%) (P ≤ .005 for each). Practices with NPs were more likely than physician-only practices to assess hemoglobin A_1c levels (66% vs 49%) and lipid levels (80% vs 68%) (P≤.007 for each). These effects could not be attributed to use of diabetes registries, health risk assessments, nurses for counseling, or patient reminder systems. Practices with either PAs or NPs were perceived as busier (P=.03) and had larger total staff (P <.001) than physician-only practices.CONCLUSIONS Family practices employing NPs performed better than those with physicians only and those employing PAs, especially with regard to diabetes process measures. The reasons for these differences are not clear.     

The cost of type 2 diabetes in Spain: the CODE-2 study

OBJECTIVE: To estimate the cost of providing health care to patients with type 2 diabetes, by differentiating costs of the disease, costs of complications, and other unrelated health costs. METHODS: Data on resource use were retrospectively collected from medical records and personal interviews in 29 primary health care centers in Spain. Patients were randomly selected from each center's diabetes registry. RESULTS: We evaluated 1004 patients (561 women) with a mean age of 67.42 years and a mean disease duration of 10.07 years. A total of 50.9% had no complications, 17.7% had macrovascular complications only, 19.5% had microvascular complications only and 11.9% presented both types of complication. The annual health cost per patient was 1305.15 euros. Of this cost, 28.6% (373.27 euros) was directly related to diabetes control, 30.51% (398.20 euros) was related to complications of the disease, and 40.89% (533.68 euros) was unrelated. The mean cost of patients with no complications was 883 euros compared with 1403 euros for those with microvascular complications, 2022 euros for those with macrovascular complications and 2133 euros for patients with both types of complication. CONCLUSIONS: Because of the high cost of treating type 2 diabetes and its complications, preventive measures should be implemented and control of the disease should be improved to reduce the costs associated with chronic complications.