Cost and benefits of a multidisciplinary intensive diabetes education programme

OBJECTIVES: To determine the cost and benefits of an intensive diabetes education programme for patients with prolonged self-management problems and to determine the inclusion criteria for optimal outcomes. METHODS: Sixty-one participants of a multidisciplinary intensive diabetes education programme (MIDEP) were measured before they started the intervention (T0), and at 1-year follow-up (T1). Data on glycaemic control (HbA1c), diabetes-related distress (PAID) and costs were obtained. Changes over time were analysed and means at T0 and T1 were compared to a reference group of 230 non-referred consecutive outpatients. The number needed to treat (NNT), that is, the number of patients to be treated to achieve one successful case, was calculated for different baseline values of HbA1c and PAID to determine optimal inclusion criteria. RESULTS: Diabetes-related costs decreased significantly and participants improved significantly in HbA1c and diabetes-related distress following MIDEP. HbA1c and distress reached the levels of the reference group. The T1 costs remained higher than in the reference group, but the reduction in costs outweighed the intervention costs. Including patients with baseline HbA1c>or=8.0% and/or PAID scores>or=40 would improve the NNT to achieve clinically relevant outcomes, while 76% of the patients matched these inclusion criteria. CONCLUSIONS: MIDEP is effective in improving glycaemic control and diabetes-related distress for patients with prolonged self-management difficulties. Besides the immediate reduction in costs found in the present study, improved glycaemic control may reduce future costs of diabetic complications. Stricter inclusion criteria with respect to HbA1c and PAID scores may further improve the programme's efficiency.     

学龄期1型糖尿病患儿疾病知识和自我管理相关性分析

目的通过了解学龄期1型糖尿病患儿对糖尿病的知识水平和自我管理水平,分析患儿的糖尿病相关知识与自我管理水平的相关关系。方法选择2006年11月—2007年2月在复旦大学附属儿科医院内分泌门诊就诊的学龄期1型糖尿病患儿40例,采用糖尿病儿童知识量表、糖尿病患儿自我管理量表和基本资料问卷进行调查。结果①40例患儿中,糖尿病相关知识的答对率为74%,其中,半数患儿的答对率低于50%;依次为运动知识、血糖和尿糖监测知识、高低血糖识别和处理的知识、用药知识、基本知识和饮食知识。②患儿的自我管理的项目平均分为1.49。依次为血糖和尿糖监测的管理、高低血糖的管理、用药管理、运动管理、饮食管理。③患儿的年龄与疾病知识及自我管理水平呈中度正相关（P〈0.01）,而患儿的病程与疾病知识及自我管理水平也分别呈低度或中度正相关（P〈0.05或0.01）。④患儿的疾病知识和自我管理水平呈高度正相关（r=0.72,P〈0.01）,尤其在运动和用药方面。但患儿在饮食控制方面的知识与其相应的自我管理行为不相关（P〉0.05）。结论学龄期1型糖尿病患儿相关知识水平和自我管理水平均较偏低,而患儿的知识水平和自我管理水平多呈正相关关系,提示护理人员应通过一定策略提高患儿的疾病知识,改善其自我管理行为。但在饮食控制方面,患儿可能存在着除疾病知识外的其他一些影响因素,需要我们做进一步探索。     

Responses to Threat Information

Using the Common Sense Model to examine responses to health risk information, a laboratory study was conducted. Subjects were assigned randomly to one of four groups by manipulating information about high or normal blood glucose (BG) and a low or high threat message about the controllability of Type II diabetes. Subjects in the high BG groups reported more diabetes-related symptoms and stronger intentions to change certain behaviors. Subjects reading a high-threat message expressed stronger intentions to see a health professional than did those reading a low-threat message. The results suggest that perceptions of one's risk status and the degree of threat associated with an illness effects symptom perceptions and behavioral intentions.     

Adjustment to diabetes mellitus in preschoolers and their mothers

Although preschool-aged children with diabetes might be at increased risk for both general and disease-specific psychological adjustment difficulties, this issue has not been investigated. We evaluated both general and diabetes-related adjustment of 20 preschool-aged children and their mothers. The mothers completed the Child Behavior Checklist, Parenting Stress Index, Parents' Diabetes Opinion Survey, and the Preschool Diabetes Behavior Checklist. The latter measure was constructed specifically for this study to measure the frequency of oppositional and avoidance behaviors of children regarding diabetes management tasks. Mothers reported that their children displayed significantly more internalizing behavior problems (anxiety, depression, withdrawal) and were a significantly greater source of parental stress compared with corresponding nondiabetic normative group samples. Also, certain maternal attitudes about diabetes and its treatment were correlated with the children's disease-specific behavior problems. The children's general psychological adjustment, however, was not predictive of these diabetes-specific behavior problems.     

Mothers' experiences of serious life events increase the risk of diabetes-related autoimmunity in their children

OBJECTIVE: Stressful life events have been shown to constitute a risk factor for type 1 diabetes during childhood. Our aim was to investigate in the general child population (i.e., irrespective of genetic risk for type 1 diabetes) whether mothers' experiences of serious life events, such as divorce and violence, were associated with diabetes-related autoimmunity in their children at age 2.5 years. RESEARCH DESIGN AND METHODS: The study cohort was comprised of the first 5,986 consecutive children and their families from the prospective population-based All Babies in Southeast Sweden project for whom 2.5-year study data were available. Data were drawn from parental questionnaires that included questions about experiences of serious life events and the blood samples taken from the children when the children were age 2.5 years. The blood samples were analyzed for diabetes-related autoantibodies against tyrosine phosphatase and GAD. RESULTS: Mothers' experiences of divorce (odds ratio 3.6, 95% CI 1.4-9.6, P < 0.05) and violence (2.9, 1.0-7.8, P < 0.05) were associated with diabetes-related autoimmunity in the children, independent of a family history of type 1 diabetes. CONCLUSIONS: The results support the beta-cell stress hypothesis and suggest that maternal experiences of serious life events such as divorce and violence seem to be involved in the induction or progression of diabetes-related autoimmunity in children at age 2.5 years, independent of family history of type 1 diabetes.     

社区2型糖尿病患者不良行为方式及其影响因素

目的了解社区2型糖尿病患者不良行为方式并探讨其影响因素。方法采用自行设计调查问卷对369例2型糖尿病患者进行调查,采用二分类logistic回归分析筛选不良行为方式的影响因素。结果 369例2型糖尿病患者中,80例(21.7%)吸烟,41例(11.1%)饮酒,65例(17.6%)业余时间体力活动缺乏。logistic回归分析结果发现:女性、糖尿病知识得分越高和有糖尿病健康需求与吸烟、饮酒和业余时间体力活动缺乏呈负相关;同未婚患者相比,已婚、离婚和丧偶患者吸烟的可能性较高,而已婚患者饮酒的可能性较小;年龄越大、家庭月均收入越高,业余时间体力活动缺乏的可能性就越小。结论 2型糖尿病患者有较高的不良行为方式,不同特征患者的不良行为方式流行率不同,良好的糖尿病知识有利于患者戒除不良行为方式。     

A comparison of decision-making by physicians and administrators in healthcare settings

Physicians and administrators are committed to the same goal of providing quality care at affordable costs. Their perceptions of each other and their resulting behaviors, however, may lead to conflict. We offer some insight into these perceptions and behaviors, and provide a framework to improve communication and to reduce misunderstanding.     

Perceptions of health and their relationship to symptoms in African American women with type 2 diabetes.

Diabetes mellitus is an incurable disease and a major cause of mortality and morbidity. Diabetes disproportionately affects members of minorities who suffer from higher rates of complications and greater disability (Cowie & Eberhardt, 1996). The purpose of this study was to (a) describe the symptoms of African American women with Type 2 diabetes and examine the relationship among diabetes-related symptoms; (b) document complications of diabetes and perceptions of health and functioning; and (c) examine the relationship between duration of diabetes and age at diagnosis and perceived health. A convenience sample of 75 African American women with Type 2 diabetes were interviewed. A 44-item questionnaire measured selected demographic variables, symptoms, documented complications, and their perceived relationship to diabetes. The SF-20 was used to measure perceptions of health status. Data show that African American women with Type 2 diabetes have a wide variety of symptoms and poor perceptions of their general health and physical functioning.     

Relationship of therapists' attitudes, children's motor ability, and parenting stress to mothers' perceptions of therapists' behaviors during early intervention

BACKGROUND AND PURPOSE: Federal law mandates family-centered care as the service delivery model in early intervention programs for children from birth to 36 months of age. This study investigated the relationship of therapists' attitudes, children's motor ability, and parenting stress to mothers' perceptions of physical therapists' family-centered behaviors during early intervention. SUBJECTS AND METHODS: Twenty-five physical therapists and 75 mother-child dyads (3 from each therapist's caseload) participated. The mean chronological age for the children was 21.2 months (SD=7.3, range=6-35). Mothers participated in a structured interview using the Measures of Processes of Care (MPOC-56), and they completed the Parenting Stress Index-Short Form (PSI-SF) and a questionnaire. The Bayley-II Motor Scale was administered to the children. Therapists completed a modified version of the Measures of Processes of Care for Service Providers (MPOC-SP) and a questionnaire. RESULTS: Scores for mothers on the MPOC-56 and for therapists on the MPOC-SP indicated strong positive perceptions and attitudes toward family-centered behaviors. Hierarchical multiple regression analyses indicated that parenting stress explained a considerable amount of the variance in mothers' perceptions of family-centered behaviors, whereas therapists' attitudes explained a considerable amount of the variance in mothers' perceptions of respectful and supportive care. Children's motor ability was inversely related to parenting stress. DISCUSSION AND CONCLUSION: Findings suggest that mothers perceive that physical therapists are using family-centered behaviors in early intervention. Findings from the questionnaires suggest that some early intervention policies may be barriers for therapists and prevent them from actualizing attitudes toward family-centered behaviors.     

Measuring diabetes self-care: a psychometric analysis of the Self-Care Inventory-Revised with adults

OBJECTIVE: To examine psychometric properties of the Self-Care Inventory-revised (SCI-R), a self-report measure of perceived adherence to diabetes self-care recommendations, among adults with diabetes. RESEARCH DESIGN AND METHODS: We used three data sets of adult type 1 and type 2 diabetic patients to examine psychometric properties of the SCI-R. Principal component and factor analyses examined whether a general factor or common factors were present. Associations with measures of theoretically related concepts were examined to assess SCI-R concurrent and convergent validity. Internal reliability coefficients were calculated. Responsiveness was assessed using paired t tests, effect size, and Guyatt's statistic for type 1 patients who completed psychoeducation. RESULTS: Principal component and factor analyses identified a general factor but no consistent common factors. Internal consistency of the SCI-R was alpha = 0.87. Correlation with a measure of frequency of diabetes self-care behaviors was r = 0.63, providing evidence for SCI-R concurrent validity. The SCI-R correlated with diabetes-related distress (r = -0.36), self-esteem (r = 0.25), self-efficacy (r = 0.47), depression (r = -0.22), anxiety (r = -0.24), and HbA(1c) (r = -0.37), supporting construct validity. Responsiveness analyses showed SCI-R scores improved with diabetes psychoeducation with a medium effect size of 0.62 and a Guyatt's statistic of 0.85. CONCLUSIONS: The SCI-R is a brief, psychometrically sound measure of perceptions of adherence to recommended diabetes self-care behaviors of adults with type 1 or type 2 diabetes.     

Use of behavioral contingencies to promote prevention of recurrent pressure ulcers

OBJECTIVE: To determine effectiveness of an intervention using monetary rewards as a consequence for preventing or reducing severity of pressure ulcers in spinal cord injury (SCI) patients with a history of chronic, recurrent ulcers. DESIGN: Multiple baseline analysis across subjects (time-lagged control), comparing severity of pressure ulcers and treatment costs during baseline and intervention. SETTING: Outpatient wound-care clinic of private, nonprofit specialty hospital. PARTICIPANTS: Nine adults (all with paraplegia) with a history of hospitalizations for treatment of pressure ulcers. INTERVENTIONS: In study 1, participants (n=6) undertook (1) a comprehensive self-care plan, (2) had a graduated schedule of visits with an advanced practice nurse, and (3) received monetary rewards for successfully preventing serious ulcers. In study 2, participants (n=3) undertook interventions 1 and 2, but monetary rewards were in staged phases so a component analysis could compare the effectiveness of visits alone to visits plus monetary rewards. MAIN OUTCOME MEASURES: Severity of pressure ulcers measured with the Pressure Ulcer Scale for Healing (PUSH Tool 3.0); and direct costs of treatment and preventive care for pressure ulcers. RESULTS: In study 1, severity of pressure ulcers-and their related treatment costs-decreased for the 6 participants. Maintenance of effects postintervention was highly variable, with only 3 participants showing long-term improvements. In study 2, for 2 participants, visits alone did not reduce pressure ulcer severity, but visits plus payments did effectively reduce ulcer severity, indicating improved prevention behaviors. CONCLUSIONS: Findings support the assumption that pressure ulcers may recur among some individuals because there are insufficient positive consequences for effective prevention.     

Health and economic effects of adding nateglinide to metformin to achieve dual control of glycosylated hemoglobin and postprandial glucose levels in a model of type 2 diabetes mellitus

BACKGROUND: Type 2 diabetes mellitus is a common disease whose complications have great costs, both in quality of life and expense of treatment. Improving glycemic control, as measured by monitoring glycosylated hemoglobin (HbA1c) levels, can reduce the rate of such complications. OBJECTIVES: The aims of this study were to estimate the lifetime costs associated with diabetes-related complications in a theoretical population receiving metformin monotherapy and to predict the health and economic effect of improving glycemic control in this theoretical population by combining metformin with nateglinide. METHODS: A pharmacoeconomic model was developed to simulate the long-term (30 years) complication rates (microvascular and macrovascular) of a cohort of patients with type 2 diabetes mellitus. The model simulated each year of life for each patient in a theoretical cohort of 10,000 patients until diabetes-related complications were present or death occurred. The mean accumulated costs (direct medical costs for acute care and subsequent care for diabetes-related complications), mean survival time, and the frequency of each type of complication were estimated. Both effectiveness and cost data were discounted at 3%. Sensitivity analyses were conducted on key model input parameters. RESULTS: Average costs of treating complications in theoretical patients undergoing metformin monotherapy were estimated at $29,565 per patient. Savings of $2,742 were estimated per patient for all complications--particularly, nephropathy ($1,166) and macrovascular disease ($632)--when nateglinide was added. The cost-effectiveness ratio of adding nateglinide to metformin was estimated at $27,131 per undiscounted life-year gained (95% CI, $23,710-$28,577) or $43,024 (95% CI, $37,285-$45,193) per additional discounted life-year gained. In the sensitivity analyses, decreasing HbA1c level at baseline, HbA1c upward drift, and duration of disease improved survival. CONCLUSIONS: Combination therapy with nateglinide and metformin, compared with metformin alone, was predicted to reduce the frequency of complications and, thus, treatment costs in this theoretical model. The major factor in cost savings was fewer complications due to nephropathy. The increased drug treatment costs were expected to be offset by the long-term savings from reducing complication rates.     

Children's views of their adaptation to type 1 diabetes mellitus

When a family learns their child has insulin-dependent type 1 diabetes mellitus, or type 1 diabetes, shock and anxiety are quickly followed by the reality of the demands of managing the condition. Demands include injections or continuous insulin infusion, blood glucose monitoring 2 to 4 times a day, regimented meal planning, and intensive planning of daily activities. Like many chronic illnesses, type 1 diabetes can have long-term effects on the child and family. Health providers must offer support in a number of ways. To determine the best way to approach children with diabetes mellitus, this study examined children's perceptions of their adaptation to type 1 diabetes. Recognizing children's own perceptions is critical for long-term understanding and management. The children in this study had overall positive self-perceptions and good attitudes toward illness. Even though many adults perceive diabetes mellitus in children as an overwhelming experience, the children's attitudes in this study were very positive.     

End-stage renal disease due to diabetes among southwestern American Indians, 1990-2001

OBJECTIVE: This study assesses trends in the incidence of diabetes-related end-stage renal disease (ESRD) among southwestern American Indians (SWAIs). RESEARCH DESIGN AND METHODS: Using the U.S. Renal Data System, we obtained the total number of new cases of treated ESRD in which diabetes was the primary cause of renal failure in 1990 through 2001. The incidence of diabetes-related ESRD was calculated using census population figures and estimates of the SWAI population with diabetes, then age-adjusted to the 2000 U.S. population. RESULTS: Between 1990 and 2001, the annual number of new patients starting treatment for diabetes-related ESRD in the SWAI total population increased from 154 to 320, and the age-adjusted diabetes-related ESRD incidence per 10,000 population increased 34% (6.2-8.3 per 10,000 people). However, after adjusting for the increasing number of people with diabetes in the SWAI population between 1993 and 2001, the age-adjusted incidence of diabetes-related ESRD among SWAIs with diabetes decreased 31%, from 80.4 to 55.8 per 10,000 people with diabetes. It decreased for both sexes and in all age-groups. CONCLUSIONS: The increasing incidence of diabetes-related ESRD in the SWAI population parallels the growing prevalence of diabetes. However, since 1993 diabetes-related ESRD incidence decreased in the SWAI population with diabetes, consistent with national trends. This may reflect the reduction in risk factors and improvements in diabetes care practices in Indian communities.     

Health perceptions and behaviors of school-age boys and girls.

This study described and compared the health perceptions and behaviors of 83 school-age boys and girls. An age-appropriate interview schedule was designed to collect data related to demographic characteristics, health perceptions, safety, life-style practices, nutrition, dental health, and care of minor injuries. Findings indicated that most boys and girls viewed themselves as healthy and managed their own care fairly well in the areas of seat belt use, exercise, and dental health. Nutrition was identified as an area of concern, with 10% of the children skipping breakfast, and over half eating snacks with empty calories. Generally, children were found to be knowledgeable in the management of simple injuries and how to respond in the event of an emergency. Boys and girls were similar in all areas of health perceptions and behaviors except for dental health, with boys reporting more regular visits to the dentist than did girls. Further research is needed to learn more about the process by which school-age children acquire positive health behaviors to assist nurses to design and implement intervention programs that appropriately address the needs of this age group.     

A comparison of insulin use,glycemic control,and health care costs with insulin detemir and insulin glargine in insulin-naive patients with type 2 diabetes

Objectives: The goal of this study was to compare daily insulin use, glycemic control, and health care costs in insulin-naive patients with type 2 diabetes who initiated treatment with either insulin detemir or insulin glargine.Methods: This was a retrospective cohort analysis of health care claims data and laboratory results for adult, insulin-naive patients with type 2 diabetes who were enrolled in a large US managed care organization and initiated basal therapy with insulin detemir or insulin glargine between May 1, 2006, and December 31, 2006. The daily average consumption (DACON) of insulin was calculated as the total number of units dispensed (excluding the last fill) divided by the number of days between the index date and the date of the last fill of the index insulin. Glycemic control was evaluated by comparing mean glycosylated hemoglobin (HbA_1c) values in the preindex period (the 180 days before the index date) and the follow-up period (the 180 days after the index date). Mean all-cause and diabetes-related health care costs in the preindex and follow-up periods were calculated and compared.Results: The analysis included 48 patients initiating therapy with insulin detemir and 258 initiating therapy with insulin glargine. The mean age of the 2 cohorts was ~54 years, and most patients in each cohort were male (52.1% and 59.7%, respectively). Few patients in either cohort had a baseline HbA_1c value <7% (13% and 10%), suggesting poor glycemic control at the time of insulin initiation. After adjustment for confounders (eg, preindex diabetes medication), the DACON of insulin was comparable between cohorts (29.3 and 29.6 U/d; P = NS), as were follow-up HbA_1c values (8.2% and 7.9%). Insulin detemir and insulin glargine also were associated with comparable mean adjusted all-cause pharmacy costs ($3074 and $2899), medical costs ($2319 and $3704), and total health care costs ($6014 and $7023). However, insulin glargine was associated with significantly higher mean adjusted diabetes-related medical costs compared with insulin detemir ($1510 vs $707, respectively; P = 0.03), as well as significantly higher mean adjusted total diabetes-related health care costs ($3408 vs $2261; P = 0.03).Conclusions: In this managed care population of insulin-naive patients who initiated therapy with insulin detemir or insulin glargine, the daily insulin dose and glycemic control did not differ significantly between the 2 insulins. However, patients receiving insulin detemir incurred lower diabetes-related medical and total health care costs.