Impact of automated calls with nurse follow-up on diabetes treatment outcomes in a Department of Veterans Affairs Health Care System: a randomized controlled trial

OBJECTIVE: We evaluated automated telephone disease management (ATDM) with telephone nurse follow-up as a strategy for improving diabetes treatment processes and outcomes in Department of Veterans Affairs (VA) clinics. We also compared the results with those of a prior ATDM trial conducted in a county health care system. RESEARCH DESIGN AND METHODS: A total of 272 VA patients with diabetes using hypoglycemic medications were randomized. During the 1-year study period, intervention patients received biweekly ATDM health assessment and self-care education calls, and a nurse educator followed up with patients based on their ATDM assessment reports. Telephone surveys were used to measure patients' self-care, symptoms, and satisfaction with care. Outpatient service use was evaluated using electronic databases and self-reports, and glycemic control was measured by HbA1c and serum glucose testing. RESULTS: At 12 months, intervention patients reported more frequent glucose self-monitoring and foot inspections than patients receiving usual care and were more likely to be seen in podiatry and diabetes specialty clinics. Intervention patients also were more likely than control patients to have had a cholesterol test. Among patients with baseline HbA1c levels > or =8%, mean end-point values were lower among intervention patients than control patients (8.7 vs. 9.2%, respectively; P = 0.04). Among intervention and control patients with baseline values > or =9%, mean end-point values were 9.1 and 10.2%, respectively (P = 0.04). At follow-up, intervention patients reported fewer symptoms of poor glycemic control than control patients and greater satisfaction with their health care. CONCLUSIONS: This intervention improved the quality of VA diabetes care. Intervention effects for most end points replicated findings from the prior county clinic trial, although intervention-control differences in the current study were smaller because of the relatively good self-care and health status among the current study's enrollees.     

Improving glycemic control in adults with diabetes mellitus: shared responsibility in primary care practices

BACKGROUND: Primary care physicians provide care for most patients with diabetes mellitus, but few have the resources to achieve the level of glycemic control needed to avert complications METHODS: Primary care physicians referred patients with unsatisfactory glycemic control, frequent hypoglycemia, or inadequate self-management to an endocrinologist-directed team of nurse and dietitian educators for a 3-month program of intensive diabetes care. Patients had at least weekly contact with a diabetes educator and received changes in insulin and/or other medication, coupled with extensive individualized instruction. The main outcome measurement was change in glycosylated hemoglobin (HbA1c) level at 3 months. RESULTS: The first 350 patients who completed the program had overall mean decrease in HbA1c level of 1.7% (95% CI 1.4%-1.9%). CONCLUSIONS: Barriers to improving glycemic control may be overcome by establishment of a system of collaboration between primary care providers and endocrinologist-directed diabetes educators.     

The effect of automated calls with telephone nurse follow-up on patient-centered outcomes of diabetes care: a randomized, controlled trial

OBJECTIVE: We evaluated the impact of automated telephone disease management (ATDM) calls with telephone nurse follow-up as a strategy for improving outcomes such as mental health, self-efficacy, satisfaction with care, and health-related quality of life (HRQL) among low-income patients with diabetes mellitus. RESEARCH DESIGN: This was a randomized, controlled trial. SUBJECTS: Two hundred forty-eight primarily English- and Spanish-speaking adults with diabetes enrolled at the time of visits to a county health care system. INTERVENTION: In addition to usual care, intervention patients received biweekly ATDM calls with telephone follow-up by a diabetes nurse educator. Patients used the ATDM calls to report information about their health and self-care and to access self-care education. The nurse used patients' ATDM reports to allocate her time according to their needs. MEASURES: Patient-centered outcomes were measured at 12 months via telephone interview. RESULTS: Compared with patients receiving usual care, intervention patients at follow-up reported fewer symptoms of depression (P = 0.023), greater self-efficacy to conduct self-care activities (P = 0.006), and fewer days in bed because of illness (P = 0.026). Among English-speaking patients, those receiving the intervention reported greater satisfaction with their health care overall and with the technical quality of the services they received, their choice of providers and continuity of care, their communication with providers, and the quality of their health outcomes (all P <0.042). Intervention and control patients had roughly equivalent scores for established measures of anxiety, diabetes-specific HRQL, and general HRQL. CONCLUSIONS: This intervention had several positive effects on patient-centered outcomes of care but no measurable effects on anxiety or HRQL.     

Failure to maintain the benefits of home-based intervention in adolescents with poorly controlled type 1 diabetes

OBJECTIVE: To determine whether a 6-month home-based intervention program in adolescents with poorly controlled diabetes improves metabolic control and whether benefits are maintained after the intervention. RESEARCH DESIGN AND METHODS: Adolescents with a mean HbA1c of > 9.0% over the preceding 12 months received either routine care in a diabetes clinic and an ambulatory intervention for 6 months (n = 37) or routine care only (n = 32). A diabetes educator provided monthly home visits and weekly phone contact to educate and support the adolescents in setting goals for insulin adjustment, blood glucose monitoring, and target blood glucose range. There was no systematic change in the frequency of insulin injections. After the intervention, there was a 12-month follow-up when the intervention and control groups both received only routine care. Outcome measures were HbA1c and Diabetes Knowledge Assessment (DKN). RESULTS: During the intervention, mean HbA1c fell (baseline: 11.1 +/- 1.3%, 6 months: 9.7 +/- 1.6%; P = 0.0001) and mean knowledge scores increased (P = 0.0001) in the intervention group but not in control subjects. However, this improvement in HbA1c and increase in knowledge was not maintained in the intervention group at 12- and 18-month follow-up assessments. Parents' knowledge scores also improved significantly from baseline levels in the intervention group at 6 and 12 months (P = 0.001, P = 0.005, respectively). CONCLUSIONS: An ambulatory program improves metabolic control and knowledge in adolescents with poorly controlled type 1 diabetes; however, it is effective only while the intervention is maintained.     

Integrating medical management with diabetes self-management training: a randomized control trial of the Diabetes Outpatient Intensive Treatment program

OBJECTIVE: This study evaluated the Diabetes Outpatient Intensive Treatment (DOIT) program, a multiday group education and skills training experience combined with daily medical management, followed by case management over 6 months. Using a randomized control design, the study explored how DOIT affected glycemic control and self-care behaviors over a short term. The impact of two additional factors on clinical outcomes were also examined (frequency of case management contacts and whether or not insulin was started during the program). RESEARCH DESIGN AND METHODS: Patients with type 1 and type 2 diabetes in poor glycemic control (A1c >8.5%) were randomly assigned to DOIT or a second condition, entitled EDUPOST, which was standard diabetes care with the addition of quarterly educational mailings. A total of 167 patients (78 EDUPOST, 89 DOIT) completed all baseline measures, including A1c and a questionnaire assessing diabetes-related self-care behaviors. At 6 months, 117 patients (52 EDUPOST, 65 DOIT) returned to complete a follow-up A1c and the identical self-care questionnaire. RESULTS: At follow-up, DOIT evidenced a significantly greater drop in A1c than EDUPOST. DOIT patients also reported significantly more frequent blood glucose monitoring and greater attention to carbohydrate and fat contents (ACFC) of food compared with EDUPOST patients. An increase in ACFC over the 6-month period was associated with improved glycemic control among DOIT patients. Also, the frequency of nurse case manager follow-up contacts was positively linked to better A1c outcomes. The addition of insulin did not appear to be a significant contributor to glycemic change. CONCLUSIONS: DOIT appears to be effective in promoting better diabetes care and positively influencing glycemia and diabetes-related self-care behaviors. However, it demands significant time, commitment, and careful coordination with many health care professionals. The role of the nurse case manager in providing ongoing follow-up contact seems important.     

The impact of outpatient diabetes management on serum lipids in urban African-Americans with type 2 diabetes.

OBJECTIVE: Treating dyslipidemia in diabetic patients is essential, particularly among minority populations with increased risk of complications. Because little is known about the impact of outpatient diabetes management on lipid outcomes, we examined changes in lipid profiles in urban African-Americans who attended a structured diabetes care program. RESEARCH DESIGN AND METHODS: A retrospective analysis of initial and 1-year follow-up lipid values was conducted among patients selected from a computerized registry of an urban outpatient diabetes clinic. The independent effects of lipid-specific medications, glycemic control, and weight loss on serum total cholesterol, LDL cholesterol, HDL cholesterol, and triglyceride levels were evaluated by analysis of covariance and multiple linear regression. RESULTS: In 345 patients (91% African-American and 95% with type 2 diabetes), HbA(1c) decreased from 9.3% at the initial visit to 8.2% at 1 year (P < 0.001); total and LDL cholesterol and triglyceride levels were significantly lower, and HDL cholesterol was higher. After stratifying based on use of lipid-specific therapy, different outcomes were observed. In 243 patients not taking dyslipidemia medications, average total cholesterol, LDL cholesterol, and triglyceride concentrations at 1 year were similar to initial values, whereas in 102 patients receiving pharmacotherapy, these lipid levels were all lower at 1 year relative to baseline (P < 0.001). Mean HDL cholesterol increased regardless of lipid treatment status (P < 0.001). After adjusting for other variables, changes in LDL cholesterol concentration were associated only with use of lipid-specific agents (P = 0.003), whereas improved HbA(1c) and weight loss had no independent effect. Lipid therapy, improved glycemic control, and weight loss were not independently related to changes in HDL cholesterol and therefore could not account for the positive changes observed. Use of lipid-directed medications, improvement in glycemic control, and weight loss all resulted in significant declines in triglyceride levels but only improved HbA(1c) and weight loss had an independent effect. CONCLUSIONS: Among urban African-Americans, diabetes management led to favorable changes in HDL cholesterol and triglyceride levels, but improved glycemic control and weight loss had no independent effect on LDL cholesterol concentration. Initiation of pharmacologic therapy to treat high LDL cholesterol levels should be considered early in the course of diabetes management to reach recommended targets and reduce the risk of cardiovascular complications in this patient population.     

The relationship between knowledge of recent HbA1c values and diabetes care understanding and self-management

OBJECTIVE: Knowledge of one's actual and target health outcomes (such as HbA(1c) values) is hypothesized to be a prerequisite for effective patient involvement in managing chronic diseases such as diabetes. We examined 1) the frequency and correlates of knowing one's most recent HbA(1c) test result and 2) whether knowing one's HbA(1c) value is associated with a more accurate assessment of diabetes control and better diabetes self-care understanding, self-efficacy, and behaviors related to glycemic control. RESEARCH DESIGN AND METHODS: We conducted a cross-sectional survey of a sample of 686 U.S. adults with type 2 diabetes in five health systems who had HbA(1c) checked in the previous 6 months. Independent variables included patient characteristics, health care provider communication, and health system type. We examined bivariate and multivariate associations between each variable and the respondents' knowledge of their last HbA(1c) values and assessed whether knowledge of HbA(1c) was associated with key diabetes care attitudes and behaviors. RESULTS: Of the respondents, 66% reported that they did not know their last HbA(1c) value and only 25% accurately reported that value. In multivariate analyses, more years of formal education and high evaluations of provider thoroughness of communication were independently associated with HbA(1c) knowledge. Respondents who knew their last HbA(1c) value had higher odds of accurately assessing their diabetes control (adjusted odds ratio 1.59, 95% CI 1.05-2.42) and better reported understanding of their diabetes care (P < 0.001). HbA(1c) knowledge was not associated with respondents' diabetes care self-efficacy or reported self-management behaviors. CONCLUSIONS: Respondents who knew their HbA(1c) values reported better diabetes care understanding and assessment of their glycemic control than those who did not. Knowledge of one's HbA(1c) level alone, however, was not sufficient to translate increased understanding of diabetes care into the increased confidence and motivation necessary to improve patients' diabetes self-management. Strategies to provide information to patients must be combined with other behavioral strategies to motivate and help patients effectively manage their diabetes.     

Implementing practice guidelines for diabetes care using problem-based learning. A prospective controlled trial using firm systems.

OBJECTIVE: A controlled trial with 15-month follow-up was conducted in two outpatient clinics to study the effects of using the problem-based learning technique to implement a diabetes clinical practice guideline. RESEARCH DESIGN AND METHODS: A total of 144 patients with type 2 diabetes aged 25-65 years in two internal medicine outpatient clinics were enrolled in the study. African-Americans and Hispanics made up > 75% of the patients. Doctors and staff in one of the clinics were trained in the use of a clinical practice guideline based on Staged Diabetes Management. A problem-based learning educational program was instituted to reach consensus on a stepped intensification scheme for glycemic control and to determine the standards of care used in the clinic. HbA1c was obtained at baseline and at 9 and 15 months after enrollment. RESULTS: At 9 months, there was a mean -0.90% within-subject change in HbA1c in the intervention group, with no significant changes in the control group. The 15-month mean within-subject change in HbA1c of -0.62% in the intervention group was also significant. Among intervention patients, those with the poorest glycemic control at baseline realized the greatest benefit in improvement of HbA1c. The intervention group also exhibited significant changes in physician adherence with American Diabetes Association standards of care. CONCLUSIONS: Clinical practice guidelines are an effective way of improving the processes and outcomes of care for patients with diabetes. Problem-based learning is a useful strategy to gain physician support for clinical practice guidelines. More intensive interventions are needed to maintain treatment gains.     

A geriatrics walking clinic improves hemoglobin A1c and timed gait in older veterans with type 2 diabetes

Over one quarter of older adults in the U.S. has diabetes; and, physical activity is important for the promotion of healthy aging in this population. The purpose of this clinical demonstration project is to evaluate the effect of physical activity in the form of walking on glycemic control and timed gait in older Veterans with type 2 diabetes (T2D). Veterans aged ≥60 years were enrolled in the Geriatrics Walking Clinic (GWC), a clinical demonstration project, at South Texas Veterans Health Care System. GWC is a 6-week clinical program that promotes physical activity and is delivered by a registered nurse/diabetes educator and geriatrician. Veterans were recruited from the VA clinics. Enrolled patients received a pedometer at an initial face-to-face visit, were followed with weekly phone calls to monitor steps/day, received encouragement, and participated in a final face-to-face visit at the end of 6 weeks. In a sub-set of patients with T2D, we performed a chart review and recorded Hemoglobin A1c (HbA1c) at 3, 6, and 12 months after completion of the program. Timed Gait, a major characteristic of frailty, was measured at baseline and after completing the program. Change in HbA1c and timed gait compared to baseline was examined using paired t-tests. Sixty-two patients had HbA1c values available and were included in this analysis. Of these, 36, 52, and 61 patients had repeat HbA1c at 3, 6, and 12 months after the intervention, respectively. Mean age was 68 ± 6 years, 58% were Hispanic, and 92% males. HbA1c improved at 3 months (–0.49, 95% CI: –0.87 to –0.12, p=0.013), at 6 months (–0.40, 95% CI: –0.68 to –0.12, p=0.006), and at 12 months (–0.30, 95% CI: –0.57 to –0.029, p=0.031) compared to baseline. Timed Gait also improved (9.3 ±1.7 vs. 10.2 ±1.8, p<0.001). The finding highlights that older patients with T2D benefit from a GWC with improved glycemic control and timed gait.     

A randomized clinical trial of a collaborative home-based diabetes intervention to reduce emergency department visits and hospitalizations in black individuals with diabetes

The prevalence of diabetes mellitus (DM) in black individuals (blacks) is twice that of white individuals (whites), and blacks are more likely to have worse glycemic control, less optimal medication regimens, and higher levels of mistrust in the medical system. These three factors account for higher rates of acute medical care use in blacks with DM. To address this disparity, we developed DM I-TEAM (Diabetes Interprofessional Team to Enhance Adherence to Medical Care), a home-based multidisciplinary behavioral intervention that integrates care from a community health worker (CHW), the participant's primary care physician (PCP), a DM nurse educator, and a clinical pharmacist. Treatment is delivered during 9 sessions over 1 year, and includes diabetes education and goal setting, telehealth visits with participants' PCP and a DM nurse educator, and comprehensive medication reviews by a pharmacist. We describe the rationale and methods for a randomized controlled trial to test the efficacy of DM I-TEAM to reduce emergency department (ED) visits and hospitalizations. We are enrolling 200 blacks with DM during an ED visit. Participants are randomized to DM I-TEAM or Usual Medical Care (UMC). Follow-up assessments are conducted at 6 and 12 months. The primary outcome is the number of ED visits and hospitalizations over 12 months, and is measured by participant self-report and medical record review. Secondary outcomes include hemoglobin A1c (HbA1c), number of potentially inappropriate medications (PIMs), and trust in health care.     

A comparison of diabetes education administered through telemedicine versus in person

OBJECTIVE: To determine whether diabetes education can be provided as effectively through telemedicine technology as through in-person encounters with diabetes nurse and nutrition educators. RESEARCH DESIGN AND METHODS: A total of 56 adults with diabetes were randomized to receive diabetes education in person (control group) or via telemedicine (telemedicine group) and were followed prospectively. The education consisted of three consultative visits with diabetes nurse and nutrition educators. The in-person and telemedicine groups were compared using measures of glycemic control (HbA(1c)) and questionnaires to assess patient satisfaction and psychosocial functioning as related to diabetes. Outcome measures were obtained at baseline, immediately after the completion of diabetes education, and 3 months after the third educational visit. RESULTS: Patient satisfaction was high in the telemedicine group. Problem Areas in Diabetes scale scores improved significantly with diabetes education (adjusted P < 0.05, before vs. immediately after education and 3 months after education), and the attainment of behavior-change goals did not differ between groups. With diabetes education, HbA(1c) improved from 8.6 +/- 1.8% at baseline to 7.8 +/- 1.5% immediately after education and 7.8 +/- 1.8% 3 months after the third educational visit (unadjusted P < 0.001, P = 0.089 adjusted for BMI and age), with similar changes observed in the telemedicine and in-person groups. CONCLUSIONS: Diabetes education via telemedicine and in person was equally effective in improving glycemic control, and both methods were well accepted by patients. Reduced diabetes-related stress was observed in both groups. These data suggest that telemedicine can be successfully used to provide diabetes education to patients.     

Monitoring of psychological well-being in outpatients with diabetes: effects on mood, HbA(1c), and the patient's evaluation of the quality of diabetes care: a randomized controlled trial.

OBJECTIVE: To investigate whether monitoring and discussing psychological well-being in outpatients with diabetes improves mood, glycemic control, and the patient's evaluation of the quality of diabetes care. RESEARCH DESIGN AND METHODS: This study was a randomized controlled trial of 461 outpatients with diabetes who were randomly assigned to standard care or to the monitoring condition. In the latter group, the diabetes nurse specialist assessed and discussed psychological well-being with the patient (with an interval of 6 months) in addition to standard care. The computerized Well-being Questionnaire was used for this purpose. Primary outcomes were mood, HbA(1c), and the patient's evaluation of the quality of diabetes care at 1-year follow-up. The number of referrals to the psychologist was analyzed as a secondary outcome. Intention-to-treat analysis was used. RESULTS: The monitoring group reported better mood compared with the standard care group, as indicated by significantly lower negative well-being and significantly higher levels of energy, higher general well-being, better mental health, and a more positive evaluation of the quality of the emotional support received from the diabetes nurse. The two groups did not differ for HbA(1c) or in their overall evaluation of the quality of diabetes care. In the monitoring condition, significantly more subjects were referred to the psychologist. CONCLUSIONS: Monitoring and discussing psychological well-being as part of routine diabetes outpatient care had favorable effects on the mood of patients but did not affect their HbA(1c). Our results support the recommendation to monitor psychological well-being in patients with diabetes.     

African-American women have higher initial HbA1c levels in diabetic pregnancy

OBJECTIVE: African-American women with diabetes are at greater risk for poor glycemic control outside of pregnancy. We evaluated the effect of race on glycemic control in a racially mixed population of women with diabetes entering prenatal care. RESEARCH DESIGN AND METHODS: HbA1c levels along with demographic data were collected at the first prenatal visit from a group of 234 women with preexisting diabetes. We applied logistic multivariate analysis to identify factors associated with HbA1c levels above the median for the group. RESULTS: The median HbA1c level for the group was 8%. HbA1c levels were 8.7 +/- 2.0% in African-Americans and 7.7 +/- 1.5% in Caucasians (P < 0.001). African-American racial designation was significantly and independently associated with high HbA1c when controlled for maternal age, parity, White classification, diabetes type, education, marital status, obesity, insurance type, and first trimester entry into care. The effect of race was confined to the nonobese patients, for whom the adjusted odds ratio for African-American race as a predictor of high HbA1c was 8.15 with a 95% CI of 2.41-27.58 (P = 0.001). CONCLUSIONS: We found a clear racial disparity in glycemic control among women entering prenatal care with preexisting diabetes. This study demonstrates that there generally is need for better glycemic control among reproductive-age women with diabetes, but especially among those who are African-American.     

How well do patients' assessments of their diabetes self-management correlate with actual glycemic control and receipt of recommended diabetes services?

OBJECTIVE: Although patient diabetes self-management is a key determinant of health outcomes, there is little evidence on whether patients' own assessments of their self-management correlates with glycemic control and key aspects of high-quality diabetes care. We explored these associations in a nationwide sample of Veterans' Affairs (VA) patients with diabetes. RESEARCH DESIGN AND METHODS: We abstracted information on achieved level of glycemic control (HbA(1c)) and diabetes processes of care (receipt of HbA(1c) test, eye examination, and nephropathy screen) from medical records of 1032 diabetic patients who received care from 21 VA facilities and had answered the Diabetes Quality Improvement Program survey in 2000. The survey included sociodemographic measures and a five-item scale assessing the patients' diabetes self-management (medication use, blood glucose monitoring, diet, exercise, and foot care [alpha = 0.68]). Using multivariable regression, we examined the associations of patients' reported self-management with HbA(1c) level and receipt of each diabetes process of care. We adjusted for diabetes severity and comorbidities, insulin use, age, ethnicity, income, education, use of VA services, and clustering at the facility level. RESULTS: Higher patient evaluations of their diabetes self-management were significantly associated with lower HbA(1c) levels (P < 0.01) and receipt of diabetes services. Those in the 95th percentile for self-management had a mean HbA(1c) level of 7.3 (95% CI 6.4-8.3), whereas those in the 5th percentile had mean levels of 8.3 (7.4-9.2). For every 10-point increase in patients' ratings of their diabetes self-management, even after adjusting for number of outpatient visits, the odds of receiving an HbA(1c) test in the past year increased by 15% (4-27%), of receiving an eye examination increased by 16% (7-27%), and of receiving a nephropathy screen increased by 13% (2-26%). CONCLUSIONS: In this sample, patients' assessments of their diabetes self-care using a simple five-question instrument were significantly associated both with actual HbA(1c) control and with receiving recommended diabetes services. These findings reinforce the usefulness of patient evaluations of their own self-management for understanding and improving glycemic control. The mechanisms by which those patients who are more actively engaged in their diabetes self-care are also more likely to receive necessary services warrant further study.     

Efficacy of a self-management education program for people with type 2 diabetes: Results of a 12 month trial

Aim:  Patient education that enhances one's self-management ability is of utmost importance for improving patient outcomes in chronic diseases. We developed a 12 month self-management education program for type 2 diabetes, based on a previous 6 month program, and examined its efficacy.
Methods:  A randomized controlled trial was carried out on outpatients with type 2 diabetes from two hospitals who met the criteria and gave consent to participate. They were randomly divided into an intervention group that followed the program and a control group that followed usual clinical practise. The intervention group received <30 min of monthly interviews based on the program's textbook and biweekly telephone calls from a nurse educator throughout the 12 months.
Results:  Of the 50 participants in the intervention group and the 25 participants in the control group, 42 and 23, respectively, completed the program (a completion rate of 84.0%). The body weight, HbA1c, self-efficacy, dietary and exercise stages, quality of life, diastolic blood pressure, and total cholesterol level were significant by two-way repeated-measures anova . As for changes over time within the groups, only the intervention group showed significant differences by Friedman's test. The complication prevention behaviors showed a high implementation rate in the intervention group. The overall evaluation of this program by the participants was very high and, therefore, they highly recognized the need for this type of program.
Conclusions:  Self-management education works successfully in relation to patients' behavior modification skills, degree of goal attainment, and self-efficacy, consequently improving their health outcomes.     

Glycemic control with insulin glargine as part of an ethnically diverse, community-based diabetes management program

OBJECTIVE: To evaluate the contribution of long-acting basal insulin therapy (insulin glargine) to glycemic control in a predominantly Hispanic population participating in a community-based diabetes management program, Project Dulce. RESEARCH DESIGN AND METHODS: This retrospective analysis included 3122 adult patients with diabetes from 17 community clinics in San Diego County, California who participated in Project Dulce between July 2000 and March 2003. A subset of 180 patients received insulin glargine because of ongoing, inadequate glycemic control (ie, elevated HbA1c). Glycemic control was evaluated by mean adjusted HbA1c during follow-up clinical visits using hierarchical linear modeling, with values determined separately before and after initiation of insulin glargine. RESULTS: At baseline, the mean number of individuals with hypoglycemia, presence of diabetic complications, and duration of diabetes were greater in the glargine group that in the reference group. HbA1c at baseline was 8.79 and 9.44 (P = 0.019) in the reference and glargine groups, respectively. Mean adjusted HbA1c in the glargine group was 8.80 at baseline, 7.89 before initiation of insulin glargine (P < 0.001 vs baseline), and 7.34 after adding insulin glargine (P < 0.001 vs pre-glargine). In the reference group, mean adjusted HbA1c decreased from 8.81 at baseline to 7.40 during follow-up (P < 0.001 vs baseline). CONCLUSIONS: A comprehensive program of diabetes care in Project Dulce improved HbA1c significantly in a predominantly Hispanic population. Adding long-acting basal insulin therapy with insulin glargine produced significant incremental improvement in HbA1c.     

Factors associated with glycemic control and diabetes self-care among outpatients with schizophrenia and type 2 diabetes

We investigated the influence of the severity of schizophrenia on diabetes self-care and glycemic control among outpatients with schizophrenia and diabetes. We conducted interviews with 38 participants and reviewed their clinical charts. The mean hemoglobin A1c (HbA1c) level in the full study population was 7.65%. There was no difference in the HbA1c level between two groups of subjects classified by the severity of schizophrenia. Some diabetes self-care indicators were significantly lower in patients with high Brief Psychiatric Rating Scale scores (P < .05). Although psychotic symptoms do not appear to affect glycemic control, psychotic symptoms might affect diabetes self-care behaviors in people with schizophrenia.     

Improving glycemic control in older adults using a videophone motivational diabetes self-management intervention

Older adults experience the greatest burden of diabetes. Resources must be available and accessible to empower older adults to perform diabetes self-care. The purpose of this study was to evaluate a videophone motivational interviewing (MI) diabetes self-management education (DSME) intervention to improve glycemic control of rural older adults. Sixty-six participants (mean age = 64.9 years, range 60-81) with uncontrolled diabetes were enrolled in a 6-month videophone intervention. Experimental group participants (n = 34) received weekly, then monthly, videophone MI DSME calls, whereas control participants (n = 32) received monthly videophone healthy-lifestyle education calls. Although both groups experienced a decreased HbA1c, there was a statistically significant difference in experimental group mean values (p = .015), but not the control group (p = .086). The experimental group demonstrated statistically significant increases in diabetes knowledge (p = .023) and diabetes self-efficacy (p = .002). Experimental group participants with high self-efficacy in contrast to low self-efficacy had a statistically significant decrease in HbA1c (p = .043).     

Intensified blood glucose monitoring improves glycemic control in stable,insulin-treated veterans with type 2 diabetes: the Diabetes Outcomes in Veterans Study (DOVES)

OBJECTIVE: To examine the effect of intensified self-monitored blood glucose (SMBG) testing on glycemic control. RESEARCH DESIGN AND METHODS: Subjects with stable, insulin-treated type 2 diabetes performed SMBG using an electronic blood glucose meter before all meals and at bedtime for 8 weeks. Baseline data were collected on demographics, clinical characteristics, diet, and exercise. HbA(1c) was measured at baseline, at 4 weeks, and at 8 weeks. After the intensified monitoring period, subjects resumed their usual monitoring. HbA(1c) was then measured at 24, 37, and 52 weeks. Multivariate linear regression was used to determine the effect of monitoring on glycemic control. RESULTS: A total of 201 subjects completed the monitoring period. The baseline HbA(1c) (8.10 +/- 1.67%) decreased during the monitoring period by 0.30 +/- 0.68% (P < 0.001) at 4 weeks and by 0.36 +/- 0.88% (P < 0.001) at 8 weeks. Although entry HbA(1c) and compliance independently predicted the week 8 HbA(1c) (r = 0.862, P < 0.001), standardized regression analysis found that compliance with the SMBG protocol influenced the week 8 HbA(1c) more than age, sex, BMI, exercise level, carbohydrate consumption, or treatment intensity at baseline. However, SMBG benefited only subjects whose testing compliance exceeded 75% or with an entry HbA(1c) >8.0%. Decreases in HbA(1c) (-0.31 +/- 1.17%, P = 0.001) persisted in the 159 subjects followed for 52 weeks. CONCLUSIONS: Intensified blood glucose monitoring improved glycemic control in a large cohort of stable, insulin-treated veterans with type 2 diabetes. SMBG provided a strong stimulus for improved self-care resulting in clinically important and sustained reductions in HbA(1c).     

A feasibility study of a culturally tailored diabetes intervention for Mexican Americans

Latinos, the fastest growing minority group in the United States, are among the hardest hit by diabetes. Among Latinos, Mexican Americans have the highest rate (23.9%) of diabetes. Good self-management can improve glycemic control and decrease diabetes complications but can be challenging to achieve. The purpose of this study was to test the feasibility and examine the effects of a culturally tailored intervention for Mexican Americans with type 2 diabetes on outcomes of self-management. The study used a pretest/posttest control group design with 10 participants in each group (N = 17). Feasibility and acceptability of the tailored diabetes self-management program was assessed by examining ease of recruitment and retention rates. The behavioral outcomes of self-efficacy, diabetes knowledge and self-care measures, and the biologic outcomes of weight, body mass index, HbA1C, and blood glucose were used to examine intervention effectiveness. Successful recruitment of participants came from personal referrals from providers or the promotora. Retention rates were 100% for the intervention group and 80% for the control group. Findings suggest that the intervention had a positive clinical and statistical effect on diabetes knowledge, weight, and body mass index. Improvements were also noted in self-efficacy scores, blood glucose, and HbA1C, but these changes did not reach statistical significance. A culturally tailored diabetes self-management program may result in improved outcomes for Mexican Americans with type 2 diabetes.