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.     

Patient knowledge improves glycemic control: is it time to go back to the classroom?

BACKGROUND: Over the last two decades, pharmaceutical intervention for the treatment of type 2 diabetes has expanded. Studies over this same time demonstrated the benefits of tight glycemic control. Unfortunately, despite the availability of novel therapies, glycemic control remains problematic. Nonpharmacologic interventions need to be explored, including patient empowerment. Improving patient knowledge of diabetes may ultimately improve glycemic control. To test this hypothesis, we compared patients' diabetes knowledge with their glycemic control. METHODS: The Michigan Diabetes Knowledge Test, designed by the University of Michigan, was administered to patients with type 2 diabetes at three University of New Mexico primary care clinics. Patient records were reviewed. The most recent hemoglobin A1c (HbA1c) value was recorded. The data were analyzed using linear regression analysis. RESULTS: Seventy-seven patients completed surveys and had HbA1c values available. Only questions 1 to 14 of the 23-question survey were used because they pertained specifically to type 2 diabetes. HbA1c was inversely correlated with the number of questions answered correctly on the test (r = -.337, p < .003). Using "all subsets" regression, a correct response to questions 1, 3, and 9 specifically correlated with a lower HbA1c (p < .0001). CONCLUSIONS: These results demonstrate that an inverse linear relationship exists between performance on this diabetes test and HbA1c values. Improvement in patient knowledge of diabetes and the importance of treatment may indeed improve glycemic control and ultimately decrease complications. Studies aimed at empowering patients with disease knowledge may help control the ramifications of the growing diabetes epidemic.     

Interpretation of hemoglobin A(1c) (HbA(1c)) values among diabetic patients: implications for quality specifications for HbA(1c).

BACKGROUND: Few studies have examined patients' views, knowledge, and understanding of glycohemoglobin A(1c) (HbA(1c)) testing. We explored such issues in patients with type 1 diabetes and used their statements to estimate analytical quality specifications for HbA(1c) testing. METHODS: We recruited 201 patients from a hospital outpatient clinic. A questionnaire was used to collect information on diabetes characteristics, perceived knowledge of HbA(1c), last HbA(1c) value, HbA(1c) target value, and thresholds for action. Patients were asked to indicate the magnitude of change in HbA(1c) from 9.4% that they would consider to be a true (real) change; from their responses, we calculated patient-derived quality specifications for HbA(1c). RESULTS: Fifty-eight percent of the patients felt they had "high" knowledge about HbA(1c), and >80% of responders knew their last HbA(1c) value, their target HbA(1c), and the threshold value of HbA(1c) for treatment intensification. The mean acceptable HbA(1c) value was 7.5%. Patients with lower values on their most recent tests reported lower target values for HbA(1c) and lower values for the upper HbA(1c) threshold for treatment intensification. An analytical CV (CV(a)) of 3.1% would be satisfactory for 75% of patients when HbA(1c) is increasing (80% confidence), and a CV(a) of 3.2% would be satisfactory for 75% when HbA(1c) is decreasing (95% confidence). CONCLUSIONS: Type 1 patients' perceived knowledge about HbA(1c) testing is high. They are well informed about their own personal results and about target values and the upper HbA(1c) threshold for action. The patient-derived analytical quality specification for imprecision (CV) is 3.1%.     

The association of diabetes specialist care with health care practices and glycemic control in patients with type 1 diabetes: a cross-sectional analysis from the Pittsburgh epidemiology of diabetes complications study

OBJECTIVE: To determine whether diabetes care characteristics and glycemic control differ by use of specialist care in a representative cohort of patients with type 1 diabetes. RESEARCH DESIGN AND METHODS: Health care, sociodemographic characteristics, and glycemic control were compared between participants in the Pittsburgh Epidemiology of Diabetes Complications Study who reported receiving specialist care (n = 212) and those who did not (n = 217). Specialist care was defined as having received care from an endocrinologist or diabetologist or diabetes clinic attendance during the last year. RESULTS: Patients who reported receiving specialist care were more likely to be female, to have an education level beyond high school, to have an annual household income >$20,000, and to have health insurance. Additionally, patients receiving specialist care were more likely to have received diabetes education during the previous 3 years, to have knowledge of HbAlc testing and to have received that test during the previous 6 months, to have knowledge of the Diabetes Control and Complications Trial results, to self-monitor blood glucose, and to inject insulin more than twice daily. A lower HbA1 level was associated with specialist care versus generalist care (9.7 vs. 10.3%; P = 0.0006) as were higher education and income levels. Multivariate analyses suggest that the lower HbA1 levels observed in patients receiving specialist care were restricted to patients with an annual income >$20,000. CONCLUSIONS: Specialist care was associated with higher levels of participation in diabetes self-care practices and a lower HbA1 level. Future efforts should research and address the failure of patients with low incomes to benefit from specialist care.     

Missed appointments and poor glycemic control: an opportunity to identify high-risk diabetic patients

OBJECTIVE: When patients miss scheduled medical appointments, continuity and effectiveness of healthcare delivery is reduced, appropriate monitoring of health status lapses, and the cost of health services increases. We evaluated the relationship between missed appointments and glycemic control (glycosylated hemoglobin or HbA1c) in a large, managed care population of diabetic patients. RESEARCH DESIGN AND METHODS: Missed appointment rate was related cross-sectionally to glycemic control among 84,040 members of the Kaiser Permanente Northern California Diabetes Registry during 2000. Adjusted least-square mean estimates of HbA1c were derived by level of appointment keeping (none missed, 1-30% missed, and >30% missed appointments for the calendar year) stratified by diabetes therapy. RESULTS: Twelve percent of the subjects missed more than 30% of scheduled appointments during 2000. Greater rates of missed appointments were associated with significantly poorer glycemic control after adjusting for demographic factors (age, sex), clinical status, and health care utilization. The adjusted mean HbA1c among members who missed >30% of scheduled appointments was 0.70 to 0.79 points higher (P <0.0001) relative to those attending all appointments. Patients who missed more than 30% of their appointments were less likely to practice daily self-monitoring of blood glucose and to have poor oral medication refill adherence. CONCLUSION: Patients who underuse care lack recorded information needed to determine level of risk. Frequently missed appointments were associated with poorer glycemic control and suboptimal diabetes self-management practice, are readily ascertained in clinical settings, and therefore could have clinical utility as a risk-stratifying criterion indicating the need for targeted case management.     

Self-management competence as a predictor of outcomes of intensive therapy or usual care in youth with type 1 diabetes

OBJECTIVE: This article evaluates prediction of HbA(1c) during an 18-month randomized trial of intensive therapy (IT) versus usual care (UC) for type 1 diabetes in 142 youth. RESEARCH DESIGN AND METHODS: Patients received a composite score for self-management competence (SMC) that combined standardized scores on baseline measures of diabetes knowledge, treatment adherence, and quality of health care interactions. They were categorized by tertiles split into low, moderate, and high SMC levels. RESULTS: IT yielded very similar mean HbA(1c) levels in all three SMC groups. However, in UC patients, HbA(1c) increased markedly for low-SMC youth but not for moderate- and high-SMC youth during the trial. Compared with the mean HbA(1c) of their UC counterparts, low-SMC patients realized greater glycemic benefit from IT than did the moderate- or high-SMC youth. Baseline SMC was more strongly correlated with HbA(1c) for UC than IT. CONCLUSIONS: All three SMC groups realized similar glycemic benefits from IT. The mean HbA(1c) levels of low-SMC patients in the UC group increased markedly over 18 months, whereas HbA(1c) levels of low-SMC patients in the IT group did not differ significantly from that of moderate- and high-SMC patients. Relative to their UC counterparts, low-SMC patients derived greater glycemic benefit from IT than did moderate- or high-SMC youth. SMC may be more critical to the success of UC than IT. Perhaps more importantly, patients should not be denied access to IT on the basis of limited competence in diabetes self-management.     

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.     

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.     

Diabetes management in a health maintenance organization. Efficacy of care management using cluster visits

OBJECTIVE: To evaluate the effectiveness of a cluster visit model led by a diabetes nurse educator for delivering outpatient care management to adult patients with poorly controlled diabetes. RESEARCH DESIGN AND METHODS: This study involved a randomized controlled trial among patients of Kaiser Permanente's Pleasanton, CA, center who were aged 16-75 years and had either poor glycemic control (HbA1c > 8.5%) or no HbA1c test performed during the previous year. Intervention subjects received multidisciplinary outpatient diabetes care management delivered by a diabetes nurse educator, a psychologist, a nutritionist, and a pharmacist in cluster visit settings of 10-18 patients/month for 6 months. Outcomes included change (from baseline) in HbA1c levels; self-reported changes in self-care practices, self-efficacy, and satisfaction; and utilization of inpatient and outpatient health care. RESULTS: After the intervention, HbA1c levels declined by 1.3% in the intervention subjects versus 0.2% in the control subjects (P < 0.0001). Several self-care practices and several measures of self-efficacy improved significantly in the intervention group. Satisfaction with the program was high. Both hospital (P = 0.04) and outpatient (P < 0.01) utilization were significantly lower for intervention subjects after the program. CONCLUSIONS: A 6-month cluster visit group model of care for adults with diabetes improved glycemic control, self-efficacy, and patient satisfaction and resulted in a reduction in health care utilization after the program.     

Effect of Culturally Tailored Diabetes Education in Ethnic Minorities With Type 2 Diabetes: A Meta-analysis

BACKGROUND:: Diabetes is a major cause of cardiovascular morbidity and mortality. Ethnic minorities experience a disproportionate burden of diabetes; however, few studies have critically analyzed the effectiveness of a culturally tailored diabetes intervention for these minorities. OBJECTIVE:: The aim of this study was to evaluate the effectiveness of a culturally tailored diabetes educational intervention (CTDEI) on glycemic control in ethnic minorities with type 2 diabetes. METHOD:: We searched databases within PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Education Resources Information Center (ERIC), PsycINFO, and ProQuest for randomized controlled trials (RCTs). We performed a meta-analysis for the effect of diabetes educational intervention on glycemic control using glycosylated hemoglobin (HbA1c) value in ethnic minority groups with type 2 diabetes. We calculated the effect size (ES) with HbA1c change from baseline to follow-up between control and treatment groups. RESULTS:: The 12 studies yielded 1495 participants with a mean age of 63.6 years and a mean of 68% female participants. Most studies (84%) used either group education sessions or a combination of group sessions and individual patient counseling. The duration of interventions ranged from 1 session to 12 months. The pooled ES of glycemic control in RCTs with CTDEI was -0.29 (95% confidence interval, -0.46 to -0.13) at last follow-up, indicating that ethnic minorities benefit more from CTDEI when compared with the usual care. The effect of intervention was greatest and significant when HbA1c level was measured at 6 months (ES, -0.41; 95% confidence interval, -0.61 to -0.21). The ES also differed by each participant's baseline HbA1c level, with lower baseline levels associated with higher ESs. CONCLUSIONS:: Based on this meta-analysis, CTDEI is effective for improving glycemic control among ethnic minorities. The magnitude of effect varies based on the settings of intervention, baseline HbA1c level, and time of HbA1c measurement. More rigorous RCTs that examine tailored diabetes education, ethnically matched educators, and more diverse ethnic minority groups are needed to reduce health disparities in diabetes care.     

Impact of health literacy and patient trust on glycemic control in an urban USA population

Diabetes, with its consequences of premature death, complications, and economic costs, is a precursor to a public health crisis that is expected to worsen over the next several decades. The improvement of diabetes outcomes, specifically glycemic control as measured by glycosylated hemoglobin concentration (HbA1c), can impact this critical situation. A quantitative study was conducted that examined health literacy and patient trust as predictors of glycemic control. The related factors of demographics, socioeconomic status, diabetes knowledge, self-care activities, and depression were also considered. Implementing a cross-sectional, predictive design, a convenience sample of 102 patients with diabetes was recruited from two urban primary care clinics in the USA. A simultaneous multiple regression was conducted. The regression analysis was significant, with patient trust and depression accounting for 28.5% of the variance in HbA1c. There was a significant positive relationship between socioeconomic status and health literacy and between diabetes knowledge and health literacy. The results support promotion of the patient–provider relationship, depression screening among individuals with diabetes, and exploration of new strategies for diabetes education. Future research is needed to advance the framework, ascertain which factors engender patient trust, and determine the role of health literacy in glycemic control.     

Education and telephone case management for children with type 1 diabetes: a randomized controlled trial

The purpose of the study was to compare three nursing interventions and their impact on glycemic control among children with type I diabetes. The 75 subjects' mean +/- SD age was 12.5 +/- 3.4 years, 55% were boys, and 55% were White. Subjects were randomly assigned to a standard care (SC), an education (ED), or an education and telephone case management (ED + TCM) group. The primary outcome measure was glycemic control (hemoglobin A1c, or HbA1c). Secondary outcome measures were diabetes knowledge (KNOW), parent-child teamwork (TEAM), and adherence (ADH). After 6 months of follow-up, results demonstrated no significant differences among groups in HbA1c. KNOW and TEAM scores improved slightly in the ED and ED + TCM groups, but no statistically significant differences were found among the three groups. Significant improvement in ADH scores among ED + TCM groups was reported when compared with the ED and SC groups. This change may represent a move toward improved adherence to diabetes care and subsequent improvement in diabetes control. The challenges of recruitment and retention of subjects in this study will also be discussed.     

Diabetes in urban African-Americans. XVI. Overcoming clinical inertia improves glycemic control in patients with type 2 diabetes.

OBJECTIVE: Diabetes care can be limited by clinical inertia-failure of the provider to intensify therapy when glucose levels are high. Although disease management programs have been proposed as a means to improve diabetes care, there are few studies examining their effectiveness in patient populations that have traditionally been underserved. We examined the impact of our management program in the Grady Diabetes Unit, which provides care primarily to urban African-American patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: We assessed glycemic outcomes in patients with type 2 diabetes who had an intake evaluation between 1992 and 1996 and who were identified on the basis of compliance with keeping the recommended number of return visits. For 698 patients, we analyzed changes in HbA1c values between baseline and follow-up visits at 6 and 12 months, and the proportion of patients achieving a target value of < or =7.0% at 12 months. Since a greater emphasis on therapeutic intensification began in 1995, we also compared HbA1c values and clinical management in 1995-1996 with that of 1992-1994. RESULTS: HbA1c averaged 9.3% on presentation. After 12 months of care, HbA1c values averaged 8.2, 8.4, 8.5, 7.7, and 7.3% for the 1992-1996 cohorts, respectively, and were significantly lower compared with values on presentation (P < 0.0025); the average fall in HbA1c was 1.4%. The percentage of patients achieving a target HbA1c < or =7.0% improved progressively from 1993 to 1996, with 57% of the patients attaining this goal in 1996. Mean HbA1c after 12 months was 7.6% in 1995-1996, significantly improved over the level of 8.4% in 1992-1994 (P < 0.0001). HbA1c levels after 12 months of care were lower in 1995-1996 versus 1992-1994, whether patients were managed with diet alone, oral agents, or insulin (P < 0.02). Improved HbA1c in 1995-1996 versus 1992-1994 was associated with increased use of pharmacologic therapy CONCLUSIONS: Structured programs can improve glycemic control in urban African-Americans with diabetes. Self-examination of performance focused on overcoming clinical inertia is essential to progressive upgrading of care.     

C-reactive protein and glycemic control in adults with diabetes

OBJECTIVE: Recent evidence suggests that poor glycemic control is significantly associated with the development of macrovascular complications of diabetes. Studies have indicated that C-reactive protein (CRP) is an important risk factor for cardiovascular disease. The purpose of this study was to determine the relation between CRP and HbA(1c) in a large national sample of individuals with diabetes. RESEARCH DESIGN AND METHODS: A nationally representative sample of noninstitutionalized U.S. adults aged 17 years and over with nongestational diabetes was derived from the National Health and Nutrition Examination Survey III (1988-1994) (n = 1,018). Respondents with diabetes were stratified by HbA(1c) level. The main outcome measure was elevated (>0.30 mg/dl) CRP. RESULTS: In unadjusted analyses, respondents with diabetes who had elevated HbA(1c) levels (> or =9.0%) had a significantly higher percent of elevated CRP than people with low (<7%) HbA(1c) levels (P < 0.001). In adjusted regression analysis, after controlling for age, race, sex, smoking, length of time with diabetes, insulin, and BMI, HbA(1c) was significantly associated with an increased likelihood of elevated CRP for HbA(1c) >9.0% (OR 2.15, 95% CI 1.07-4.32) and for HbA(1c) >11.0% (4.40, 1.87-10.38). Higher HbA(1c) also predicted elevated CRP in the regression model when HbA(1c) was analyzed as a continuous variable (1.20, 1.07-1.34). CONCLUSIONS: In this study, the likelihood of elevated CRP concentrations increased with increasing HbA(1c) levels. These findings suggest an association between glycemic control and systemic inflammation in people with established diabetes.     

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.     

Racial differences in glycemic control in a well-functioning older diabetic population: findings from the Health,Aging and Body Composition Study

OBJECTIVE: To evaluate racial differences and factors associated with worse glycemic control in well-functioning older individuals with type 2 diabetes. Our hypothesis was that glycemic control would be worse among black than white diabetic individuals but that this association would be explained by differences in severity of diabetes, health status, health care indicators, and social, psychological, or behavioral factors. We further hypothesized that the association of race with poorer glycemic control would be limited to those with lower education or lower income. RESEARCH DESIGN AND METHODS: Cross-sectional analysis of 468 diabetic participants among a cohort of 3,075 nondisabled blacks and whites aged 70-79 years living in the community enrolled in the Health, Aging and Body Composition Study. Glycemic control was measured by the level of HbA(1c). RESULTS: A total of 58.5% of the diabetic individuals were black. Although control was poor in all diabetic participants (HbA(1c) > or =7% in 73.7%), blacks had worse glycemic control than whites (age- and sex-adjusted mean HbA(1c), 8.4% in blacks and 7.4% in whites; P < 0.01). Race differences in glycemic control remained significant, even after adjusting for current insulin therapy, cardiovascular disease, higher total cholesterol, and not receiving a flu shot in the previous year, all of which were associated with higher HbA(1c) concentrations. Controlling for these factors reduced the association by 27%. Race remained an important factor in glycemic control, even when results were stratified by education or income. CONCLUSIONS: HbA(1c) concentrations were higher in older black diabetic individuals. Differences in glycemic control by race were associated with disease severity, health status, and poorer quality of care, but these factors did not fully explain the higher HbA(1c) levels in older black diabetic individuals.     

Relationship of depression and diabetes self-care, medication adherence, and preventive care

OBJECTIVE: We assessed whether diabetes self-care, medication adherence, and use of preventive services were associated with depressive illness. RESEARCH DESIGN AND METHODS: In a large health maintenance organization, 4,463 patients with diabetes completed a questionnaire assessing self-care, diabetes monitoring, and depression. Automated diagnostic, laboratory, and pharmacy data were used to assess glycemic control, medication adherence, and preventive services. RESULTS: This predominantly type 2 diabetic population had a mean HbA(1c) level of 7.8 +/- 1.6%. Three-quarters of the patients received hypoglycemic agents (oral or insulin) and reported at least weekly self-monitoring of glucose and foot checks. The mean number of HbA(1c) tests was 2.2 +/- 1.3 per year and was only slightly higher among patients with poorly controlled diabetes. Almost one-half (48.9%) had a BMI >30 kg/m(2), and 47.8% of patients exercised once a week or less. Pharmacy refill data showed a 19.5% nonadherence rate to oral hypoglycemic medicines (mean 67.4 +/- 74.1 days) in the prior year. Major depression was associated with less physical activity, unhealthy diet, and lower adherence to oral hypoglycemic, antihypertensive, and lipid-lowering medications. In contrast, preventive care of diabetes, including home-glucose tests, foot checks, screening for microalbuminuria, and retinopathy was similar among depressed and nondepressed patients. CONCLUSIONS: In a primary care population, diabetes self-care was suboptimal across a continuum from home-based activities, such as healthy eating, exercise, and medication adherence, to use of preventive care. Major depression was mainly associated with patient-initiated behaviors that are difficult to maintain (e.g., exercise, diet, medication adherence) but not with preventive services for diabetes.     

Spurious elevation of hemoglobin A1c by hereditary persistence of fetal hemoglobin

We present the case of a 61- year-old black woman with a diagnosis of type 2 diabetes and a falsely elevated hemoglobin A1c (HbA1c) due to hereditary persistence of fetal hemoglobin. Physicians and allied health care professionals are alerted to this potentially significant problem in the diagnosis and management of diabetes mellitus (DM), particularly in the wake of the Diabetes Complications and Control Trial when "strict" glycemic control assessed by HbA1c is now the standard of care.     

Diabetes care in the U.S. and Canada

OBJECTIVE: To compare the glycemic control of patients with type 1 diabetes treated in the U.S. and Canada. RESEARCH DESIGN AND METHODS: A large multicenter randomized clinical trial conducted in the U.S. and Canada was analyzed. Patients with type 1 diabetes, screened from 1983 to 1989 for enrollment in the Diabetes Control and Complications Trial (DCCT), were categorized as treated in the U.S. (n = 2,604) or Canada (n = 245). HbA(1c) levels were compared between U.S. and Canadian patients, both before and after adjustment for predictors of HbA(1c). RESULTS: In general, volunteers screened for the DCCT were highly educated and following healthy lifestyles. Canadians were somewhat younger (25 vs. 27 years of age, P = 0.002), less likely to be college educated (62 vs. 71%, P = 0.002), more likely to receive care through a family doctor (41 vs. 28%, P = 0.001), and had a higher frequency of out-patient visits (4 vs. 3 per year, P = 0.004). Despite these differences in health care delivery, the mean HbA(1c) at baseline was identical in the two countries (8.9 vs. 9.0, P = 0.40). Adjustment for demographic, lifestyle, and clinical predictors of HbA(1c) yielded similar findings (9.0 vs. 9.2, P = 0.15). Equal percentages of American and Canadian patients who were screened ultimately entered the trial (21 vs. 19%, P = 0.20), and those randomized to conventional care achieved similar mean HbA(1c) levels (9.1 vs. 9.2, P = 0.50). CONCLUSIONS: Differences in care delivery patterns do not yield large differences in glycemic control for patients with type 1 diabetes who were recruited in the U.S. and Canada for a large randomized trial.