Diabetes management

About: Diabetes management is a research topic. Over the lifetime, 6060 publications have been published within this topic receiving 164670 citations.

Cost-effectiveness of diabetes case management for low-income populations.

Abstract: Diabetes is a common and costly chronic disease that increasingly affects low-income and minority populations (Hogan, Dall, and Nikolov 2003). The Centers for Disease Control and Prevention have estimated that the lifetime risk of developing diabetes for individuals born in the United States in 2000 is 32.8 percent for males and 38.5 percent for females (Narayan et al. 2003). These risks are greatest for Latinos, among whom they are 45.4 percent and 52.5 percent, respectively. The importance of ethnic differentials has been supported by findings from the UCLA Center for Health Policy and Research that show among adults in California age 50 and over, the 1 year prevalence of diagnosed diabetes is 21.2 percent among those who report Mexican ancestry, compared with 10.1 percent among non-Latino whites (Diamant et al. 2003). Recent studies have shown that culturally specific diabetes management programs can be effective at improving clinical outcomes among ethnic groups disproportionately affected by diabetes. The California Medi-Cal type 2 diabetes study group found that providing case management to an ethnically diverse population of Medicaid beneficiaries at clinical sites in southern California resulted in improved levels of glycosylated hemoglobin (A1c) (2004). Philis-Tsimikas et al. (2004) examined the provision of case management and self-management training to a high risk, low-income, and predominately Latino population in San Diego County and observed significant improvements in A1c and total cholesterol, and demonstrated increases in diabetes knowledge and a reduction in misrepresented cultural beliefs and the use of cultural based remedies (Philis-Tsimikas et al. 2004). Gilmer, Philis-Tsimikas, and Walker (2005) studied the same program in a more general low-income population and found improvements in clinical outcomes along with increased costs for pharmaceuticals and supplies. The per-capita cost of the program itself was relatively modest ($507 in 2002 dollars). Simulation models are currently being used to estimate the long-term cost-effectiveness of improvements in diabetes care. These models employ data from large-scale clinical trials such as the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) along with smaller observational studies, survey-based QALY measures, and cost data from claims databases in order to construct statistical models that provide estimates of long-term outcomes associated with diabetes interventions. A model developed by the CDC Diabetes Cost-Effectiveness Workgroup has been used to demonstrate differences in the cost-effectiveness for intensive glycemic control ($41,484/QALY, 1997 dollars), blood pressure control (cost saving), and lipid control ($51,889/QALY) compared with usual care, as well as variations in cost-effectiveness by age (2002). A model developed by CORE—Center for Outcomes Research (a unit of IMS Health) has been used to project the long-term clinical outcomes, cost, and cost-effectiveness of alternative diabetes interventions (Palmer, Roze, Lammert et al. 2004; Palmer, Roze, Valentine, Smith et al. 2004; Minshall et al. 2005; Roze et al. 2005; Valentine et al. 2005). The CDC, CORE, and Archimedes models have been used to estimate the long-term cost-effectiveness of diabetes prevention (Palmer, Roze, Valentine, Spinas et al. 2004; Eddy, Schlessinger, and Kahn 2005; Herman et al. 2005). Less attention has been paid to the cost-effectiveness of providing care to differing populations, particularly the relative cost-effectiveness of improving diabetes management for those populations that have low-incomes, are ethnically diverse, and who are often uninsured or underinsured. In this paper, we provide an economic evaluation of the relative long-term cost-effectiveness of Project Dulce, a case management and self-management training program, as provided to four cohorts defined by insurance status in San Diego County: those who are uninsured, those covered by County Medical Services (CMS), those who have Medi-Cal coverage (California's Medicaid Program), and those who have commercial insurance. These populations differ in their demographics and their clinical indictors at baseline. This study examines their long-term outcomes when exposed to the same diabetes management model.

Understanding multifactorial brain changes in type 2 diabetes : a biomarker perspective

Abstract: People with type 2 diabetes are at an increased risk of cognitive impairment and dementia (including Alzheimer's disease), as well as subtle forms of cognitive dysfunction. Current diabetes guidelines recommend screening for cognitive impairment in groups at high risk and providing guidance for diabetes management in patients with diabetes and cognitive impairment. Yet, no disease-modifying treatment is available and important questions remain about the mechanisms underlying diabetes-associated cognitive dysfunction. These mechanisms are likely to be multifactorial and different for subtle and more severe forms of diabetes-associated cognitive dysfunction. Over the past years, research on dementia, brain ageing, diabetes, and vascular disease has identified novel biomarkers of specific dementia aetiologies, brain parenchymal injury, and cerebral blood flow and metabolism. These markers shed light on the processes underlying diabetes-associated cognitive dysfunction, have clear applications in current research and increasingly in clinical diagnosis, and might ultimately guide targeted treatment.

Structured, intensive education maximising engagement, motivation and long-term change for children and young people with diabetes: a cluster randomised controlled trial with integral process and economic evaluation - the CASCADE study.

Abstract: BACKGROUND: Type 1 diabetes (T1D) in children and young people is increasing worldwide with a particular increase in children under the age of 5 years. Fewer than one in six children and young people achieve glycosylated fraction of haemoglobin (HbA1c) values in the range identified as providing best future outcomes. There is an urgent need for clinic-based pragmatic, feasible and effective interventions that improve both glycaemic control and quality of life (QoL). The intervention offers both structured education, to ensure young people know what they need to know, and a delivery model designed to motivate self-management. OBJECTIVE: To assess the feasibility of providing a clinic-based structured educational group programme incorporating psychological approaches to improve long-term glycaemic control, QoL and psychosocial functioning in a diverse range of young people. DESIGN: The study was a pragmatic, cluster randomised control trial with integral process and economic evaluation. SETTING: Twenty-eight paediatric diabetes services across London, south-east England and the Midlands. RANDOMISATION: Minimised by clinic size, age (paediatric or adolescent) and specialisation (district general hospital clinic or teaching hospital/tertiary clinic). ALLOCATION: Half of the sites were randomised to the intervention arm and half to the control arm. Allocation was concealed until after clinics had consented and the first participant was recruited. Where possible, families were blind to allocation until recruitment finished. PARTICIPANTS: Forty-three health-care practitioners (14 teams) were trained in the intervention. The study recruited 362 children aged 8-16 years, diagnosed with T1D for > 12 months, with a mean 12-month HbA1c level of ≥ 8.5%. INTERVENTION: Two 1-day workshops taught intervention delivery. A detailed manual and resources were provided. The intervention consists of four group education sessions led by a paediatric diabetes specialist nurse with another team member. OUTCOMES: The primary outcome was glycaemic control, assessed at the individual level using venous HbA1c values, measured at baseline, 12 and 24 months. Secondary outcomes were directly and indirectly related to diabetes management, including hypoglycaemic episodes, hospital admissions, diabetes regimen, knowledge, skills and responsibility for diabetes management, intervention compliance, clinic utilisation, emotional and behavioural adjustment, and general and diabetes-specific QoL. PROCESS EVALUATION: Questionnaires, semistructured interviews, informal discussion following observation sessions, fieldwork notes and case note review were used to collect qualitative and quantitative data from key stakeholder groups at specific time points in the trial. STATISTICAL ANALYSES: Primary and secondary analyses were intention-to-treat comparisons of outcomes at 12 and 24 months, using analysis of covariance with a random effect for clinic. Prespecified subgroup analyses based on age, gender, initial HbA1c value and socioeconomic status were estimated from models that included an interaction term. The economic analysis compared long-term costs and predicted quality-adjusted life-years (QALYs). RESULTS: The intervention did not improve HbA1c at 12 months [intervention effect 0.11; 95% confidence interval (CI) -0.28 to 0.50; p = 0.584] or 24 months (intervention effect 0.03; 95% CI -0.36 to 0.41; p = 0.891). A total of 298/362 patients (82.3%) provided blood samples at 12-month follow-up, and 284/362 (78.5%) provided blood samples at 24-month follow-up. Follow-up questionnaires were completed by 307 patients (85.3%) at 12 months and by 295 patients (81.5%) at 24 months. Intervention group parents at 12 months (95% CI 0.74; 0.03 to 1.52) and young people at 24 months (0.85; 95% CI 0.03 to 1.61) had higher scores on the diabetes family responsibility questionnaire. Young people reported reduced happiness with body weight at 12 months (-0.56; 95% CI -1.03 to -0.06). Only 68% of groups were run. Of the 180 families recruited, 96 (53%) attended at least one module. Reasons for low uptake included difficulties organising groups, and work and school commitments. Young people with higher HbA1c levels were less likely to attend. Parents and young people who attended groups described improved family relationships, improved knowledge and understanding, greater confidence and increased motivation to manage diabetes. Twenty-four months after the intervention, nearly half of the young people reported that the groups had made them want to try harder and that they had carried on trying. A high-quality, complex, pragmatic trial of structured education can be delivered alongside standard care in NHS diabetes clinics. Health-care providers benefited from behaviour change skill training and can deliver pragmatic aspects of a National Institute for Health and Care Excellence (NICE)-compliant structured education programme after relatively brief training. The process evaluation provides insight into aspects of the model, and highlights strengths and aspects that may have contributed to the failure to influence primary and secondary outcomes. Current NHS practice dominates CASCADE (Child and Adolescent Structured Competencies Approach to Diabetes Education) in that it achieves the same number of QALYs at a lower cost. The mean cost of providing the intervention was £5098 per site or £683 per child. Members of paediatric diabetes services trained to deliver the CASCADE structured education package using behaviour change techniques did not improve glycaemic control in patients compared with control subjects 1 and 2 years after the intervention. The training workshops for practitioners were well evaluated; however, more intensive training was needed. The intervention cost £683 per patient but was not cost-effective because it did not improve metabolic control. CONCLUSIONS: A high-quality, complex, pragmatic trial of structured education can be successfully conducted alongside standard care in NHS diabetes clinics. Pragmatic components of a NICE-compliant structured education programme can be successfully delivered following a relatively brief 2-day training while paediatric health-care professionals benefit from training in behaviour change skills. The study provides invaluable information on barriers and opportunities regarding future, similar interventions. A low dropout rate and good attendance for the subgroup that attended the intervention suggests there might be improved uptake if offered to young people with lower HbA1c. Testing whether this approach can be more successful with a robust ongoing supervisory element should be a target of further research. TRIAL REGISTRATION: Current Controlled Trials ISRCTN52537669. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 20. See the NIHR Journals Library website for further project information.

The Empirical Evidence for the Telemedicine Intervention in Diabetes Management

Abstract: Objective: The research presented here assesses the scientific evidence for the telemedicine intervention in the management of diabetes (telediabetes), gestational diabetes, and diabetic r...