A L Graber

Vanderbilt University, Nashville, MI, United States

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Publications (13)43.54 Total impact

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    Diabetes Care 06/2003; 26(5):1645-6. · 7.74 Impact Factor
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    ABSTRACT: 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 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. The first 350 patients who completed the program had overall mean decrease in HbA1c level of 1.7% (95% CI 1.4%-1.9%). Barriers to improving glycemic control may be overcome by establishment of a system of collaboration between primary care providers and endocrinologist-directed diabetes educators.
    Southern Medical Journal 08/2002; 95(7):684-90. · 0.92 Impact Factor
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    ABSTRACT: A 70-year-old woman was referred for F-18 fluorodeoxyglucose (FDG) positron emission tomographic (PET) imaging of the brain to evaluate progressive dementia and neuropsychiatric symptoms. Although she had a history of hypertension and diabetes mellitus, she did not exhibit phenotypic features of Cushing's disease. The FDG-PET images revealed marked FDG uptake in the pituitary gland but no evidence of degenerative dementia. Two macroadenomas were confirmed by magnetic resonance imaging. Endocrinologic evaluation revealed Cushing's disease. After surgical resection of the tumors, the patient's symptoms decreased markedly.
    Clinical Nuclear Medicine 04/2002; 27(3):176-8. · 2.96 Impact Factor
  • American Journal of Respiratory and Critical Care Medicine 12/2001; 164(10 Pt 1):1763-7. · 11.04 Impact Factor
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    ABSTRACT: Collaboration between primary care physicians (PCPs) and endocrinologists should be the first step in improving care of patients with diabetes. However, the coordination of care between specialists and PCPs often does not work well. At Vanderbilt University Medical Center, a collaborative model between PCPs and endocrinology was used in an effort to improve glycemic control for patients with diabetes. In 1998 a project team was formed; the team members attempted to find ways to improve the care of patients with diabetes, specifically patients with poor glycemic control. The team proceeded through ten iterations of the model before reaching one accepted by all-one with clear responsibilities and referral criteria. Survey results indicated a high level of satisfaction with the collaborative model among patients and PCPs. Appropriate referrals to the diabetes improvement program--a 12-week outpatient program consisting of instruction and support in diabetes self-management coupled with adjustment of insulin and oral hypoglycemic medications-increased during the team effort, and a control chart indicated a change in the process that was significant and sustained. The patients enrolled in the program experienced a reduction of mean glycated hemoglobin levels from 9.2% at entry to 7.5% after 3 months (p < 0.05). An initial first step to improving care is to create an environment of trust and collaboration between the PCPs and specialists who assist in that care. After this collaboration has been established, many of the improvements identified in other studies can more easily be implemented.
    The Joint Commission journal on quality improvement 05/2001; 27(5):255-64.
  • A W Brown, K L Wolff, T A Elasy, A L Graber
    The Diabetes Educator 01/2001; 27(4):492-6, 498-500, 502. · 1.94 Impact Factor
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    ABSTRACT: To determine annual hospitalization rates for patients with diabetes mellitus, we retrospectively analyzed the frequency of hospitalization among 905 patients with diabetes receiving primary care in a private practice outpatient program during a 20-month period (1,508 patient-years). We assessed the annual hospitalization rates stratified by diabetes clinical severity index, type of diabetes, type of treatment, age, sex, and mean glycosylated hemoglobin. The all-cause annual hospitalization rate was 211 per 1,000 patients (95% confidence interval, 184 to 238). Hospitalization rates were strongly correlated with measures of clinical severity; hospitalization rates did not vary significantly with type of diabetes, age, or sex. Among patients with type II diabetes, rates were higher in the group treated with insulin. A trend was noted for hospitalization rates to increase with mean glycosylated hemoglobin (not statistically significant in this sample). Overall, 14% of hospitalizations were for metabolic reasons, 45% were related to clinical complications of diabetes, and 41% were unrelated to the presence of diabetes. In analysis of hospitalization rates and therefore health-care expenditures for patients with diabetes, the characteristics of the patient population--and especially measures of clinical severity--must be considered. Interventions to reduce hospitalization can be targeted at high-risk groups.
    Endocrine Practice 01/1995; 1(6):399-403. · 2.49 Impact Factor
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    ABSTRACT: To determine factors associated with dropout and relapse during chronic diabetes care. Private practice outpatient treatment-education program for adult diabetes was surveyed. Retrospective analysis was done, involving 422 patients for up to 3 yr. Of the patients in the study, 12% dropped out after the initial visit, and 33% of the residual cohort dropped out during each subsequent 6-mo period. Factors associated with dropout included distance from home to clinic > 100 miles, lack of insulin treatment, and cigarette smoking. In patients who remained in follow-up, a significant decrease in HbA1C occurred during the first 6 mo, but 40% of the patients relapsed between 6 and 12 mo. Frequency of relapse declined as time passed. Relapse was more frequent in women. Dropout from treatment and relapse after temporary improvement account for a substantial amount of uncontrolled diabetes, and overcoming the obstacles of dropout and relapse has potential for significant improvement in diabetes care.
    Diabetes Care 12/1992; 15(11):1477-83. · 7.74 Impact Factor
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    ABSTRACT: There is evidence that an individual's health beliefs influence performance of health behaviors. The purpose of this study was to determine whether health beliefs in persons with diabetes could be modified during a clinical education program and whether the health beliefs were related to adherence to self-care instructions and metabolic control of diabetes. Health beliefs and HbA1c were measured at baseline in 189 adult outpatients with diabetes. Diabetes educators then attempted to modify health beliefs that were not conducive to positive health behaviors. Following education, some health beliefs were modified in a positive direction. Modest, but statistically significant increases in perceived severity of diabetes, perceived ability to carry out recommended behaviors, and perceived benefits of treatment were observed. Although HbA1c improved significantly in a subgroup of patients, this improvement could not be directly associated with any health belief or with self-reported adherence by the measures used in this study.
    The Diabetes Educator 01/1992; 18(6):495-500. · 1.94 Impact Factor
  • A L Graber, K Wooldridge, A Brown
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    ABSTRACT: Control of diabetes mellitus requires active participation of patients in self-care and ongoing support from medical professionals. This study examines the hypothesis that control of diabetes can be improved by more frequent communication between patients and medical professionals. We instructed 233 insulin-requiring diabetic patients to mail the results of home blood glucose monitoring to the physician's office at least every two weeks. Feedback from office nurse practitioners followed receipt of these reports, providing frequent two-way communication between regularly scheduled office appointments. In the group of patients who mailed reports more than 26 weeks during the year, the mean glycosylated hemoglobin (GHb) value was 10.4% at baseline, and there was a mean decrease in GHb of 1.0% during the succeeding year (P = .001). In patients who mailed reports less than 26 weeks during the year, mean GHb was 10.2% at baseline, and there was no significant change during the succeeding year. Since mean GHb was virtually identical in the two groups at baseline, mailing the reports of home-determined blood glucose levels and receiving feedback between office visits resulted in improved control of diabetes.
    Southern Medical Journal 11/1986; 79(10):1205-9. · 0.92 Impact Factor
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    ABSTRACT: In an inpatient diabetes control unit established to fulfill the special needs of hospitalized diabetic patients, 29% of the admissions were for control of diabetes. In 71% the metabolic abnormalities of diabetes were incidental to the cause of admission. Of the first 232 patients, 162 had type II diabetes. The degree of hyperglycemia in the type II patients was virtually identical to that in the type I patients, as measured by hemoglobin A1C levels at admission and by mean blood glucose values in the hospital. The mean hemoglobin A1C level at admission was 9.1% in both groups (normal 3.2 to 6.1). During hospitalization the patients admitted for medical and surgical problems achieved average blood glucose levels similar to levels in those who were admitted strictly for diabetes control. Regardless of the reason for admission, hospitalization of a diabetic patient is an opportunity for improvement in metabolic control and for patient education.
    Southern Medical Journal 04/1986; 79(3):281-4. · 0.92 Impact Factor
  • A L Graber
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    ABSTRACT: To describe the syndrome of lipodystrophy, hyperlipidemia, insulin resistance, and diabetes in patients with human immunodeficiency virus (HIV) infection treated with protease inhibitor drugs. This is a case series of patients referred from an infectious disease clinic to a diabetes-endocrinology clinic in an academic medical center because of severe metabolic problems that occurred during the course of otherwise-successful treatment of HIV infection. The clinical course, abnormalities on physical examination, laboratory data, and complications are described and analyzed. The pathogenesis of the syndrome is discussed and compared with that of type 2 diabetes, lipoatrophic diabetes, and mouse models of lipodystrophy. In six male patients receiving antiretroviral therapy for HIV infection, a syndrome of lipoatrophy of the face, legs, and buttocks, hyperlipidemia (predominantly hypertriglyceridemia), and type 2 diabetes mellitus was noted. Two patients had pronounced abdominal obesity, in contrast to their thin extremities. Five of the six patients were receiving protease inhibitor drugs, which have been thought to contribute to metabolic abnormalities. In two patients, ischemic heart disease had developed. Protease inhibitors frequently cause insulin resistance and lipoatrophy in subcutaneous adipose tissue. These abnormalities are associated with visceral adiposity, hyperlipidemia, diabetes, and cardiovascular consequences and represent an important and unsolved problem in the treatment of HIV-infected patients.
    Endocrine Practice 7(6):430-7. · 2.49 Impact Factor
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    ABSTRACT: To characterize the occurrence of glycemic relapse after initial improvement in blood glucose levels and to describe predictors of relapse in patients with type 2 diabetes. Occurrence of glycemic relapse was analyzed in 393 consecutive patients with type 2 diabetes after participation in a 3-month intensive outpatient intervention. All patients had hemoglobin A1c (A1C) values (3)7% before the intervention and had achieved adequate glycemic control (nadir A1C<7%) afterward. The median follow-up time was 26.5 months. Relapse was defined as a subsequent increase in A1C to (3)7%. The probability of glycemic relapse was 45% at 1 year after the intervention and was 76% at 3 years. The median time to relapse was 15.2 months. Cox multivariate regression analysis indicated that treatment with insulin was associated with a greater risk of relapse-- hazard ratio=1.5 (95% confidence interval, 1.1 to 2.2), after controlling for the patient's age, sex, race, body mass index, duration of diabetes, weight change during the intervention, and nadir A1C value. Among those patients not treated with insulin at the end of the intervention, a shorter duration of diabetes and weight loss during the intervention period were significantly associated with decreased risk of relapse. The majority of study patients with type 2 diabetes who attained satisfactory glycemic control after intensive outpatient intervention had a relapse after the end of the intervention period. Patients receiving insulin therapy were at particular risk of glycemic relapse. Therefore, such patients should receive high priority for continuation of intensive care or for other relapse prevention measures.
    Endocrine Practice 12(2):145-51. · 2.49 Impact Factor