[Show abstract][Hide abstract] ABSTRACT: Carbohydrate counting may improve glycemic control in hospitalized cardiology patients by providing individualized insulin doses tailored to meal consumption. The purpose of this study was to compare glycemic outcomes with mealtime insulin dosed by carbohydrate counting versus fixed dosing in the inpatient setting.
This single-center retrospective cohort study included 225 adult medical cardiology patients who received mealtime, basal, and correction-scale insulin concurrently for at least 72 h and up to 7 days in the interval March 1, 2010-November 7, 2013. Mealtime insulin was dosed by carbohydrate counting or with fixed doses determined prior to meal intake. An inpatient diabetes consult service was responsible for insulin management. Exclusion criteria included receipt of an insulin infusion. The primary end point compared mean daily postprandial glucose values, whereas secondary end points included comparison of preprandial glucose values and mean daily rates of hypoglycemia.
Mean postprandial glucose level on Day 7 was 204 and 183 mg/dL in the carbohydrate counting and fixed mealtime dose groups, respectively (unadjusted P=0.04, adjusted P=0.12). There were no statistical differences between groups on Days 2-6. Greater rates of preprandial hypoglycemia were observed in the carbohydrate counting cohort on Day 5 (8.6% vs. 1.5%, P=0.02), Day 6 (1.7% vs. 0%, P=0.01), and Day 7 (7.1% vs. 0%, P=0.008). No differences in postprandial hypoglycemia were seen.
Mealtime insulin dosing by carbohydrate counting was associated with similar glycemic outcomes as fixed mealtime insulin dosing, except for a greater incidence of preprandial hypoglycemia. Additional comparative studies that include hospital outcomes are needed.
[Show abstract][Hide abstract] ABSTRACT: Many US adults have multiple chronic conditions, and hypertension and diabetes are among the most common dyads. Diabetes and prediabetes prevalence are increasing, and both conditions negatively affect cardiovascular health. Early diagnosis and treatment of diabetes and prediabetes can benefit people with hypertension by preventing cardiovascular complications.
We analyzed 2011 Minnesota Behavioral Risk Factor Surveillance System data to describe the proportion of adults with hypertension screened for diabetes according to US Preventive Services Task Force Recommendations for blood glucose testing. Covariates associated with lower odds of recent screening among adults without diabetes were determined using weighted logistic regression.
Of Minnesota adults with self-reported hypertension, 19.6% had a diagnosis of diabetes and 10.7% had a diagnosis of prediabetes. Nearly one-third of adults with hypertension without diabetes had not received blood glucose screening in the past 3 years. Factors associated with greater odds of not being screened in multivariable models included being aged 18 to 44 years (adjusted odds ratio [AOR], 1.77; 95% confidence interval [CI], 1.23-2.55); being nonobese, with stronger effects for normal body mass index; having no check-up in the past 2 years (AOR, 2.49; 95% CI, 1.49-4.17); having hypertension treated with medication (AOR, 2.01; 95% CI, 1.49-2.71); and completing less than a college degree (AOR, 1.45; 95% CI, 1.14-1.84). Excluding respondents with prediabetes or those not receiving a check-up did not change the results.
Failure to screen among providers and failure to understand the importance of screening among individuals with hypertension may mean missed opportunities for early detection, clinical management, and prevention of diabetes.
Preview · Article · Nov 2014 · Preventing chronic disease
[Show abstract][Hide abstract] ABSTRACT: Background The Patient Assessment of Chronic Illness Care (PACIC) survey is a widely used instrument to assess the patient experience with healthcare delivery. Purpose This study aims to evaluate the factorial structure of PACIC from the patient perspective. Methods A postal survey was mailed to 4,796 randomly selected adults with diabetes from 34 primary care clinics. Internal consistencies of PACIC subscales were assessed by Cronhach’s α. Factorial structure was evaluated by confirmatory and exploratory factor analyses. Results Based on responses of 2,055 patients (43 % response rate), exploratory factor analysis discerned a 4-factor, not 5-factor, model dominated by patient evaluation of healthcare services (explaining 74 % of the variance). The other 3 factors addressed patient involvement (goal setting, participating in the healthcare team) and social support for self-management. Conclusions The underlying factorial structure of PACIC, which reflects the patient perspective, is dynamic, patient-centered, and differs from the original 5-factor model that was more aligned with views of healthcare delivery stakeholders.
No preview · Article · Sep 2014 · Annals of Behavioral Medicine
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE
While metformin is generally accepted as the first-line agent in treatment of type 2 diabetes, there are insufficient evidence and extensive debate about the best second-line agent. We aimed to assess the benefits and harms of four commonly used antihyperglycemia treatment regimens considering clinical effectiveness, quality of life, and cost.RESEARCH DESIGN AND METHODS
We developed and validated a new population-based glycemic control Markov model that simulates natural variation in HbA1c progression. The model was calibrated using a U.S. data set of privately insured individuals diagnosed with type 2 diabetes. We compared treatment intensification of metformin monotherapy with sulfonylurea, dipeptidyl peptidase-4 inhibitor, glucagon-like peptide-1 receptor agonist, or insulin. Outcome measures included life-years (LYs), quality-adjusted life-years (QALYs), mean time to insulin dependence, and expected medication cost per QALY from diagnosis to first diabetes complication (ischemic heart disease, myocardial infarction, congestive heart failure, stroke, blindness, renal failure, amputation) or death.RESULTSAccording to our model, all regimens resulted in similar LYs and QALYs regardless of glycemic control goal, but the regimen with sulfonylurea incurred significantly lower cost per QALY and resulted in the longest time to insulin dependence. An HbA1c goal of 7% (53 mmol/mol) produced higher QALYs compared with a goal of 8% (64 mmol/mol) for all regimens.CONCLUSIONS
Use of sulfonylurea as second-line therapy for type 2 diabetes generated glycemic control and QALYs comparable with those associated with other agents but at lower cost. A model that incorporates HbA1c and diabetes complications can serve as a useful clinical decision tool for selection of treatment options.
[Show abstract][Hide abstract] ABSTRACT: Population health data are used to profile local conditions, call attention to areas of need, and evaluate health-related programs. Demand for data to inform health care decision making has spurred development of data sources and online systems, but these are often poorly integrated or limited in scope. Our objective was to identify existing data about diabetes mellitus-related conditions in Minnesota, build an online data resource, and identify what data are currently missing that, if available, would better inform assessment of health conditions in the state. A Web site was developed and populated with existing data and data not available elsewhere. It features functionality identified as most important by users, such as maps and county profiles. The site could serve as a flexible tool for stakeholder engagement, but issues were identified during development, including concerns about interpreting map data and open questions about sustainability, that need to be addressed.
No preview · Article · Jan 2014 · Journal of public health management and practice: JPHMP
[Show abstract][Hide abstract] ABSTRACT: Jeff Sloan and colleagues describe the development of the Patient-Reported Outcomes Quality of Life (PROQOL) instrument, which captures and stores patient-recorded outcomes in the medical record for patients with diabetes.
Please see later in the article for the Editors' Summary
[Show abstract][Hide abstract] ABSTRACT: Objective: To establish the prevalence of patient-reported hypoglycemia among ambulatory patients with diabetes and assess its impact on health-related quality of life (HRQoL).Methods: This study was a cross-sectional analysis of a postal survey disbursed during quarter 1 of 2010 to 875 adults with type 1 or 2 diabetes identified on the basis of an index clinical encounter for diabetes management between August 1, 2005 and June 30, 2006. The survey included questions about hypoglycemia, self-rating of health, and questions adapted from the Confidence in Diabetes Self-Care, Generalized Anxiety Disorder-7, EuroQol5-D, and Hypoglycemic Fear Survey. Data was analyzed using two sample t-test for continuous and Chi-square for categorical variables, with multivariate analysis to adjust for age, gender, diabetes duration, and Charlson comorbidity index.Results: The survey was completed by 418 patients (47.8% response rate). Of the respondents, 26 of 92 (28.3%) with type 1 and 55 of 326 (16.9%) with type 2 diabetes reported at least one episode of severe hypoglycemia within 6 months. Fear of hypoglycemia, including engagement in anticipatory avoidance behaviors, was highest in patients with type 2 diabetes reporting severe hypoglycemia and all patients with type 1 diabetes (p < 0.001). HRQoL was lower in patients with type 2, but not type 1, diabetes reporting severe hypoglycemia (p < 0.01).Conclusion: Clinicians and health systems should incorporate screening for hypoglycemia into routine health assessment of all patients with diabetes. It places patients at risk for counterproductive behaviors, impairs HRQoL, and should be used in individualizing glycemic goals.
No preview · Article · Jun 2013 · Endocrine Practice
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: The extant literature lacks breadth on psychological variables associated with health outcome for type 2 diabetes mellitus (T2DM). This investigation extends the scope of psychological information by reporting on previously unpublished factors. OBJECTIVE: To investigate if intolerance of uncertainty, emotion regulation, or purpose in life differentiate T2DM adults with sustained high HbA1c (HH) vs. sustained acceptable HbA1c (AH). SUBJECTS AND METHODS: Cross-sectional observational study. Adult patients with diagnosed T2DM meeting inclusionary criteria for AH, HH, or a nondiabetic reference group (NDR) were randomly selected and invited to participate. Patients who consented and participated resulted in a final sample of 312 subgrouped as follows: HH (n=108); AH (n=98); and NDR (n=106). Data sources included a survey, self-report questionnaires, and electronic medical record (EMR). RESULTS: HH individuals with T2DM reported lower purpose in life satisfaction (p=0.005) compared to the NDR group. The effect size for this finding is in the small-to-medium range using Cohen's guidelines for estimating clinical relevance. The HH-AH comparison on purpose in life was nonsignificant. The emotion regulation and intolerance of uncertainty comparisons across the three groups were not significant. CONCLUSIONS: The present study determined that lower purpose in life satisfaction is associated with higher HbA1c. In a T2DM patient with sustained high HbA1c, the primary care clinician is encouraged to consider screening for purpose in life satisfaction by asking a single question such as "Do the things you do in your life seem important and worthwhile?" The patient's response will assist the clinician in determining if meaning or purpose in life distress may be interferring with diabetes self-care. If this is the case, the clinician can shift the conversation to the value of behavioral and emotional health counseling.
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND & AIMS: RM-131, a synthetic ghrelin agonist, greatly accelerates gastric emptying of solids in patients with type 2 diabetes and delayed gastric emptying (DGE). We investigated the safety and effects of a single dose of RM-131 on gastric emptying and upper gastrointestinal (GI) symptoms in patients with type 1 diabetes and previously documented DGE. METHODS: In a double-blind crossover study, 10 patients with type 1 diabetes (age 45.7±4.4 y; body mass index 24.1±1.1 kg/m(2)) and previously documented DGE were assigned in random order to receive a single dose of RM-131 (100 μg, subcutaneously) or placebo. Thirty min later, they ate a radiolabeled solid-liquid meal containing Eggbeaters®, and then underwent 4 h gastric emptying and 6 h colonic filling analyses by scintigraphy. Upper GI symptoms were assessed using daily diaries, to determine gastroparesis cardinal symptom index (total GCSI-DD) and nausea, vomiting, fullness, and pain (NVFP) scores (scales of 0-5). RESULTS: At screening, participants' mean level of hemoglobin A1c was 9.1%±0.5%; their total GCSI-DD score was 1.66±0.38 (median 1.71) and total NVFP score was 1.73±0.39 (median 1.9). The t1/2 of solid gastric emptying was 84.9±31.6 min when subjects were given RM-131 and 118.7±26.7 when they were given placebo. The median reduction in t1/2 following administration of RM-131 was 33.9 min (interquartile range [IQR], 12 to 49), or 54.7% (IQR, 21%-110%). RM-131 decreased gastric retention of solids at 1 h (P=.005) and 2 h (P=.019). Numerical differences in t1/2 for gastric emptying of liquids, solid gastric emptying lag time, and colonic filling at 6 h were not significant. Total GCSI-DD scores were 0.79 on placebo (IQR, 0.75-2.08) and 0.17 on RM-131 (IQR, 0.00-0.67; P=.026); NVFP scores were lower on RM-131 (P=.041). There were no significant adverse effects. CONCLUSIONS: RM-131 significantly reduces the t1/2 of gastric emptying of solids and upper GI symptoms in patients with type 1 diabetes and documented DGE. CLINICALTRIALS.GOV: NCT01394055.
No preview · Article · Apr 2013 · Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE
To investigate the pharmacokinetics (PK), pharmacodynamics, and safety of single-dose RM-131 in type 2 diabetic patients with gastrointestinal cardinal symptoms (GCSI) and previously documented delayed gastric emptying (DGE).RESEARCH DESIGN AND METHODS
In a randomized crossover study, 10 female patients received RM-131 (100 μg s.c.) or placebo and underwent scintigraphic gastric emptying (GE) and colonic filling at 6 h (CF6) of a solid-liquid meal administered 30 min postdosing. Adverse events, plasma glucose, and hormonal levels were assessed. GCSI daily diary (GCSI-DD) was completed during treatments. PK was assessed in this cohort and healthy volunteers (HVs).RESULTSAt screening, HbA(1c) was 7.2 ± 0.4% (SEM) and total GCSI-DD score was 1.32 ± 0.21. RM-131 accelerated GE t(1/2) of solids (P = 0.011); mean difference (Δ) in solid GE t(1/2) was 68.3 min (95% CI 20-117) or 66.1%. There were numerical differences in GE lag time, CF6 solids, and GE t(1/2) liquids (all P < 0.14). With a significant (P < 0.014) order effect, further analysis of the first treatment period (n = 5 per group) confirmed significant RM-131 effects on GE t(1/2) (solids, P = 0.016; liquids, P = 0.024; CF6, P = 0.013). PK was similar in DGE patients and HVs. There were increases in 120-min blood glucose (P = 0.07) as well as 30-90-min area under the curve (AUC) levels of growth hormone, cortisol, and prolactin (all P < 0.02) with single-dose RM-131. Only light-headedness was reported more on RM-131.CONCLUSIONSRM-131 greatly accelerates the GE of solids in patients with type 2 diabetes and documented DGE. PK is similar in diabetic patients and HVs.
[Show abstract][Hide abstract] ABSTRACT: Objective To report population burden of ambulance requiring hypoglycemia and long term outcomes in type 1 diabetes (T1DM) on different insulin therapeutic programs.Methods We retrieved all ambulance calls activated by T1DM for hypoglycemia in Olmsted County between 1/1/03 and 12/31/09 and reviewed medical records.Results 531 ambulance calls were made by 208 TIDM patients, age 47 ± 13 years, 54 % males. 137 (66%) were on multiple daily insulin injections (MDI), 50 (24%) on continuous subcutaneous insulin infusion (CSII), 15 (7%) on simple insulin (SI), 4 (2%) on Metformin + MDI, and 2 (1%) off treatment (post pancreas transplant). The latter 2 groups were excluded from further analysis due to small sample size. The remaining three treatments differed by age (p<0.02) with the oldest patients on SI. Repeated calls, emergency room transportation (ERT) and hospitalization was 32%, 51% and 19 % respectively, and did not differ between the treatment groups. In a multivariate model, mortality was significantly associated with treatment type [SI group had higher risk for mortality than MDI (p=0.03) after excluding 27 patients who changed treatment during follow-up], age (p<0.0001) and ERT (p=0.04).Conclusion Population burden of ambulance requiring hypoglycemia in T1DM is high. Medical resources utilization was similar among the three treatment groups. Mortality was higher in the SI group (limited by small sample size) and among ERT requiring patients and increased with age. Further research could be directed towards understanding the impact of expert evaluation of high risk patients on long term outcomes.
Full-text · Article · Jul 2012 · Endocrine Practice
[Show abstract][Hide abstract] ABSTRACT: Hypoglycemia is a cause of significant morbidity among patients with diabetes and may be associated with greater risk of death. We conducted a retrospective study to determine whether patient self-report of severe hypoglycemia is associated with increased mortality.
Adult patients (N = 1,020) seen in a specialty diabetes clinic between August 2005 and July 2006 were questioned about frequency of hypoglycemia during a preencounter interview; 7 were lost to follow-up and excluded from analysis. Mild hypoglycemia was defined as symptoms managed without assistance, and severe hypoglycemia was defined as symptoms requiring external assistance. Mortality data, demographics, clinical characteristics, and Charlson comorbidity index (CCI) were obtained from the electronic medical record after 5 years. Patients were stratified by self-report of hypoglycemia at baseline, demographics were compared using the two-sample t test, and risk of death was expressed as odds ratio (95% CI). Associations were controlled for age, sex, diabetes type and duration, CCI, HbA(1c), and report of severe hypoglycemia.
In total, 1,013 patients with type 1 (21.3%) and type 2 (78.7%) diabetes were questioned about hypoglycemia. Among these, 625 (61.7%) reported any hypoglycemia, and 76 (7.5%) reported severe hypoglycemia. After 5 years, patients who reported severe hypoglycemia had 3.4-fold higher mortality (95% CI 1.5-7.4; P = 0.005) compared with those who reported mild/no hypoglycemia.
Self-report of severe hypoglycemia is associated with 3.4-fold increased risk of death. Patient-reported outcomes, including patient-reported hypoglycemia, may therefore augment risk stratification and disease management of patients with diabetes.