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Current Diabetes Reviews
ISSN: 1573-3998
Current Diabetes Reviews
Volume 3, Number 4, November 2007
Contents
Translating Clinical Evidence into the Practice of
Diabetes Care
Guest Editor: Richard W. Grant
Editorial Pp. 217
Diabetes and the Chronic Care Model: A Review Pp.
219-225
Eric J. Warm
[Abstract]
Interventions to Support Diabetes Self-Management:
The Key Role of the Patient in Diabetes Care Pp.
226-228
Jim Nuovo, Thomas Balsbaugh, Sue Barton, Ronald Fong,
Jane Fox-Garcia, Bridget Levich and Joshua J. Fenton
[Abstract]
Connected Health: A New Framework for Evaluation of
Communication Technology Use in Care Improvement Strategies
for Type 2 Diabetes Pp. 229-234
Anshul Mathur, Joseph C. Kvedar and Alice J. Watson
[Abstract]
Re-Centering Diabetes Care through Community: The
iHealthSpace Example Pp. 235-238
Jeanhee Chung, Stephanie Eisentstat, Evan Pankey and Henry
Chueh
[Abstract]
Inpatient Diabetes Management in Non-ICU Settings:
Evidence and Strategies Pp. 239-243
Deborah J. Wexler and Enrico Cagliero
[Abstract]
Patient, System and Clinician Level Interventions
to Address Disparities in Diabetes Care Pp. 244-248
Arleen F. Brown
[Abstract]
The Interaction of Depression and Diabetes: A Review
Pp. 249-251
Paul A. Pirraglia and Smita Gupta
[Abstract]
A Review of the Evidence for a Neuroendocrine Link
Between Stress, Depression and Diabetes Mellitus
Pp. 252-259
Sherita Hill Golden
[Abstract]
Appropriate Application of Evidence to the Care of
Elderly Patients with Diabetes Pp. 260-263
Elbert S. Huang
[Abstract]
General Articles
The ATP-Binding Cassette Transporter Subfamily A Member 1
(ABC-A1) and Type 2 Diabetes: An Association Beyond HDL Cholesterol
Pp. 264-267
Carlos A. Aguilar Salinas, Ivette Cruz-Bautista, Roopa
Mehta, Ma T. Villarreal-Molina, Francisco J. G. Pérez,
Ma T. Tusié-Luna and Samuel Canizales-Quinteros
[Abstract]
Insulin Resistance and Postprandial Hyperglycemia
the Bad Companions in Natural History of Diabetes: Effects
on Health of Vascular Tree Pp. 268-273
Clara Di Filippo, Mario Verza, Ludovico Coppola, Francesco
Rossi, Michele D’Amico and Raffaele Marfella
[Abstract]
The Association Between Low Fasting Blood Glucose
Value and Mortality Pp. 274-279
Per E. Wändell and Holger Theobald
[Abstract]
The Effectiveness of Nurse- and Pharmacist-Directed Care in
Diabetes Disease Management: A Narrative Review Pp.
280-286
Mayer B. Davidson
[Abstract]
Abstracts
[Back to top]
Editorial
Translating Clinical Evidence into the Practice of
Diabetes Care
Hand-in-hand with obesity, the type 2 diabetes epidemic has
become a major health problem in both developed and developing
countries, with the estimated number of cases increasing from
170 million to 366 million worldwide by 2030 [1,2]. In the
US, diabetes is the 6th leading cause of death and in some
race/ethnic groups the predicted chance of developing diabetes
among children born today is 40% [3, 4].
Proportionate with its impact on society, diabetes has also
been the focus of years of both basic and clinical research.
In particular, some of the most groundbreaking and important
randomized controlled trials have been conducted among patients
with diabetes. From the venerable UKPDS and DCCT studies to
a plethora of cardiology trials, the evidence base for managing
diabetes is considerable [5-10]. And the drug development
process continues to yield new therapies from novel drug classes
designed to treat the underlying pathophysiology of diabetes
and associated metabolic derangements [11,12].
In the United States, an estimated 5.6% of total health expenditures
are spent on biomedical research, more than any other country
[13]. However, less than 0.1% of this effort is devoted to
health services research. Measured another way, less than
1 cent is spent on evaluating health care delivery for every
dollar spent on health care. Given this relative lack of funding
for research specifically aimed at translating and implementing
clinical advances into more effective clinical care, it should
come as no surprise that most people with diabetes remain
poorly controlled. In the U.S., fewer than 40% of patients
with diabetes have HbA1c levels below goal and fewer than
5% meet all evidence-based goals of care [14-16].
Although future and ongoing scientific research developments
hold tremendous promise for patients with diabetes, the fact
remains that more effective use of existing therapies will
have a much greater impact on diabetes control [17]. For example,
as described by Woolf and Johnson in their seminal analysis
“The Break-Even Point: When Medical Advances are less
Important than Improving the Fidelity with which they are
Delivered”, the next generation of cholesterol-lowering
drugs would have to be three times more potent than today's
statins to deliver the same population health benefits that
would occur if everyone who currently needed a statin was
prescribed one and took it regularly [18].
The barrier between clinical evidence and clinical practice
has been described as a “quality chasm” by the
Institute of Medicine [19]. Overcoming this barrier between
evidence and practice is the goal of translation research.
In this special issue of Current Diabetes Reviews,
leading translational researchers review the current evidence
for changing current diabetes care. This issue begins with
a review of the Chronic Care Model as a conceptual framework
for understanding the role of clinical care systems, clinicians,
and patients in the process of diabetes management. The next
four papers review specific elements within this framework:
1) Interventions to support patient self-management 2) Interventions
using Health Information Technology, 3) The role of patient/provider
communities linked via electronic personal health
records, and 4) The transition between in-patient and outpatient
care.
The remainder of the issue focuses on the unique barriers
faced by specific patient groups. Professor Arlene Brown addresses
the role of race/ethnic disparities in diabetes care with
an emphasis on patients, clinicians, health systems, and communities.
Additional articles review the role of depression in diabetes,
the link between neuroendocrine activity and diabetes, and
how to apply the current evidence base to elderly patients
with diabetes. This last topic introduces the key concept
that translating evidence into practice requires a sophisticated
understanding of the risks and benefits of therapy and discourages
the notion of “one-size-fits-all” algorithmic
medicine for this complex disease.
Ultimately, interventions to improve outpatient diabetes management
must be time-saving for busy clinical practices, affordable
to ensure that they can be disseminated widely, and generalizable
so that they can be used by clinicians with varying practice
styles and with access to different resources. Achieving these
goals will require rigorous research that investigates new
interventional strategies to overcome social, system, clinician,
and patient-level barriers to evidence-based diabetes care.
Advances in this realm offer the potential for clinical benefits
that far outweigh the current impact of new scientific advances
[20,21].
REFERENCES
[1] Manson JE, Skerrett PJ, Greenland P, VanItallie TB. The
escalating pandemics of obesity and sedentary lifestyle: a
call to action for clinicians. Arch Intern Med 2004; 164:
249-58.
[2] Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence
of diabetes: estimates for the year 2000 and projections for
2030. Diabetes Care 2004; 27: 1047-53.
[3] Gu K, Cowie CC, Harris MI. Mortality in adults with and
without diabetes in a national cohort of the U.S. population,
1971-1993. Diabetes Care 1998; 21(7): 1138-45.
[4] Engelgau MM, Geiss LS, Saaddine JB, et al. The
evolving diabetes burden in the United States. Ann Intern
Med 2004; 140: 945-50.
[5] UK Prospective Diabetes Study (UKPDS) Group. Intensive
blood-glucose control with sulphonylureas or insulin compared
with conventional treatment and risk of complications in patients
with type 2 diabetes (UKPDS 33). Lancet 1998; 352(9131): 837-53.
[6] The Diabetes Control and Complications Trial Research
Group. The effect of intensive treatment of diabetes on the
development and progression of long-term complications in
insulin-dependent diabetes mellitus. N Engl J Med 1993; 329(14):
977-86.
[7] Curb JD, Pressel SL, Cutler JA, et al. Effect
of diuretic-based antihypertensive treatment on cardiovascular
disease risk in older diabetic patients with isolated systolic
hypertension. Systolic Hypertension in the Elderly Program
Cooperative Research Group. JAMA 1996; 276(23): 1886-92.
[8] Pyorala K, Pedersen TR, Kjekshus J, Faergeman O, Olsson
AG, Thorgeirsson G. Cholesterol lowering with simvastatin
improves prognosis of diabetic patients with coronary heart
disease. A subgroup analysis of the Scandinavian Simvastatin
Survival Study (4S). Diabetes Care 1997; 20(4): 614-20.
[9] Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais
G. Effects of an angiotensin-converting-enzyme inhibitor,
ramipril, on cardiovascular events in high-risk patients.
The Heart Outcomes Prevention Evaluation Study Investigators.
N Engl J Med 2000; 342(3): 145-53.
[10] Gaede P, Vedel P, Larsen N, Jensen GVH, Parving HH, Pedersen
O. Multifactorial intervention and cardiovascular disease
in patients with type 2 diabetes. N Engl J Med 2003; 348:
383-93.
[11] Lebovitz HE. Therapeutic options in development for management
of diabetes: pharmacologic agents and new technologies. Endocrine
Practice 2006; 12: 142-147.
[12] Bloomgarden ZT. Gut-Derived Incretin Hormones and New
Therapeutic Approaches. Diabetes Care 2004; 27(10):
2554-2559.
[13] Moses H, Dorsey ER, Matheson DHM, Their SO. Financial
Anatomy of Biomedical Research. JAMA 2005; 294: 1333 -1342.
[14] McGlynn EA, Asch SM, Adams J, et al. The Quality of Health
Care Delivered to Adults in the United States. N Engl J Med
2003; 348: 2635-45.
[15] Saydah SH, Fradkin J, Cowie CC. Poor control of risk
factors for vascular disease among adults with previously
diagnosed diabetes. JAMA 2004; 291(3): 335-42.
[16] Beckles GL, Engelgau MM, Narayan KM, Herman WH, Aubert
RE, Williamson DF. Population-based assessment of the level
of care among adults with diabetes in the U.S. Diabetes Care
1998; 21(9): 1432-8.
[17] Brown JB, Nichols GA, Perry A. The Burden of Treatment
Failure in Type 2 Diabetes. Diabetes Care 2004; 27(7): 1535-40.
[18] Woolf SH, Johnson RE. The break-even point: when medical
advances are less important than improving the fidelity with
which they are delivered. Ann Fam Med 2005; 3(6): 545-52.
[19] Crossing the Quality Chasm: A New Health System for the
21st Century Health Care Services. Washington, D.C. National
Academy Press; 2001.
[20] Narayan KM, Benjamin E, Gregg EW, Norris SL, Engelgau
MM. Diabetes translation research: where are we and where
do we want to be? Ann Intern Med 2004; 140(11): 958-63.
[21] Garfield SA, Malozowski S, Chin MH, et al. Considerations
for diabetes translational research in real-world settings.
Diabetes Care 2003; 26(9): 2670-74.
Richard W. Grant, MD MPH
50-9 Staniford St., Boston
MA 02114
USA
Tel: 617-724-3502
Fax: 617-724-3544
E-mail: Rgrant@partners.org
[Back to top]
Diabetes and the Chronic Care Model: A Review
Eric J. Warm
There is a significant gap between evidenced-based diabetes
care and actual care delivery. The Chronic Care Model (CCM)
was developed to bridge this gap and translate scientific
knowledge directly to the care of patients. The CCM is a primary
care based framework that identifies the essential elements
of high quality chronic disease care. It includes attention
to self-management support, delivery system design, decision
support, information technology, community linkages, and the
health care organization as a whole. This review will describe
these elements and provide evidence for their use in improving
diabetes care. Evidence for the CCM as a whole will also be
presented.
[Back to top]
Interventions to Support Diabetes Self-Management:
The Key Role of the Patient in Diabetes Care
Jim Nuovo, Thomas Balsbaugh, Sue Barton, Ronald Fong,
Jane Fox-Garcia, Bridget Levich and Joshua J. Fenton
More so than most other diseases, effective control of type
2 diabetes (DM) requires that patients are actively engaged
in the self-management of their health. In this paper we define
and characterize the elements of self-management and review
the published literature for the evidence of the benefit of
interventions that support patient self-management.
[Back to top]
Connected Health: A New Framework for Evaluation of
Communication Technology Use in Care Improvement Strategies
for Type 2 Diabetes
Anshul Mathur, Joseph C. Kvedar and Alice J. Watson
Current methods of analyzing the use of communication technologies
in diabetes care improvement programs are limited by a poor
understanding of the impact of technology on the delivery
of care. We applied a standardized methodology using a functional
framework to analyze 14 diabetes care improvement programs
that used communications technology. Controlled trials and
observational studies were selected after searching 5 electronic
databases to identify care improvement programs for type 2
diabetes that used communications technology in the past 10
years with greater than 10 subjects. A 3-stage framework was
used to analyze intervention elements: 1) functional components,
2) structural components, and 3) level of automation in program
design. Using this methodology we found marked variability
in operational design of programs and poor rationalization
of choice of outcome metrics with program components. Although
11 of 14 studies showed significant declines in HbA1c, our
analysis indicated that the causal pathways remain unclear.
Recent systematic reviews have highlighted the difficulties
in evaluating communication technology use in diabetes. The
functional framework presented in this review provides a systems
approach to the problem and represents a standardized methodology
for analyzing communications technology use in diabetes care.
[Back to top]
Re-Centering Diabetes Care through Community: The
iHealthSpace Example
Jeanhee Chung, Stephanie Eisentstat, Evan Pankey and Henry
Chueh
Wagner’s modern construct for chronic care recognizes
the primacy of ‘productive interactions’ among
the patient, their personal community and the care provider
team. No longer the only locus of care, the health system
should operate within the context of and have access to the
people and resources of the larger community involved in the
patient’s care. Shared medical visits in the care of
patients with diabetes serve as a model for collaborative
care inclusive of the patient community in complex
chronic disease management. We describe the design considerations
for a web-based personal health application iHealthSpace
enabling multi-faceted connectivity and collaborative services
needed to support shared medical visits for patients with
diabetes in a large academic practice.
[Back to top]
Inpatient Diabetes Management in Non-ICU Settings:
Evidence and Strategies
Deborah J. Wexler and Enrico Cagliero
The epidemic of diabetes and results from several recent trials
demonstrating the benefits of intensive glycemic control in
the ICU setting have focused attention on inpatient glycemic
control on general hospital wards, where over 25% of patients
have diabetes. Current management of inpatient glycemia is
haphazard, relying on corrective doses of insulin after hyperglycemia
has occurred (the insulin “sliding scale”). Although
data to guide evidence-based management of inpatient glycemia
in non-critically ill patients are scant, the American College
of Endocrinology and the American Diabetes Association have
advocated more intensive therapy in the general inpatient
setting, and the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) has followed suit, launching an initiative
on inpatient glycemic control. Extrapolation from basic and
clinical studies suggests that improved diabetes management
in general medical settings is likely to be beneficial, though
the appropriate intensity of glycemic control in non-ICU settings
has yet to be determined. Independent of the acute impact
of inpatient glycemia, inpatient diabetes management is also
important because hospitalization offers an opportunity to
optimize care upon discharge for patients with poorly controlled
diabetes. Finally, systems-level strategies likely to improve
inpatient diabetes management are reviewed.
[Back to top]
Patient, System and Clinician Level Interventions
to Address Disparities in Diabetes Care
Arleen F. Brown
Type 2 diabetes disproportionately affects socially disadvantaged
groups, including racial and ethnic minority groups and low
income and less educated persons [1-7]. Although effective
therapies are available for managing diabetes and preventing
or treating its complications, these therapies are underutilized,
particularly among these socially disadvantaged groups [8-10].
Social disadvantage may affect diabetes outcomes through a
number of different pathways, including access to care, the
quality of care received, psychosocial characteristics, and
neighborhood or community factors [11]. Because of the high
prevalence of diabetes in socially disadvantaged persons,
interventions to reduce racial/ethnic and social disparities
in health may have a profound impact on the morbidity and
mortality associated with diabetes. In this review, we will
discuss evidence on interventions at the individual, provider,
health care system, and community levels that have the potential
to reduce diabetes disparities and highlight gaps in our understanding
of social disparities and health for persons with diabetes.
[Back to top]
The Interaction of Depression and Diabetes: A Review
Paul A. Pirraglia and Smita Gupta
Depression is a severe medical illness that can interfere
with an individual’s self-care behaviors. Depression
is prevalent [1], burdensome [2], treatable [3], and costly
[4]. Recognizing depression in diabetic individuals is critical
because depression may play a role in worse control of diabetes
and worse diabetes outcomes [5-10]. Depression also appears
to increase the costs associated with treating diabetes [11].
A number of clinical trials have recently focused on whether
treatment of depression can lead to improved diabetes outcomes
[12-15]. In this review, we examine the present state of knowledge
on the interaction of depression and diabetes, discuss the
epidemiologic and physiologic evidence for the co-occurrence
of these conditions, and describe the ways in which diabetes
control is worsened by depression, how depression interferes
with diabetes care, and how depression acts to increase costs
in diabetics. We focus specifically on interventions to treat
depression in patients with diabetes and suggest areas of
future research and practice with respect to improving care
and outcomes those suffering in the intersection of these
diseases.
[Back to top]
A Review of the Evidence for a Neuroendocrine Link
Between Stress, Depression and Diabetes Mellitus
Sherita Hill Golden
Obesity and type 2 diabetes continue to be major public health
burdens with type 2 diabetes rising in epidemic proportions.
Since known risk factors do not explain all of the variance
in the population, it is important to identify novel risk
factors that can lead to development of new preventive measures.
Chronic psychological stress and depression are associated
with type 2 diabetes but the mechanism remains unclear. Neuroendocrine
changes induced by these stressors, specifically activation
of the hypothalamic-pituitary-adrenal (HPA) axis and sympathetic
nervous system (SNS), might provide a unifying explanation.
The objectives of this review are (1) to summarize the metabolic
impact of HPA axis and SNS dysfunction induced by depression
and stress, (2) to summarize the relation of neuroendocrine
parameters to risk factors for diabetes, (3) to discuss the
limitations of assessing neuroendocrine function in population-based
and intervention studies, and (4) to summarize the evidence
of the impact of stress reduction, by cognitive behavior therapy
(CBT), on neuroendocrine factors and on outcomes in diabetes
and obesity.
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Appropriate Application of Evidence to the Care of
Elderly Patients with Diabetes
Elbert S. Huang
Modern diabetes care may benefit a significant proportion
of adults living with diabetes; however, these benefits may
not be consistently realized among the heterogeneous subpopulation
of elderly patients over 65 years of age. There are three
clinical constraints that have been proposed as important
considerations for individualizing diabetes care among elderly
patients. Life expectancy should be an important determinant
of the intensity of glucose control because intensive control
has been found to prevent complications only after extended
periods of treatment. Therefore, patients with limited life
expectancy may not benefit from intensive glucose control.
The time and attention of health care providers should also
be considered a constrained resource that can be optimally
allocated to care for elderly diabetes patients. In the face
of multiple chronic conditions and symptomatic complaints,
patients and their providers should prioritize diabetes care
within the context of a patient’s overall health care
plan. The complexity of chronic medications or polypharmacy
is the final clinical constraint. Polypharmacy may increase
the probability of adverse drug events and represent a significant
burden on quality of life. More direct clinical investigation
of elderly diabetes patients will be needed if we are to truly
improve the quality of life of this growing subpopulation.
[Back to top]
The ATP-Binding Cassette Transporter Subfamily A Member 1
(ABC-A1) and Type 2 Diabetes: An Association Beyond HDL Cholesterol
Carlos A. Aguilar Salinas, Ivette Cruz-Bautista, Roopa
Mehta, Ma T. Villarreal-Molina, Francisco J. G. Pérez,
Ma T. Tusié-Luna and Samuel Canizales-Quinteros
Recent findings from several groups demonstrate that ABC-A1
participates in the pathogenesis of the metabolic syndrome
and type 2 diabetes. A variant of the ABC-A1 gene (R230C)
is associated with the metabolic syndrome and its co-morbidities
in Mexicans. Its presence is associated with an increased
risk for obesity, the metabolic syndrome and type 2 diabetes.
R230C is found exclusively in Amerindian and Amerindian-derived
populations. Moreover, animal models confirm the participation
of ABC-A1 in the pathogenesis of diabetes. Mice lacking AbcA1
specifically in beta cells had glucose intolerance at 8 weeks
of age. The absence of ABC-A1 led to cholesterol accumulation
within the beta cell plasma membrane, suggesting that cholesterol
may play a role in the insulin secretory pathway. In conclusion,
ABC-A1 may be more than a determinant of HDL-cholesterol.
It may provide a link between components of the metabolic
syndrome and atherosclerosis.
[Back to top]
Insulin Resistance and Postprandial Hyperglycemia
the Bad Companions in Natural History of Diabetes: Effects
on Health of Vascular Tree
Clara Di Filippo, Mario Verza, Ludovico Coppola, Francesco
Rossi, Michele D’Amico and Raffaele Marfella
In diabetic patients the incidence of cardiovascular diseases
(CVD) is higher compared with those without diabetes. This
elevated incidence may be due to an increased prevalence of
established risk factors, such as obesity, dyslipidemia and
hypertension. However, several other determinants must be
considered. Attention must be paid to the role that specific
factors strictly related to diabetes, insulin-resistance and
post-prandial hyperglycemia, play in the etiopathogenesis
of CVD, as for example atherosclerosis. This review acknowledges
the incidence of diabetes on cardiovascular diseases and atherosclerosis
from endothelial dysfunction to plaque destabilization, suggesting
that insulin resistance and postprandial hyperglycemia should
be considered keys in the generation of these worst diabetic
cardiovascular outcomes. It finds in hyperglycemia the primum
movens that mediates the cascade of vascular damaging events
from the beginning of ROS formation to plaque rupture, through
increased inflammation. It also adds insights of why diverse
therapeutic interventions, which have in common the ability
to reduce oxidative stress and inflammation, can impede or
delay the onset of complication of atherosclerosis in diabetic
patients.
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The Association Between Low Fasting Blood Glucose
Value and Mortality
Per E. Wändell and Holger Theobald
Earlier studies and reviews have shown an association between
high fasting blood glucose levels (FBG) and increased mortality.
Less is known about the association between low FBG and mortality.
This study aimed at reviewing the literature on this topic.
A search was performed primarily of Medline through PubMed,
and secondarily by searching other databases and using the
information from articles already found. Altogether 5 articles
meeting the quality demands of the search were found, all
supporting the association between low FBG and increased all-cause
mortality, with multivariate adjusted hazard ratios between
1.2 and 3.2. Another 22 articles not fulfilling the quality
criteria were studied, and actually no study contradicted
this association. Most studies were focused on the relation
between high FBG and mortality, and did not analyze the association
between low FBG and mortality specifically, hence explaining
the low number of conclusive articles focusing on this. Thus
we conclude, that low FBG is associated with increased mortality,
but the cause of this association is unclear. We hypothesize,
that low FBG could be a marker of low fat-free mass and low
nutrition intake. This topic needs further studies.
[Back to top]
The Effectiveness of Nurse- and Pharmacist-Directed Care in
Diabetes Disease Management: A Narrative Review
Mayer B. Davidson
People with diabetes have a marked increase in morbidity and
mortality. The American Diabetes Association has recommended
evidence-based process and outcome measures to improve diabetes
care. However, these are not met in the majority of patients
under our current medical care system. There have been many
(mostly unsuccessful) approaches to improving these outcomes
including reminding patients about appointments, feeding back
information on the patient to the physician, even when specific
treatment recommendations for the individual patient were
included, case management (when the case manager could not
make treatment decisions), education of physicians and multifaceted
quality improvement interventions in the practice setting.
One approach has consistently been successful; case management
when a nurse or pharmacist had the authority to make independent
treatment decisions. In randomized clinical trials, Hb A1c
levels were lowered approximately three times as much by nurses
or pharmacists following approved detailed treatment algorithms
(under the supervision of a physician) compared to usual care.
Given the approaching epidemic of diabetes, our medical care
system should strongly consider this approach to improving
diabetes care to forestall the devastation of diabetic complications
and the overwhelming costs of caring for these patients.
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