Gabriele Müller

Evaluation of a Diabetes Management System Based on Practice Guidelines, Integrated Care, and Continuous Quality Management in a Federal State of Germany : A population-based approach to health care research

OBJECTIVE—The aim of this study was to evaluate the Saxon Diabetes Management Program (SDMP), which is based on integrated practice guidelines, shared care, and integrated quality management. The SDMP was implemented into diabetes contracts between health insurance providers, general practitioners (GPs), and diabetes specialized practitioners (DSPs) unified in the Saxon association of Statutory Health Insurance Physicians. RESEARCH DESIGN AND METHODS—The evaluation of the SDMP in Germany represents a real-world study by using clinical data collected from participating physicians. Between 2000 and 2002 all DSPs and about 75% of the GPs in Saxony participated. Finally, 291,771 patients were included in the SDMP. Cross-sectional data were evaluated at the beginning of 2000 (group A1) and at the end of 2002 (group A2). A subcohort of 105,204 patients was followed over a period of 3 years (group B). RESULTS—The statewide implementation of the SDMP resulted in a change in therapeutic practice and in better cooperation. The median A1C at the time of referral to DSPs decreased from 8.5 to 7.5%, and so did the overall mean. At the end, 78 and 61% of group B achieved the targets for A1C and blood pressure, respectively, recommended by the guidelines compared with 69 and 50% at baseline. Patients with poorly controlled diabetes benefited the most. Preexisting regional differences were aligned. CONCLUSIONS—Integrated care disease management with practicable integrated quality management including collaboration between GPs and specialist services is a significant innovation in chronic care management and an efficient way to improve diabetes care continuously.

Role of glycated hemoglobin in the prediction of future risk of T2DM.

AIM The aim of this study was to assess the predictive power of glycated hemoglobin (HbA1c) for future type 2 diabetes risk. RESEARCH DESIGN AND METHODS Six hundred eighty-seven subjects who were free of type 2 diabetes mellitus (T2DM) participated in the study. Each subject received a 75-g oral glucose tolerance test at baseline and 624 received a repeat oral glucose tolerance test after 3.5 ± 0.1 yr of follow-up. Anthropometric measurements, lipid profile, and HbA1c were measured during the baseline visit. Logistic multivariate models were created with T2DM status at follow-up as the dependent variable and other parameters as the independent variables. The receiver-operating characteristic (ROC) was used to assess the predictive discrimination of the various models. RESULTS HbA1c was a significant predictor of future T2DM risk (area under the ROC curve = 0.73, P < 0.0001). A HbA1c cut point of 5.65% had the maximal sum of sensitivity and specificity. Although the area under the ROC curve of HbA1c was smaller than the area under the ROC curve of both the 1-h plasma glucose concentration and a multivariate logistic model (including anthropometric parameters, lipid profile, and fasting plasma glucose), the addition of HbA1c to both the 1-h plasma glucose and the multivariate logistic model significantly increased their predictive power. CONCLUSION Although HbA1c alone is a weaker predictor of future T2DM risk compared with the 1-h plasma glucose, it provides additive information about future T2DM risk when added to previously published prediction models.

Global Diabetes Survey—An annual report on quality of diabetes care

Adequate quality of diabetes care and the best concept for the implementation of national diabetes plans remain controversial. In September 2011 the United Nations High Level Meeting on Non Communicable Diseases agreed on a consensus that national plans for the prevention and control of diabetes should be developed, implemented and monitored. The Global Diabetes Survey (GDS) is a standardised, annual, global questionnaire that will be used to assess responses of representatives from 19 diabetes-related stakeholder groups. It was designed with the goal of generating an annual report on the quality of national diabetes care and to compare findings from different regions and countries. The findings will be freely available for everyones use and will be used to inform politicians and stakeholders to encourage the improvement of the quality of diabetes care in its medical, economical, structural and political dimensions.

Who Should We Target for Diabetes Prevention and Diabetes Risk Reduction

Screening for individual diabetes risk is crucial to identify adult and pediatric high-risk target populations for referral into successful diabetes prevention programs. Determination of impaired glucose tolerance or elevated fasting glucose levels has been the “gold standard” to classify subjects at increased risk for and/or to diagnose type 2 diabetes (T2DM). However, this led to ignoring many individuals prone to develop the disease. Therefore, using a stepped strategy consisting of a preliminary assessment of risk factors, by using risk scores such as the Finnish Diabetes Risk Score (FINDRISC) adapted to the respective population, followed by a single blood test determining blood glucose or hemoglobin A1c, respectively, or an oral glucose tolerance test is a feasible and pragmatic method to more accurately detect individuals at risk for T2DM. Inclusion of further risk factors into the assessment such as physical inactivity, waist circumference, and prenatal factors needs to be thoroughly discussed to establish a valid and reliable stepped approach applicable to real world health care. This article provides an overview of the current literature and is intentionally focused on the identification of high-risk populations (both adult and pediatric) that will help to address the key issues around the prevention of T2DM in health care settings.

Views of People With High and Low Levels of Health Literacy About a Digital Intervention to Promote Physical Activity for Diabetes: A Qualitative Study in Five Countries

Background Low health literacy is associated with poor health-related knowledge, illness self-management, health service use, health, and survival, and thus addressing issues related to low health literacy has been highlighted as a pressing international priority. Objective To explore views of a digital health promotion intervention designed to be accessible to people with lower levels of health literacy, in particular examining reactions to the interactive and audiovisual elements of the intervention. Methods Qualitative think-aloud interviews were carried out with 65 adults with type 2 diabetes in the UK, Ireland, USA, Germany, and Austria, with purposive sampling to ensure representation of people with lower levels of health literacy. Inductive thematic analysis was used to identify common themes. We then systematically compared views in subgroups based on country, health literacy level, age, gender, and time since diagnosis. Results Most participants from the chosen countries expressed positive views of most elements and features of the intervention. Some interactive and audiovisual elements required modification to increase their usability and perceived credibility and relevance. There were some differences in views based on age and gender, but very few differences relating to health literacy level or time since diagnosis. Conclusions In general, participants found the intervention content and format accessible, appropriate, engaging, and motivating. Digital interventions can and should be designed to be accessible and engaging for people with a wide range of health literacy levels.

Impact of the Triglyceride/High-Density Lipoprotein Cholesterol Ratio and the Hypertriglyceremic-Waist Phenotype to Predict the Metabolic Syndrome and Insulin Resistance

Insulin resistance is the underlying mechanism for the metabolic syndrome and associated dyslipidaemia that theoretically implies a practical tool for identifying individuals at risk for cardiovascular disease and type-2-diabetes. Another screening tool is the hypertriglyceremic-waist phenotype (HTW). There is important impact of the ethnic background but a lack of studied European populations for the association of the triglyceride/high-density lipoprotein cholesterol (HDL-C) ratio and insulin resistance. This observational, retrospective study evaluated lipid ratios and the HTW for predicting the metabolic syndrome/insulin resistance in 1932 non-diabetic individuals from Germany in the fasting state and during a glucose tolerance test. The relations of triglyceride/HDL-C, total-cholesterol/HDL-C, and low-density lipoprotein cholesterol/HDL-C with 5 surrogate estimates of insulin resistance/sensitivity and metabolic syndrome were analysed by linear regression analysis and receiver operating characteristics (ROC) in participants with normal (n=1 333) or impaired fasting glucose (n=599), also for the impact of gender. Within the lipid ratios, triglyceride/HDL-C had the strongest associations with insulin resistance/sensitivity markers. In the prediction of metabolic syndrome, diagnostic accuracy was good for triglyceride/HDL-C (area under the ROC curve 0.817) with optimal cut-off points (in mg/dl units) of 2.8 for men (80% sensitivity, 71% specificity) and 1.9 for women (80% sensitivity, 75% specificity) and fair for HTW and HOMA-IR (area under the curve 0.773 and 0.761). These data suggest the triglyceride/HDL-C ratio as a physiologically relevant and practical index for predicting the concomitant presence of metabolic syndrome, insulin resistance and dyslipidaemia for therapeutic and preventive care in apparently healthy European populations.

Assessment of small fiber neuropathy to predict future risk of type 2 diabetes.

OBJECTIVE Sudomotor dysfunction due to small fiber neuropathy can be observed very early in pre-diabetes. The aim of this study was to assess the predictive power of EZSCAN, a non invasive, quick and simple measurement of sudomotor function to identify glucose impairment. RESEARCH DESIGN AND METHODS The study was performed in 76 German subjects at risk of diabetes. Glucose metabolism was assessed by using, oral glucose tolerance test (OGTT) at baseline and after 2 year follow-up. Sudomotor function was evaluated by measuring hand and foot electrochemical sweat conductances to calculate a risk score. RESULTS At baseline, 38 patients had normal glucose tolerance (NGT), 34 had pre-diabetes (impaired fasting glucose, IFG and/or impaired glucose tolerance, IGT) and 4 had newly diagnosed type 2 diabetes. The AUC values for FPG, 2h-OGTT glucose, 1h-OGTT glucose, HbA1C and EZSCAN score to predict pre-diabetes were 0.50, 0.65, 0.64, 0.72 and 0.76, respectively. Subjects having a moderate or high EZSCAN score (>50) at baseline had a substantially increased risk for having IFG and/or IGT at follow-up visit presented by an odds ratio of 12.0 [1.4-100.5], the OR for having 1h-OGTT ≥ 8.6mmol/L at follow-up was 9.8 [1.0-92.8] and for having HbA1C ≥ 5.7% was 15.7 [1.9-131.5] compared to subjects with low EZSCAN risk. CONCLUSIONS This preliminary study, which must be confirmed in a larger population, shows that EZSCAN risk score is associated with diabetes progression which have implications for prevention and disease management.

Increased gene expression of the cardiac endothelin system in obese mice.

Obesity is a well-known risk factor of atherosclerosis and heart failure. In the human heart, a local endothelin system containing prepro-endothelin-1, endothelin-converting enzyme-1, and endothelin receptors A and B has been described. The endothelin system is activated in heart failure; however, the impact of obesity on the cardiac endothelin system is unknown. In this study, 18-week-old male C57BL/6 mice fed either a control diet or a high-fat diet for 10 weeks were analyzed. High-fat diet significantly increased the body weight of the animals and augmented low-density lipoprotein, high-density lipoprotein, and cholesterol plasma levels, compared to control. The animal groups showed no significant differences in left ventricular size or function (heart rate, ejection fraction, fractional shortening, left ventricular posterior wall thickness, cardiac output) after control or high-fat diet. We did not observe signs of cardiac hypertrophy or changes in markers of cardiac fibrosis in these heart samples. The cardiac expression of prepro-endothelin-1 mRNA, endothelin-converting enzyme-1 mRNA, and protein and endothelin receptors A and B mRNA was increased in 18-week-old obese C57BL/6 mice compared to animals with normal weight (p<0.05 vs. control). Furthermore, endothelin-1 plasma levels showed an increasing trend. In conclusion, an increased expression of genes of the endothelin system was observed in the hearts of 18-week-old mice after high-fat diet, possibly contributing to later cardiovascular complications of obesity.

Comparative analysis of diabetes self-management education programs in the European Union Member States

Diabetes self-management education (DSME) is generally considered as an integral part of diabetes care. The availability of different types of self-management in the European Union Member States (EUMS) remains uncertain. The aim of this study is to perform a comparative analysis of existing DSME programs (DSMEP) implemented in EUMS. Unpublished data regarding DSME in the EUMS was assessed with Diabetes Literacy Survey using wiki tool (WT) targeting patients and different stakeholders. An additional literature review (LR) was performed in PubMed to identify published studies regarding DSMEP in the EUMS from 2004 to 2014. A total of 102 DSMEP implemented in EUMS were reported in the WT and 154 programs were identified from the LR. Comparative analysis of the data indicated that a majority of programs are aimed at adults and only a minority at children and elderly. Only a small percentage of the programs utilize information technology for teaching and learning, and only one out of five programs pay attention to depression. The identified DSMEP aimed primarily to empower patients through increasing knowledge and changing attitudes and beliefs towards diabetes. This study provides an overview of the present state-of-the-art on diabetes self-management education programs in the 28 EUMS. To increase participation, existing DSMEP should be made more accessible to the patients as well as tailored to specific patient groups.

Non-invasive Screening of Diabetes Risk by Assessing Abnormalities of Sudomotor Function

BACKGROUND The early detection of diabetes, and subsequent lifestyle intervention, may reduce the burden of diabetes and its complications. Several studies have identified a link between sudomotor dysfunction, insulin resistance, and pre-diabetes. The aim of this study was to evaluate the ability of a new non-invasive device EZSCAN evaluating sudomotor function to detect pre-diabetes in a German population at risk for diabetes. METHODS AND FINDINGS 200 German subjects at risk for diabetes (mean age 56±14 years, BMI 28.4±5.4 kg/m2) were measured for anthropometric data on inflammatory parameters, including high sensitivity C reactive protein (hs-CRP). The subjects also underwent an oral glucose tolerance test with measurements of plasma glucose, insulin, proinsulin, C-peptide and free fatty acids during 2 h following glucose challenge. Indexes for sensitivity to insulin were calculated: SI using minimal model, HOMA-IR and Matsuda index. Based on the measurement of electrochemical sweat conductance, subjects were classified as no risk, moderate risk or high risk. According to this risk model classification, a significant difference was observed between OGTT-1 h (p=0.004), AUC glucose (p=0.011), AUC C-peptide (p<0.001), HOMA-IR (p=0.009), Matsuda (p=0.002), SI (p<0.001) and hs-CRP (p=0.025) after adjustment for age. Among the 54 subjects with impaired fasting glucose or impaired glucose tolerance according to WHO classification, 37 had a moderate risk and 15 a high risk according to the EZSCAN risk model classification. Among the 12 subjects with newly diagnosed diabetes, 2 had a moderate risk and 10 a high risk according to the risk model classification. No adverse event was reported during or after the study. CONCLUSIONS These results, in accordance with a previous study performed in India, show that EZSCAN could be developed as a screening tool for diabetes risk, and could help to improve diabetes screening strategies. Results obtained from an at-risk population would have to be confirmed in a larger population.