Harry Glauber

Intensive Conventional Insulin Therapy for Type II Diabetes: Metabolic effects during a 6-mo outpatient trial

Objective— To determine whether tight glycemic control can be obtained using intensive conventional split-dose insulin therapy in the outpatient management of type II diabetes without development of unacceptable side effects. Research Design and Methods— Fourteen type II diabetic subjects were treated with an intensive program of conventional insulin (subcutaneous NPH and regular insulin before breakfast and supper) for 6 mo. Insulin dose adjustments were based on an algorithm built on frequent CPG measurements (4–6 times/day). Patients were monitored biweekly as outpatients and admitted 1 day/mo for metabolic evaluation. Results— Glycemic control was achieved by 1 mo (mean plasma glucose fell from 17.5 ± 0.9 to 7.7 ± 0.7 mM, P < 0.001) and remained in this range thereafter. Hypoglycemic events at 1 mo were infrequent (mean ± SE events per patient per month: 4.1 ± 0.3) and mild in nature, and progressively decreased to 1.3 ± 0.5 events/mo by 6 mo. After treatment, basal HGO fell 44% from 628 ± 44 to 350 ± 17 μmol·m−2·min−1 (P < 0.001), and maximal rates of glucose disposal measured by hyperinsulinemic euglycemic clamp (1800 pmol·m−2·min−1) improved from 1418 ± 156 to 1657 ± 128 μmol·m−2·min−1 (P < 0.05). The total dose of exogenous insulin required was 86 ± 13 U at 1 mo and 100 ± 24 U at 6 mo. During treatment, mean serum insulin levels increased from 308 ± 80 to 510 ± 102 pM (P < 0.05), while body weight increased from 93.5 ± 5.8 to 102.2 ± 6.8 kg (P < 0.001). Both pre- and posttreatment glucose disposal rates correlated with the total exogenous insulin dose required to achieve glycemic control (r = −0.75 and −0.78, both P < 0.005). Weight gain was inversely related to the pretreatment glucose disposal rate (r = −0.53, P < 0.05) and directly correlated with both mean day-long serum insulin level (r = 0.67, P < 0.01) and total exogenous insulin dose (r = 0.62, P < 0.02). Conclusions— Intensive CIT, when combined with CBG measurements, can be used to rapidly improve glycemic control in type II diabetes without development of unacceptable hypoglycemia. This degree of metabolic improvement, however, requires large doses of exogenous insulin to overcome peripheral insulin resistance and results in greater hyperinsulinemia with progressive weight gain.

Impact of cardiovascular disease on health care utilization in a defined diabetic population.

We studied the impact on annual medical care utilization and costs in 1988 of cardiovascular disease (CVD) in a population-based sample of 435 diabetic (DM) and 435 matched non-DM members of a Health Maintenance Organization. 58% of DM had at least one diagnosed CVD, compared to 26% of non-DM. 22.7% of outpatient visits, 38.7% of hospital days, and 30% of pharmacy expenditures by those with DM were primarily attributable to CVD. Up to 27% of all CABG recipients in the population had diabetes. In total, CVD directly accounted for at least 24% of total medical care costs among DM, compared to 12% of costs for non-DM. The HMO spent 4.5 times per person more on CVD care in DM than in non-DM members. Treatment with insulin was associated with increased peripheral vascular disease. After adjusting for age, CVD was more prevalent and generated longer hospital stays in DMs with nephropathy. The etiologic association between CVD and DM is well documented but CVDs clinical and economic importance in DM seems underappreciated.

Use of Health Maintenance Organization Data Bases to Study Pharmacy Resource Usage in Diabetes Mellitus

Objective To evaluate use of medications by patients with diabetes. Research Design and Methods We analyzed the computerized pharmacy data base of a large health maintenance organization to evaluate cost impact and patterns of usage for all pharmacy products by a defined population of diabetic patients. Results Diabetic patients received 31.2 dispenses/yr compared with 11.5 for control patients. Total pharmacy costs were threefold higher for diabetic patients (

An Outreach Program Improved Osteoporosis Management After a Fracture

621 vs. 207/yr) and accounted for ∼ 17% of their total health-care costs. Products specifically for the care of diabetes averaged

Impact on a population-based registry of changing diagnostic thresholds for diabetes.

175/yr or ∼ 4.5% of their total health-care costs: 57% received an oral hypoglycemic agent, 34% received insulin, and 6% received both. Cardiovascular drugs accounted for 29% of total costs. There was increased use of most classes of medication by patients with diabetes. Conclusions Health maintenance organization management data bases, particularly those storing pharmacy dispensing data, provide useful information on the impact of chronic disease. People with diabetes receive a greater number of most types of medication with a greater overall cost than do nondiabetic people. Previous studies have underestimated the contribution of pharmacy purchases to the costs of caring for a diabetic population.

Body weight versus body fat distribution, adiposity, and frame size as predictors of bone density.

This longitudinal retrospective cohort study evaluated implementation of an intervention to improve management of osteoporosis after a fracture in a nonprofit group‐model health maintenance organization (HMO) in the U.S. Pacific Northwest with 480,000 members and electronic medical record data. Participants were female HMO members aged 67 and older who sustained a qualifying clinical fracture(s) and who had not received a bone mineral density (BMD) measurement or osteoporosis treatment in the 12 months before the fracture (N=3,588). Phase 1 included outreach to clinicians and patients; Phase 2 added clinician and staff incentives. Primary outcome was “osteoporosis management”—receipt of a BMD measurement or osteoporosis medication in the 6 months after an index fracture. Before the intervention, 13.4% (95% confidence interval (CI)=12.0–14.8%) of patients had received osteoporosis management, and the time trend was not significant. Postintervention, the probability of osteoporosis management increased on average 3.1% (95% CI=2.6–3.5%) every 2 months throughout both study phases without a significant added improvement in Phase 2. Improvement varied according to clinic and was less likely for patients with dementia. Overall, the probability of osteoporosis management increased from the baseline level of 13.4% to 44.0% (95% CI=40.0–48.0%) by the end of the study period (20 months post‐intervention). The study found that an outreach program to primary care providers and patients improved the management of osteoporosis after a fracture. If widely implemented, this intervention could substantially improve the secondary prevention of osteoporosis. More‐individualized interventions may be necessary for high‐risk subgroups.

Type 2 diabetes: incremental medical care costs during the first 8 years after diagnosis.

is relatively rare, it is reasonable to assume that open wounds on the finger increase the likelihood of infection. Because of the density of nerve fibers, the finger is one of the most sensitive areas on the body. Even though narrower gauge needles have recently been introduced, in practice, these do not appear to significantly lessen pain. This is probably because greater depth of penetration is required to obtain a sufficient blood sample. We have previously reported on alternative site sampling (1) as a means to address the fear of pain that prevented many patients from adhering to their recommended SMBG regimen and confirmed the correlation with blood sampled from the fingers (2). We have had considerable experience and success with a new lancing device that enables blood samples to be obtained painlessly from sites other than fingers. The Microlet Choice (Bayer) lances the selected area and simultaneously creates a vacuum around the penetration site that enables sufficient blood to be obtained for SMBG (using one of the new generation of monitors that require low blood volume and aspirate the blood sample through capillary action). The use of this apparatus enables selection of sites that considerably lessen the chances of infection, particularly in those patients whose occupations and/or pastimes expose fingers to surfaces that could be potential sources of infection. In our clinic, the apparatus has become widely accepted for use by farmers, chemical researchers, medical professionals, housewives, typists, instrumental musicians (e.g., pianists), and patients who have peripheral neuropathy with numbness in the fingertips.