Viktor Jörgens

Patient education as the basis for diabetes care in clinical practice and research

Despite the obvious improvements made in the field of diabetes therapy during this century [1] the quality of diabetes care has, in general, remained poor. The widespread failure to acknowledge the impact of patient education appears to evolve as the primary reason for this unsatisfactory situation. Despite the firm and well founded recommendations put forward by some of the pioneers of modem diabetology, e.g. Drs. E.P.Joslin and R.D. Lawrence in the 1920s, it has taken almost 50 years for the beneficial effects of patient education to have finally and unequivocally been proven. The recently developed strategies for a global approach to diabetes therapy which combines biomedical, psychosocial and educational elements represents an exemplary therapeutic model for the care of many chronic diseases.

Evaluation of an intensified insulin treatment and teaching programme as routine management of Type 1 (insulin-dependent) diabetes

SummaryIt has been questioned whether aiming at near-normoglycaemia by intensified insulin treatment regimens is feasible and safe for the majority of patients with insulin-dependent diabetes. In this study, intensified insulin injection therapy (including blood glucose self-monitoring and multiple insulin injections) based upon a 5-day inpatient group teaching programme was evaluated in Type 1 (insulin-dependent) diabetes mellitus in the centralised health care system of Bucharest. One hundred patients (group A, initial HbA1 12.5%) were followed for 1 year on their standard therapy (individual teaching, no metabolic self-monitoring), and thereafter for 1 year on intensified therapy. Another 100 patients (group B, HbA1 12.3%) were followed for 2 years on intensified therapy. A third 100 patients (group C, HbA1 11.7%) were assigned to a basic 4-day inpatient group teaching programme with conventional insulin therapy (including self-monitoring of glucosuria and acetonuria) and followed for 1 year. Mean HbA1 remained unchanged after standard treatment (group A: 12.8% at 12 months), but decreased during intensified therapy (group A: 10.1% at 24 months; group B: 9.3% at 12 months, 9.5% at 24 months; p<0.0001). In group C, no change was found compared to standard treatment (i.e. group A at 12 months). Incidence rates of ketoacidosis were 0.16 episodes per patient per year during standard treatment, 0.01 during intensified treatment (p<0.01) and 0.04 in group C (p<0.025). Hospitalisation rates were reduced by 60% during intensified therapy and by 40% in group C. Frequency of severe hypoglycaemia was not significantly different between the three treatment regimens. Thus, under the condition that insulin treatment is based upon a structured and comprehensive training of the patient, intensified insulin injection therapy performed as routine treatment of Type 1 diabetes significantly lowers HbA1 levels without increasing the risk of severe hypoglycaemia.

EVALUATION OF A STRUCTURED TREATMENT AND TEACHING PROGRAMME ON NON-INSULIN-DEPENDENT DIABETES

A structured treatment and teaching programme for non-insulin-treated non-insulin-dependent (type 2) diabetes was evaluated prospectively in general practice. The four group sessions were mainly conducted by paramedical personnel. 65 patients from five general practices were assessed at the start of the programme and 50 (mean age 65 years, diabetes duration 7 years) completed the 1 year follow-up (intervention group). The control group consisted of 49 patients (mean age 63 years, diabetes duration 7 years) from three other general practices without the programme. In the intervention group the percentage of patients receiving sulfonylureas fell from 68% at the start of the study to 38% after 1 year (mean difference 30%, 95% confidence interval [CI] 16-44%); the mean weight loss was 2.7 kg (95% CI 1.6-3.8 kg), and non-fasting triglycerides were reduced by 0.77 mmol/1 (95% CI 0.35-1.19 mmol/l); and glycosylated haemoglobin remained unchanged (7.1% of total haemoglobin). In the control group none of these indices was changed during the study year, and 10% of patients started insulin treatment. The structured treatment and teaching programme improved the overall quality of patient care in elderly non-insulin-dependent diabetic patients treated by general practitioners.

Cigarette Smoking and Progression of Retinopathy and Nephropathy in Type 1 Diabetes

The objective of the present study was to analyse the association between cigarette smoking and progression of retinopathy and nephropathy, respectively, in a prospective multicentre study including 636 people with Type 1 diabetes: 81 % of the original cohort of consecutively referred patients, aged 15 to 40 years and free of severe late diabetic complications. At baseline, all patients had participated in a 5‐day in‐patient group treatment and teaching programme for intensification of insulin therapy. Patients were examined at recruitment, and after 1, 2, 3 and 6 years including assessment of smoking status, blood pressure, metabolic control, and degree of nephropathy. Degree of retinopathy was assessed by ophthalmoscopy or fundus photography at baseline and after 6 years. Several logistic regression analyses were performed by describing the responses retinopathy and nephropathy, respectively, either as progression yes/no or as actual status at the 6‐year follow‐up and by using different measures for smoking. Adjustments for important covariables were made. While significant associations between smoking, and retinopathy and nephropathy respectively, were found, the relations were variable depending on the statistical model used. The results show that the real associations between smoking and retinopathy and nephropathy are complex and that more emphasis should be put on the complete description of the response variables and the statistical models used in clinical and epidemiological research.

Predictors of Glycaemic Control in Type 1 Diabetic Patients after Participation in an Intensified Treatment and Teaching Programme

The aim of the study was to identify predictors of long‐term glycaemic control in Type 1 diabetic patients after participation in an intensified insulin treatment and teaching programme. The study population consisted of 697 Type 1 diabetic patients (mean age 26 ± 7 (SD) years, duration of diabetes 8 ± 7 years) who participated in the same structured intensified insulin treatment and teaching programme in 10 hospitals and who were re‐examined after 1, 2, and 3 years. Multiple and logistic regression analyses were performed including a set of demographic, disease‐related, social, and psychosocial variables as potential predictors. As dependent variables the average HbA1 values during the 3‐year follow‐up period and a composite variable (average HbA1 values/frequency of severe hypoglycaemia)—dividing patients into three groups with good, moderate or poor metabolic control—were considered. Regression analysis of average HbA1 values revealed significance (p <0.05) for seven independent predictors in descending order: smoking, age at onset of diabetes, frequency of home blood glucose monitoring, socioeconomic status, diabetes‐related knowledge, perceived coping abilities, and sex (R2 (percentage of variation explained by the model) = 17%). In a second regression model, HbA1 values before the intervention programme were added to the model and achieved the highest standardized regression coefficient (0.38), increasing R2 to 29%. In the logistic regression models considering both HbA1 and severe hypoglycaemia as a composite dependent variable, diabetes‐related knowledge, HbA1 values before the intervention, smoking, perceived coping abilities, age at onset of diabetes, and C‐peptide levels were the strongest predictors of glycaemic control. In conclusion, the relationship between demographic, disease‐related, psychosocial, and social variables and metabolic control is complex. Therefore, simplistic concepts of linear causality should be abandoned. In addition to HbA1 values before the intervention, smoking, diabetes‐related knowledge, home blood glucose monitoring, age at onset of diabetes, perceived coping abilities and C‐peptide levels were the most significant and consistent predictors of glycaemic control.

Effective and safe translation of intensified insulin therapy to general internal medicine departments

SummaryUp to now all published experience with intensified insulin therapy has originated from specialized diabetes centres. However, even in diabetes centres and under research conditions intensification of insulin therapy may substantially increase the risk of severe hypoglycaemia. The aim of the present study was to demonstrate the feasibility of effectively and safely transfering intensified insulin therapy based upon a 5-day in-patient treatment and teaching programme from a University diabetes centre to non-specialized general hospitals. A total of nine general hospitals were recruited; the University diabetes centre served as a reference centre. From each general hospital a nurse and a dietitian were trained as diabetes educators, and a diabetes unit with about 10 beds was organized within each department of internal medicine. A total of 697 consecutively admitted Type 1 (insulin-dependent) diabetic patients (age 26±7 years, duration of diabetes 8±7 years) who participated in the programme either in one of the general hospitals (n=579) or in the reference centre (n=118) were re-examined after 1, 2 and 3 years. Insulin therapy was intensified to a similar extent in the reference centre and the general hospitals: at the 3-year follow-up about 80% of the patients injected insulin at least three times daily or used continuous subcutaneous insulin infusion (10%), and about 70% reported measuring blood glucose levels more than twice per day. HbA1 levels were lowered (p<0.0001) to comparable levels, i. e. from 10.6 % (reference centre) and 9.9 % (general hospital), respectively, at baseline to 9.4 % and 9.3 %, respectively, at the 3-year follow-up. The yearly incidence rates of severe hypoglycaemia decreased from 0.23 (reference centre) and 0.29 (general hospitals), respectively, during the year before intensification of insulin therapy, to 0.19 (NS) and 0.12 (p<0.005), respectively, during the third year of follow-up. Days spent in hospital were reduced in both groups (from 11 and 7 days per patient per year, respectively, to 5 and 4 days, respectively, p<0.0001). In conclusion, this study shows that intensified insulin therapy based upon a structured and comprehensive training of the patients by diabetes educators can be effectively and safely translated from a specialized University diabetes centre to general medicine departments.

Social status and the quality of care for adult people with type I (insulin-dependent) diabetes mellitus--a population-based study.

Summary The objective of this study was to assess the degree of diabetes care and education achieved for Type I (insulin-dependent) diabetes mellitus at the community level in relation to social status and to elucidate potential pathways that mediate any social class gradient. A population-based sample of 684 adults with Type I diabetes (41 % women, mean ± SD age 36 ± 11, diabetes duration 18 ± 11 years) in the district of North-Rhine (9.5 million inhabitants), Germany, were examined in their homes using a mobile ambulance. Results: HbA1c (normal 4.3–6.1 %) 8.0 ± 1.5 %, incidence of severe hypoglycaemia (injection of glucose or glucagon) 0.21 cases per patient-year; 62 % of patients had participated in a structured group treatment and teaching programme for intensification of insulin therapy; 70 % used 3 or more insulin injections per day, 9 % were on continuous subcutaneous insulin infusion; 91 % reported to have had measurements of HbA1c during the preceding year, and 80 % to have had an examination of the retina by an ophthalmologist. Care was insufficient with respect to the quality of blood pressure control (70 % of patients on antihypertensive drugs had blood pressure values ≥ 160/95 mmHg), patient awareness of proteinuria/albuminuria (27 % of patients had not heard about it) and prevention of foot complications (only 42 % with a diabetes duration over 10 years had remembered to have a foot examination during the preceding 12 months). There was a pronounced social gradient with respect to micro- and macrovascular complications (prevalence of overt nephropathy 7 vs 20 % for highest vs lowest quintiles of social class [OR 3.5, 95 % CI 1.6–7.5, p = 0.002]) and diabetes-specific quality of life. HbA1c, blood pressure and smoking accounted for part of the association between social class and microvascular complications. The social class gradient was not due to inequality to access to health services, but to lower acceptance among low social class patients of preventive and health maintaining behaviour. In conclusion, achieved standards of care are high with respect to the implementation of intensified treatment regimens, the level of patient education achieved, treatment control and eye care, whereas areas for improvement are blood pressure control and preventive measures for foot care. A substantial social gradient in diabetes care persists despite equal access of patients to health services. [Diabetologia (1998) 41: 1139–1150]

Effectiveness and cost-benefit analysis of intensive treatment and teaching programmes for Type 1 (insulin-dependent) diabetes mellitus in Moscow—blood glucose versus urine glucose self-monitoring

SummaryIn a prospective controlled trial the effects of a 5-day in-patient treatment and teaching programme for Type 1 (insulin-dependent) diabetes mellitus on metabolic control and health care costs were studied in Moscow. Two different intervention programmes were compared, one based upon urine glucose self-monitoring (UGSM, n = 61) and one using blood glucose selfmonitoring (BGSM, n = 60). Follow-up was 2 years. A control group (n = 60) continued the standard treatment of the Moscow diabetes centre and was followedup for 1 year. Costs and benefits with respect to hospitalizations and lost productivity (according to average wage) were measured in November 1992 roubles (Rb.), with respect to imported drugs and test strips in 1992 German marks (DM). In the intervention groups there were significant decreases of HbA1 values [UGSM: 12.5% before, 9.4% after 1 year, 9.2% after 2 years (p < 0.0001); BGSM: 12.6% before, 9.3% after 1 year, 9.2 % after 2 years (p < 0.0001) compared to no change in the control group (12.2% before, 12,3% after 1 year)], and of the frequency of ketoacidosis. The frequency of severe hypoglycaemia was comparable between the UGSM (10 cases during 2 years), BGSM (10 cases during 2 years), and the control group (8 cases during 1 year). In the combined intervention groups, there were significant decreases of hospital days per patient per year (12.1 during the year before, 1.0 year one after, 3.6 year two after, p < 0.005), and of additional sick leave days (16.6 during the year before, 2.4 year one, 7.8 year two after, p < 0.01), whereas these parameters remained unchanged in the control group. The initial costs of the intervention were outweighed by this subsequent reduction in hospitalizations and lost productivity. Net savings totalled up to 14400 Rb./patient within 2 years. Patients of the intervention groups were told to discontinue drugs which were not indicated and/or ineffective (clofibrate, pentoxifylline, calcium dobesilate). This caused estimated average savings of DM 240 per patient per year. Costs of test strips for UGSM were DM 180 per patient per year; for BGSM they were estimated to lie between DM 370 and DM 550 per patient per year, depending on the frequency of measurements. In conclusion, the intervention led to an improvement of metabolic control and saved resources for health care by reducing hospitalizations and sick leave days. When UGSM is used, costs of test strips are approximately outweighed by discontinuing ineffective drugs.

Predictors of mortality and end‐stage diabetic complications in patients with Type 1 diabetes mellitus on intensified insulin therapy

SUMMARY

Liberalized diet in patients with type 1 diabetes

Abstract. Objective. To document that strict dietary regimen are not necessary in the context of intensified insulin therapy.