Control of hyperglycemia delays or prevents complications of diabetes, but many persons with diabetes do not achieve optimal control.
To compare diabetes control in patients receiving nurse case ...management and patients receiving usual care.
Randomized, controlled trial.
Primary care clinics in a group-model health maintenance organization (HMO).
17 patients with type 1 diabetes mellitus and 121 patients with type 2 diabetes mellitus.
The nurse case manager followed written management algorithms under the direction of a family physician and an endocrinologist. Changes in therapy were communicated to primary care physicians. All patients received ongoing care through their primary care physicians.
The primary outcome, hemoglobin A1c (HbA1c) value, was measured at baseline and at 12 months. Fasting blood glucose levels, medication type and dose, body weight, blood pressure, lipid levels, patient-perceived health status, episodes of severe hypoglycemia, and emergency department and hospital admissions were also assessed.
72% of patients completed follow-up. Patients in the nurse case management group had mean decreases of 1.7 percentage points in HbA1c values and 43 mg/dL (2.38 mmol/L) in fasting glucose levels; patients in the usual care group had decreases of 0.6 percentage points in HbA1c values and 15 mg/dL (0.83 mmol/L) in fasting glucose levels (P < 0.01). Self-reported health status improved in the nurse case management group (P = 0.02). The nurse case management intervention was not associated with statistically significant changes in medication type or dose, body weight, blood pressure, or lipids or with adverse events.
A nurse case manager with considerable management responsibility can, in association with primary care physicians and an endocrinologist, help improve glycemic control in diabetic patients in a group-model HMO.
Warfarin Genotyping Reduces Hospitalization Rates Epstein, Robert S., MD, MS; Moyer, Thomas P., PhD; Aubert, Ronald E., PhD ...
Journal of the American College of Cardiology,
06/2010, Volume:
55, Issue:
25
Journal Article
Peer reviewed
Open access
Objectives This study was designed to determine whether genotype testing for patients initiating warfarin treatment will reduce the incidence of hospitalizations, including those due to bleeding or ...thromboembolism. Background Genotypic variations in CYP2C9 and VKORC1 have been shown to predict warfarin dosing, but no large-scale studies have prospectively evaluated the clinical effectiveness of genotyping in naturalistic settings across the U.S. Methods This national, prospective, comparative effectiveness study compared the 6-month incidence of hospitalization in patients receiving warfarin genotyping (n = 896) versus a matched historical control group (n = 2,688). To evaluate for temporal changes in the outcomes of warfarin treatment, a secondary analysis compared outcomes for 2 external control groups drawn from the same 2 time periods. Results Compared with the historical control group, the genotyped cohort had 31% fewer hospitalizations overall (adjusted hazard ratio HR: 0.69, 95% confidence interval CI: 0.58 to 0.82, p < 0.001) and 28% fewer hospitalizations for bleeding or thromboembolism (HR: 0.72, 95% CI: 0.53 to 0.97, p = 0.029) during the 6-month follow-up period. Findings from a per-protocol analysis were even stronger: 33% lower risk of all-cause hospitalization (HR: 0.67, 95% CI: 0.55 to 0.81, p < 0.001) and 43% lower risk of hospitalization for bleeding or thromboembolism (HR: 0.57, 95% CI: 0.39 to 0.83, p = 0.003) in patients who were genotyped. During the same period, there was no difference in outcomes between the 2 external control groups. Conclusions Warfarin genotyping reduced the risk of hospitalization in outpatients initiating warfarin. (The Clinical and Economic Impact of Pharmacogenomic Testing of Warfarin Therapy in Typical Community Practice Settings MHSMayoWarf1; NCT00830570 )
(+)‐Epi‐biotin differs from (+)‐biotin in the configuration of the chiral center at atom C2. This could lead to a difference in the mode of binding of (+)‐epi‐biotin to streptavidin, a natural ...protein receptor for (+)‐biotin. Diffraction data were collected to a maximum of 0.85 Å resolution for structural analysis of the complex of streptavidin with a sample of (+)‐epi‐biotin and refinement was carried out at both 1.0 and 0.85 Å resolution. The structure determination shows a superposition of two ligands in the binding site, (+)‐biotin and (+)‐epi‐biotin. The molecules overlap in the model for the complex except for the position of S1 in the tetrahydrothiophene ring. Differences in the conformation of the ring permits binding of each molecule to streptavidin with little observable difference in the protein structures at this high resolution.
Study Objective. To measure the rate of dispensing errors and to identify the types and sources of dispensing errors in a highly automated mail‐service pharmacy practice.
Design. Descriptive analysis ...of a random sample of completed prescriptions.
Setting. A high‐volume mail‐service pharmacy practice comprising a network of prescription processing and dispensing pharmacies in the United States.
Measurements and Main Results. During September and October 2003, new and refill prescriptions were retrieved before shipping and evaluated for dispensing accuracy. Container contents were compared against the container label, and the label record was compared against the original prescription order. The overall dispensing error rate was 0.075% (16 dispensing errors among 21,252 prescriptions, 95% confidence interval 0.043–0.122). Fourteen errors involved incomplete or incorrect directions on the final label. All dispensing errors were associated with the initial stages of prescription processing (including order entry); no errors were associated with the mechanical stages of product dispensing.
Conclusion. A highly automated mail‐service pharmacy can achieve a dispensing error rate of less than 1 error/1000 prescriptions, which is substantially lower than the rates reported for retail pharmacies. A high degree of automation in the mechanical aspects of dispensing appears to be a key factor in achieving this high dispensing accuracy.
The St. George's Respiratory Questionnaire (SGRQ) has been validated and widely used in assessing quality of life among patients with chronic obstructive pulmonary disease (COPD), but it is ...time-consuming and complicated to score. A more concise instrument, the Airways Questionnaire (AQ), was developed to measure quality of life (QoL) among patients with asthma and COPD. The shorter version of this instrument has 20 items (AQ20) and the longer version has 30 items (AQ30). The purpose of this study was to determine the relationship between QoL scores measured by the AQ20/30 or the SGRQ scale and utilization of health-care services by COPD patients and to evaluate the comparative advantage of any one of these instruments in measuring the QoL of COPD patients.
Results from a survey of 1000 patients participating in a pilot COPD health management program were used for this analysis. A total of 303 patients completed both the AQ20/30 and the SGRQ questionnaires. Logistic regression models were used to analyze the relationship between utilization of health care services and QoL scores while controlling for a set of covariates. Spearman's rank correlation was used to determine whether the AQ30 and the SGRQ scores for symptoms, activity, and impact, and the overall scores were correlated.
The regression results demonstrate that there is a strong relationship between quality-of-life scores and health-care utilization variables. Moreover, the degree of association between the AQ20/30 scores and utilization variables and the SGRQ and utilization variables are comparable. Both the AQ20 and the AQ30 were highly correlated with the overall SGRQ score and with symptoms, activity, and impact component scores.
The AQ20/30 and the SGRQ scores are comparable in terms of measuring QoL in COPD patients and are equally useful in determining the association between utilization of health-care services and QoL.
OBJECTIVE--Because half of the people with non-insulin-dependent diabetes mellitus (NIDDM) are undiagnosed and because near-normal glycemic control can prevent diabetic complications, we evaluated ...the use of field-based random capillary blood glucose measurement as a screening test for NIDDM. RESEARCH DESIGN AND METHODS--A cross-sectional sample of 828 Egyptians greater than or equal to 20 years of age underwent both a random capillary blood glucose measurement performed with a portable reflectance meter in the field and an oral glucose tolerance test in the laboratory. The sensitivity and specificity of random capillary blood glucose measurements in predicting the presence of NIDDM were evaluated. RESULTS--Multivariate analyses showed that the screening test performed better when subjects had eaten shortly before the test (area under receiver operating characteristic curve, 0.87 for a 1-h postprandial period compared with 0.69 for an 8-h postprandial period) and that the optimal capillary blood glucose cutoff points to define a positive test increased with age. For a postprandial period of 1 h, cutoff points of 115 mg/dl for individuals 30 years of age and 140 mg/dl for those 75 years of age yielded similar performance characteristics (sensitivity 82% and specificity 78% for those 30 years old; sensitivity 81% and specificity 80% for those 75 years old). CONCLUSIONS--Adjusting random capillary blood glucose measurements for the postprandial period and using age-specific cutoff point values can improve performance of the screening test.
This study estimated the prevalence of self-rated visual impairment among US adults with diabetes and identified correlates of such impairment.
Self-reported data from the 1995 Behavioral Risk Factor ...Surveillance System survey of adults 18 years and older with diabetes were analyzed. Correlates of visual impairment were examined by multiple logistic regression analysis.
The prevalence of self-rated visual impairment was 24.8% (95% confidence interval CI = 22.3%, 27.3%). Among insulin users, multivariable-adjusted odds ratios were 4.9 (95% CI = 2.6, 9.2) for those who had not completed high school and 1.8 (95% CI = 1.0, 2.8) for those who had completed high school compared with those with higher levels of education. Comparable estimates of odds ratios for nonusers of insulin were 2.2 (95% CI = 1.4, 3.4) and 1.3 (95% CI = 0.9, 2.0), respectively. Among nonusers, the adjusted odds for minority adults were 2.4 (95% CI = 1.0, 3.7) times the odds for non-Hispanic Whites.
By these data, 1.6 million US adults with diabetes reported having some degree of visual impairment. Future research on the specific causes of visual impairment may help in estimating the avoidable public health burden.
To evaluate the impact of telephone counseling and educational materials on medication adherence and persistency among members with newly diagnosed depression enrolled in a pharmacy benefit ...management-sponsored disease management program.
Longitudinal cohort observation.
The study population comprised 505 members with a new or recurrent episode of depression who consented and enrolled in a depression disease management program. After written consent was obtained, program participants received up to 4 telephone-counseling calls and 5 educational mailings focused on the importance of medication compliance, barriers to medication compliance, quality of life, symptoms, and satisfaction with the program. A control group of 3744 members was selected from client companies that opted not to offer the depression program. Measures of medication adherence, persistency with prescription drug therapy, and patient refill timeliness were computed for both groups and compared.
Patients enrolled in the depression disease management program were significantly more likely to adhere to their medication regimen during acute (89.0% vs 67.7%, P < .001) and continuation treatment phases (81.1% vs 57.6%, P < .001). In addition, members enrolled in the program were significantly more likely to continue their therapy after 7 months (77.8% vs 49.5%, P < .001) and refilled their prescriptions on a more timely basis (0 vs 18 days, P < .001).
A pharmacy benefit management-sponsored health management depression program succeeded in encouraging patients with new or recurrent depression to stay on antidepressant medication and to reach treatment goals outlined by best practice guidelines.
We evaluated a community-based 12-week healthy lifestyle program in Moloka‘i, HI, called Ke ‘Ano Ola, which was developed to decrease chronic disease risk through health education emphasizing weight ...loss, exercise, and risk factor reduction. Program leaders' strong commitment and positive role modeling, along with social and group support and community involvement, were key elements. A pre–post evaluation of weight, blood pressure, total cholesterol, and blood sugar showed significant improvements for weight (mean change Δ = −7.4 lbs; P < .001), systolic blood pressure (Δ = –3.8 mm Hg; P = .027), diastolic blood pressure (Δ = –4.6 mm Hg; P < .001), and total cholesterol (Δ = –9.7 mg/dL; P < .001). Attrition was low, with 89% of participants attending all 12 sessions. Our findings show that lifestyle improvements in a predominantly Native Hawaiian community are achievable in a support group setting.
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