Chronic care: a need in search of a system.

Currently, the bulk of our healthcare dollars is being spent on chronic illnesses and their associated complications. Given this use of resources, it is essential to identify, develop, and implement a system of care that is unique to those with long-term health concerns. Effective management of these problems depends largely on patient participation and strategies that are appropriate for the primary delivery site, which is the home. Such concepts are foreign to most current disease-management programs, and years will be required for acceptance and implementation. Quality long-term management requires a systematic, comprehensive system of care that is unique to the needs of both patients and providers. Such a system consists of a series of integrated, interdependent components that will be presented in this article.

Staged diabetes management. Toward an integrated model of diabetes care.

This paper introduces a new and innovative approach to diabetes management in the primary-care setting. Staged diabetes management (SDM) represents a four-year effort to develop and test a data-based approach to diabetes management that could be easily adapted to a variety of health-care settings in which diabetes management is principally under the direction of primary-care physicians was limited access to specialists. After testing under controlled circumstances at the International Diabetes Center (Minneapolis, MN), SDM was subjected to substantial field trials under conditions that represent the scope and variety of primary-care practices in diabetes. The following represents the work of several investigators who independently undertook a review of SDM.

Clinical evaluation of the impact of a patient education program.

A 5-day patient education program, taught on an outpatient basis, was evaluated to determine its effect on metabolic control as reflected by glycosylated hemoglobin test values. A quasi-experimental design was used, consisting of a pretest, a posttest, and a follow-up assessment made approximately 6 months after the posttest. The 72 experimental and 324 comparison subjects all had insulin-dependent diabetes mellitus (IDDM), were between 14 and 78 years of age, and had a duration of diabetes ranging from 1 to 20 years. The experimental group demonstrated a statistically significant improvement in Hb A1 values from pre- to posttest and sustained these posttest levels upon follow-up, although not at statistically significant levels. The comparison group showed no pre- to posttest difference, but demonstrated an improvement from posttest to follow-up assessment.

Rapid decrease of insulin-specific IgG antibody levels in insulin-dependent patients transferred to semi-synthetic human insulin.

A multicenter, open trial was designed to examine the efficacy and safety of semi-synthetic human insulin (SSHI; Novolin R and Novolin L, SQUIBB-NOVO) in patients with insulin-dependent diabetes mellitus who were transferred from other commercially-available insulins. Whether such a change in therapy would reduce circulating IgG antibodies to antibovine insulin was also evaluated. A total of 68 males and females, 8-62 yr of age, were maintained on their original insulin therapy for 4 weeks, when both glycosylated hemoglobin and fasting blood glucose were assessed. IgG antibody titers to antibovine insulin were also measured. All patients were then transferred to SSHI for a period of 20 weeks. The same variables were evaluated at Weeks 2, 4, 8, and 20. Mean fasting blood glucose levels rose monotonically from 189-226.3 mg/dl over the course of the 20-week clinical trial. There was a slight but insignificant increase in glycosylated hemoglobin by the end of the test period. The average value for antibovine insulin IgG antibodies decreased from 2.54 mu/ml at baseline to 1.32 mu/ml by the completion of the trial. Significant decreases were first observed 4 weeks after the patients were placed on SSHI therapy. After transfer to SSHI, 43.3% of the patients achieved some improvement in glycemic control and only 16.4% were worse than at baseline. A decrease in weekly hypoglycemic reactions occurred during the course of the SSHI therapy. It appears that SSHI provides safe and effective treatment for insulin-dependent diabetic patients and that its use results in a rapid and significant decrease in insulin antibody formation.

Psychometric study of patient knowledge test.

The results of a psychometric study of the Test of Patient Knowledge are reported. The 50-item, multiple-choice test, developed by Etzwiler and associates at the International Diabetes Center, consists of a total score and seven subscores based on seven nonoverlapping content categories: nutrition, insulin, general knowledge, methods of control, pattern control, exercise, and complications. The results described herein provide evidence for the validity of the test (content, concurrent, and discriminant validity), a high level of reliability (Cronbach's alpha = .88), readability for the layperson at the 7th- to 8th-grade level, and sensitivity to instructional gains. The literature on psychometric research with other tests of patient knowledge of diabetes is reviewed and compared with the results of this study.

Diabetes management. The importance of patient education and participation.

Since its establishment in 1967, the International Diabetes Center, Minneapolis, has broadened its interest in patient education from an active concern to a worldwide effort. In addition to providing formal educational programs for diabetics and their families, the Center has trained thousands of health professionals, many of whom have returned to their own clinics, hospitals, and other facilities to initiate similar programs. In 1984, building on its long history of consulting with health care provider organizations in the development of diabetes education programs, the International Diabetes Center initiated a systems development program. Under this program, the Center works with selected hospitals and clinics to develop a national network of sophisticated, integrated diabetes management centers. These Affiliates work with the Center to develop education, clinical care, and research programs that mirror those at the Center.

Patient recall of self-care recommendations in diabetes.

Twenty-four insulin-dependent diabetic patients were interviewed immediately after a follow-up visit to an outpatient pediatric clinic to determine which of the recorded instructions delivered by professionals were recalled by patients. The health care team reported giving an average of seven recommendations per patient, or a total of 168 items listed by team members as important. Patients recalled an average of two recommendations, or a total of 50 items, 40% of which had not been recorded by team members. Recommendations concerning diet, insulin dosage and injections, urine testing, and exercise represented 80% of those recalled by patients and only 58% of those recorded by professionals. The results were interpreted to suggest that health care teams focus on fewer items to insure communication of the most appropriate recommendations for individual patients.

Urine C-peptide, beta-cell function, and insulin requirement.

Urinary C-peptide excretion was investigated as a method for monitoring beta-cell function in diabetic patients and for studying the contribution of endogenous insulin production to diabetic control. Control subjects had variations in serum and urine C-peptide immunoreactivity that correlated with basal and meal-related insulin secretion. In a group of well-controlled juvenile diabetic patients, those receiving high doses of insulin had low or negligible C-peptide excretion, whereas most patients with low exogenous insulin requirements had near-normal urinary C-peptide excretion. Patients treated for diabetic ketoacidosis had recovery of beta-cell function as measured by C-peptide immunoreactivity in serial urine specimens. Thus, measurement of urinary C-peptide excretion is a simple technique that may be useful in assessing endogenous insulin production in juvenile diabetic patients.