Diabetes: how are we diagnosing and initially managing it?

PURPOSE: We undertook this study to examine the symptoms, clinical events, and types of health care encounters that preceded the diagnosis of diabetes mellitus in adults, and to examine changes in glycemic control and cardiovascular risk factors in the first year after a diabetes diagnosis. METHODS: We conducted a historical cohort study of patients in a large multispecialty medical group in Minnesota. Among 55,121 adults who were continuously enrolled in the health plan and receiving care at the study medical group from January 1, 1993, to December 31, 1996, we identified 504 who received a new diagnosis of diabetes in 1995 or 1996. Our main outcome measures were the type of symptoms at diagnosis; the clinical circumstances and type of encounter that led to diabetes diagnosis; and changes in glycemic control (assessed by hemoglobin A1c [HbA1c] value), low-density lipoprotein cholesterol level, blood pressure (BP), aspirin use, and body weight in the first year after diagnosis, ascertained from a detailed review of medical records. RESULTS: Almost one third (32.3%) of adults with newly diagnosed diabetes had symptoms of hyperglycemia at initial diagnosis. Compared with patients who did not have hyperglycemia symptoms at diagnosis, those who did were younger and more often male, and had lower comorbidity scores and higher HbA1c values (9.9% vs 8.1%) at diagnosis (P <.01 for each comparison). In the 12 months after diagnosis, the group as a whole had significant improvements (P <.001) in HbA1c values (from 8.8% to 7.1%), systolic blood pressure (137.5 to 133.2 mm Hg), diastolic blood pressure (80.7 to 77.3 mm Hg), weight (207.7 to 201.1 lb), and aspirin use (15.3% to 26.1%). Improvements were seen in all patient subgroups, including those defined by symptoms at diagnosis and by visit type at diagnosis. CONCLUSIONS: Primary care practices may improve detection of undiagnosed diabetes in primary care and improve 1-year outcomes by being vigilant for symptoms of diabetes, by evaluating those at high risk for this disorder, and by instituting appropriate treatments at the time of diagnosis.

Randomized trial of quality improvement intervention to improve diabetes care in primary care settings.

OBJECTIVE: To assess the impact of a quality improvement (QI) intervention on the quality of diabetes care at primary care clinics. RESEARCH DESIGN AND METHODS: Twelve primary care medical practices were matched by size and location and randomized to intervention or control conditions. Intervention clinic staff were trained in a seven-step QI change process to improve diabetes care. Surveys and medical record reviews of 754 patients, surveys of 329 clinic staff, interviews with clinic leaders, and analysis of training session videotapes evaluated compliance with and impact of the intervention. Mixed-model nested analyses compared differences in the quality of diabetes care before and after intervention. RESULTS: All intervention clinics completed at least six steps of the seven-step QI change process in an 18-month period and, compared with control clinics, had broader staff participation in QI activities (P = 0.04), used patient registries more often (P = 0.03), and had better test rates for HbA(1c) (A1C), LDL, and blood pressure (P = 0.02). Other processes of diabetes care were unchanged. The intervention did not improve A1C (P = 0.54), LDL (P = 0.46), or blood pressure (P = 0.69) levels or a composite of these outcomes (P = 0.35). CONCLUSIONS: This QI change process was successfully implemented but failed to improve A1C, LDL, or blood pressure levels. Data suggest that to be successful, such a QI change process should direct more attention to specific clinical actions, such as drug intensification and patient activation.

Do whole-grain oat cereals reduce the need for antihypertensive medications and improve blood pressure control?

OBJECTIVES: Our study compared 2 whole grain oat-based cereals with 2 refined grain wheat-based cereals to determine their effects on the need for antihypertensive medications in people with high blood pressure (BP). STUDY DESIGN: This 12-week, randomized controlled parallel-group trial with = 6 weeks of voluntary follow-up was designed to investigate the antihypertensive effects of oats. After 4 weeks of baseline feeding, medication dose was maintained or reduced by half or completely throughout the middle 4 weeks of the study. In the final 4 weeks, participants continued cereal consumption; medication was adjusted according to the protocol. POPULATION: Men and women (n = 88) being treated for hypertension with a mean baseline BP below 160/100. OUTCOMES MEASURED: Primary study outcomes included change in SBP and DBP as well as antihypertensive medication reduction. Secondary measures included blood lipid, fasting glucose, and insulin levels and side effects related to elevated BP and increased dietary fiber intake. RESULTS: Seventy-three percent of participants in the oats group versus 42% in the control group were able to stop or reduce their medication by half. Treatment group participants whose medication was not reduced had substantial decreases in BP. The oats group experienced a 24.2-mg/dL reduction in total cholesterol levels, a 16.2-mg/dL decrease in low-density lipoprotein cholesterol levels, and a 15.03-mg/dL drop in plasma glucose levels vs controls. CONCLUSIONS: Results suggest that a diet containing soluble fiber-rich whole oats can significantly reduce the need for antihypertensive medication and improve BP control. Considering the lipid and glucose improvements as well, increased consumption of whole oats may significantly reduce cardiovascular disease risk.