Bridging the quality gap in diabetic hyperlipidemia: a practice-based intervention.

PURPOSE: Dyslipidemia treatment dramatically decreases coronary heart disease risk in diabetes, yet only a minority of these patients are screened or achieve optimal low-density lipoprotein (LDL) cholesterol levels. Our aim was to increase the percentage of diabetic patients in whom lipid management was achieved through electronic and direct educational detailing. METHODS: The study cohort comprised 884 diabetic patients at 12 primary care practices. Practice sites were randomized to one of three intervention groups: electronic educational detailing, direct (face-to-face) educational detailing, or control. Direct and electronic detailing were performed over a 12-month period. All sites were notified of our goal to enhance lipid testing among diabetic patients. Chart abstraction was performed 15 months after the start of the intervention. For the entire population (n=884), the proportion of patients with lipid testing was calculated, and changes from pre- to postintervention were compared across groups. We compared pre- and postintervention LDL-cholesterol changes between groups using least square means to account for site variation. RESULTS: Favorable provider actions increased significantly with the intervention (+22% compared with +6% in controls, P=.01). By logistic regression, electronic detailing increased the likelihood of lipid testing (odds ratio 3.0, confidence interval 1.6-5.7), as did direct detailing (odds ratio 1.8, confidence interval 0.9-3.7) in patients with no preintervention LDL test (n=432). Lipid testing tended to increase to a greater extent at intervention sites (+23% for the combination of electronic and direct detailing vs +11% for controls, P=.06). CONCLUSIONS: Brief educational detailing either through direct or electronic communication favorably impacts provider behavior regarding dyslipidemia care for diabetic patients.

Albuminuria as a predictor of heart failure hospitalizations in patients with type 2 diabetes.

BACKGROUND: Heart failure (HF) occurs more frequently and is a significant cause of mortality in diabetic patients. The purpose of the current study is to ascertain risk factors that are predictive of HF hospitalizations in type 2 diabetic patients. METHODS: Longitudinal observational study of type 2 diabetic patients with baseline diastolic blood pressures > or =80 mm Hg and no history of New York Heart Association class III-IV HF or a serum creatinine > or =2.5 mg/dL nested within a randomized clinical trial. The outcome measure of this study was the first occurrence of HF hospitalization over a 5-year follow-up period. RESULTS: Patients with overt albuminuria at baseline had a higher and earlier occurrence of HF hospitalizations than those with micro- or normoalbuminuria (13.6% versus 3.3%, odds ratio [OR]=3.1, 95% confidence interval [CI]=2.15-4.60, P<.0001). In the multiple logistic regression analyses, the presence of overt albuminuria (OR 5.4, 95% CI=2.3-12.5, P<.001), history of myocardial infarction (OR 4.6, 95% CI=1.6-13.1, P=.004) and a history of New York Heart Association Class I or II HF (OR 8.0, 95% CI=2.2-28.6, P=.0014) at baseline were independently associated with HF hospitalizations. CONCLUSIONS: Overt albuminuria predicts the occurrence of HF hospitalizations in type 2 diabetic patients. Thus early aggressive treatment of diabetic nephropathy should be investigated as a means of preventing of HF.

A community study of language concordance in Russian patients with diabetes.

PURPOSE: Unique challenges exist in the provision of culturally and linguistically appropriate health care to ethnically diverse populations. The purpose of this study was to improve the metabolic control of Russian patients with diabetes through increased attention to language and cultural concordance between the provider and patient. PROCEDURES: This is a retrospective cohort study of 55 Russian immigrant type 2 patients with diabetes to assess levels of glycemic, lipid, and blood pressure control before and after the arrival of a bilingual Russian internist trained in both the United States and Russia. Paired t test was used to compare these parameters before and after the bilingual Russian provider joined our practice. FINDINGS: Overall, the mean low density lipoprotein (LDL) level decreased by 20% from 126 mg/dL to 102 mg/dL (P=.0002) respectively before and after the Russian provider began treating these patients. Mean hemoglobin A1c decreased from 8.4% to 8.0% (P=.007), and diastolic blood pressure was reduced from 82.7 mm Hg to 76.3 mm Hg (P=.0002). Systolic blood pressure also improved from 143.2 mm Hg to 140.6 mm Hg (P=.3). At the end of the study period more than 90% of the patients with diabetes were appropriately taking lipid-lowering medications and an angiotensin converting enzyme (ACE) inhibitor. CONCLUSION: Our findings suggest that it is important to facilitate the health care of ethnically diverse minority populations in a manner that attempts to maximize language and cultural concordance. These potential benefits will assume an even greater importance with the expansive growth of ethnic minorities in the United States and their unique healthcare needs.

Diabetic autonomic neuropathy is associated with an increased incidence of strokes.

OBJECTIVE: To ascertain risk factors associated with the occurrence of strokes in type 2 diabetes over a 5-year follow-up period. BACKGROUND: Diabetic patients are at increased risk for cardiovascular disease when compared to non-diabetic patients. Strokes are a significant source of morbidity and mortality. DESIGN/METHODS: We evaluated the relationship between a number cardiovascular risk factors in 950 normotensive and hypertensive type 2 diabetic patients enrolled in the Appropriate Blood Pressure Control in Diabetes (ABCD) trial on the incidence of stroke. We analyzed data from this longitudinal study to evaluate the relationships between various baseline risk factors and the occurrence of strokes. RESULTS: A number of baseline risk factors were associated with the occurrence of strokes including history of a stroke (p=0.02) and heart failure (p=0.004) at baseline, age (p=0.004), longer duration of diabetes (p=0.03), higher systolic blood pressure (p=0.005), an abnormal ankle/brachial index (p=0.05), decreased duration on the exercise treadmill test at baseline (p=0.009), the presence of retinopathy (p=0.02), overt albuminuria (p=0.03) and the presence of diabetic autonomic neuropathy (DAN) as defined as a borderline or abnormal E/I ratio (p=0.016). Other variables that were tested but were not significantly associated included gender, duration of hypertension, diastolic blood pressure and smoking. When applying a multiple logistic regression model, DAN (OR=2.2, 95% CI=1.10-4.44), along with a history of heart failure (OR=7.4, 95% CI=2.12-26.15) and strokes (OR=3.4, 95% CI=1.02-11.00) at baseline were each associated with the occurrence of strokes. CONCLUSIONS: In the present study of type 2 diabetic patients, DAN is a significant independent risk factor for the occurrence of stroke. This may occur due to accelerated cerebral vascular damage and alterations in the regulation of cerebral blood flow in diabetic patients with DAN.