The locus of control in patients with Type 1 and Type 2 diabetes managed by individual and group care.

AIMS: The locus of control theory distinguishes people (internals) who attribute events in life to their own control, and those (externals) who attribute events to external circumstances. It is used to assess self-management behaviour in chronic illnesses. Group care is a model of systemic group education that improves lifestyle behaviour and quality of life in patients with Type 1 and Type 2 diabetes. This study investigated the locus of control in Type 1 and Type 2 diabetes and the possible differences between patients managed by group care and control subjects followed by traditional one-to-one care. METHODS: Cross-sectional administration of two questionnaires (one specific for diabetes and one generic for chronic diseases) to 83 patients followed for at least 5 years by group care (27 Type 1 and 56 Type 2) and 79 control subjects (28 Type 1 and 51 Type 2) of similar sex, age and diabetes duration. Both tools explore internal control of disease, the role of chance in changing it and reliance upon others (family, friends and health professionals). RESULTS: Patients with Type 1 diabetes had lower internal control, greater fatalistic attitudes and less trust in others. Patients with either type of diabetes receiving group care had higher internal control and lower fatalism; the higher trust in others in those with Type 1 diabetes was not statistically significant. The differences associated with group care were independent of sex, age and diabetes duration. CONCLUSIONS: Patients with Type 1 diabetes may have lower internal control, fatalism and reliance upon others than those with Type 2 diabetes. Receiving group care is associated with higher internal control, reduced fatalism and, in Type 1 diabetes, increased trust in others.

Evaluation of the locus of control in patients with type 2 diabetes after long-term management by group care.

AIM: To investigate the locus of control in patients with type 2 diabetes followed by systemic group education (Group Care) and traditional one-to-one care. METHODS: In a post-hoc analysis, two questionnaires were administered to 56 patients who had been followed for 5-7 years by Group Care and 51 controls followed by individual care, similar by age, sex, diabetes duration, glycaemia, insulinaemia, weight and other clinical variables. Patients on Group Care had lower HbA1c (7.40 +/- 1.21%) than controls (7.99 +/- 1.48%), P = 0.027. The Peyrot and Rubin questionnaire, specific for diabetes, and the Wallston and Wallston questionnaire, more generic for chronic diseases, were administered. Both questionnaires explore 3 areas: internal control of disease, and the role of chance or powerful other people, including health operators, in changing the disease. RESULTS: Both questionnaires showed lower scores for chance in patients followed by Group Care (P < 0.001), while scores for powerful others did not differ from those of patients followed by traditional care. The Peyrot and Rubin tool showed increased Internal Control (P < 0.001) in the patients followed by Group Care. Multivariate analysis showed that the HOMA index of insulin resistance was inversely related to Internal Control (B = -0.144, P = 0.005) independently of BMI and HbA1c. CONCLUSION: Fatalistic attitudes were lower and internal control higher in patients with type 2 diabetes followed by Group Care. These changes may be related to insulin resistance, above and beyond the effects of body weight and metabolic control.

A 3-year prospective randomized controlled clinical trial of group care in type 1 diabetes.

BACKGROUND AND AIMS: We showed that continuing education can be embedded into routine diabetes care by seeing patients in small groups rather than individually. Group care was cost-effective in improving quality of life, knowledge of diabetes, health behaviours and clinical outcomes in people with type 2 diabetes. The aim of this study was to verify if group care can also be applied to type 1 diabetes. METHODS AND RESULTS: Randomized, controlled clinical trial comparing 31 patients managed by group care with 31 managed by traditional one-to-one care. A syllabus was built and later remodulated with the patients in a series of focus-group meetings. The primary end-point was changes in quality of life. Secondary end-points were: knowledge of diabetes, health behaviours, HbA1c and circulating lipids. Differential costs to the Italian National Health System and to the patients were also calculated. After 3 years, quality of life improved among patients on group care, along with knowledge and health behaviours (p<0.001, all). Knowledge added its effects to those of group care by independently influencing behaviours (p=0.004) while quality of life changed independently of either (p<0.001). Among controls, quality of life worsened (p<0.001) whereas knowledge and behaviours remained unchanged. HDL cholesterol increased among patients on group care (p=0.027) and total cholesterol decreased in the controls (p<0.05). HbA1c decreased, though not significantly, in both. Direct costs for group and one-to-one care were Euros 933.19 and Euros 697.10 per patient, respectively, giving a cost-effectiveness ratio of Euros 19.42 spent per point gained in the quality of life scale. CONCLUSIONS: Group care is applicable and also cost-effective in type 1 diabetes. It improves quality of life, knowledge and behaviours. Future programme adjustments should strive to impact more on metabolic control.

Lifestyle intervention by group care prevents deterioration of Type II diabetes: a 4-year randomized controlled clinical trial.

AIMS/HYPOTHESIS: Metabolic control worsens progressively in Type II (non-insulin-dependent) diabetes mellitus despite intensified pharmacological treatment and lifestyle intervention, when these are implemented on a one-to-one basis. We compared traditional individual diabetes care with a model in which routine follow-up is managed by interactive group visits while individual consultations are reserved for emerging medical problems and yearly checks for complications. METHODS: A randomized controlled clinical trial of 56 patients with non-insulin-treated Type II diabetes managed by systemic group education and 56 control patients managed by individual consultations and education. RESULTS: Observation times were 51.2+/-2.1 months for group care and 51.2+/-1.8 for control subjects. Glycated haemoglobin increased in the control group but not in the group of patients ( p<0.001), in whom BMI decreased ( p<0.001) and HDL-cholesterol increased ( p<0.001). Quality of life, knowledge of diabetes and health behaviours improved with group care ( p<0.001, all) and worsened among the control patients ( p=0.004 to p<0.001). Dosage of hypoglycaemic agents decreased ( p<0.001) and retinopathy progressed less ( p<0.009) among the group care patients than the control subjects. Diastolic blood pressure ( p<0.001) and relative cardiovascular risk ( p<0.05) decreased from baseline in group patients and control patients alike. Over the study period, group care required 196 min and 756.54 US dollars per patient, compared with 150 min and 665.77 US dollars for the control patients, resulting in an additional 2.12 US dollars spent per point gained in the quality of life score. CONCLUSION/INTERPRETATION: Group care by systemic education is feasible in an ordinary diabetes clinic and cost-effective in preventing the deterioration of metabolic control and quality of life in Type II diabetes without increasing pharmacological treatment.

Group visits improve metabolic control in type 2 diabetes: a 2-year follow-up.

OBJECTIVE: To evaluate whether group visits, delivered as routine diabetes care and structured according to a systemic education approach, are more effective than individual consultations in improving metabolic control in non-insulin-treated type 2 diabetes. RESEARCH DESIGN AND METHODS: In a randomized controlled clinical trial of 112 patients, 56 patients were allocated to groups of 9 or 10 individuals who participated in group consultations, and 56 patients (considered control subjects) underwent individual visits plus support education. All visits were scheduled every 3 months. RESULTS: After 2 years, HbA(1c) levels were lower in patients seen in groups than in control subjects (P < 0.002). Levels of HDL cholesterol had increased in patients seen in groups but had not increased in control subjects (P = 0.045). BMI (P = 0.06) and fasting triglyceride level (P = 0.053) were lower. Patients participating in group visits had improved knowledge of diabetes (P < 0.001) and quality of life (P < 0.001) and experienced more appropriate health behaviors (P < 0.001). Physicians spent less time seeing 9-10 patients as a group rather than individually, but patients had longer interaction with health care providers. CONCLUSIONS: Group consultations may improve metabolic control in the medium term by inducing more appropriate health behaviors. They are feasible in everyday clinical practice without increasing working hours.

Comparison of the cost-effectiveness of three approaches to screening for and treating sight-threatening diabetic retinopathy.

The purpose of this study was to analyse and compare the costs involved in screening for and treating sight-threatening diabetic retinopathy in three different clinical settings. In the first setting, diabetologists screened using ophthalmoscopy and color photography, according to the St. Vincent Declaration guidelines, and selected patients for further assessment by a visiting ophthalmologist and for treatment in another hospital. In the second setting, all patients were regularly referred to ophthalmologists, either in the same hospital or elsewhere, for all aspects of eye care. In the third setting, screening was done again with ophthalmoscopy alone by diabetologists who followed the St. Vincent Declaration guidelines; however, further assessment and treatment were carried out in the eye department of the same hospital. Costs to the Italian National Health Service and to patients were calculated per screening performed and per patient subjected to laser treatment as a result of screening. A sensitivity analysis was then performed to simulate the costs of standardised patient populations going through the three different settings. It is concluded that absolute costs would be lower, both for the Italian National Health Service and for patients, if screening, assessment and treatment were all carried out in the same hospital. Equipping a diabetic clinic specially for screening would not be more expensive than delegating eye care to external parties, even for a hospital without an eye department. Moreover, delegating eye care more than doubles costs for patients. Screening for, assessing and treating sight-threatening diabetic retinopathy may be a cost-effective procedure for society as a whole in Italy.

Diabetic retinopathy as a cause of blindness in the province of Turin, north-west Italy, in 1967-1991.

Diabetes is known to be a major contributor to blindness in industrialized countries but few data are available on the situation in Italy. As an introductory step to the implementation of permanent screening for diabetic retinopathy, a search was carried out on the causes of visual loss in the provincial territory surrounding Turin, the main city of North-West Italy. The case notes of all 4549 residents in the province who were certified blind between 1967 and 1991 were examined with regard to cause, age at onset, and year of onset of visual acuity < or = 1/20. Diabetic retinopathy was the second commonest cause of bilateral blindness (13.1% of cases), preceded by cataract (26.7%) and followed by myopia (11.1%), optic atrophy (8.9%), glaucoma (8.9%), retinitis pigmentosa (7.2%), and senile macular degeneration (4.1%). Diabetic retinopathy was the commonest eye disease among those who became blind between the ages of 50 and 70 and remained the leading cause of visual loss when the age groups 20 to 70 were pooled together. The incidence of diabetic retinopathy-related blindness did not show any trend to decrease over the 25 years investigated. It is concluded that, in spite of widespread availability of facilities for its assessment and treatment, diabetic retinopathy remains a leading cause of blindness in North-West Italy. This fully justifies the implementation of screening programmes and efficient referral chains for the early detection and prompt treatment of this complication of diabetes.

Urinary excretion of glycated albumin in insulin-dependent diabetic patients with micro- and macroalbuminuria.

Non-enzymatic glycosylation (glycation) involves both circulating proteins, such as albumin and structural proteins, such as the components of the glomerular basement membrane. Glycated albumin is more anionic than unmodified plasma albumin at physiologic pH. Preferential urinary excretion of glycated proteins has occasionally been reported in diabetes. We therefore investigated the selectivity index (renal clearance of non-glycated/glycated albumin) in 25 insulin-dependent diabetic patients (17 with microalbuminuria and 8 with macroalbuminuria), and 19 healthy subjects. The selectivity index was significantly higher (p less than 0.01) in the microalbuminuric patients than in the macroalbuminuric patients and the control subjects: 1.11 +/- 0.03 SEM vs 0.94 +/- 0.08 vs 0.98 +/- 0.02. These results are not consistent with preferential urinary excretion of glycated albumin in insulin-dependent diabetic patients with increased urinary albumin excretion.

The increase in albuminuria induced by exercise is not associated with preferential excretion of glycated albumin in type 1 (insulin-dependent) diabetic patients.

The increase in urinary albumin excretion induced by acute exercise in Type 1 (insulin-dependent) diabetic patients is associated with the urinary excretion of cationic proteins. To test whether the renal excretion of glycated albumin (more anionic than non-glycated albumin) is affected by exercise, we submitted seven normoalbuminuric (albumin excretion rate less than 30 mg/24 h) Type 1 diabetic patients and six well-matched healthy subjects to an exercise test (600 kpm/min for 20 min) on a bicycle ergometer, preceded and followed by a 1-h resting period. The selectivity index (renal clearance of non-glycated/glycated albumin) was not significantly different among the pre-exercise, exercise and post-exercise periods, either in the normal subjects (1.01 +/- 0.03 vs 1.08 +/- 0.06 vs 1.08 +/- 0.05) or in the diabetic patients (1.25 +/- 0.09 vs 1.20 +/- 0.07 vs 1.20 +/- 0.06), whereas it was significantly higher (p less than 0.05) in diabetic patients compared to healthy subjects during pre-exercise. These results are not consistent with the hypothesis that acute exercise may induce a preferential excretion of glycated albumin.

Urinary excretion of glycated albumin in insulin-dependent diabetic patients with normal urinary albumin excretion.

Glycation involves both circulating proteins, such as albumin, and structural proteins, such as the components of the glomerular basement membrane. A preferential excretion of glycated albumin (more anionic at physiological pH compared with unmodified plasma albumin) has been reported by some authors, but not by others. We therefore investigated the selectivity index (renal clearance of non-glycated albumin/clearance of glycated albumin) in 25 insulin-dependent diabetic patients with normal urinary albumin excretion and in 19 well-matched control subjects. The selectivity index was significantly higher in diabetic patients than in control subjects: 1.38 +/- 0.05 SEM vs 0.98 +/- 0.02, p less than 0.0001. This result is not consistent with a preferential urinary excretion of glycated albumin, at least in normoalbuminuric uncomplicated insulin-dependent diabetic patients.