An update on primary care management of type 2 diabetes.

Diabetes is one of the deadliest and costliest chronic diseases in the United States. New criteria indicate a diabetes diagnosis if the fasting plasma glucose is greater than or equal to 126 mg/dl or if random plasma glucose is greater than or equal to 200 mg/dl. Use of these criteria enables early detection and treatment of the one-third of Americans with type 2 diabetes who are undiagnosed and at high risk for complications. Treatment incorporating nutrition, exercise, pharmacologic therapy, and insulin can effectively control blood glucose, hypertension, and lipids. In the managed-care environment, primary care providers will be increasingly accountable for the delivery of care based on national quality indicators. The treatment strategies discussed in this article can help clinicians meet this responsibility.

Diabetes patient education programs. Quality and reimbursement.

To inform health-care providers and third-party carriers of the national quality assurance systems in place for diabetes education programs and the health professionals who provide education services and to indicate the need for consistent reimbursement of essential outpatient diabetes education services. The components of an independent quality assurance mechanism were examined and a survey was conducted to determine reimbursement coverage of ADA recognized programs. A national program to evaluate whether programs meet national standards is in place. Many ADA approved programs were reimbursed and official recognition helped in the process of attaining reimbursement. Insurance coverage decisions made by third-party carriers, however, were inconsistent and largely unpredictable. Outpatient education and follow-up for diabetes is an integral component of care. These services need to be more clearly defined to enable appropriate coding and coverage decisions to be made by third-party payors.

Understanding diabetes routines: a professional training exercise.

As part of the continuing education programs conducted at the Washington University Diabetes Research and Training Center, 65 health professionals participated in a 4-day simulation exercise which required them to adhere to a diabetic regimen. Instructions covered injections, urine testing, recording results, and calculating and following a meal plan. Evaluation of the simulation focused on the degree of participant adherence to each component, the problems they encountered, and how the experience influenced their patient/clinician interaction. Mean scores for adherence over the 4-day period for each component of the regimen were injections (82%), diet (67%), urine testing (58%), and recording results (56%). Of the total number of adherence problems encountered by the participants, 52% were diet-related, 17% involved urine testing, 17% time constraints, 10% loss of spontaneity, and 4% involved injections. Analysis of the impact of the experience in the work setting indicated improved participant sensitivity to diabetic patient adherence problems and increased ability to effectively counsel patients and family members.

A group approach to the management of diabetes in adolescents and young adults.

An interdisciplinary team of health professionals developed a model treatment program to improve adherence, self-management, and metabolic control for five inner city, black, young adult, diabetic women. Following an initial in-hospital evaluation, the staff met with the patients as a group once a month for 18 mo. The professional approach was suppurative and nonjudgmental to assist the group members in developing confidence and assuming responsibility for the successful management of their diabetes. Discussions covered the group's educational needs, insulin requirements, and psychosocial problems of adjusting to living with chronic disease. Analysis of clinical findings showed a significant improvement in plasma glucose, hemoglobin A1c, and cholesterol levels.