Staged Diabetes Management

Next, key 75 of the control group were the auspices of the National Kidney physicians from the University Medical re-evaluated.

Staged diabetes management: computerizing a disease state management program.

This study sug- India with the Madras Diabetes program. During the third current gested that the SDM programme was Foundation in collaboration with year supply and training centres will applicable in Chinese patients with Lions International. Through this pro- type 2 diabetes. In Thailand, a partnership between the Diabetes Educator Society, Diabetes Taiwan Association and Endocrine Society Collaboration between government, resulted in over primary care phys- regional and national diabetes organiz- icians being trained in SDM.

Several medical ii university residency training pro- the overall quality of care provided by centres choose to implement SDM as grammes, iii Native American com- both specialists and general physicians. Currently more Minnesota Programme. Following a needs cemic control, reducing the rate of Additionally, many large centres assessment, which includes a review of complications and cost.

Many of these have evaluated the cost of providing all systems that impact on diabetes studies have been undertaken by large SDM-based care using nurse case man- care, as well as an extensive baseline managed care organizations that agement.

In one analysis, patients chart audit, staff of the IDC hold a routinely maintain both process and treated according to SDM were com- site visit. Working closely with a local outcome measures related to the pared to an equal number of patients diabetes team medical director, nurse implementation of SDM. In one such receiving routine care.

After adjusting for the health care centre. This is a four-part diabetes-related processes when base- data were pooled, resulting in an aver- process: The cost Practice Guidelines and Master Many of the large centres choose of routine care for diabetes-related DecisionPaths for type 1, type 2 and to use SDM as the basis of a nurse physician visits, diabetes medications, GDM; iii application of SDM to case management approach. This DecisionPaths, together with the HbA1c of 1. The rou- two-day process is then followed by a patient and primary care physician, tine care group had no change in three, six and twelve-month review.

A metabolic targets along with time- HbA1c. When these targets are calculated by subtracting the effect developed to permit large medical not met, nurse case managers are achieved by routine care from the centres to prepare health care pro- empowered to alter dosage or change effect achieved by SDM intervention fessionals at local sites so that they can therapy as long as they follow the SDM 1. Similarly, the incremental cost organization. Finally, the cost to Table 3. However, the cost savings SDM in residency US Public Health Service, whose require a calculation of the true cost programmes tenure in any one clinic averages three of higher HbA1c levels.

In a study of a SDM was also tested in programmes years. Residency programmes also gramme directors of the IHS, tribal or heart disease alone. If we apply these data of the patients served in teaching hos- undertaken. The principal aim was to to the nurse case manager study cohort, pitals having diabetes.

Staged diabetes management: computerizing a disease state management program.

SDM, it was improve screening, detection, treat- it appears that while the incremental believed, could help bring consistency ment, surveillance and follow-up cost of lowering blood glucose was within the clinical faculty of medical within strictly limited resources. As an high the savings would be still higher.

A second aim was to address subtracted from the savings, the net better utilization of a team approach. Thus, for At Tufts University, for example, healthcare professionals serving these the patients in this study, the referral to diabetes educator and communities. At the onset of SDM period. In contrast, an increase in both HbA1c ics providing care to one million Because many patients did not have 8.

Costs analysis revealed SDM. Change in HbA1c 2. In a second study carried out in Minnesota, 76 patients with type 2 diabetes were followed for one year. A third study performed in at highest risk for foot complications. In a four- teen-year study at one Indian Health Service clinic in Minnesota it was poss- ible to ascertain the long-term efficacy of SDM.

The purpose of the study was to evaluate the impact of practice guidelines and algorithms designed to screen for, and manage, foot compli- cations associated with diabetes in an American Indian population seeking care in a community-based clinic. The primary study endpoints were lower extremity amputation LEA rates and estimated cost associated with the intervention relative to standard care.

LEAs were tracked over the study period using a diabetes registry. The study was divided into four periods: This was followed by the public health period — , during which time rou- S12 Pract Diab Int September Vol. It identified individuals foot ulcers according to the SDM The Lions International is among the with abnormal blood glucose levels. The final largest service organizations in the Additionally, people identified period began in , when vascular United States and throughout the world.

The annual incidence rates for the visually impaired. Through a also provided preventive and edu- LEA are shown in Table 5. It treatment of diabetes and its compli- into four overlapping chapters: Overview of the natural history glycaemia in a genetically identified Care and education of diabetes high-risk population. From its inception, SDM has pro- moted the integration of care and edu- Screening and detection cation in order to ensure that the In the absence of genetic screening, patient and all health care team mem- more traditional approaches to ident- bers are acquainted with diabetes and ifying a population at risk become with the treatment options and goals.

In the United States and else- This expansion of chapter iv in the where type 2 diabetes is often diag- diabetes continuum led to the develop- nosed seven to ten years after the ment of a systematic and consistent pre-diabetes; iii the detection of dia- development of overt hyperglycaemia. In BASICS, the programme developed by in addressing chapter iv of the natural a sense these patients find themselves the IDC provides a systematic, consist- history but this is, in a sense, the in chapter iv of the diabetes con- ent, research-based plan for diabetes omega of the story. In an attempt to utilize the educators to use when educating newly principles of early detection chapters diagnosed patients with type 2 dia- Prevention ii and iii and reverse this trend, betes.

The task is to ident- diabetes DM by screening for hyper- maintenance. The content is sequen- ify ways of connecting these chapters glycaemia, hypertension, obesity and tial, successive, and cumulative, with The important goal would be to ident- renal disease. A what they did and how they could help participated in the screening pro- data collection and evaluation system us better manage our patients and gramme.

In this mixed ethnic popu- helps achieve measurable clinical and thereby modify SDM protocols in the lation Chinese, Indian and Malay the educational targets. Epidemiological databases and mean age was Type 2 has been used in both group and DNA are both starting points for identi- diabetes was found in 46 individ- individual education settings.

The fication of candidate genes. By such techniques, individuals neither hyperglycaemia nor hyperten- The possibility of future electronic ver- at risk for diabetes within families with sion 11 versus 1. Such identification may the ESRD patients undergoing dialysis relying on DecisionPaths as the major eventually be the basis for medical inter- had type 2 diabetes, a national preven- guide to clinical decision-making, it is ventions that take into account the tion programme was planned by the possible to convert a paper version of natural history of diabetes.

Over well in advance of the development of of detection and treatment of diabetes the past two years the IDC has been type 2 diabetes, such preventive inter- and hypertension. Screening tests considering various models. Follow-up for ment include under-reporting of preva- existing SDM protocols. These preven- those identified at risk include coun- lence and wide varieties in standards tive measures are currently available and selling. Already, screening has been of care and treatment outcomes. Self-monitored blood pressure profile: A Tukey smoothing algorithm is used to design represent two-weeks approximately 80 BP measurements BP data as if they occurred in one day.

The data are collapsed into a single 24 hour period and plotted by time alone. Then for each time period the data are placed in the 10th, 25th, 50th, 75th and 90th percentiles. Data in each percentile is then subjected to smoothing by calculating the average value within the percentile, the average value immediately before and after the time period and the residual values.

These values are connected by a best fit curve. The result is a modal day profile that appears continuous, but is actually representative of numerous days of periodic monitoring second consideration was the need to provide updated information on new treatment approaches and recently approved pharmacologic agents. As a dynamic system, SDM has to respond to the most recent scientific findings, and to rapidly translate them into practice.

A third consideration was the need to be in close contact with patients, especially as regards the trend towards home monitoring of lipids, for the representation of blood pressure customizable reporting function for HbA1c, creatinine, blood pressure and values measured by patients using an standard reports such as those required blood glucose. Systolic and diastolic press- ping chapters, i genetics, ii pre- tion from patients and laboratories, ure plus heart rate were recorded by diabetes, iii detection and iv overt analysis, reference, clinical decision- the device along with the time and diabetes with its attendant compli- making and reports Figure 8.

The data cations, presents an interesting para- in part, with object-oriented technol- were offloaded on to a computer and digm. It is clear that each chapter ogy, this innovative approach to self-monitored blood pressure profiles software development will permit needs to be addressed.

SDM, while Figure 9 were created to depict pat- successful in addressing chapter iv of on-site modifications by the user with- terns in blood pressure throughout a out the barriers of fixed features and the natural history, now must turn modal day. This form of representation hard-coded functions. Accessible over almost equal attention to the earlier enables the rapid detection of unre- the Internet through a secure, appli- chapters if this international epidemic ported hypertension.

This strategy will be able to integrate this information for their participation in the enable the rapid implementation and in one comprehensive data base that Symposium, Professor Roger Mazze, upgrade of eSDM across multiple clini- will further support clinical decisions.

Designed principally for use The data can be integrated with labora- up the future vision by saying with a central server and data reposi- tory measurements. In this browser technology does not sustain. Diabetes Res Care ; Diabetes Clin Practice ; 50 suppl. Long Term Impact of 2. Diabetes ; 47 suppl. Assessment of the Impact of Diabetes Bradley R, Mazze R. Improving Glycemic progression of long term complications in Res Clin Practice ; 50 suppl. Control in Native American Communities: The role of Staged Diabetes Management Care.

Diabetes ; 48 suppl. Ohkubo Y et al. Intensive insulin therapy in improving care in Poland. Reducing vascular complications in Japanese patients Matsuoka K representing Japan Study Group. Klinge A, Dreyer M. Diabetes Res Clin Practice — Intensive blood-glucose control with sulphon- ; 50 suppl.

Editorial Reviews

Staged diabetes care in rural communities of ; Diabetes Res Clin Practice ; 6. Diabetes Res Clin Practice 50 suppl.

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Diabetes Res Clin Reliability of blood glucose monitoring by Practice ; 50 suppl. Assessment of Group Versus Individual patients with diabetes. Am J Med ; The ambulatory glucose profile: Staged Diabetes Management —Decision blood glucose data. Diabetes Care ; 10 in Primary Care Settings. Practice ; 50 suppl: Diabetes Res Clin 9. Langer O, Mazze R. The relationship between The cost to health plans of poor Please try again later.

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Pre - release comment: I have had at least 3 other popular textbooks on diabetes, and this author's work is the best by far to use in actual clinical practice. I started using an earlier edition when I was in active practice. Now I supervise a large group of physicians, and I use the current edition of this book frequently to give them advice for their more challenging patients. This book is fast, thorough, and precise. One person found this helpful.

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