title: Insulin adjustment by a diabetes nurse educator improves glucose control in insulin-requiring diabetic patients: a randomized trial. Monitoring of psychological well-being in outpatients with diabetes: effects on mood, HbA(1c), and the patient's evaluation of the quality of diabetes care: a randomized controlled trial. The effects of participation in a support group on self-assessed quality of life in people with insulin-dependent diabetes mellitus. Foot Education Improves Knowledge and Satisfaction Among Patients at High Risk for Diabetic Foot Ulcer Effects of an Intervention by a Diabetes Team in Hospitalized Patients With Diabetes The development and evaluation of a computer-aided diabetes education program. Evaluation of a hospital diabetes specialist nursing service: a randomized controlled trial. Impact of automated calls with nurse follow-up on diabetes treatment outcomes in a Department of Veterans Affairs Health Care System: a randomized controlled trial. Influence of Small-Group Education Sessions on Glucose Homeostasis in NIDDM The methodologic quality of randomization as assessed from reports of trials in specialist and general medical journals. Diabetes management in a health maintenance organization. Efficacy of care management using cluster visits. Longitudinal study on glycaemic control and quality of life in patients with Type 2 diabetes mellitus referred for intensified control. The effect of automated calls with telephone nurse follow-up on patient-centered outcomes of diabetes care: a randomized, controlled trial. A Controlled Trial on the Effects of Patient Education in the Treatment of Insulin-dependent Diabetes Substitution model with central role for nurse specialist is justified in the care for stable type 2 diabetic outpatients. An economic evaluation of home care for children with newly diagnosed diabetes: results from a randomized controlled trial. Group Education for Obese Patients with Type 2 Diabetes: Greater Success at Less Cost Using Telecommunication Technology to Manage Children with Diabetes: The Computer-Linked Outpatient Clinic (CLOC) Study Home-based Management Can Achieve Intensification Cost-effectively in Type I Diabetes Reducing hospital inpatient length of stay for patients with diabetes. Failure to maintain the benefits of home-based intervention in adolescents with poorly controlled type 1 diabetes. Implementation of Treatment Protocols in the Diabetes Control and Complications Trial Efficacy of dietary instructions in newly diagnosed non-insulin-dependent diabetic patients. Comparison of two different patient education regimens. Renal assessment practices and the effect of nurse case management of health maintenance organization patients with diabetes. Improved control of type 2 diabetes mellitus: a practical education/behavior modification program in a primary care clinic. Nurse Case Management To Improve Glycemic Control in Diabetic Patients in a Health Maintenance Organization A Trial of Cognitive Analytic Therapy in Poorly Controlled Type I Patients Do automated calls with nurse follow-up improve self-care and glycemic control among vulnerable patients with diabetes? Adherence Behaviors in Research Protocols: Comparison of Two Interventions Evaluation of a diabetes patient education program consisting of a three-day hospitalization and a six-month follow-up by telephone counseling for mild type 2 diabetes and IGT A Randomized Study of the Effects of a Home Diabetes Education Program Follow-up Intervention: Its Effect on Compliance Behavior to a Diabetes Regimen Reduction of Lower Extremity Clinical Abnormalities in Patients with Non-Insulin-Dependent Diabetes Mellitus A Telephone-Delivered Intervention for Patients With NIDDM: Effect on coronary risk factors Using a Primary Nurse Manager to Implement DCCT Recommendations in a Large Pediatric Program Telemedicine improved diabetic management. Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial. An Inpatient Diabetes Educator's Impact on Length of Hospital Stay A Community-Based, Culturally Sensitive Education and Group-Support Intervention for Mexican Americans With NIDDM: A Pilot Study of Efficacy Can patients set their own educational priorities? Effect of a Bicultural Community Health Worker on Completion of Diabetes Education in a Hispanic Population
abstract: BACKGROUND Diabetic patients taking insulin  often have suboptimal glucose control , and st and ard methods of health care delivery are ineffective in improving such control . This study was undertaken to determine if insulin adjustment according to advice provided by telephone by a diabetes nurse educator could lead to better glucose control , as indicated by level of glycated hemoglobin ( HbA1c ) . METHODS The authors conducted a prospect i ve r and omized trial involving 46 insulin-requiring diabetic patients who had poor glucose control ( HbA1c of 0.085 or more ) . Eligible patients were those already taking insulin and receiving endocrinologist-directed care through a diabetes centre and whose most recent HbA1c level was 0.085 or higher . The patients were r and omly assigned to receive st and ard care or to have regular telephone contact with a diabetes nurse educator for advice about adjustment of insulin therapy . RESULTS At baseline there was no statistically significant difference between the 2 groups in terms of HbA1c level ( mean [ and st and ard deviation ] for st and ard-care group 0.094 [ 0.008 ] and for intervention group 0.096 [ 0.010 ] ) , age , sex , type or duration of diabetes , duration of insulin therapy or complications . After 6 months , the mean HbA1c level in the st and ard-care group was 0.089 ( 0.010 ) , which was not significantly different from the mean level at baseline . However , the mean HbA1c level in the intervention group had fallen to 0.078 ( 0.008 ) , which was significantly lower than both the level at baseline for that group ( p < 0.001 ) and the level for the st and ard-care group at 6 months ( p < 0.01 ) . INTERPRETATION Insulin adjustment according to advice from a diabetes nurse educator is an effective method of improving glucose control in insulin-requiring diabetic patients OBJECTIVE To investigate whether monitoring and discussing psychological well-being in out patients with diabetes improves mood , glycemic control , and the patient 's evaluation of the quality of diabetes care . RESEARCH DESIGN AND METHODS This study was a r and omized controlled trial of 461 out patients with diabetes who were r and omly assigned to st and ard care or to the monitoring condition .  In the latter group , the diabetes nurse specialist assessed and discussed psychological well-being with the patient ( with an interval of 6 months ) in addition to st and ard care . The computerized Well-being Question naire was used for this purpose . Primary outcomes were mood , HbA(1c ) , and the patient 's evaluation of the quality of diabetes care at 1-year follow-up . The number of referrals to the psychologist was analyzed as a secondary outcome . Intention-to-treat analysis was used . RESULTS The monitoring group reported better mood compared with the st and ard care group , as indicated by significantly lower negative well-being and significantly higher levels of energy , higher general well-being , better mental health , and a more positive evaluation of the quality of the emotional support received from the diabetes nurse . The two groups did not differ for HbA(1c ) or in their overall evaluation of the quality of diabetes care . In the monitoring condition , significantly more subjects were referred to the psychologist . CONCLUSIONS Monitoring and discussing psychological well-being as part of routine diabetes outpatient care had favorable effects on the mood of patients but did not affect their HbA(1c ) . Our results support the recommendation to monitor psychological well-being in patients with diabetes The aim of the present study was to examine the effect of participation in a support group on self-assessed quality of life . Based on an initial self-report assessment of  quality of life 25 people were allocated to 5 groups comprising 4 - 6 participants ( intervention group ) and 36 controls .  The support groups met fort-nightly for 6 months and were facilitated by the investigator and a diabetic nurse specialist . Group processes were aim ed at alleviating distress and improve satisfaction with life and included installation of hope , imparting information and group cohesiveness . Both the intervention and control group completed the quality of life measure at the end of 6 months . There were no significant differences between the intervention and control group on background characteristics or quality of life pre-test scores . No significant differences were found between the intervention and control group on difference in pre and post-test scores , indicating that support group participation did not effect self-assessed quality of life . This finding may be due to method ological issues i.e. selection , sample size and the instrument used , the implementation of the intervention and /or the concept of quality of life as an outcome variable PURPOSE The purpose of this study was to evaluate an intensive diabetes foot education program for veterans at high risk for foot ulcer . METHODS We invited 100 consecutive patients with diabetes from a Department of Veterans Affairs Medical Center clinic who were insensate to the Semmes-Weinstein 5.07 monofilament to participate in a foot care education program . Two sessions were conducted by a nurse diabetes educator 3 months apart . Multiple educational approaches were used to teach patients foot self-examination , foot washing , proper footwear , and encouragement in enlisting proper physician foot care . Knowledge and satisfaction with care was measured before and after each visit . RESULTS The 34 patients who attended both education sessions improved their foot care knowledge over the course of the program . After the second session , the mean improvement over baseline was 14 % . These patients also reported improved satisfaction with foot care ; mean improvement was 33 % . CONCLUSIONS An intensive education program improved the foot care knowledge and behavior of high-risk patients . Those who adhered to a foot care education program were more satisfied with their foot care than prior to the program . Ways to improve accessibility of education sessions must be explored OBJECTIVE Hospitalized patients with diabetes have a prolonged length of stay  in the hospital . We conducted a controlled prospect i ve r and omized feasibility study of the effects of a diabetes team ( a diabetes nurse educator and an endocrinologist ) on the length of stay and other outcomes of hospitalization in these patients . RESEARCH DESIGN AND METHODS A total of 179 hospitalized patients with diabetes were r and omly assigned to receive usual care supplemented with ( 85 patients ) or without ( 94 control patients ) a diabetes team intervention . Outcome measures included the length of stay , blood glucose control , and rates of readmission . RESULTS For the primary diagnosis of diabetes , the median length of stay was 5.5 days ( 95 % CI 4 - 8 days ) for patients who received diabetes team intervention and 7.5 days ( 5–11 days ) for the control patients ( NS ) . For the secondary diagnosis of diabetes , the median length of stay was 10.0 days ( 8–13 days ) in the intervention group and 10.5 days ( 8–13 days ) in the control group ( NS ) . One month after the team intervention was initiated , 75 % of patients in the intervention group were in good glycemic control , compared with 46 % in the control group . Readmissions at 3 months after discharge included 13 ( 15 % ) patients from the intervention group and 30 ( 32 % ) patients in the control group ( P = 0.01 ) . CONCLUSIONS R and omized controlled prospect i ve trials of clinical interventions in hospitalized patients with diabetes are feasible . Diabetes team intervention appears to reduce the hospital length of stay and to improve glycemic control . Team intervention significantly reduces the rate of recurrent hospitalization This paper describes the development and evaluation of a computer-aided learning ( CAL ) program . The program was tested in a trial that involved 36 people with diabetes ; 20 received CAL lessons in diabetes management and 16 attended conventional diabetes classes conducted by diabetes educators . When measurements taken before and three months after the education were compared , both groups showed significant improvement in their knowledge ; the blood glucose levels of the CAL group were significantly lower but those of the conventional education group were higher . This means that the CAL program was as effective as conventional education in imparting knowledge but it was more likely to motivate people to control their glucose levels . The CAL program allows diabetes educators to spend less time on education in basic knowledge and to concentrate more on motivational and social factors that are important determinants of patient compliance . It can also benefit people with diabetes whose access to health professionals and /or conventional diabetes education is restricted AIMS To evaluate the effectiveness and cost implication s of a  hospital diabetes specialist nursing service . METHODS We conducted a prospect i ve , open , r and omized , controlled trial of st and ard in-patient care for adults with diabetes , with and without the intervention of a diabetes specialist nursing ( DSN ) service . The setting was a single UK university hospital . SUBJECTS were unselected patients referred to the hospital DSN service . Primary outcome measures were length of hospital stay and patterns of readmission ( frequency and time to first readmission ) . Secondary outcome measures were subjects ' diabetes-related quality of life , diabetes knowledge score , satisfaction with treatment , and GP and community care contacts following discharge . Costs were estimated from the hospital and published sources . RESULTS Median length of stay was lower in the intervention group ( 11.0 vs. 8.0 days , P < 0.01 ) . Readmission rates were the same in the two groups ( 25 % ) , and mean time to readmission was similar in the two groups , although slightly less in the control group ( 278 vs. 283 days , P = 0.80 ) . The cost per patient for nursing input was 38.94 pounds sterling . However , when the reduced length of stay was accounted for , the intervention produced a mean cost per admission of 436 ponds sterling lower than that of the control group ( P = 0.19 ) . Patients in the intervention group were more knowledgeable regarding their diabetes and more satisfied with their care . CONCLUSIONS Diabetes specialist nurses are potentially cost saving by reducing hospital length of stay ( LOS ) . There was no evidence of an adverse effect of reduced LOS on re-admissions , use of community re sources , or patient perception of quality of care OBJECTIVE We evaluated automated telephone disease management ( ATDM ) with telephone nurse follow-up as a strategy for improving diabetes treatment processes and outcomes in Department of Veterans Affairs ( VA ) clinics . We also compared the results with those of a prior ATDM trial conducted in a county health care system . RESEARCH DESIGN AND METHODS A total of 272 VA patients with diabetes using hypoglycemic medications were r and omized . During the 1-year study period , intervention patients received biweekly ATDM health assessment and self-care education calls , and a nurse educator followed up with patients based on their ATDM assessment reports . Telephone surveys were used to measure patients ' self-care , symptoms , and satisfaction with care . Outpatient service use was evaluated using electronic data bases and self-reports , and glycemic control was measured by HbA1c and serum glucose testing . RESULTS At 12 months , intervention patients reported more frequent glucose self-monitoring and foot inspections than patients receiving usual care and were more likely to be seen in podiatry and diabetes specialty clinics . Intervention patients also were more likely than control patients to have had a cholesterol test . Among patients with baseline HbA1c levels > or = 8 % , mean end-point values were lower among intervention patients than control patients ( 8.7 vs. 9.2 % , respectively ; P = 0.04 ) . Among intervention and control patients with baseline values > or = 9 % , mean end-point values were 9.1 and 10.2 % , respectively ( P = 0.04 ) . At follow-up , intervention patients reported fewer symptoms of poor glycemic control than control patients and greater satisfaction with their health care . CONCLUSIONS This intervention improved the quality of VA diabetes care . Intervention effects for most end points replicated findings from the prior county clinic trial , although intervention-control differences in the current study were smaller because of the relatively good self-care and health status among the current study 's enrollees In patients with non-insulin-dependent diabetes mellitus ( NIDDM ) , the influence of knowledge about their disease on the treatment and control of the disease is not clear . We evaluated the efficacy of educational group meetings with NIDDM patients on improving their knowledge of the disease and on disease management .  Fifty-one NIDDM patients were r and omly assigned to either intervention or control groups . The intervention group participated in courses of three weekly lessons presented by a physician , nurse , and dietitian once every 4 mo . The intervention and control groups were also followed once every 2 mo in the clinic by the same staff . Medical treatment remained unchanged during the study . After a 12-mo follow-up of the intervention group , no significant improvement in their knowledge of diabetes could be demonstrated . However , mean fasting and postpr and ial blood glucose levels and HbA1c improved significantly in comparison with the control goup . The same tendency was evident with the weight and lipoprotein profile . We conclude that educational group therapy can improve diabetes control in patients with NIDDM OBJECTIVE To assess the quality of r and omization  from reports of trials in a sample of specialist journals , and to compare those results with a similar assessment from a sample of general medical journals . DESIGN Evaluation of all 206 reports of parallel-group r and omized trials published in the 1990 and 1991 volumes of four journals of obstetrics and gynecology and of 81 reports of trials published during 1987 in four general medical journals . RESULTS Of the reports published in the specialist and in the general medical journals , only 32 % and 48 % , respectively , reported having used an adequate method to generate r and om numbers ; only 23 % and 26 % , respectively , contained information showing that steps had been taken to conceal assignment until the point of treatment allocation ; and merely 9 % and 15 % , respectively , described adequate methods of both sequence generation and allocation concealment . In those reports of trials that had apparently used unrestricted r and omization , the differences in sample sizes between treatment and control groups were much smaller than would be expected by chance , and that feature was more marked in the specialist journals . In reports of trials in which hypothesis tests had been used to compare baseline characteristics , only 2 % of tests reported in specialist journals and 4 % of tests reported in general journals were statistically significant , lower than the expected rate of 5 % . CONCLUSIONS Generating unbiased comparison groups requires proper r and omization , yet the reports in these specialist and general journals usually provided inadequate or unacceptable information . Additional analyses suggest that nonr and om manipulation of comparison groups and selective reporting of baseline comparisons may have occurred OBJECTIVE To evaluate the effectiveness of a cluster visit model led by a diabetes nurse educator for delivering outpatient care management to adult patients with poorly controlled diabetes . RESEARCH DESIGN AND METHODS This study involved a r and omized controlled trial among patients of Kaiser Permanente 's Pleasanton , CA , center who were aged 16 - 75 years and had either poor glycemic control ( HbA1c > 8.5 % ) or no HbA1c test performed during the previous year . Intervention subjects received multidisciplinary outpatient diabetes care management delivered by a diabetes nurse educator , a psychologist , a nutritionist , and a pharmacist in cluster visit setting s of 10 - 18 patients /month for 6 months . Outcomes included change ( from baseline ) in HbA1c levels ; self-reported changes in self-care practice s , self-efficacy , and satisfaction ; and utilization of inpatient and outpatient health care . RESULTS After the intervention , HbA1c levels declined by 1.3 % in the intervention subjects versus 0.2 % in the control subjects ( P < 0.0001 ) . Several self-care practice s and several measures of self-efficacy improved significantly in the intervention group . Satisfaction with the program was high . Both hospital ( P = 0.04 ) and outpatient ( P < 0.01 ) utilization were significantly lower for intervention subjects after the program . CONCLUSIONS A 6-month cluster visit group model of care for adults with diabetes improved glycemic control , self-efficacy , and patient satisfaction and result ed in a reduction in health care utilization after the program AIM The aim of our study was to describe investigate and association between improved glycaemic control on quality of life ( QoL ) during 1 year of treatment in a sample of 94 Type 2 diabetic patients referred for insulin therapy to an outpatient department ( OPD ) . Treatment was aim ed at achieving acceptable glycaemic control by means of maximizing oral therapy , if necessary switching over to insulin therapy , and information and education provided by a diabetes specialist nurse and dietitian . METHODS QoL was measured using a disease-specific ( Diabetes Health Profile ( DHP ) ) and a generic question naire ( R AND -36 ) . After 1 year the medical examination and QoL measurements were repeated . The association between 1-year changes in QoL and achievement of good metabolic control ( final glycosylated haemoglobin ( HbA1c ) < or = 8 % ) , switch to insulin therapy , and presence of hyperglycaemic complaints at baseline was analysed after adjustment for appropriate confounders . RESULTS After 1 year , mean HbA1c was reduced from 10.4 % to 7.8 % . Also QoL improved in the total group . Patients who achieved good glycaemic control after 1 year ( 61 % ) improved in a similar manner as the others . Patients switched over to insulin ( 65 % ) improved in a similar manner as the others , but at the final examination they experienced more problems with social functioning and pain . Patients with hyperglycaemic complaints at baseline ( 49 % ) improved more in QoL than those without , especially in physical functioning , vitality and health change , but at the final examination still scored lower on a majority of the DHP and R AND -36 dimensions . CONCLUSION Symptoms of hyperglycaemia predict the strength of an association between improvements of glycaemic control and OBJECTIVE We evaluated the impact of automated telephone disease management ( ATDM ) calls with telephone nurse follow-up as a strategy for improving outcomes such as mental health , self-efficacy , satisfaction with care , and health-related quality of life ( HRQL ) among low-income patients with diabetes mellitus . RESEARCH DESIGN This was a r and omized , controlled trial . SUBJECTS Two hundred forty-eight primarily English- and Spanish-speaking adults with diabetes enrolled at the time of visits to a county health care system . INTERVENTION In addition to usual care , intervention patients received biweekly ATDM calls with telephone follow-up by a diabetes nurse educator . Patients used the ATDM calls to report information about their health and self-care and to access self-care education . The nurse used patients ' ATDM reports to allocate her time according to their needs . MEASURES Patient-centered outcomes were measured at 12 months via telephone interview . RESULTS Compared with patients receiving usual care , intervention patients at follow-up reported fewer symptoms of depression ( P = 0.023 ) , greater self-efficacy to conduct self-care activities ( P = 0.006 ) , and fewer days in bed because of illness ( P = 0.026 ) . Among English-speaking patients , those receiving the intervention reported greater satisfaction with their health care overall and with the technical quality of the services they received , their choice of providers and continuity of care , their communication with providers , and the quality of their health outcomes ( all P < 0.042 ) . Intervention and control patients had roughly equivalent scores for established measures of anxiety , diabetes-specific HRQL , and general HRQL . CONCLUSIONS This intervention had several positive effects on patient-centered outcomes of care but no measurable effects on anxiety or HRQL The effect of patient education on diabetic control in insulin-treated diabetic adults was studied in 77 subjects r and omized into two groups : intensive patient education ( group A ) and control ( group B ) . The subjects in group A received intensive patient instruction , both individually and in small groups , from a team of physicians , teaching nurses , and a dietitian . The patients in group B received a short instruction course consisting mainly of printed material . A highly significant improvement in diabetic control was observed in both groups immediately after the education programs , with gradual return to the original level during the following 3–6 mo . No difference was observed between the two groups in any of the measured parameters during the 18-mo investigation . Factors related to good control during the study included the length of school education , the quality of the control at the beginning of the study , and the high degree of self-confidence and lack of signs of anxiety in the psychological tests . The results demonstrate that the effects of educational programs are of limited value if they do not lead to permanent changes in attitudes and motivation , which are critical factors affecting long-term diabetic control AIM OF THE STUDY Assessment of effects on quality of care , in terms of patient outcomes , when tasks in the care for out patients with stable type 2 diabetes are transferred from internist to nurse specialist and from outpatient clinic to general practice . BACKGROUND For the management of chronic diseases with a high prevalence and requiring current monitoring , it is suggested that substitution of care may be an appropriate solution to safeguard high quality care . DESIGN AND METHODS A 12-month nonequivalent control group design was used . General practitioners ( GPs ) referring diabetes patients to the University Hospital Maastricht were asked to choose for the traditional model or the nurse specialist model . Informed consent was obtained from patients with stable diabetes type 2 attending these practice s. All patients received care according to the model chosen by their GP . Identified outcomes were : clinical status , health status , self-care behaviour , knowledge of diabetes , patient satisfaction , and consultation with care-providers . RESULTS In the control group ( n=47 ) no patients were treated with oral hypoglycaemic agents ( OHA ) only . The control group was compared with an intervention subgroup ( n=52 ) also without patients receiving OHA only . Clinical data were available for all patients . Patients without complete data from question naires had better mean concentration of HbA1c than patients with complete data ( P=0.004 ) . The traditional care model and the nurse specialist model achieved equal outcomes , while glycaemic control of patients in the nurse specialist model improved ( from 8.6 % to 8.3 % ) but deteriorated in the traditional model ( from 8.6 % to 8.8 % ; P-value between groups=0.001 ) . CONCLUSIONS The model with nurse specialists taking on roles and tasks beyond those traditionally regarded as their remit as well as new ones , is effective for the care of stable diabetic out patients OBJECTIVE This study was undertaken to determine the health and cost effects of using home care to treat newly diagnosed Type I diabetic children rather than traditional inpatient hospital care . There had been no well- design ed evaluations of home care for such children , and very few for children with other health conditions . METHODS Sixty-three children seen at the Montreal Children 's Hospital were r and omly assigned at diagnosis to home care or traditional inpatient care . The children in the former group were discharged once their metabolic condition stabilized ; insulin adjustments and teaching were done in their homes by a trained nurse . The children in the latter group remained hospitalized for insulin adjustments and teaching . All were followed for 24 months . The cost effects were estimated using hospital and parental data . RESULTS Social costs were only $ 48 higher with home care . It had little effect on social costs , because the increased costs of health care services with home care ( $ 768 ) were largely offset by parental cost savings ( $ 720 ) . Home care improved the children 's metabolic outcomes without adversely affecting their psychosocial outcomes . CONCLUSIONS Using home care to reduce hospital stays for children with newly diagnosed Type I diabetes improved the  children 's health outcomes without significantly increasing social costs It has been suggested that much effort expended in teaching diabetic diets is ineffective and wasteful . We have tested a different system by r and omly allocating 75 newly diagnosed obese Type 2 diabetic patients to usual ‘ unstructured ’ clinic care or to group education by diabetes specialist nurses and a dietitian . Patients allocated to group education attended five 90‐min group sessions during the first 6 months . Six months after diagnosis they had lost more weight ( median ( 95 % CI ) , 7 ( 5.5–9 ) vs 2 ( 1–5 ) kg , p<0.002 ) and were better controlled ( HbA1 : 7.5 ( 7.0–8.1 ) vs 9.5 ( 8.7–10.4 ) % , p<0.001 ) than those r and omized to the usual clinic system . At 1 year ( after no further visits ) the difference in weight loss was less ( 5.5 ( 4–6.5 ) vs 3 ( 2–4 ) kg , p<0.05 ) and diabetic control was similar ( HbA1:9.0 ( 8.2–9.8 ) vs 9.9 ( 8.9–10.9 ) % . At 1 year only 14 ( 39 % ) of the education group and 9 ( 23 % ) of those attending the clinic had a fasting blood glucose less than 7.0 mmol l−1 The purpose of this study was to evaluate the effrcacy of using a telecommunication system to assist in the outpatient management of pediatric patients with insulin- dependent diabetes .  Metabolic control , patients ' psychosocial status , family functioning , perceived quality of life , patterns of parental/child responsibility for daily diabetes maintenance , and nursing time-on-task were evaluated . One hundred six pediatric patients ( mean age= 13.3 years ) were r and omly assigned to an experimental or control outpatient clinic for 1 year . Experimental subjects transmitted self-monitoring blood glucose data by modem to the hospital every 2 weeks . Transmitted data were review ed by nurse practitioners who telephoned subjects to discuss regimen adjustments . Control subjects received st and ard care with regimen adjustments made by physicians . There were no significant between-group differences for metabolic control , rates of hospitalization or emergency-room visits , psychological status , general family functioning , quality of life , or parent-child responsibility . A significant decrease was noted in nursing time-on-task for experimental subjects Background . Newly diagnosed insulin-dependent diabetic children are most often admitted to hospital for education and insulin management and subsequently followed in outpatient clinics or office setting s. However , most could be managed at home , given adequate family and health care team support and subsequent follow-up facilitated by home-based nursing intervention . We conducted a r and omized trial of clinical , psychosocial , and cost effects of home-based management in a 2-year follow-up study of newly diagnosed diabetic children . Methods . Sixty three patients were r and omly assigned to  traditional hospitalization and outpatient follow-up ( hospital-based group ) or home management ( home-based group ) . Treatment differences between the two groups consisted of duration of initial hospital stay , site and timing of initial teaching , and nature and extent of subsequent nursing follow-up . Metabolic control was assessed by means of quarterly glycosylated hemoglobin measurements for 24 months and then at 36 months . Diabetes-related adverse events , knowledge of diabetes , adherence to the diabetes regimen , psychosocial impact , and social ( total ) costs incurred were assessed for 24 months . Findings . Glycosylated hemoglobin concentrations were significantly lower in the home-based group at 12 to 24 months and at 36 months . Both groups had comparable numbers of diabetes-related adverse events . There were no significant group differences in psychosocial impact . Parents in the home-based group spent significantly fewer hours on diabetes care and incurred significantly lower out-of-pocket expenses during the 1st month . Health care sector costs were significantly higher . Hospital costs were $ 889 higher , and government costs $ 890 higher per child . Social ( total ) costs were only $ 48 higher per case ( NS ) with home care when parents ' time was valued at $ 11.88 per hour . Interpretation . Home-based management for newly diagnosed diabetic children can result in better metabolic control and similar psychosocial outcomes compared with traditional hospital- and clinic-based care without notable effects on social ( total ) costs AIMS To ascertain the effect of routine review by a diabetes nurse advisor on length of stay for medical and surgical in patients with diabetes . METHODS In patients with diabetes were identified prospect ively from January 1997 until December 1998 ( 792 in 1997 and 819 in 1998 ) . A new post of diabetes nurse advisor was introduced in January 1998 to optimize diabetes management . Length of stay was calculated retrospectively from hospital computer records . RESULTS Median length of stay in 1997 was 11 days in medicine and 8 days in surgery . In 1998 , the nurse advisor made 1936 visits to 819 patients ; median length of stay fell to 8 days in medicine and 5 days in surgery ( P < 0.001 ) . Bed occupancy by patients with diabetes fell from 6.8 to 4.0 % . Mean length of stay across the hospital remained unchanged . CONCLUSIONS The introduction of a ward-based diabetes nurse advisor was associated with significant reductions in length of stay in in patients with diabetes . Since this study was not a r and omized study , other factors may have contributed to this change . However , the consistency of the reduction across specialities suggests the post itself had an important effect OBJECTIVE To determine whether a 6-month home-based intervention program in adolescents with poorly controlled diabetes improves metabolic control and whether benefits are maintained after the intervention . RESEARCH DESIGN AND METHODS Adolescents with a mean HbA1c of > 9.0 % over the preceding 12 months received either  routine care in a diabetes clinic and an ambulatory intervention for 6 months ( n = 37 ) or routine care only ( n = 32 ) . A diabetes educator provided monthly home visits and weekly phone contact to educate and support the adolescents in setting goals for insulin adjustment , blood glucose monitoring , and target blood glucose range . There was no systematic change in the frequency of insulin injections . After the intervention , there was a 12-month follow-up when the intervention and control groups both received only routine care . Outcome measures were HbA1c and Diabetes Knowledge Assessment ( DKN ) . RESULTS During the intervention , mean HbA1c fell ( baseline : 11.1 + /- 1.3 % , 6 months : 9.7 + /- 1.6 % ; P = 0.0001 ) and mean knowledge scores increased ( P = 0.0001 ) in the intervention group but not in control subjects . However , this improvement in HbA1c and increase in knowledge was not maintained in the intervention group at 12- and 18-month follow-up assessment s. Parents ' knowledge scores also improved significantly from baseline levels in the intervention group at 6 and 12 months ( P = 0.001 , P = 0.005 , respectively ) . CONCLUSIONS An ambulatory program improves metabolic control and knowledge in adolescents with poorly controlled type 1 diabetes ; however , it is effective only while the intervention is maintained OBJECTIVE To describe the methods used to implement intensive and conventional therapies in the Diabetes Control and Complications Trial ( DCCT ) and the metabolic results that occurred with the different treatment regimens . RESEARCH DESIGN AND METHODS The DCCT was a controlled clinical trial that demonstrated the beneficial effect of intensive therapy on the long-term complications of insulin-dependent diabetes mellitus ( IDDM ) . A total of 1,441 volunteers with IDDM , aged 13–39 , from 29 centers in the U.S. and Canada , were r and omly assigned to conventional or intensive diabetes therapy . Intensive therapy , which used multiple daily injections ( MDI ) of insulin ( ≥3 injections/day ) or continuous subcutaneous insulin infusion ( CSI1 ) , was implemented by a team that included diabetes nurses , dietitians , behavioral experts , and diabetologists . Volunteers in the intensive treatment group could use MDI or CSII , based on patient and clinic preference , and could switch between therapies over the course of the study . The volunteers were followed for a mean of 6.5 years ( range 3–9 years ) . RESULTS A detailed analysis of implementation of the two treatments indicates that intensive and conventional treatment subjects adhered to their respective insulin injection regimens > 97 % of the time . Adherence to other elements of intensive treatment was similarly high and result ed in median HbAlc values between 6.7 and 7.2 , compared with 8.7–9.2 with conventional therapy , over the course of the study . Severe hypoglycemia occurred three times more often in intensively treated subjects . Although subjects on intensive treatment were not r and omly assigned to MDI or CSII , we compared those subjects who used either of these methods for > 90 % of the study time . CSIIy-treated patients maintained a mean HbAlc of 6.8 vs. 7.0 in MDI-treated subjects during the trial ( P < 0.05 ) . The frequency of hypoglycemia with coma and seizure and diabetic ketoacidosis was modestly higher with CSII than with MDI . CONCLUSIONS Intensive therapy was implemented successfully in the DCCT . The detailed description herein will serve to facilitate translation of the DCCT results to the clinical setting Eighty consecutive newly diagnosed non-insulin-dependent diabetic patients were r and omly allocated into two groups to compare two different patient education regimens . One group received individual dietary instructions by a nurse and the other a short , written leaflet given by a doctor . The principal aim of the dietary instructions was weight reduction . A significant weight loss and improvement in the control of diabetes occurred in both groups , and these changes were similar in the two groups . At the end of one year 's follow-up , however , only 25 % of the patients were satisfactorily controlled ( fasting blood glucose less than or equal to 6.0 mmol/l ) . The degree of weight loss correlated only weakly with the improvement in the metabolic control . The degree of obesity and insulin secretion capacity as measured at the beginning of the study did not predict the improvement of glycaemic control during the study . At the end of the study a significant improvement was observed in serum lipids of patients with good control ( fasting blood glucose less than or equal to 6.0 mmol/l ) or weight loss ( greater than 5 kg ) . In conclusion , both brief , written and individual dietary instructions induced a significant weight loss as well as improved glucose and lipid metabolism in newly diagnosed non-insulin-dependent diabetic patients , but satisfactory metabolic control was achieved only in a minority of the patients OBJECTIVE To examine baseline renal screening practice s and the effect of nurse case management of patients with diabetes in a group model health maintenance organization ( HMO ) . RESEARCH DESIGN AND METHODS We performed both 1-year retrospective and 1-year prospect i ve studies of renal assessment practice s and ACE inhibitor usage in a cohort of 133 diabetic patients enrolled in a r and omized controlled trial of a diabetes nurse case management program in a group model HMO . In accordance with American Diabetes Association recommendations , urine dipstick and quantitative protein and microalbuminuria testing rates were calculated . RESULTS At baseline , 77 % of patients were screened for proteinuria with dipsticks or had quantitative urine testing . Of patients with negative dipstick findings , 30 % had appropriate quantitative protein or microalbumin follow-up at baseline . Baseline ACE inhibitor usage was associated with decreased follow-up testing ( relative risk = 0.47 ) . Nurse case management was associated with increased quantitative protein or or microalbumin testing and increased follow-up testing ( relative risk = 1.65 and 1.60 , respectively ) . CONCLUSIONS We found a higher degree of adherence to recommendations for renal testing than has been reported previously . Nurse case management intervention further increased renal screening rates . The inverse association between ACE inhibitor usage and microalbumin testing highlights a potentially ambiguous area of current clinical pathways BACKGROUND This study was done to determine the efficacy and ease of administration of education/behavior modification classes , provided by a nurse and a dietitian in a primary care clinic for improving control of type 2 diabetes mellitus .  METHODS Patients were divided r and omly into two groups . Eighteen patients completed 6 months of structured , office-based classes , and 20 similar patients served as control subjects . All were patients of the same group practice and had their usual office visits .  Glycemic control , lipid levels , body weight , knowledge about diabetes , medication requirements , and symptoms were monitored during the 6 months , with follow-up at 12 months . RESULTS At the end of 6 months , the intervention group had significant reductions in mean fasting blood glucose , glycosylated hemoglobin , total cholesterol , and low-density lipoprotein cholesterol ( LDL-C ) values . Their mean body weight was significantly reduced at 12 months , and their knowledge of diabetes was improved . Control patients had significant improvement only in glycosylated hemoglobin and body weight at 6 months . Minimal physician time was required . CONCLUSION The education/behavior modification program was clinical ly worthwhile , and it was easy to administer The Diabetes Control and Complications Trial ( DCCT ) and the Kumamoto study [ 1 , 2 ] showed that near-normal glycemic control reduces the development and progression of microvascular and neuropathic complications by approximately 50 % in type 1 and type 2 diabetes mellitus . Additional analyses [ 3 - 5 ] indicate that therapy to achieve near normalization of blood glucose levels is cost-effective compared with other treatments . Thus , the American Diabetes Association has recommended that all persons with diabetes attempt to achieve near normalization of blood glucose levels [ 6 ] . This recommendation is not routinely followed in medical practice . In a 1989 national survey of physician practice behaviors in the United States , 64 % of physicians agreed that achieving target HbA1c values is very important but only 18 % reported that they ordered HbA1c tests every 2 to 3 months for patients with type 1 diabetes [ 7 ] . Although 98 % agreed that patient education improves glucose control , only 55 % reported that they routinely used a dietitian or a diabetes educator in patient care . Studies indicate that bringing clinical practice into line with scientific knowledge can be difficult . Methods used to achieve diabetes control in clinical trials are re source intensive . The American Diabetes Association currently recommends that patients with diabetes see their primary care physicians two to four times per year . Data from the National Health Interview Survey , a nationally representative survey [ 8 ] , indicate that most patients with diabetes are seen by nonspecialists and that 69 % of physician visits last less than 15 minutes . Algorithms for diabetes care exist but may be complex and difficult for physicians to follow , given patient load , diversity of patients seen , lack of information systems , and time constraints . Simple , low-cost methods of translating guidelines into clinical care are required . One solution may be to make greater use of personnel other than physicians . Nurse case management was an integral part of intensive therapy in the DCCT and has proven to be effective in reducing smoking and cholesterol levels after acute myocardial infa rct ion [ 3 , 9 ] . A nonr and omized study [ 10 ] of more than 700 patients with diabetes in a health maintenance organization suggests that nurse case management may be effective in improving metabolic control . Other studies [ 11 , 12 ] show a strong association between algorithm-directed nurse interventions and improved glycemic control . To our knowledge , no r and omized , controlled clinical trial of nurse case management in diabetes has yet been published . In a 12-month r and omized , controlled trial , we compared a nurse case management model of diabetes care with usual diabetes management in a primary care setting . Methods Patients Our study was approved by the institutional review board of the Prudential Center for Health Care Research , and all patients gave written informed consent . Participants were recruited from two of the largest clinics within the Jacksonville Health Care Group , which is the largest provider of primary care services for the Prudential HealthCare HMO plan of Jacksonville , Florida . The Jacksonville Health Care Group is a group of 43 primary care physicians who provide care in eight clinics to more than 75 000 Prudential HealthCare plan members . Potential study participants were identified through a data base used to support quality -improvement activities . Prudential HealthCare HMO members who had diabetes were included in the data base if they had visited a physician for diabetes ( International Classification of Diseases , 9th Revision , codes 250.0 to 250.9 ) , had had a hospital cl aim processed for diabetes , had been seen by the utilization management nurse , or had been referred to an ophthalmologist for a diabetic retinal examination . This data base is up date d regularly . A list with each member 's name , address , telephone number , medical record number , member identification number , age , sex , physician , and clinic was generated by merging the data from the data base with enrollment information . In addition , a list of members who may have had diabetes was created by using pharmacy data . Adult members with diabetes who were potential study participants each received a recruitment call and were invited to schedule an appointment with a research assistant to discuss participation in the study . We made a total of 14 calls at different times and on different days before coding a member as unavailable . After consent was given and the eligibility assessment was completed , baseline information was obtained and an HbA1c test was ordered if the result of one given within the previous 60 days was not available . Patients were ineligible for the study if they had a recent HbA1c value less than 7.0 % ; had uncontrolled hypertension ( blood pressure > 180/110 mm Hg ) ; had unstable angina ( class 4 ) ; had had a myocardial infa rct ion in the past 3 months ; had had two or more episodes of seizures ; had alcoholism or drug abuse documented in the chart ; had late-stage complications of diabetes or other chronic conditions , such as severe immunodeficiency or cirrhosis ; were pregnant or were planning to become pregnant in the next 12 months ; or were unable to perform self-management . Patients were r and omly assigned in blocks to either the nurse case management ( intervention ) group or the usual care group . R and omization was based on a 1:1 allocation ratio and a block size of three . Each block contained six patients , three in each study group . This r and omization scheme ensured that the desired allocation ratio-one intervention patient to one usual care patient-was maintained after sequential enrollment of every sixth patient . Outcome Measures Change in HbA1c value was the primary outcome measure . Decreased HbA1c values correlate directly with reduced risk for diabetes-related microvascular and neuropathic complications in type 1 and type 2 diabetes [ 1 , 3 ] . We also assessed health-related quality of life by using four generic questions developed by the Centers for Disease Control and Prevention for the Behavioral Risk Factor Surveillance System ( BRFSS ) [ 13 , 14 ] . These questions evaluate key conceptual domains of health-related quality of life : 1 ) patient-perceived general health status , 2 ) patient-perceived physical dysfunction during the previous 30 days , 3 ) patient-perceived mental dysfunction during the previous 30 days , and 4 ) patient-perceived functional incapacity during the previous 30 days for either mental or physical reasons . The BRFSS quality -of-life measures have been vali date d in a national sample of adults in the United States [ 15 ] . Patient-perceived health was found to be a good proxy indicator for chronic disease conditions . The other three domains further characterize general health functioning and quality of life [ 15 ] . In this analysis , we report findings related to the patient-perceived general health status domain . Intervention and Follow-up The nurse case manager was a registered nurse and a certified diabetes educator . She was trained to follow a set of detailed management algorithms under the direction of a board-certified family medicine physician and an endocrinologist who were responsible for all diabetes management decisions for patients in the intervention group but were not primary care providers for these patients . The algorithms were specific for type of diabetes and were developed by a multidisciplinary team on which endocrinology , family medicine , nursing , pharmacy , health services research , and epidemiology were represented . The algorithms progressively moved a patient toward improvement of glycemic control through adjustments in medication , meal planning , and reinforcement of exercise ( Figure 1 ) . Figure 1 . Algorithm for management of type 2 diabetes mellitus . Patients assigned to receive nurse case management met with the nurse for an initial assessment , were instructed about a blood glucose monitoring schedule , and returned for a follow-up visit 2 weeks later . The initial visit with the nurse averaged 45 minutes . At the 2-week follow-up visit , the nurse review ed the patient 's blood glucose log ; explained the algorithm step to which the patient had been assigned ; and used this information as the baseline for subsequent medication adjustments , meal planning , and exercise reinforcement . Patients receiving nurse case management  were also referred to a 5-week , 12-hour diabetes education program that included individual counseling by a dietitian , individual counseling by an exercise therapist , and group diabetes education classes . Subsequent in-person follow-up visits occurred quarterly . Patients in the nurse case management group  who were taking insulin  received weekly follow-up telephone calls . After the nurse review ed the blood glucose log and discussed glucose values with the patient , medication regimens were adjusted as needed and meal planning and exercise were reinforced . Patients treated with oral agents or diet and exercise  received follow-up telephone calls every 2 weeks . The nurse case manager met at least biweekly with the family medicine physician and the endocrinologist to review patient progress , medication adjustments , and other issues related to diabetes care . All medication adjustments or changes were communicated to the patients ' regular primary care physicians . Patients assigned to receive usual care were given blood glucose meters and strips , were encouraged to discuss enrollment in the diabetes education class with their physicians if they had not done so in the past year , and continued to receive diabetes care and follow-up from their primary care physicians . The 5-week diabetes education program is a st and ard , free-of-charge benefit for all HMO members with diabetes . All Jacksonville Health Care Group primary care physicians participate in an annual diabetes care seminar and undergo regular peer review of their adherence to published diabetes care st and ards . Tests to OBJECTIVE This study compared the effect of cognitive analytic therapy ( CAT ) , a focused time-limited psychotherapy , and diabetes specialist nurse education ( DSNE ) in a controlled trial of 26 chronically poorly controlled adult type I patients . RESEARCH DESIGN AND METHODS Patients were r and omized to either 16 sessions of CAT ( treatment )  or 14–18 sessions of DSNE ( control ) . Pre- and post-treatment blood glucose control ( HbA1 ) , interpersonal difficulties , and diabetes knowledge were measured before and up to 9 months after treatment was completed . RESULTS Although HbA1 levels improved in the DSNE group , at the end of treatment ( mean fall 1.2 % , P = 0.004 ) this was not maintained ; so by the 9-month follow-up , the overall net fall was limited to 0.9 % ( P = 0.03 vs. entry value ) . There were no significant improvements in interpersonal difficulties in DSNE subjects at any retest point ( P > 0.05 ) . In contrast , glycemic control and interpersonal difficulties both improved after CAT . In contrast to DSNE , this improvement continued so that at the 9-month follow-up visit , the changes were significant ( mean fall in HbA1 = 2 % , P = 0.002 and P = 0.03 for the Inventory of Interpersonal Problems [ IIP ] scores ) . CONCLUSIONS These results suggest that although there is no statistical difference between CAT and DSNE , the effects of CAT produce a more prolonged effect on glycemic control . If psychological difficulties underlying problems with self-care in a type I population are addressed , then improvements in diabetes control are likely to continue PURPOSE We sought to evaluate the effect of automated telephone assessment and self-care education calls with nurse follow-up on the management of diabetes . SUBJECTS AND METHODS We enrolled 280 English- or Spanish-speaking adults with diabetes who were using hypoglycemic medications and who were treated in a county health care system . Patients were r and omly assigned to usual care or to receive an intervention that consisted of usual care plus bi-weekly automated assessment and self-care education calls with telephone follow-up by a nurse educator . Outcomes measured at 12 months included survey-reported self-care , perceived glycemic control , and symptoms , as well as glycosylated hemoglobin ( Hb A1c ) and serum glucose levels . RESULTS We collected follow-up data for 89 % of enrollees ( 248 patients ) . Compared with usual care patients , intervention patients reported more frequent glucose monitoring , foot inspection , and weight monitoring , and fewer problems with medication adherence ( all P -0.03 ) . Follow-up Hb A , , levels were 0.3 % lower in the intervention group ( P = 0.1 ) , and about twice as many intervention patients had Hb A1c levels within the normal range ( P = 0.04 ) . Serum glucose levels were 41 mg/dL lower among intervention patients than usual care patients ( P = 0.002 ) . Intervention patients also reported better glycemic control ( P = 0.005 ) and fewer diabetic symptoms ( P < 0.0001 ) , including fewer symptoms of hyperglycemia and hypoglycemia . CONCLUSIONS Automated calls with telephone nurse follow-up may be an effective strategy for improving self-care behavior and glycemic control , and for decreasing symptoms among vulnerable patients with diabetes The effectiveness of an enhanced preparation intervention was compared with the staiidard preparation intervention for accuracy in overnight urine specimen collection s. The sample consisted of 179 individuals with type I insulin-dependent diabetes mellitus ( IDDM ) . Subjects were assigned r and omly to an enhanced or st and ard preparation group . The enhanced preparation included written instructions , a reminder to post instructions in the bathroom , a toilet seat cover with a reminder to save urine , and a nurse-initiated telephone call to review the instnlctions . The st and ard preparation included written instructions and a telephone number to call with any questions . For subjects without previous collection experience , significantly fewer inaccurate collection s were reported in the enhanced preparation group than in the st and ard group ( x2 = 4.61 , P<.05 ) . There were no differences in collection accuracy between enhanced and st and ard groups for subjects with collection experience ( x 2 = .4598 , P>.05 ) The purpose of this study was to evaluate the efficacy and feasibility of a newly developed diabetes patient education program consisting of a three-day hospitalization and a six-month follow-up by telephone counseling for patients with mild type 2 diabetes or impaired glucose tolerance ( IGT ) by a r and omized controlled trial ( RCT ) method . Fifty-two patients with mild type 2 diabetes or IGT ( HbAlc<8 ) were r and omly assigned to either an intervention group or a control group . The current care was continued for the control group and the new education program was provided in addition to the current care for the intervention group . Changes in weight , blood glucose in a 75g-oral glucose tolerance test ( 75g-OGTT ) , and HbAlc were measured in June 1997 as baseline data and again in Dec. 1997 . Scores for knowledge of diabetes , dietary habits , physical activity , health practice index , diabetes quality of life ( DQOL ) , and self-efficacy were also obtained . After six months , the intervention group showed a statistically significant weight loss and blood glucose reduction in the 75g-OGTT test , but the control group did not . A significant improvement in lifestyle was observed in the intervention group , especially in terms of dietary habits and physical activity . The knowledge test scores increased in both groups . There were no significant differences in HbAlc , DQOL , or self-efficacy between the two groups . The results of this study show that the combination of a three-day hospitalization and a six-month follow-up by telephone counseling is effective in metabolic control and improvement of lifestyle for patients with mild type 2 diabetes or IGT . The reasons for the effectiveness were considered to be that l)changes in lifestyle were based on autonomous decision-making ; 2)regular , consistent counseling was provided by the nurse in charge of each patient ; 3)extended follow-up is more effective than initial education in preventing a rebound of weight or metabolic control Home health nurses provided individualized instruction in diabetes self-care within the home environment of 393 diabetic individuals . Each subject was r and omly assigned to either the intervention ( those receiving home teaching ) or control ( those not receiving home teaching ) group . At 6 mo postenrollment , intervention subjects showed significantly greater self-care knowledge and skills than control subjects , although the actual differences between the two groups in terms of self-care skills were probably too small to have any practical meaning . The primary objective of the study , which was the reduction of the number of preventable diabetes-related hospitalizations ( ketoacidosis , ketotic coma , nonketotic coma , insulin reaction , and diabetes out of control ) , was not achieved ; no differences between the groups were noted after 12 mo of follow-up . Similarly , length of hospital stay , foot problems , emergency room and physician visits , and sick days were roughly equivalent in both groups during the follow-up year . These results suggest that , in the absence of concurrent changes in the health-care delivery system and strategies for influencing attitudes toward self-care , education alone is ineffective This study tested the hypothesis that follow-up intervention ( by telephone calls and home visit ) affects compliance in patients with non-insulin-dependent diabetes mellitus ( NIDDM ) . Sixty NIDDM patients were r and omly assigned to two groups — a control group , which received the st and ard protocol ( 3-day educational program and a review session 1 month after the program ) ; and an intervention group , which received the st and ard protocol as well as a series offour telephone calls and one home visit by a registered nurse over a 3-month period .  Compliance to prescribed regimens was determined by analyzing three sets of data : changes in pre- to post study glycosylated hemoglobin ( HbA1c ) values ; changes in pre- to post study weight ; and frequency with which self-monitoring of blood glucose ( SMBG ) was practice d. Results showed that SMBG practice was significantly better for the intervention group . No significant differences were seen in post study HbA 1c values and weight changes between the two groups . Follow-up inter vention by telephone calls and home visit can enhance patient compliance to certain aspects of the prescribed diabetes management plan Given that 14 million Americans have diabetes [ 1 ] , the common complications of this disorder , such as foot ulcers and lower extremity amputations , are of major concern to the medical community . Approximately 20 % of all diabetic patients hospitalized in the United States are admitted because of foot complications [ 2 , 3 ] . Furthermore , about 50 % of all nontraumatic amputations in the United States are done in patients with diabetes [ 1 , 4 ] . This proportion equates to about 55 000 amputations a year [ 1 ] or 59.7 amputations for every 10 000 persons with diabetes [ 5 ] . Patients who undergo an amputation are at greater risk for a second similar procedure on either the same or the other leg [ 6 , 7 ] . Yet , it has been estimated that about one half of the amputations in patients with diabetes , or about one fourth of the total amputations done in the United States , are preventable [ 1 , 4 ] . Recently , the focus has been on preventive strategies that minimize foot damage in diabetic patients and thereby reduce the rates of ulcers and amputations . These preventive strategies are based on two observations : first , that simple efforts on the part of the health care provider or patient can reduce the likelihood of subsequent amputation due to diabetes-associated foot disease [ 8 ] ; and second , that many of these simple procedures are not being systematic ally applied by health care providers or patients [ 9 ] . For example , studies indicate that physicians infrequently examine the feet of patients with diabetes [ 9 , 10 ] . Also , most patients with diabetes do not engage in simple foot-care assessment s to identify lesions requiring early treatment [ 11 ] . Preventive strategies are not systematic ally applied for several reasons : First , patients may not be aware of foot-care procedures or how to do them , or they may not believe that such procedures can make a difference ; second , podiatry and orthopedics services that could assist in foot salvage in diabetic patients may not be available ; and , finally , the health care system may make it difficult for patients or health care providers to examine the feet of patients with diabetes [ 10 ] . Several uncontrolled studies found that implementation of improved foot-care programs can significantly reduce lower extremity complications in patients with diabetes ; these studies showed a 44 % to 85 % reduction in the rate of lower extremity amputations [ 4 , 12 - 14 ] . A recent casecontrol study also supports the implementation of preventive strategies , such as foot care , use of protective footwear , and aggressive treatment of foot  infection by patients or health care providers , to decrease the risk for lower extremity amputation [ 15 ] . The intervention in our study was design ed to reduce the prevalence of risk factors for lower extremity amputations  in patients with noninsulin-dependent diabetes and involved the three major elements of a prevention program : the patient , health care providers , and the health care system . Specifically , we did a r and omized , controlled trial to determine whether a comprehensive foot-care intervention could improve patients ' knowledge and performance of appropriate foot care ; increase the number of referrals to specialty clinics such as the podiatry clinic ; increase the frequency of foot examinations by health care providers and the documentation of risk factors in the medical record ; and improve short-term patient outcomes such as skin and nail conditions known to be risk factors for ulcers and amputations . Methods Setting Our study , the design of which is summarized in Figure 1 , was done from April 1989 to March 1991 in the academic general medicine practice of the Regenstrief Health Center in Indianapolis , Indiana [ 16 ] . The practice is subdivided into four primary care teams ( labeled A , B , C , and D ) , each with its own nursing and clerical staff . Each team sees patients for eight half-day sessions per week , with each session staffed by one or two faculty internists and two to four housestaff . Teams A and C were r and omly assigned to the intervention group ; teams B and D were assigned to the control group . Previous studies in which this method of r and omization was used have shown no baseline interteam differences in patient characteristics and physician practice behavior and no effect of the team on the study outcome [ 16 - 19 ] . Figure 1 . Summary of the study design . Patient Identification and Recruitment The computerized Regenstrief Medical Record System [ 20 ] was used to identify approximately 3000 patients with noninsulin-dependent diabetes , as well as the date and time of their next appointment . Only patients with noninsulin-dependent diabetes who were seen at least two times in the preceding year by the same provider were included in the study . Additional criteria for inclusion were as follows : an age greater than 40 years ; a diagnosis of diabetes after 30 years of age ; a diagnosis of diabetes based on National Diabetes Data Group criteria [ 21 ] or the presence of disease requiring medication for the control of hyperglycemia ; an intention to obtain care at the general medicine practice for the next 2 years ; and a body weight that was either ideal or heavier than ideal . Exclusion criteria included pregnancy ; major psychiatric illness , including dementia ; terminal illness likely to cause death within 1 year ; renal failure ( serum creatinine > 440 mol/L ) ; previous bilateral amputations above or below the knee ; or an inability to provide any self-care . Patients of investigators involved in the protocol were also excluded from the study . Of the 728 eligible patients , 244 refused to participate , 89 enrolled in the study but failed to keep their appointments for assessment , and 395 were assessed by trained nurse-clinicians . Of the 395 patients assessed , 352 ( 89 % ) completed the study ; 43 patients ( 11 % ) did not complete the study for the following reasons : death ( 11 patients ) ; change of residence ( 15 patients ) ; illness ( 6 patients ) ; transportation problems ( 3 patients ) ; and miscellaneous reasons ( 8 patients ) . Patient Assessment Sample s for determining fasting plasma glucose , cholesterol , triglyceride , high-density lipoprotein , hemoglobin A1C , and C-peptide levels were obtained from enrolled patients and immediately transported to a certified laboratory for analysis . Patients gave a history and had a physical examination at study entry and approximately 1 year later ( mean , 11.8 1.5 months ) . These examinations focused on risk factors for amputation and were administered by two trained nurse-clinicians who were blinded to the patients ' experimental conditions . Foot-related data derived from the history and physical examination included the patient 's self-reported foot-care behaviors ; the quality of the patient 's examination of his or her feet ; the severity of any foot lesions ; and the presence of musculoskeletal abnormalities , dermatologic conditions , peripheral vascular disease , and peripheral neuropathy ( the neuropathy assessment included quantitative measures of pressure and temperature sensation ) . Patients were question ed about their regular foot-care routine and were asked to show how they examined their feet . During this self-examination , nurse-clinicians observed whether patients ' scrutinized the toenails , the soles of the feet , and the area between toes . Musculoskeletal and dermatologic abnormalities were assessed using st and ard definitions of findings such as callus , hammer toe , and Charcot foot [ 3 , 22 ] . The nurse-clinicians palpated the dorsalis pedis , posterior tibial , and femoral pulses bilaterally in their assessment for peripheral vascular disease . If a pulse was absent at any one of the six sites palpated , the assessment was considered abnormal . Foot lesions were rated for severity using the Seattle Wound Classification System [ 23 ] , which ranges from a grade of 1.1 ( absence of lesions ) to a grade of 10 ( entire foot or leg is gangrenous ) . In our study , a foot lesion was defined as any wound , with or without functional interruption of the protective cutaneous barrier , ranging from a superficial scratch to an ulcer involving the epidermis . A serious foot lesion was defined by a severity grade of at least 1.3 , which indicates a minor , nonulcerated lesion with clinical evidence of healing sufficient to close previous interruption of the cutaneous barrier [ 23 ] or a blister . Pressure and temperature sensations were measured using the 5.07-log ( 0.1 mg)-force Semmes-Weinstein monofilament and the thermal sensitivity testing apparatus , according to st and ard techniques [ 24 - 26 ] . Thermal sensitivity was considered abnormal if the patient had a value greater than 2 st and ard deviations from the mean value for a group of healthy persons without diabetes ( warm > 2.04 C ; cool > 1.58 C ) . Practice Patterns of Health Care Providers Immediately after each scheduled visit , study patients had a structured interview [ 10 ] with a research assistant , who asked about foot self-examination and foot-care education given by health care providers ( the primary care physician or nursing personnel ) . In addition , a chart audit was conducted by a nurse-clinician who was blinded to the patients ' experimental condition . Information abstract ed from the medical record included the physician 's documentation of the findings from the history and physical examination ; any referral to podiatry , orthopedics , or vascular surgery clinics ; and diagnostic-test ordering related to the evaluation and treatment of diabetes-associated foot problems . Intervention The intervention cohort was exposed to several risk-reduction strategies . The nurse-clinicians conducted the patient education session with one to four patients , covering appropriate foot-care behaviors and footwear , using a commercially available slide and audiotape presentation [ 27 ] and pamphlets [ 28 ] . Behavioral contracts regarding desired foot-care behaviors were negotiated with each patient . Follow-up was done by telephone 2 weeks after the education sessions to remind patients OBJECTIVE To examine whether a telephone-delivered intervention ( TDI ) , design ed to improve glycemie control in patients with non-insulin-dependent diabetes mellitus ( N1DDM ) , improved coronary risk factors in high-risk patients . RESEARCH DESIGN AND METHODS This r and omized controlled trial involved 275 veterans with N1DDM followed in a general medical clinic .  Intervention ( TDI ) patients were telephoned at least monthly by a nurse . Calls emphasized compliance with the medical regimen ( diet , medications , and exercise ) , encouraged behavioral changes , and facilitated referrals to a dietitian or smoking cessation clinic .  Control patients received no such calls . Baseline and 12-month follow-up measurements included fasting lipid profiles , weight , smoking status ( self-reported ; cessation verified by measurement of exhaled CO ) , adherence to diet and exercise ( self-reported ) , appointments , and medications ( hospital computerized data base ) . RESULTS After 12 months , equal numbers of obese patients in the two groups reported adhering to a diabetic diet and exercising  , although more obese TDI patients had seen a dietitian ( 30 vs. 7 % , P = 0.003 ) . Weight loss was not seen in either group ( —0.9 ± 5.3 vs. —0.1 ± 3.6 kg , P = 0.202 ) . Hyperlipidemic TDI patients were more likely to see a dietitian ( 31 vs. 6 % , P = 0.003 ) and receive lipid-lowering medications ( 22 vs. 9 % , P = 0.096 ) , but serum cholesterol reduction was similar between groups ( –11.7 ± 33.4 vs. –4.3 ± 32.7 mg/dl , P = 0.270 ) ; comparable results were seen for high-density lipoprotein , low-density lipoprotein , and triglyceride levels . More TDI group smokers reported quitting ( 26 vs. 0 % , P = 0.033 ) , but the difference was not significant for CO-verified abstention ( 10 vs. 0 % , P = 0.231 ) . CONCLUSIONS The TDI improved self-reported adherence to regimens that might reduce coronary risk , but had little effect on objective measures of risk PURPOSE this study was conducted to determine whether recommendations from the Diabetes Control and Complications Trial ( DCCT ) could be implemented in a large pediatric population using a diabetes clinical nurse specialist program coordinator dedicated to intensive management . METHODS Patients ' charts were review ed to examine HbAic levels from before the results of the DCCT were published and again 1 year after the recommendations were implemented . Patients who met the following criteria ( N=124 ) were enrolled : type 1 diabetes , less than 18 years old , followed at Yale for 1 year prior to the results of the DCCT and 1 year after , and HbA1c level recorded in the medical chart . RESULTS HbA1c levels were significantly lower 1 year after implementing the DCCT protocol ; 3 years later these same patients improved even further as evidence d by another decrease in HbAlC levels . The patients were taking more insulin ( more Ultralente and regular insulin and less NPH ) and had an increased number of injections at both the 1-year and 3-year follow-up points . CONCLUSIONS The DCCT protocol can be implemented in a large population of pediatric patients with the help of a nurse who is dedicated and available to the patients for ongoing adjustments and provides creative ways to overcome the barriers to achieving normoglycemia Effective control of diabetes is known to delay or prevent the end-organ complications of this disease . Can telemedicine improve a patient 's ability to self-manage diabetes  ? Twenty-eight patients entered a study comparing home telemedicine consultation with st and ard outpatient care . A nurse case manager contacted the telemedicine group once a week under the direction of a primary care physician , who contacted the telemedicine group once a month . Laboratory studies and total body weight were measured at the beginning and at the end of the 3-month study . The hemoglobin A1c ( HbA1c ) and total body weight improved significantly in the intervention ( telemedicine ) group , as shown by a 16 % reduction in mean HbA1c level ( from 9.5 to 8.2 % ) and a 4 % mean weight reduction ( from 214.3 to 206.7 pounds ) . Based on our experience , we present a functionally based telemedicine classification system to improve the application of electronic medicine in future studies CONTEXT Studies have suggested that the quality of primary care delivered by  nurse practitioners is equal to that of physicians . However , these studies did not measure nurse practitioner practice s that had the same degree of independence as the comparison physician practice s , nor did previous studies provide direct comparison of outcomes for patients with nurse practitioner or physician providers . OBJECTIVE To compare outcomes for patients r and omly assigned to nurse practitioners or physicians  for primary care follow-up and ongoing care after an emergency department or urgent care visit . DESIGN R and omized trial conducted between August 1995 and October 1997 , with patient interviews at 6 months after initial appointment and health services utilization data recorded at 6 months and 1 year after initial appointment . SETTING Four community-based primary care clinics ( 17 physicians ) and 1 primary care clinic ( 7 nurse practitioners ) at an urban academic medical center . PATIENTS Of 3397 adults originally screened , 1316 patients ( mean age , 45.9 years ; 76.8 % female ; 90.3 % Hispanic ) who had no regular source of care and kept their initial primary care appointment were enrolled and r and omized with either a nurse practitioner ( n = 806 ) or physician ( n = 510 ) . MAIN OUTCOME MEASURES Patient satisfaction after initial appointment ( based on 15-item question naire ) ; health status ( Medical Outcomes Study Short-Form 36 ) , satisfaction , and physiologic test results 6 months later ; and service utilization ( obtained from computer records ) for 1 year after initial appointment , compared by type of provider . RESULTS No significant differences were found in patients ' health status ( nurse practitioners vs physicians ) at 6 months ( P = .92 ) . Physiologic test results for patients with diabetes ( P = .82 ) or asthma ( P = .77 ) were not different . For patients with hypertension , the diastolic value was statistically significantly lower for nurse practitioner patients ( 82 vs 85 mm Hg ; P = .04 ) . No significant differences were found in health services utilization after either 6 months or 1 year . There were no differences in satisfaction ratings following the initial appointment ( P = .88 for overall satisfaction ) . Satisfaction ratings at 6 months differed for 1 of 4 dimensions measured ( provider attributes ) , with physicians rated higher ( 4.2 vs 4.1 on a scale where 5 = excellent ; P = .05 ) . CONCLUSIONS In an ambulatory care situation in which patients were r and omly assigned to either nurse practitioners or physicians , and where nurse practitioners had the same authority , responsibilities , productivity and administrative requirements , and patient population as primary care physicians , patients ' outcomes were comparable This study assessed the impact of an inpatient diabetes education program on : 1 ) staff nurses ' and patients ' knowledge about diabetes , 2 ) hospital length of stay , and 3 ) patients ' glycemic control . Over the course of 1 year , a certified diabetes educator up date d nursing staff about diabetes care and education and coordinated a diabetes education program on two experimental medical units . Length of stay of insuliti-requiritig patients with diabetes and their diabetes knowledge and glycemic control were compared with two control medical units that received no structured diabetes education program .  Results showed a significant difference in length of stay and patient knowledge between experimental and control units . Three conditions commonly associated with diabetes ( diabetic ketoacidosis , osteomyelitis , foot ulcer ) did not account for this difference in length of stay . There was no significant difference between the groups in glycemic control following discharge . While all groups showed improvement in their glycosylated hemoglobin values , only the change in the values of the total population and the control groups was significant . The findings suggest that a Certified Diabetes Educator can decrease length of stay in the hospital setting The purpose of this study was to determine the feasibility of providing a diabetes patient education and group-support intervention that was directed by a Mexican-American clinical nurse specialist ( CNS ) , dietitian , and community worker ; consistent with national st and ards ; and design ed for the Mexican-American culture . In a rural Texas-Mexico border community , subjects with diabetes were r and omly selected to participate in the intervention , and a family member of each subject participated as a support person . The intervention involved 8 weeks of educational sessions with instruction on nutrition , blobd glucose self-monitoring , exercise , and other diabetes self-management topics , and provided group support . Group discussion was facilitated using a series of Spanish- language videotapes that had been developed and previously tested in the target Mexican-American community . Results suggested statistically significant improvements in diabetes knowledge , fasting blood sugar levels , and glycosylated hemoglobin levels . The study documented the feasibility and potential benefits of the intervention This study aim ed to determine if patients can set their own educational priorities accurately and if the impact of diabetes education on knowledge differed between patients who did and did not set their own priorities . Forty patients referred for individual education were r and omly assigned to one of two groups . Prior to education with a diabetes specialist nurse ( DSN ) patients ranked 10 diabetes care topics in order of perceived importance and relevance to their needs and completed a knowledge question naire . Group 1 set their own priorities and the DSN directed education according to the patients stated priorities . In Group 2 the DSN set the educational priorities without seeing the patients priority list . The priority ranking by the two groups of the 10 topics and their pre-education knowledge score were not significantly different . Post-education knowledge scores improved equally and significantly in both groups ( Group 1 from 23 to 87 % ; Group 2 from 21 to 79 % ) ; P < 0.0001 ) . In both groups , knowledge scores for the top three priorities were significantly higher than for the three lowest ranked topics . Knowledge is neither dependent on , nor a good discriminator of , patient-selected priorities . There may be reasons why it is important for patients to set their own priorities , but education directed solely at those priorities may leave knowledge deficits which could compromise diabetes care OBJECTIVE To determine the effect of a bicultural community health worker ( CHW ) on completion of diabetes education in an inner-city Hispanic patient population and to evaluate the impact of completion of the education program on patient knowledge , self-care behaviors , and glycemic control . RESEARCH DESIGN AND METHODS Patients were r and omized into CHW intervention and non-CHW intervention groups . All patients received individualized , comprehensive diabetes education from a certified diabetes nurse educator after baseline demographic information , diabetes knowledge , diabetes self-care practice s , and glycohemoglobin levels were assessed . Rates of education program completion were determined . Diabetes knowledge , self-care practice s , and glycohemoglobin levels were reassessed at program completion and at a later postprogram follow-up medical appointment and compared to baseline . Logistic regression analysis and the Mantel-Haenszel χ2 statistic were used to determine the effect of the CHW assignment on program completion . Analyses of covariance were performed with end-of-treatment behavior scores , knowledge scores , and glycohemoglobin levels as outcome variables , controlling for baseline values and testing for the effect of CHW assignment . RESULTS Of 64 patients enrolled in the study , 40 ( 63 % ) completed and 24 ( 37 % ) dropped out before completing the diabetes education program . Of the patients having CHW intervention , 80 % completed the education program , compared with 47 % of patients without CHW intervention ( P = 0.01 ) . “ Dropouts ” were younger ( age 47.5 ± 12.5 years [ mean ± SD ] ) compared with patients who completed the program ( 55.9 ± 9.9 years ) ( P = 0.004 ) . Dropout status showed no significant relationship to educational level achieved or literacy level . For the program “ completers , ” knowledge levels and selected self-care practice s significantly improved , and glycohemoglobin levels improved from a baseline level of 11.7 % to 9.9 % at program completion ( P = 0.004 ) and 9.5 % at the postprogram follow-up ( P < 0.001 ) . The effect of the CHW assignment on program completion , controlling for financial status and language spoken , was extremely robust ( P = 0.007 ) . The effect of the CHW on knowledge , self-care behavior , or glycohemoglobin outcome variables was not statistically significant . CONCLUSIONS These findings suggest that intervention with a bicultural CHW improved rates of completion of a diabetes education program in an inner-city Hispanic patient population irrespective of literacy or educational levels attained . Our data further suggests that completion of individualized diabetes educational strategies leads to improved patient knowledge , self-care behaviors , and glycemic control
target: Where reported , emergency admissions and quality of life were not found to be significantly different between groups .
  No information was found regarding BMI , mortality , long term diabetic complications , adverse effects , or costs .
  REVIEW ER 'S CONCLUSIONS The presence of a diabetes specialist nurse / nurse case manager may improve patients ' diabetic control over short time periods , but from currently available trials the effects over longer periods of time are not evident .
  There were no significant differences overall in hypoglycaemic episodes , hyperglycaemic incidents , or hospital admissions .
  Quality of life was not shown to be affected by input from a diabetes specialist nurse/nurse case manager
background: BACKGROUND The patient with diabetes has many different learning needs relating to diet , monitoring , and treatments .
  In many health care systems specialist nurses provide much of these needs , usually aim ing to empower patients to self-manage their diabetes .
  The present review aims to assess the effects of the involvement of specialist nurse care on outcomes for  people with diabetes  , compared to usual care in hospital clinics or primary care with no input from specialist nurses .
  OBJECTIVES To assess the effects of diabetes specialist nurses / nurse case manager in diabetes on the metabolic control of patients with type 1 and type 2 diabetes mellitus .