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• W2086572905 abstract "The estimated prevalence of diabetes among adults was 7.4% in 1995 and is expected to increase to about 9% in 2025 (1American Diabetes AssociationClinical practice recommendations 2002.Diabetes Care. 2002; 25: S33-S49Google Scholar). Type 2 diabetes is frequently diagnosed many years after the onset of hyperglycemia because it develops gradually and is asymptomatic at the earlier stages. Life expectancy is about 8 years shorter for adults with diabetes aged 55 to 64 years than for nondiabetic subjects, and 4 years shorter for those aged 65 to 74 years (2Gu K. Cowie C.C. Harris M.I. Mortality in adults with and without diabetes in a national cohort of the U.S. population, 1971-1993.Diabetes Care. 1998; 21: 1138-1145Crossref PubMed Scopus (722) Google Scholar). Cardiovascular disease is the cause of most deaths (approximately 70%); hence, prevention and treatment of cardiovascular disease are important in reducing mortality (2Gu K. Cowie C.C. Harris M.I. Mortality in adults with and without diabetes in a national cohort of the U.S. population, 1971-1993.Diabetes Care. 1998; 21: 1138-1145Crossref PubMed Scopus (722) Google Scholar). Type 2 diabetes, which is an independent risk factor for macrovascular disease, increases the risk of coronary events twofold in men and fourfold in women (1American Diabetes AssociationClinical practice recommendations 2002.Diabetes Care. 2002; 25: S33-S49Google Scholar). The incidence of cardiovascular disease in diabetic patients without prior myocardial infarction is similar to that in nondiabetic patients who have had a prior myocardial infarction, after adjustment for age, sex, and other cardiovascular risk factors (3Haffner S.M. Lehto S. Ronnemaa T. et al.Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction.N Engl J Med. 1998; 4: 229-234Crossref Scopus (5857) Google Scholar). The 1-year fatality rate after the first myocardial infarction is significantly higher in diabetic patients (4Miettinen H. Lehto S. Salomaa V. et al.Impact of diabetes on mortality after the first myocardial infarction.Diabetes Care. 1998; 21: 69-75Crossref PubMed Scopus (606) Google Scholar). Importantly, about half of those who die do so before they reach the hospital, emphasizing the importance of primary prevention of cardiovascular risk factors before the onset of clinical coronary heart disease.Diabetes is commonly associated with hypertension and dyslipidemia, each of which increases the already high risk of cardiovascular disease in diabetic patients. The prevalence of hypertension in patients with type 2 diabetes is higher than in the general population, affecting 20% to 60% of those with diabetes. Hypertension exacerbates the vascular complications of diabetes, including renal disease, coronary heart disease, stroke, peripheral vascular disease, lower extremity amputations, and retinopathy. Several studies have documented the beneficial effect of treating hypertension on clinical outcomes. In the Hypertension Optimal Treatment trial, the risk of major cardiovascular events was halved in patients with a diastolic blood pressure <80 mm Hg in comparison with <90 mm Hg (5Hansson L. Zanchetti A. Carruthers S.G. et al.Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension principal results of the Hypertension Optimal Treatment (HOT) randomized trial.Lancet. 1998; 351: 1755-1762Abstract Full Text Full Text PDF PubMed Scopus (5403) Google Scholar), whereas another study reported that tight control of blood pressure (mean, 144/82 mm Hg) in patients with hypertension and type 2 diabetes significantly reduced the risk of endpoints related to diabetes, death, stroke, microvascular disease, and heart failure (6UK Prospective Diabetes Study GroupTight blood pressure control and risk of macrovascular complications in type 2 diabetes UKPDS 38.BMJ. 1998; 317: 703-712Crossref PubMed Scopus (0) Google Scholar). The recommended blood pressure in patients with diabetes is <130/80 mm Hg (7Bakris G.L. Williams M. Dworkin L. et al.Preserving renal function in adults with hypertension and diabetes a consensus approach.Am J Kidney Dis. 2000; 36: 646-661Abstract Full Text Full Text PDF PubMed Scopus (1236) Google Scholar), and <125/75 mm Hg for those with proteinuria >1g/d.The excessive risk of coronary heart disease can be partly explained by an increased prevalence of lipid abnormalities in patients with diabetes. The United Kingdom Prospective Diabetes Study (UKPDS) showed that the risk factors for coronary heart disease (fatal and nonfatal myocardial infarction, angina pectoris) were high low-density lipoprotein (LDL) cholesterol, low high-density lipoprotein (HDL) cholesterol, hemoglobin A1c(HbA1c) levels, diastolic blood pressure, and smoking. Whereas previous trials of statins reported a decrease in cardiovascular and all-cause mortality in nondiabetic subjects, a recent study suggested that this benefit was similar in patients with diabetes (8MRC/BHF Heart Protection Study of cholesterol-lowering therapy and of antioxidant vitamin supplementation in a wide range of patients at increased risk of coronary heart disease death early safety and efficacy experience.Eur Heart J. 1999; 20: 725-741Crossref PubMed Scopus (254) Google Scholar). The recommended goal for lipids in patients with diabetes is an LDL cholesterol level <100 mg/dL and a non-HDL cholesterol level <130 mg/dL.There is strong evidence of a substantial benefit of aspirin in the primary and secondary prevention of cardiovascular events in diabetic patients (5Hansson L. Zanchetti A. Carruthers S.G. et al.Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension principal results of the Hypertension Optimal Treatment (HOT) randomized trial.Lancet. 1998; 351: 1755-1762Abstract Full Text Full Text PDF PubMed Scopus (5403) Google Scholar, 9ETDRS InvestigatorsAspirin effects on mortality and morbidity in patients with diabetes mellitus. Early Treatment Diabetic Retinopathy Study report 14.JAMA. 1992; 268: 1292-1300Crossref PubMed Scopus (514) Google Scholar). Aspirin therapy (75 to 325 mg/d) is recommended for primary prevention in diabetic patients >30 years who have one or more cardiovascular risk factors, as well as in all adult diabetic patients who have macrovascular disease (1American Diabetes AssociationClinical practice recommendations 2002.Diabetes Care. 2002; 25: S33-S49Google Scholar). Whereas interventions aimed at reducing macrovascular complications have demonstrated effectiveness, interventions that achieve near normal blood glucose concentrations have been shown to reduce microvascular complications, as was reported in the UKPDS (10UK Prospective Diabetes Study GroupIntensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33).Lancet. 1998; 352: 837-853Abstract Full Text Full Text PDF PubMed Scopus (18810) Google Scholar).Thus, based on an increasing number of well-performed, well-powered, randomized clinical trials, there is substantial evidence that we have a pharmacological armamentarium that can be highly effective in improving mortality and reducing complications in patients with type 2 diabetes. However, how good are we at applying these therapies in clinical practice?In this issue of The American Journal of Medicine, Grant et al. (11Grant R.W. Cagliero E. Murphy-Sheehy P. et al.Comparison of hyperglycemia, hypertension, and hypercholesterolemia management in patients with type 2 diabetes.Am J Med. 2002; 112: 603-609Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar) evaluate the effectiveness of clinical management of hyperglycemia, hypertension, and hypercholesterolemia in patients with type 2 diabetes who were followed in general medicine and diabetes specialty clinics at an academic medical center. Using national guidelines, the authors evaluated the frequency with which these risk factors were measured, whether drug therapy was prescribed when a risk factor was above goal, and whether a greater-than-starting-dose of the drug was prescribed when the risk factor remained above goal during an 18-month period. They found that whereas 99% of patients underwent blood pressure measurements and most (92%) had HbA1c levels measured, only about 75% had cholesterol levels measured. Among those with measured risk factors, only 32% met the recommended goal for HbA1c, 42% for blood pressure, and 40% for LDL cholesterol. Moreover, in patients who had not achieved recommended goals, an elevated HbA1c level was treated more often (92% vs. 78% for blood pressure and 38% for LDL cholesterol) and with a greater-than-starting-dose of drug (80% vs. 62% for blood pressure and 13% for LDL cholesterol). Only 37% of patients were treated with aspirin, although this was higher in patients with known coronary artery disease (54%). Patients with known coronary artery disease were also more likely to be prescribed drugs for hypertension (72%) and LDL cholesterol (48%), although these rates were still disappointingly low. The authors also found that diabetes specialty clinics were more aggressive in managing elevated HbA1c levels, whereas their management of blood pressure and LDL cholesterol was similar to that in general medicine clinics.The study by Grant et al. (11Grant R.W. Cagliero E. Murphy-Sheehy P. et al.Comparison of hyperglycemia, hypertension, and hypercholesterolemia management in patients with type 2 diabetes.Am J Med. 2002; 112: 603-609Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar) highlights the shortcomings in the effectiveness of treatment and prevention of risk factors that are associated with high morbidity and mortality. These findings are neither unique nor restricted to clinics in an academic center in the northeast. The U.S. National Health and Nutrition Education Examination Survey III reported that 51% of insulin-treated patients and 42% of those who received oral hypoglycemic agents had HbA1c levels >8% (12Harris M.I. Frequency of blood glucose monitoring in relation to glycemic control in patients with type 2 diabetes.Diabetes Care. 2001; 24: 979-982Crossref PubMed Scopus (195) Google Scholar). Epidemiological surveys in other countries indicate that <30% of patients with hypertension have blood pressure <140/90 mm Hg (13Alexander M. Tekawa I. Hunkeler E. et al.Evaluating hypertension control in a managed care setting.Arch Intern Med. 1999; 159: 2673-2677Crossref PubMed Scopus (91) Google Scholar), and other studies have found that only 33% of patients met the recommended LDL cholesterol level (14Marcelino J.J. Feingold K.R. Inadequate treatment with HMG-CoA reductase inhibitors by health care providers.Am J Med. 1996; 100: 605-610Abstract Full Text PDF PubMed Scopus (176) Google Scholar).Since the authors’ analysis of the effectiveness of clinical management was based on recommendations of the American Diabetes Association that were issued in 1994, and these recommendations have since changed (blood pressure: ≤130/85 mm Hg vs. <130/80 mm Hg; LDL cholesterol: ≤130 mg/dL vs. <100 mg/dL), the relatively poor results they observed would be even worse if current guidelines were applied.Why have the adoption of preventive measures and the implementation of clinical practice recommendations in the everyday management of diabetes been slow? And, most importantly for patient care, how can the current situation be improved? Practice guidelines need to be based on scientific data, and should be updated on a regular basis and made readily available to practitioners. For physicians to follow clinical practice guidelines, they need to be aware of the guidelines and to accept their scientific validity before they can adopt the guidelines in their practices and, finally, comply with them. In many instances, successful dissemination of guidelines to physicians can be achieved if coupled with active steps to change behaviors. In the study by Grant et al., since some of the physicians practiced in diabetes specialty clinics, they were likely to be aware of the guidelines for diabetes management and unlikely to question the scientific validity of the guidelines or to be resistant to adopting them. Getting physicians to follow practice guidelines means combating forgetfulness and overcoming logistical hurdles, perhaps with system changes, such as computerized records and patient-specific automatic reminders of targeted goals and interventions, or adoption of specific protocols for patient care that can be followed by primary care physicians, nurse case managers, or diabetologists. Diabetes self-management education and empowerment of the patient to serve as his or her own advocate can also help to improve health outcomes. Efforts and solutions to change the clinical inertia in diabetes management and treatment of cardiovascular risk factors will be essential if we are to decrease the mortality and to increase the life expectancy of patients with diabetes. The estimated prevalence of diabetes among adults was 7.4% in 1995 and is expected to increase to about 9% in 2025 (1American Diabetes AssociationClinical practice recommendations 2002.Diabetes Care. 2002; 25: S33-S49Google Scholar). Type 2 diabetes is frequently diagnosed many years after the onset of hyperglycemia because it develops gradually and is asymptomatic at the earlier stages. Life expectancy is about 8 years shorter for adults with diabetes aged 55 to 64 years than for nondiabetic subjects, and 4 years shorter for those aged 65 to 74 years (2Gu K. Cowie C.C. Harris M.I. Mortality in adults with and without diabetes in a national cohort of the U.S. population, 1971-1993.Diabetes Care. 1998; 21: 1138-1145Crossref PubMed Scopus (722) Google Scholar). Cardiovascular disease is the cause of most deaths (approximately 70%); hence, prevention and treatment of cardiovascular disease are important in reducing mortality (2Gu K. Cowie C.C. Harris M.I. Mortality in adults with and without diabetes in a national cohort of the U.S. population, 1971-1993.Diabetes Care. 1998; 21: 1138-1145Crossref PubMed Scopus (722) Google Scholar). Type 2 diabetes, which is an independent risk factor for macrovascular disease, increases the risk of coronary events twofold in men and fourfold in women (1American Diabetes AssociationClinical practice recommendations 2002.Diabetes Care. 2002; 25: S33-S49Google Scholar). The incidence of cardiovascular disease in diabetic patients without prior myocardial infarction is similar to that in nondiabetic patients who have had a prior myocardial infarction, after adjustment for age, sex, and other cardiovascular risk factors (3Haffner S.M. Lehto S. Ronnemaa T. et al.Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction.N Engl J Med. 1998; 4: 229-234Crossref Scopus (5857) Google Scholar). The 1-year fatality rate after the first myocardial infarction is significantly higher in diabetic patients (4Miettinen H. Lehto S. Salomaa V. et al.Impact of diabetes on mortality after the first myocardial infarction.Diabetes Care. 1998; 21: 69-75Crossref PubMed Scopus (606) Google Scholar). Importantly, about half of those who die do so before they reach the hospital, emphasizing the importance of primary prevention of cardiovascular risk factors before the onset of clinical coronary heart disease. Diabetes is commonly associated with hypertension and dyslipidemia, each of which increases the already high risk of cardiovascular disease in diabetic patients. The prevalence of hypertension in patients with type 2 diabetes is higher than in the general population, affecting 20% to 60% of those with diabetes. Hypertension exacerbates the vascular complications of diabetes, including renal disease, coronary heart disease, stroke, peripheral vascular disease, lower extremity amputations, and retinopathy. Several studies have documented the beneficial effect of treating hypertension on clinical outcomes. In the Hypertension Optimal Treatment trial, the risk of major cardiovascular events was halved in patients with a diastolic blood pressure <80 mm Hg in comparison with <90 mm Hg (5Hansson L. Zanchetti A. Carruthers S.G. et al.Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension principal results of the Hypertension Optimal Treatment (HOT) randomized trial.Lancet. 1998; 351: 1755-1762Abstract Full Text Full Text PDF PubMed Scopus (5403) Google Scholar), whereas another study reported that tight control of blood pressure (mean, 144/82 mm Hg) in patients with hypertension and type 2 diabetes significantly reduced the risk of endpoints related to diabetes, death, stroke, microvascular disease, and heart failure (6UK Prospective Diabetes Study GroupTight blood pressure control and risk of macrovascular complications in type 2 diabetes UKPDS 38.BMJ. 1998; 317: 703-712Crossref PubMed Scopus (0) Google Scholar). The recommended blood pressure in patients with diabetes is <130/80 mm Hg (7Bakris G.L. Williams M. Dworkin L. et al.Preserving renal function in adults with hypertension and diabetes a consensus approach.Am J Kidney Dis. 2000; 36: 646-661Abstract Full Text Full Text PDF PubMed Scopus (1236) Google Scholar), and <125/75 mm Hg for those with proteinuria >1g/d. The excessive risk of coronary heart disease can be partly explained by an increased prevalence of lipid abnormalities in patients with diabetes. The United Kingdom Prospective Diabetes Study (UKPDS) showed that the risk factors for coronary heart disease (fatal and nonfatal myocardial infarction, angina pectoris) were high low-density lipoprotein (LDL) cholesterol, low high-density lipoprotein (HDL) cholesterol, hemoglobin A1c(HbA1c) levels, diastolic blood pressure, and smoking. Whereas previous trials of statins reported a decrease in cardiovascular and all-cause mortality in nondiabetic subjects, a recent study suggested that this benefit was similar in patients with diabetes (8MRC/BHF Heart Protection Study of cholesterol-lowering therapy and of antioxidant vitamin supplementation in a wide range of patients at increased risk of coronary heart disease death early safety and efficacy experience.Eur Heart J. 1999; 20: 725-741Crossref PubMed Scopus (254) Google Scholar). The recommended goal for lipids in patients with diabetes is an LDL cholesterol level <100 mg/dL and a non-HDL cholesterol level <130 mg/dL. There is strong evidence of a substantial benefit of aspirin in the primary and secondary prevention of cardiovascular events in diabetic patients (5Hansson L. Zanchetti A. Carruthers S.G. et al.Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension principal results of the Hypertension Optimal Treatment (HOT) randomized trial.Lancet. 1998; 351: 1755-1762Abstract Full Text Full Text PDF PubMed Scopus (5403) Google Scholar, 9ETDRS InvestigatorsAspirin effects on mortality and morbidity in patients with diabetes mellitus. Early Treatment Diabetic Retinopathy Study report 14.JAMA. 1992; 268: 1292-1300Crossref PubMed Scopus (514) Google Scholar). Aspirin therapy (75 to 325 mg/d) is recommended for primary prevention in diabetic patients >30 years who have one or more cardiovascular risk factors, as well as in all adult diabetic patients who have macrovascular disease (1American Diabetes AssociationClinical practice recommendations 2002.Diabetes Care. 2002; 25: S33-S49Google Scholar). Whereas interventions aimed at reducing macrovascular complications have demonstrated effectiveness, interventions that achieve near normal blood glucose concentrations have been shown to reduce microvascular complications, as was reported in the UKPDS (10UK Prospective Diabetes Study GroupIntensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33).Lancet. 1998; 352: 837-853Abstract Full Text Full Text PDF PubMed Scopus (18810) Google Scholar). Thus, based on an increasing number of well-performed, well-powered, randomized clinical trials, there is substantial evidence that we have a pharmacological armamentarium that can be highly effective in improving mortality and reducing complications in patients with type 2 diabetes. However, how good are we at applying these therapies in clinical practice? In this issue of The American Journal of Medicine, Grant et al. (11Grant R.W. Cagliero E. Murphy-Sheehy P. et al.Comparison of hyperglycemia, hypertension, and hypercholesterolemia management in patients with type 2 diabetes.Am J Med. 2002; 112: 603-609Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar) evaluate the effectiveness of clinical management of hyperglycemia, hypertension, and hypercholesterolemia in patients with type 2 diabetes who were followed in general medicine and diabetes specialty clinics at an academic medical center. Using national guidelines, the authors evaluated the frequency with which these risk factors were measured, whether drug therapy was prescribed when a risk factor was above goal, and whether a greater-than-starting-dose of the drug was prescribed when the risk factor remained above goal during an 18-month period. They found that whereas 99% of patients underwent blood pressure measurements and most (92%) had HbA1c levels measured, only about 75% had cholesterol levels measured. Among those with measured risk factors, only 32% met the recommended goal for HbA1c, 42% for blood pressure, and 40% for LDL cholesterol. Moreover, in patients who had not achieved recommended goals, an elevated HbA1c level was treated more often (92% vs. 78% for blood pressure and 38% for LDL cholesterol) and with a greater-than-starting-dose of drug (80% vs. 62% for blood pressure and 13% for LDL cholesterol). Only 37% of patients were treated with aspirin, although this was higher in patients with known coronary artery disease (54%). Patients with known coronary artery disease were also more likely to be prescribed drugs for hypertension (72%) and LDL cholesterol (48%), although these rates were still disappointingly low. The authors also found that diabetes specialty clinics were more aggressive in managing elevated HbA1c levels, whereas their management of blood pressure and LDL cholesterol was similar to that in general medicine clinics. The study by Grant et al. (11Grant R.W. Cagliero E. Murphy-Sheehy P. et al.Comparison of hyperglycemia, hypertension, and hypercholesterolemia management in patients with type 2 diabetes.Am J Med. 2002; 112: 603-609Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar) highlights the shortcomings in the effectiveness of treatment and prevention of risk factors that are associated with high morbidity and mortality. These findings are neither unique nor restricted to clinics in an academic center in the northeast. The U.S. National Health and Nutrition Education Examination Survey III reported that 51% of insulin-treated patients and 42% of those who received oral hypoglycemic agents had HbA1c levels >8% (12Harris M.I. Frequency of blood glucose monitoring in relation to glycemic control in patients with type 2 diabetes.Diabetes Care. 2001; 24: 979-982Crossref PubMed Scopus (195) Google Scholar). Epidemiological surveys in other countries indicate that <30% of patients with hypertension have blood pressure <140/90 mm Hg (13Alexander M. Tekawa I. Hunkeler E. et al.Evaluating hypertension control in a managed care setting.Arch Intern Med. 1999; 159: 2673-2677Crossref PubMed Scopus (91) Google Scholar), and other studies have found that only 33% of patients met the recommended LDL cholesterol level (14Marcelino J.J. Feingold K.R. Inadequate treatment with HMG-CoA reductase inhibitors by health care providers.Am J Med. 1996; 100: 605-610Abstract Full Text PDF PubMed Scopus (176) Google Scholar). Since the authors’ analysis of the effectiveness of clinical management was based on recommendations of the American Diabetes Association that were issued in 1994, and these recommendations have since changed (blood pressure: ≤130/85 mm Hg vs. <130/80 mm Hg; LDL cholesterol: ≤130 mg/dL vs. <100 mg/dL), the relatively poor results they observed would be even worse if current guidelines were applied. Why have the adoption of preventive measures and the implementation of clinical practice recommendations in the everyday management of diabetes been slow? And, most importantly for patient care, how can the current situation be improved? Practice guidelines need to be based on scientific data, and should be updated on a regular basis and made readily available to practitioners. For physicians to follow clinical practice guidelines, they need to be aware of the guidelines and to accept their scientific validity before they can adopt the guidelines in their practices and, finally, comply with them. In many instances, successful dissemination of guidelines to physicians can be achieved if coupled with active steps to change behaviors. In the study by Grant et al., since some of the physicians practiced in diabetes specialty clinics, they were likely to be aware of the guidelines for diabetes management and unlikely to question the scientific validity of the guidelines or to be resistant to adopting them. Getting physicians to follow practice guidelines means combating forgetfulness and overcoming logistical hurdles, perhaps with system changes, such as computerized records and patient-specific automatic reminders of targeted goals and interventions, or adoption of specific protocols for patient care that can be followed by primary care physicians, nurse case managers, or diabetologists. Diabetes self-management education and empowerment of the patient to serve as his or her own advocate can also help to improve health outcomes. Efforts and solutions to change the clinical inertia in diabetes management and treatment of cardiovascular risk factors will be essential if we are to decrease the mortality and to increase the life expectancy of patients with diabetes." @default.
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• W2086572905 title "Effectiveness of diabetes management: is improvement feasible?" @default.
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