Randomized trial of fructosamine home monitoring in patients with diabetes.

CONTEXT: Recognition of the importance of glycemic control in type 2 diabetes has generated interest in developing ways to improve such control. Levels of fructosamine, 1-amino-1-deoxyfructose, are highly correlated with those of hemoglobin A1c (HbA1c) and can be monitored in the home. DESIGN: Randomized trial. PARTICIPANTS: 140 adult patients with HbA1c values of 8% or greater were recruited to the trial through referral from physicians and a direct mailing to potentially eligible persons. INTERVENTION: Weekly home fructosamine monitoring in addition to daily glucose monitoring. Control patients monitored daily glucose only. Both groups of patients were contacted regularly by telephone and were given the same instructions on diet and exercise. OUTCOME: Measures of glycemic control 3 and 6 months after randomization. RESULTS: No significant difference was found between the two groups in the mean absolute decrease of HbA1c levels at 3 months (0.5% in the fructosamine group vs. 0.8% in the control group; P > 0.2), and the difference favored the control group at 6 months (0.7% fructosamine vs. 1.2% control; P = 0.04). Both groups had a statistically significant improvement in glycemic control. CONCLUSIONS: The addition of home fructosamine monitoring to routine glucose monitoring did not improve glycemic control.

Evaluation of the effect of performance monitoring and feedback on care process, utilization, and outcome.

OBJECTIVE: We evaluated a program of performance measurement and monitoring by assessing care process, utilization of services, and outcomes. RESEARCH DESIGN AND METHODS: Information on 63,264 diabetic individuals who were continuously enrolled as members of Kaiser Permanente Southern California from 1 January 1994 to 31 December 1997 was used to evaluate the program. Time trends in testing for glycemic test and control and screening for dyslipidemia, use of lipid-lowering drugs, and microalbuminuria were evaluated as measures of care process. Time trends in hospitalization, outpatient appointments, prescriptions, and laboratory tests were evaluated as measures of utilization. Outcomes were hospitalization for myocardial infarction, ischemic stroke, and lower-limb amputation. RESULTS: Between 1994 and 1997, improvements were evident in the process measures. The mean number of hospitalizations and the mean and median number of outpatients visits did not change. The mean number of laboratory tests increased from 13.2 in 1994 to 23.6 in 1997. The mean number of prescriptions for any medication increased from 19.7 to 24.3. Hospitalization rates for myocardial infarction did not change, but rates increased for ischemic stroke and lower-limb amputation. CONCLUSIONS: Our findings suggest that measurement and monitoring of clinical performance can bring about modest improvements in measures of the processes of care in the absence of financial incentives, centrally driven interventions, and specialty care for all patients. In our setting, process improvements were associated with higher utilization of laboratory services and more prescriptions without an immediate return in terms of lower hospital utilization.

Osteoporosis in corticosteroid-treated asthmatic patients: clinical correlates.

This study sought to identify clinical and laboratory characteristics associated with the development of osteoporosis in 44 corticosteroid (CS)-treated asthmatic patients. Percentage predicted bone density was inversely correlated with both the duration of CS therapy (r = -.39, p = 0.009) and 24-hour urine calcium excretion (chi 2 = 5.2, p = 0.022). Bone density was not related to prednisone equivalent dose, alternate day versus daily therapy or serum cortisol levels. These data suggest that (1) long duration of CS therapy and increased urine calcium may identify patients at increased risk of developing CS-induced osteoporosis, and (2) urinary loss of calcium may be of particular importance in the pathogenesis of this condition.