Letter: Evaluation of a structured 4-day educational programme for intensive insulin therapy

LETTERSTable 1. Major self-management end diabetes control indicators Diabetologia 1987; 30: 681–690.

5. Cox D, Gonder-Frederick L, PolonskyW, Schlundt D, Julian D, Clarke W.Month 0 3 12A multicenter evaluation of bloodglucose awareness training—II. Dia-Capillary glucose tests (n day−1) 4.1 ± 0.3 5.3 ± 0.2b 4.6 ± 0.2a

betes Care 1995; 18: 523–528.Insulin injections (n day−1) 2.9 ± 0.2 2.9 ± 0.1 3.2 ± 0.2a

6. Haardt MJ, Bruzzo F, Slama G, SelamHbA1c (%) 9.2 ± 0.3 8.7 ± 0.3b 8.8 ± 0.2b

JL. Frequent outpatient follow upMild hypoglycaemia (n week−1) 3.9 ± 0.3 3.8 ± 0.3 3.2 ± 0.4improves severe hypoglycemia andSevere hypoglycaemia (n patient-years−1) 1.6 ± 0.8 1.3 ± 0.5 0.3 ± 0.1a

moderate hyperglycemia in insulin-dependent diabetic patients. Diabetesap , 0.05, bp , 0.01 vs t0. Metabolism 1997; 23: 84–86.control, only the frequency of severe

7. Cranston I, Lomas J, Maran A, Mac-hypoglycaemia was clearly reduced afterLETTERSdonald I, Amiel SA. Restoration of12 months. When satisfactory control washypoglycemia awareness in patientsdefined as HbA1c levels ,8 % and nowith long-duration insulin-dependentsevere hypoglycaemia in the last 12Evaluation of a Structured 4-Day Edu- diabetes. Lancet 1994; 344: 283–287.months, then only 6 vs 18 % of thecational Programme for Intensive Insu- patients may be considered as well-lin Therapy controlled before vs 1 year after the

teaching programme (p , 0.03). Finally 7There is a clear consensus for improvingof the 14 items of a DCCT-derived quality Admission Plasma Glucoseglycaemic control in most IDDM,1 butof life questionnaire (4 questions assessingnot on the methods to attain this goalsatisfaction, 2 worriness, and 1 impact of I was interested to read the recent paperin routine practice.2 Intensification ofdiabetes) were scored better at 3 and by Croxson et al.1 discussing the use ofeducation3–5 and outpatient contacts6,7

12 months. an admission plasma glucose to screenseem necessary though the substantialThese results suggest that intensive for undiagnosed diabetes mellitus in aninvolvement of time and effort by both

diabetes management limited to a 4-day elderly hospitalized population. Theythe patient and the care team may forcespecial educational programme with no found a cut-off level of $7 mmol l−1them to choose between, rather thanintensification in insulin administration resulted in 36 % of patients requiringcombine, the two strategies.techniques and/or out-patient follow-up, further investigation (149/419) whichWe have evaluated a 4-day inpatientis able to improve patients’ attitudes and compares to the 18.5% we reported onstructured reinforcement educational pro-quality of life, but has only modest effects a similar population using a cut-off of 8gramme that we have recently designedon diabetes control at 1 year, except for mmol l−1.2 A suitable cut-off level tofor IDDM patients with near-a reduction in severe hypoglycaemia. reduce the number of patients subject tonormoglycaemic goals. Major criteria of

further screening is important but only ifinclusion included difficulties in copingV. Jullien, F. Elgrably, P.Y. Traynard, this does not miss significant numbers ofwith diabetes and treatment goals, and/orG. Slama and J.-L. Selam undiagnosed patients with diabetes.HbA1c levels .8 % (normal valuesDepartment of Diabetology, Inserm U. In their paper they mention the lack of# 6.0 %) and/or frequent hypoglycaemic341, Hotel-Dieu, Paris, France studies looking at geriatric patients usingattacks. The programme included inter-

full WHO criteria. Bitzen and Scherstenactive sessions (total duration 25 h) onexamined such a population, although intreatment goals, multiple injections anda primary care setting.3 They took 1082external pump techniques, detailed diet

References patients who were being investigated byexchanges and insulin dose adjustments,their GP for other reasons and collectedearly recognition and management ofa random blood glucose if other bloodhypo and hyperglycaemia, and manage- 1. The Diabetes Control and Compli-tests were being performed. Of the 1082ment of physical activity and other destab- cations Trial Research Group (DCCT).patients examined 208 were aged 65–74ilizing events, e.g. stress and travels. The effects of intensive treatment ofyears, 156 were 75–84 years, and 15Frequency and quality of subsequent out- diabetes on the development andwere .85 years old. They found that apatient follow-up was kept unchanged, progression of long-term compli-random venous blood glucose cut-offi.e. conventional diabetologist visits every cations in insulin-dependent diabeteslevel of $7 mmol l−1 had a sensitivity of3–4 months. A total of 73 IDDM patients mellitus. New Engl J Med 1993; 329:95 % and specificity of 97 %. However,(34 female, 39 male), aged 42 ± SD 10 977–986.using this cut-off level they detected onlyyears (23–71 years) with diabetes duration 2. Lorenz RA, Bubb J, Davis D, Jacobson35 of the 37 patients with undiagnosed18 ± 10 years and routinely followed by A, Jannasch K, Kramer J, et al. Practi-diabetes subsequently found using aus, were consecutively recruited and cal lessons from the diabetes controlWHO oral glucose tolerance test (OGTT).instructed in groups of 9–13 patients. A and complications trial. Diabetes Care

An admission plasma glucose is a quicknumber of items (Table 1) were collected 1996; 19: 648–652.and easy screening tests but as with anyretrospectively at month 0, 3, and 12. For 3. Pieber TR, Brunner A, Schnedl J,screening test we need something whicheach value, the numbers presented in Shattenberg S, Kaufmann P, Krejs G.will not miss too many people. The cut-Table 1 represent the mean ± SEM of the Evaluation of a structured outpatientoff chosen is therefore important. Ideally3 months preceding each time point. group education program for intensivea formal OGTT is required on a largeMost self-management indicators insulin therapy. Diabetes Care 1995;hospital-based population in the sameimproved significantly, e.g. number of 18: 625–630.way that Bitzen and Schersten examinedglucose testings, use of a log book and 4. Mulhauser I, Bruckner I, Berger M,their community-based patients to deter-adequate insulin injections technique, but Cheta D, Jorgens V, Ionesur-Tirgovistemine the cut-off level which missed nothe number of injections increased only C, et al. Evaluation of an intensifiedundiagnosed patients with diabetes.slightly and use of insulin pens (78 % of insulin treatment and teaching pro-

gramme as routine management ofpatients) or pumps (3 % of patients) didnot change. Among indicators of diabetes type I (insulin-dependant) diabetes. Dr. Kevin Shotliff

894 CCC 0742–3071/97/100894–02$17.50 1997 by John Wiley & Sons, Ltd. DIABETIC MEDICINE, 1997; 14: 894–895