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Published online March 19, 2007
Diabetes Care 30:1587-1589, 2007
DOI: 10.2337/dc06-2026
© 2007 by the American Diabetes Association
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Clinical Care/Education/Nutrition
Brief Report

Gain in Patients' Knowledge of Diabetes Management Targets Is Associated With Better Glycemic Control

Padmalatha Berikai, MD, MS1, Peter M. Meyer, PHD2, Rasa Kazlauskaite, MD, MS1,3, Barbara Savoy, MS, RD, CDE3, Kelly Kozik, RD, CDE3 and Leon Fogelfeld, MD1,3

1 Division of Endocrinology, Rush University Medical Center, Chicago, Illinois
2 Department of Preventative Medicine, Rush University Medical Center, Chicago, Illinois
3 Division of Endocrinology, John H. Stroger, Jr. Hospital, Chicago, Illinois

Address correspondence and reprint requests to Leon Fogelfeld, MD, 1900 W. Polk St., Room 812, Chicago, IL 60612. E-mail: lfogelfe{at}cchil.org

Abbreviations: DSME, diabetes self-management education


   INTRODUCTION
TOP
 INTRODUCTION
RESEARCH DESIGN AND METHODS--
 RESULTS--
 CONCLUSIONS--
 References
 
Optimal glycemic, lipid, and blood pressure control has been shown to decrease the microvascular and macrovascular complications of diabetes (1–10). However, the status of control of these cardiovascular risk factors in individuals with diabetes is far from optimal (11,12). Lack of patients' knowledge of the targets of diabetes care might be one of the reasons for the low level of control of risk factors. Some studies showed that only 23–25% of individuals with diabetes know what the target A1C level is (<7%), and about the same percent of patients know how to interpret A1C values in relation to their own glycemic control (13,14). Improving patients' knowledge might help attain the goals of diabetes management, but the supporting studies are limited (14–18).

We investigated whether the gain in the knowledge of the targets of diabetes care after receiving diabetes self-management education (DSME) predicts the achievement of target A1C levels (<7%) at 6 months.


   RESEARCH DESIGN AND METHODS—
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS--
RESULTS--
 CONCLUSIONS--
 References
 
This is a retrospective study of adult diabetic subjects who received DSME in the American Diabetes Association–certified Diabetes Center of John H. Stroger, Jr. Hospital of Cook County between 2001 and 2004.

Patients with baseline A1C levels ≥7% measured within 1 month of receiving DSME and with an ~6-month follow-up A1C measurement (ranging 3–12 months and at least 3 months from the baseline A1C) were selected for this study. A1C was measured by the high-performance liquid chromatography method throughout the study period. After the educational sessions, patients received follow-up medical care by endocrinologists in conjunction with their primary care providers.

A simple five-item questionnaire (found in an online appendix, "ABC test," at http://dx.doi.org.10.2337/dc06-2026) on glycemic control, blood pressure, and LDL cholesterol targets, as recommended by American Diabetes Association (19), was administered to English-speaking patients before (pretest) and after (posttest) DSME. The correct answer for each question carried a score of 20%. The test was validated by a method similar to the one developed by Paddock et al. (20).

The opportunity to show improvement from pretest to posttest was not the same for all individuals. It was higher for patients with lower pretest scores and vice versa, as was also noted in other training programs (21). Based on this consideration, the knowledge gain was measured in relation to the baseline score. Subjects were classified into "low baseline knowledge group" if their pretest score was ≤40% and "high baseline knowledge group" if their pretest score was >40%. We defined knowledge gainers as achievers of a posttest score of ≥80 and 100% for the low and high baseline knowledge groups, respectively. Patients with lower than these posttest scores were classified as nongainers. The posttest score cutoff, ≥80%, was chosen for the first group to assess the effect of considerable knowledge gain (≥ x2) on study outcome, and the posttest score of 100% was chosen for the next group to allow maximal possible gain in the score. Patients with a pretest score of 100% were classified as nongainers if their posttest score was lower.

Knowledge gain as a predictor of target A1C achievement was tested by logistic regression using SPSS version 12.0 (Chicago, IL). The tests were two-sided with a 5% significance level.


   RESULTS—
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS--
 RESULTS--
CONCLUSIONS--
 References
 
A total of 155 subjects met the eligibility criteria, 94% had the baseline A1C performed on or within 1 month before the day of receiving DSME, and 97% had type 2 diabetes. A total of 93 subjects (60%) were classified as knowledge gainers, and 62 subjects (40%) were classified as nongainers. Patient characteristics including demographic variables, duration of diabetes, BMI, baseline A1C, number of follow-up visits to the diabetes center, and the duration of follow-up were similar between knowledge gainers and nongainers as shown in Table 1.


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  		Table 1— Comparison of baseline and follow-up characteristics in knowledge gainers and nongainers

 
Overall, 5.2% of the patients were new to diabetes therapy during the study, and there was a slightly higher use of combination therapy with oral agents plus insulin (13.5 vs. 16.8%) at follow-up. Though the hypoglycemic therapy deemed appropriate by the treating physicians somewhat changed over time, there were no significant differences in the type of therapy between study groups at baseline (P = 0.47) or at follow-up (P = 0.74), as shown in Table 1. Furthermore, there was no difference in the number of oral agents between gainers and nongainers at follow-up (monotherapy, 87.5 vs. 86.4%; dual therapy 12.5 vs. 11,4%; and triple therapy, 0 vs. 2.3%, respectively).

Overall, A1C decreased from 10.1 ± 2.3% at baseline to 7.7 ± 1.9% at 6.4 ± 2.1 months follow-up (P < 0.001) with 39.4% achieving the target A1C levels of <7%. The target A1C achievement was higher in knowledge gainers versus nongainers (46 vs. 29%, P = 0.032). Knowledge gain remained an independent predictor of target A1C achievement with an odds ratio of 2.3 (95% CI of 1.1–5.0%, P = 0.028) after adjusting for baseline A1C, duration of diabetes, sex, ethnicity, BMI, and the number of visits to the diabetes center.

In particular, subgroup analysis showed the gainers in the low baseline knowledge group attained more than twofold higher target A1C rate (45.5%) than nongainers (20%, P = 0.021). In the high baseline knowledge group, target A1C rates were higher in the gainers (46.9%) than nongainers (37.5%), but the difference was not statistically significant (P = 0.2).


   CONCLUSIONS—
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS--
 RESULTS--
 CONCLUSIONS--
References
 
Our results showed that the gain in the knowledge of the targets of diabetes care after receiving DSME independently predicted the achievement of target A1C levels. The difference in the target A1C achievement rate between knowledge gainers and nongainers was significant in the low baseline knowledge group but not in the high baseline knowledge group.

Rothman et al. (22) reported similar results with their multidisciplinary diabetes management program, where the intervention patients achieved significantly higher target A1C rates than control subjects in the low literacy group but not in the high literacy group.

Knowledge gain, measured in relation to the baseline knowledge, was found to be a good indicator of the impact of diabetes education on glycemic control in this study. The DSME might have improved patients' understanding of the importance of reaching the targets and motivated them to adopt better self-management practices leading to better glycemic control in gainers, though our study is limited in that we did not evaluate the self-management behaviors.

The significant drop in A1C at follow-up for the entire group might be the result of a combination of factors—the effect of the multidisciplinary intervention, especially for some of the patients who might have previously lacked regular diabetes care. In addition, about one-half of the subjects had diabetes of relatively short duration (<1.5 years), which is more responsive to therapy.

This study suggests that patients with low baseline knowledge should receive special attention in DSME programs, as knowledge gain in this group can significantly improve glycemic control. Special educational interventions need to be considered for individuals who do not gain adequate knowledge after standard DSME. Evaluation by simple pre- and posttests may help to identify such subjects.


   Acknowledgments
 
The members of the Diabetes Center of John H. Stroger, Jr. Hospital, and the faculty of the Masters of Science in Clinical Research Program at Rush University are gratefully acknowledged for their contribution and suggestions. We thank Lucia Freeman for technical assistance.


   Footnotes
 
Published ahead of print at http://care.diabetesjournals.org on 19 March 2007. DOI: 10.2337/dc06-2026.

Additional information for this article can be found in an online appendix at http://dx.doi.org.10.2337/dc06-2026.

A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked "advertisement" in accordance with 18 U.S.C Section 1734 solely to indicate this fact.

Received for publication October 3, 2006. Accepted for publication March 12, 2007.


   References
TOP
 INTRODUCTION
 RESEARCH DESIGN AND METHODS--
 RESULTS--
 CONCLUSIONS--
 References
 

  1. Stratton IM, Adler AI, Neil HA, Matthews DR, Manley SE, Cull CA, Hadden D, Turner RC, Holman RR: Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 321:405–412, 2000[Abstract/Free Full Text]
  2. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus: the Diabetes Control and Complications Trial Research Group. N Engl J Med 329:977–986, 1993[Abstract/Free Full Text]
  3. Nathan DM, Cleary PA, Backlund JY, Genuth SM, Lachin JM, Orchard TJ, Raskin P, Zinman B, Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study Research Group: Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med 353:2643–53, 2005[Abstract/Free Full Text]
  4. Selvin E, Marinopoulos S, Berkenblit G, Rami T, Brancati FL, Powe NR, Golden SH: Meta-analysis: glycosylated hemoglobin and cardiovascular disease in diabetes mellitus. Ann Intern Med 141:421–431, 2004[Abstract/Free Full Text]
  5. Gaede P, Vedel P, Larsen N, Jensen GV, Parving HH, Pedersen O: Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 348:383–393, 2003[Abstract/Free Full Text]
  6. UK Prospective Diabetes Study Group: Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 317:703–713, 1998[Abstract/Free Full Text]
  7. Collins R, Armitage J, Parish S, Sleigh P, Peto R, Heart Protection Study Collaborative Group: MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5,963 people with diabetes: a randomised placebo-controlled trial. Lancet 361:2005–2016, 2003[Medline]
  8. Colhoun HM, Betteridge DJ, Durrington PN, Hitman GA, Neil HA, Livingstone SJ, Thomason MJ, Mackness MI, Charlton-Menys V, Fuller JH;, CARDS Investigators: Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial. Lancet 364:685–696, 2004[Medline]
  9. Pyorala K, Pedersen TR, Kjekshus J, Faergeman O, Olsson AG, Thorgeirsson G: Cholesterol lowering with simvastatin improves prognosis of diabetic patients with coronary heart disease: a subgroup analysis of the Scandinavian Simvastatin Survival Study (4S). Diabetes Care 20:614–620, 1997[Abstract]
  10. Goldberg RB, Mellies MJ, Sacks FM, Moye LA, Howard BV, Howard WJ, Davis BR, Cole TG, Pfeffer MA, Braunwald E, CARE Investigators: Cardiovascular events and their reduction with pravastatin in diabetic and glucose-intolerant myocardial infarction survivors with average cholesterol levels: subgroup analyses in the cholesterol and recurrent events (CARE) trial. Circulation 98:2513–2519, 1998[Abstract/Free Full Text]
  11. Saydah SH, Fradkin J, Cowie CC: Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA 291:335–342, 2004[Abstract/Free Full Text]
  12. Chuang LM, Tsai ST, Huang BY, Tai TY: The status of diabetes control in Asia: a cross-sectional survey of 24 317 patients with diabetes mellitus in 1998. Diabet Med 19:978–985, 2002[Medline]
  13. Harwell TS, Dettori N, McDowall JM, Quesenberry K, Priest L, Butcher MK, Flook BN, Helgerson SD, Gohdes D: Do persons with diabetes know their (A1C) number? Diabetes Educ 28:99–105, 2002[Abstract/Free Full Text]
  14. Agrawal V, Korb P, Cole R, Barnes CS, Rhee MK, Ziemer DC, Caudle JM, Khedkar S, Phillips LS: Patients who know the A1C goal have better glycemic control. (Abstract) Diabetes54(Suppl. 1):298-OR, 2004
  15. Norris SL, Engelgau MM, Narayan KM: Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care 24:561–587, 2001[Abstract/Free Full Text]
  16. Norris SL, Lau J, Smith SJ, Schmid CH, Engelgau MM: Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control. Diabetes Care 25:1159–1171, 2002[Abstract/Free Full Text]
  17. Norris SL: Self-management education in type 2 diabetes: what works? Practical Diabetology 22:7–13, 2003
  18. Levetan CS, Dawn KR, Robbins DC, Ratner RE: Impact of computer-generated personalized goals on HbA1c. Diabetes Care 25:2–8, 2002[Abstract/Free Full Text]
  19. American Diabetes Association: Standards of medical care in diabetes—2006 (Position Statement). Diabetes Care 29(Suppl. 1):S4–S42, 2006
  20. Paddock LE, Veloski J, Chatterton ML, Gevirtz FO, Nash DB: Development and validation of a questionnaire to evaluate patient satisfaction with diabetes disease management. Diabetes Care 23:951–956, 2000[Abstract]
  21. Hovland CI, Lumsdaine AA, Sheffield FD: The baseline for measurement of percentage change. In Experiments on Mass Communication. Princeton, NJ, Princeton University Press, 1949, p. 284–289
  22. Rothman RL, DeWalt DA, Malone R, Bryant B, Shintani A, Crigler B, Weinberger M, Pignone M: Influence of patient literacy on the effectiveness of a primary care-based diabetes disease management program. JAMA 292:1711–1716, 2004[Abstract/Free Full Text]

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This Article
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