1. Molyneux, Jacob senior editor


Case management and self-management training make the difference.


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With rising rates of obesity-one-third of Americans are obese, according to the National Institute of Diabetes and Digestive and Kidney Diseases-come increases in cases of type 2 diabetes. A new study reveals that case management and training in self-management could extend lives and reduce the numbers of complications among low-income minority populations.


Researchers in San Diego used data from Project Dulce, a culturally specific diabetes-management program in which an RN (also a certified diabetes educator) meets an average of five times with each patient, with the goal of improving hemoglobin (Hb)AIc, low-density lipoprotein cholesterol, and blood pressure levels. Nearly half of the participants in Project Dulce also meet with a bilingual nutritionist, and 50% take part in an eight-week self-management training group taught in the patients' native language by trained peer educators (promotoras, in Spanish). Patients learn about regular blood glucose level testing, medications, diet, and exercise and discuss their feelings about the disease and its treatment as well as beliefs that may impede self-care.


The researchers projected patients' probable health outcomes and the cost-effectiveness of their care over a 40-year period. They examined four cohorts: the uninsured, those with Medi-Cal coverage, those covered by County Medical Services (San Diego's insurance program for low-income adults who aren't eligible to receive Medi-Cal), and those with commercial insurance.

Figure. A nurse teac... - Click to enlarge in new windowFigure. A nurse teaching a class of patients with diabetes. Teaching programs have been shown to be cost-effective and improve outcomes.

The program was found to be most cost-effective and most successful in preventing complications in the uninsured cohort, which was 81% Latino and had a mean baseline hemoglobin HbAIc value of 9.4%; this group showed the steepest decrease in HbAIc levels (1.3%) and the greatest gain in life expectancy (1.1 years). In contrast, only 16% of participants with commercial insurance were Latino, and that group had a much lower mean baseline HbAIc level (7.8); they also had the smallest reduction in HbAIc level (0.4%) and the slightest increase in life expectancy (0.2 years). The uninsured group also displayed the greatest improvements in low-density lipoprotein cholesterol and blood pressure levels.


According to projections, Project Dulce was most cost-effective in the uninsured group and least so in the group with commercial insurance. The long-term reduction in complications in the uninsured group could offset one-third of the program's costs. The authors conclude that because the underinsured and uninsured groups were younger overall, had had diabetes for less time, and had higher mean baseline HbAIc levels, these populations have the most to gain from a program like Project Dulce.


Jacob Molyneux, senior editor



Saline is preferable for resuscitation after severe traumatic brain injury, according to a study published in the August 30 issue of the New England Journal of Medicine. After 24 months, nearly 42% of patients with severe traumatic brain injury (defined as a Glasgow Coma Scale [GCS] score of 3 to 8) who were resuscitated with 4% albumin had died, compared with 22% of those who received physiologic saline. (The adjusted risk of death among the patients resuscitated with albumin was more than twice as high.) However, among patients with moderate traumatic brain injury (a GSC score of 9 to 12), the rates of death were 16% and 21.6% in the albumin and saline groups, respectively. In both groups, more than 85% of the deaths occurred in the first 28 days. Neurologic outcomes among survivors were similar at 24 months.


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