A Study Comparing Standard Care for Diabetes to Case-Managed Care for Diabetes in Patients With Coronary Artery Disease
NCT ID: NCT00248352
Last Updated: 2007-10-26
Study Results
Results pending
The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.
Basic Information
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Recruitment Status
COMPLETED
Clinical Phase
NA
Total Enrollment
212 participants
Study Classification
INTERVENTIONAL
Study Start Date
2005-02-28
Study Completion Date
2007-10-31
Brief Summary
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The purpose of this study is to compare two ways to treat patients with Type 2 Diabetes, Standard Care or Case-Managed Care.
In-Patient Standard Care is guided by the assigned cardiologist and Out-Patient Standard Care by the existing diabetes care givers.
Case-Managed care involves a consult with an endocrinologist and counseling from a diabetic educator and a dietician.
In-Patient Standard Care is guided by the assigned cardiologist and Out-Patient Standard Care by the existing diabetes care givers.
Case-Managed care involves a consult with an endocrinologist and counseling from a diabetic educator and a dietician.
Detailed Description
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Patients with diabetes have a higher incidence of coronary artery disease and a worsened cardiac prognosis. Death from cardiovascular disease accounts for about 70% of all diabetes-related deaths (Booth, 2003). Diabetes is also a common problem among hospitalized cardiac patients. In Ontario, from 1995 to 1997, nearly 1/3 of the 104,471 patients admitted for acute myocardial infarction had diabetes (Booth, 2003). In these patients, hyperglycemia remains a marker for poor outcome despite improvements in coronary care (Wahab, 2002; Capes, 2000).
Several important questions regarding the diabetes care of cardiac patients admitted to hospital wards are yet to be answered. First, it is not known if better glycemic control during the ward phase of hospitalization in itself improves short-term outcomes. Second, assuming that short-term glycemic control is beneficial, it is not known which interventions are effective in accomplishing this. Third, assuming that putting more resources into the management and education of patients with diabetes will translate into long term benefits, it is not known whether this should be done during the "window of opportunity" provided by a cardiac admission or whether this intervention will be more effective if it is deferred until after discharge.
These critical treatment dilemmas have prompted the proposal for the GLUCOSE Pilot Study, a randomized, controlled study to examine the effectiveness of case-managed diabetes care using a multidisciplinary team approach in patients with diabetes admitted to manage concomitant ischemic heart disease. We have designed this protocol to study the effectiveness of case-managed diabetes care by a specialized endocrinology team and compare it to usual care as delivered by the attending cardiologist. Patients will be randomized to specialized endocrinology care or usual care at the time of their admission to the ward. The short-term outcome will be glycemic control of cardiac patients with diabetes while they are admitted to a cardiology ward. In order to compare this with a more typical model of post-discharge care, patients will be re-randomized at the time of discharge into case-managed or usual care groups. The long-term (primary) outcome will be glycemic control and risk factor reduction at 6 months. This factorial design will allow us to compare several treatment models and determine which is the most efficient and effective way to achieve the best long-term diabetes control and risk factor management in our patients.
Several important questions regarding the diabetes care of cardiac patients admitted to hospital wards are yet to be answered. First, it is not known if better glycemic control during the ward phase of hospitalization in itself improves short-term outcomes. Second, assuming that short-term glycemic control is beneficial, it is not known which interventions are effective in accomplishing this. Third, assuming that putting more resources into the management and education of patients with diabetes will translate into long term benefits, it is not known whether this should be done during the "window of opportunity" provided by a cardiac admission or whether this intervention will be more effective if it is deferred until after discharge.
These critical treatment dilemmas have prompted the proposal for the GLUCOSE Pilot Study, a randomized, controlled study to examine the effectiveness of case-managed diabetes care using a multidisciplinary team approach in patients with diabetes admitted to manage concomitant ischemic heart disease. We have designed this protocol to study the effectiveness of case-managed diabetes care by a specialized endocrinology team and compare it to usual care as delivered by the attending cardiologist. Patients will be randomized to specialized endocrinology care or usual care at the time of their admission to the ward. The short-term outcome will be glycemic control of cardiac patients with diabetes while they are admitted to a cardiology ward. In order to compare this with a more typical model of post-discharge care, patients will be re-randomized at the time of discharge into case-managed or usual care groups. The long-term (primary) outcome will be glycemic control and risk factor reduction at 6 months. This factorial design will allow us to compare several treatment models and determine which is the most efficient and effective way to achieve the best long-term diabetes control and risk factor management in our patients.
Conditions
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Diabetes Mellitus, Type 2
Coronary Disease
Keywords
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Coronary Artery Disease
Diabetes Mellitus
Type 2
Chronic Disease
Study Design
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Allocation Method
RANDOMIZED
Intervention Model
CROSSOVER
Blinding Strategy
NONE
Interventions
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Consultation with Endocrinologist
Intervention Type
BEHAVIORAL
Counseling from Dietician
Intervention Type
BEHAVIORAL
Counseling from Diabetes Educator
Intervention Type
BEHAVIORAL
Eligibility Criteria
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Inclusion Criteria
* Diabetes Mellitus, type 2, as defined by at least one of the following:
* Previous diagnosis of diabetes
* two glucose levels consistent with diabetes (fasting glucose \>7.0 mmol/L or random glucose \>11.0 mmol/L )
* HbA1C \> 6.5% using DCCT standardized methods And
Coronary Disease, as defined by at least one of the following:
* Admitting diagnosis of acute coronary syndrome defined by 2/3 of typical history, enzyme changes, dynamic ECG changes
* Prior history of acute coronary syndrome defined as above
* Previously documented myocardial infarction
* Previous coronary revascularization procedure
* Coronary artery disease defined by coronary angiography
* Exercise or persantine nuclear perfusion imaging positive for ischemia
* Previous diagnosis of diabetes
* two glucose levels consistent with diabetes (fasting glucose \>7.0 mmol/L or random glucose \>11.0 mmol/L )
* HbA1C \> 6.5% using DCCT standardized methods And
Coronary Disease, as defined by at least one of the following:
* Admitting diagnosis of acute coronary syndrome defined by 2/3 of typical history, enzyme changes, dynamic ECG changes
* Prior history of acute coronary syndrome defined as above
* Previously documented myocardial infarction
* Previous coronary revascularization procedure
* Coronary artery disease defined by coronary angiography
* Exercise or persantine nuclear perfusion imaging positive for ischemia
Exclusion Criteria
* Refusal to enter the study
* Inability to understand consent forms and provide informed consent
* Anticipated length of non-ICU hospital stay less than 48 hours
* Diabetes Mellitus, type 1
* Inability to understand consent forms and provide informed consent
* Anticipated length of non-ICU hospital stay less than 48 hours
* Diabetes Mellitus, type 1
Eligible Sex
ALL
Accepts Healthy Volunteers
No
Sponsors
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Sanofi
INDUSTRY
Sponsor Role
collaborator
Pfizer
INDUSTRY
Sponsor Role
collaborator
Ottawa Heart Institute Research Corporation
OTHER
Sponsor Role
lead
Principal Investigators
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Richard F. Davies, M.D.
Role: PRINCIPAL_INVESTIGATOR
University of Ottawa Heart Instittue
Janine Malcolm, M.D.
Role: PRINCIPAL_INVESTIGATOR
Ottawa Hospital
Locations
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University of Ottawa Heart Institute
Ottawa, Ontario, Canada
Site Status
Countries
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Canada
References
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Bhattacharyya A, Christodoulides C, Kaushal K, New JP, Young RJ. In-patient management of diabetes mellitus and patient satisfaction. Diabet Med. 2002 May;19(5):412-6. doi: 10.1046/j.1464-5491.2002.00716.x.
Reference Type
BACKGROUND
Booth G, Fang J. Acute complications of Diabetes: In Hux JE, Booth GL, Slaughter PM, Laupacis A (eds.). Diabetes in Ontario: An ICES Practice Atlas. Institute for Clinical Evaluative Sciences. 2003:2.21-2.51.
Reference Type
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Brown SA. Meta-analysis of diabetes patient education research: variations in intervention effects across studies. Res Nurs Health. 1992 Dec;15(6):409-19. doi: 10.1002/nur.4770150603.
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Canadian Diabetes Association Clinical Practice Guidelines Expert Committee; Cheng AY. Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada. Introduction. Can J Diabetes. 2013 Apr;37 Suppl 1:S1-3. doi: 10.1016/j.jcjd.2013.01.009. Epub 2013 Mar 26. No abstract available.
Reference Type
BACKGROUND
Capes SE, Hunt D, Malmberg K, Gerstein HC. Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet. 2000 Mar 4;355(9206):773-8. doi: 10.1016/S0140-6736(99)08415-9.
Reference Type
BACKGROUND
Cavan DA, Hamilton P, Everett J, Kerr D. Reducing hospital inpatient length of stay for patients with diabetes. Diabet Med. 2001 Feb;18(2):162-4. doi: 10.1046/j.1464-5491.2001.00420.x.
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BACKGROUND
Clement S. Diabetes self-management education. Diabetes Care. 1995 Aug;18(8):1204-14. doi: 10.2337/diacare.18.8.1204. No abstract available.
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Davies M, Dixon S, Currie CJ, Davis RE, Peters JR. Evaluation of a hospital diabetes specialist nursing service: a randomized controlled trial. Diabet Med. 2001 Apr;18(4):301-7. doi: 10.1046/j.1464-5491.2001.00470.x.
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Egan BM, Greene EL, Goodfriend TL. Nonesterified fatty acids in blood pressure control and cardiovascular complications. Curr Hypertens Rep. 2001 Apr;3(2):107-16. doi: 10.1007/s11906-001-0021-y.
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Furnary AP, Zerr KJ, Grunkemeier GL, Starr A. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg. 1999 Feb;67(2):352-60; discussion 360-2. doi: 10.1016/s0003-4975(99)00014-4.
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BACKGROUND
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. 2003 Jan 30;348(5):383-93. doi: 10.1056/NEJMoa021778.
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Golden SH, Peart-Vigilance C, Kao WH, Brancati FL. Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes. Diabetes Care. 1999 Sep;22(9):1408-14. doi: 10.2337/diacare.22.9.1408.
Reference Type
BACKGROUND
Hux JE, Tang M. Patterns of prevalence and incidence of diabetes: In Hux JE, Booth GL, Slaughter APM, Laupacis (eds). Diabetes in Ontario: An ICES Practice Atlas. Institute for Clinical and Evaluative Sciences. 2003:1.1-1.18.
Reference Type
BACKGROUND
Janes JM, Bradley C, Rees A. Preferences for, and improvements in aspects of quality of life (QoL) with, insulin lispro in a multiple injection regimen. Diabetologia. 1997;40, Suppl. 1:A353.
Reference Type
BACKGROUND
Renders CM, Valk GD, Griffin SJ, Wagner EH, Eijk Van JT, Assendelft WJ. Interventions to improve the management of diabetes in primary care, outpatient, and community settings: a systematic review. Diabetes Care. 2001 Oct;24(10):1821-33. doi: 10.2337/diacare.24.10.1821.
Reference Type
BACKGROUND
Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998 Sep 12;352(9131):837-53.
Reference Type
BACKGROUND
van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001 Nov 8;345(19):1359-67. doi: 10.1056/NEJMoa011300.
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Wahab NN, Cowden EA, Pearce NJ, Gardner MJ, Merry H, Cox JL; ICONS Investigators. Is blood glucose an independent predictor of mortality in acute myocardial infarction in the thrombolytic era? J Am Coll Cardiol. 2002 Nov 20;40(10):1748-54. doi: 10.1016/s0735-1097(02)02483-x.
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Lawlor D, Vandewater D, Ur E. Diabetes. Case management. Can Nurse. 2002 Jan;98(1):27-30. No abstract available.
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Levetan CS, Passaro MD, Jablonski KA, Ratner RE. Effect of physician specialty on outcomes in diabetic ketoacidosis. Diabetes Care. 1999 Nov;22(11):1790-5. doi: 10.2337/diacare.22.11.1790.
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Levetan CS, Salas JR, Wilets IF, Zumoff B. Impact of endocrine and diabetes team consultation on hospital length of stay for patients with diabetes. Am J Med. 1995 Jul;99(1):22-8. doi: 10.1016/s0002-9343(99)80100-4.
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Malmberg K. Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. DIGAMI (Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction) Study Group. BMJ. 1997 May 24;314(7093):1512-5. doi: 10.1136/bmj.314.7093.1512.
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BACKGROUND
Malmberg K, Ryden L, Efendic S, Herlitz J, Nicol P, Waldenstrom A, Wedel H, Welin L. Randomized trial of insulin-glucose infusion followed by subcutaneous insulin treatment in diabetic patients with acute myocardial infarction (DIGAMI study): effects on mortality at 1 year. J Am Coll Cardiol. 1995 Jul;26(1):57-65. doi: 10.1016/0735-1097(95)00126-k.
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BACKGROUND
Queale WS, Seidler AJ, Brancati FL. Glycemic control and sliding scale insulin use in medical inpatients with diabetes mellitus. Arch Intern Med. 1997 Mar 10;157(5):545-52.
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Polonsky WH, Earles J, Smith S, Pease DJ, Macmillan M, Christensen R, Taylor T, Dickert J, Jackson RA. Integrating medical management with diabetes self-management training: a randomized control trial of the Diabetes Outpatient Intensive Treatment program. Diabetes Care. 2003 Nov;26(11):3048-53. doi: 10.2337/diacare.26.11.3048.
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BACKGROUND
Manzella D, Carbonella M, Ragno E, Passariello N, Grella R, Paolisso G. Relationship between autonomic cardiac activity, beta-cell function, anthropometrics and metabolic indices in type II diabetics. Clin Endocrinol (Oxf). 2002 Aug;57(2):259-64. doi: 10.1046/j.1365-2265.2002.01596.x.
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Koproski J, Pretto Z, Poretsky L. Effects of an intervention by a diabetes team in hospitalized patients with diabetes. Diabetes Care. 1997 Oct;20(10):1553-5. doi: 10.2337/diacare.20.10.1553.
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Other Identifiers
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Glucose 101
Identifier Type: -
Identifier Source: org_study_id