Research Proposal on "Hyperglycemia Chronic Hyperglycemia: Management and Care"

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Diabetes Management

When one undertakes the management of diabetes, an effective healthcare choice is imperative. The most basic decision one must make is between hospitalized or at-home care from a nurse-practitioner. While supportive evidence exists for both scenarios, Huan-Cheng Chang found in his study, "The Effectiveness of Hospital-Based Diabetes Case Management" (2007), that hospital-based management is most efficacious. Huan-Cheng, examining a hospital in northern Taiwan, performed a prospective study following 60 patients for exactly one year, collecting data at enrollment as well as over four follow-times. Care goals were designed according to public health insurance strategies. Using these goals, evidence-based guidelines, and self-care booklets, Huan-Cheng was able to conclude that the diabetes programs implemented were successful in improving patient self-care in addition to meeting the desired care goals.

Although many would agree with Huan-Cheng that hospital-based diabetes management is an effective method of healthcare, management must also be assessed by the care giver himself. One study conducted by Pamela a. Ohman-Strickland entitled "Quality of Diabetes Care in Family Medicine practices: Influence of Nurse Practitioners and Physician's Assistants" (2008) followed the treatment of patients with and without NPs and/or PAs. By studying 846 patients across 46 New Jersey and Pennsylvania family medicine practices, Ohman-Strickland and her team were able to conclusively resolve that "family practices employing NPs performed better than those with physicians only and those employing PAs, especially with regard to diabetes process measures" (p. 14). To determine these results, Ohman-Strickland set up hierarchical models differentiating between practices with NPs or PAs. Further, she identified practice characteristics by having each staff complete a survey. Although the reasons for differences in each practice were unclear, practices employing NPs were definitely more effective than those who did not.

In a study completed in 2007, Karen Chang went one step further in her study of practices with NPs, "Nurse Practioner-Based Diabetes Care Management" (2007), comparing the emerging management method of telehealth with the existing management method of telephone intervention. By setting up a retrospective pre-post cohort study in primary care clinics, Chang and her team were able to study 259 patients. The patients were enrolled separately and were administered their treatment for varying lengths of time. In this, Chang was able to not only compare the efficacy of each management method, but also to identify a duration of use for each method that would produce the optimal results, as well as chronicle the impact of exposure following a patient's disenrollment from the program.

What Chang found in this research was the overwhelming similarities between results from telehealth and telephone interventions. Both methods are comparably effective in managing diabetes in the home. More importantly, however, Chang's study of patients post-disenrollment revealed that continuous individualized care as well as routine check-ups were necessary to properly manage diabetes.

Diabetes Care

Perhaps one of the most established methods of care beyond insulin injections, particularly in type I diabetes, is aerobic exercise. The long-term effects of aerobic exercise in patients may be more beneficial than just insulin and dietary refinements alone, as suggested by Rajprasad Loganathan in his study "Exercise-Induced Benefits in Individulas with Type I Diabetes" (2006). By observing diabetic animal models, Loganathan concluded that the beneficial effects on diabetic tissue was a result of cellular mechanisms revealed through exercise. He suggests, then, that "exercise training leads to improved tissue function by targeting specific adptive mechanisms in diabetes, especially when initiated at the early stages of the disease" (p 77). Thus, long-term aerobic exercise remains one of the most proffered treatments for diabetes.

Because aerobic exercise is self-motivated and may not be appropriate for patients with more progressive forms of diabetes, however, healthcare providers rely on many other, clinical treatments, the most prevalent of which is insulin injections. Since its inception as a treatment for diabetes in the 1920s, insulin treatments have been painstakingly refined and developed. One of the more recent developments is the use of insulin pump therapy. In her study, " Experiences of Parent of Young People with Diabetes Using Insulin Pump Therapy" (2008), Valerie Wilson examined the experiences of patients currently incorporating pump therapy in their diabetic care plan. According to her findings, Wilson found that within a group of parents of 44 children and young people, "in addition to improving gylcaemic control, insulin pump therapy offers flexibility, choice, and a better quality of life" (p. 14). The results came from a collection of self-completion questionnaires received by the parents of the patients via both electronic and postal venues. In her report, Wilson states that many healthcare providers remain reluctant to incorporate pump therapy, due to patient acceptance, safety, and efficacy. Despite these concerns, nouveau administrations of insulin continue to emerge in the world of diabetic care.

Many treatments in use today, however, reach beyond the means of insulin. Currently, much focus has been placed on protein kinase c-? (PKC-?). Because of its link to the development of adverse effects associated with hyperglycemia, such as retinopathy and nephropathy, many suggest that regulation of this particular protein may aid in reducing further deterioration in diabetics. Two such scientists are Yuzuru Ohshiro and Nobuyuki Takasu. In their study, "Role of Protein Kinase C-? Activation in Diabetic Nephropathy" (2007), Ohshiro and Takasu propose that in the near future PKC-? inhibition may be combined with standard treatments. These findings were the result of a series of clinical studies as well as observations of diabetic animal models. Ohshiro and Nobuyuki report that "the overactivation of the PKC-? isoform appears to play a critical role in diabetic complications" (64). Further, the specific PKC-? inhibitor RBX has proved to be effective against retinopathy as well as nephropathy. Thus, PKC-? inhibitors are part of the most modern methods of treating hyperglycemia.

As on may easily see, treatments, like the use of RBX, are continually being developed to effectively care for diabetes. Other treatments, though effective, have caused harsher problems for some patients. One such treatment that has been prevalent in recent years is the administration of thiazolidinediones. Thiazolidinediones, sometimes called glitazones, was introduced in the late 1990's as an adjunctive therapy for diabetes. Curt D. Furberg, MD, PhD, professor, Departement of Public Health Science, Wake Forest University School of Medicine, Winston-Salem, NC has found that glitazones are particularly precarious for patients with a family history of heart failure. In randomized studies, heart failure was apparent, regardless of drug dosage (Davis, 2007).

Conclusion

Because occurrences of diabetes continue to increase rapidly around the world, diabetes management and care will remain a hot topic in medical research and study. Researchers will persist in studying the questions between home-based and hospital-based management, NP vs. PA assistance, and over specific diabetic care techniques. Further, as new studies continue to develop, such as those concerning PKC-? inhibitors, new and better treatments and care plans will emerge to be used in conjunction with classic exercise and insulin for patients with diabetes. It is this constant influx of study and development of treatment that has kept and will maintain the interest in chronic hyperglycemia.

References

Balagopal, P., Kamalamma, N., Patel, T.G., & Misra, R. (2008). "A community-based diabetes prevention and management education program in a rural village in india." Diabetes Care, 31, 1097-1104.

Bloomgarden, Z.T. (2007). Screening for and managing diabetic retinopathy: current approaches. American Journal of Health-System Pharmacy, 64(S), S8-S14.

Chang, K., Davis, R., Birt, J., Castelluccio, P., Woodbridge, P., & Marrero, D. (2007). Nurse practioner-based diabetes care management. Disease Management & Health Outcomes, 15, 377-385.

Davis, S., Asch-Goodkin, J. (2007). Heart failure risk climbs with use of glitazones. Geriatrics, 62(9), 11-11.

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