*Hun-Sung Kim and Hyunah Kim contributed equally to this study as first authors.
When patients with diabetes mellitus (DM) are first referred to a hospital from primary health care clinics, physicians have to decide whether to administer an oral hypoglycemic agent (OHA) immediately or postpone a medication change in favor of diabetes education regarding diet or exercise. The aim of this study was to determine the effect of diabetes education alone (without alterations in diabetes medication) on blood glucose levels.
The study was conducted between January 2009 and December 2013 and included patients with DM. The glycosylated hemoglobin (HbA1c) levels were evaluated at the first visit and after 3 months. During the first medical examination, a designated doctor also conducted a diabetes education session that mainly covered dietary management.
Patients were divided into those who received no diabetic medications (
For patients who had DM for more than 5 years, higher doses or changes in medication were more effective than intensive active education. Therefore, individualized and customized education are needed for these patients. For patients with a shorter duration of DM, it may be more effective to provide initial intensive education for diabetes before prescribing medicines, such as OHAs.
There are approximately 3.2 million patients with diabetes in Korea, comprising approximately 10% of the adult population [
It is reported that 60.6% of patients have never received any education about DM [
To implement a more effective, individualized diabetes education program, a study of patient characteristics and education programs based on these characteristics are needed. The aim of this study was to investigate the effect of DM education alone without changes in medication on blood glucose levels among patients visiting a hospital for the first time. The purpose of this study was to determine the direct effect of education and emphasize its importance, and the secondary goal was to select effective groups for DM education by analyzing the characteristics of patients in whom education is effective. The study then attempted to classify the group that experienced the greatest effect to prepare an individualized framework for diabetes education.
This study was an electronic medical record (EMR)-based retrospective cohort study. The study was conducted among patients who visited a tertiary teaching hospital for the first time between January 1, 2009, and December 31, 2013. The study focused on patients who visited the department of internal medicine (division of endocrinology and metabolism) for the first time after being diagnosed with DM externally or those who were diagnosed with DM during their first visit to the hospital. We extracted data of patients aged 18 to 80 years whose goal was to manage their blood glucose. The study was only conducted among patients who managed their blood glucose with diabetes education alone without changing their oral hypoglycemic agent (OHA). Patients receiving insulin treatment outside the hospital were excluded, as were those who were started on insulin treatment or were hospitalized after their first medical examination. Patients with gestational DM and those who visited the hospital for a check-up prior to surgery were also excluded. Patients whose medication was initiated after the first medical examination or those whose dosage was changed were also excluded. To maintain the consistency of diabetes education, only one doctor in the department of internal medicine with the most experience in DM was designated for the patient education sessions.
This study evaluated the HbA1c level, blood pressure, height, weight, and DM duration, which were measured during the first medical examination. Data related to DM were reported by one researcher directly by reviewing charts. Because this is an EMR study, it was difficult to find patients who visited the hospital at exactly 3 months. Cases for which there was no visit within 2 to 5 months were excluded from this study. Therefore, the HbA1c levels were determined during the second visit, ranging from 2 to 5 months (average of 3 months) after the individual diabetes education was administered.
During the first medical examination, one designated doctor managing the patients conducted a diabetes education session, mainly on dietary management. The recommended caloric intake was calculated based on the patient's body mass index (BMI; according to their height and weight). The main objectives of education included the individualized limitations of energy intake (considering the patients' age and gender), blood pressure, HbA1c, and any complications. This education was steadily and consistently given each time patients visited the hospital. Patients who were overweight or obese with DM were instructed to reduce their caloric intake and lose weight while maintaining healthy eating habits. The education session also included information on the seriousness of the patient's blood glucose level, importance of self-management, and its necessity depending on their age and sex. Information regarding self-blood glucose tests, importance of exercise, and changes in lifestyle was also included. All patients received diabetes education as it was conducted in the doctor's office.
Because of the anonymity of the data and retrospective nature of the study, informed consent was not required. Coded EMR data were used, and patients' hospital registration numbers were deleted to prevent identification of each patient. The study design was such that the actual patient number cannot be detected by any third party and the patient is completely free from the risk of additional physical harm. The Institutional Review Board of the Catholic University of Korea approved this study (KC15RISI0849).
Summary statistics are presented as a number (%) for categorical variables and as the mean±standard deviation, median (interquartile range) for continuous variables. The Wilcoxon signed-rank test was used to compare the patients' pre- and post-visit HbA1c. A logistic regression model was used to analyze the relationship and to estimate the odds ratio (OR), 95% confidence interval between covariates, and HbA1c of postvisit patients in the OHA group. Statistical analysis for the trend in HbA1c according to the order of categorical variables was assessed using the Cochran-Armitage test. All of the results were analyzed using SAS version 9.4 (SAS Institute, Cary, NC, USA). A
A total of 364 patients revisited the hospital 2 to 5 months after the first examination without being hospitalized. Of these, 174 patients were excluded because their medication was changed. The study was conducted among 66 patients who were not prescribed any diabetic medication and 124 who were prescribed an OHA, for a total of 190 patients (
DM education was not effective in patients who visited the hospital for the first time without being prescribed OHA (
In the OHA group, the HbA1c target achievement rate was 37.9% (
The Cochran-Armitage trend test showed that the DM duration had the largest effect on the target achievement rate (
DM cannot be completely cured and requires strict lifelong blood glucose control as well as self-management. Continuous education for self-management is required to treat and manage chronic complications; however, this education is rarely conducted, and most patients are not aware of how to manage their blood glucose. Moreover, education is not systematically provided by the patient's medical team. It is already well known that knowledge of diabetes and education regarding disease management is more important than medication treatment [
is already well known that blood glucose levels can be improved by DM education and changes in lifestyle habits without prescribing an OHA [
Notably, patients over 60 years of age tended to have a high target achievement rate after receiving DM education. The results of this study suggest that it is better to focus on DM education than to change medications in older patients with diabetes. According to research conducted in Korea, patients over 60 years of age showed a higher medication adherence than younger patients [
However, this study also has several limitations due to the characteristics of an EMR-based retrospective cohort study. First, this study assessed the effect of diabetes education conducted after patients visited the tertiary hospital, but patients with a DM duration of more than 10 years could have received education at least once outside the hospital. Second, some data were omitted, such as height or weight information, as the study was conducted using EMR data. Thus, the study did not investigate other factors that could affect diabetes education. In particular, because EMR data does not include whether patients received diabetes education and socioeconomic factors, such as the education and household income levels, such influences were not reflected in the EMR data. Finally, the baseline HbA1c of the group that did not take medication was only 6.1%, which was unexpected, because better results were found with the patients taking medication. A comparison with a control group without diabetes education would have been more accurate, but there was no control group in this study. However, there was no additional administration or changes in diabetes medications, so if diabetes education was not given, there could have been ethical issues. Therefore, setting a control group for this study was a challenge.
The results of a previous study suggested that patients' compliance after receiving education depends on the quality of the conversation between the medical team and patient at the time of diagnosis of type 2 diabetes mellitus (T2DM) [
The statistical consultation was supported by a grant from the Korean Health Technology R&D Project, Ministry of Health and Welfare, Republic of Korea (HI14C1731).
Characteristic | Total | Without OHA | With OHA |
---|---|---|---|
Number | 190 | 66 (34.7) | 124 (65.3) |
Duration of DM, yr | 3.7±6.3 | 0.1±0.4 | 5.6±7.1 |
HbA1c, % | 6.9±1.4 | 6.1±0.8 | 7.3±1.5 |
Sex | |||
Male | 90 (47.4) | 26 (39.4) | 64 (51.6) |
Female | 100 (52.6) | 40 (60.6) | 60 (48.4) |
Age, yr | 56.4±10.6 | 56.8±9.4 | 56.2±11.1 |
<50 | 43 (22.6) | 15 (22.7) | 28 (22.6) |
≥50 to <60 | 71 (37.4) | 27 (40.9) | 44 (35.5) |
≥60 | 76 (40.0) | 24 (36.4) | 52 (41.9) |
Height, cm | 163.6±8.4 | 162.6±8.6 | 164.0±8.3 |
Weight, kg | 65.0±12.2 | 64.7±11.3 | 65.2±12.6 |
BMI, kg/m2 | 24.4±3.3 | 24.7±3.1 | 24.3±3.3 |
SBP, mm Hg | 131±18 | 135±19 | 131±18 |
DBP, mm Hg | 81±12 | 83±12 | 81±12 |
Values are presented as number (%) or mean±standard deviation.
OHA, oral hypoglycemic agent; DM, diabetes mellitus; HbA1c, glycosylated hemoglobin; BMI, body mass index; SBP, systolic blood pressure; DBP, diastolic blood pressure.
Variable | Without OHA | With OHA | ||||||
---|---|---|---|---|---|---|---|---|
Number | Baseline HbA1c | 3 Months later | Number | Baseline HbA1c | 3 Months later | |||
Total | 66 | 6.1±0.8 | 6.0±0.4 | NS | 0124 | 7.3±1.5 | 7.0±1.1 | <0.01 |
Duration of DM, yr | ||||||||
≤1 | 65 | 6.1±0.8 | 6.0±0.4 | NS | 48 | 7.0±1.3 | 6.6±0.9 | <0.01 |
>1 to ≤5 | 1 | 6.5 | 6.5 | 33 | 7.5±1.8 | 6.9±1.1 | <0.01 | |
>5 to ≤10 | 22 | 7.5±1.4 | 7.3±1.2 | NS | ||||
>10 | 21 | 7.6±1.2 | 7.5±1.1 | NS | ||||
Sex | ||||||||
Male | 26 | 6.4±1.1 | 6.1±0.5 | NS | 64 | 7.6±1.7 | 6.9±1.1 | <0.01 |
Female | 40 | 5.9±0.3 | 6.0±0.4 | NS | 60 | 7.1±1.1 | 7.0±1.1 | NS |
BMI, kg/m2 | ||||||||
<23 | 33 | 5.9±0.3 | 6.0±0.4 | NS | 51 | 7.2±1.5 | 6.9±1.2 | NS |
≥23 to <25 | 11 | 6.1±0.5 | 6.0±0.4 | NS | 34 | 7.8±1.3 | 7.0±0.9 | <0.01 |
≥25 | 22 | 6.4±1.2 | 6.2±0.5 | NS | 39 | 7.2±1.5 | 7.0±1.1 | NS |
Values are presented as mean±standard deviation.
HbA1c, glycosylated hemoglobin; OHA, oral hypoglycemic agent; NS, not significant; DM, diabetes mellitus; BMI, body mass index.
Variable | Target achievement rate <6.5% | |||
---|---|---|---|---|
No. (%) | Odds ratio | 95% CI | ||
Total | 47 (37.9) | |||
Duration of DM, yr | ||||
≤1 | 26 (55.32) | Reference | - | |
>1 to ≤5 | 14 (29.79) | 0.623 | 0.255–1.524 | NS |
>5 to ≤10 | 5 (10.64) | 0.249 | 0.079–0.784 | 0.0175 |
>10 | 2 (4.26) | 0.089 | 0.019–0.425 | 0.0024 |
Sex | ||||
Male | 24 (51.06) | Reference | - | |
Female | 23 (48.94) | 1.036 | 0.501–2.141 | NS |
Age, yr | ||||
<50 | 10 (21.28) | Reference | - | |
≥50 to <60 | 16 (34.04) | 1.029 | 0.383–2.761 | NS |
≥60 | 21 (44.68) | 1.219 | 0.471–3.156 | NS |
Height, cm | 0.998 | 0.953–1.045 | NS | |
Weight, kg | 0.987 | 0.958–1.018 | NS | |
BMI, kg/m2 | ||||
<23 | 24 (51.06) | Reference | - | NS |
≥23 to <25 | 10 (21.28) | 0.469 | 0.187–1.176 | NS |
≥25 | 13 (27.66) | 0.563 | 0.237–1.334 | NS |
Systolic blood pressure, mm Hg | 1.013 | 0.991–1.035 | NS | |
Diastolic blood pressure, mm Hg | 1.026 | 0.993–1.060 | NS |
HbA1c, glycosylated hemoglobin; CI, confidence interval; DM, diabetes mellitus; NS, not significant; BMI, body mass index.
Variable | 3 Months later HbA1c | ||
---|---|---|---|
≥6.5% | <6.5% | ||
Baseline HbA1c, % | 0.0253 | ||
≥6.5 | 72 (93.5) | 15 (31.9) | |
<6.5 | 5 (6.5) | 32 (68.1) | |
Total | 77 | 47 |
Values are presented as number (%).
HbA1c, glycosylated hemoglobin.
Variable | Duration of DM | BMI | Sex |
---|---|---|---|
HbA1c <6.5% Cochran-Armitage trend test | <0.0001 | 0.0537 | 0.2447 |
Values are presented as
DM, diabetes mellitus; BMI, body mass index; HbA1c, glycosylated hemoglobin.