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21 April 2009 Annals of Internal Medicine Tip Sheet

Annals of Internal Medicine is published by the American College of Physicians on the first and third Tuesday of every month. These highlights are not intended to substitute for articles as sources of information. For a copy of an article, call 1-800-523-1546, ext. 2656, or 215-351-2656, or visit Past highlights are accessible as well.

EARLY RELEASE ARTICLE: Article available online April 21 (in print June 2)

1. Patient-Tailored Treatment Regimens May Have a More Positive Impact than Strict Glycemic Control in Managing Type 2 Diabetes

Physicians routinely emphasize tight glycemic control for patients with type 2 diabetes. However, tight glycemic control may require highly complex treatment regimens that can result in frustration, non adherence, and financial stress for some patients. Researchers reviewed large trials in which type 2 diabetic patients were randomly assigned to either tight or loose targets for glycemic control. Based on the evidence, the researchers developed practical suggestions for managing these patients. According to the authors, physicians should support healthy lifestyles, preventive care, and cardiovascular risk reduction in patients with type 2 diabetes. Physicians should individualize drug treatment approaches so that patients can aim for a blood glucose level that best balances the burden of medication with the benefit in reducing symptoms and complications of diabetes. The authors advocate for tools and tactics that encourage patient involvement in treatment decisions, as these may lead to treatment programs that are both evidence-based and consistent with patients’ lifestyles and informed values.

2. Universal Insurance Coverage May Reduce Race-based Health Care Disparities

Does access to health insurance reduce race-based health care disparities? To find out, researchers studied National Health and Nutrition Examination Survey data collected from 1998 to 2006 on more than 9,000 adults with chronic conditions such as hypertension, diabetes, or coronary heart disease. The authors assessed changes over time in chronic disease control as measured by blood pressure, hemoglobin A1c, and LDL cholesterol. These measures were then compared by race, ethnicity, and education. Finally, the authors compared sociodemographic differences above and below the age of eligibility for Medicare. The researchers found that while control of hypertension, diabetes, and coronary heart disease improved over the years, gaps in disease control between white and nonwhite patients did not change. However, the gaps narrowed after age 65 when Medicare insurance begins. The authors conclude that universal health insurance could reduce disparities in care among patients from different racial or ethnic groups.

3. The USPSTF Reaffirms its Recommendations on Physician Counseling and Interventions to Prevent Tobacco Use

Smoking increases risks for heart disease, lung disease, and cancer. In pregnant women, smoking also increases the risk for miscarriage, low birthweight, and premature delivery. Quitting smoking reduces these risks. Primary care physicians have a unique opportunity to counsel adult patients about preventive healthcare, including quitting smoking. In 2003, the USPSTF concluded that the benefits of smoking cessation interventions by primary care physicians outweighed the risks. Following a review of published research since then, the USPSTF reaffirms its 2003 recommendation on counseling to prevent tobacco use. Clinicians should ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. For pregnant women, clinicians should ask about tobacco use and provide pregnancy-tailored counseling for those who smoke.

4. Considering Genetic and Other Risk Factors May Help Identify Patients at Highest Risk for Type 2 Diabetes

Type 2 diabetes is a chronic condition that affects the way the body metabolizes sugar. Type 2 diabetes is mainly attributable to environmental factors such as body weight, lifestyle, and family history. However, genetic factors also play a role in causing the disease. Researchers sought to determine if combining genetic screening with an assessment of conventional risk factors could help physicians identify high-risk populations. The study consisted of 2 cohorts of European ancestry – 2,809 case patients with type 2 diabetes, and 3,501 healthy control patients. After developing a genetic risk score that combined data on 10 diabetes-related mutations, the investigators examined the score’s contribution to the prediction of type 2 diabetes. The researchers found that genetic testing in combination with conventional risk factors identifies subgroups of a population with a particularly high risk for type 2 diabetes. However, clinical predictions using clinical predictors of diabetes risk plus genetic test results were only slightly better than clinical predictions using only conventional risk factors.

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