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From the JAMA Network |

Diabetes Risk Assessment and Glycemic Control

Sandeep Vijan, MD, MS1; Angela Fagerlin, PhD1
[+] Author Affiliations
1Center for Clinical Management Research, Department of Internal Medicine, Ann Arbor Veterans Affairs Hospital, University of Michigan, Ann Arbor
JAMA. 2015;314(17):1861-1862. doi:10.1001/jama.2015.11518.
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This commentary discusses a cluster randomized trial published in JAMA Ophthalmology that compared the effects of personalized education and risk assessment vs usual care during retinal ophthalmologic visits on hemoglobin A1c levels among patients with diabetes.

JAMA Ophthalmology

Assessing the Effect of Personalized Diabetes Risk Assessments During Ophthalmologic Visits on Glycemic Control: A Randomized Clinical Trial

Lloyd Paul Aiello, MD, PhD; Allison R. Ayala, MS; Andrew N. Antoszyk, MD; Bambi Arnold-Bush, MPH; Carl Baker, MD; Neil M. Bressler, MD; Michael J. Elman, MD; Adam R. Glassman, MS; Lee M. Jampol, MD; Michele Melia, ScM; Jared Nielsen, MD; Howard A. Wolpert, MD; for the Diabetic Retinopathy Clinical Research Network

Importance Optimization of glycemic control is critical to reduce the number of diabetes mellitus–related complications, but long-term success is challenging. Although vision loss is among the greatest fears of individuals with diabetes, comprehensive personalized diabetes education and risk assessments are not consistently used in ophthalmologic settings.

Objective To determine whether the point-of-care measurement of hemoglobin A1c (HbA1c) and personalized diabetes risk assessments performed during retinal ophthalmologic visits improve glycemic control as assessed by HbA1c level.

Design, Setting, and Participants Ophthalmologist office–based randomized, multicenter clinical trial in which investigators from 42 sites were randomly assigned to provide either a study-prescribed augmented diabetes assessment and education or the usual care. Adults with type 1 or 2 diabetes enrolled into 2 cohorts: those with a more-frequent-than-annual follow-up (502 control participants and 488 intervention participants) and those with an annual follow-up (368 control participants and 388 intervention participants). Enrollment was from April 2011 through January 2013.

Interventions Point-of-care measurements of HbA1c, blood pressure, and retinopathy severity; an individualized estimate of the risk of retinopathy progression derived from the findings from ophthalmologic visits; structured comparison and review of past and current clinical findings; and structured education with immediate assessment and feedback regarding the participant’s understanding. These interventions were performed at enrollment and at routine ophthalmic follow-up visits scheduled at least 12 weeks apart.

Main Outcomes and Measures Mean change in HbA1c level from baseline to 1-year follow-up. Secondary outcomes included body mass index, blood pressure, and responses to diabetes self-management practices and attitudes surveys.

Results In the cohort with more-frequent-than-annual follow-ups, the mean (SD) change in HbA1c level at 1 year was −0.1% (1.5%) in the control group and −0.3% (1.4%) in the intervention group (adjusted mean difference, −0.09% [95% CI, −0.29% to 0.12%]; P = .35). In the cohort with annual follow-ups, the mean (SD) change in HbA1c level was 0.0% (1.1%) in the control group and −0.1% (1.6%) in the intervention group (mean difference, −0.05% [95% CI, −0.27% to 0.18%]; P = .63). Results were similar for all secondary outcomes.

Conclusions and Relevance Long-term optimization of glycemic control is not achieved by a majority of individuals with diabetes. The addition of personalized education and risk assessment during retinal ophthalmologic visits did not result in a reduction in HbA1c level compared with usual care over 1 year. These data suggest that optimizing glycemic control remains a substantive challenge requiring interventional paradigms other than those examined in our study.

JAMA Ophthalmol. 2015;133(8):888-896. doi:10.1001/jamaophthalmol.2015.1312

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