Controlled trial of a multifaceted intervention for improving quality of care for rural patients with type 2 diabetes

A meta-analysis of continuing medical education effectiveness

INTRODUCTION

We undertook a meta-analysis of the Continuing Medical Education (CME) outcome literature to examine the effect of moderator variables on physician knowledge, performance, and patient outcomes.

METHODS

A literature search of MEDLINE and ERIC was conducted for randomized controlled trials and experimental design studies of CME outcomes in which physicians were a major group. CME moderator variables included the types of intervention, the types and number of participants, time, and the number of intervention sessions held over time.

RESULTS

Thirty-one studies met the eligibility criteria, generating 61 interventions. The overall sample-size weighted effect size for all 61 interventions was r = 0.28 (0.18). The analysis of CME moderator variables showed that active and mixed methods had medium effect sizes (r = 0.33 [0.33], r = 0.33 [0.26], respectively), and passive methods had a small effect size (r = 0.20 [0.16], confidence interval 0.15, 0.26). There was a positive correlation between the effect size and the length of the interventions (r = 0.33) and between multiple interventions over time (r = 0.36). There was a negative correlation between the effect size and programs that involved multiple disciplines (r = -0.18) and the number of participants (r = -0.13). The correlation between the effect size and the length of time for outcome assessment was negative (r = -0.31).

DISCUSSION

The meta-analysis suggests that the effect size of CME on physician knowledge is a medium one; however, the effect size is small for physician performance and patient outcome. The examination of moderator variables shows there is a larger effect size when the interventions are interactive, use multiple methods, and are designed for a small group of physicians from a single discipline.

Impact of opinion leader-endorsed evidence summaries on the quality of prescribing for patients with cardiovascular disease: a randomized controlled trial

BACKGROUND

Local opinion leaders are educationally and socially influential physicians. Although they can accelerate the adoption of new evidence in hospitals, their impact on the quality of prescribing for outpatients has only been examined by a few studies. We hypothesized that an intervention consisting of patient-specific one-page evidence summaries, generated and endorsed by local opinion leaders, would improve prescribing of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in heart failure (HF) and that of statins in ischemic heart disease (IHD).

METHODS

We conducted a community-based randomized controlled trial in patients with HF (not receiving ACE inhibitors or ARBs) and those with IHD (not receiving statins) who were recruited from 40 pharmacies and allocated either to the opinion leader intervention or to usual care based on randomization of their primary care physician. The primary outcome was an increase in the use of efficacious therapies (ACE inhibitors or ARBs in HF and statins in IHD) within 6 months; the secondary outcomes were prescribing changes for HF or IHD.

RESULTS

A total of 171 patients participated in the study; 87 were allocated to the intervention, whereas 84 were assigned to the control group. The median age of the participants was 75 years; 103 (60%) were female, 54 (32%) had HF, and 117 (68%) had IHD. Overall, 21 (24%) intervention patients started receiving an efficacious medication within 6 months, as compared with 15 (18%) control subjects (relative risk of improvement 1.32, 95% CI 0.73-2.40, P = .31). In the HF subgroup, 38% of the intervention patients started receiving an ACE inhibitor or ARB therapy, as compared with 20% of control subjects (relative risk of improvement 1.90, 95% CI 0.76-4.72, P = .15). In the IHD subgroup, 17% of the intervention patients and 17% of the control subjects started receiving statin therapy (P = .97).

CONCLUSIONS

The influence of local opinion leaders may be useful for improving the quality of cardiovascular prescribing in the community, but the benefits are likely modest and may be disease specific. Further studies on this method are warranted.

Aboriginal participation in the DOVE study

OBJECTIVE/BACKGROUND

Aboriginals constitute a substantial portion of the population of Northern Alberta. Determinants such as poverty and education can compound health-care accessibility barriers experienced by Aboriginals compared to non-Aboriginals. A diabetes care enhancement study involved the collection of baseline and follow-up data on Aboriginal and non-Aboriginal patients with known type 2 diabetes in two rural communities in Northern Alberta. Analyses were conducted to determine any demographic or clinical differences existing between Aboriginals and non-Aboriginals.

METHODS

394 diabetes patients were recruited from the Peace and Keeweetinok Lakes health regions. 354 self-reported whether or not they were Aboriginal; a total of 94 self-reported being Aboriginal. Baseline and follow-up data were collected through interviews, standardized physical assessments, laboratory testing and self-reporting questionnaires (RAND-12 and HUI3).

RESULTS

Aboriginals were younger, with longer duration of diabetes, more likely to be female, and less likely to have completed high school. At baseline, self-reported health status was uniformly worse, but the differences disappeared with adjustments for sociodemographic confounders, except for perceived mental health status. Aboriginals considered their mental health status to be worse than non-Aboriginals at baseline. Some aspects of health utilization were also different.

DISCUSSION

While demographics were different and some utilization differences existed, overall this analysis demonstrates that "Aboriginality" does not contribute to diabetes outcomes when adjusted for appropriate variables.

Setting and organization of care for persons living with HIV/AIDS

BACKGROUND

Treating the world's 40.3 million persons currently infected with HIV/AIDS is an international responsibility that involves unprecedented organizational challenges. Key issues include whether care should be concentrated or decentralized, what type and mix of health workers are needed, and which interventions and mix of programs are best. High volume centres, case management and multi-disciplinary care have been shown to be effective for some chronic illnesses. Application of these findings to HIV/AIDS is less well understood.

OBJECTIVES

Our objective was to evaluate the association between the setting and organization of care and outcomes for people living with HIV/AIDS.

SEARCH STRATEGY

Computerized searches from January 1, 1980 to December 31, 2002 of MEDLINE, EMBASE, Dissertation Abstracts International (DAI), CINAHL, HealthStar, PsychInfo, PsychLit, Social Sciences Abstracts, and Sociological Abstracts as well as searches of meeting abstracts and relevant journals and bibliographies in articles that met inclusion criteria. Searches included articles published in English and other languages.

SELECTION CRITERIA

Articles were considered for inclusion if they were observational or experimental studies with contemporaneous comparison groups of adults and/or children currently infected with HIV/AIDS that examined the impact of the setting and/or organization of care on outcomes of mortality, opportunistic infections, use of HAART and prophylaxis, quality of life, health care utilization, and costs for patient with HIV/AIDS.

DATA COLLECTION AND ANALYSIS

Two authors independently screened abstracts to determine relevance. Full paper copies were reviewed against the inclusion criteria. The findings were extracted by both authors and compared. The 28 studies that met inclusion criteria were too disparate with respect to populations, interventions and outcomes to warrant meta-analysis.

MAIN RESULTS

Twenty-eight studies were included involving 39,776 study subjects. The studies indicated that case management strategies and higher hospital and ward volume of HIV-positive patients were associated with decreased mortality. Case management was also associated with increased receipt of ARVs. The results for multidisciplinary teams or multi-faceted treatment varied. None of the studies examined quality of life or immunological or virological outcomes. Healthcare utilization outcomes were mixed.

AUTHORS' CONCLUSIONS

Certain settings of care (i.e. high volume of HIV positive patients) and models of care (i.e. case management) may improve patient mortality and other outcomes. More detailed descriptions of care models, consistent definition of terms, and studies on innovative models suitable for developing countries are needed. There is not yet enough evidence to guide policy and clinical care in this area.

Effect of nurse-directed hypertension treatment among First Nations people with existing hypertension and diabetes mellitus: the Diabetes Risk Evaluation and Microalbuminuria (DREAM 3) randomized controlled trial

BACKGROUND

First Nations people with diabetes mellitus and hypertension are at greater risk of renal and cardiovascular complications than are non-native patients because of barriers to health care services. We conducted this randomized controlled trial to assess whether a community-based treatment strategy implemented by home care nurses would be effective in controlling hypertension in First Nations people with existing hypertension and type 2 diabetes.

METHODS

We compared 2 community-based strategies for controlling hypertension in First Nations people with existing hypertension and diabetes. In the intervention group, a home care nurse followed a predefined treatment algorithm of pharmacologic antihypertensive therapy. In the control group, treatment decisions were made by each subject's primary care physician. The primary outcome measure was the difference between the 2 groups in the change in systolic blood pressure after 12 months. Secondary outcome measures were the change in diastolic blood pressure over time, the change in urine albumin status and the incidence of adverse events.

RESULTS

Both groups experienced a significant reduction in systolic blood pressure by the final visit (by 24.0 [standard deviation (SD) 13.5] mm Hg in the intervention group and by 17.0 [SD 18.6] mm Hg in the control group); p < 0.001 in each case). However, the difference between the 2 groups in this change was not significant. Patients in the intervention group had a larger decrease in diastolic blood pressure over time than did those in the control group (by 11.6 [SD 10.6] mm Hg v. 6.8 [SD 11.1] mm Hg respectively; p = 0.05). The groups did not differ significantly in terms of changes in urine albumin excretion or incidence of adverse events.

INTERPRETATION

High rates of blood pressure control in the community were achieved in both groups in the DREAM 3 study. The addition of a home care nurse to implement a treatment strategy for blood pressure control was more effective in lowering diastolic than systolic blood pressure compared with home care visits for blood pressure monitoring alone and follow-up treatment by a family physician.

Improving Pharmacotherapy After Myocardial Infarction by Group Academic Detailing Using Feedback Data on a Patient Level

STUDY OBJECTIVE

To develop and evaluate a peer review group (PRG) meeting using feedback data on a patient level to improve the quality of drug therapy for prevention of recurrent myocardial infarction.

DESIGN

Prospective follow-up study.

DATA SOURCE

General practitioners' computerized patients records (intervention patients) and the PHARMO record linkage system (controls).

PATIENTS

Forty patients in the intervention group and 1030 control patients; both groups had documented myocardial infarction.

INTERVENTION

The intervention, which was based on the principles of group academic detailing, consisted of scoring current cardiovascular treatment on separate forms for each patient, presenting an overview of, and discussing, evidence-based treatment after myocardial infarction, defining the target population, formulating a binding consensus, and identifying patients who were eligible for improvement of pharmacotherapy.

MEASUREMENTS AND MAIN RESULTS

Drug therapy and adherence to the newly formulated PRG consensus were assessed at baseline and 1 year after the intervention. Of the patients who received the intervention and were not treated according to the PRG consensus at baseline, 40% received treatment according to the consensus 12 months after the PRG meeting. In the control group, the proportion of patients was 9.5% (prevalence ratio 4.2, 95% confidence interval 1.8-9.7).

CONCLUSION

Peer review group meetings can be a valuable tool for improving pharmacotherapy after myocardial infarction.

Impact of a two-arm educational program for improving diabetes care in primary care centres

Improvement of the quality of diabetes care is essential for reducing diabetes complications. Nevertheless, compliance with diabetes clinical practice recommendations is inadequate in primary care. The aim of this study was to assess the impact of diabetes education, when directed simultaneously to both diabetes care providers and patients, on the frequency of performance of relevant laboratory tests and improvement of metabolic control. A three-step educational program was applied at 45 community clinics of a health-managed organisation comprising 175 health care providers and 16,275 diabetic patients. At the end of a 2-year period, the proportion of diabetic patients with HbA1c tested at least once a year rose from 60 to 85%. The percentage of patients with HbA1c <7% rose from 38 to 50%, whereas the percentage with HbA1c >8.5% decreased from 27 to 19%. The number of patients visiting an eye clinic at least once yearly rose from 55 to 65% and of those undergoing microalbumin testing from 27 to 37%. There was a 20% increase in the number of patients with low-density lipoprotein cholesterol measurements. Our study demonstrates the efficacy of diabetes education when directed simultaneously to health care providers and diabetic patients. The improvement in quality of care induced by such intervention can translate into better metabolic control and, ultimately, the prevention of diabetes complications.

Understanding the complex associations between patient–provider relationships, self-care behaviours, and health-related quality of life in type 2 diabetes: A structural equation modeling approach

OBJECTIVES

To assess associations between perceptions of the patient-provider relationship (PPR), BMI, and adherence to diet and exercise in a rural population with type 2 diabetes and determine how these variables relate to HRQL.

METHODS

A model of the hypothesized relationships between the constructs was proposed and tested using structural equation modeling (SEM) and data collected as part of a controlled study to improve care for individuals with type 2 diabetes in rural health regions.

RESULTS

In the final model, positive perceptions of the PPR had a direct impact on adherence to diet (beta = 0.23; p < 0.05), exercise (beta = 0.13; p < 0.05) and diabetes management attitudes (beta = 0.33; p < 0.05). The direct path from management attitudes to exercise was also significant (beta = 0.12; p < 0.05). Direct predictors of HRQL included management attitudes (beta = 0.16; p < 0.05), exercise adherence (beta = 0.14, p < 0.05) and BMI (beta = -0.23; p < 0.05). Exercise adherence predicted BMI, whereas adherence to diet did not. The final model had an acceptable fit with the measured data (chi2 = 30.6 (26, N = 372), p = 0.25; RMSEA = 0.02; TLI = 0.98; SRMR = 0.02).

CONCLUSION

Patient-provider relationship and exercise adherence appeared to be key constructs in the model. HRQL in people with type 2 diabetes was positively associated with exercise adherence, which was related to a positive PPR. Adherence to diet was also related to a positive PPR, but diet adherence had no association with HRQL.

Can the atherosclerosis prevention targets be achieved in type 2 diabetes?

Type 2 diabetes mellitus is beside hyperglycemia frequently accompanied by dyslipidemia, arterial hypertension, obesity and other atherosclerosis risks. The article summarizes current status demonstrating that we are far from recommended targets, especially with diabetes, blood pressure and lipid controls. More aggressive drug treatment together with life style changes will be necessary to reach our goals in Type 2 diabetic patients.

Group versus individual academic detailing to improve the use of antihypertensive medications in primary care: a cluster-randomized controlled trial

PURPOSE

To compare group versus individual academic detailing to increase diuretic or beta-blocker use in hypertension.

METHODS

We conducted a cluster-randomized controlled trial in a large health maintenance organization. Subjects (N=9820) were patients with newly treated hypertension in the year preceding the intervention (N=3692), the 9 months following the intervention (N=3556), and the second year following intervention (N=2572). We randomly allocated 3 practice sites to group detailing (N=227 prescribers), 3 to individual detailing (N=235 prescribers), and 3 to usual care (N=319 prescribers). Individual detailing entailed a physician-educator meeting individually with clinicians to address barriers to prescribing guideline-recommended medications. The group detailing intervention incorporated the same social marketing principles in small groups of clinicians.

RESULTS

In the first year following the intervention, the rates of diuretic or beta-blocker use increased by 13.2% in the group detailing practices, 12.5% in the individual detailing practices, and 6.2% in the usual care practices. As compared with usual care practices, diuretic or beta-blocker use was more likely in group detailing practices (adjusted odds ratio (OR), 1.40; 95% confidence interval (CI), 1.11 - 1.76) and individual detailing practices (adjusted OR, 1.30; 95% CI, 0.95 - 1.79). Neither intervention affected blood pressure control. Two years following this single-visit intervention, there was still a trend suggesting a persistent effect of individual (OR, 1.22; 95% CI, 0.92 - 1.62), but not group, detailing (OR, 1.06; 95% CI, 0.80 - 1.39), as compared with usual care.

CONCLUSION

Both group and individual academic detailing improved antihypertensive prescribing over and above usual care but may require reinforcement to sustain improvements.

Controlled trial of interventions to increase testing and treatment for Helicobacter pylori and reduce medication use in patients with chronic acid-related symptoms

BACKGROUND

Many symptomatic patients take proton pump inhibitors or histamine-2 blockers for years and those without gastro-oesophageal reflux disease might benefit from Helicobacter pylori eradication.

AIM

To increase testing and treatment of H. pylori and reduce chronic use of proton pump inhibitors and histamine-2 blockers.

METHODS

We conducted a three-armed controlled trial in 14 managed care practices. We included adults who used proton pump inhibitors or histamine-2 blockers for >1 year and excluded those with gastro-oesophageal reflux disease or previous endoscopy. We compared usual care (n = 312 patients from 6 practices) to low-intensity (n = 147 from 3 practices) and high-intensity (n = 122 from 5 practices) interventions. Low-intensity intervention consisted of guidelines, patient-lists, and a "toolkit"; high-intensity intervention added academic group detailing by a gastroenterologist with reinforcement by pharmacists.

RESULTS

Compared with usual care, the high-intensity intervention increased H. pylori test-ordering (29% versus 9% at 12 months, P = 0.02). About half (23 of 58) of patients tested positive and 22 received eradication treatments. The high-intensity intervention decreased proton pump inhibitor use by 9% per year (P = 0.028), but did not alter histamine-2 blocker use. The low intensity intervention was ineffective.

CONCLUSIONS

Providing guidelines, patient-lists, and toolkits was no better than usual care. Adding group detailing and pharmacist reinforcements led to improvements in H. pylori management and decreases in proton pump inhibitor use.

Generalizability and persistence of a multifaceted intervention for improving quality of care for rural patients with type 2 diabetes

OBJECTIVE

Most quality improvement efforts for type 2 diabetes have neglected cardiovascular risk factors and are limited by a lack of information about generalizability across settings or persistence of effect over time.

RESEARCH DESIGN AND METHODS

We previously reported 6-month results of a controlled study of an intervention that improved cardiovascular risk factors for rural patients with type 2 diabetes. We subsequently provided the identical intervention to the control region after the main study was completed. The primary outcome was 10% improvement in systolic blood pressure, total cholesterol, or HbA(1c). We compared the previously reported 6-month effect of the original intervention with the effect of the crossed-over intervention to the former control region and remeasured outcomes in the original intervention region 12 months later.

RESULTS

Our analysis included 200 original intervention and 181 crossed-over intervention subjects. The age of the population was 62.4 +/- 12.4 years (mean +/- SD), and 54.3% were women. A similar proportion of patients in the crossed-over intervention group achieved improvement in the primary composite outcome compared with the original intervention group (38 vs. 44%, respectively; P = 0.29). In adjusted analyses, we observed less improvement in blood pressure (adjusted odds ratio 0.40 [95% CI 0.17-0.75]) but greater improvements in total cholesterol (1.86 [0.93-3.7]) with the crossed-over intervention compared with the original intervention. We observed sustained improvements in total cholesterol and HbA(1c) levels in the original intervention group, whereas previous large gains in control of blood pressure diminished over time.

CONCLUSIONS

We found that our intervention was generalizable across settings, and its effect persisted over time. Nevertheless, without ongoing intervention or reinforcement, we noted some loss of the original benefits that had accrued. Future translational work should incorporate interventions such as ours into ongoing systems of rural care.

Cardiovascular risk factors in type 2 diabetic patients: Multifactorial intervention in primary care

BACKGROUND

Cardiovascular disease is the main cause of morbidity and mortality in patients with type 2 diabetes mellitus (DM). Intervention on cardiovascular risk factors (CVRF) is essential to obtain clinical results reducing the excess of cardiovascular risk (CVR) in these patients.

METHODS

The objective of this study was to describe the association of type 2 DM with modifiable cardiovascular risk factors and the degree of control of these in a population of type 2 diabetics in attendance in primary care clinics, and also to establish prospectively whether an integral and multifactorial intervention on uncontrolled cardiovascular risk factors, carried out in conditions of routine clinical practice by applying an open protocol, could significantly reduce the estimated CVR according to the Framingham scale. The proposed intervention included both actions aimed at modifying habits, and pharmacologic intervention to achieve an optimum level of control in accordance with international recommendations for the objectives and treatment for type 2 diabetes.

RESULTS

A total of 3466 patients with a mean age of 58 +/- 7.5 years were studied and followed-up for 1 year. Of these, 90.4% of patients had high blood pressure; 60.1% of men and 32.7% of women presented CVR >20% in 10 years according to the Framingham scale by categories. Intervention at 1 year of follow-up had achieved statistically significant reductions in blood pressure, glycated hemoglobin, and lipid levels, but not of patients' body weight. After 1 year of follow-up, 29% of males and 24% of women with a high CVR (>20%) at the start of the study presented reduced risk levels.

CONCLUSION

The results of the study demonstrate that an integrated and multifactorial intervention in type 2 diabetic patients can achieve clinically significant reductions in CVR. However, conducted in effective conditions, it is not able to achieve optimum levels of control in spite of the initial proposal, possibly due to some degree of inertia in routine clinical practice.

Teleconferenced educational detailing: diabetes education for primary care physicians

INTRODUCTION

Formal didactic continuing medical education (CME) is relatively ineffective for changing physician behaviour. Diabetes mellitus is an increasingly prevalent disease, and interventions to improve adherence to clinical practice guidelines (CPGs) are needed.

METHODS

A stratified, cluster-randomized, controlled trial design was used to evaluate the effects of a teleconferenced educational detailing (TED) CME on glycemic control (hemoglobin [Hb] A1c) and family physician adherence to national diabetes guidelines. TED employed sequential, small-group, case-based education using CPGs delivered by a diabetes specialist. Medical record audit data from baseline through the end of a 12-month postintervention period were compared for the control and intervention groups. Satisfaction with the intervention was evaluated.

RESULTS

Sixty-one physicians provided 660 medical records. The intervention did not affect mean Hb A1c levels but did significantly (p = .04) alter the distribution of patients by category of glycemic control, with fewer in the intervention group in inadequate control (15.8% versus 23.9%). More patients took insulin (alone or with oral agents) in the intervention group (21.2% versus 12.0%, p = .03), and more took oral agents only in the control group (89.0% versus 82.9%, p = .005). More patients in the intervention group had documentation of body mass index (7.8% versus 1.9%, p < .02), eye exam (12.1% versus 5.1%, p = .02), and treatment plan (43.5% versus 23.6%, p = .01) and used a flow sheet (14.6% versus 7.7%, p < .03). Although there was general satisfaction with the teleconferencing format, specialist educators found the format more challenging than the family physicians.

DISCUSSION

CME delivered by teleconference was feasible, well attended, well received by participants, and improved some key diabetes management practices and outcomes.

Improvements in patient-reported outcomes associated with an intervention to enhance quality of care for rural patients with type 2 diabetes: results of a controlled trial

OBJECTIVE

The aim of this study was to examine patient-reported outcomes in a controlled trial of a multifaceted provider-level intervention to improve quality of care for rural patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

We conducted a before/after intervention study with concurrent controls in two rural regions in Alberta, Canada. The intervention consisted of six monthly visits by a multidisciplinary health care team and was primarily directed at primary care providers. Clinical and patient-reported outcomes were assessed after 6 months. Patient-reported outcomes included changes in health-related quality of life (Health Utilities Index Mark 3 [HUI3]), satisfaction with care, lifestyle (Diabetes Lifestyle Form), and adherence to self-care activities. Analysis of covariance was used to assess differences over time between the control and intervention regions.

RESULTS

A total of 200 intervention and 172 control subjects were included in this analysis. After adjusting for important clinical and demographic differences, a statistically significant and clinically important improvement in the overall HUI3 score was seen at the 6-month follow-up in the intervention region (0.06 [95% CI 0.02-0.10]) compared with the control region (0.01 [-0.04 to 0.04]) (P = 0.03 for the difference between groups). Satisfaction with general medical care (P < 0.001 between groups) and diabetes care (P < 0.001 between groups) increased among patients in the intervention region compared with the control region. Self-efficacy, attitudes, and beliefs about diabetes control all increased in the intervention region when compared with the control region, but adherence to self-care activities did not.

CONCLUSIONS

A provider-level intervention directed at improving quality of clinical care for patients with type 2 diabetes also had a favorable impact on overall health-related quality of life, satisfaction with care, and other humanistic outcomes.

Health-related quality of life deficits associated with varying degrees of disease severity in type 2 diabetes

BACKGROUND

Diabetes is a chronic medical condition accompanied by a considerable health-related quality of life (HRQL) burden. The purpose of this analysis was to use generic measures of HRQL to describe HRQL deficits associated with varying degrees of severity of type 2 diabetes.

METHODS

The RAND-12 physical and mental health composites (PHC and MHC, respectively) and Health Utilities Index Mark 3 (HUI3) were self-completed by 372 subjects enrolled in a prospective, controlled study of an intervention to improve care for individuals with type 2 diabetes in rural communities. Analysis of covariance was used to assess differences in HRQL according to disease severity and control of blood glucose. Disease severity was defined in terms of treatment intensity, emergency room visits and absenteeism from work specifically attributable to diabetes. To control for potential confounding, the analysis was adjusted for important sociodemographic and clinical characteristics.

RESULTS

The PHC and MHC were significantly lower for individuals treated with insulin as compared to diet alone (PHC: 41.01 vs 45.11, MHC: 43.23 vs 47.00, p < 0.05). Individuals treated with insulin had lower scores on the vision, emotion and pain attributes of the HUI3 than individuals managed with oral medication or diet. The PHC, MHC, pain attribute and overall score on the HUI3 captured substantial decrements in HRQL associated with absenteeism from work due to diabetes, while the burden associated with emergency room utilization for diabetes was seen in the PHC and HUI3 pain attribute.

CONCLUSIONS

We concluded that generic measures of HRQL captured deficits associated with more severe disease in type 2 diabetes.