Diabetes management in a health maintenance organization. Efficacy of care management using cluster visits

Shared and individual medical appointments for children and adolescents with type 1 diabetes; differences in topics discussed?

OBJECTIVE

The purpose of this study was to examine differences in the type of topics discussed during shared medical appointments (SMAs) and traditional individual outpatient visits for children and adolescents with type 1 diabetes. In addition, differences between the conversational contributions of the participants were examined.

METHODS

Videotapes of 42 individual outpatient visits and 5 SMAs with 31 children or adolescents were collected and observed using a checklist of topics adapted from the international consensus guideline for the management of type 1 diabetes in childhood and adolescents. Furthermore, patients reported about their experience with the information and support provided during an SMA. Data analysis was performed using one-way ANOVAs and univariate variance analysis.

RESULTS

In SMAs, more diabetes-related topics were discussed. During SMAs, the conversational contributions of the different participants seemed to be more equally distributed than during traditional individual outpatient visits. Participants felt that they had learned most from the presence of other patients and their questions.

CONCLUSION

More diabetes-related topics are covered in SMAs than in individual outpatient pediatric follow-up visits.

PRACTICE IMPLICATION

SMAs seem to offer an appreciated variation on the regular diabetes care for children and adolescents.

Predictors of initiating rapid-acting insulin analog using vial/syringe, prefilled pen, and reusable pen devices in patients with type 2 diabetes

BACKGROUND

Limited data are available on the predictors of insulin delivery device choice. This study assessed the patient- and health-care-system-related factors that predict the initiation of one rapid-acting insulin analog (RAIA) delivery system over another.

METHODS

A retrospective analysis using a claims database (January 1, 2007, through March 31, 2009) was conducted. Patients were required to be diagnosed with type 2 diabetes mellitus, and have >or=12 months of continuous eligibility prior to their first prescription of a RAIA on or after January 1, 2008. The three cohorts in the study were vial/syringe (n = 6820), prefilled pen (n = 5840), and reusable pen (n = 2052). Multiple factors were examined using stepwise logistic regression.

RESULTS

Factors that increased the likelihood of initiating RAIA using prefilled pen versus vial/syringe included endocrinologist visit [odds ratio (OR) = 3.13, 95% confidence interval (CI) = 2.56, 3.82], prior basal insulin use with pen (OR = 4.85, 95% CI = 4.21, 5.59), and use of >or=1 oral antihyperglycemic agents (OR = 1.32, 95% CI = 1.20, 1.45). Factors that decreased the likelihood included inpatient admission (OR = 0.76, 95% CI = 0.70, 0.83), nursing home visit (OR = 0.22, 95% CI = 0.18, 0.27), and obesity (OR = 0.67, 95% CI = 0.53, 0.83). There were fewer differences between prefilled and reusable pen initiators. Factors that increased the likelihood of initiating with prefilled versus reusable pen included endocrinologist visit (OR = 1.87, CI = 1.50, 2.34) and inpatient admission (OR = 1.46, 95% CI = 1.30, 1.64).

CONCLUSION

Significant differences in predictors were observed between prefilled pen and vial/syringe initiators. The differences were fewer between prefilled and reusable pen initiators. These differences should be taken into consideration when evaluating outcomes associated with specific insulin delivery systems.

Nurse diabetes case management interventions and blood glucose control: results of a meta-analysis

We conducted a meta-analysis of studies reporting diabetes case management interventions to examine the impact of case management on blood glucose control (HbA1c). Databases used for the search included Medline, PubMed, Cochrane EPOC, Cumulative Index to Nursing & Allied Health Literature database guide (CINAHL), and PsychInfo. A composite estimate of effect size was calculated using a random effects model and subgroup analyses were conducted. Twenty-nine salient studies involving 9397 patients had sufficient data for analysis. Mean patient age was 63.2 years, 49% were male, and ethnicity/race was 54% White. Type 2 diabetes was the focus in 91% of studies. Results showed a large overall effect size favoring case management intervention over controls or baseline values on HbA1c (ES=0.86, 95%CI: 0.52-1.19, Z=5.0, p<0.001). This corresponds to a mean HbA1c reduction of 0.89 (95%CI: 0.63-1.15). Subgroup analyses showed clinical setting, team composition, and baseline HbA1c were important predictors of effect size, but not diabetes self-management education which was poorly described or absent in most diabetes case management interventions examined. Nurse-led case management provides an effective clinical strategy for poorly controlled diabetes based on a meta-analysis of clinical trials focusing on blood glucose control.

Professional development of pharmaceutical care in type 2 diabetes mellitus: a multidisciplinary conceptual model

Objective

To generate a validated model of care providing a framework for continued professional development of the community pharmacist for patients with type 2 diabetes mellitus.

Setting

A purposive sample of medical, nursing and community pharmacist interviewees in 10 health boards in Scotland.

Method

Investigation, using a semi-structured questionnaire approach, of the views held by 19 healthcare practitioners.

Key findings

A model of multidisciplinary diabetes care was generated to aid definition of pharmaceutical care provision. Processes emphasised in the model were: compliance monitoring, agreed multidisciplinary protocols and the continuity of patient education. Potential areas for community pharmacist contributions included the running of diabetes clinics, provision of patient education, near-patient testing, repeat dispensing and identification of clinic defaulters.

Conclusions

Development of the community pharmacists' role for patients with type 2 diabetes mellitus requires extensions to current independently delivered patient-centred services through working in partnership with other professionals. Methods of improved communication and attention to methods of referral, where appropriate, are important focal points. The targeting of this care and the care model that is best suited to particular settings will be subject to local variation. The generation of a diabetes care model offers pharmacists a means of matching learning opportunities to their needs. It is also a step towards the development of appropriate continued professional development tools and systems to equip community pharmacists for the future.

A consensus model for delivery of structured pharmaceutical care for the patient with type 2 diabetes mellitus by Scottish community pharmacists

Objective

To generate a model of pharmaceutical care for the patient with type 2 diabetes mellitus in primary care, from a consensus determined among community pharmacists in Scotland. Setting Community pharmacists within Scotland already involved in providing structured pharmaceutical care.

Method

The Delphi questionnaire was based on a validated multidisciplinary model of care for the patient with type 2 diabetes mellitus in primary care comprising 47 items under five themes: assessment, treatment plan, treatment administration, patient monitoring, confirmation/review. Seventy participants already participating in a pharmaceutical care model schemes initiative to encourage pharmaceutical care from community pharmacies and with an interest in diabetes mellitus were sent an initial questionnaire. Thirty-seven participants agreed to enter two further rounds; response rates were 22/37 (59%) and 18/22 (82%). Final round cut-off defining consensus was 80% scoring 6–7 from a seven-point Likert scale.

Key findings

A model emerged from the achieved consensus. There was an early consensus achieved on the core functions that participants were already delivering to the patient with diabetes mellitus. These are functions that have been highlighted and delivered in previous studies within this disease state: receiving and sharing patient information, individualising treatment, identifying unsatisfactory treatment and monitoring and prescribing analgesia.

Conclusions

For service development and linked continued professional development a well-defined service model for delivering pharmaceutical care to patients is required. This study proposes such a model based on consensus among a self-selected group of community pharmacists leading diabetes pharmacy practice in Scotland.

Hearing aid effectiveness after aural rehabilitation - individual versus group (HEARING) trial: RCT design and baseline characteristics

BACKGROUND

Hearing impairment is the most common body system disability in veterans. In 2008, nearly 520,000 veterans had a disability for hearing loss through the Department of Veterans Affairs (VA). Changes in eligibility for hearing aid services, along with the aging population, contributed to a greater than 300% increase in the number of hearing aids dispensed from 1996 to 2006. In 2006, the VA committed to having no wait times for patient visits while providing quality clinically-appropriate care. One approach to achieving this goal is the use of group visits as an alternative to individual visits. We sought to determine: 1) if group hearing aid fitting and follow-up visits were at least as effective as individual visits, and 2) whether group visits lead to cost savings through the six month period after the hearing aid fitting. We describe the rationale, design, and characteristics of the baseline cohort of the first randomized clinical trial to study the impact of group versus individual hearing aid fitting and follow-up visits.

METHODS

Participants were recruited from the VA Puget Sound Health Care System Audiology Clinic. Eligible patients had no previous hearing aid use and monaural or binaural air-conduction hearing aids were ordered at the evaluation visit. Participants were randomized to receive the hearing aid fitting and the hearing aid follow-up in an individual or group visit. The primary outcomes were hearing-related function, measured with the first module of the Effectiveness of Aural Rehabilitation (Inner EAR), and hearing aid adherence. We tracked the total cost of planned and unplanned audiology visits over the 6-month interval after the hearing aid fitting.

DISCUSSION

A cohort of 659 participants was randomized to receive group or individual hearing aid fitting and follow-up visits. Baseline demographic and self-reported health status and hearing-related measures were evenly distributed across the treatment arms.Outcomes after the 6-month follow-up period are needed to determine if group visits were as least as good as those for individual visits and will be reported in subsequent publication.

TRIAL REGISTRATION

NCT00260663.

Pharmacist-Led Group Medical Appointment Model in Type 2 Diabetes

Purpose

The purpose of this study was to assess whether the VA-MEDIC (Veterans Affairs Multi-disciplinary Education and Diabetes Intervention for Cardiac risk reduction), a pharmacist-led group medical visit program, could improve achievement of target goals in hypertension, hyperglycemia, hyperlipidemia, and tobacco use in patients with type 2 diabetes compared to usual care.

Methods

This was a randomized controlled trial of VA-MEDIC intervention in addition to usual care versus usual care alone in diabetic patients to reduce cardiac risk factors. VA-MEDIC consisted of a 40- to 60-minute educational component by nurse, nutritionist, physical therapist, or pharmacist followed by pharmacist-led behavioral and pharmacological interventions over 4 weekly sessions.

Measures

The attainment of target goals in hemoglobin A1C (A1C), blood pressure, fasting lipids, and tobacco use recommended by the American Diabetes Association.

Results

Of 118 participants, 109 completed the study. VA-MEDIC (n = 58) participants were younger and had greater tobacco use at baseline than usual care but were similar in other cardiovascular risk factors. After 4 months, a greater proportion of VA-MEDIC participants versus controls achieved an A1C of less than 7% and a systolic blood pressure less than 130 mm Hg. No significant change was found in lipid control or tobacco use between the 2 study arms.

Conclusion

Pharmacist-led group medical visits are feasible and efficacious for improving cardiac risk factors.

Health literacy and quality: focus on chronic illness care and patient safety

Despite a heightened focus on improving quality, recent studies have suggested that children only receive half of the indicated preventive, acute, or chronic care. Two major areas in need of improvement are chronic illness care and prevention of medical errors. Recently, health literacy has been identified as an important and potentially ameliorable factor for improving quality of care. Studies of adults have documented that lower health literacy is independently associated with poorer understanding of prescriptions and other medical information and worse chronic disease knowledge, self-management behaviors, and clinical outcomes. There is also growing evidence to suggest that health literacy is important in pediatric safety and chronic illness care. Adult studies have suggested that addressing literacy can lead to improved patient knowledge, behaviors, and outcomes. Early studies in the field of pediatrics have shown similar promise. There are significant opportunities to evaluate and demonstrate the importance of health literacy in improving pediatric quality of care. Efforts to address health literacy should be made to apply the 6 Institute of Medicine aims for quality-care that is safe, effective, patient centered, timely, efficient, and equitable. Efforts should also be made to consider the distinct nature of pediatric care and address the "4 D's" unique to child health: the developmental change of children over time; dependency on parents or adults; differential epidemiology of child health; and the different demographic patterns of children and their families.

Does health service use in a diabetes management program contribute to health disparities at a facility level? Optimizing resources with demographic predictors

The objective of this study was to determine if demographic variation in the use of health service resources among type 2 diabetes patients contributes to health disparities. A prospective cohort design was used to analyze differences in health care utilization among 315 adults registered in primary care internal medicine clinics of an academic medical center. Patients were cared for by interdisciplinary teams of internal medicine residents, nurse practitioner students, and pharmacy students supervised by interdisciplinary faculty. A post hoc multivariate repeated measures analysis, using generalized estimating equation (GEE) statistical modeling, was used to determine if age, sex, race, ethnicity, marital status, primary language, and insurance predicted use of health care services (ie, primary care, acute care, emergency department [ED], hospitalization). Medicare/Medicaid-insured patients had an average of 2.49 primary care visits per month (P < .0001) and 75% more ED visits (P < .001) during the study than patients with other insurance types. ED visits for Hispanics grew by a factor of 3.3 compared to non-Hispanics (P < .0001). Females had 52% more hospitalizations than males (P < .05), and Hispanics had 44% fewer hospitalizations than non-Hispanics (P < .05). Analysis of selected health status indicators showed no significant differences for HbA1c, significantly greater likelihood of blood pressure >130/80 with every 5-year increase in age, and significantly greater likelihood of low-density lipoprotein >100 among Medicare/Medicaid-insured patients. Sociodemographic characteristics are predictive of health care services use and suggest that, although equally available to all participants, the use of health care resources vary at the facility level and are independent of diabetes health status outcomes.

Untangling practice redesign from disease management: how do we best care for the chronically ill?

In the past 10 years, a wide spectrum of chronic care improvement interventions has been tried and evaluated to improve health outcomes and reduce costs for chronically ill individuals. On one end of the spectrum are disease-management interventions--often organized by commercial vendors--that work with patients but do little to engage medical practice. On the other end are quality-improvement efforts aimed at redesigning the organization and delivery of primary care and better supporting patient self-management. This qualitative review finds that carve-out disease management interventions that target only patients may be less effective than those that also work to redesign care delivery. Imprecise nomenclature and poor study design methodology limit quantitative analysis. More innovation and research are needed to understand how disease-management components can be more meaningfully embedded within practice to improve patient care.

Effectiveness and safety of medication adjustments by nurse case managers to control hyperglycemia

PURPOSE

The purpose of this study was to determine the safety and effectiveness of implementing standing orders for nurse case managers to adjust antihyperglycemic medications.

METHODS

A retrospective cohort design was used to assess outcomes in American Indian and Alaska Native people who received case management and medication adjustment and those who received only standard primary care. Patients with diabetes and evidence of keeping regular follow-up appointments for diabetes care (N = 2345) who all had baseline A1C >or= 7.0% were divided into 3 mutually exclusive groups for analysis: (1) those seen only by primary care providers (PCP; n = 1574); (2) those seen by nurse case managers (NCM; in addition to primary care) for diabetes education services only (n = 711); and (3) those who, in addition to a PCP and NCM visit, had medications adjusted by the nurse case managers (MA; n = 60). Outcome variables were number of visits with documentation of hypoglycemia (safety) and rate of A1C change (effectiveness).

RESULTS

Documented hypoglycemia occurred more frequently with more intensive treatment. The MA group experienced the greatest rate of hypoglycemic events. The difference in hypoglycemia incidence between the groups was significant, but the number of events was small. Glycemic control improved most rapidly in the MA group, even after adjusting for potentially confounding variables.

CONCLUSIONS

In this setting, hypoglycemia occurs infrequently in all groups, but at higher rates with more intensive treatment. Nurse case management, whether with or without medication adjustment, is effective in improving short-term glucose control.

[Non-physician health care providers for the treatment and care of the chronically ill (focusing on DMP diagnoses)]

BACKGROUND

This systematic review will investigate the question of how non-physician health care providers may be involved in the care and treatment of patients with chronic disease and which role they could play within the scope of the German Disease Management Programmes (DMP).

METHODS

This article is limited to the German DMP diagnoses asthma, COPD, coronary heart disease, and type-1 and -2 diabetes mellitus. Several databases were systematically searched to find national and international studies with interventions carried out by non-physician health care providers such as nurses, dieticians, physiotherapists or occupational therapists.

RESULTS

More than 300 studies and reviews were included in this systematic review. Nurses and dieticians were by far the prevailing professional groups performing the largest number of the interventions identified. Transferring. the results of the literature review to the German setting, non-physician health care providers could both undertake certain tasks on their own responsibility and provide other services in support of the medical treatment of the chronically ill. Some interventions are given as examples.

Group visits in the management of diabetes and hypertension: effect on glycemic and blood pressure control

Diabetes is a major public health problem that is reaching epidemic proportions in the United States and worldwide. Over 22 million Americans currently have diabetes and it is forecast that over 350 million people worldwide will be affected by 2030. Furthermore, the economic cost of diabetes care is enormous. Despite current efforts on the part of health care providers and their patients, outcomes of care remain largely suboptimal, with only 3% to 7% of the entire diabetes population meeting recommended treatment goals for glycemic, blood pressure, and lipid control. Therefore, alternative approaches to diabetes care are desperately needed. Group visits may provide a viable option for patients and health care providers, with the potential to improve outcomes and cost effectiveness. In this review, we highlight the magnitude of the diabetes epidemic, the barriers to optimal diabetes care, and the utility of the concept of group visits as a chronic disease management strategy for diabetes care.

A Review of Pharmacist Contributions to Diabetes Care in the United States

This paper summarizes the outcomes associated with pharmacist involvement in diabetes care in all pharmacy practice settings. Published literature was identified through a search of MEDLINE (1960 to September, week 1, 2008) and International Pharmaceutical Abstracts using the search terms “pharmacist,” “pharmaceutical care,” and “diabetes mellitus.” Only articles reporting clinical or behavior change outcomes were selected for review; papers written outside the United States and citations only in abstract form were not reviewed. The specific data extracted included the following: practice setting, model of care, roles of the pharmacist, study design, number of patients studied, duration of the evaluation, and documented outcomes such as changes in hemoglobin A1c values, adherence to standards of care (lipids, blood pressure, eye exams, foot exams, aspirin use), and changes in quality of life. The greatest improvements in hemoglobin A1c values tend to be observed when pharmacists work in collaborative practice models. Growing evidence demonstrates that pharmacists, working as educators, consultants, or clinicians in partnership with other health care professionals, are able to contribute to improved patient outcomes.

Effects of self-management support on structure, process, and outcomes among vulnerable patients with diabetes: a three-arm practical clinical trial

OBJECTIVE

Despite the importance of self-management support (SMS), few studies have compared SMS interventions, involved diverse populations, or entailed implementation in safety net settings. We examined the effects of two SMS strategies across outcomes corresponding to the Chronic Care Model.

RESEARCH DESIGN AND METHODS

A total of 339 outpatients with poorly controlled diabetes from county-run clinics were enrolled in a three-arm trial. Participants, more than half of whom spoke limited English, were uninsured, and/or had less than a high school education, were randomly assigned to usual care, interactive weekly automated telephone self-management support with nurse follow-up (ATSM), or monthly group medical visits with physician and health educator facilitation (GMV). We measured 1-year changes in structure (Patient Assessment of Chronic Illness Care [PACIC]), communication processes (Interpersonal Processes of Care [IPC]), and outcomes (behavioral, functional, and metabolic).

RESULTS

Compared with the usual care group, the ATSM and GMV groups showed improvements in PACIC, with effect sizes of 0.48 and 0.50, respectively (P < 0.01). Only the ATSM group showed improvements in IPC (effect sizes 0.40 vs. usual care and 0.25 vs. GMV, P < 0.05). Both SMS arms showed improvements in self-management behavior versus the usual care arm (P < 0.05), with gains being greater for the ATSM group than for the GMV group (effect size 0.27, P = 0.02). The ATSM group had fewer bed days per month than the usual care group (-1.7 days, P = 0.05) and the GMV group (-2.3 days, P < 0.01) and less interference with daily activities than the usual care group (odds ratio 0.37, P = 0.02). We observed no differences in A1C change.

CONCLUSIONS

Patient-centered SMS improves certain aspects of diabetes care and positively influences self-management behavior. ATSM seems to be a more effective communication vehicle than GMV in improving behavior and quality of life.

A low-fat vegan diet elicits greater macronutrient changes, but is comparable in adherence and acceptability, compared with a more conventional diabetes diet among individuals with type 2 diabetes

BACKGROUND

Although therapeutic diets are critical to diabetes management, their acceptability to patients is largely unstudied.

OBJECTIVE

To quantify adherence and acceptability for two types of diets for diabetes.

DESIGN

Controlled trial conducted between 2004 and 2006.

SUBJECTS/SETTING

Individuals with type 2 diabetes (n=99) at a community-based research facility. Participants were randomly assigned to a diet following 2003 American Diabetes Association guidelines or a low-fat, vegan diet for 74 weeks.

MAIN OUTCOME MEASURES

Attrition, adherence, dietary behavior, diet acceptability, and cravings.

STATISTICAL ANALYSES

For nutrient intake and questionnaire scores, t tests determined between-group differences. For diet-acceptability measures, the related samples Wilcoxon sum rank test assessed within-group changes; the independent samples Mann-Whitney U test compared the diet groups. Changes in reported symptoms among the groups was compared using chi(2) for independent samples.

RESULTS

All participants completed the initial 22 weeks; 90% (45/50) of American Diabetes Association guidelines diet group and 86% (42/49) of the vegan diet group participants completed 74 weeks. Fat and cholesterol intake fell more and carbohydrate and fiber intake increased more in the vegan group. At 22 weeks, group-specific diet adherence criteria were met by 44% (22/50) of members of the American Diabetes Association diet group and 67% (33/49) of vegan-group participants (P=0.019); the American Diabetes Association guidelines diet group reported a greater increase in dietary restraint; this difference was not significant at 74 weeks. Both groups reported reduced hunger and reduced disinhibition. Questionnaire responses rated both diets as satisfactory, with no significant differences between groups, except for ease of preparation, for which the 22-week ratings marginally favored the American Diabetes Association guideline group. Cravings for fatty foods diminished more in the vegan group at 22 weeks, with no significant difference at 74 weeks.

CONCLUSIONS

Despite its greater influence on macronutrient intake, a low-fat, vegan diet has an acceptability similar to that of a more conventional diabetes diet. Acceptability appears to be no barrier to its use in medical nutrition therapy.

Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: the IDEATel project

BACKGROUND

with increasing prevalence of diabetes in older people, it is important to understand factors that affect their outcomes. The Informatics for Diabetes Education and Telemedicine (IDEATel) project is a demonstration project to evaluate the feasibility and effectiveness of telemedicine with diverse, medically underserved, older diabetes patients. Subjects were randomised to telemedicine case management or usual care. This intervention has been shown to result in improved medical outcomes and self-efficacy. Self-efficacy refers to one's belief that (s)he can successfully engage in a behaviour. Self-efficacy has been shown to relate to behaviour change and glycaemic control in middle-aged individuals, but not studied in older individuals.

OBJECTIVES

to assess whether (a) diabetes self-efficacy relates to the primary medical outcome of glycaemic control, and to secondary outcomes (blood pressure and cholesterol), and (b) whether, after an intervention, change in diabetes self-efficacy relates to change in these medical outcomes in a group of older, ethnically diverse individuals.

METHODS

three waves of longitudinal data from participants in IDEATel were analysed.

RESULTS

diabetes self-efficacy at baseline correlated with glycaemic control, blood pressure and cholesterol. An increase in diabetes self-efficacy over time was related to an improvement in glycaemic control (P < 0.0001), but not in blood pressure and lipid levels. The intervention was significantly related to improved self-efficacy over time (P < 0.0001), and both directly (P = 0.022) and indirectly through self-efficacy (P < 0.001) to improved glycaemic control. The mediation effect of self-efficacy was also significant (P< 0.004).

CONCLUSIONS

diabetes self-efficacy is a relevant construct for older diabetes patients. Thus, interventions that target enhanced self-efficacy may also result in improved glycaemic control.

The burden of chronic disorders on hospital admissions prompts the need for new modalities of care: a cross-sectional analysis in a tertiary hospital

BACKGROUND

Chronic disorders constitute a primary concern because of their burden on healthcare systems worldwide. Integrated care strategies enhancing the interface between tertiary care and primary care are pivotal to improve chronic care.

AIM

To asses the prevalence of chronic disorders on hospital discharges and their impact on unplanned admissions and mortality.

DESIGN

Cross-sectional analysis of discharge information over 1 year (2004) in one University hospital.

METHODS

Adoption of an operational definition of chronic disorder based on the WHO.

MAIN OUTCOME

co-morbid conditions, emergency room and hospital admissions, outpatient consultations and mortality.

RESULTS

Fifty-eight percent of patients presented at least one chronic condition (19 192 patients, 53% males, 63 +/- 18 years) as primary (12 526 patients, 38%) or secondary diagnosis. The Charlson index was 2 +/- 3. Each chronic condition was associated with a 30% increase of having had an admission in the previous year. Up to 9% (1 656) of chronic patients showed multiple admissions in the previous year: two (917 patients, 55%), three (360, 22%) and four or beyond (379, 23%), being mostly unscheduled hospitalizations. The three most prevalent chronic disorders were cancer, cardiovascular diseases and chronic obstructive pulmonary disease (COPD). The rate of admissions was associated with co-morbidity (P < 0.001) and mortality (P < 0.001).

CONCLUSION

The study shows a high impact of cancer on planned hospitalizations whereas cardiovascular diseases and COPD generates a high percentage of unscheduled admissions. We conclude that integrated care services including patient-oriented guidelines are strongly needed to enhance both health and managerial outcomes.

Introduction of CenteringPregnancy in a public health clinic

CenteringPregnancy is a promising group visit prenatal care innovation that provides substantial health promotion content. Elements unique to group care include peer support and self-management training and activities. CenteringPregnancy was introduced at a large public health clinic serving predominantly low-income African American pregnant women. All prenatal care at this clinic was provided by certified nurse-midwives, and all providers were trained in the CenteringPregnancy model. One hundred and ten women received prenatal care in CenteringPregnancy groups. Focus groups of pregnant women, providers, and health center staff reported that the program benefited women despite implementation challenges such as scheduling changes. Compared to women in individual care, women in CenteringPregnancy had significantly more prenatal visits, increased weight gain, increased breast feeding rates, and higher overall satisfaction. This pilot project demonstrated that CenteringPregnancy can be implemented in a busy public health clinic serving predominantly low-income pregnant women and is associated with positive health outcomes.

Synchronous Provider Visit and Self-management Education Improves Glycemic Control in Hispanic Patients With Long-Standing Type 2 Diabetes

Purpose The purpose of this study was to evaluate the efficacy of a multidisciplinary diabetes self-management program. The study focused on improving diabetes control by synchronizing regularly scheduled provider visits with a multidisciplinary diabetes education program. This intervention was instituted in Hispanic patients with long-standing poorly controlled type 2 diabetes.

Methods The study was initiated as a performance improvement project. A group of 44 type 2 diabetes patients followed by the internal medicine faculty with HbA1c levels greater than 9.5 over a 12-month period was identified. Twenty-three of the identified patients were enrolled in a synchronous care group. A cohort control group of the remaining 21 patients not participating in the intervention was followed with routine care. The intervention group shared similar demographic characteristics, medication regimens, initial diabetes control, and a number of provider visits with the control group. The primary outcome of interest for the study is the HbA1c level.

Results The findings demonstrated that our synchronous management approach significantly improved HbA1c level over standard management for medically indigent Hispanic patients with long-standing poorly controlled type 2 diabetes (P < .001). The majority of the patients (89%) in the Intensive Management Group had declines in HbA1c level from baseline, compared to the Standard Management Group (60%, P = .04).

Conclusion The temporal linkage between routine provider visits and a diabetes self-management education intervention in poorly controlled Hispanic patients with long-standing type 2 diabetes led to a significant improvement in HbA1c levels.

Improving the prevention and management of chronic disease in low-income and middle-income countries: a priority for primary health care

The burden of chronic diseases, such as heart disease, cancer, diabetes, and mental disorders is high in low-income and middle-income countries and is predicted to increase with the ageing of populations, urbanisation, and globalisation of risk factors. Furthermore, HIV/AIDS is increasingly becoming a chronic disorder. An integrated approach to the management of chronic diseases, irrespective of cause, is needed in primary health care. Management of chronic diseases is fundamentally different from acute care, relying on several features: opportunistic case finding for assessment of risk factors, detection of early disease, and identification of high risk status; a combination of pharmacological and psychosocial interventions, often in a stepped-care fashion; and long-term follow-up with regular monitoring and promotion of adherence to treatment. To meet the challenge of chronic diseases, primary health care will have to be strengthened substantially. In the many countries with shortages of primary-care doctors, non-physician clinicians will have a leading role in preventing and managing chronic diseases, and these personnel need appropriate training and continuous quality assurance mechanisms. More evidence is needed about the cost-effectiveness of prevention and treatment strategies in primary health care. Research on scaling-up should be embedded in large-scale delivery programmes for chronic diseases with a strong emphasis on assessment.

Evidence-based nutrition practice guidelines for diabetes and scope and standards of practice

In the 1990s, the American Dietetic Association (ADA) began developing nutrition practice guidelines for registered dietitians (RDs) and evaluating how their use affected clinical outcomes. Clinical trials and outcomes research report that diabetes medical nutrition therapy, delivered using a variety of nutrition interventions and multiple encounters, is effective in improving glycemic and other metabolic outcomes. The process of developing nutrition practice guidelines has evolved into evidence-based nutrition practice guidelines, which are disease/condition-specific recommendations and toolkits. An expert work group identified important clinical questions related to diabetes nutrition therapy. Research studies were analyzed and evidence summaries and conclusion statements written and graded for strength of research design. Based on the research conclusions, evidence-based nutrition recommendations and guidelines for adults with type 1 and type 2 diabetes were formulated. The ADA evidence-based nutrition practice guidelines for diabetes are published in the Web-based evidence analysis library. The recommendations are similar to those of the American Diabetes Association, although developed using a different method. To define the RD's professional practice, the ADA has published the Scope of Dietetics Practice Framework, the Standards of Practice and Standards of Professional Performance, and specialized standards for the RD in diabetes nutrition care. The latter defines the knowledge, skills, and competencies required by RDs to provide diabetes care at the generalist, specialist, and advanced practice level.

Evaluation of a diabetes management system based on practice guidelines, integrated care, and continuous quality management in a Federal State of Germany: a population-based approach to health care research

OBJECTIVE

The aim of this study was to evaluate the Saxon Diabetes Management Program (SDMP), which is based on integrated practice guidelines, shared care, and integrated quality management. The SDMP was implemented into diabetes contracts between health insurance providers, general practitioners (GPs), and diabetes specialized practitioners (DSPs) unified in the Saxon association of Statutory Health Insurance Physicians.

RESEARCH DESIGN AND METHODS

The evaluation of the SDMP in Germany represents a real-world study by using clinical data collected from participating physicians. Between 2000 and 2002 all DSPs and about 75% of the GPs in Saxony participated. Finally, 291,771 patients were included in the SDMP. Cross-sectional data were evaluated at the beginning of 2000 (group A1) and at the end of 2002 (group A2). A subcohort of 105,204 patients was followed over a period of 3 years (group B).

RESULTS

The statewide implementation of the SDMP resulted in a change in therapeutic practice and in better cooperation. The median A1C at the time of referral to DSPs decreased from 8.5 to 7.5%, and so did the overall mean. At the end, 78 and 61% of group B achieved the targets for A1C and blood pressure, respectively, recommended by the guidelines compared with 69 and 50% at baseline. Patients with poorly controlled diabetes benefited the most. Preexisting regional differences were aligned.

CONCLUSIONS

Integrated care disease management with practicable integrated quality management including collaboration between GPs and specialist services is a significant innovation in chronic care management and an efficient way to improve diabetes care continuously.

Nutritionist visits, diabetes classes, and hospitalization rates and charges: the Urban Diabetes Study

OBJECTIVE

We evaluated the association of different types of educational visits for diabetic patients of the eight Philadelphia Health Care Centers (PHCCs) (public safety-net primary care clinics), with hospital admission rates and charges reported to the Pennsylvania Health Care Cost Containment Council.

RESEARCH DESIGN AND METHODS

The study population included 18,404 patients who had a PHCC visit with a diabetes diagnosis recorded between 1 March 1993 and 31 December 2001 and had at least 1 month follow-up time.

RESULTS

A total of 31,657 hospitalizations were recorded for 7,839 (42.6%) patients in the cohort. After adjustment for demographic variables, baseline comorbid conditions, hospitalizations before the diabetes diagnosis, and number of other primary care visits, having had any type of educational visit was associated with 9.18 (95% CI 5.02-13.33) fewer hospitalizations per 100 person-years and $11,571 ($6,377 to $16,765) less in hospital charges per person. Each nutritionist visit was associated with 4.70 (2.23-7.16) fewer hospitalizations per 100 person-years and a $6,503 ($3,421 to $9,586) reduction in total hospital charges.

CONCLUSIONS

Any type of educational visit was associated with lower hospitalization rates and charges. Nutritionist visits were more strongly associated with reduced hospitalizations than diabetes classes. Each nutritionist visit was associated with a substantial reduction in hospital charges, suggesting that providing these services in the primary care setting may be highly cost-effective for the health care system.

Veterans Affairs research on health information technologies for diabetes self-management support

BACKGROUND

Like many patients with diabetes, Department of Veterans Affairs (VA) patients frequently fall short of self-management goals and experience multiple barriers to self-care. Health information technologies (HITs) may provide the tools that patients need to manage their illness under the direction of their primary care team.

METHODS

We describe several ongoing projects focused on HIT resources for self-management in VA. VA researchers are developing HITs that seek to bolster a variety of potential avenues for self-management support, including patients' relationships with other patients, connections with their informal care networks, and communication with their health care teams.

RESULTS

Veterans Affairs HIT research projects are developing services that can address the needs of patients with multiple challenges to disease self-care, including multimorbidity, health literacy deficits, and limited treatment access. These services include patient-to-patient interactive voice response (IVR) calling systems, IVR assessments with feedback to informal caregivers, novel information supports for clinical pharmacists based on medication refill data, and enhanced pedometers.

CONCLUSION

Large health care systems such as the VA can play a critical role in developing HITs for diabetes self-care. To be truly effective, these efforts should include a continuum of studies: observational research to identify barriers to self-management, developmental studies (e.g., usability testing), efficacy trials, and implementation studies to evaluate utility in real-world settings. VA HIT researchers partner with operations to promote the dissemination of efficacious services, and such relationships will be critical to move HIT innovations into practice.

Preferences for self-management support: findings from a survey of diabetes patients in safety-net health systems

OBJECTIVE

We sought to identify interest in different modes of self-management support among diabetes patients cared for in public hospitals, and to assess whether demographic or disease-specific factors were associated with patient preferences. We explored the possible role of a perceived communication need in influencing interest in self-management support.

METHODS

Telephone survey of a random sample of 796 English and Spanish-speaking diabetes patients (response rate 47%) recruited from four urban US public hospital systems. In multivariate models, we measured the association of race/ethnicity, primary language, self-reported health literacy, self-efficacy, and diabetes-related factors on patients' interest in three self-management support strategies (telephone support, group medical visits, and Internet-based support). We explored the extent to which patients believed that better communication with providers would improve their diabetes control, and whether this perception altered the relationship between patient factors and self-management support acceptance.

RESULTS

Sixty-nine percent of respondents reported interest in telephone support, 55% in group medical visits, and 42% in Internet. Compared to Non-Hispanic Whites, Spanish-speaking Hispanics were more interested in telephone support (OR 3.45, 95% CI 1.97-6.05) and group medical visits (OR 2.45, 95% CI 1.49-4.02), but less interested in Internet self-management support (OR 0.56, 95% CI 0.33-0.93). African-Americans were more interested than Whites in all three self-management support strategies. Patients with limited self-reported health literacy were more likely to be interested in telephone support than those not reporting literacy deficits. Forty percent reported that their diabetes would be better controlled if they communicated better with their health care provider. This perceived communication benefit was independently associated with interest in self-management support (p<0.001), but its inclusion in models did not alter the strengths of the main associations between patient characteristics and self-management support preferences.

CONCLUSION

Many diabetes patients in safety-net settings report an interest in receiving self-management support, but preferences for modes of delivery of self-management support vary by race/ethnicity, language proficiency, and self-reported health literacy.

PRACTICE IMPLICATIONS

Public health systems should consider offering a range of self-management support services to meet the needs of their diverse patient populations. More broad dissemination and implementation of self-management support may help address the unmet need for better provider communication among diabetes patients in these settings.

Shared medical appointments based on the chronic care model: a quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk

OBJECTIVE

The epidemic proportions and management complexity of diabetes have prompted efforts to improve clinic throughput and efficiency. One method of system redesign based on the chronic care model is the Shared Medical Appointment (SMA) in which groups of patients (8-20) are seen by a multi-disciplinary team in a 1-2 h appointment. Evaluation of the impact of SMAs on quality of care has been limited. The purpose of this quality improvement project was to improve intermediate outcome measures for diabetes (A1c, SBP, LDL-cholesterol) focusing on those patients at highest cardiovascular risk.

SETTING

Primary care clinic at a tertiary care academic medical center.

SUBJECTS

Patients with diabetes with one or more of the following: A1c >9%, SBP blood pressure >160 mm Hg and LDL-c >130 mg/dl were targeted for potential participation; other patients were referred by their primary care providers. Patients participated in at least one SMA from 4/05 to 9/05.

STUDY DESIGN

Quasi-experimental with concurrent, but non-randomised controls (patients who participated in SMAs from 5/06 through 8/06; a retrospective period of observation prior to their SMA participation was used).

INTERVENTION

SMA system redesign. ANALYTICAL METHODS: Paired and independent t tests, chi(2) tests and Fisher Exact tests.

RESULTS

Each group had up to 8 patients. Patients participated in 1-7 visits. At the initial visit, 83.3% had A1c levels >9%, 30.6% had LDL-cholesterol levels >130 mg/dl, and 34.1% had SBP >or=160 mm Hg. Levels of A1c, LDL-c and SBP all fell significantly postintervention with a mean (95% CI) decrease of A1c 1.4 (0.8, 2.1) (p<0.001), LDL-c 14.8 (2.3, 27.4) (p = 0.022) and SBP 16.0 (9.7, 22.3) (p<0.001). There were no significant differences at baseline between control and intervention groups in terms of age, baseline intermediate outcomes, or medication use. The reductions in A1c in % and SBP were greater in the intervention group relative to the control group: 1.44 vs -0.30 (p = 0.002) for A1c and 14.83 vs 2.54 mm Hg (p = 0.04) for SBP. LDL-c reduction was also greater in the intervention group, 16.0 vs 5.37 mg/dl, but the difference was not statistically significant (p = 0.29).

CONCLUSIONS

We were able to initiate a programme of group visits in which participants achieved benefits in terms of cardiovascular risk reduction. Some barriers needed to be addressed, and the operations of SMAs evolved over time. Shared medical appointments for diabetes constitute a practical system redesign that may help to improve quality of care.

Sensitivity of patient outcomes to pharmacist interventions. Part I: systematic review and meta-analysis in diabetes management

BACKGROUND

Pharmacists participate in managing diabetes therapy. Despite many reviews, few have quantified the impact of pharmacists' interventions.

OBJECTIVES

To identify outcomes sensitive to pharmacists' interventions and quantify their impact through critical literature review.

METHODS

All original research describing the impact of pharmacists' interventions in the management of diabetic pharmacotherapy was sought in International Pharmaceutical Abstracts, MEDLINE, Embase, Cochrane Register, and Cumulative Index to Nursing & Allied Health Literature from inception through 2006. Two independent reviewers identified articles, compared results, and settled differences through consensus. The Downs-Black scale was used to assess quality. Data included intervention type, patient numbers, demographics, study characteristics, instruments used, data compared, and outcomes reported. A random-effects meta-analysis combined amenable results.

RESULTS

Of 302 articles identified, 108 involved pharmacists' interventions; 36 addressed diabetes (14 medical clinics, 11 community pharmacies, 7 ambulatory care clinics, 4 hospital wards, 1 physician's office, 1 prison, and 3 in both medical clinics and community pharmacies; 1 did not describe its practice site). Research designs included randomized (n = 18) and nonrandomized (n = 9) controlled trials, pre- and postobservational cohorts (n = 2), retrospective cohort study (n = 1), chart reviews (n = 5), and database study (n = 1). Diabetes education (69%) and medication management (61%) were the most frequently used interventions. Mean +/- SD quality was 62 +/- 11% (fair). Fifty-one (69%) study results were sensitive. Meta-analysis of data from 2247 patients in 16 studies found a significant reduction in hemoglobin A1C (A1C) levels in the pharmacists' intervention group (1.00 +/- 0.28%; p < 0.001) but not in controls (0.28 +/- 0.29%; p = 0.335). Pharmacists' interventions further reduced A1C values 0.62 +/- 0.29% (p = 0.03) over controls.

CONCLUSIONS

A1C is sensitive to pharmacists' interventions. Several potentially sensitive outcomes were identified, but too few studies were available for quantitative summaries. More research is needed.

Nurse care manager collaboration with community-based physicians providing diabetes care: a randomized controlled trial

PURPOSE

The purpose of this study was to demonstrate the potential value of close collaboration at the office level of a nurse care manager with community-based primary care physicians in the care of adult patients with type 2 diabetes, particularly those physicians not affiliated with an integrated care system that some managed care organizations provide.

METHODS

Patients with type 2 diabetes were recruited from the general population of a large metropolitan area. Each received a comprehensive evaluation of his or her diabetes with results reported to patients and their physicians (basic intervention). A random one-half of patients were additionally assigned to individual counseling, problem identification, care planning, and management recommendations by a nurse care manager (individualized intervention). The patients receiving only the basic intervention served as the control group to those receiving the individualized intervention. Re-evaluation of all patients at 6 months after their entry into the study determined the effectiveness of the nurse-directed individualized intervention using A1C, blood pressure, and cholesterol as outcome measures.

RESULTS

Of 220 patients recruited, 197 had type 2 diabetes, randomly assigned only the basic intervention (102 patients) or individualized intervention (95 patients). Postintervention data were obtained on 164 patients (83%). Significant improvement occurred in mean systolic blood pressure and A1C of all patients in the individualized but not the basic intervention only group. Patients with a systolic blood pressure>or=130 mm Hg at baseline showed improvement if they had more than 2 contacts with the study nurse but not if they had less than 2 contacts.

CONCLUSIONS

A nurse care manager collaborating at the office level with community-based primary care physicians can enhance the care provided to adult patients with type 2 diabetes. For those many physicians not affiliated with an integrated care system featured by some managed care organizations, this collaboration could underlie a team approach (nurse/patient/physician) for the ambulatory patient with diabetes that would be an essential element in a chronic disease model of care for diabetes at the community level.

Seeing in 3-D: examining the reach of diabetes self-management support strategies in a public health care system

The authors examined whether tailored self-management support (SMS) strategies reach patients in a safety net system and explored variation by language, literacy, and insurance. English-, Spanish-, and Cantonese-speaking diabetes patients were randomized to weekly automated telephone disease management (ATDM) or monthly group medical visits. The SMS programs employ distinct communication methods but share common objectives, including behavioral "action plans." Reach was measured using three complementary dimensions: (a) participation among clinics, clinicians, and patients; (b) patient representativeness; and (c) patient engagement with SMS. Participation rates were high across all levels and preferentially attracted Spanish-language speakers, uninsured, and Medicaid recipients. Although both programs engaged a significant proportion in action planning, ATDM yielded higher engagement, especially among those with limited English proficiency and limited literacy. These results provide important insights for health communication and translational research with respect to realizing the public health benefits of SMS and can inform system-level planning to reduce health disparities.

Benefits of information technology-enabled diabetes management

OBJECTIVE

To determine the financial and clinical benefits of implementing information technology (IT)-enabled disease management systems.

RESEARCH DESIGN AND METHODS

A computer model was created to project the impact of IT-enabled disease management on care processes, clinical outcomes, and medical costs for patients with type 2 diabetes aged >25 years in the U.S. Several ITs were modeled (e.g., diabetes registries, computerized decision support, remote monitoring, patient self-management systems, and payer-based systems). Estimates of care process improvements were derived from published literature. Simulations projected outcomes for both payer and provider organizations, scaled to the national level. The primary outcome was medical cost savings, in 2004 U.S. dollars discounted at 5%. Secondary measures include reduction of cardiovascular, cerebrovascular, neuropathy, nephropathy, and retinopathy clinical outcomes.

RESULTS

All forms of IT-enabled disease management improved the health of patients with diabetes and reduced health care expenditures. Over 10 years, diabetes registries saved $14.5 billion, computerized decision support saved $10.7 billion, payer-centered technologies saved $7.10 billion, remote monitoring saved $326 million, self-management saved $285 million, and integrated provider-patient systems saved $16.9 billion.

CONCLUSIONS

IT-enabled diabetes management has the potential to improve care processes, delay diabetes complications, and save health care dollars. Of existing systems, provider-centered technologies such as diabetes registries currently show the most potential for benefit. Fully integrated provider-patient systems would have even greater potential for benefit. These benefits must be weighed against the implementation costs.

Group visits: promoting adherence to diabetes guidelines

BACKGROUND

Current diabetes management guidelines offer blueprints for providers, yet type 2 diabetes control is often poor in disadvantaged populations. The group visit is a new treatment modality originating in managed care for efficient service delivery to patients with chronic health problems. Group visits offer promise for delivering care to diabetic patients, as visits are lengthier and can be more frequent, more organized, and more educational.

OBJECTIVE

To evaluate the effect of group visits on clinical outcomes, concordance with 10 American Diabetes Association (ADA) guidelines [American Diabetes Association, Diabetes Care, 28:S4-36, 2004] and 3 United States Preventive Services Task Force (USPSTF) cancer screens [U.S. Preventive Services Task Force, http://www.ahrq.gov/clinic/uspstf/resource.htm, 2003].

RESEARCH DESIGN AND METHODS

A 12-month randomized controlled trial of 186 diabetic patients comparing care in group visits with care in the traditional patient-physician dyad. Clinical outcomes (HbA1c, blood pressure [BP], lipid profiles) were assessed at 6 and 12 months and quality of care measures (adherence to 10 ADA guidelines and 3 USPSTF cancer screens) at 12 months.

RESULTS

At both measurement points, HbA1c, BP, and lipid levels did not differ significantly for patients attending group visits versus those in usual care. At 12 months, however, patients receiving care in group visits exhibited greater concordance with ADA process-of-care indicators (p < .0001) and higher screening rates for cancers of the breast (80 vs. 68%, p = .006) and cervix (80 vs 68%, p = .019).

CONCLUSIONS

Group visits can improve the quality of care for diabetic patients, but modifications to the content and style of group visits may be necessary to achieve improved clinical outcomes.

Novel approaches to diabetes care: a population perspective

PURPOSE OF REVIEW

The purpose of this review is to outline the current state of diabetes in the United States and to explore novel, population-based approaches that involve the patient, provider and community, in the context of the health system, to improve diabetes care.

RECENT FINDINGS

Currently, there is sub-optimal delivery of diabetes processes and outcomes in the United States. The US healthcare system remains rooted in acute and episodic care, resulting in consistently low-quality healthcare, and is not equipped to handle the diabetes epidemic. Evidence demonstrates that models of chronic care are needed in order for system changes to occur. Recent studies that have implemented such models are beginning to demonstrate improvements in both process measures and clinical outcomes following interventions which incorporate a comprehensive approach to chronic illness care.

SUMMARY

Research over the past 5+ years demonstrates that a more comprehensive approach to diabetes care is needed. Only recently have studies been able to validate this concept, however. Applied research that strives to translate available knowledge and operationalize it in clinical and public health practice is needed in order for diabetes care to improve.

New global recommendations: a multidisciplinary approach to improving outcomes in diabetes

Up to two-thirds of people with type-2 diabetes do not achieve glycaemic targets, increasing their risk of serious complications. New global recommendations from The Global Partnership for Effective Diabetes Management offer practical, simple advice for the diabetes management team to help individuals reach glycaemic goals. The recommendations focus on four areas: achieving optimal glycaemic control, targeting the underlying pathophysiology of the disease, treating earlier and intensively with combination therapy, and adopting a holistic approach. This article reviews the new recommendations and suggests that they offer a route to achieving guideline-based targets and improving outcomes in the real-life healthcare setting.

The association between clinical care strategies and the attenuation of racial/ethnic disparities in diabetes care: the Translating Research Into Action for Diabetes (TRIAD) Study

OBJECTIVE

We sought to determine whether greater implementation of clinical care strategies in managed care is associated with attenuation of known racial/ethnic disparities in diabetes care.

RESEARCH DESIGN AND METHODS

Using cross-sectional data, we examined the quality of diabetes care as measured by frequencies of process delivery as well as medication management of intermediate outcomes, for 7426 black, Latinos, Asian/Pacific Islanders, and white participants enrolled in 10 managed care plans within 63 provider groups. We stratified models by intensity of 3 clinical care strategies at the provider group level: physician reminders, physician feedback, or use of a diabetes registry.

RESULTS

Exposure to clinical care strategy implementation at the provider group level varied by race and ethnicity, with <10% of black participants enrolled in provider groups in the highest-intensity quintile for physician feedback and <10% of both black and Asian/Pacific Islander participants enrolled in groups in the highest-intensity quintile for diabetes registry use. Although disparities in care were confirmed, particularly for black relative to white subjects, we did not find a consistent pattern of disparity attenuation with increasing implementation intensity for either processes of care or medication management of intermediate outcomes.

CONCLUSIONS

For the most part, high-intensity implementation of a diabetes registry, physician feedback, or physician reminders, 3 clinical care strategies similar to those used in many health care settings, are not associated with attenuation of known disparities of diabetes care in managed care.

Use of chronic care model elements is associated with higher-quality care for diabetes

PURPOSE

In 30 small, independent primary care practices, we examined the association between clinician-reported use of elements of the Chronic Care Model (CCM) and diabetic patients' hemoglobin A(1c) (HbA(1c)) and lipid levels and self-reported receipt of care.

METHODS

Ninety clinicians (60 physicians, 17 nurse-practitioners, and 13 physician's assistants) completed a questionnaire assessing their use of elements of the CCM on a 5-point scale (never, rarely, occasionally, usually, and always). A total of 886 diabetic patients reported their receipt of various diabetes care services. We computed a clinical care composite score that included patient-reported assessments of blood pressure, lipids, microalbumin, and HbA(1c); foot examinations; and dilated retinal examinations. We computed a behavioral care composite score from patient-reported support from their clinician in setting self-management goals, obtaining nutrition education or therapy, and receiving encouragement to self-monitor their glucose. HbA(1c) values and lipid profiles were obtained by independent laboratory assay. We used multilevel regression models for analyses to account for the hierarchical nature of the data.

RESULTS

Clinician-reported use of elements of CCM was significantly associated with lower HbA(1c) values (P = .002) and ratios of total cholesterol to high-density lipoprotein cholesterol (P = .02). For every unit increase in clinician-reported CCM use (eg, from "rarely" to "occasionally"), there was an associated 0.30% reduction in HbA(1c) value and 0.17 reduction in the lipid ratio. Clinician use of the CCM elements was also significantly associated with the behavioral composite score (P = .001) and was marginally associated with the clinical care composite score (P = .07).

CONCLUSIONS

Clinicians in small independent primary care practices are able to incorporate elements of the CCM into their practice style, often without major structural change in the practice, and this incorporation is associated with higher levels of recommended processes and better intermediate outcomes of diabetes care.

Improved Intermediate Clinical Outcomes From Participation in a Diabetes Health Education Program

Diabetes self-management education programs are an essential strategy for improving health behaviors of adults with diabetes and, therefore, intermediate clinical outcomes. We conducted a retrospective observational study using a case:control design to estimate the impact of participation in a diabetes health education program on glycemic and lipid levels, accounting for nonrandom participation of adults with diabetes in the program ("regression to the mean"). Adults with diabetes in a group-model managed care organization who attended the diabetes health education program during the period January 1, 2003, through June 30, 2004 ("participants"), were randomly matched with 4 adults with diabetes who did not participate ("nonparticipants"). Participants (N=1991) and nonparticipants (N=7964) were matched on age group, gender, mean hemoglobin A1c (Hb A1c) (or low-density lipoprotein) in the 6 months prior to the class (or randomly selected index month for nonparticipants), and primary care practice where the patients received regular care. On average, participants had significantly (P < .05) worse glycemic and lipid levels in the 6 months prior to participation compared to nonparticipants. Participation in the diabetes education program significantly improved glycemic and lipid levels between baseline and follow-up periods above the improvement attributable to regression to the mean. For example, nonparticipants with baseline Hb A1c levels greater than 10.0% had improved Hb A1c levels of -1.7% (P < .01); however, among participants, mean Hb A1c levels improved an additional -1.6% (P < .01). Overall, the evidence suggests that participation in a multifactorial diabetes health education program significantly improved glycemic and lipid levels in the short-term, particularly among participants with extremely adverse Hb A1c or low-density lipoprotein levels prior to participation.

Metabolic Control of Adults With Type 2 Diabetes Mellitus Through Education and Counseling

PURPOSE

To test the efficacy of a controlled nursing intervention focused on education and counseling to improve metabolic control of adults diagnosed with diabetes mellitus type 2 in (DMT2) ambulatory care.

DESIGN

A quasi-experimental design with repeated measures was selected. A sample of 45 subjects participated, of which 25 were in the experimental group, and 20 in the comparison group. Measures were taken at 0, 3, 6, 9, and 12 months, including glycosylated hemoglobin (HbAlc), psychosocial, and clinical variables.

FINDINGS

Results showed a significant decrease in HbAlc in the experimental group, as well as positive effects of self-care agency, adaptation, and barriers to treatment (plus one interaction) on the HbA1c levels and on the scores of self-care actions.

CONCLUSIONS

The counseling and educational model applied in the intervention was effective to improve the metabolic control of diabetic patients in the experimental group. Self-care agency, adaptation, and barriers were predictors of self-care measures and level of HbA1c.

Differences in self-management behaviors and use of preventive services among diabetes management enrollees by race and ethnicity

We assessed the degree that managed care organization (MCO) enrollees used preventive services and engaged in diabetes self-management behaviors by race/ethnicity. A 40-item selfadministered survey was mailed to 19,483 diabetic MCO enrollees. The survey measured use of eight preventive services and engagement in four self-management behaviors among enrollees who self-identified as black, white, or Hispanic. Of the 6,035 surveys analyzed, 4,623 respondents (76.6%) were white, 984 (16.3%) were black, and 428 (7.0%) were Hispanic. Black and Hispanic respondents reported more healthcare visits (mean of 7.0 and 6.5, respectively) in the past year compared to whites (mean, 5.7; p < 0.0001). However, compared to whites, blacks had significantly lower utilization of five of the eight preventive services measured, and Hispanics had significantly lower utilization of seven of the eight preventive services (p < 0.005). With regard to self-management behaviors, blacks were significantly less likely than whites to monitor their diet (65.9% vs. 73.7%, p < 0.0001), exercise (46.4% vs. 52.8%; p = 0.0004) and not smoke (85.1% vs. 89.3%; p = 0.0002); while Hispanics were less likely to monitor their diet (67.3% vs. 73.7%, p = 0.0051). All racial/ethnic groups had low levels of selfmanagement behaviors. Further research is warranted to identify why disparities remain in settings where services are universally available, and to find practical ways to eliminate disparities in a group with routine healthcare encounters.