The impact of a programme to improve quality of care for people with type 2 diabetes on hard to reach groups: The GEDAPS study

Interventions to improve primary healthcare in rural settings: A scoping review

BACKGROUND

Residents of rural areas have poorer health status, less healthy behaviours and higher mortality than urban dwellers, issues which are commonly addressed in primary care. Strengthening primary care may be an important tool to improve the health status of rural populations.

OBJECTIVE

Synthesize and categorize studies that examine interventions to improve rural primary care.

ELIGIBILITY CRITERIA

Experimental or observational studies published between January 1, 1996 and December 2022 that include an historical or concurrent control comparison.

SOURCES OF EVIDENCE

Pubmed, CINAHL, Cochrane Library, Embase.

CHARTING METHODS

We extracted and charted data by broad category (quality, access and efficiency), study design, country of origin, publication year, aim, health condition and type of intervention studied. We assigned multiple categories to a study where relevant.

RESULTS

372 papers met our inclusion criteria, divided among quality (82%), access (20%) and efficiency (13%) categories. A majority of papers were completed in the USA (40%), Australia (15%), China (7%) or Canada (6%). 35 (9%) papers came from countries in Africa. The most common study design was an uncontrolled before-and-after comparison (32%) and only 24% of studies used randomized designs. The number of publications each year has increased markedly over the study period from 1-2/year in 1997-99 to a peak of 49 papers in 2017.

CONCLUSIONS

Despite substantial inequity in health outcomes associated with rural living, very little attention is paid to rural primary care in the scientific literature. Very few studies of rural primary care use randomized designs.

Glycemic variability and all-cause mortality in a large prospective southern European cohort of patients with differences in glycemic status

Background

Few studies have analyzed the relationship between glucose variability (GV) and adverse health outcomes in patients with differences in glycemic status. The present study tests the hypothesis that GV predicts all-cause mortality regardless of glycemic status after simple adjustment (age and sex) and full adjustment (age, sex, cardiovascular disease, hypertension, use of aspirin, statins, GLP-1 receptor agonists, SGLT-2 inhibitors and DPP-4 inhibitors, baseline FPG and average HbA1c).

Methods

Prospective cohort study with 795 normoglycemic patients, 233 patients with prediabetes, and 4,102 patients with type 2 diabetes. GV was measured using the coefficient of variation of fasting plasma glucose (CV-FPG) over 12 years of follow-up. The outcome measure was all-cause mortality.

Results

A total of 1,223 patients (657 men, 566 women) died after a median of 9.8 years of follow-up, with an all-cause mortality rate of 23.35/1,000 person-years. In prediabetes or T2DM patients, the fourth quartile of CV-FPG exerted a significant effect on all-cause mortality after simple and full adjustment. A sensitivity analysis excluding participants who died during the first year of follow-up revealed the following results for the highest quartile in the fully adjusted model: overall, HR (95%CI) = 1.54 (1.26–1.89); dysglycemia (prediabetes and T2DM), HR = 1.41 (1.15–1.73); T2DM, HR = 1.36 (1.10–1.67).

Conclusion

We found CV-FPG to be useful for measurement of GV. It could also be used for the prognostic stratification of patients with dysglycemia.

Association between the reduction of face-to-face appointments and the control of patients with type 2 diabetes mellitus during the Covid-19 pandemic in Catalonia

AIM

To analyse the relation between face-to-face appointments and management of patients with type 2 diabetes mellitus (T2DM) visited in primary care practices (PCP).

METHODS

Retrospective study in 287 primary care practices (PCPs) attending>300,000 patients with T2DM. We analysed the results of 9 diabetes-related indicators of the Healthcare quality standard, comprising foot and retinopathy screening, blood pressure (BP) and glycemic control; and the incidence of T2DM. We calculated each indicator's percentage of change in 2020 with respect to the results of 2019.

RESULTS

Indicators' results were reduced in 2020 compared to 2019, highlighting the indicators of foot and retinopathy screening (-51.6% and -25.7%, respectively); the glycemic control indicator (-21.2%); the BP control indicator (-33.7%) and the incidence of T2DM (-25.6%). Conversely, the percentage of type 2 diabetes patients with HbA1c > 10% increased by 34%. PCPs with<11 weekly face-to-face appointments offered per professional had greater reductions than those PCPs with more than 40. For instance, a reduction of -60.7% vs -38.2% (p-value < 0.001) in the foot screening's indicator; -27.5% vs -12.5% (p-value < 0.001) in glycemic control and -40.2 vs -24.3% (p-value < 0.001) in BP control.

CONCLUSIONS

Reducing face-to-face visits offered may impact T2DM patients' follow-up and thus worsen their control.

Quality criteria/key components for high quality of diabetes management to avoid diabetes-related complications

Aim

The aim of this review shoud be to map data and to identify quality indicators for good practices for diabetes management and secondary prevention, specifically of type 2 diabetes.

Methods

To achieve this aim we performed the following steps: (i) a literature review on evaluation criteria, (ii) selection of quality criteria and key components for high quality of care, (iii) creation of a checklist to identify the best practice of diabetes management based on the detected criteria.

Results

The literature search about the quality indicators for diabetes care resulted in the following: identifying of key components and quality indicators for structure, process and outcome quality.

Conclusions

The set of quality criteria will be discussed and used to identify the best practice diabetes management programs for secondary prevention of type 2 diabetes.

Cardiovascular risk factors associated with acute myocardial infarction and stroke in the MADIABETES cohort

We aimed to develop two models to estimate first AMI and stroke/TIA, respectively, in type 2 diabetes mellitus patients, by applying backward elimination to the following variables: age, sex, duration of diabetes, smoking, BMI, and use of antihyperglycemic drugs, statins, and aspirin. As time-varying covariates, we analyzed blood pressure, albuminuria, lipid profile, HbA1c, retinopathy, neuropathy, and atrial fibrillation (only in stroke/TIA model). Both models were stratified by antihypertensive drugs. We evaluated 2980 patients (52.8% women; 67.3 ± 11.2 years) with 24,159 person-years of follow-up. We recorded 114 cases of AMI and 185 cases of stroke/TIA. The factors that were independently associated with first AMI were age (≥ 75 years vs. < 75 years) (p = 0.019), higher HbA1c (> 64 mmol/mol vs. < 53 mmol/mol) (p = 0.003), HDL-cholesterol (0.90–1.81 mmol/L vs. < 0.90 mmol/L) (p = 0.002), and diastolic blood pressure (65–85 mmHg vs. < 65 mmHg) (p < 0.001). The factors that were independently associated with first stroke/TIA were age (≥ 75 years vs. < 60 years) (p < 0.001), atrial fibrillation (first year after the diagnosis vs. more than one year) (p = 0.001), glomerular filtration rate (per each 15 mL/min/1.73 m² decrease) (p < 0.001), total cholesterol (3.88–6.46 mmol/L vs. < 3.88 mmol/L) (p < 0.001), triglycerides (per each increment of 1.13 mmol/L) (p = 0.031), albuminuria (p < 0.001), neuropathy (p = 0.01), and retinopathy (p = 0.023).

2017 National Standards for Diabetes Self-Management Education and Support

PURPOSE

The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends.

METHODS

The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision.

RESULTS

Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes.

CONCLUSION

Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

[Prevalence and risk factors associated with diabetic retinopathy in Santander. Northern Spain]

OBJETIVE

To assess the prevalence and risk factors associated with diabetic retinopathy (DR) in Cantabria.

DESIGN

ross-sectional population based study.

LOCATION

Health center of Cantabria.

PARTICIANTS

A random sample of 442 patients with type 2 diabetes.

MAIN MEASUREMENTS

Non-mydiatric retinography, classifying them according to the International Clinical Diabetic Retinopathy Disease Severity Scale. The analyzed risk factors were: age, gender, age at diabetes onset, duration of diabetes, glycated haemoglobin levels (A1C), treatment of diabetes, blood pressure (systolic and diastolic), serum lipids concentration, body mass index, smoking status, hematocrit, pregnancy, serum vitamin D (25 OH D) levels, nephropathy and cardiovascular events.

RESULTS

The prevalence of DR was 8.56% (CI: 5.81-11.32): Mild non-proliferative DR: 5.07% (CI: 2.89-7.25); Moderate non-proliferative DR: 1.38% (CI: 0.17-2.60); Severe non-proliferative DR: 0.27% (CI: 0.006-1.28); proliferative DR: 1.84% (CI: 0.46-3.22). Diabetic macular oedema: 2.30% (CI: 0.77-3.83). Mean age: 70 years, mean diagnostic age: 58.97 years, mean body mass index 29.86, 78.40% patients with hypertension, 67.30% dyslipidemia and median A1C: 6.7%. A deficit of 25 (OH) D was identified in 77% of patients. In the multivariate analysis, treatment of type 2 diabetes, body mass index, duration of diabetes and metabolic control of glycaemia were identified as independent risk factors.

CONCLUSIONS

The prevalence of DR, compared with former studies, has decreased to 8.56%; this decrease is associated with the improvement in the control of modifiable risk factors. The associated independent risk factors were: treatment, body mass index, duration and control of diabetes. The variables antihypertensive treatment, cardiovascular events and nephropathy showed predictive value for DR.

2017 National Standards for Diabetes Self-Management Education and Support

PURPOSE

The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends.

METHODS

The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision.

RESULTS

Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes.

CONCLUSION

Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

2017 National Standards for Diabetes Self-Management Education and Support

PURPOSE

The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends.

METHODS

The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision.

RESULTS

Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes.

CONCLUSION

Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

2017 National Standards for Diabetes Self-Management Education and Support

Purpose

The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends.

Methods

The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision.

Results

Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes.

Conclusion

Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

2017 National Standards for Diabetes Self-Management Education and Support

This article was copublished in Diabetes Care 2017;40:1409-1419 and The Diabetes Educator 2017;43:449-464 and is reprinted with permission. The previous version of this article, also copublished in Diabetes Care and The Diabetes Educator, can be found at Diabetes Care 2012;35:2393-2401 (https://doi.org/10.2337/dc12-1707).

2017 National Standards for Diabetes Self-Management Education and Support

Purpose The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends. Methods The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision. Results Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes. Conclusion Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

Considerations for management of patients with diabetic macular edema: Optimizing treatment outcomes and minimizing safety concerns through interdisciplinary collaboration

Diabetes is a growing worldwide epidemic and a leading cause of blindness in working-age people around the world. Diabetic retinopathy (DR) and diabetic macular edema (DME) are common causes of visual impairment in people with diabetes and often indicate the presence of diabetes-associated preclinical micro- and macrovascular complications. As such, patients with DR and DME often display complex, highly comorbid profiles. Several treatments are currently available for the treatment of DME, including anti-vascular endothelial growth factor (VEGF) agents, which are administered via intravitreal injection. While the safety profiles of approved ocular anti-VEGF therapies have been reassuring, the high-risk nature of the DME patient population means that treatment must be carefully considered and a holistic approach to disease management should be taken. This requires multidisciplinary, collaborative care involving all relevant specialties to ensure that patients not only receive prompt treatment for DME but also appropriate consideration is taken of any systemic comorbidities to evaluate and minimize potentially serious safety issues.

Factors associated with delivery outside a health facility: cross-sectional study in rural Malawi

OBJECTIVE

To identify factors associated with delivery outside a health facility in rural Malawi.

METHOD

A cross-sectional survey was conducted in Balaka, Dedza, Mchinji and Ntcheu districts in Malawi in 2013 among women who had completed a pregnancy 12 months prior to the day of the survey. Multilevel logistic regression was used to assess factors associated with delivery outside a facility.

RESULTS

Of the 1812 study respondents, 9% (n = 159) reported to have delivered outside a facility. Unmarried women were significantly more likely [OR = 1.88; 95% CI (1.086-3.173)] to deliver outside a facility, while women from households with higher socio-economic status [third-quartile OR = 0.51; 95% CI (0.28-0.95) and fourth-quartile OR = 0.48; 95% CI (0.29-0.79)] and in urban areas [OR = 0.39; 95%-CI (0.23-0.67)] were significantly less likely to deliver outside a facility. Women without formal education [OR 1.43; 95% CI (0.96-2.14)] and multigravidae [OR = 1.14; 95% CI (0.98-1.73)] were more likely to deliver outside a health facility at 10% level of significance.

CONCLUSION

About 9% of women deliver outside a facility. Policies to encourage facility delivery should not only focus on health systems but also be multisectoral to address women's vulnerability and inequality. Facility-based delivery can contribute to curbing the high maternal illness burden if authorities provide incentives to those not delivering at the facility without losing existing users.