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Arditi C, Rège‐Walther M, Durieux P, Burnand B. Computer-generated reminders delivered on paper to healthcare professionals: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2017; 7:CD001175. [PMID: 28681432 PMCID: PMC6483307 DOI: 10.1002/14651858.cd001175.pub4] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting them to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time. This is an update of a previously published review. OBJECTIVES To evaluate the effects of reminders automatically generated through a computerized system (computer-generated) and delivered on paper to healthcare professionals on quality of care (outcomes related to healthcare professionals' practice) and patient outcomes (outcomes related to patients' health condition). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, six other databases and two trials registers up to 21 September 2016 together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA We included individual- or cluster-randomized and non-randomized trials that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals, alone (single-component intervention) or in addition to one or more co-interventions (multi-component intervention), compared with usual care or the co-intervention(s) without the reminder component. DATA COLLECTION AND ANALYSIS Review authors working in pairs independently screened studies for eligibility and abstracted data. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median improvement and interquartile range (IQR) across included studies using the primary outcome or median outcome as representative outcome. We assessed the certainty of the evidence according to the GRADE approach. MAIN RESULTS We identified 35 studies (30 randomized trials and five non-randomized trials) and analyzed 34 studies (40 comparisons). Twenty-nine studies took place in the USA and six studies took place in Canada, France, Israel, and Kenya. All studies except two took place in outpatient care. Reminders were aimed at enhancing compliance with preventive guidelines (e.g. cancer screening tests, vaccination) in half the studies and at enhancing compliance with disease management guidelines for acute or chronic conditions (e.g. annual follow-ups, laboratory tests, medication adjustment, counseling) in the other half.Computer-generated reminders delivered on paper to healthcare professionals, alone or in addition to co-intervention(s), probably improves quality of care slightly compared with usual care or the co-intervention(s) without the reminder component (median improvement 6.8% (IQR: 3.8% to 17.5%); 34 studies (40 comparisons); moderate-certainty evidence).Computer-generated reminders delivered on paper to healthcare professionals alone (single-component intervention) probably improves quality of care compared with usual care (median improvement 11.0% (IQR 5.4% to 20.0%); 27 studies (27 comparisons); moderate-certainty evidence). Adding computer-generated reminders delivered on paper to healthcare professionals to one or more co-interventions (multi-component intervention) probably improves quality of care slightly compared with the co-intervention(s) without the reminder component (median improvement 4.0% (IQR 3.0% to 6.0%); 11 studies (13 comparisons); moderate-certainty evidence).We are uncertain whether reminders, alone or in addition to co-intervention(s), improve patient outcomes as the certainty of the evidence is very low (n = 6 studies (seven comparisons)). None of the included studies reported outcomes related to harms or adverse effects of the intervention. AUTHORS' CONCLUSIONS There is moderate-certainty evidence that computer-generated reminders delivered on paper to healthcare professionals probably slightly improves quality of care, in terms of compliance with preventive guidelines and compliance with disease management guidelines. It is uncertain whether reminders improve patient outcomes because the certainty of the evidence is very low. The heterogeneity of the reminder interventions included in this review also suggests that reminders can probably improve quality of care in various settings under various conditions.
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Affiliation(s)
- Chantal Arditi
- Lausanne University HospitalCochrane Switzerland, Institute of Social and Preventive MedicineLausanneSwitzerlandCH‐1005
| | - Myriam Rège‐Walther
- Lausanne University HospitalInstitute of Social and Preventive MedicineBiopôle 2Route de la Corniche 10LausanneSwitzerland1010
| | - Pierre Durieux
- Georges Pompidou European HospitalDepartment of Public Health and Medical Informatics20 rue LeblancParisFrance75015
| | - Bernard Burnand
- Lausanne University HospitalCochrane Switzerland, Institute of Social and Preventive MedicineLausanneSwitzerlandCH‐1005
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Golden SH, Maruthur N, Mathioudakis N, Spanakis E, Rubin D, Zilbermint M, Hill-Briggs F. The Case for Diabetes Population Health Improvement: Evidence-Based Programming for Population Outcomes in Diabetes. Curr Diab Rep 2017; 17:51. [PMID: 28567711 PMCID: PMC5553206 DOI: 10.1007/s11892-017-0875-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE OF REVIEW The goal of this review is to describe diabetes within a population health improvement framework and to review the evidence for a diabetes population health continuum of intervention approaches, including diabetes prevention and chronic and acute diabetes management, to improve clinical and economic outcomes. RECENT FINDINGS Recent studies have shown that compared to usual care, lifestyle interventions in prediabetes lower diabetes risk at the population-level and that group-based programs have low incremental medial cost effectiveness ratio for health systems. Effective outpatient interventions that improve diabetes control and process outcomes are multi-level, targeting the patient, provider, and healthcare system simultaneously and integrate community health workers as a liaison between the patient and community-based healthcare resources. A multi-faceted approach to diabetes management is also effective in the inpatient setting. Interventions shown to promote safe and effective glycemic control and use of evidence-based glucose management practices include provider reminder and clinical decision support systems, automated computer order entry, provider education, and organizational change. Future studies should examine the cost-effectiveness of multi-faceted outpatient and inpatient diabetes management programs to determine the best financial models for incorporating them into diabetes population health strategies.
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Affiliation(s)
- Sherita Hill Golden
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite no. 333, Baltimore, MD, 21287, USA.
- Departments of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Nisa Maruthur
- Departments of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nestoras Mathioudakis
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite no. 333, Baltimore, MD, 21287, USA
| | - Elias Spanakis
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland Medical System, Baltimore, MD, USA
| | - Daniel Rubin
- Division of Endocrinology and Metabolism, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite no. 333, Baltimore, MD, 21287, USA
- Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Felicia Hill-Briggs
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite no. 333, Baltimore, MD, 21287, USA
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health, Behavior, and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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Ziemer DC, Miller CD, Rhee MK, Doyle JP, Watkins C, Cook CB, Gallina DL, El-Kebbi IM, Barnes CS, Dunbar VG, Branch WT, Phillips LS. Clinical Inertia Contributes to Poor Diabetes Control in a Primary Care Setting. DIABETES EDUCATOR 2016; 31:564-71. [PMID: 16100332 DOI: 10.1177/0145721705279050] [Citation(s) in RCA: 165] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Purpose The purpose of this study was to determine whether “clinical inertia”—inadequate intensification of therapy by the provider—could contribute to high A1C levels in patients with type 2 diabetes managed in a primary care site. Methods In a prospective observational study, management was compared in the Medical Clinic, a primary care site supervised by general internal medicine faculty, and the Diabetes Clinic, a specialty site supervised by endocrinologists. These municipal hospital clinics serve a common population that is largely African American, poor, and uninsured. Results Four hundred thirty-eight African American patients in the Medical Clinic and 2157 in the Diabetes Clinic were similar in average age, diabetes duration, body mass index, and gender, but A1C averaged 8.6% in the Medical Clinic versus 7.7% in the Diabetes Clinic (P < .0001). Use of pharmacotherapy was less intensive in the Medical Clinic (less use of insulin), and when patients had elevated glucose levels during clinic visits, therapy was less than half as likely to be advanced in the Medical Clinic compared to the Diabetes Clinic (P < .0001). Intensification rates were lower in the Medical Clinic regardless of type of therapy (P < .0001), and intensification of therapy was independently associated with improvement in A1C (P < .001). Conclusions Medical Clinic patients had worse glycemic control, were less likely to be treated with insulin, and were less likely to have their therapy intensified if glucose levels were elevated. To improve diabetes management and glycemic control nationwide, physicians in training and generalists must learn to overcome clinical inertia, to intensify therapy when appropriate, and to use insulin when clinically indicated.
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Affiliation(s)
- David C Ziemer
- Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
| | - Christopher D Miller
- Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
| | - Mary K Rhee
- Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
| | - Joyce P Doyle
- Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
| | - Clyde Watkins
- Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
| | - Curtiss B Cook
- The Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia, and Mayo Clinic, Scottsdale, Arizona (Dr Cook)
| | - Daniel L Gallina
- Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
| | - Imad M El-Kebbi
- Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
| | - Catherine S Barnes
- Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
| | - Virginia G Dunbar
- Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
| | - William T Branch
- Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
| | - Lawrence S Phillips
- Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
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Barnes CS, Ziemer DC, Miller CD, Doyle JP, Watkins C, Cook CB, Gallina DL, el-Kebbi I, Branch WT, Phillips LS. Little Time for Diabetes Management in the Primary Care Setting. DIABETES EDUCATOR 2016; 30:126-35. [PMID: 14999900 DOI: 10.1177/014572170403000120] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE This study was conducted to determine how time is allocated to diabetes care. METHODS Patients with type 2 diabetes who were receiving care from the internal medicine residents were shadowed by research nurses to observe the process of management. The amount of time spent with patients and the care provided were observed and documented. RESULTS The total time patients spent in the clinic averaged 2 hours and 26 minutes: 1 to 9 minutes waiting, 25 minutes with the resident, and 12 minutes with medical assistants and nurses. The residents spent an average of only 5 minutes on diabetes. Glucose monitoring was addressed in 70% of visits; a history of hypoglycemia was sought in only 30%. Blood pressure values were mentioned in 75% of visits; hemoglobin A1c (A1C) values were addressed in only 40%. The need for proper foot care was discussed in 55% of visits; feet were examined in only 40%. Although 65% of patients had capillary glucose levels greater than 150 mg/dL during the visit and their A1C averaged 8.9%, therapy was intensified for only 15% of patients. CONCLUSIONS During a routine office visit in a resident-staffed general medicine clinic, little time is devoted to diabetes management. Given the time pressures on the primary care practitioner and the need for better diabetes care, it is essential to teach an efficient but systematic approach to diabetes care.
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Affiliation(s)
- Catherine S Barnes
- Divisions of Endocrinology and Metabolism, and General Internal Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia, USA
| | - David C Ziemer
- Divisions of Endocrinology and Metabolism, and General Internal Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia, USA
| | - Chris D Miller
- Divisions of Endocrinology and Metabolism, and General Internal Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia, USA
| | - Joyce P Doyle
- Divisions of Endocrinology and Metabolism, and General Internal Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia, USA
| | - Clyde Watkins
- Divisions of Endocrinology and Metabolism, and General Internal Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia, USA
| | - Curtiss B Cook
- Divisions of Endocrinology and Metabolism, and General Internal Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia, USA
| | - Dan L Gallina
- Divisions of Endocrinology and Metabolism, and General Internal Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia, USA
| | - Imad el-Kebbi
- Divisions of Endocrinology and Metabolism, and General Internal Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia, USA
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Ricci-Cabello I, Olry de Labry–Lima A, Bolívar-Muñoz J, Pastor-Moreno G, Bermudez-Tamayo C, Ruiz-Pérez I, Quesada-Jiménez F, Moratalla-López E, Domínguez-Martín S, de los Ríos-Álvarez AM, Cruz-Vela P, Prados-Quel MA, López-De Hierro JA. Effectiveness of two interventions based on improving patient-practitioner communication on diabetes self-management in patients with low educational level: study protocol of a clustered randomized trial in primary care. BMC Health Serv Res 2013; 13:433. [PMID: 24153053 PMCID: PMC4016588 DOI: 10.1186/1472-6963-13-433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Accepted: 10/10/2013] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND In the last decades the presence of social inequalities in diabetes care has been observed in multiple countries, including Spain. These inequalities have been at least partially attributed to differences in diabetes self-management behaviours. Communication problems during medical consultations occur more frequently to patients with a lower educational level. The purpose of this cluster randomized trial is to determine whether an intervention implemented in a General Surgery, based in improving patient-provider communication, results in a better diabetes self-management in patients with lower educational level. A secondary objective is to assess whether telephone reinforcement enhances the effect of such intervention. We report the design and implementation of this on-going study. METHODS/DESIGN The study is being conducted in a General Practice located in a deprived neighbourhood of Granada, Spain. Diabetic patients 18 years old or older with a low educational level and inadequate glycaemic control (HbA1c > 7%) were recruited. General Practitioners (GPs) were randomised to three groups: intervention A, intervention B and control group. GPs allocated to intervention groups A and B received training in communication skills and are providing graphic feedback about glycosylated haemoglobin levels. Patients whose GPs were allocated to group B are additionally receiving telephone reinforcement whereas patients from the control group are receiving usual care. The described interventions are being conducted during 7 consecutive medical visits which are scheduled every three months. The main outcome measure will be HbA1c; blood pressure, lipidemia, body mass index and waist circumference will be considered as secondary outcome measures. Statistical analysis to evaluate the effectiveness of the interventions will include multilevel regression analysis with three hierarchical levels: medical visit level, patient level and GP level. DISCUSSION The results of this study will provide new knowledge about possible strategies to promote a better diabetes self-management in a particularly vulnerable group. If effective, this low cost intervention will have the potential to be easily incorporated into routine clinical practice, contributing to decrease health inequalities in diabetic patients. TRIAL REGISTRATION Clinical Trials U.S. National Institutes of Health, NCT01849731.
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Affiliation(s)
- Ignacio Ricci-Cabello
- Department of Primary Care Health Sciences, Health Services and Policy Research Group, NIHR School for Primary Care Research, University of Oxford, Oxford, England
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Antonio Olry de Labry–Lima
- Escuela Andaluza de Salud Pública, Campus Universitario de Cartuja, Cuesta del Observatorio 4, Apdo. 2070, 18080, Granada, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Julia Bolívar-Muñoz
- Escuela Andaluza de Salud Pública, Campus Universitario de Cartuja, Cuesta del Observatorio 4, Apdo. 2070, 18080, Granada, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Guadalupe Pastor-Moreno
- Escuela Andaluza de Salud Pública, Campus Universitario de Cartuja, Cuesta del Observatorio 4, Apdo. 2070, 18080, Granada, Spain
| | - Clara Bermudez-Tamayo
- Escuela Andaluza de Salud Pública, Campus Universitario de Cartuja, Cuesta del Observatorio 4, Apdo. 2070, 18080, Granada, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
- Hospital Universitario Virgen de las Nieves, Av Fuerzas Armadas, 2, 18014, Granada, Spain
| | - Isabel Ruiz-Pérez
- Escuela Andaluza de Salud Pública, Campus Universitario de Cartuja, Cuesta del Observatorio 4, Apdo. 2070, 18080, Granada, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | | | | | | | | | - Pilar Cruz-Vela
- Centro de Salud Cartuja, Casería del Cerro, s/n, 18013, Granada, Spain
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Arditi C, Rège-Walther M, Wyatt JC, Durieux P, Burnand B. Computer-generated reminders delivered on paper to healthcare professionals; effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2012; 12:CD001175. [PMID: 23235578 DOI: 10.1002/14651858.cd001175.pub3] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting the doctor to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time. OBJECTIVES To evaluate the effects of reminders automatically generated through a computerized system and delivered on paper to healthcare professionals on processes of care (related to healthcare professionals' practice) and outcomes of care (related to patients' health condition). SEARCH METHODS For this update the EPOC Trials Search Co-ordinator searched the following databases between June 11-19, 2012: The Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Library (Economics, Methods, and Health Technology Assessment sections), Issue 6, 2012; MEDLINE, OVID (1946- ), Daily Update, and In-process; EMBASE, Ovid (1947- ); CINAHL, EbscoHost (1980- ); EPOC Specialised Register, Reference Manager, and INSPEC, Engineering Village. The authors reviewed reference lists of related reviews and studies. SELECTION CRITERIA We included individual or cluster-randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals on processes and/or outcomes of care. DATA COLLECTION AND ANALYSIS Review authors working in pairs independently screened studies for eligibility and abstracted data. We contacted authors to obtain important missing information for studies that were published within the last 10 years. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median absolute improvement and interquartile range (IQR) in process adherence across included studies using the primary outcome or median outcome as representative outcome. MAIN RESULTS In the 32 included studies, computer-generated reminders delivered on paper to healthcare professionals achieved moderate improvement in professional practices, with a median improvement of processes of care of 7.0% (IQR: 3.9% to 16.4%). Implementing reminders alone improved care by 11.2% (IQR 6.5% to 19.6%) compared with usual care, while implementing reminders in addition to another intervention improved care by 4.0% only (IQR 3.0% to 6.0%) compared with the other intervention. The quality of evidence for these comparisons was rated as moderate according to the GRADE approach. Two reminder features were associated with larger effect sizes: providing space on the reminder for provider to enter a response (median 13.7% versus 4.3% for no response, P value = 0.01) and providing an explanation of the content or advice on the reminder (median 12.0% versus 4.2% for no explanation, P value = 0.02). Median improvement in processes of care also differed according to the behaviour the reminder targeted: for instance, reminders to vaccinate improved processes of care by 13.1% (IQR 12.2% to 20.7%) compared with other targeted behaviours. In the only study that had sufficient power to detect a clinically significant effect on outcomes of care, reminders were not associated with significant improvements. AUTHORS' CONCLUSIONS There is moderate quality evidence that computer-generated reminders delivered on paper to healthcare professionals achieve moderate improvement in process of care. Two characteristics emerged as significant predictors of improvement: providing space on the reminder for a response from the clinician and providing an explanation of the reminder's content or advice. The heterogeneity of the reminder interventions included in this review also suggests that reminders can improve care in various settings under various conditions.
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Affiliation(s)
- Chantal Arditi
- Institute of Social and Preventive Medicine, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland.
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Pemu PE, Quarshie AQ, Josiah-Willock R, Ojutalayo FO, Alema-Mensah E, Ofili EO. Socio-demographic psychosocial and clinical characteristics of participants in e-HealthyStrides©: an interactive ehealth program to improve diabetes self-management skills. J Health Care Poor Underserved 2011; 22:146-64. [PMID: 22102311 PMCID: PMC3571092 DOI: 10.1353/hpu.2011.0162] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Diabetes self-management (DSM) training helps prevent diabetic complications. eHealth approaches may improve its optimal use. The aims were to determine a) acceptability of e-HealthyStrides© (an interactive, Internet-based, patient-driven, diabetes self-management support and social networking program) among Morehouse Community Physicians' Network diabetics; b) efficacy for DSM behavior change c) success factors for use of e-HealthyStrides©. Baseline characteristics of pilot study participants are reported. Of those approached, 13.8% agreed to participate. Among participants, 96% were Black, 77% female; age 56±9.2 years; education: 44% college or higher and 15% less than 12th grade; 92.5% with home computers. Over half (51%) failed the Diabetes Knowledge Test. Nearly half (47%) were at goal A1C; 24% at goal blood pressure; 3% at goal LDL cholesterol level. Median (SD) Diabetes Empowerment Scale score = 3.93 (0.72) but managing psychosocial aspects = 3.89 (0.89) scored lower than other domains. There was low overall confidence for DSM behaviors. Assistance with healthy eating was the most frequently requested service. Requestors were more obese with worse A1C than others. Chronic care delivery scored average with high scores for counseling and problem solving but low scores for care coordination and follow up.
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Affiliation(s)
- Priscilla E Pemu
- Morehouse School of Medicine, 720 Westview Drive SW, Atlanta, GA 30310, USA.
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Borgermans L, Goderis G, Broeke CVD, Mathieu C, Aertgeerts B, Verbeke G, Carbonez A, Ivanova A, Grol R, Heyrman J. A cluster randomized trial to improve adherence to evidence-based guidelines on diabetes and reduce clinical inertia in primary care physicians in Belgium: study protocol [NTR 1369]. Implement Sci 2008; 3:42. [PMID: 18837983 PMCID: PMC2569961 DOI: 10.1186/1748-5908-3-42] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2008] [Accepted: 10/06/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Most quality improvement programs in diabetes care incorporate aspects of clinician education, performance feedback, patient education, care management, and diabetes care teams to support primary care physicians. Few studies have applied all of these dimensions to address clinical inertia. AIM To evaluate interventions to improve adherence to evidence-based guidelines for diabetes and reduce clinical inertia in primary care physicians. DESIGN Two-arm cluster randomized controlled trial. PARTICIPANTS Primary care physicians in Belgium. INTERVENTIONS Primary care physicians will be randomly allocated to 'Usual' (UQIP) or 'Advanced' (AQIP) Quality Improvement Programs. Physicians in the UQIP will receive interventions addressing the main physician, patient, and office system factors that contribute to clinical inertia. Physicians in the AQIP will receive additional interventions that focus on sustainable behavior changes in patients and providers. OUTCOMES Primary endpoints are the proportions of patients within targets for three clinical outcomes: 1) glycosylated hemoglobin < 7%; 2) systolic blood pressure differences < or =130 mmHg; and 3) low density lipoprotein/cholesterol < 100 mg/dl. Secondary endpoints are individual improvements in 12 validated parameters: glycosylated hemoglobin, low and high density lipoprotein/cholesterol, total cholesterol, systolic blood pressure, diastolic blood pressure, weight, physical exercise, healthy diet, smoking status, and statin and anti-platelet therapy. PRIMARY AND SECONDARY ANALYSIS: Statistical analyses will be performed using an intent-to-treat approach with a multilevel model. Linear and generalized linear mixed models will be used to account for the clustered nature of the data, i.e., patients clustered withinimary care physicians, and repeated assessments clustered within patients. To compare patient characteristics at baseline and between the intervention arms, the generalized estimating equations (GEE) approach will be used, taking the clustered nature of the data within physicians into account. We will also use the GEE approach to test for differences in evolution of the primary and secondary endpoints for all patients, and for patients in the two interventions arms, accounting for within-patient clustering.
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Affiliation(s)
- Liesbeth Borgermans
- Catholic University Leuven, Department of General Practice, Kapucijnenvoer 33/J Box 7001, 3000 Leuven, Belgium
| | - Geert Goderis
- Catholic University Leuven, Department of General Practice, Kapucijnenvoer 33/J Box 7001, 3000 Leuven, Belgium
| | - Carine Van Den Broeke
- Catholic University Leuven, Department of General Practice, Kapucijnenvoer 33/J Box 7001, 3000 Leuven, Belgium
| | - Chantal Mathieu
- University Hospitals Leuven, Experimental Medicine, Herestraat 49, 3000 Leuven, Belgium
| | - Bert Aertgeerts
- Catholic University Leuven, Department of General Practice, Kapucijnenvoer 33/J Box 7001, 3000 Leuven, Belgium
| | - Geert Verbeke
- Catholic University Leuven, Leuven Statistics Research Centre (LStat), Celestijnenlaan 200 B, 3001 Heverlee, Belgium
| | - An Carbonez
- Catholic University Leuven, Leuven Statistics Research Centre (LStat), Celestijnenlaan 200 B, 3001 Heverlee, Belgium
| | - Anna Ivanova
- Catholic University Leuven, Leuven Statistics Research Centre (LStat), Celestijnenlaan 200 B, 3001 Heverlee, Belgium
| | - Richard Grol
- Radboud University of Nijmegen, Faculty of Medicine, Centre for Quality of Care, PO BOX 9101, KWAZO 114, 6500 HB Nijmegen, The Netherlands
| | - Jan Heyrman
- Catholic University Leuven, Department of General Practice, Kapucijnenvoer 33/J Box 7001, 3000 Leuven, Belgium
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Hawthorne K, Robles Y, Cannings-John R, Edwards AG. Culturally appropriate health education for type 2 diabetes mellitus in ethnic minority groups. Cochrane Database Syst Rev 2008:CD006424. [PMID: 18646153 DOI: 10.1002/14651858.cd006424.pub2] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Ethnic minority groups in upper-middle and high income countries tend to be socio-economically disadvantaged and to have higher prevalence of type 2 diabetes than the majority population. OBJECTIVES To assess the effectiveness of culturally appropriate diabetes health education on important outcome measures in type 2 diabetes. SEARCH STRATEGY We searched the The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, ERIC, SIGLE and reference lists of articles. We also contacted authors in the field and handsearched commonly encountered journals. SELECTION CRITERIA RCTs of culturally appropriate diabetes health education for people over 16 years with type 2 diabetes mellitus from named ethnic minority groups resident in upper-middle or high income countries. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. Where there were disagreements in selection of papers for inclusion, all four authors discussed the studies. We contacted study authors for additional information when data appeared to be missing or needed clarification. MAIN RESULTS Eleven trials involving 1603 people were included, with ten trials providing suitable data for entry into meta-analysis. Glycaemic control (HbA1c), showed an improvement following culturally appropriate health education at three months (weight mean difference (WMD) - 0.3%, 95% CI -0.6 to -0.01), and at six months (WMD -0.6%, 95% CI -0.9 to -0.4), compared with control groups who received 'usual care'. This effect was not significant at 12 months post intervention (WMD -0.1%, 95% CI -0.4 to 0.2). Knowledge scores also improved in the intervention groups at three months (standardised mean difference (SMD) 0.6, 95% CI 0.4 to 0.7), six months (SMD 0.5, 95% CI 0.3 to 0.7) and twelve months (SMD 0.4, 95% CI 0.1 to 0.6) post intervention. Other outcome measures both clinical (such as lipid levels, and blood pressure) and patient centred (quality of life measures, attitude scores and measures of patient empowerment and self-efficacy) showed no significant improvement compared with control groups. AUTHORS' CONCLUSIONS Culturally appropriate diabetes health education appears to have short term effects on glycaemic control and knowledge of diabetes and healthy lifestyles. None of the studies were long-term, and so clinically important long-term outcomes could not be studied. No studies included an economic analysis. The heterogeneity of studies made subgroup comparisons difficult to interpret with confidence. There is a need for long-term, standardised multi-centre RCTs that compare different types and intensities of culturally appropriate health education within defined ethnic minority groups.
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Affiliation(s)
- Kamila Hawthorne
- Department of Primary Care and Public Health, Cardiff University, 3rd Floor, Neuadd Meirionnydd Building. School of Medicine, Heath Park, Cardiff, UK, CF14 4XN
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Peek ME, Cargill A, Huang ES. Diabetes health disparities: a systematic review of health care interventions. Med Care Res Rev 2007. [PMID: 17881626 DOI: 10.1177/1077558707305409; 17881626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Racial and ethnic minorities bear a disproportionate burden of the diabetes epidemic; they have higher prevalence rates, worse diabetes control, and higher rates of complications. This article reviews the effectiveness of health care interventions at improving health outcomes and/or reducing diabetes health disparities among racial/ethnic minorities with diabetes. Forty-two studies met inclusion criteria. On average, these health care interventions improved the quality of care for racial/ethnic minorities, improved health outcomes (such as diabetes control and reduced diabetes complications), and possibly reduced health disparities in quality of care. There is evidence supporting the use of interventions that target patients (primarily through culturally tailored programs), providers (especially through one-on-one feedback and education), and health systems (particularly with nurse case managers and nurse clinicians). More research is needed in the areas of racial/ethnic minorities other than African Americans and Latinos, health disparity reductions, long-term diabetes-related outcomes, and the sustainability of health care interventions over time.
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Affiliation(s)
- Monica E Peek
- Section of General Internal Medicine, The University of Chicago, Chicago, IL 60637, USA.
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Peek ME, Cargill A, Huang ES. Diabetes health disparities: a systematic review of health care interventions. Med Care Res Rev 2007; 64:101S-56S. [PMID: 17881626 PMCID: PMC2367214 DOI: 10.1177/1077558707305409] [Citation(s) in RCA: 317] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Racial and ethnic minorities bear a disproportionate burden of the diabetes epidemic; they have higher prevalence rates, worse diabetes control, and higher rates of complications. This article reviews the effectiveness of health care interventions at improving health outcomes and/or reducing diabetes health disparities among racial/ethnic minorities with diabetes. Forty-two studies met inclusion criteria. On average, these health care interventions improved the quality of care for racial/ethnic minorities, improved health outcomes (such as diabetes control and reduced diabetes complications), and possibly reduced health disparities in quality of care. There is evidence supporting the use of interventions that target patients (primarily through culturally tailored programs), providers (especially through one-on-one feedback and education), and health systems (particularly with nurse case managers and nurse clinicians). More research is needed in the areas of racial/ethnic minorities other than African Americans and Latinos, health disparity reductions, long-term diabetes-related outcomes, and the sustainability of health care interventions over time.
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Affiliation(s)
- Monica E Peek
- Section of General Internal Medicine, The University of Chicago, Chicago, IL 60637, USA.
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Phillips LS, Ziemer DC, Doyle JP, Barnes CS, Kolm P, Branch WT, Caudle JM, Cook CB, Dunbar VG, El-Kebbi IM, Gallina DL, Hayes RP, Miller CD, Rhee MK, Thompson DM, Watkins C. An endocrinologist-supported intervention aimed at providers improves diabetes management in a primary care site: improving primary care of African Americans with diabetes (IPCAAD) 7. Diabetes Care 2005; 28:2352-60. [PMID: 16186262 DOI: 10.2337/diacare.28.10.2352] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Management of diabetes is frequently suboptimal in primary care settings, where providers often fail to intensify therapy when glucose levels are high, a problem known as clinical inertia. We asked whether interventions targeting clinical inertia can improve outcomes. RESEARCH DESIGN AND METHODS A controlled trial over a 3-year period was conducted in a municipal hospital primary care clinic in a large academic medical center. We studied all patients (4,138) with type 2 diabetes who were seen in continuity clinics by 345 internal medicine residents and were randomized to be control subjects or to receive one of three interventions. Instead of consultative advice, the interventions were hard copy computerized reminders that provided patient-specific recommendations for management at the time of each patient's visit, individual face-to-face feedback on performance for 5 min every 2 weeks, or both. RESULTS Over an average patient follow-up of 15 months within the intervention site, improvements in and final HbA1c (A1C) with feedback + reminders (deltaA1C 0.6%, final A1C 7.46%) were significantly better than control (deltaA1C 0.2%, final A1C 7.84%, P < 0.02); changes were smaller with feedback only and reminders only (P = NS vs. control). Trends were similar but not significant with systolic blood pressure (sBP) and LDL cholesterol. Multivariable analysis showed that the feedback intervention independently facilitated attainment of American Diabetes Association goals for both A1C and sBP. Over a 2-year period, overall glycemic control improved in the intervention site but did not change in other primary care sites (final A1C 7.5 vs. 8.2%, P < 0.001). CONCLUSIONS Feedback on performance aimed at overcoming clinical inertia and given to internal medicine resident primary care providers improves glycemic control. Partnering generalists with diabetes specialists may be important to enhance diabetes management in other primary care settings.
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Affiliation(s)
- Lawrence S Phillips
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
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