Management of type 2 diabetes: a challenge for patient and physician

Carnosine supplementation improves glucose control in adults with pre-diabetes and type 2 diabetes: A randomised controlled trial

BACKGROUND AND AIMS

Type 2 diabetes (T2DM) is a major cause of morbidity and mortality globally. Carnosine, a naturally occurring dipeptide, has anti-inflammatory, antioxidant, and anti-glycating effects, with preliminary evidence suggesting it may improve important chronic disease risk factors in adults with cardiometabolic conditions.

METHODS AND RESULTS

In this randomised controlled trial, 43 adults (30%F) living with prediabetes or T2DM consumed carnosine (2 g) or a matching placebo daily for 14 weeks to evaluate its effect on glucose metabolism assessed via a 2-h 75 g oral glucose tolerance test. Secondary outcomes included body composition analysis by dual energy x-ray absorptiometry (DEXA), calf muscle density by pQCT, and anthropometry. Carnosine supplementation decreased blood glucose at 90 min (-1.31 mmol/L; p = 0.02) and 120 min (-1.60 mmol/L, p = 0.02) and total glucose area under the curve (-3.30 mmol/L; p = 0.04) following an oral glucose tolerance test. There were no additional changes in secondary outcomes. The carnosine group results remained significant before and after adjustment for age, sex, and change in weight (all>0.05), and in further sensitivity analyses accounting for missing data. There were no significant changes in insulin levels.

CONCLUSION

This study provides preliminary support for larger trials evaluating carnosine as a potential treatment for prediabetes and the initial stages of T2DM. Likely mechanisms may include changes to hepatic glucose output explaining the observed reduction in blood glucose without changes in insulin secretion following carnosine supplementation.

Impact of Expanded Medicaid Eligibility on the Diabetes Continuum of Care Among Low-Income Adults: A Difference-in-Differences Analysis

INTRODUCTION

The impact of Medicaid expansion on linkage to care, self-maintenance, and treatment among low-income adults with diabetes was examined.

METHODS

A difference-in-differences design was used on data from the Behavioral Risk Factor Surveillance System, 2008-2018. Analysis was restricted to states with diabetes outcomes and nonpregnant adults aged 18-64 years who were Medicaid eligible on the basis of income. Separate analyses were performed for early postexpansion (1, 2, 3) and late postexpansion years (4, 5). Analyses were performed from September 2019 to March 2020.

RESULTS

In comparing expansion with control states, low-income residents with diabetes had similar ages (48.9 vs 49.1 years) and similar proportions who were female (54.4% vs 55.0%) but were less likely to be Black, non-Hispanic (20.8% vs 29.2%, standardized difference= -16.3%). In expansion states, health insurance increased by 7.2 percentage points (95% CI=3.9, 10.4), and the ability to afford a physician increased by 5.5 percentage points (95% CI=1.9, 9.1) in the early years, but no difference was found in late years. Medicaid expansion led to a 5.3-percentage point increase in provider foot examinations in the early period (95% CI=0.14, 10.4) and a 7.2-percentage point increase in self-foot examinations in the late period (95% CI=1.1, 13.3). No statistically significant changes were detected in self-reported linkage to care, self-maintenance, or treatment.

CONCLUSIONS

Although health insurance, ability to afford a physician visit, and foot examinations increased for Medicaid-eligible people with diabetes, there was no statistically significant difference found for other care continuum measures.

How patients make sense of a diabetes diagnosis: An application of Weick's model of organizing

AIMS

To identify communication cycles patients use to make sense of a diabetes diagnosis and barriers patients encounter in their sensemaking process.

METHODS

Researchers conducted interviews with 33 participants with type 2 diabetes mellitus or prediabetes at medical centers in Georgia and Nevada. A thematic analysis using the constant comparative method identified communication cycles.

RESULTS

Patients reported engaging three communication cycles to make sense of the diagnosis: (1) interacting with healthcare clinicians; (2) seeking information online; and (3) taking a nutrition/diabetes management class. Patients reported system-level barriers that impact sensemaking: (1) lack of consistent or routine care; and (2) lack of access to resources.

CONCLUSION

Results here reinforce the theoretical proposition that receiving a diagnosis is an equivocal process that requires patients to make sense of new information through communication cycles. Patients in this sample repeatedly described communication cycles to interpret this new information rather than relying on assembly rules. Clinicians can promote patient understanding of diabetes and self-management by taking time to explain the diagnosis, maintaining consistent care, providing guidance to online sources, and ensuring patients have access to diabetes education.

Development of a Deep Learning Model for Dynamic Forecasting of Blood Glucose Level for Type 2 Diabetes Mellitus: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a major public health burden. Self-management of diabetes including maintaining a healthy lifestyle is essential for glycemic control and to prevent diabetes complications. Mobile-based health data can play an important role in the forecasting of blood glucose levels for lifestyle management and control of T2DM.

OBJECTIVE

The objective of this work was to dynamically forecast daily glucose levels in patients with T2DM based on their daily mobile health lifestyle data including diet, physical activity, weight, and glucose level from the day before.

METHODS

We used data from 10 T2DM patients who were overweight or obese in a behavioral lifestyle intervention using mobile tools for daily monitoring of diet, physical activity, weight, and blood glucose over 6 months. We developed a deep learning model based on long short-term memory-based recurrent neural networks to forecast the next-day glucose levels in individual patients. The neural network used several layers of computational nodes to model how mobile health data (food intake including consumed calories, fat, and carbohydrates; exercise; and weight) were progressing from one day to another from noisy data.

RESULTS

The model was validated based on a data set of 10 patients who had been monitored daily for over 6 months. The proposed deep learning model demonstrated considerable accuracy in predicting the next day glucose level based on Clark Error Grid and ±10% range of the actual values.

CONCLUSIONS

Using machine learning methodologies may leverage mobile health lifestyle data to develop effective individualized prediction plans for T2DM management. However, predicting future glucose levels is challenging as glucose level is determined by multiple factors. Future study with more rigorous study design is warranted to better predict future glucose levels for T2DM management.

Care providers' perceptions towards challenges and opportunities for service improvement at diabetes management clinics in public primary health care in Muscat, Oman: a qualitative study

Background

The literature has described several challenges related to the quality of diabetes management clinics in public primary health care centres in Oman. These clinics continue to face challenges due to the continuous growth of individuals diagnosed with type 2 diabetes. We sought to explore the challenges faced in these clinics and discuss opportunities for improvement in Oman.

Methods

This qualitative study was designed to include non-participant observations of diabetic patients and care providers during service provision at diabetes management clinics, as well as semi-structured interviews with care providers, at five purposively selected public primary health care centres. Care providers included physicians, nurses, dieticians, health educators, pharmacists, an assistant pharmacist, a psychologist, and a medical orderly. The data were analysed using qualitative content analysis.

Results

The study disclosed three different models of service delivery at diabetes management clinics, which, to varying degrees, face challenges related to health centre infrastructure, technical and pharmaceutical support, and care providers’ interests, knowledge, and skills. Challenges related to the community were also found in terms of cultural beliefs, traditions, health awareness, and public transportation.

Conclusion

The challenges encountered in diabetes management clinics fall within two contexts: health care centres and community. Although many challenges exist, opportunities for improvement are available. However, improvements in the quality of diabetic clinics in primary health care centres might take time and require extensive involvement, shared responsibilities, and implications from the government, health care centres, and community.

"Antibiotics kill things very quickly" - consumers' perspectives on non-prescribed antibiotic use in Saudi Arabia

Background

In recent decades, the Kingdom of Saudi Arabia has seen an exponentially growing antibiotic resistance, which is exacerbated by the use of antibiotics without a prescription and other various factors. However, no published data are available on factors influencing non-prescription use of antibiotics among the general public in Saudi Arabia using an in-depth interview technique.

Methods

Semi-structured interviews were carried out with 40 Saudi participants from the Eastern Province of Saudi Arabia, selected via snowball sampling technique. Participants were enrolled based on the following inclusion criteria: 18 years of age or older and had self-medicated themselves with antibiotics in the past two years. Data collection was continued until data saturation was attained. Interviews were audiotaped, transcribed verbatim and analysed using NVivo 10 software.

Results

Participants (80% female) had a mean (SD) age of 30 years (10.2). Self-medication with antibiotics was associated with various inappropriate antibiotic use behaviours and negative outcomes such as antibiotic resistance, treatment failures and adverse events. Interviews revealed that different reasons contribute to the rise of self-medication with antibiotics, ranging from difficulty accessing healthcare services, participant’s cultural beliefs and practices, lack of knowledge about antibiotics and antibiotic resistance, and weak regulatory enforcement.

Conclusions

The findings of the present study will aid in generating data that may provide an insight when designing future interventions to promote public health awareness regarding safe and effective use of antibiotics.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6088-z) contains supplementary material, which is available to authorized users.

Identifying and Prioritizing the Barriers and Facilitators to the Self-Management of Type 2 Diabetes Mellitus: A Community-Centered Approach

OBJECTIVE

Self-management of type 2 diabetes mellitus is crucial to controlling the disease and preventing harm. Multiple factors have been identified in the literature as potential barriers and facilitators to self-management, but the magnitude and directionality of these factors are seldom studied. We sought to develop and test an instrument to identify and quantify the barriers and facilitators to self-management of type 2 diabetes.

METHODS

A community-centered approach was used to design, implement, and interpret the results of a stated-preference study. All activities were guided by a diverse stakeholder board. Based on previously reported development work, a novel survey instrument consisting of 13 potential barriers and facilitators was pretested and piloted in our local community. Participants were asked to discuss, rate, and rank each factor. A simple self-explicated method was used to quantify the data and Z scores were used for hypothesis testing.

RESULTS

In total, 25 patients with self-reported type 2 diabetes (64% female; 92% minorities) participated in the pretest and pilot. Time commitments (Z = -3.72), lack of active support groups (Z = -3.39) and other resources in the local community (Z = -2.96), and language/culture (Z = -2.69) were identified as barriers to self-management. Access to healthy food (Z = +5.68), personal understanding (Z = +4.81), and communication with healthcare providers (Z = +4.62) were identified as facilitators.

CONCLUSION

We demonstrate that factors impacting self-management can be quantified and categorized as barriers and facilitators. While further refinement to some factors and investigation into alternative prioritization methods is necessary, our stakeholder board endorsed moving this to a large nationally representative study to see how these factors vary across different people.

Patients' involvement in improvement initiatives: a qualitative systematic review

BACKGROUND

Over the last 20 years, quality improvement in health has become an important strategy in health services in many countries. With the emphasis on quality health care, there has been a shift in social paradigms towards including service users in their own health on different levels. There is growing evidence in literature on the positive impact on health outcomes where patients are active participants in their personal care. There is however less information available on the broader influence of users on improvement in systems.

OBJECTIVES

The objective of this review was to identify the barriers and enablers to patients being involved in quality improvement efforts directed towards their own health care.

INCLUSION CRITERIA

This review considered studies that included adults and children of any age experiencing any health problem.The review considered studies that explored patient or user participation in quality improvement and the factors enabling and hindering this processThe qualitative component of this review considered studies that focused on qualitative data, including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research. Other texts such as opinion papers and reports were also considered.

SEARCH STRATEGY

The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized in this review. The searches using all identified keywords and index terms included the databases PubMed, PsycINFO, Medline, Scopus, EBSCOhost and CINAHL.Qualitative, text and opinion papers were considered for inclusion in this review.Closely related concepts like community involvement, family involvement, patients' involvement in their own care (for example, in the case of shared decision making), and patient centeredness in the context of a consultation were excluded.

METHODOLOGICAL QUALITY

Qualitative and textual papers selected for retrieval were assessed by two independent reviewers for authenticity prior to inclusion in the review using the standardized critical appraisal instruments from the Joanna Briggs Institute.

DATA EXTRACTION

Qualitative and textual data were extracted from papers included in the review using the standardized data extraction tool from the Joanna Briggs Institute.

DATA SYNTHESIS

The above findings were pooled and through the identification of categories, a final meta-synthesis was formulated.

RESULTS

Two synthesized findings were created from the included papers. Firstly, there are barriers to patients' participation in quality improvement in health and in spite of policy support for user involvement in quality improvement, it is a difficult strategy to implement. The second synthesized finding was that there are enablers to patients' involvement in quality improvement: when patients are involved in quality improvement efforts in health care, there are innovative, often unexpected, outcomes at different levels of the process, and sustaining these efforts is possible with ongoing individual or group support.Five categories which supported the synthesized findings were created through the meta-aggregative process.

CONCLUSIONS

There are enablers and barriers to involving patients in quality improvement in health care that need to be considered when planning such interventions.Relationships and roles will need to be very clear from the outset. A developmental approach needs to be considered where support and training is part of the project. Where patients are truly engaged in service improvement, unexpected innovation occurs.There are many more reports and opinion papers published regarding this topic than there are rigorous research studies. This leaves the field open to the development of good methodological studies related to quality improvement and in particular to the participation of patients.

Dental Implant Survival and Complication Rate over 2 Years for Individuals with Poorly Controlled Type 2 Diabetes Mellitus

BACKGROUND

Emerging evidence suggests that implant therapy may be a viable option for diabetic individuals with elevated glycemic levels.

PURPOSE

The purpose of this 2 year observational study was to evaluate survival and clinical complications of dental implants following placement in type 2 diabetes individuals having poor glycemic control.

MATERIALS AND METHODS

Adult participants (n = 24) with poorly controlled type 2 diabetes (8.0% ≤ HbA1c ≤ 12.0%) received two or more transgingival dental implants. Survival was evaluated after 1 (23 participants, 72 implants) and 2 (20 participants, 59 implants) years. Clinical complications were evaluated in 18 participants (52 implants) after 21-34 months. Relationships between complications and stratified HbA1c levels were assessed using Pearson's correlation test.

RESULTS

Survival rates were 98.6% (71/72 implants) after 1 year and 96.6% (57/59 implants) after 2 years. Complications were identified in 29% of participants with peri-implant mucositis, the most common event. Complications correlated directly with number of implants across HbA1c strata (0.42, R2  = 0.66). There was no correlation between HbA1c and the occurrences of complications or mucositis.

CONCLUSIONS

This 2-year evaluation supports the broader application of implant therapy in type 2 diabetes individuals with poor glycemic control in demonstrating high survival rates with limited complications.

Glycaemic control and associated factors among patients with diabetes at public health clinics in Johor, Malaysia

OBJECTIVES

To determine the prevalence of glycaemic control and factors associated with poor glycaemic control [glycosylated haemoglobin (HbA1c) ≥6.5%] among patients with type 2 diabetes treated in public health clinics in Johor, Malaysia.

STUDY DESIGN

Cross-sectional study.

METHODS

A review of all patients aged over 18 years and with a diagnosis of type 2 diabetes for >1 year. The National Diabetic Registry was used as the database for attendees at public health clinics in Johor Bahru between January and December 2013. A required sample of 660 was calculated, and a random sampling method was applied to acquire patient information across the 13 public health clinics in Johor Bahru. All relevant information (e.g. HbA1c, type of treatment and other parameters for glycaemic control) were abstracted from the registry.

RESULTS

Sixty-eight percent of 706 patients had HbA1c >6.5%, and mean HbA1c was 7.8%. Younger patients (72.3%) had poorer glycaemic control than older patients (63.0%), and most patients with poor glycaemic control were obese (79.2%). Approximately 31.7% of patients did not achieve the target blood pressure <130/80 mmHg, and 58.5% did not achieve the target lipid profile. Multiple logistic regression analysis revealed that age (<60 years), sex (male), duration of diabetes (>5 years), body mass index (obese), type of treatment (diet therapy vs combination therapy) and abnormal lipid profile were significantly associated with increased odds of HbA1C >6.5%.

CONCLUSIONS

More than half (68%) of the patients with diabetes had HbA1c >6.5%. This highlights the importance of providing organized care to manage patients with diabetes in the primary care setting, such as weight reduction programmes, proper prescribing treatment, and age- and gender-specific groups to ensure good glycaemic control.

Patients' management of type 2 diabetes in Middle Eastern countries: review of studies

The increased prevalence of diabetes in Middle Eastern countries is a health policy priority. Important risk factors for diabetes have been identified. Lifestyle interventions and adherence to medications are central to disease prevention and management. This review focuses on the management of type 2 diabetes mellitus in Middle Eastern countries. The aim is to identify the ways in which knowledge, health beliefs, and social and cultural factors influence adherence to medication and lifestyle measures. Thirty-four studies were identified following a systematic search of the literature. The studies describe the influence of knowledge, health beliefs, culture, and lifestyle on the management of type 2 diabetes mellitus in the Middle East. Findings indicate a lack of health knowledge about diabetes among populations, which has implications for health behaviors, medication adherence, and treatment outcomes. Many identified health beliefs and cultural lifestyle factors, such as religious beliefs, beliefs about fasting during Ramadan, and sedentary lifestyles played a role in patients' decisions. For better management of this disease, a collaborative approach between patients, their families, health care professionals, and governments should be adopted. Implementing behavioral strategies and psychological interventions that incorporate all health care professionals in the management process have been shown to be effective methods. Such services help patients change their behavior. However, the utilization of such services and interventions is still limited in Arabian countries. Physicians in the Middle East are the health care professionals most involved in the care process.

Health literacy issues in the care of Chinese American immigrants with diabetes: a qualitative study

OBJECTIVES

To investigate why first-generation Chinese immigrants with diabetes have difficulty obtaining, processing and understanding diabetes related information despite the existence of translated materials and translators.

DESIGN

This qualitative study employed purposive sampling. Six focus groups and two individual interviews were conducted. Each group discussion lasted approximately 90 min and was guided by semistructured and open-ended questions.

SETTING

Data were collected in two community health centres and one elderly retirement village in Los Angeles, California.

PARTICIPANTS

29 Chinese immigrants aged ≥45 years and diagnosed with type 2 diabetes for at least 1 year.

RESULTS

Eight key themes were found to potentially affect Chinese immigrants' capacity to obtain, communicate, process and understand diabetes related health information and consequently alter their decision making in self-care. Among the themes, three major categories emerged: cultural factors, structural barriers, and personal barriers.

CONCLUSIONS

Findings highlight the importance of cultural sensitivity when working with first-generation Chinese immigrants with diabetes. Implications for health professionals, local community centres and other potential service providers are discussed.

Perceived racial discrimination in health care, completion of standard diabetes services, and diabetes control among a sample of American Indian women

PURPOSE

The purpose of this study is to examine perceived experiences of racial discrimination (perceived discrimination) in health care and its associations with completing standards of care for diabetes management and diabetes control.

METHODS

This cross-sectional study included 200 adult American Indian (AI) women with type 2 diabetes from 4 health care facilities located on tribal reservations in the Pacific Northwest. Participants completed a survey, and medical records were abstracted. Logistic regression was completed to assess associations.

RESULTS

Sixty-seven percent of AI women reported discrimination during their lifetime of health care. After adjusting for patient characteristics, perceived discrimination was significantly associated with lower rates of dental exam; checks for blood pressure, creatinine, and total cholesterol; and pneumococcal vaccination. The association between perceived discrimination and total number of diabetes services completed was not statistically significant. Perceived discrimination was associated with having A1C values above target levels for diabetes control in unadjusted and adjusted models, but no association was observed for blood pressure or total cholesterol.

CONCLUSIONS

In our sample of AI women with diabetes, two-thirds reported experiencing racial discrimination in their health care experience. Those reporting perceived discrimination completed fewer diabetes services and therefore may be at increased risk for comorbidities of diabetes. This finding supports the continued need for culturally responsive health care and programs of diabetes education to recognize perceived discrimination and its potential to impact success in self-management and services utilization.

Is adherence a relevant issue in the self-management education of diabetes? A mixed narrative review

While therapeutic patient education is now recognized as essential for optimizing the control of chronic diseases and patient well-being, adherence to treatment and medical recommendations is still a matter of debate. In type 2 diabetes, the nonadherence to therapy, estimated at more than 40%, is perceived as a barrier for improving the prognosis despite recent therapeutic advances. Interventional studies have barely begun to demonstrate the effectiveness of technical and behavioral actions. The aim of this review is to question the concept of adherence in terms of therapeutic education based on quantitative and qualitative data. The research on therapeutic education has shown the effectiveness of structured actions in type 2 diabetes, but adherence is rarely an end point in randomized trials. A positive but inconsistent or moderate effect of education actions on adherence has been shown in heterogeneous studies of varying quality. Program types, outlines, theoretical bases, and curricula to set up for action effectiveness are still being discussed. Qualitative studies, including sociological studies, provide a useful and constructive focus on this perspective. Adherence is a soft and flexible tool available to the patient in his/her singular chronic disease trajectory, and as such, integrates into individual therapeutic strategies, including socio-cultural interactions, beyond the medical explanation of the disease and the patient. Four key elements for the development of structured therapeutic education are discussed: 1) the access to health literacy, 2) the contextualization of education activities, 3) the long-term chronic dimension of self-management, and 4) the organizational aspects of health and care. Rather than focusing the objective on behavioral changes, structured therapeutic education actions should attempt to provide tools and resources aimed at helping individuals to manage their disease in their own context on a long-term basis, by developing health literacy and relational and organizational aspects of the health professionals and system.

The concomitant relationship shared by sleep disturbances and type 2 diabetes: developing telemedicine as a viable treatment option

Individually, sleep disturbances and type 2 diabetes pose pervasive challenges to health. In addition, the negative symptomology associated with each condition is exacerbated further when presenting concomitantly. This relationship formulates a destructive loop wherein those with diabetes experience decreased sleep quality, which, in turn, worsens a wide range of health threats experienced by those with diabetes, including obesity and glucose intolerance. Because major lifestyle changes and daily care are needed to effectively manage both diabetes and sleep disturbances, an efficient and timely modality of treatment is essential. Advanced technology incorporating telemedicine and telehealth has the potential to enhance treatment by delivering accepted standard of care, medical monitoring, and education quickly and seamlessly--even in rural locations. This type of intervention has the added potential benefit of fostering patient empowerment.

Factors influencing self-management in patients with type 2 diabetes: a quantitative systematic review protocol

AIM

To describe a protocol for a quantitative systematic review, to identify critique and summarize factors that influence self-management education.

BACKGROUND

Self-management education enables patients to manage their condition successfully and it is associated with better self-care, good control over lifestyle and leading the best possible quality of life, notwithstanding the presence of a chronic disease. Type II Diabetes is a chronic disease that requires lifestyle adjustments and disease management to keep glycaemia and long-term complications under control. Education has to be customized and based on an assessment that includes factors influencing self-management, such as personal characteristics that can optimize the educational intervention.

DESIGN

The protocol for the systematic review was conducted according to the guidelines of the Centre for Reviews and Dissemination, York (UK).

METHOD

The review question was defined in terms of population, interventions, comparators, outcomes and study designs. The protocol included decisions about the review question, inclusion criteria, search strategy, study selection, data extraction, quality assessment, data synthesis and plans for dissemination. Funding for the review was confirmed on January 2011 by the Centre of Excellence for Nursing Scholarship in Rome.

DISCUSSION

An initial summary will be made by tabulating the data; the review will be reported in a narrative style and be developed according to the PRISMA guidelines. The protocol for the systematic review will allow us to identify, among the factors influencing self-management in people with Type II diabetes, the personal characteristics most relevant to the factors of motivation and empowerment. In addition, the systematic review will also identify an appropriate self-management model.

Organizational justice in primary-care health centers and glycemic control in patients with type 2 diabetes

BACKGROUND

Organizational justice has been put forward as a measure of leadership quality that is associated with better health among employees.

OBJECTIVES

We extended that idea to test whether perceived organizational justice among health care providers might be positively associated with glycemic control among their diabetic patients.

SETTING

Eighteen primary-care health centers (HCs) in Finland.

PARTICIPANTS

Type 2 diabetes patients (n=8954) and HC staff (n=422).

MEASUREMENTS

: Mean of 1 year's measurements of glycated hemoglobin [≥ 7.0 (the least optimal); 6.5-6.9; 6.0-6.4; and 4.5-5.9 (the most optimal)], health-center psychosocial work characteristics (staff-reported procedural justice and relational justice, effort-reward imbalance, and work-unit team climate), and individual-level and work-unit-level covariates.

RESULTS

Perceptions of higher levels of procedural justice among staff were associated with more optimal glycated hemoglobin levels among patients (cumulative odds ratio per 1-U increase in justice=1.54, 95% confidence interval, 1.08-2.18) after adjustment for patient-level and unit-level covariates. Relational justice, effort-reward imbalance, and work-unit team climate were not associated with glycemic control.

CONCLUSION

The quality of leadership at HCs, as indicated by staff perceptions of procedural justice, may play a role in achieving good glycemic control among type 2 diabetes patients.

Antidiabetic effects of SGLT2-selective inhibitor ipragliflozin in streptozotocin-nicotinamide-induced mildly diabetic mice

Sodium-glucose cotransporter (SGLT) 2 plays an important role in renal glucose reabsorption, and inhibition of renal SGLT2 activity represents an innovative strategy for the treatment of hyperglycemia in diabetic patients. The present study investigated the antidiabetic effects of ipragliflozin, a SGLT2-selective inhibitor, in streptozotocin-nicotinamide-induced mildly diabetic mice, which exhibited a mild decline in glucose tolerance associated with the loss of early-phase insulin secretion. Oral administration of ipragliflozin increased urinary glucose excretion in a dose-dependent manner, an effect which was significant at doses of 0.3 mg/kg or higher and lasted over 12 h. In addition, ipragliflozin dose-dependently improved hyperglycemia and glucose intolerance with concomitant decreases in plasma insulin levels without causing hypoglycemia. Once-daily dosing of ipragliflozin (0.1 - 3 mg/kg) for 4 weeks attenuated hyperglycemia, glucose intolerance, and impaired insulin secretion. These results suggest that the SGLT2-selective inhibitor ipragliflozin increases urinary glucose excretion by inhibiting renal glucose reabsorption, improves hyperglycemia in streptozotocin-nicotinamide-induced mildly diabetic mice, and may be useful for treating type 2 diabetes.

Neighborhood deprivation and inequities in coronary heart disease among patients with diabetes mellitus: a multilevel study of 334,000 patients

We used multilevel models to investigate whether the odds of coronary heart disease (CHD) is higher in patients with diabetes mellitus (DM) living in deprived neighborhoods versus those living in wealthy neighborhoods. The Swedish nationwide prescription register was used to identify 334,000 patients aged 30 years and older with DM. The OR of CHD was significantly higher among patients with DM living in deprived neighborhoods than among patients with DM living in wealthy neighborhoods. These findings are useful for clinicians working in deprived neighborhoods. Future research could focus on how to reduce inequities in CHD among patients with DM.

Evaluation of the web-based Diabetes Interactive Education Programme (DIEP) for patients with type 2 diabetes

OBJECTIVE

The objective in this study was to evaluate a web-based type 2 diabetes self-management education programme aimed at improving knowledge, encouraging active patient participation and providing supportive self-management tools.

METHODS

(1) An effect evaluation was conducted using a randomized controlled trial with a pre-test and post-test design (n=99) and a knowledge questionnaire. (2) A user evaluation was conducted using an online questionnaire (n=564) and one-on-one interviews (n=11) to examine the perceived quality, use of functionalities and use of the programme as a supportive tool in education.

RESULTS

The effect evaluation showed a significant intervention effect (p<0.01) on knowledge. The user evaluation showed high satisfaction with the programme's content, credibility and user-friendliness. However, functionalities and self-management tools were used by less than half of the participants.

CONCLUSION

The programme can improve knowledge, but it is not fully used as intended. A more optimal use of the programme is necessary for higher efficacy.

PRACTICE IMPLICATIONS

The use of mostly spoken text instead of written text was highly appreciated and could be used more often for educational websites. Furthermore, health care practitioners need support in implementing new educational programmes during consultations.

Hospitalization for type 2 diabetes: the effects of the suspension of reality on patients' subsequent management of their condition

Hospitalization still plays a major part in the management of uncontrolled type 2 diabetes and its complications. In this article, we assess the effects of self-management education on the individual practices of 42 patients after discharge from specialized diabetes units on the French island of Reunion. Hospitalization offers respite and temporarily suspends the realities of daily life. When patients leave the unit where they have acquired new knowledge and practices, the extent to which the latter can be maintained depends on the practice in question, the individual's circumstances, and his or her social relationships and support systems. In the longer term, therefore, the effects of self-management education interventions can be weak. The study findings reveal the complexities surrounding the acquisition of habits that maintain health and prevent illness. The article makes a significant contribution to the debate on patient support and the role of inpatient educational units.

Investing time in health: do socioeconomically disadvantaged patients spend more or less extra time on diabetes self-care?

BACKGROUND

Research on self-care for chronic disease has not examined time requirements. Translating Research into Action for Diabetes (TRIAD), a multi-site study of managed care patients with diabetes, is among the first to assess self-care time.

OBJECTIVE

To examine associations between socioeconomic position and extra time patients spend on foot care, shopping/cooking, and exercise due to diabetes.

DATA

Eleven thousand nine hundred and twenty-seven patient surveys from 2000 to 2001.

METHODS

Bayesian two-part models were used to estimate associations of self-reported extra time spent on self-care with race/ethnicity, education, and income, controlling for demographic and clinical characteristics.

RESULTS

Proportions of patients spending no extra time on foot care, shopping/cooking, and exercise were, respectively, 37, 52, and 31%. Extra time spent on foot care and shopping/cooking was greater among racial/ethnic minorities, less-educated and lower-income patients. For example, African-Americans were about 10 percentage points more likely to report spending extra time on foot care than whites and extra time spent was about 3 min more per day.

DISCUSSION

Extra time spent on self-care was greater for socioeconomically disadvantaged patients than for advantaged patients, perhaps because their perceived opportunity cost of time is lower or they cannot afford substitutes. Our findings suggest that poorly controlled diabetes risk factors among disadvantaged populations may not be attributable to self-care practices.

'Aiming for the stars'--GPs' dilemmas in the prevention of cardiovascular disease in type 2 diabetes patients: focus group interviews

BACKGROUND

Studies have revealed low adherence to guidelines for treatment of diabetes and cardiovascular risk factors.

OBJECTIVE

To explore GPs' experiences regarding treatment practice in type 2 diabetes with specific focus on the prevention of cardiovascular disease.

METHODS

Fourteen experienced GPs from nine health care centres with group practices were interviewed in focus groups. The interviews were digitally recorded, transcribed verbatim and analysed by qualitative content analysis.

RESULTS

The overall theme was 'dilemmas' in GPs' treatment practice for type 2 diabetes patients. Five main dilemma categories were identified. First, the GPs were hesitant about labelling someone who feels healthy as ill. Second, regarding communicating a diabetes diagnosis and its consequences; should the patient be frightened or comforted? Third, the GPs experienced uncertainty in their role; were they to take responsibility for the care or not? Fourth, the GPs expressed a conflict between lifestyle changes and drug treatment. Fifth, the GPs described difficulties in integrating science into reality.

CONCLUSIONS

The five dilemmas in the GPs' approach to diabetes patients and the treatment of their cardiovascular risk were related to the GPs' professional role and communication with the patient. To consider these dilemmas in educational efforts is probably essential to achieve improved diabetes care and guideline adherence.

Nurse-led motivational interviewing to change the lifestyle of patients with type 2 diabetes (MILD-project): protocol for a cluster, randomized, controlled trial on implementing lifestyle recommendations

Background

The diabetes of many patients is managed in general practice; healthcare providers aim to promote healthful behaviors, such as healthful diet, adequate physical activity, and smoking cessation. These measures may decrease insulin resistance, improve glycemic control, lipid abnormalities, and hypertension. They may also prevent cardiovascular disease and complications of diabetes. However, professionals do not adhere optimally to guidelines for lifestyle counseling. Motivational interviewing to change the lifestyle of patients with type 2 diabetes is intended to improve diabetes care in accordance with the national guidelines for lifestyle counseling. Primary care nurses will be trained in motivational interviewing embedded in structured care in general practice. The aim of this paper is to describe the design and methods of a study evaluating the effects of the nurses' training on patient outcomes.

Methods/Design

A cluster, randomized, controlled trial involving 70 general practices (35 practices in the intervention arm and 35 in the control arm) starting in March 2007. A total of 700 patients with type 2 diabetes will be recruited. The patients in the intervention arm will receive care from the primary care nurse, who will receive training in an implementation strategy with motivational interviewing as the core component. Other components of this strategy will be adaptation of the diabetes protocol to local circumstances, introduction of a social map for lifestyle support, and educational and supportive tools for sustaining motivational interviewing. The control arm will be encouraged to maintain usual care. The effect measures will be the care process, metabolic parameters (glycosylated hemoglobin, blood pressure and lipids), lifestyle (diet, physical activity, smoking, and alcohol), health-related quality of life, and patients' willingness to change behaviors. The measurements will take place at baseline and after 14 months.

Discussion

Applying motivational interviewing for patients with diabetes in primary care has been studied, but to our knowledge, no other study has yet evaluated the implementation and sustainability of motivating and involving patients in day-to-day diabetes care in general practice. If this intervention proves to be effective and cost-effective, large-scale implementation of this nurse-oriented intervention will be considered and anticipated.

Trial registration

Current Controlled Trials ISRCTN68707773.

Dapagliflozin, a novel SGLT2 inhibitor, induces dose-dependent glucosuria in healthy subjects

Dapagliflozin selectively inhibits renal glucose reabsorption by inhibiting sodium-glucose cotransporter-2 (SGLT2). It was developed as an insulin-independent treatment approach for type 2 diabetes mellitus (T2DM). The safety, tolerability, pharmacokinetics, and pharmacodynamics of the drug were evaluated in single-ascending-dose (SAD; 2.5-500 mg) and multiple-ascending-dose (MAD; 2.5-100 mg daily for 14 days) studies in healthy subjects. Dapagliflozin exhibited dose-proportional plasma concentrations with a half-life of approximately 17 h. The amount of glucosuria was also dose-dependent. Cumulative amounts of glucose excreted on day 1, relating to doses from 2.5-100 mg (MAD), ranged from 18 to 62 g; day 14 values were comparable to day 1 values, with no apparent changes in glycemic parameters. Doses of approximately 20-50 mg provided close-to-maximal SGLT2 inhibition for at least 24 h. Dapagliflozin demonstrates pharmacokinetic (PK) characteristics and dose-dependent glucosuria that are sustained over 24 h, which indicates that it is suitable for administration in once-daily doses and suggests that further investigation of its efficacy in T2DM patients is warranted.

Self-Monitoring of Blood Glucose (SMBG) in insulin- and non-insulin-using adults with diabetes: consensus recommendations for improving SMBG accuracy, utilization, and research

Current clinical guidelines for diabetes care encourage self-monitoring of blood glucose (SMBG) to improve glycemic control. Specific protocols remain variable, however, particularly among non-insulin-using patients. This is due in part to efficacy studies that neglect to consider (1) the performance of monitoring equipment under real-world conditions, (2) whether or how patients have been taught to take action on test results, and (3) the physiological, behavioral, and social circumstances in which SMBG is carried out. As such, a multidisciplinary group of specialists, including several endocrinologists, a health psychologist, a diabetes nurse practitioner, and a patient advocate (the Panel), discuss within this review article how the potential of SMBG might be fully realized in today's healthcare environment. The resulting recommendations cover technological, clinical, behavioral, and research considerations with the aim of achieving short- and long-term benefits, ranging from fewer hypoglycemic episodes to lower complication-related costs. The panel also made suggestions for designing future studies that increase the ability to discern optimal models of SMBG utilization for individuals with diabetes who may, or may not, use insulin.

Diabetes treatments

With the aging of the population, physical inactivity, and growing rates of obesity, there has been a dramatic rise in the incidence of diabetes. Diabetes and its treatment is a holistic and dynamic experience, shaping many aspects of a person's life and well-being. Despite the biopsychosocial nature of this chronic disease, medications tend to be the principal intervention among medical professionals. Over the past fifteen years, however, diabetes researchers and clinicians have begun to develop interventions addressing the psychosocial aspects of diabetes. The majority of these interventions fall within the knowledge base and clinical abilities of social work practitioners. This paper systematically reviews psychosocial intervention studies with older adults, identifying and summarizing treatment protocols.

Lifestyle counseling in type 2 diabetes prevention: a case study of a nurse's communication activity to produce change talk

As a case study, this article describes a nurse's communication activity, focusing on change talk during lifestyle counseling in primary healthcare. All videotaped counseling sessions with a single patient within a period of two years were transcribed verbatim. In the analysis, an emphasis was placed on the nurse's communication activity that produced change talk, how the nurse initiated change talk, and how the patient received it. The observations provide evidence that the dilemma of simultaneously maintaining professional authority and patient perspective leads to sensitivity in lifestyle counseling. Three categories of change talk were identified: rejected, restrictive, and expansive change talk. Producing change talk is a very demanding task for counselors. It is best produced when the nurse stays within the patient's frame of reference with a combination of reflective, change-inducing questions, encouraging assessments and conversational space. On the basis of our results, we suggest that nurses need training to identify and to encourage patients' change talk and to communicate flexibly according to patients' values during lifestyle counseling. In addition, in order to insist on change talk, we need to demonstrate how change talk could be carried out so that nurses could orient to it.

Patients with diabetes speak: exploring the implications of patients' perspectives for their diabetes appointments

Type 2 diabetes puts patients at risk for serious health consequences that they can prevent or delay by achieving glycemic control. However, glycemic control depends largely on self-management. Consequently, determining what physicians might do in medical appointments to improve patients' self-management is of utmost concern. Patients were asked to discuss, in focus groups, their illness experience and their goals for regularly scheduled appointments. Six interrelated themes emerged from the analysis of transcripts: complications and comorbidities, time, control, information, family influences, and the physician-patient encounter. These themes and their implications for diabetes appointments were explored, specifically considering how physicians might use information about patients' perspectives to improve patients' self-management and thereby their glycemic control.

Patient knowledge improves glycemic control: is it time to go back to the classroom?

BACKGROUND

Over the last two decades, pharmaceutical intervention for the treatment of type 2 diabetes has expanded. Studies over this same time demonstrated the benefits of tight glycemic control. Unfortunately, despite the availability of novel therapies, glycemic control remains problematic. Nonpharmacologic interventions need to be explored, including patient empowerment. Improving patient knowledge of diabetes may ultimately improve glycemic control. To test this hypothesis, we compared patients' diabetes knowledge with their glycemic control.

METHODS

The Michigan Diabetes Knowledge Test, designed by the University of Michigan, was administered to patients with type 2 diabetes at three University of New Mexico primary care clinics. Patient records were reviewed. The most recent hemoglobin A1c (HbA1c) value was recorded. The data were analyzed using linear regression analysis.

RESULTS

Seventy-seven patients completed surveys and had HbA1c values available. Only questions 1 to 14 of the 23-question survey were used because they pertained specifically to type 2 diabetes. HbA1c was inversely correlated with the number of questions answered correctly on the test (r = -.337, p < .003). Using "all subsets" regression, a correct response to questions 1, 3, and 9 specifically correlated with a lower HbA1c (p < .0001).

CONCLUSIONS

These results demonstrate that an inverse linear relationship exists between performance on this diabetes test and HbA1c values. Improvement in patient knowledge of diabetes and the importance of treatment may indeed improve glycemic control and ultimately decrease complications. Studies aimed at empowering patients with disease knowledge may help control the ramifications of the growing diabetes epidemic.

The impact of formal diabetes education on the preventive health practices and behaviors of persons with type 2 diabetes

BACKGROUND

Diabetes-related morbidity and mortality are primarily attributable to complications such as heart disease, stroke, lower extremity amputation, kidney disease, blindness, and visual impairment, many of which potentially can be delayed or prevented.

METHODS

We examined the association of diabetes self-management education (DSME) with preventive health practices and behaviors among 22,682 persons with type 2 diabetes using data from the 2001 and 2002 Behavioral Risk Factor Surveillance System (BRFSS). BRFSS is an ongoing, state-based, random-digit-dialed telephone survey of noninstitutionalized adults aged > or = 18 years.

RESULTS

Approximately 48% of all adults with type 2 diabetes had never attended a DSME course. Among both diabetic persons who used insulin and those who did not, persons who received DSME were significantly more likely than those who had not received training to be physically active, to have received an annual dilated eye exam and flu vaccine, to have received a pneumococcal vaccine, to have checked their blood sugar daily, and to have had a physician or other health professional check their feet for sores or irritations and their hemoglobin A1C level in the past year.

CONCLUSIONS

These data indicate the importance of DSME in the promotion of health practices that could prevent or delay potential diabetes complications among persons with type 2 diabetes.

Lay perceptions of type 2 diabetes in Scotland: bringing health services back in

The growing prevalence of type 2 diabetes is placing Scottish health services under considerable strain. Consequently, diabetes services are undergoing a major process of reorganisation, including the devolvement of routine diabetes care/diabetic review from secondary to primary healthcare settings. This qualitative study was devised to explore newly diagnosed type 2 diabetes patients' perceptions of their disease and the health services they receive at a time when this restructuring of services is taking place. The sample comprised 40 patients resident in Lothian, Scotland, who had diverse experiences of services, some receiving GP-based care only, others having varying contact with hospital diabetes clinics. In-depth interviews were undertaken with patients, three times at six monthly intervals over 1 year, enabling their experiences to be tracked at critical junctures during the post-diagnostic period. Disease perceptions and health service delivery were found to be mutually informing and effecting. Not only did (different types of) health service delivery influence the ways in which patients thought about and self-managed their disease, over time patients' disease perceptions also informed their expectations of, and preferences for, diabetes services. We thus argue that there is a need for a reconceptualisation within the medical social sciences to take into account the context of healthcare and the economic/policy factors that inform health service delivery when looking at patients' disease perceptions. We also discuss the logistical and ethical challenges of drawing upon patients' perspectives, preferences and views in the design and delivery of future health services.

GPs' perspectives of type 2 diabetes patients' adherence to treatment: A qualitative analysis of barriers and solutions

BACKGROUND

The problem of poor compliance/adherence to prescribed treatments is very complex. Health professionals are rarely being asked how they handle the patient's (poor) therapy compliance/adherence. In this study, we examine explicitly the physicians' expectations of their diabetes patients' compliance/adherence. The objectives of our study were: (1) to elicit problems physicians encounter with type 2 diabetes patients' adherence to treatment recommendations; (2) to search for solutions and (3) to discover escape mechanisms in case of frustration.

METHODS

In a descriptive qualitative study, we explored the thoughts and feelings of general practitioners (GPs) on patients' compliance/adherence. Forty interested GPs could be recruited for focus group participation. Five open ended questions were derived on the one hand from a similar qualitative study on compliance/adherence in patients living with type 2 diabetes and on the other hand from the results of a comprehensive review of recent literature on compliance/adherence. A well-trained diabetes nurse guided the GPs through the focus group sessions while an observer was attentive for non-verbal communication and interactions between participants. All focus groups were audio taped and transcribed for content analysis. Two researchers independently performed the initial coding. A first draft with results was sent to all participants for agreement on content and comprehensiveness.

RESULTS

General practitioners experience problems with the patient's deficient knowledge and the fact they minimize the consequences of having and living with diabetes. It appears that great confidence in modern medical science does not stimulate many changes in life style. Doctors tend to be frustrated because their patients do not achieve the common Evidence Based Medicine (EBM) objectives, i.e. on health behavior and metabolic control. Relevant solutions, derived from qualitative studies, for better compliance/adherence seem to be communication, tailored and shared care. GPs felt that a structured consultation and follow-up in a multidisciplinary team might help to increase compliance/adherence. It was recognized that the GP's efforts do not always meet the patients' health expectations. This initiates GPs' frustration and leads to a paternalistic attitude, which may induce anxiety in the patient. GPs often assume that the best methods to increase compliance/adherence are shocking the patients, putting pressure on them and threatening to refer them to hospital.

CONCLUSION

GPs identified a number of problems with compliance/adherence and suggested solutions to improve it. GPs need communication skills to cope with patients' expectations and evidence based goals in a tailored approach to diabetes care.

Implementing empowerment group education in diabetes

The overall aim was to gain insight into and understand how physicians and nurses view the implementation of empowerment group education (EGE) in diabetes. Prior to the study the physicians and nurses attended a 2-day empowerment workshop. Further, they had implemented the empowerment approach in two groups of patients with type II diabetes. Three to 9 months later they (five physicians and 11 nurses from six family practices) participated in focus group interviews to evaluate the implementation of the EGE. The interviews were audio-taped, transcribed and analysed using the constant comparative method. The main result showed a conflict in roles. The physicians and nurses knew their role in the traditional approach but not with respect to the empowerment approach, which they needed to grow into. At the same time as they started a new way of working, their role had changed from being an expert to being a facilitator. As experts they felt secure; as facilitators they needed support in their educational process. To implement EGE they required support both from the family practice and from a supervisor in direct connection with the EGE.

Diagnosis of type 2 diabetes: a qualitative analysis of patients' emotional reactions and views about information provision

Research about diagnosis of chronic illness indicates this is an emotional time for patients. Information provision is especially salient for diabetes management. Yet current orthodoxy suggests that too much information at the time of diagnosis is unhelpful for patients. In this study, we used in-depth interviews with 40 newly diagnosed type 2 diabetic (T2DM) patients in Scotland, to explore their emotional reactions about diagnosis, and their views about information provision at the time of diagnosis. Data were analysed using a thematic approach. Our results showed three main 'routes' to diagnosis: 'suspected diabetes' route; 'illness' route; and 'routine' route. Those within the 'routine' route described the most varied emotional reactions to their diagnosis. We found that most patients, irrespective of their route to diagnosis, wanted more information about diabetes management at the time of diagnosis. We suggest that practitioners would benefit from being sensitive to the route patients follow to diagnosis, and prompt, simple but detailed advice about T2DM management would be helpful for newly diagnosed patients.

Adherence to Oral Therapy for Type 2 Diabetes: Opportunities for Enhancing Glycemic Control

PURPOSE

Although diet and exercise are important parts of type 2 diabetes treatment, most patients require pharmacological intervention with multiple agents to maintain adequate glycemic control. This article addresses the numerous patient-related, disease-related, and demographic variables affecting medication adherence in this patient population.

DATA SOURCES

Extensive review of scientific literature, clinical practice guidelines, and Internet sources.

CONCLUSIONS

Studies have demonstrated that treatments including multiple medications or frequent dosing had a negative impact on adherence. Practitioners have used several approaches in an effort to improve adherence to oral antidiabetic medical therapy, including increased communication between health care providers and patients, implementation of multidisciplinary programs, and use of treatment regimens with easier dosing (i.e., reduced number of drugs or doses taken per day).

IMPLICATIONS FOR PRACTICE

Options for type 2 diabetes treatments that combine effective medications into a simpler oral-dosage form may motivate and improve patient adherence. Ultimately, simplifying dosing may lead to better glycemic control, thereby reducing the risks associated with long-term consequences of the disease.

Swedish health care professionals' diverse understandings of diabetes care

Knowledge of health care professionals' different understandings of diabetes care is important when preparing such professionals in patient education. For patients to manage illness effectively, the actions of health care professionals are crucial. Patients' understanding of their condition should be taken as the point of departure when creating a learning situation. The professionals' understandings of diabetes care were mapped using a survey including 169 primary care doctors, nurses, assistant nurses and chiropodists in Stockholm, Sweden. The responses were analysed using a phenomenographic approach. Five understandings were identified: the professionals treat the patients, the professionals give information, the professionals focus relation and organisation, the professionals seek the patient's agreement, and the professionals focus the patient's understanding of the situation. Only 20 (12%) of the 169 professional caregivers focused the patient's understanding. Professionals need to develop their understandings of health care and the professional-patient interaction in order to support the patients' learning.

Effect of part-time practice on patient outcomes

BACKGROUND

Primary care physicians are spending fewer hours in direct patient care, yet it is not known whether reduced hours are associated with differences in patient outcomes.

OBJECTIVE

To determine whether patient outcomes vary with physicians' clinic hours.

DESIGN

Cross-sectional retrospective design assessing primary care practices in 1998.

SETTING

All 25 outpatient-clinics of a single medical group in western Washington.

PARTICIPANTS

One hundred ninety-four family practitioners and general internists, 80% of whom were part-time, who provided ambulatory primary care services to specified HMO patient panels. Physician appointment hours ranged from 10 to 35 per week (30% to 100% of full time).

MEASUREMENTS

Twenty-three measures of individual primary care physician performance collected in an administrative database were aggregated into 4 outcome measures: cancer screening, diabetic management, patient satisfaction, and ambulatory costs. Multivariate regression on each of the 4 outcomes controlled for characteristics of physicians (administrative role, gender, seniority) and patient panels (size, case mix, age, gender).

MAIN RESULTS

While the effects were small, part-time physicians had significantly higher rates for cancer screening (4% higher, P =.001), diabetic management (3% higher, P =.033), and for patient satisfaction (3% higher, P =.035). After controlling for potential confounders, there was no significant association with patient satisfaction (P =.212) or ambulatory costs (P =.323).

CONCLUSIONS

Primary care physicians working fewer clinical hours were associated with higher quality performance than were physicians working longer hours, but with patient satisfaction and ambulatory costs similar to those of physicians working longer hours. The trend toward part-time clinical practice by primary care physicians may occur without harm to patient outcomes.

Physician performance assessment: nonequivalence of primary care measures

BACKGROUND

Assessment of the performance of primary care physicians requires multiple, reliable measures. This article explores the appropriateness of selected Health Plan Employer Data and Information Set (HEDIS) measures, developed to assess health plans, to assess individual physician performance.

OBJECTIVES

To determine the consistency and reliability of 4 measures of primary care physician performance measures: cancer screening, diabetic management, patient satisfaction, and ambulatory costs.

METHODS

The study population consisted of all 194 family practitioners and general internists providing ambulatory services in 1998 to a defined patient panel of 320,000 adult health maintenance organization members. Administrative data on physician practice and performance were assessed with multiple regression and analysis of variance.

RESULTS

Each performance measure was significantly related to 1 or 2 of the other measures: high cancer screening rates with good diabetic management and high patient satisfaction, good diabetic management with high cancer screening rates, high patient satisfaction with high cancer screening rates and high ambulatory costs, or high ambulatory costs with higher patient satisfaction. Although 76% of the physicians ranked in the highest third for at least 1 measure, 81% of these high performers ranked in the lower third for at least 1 other measure. Three percent of physicians ranked exclusively in the top or bottom third on all measures.

CONCLUSIONS

Care should be taken in assessing physicians based on narrow performance measures. Assessments of individual physicians with current performance measures might identify areas in which improvement is needed and to provide feedback to improve performance quality and efficiency. However, assumptions should not be made from one measure of performance to another.

Improving glycaemic control in patients with Type 2 diabetes mellitus without insulin therapy

AIMS

In general practice at least 30% of those with Type 2 diabetes do not achieve good glycaemic control. We studied the effect of improving oral glucose-lowering medication in a primary care setting in patients treated with oral hypoglycaemic agents without satisfactory glycaemic control.

METHODS

We provided flowcharts to general practitioners and outreach visits by trained facilitators, who checked adherence to the protocol. Fifty-two Dutch general practices with 2140 Type 2 diabetes mellitus (DM) patients recruited 288 patients < or = 75 years old inadequately controlled (HbA1c >7%) by diet or oral medication. Outcome measures were decrease of HbA1c, number of patients with HbA1c < or = 7%, and non-compliance rate.

RESULTS

After a mean of 3.3 consultations over 14 weeks, 209 patients were following the protocol fully with a reduction in HbA1c from 8.7% to 6.7% (P<0.001). One hundred and fifty-eight patients (55%) achieved HbA1c < or =7%, and 51 (18%) persisted with HbA1c >7% unless fasting blood glucose < or =7 mmol/l (n=18) or a maximum of medication (n=33). Seventy-nine patients (27%) did not adhere to the protocol, mostly due to loss of motivation and non-attendance.

CONCLUSIONS

A simple flowchart and relatively little support by trained facilitators results in improved glycaemic control.

Assessment of periodontal conditions and systemic disease in older subjects

BACKGROUND

An increased risk for periodontitis has been associated both with type-1 or insulin dependent diabetes (IDDM) and with type-2 or non-insulin dependent diabetes (NIDDM).

AIMS

1) To describe and analyze periodontal conditions in older low-income ethnic diverse subjects with or without a diagnosis of diabetes. 2) To assess to what extent diabetes mellitus is associated with periodontal status, and 3) how periodontitis ranks as a coexisting disease among other diseases in subjects with diabetes mellitus.

MATERIAL AND METHODS

Radiographic signs of alveolar bone loss were studied in 1101 older subjects 60-75 years old (mean age 67.6, SD+/-4.7). The number of periodontal sites and the proportions of teeth with probing depth (PD) > or =5 mm, clinical attachment levels (CAL) > or =4 mm were studied in a subset of 701 of the subjects.

RESULTS

IDDM was reported by 2.9% and NIDDM by 9.2% of the subjects. The number of remaining teeth did not differ by diabetic status. The number of sites with PD > or =5 mm and the proportion of PD with > or =5 mm was significantly smaller in the non-diabetic group (chi2=46.8, p<0.01, and chi2=171.1, p<0.001, respectively). Statistical analysis failed to demonstrate group differences for the number and proportions of sites with CAL > or =4 mm and for radiographic findings of alveolar bone loss. Combining all periodontal parameters revealed that the Mantel-Haenszel common odds of having IDDM/NIDDM and periodontitis was 1.8 : 1 (95% CI: 1.1-3.1, p<0.03). The common odds ratio estimate of an association between heart disease and diabetes was 3.6 : 1 (95% CI: 2.1-2.6, p<0.001).

CONCLUSIONS

Probing depth differences between IDDM/NIDDM vs. non-diabetic subjects may reflect the presences of pseudo-pockets and not progressive periodontitis in many subjects with diabetes mellitus. Periodontitis is not a predominant coexisting disease in older subjects with diabetes mellitus.

Long-term effectiveness of a quality improvement program for patients with type 2 diabetes in general practice

OBJECTIVE

To assess the long-term effectiveness of a quality improvement program on care provided and patient outcomes in patients with diabetes.

RESEARCH DESIGN AND METHODS

A nonrandomized trial was performed with 312 patients with type 2 diabetes in the intervention group and 77 patients with type 2 diabetes in the reference group. The follow-up period was 42 months. The quality improvement program focused on improving both the provision of diabetes care and the patient outcomes. The program consisted of clinical practice guidelines, postgraduate education, audit and feedback, templates to register diabetes care, and a recall system. Data on the care provided were abstracted from medical records. Main outcomes on the provision of care were annual number of patient visits, blood pressure, and HbA(1c) and blood lipid levels. Main patient outcomes were blood pressure and HbA(1c) and blood lipid levels. Multilevel analysis was used to adjust for dependency between repeated observations within one patient and for clustering of patients within general practices.

RESULTS

Patients in the intervention group received care far more in accordance with the guidelines than patients in the reference group. Odds ratios ranged from 2.43 (95% CI 1.01-5.82) for the measurement of urine albumin to 12.08 (4.70-31.01) for the measurement of blood pressure. No beneficial effect was found on any patient outcome.

CONCLUSIONS

The quality improvement program improved the provision of diabetes care, but this was not accompanied by any effect on patient outcomes.