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Kayira AB, Painter H, Mathur R, Ford J. Practice list size, workforce composition and performance in English general practice: a latent profile analysis. BMC PRIMARY CARE 2024; 25:207. [PMID: 38862906 PMCID: PMC11165807 DOI: 10.1186/s12875-024-02462-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 06/03/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Following government calls for General Practices in England to work at scale, some practices have grown in size from traditionally small, General Practitioner (GP)-led organisations to large multidisciplinary enterprises. We assessed the effect of practice list size and workforce composition on practice performance in clinical outcomes and patient experience. METHODS We linked five practice-level datasets in England to obtain a single dataset of practice workforce, list size, proportion of registered patients ≥ 65 years of age, female-male sex ratio, deprivation, rurality, GP contract type, patient experience of care, and Quality and Outcomes Framework (QOF) and non-QOF clinical processes and outcomes. Latent Profile Analysis (LPA) was used to cluster general practices into groups based on practice list size and workforce composition. Bayesian Information Criterion, Akaike Information Criterion and deliberation within the research team were used to determine the most informative number of groups. One-way ANOVA was used to assess how groups differed on indicator variables and other variables of interest. Linear regression was used to assess the association between practice group and practice performance. RESULTS A total of 6024 practices were available for class assignment. We determined that a 3-class grouping provided the most meaningful interpretation; 4494 (74.6%) were classified as 'Small GP-reliant practices', 1400 (23.2%) were labelled 'Medium-size GP-led practices with a multidisciplinary team (MDT) input' and 131 (2.2%) practices were named 'Large multidisciplinary practices'. Small GP-reliant practices outperformed larger multidisciplinary practices on all patient-reported indicators except on confidence and trust where medium-size GP-led practices with MDT input appeared to do better. There was no difference in performance between small GP-reliant practices and larger multidisciplinary practices on QOF incentivised indicators except on asthma reviews where medium-size GP-led practices with MDT input performed worse than smaller GP-reliant practices and immunisation coverage where the same group performed better than smaller GP-reliant practices. For non-incentivised indicators, larger multidisciplinary practices had higher cancer detection rates than small GP-reliant practices. CONCLUSION Small GP-reliant practices were found to provide better patient reported access, continuity of care, experience and satisfaction with care. Larger multidisciplinary practices appeared to have better cancer detection rates but had no effect on other clinical processes and outcomes. As England moves towards larger multidisciplinary practices efforts should be made to preserve good patient experience.
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Affiliation(s)
- Alfred Bornwell Kayira
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, Whitechapel, London, UK.
| | - Helena Painter
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, Whitechapel, London, UK
| | - Rohini Mathur
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, Whitechapel, London, UK
| | - John Ford
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, Whitechapel, London, UK
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Yu D, Cai Y, Levi Osuagwu U, Pickering K, Baker J, Cutfield R, McKree Jansen R, Orr-Walker BJ, Sundborn G, Zhao Z, Simmons D. Ethnic differences in metabolic achievement between Māori, Pacific, and European New Zealanders with type 2 diabetes. Diabetes Res Clin Pract 2022; 189:109910. [PMID: 35537520 DOI: 10.1016/j.diabres.2022.109910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 03/07/2022] [Accepted: 05/03/2022] [Indexed: 11/25/2022]
Abstract
AIMS To compare variations in metabolic target achievement by ethnicity (Europeans, Māori and Pasifika) among patients with type 2 diabetes (T2DM) in Auckland, New Zealand (NZ) between 1994 and 2013. METHODS 32,237 patients were enrolled. Adjusted marginal difference (European as reference) of systolic blood pressure (SBP), body mass index (BMI), HbA1c and total cholesterol, alongside the proportion achieving metabolic targets were estimated using multivariable mixed effect models at baseline, 1-, 2-, 3-, 4-, and 5-years, adjusted for covariates. RESULTS Compared with Europeans, Māori and Pasifika had continuously, significantly higher HbA1c (by 0.3% (+3.5 mmol/mol) and 0.6% (+6.8 mmol/mol) respectively and BMI (+1.5 and +0.3 kg/m2 respectively) but lower SBP (-1.8 and -3.4 mmHg respectively) and TG (-0.03 and -0.34 mmol/L respectively), and insignificantly TC (+0.004 and +0.01 respectively), by 5-years of follow-up. While 49% Europeans were within target HbA1c, this was achieved by only 30% Māori and 27% Pasifika. Conversely, 41% Europeans, 46% Māori and 59% Pasifika achieved the SBP target (all P < 0.0001). CONCLUSIONS Managing hyperglycemia appears to be more challenging than treating hypertension and dyslipidemia among Māori and Pasifika. New anti-hyperglycemia treatments, addressing health literacy, socioeconomic and any cultural barriers to management and self-management are urgently needed to reduce these disparities.
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Affiliation(s)
- Dahai Yu
- Department of Nephrology, the First Affiliated Hospital, Zhengzhou University, Zhengzhou 450052, China; Primary Care Centre Versus Arthritis, School of Medicine, Keele University, Keele ST5 5BG, UK
| | - Yamei Cai
- Department of Nephrology, the First Affiliated Hospital, Zhengzhou University, Zhengzhou 450052, China
| | - Uchechukwu Levi Osuagwu
- Macarthur Clinical School, Western Sydney University, Campbelltown, Sydney NSW 2751, Australia
| | | | - John Baker
- Diabetes Foundation Aotearoa, Otara, New Zealand; Department of Diabetes and Endocrinology, Counties Manukau Health, South Auckland, New Zealand
| | - Richard Cutfield
- Diabetes Foundation Aotearoa, Otara, New Zealand; Department of Diabetes and Endocrinology, Waitemata District Health Board, Auckland, New Zealand
| | | | - Brandon J Orr-Walker
- Diabetes Foundation Aotearoa, Otara, New Zealand; Department of Diabetes and Endocrinology, Counties Manukau Health, South Auckland, New Zealand
| | - Gerhard Sundborn
- Section of Epidemiology and Biostatistics, the University of Auckland, Auckland, New Zealand
| | - Zhanzheng Zhao
- Department of Nephrology, the First Affiliated Hospital, Zhengzhou University, Zhengzhou 450052, China.
| | - David Simmons
- Department of Nephrology, the First Affiliated Hospital, Zhengzhou University, Zhengzhou 450052, China; Macarthur Clinical School, Western Sydney University, Campbelltown, Sydney NSW 2751, Australia.
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Lim YMF, Ang SH, Nasir NH, Ismail F, Ismail SA, Sivasampu S. Clinic and patient variation in intermediate clinical outcomes for type 2 diabetes: a multilevel analysis. BMC FAMILY PRACTICE 2019; 20:158. [PMID: 31729951 PMCID: PMC6857311 DOI: 10.1186/s12875-019-1045-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 10/29/2019] [Indexed: 11/12/2022]
Abstract
Background Variation at different levels of diabetes care has not yet been quantified for low- and middle-income countries. Understanding this variation and its magnitude is important to guide policy makers in designing effective interventions. This study aims to quantify the variation in the control of glycated haemoglobin (HbA1c), systolic blood pressure (SBP) and low-density lipoprotein cholesterol (LDL-C) for type 2 diabetes (T2D) patients at the clinic and patient level and determine patient and clinic factors associated with control of these outcomes in T2D. Methods This is a cross-sectional study within the baseline data from the impact evaluation of the Enhanced Primary Health Care (EnPHC) intervention on 40 public clinics in Malaysia. Patients aged 30 and above, diagnosed with T2D, had a clinic visit for T2D between 01 Nov 2016 and 30 April 2017 and had at least one HbA1c, SBP and LDL-C measurement within 1 year from the date of visit were included for analysis. Multilevel linear regression adjusting for patient and clinic characteristics was used to quantify variation at the clinic and patient levels for each outcome. Results Variation in intermediate clinical outcomes in T2D lies predominantly (93% and above) at the patient level. The strongest predictors for poor disease control in T2D were the proxy measures for disease severity including duration of diabetes, presence of microvascular complications, being on insulin therapy and number of antihypertensives. Among the three outcomes, HbA1c and LDL-C results provide greatest opportunity for improvement. Conclusion Clinic variation in HbA1c, SBP and LDL-C accounts for a small percentage from total variation. Findings from this study suggest that standardised interventions need to be applied across all clinics, with a focus on customizing therapy based on individual patient characteristics.
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Affiliation(s)
- Yvonne Mei Fong Lim
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, No.1, Jalan Setia Murni U13/52, Setia Alam, Selangor, Malaysia. .,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Swee Hung Ang
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, No.1, Jalan Setia Murni U13/52, Setia Alam, Selangor, Malaysia.,Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Nazrila Hairizan Nasir
- Family Health Development Division, Public Health Department, Ministry of Health Malaysia, Level 4, Block E6, Complex E, 62590, Putrajaya, Malaysia
| | - Fatanah Ismail
- Family Health Development Division, Public Health Department, Ministry of Health Malaysia, Level 4, Block E6, Complex E, 62590, Putrajaya, Malaysia
| | - Siti Aminah Ismail
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, No.1, Jalan Setia Murni U13/52, Setia Alam, Selangor, Malaysia
| | - Sheamini Sivasampu
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, No.1, Jalan Setia Murni U13/52, Setia Alam, Selangor, Malaysia
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Sabione I, Cavalot F, Paccotti P, Massucco P, Vigna-Taglianti FD. Outcomes of integrated management versus specialized care for patients with type 2 diabetes: An observational study. Diabetes Res Clin Pract 2018; 140:208-215. [PMID: 29626586 DOI: 10.1016/j.diabres.2018.03.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 03/16/2018] [Accepted: 03/29/2018] [Indexed: 11/21/2022]
Abstract
AIMS To compare type 2 diabetes (T2D) patients included in a Diabetes Integrated Management (DIM) program with those followed in Diabetes Specialized Care (DSC), investigating differences in general characteristics, changes in clinical outcomes, and factors related with the inclusion in the DIM program. METHODS T2D patients living in the ASLTO3 district and included into the DIM program, a shared disease management between general practitioners and diabetes specialists, from 2008 to 2014 were compared with T2D patients living in the same district and in charge of the local DSC. Demographic, anthropometric and clinical data for both groups of patients were obtained from the electronic records of DSC. RESULTS 1326 DIM patients were compared with 3494 DSC patients. A higher proportion of females was observed among DIM patients than among DSC patients. DIM patients were older, more frequently in therapy with diet only or with oral hypoglycemic, and had HbA1c and creatinine lower than DSC patients. The analyses of changes in clinical parameters during the study period showed a good and statistically significant improvement of most parameters, independently of the inclusion in DIM or DSC, with the exception of creatinine level. CONCLUSIONS Integrated Management is an efficient and effective way to achieve good long-term clinical outcomes for patients with diabetes.
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Affiliation(s)
- I Sabione
- School of Medicine, Department of Clinical and Biological Sciences, University of Torino, Italy
| | - F Cavalot
- Metabolic Diseases and Diabetes Unit, San Luigi Gonzaga Hospital, Orbassano, Torino, Italy
| | - P Paccotti
- School of Medicine, Department of Clinical and Biological Sciences, University of Torino, Italy; Internal Medicine Unit, San Luigi Gonzaga Hospital, Orbassano, Torino, Italy
| | - P Massucco
- Metabolic Diseases and Diabetes Unit, San Luigi Gonzaga Hospital, Orbassano, Torino, Italy
| | - F D Vigna-Taglianti
- School of Medicine, Department of Clinical and Biological Sciences, University of Torino, Italy.
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Simmons D, Zgibor JC. Should we screen for type 2 diabetes among asymptomatic individuals? Yes. Diabetologia 2017; 60:2148-2152. [PMID: 28831523 DOI: 10.1007/s00125-017-4397-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 07/14/2017] [Indexed: 12/21/2022]
Abstract
RCTs of whether screening asymptomatic individuals for undiagnosed diabetes results in reduced mortality or has other benefits have been suggestive, but inconclusive. In this issue of Diabetologia, two additional controlled studies (DOIs: 10.1007/s00125-017-4323-2 and 10.1007/s00125-017-4299-y ) that investigated whether screening for type 2 diabetes in asymptomatic individuals is associated with a reduction in mortality are presented. Treating diabetes early, and identifying and treating impaired glucose tolerance, are of benefit, and economic modelling indicates such screening is cost-effective. Now that such screening is already underway in many countries, new data, along with the existing evidence, suggests opportunistic screening is the best way forward. More research is needed, however, on how best to screen and how to improve risk-factor control once dysglycaemia is detected.
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Affiliation(s)
- David Simmons
- School of Medicine, Western Sydney University, Locked Bag 1797, Campbelltown, NSW, 2751, Australia.
| | - Janice C Zgibor
- Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL, USA
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Cemalettin E, Ünlüoğlu İ, Bilge U, Akalın A, Yılmaz H. Tip 2 Diabetes Mellituslu Hastalar Tarafından Başvurulan Hekim Sayısının Hedef Değerlere Ulaşma ve Tedaviye Uyum Oranları Üzerine Etkileri. KONURALP TIP DERGISI 2017. [DOI: 10.18521/ktd.296809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Bain SC, Feher M, Russell-Jones D, Khunti K. Management of type 2 diabetes: the current situation and key opportunities to improve care in the UK. Diabetes Obes Metab 2016; 18:1157-1166. [PMID: 27491724 DOI: 10.1111/dom.12760] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 08/01/2016] [Indexed: 12/22/2022]
Abstract
In common with global trends, the number of individuals with type 2 diabetes in the UK is rising, driven largely by obesity. The increasing prevalence of younger individuals with type 2 diabetes is of particular concern because of the accelerated course of diabetes-related complications that is observed in this population. The importance of good glycaemic control in the prevention of microvascular complications of diabetes is widely accepted, and there is a growing body of evidence to support a benefit in the reduction of cardiovascular events in the long term. Despite the importance of maintaining a healthy weight for the prevention of type 2 diabetes, the results from trials of lifestyle intervention strategies to reduce body weight have been disappointing. New glucose-lowering agents offer some promise in this regard, offering an opportunity to combat the dual burden of hyperglycaemia and obesity simultaneously. The timing and appropriate choice of glucose-lowering therapy has never been more complex as a result of rising prevalence of obesity in the young, concomitant obesity in some 90% of adults with type 2 diabetes and an ever-increasing range of therapeutic options. The present review evaluates performance measures specific to weight and glycaemic control in type 2 diabetes in the UK using data from the Quality and Outcomes Framework in England and Wales, and the Scottish Diabetes Survey. Potential barriers to improvement in standards of care for people with type 2 diabetes are considered, including patient factors, clinical inertia and the difficulties in translating therapeutic guidelines into everyday clinical practice.
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Affiliation(s)
- S C Bain
- Institute of Life Sciences, University of Swansea, Swansea, UK
| | - M Feher
- Beta Cell Diabetes Centre, Chelsea and Westminster Hospital, London, UK
| | - D Russell-Jones
- Diabetes and Research, Centre for Endocrinology, Royal Surrey County Hospital, Guildford, UK
- Diabetes and Metabolic Medicine, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - K Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
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Simmons D, Yu D, Wenzel H. Changes in hospital admissions and inpatient tariff associated with a Diabetes Integrated Care Initiative: preliminary findings. J Diabetes 2014; 6:81-9. [PMID: 23782469 DOI: 10.1111/1753-0407.12071] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Revised: 06/06/2013] [Accepted: 06/17/2013] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The Diabetes Integrated Care Initiative (DICI) has tested whether hospital admissions and total amounts paid for inpatient care have declined through closer (integrated) working between primary, secondary and community diabetes services in Cambridgeshire. METHOD Poisson regression models were used to compare the percentage change in hospital admissions, and tariff paid, before and after each of 43 months (April 2007 - November 2010). East Cambridgeshire and Fenland (ECF) practices were divided into those fully (n = 10) and less (n = 7) "engaged" with the intervention defined by the extent of their uptake of intervention components between July 2009 and June 2010. Other parts of the county were "controls". RESULTS Among patients with diabetes in the fully engaged ECF practices, the monthly average hospital admission rate was 19.0% (13.9, 24.2) higher (7.7 hospital admissions per 1000 patients) and the monthly tariff paid was 28.8% (28.7, 28.9) higher (£19.60 per patient per month), at the time of introducing the DICI versus the pre-implementation period (April 2007 to June 2009). These differences, had dropped to 8.7% (1.9, 15.6) and 13.4% (13.2, 13.5) (£9.92 per patient per month) higher 12 months after introduction. Comparable reductions in the rate of increase were not seen among those without diabetes or in control areas. CONCLUSION During the DICI, patients with diabetes from "fully engaged" practices experienced increased hospitalization and amount paid for in-patient care, the extent of which trended downwards by 12 months. Further time is needed to monitor whether this trend is sustained.
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Affiliation(s)
- David Simmons
- Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Ng CWL, Ng KP. Does practice size matter? Review of effects on quality of care in primary care. Br J Gen Pract 2013; 63:e604-10. [PMID: 23998840 PMCID: PMC3750799 DOI: 10.3399/bjgp13x671588] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 01/30/2013] [Accepted: 05/07/2013] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND There is a trend towards consolidating smaller primary care practices into larger practices worldwide. However, the effects of practice size on quality of care remain unclear. AIM This review aims to systematically appraise the effects of practice size on the quality of care in primary care. DESIGN AND SETTING A systematic review and narrative synthesis of studies examining the relationship between practice size and quality of care in primary care. METHOD Quantitative studies that focused on primary care practices or practitioners were identified through PubMed, CINAHL, Embase, Cochrane Library, CRD databases, ProQuest dissertations and theses, conference proceedings, and MedNar databases, as well as the reference lists of included studies. Independent variables were team or list size; outcome variables were measures of clinical processes, clinical outcomes, or patient-reported outcomes. A narrative synthesis of the results was conducted. RESULTS The database search yielded 371 articles, of which 34 underwent quality assessment, and 17 articles (13 cross-sectional studies) were included. Ten studies examined the association of practice size and clinical processes, but only five found associations of larger practices with selected process measures such as higher specialist referral rates, better adherence to guidelines, higher mammography rates, and better monitoring of haemoglobin A1c. There were mixed results for cytology and pneumococcal coverage. Only one of two studies on clinical outcomes found an effect of larger practices on lower random haemoglobin A1 value. Of the three studies on patient-reported outcomes, smaller practices were consistently found to be associated with satisfaction with access, but evidence was inconsistent for other patient-reported outcomes evaluated. CONCLUSION There is limited evidence to support an association between practice size and quality of care in primary care.
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Affiliation(s)
- Charis Wei Ling Ng
- National Healthcare Group, Health Services & Outcomes Research, Singapore.
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Hansen LJ, Siersma V, Beck-Nielsen H, de Fine Olivarius N. Structured personal care of type 2 diabetes: a 19 year follow-up of the study Diabetes Care in General Practice (DCGP). Diabetologia 2013; 56:1243-53. [PMID: 23549519 DOI: 10.1007/s00125-013-2893-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 02/27/2013] [Indexed: 10/27/2022]
Abstract
AIMS/HYPOTHESIS This study is a 19 year observational follow-up of a pragmatic open multicentre cluster-randomised controlled trial of 6 years of structured personal diabetes care starting from diagnosis. METHODS A total of 1,381 patients aged ≥ 40 years and newly diagnosed with type 2 diabetes were followed up in national registries for 19 years. Clinical follow-up was at 6 and 14 years after diabetes diagnosis. The original 6 year intervention included regular follow-up and individualised goal setting, supported by prompting of doctors, clinical guidelines, feedback and continuing medical education (ClinicalTrials.gov NCT01074762). The registry-based endpoints were: incidence of any diabetes-related endpoint; diabetes-related death; all-cause mortality; myocardial infarction (MI); stroke; peripheral vascular disease; and microvascular disease. RESULTS At 14 year clinical follow-up, group differences in risk factors from the 6 year follow-up had levelled out, although the prevalence of (micro)albuminuria and level of triacylglycerols were lower in the intervention group. During 19 years of registry-based monitoring, all-cause mortality was not different between the intervention and comparison groups (58.9 vs 62.3 events per 1,000 patient-years, respectively; for structured personal care, HR 0.94, 95% CI 0.83, 1.08, p = 0.40), but a lower risk emerged for fatal and non-fatal MI (27.3 vs 33.5, HR 0.81, 95% CI 0.68, 0.98, p = 0.030) and any diabetes-related endpoint (69.5 vs 82.1, HR 0.83, 95% CI 0.72, 0.97, p = 0.016). These differences persisted after extensive multivariable adjustment. CONCLUSIONS/INTERPRETATION In concert with features such as prompting, feedback, clinical guidelines and continuing medical education, individualisation of goal setting and drug treatment may safely be applied to treat patients newly diagnosed with type 2 diabetes to lower the risk of diabetes complications.
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Affiliation(s)
- L J Hansen
- Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, PO Box 2099, 1014 Copenhagen K, Denmark
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Desroches S, Lapointe A, Ratté S, Gravel K, Légaré F, Turcotte S. Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults. Cochrane Database Syst Rev 2013:CD008722. [PMID: 23450587 PMCID: PMC4900876 DOI: 10.1002/14651858.cd008722.pub2] [Citation(s) in RCA: 104] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND It has been recognized that poor adherence can be a serious risk to the health and wellbeing of patients, and greater adherence to dietary advice is a critical component in preventing and managing chronic diseases. OBJECTIVES To assess the effects of interventions for enhancing adherence to dietary advice for preventing and managing chronic diseases in adults. SEARCH METHODS We searched the following electronic databases up to 29 September 2010: The Cochrane Library (issue 9 2010), PubMed, EMBASE (Embase.com), CINAHL (Ebsco) and PsycINFO (PsycNET) with no language restrictions. We also reviewed: a) recent years of relevant conferences, symposium and colloquium proceedings and abstracts; b) web-based registries of clinical trials; and c) the bibliographies of included studies. SELECTION CRITERIA We included randomized controlled trials that evaluated interventions enhancing adherence to dietary advice for preventing and managing chronic diseases in adults. Studies were eligible if the primary outcome was the client's adherence to dietary advice. We defined 'client' as an adult participating in a chronic disease prevention or chronic disease management study involving dietary advice. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the eligibility of the studies. They also assessed the risk of bias and extracted data using a modified version of the Cochrane Consumers and Communication Review Group data extraction template. Any discrepancies in judgement were resolved by discussion and consensus, or with a third review author. Because the studies differed widely with respect to interventions, measures of diet adherence, dietary advice, nature of the chronic diseases and duration of interventions and follow-up, we conducted a qualitative analysis. We classified included studies according to the function of the intervention and present results in a narrative table using vote counting for each category of intervention. MAIN RESULTS We included 38 studies involving 9445 participants. Among studies that measured diet adherence outcomes between an intervention group and a control/usual care group, 32 out of 123 diet adherence outcomes favoured the intervention group, 4 favoured the control group whereas 62 had no significant difference between groups (assessment was impossible for 25 diet adherence outcomes since data and/or statistical analyses needed for comparison between groups were not provided). Interventions shown to improve at least one diet adherence outcome are: telephone follow-up, video, contract, feedback, nutritional tools and more complex interventions including multiple interventions. However, these interventions also shown no difference in some diet adherence outcomes compared to a control/usual care group making inconclusive results about the most effective intervention to enhance dietary advice. The majority of studies reporting a diet adherence outcome favouring the intervention group compared to the control/usual care group in the short-term also reported no significant effect at later time points. Studies investigating interventions such as a group session, individual session, reminders, restriction and behaviour change techniques reported no diet adherence outcome showing a statistically significant difference favouring the intervention group. Finally, studies were generally of short duration and low quality, and adherence measures varied widely. AUTHORS' CONCLUSIONS There is a need for further, long-term, good-quality studies using more standardized and validated measures of adherence to identify the interventions that should be used in practice to enhance adherence to dietary advice in the context of a variety of chronic diseases.
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Affiliation(s)
- Sophie Desroches
- Centre de recherche du Centre hospitalier universitaire de Québec (CHUQ), St-François d’Assise Hôpital, Québec, Canada.
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Alhyas L, Nielsen JDJ, Dawoud D, Majeed A. Factors affecting the motivation of healthcare professionals providing care to Emiratis with type 2 diabetes. JRSM SHORT REPORTS 2013; 4:14. [PMID: 23476735 PMCID: PMC3591689 DOI: 10.1177/2042533313476419] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Objective We aimed to identify facilitators of and barriers to healthcare professionals' motivation in a diabetes centre in the United Arab Emirates (UAE). Design A qualitative research approach was employed using semistructured interviews to assess perception of and attitudes regarding healthcare professionals' motivation in providing good quality diabetes care. Setting A diabetes centre located in Abu-Dhabi, UAE. Participants Healthcare professionals including specialist physicians, dieticians, podiatrists, health educators and nurses were recruited through purposive sampling. Main outcome measures After data collection, the audiotaped interviews were transcribed verbatim and subjected to content analysis. Results Nine semistructured interviews were conducted with healthcare professionals of various professional backgrounds. Important facilitators and barriers related to patient, professional, organization and cultural factors were identified. Barriers that related to heavy workload, disjointed care, lack of patient compliance and awareness, and cultural beliefs and attitudes about diabetes were common. Key facilitators included the patient's role in achieving therapeutic outcomes as well as compliance, cooperation and communication. Conclusion This qualitative study provides some unique insights about factors affecting healthcare professionals' motivation in providing good quality care. To improve the motivation of healthcare professionals in the management of diabetes and therefore the quality of diabetes care, several steps are needed. Importantly, the role of primary care should be reinforced and strengthened regarding the management of type 2 diabetes mellitus, privacy of the consultation time should be highly protected and regulated, and awareness of the Emirate culture and its impact on health should be disseminated to the healthcare professionals providing care to Emirates with diabetes. Also, greater emphasis should be placed on educating Emiratis with diabetes on, and involving them in, the management of their condition.
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Affiliation(s)
- Layla Alhyas
- Department of Primary Care & Public Health, Imperial College London , London , UK
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Al-Taweel DM, Awad AI, Johnson BJ. Evaluation of adherence to international guidelines for treating patients with type 2 diabetes mellitus in Kuwait. Int J Clin Pharm 2012; 35:244-50. [PMID: 23254942 DOI: 10.1007/s11096-012-9738-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Accepted: 12/11/2012] [Indexed: 01/24/2023]
Abstract
BACKGROUND Clinical guidelines derived from scientific evidence provide the basis of consistent standardized prescribing. Despite an alarming increase of diabetes in Kuwait, no studies related to the quality of prescribing in diabetes were found. Before pharmaceutical care can be implemented to improve the quality of care of patients with diabetes, it is important to determine whether prescribers are compliant with comprehensive international guidelines for cardioprevention and glycaemic control. OBJECTIVE To evaluate the adherence to clinical guidelines for treating patients with type 2 diabetes mellitus in primary care centres and secondary care centres (hospitals) using a developed and validated medication assessment tool with reference to international guidelines. SETTING Outpatient diabetes clinics in 8 primary care centres and 4 secondary care centres across four healthcare regions in Kuwait. METHOD A quantitative, cross-sectional study involving a sample of 652 Kuwaiti patients with type 2 diabetes, who were selected using systematic sampling from the study settings. Data were collected retrospectively from the patients' medical records using a validated 43-criterion medication assessment tool (MATKW) designed to assess cardioprevention and treatment in patients with type 2 diabetes. Descriptive and comparative analysis was conducted using SPSS version 17. MAIN OUTCOME MEASURE Frequency of prescribing adherence to agreed definitions of criteria derived from international guidelines. RESULTS Overall adherence to prescribing diabetes guidelines was 77.7 % (95 % CI 76.7-78.6 %). Significantly higher prescribing adherence was found in the secondary care facilities, 82.4 % (95 % CI 81.2-83.6 %) compared to primary care 72.5 % (95 % CI 71.0-73.9 %) (p < 0.001). Nineteen criteria out of 43 achieved an adherence >80 % in secondary care compared to ten criteria in primary care. The documentation of patients' records was found to be inconsistent at the study healthcare facilities. Nonoptimal achievement of target goals for HbA1c, blood pressure and BMI was prevalent among the study population. CONCLUSION A tool such as MATKW highlights areas for review and possible improvement in prescribing adherence. Our findings reveal problem areas in prescribing practices and documentation of patients' records. Cost-effective multifaceted interventions are needed to improve current prescribing practices and documentation.
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Affiliation(s)
- Dalal M Al-Taweel
- Strathclyde Institute of Pharmacy and Biomedical Science, University of Strathclyde, Glasgow, UK
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Bener A, Abdulmalik M, Al-Kazaz M, Sanya R, Buhmaid S, Al-Harthy M, Mohammad AG. Does good clinical practice at the primary care improve the outcome care for diabetic patients? Gender differences. Prim Care Diabetes 2012; 6:285-292. [PMID: 22622594 DOI: 10.1016/j.pcd.2012.04.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 12/27/2011] [Accepted: 04/27/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND The Middle East region is predicted to have one of the highest prevalence of diabetes mellitus (DM) in the world. This is the first study in the region to assess treatment outcome of DM according to gender. OBJECTIVE To assess the quality and effectiveness of diabetes care provided to patients attending primary care settings according to gender in the State of Qatar. DESIGN It is an observational cohort study. SETTING The survey was carried out in primary health care (PHC) centers in the State of Qatar. SUBJECTS AND METHODS The study was conducted from January 2010 to August 2010 among diabetic patients attending (PHC) centers. Of the 2334 registered with diagnosed diabetes, 1705 agreed and gave their consent to take part in this study, thus giving a response rate of 73.1%. Face to face interviews were conducted using a structured questionnaire including socio-demographic, clinical and satisfaction score of the patients. RESULTS Majority of subjects were diagnosed with type 2 DM (84.9%). A significantly larger proportion of females with DM were divorced or widowed (9.1%) in comparison to males with DM (3.4%; p<0.001). A significantly larger proportion of females were overweight (46.5%; p=0.009) and obese (29.5%; p=0.003) in comparison to males. Males reported significantly greater improvements in mean values of blood glucose (mmol/l) (-2.11 vs. -0.66; p=0.007), HbA1c (%) (-1.44 vs. -0.25; p=0.006), cholesterol (mmol/l) (-0.16 vs. 0.12; p=0.053) and systolic blood pressure (mmHg) (-9.04 vs. -6.62; p<0.001) in comparison to females. While there was a remarkable increase in male patients with normal range of fasting blood glucose (FBG; 51.6%) as compared to the FBG measurement 1 year before (28.5%: p<0.001) there was only a slight increase in females normal range FBG during this period from 28.0% to 30.4% (p=0.357). CONCLUSION The present study revealed that the current form of PHC centers afforded to diabetic patients provided significantly improved outcomes for males, but only minor improved outcomes for females. This study reinforces calls for a gender-specific approach to diabetes care.
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Affiliation(s)
- Abdulbari Bener
- Department of Medical Statistics & Epidemiology, Hamad Medical Corporation, Hamad General Hospital, Qatar.
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How CB, Ai-Theng C, Ahmad Z, Ismail M. Men suffer more complications from diabetes than women despite similar glycaemic control and a better cardiovascular risk profile: the ADCM study 2008. JOURNAL OF MENS HEALTH 2012. [DOI: 10.1016/j.jomh.2012.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Narayan KMV, Echouffo-Tcheugui JB, Mohan V, Ali MK. Analysis & commentary: Global prevention and control of type 2 diabetes will require paradigm shifts in policies within and among countries. Health Aff (Millwood) 2012; 31:84-92. [PMID: 22232098 DOI: 10.1377/hlthaff.2011.1040] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Continued increases in the prevalence of and disproportionate health spending associated with type 2 diabetes argue for policies focused on preventing that condition and treating it appropriately, even as we strive to improve coordination of care for coexisting chronic diseases. This article argues that four policy paradigm shifts will be necessary to achieve that specific emphasis on type 2 diabetes: conceptually integrating primary and secondary prevention along a clinical continuum; recognizing the central importance of early detection of prediabetes and undiagnosed diabetes in implementing cost-effective prevention and control; integrating community and clinical expertise, and resources, within organized and affordable service delivery systems; and sharing and adopting evidence-based policies at the global level.
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Sidorenkov G, Haaijer-Ruskamp FM, de Zeeuw D, Bilo H, Denig P. Review: relation between quality-of-care indicators for diabetes and patient outcomes: a systematic literature review. Med Care Res Rev 2011; 68:263-89. [PMID: 21536606 DOI: 10.1177/1077558710394200] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The authors conducted a systematic literature review to assess whether quality indicators for diabetes care are related to patient outcomes. Twenty-four studies were included that formally tested this relationship. Quality indicators focusing on structure or processes of care were included. Descriptive analyses were conducted on the associations found, differentiating for study quality and level of analysis. Structure indicators were mostly tested in studies with weak designs, showing no associations with surrogate outcomes or mixed results. Process indicators focusing on intensification of drug treatment were significantly associated with better surrogate outcomes in three high-quality studies. Process indicators measuring numbers of tests or visits conducted showed mostly negative results in four high-quality studies on surrogate and hard outcomes. Studies performed on different levels of analysis and studies of lower quality gave similar results. For many widely used quality indicators, there is insufficient evidence that they are predictive of better patient outcomes.
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Affiliation(s)
- Grigory Sidorenkov
- University Medical Center Groningen, University of Groningen, the Netherlands
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18
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Mohamed H. How Effective is Systematic Care of Diabetic Patients? Qatar Med J 2010. [DOI: 10.5339/qmj.2010.2.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
With the ultimate goal of improving medical care for diabetes, a study of four Primary Healthcare Centers (PHC) surveyed the composition of PHC population, completeness of patient data, changes in biochemical variables two years before and after establishing specialized diabetic clinics. Patients with diabetes of less than four years duration were excluded from the study. Most (71.7%) of 403 patients with Type II diabetes were aged 40-59 years. Diabetes regulation (HbA1 C), lipid levels (total cholesterol), systolic blood pressure and creatinine improved significantly after inclusion in the specialized diabetic clinic demonstrating that the introduction of systematic care for diabetic patients was effective and lead to an improvement in the recorded process measures and outcome criteria.
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Kenealy TW, Eggleton KS, Robinson EM, Sheridan NF. Systematic care to reduce ethnic disparities in diabetes care. Diabetes Res Clin Pract 2010; 89:256-61. [PMID: 20570383 DOI: 10.1016/j.diabres.2010.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2010] [Revised: 05/02/2010] [Accepted: 05/06/2010] [Indexed: 11/20/2022]
Abstract
AIMS We sought to determine whether systematic care can reduce the gap in diabetes control between Maori and non-Maori. METHODS A Primary Health Organisation implemented a chronic care management programme for diabetes in 2005. The data constitute an open, prospective cohort followed for approximately two years. Data describing process were also collected. RESULTS There were 1311 people with diabetes (354 Maori, 957 non-Maori). Maori started with higher HbA(1c) (mean 8.1%, SD 1.9) than non-Maori (7.1%, SD 1.4) but over about 2 years HbA(1c) for Maori improved to that of non-Maori. LDL and systolic blood pressure decreased for both groups. Improved glucose in Maori was not due to starting insulin or metformin, and rates of sulphonylurea prescription increased in both groups. Urinary albumin:creatinine ratio remained higher for Maori throughout. Smoking rates and Body Mass Index (both higher in Maori) did not change. There is no evidence of selective retention in the cohort. CONCLUSION Likely essential components of the programme were that governance was equally shared between Maori and non-Maori; prolonged nurse consultations were free to the patient; nurses used a formal written wellness plan; nurses were formally trained to support patient self-management; and a computer template supported structured care.
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Olivarius NDF, Siersma V, Hansen LJ, Drivsholm T, Hørder M. Changes in levels of haemoglobin A1c during the first 6 years after diagnosis of clinical type 2 diabetes. Scandinavian Journal of Clinical and Laboratory Investigation 2010; 69:851-7. [PMID: 19929282 DOI: 10.3109/00365510903323191] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To assess the variability in levels of glycosylated haemoglobin (HbA(1c)) during the first six years after diagnosis of clinical type 2 diabetes in relation to possible predictors. MATERIAL AND METHODS Data were from a population-based sample from general practice of 581 newly diagnosed diabetic patients aged 40 or over. Estimation of HbA(1c) was centralized. The changes in levels of HbA(1c) were described by HbA(1c) at diagnosis and a regression line fitted to the HbA(1c) measurements after 1-year follow-up for each patient. The predictive effect of patient characteristics for changes in HbA(1c) was investigated in a multivariate mixed model. RESULTS During the first year after diabetes diagnosis, HbA(1c) dropped to near normal average level and then started rising almost linearly. A sharp rise in long-term glycaemic level was observed in approximately a quarter of the patients, especially the relatively young. Of 581 patients, 156 (26.9%) patients, however, experienced a fall in HbA(1c) after 1-year follow-up and another quarter showed constant or only slowly rising HbA(1c). The changes in levels of HbA(1c) were only predicted by diagnostic HbA(1c) and age. CONCLUSIONS During the first 6 years after the diagnosis of clinical type 2 diabetes, changes in levels of HbA(1c) show considerable inter-individual variability with age as the only long-term predictor. The results indicate that it is important to monitor changes in HbA(1c) more closely and intensify treatment of those often relatively young patients who actually experience the beginning of an apparently relentless deterioration of their glycaemic control.
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Affiliation(s)
- Niels de Fine Olivarius
- The Research Unit and Department for General Practice, University of Copenhagen, Copenhagen, Denmark
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Jørgensen TMM, Grauslund J, Sjølie AK, Green A, Rasmussen LM, Nybo M. Major diabetes-related vascular events do not improve glycaemic control in a population-based cohort of type 1 diabetic individuals. Scandinavian Journal of Clinical and Laboratory Investigation 2010; 69:748-51. [PMID: 19929717 DOI: 10.3109/00365510903108410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE It is known that sudden serious events alter life styles related to treatment efficiency, as for example in cancer patients. However, it has not been specifically addressed if a first-time diabetes-related clinical event has impact on glycaemic regulation. We therefore assessed this in a population-based cohort of patients with long-term type 1 diabetes. METHODS This study was based on a cohort of type 1 diabetes patients with at least 20 years duration of diabetes. Of the 460 patients from the original cohort still alive at 1 January 1994, all patients with a major first-time diabetes-related clinical event (limb amputation, blindness, stroke, cardiac event, or panretinal photocoagulation) and glycated haemoglobin (HbA(1c)) measurements before, 3 and/or 12 months after the event were included. Differences in HbA(1c) measurements before and after the event were tested with Wilcoxon's test. RESULTS A total of 64 patients with a major clinical event between 1994 and 2006 entered the study. Mean HbA(1c) measurements decreased from 8.8% at baseline to 8.6% at 3 months and 8.7% after 12 months, a non-significant decrease. In all event groups, glycaemic regulation was unaltered in the majority of the patients. Only a minority worsened or improved their regulation, and in all groups only non-significant changes were seen. CONCLUSIONS Surprisingly, complication-related events did not improve glycaemic regulation in long-term type 1 diabetes patients. This is in contrast with the experience from other patient categories and shows how difficult it can be to alter glycaemic regulation in diabetes patients with stabilized disease.
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Affiliation(s)
- Trine Maria Mejnert Jørgensen
- Department of Biochemistry, Pharmacology and Genetics, Odense University Hospital, Sdr. Boulevard 29, Odense, Denmark
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Maruyama S, Sakura H, Kanno H, Iwamoto Y. Factors associated with glycemic control after an inpatient program. Metabolism 2009; 58:843-7. [PMID: 19446113 DOI: 10.1016/j.metabol.2009.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2007] [Accepted: 02/23/2009] [Indexed: 11/30/2022]
Abstract
In this study, we investigated the factors predicting poor glycemic control after an inpatient program. Using the hospital database from April 1999 to May 2003, we retrospectively identified patients with type 2 diabetes mellitus and hemoglobin A(1C) (HbA(1C)) of at least 8.0% at the time of admission for an inpatient program. In the primary analysis, factors potentially related to poor glycemic control (HbA(1C) > or =7.0%) at 6 months after admission were investigated. Stepwise multivariate regression analysis identified the duration of diabetes (odds ratio, 2.43; 95% confidence interval [CI], 1.54-3.82; P < .001), period from the first attendance at our hospital until admission (odds ratio, 1.60; 95% CI, 1.01-2.54; P = .047), and number of admissions (odds ratio, 2.28; 95% CI, 1.36-3.82; P = .002) as predictors of poor glycemic control. In the secondary analysis, factors related to poor glycemic response (an absolute decrease of HbA(1C) by <1.5% from the baseline) at 6 months after admission were investigated. Stepwise multivariate regression analysis identified the duration of diabetes (odds ratio, 2.17; 95% CI, 1.19-3.93; P = .011), period from the first attendance at our hospital until admission (odds ratio, 2.17; 95% CI, 1.43-3.29; P < .001), treatment of diabetes at discharge (oral hypoglycemic agents: odds ratio, 2.52; 95% CI, 1.15-5.51; P = .021; insulin: odds ratio, 4.44; 95% CI, 1.96-10.07; P < .001), baseline HbA(1C) (odds ratio, 0.44; 95% CI, 0.37-0.53; P < .001), and addition of new medications (odds ratio, 0.41; 95% CI, 0.27-0.62; P < .001) as predictors of poor glycemic control.
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Affiliation(s)
- Satoko Maruyama
- Diabetes Center, Tokyo Women's Medical University, Tokyo 162-8666, Japan
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Impact of practice size on delivery of diabetes care before and after the Quality and Outcomes Framework implementation. Br J Gen Pract 2008; 58:576-9. [PMID: 18682020 DOI: 10.3399/bjgp08x319729] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
General practice characteristics are important for healthcare providers to maximise outcomes. Although different aspects of general practice characteristics have been studied previously, the impact of practice size on the delivery of care has been sparsely studied, particularly in relation to diabetes care. This brief report presents a longitudinal study in Shropshire (66 practices, 16,858 patients with diabetes) to assess the impact of practice size on diabetes care before and after implementation of the Quality and Outcomes Framework (QOF). Achievement of glycaemic control targets was better before the QOF for larger as compared to smaller practices (P=0.02 and P=0.003 for haemoglobin A1c [HbA1c]<or=7.4% and 10% respectively). This difference disappeared following QOF implementation. Repeated measures analysis showed significant improvement in achieving glycaemic control targets following QOF implementation in both large and small practices (P<0.001 for HbA1c<or=7.4% and 10%). The study failed to reveal an impact of practice size on achieving the HbA1c target<or=7.4% (P=0.1) by this analysis. However, it did show an impact on reaching the target of HbA1c<10% (P=0.04) in favour of smaller practices. There was a significant difference in favour of smaller practices for achievement of prescription of angiotensin-converting enzyme inhibitors (P=0.001).
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Mold F, While A, Forbes A. The management of type 2 diabetes care: the challenge within primary care. ACTA ACUST UNITED AC 2008. [DOI: 10.1002/pdi.1195] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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van Avendonk MJP, Gorter KJ, van den Donk M, Rutten GEHM. Niet alle huisartsen hebben de praktijkorganisatie om optimale diabeteszorg te leveren. ACTA ACUST UNITED AC 2007. [DOI: 10.1007/bf03085335] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Alberti H, Boudriga N, Nabli M. "Damm sokkor": factors associated with the quality of care of patients with diabetes: a study in primary care in Tunisia. Diabetes Care 2007; 30:2013-8. [PMID: 17507697 DOI: 10.2337/dc07-0520] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To identify the organizational, physician, and patient factors associated with the quality of care of patients with diabetes in a low-/middle-income country. RESEARCH DESIGN AND METHODS Data from 2,160 randomly selected patients with diabetes were extracted from the manual medical records of a nationwide sample of 48 randomly selected health centers. Physician and organizational characteristics were collected from national reports, questionnaires, interviews, and observation at the centers. Univariate and multivariate regression analyses were undertaken to identify associations with four quality-of-care scores, based on processes and intermediate outcomes of care and 53 potential explanatory factors. RESULTS The mean age of the study population was 62.4 years, mean duration of diabetes was 8.4 years, 62% were female, and 94% had type 2 diabetes. In the final multivariate models, factors independently and significantly associated with higher process-of-care scores were regional affluence, doctor motivation, and the use of chronic disease clinics (P < 0.05). Health centers with younger patients and increased availability of medication were independently and significantly associated with improved outcome-of-care scores (P < 0.05). The final models of the four quality-of-care scores explained 55-71% of the variations in scores. CONCLUSIONS Use of chronic disease clinics, availability of medication, and possibly doctor motivation appear to be the most strongly related modifiable factors influencing diabetes care. These findings will be used to develop and implement culturally appropriate quality improvement interventions to improve the quality of diabetes care. We recommend our findings be taken into account in other low-/middle-income countries.
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Affiliation(s)
- Hugh Alberti
- Direction des Soins de Santé de Base, Primary Health Care Department, Ministry of Public Health, Tunis, Tunisia.
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Grant R, Adams AS, Trinacty CM, Zhang F, Kleinman K, Soumerai SB, Meigs JB, Ross-Degnan D. Relationship between patient medication adherence and subsequent clinical inertia in type 2 diabetes glycemic management. Diabetes Care 2007; 30:807-12. [PMID: 17259469 DOI: 10.2337/dc06-2170] [Citation(s) in RCA: 152] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Clinical inertia has been identified as a critical barrier to glycemic control in type 2 diabetes. We assessed the relationship between patients' initial medication adherence and subsequent regimen intensification among patients with persistently elevated A1C levels. RESEARCH DESIGN AND METHODS We analyzed an inception cohort of 2,065 insured patients with type 2 diabetes who were newly started on hypoglycemic therapy and were followed for at least 3 years between 1992 and 2001. Medication adherence was assessed by taking the ratio of medication days dispensed (from pharmacy records) to medication days prescribed (as documented in the medical record) for the first prescribed hypoglycemic drug. Adherence was measured for the period between medication initiation and the next elevated A1C result measured at least 3 months later; intensification was defined as a dose increase or the addition of a second hypoglycemic agent. RESULTS Patients were aged (mean +/- SD) 55.4 +/- 12.2 years; 53% were men, and 19% were black. Baseline medication adherence was 79.8 +/- 19.3%. Patients in the lowest quartile of adherence were significantly less likely to have their regimens increased within 12 months of their first elevated A1C compared with patients in the highest quartile (27 vs. 37%, respectively, with increased regimens if A1C is elevated, P < 0.001). In multivariate models adjusting for patient demographic and treatment factors, patients in the highest adherence quartile had 53% greater odds of medication intensification after an elevated A1C (95% CI 1.11-1.93, P = 0.01). CONCLUSIONS Among insured diabetic patients with elevated A1C, level of medication adherence predicted subsequent medication intensification. Poor patient self-management behavior increases therapeutic clinical inertia.
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Affiliation(s)
- Richard Grant
- General Medicine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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Abdulhadi N, Al-Shafaee MA, Östenson CG, Vernby Å, Wahlström R. Quality of interaction between primary health-care providers and patients with type 2 diabetes in Muscat, Oman: an observational study. BMC FAMILY PRACTICE 2006; 7:72. [PMID: 17156424 PMCID: PMC1764013 DOI: 10.1186/1471-2296-7-72] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/18/2006] [Accepted: 12/07/2006] [Indexed: 11/10/2022]
Abstract
Background A good patient-physician interaction is particularly important in chronic diseases like diabetes. There are so far no published data regarding the interaction between the primary health-care providers and patients with type 2 diabetes in Oman, where diabetes is a major and growing health problem. This study aimed at exploring how health-care providers interact with patients with type 2 diabetes at primary health-care level in Muscat, Oman, focusing on the consultation environment, and some aspects of care and information. Methods Direct observations of 90 consultations between 23 doctors and 13 diabetes nurses concerned with diabetes management during their consultations with type 2 diabetes patients in six primary health-care centres in the Muscat region, using checklists developed from the National Diabetes Guidelines. Consultations were assessed as optimal if more than 75% of observed aspects were fulfilled and sub-optimal if less than 50% were fulfilled. Results Overall 52% of the doctors' consultations were not optimal. Some important aspects for a positive consultation environment were fulfilled in only about half of the doctors' consultations: ensuring privacy of consultation (49%), eye contact (49%), good attention (52%), encouraging asking questions (47%), and emphasizing on the patients' understanding of the provided information (52%). The doctors enquired about adverse effects of anti-diabetes drugs in less than 10% of consultations. The quality of the nurses' consultations was sub-optimal in about 75% of 85 consultations regarding aspects of consultation environment, care and information. Conclusion The performance of the primary health-care doctors and diabetes nurses needs to be improved. The role of the diabetes nurses and the teamwork should be enhanced. We suggest a multidisciplinary team approach, training and education to the providers to upgrade their skills regarding communication and care. Barriers to compliance with the guidelines need to be further explored. Improving the work situation mainly for the diabetes nurses and further improvement in the organizational efficiency of diabetes services such as lowering the number of patients in diabetes clinic, are suggested.
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Affiliation(s)
- Nadia Abdulhadi
- Department of Public Health Sciences, Division of International Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
- Department of Health Affairs, Ministry of Health, Muscat, Oman
| | - Mohammed Ali Al-Shafaee
- Department of Family Medicine and Public Health, Sultan Qaboos University, College of Medicine and Health Sciences, Muscat, Oman
| | - Claes-Göran Östenson
- Department of Molecular Medicine and Surgery, Endocrine and Diabetes Unit, Karolinska Institutet, Stockholm, Sweden
| | - Åsa Vernby
- Department of Public Health Sciences, Division of International Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
| | - Rolf Wahlström
- Department of Public Health Sciences, Division of International Health (IHCAR), Karolinska Institutet, Stockholm, Sweden
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Ismail H, Wright J, Rhodes P, Scally A. Quality of care in diabetic patients attending routine primary care clinics compared with those attending GP specialist clinics. Diabet Med 2006; 23:851-6. [PMID: 16911622 DOI: 10.1111/j.1464-5491.2006.01900.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To determine the impact on clinical outcomes of specialist diabetes clinics compared with routine primary care clinics. METHODS Observational study measuring clinical performance (process/outcome measures) in the primary care sector. A cohort of patients attending specialist diabetes clinics was compared with a control cohort of patients attending routine primary care clinics. RESULTS Patients seen in specialist diabetes clinics had a significantly higher HbA1c than patients in routine primary care clinics (mean difference 0.58%; P < 0.001) but there was no significant difference in rate of improvement with visits compared with primary care clinics. In contrast, patients seen in the routine primary care clinics had significantly higher cholesterol levels (mean difference 0.24 mmol/l; P < 0.001) compared with patients in specialist diabetes clinics and their improvement was significantly greater over time (mean difference 0.14 mmol/l per visit compared with 0.10 mmol/l; P < 0.006). Patients in routine primary care clinics also had significantly higher diastolic blood pressure (mean difference 1.6 mmHg; P < 0.007) but there was no difference in improvement with time compared with specialist diabetes clinics. Uptake of podiatry and retinal screening was significantly lower in patients attending routine primary care clinics, but this difference disappeared with time, with significant increases in uptake in the primary care clinic group. Weight increased in both groups significantly with time, but more so in the specialist clinic patients (mean increase 0.18 kg per visit more compared with routine clinic primary care patients; P < 0.001). CONCLUSIONS This study provides evidence that the provision of primary care services for patients with diabetes, whether traditional general practitioner clinics or diabetes clinics run by general practitioners with special interests, is effective in reducing HbA1c, cholesterol and blood pressure. However, the same provision of care was unable to prevent increasing weight or creatinine over time. No evidence was found that patients in specialist clinics do better than patients in routine primary care clinics.
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Affiliation(s)
- H Ismail
- Health Services Research Unit, Bradford Teaching Hospitals NHS Trust, UK
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Haque M, Emerson SH, Dennison CR, Navsa M, Levitt NS. Barriers to initiating insulin therapy in patients with type 2 diabetes mellitus in public-sector primary health care centres in Cape Town. S Afr Med J 2006. [PMID: 16341336 DOI: 10.1080/22201009.2005.10872127] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The majority of patients with type 2 diabetes mellitus in Cape Town who attend primary care community health centres (CHCs) have unsatisfactory glycaemic control. Insulin is rarely prescribed despite its being indicated for type 2 diabetic patients with inadequate metabolic control on maximum oral glucose-lowering agent (OGLA) therapy. OBJECTIVE The study examined barriers to initiating insulin therapy in poorly controlled type 2 diabetes patients on maximum OGLAs in CHCs in the Cape Town metropolis. METHODS Five focus group discussions and 10 in-depth semistructured individual interviews were conducted with 46 medical officers working at the CHCs. The discussions and interviews were transcribed and common themes were identified and categorised. RESULTS Doctor, patient, and system barriers to initiating insulin therapy were identified. Doctors' barriers include lack of knowledge, lack of experience with and use of guidelines related to insulin therapy, language barriers between doctor and patients, and fear of hypoglycaemia. Patient barriers were mistaken beliefs about insulin, non-compliance, lack of understanding of diabetes, use of traditional herbs, fear of injections, and poor socioeconomic conditions. System barriers were inadequate time, lack of continuity of care and financial constraints. CONCLUSION Suggestions for overcoming barriers include further education of doctors on insulin initiation and the use of standardised guidelines. In addition, a patient-centred approach with better communication between doctors and patients, which may be achieved by reorganising aspects of the health system, may improve patient knowledge, address mistaken beliefs, improve compliance and help overcome barriers. Further research is needed to investigate these recommendations and assess patients' and nurses' perceptions on initiating insulin therapy.
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Affiliation(s)
- M Haque
- Primary Health Care, Department of Public Health, University of Cape Town Cape Town, South Africa
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Is Clinical Inertia the Biggest Challenge to Diabetes Care? Can J Diabetes 2006. [DOI: 10.1016/s1499-2671(06)03005-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Alfadda A, Abdulrahman KAB. Assessment of care for type 2 diabetic patients at the primary care clinics of a referral hospital. J Family Community Med 2006; 13:13-8. [PMID: 23012097 PMCID: PMC3410072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is rapid increase in the incidence of Diabetes Mellitus (DM) in the Kingdom of Saudi Arabia (KSA), as in other countries. An optimal care of diabetic patients depends on the health care providers as well as the type of health care setting. Due to the severity of chronic complications in Type 2 diabetic patients, it is essential to assess both the practices of the providers and the patient outcomes at any clinical setting. OBJECTIVES To assess the screening patterns of diabetes associated health care problems in primary care clinics of King Khalid University Hospital (KKUH) and while compare them to the current diabetes clinical practice recommendations of American Diabetes Association (ADA). METHODS The retrospective review of charts of 103 eligible patients who attended the primary care clinics of KKUH over a 3 year-period (1/12001-31/12/2003) had provided 99 type 2 diabetic patients. The study variables included demographic data, complications, treatment, the provider screening practices (measurements of HbA1c, BP, Lipid profile, number of eye and foot examination). From these data, the frequency of provider screening tests, normalized by patient-year could be compared with the ADA guidelines. RESULTS The mean age of 99 type 2 diabetic patients was 57 years, with a mean BMI of 30.8 kg/m2 and with a mean duration of diabetes of 11.8 years. Many had comorbidites or complications: 25% had retinopathy, 17.2% had nephropathy, and 12.1% had neuropathy. The HbA1c level of ≤ 7.0 was maintained by only 24.7% of patients. About 85% of patients had ≥ 1 lipid profile, during their follow-up period. During 2(nd) and 3(rd) year follow up only 30% had ≥ 1 HbA1c measurement and 26.5% (at 2(nd) year), 22%(at 3(rd) year) had ≥ 1 foot examination. The proportion of patients, who had ≥ 1 eye examination was also reduced during their follow up. The provider practice screening results per patient-year was well below the specified guidelines of ADA. CONCLUSION Type 2 diabetic patients care at our primary care clinics did not adhere to the guidelines of ADA. The reasons for the deficiencies were not evident from this study. More detailed studies are needed to find out the relevant causes for the lack of adequate diabetic care at primary care clinics.
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Affiliation(s)
- Assim Alfadda
- Department of Medical Biochemistry, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Khalid A. Bin Abdulrahman
- Department of Family Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia,Correspondence to: Dr. Khalid B. Abdulrahman, Associate Professor of Family Medicine, Vice Dean, Postgraduate and CME, College of Medicine, King Saud University, P.O. Box 2925, Riyadh 11461, Saudi Arabia - E-mail:
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Harris SB, Ekoé JM, Zdanowicz Y, Webster-Bogaert S. Glycemic control and morbidity in the Canadian primary care setting (results of the diabetes in Canada evaluation study). Diabetes Res Clin Pract 2005; 70:90-7. [PMID: 15890428 DOI: 10.1016/j.diabres.2005.03.024] [Citation(s) in RCA: 157] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2004] [Revised: 12/17/2004] [Accepted: 03/02/2005] [Indexed: 10/25/2022]
Abstract
The objective of this national, cross-sectional study was to provide insight into the care and treatment of type 2 diabetes (T2DM) in the Canadian primary care setting. Specifically, the study examines glycemic control, management and morbidity load among T2DM patients, and investigates the relationship of glycemic control and morbidity load with duration of diabetes. Participating primary care physicians (PCPs) (N=243) completed a chart audit for the first 10 patients with T2DM attending their clinics (2473 eligible patient records). The mean A1C was 7.3% with 49% of patients not at target (A1C>or=7.0%). Glycemic control eroded significantly with increasing duration of diabetes in spite of increasing therapeutic intervention. T2DM patients experienced a high morbidity load (hypertension 63%; dyslipidemia 59%; macrovascular complications 28%; microvascular complications 38%) each of which increased significantly with duration of diabetes. For 79% of patients not at target, PCPs identified lifestyle intervention as the strategy for achieving glycemic targets while more aggressive treatment plans were identified for only 56%. These results underscore the complexity of primary care management of T2DM and suggest that current treatment approaches are not intensive enough for a large proportion of patients especially those with longer duration of disease.
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Affiliation(s)
- Stewart B Harris
- The University of Western Ontario, Department of Family Medicine, Centre for Studies in Family Medicine, London, Ont., Canada.
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Bebb C, Kendrick D, Stewart J, Coupland C, Madeley R, Brown K, Burden R, Sturrock N. Inequalities in glycaemic control in patients with Type 2 diabetes in primary care. Diabet Med 2005; 22:1364-71. [PMID: 16176198 DOI: 10.1111/j.1464-5491.2005.01662.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS To quantify relationships between patient and practice factors and glycaemic control in patients with Type 2 diabetes. METHODS A cross-sectional study involving 1534 patients with Type 2 diabetes from 42 general practices in Nottingham, UK was undertaken. Patient characteristics were assessed by a clinical interview and case note review and practice characteristics by a questionnaire. The outcome measure was serum HbA(1c) concentration measured at entry to the study. Random effects linear regression was used to model patient and practice factors associated with glycaemic control. RESULTS In multivariable regression analysis, HbA(1c) increased with increasing body mass index (BMI) [change in HbA(1c) for one unit increase in BMI: 0.03%, 95% confidence interval (CI) 0.01, 0.04], and was higher in those using oral medication (mean difference 0.75%, 95% CI 0.59, 0.92) or insulin compared with diet (mean difference 1.36%, 95% CI 1.10, 1.62). There was a dose-response relationship between HbA(1c) and increasing time since diagnosis. HbA(1c) was negatively associated with age (change per year -0.01%, 95% CI -0.02, -0.004). Patients registered at the most deprived practices had higher HbA(1c) values than those in the least deprived practices (mean difference 0.42%, 95% CI 0.14, 0.71), as did those in practices where annual reviews were carried out by the nurse alone (mean difference 0.24%, 95% CI 0.04, 0.44). CONCLUSIONS Several patient and practice factors are related to glycaemic control. Poorer glycaemic control was associated with practice level deprivation and nurses undertaking annual reviews alone. Further research is required to explore outcomes of annual reviews undertaken by nurses alone. Greater resources may be needed by primary care teams working in deprived areas to address inequalities in diabetic control.
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Affiliation(s)
- C Bebb
- Department of Diabetes, Nottingham City Hospital, Nottingham, UK.
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Alberti H, Boudriga N, Nabli M. Factors affecting the quality of diabetes care in primary health care centres in Tunis. Diabetes Res Clin Pract 2005; 68:237-43. [PMID: 15936466 DOI: 10.1016/j.diabres.2004.09.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2004] [Revised: 09/10/2004] [Accepted: 09/24/2004] [Indexed: 11/19/2022]
Abstract
We have conducted a retrospective medical record review of a random sample of 580 patients with diabetes from 12 primary health care centres (PHCCs) in Greater Tunis. The aim was to assess the quality of diabetes care in PHCCs and to explore factors associated with quality of care. Data were collected concerning patient characteristics, health centre characteristics and process of care criteria. In our sample, recording of care varied significantly between the health centres for all of the process of care criteria studied. Factors significantly associated with improved recording of care were younger patient age (found in 5 of the 10 process of care criteria), use of the new medical records (8 of the 10 criteria), urban health centres (8 of the 10 criteria) and those centres with a doctor with a special interest in diabetes (7 of the 10 criteria). Gender and socio-economic status were not found to be associated with recording of care. The quality of diabetes care in Greater Tunis varies widely between PHCCs and a number of associated factors have been highlighted. A fuller understanding of quality of care within the context of the patients' environment is essential in order to develop appropriate health interventions.
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Affiliation(s)
- Hugh Alberti
- DSSB (Direction du Soins de Santé de Base), 31 Rue Khartoum, Tunis, Tunisia.
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Stewart J, Kendrick D. Setting and negotiating targets in people with Type 2 diabetes in primary care: a cross sectional survey. Diabet Med 2005; 22:683-7. [PMID: 15910616 DOI: 10.1111/j.1464-5491.2005.01496.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS To investigate the provision of diabetes care, the frequency of practices setting targets for their diabetic population, the targets set and the frequency of targets being negotiated with people with diabetes. METHODS Cross-sectional study using a survey of 123 general practices within four Primary Care Trusts in Nottingham UK. RESULTS Eighty per-cent (99) of practices responded. Of these, 88 and 89%, respectively, had set glycosolated haemoglobin (HbA1c) and blood pressure targets for people with Type 2 diabetes. Twenty-five per-cent (24) of practices reported negotiating targets with almost all people with Type 2 diabetes for HbA1c and 31% (30) for blood pressure. In 46% (45) of practices, the annual diabetic review for some or all of the people with Type 2 diabetes was carried out by the practice nurse alone. In these practices, targets were negotiated with a smaller proportion of people than those where the doctor was involved in the annual review for both blood pressure [43 vs. 64% negotiated blood pressure targets with almost all or many people odds ratio (OR) 0.42 (95% CI 0.19, 0.96), P = 0.04] and HbA1c [39 vs. 60% negotiated HbA1c targets with almost all or many people, OR 0.41 (95% CI 0.18, 0.94), P = 0.03]. CONCLUSIONS Negotiating targets with people with Type 2 diabetes does not routinely occur in primary care. Targets are negotiated less often in practices where nurses undertake reviews alone and further work is needed to explore the reasons for this.
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Affiliation(s)
- J Stewart
- Nottingham Primary Care Research Partnership, Hucknall Health Centre, Nottingham, UK.
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Dijkstra RF, Braspenning JCC, Huijsmans Z, Akkermans RP, van Ballegooie E, ten Have P, Casparie T, Grol RPTM. Introduction of diabetes passports involving both patients and professionals to improve hospital outpatient diabetes care. Diabetes Res Clin Pract 2005; 68:126-34. [PMID: 15860240 DOI: 10.1016/j.diabres.2004.09.020] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2004] [Accepted: 09/02/2004] [Indexed: 11/15/2022]
Abstract
AIM To investigate whether a comprehensive strategy involving both patients and professionals, with the introduction of a diabetes passport as a key component, improves diabetes care. METHODS The first 150 consecutive patients who visited their internist for a diabetes check up at the internal medicine outpatient departments at each of nine Dutch general hospitals were included in this 1 year clustered, randomised, controlled trial. Health care professionals attended an educational meeting about the use and dissemination of the diabetes passport which is a patient held record. They also received aggregated feedback on baseline data and personal feedback. Educational meetings were also organised for patients. Patient files were used in conjunction with questionnaires to determine adherence rates. Data were analysed using multilevel regression analysis. RESULTS Small but significant changes were found in mean HbA1c levels. In the intervention group, positive health changes for patients were found (-0.3%) when compared to those in the control group (+0.2%). Diastolic blood pressure improved slightly, but no changes were found in systolic blood pressure or cholesterol. Improvements were found with regard to levels of examination of patients' feet and in patient education. CONCLUSIONS Efforts to improve professional practice involving both professionals and patients led to small improvements in HbA1c and diastolic blood pressure levels. Further study is needed to establish whether a better structured health care delivery, operating in a more supportive environment can enhance these effects.
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Affiliation(s)
- R F Dijkstra
- Centre for Quality of Care Research, University Medical Centre, Nijmegen, The Netherlands.
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Lerman I, Lozano L, Villa AR, Hernández-Jiménez S, Weinger K, Caballero AE, Salinas CA, Velasco ML, Gómez-Pérez FJ, Rull JA. Psychosocial factors associated with poor diabetes self-care management in a specialized center in Mexico City. Biomed Pharmacother 2005; 58:566-70. [PMID: 15589064 DOI: 10.1016/j.biopha.2004.09.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2004] [Indexed: 11/17/2022] Open
Abstract
To examine the relationship between demographic, clinical and psychosocial variables and diabetes self-care management in Mexican type 2 diabetic patients. Cross-sectional study of 176 consecutive patients with type 2 diabetes aged 30-75 years, attending a tertiary health-care center in Mexico City. A brief medical history and previously validated questionnaires were completed. The study group consisted of 64 males/112 females, aged 55 +/- 11 years, mean diabetes duration of 12 +/- 8 years and HbA1c of 9.0 +/- 2.0%, 78.4% reported following the correct dose of diabetes pills or insulin, 58% ate the recommended food portions, and 44.3% did exercise three or more times per week. A good adherence to these three recommendations was observed in only 26.1% of the patients. These patients considered as a group were characterized by a greater knowledge about the disease (P < 0.00001), regular home blood glucose monitoring (P < 0.01), an inner perception of better diabetes control (P = 0.007), good health (P = 0.004) and better communication with their physician (P < 0.02). A poor adherence to two or the three main diabetes care recommendations was associated with a depressive state (OR 2.38, 95% CI 1.1-4.9, P < 0.01) and a history of excessive alcohol intake (OR 4.03, 95% CI 1.1-21.0, P = 0.03). Poor adherence to standard diabetes care recommendations is frequently observed in patients with type 2 diabetes attending a specialized health care center in Mexico City. Depression must be identified and treated effectively.
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Affiliation(s)
- Israel Lerman
- Departmento de Endocrinología y Metabolismo, Instituto Nacional de Ciencias Medicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Tlalpan, 14000 Mexico City, Mexico.
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Drivsholm T, Olivarius NDF. Routine diagnosis of Type 2 diabetes mellitus in general practice and hospitals: how do patients differ? Diabet Med 2005; 22:336-9. [PMID: 15717884 DOI: 10.1111/j.1464-5491.2005.01427.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To study how Type 2 diabetic patients diagnosed by routine case-finding in primary care differ from patients diagnosed in secondary care with regard to clinical characteristics, symptom-burden and prevalence of complications. RESEARCH DESIGN AND METHODS A Danish population-based sample of 1633 newly diagnosed Type 2 diabetic patients, of whom we had detailed information of sociodemographic and clinical characteristics, biochemical measurements, and complications among 1381. Blood and urine analyses were centralized. RESULTS Of the patients, 76.8% were diagnosed in general practice. Compared with those diagnosed in secondary care, patients diagnosed in general practice on average had higher levels of cardiovascular risk factors (BMI: 29.8 vs. 28.5 kg/m2, P < 0.001; systolic blood pressure: 149.4 vs. 143.2 mmHg, P < 0.001; diastolic blood pressure: 85.2 vs. 82.5 mmHg, P < 0.001; haemoglobin A(1c): 10.1 vs. 8.4%, P < 0.0001; total cholesterol: 6.4 vs. 6.1 mmol/l, P < 0.01), more frequently presented with hyperglycaemic symptoms (80.1 vs. 63.4%, P < 0.0001), while fewer had macrovascular complications (28.5 vs. 43.6%, P < 0.0001). CONCLUSIONS Judged from their risk profile, Type 2 diabetic patients diagnosed in primary care are at no less risk of developing diabetic complications than those diagnosed in secondary care.
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Affiliation(s)
- T Drivsholm
- Research Unit, Department of General Practice, University of Copenhagen, Denmark.
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Thapar AK, Roland MO. General practitioner attitudes to the care of people with epilepsy: an examination of clustering within practices and prediction of patient-rated quality of care. BMC FAMILY PRACTICE 2005; 6:9. [PMID: 15740630 PMCID: PMC554779 DOI: 10.1186/1471-2296-6-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/19/2004] [Accepted: 03/01/2005] [Indexed: 11/10/2022]
Abstract
BACKGROUND There is wide variation in the quality of care provided by primary care practices to individuals with chronic illnesses. Individual doctor attitudes and interest have been demonstrated to influence patient outcomes in some instances. Given the trend towards larger practices and part-time working, continuity of care is likely to fall and thus practice-based rather than individual general practitioner attributes and attitudes are likely to become increasingly important. The aim in this paper was to examine the extent to which individual general practitioner (G.P.) attitudes to the care of people with epilepsy cluster within practices and predict patient-rated quality of care. METHODS The sample consisted of 1255 people with active epilepsy (a recent seizure or on anti-convulsant medication for epilepsy) and 199 GPs from 82 general practices. Measures of GP attitudes (a 17-item GP attitudes questionnaire) and patient-rated quality of epilepsy care were obtained. 1210 individuals completed initial questionnaires and 975 patients filled in final questionnaires one year later. Responses were achieved from 64 practices (83% of total) and 115 GPs (60% of total). RESULTS 2 main factors were found to underlie GP attitudes to the care of people with epilepsy and these demonstrated clustering within practices "epilepsy viewed as a primary care responsibility" (Eigenvalue 3.98, intra-class correlation coefficient (ICC) 0.40), and "medication skills"(Eigenvalue 2.74, ICC 0.35). GP-rated scores on "epilepsy care being a primary care responsibility" were a significant predictor of patient-rated quality of GP care (p = 0.031). Other contributory factors were seizure frequency (p = 0.044), and patient-rated "shared decision making" (p = 0.022). CONCLUSION Specific general practitioner attitudes to the care of people with epilepsy cluster within practices and are significantly associated with patient-rated quality of epilepsy care. It is important to take these findings into consideration when planning primary care interventions to ensure people with epilepsy receive the benefits of available medical and surgical expertise.
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Affiliation(s)
- Ajay K Thapar
- School of Psychology, Cardiff University, Tower Building, Park Place, Box 901, Cardiff, UK
- Taff Riverside Practice, Riverside Health Centre, Cardiff, UK
| | - Martin O Roland
- National Primary Care Research and Development Centre, University of Manchester, Manchester, UK
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Goudswaard AN, Stolk RP, Zuithoff P, Rutten GEHM. Patient characteristics do not predict poor glycaemic control in type 2 diabetes patients treated in primary care. Eur J Epidemiol 2004; 19:541-5. [PMID: 15330126 DOI: 10.1023/b:ejep.0000032351.42772.e7] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Many diabetic patients in general practice do not achieve good glycaemic control. The aim of this study was to assess which characteristics of type 2 diabetes patients treated in primary care predict poor glycaemic control (HbA1c > or = 7%). Data were collected from the medical records. 1641 patients were included who had mean HbA1c 7.1(SD 1.7)% , and 42% had HbA1c > or = 7%. On univariate analysis younger age; longer duration of diabetes; higher levels of blood glucose at diagnosis; most recent fasting blood glucose (FBG), total cholesterol, and triglyceride; higher body mass index (BMI); treatment with oral hypoglycaemic agents (OHA); treatment with insulin; more GP-visits for diabetes in the last year; and lower educational level were associated with poor control. Both in multiple linear regression and in multiple logistic regression higher levels of FBG (odds ratio (OR): = 1.6, 95% confidence interval (CI): 1.49, 1.70), treatment with OHA (OR: 2.1, 95% CI: 1.41, 3.04), treatment with insulin (OR: 7.2, 95% CI: 4.18, 12.52), lower educational level (OR: 1.26, 95% CI: 1.01, 1.56) were independently associated with poor levels of HbA1c. When FBG levels were excluded from the model, higher blood glucose at diagnosis, higher values for triglyceride and total cholesterol, and younger age predicted poor glycaemic control, but these variables explained only 15% of the variation in HbA1c. In conclusion prediction of poor glycaemic control from patient characteristics in diabetic patients in general practice is hardly possible. FBG appeared to be a strong predictor of HbA1c, which underlines the usefulness of this simple test in daily diabetes care. The worse metabolic control in those treated with either OHA or insulin suggests that current treatment regimes might be not sufficiently applied to reach the targets of care. Providers of diabetes care should be attentive to patients with lower educational level.
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Affiliation(s)
- Alex N Goudswaard
- Julius Center for Health Science and Primary Care, University Medical Center, Utrecht, The Netherlands.
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Whitford DL, Roberts SH, Griffin S. Sustainability and effectiveness of comprehensive diabetes care to a district population. Diabet Med 2004; 21:1221-8. [PMID: 15498089 DOI: 10.1111/j.1464-5491.2004.01324.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIMS To evaluate whether diabetes care in a district population can be sustained over time and intensive management of multiple risk factors can be achieved against a background of rising prevalence of known diabetes and shift of responsibility towards primary care. METHODS Assessment of process and outcome measures achieved by a comprehensive diabetes service. Routine data were collected from patients registered with diabetes in a district population by repeated cross-sectional survey in 1991 (n = 2284 patients) and 2001 (n = 5809 patients). RESULTS Between 1991 and 2001 the recording of body mass index (76.8 vs. 71.3%, P = 0.01) and HbA(1c) measurement (92.2 vs. 86.4%, P < 0.001) decreased, whereas recording of smoking status (72.4 vs. 82%, P < 0.001), cholesterol level (54.7 vs. 82.5%, P < 0.001) and eye screening result (86.1 vs. 91.3%, P < 0.001) improved. Surviving patients with Type 2 diabetes had significant improvements in systolic blood pressure, diastolic blood pressure and cholesterol, significant deterioration in HbA(1c) and creatinine, and no change in body mass index. Changes in blood pressure and HbA(1c) over time were similar to those reported in the UKPDS. CONCLUSIONS The delivery of processes and outcomes of care to a district population can be sustained at a high level over a 10-year period within a comprehensive diabetes service. We would suggest that a multifaceted complex intervention is required to achieve these results.
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Affiliation(s)
- D L Whitford
- Department of Family Medicine and General Practice, Royal College of Surgeons of Ireland, Mercer's Medical Centre, Lower Stephen Street, Dublin 2, Ireland.
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Simmons D, Lillis S, Swan J, Haar J, Smith JF. Should we trust results of meta-analyses? Lancet 2004; 364:1402; author reply 1402-3. [PMID: 15488212 DOI: 10.1016/s0140-6736(04)17217-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Kenealy T, Arroll B, Kenealy H, Docherty B, Scott D, Scragg R, Simmons D. Diabetes care: practice nurse roles, attitudes and concerns. J Adv Nurs 2004; 48:68-75. [PMID: 15347412 DOI: 10.1111/j.1365-2648.2004.03173.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Practice nurses (PNs) are the largest group of nurses providing primary care for patients with diabetes in New Zealand, and changes in the health system are likely to have a substantial effect on their roles. To inform the development of a new primary health care nursing structure and evaluate the new role associated with this, it will be important to have data on current practice nurse roles. AIMS The aim of this paper is to report a study to compare the diabetes-related work roles, training and attitudes of practice nurses in New Zealand surveyed in 1990 and 1999, to consider whether barriers to practice nurse diabetes care changed through that decade, and whether ongoing barriers will be addressed by current changes in primary care. METHODS Questionnaires were mailed to all 146 PNs in South Auckland in 1990 and to all 180 in 1999, asking about personal and practice descriptions, practice organization, time spent with patients with diabetes, screening practices, components of care undertaken by practice nurses, difficulties and barriers to good practice, training in diabetes and need for further education. The 1999 questionnaire also asked about nurse prescribing and influence on patient quality of life. RESULTS More nurses surveyed in 1999 had postregistration diabetes training than those in 1990, although most of those surveyed in both years wanted further training. In 1999, nurses looked after more patients with diabetes, without spending more time on diabetes care than nurses in 1990. Nevertheless, they reported increased involvement in the more complex areas of diabetes care. Respondents in 1999 were no more likely than those in 1990 to adjust treatment, and gave a full range of opinion for and against proposals to allow nurse prescribing. The relatively low response rate to the 1990 survey may lead to an underestimate of changes between 1990 and 1999. CONCLUSIONS Developments in New Zealand primary care are likely to increase the role of primary health care nurses in diabetes. Research and evaluation is required to ascertain whether this increasing role translates into improved outcomes for patients.
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Affiliation(s)
- Tim Kenealy
- Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand.
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Grant RW, Cagliero E, Sullivan CM, Dubey AK, Estey GA, Weil EM, Gesmundo J, Nathan DM, Singer DE, Chueh HC, Meigs JB. A controlled trial of population management: diabetes mellitus: putting evidence into practice (DM-PEP). Diabetes Care 2004; 27:2299-305. [PMID: 15451891 DOI: 10.2337/diacare.27.10.2299] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Population-level strategies to organize and deliver care may improve diabetes management. We conducted a multiclinic controlled trial of population management in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS We created diabetic patient registries (n = 3,079) for four primary care clinics within a single academic health center. In the intervention clinic (n = 898), a nurse practitioner used novel clinical software (PopMan) to identify patients on a weekly basis with outlying values for visit and testing intervals and last measured levels of HbA1c, LDL cholesterol, and blood pressure. For these patients, the nurse practitioner e-mailed a concise patient-specific summary of evidence-based management suggestions directly to primary care providers (PCPs). Population changes in risk factor testing, medication prescription, and risk factor levels from baseline (1 January 2000 to 31 August 2001) to follow-up (1 December 2001 to 31 July 2003) were compared with the three usual-care control clinics (n = 2,181). RESULTS Patients had a mean age of 65 years, were mostly white (81%), and the majority were insured by Medicare/Medicaid (62%). From baseline to follow-up, the increase in proportion of patients tested for HbA1c (P = 0.004) and LDL cholesterol (P < 0.001) was greater in the intervention than control sites. Improvements in diabetes-related medication prescription and levels of HbA1c, LDL cholesterol, and blood pressure in the intervention clinic were balanced by similar improvements in the control sites. CONCLUSIONS Population-level clinical registries combined with summarized recommendations to PCPs had a modest effect on management. The intervention was limited by good overall quality of care at baseline and temporal improvements in all control clinics. It is unknown whether this intervention would have had greater impact in clinical settings with lower overall quality. Further research into more effective methods of translating population registry information into action is required.
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Affiliation(s)
- Richard W Grant
- General Medicine Division, Massachusetts General Hospital, Boston, MA, USA.
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Ward MM, Yankey JW, Vaughn TE, BootsMiller BJ, Flach SD, Welke KF, Pendergast JF, Perlin J, Doebbeling BN. Physician Process and Patient Outcome Measures for Diabetes Care. Med Care 2004; 42:840-50. [PMID: 15319609 DOI: 10.1097/01.mlr.0000135809.92048.d9] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Optimal diabetes management relies on providers adhering to evidence-based practice guidelines in the processes of care delivery and patients adhering to self-management recommendations to maximize patient outcomes. PURPOSE To explore: (1) the degree to which providers adhere to the guidelines; (2) the extent of glycemic, lipid, and blood pressure control in patients with diabetes; and (3) the roles of organizational and patient population characteristics in affecting both provider adherence and patient outcome measures for diabetes. DESIGN Secondary data analysis of provider adherence and patient outcome measures from chart reviews, along with surveys of facility quality managers. SAMPLE We sampled 109 Veterans Affairs medical centers (VAMCs). RESULTS Analyses indicated that provider adherence to diabetes guidelines (ie, hemoglobin A1c, foot, eye, renal, and lipid screens) and patient outcome measures (ie, glycemic, lipid, and hypertension control plus nonsmoking status) are comparable or better in VAMCs than reported elsewhere. VAMCs with higher levels of provider adherence to diabetes guidelines had distinguishing organizational characteristics, including more frequent feedback on diabetes quality of care, designation of a guideline champion, timely implementation of quality-of-care changes, and greater acceptance of guideline applicability. VAMCs with better patient outcome measures for diabetes had more effective communication between physicians and nurses, used educational programs and Grand Rounds presentations to implement the diabetes guidelines, and had an overall patient population that was older and with a smaller percentage of black patients. CONCLUSIONS Healthcare organizations can adopt many of the identified organizational characteristics to enhance the delivery of care in their settings.
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Affiliation(s)
- Marcia M Ward
- Department of Health Management and Policy, University of Iowa, Iowa City, Iowa 52242-1008, USA.
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Dijkstra RF, Braspenning JCC, Huijsmans Z, Peters S, van Ballegooie E, ten Have P, Casparie AF, Grol RPTM. Patients and nurses determine variation in adherence to guidelines at Dutch hospitals more than internists or settings. Diabet Med 2004; 21:586-91. [PMID: 15154944 DOI: 10.1111/j.1464-5491.2004.01195.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS To measure adherence to recently developed diabetes guidelines at Dutch hospital outpatient clinics and distinguish determinants for variations in care on hospital, internist and patient levels. METHODS Thirteen general hospitals with 58 internists recruited 1950 diabetic patients. Data were extracted from medical files (n = 1915) and from patient questionnaires (n = 1465). Multilevel logistic regression analysis was performed to explain differences in adherence rates to the guidelines. RESULTS Adherence to process measures was high, except for the examination of feet, calculation of the body mass index and patient education activities (the mean of 12 process measures was 64%). Adherence to intermediate outcome indicators was moderate. The mean percentage of patients with HbA(1c) < 7.0% was 23%. Adherence variation on a hospital level was very small (0.6-7.9%), on an internist level moderate (0.4-18.8%) and on a patient level high (74.4-98.8%). Adherence to all process measures and most of the intermediate outcome indicators was highest in the patients seen by a diabetes specialist nurse. DISCUSSION More focus on patient involvement in diabetic care and the contribution of diabetes specialist nurses may be important factors in improving the quality of diabetes care.
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Affiliation(s)
- R F Dijkstra
- Centre for Quality of Care Research, University Medical Centre St Radboud, Nijmegen, The Netherlands.
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Christopher D, Kendrick D. Differences in the process of diabetic care between south Asian and white patients in inner-city practices in Nottingham, UK. HEALTH & SOCIAL CARE IN THE COMMUNITY 2004; 12:186-193. [PMID: 19777708 DOI: 10.1111/j.1365-2524.2004.00487.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The prevalence and complication rate of diabetes is higher amongst British south Asians when compared to the rest of the adult population. There is some evidence to suggest that there are differences in access to healthcare in the UK for different ethnic groups, but there has been little research examining differences in processes of care between ethnic groups and place of delivery of diabetic care. The present study was a retrospective, multi-practice audit exploring differences in the processes of diabetic care provided to white and south Asian patients. Data were obtained from eight practices located in deprived areas in Nottingham, UK. A review of the evidence-based protocols for the monitoring of diabetic care generated a list of process criteria to be measured. All primary care data sources were examined over a 12-month period by a single investigator. The data were analysed with respect to patient ethnicity and place of diabetic care after adjusting for confounders. Eight hundred and thirty-nine diabetic patients were included in the audit and 671 (80.0%) received a formal annual diabetic review. One hundred and five (12.5%) patients were classified as south Asian. They were significantly less likely to have their blood pressure [86% versus 89%, odds ratio (OR) = 0.62, 95% confidence interval (95% CI) = 0.54-0.72] or serum creatinine (67% versus 76%, OR = 0.41, 95% CI = 0.32-0.52) measured when compared to white patients. Patients receiving shared care from a hospital-based diabetic team were more likely to have a range of items of the annual review recorded. When examined by ethnicity, south Asians receiving shared care were again less likely than white patients to have their blood pressure and serum creatinine measured. There was also some evidence that they may be less likely to have their body mass index recorded and their feet examined. The findings of the present study showed that, although most diabetic patients received a formal annual clinical review, scope for improvement remained. Shared care of patients with a hospital-based team produced better results when processes of care were examined. However, this benefit did not apply equally to south Asian and white patients. Further studies are indicated to confirm these results, which may have wider implications for the planning and provision of diabetic care.
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Affiliation(s)
- David Christopher
- Division of Primary Care, School of Community Health Sciences, University of Nottingham, Nottingham NG7 2RD, UK.
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Alberti HP, Boudriga N, Nabli M. Variations in care of diabetes in primary care centres in Tunis. DIABETES & METABOLISM 2004; 30:197-200. [PMID: 15223994 DOI: 10.1016/s1262-3636(07)70108-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The aim of this study was to investigate the care of diabetes in primary care in the public sector in Greater Tunis and in particular, to assess variations in care across centres with the intention of seeking explanations for any differences identified. We undertook a retrospective medical review of patients with diabetes from four primary care health centres. Data were collected concerning patient characteristics, process of care criteria, outcome of care criteria, attendance rates, treatment and health centre characteristics. The total sample size was 235 patients. Outcome of care criteria were found to be similar across each of the centres. Process of care criteria were found to be significantly varied between the centres for all measurements used. Variations were also found in treatment and attendance rates across the health centres. In conclusion, there is a significant variation in the management of diabetes in primary care across centres within Greater Tunis, despite the use of standardised, national guidelines. A number of factors related to the centres may have given rise to these variations.
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Affiliation(s)
- H P Alberti
- Directions de soins de Santé de Base, Rue de Khartoum, Tunis, Tunisia.
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Grant RW, Cagliero E, Dubey AK, Gildesgame C, Chueh HC, Barry MJ, Singer DE, Nathan DM, Meigs JB. Clinical inertia in the management of Type 2 diabetes metabolic risk factors. Diabet Med 2004; 21:150-5. [PMID: 14984450 DOI: 10.1111/j.1464-5491.2004.01095.x] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS Delays in the initiation and intensification of medical therapy may be one reason patients with diabetes do not reach evidence-based goals for metabolic control. We assessed intensification of medical therapy over time, comparing the management of hyperglycaemia, hypertension, and hyperlipidaemia. METHODS Prospective cohort study of 598 adults with Type 2 diabetes receiving primary care in an academic medical centre from May 1997 to April 1999. We assessed whether patients failing to achieve standard treatment goals for haemoglobin A1c (HbA1c), systolic blood pressure (SBP), or low density lipoprotein (LDL) cholesterol when last measured during 12 months (Year 1, 5/97-4/98) had increases in their corresponding medical regimen during the following 12 months (Year 2, 5/98-4/99). RESULTS Among untreated patients in Year 1, seven of 12 (58%) of those above goal for HbA1c were initiated on medical therapy in Year 2, compared with 16 of 48 (34%) above SBP goal (P=0.02) and 26 of 115 (23%) above LDL cholesterol goal (P=0.02). Among patients on therapy and above goal, 124 of 244 (51%) patients with elevated HbA1c had their regimen increased in Year 2, compared with 85 of 282 (30%) with elevated SBP (P<0.001) and 22 of 79 (30%) with elevated LDL cholesterol (P<0.001). From Year 1 to Year 2 there was a decline in the overall proportion of patients above goal for LDL cholesterol (from 58% to 45%, P=0.002) but not for HbA1c or blood pressure. CONCLUSIONS Greater initiation and intensification of pharmaceutical therapy, particularly for elevated blood pressure or cholesterol, may represent a specific opportunity to improve metabolic control in Type 2 diabetes.
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Affiliation(s)
- R W Grant
- General Medicine Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
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