Dissemination of diabetes care guidelines: lessons learned from community health centers

Factors Influencing Diabetes Self-Management Among Medically Underserved Patients With Type II Diabetes

In this study, researchers compare and contrast issues regarding diabetes self-management between persons in good versus poor glycemic control. The sample comprises low-income racially diverse adults with diabetes from four mid-western community health centers; 44 patients participated in eight focus groups divided by control status (HbA1c of > 9 [uncontrolled] or < 7 [controlled]). Themes common to both groups included the impact of dietary restrictions on social interactions, food cravings, the impact of mental health on self-management, and the importance of formal and informal (friends and family) support. Those in the uncontrolled groups described fear about being able to control their diabetes, confusion about self-management, and difficulty managing their diabetes while caring for family members. Although those in the controlled groups acknowledged difficulties, they discussed resisting cravings, making improvements with small changes, positive feelings about their ability to control their diabetes, and enjoying new foods and exercise. Interventions should include mental health support, incorporate formal and informal patient support structures, and address literacy issues. Health care providers and intervention personnel should be very concrete about how to do self-management tasks and guide patients on how to alter their diabetes regimens for social and other important life events.

Determinants of Health Behaviors After Gestational Diabetes Mellitus: A Prospective Cohort Study in Geneva

INTRODUCTION

Gestational diabetes mellitus (GDM) is one of the most common complications in pregnancy. The objective of this study was to specify the determinants of postpartum physical activity and dietary habits after a pregnancy complicated by GDM in a population of Swiss women. This information will be used to improve health promotion and diabetes prevention interventions for women with a history of GDM.

METHODS

A prospective cohort study of 173 pregnant women with a diagnosis of GDM was carried out. Quantitative data were collected at the end of pregnancy (T1) and at 6 months postpartum (T3). Bivariate and multivariate logistic regression analysis was conducted to assess associations between the level of healthy lifestyle at 6 months postpartum, clinical and sociodemographic characteristics, motivation to adopt a healthy lifestyle after birth at the end of pregnancy, and postulated psychosocial correlates of health behaviors.

RESULTS

Multivariate regression analysis showed that only 2 variables were determinants in a low adherence to healthy lifestyle in the postpartum period after GDM: a lower level of social support (odds ratio [OR], 1.5; P < .001) and more perceived barriers to a healthy lifestyle (OR, 1.2; P = .002).

DISCUSSION

This study shows that, for women who had GDM, the problem of low adherence to a healthy lifestyle to prevent the onset of type 2 diabetes may be secondary to the lack of resources available for the promotion and development of healthy eating habits and regular physical activity. The findings of this study suggest that some women with a history of GDM do not have the means and resources in the postpartum period to apply the advice given during antenatal monitoring.

The future of community-centred health services in Australia: lessons from the mental health sector

•It is apparent that hospital-dominated health care produces limited health outcomes and is an unsustainable health care system strategy. •Community-centred health care has been demonstrated to be a more cost-efficient and cost-effective alternative to hospital-centred care, particularly for prevention and care of persistent, long-term or recurrent conditions. Nevertheless, hospital-centred services continue to dominate health care services in Australia, and some state governments have presided over a retreat from, or even dismantling of, community health services. •The reasons for these trends are explored. •The future of community health services in Australia is uncertain, and in some states under serious threat. We consider lessons from the partial dismantling of Australian community mental health services, despite a growing body of Australian and international studies finding in their favour. •Community-centred health services should be reconceptualised and resourced as the centre of gravity of local, effective and affordable health care services for Australia. A growing international expert consensus suggests that such community-centred health services should be placed in the centre of their communities, closely linked or collocated where possible with primary health care, and functionally integrated with their respective hospital-based services. What is known about the topic?Community-centred health care has been widely demonstrated to be a more cost-efficient and cost-effective alternative to hospital-centred care, particularly for prevention and care of persistent, long-term or recurrent conditions, e.g. in mental health service systems. A growing international expert consensus suggests that such community-centred health services should be placed in the centre of their communities, closely linked or collocated where possible with primary health care, and functionally integrated with their respective hospital-based services. What does this paper add?Despite this global consensus, hospital-centred services continue to dominate health care services in Australia, and some state governments have presided over a retreat from, or even dismantling of, community health services. The reasons for these trends and possible solutions are explored. What are the implications for practitioners?Unless this trend is reversed, the loss of convenient public access to community health services at shopping and transport hubs and the consequent compromising of intensive home-based clinical care, will lead to a deterioration of preventative interventions and the health care of long-term conditions, contrary to international studies and reviews.

Improving and sustaining diabetes care in community health centers with the health disparities collaboratives

BACKGROUND

In 1998, the Health Resources and Services Administration's Bureau of Primary Health Care began the Health Disparities Collaboratives (HDC) to improve chronic disease management in community health centers (HCs) nationwide. The HDC incorporates rapid quality improvement, a chronic care model, and best practice learning sessions.

OBJECTIVES

To determine whether the HDC improves diabetes care in HCs over 4 years and whether more intensive interventions enhance care further.

SUBJECTS

Chart review of 2364, 2417, and 2212 randomly selected patients with diabetes from 34 HCs in 17 states in 1998, 2000, and 2002, respectively.

MEASURES

American Diabetes Association standards.

RESEARCH DESIGN

We performed a randomized controlled trial with an embedded prospective longitudinal study. We randomized 34 HCs that had undergone 1-2 years of the HDC. The standard-intensity arm continued the baseline HDC intervention. High-intensity arm centers received 4 additional learning sessions, provider training in behavioral change, and patient empowerment materials. To assess the impact of the HDC, we analyzed changes in clinical processes and outcomes in the standard-intensity centers. To determine the effect of more intensive interventions, we compared the standard- and high-intensity centers.

RESULTS

Between 1998 and 2002, HCs undertaking the standard HDC improved 11 diabetes processes and lowered hemoglobin A1c [-0.45%; 95% confidence interval (CI), -0.72 to -0.17] and low-density lipoprotein cholesterol (-19.7 mg/dL; 95% CI, -25.8 to -13.6). High-intensity intervention centers had greater use of angiotensin converting enzyme inhibitors [adjusted odds ratio (OR), 1.47; 95% CI, 1.07-2.01] and aspirin (OR, 2.20; 95% CI, 1.28-3.76), but lower use of dietary (OR, 0.24; 95% CI, 0.08-0.68) and exercise counseling (OR, 0.34; 95% CI, 0.15-0.75).

CONCLUSIONS

Diabetes care and outcomes improved in HCs during the first 4 years of the HDC quality improvement collaborative. More intensive interventions helped marginally.

Organizational interventions employing principles of complexity science have improved outcomes for patients with Type II diabetes

BACKGROUND

Despite the development of several models of care delivery for patients with chronic illness, consistent improvements in outcomes have not been achieved. These inconsistent results may be less related to the content of the models themselves, but to their underlying conceptualization of clinical settings as linear, predictable systems. The science of complex adaptive systems (CAS), suggests that clinical settings are non-linear, and increasingly has been used as a framework for describing and understanding clinical systems. The purpose of this study is to broaden the conceptualization by examining the relationship between interventions that leverage CAS characteristics in intervention design and implementation, and effectiveness of reported outcomes for patients with Type II diabetes.

METHODS

We conducted a systematic review of the literature on organizational interventions to improve care of Type II diabetes. For each study we recorded measured process and clinical outcomes of diabetic patients. Two independent reviewers gave each study a score that reflected whether organizational interventions reflected one or more characteristics of a complex adaptive system. The effectiveness of the intervention was assessed by standardizing the scoring of the results of each study as 0 (no effect), 0.5 (mixed effect), or 1.0 (effective).

RESULTS

Out of 157 potentially eligible studies, 32 met our eligibility criteria. Most studies were felt to utilize at least one CAS characteristic in their intervention designs, and ninety-one percent were scored as either "mixed effect" or "effective." The number of CAS characteristics present in each intervention was associated with effectiveness (p = 0.002). Two individual CAS characteristics were associated with effectiveness: interconnections between participants and co-evolution.

CONCLUSION

The significant association between CAS characteristics and effectiveness of reported outcomes for patients with Type II diabetes suggests that complexity science may provide an effective framework for designing and implementing interventions that lead to improved patient outcomes.

Improving diabetes care in midwest community health centers with the health disparities collaborative

OBJECTIVE

To evaluate the Diabetes Health Disparities Collaborative, an initiative by the Bureau of Primary Health Care to reduce health disparities and improve the quality of diabetes care in community health centers.

RESEARCH DESIGN AND METHODS

One year before- after trial. Beginning in 1998, 19 Midwestern health centers undertook a diabetes quality improvement initiative based on a model including rapid Plan-Do-Study-Act cycles from the continuous quality improvement field; a Chronic Care Model emphasizing patient self-management, delivery system redesign, decision support, clinical information systems, leadership, health system organization, and community outreach; and collaborative learning sessions. We reviewed charts of 969 random adults for American Diabetes Association standards, surveyed 79 diabetes quality improvement team members, and performed qualitative interviews.

RESULTS

The performance of several key processes of care assessed by chart review increased, including rates of HbA(1c) measurement (80-90%; adjusted odds ratio 2.1, 95% CI 1.6-2.8), eye examination referral (36-47%; 1.6, 1.1-2.3), foot examination (40-64%; 2.7, 1.8-4.1), and lipid assessment (55-66%; 1.6, 1.1-2.3). Mean value of HbA(1c) tended to improve (8.5-8.3%; difference -0.2, 95% CI -0.4 to 0.03). Over 90% of survey respondents stated that the Diabetes Collaborative was worth the effort and was successful. Major challenges included needing more time and resources, initial difficulty developing computerized patient registries, team and staff turnover, and occasional need for more support by senior management.

CONCLUSIONS

The Health Disparities Collaborative improved diabetes care in health centers in 1 year.