Implementing the Chronic Care Model for Improvements in Diabetes Care and Education in a Rural Primary Care Practice

Treatment approaches and costs associated with diabetes clinical metrics as measured by Healthcare Effectiveness Data and Information Set (HEDIS)

BACKGROUND

The clinical outcomes of diabetes can be influenced by primary care providers' (PCP) treatment approaches. This study explores the association between PCP approaches to management and performance measured by established diabetes metrics and related costs.

METHODS

In phase one, Electronic Medical Records were used to extract diabetes related metrics using Healthcare Effectiveness Data and Information Set (HEDIS), for patients with diabetes who had office visits to 44 PCP practices from April 2019 to March 2020. Using those metrics and scoring system, PCP practices were ranked and then categorized into high- and low-performing groups (top and bottom 25%, n = 11 each), with a total of 19,059 clinic visits by patients with a diagnosis of diabetes. Then extensive analysis was performed to evaluate a correlation between treatment approaches and diabetes outcomes across the top and bottom performing practices. In phase 2, patients with diabetes who were attributed to the aforementioned PCP practices were identified in a local health plan claims data base (a total of 3,221 patients), and the allowed amounts from their claims were used to evaluate differences in total and diabetes-related healthcare costs by providers' performance.

RESULTS

Comparing 10,834 visits in high-performing practices to 8,235 visits in low-performing practices, referrals to certified diabetes care and education specialists and provider-to-provider electronic consults (e-consults) were higher in high-performing practices (Z = 6.06, p < .0001), while traditional referrals were higher in low-performing practices (Z = -6.94, p < .0001). The patient-to-provider ratio was higher in the low-performing group (M = 235.23) than in the high-performing group (M = 153.26) (Z = -2.82, p = .0048). Claims data analysis included 1,825 and 1,396 patients from high- and low-performing providers, respectively. The patient-to-provider ratio was again higher in the low-performing group (p = .009, V = 0.62). Patients receiving care from lower-performing practices were more likely to have had a diabetes-related hospital observation (5.7% vs. 3.9%, p = .02; V = 0.04) and higher diabetes-related care costs (p = .002; d = - 0.07); these differences by performance status persisted when controlling for differences in patient and physician characteristics. Patients seeing low-performing providers had higher Charlson Comorbidity Index scores (Mdn = 3) than those seeing high-performing providers (Mdn = 2).

CONCLUSIONS

Referrals to the CDCES and e-Consult were associated with better measured diabetes outcomes, as were certain aspects of cost and types of hospital utilization. Higher patients to providers ratio and patients with more comorbidities were observed in low performing group.

Experiences of care-seeking by schizophrenia patients with delayed diagnosis and treatment in rural China: A qualitative study

BACKGROUND

Patients with schizophrenia in rural areas of China face severe delays in getting appropriate treatment due to poverty, transportation, and limited availability of mental healthcare services. However, the experiences of care-seeking among patients with delayed diagnosis and treatment in rural areas remain poorly understood, and it remains unclear how these experiences influence patients' medical mistrust or expectations of care. This study aims to fill that void.

METHODS

We applied a qualitative phenomenological method. Patients were recruited through purposive sampling at a psychiatric hospital in Harbin, China. Semi-structured, one-to-one interviews were conducted, guided by an interview outline. Thematic analysis was performed using Colaizzi's seven-step method.

RESULTS

Data saturation was achieved after interviewing 13 participants aged 21 to 53 years. Three themes with eight subthemes were identified: (i) Barriers to seeking care, (ii) Feelings for psychiatric treatment, and (iii) Demand for mental healthcare. Several factors that may impede the timely diagnosis and treatment were identified, including patients, physicians, and institutions. The participants described their feelings of adverse treatment experiences, as well as expectations arising from this process. It predominantly covers awareness of the disease, supportive access to care, and geographic accessibility of services.

CONCLUSION

Patients with delayed diagnosis and treatment in rural areas often have negative experiences and various needs for mental health services in the pursuit of effective treatments. Policymakers and health planners should seriously consider the current challenges in rural mental healthcare to develop comprehensive strategies for improving prehospital delays and medical experience for this group of patients.

Examining a Diabetes Self-Management Education and Support Telemedicine Model With High-Risk Patients in a Rural Community

BACKGROUND

Ongoing support is critical to diabetes self-management education and support (DSMES) effectiveness, but difficult to realize, particularly in areas with limited resources. The objective of this feasibility study was to assess the impact of a virtual support model on diabetes outcomes and acceptability with high-risk patients with type 2 diabetes in a rural community.

METHODS

In a 12-month nonrandomized trial in federally qualified health centers (FQHCs), patients with hemoglobin A1c (HbA1c) >9% were referred to the Telemedicine for Reach, Education, Access, Treatment, and Ongoing Support (TREAT-ON) program where a Diabetes Care and Education Specialist provided DSMES through videoconferencing. HbA1c change was compared in 30 patients in the intervention group (IG) to a propensity score-matched retrospective control group (CG) of patients who received in-person DSMES delivered by a DCES. Changes in HbA1c, diabetes distress, empowerment, self-care and acceptability were assessed within the intervention group (IG) between those who did and did not meet self-management goals.

RESULTS

The IG experienced similar significant reductions in HbA1c as the CG. Most (64%) IG participants achieved their self-management goal. Goal attainers had a significant HbA1c decrease of 0.21% every 3 months as well as significant reduction in diabetes distress and improvement in general dietary intake. Regardless of goal attainment, IG participants reported high levels of acceptability with TREAT-ON.

CONCLUSIONS

This feasibility study suggests that TREAT-ON was well-received and as effective as traditional in-person DSMES. While findings augment ample evidence regarding DSMES benefits, the TREAT-ON model offers additional advantages and provides validation for telehealth to inform future practice in reaching and supporting self-management for high-risk patients in underserved areas.

TRIAL REGISTRATION

Clinicaltrials.gov, # NCT04107935.

Factors related to recruitment and retention of patients into diabetes group visits in Federally Qualified Health Centers

RATIONALE, AIMS AND OBJECTIVES: To examine factors related to recruitment of eligible patients and retention of enrolled patients in diabetes group visits (GVs).

METHOD

As part of a cluster randomized trial, 272 eligible patients were contacted and 75 patients were eventually enrolled in GVs at six community health centers (CHC). Fisher's exact tests and χ² tests were used to compare enrolled and nonenrolled patients by patient recruitment method, gender and preferred language. Linear mixed models were used to evaluate characteristics associated with GV attendance such as diabetes self-empowerment and diabetes-associated distress. Content analysis was used to analyse patients' open-ended survey responses, and template analysis was used to analyse CHC staff interviews.

RESULTS

In terms of recruitment and enrollment analysis, patients who received in-person contact only and both phone and in-person contact comprised a greater fraction of the enrolled than unenrolled group, while those who received phone only and both phone and mail comprised a smaller fraction of the enrolled than unenrolled group (p = 0.004). In terms of retention analysis, 70 of the 75 enrolled patients attended at least one GV (93%). The average number of GVs was 3.2 out of 6 visits. Higher GV attendance was associated with lower baseline diabetes empowerment (p = 0.03). Patients' most common self-reported motivating factors to attend GVs were to learn more about diabetes, gain improved blood glucose control and find support from peers.

CONCLUSION

In-person recruitment for GVs at CHCs was more effective than recruitment by telephone/mail. Patients who felt less empowered to manage their diabetes were most motivated to attend GVs. These findings could help clinicians implement targeted recruitment of patient populations who are more likely to attend diabetes GVs and tailor self-management education interventions to their patient populations, particularly for underserved patients who face disparate clinical outcomes.

Diabetes Care Network: A Novel Model to Disseminate Team-Based Diabetes Specialty Care in a Rural Population

PURPOSE

The purpose of the study was to examine the impact of a novel approach to provide diabetes specialty team care to rural patients with type 2 diabetes (T2DM) on clinical outcomes and processes of care.

METHODS

Diabetes Care Network (DCN) provides Veterans with T2DM and elevated A1C an initial 6-week period of remote self-management education and support and medication management by a centrally located team of diabetes specialists. Participants are then comanaged by remote liaisons embedded in rural primary care facilities for the remainder of the 12-month intervention. In this pre-post intervention study, 87 Veterans enrolled in DCN from 2 different clinical sites had baseline and 12-month postenrollment A1C, systolic blood pressure, weight, and LDL cholesterol levels collected and compared using paired t tests.

RESULTS

Participants were mostly male and White with elevated baseline A1C. Participants from both sites had significant improvement in A1C over the 12-month intervention period compared to an increase in the 12 months prior to enrollment. There were also significant improvements in LDL and systolic blood pressure at 1 site, with no significant change in weight at either site.

CONCLUSIONS

DCN participants had significant improvement in A1C after not meeting similar goals previously in a robust primary care setting. A technology-enabled collaborative partnership between centrally located diabetes care teams and local liaisons is a feasible approach to enhance access to diabetes specialty care for rural populations.

Informing a Randomized Control Trial in Rural Populations: Adaptation of a Diabetes Self-Management Education and Support Intervention

BACKGROUND

Over 34 million people in the United States have diabetes, with 1.5 million diagnosed every year. Diabetes self-management education and support (DSMES) is a crucial component of treatment to delay or prevent complications. Rural communities face many unique challenges in accessing DSMES, including geographic barriers and availability of DSMES programs that are culturally adapted to rural context.

OBJECTIVE

Boot Camp Translation (BCT) is an established approach to community-based participatory research used to translate complex clinical and scientific information into concepts, messages, and materials that are understandable, meaningful, and relevant to community members and patients. This study aimed to utilize BCT to adapt an existing DSMES program for delivery in rural primary care for English- and Spanish-speaking people with diabetes.

METHODS

The High Plains Research Network (HPRN) Community Advisory Council (C.A.C.) partnered with researchers at the University of Colorado and University of Utah to use BCT to aid in translating medical jargon and materials from an existing DSMES program, called "Diabetes One Day (D1D)." BCT consisted of 10 virtual meetings over a 6-month period among the C.A.C., which included 15 diverse community stakeholders. Both English-speaking and bilingual Spanish-English-speaking C.A.C. members were recruited to reflect the diversity of the rural communities in which the adapted program would be delivered.

RESULTS

The BCT process guided adaptations to D1D for use in rural settings (R-D1D). R-D1D adaptations reflect both content and delivery to assure that the intervention is appropriate and likely to be accepted by rural English- and Spanish-speaking people with diabetes. Additionally, BCT informed the design of recruitment and program materials and identification of recruitment venues. During the BCT process, the importance of tailoring materials to reflect culture differences in English- and Spanish-speaking patients was identified.

CONCLUSIONS

BCT was an effective strategy for academic researchers to partner with rural community members to adapt an existing DSMES intervention for delivery in rural areas to both English- and Spanish-speaking patients with diabetes. Through BCT, adaptations to recruitment materials and methods, program content and delivery, and supplemental materials were developed. The need to culturally adapt Spanish materials with input from stakeholders rather than simply translate materials into Spanish was highlighted. The importance of increasing awareness of the connection between diabetes and depression or diabetes distress, adaptations to include local foods, and the importance of the relationship between people with diabetes and their primary care practices were identified.

Effect of Comprehensive Multi-Provider Primary Care Visits in Type 2 Diabetes Management in a Primarily Uninsured, Ethnic Minority Population: The Comprehensive Care Initiative (CCI) Program

The Comprehensive Care Initiative (CCI) utilized a quasi-experimental design to evaluate the effects of same room, multi-provider primary care visits on the management of type 2 diabetes (T2D). Patients with T2D were invited to enroll in CCI if they had T2D with glycated hemoglobin (HbA1c) >8.0% or T2D with BMI >30. CCI intervention included delivery of comprehensive same room multi-provider visits with a primary care physician, community health worker, pharmacist, dietitian, medical assistant, and licensed social worker at the same appointment. CCI patients were compared with a propensity score matched control group receiving usual care (n = 56, 50 ± 11 years old, 77% female, 41% African American, 95% uninsured). After 6 months, the adjusted average reduction in HbA1c in the CCI group was 0.97% (SE = 0.45) in comparison to 0.05% (SE = 0.20) in the control group (P = .04). This pilot study showed promising results in lowering HbA1c in an uninsured, ethnic minority population of T2D patients through delivery of comprehensive multi-provider primary care visits.

The Impact of the Filipino Plate Method versus Standard Nutrition Education on Food Group Proportions and 2-hour Postprandial Blood Glucose for Type 2 Diabetes

Objectives

To compare the efficacy of the Filipino plate method against standard nutrition education in the selection of food group proportions and in reducing 2-hour postprandial blood glucose levels (2h-PPG) among patients with type 2 diabetes.

Methodology

This randomized, open-label trial assigned 148 subjects with type 2 diabetes to receive nutrition education using either the Filipino plate method or standard nutrition education, as recommended by the American Diabetes Association (ADA). The subjects were given meals before and three days after the intervention, at which time the contents of their plate were scored based on food group proportions. After the meal, 2h-PPG levels were obtained. Pre- and post-intervention plate scores and 2h-PPG were compared in both groups.

Results

Plate scores were significantly increased from pre to post-teaching for both groups (p value <0.001). There was no statistically significant difference in post-teaching scores between the two modes of nutrition education (Filipino plate method median score 8/9 vs standard nutrition education 7/9, p=0.018). The 2h-PPG results decreased significantly from baseline to post-teaching for both groups (p=0.008). There was no significant difference in the reduction in 2h-PPG between the two groups (p=.741).

Conclusion

The Filipino plate method was comparable to standard nutrition education in improving food group choices and proportions as well as 2h-PPG in patients with type 2 diabetes.

Differences in Secure Messaging, Self-management, and Glycemic Control Between Rural and Urban Patients: Secondary Data Analysis

BACKGROUND

Rural patients with diabetes have difficulty accessing care and are at higher risk for poor diabetes management. Sustained use of patient portal features such as secure messaging (SM) can provide accessible support for diabetes self-management.

OBJECTIVE

This study explored whether rural patients' self-management and glycemic control was associated with the use of SM.

METHODS

This secondary, cross-sectional, mixed methods analysis of 448 veterans with diabetes used stratified random sampling to recruit a diverse sample from the United States (rural vs urban and good vs poor glycemic control). Administrative, clinical, survey, and interview data were used to determine patients' rurality, use of SM, diabetes self-management behaviors, and glycemic control. Moderated mediation analyses assessed these relationships.

RESULTS

The sample was 51% (n=229) rural and 49% (n=219) urban. Mean participant age was 66.4 years (SD 7.7 years). More frequent SM use was associated with better diabetes self-management (P=.007), which was associated with better glycemic control (P<.001). Among rural patients, SM use was indirectly associated with better glycemic control through improved diabetes self-management (95% CI 0.004-0.927). These effects were not observed among urban veterans with diabetes (95% CI -1.039 to 0.056). Rural patients were significantly more likely than urban patients to have diabetes-related content in their secure messages (P=.01).

CONCLUSIONS

More frequent SM use is associated with engaging in diabetes self-management, which, in turn, is associated with better diabetes control. Among rural patients with diabetes, SM use is indirectly associated with better diabetes control. Frequent patient-team communication through SM about diabetes-related content may help rural patients with diabetes self-management, resulting in better glycemic control.

Challenges of Shifting Diabetes Mellitus Care From Secondary- to Primary-Level Care in Urban and Rural Districts: A Qualitative Inquiry Among Health Providers

Objectives: The study aims to understand the acceptability of Prolanis, a program that shifts the diabetes mellitus type 2 (T2DM) patient management from secondary to primary care, among Indonesian primary health care providers. Method: We completed face-to-face semistructured interviews with 14 health professionals from 3 urban and 4 rural government-owned primary health care clinics (Puskesmas) in 4 districts. We performed content analysis using the theoretical framework of acceptability (TFA) to understand which factors could facilitate or reduce acceptability. Results: Our study identifies that lack of health care providers’ acceptability to Prolanis was attributable to the negative affective attitude, low perceived effectiveness, poor self-efficacy, and work burden. The use of Prolanis output as one of the pay-for-performance indicators was deemed unsuitable because it could demotivate health providers to capture more undetected T2DM cases. This, compounded by lacking perceived benefit for the health care providers, leading to negative attitudes. Participants believed that the program improved patients’ adherence to visiting clinics routinely; however, the absence of a formal evaluation of reductions of key T2DM indicators—blood glucose level and HbA1c—causing the health providers to doubt the program effectiveness. Availability of or access to adequate blood glucose testing equipment is also of paramount importance to improve acceptability. Although the significant increase in patient load only occurred to Puskesmas with lacking doctors, an increased workload burden due to clerical works was experienced by the nonmedical workforce. The program appears to be more acceptable for health care providers in urban Puskesmas compared with their rural counterparts, attributable to better geographical accessibility and care-seeking behavior among people living in urban locations. Conclusions: This study highlights critical issues that should be addressed to improve the acceptability of Prolanis among health care professionals. Government or stakeholders play a critical role in improving program acceptability. More study is needed to capture wider variety of health care facilities’ characteristics.

Effect of a Primary Care-Based Diabetes Education Model on Provider Referrals and Patient Participation

PURPOSE

The purpose of this study was to evaluate the impact of a primary care (PC)-based delivery model on diabetes self-management education and support (DSMES) referrals and participation. Despite evidence that DSMES is a critical component of diabetes care, referrals and participation remain low.

METHODS

PC practices were assigned to the intervention (n = 6) or usual care (n = 6). Intervention practices had direct access to a diabetes educator (DE) and applied patient-centered medical home elements to DSMES delivery. Usual care practices referred patients to traditional hospital-based outpatient DSMES programs. DSMES referrals and participation were examined for patients with diabetes, 18 to 75 years old, presenting to PC over 18 months (n = 4,894) and compared between groups.

RESULTS

Compared to the usual care group, a higher percentage of patients in the intervention practices were referred to DSMES (18.4% vs 13.4%; P < .0001), and of those referred, a higher percentage of patients in the intervention practices participated in DSMES (34.9% vs 26.1%; P = .02). Patient-level factors predicting referrals were obesity (odds ratio [OR] = 1.6), higher A1C (OR = 1.4), female (OR = 1.3), and younger age (OR = 0.98). The only patient-level factor that predicted DSMES participation was lower A1C (OR = 0.9).

CONCLUSIONS

This study demonstrates the positive influence of a PC-based intervention on DSMES referral and participation. However, modest improvements in DSMES rates, even with targeted efforts to address reported barriers, raise questions as to what is truly needed to drive meaningful change.

Meal replacement in dietary management of type-2 diabetes mellitus: a scoping review protocol

BACKGROUND

The prevalence of type-2 diabetes mellitus (T2DM) has been increasing globally. Without proper management, T2DM can develop into serious complications and even death. Diet modification is one of the most effective tools in managing T2DM at the early stage, but it requires knowledge and compliance from the patients. Thus, meal replacement (MR) has gained its popularity as a tool for diet modification to improve glycemic control and also reducing weight in T2DM patients. There are several existing meal replacement studies but not much is known on the general scope and effect of these existing MRs. Hence, this review is aimed to provide an overview of the existing evidences regarding the application of meal replacement on T2DM patients and identify the gaps or limitations in the studies.

METHODOLOGY

The scoping review will be carried out in six stages: (1) identifying the research question, (2) identifying relevant studies through electronic databases (i.e., PubMed, Scopus, Cochrane Reviews, Google Scholar, EBSCOHOST, Science Direct) and also gray literature, and (3) selection of studies to be included based on inclusion criteria. Search and initial screening of studies to be included will be conducted by two independent reviewers. Discrepancies will then be solved through discussion with other reviewers; (4) charting and categorizing extracted data in a pretested data extraction form; (5) collating, summarizing, and reporting the results; and lastly, (6) conducting consultation with stakeholders and experts in diabetes.

DISCUSSION

This scoping review protocol is aimed to provide a framework enabling us to map and summarize the findings from existing studies involving meal replacement. It will help researchers to identify the research gap and provide recommendations for future meal replacement studies. The results from this scoping review will be useful to various stakeholders in healthcare. It is also part of a research project in which the information obtained will be utilized in a clinical trial of a developed meal replacement plan. Dissemination of knowledge will also be done through presentations at related scientific conferences.

Impact of Quality Improvement (QI) Program on 5-Year Risk of Diabetes-Related Complications: A Simulation Study

OBJECTIVE

We successfully implemented the American Diabetes Association's (ADA) Diabetes INSIDE (INspiring System Improvement with Data-Driven Excellence) quality improvement (QI) program at a university hospital and safety-net health system (Tulane and Parkland), focused on system-wide improvement in poorly controlled type 2 diabetes (HbA1c >8.0% [64 mmol/mol]). In this study, we estimated the 5-year risk reduction in complications and mortality associated with the QI program.

RESEARCH DESIGN AND METHODS

The QI implementation period was 1 year, followed by the postintervention period of 6 months to evaluate the impact of QI on clinical measures. We measured the differences between the baseline and postintervention clinical outcomes in 2,429 individuals with HbA1c >8% (64 mmol/mol) at baseline and used the Building, Relating, Assessing, and Validating Outcomes (BRAVO) diabetes model to project the 5-year risk reduction of diabetes-related complications under the assumption that intervention benefits persist over time. An alternative assumption that intervention benefits diminish by 30% every year was also tested.

RESULTS

The QI program was associated with reductions in HbA1c (-0.84%) and LDL cholesterol (LDL-C) (-5.94 mg/dL) among individuals with HbA1c level >8.0% (64 mmol/mol), with greater reduction in HbA1c (-1.67%) and LDL-C (-6.81 mg/dL) among those with HbA1c level >9.5% at baseline (all P < 0.05). The implementation of the Diabetes INSIDE QI program was associated with 5-year risk reductions in major adverse cardiovascular events (MACE) (relative risk [RR] 0.78 [95% CI 0.75-0.81]) and all-cause mortality (RR 0.83 [95% CI 0.82-0.85]) among individuals with baseline HbA1c level >8.0% (64 mmol/mol), and MACE (RR 0.60 [95% CI 0.56-0.65]) and all-cause mortality (RR 0.61 [95% CI 0.59-0.64]) among individuals with baseline HbA1c level >9.5% (80 mmol/mol). Sensitivity analysis also identified a substantially lower risk of diabetes-related complications and mortality associated with the QI program.

CONCLUSIONS

Our modeling results suggest that the ADA's Diabetes INSIDE QI program would benefit the patients and population by substantially reducing the 5-year risk of complications and mortality in individuals with diabetes.

The Effect of Care Provided at Home by Public Health Nurse on Control of Type II Diabetes Mellitus

AIM

The aim of the study was to examine the effect of home care provided for patients with type II diabetes by public health nurse on HbA1c, and to investigate the opinions of these patients regarding diabetes.

METHOD

The quantitative aspect of the study consisted of a pre and posttest with the control group; the qualitative aspect consisted of a semi-structured interviewing technique. The sample size was 48 patients receiving treatment within the clinic of hospital during 11th-30th April 2016. Because some patients were excluded from the study, the research was completed with a sample size of 20 for the experiment and 20 for the control group. The following forms were used during data: Pre and post measurement and qualitative interview forms. A total of seven home visits were conducted for the experiment group and two home visits for the control group, during 2nd May to 27th October, 2016.

RESULTS

HbA1c decreased by 0.75% in the experiment group (p<0.05). It was found that faulty usage of insulin was treated; all patients developed the habit of tracking blood glucose. Blood glucose of three patients continued to remain at high levels, and most of the patients failed to develop healthy eating habits and regular exercising.

CONCLUSION

According to these results, it is advised that long-term interventions be planned with the contributions of other experts.

Challenges to Introducing Integrated Diabetes Care to an Inner-Regional Area in South Western Sydney, Australia

Introduction

Diabetes care often requires collaboration between general practitioners, allied health professionals, nurses, and/or medical specialists. This study aimed to describe the establishment of an integrated diabetes prevention and care approach in an area with limited access to primary and secondary care, and the challenges faced in its initial development.

Description

A qualitative research approach to identify challenges was taken. Data included meeting minutes, observational data and reports involving local clinical and non-clinical stakeholders from June 2016- December 2018 and were thematically analysed.

Discussion

Key challenges were low patient attendance in general practice, healthcare professional time, low participation at health promotion activities/peer support groups and diabetes education reflecting a low priority among people with and at risk of diabetes. Coordination between services remained a challenge.

Conclusion

This study highlights the need to integrate new diabetes services with existing health activities in the community and the importance of allowing flexibility and regular contact with local healthcare professional and community to encourage their involvement. Regular meetings with the funders, internal and external stakeholders are key for sustainability and to adapt programmes to the local situation. Further work is needed to identify and implement strategies to overcome these challenges.

The Manage Care Model - Developing an Evidence-Based and Expert-Driven Chronic Care Management Model for Patients with Diabetes

BACKGROUND

Most current care models are disease- or symptom-focused and mostly do not account for the individual needs of patients with chronic diseases. The aim of this study was to develop an innovative, evidence-based and expert-based practice model for the management of patients with type 2 diabetes mellitus.

METHOD

An iterative approach was used combining systematic literature search with qualitative methods, including a standardised survey of experts in chronic care (n = 92), an expert workshop of professionals (n = 22) and a multilingual online survey (n = 659). Using three consensus meetings involving researchers, policy makers and experts in chronic care, a limited number of core components and care recommendations was set up to develop a new chronic care model.

RESULTS

The developed 'MANAGE CARE MODEL' includes aspects of the health and social care system, resources derived from the living environment, aspects of health promotion and prevention, as well as an expanded understanding of improved outcomes as an integral part of chronic care.

CONCLUSION

The MANAGE CARE MODEL provides guidance for the development and implementation of chronic care programs, regional networks and national strategies. Future research is needed to validate the model as an instrument of regional chronic care management.

Impact of diabetes education teams in primary care on processes of care indicators

AIMS

To evaluate the impact of the integration of onsite diabetes education teams in primary care on processes of care indicators according to practice guidelines.

METHODS

Teams of nurse and dietitian educators delivered individualized self-management education counseling in 11 Ontario primary care sites. Of the 771 adult patients with HbA1c ≥7% who were recruited in a prospective cohort study, 487 patients attended appointments with the education teams, while the remaining 284 patients did not (usual care group). Baseline demographic, clinical information, and patient care processes (diabetes medical visit, HbA1c test, lipid profile, estimated glomerular filtration rate, and albumin-to-creatinine ratio, measuring blood pressure, performing foot exams, provision of flu vaccine, and referral for dilated retinal exam) were collected from patient charts one year before (pre period) and after (post period) the integration began. A multi-level random effects model was used to analyze the effect of group and period on whether the process indicators were met based on practice guidelines.

RESULTS

Compared to the usual care group, patients seen by the education teams had significant improvements on indicators for semi-annual medical visit and annual foot exam. No significant improvements were found for other process of care indicators.

CONCLUSIONS

Onsite education teams in primary care settings can potentially improve diabetes management as shown in two process of care indicators: medical visits and foot exams. The results support the benefits of having education teams in primary care settings to increase adherence to practice guidelines.

Evaluating the impact of onsite diabetes education teams in primary care on clinical outcomes

BACKGROUND

To evaluate the impact of integrating diabetes education teams in primary care on glycemic control, lipid, and blood-pressure management in type 2 diabetes patients.

METHODS

A historical cohort design was used to assess the integration of teams comprising nurse and dietitian educators in 11 Ontario primary-care sites, which delivered individualized self-management education. Of the 771 adult patients with A1C ≥ 7% recruited, 487 patients attended appointments with the diabetes teams, while the remaining 284 patients did not. The intervention's primary goal was to increase the proportion of patients with A1C ≤7%. Secondary goals were to reduce mean A1C, low-density lipoprotein, total cholesterol-high density lipoprotein, and diastolic and systolic blood pressure, as recommended by clinical-practice guidelines.

RESULTS

After 12 months, a higher proportion of intervention-group patients reached the target for A1C, compared with the control group. Mean A1C levels fell significantly among all patients, but the mean reduction was larger for the intervention group than the control group. Although more intervention-group patients reached targets for all clinical outcomes, the between-group differences were not statistically significant, except for A1C.

CONCLUSIONS

Nurse and dietitian diabetes-education teams can have a clinically meaningful impact on patients' ability to meet recommended A1C targets. Given the study's historical cohort design, results are generalizable and applicable to day-to-day primary-care practice. Longer follow-up studies are needed to investigate whether the positive outcomes of the intervention are sustainable.

A Diabetes Education Model in Primary Care: Provider and Staff Perspectives

Purpose

The purpose of this qualitative study was to explore the effectiveness of Glucose to Goal (G2G), a diabetes self-management education and support (DSMES) model for primary care (PC).

Methods

PC providers and staff were recruited from 5 PC practices participating in the 18-month intervention to participate in focus groups and interviews, which were used to gain insights about their perspectives on DSMES and how G2G was implemented across the intervention. Data were collected by qualitative researchers at baseline, midpoint, and study completion.

Results

At baseline, PC participants held a favorable view of DSMES and welcomed having a diabetes educator (DE) in their practice. Most participants suggested DEs would be helpful in meeting patients’ nutrition needs but should give therapeutic advice only with a doctor’s oversight. Participants anticipated that having a DE onsite would mitigate transportation, scheduling, communication, and cost barriers. Participant viewpoints about G2G remained unchanged from midpoint to study end, while barriers regarding location and transportation were perceived as being reduced by having a DE in the practice. Despite referral rates remaining low in some practices, many concerns stated at earlier timepoints appeared to have been attenuated by G2G components (eg, bringing the DE onsite, preidentifying patients, and DE ability to communicate and make diabetes management recommendations).

Conclusions

This study demonstrates that G2G, providing DSMES in PC, appeared to be a welcome service where acceptance of and enthusiasm for the model grew over the course of the intervention.

Conformity of Diabetes Mobile apps with the Chronic Care Model

Background

Despite the growing use of mobile applications (apps) for chronic disease management, the evidence on the effectiveness of this technology on clinical and behavioural outcomes of the patients is scant. Many studies highlight the importance of the theoretical foundations of mobile-based interventions. One of the most widely accepted models for the management of chronic diseases, such as diabetes, is the Chronic Care Model (CCM). In this study, we investigated the conformity of the selected diabetes mobile apps with CCM.

Method

We searched online journal databases related to diabetes mobile apps to find common features. Then considering the components of the CCM as a reference model, features of some popular and top-ranking apps were compared with CCM.

Results

Among 23 studied apps, 34 per cent of them had medium conformity and 66 per cent of these apps were in weak conformity. The self-management support component is covered by 100 per cent of them. Ninety-five per cent of apps have covered the proactive follow-up component.

Conclusions

App conformance with CCM is generally weak. App developers are recommended to give greater consideration to established theoretical models in their design and implementation.

Efficacy of intermittent empagliflozin supplementation on dietary self-management and glycaemic control in patients with poorly controlled type 2 diabetes: A 24-week randomized controlled trial

AIMS

To explore the effects of intermittent use of empagliflozin, a sodium-glucose co-transporter-2 inhibitor, on dietary self-management and glycaemic control in patients with inadequately controlled type 2 diabetes.

MATERIALS AND METHODS

We conducted a prospective, randomized, open-label, blinded-endpoint, parallel-group, comparative clinical trial of 50 patients with type 2 diabetes, treated with no more than three oral antidiabetic drugs (glycated haemoglobin [HbA1c] ≥52 mmol/mol but <86 mmol/mol). The participants were randomized to take 10 mg/d empagliflozin either every day (regular group, n = 25) or on the day on which they considered they had overeaten (intermittent group, n = 25) for 24 weeks. We limited empagliflozin prescription to half of the required period in the intermittent group. The primary endpoint was change in HbA1c at the end of the 24-week treatment period relative to baseline. The secondary outcomes included changes in body weight, daily energy intake and diabetes treatment-related quality of life (QoL). Energy intake was assessed using a diet-specific validated questionnaire rather than actual assessments of food intake.

RESULTS

The intake rate of empagliflozin was 96.7 ± 7.2% for the regular group and 45.7 ± 7.0% for the intermittent group. Interestingly, ΔHbA1c was identical in the two groups (-0.64 ± 0.19% and - 0.65 ± 0.17%, respectively). Body weight decreased (-2.72 ± 0.52 and - 1.50 ± 0.45 kg, respectively) and diabetes treatment-related QoL increased significantly from baseline in both groups. Energy intake, however, decreased significantly only in the intermittent group (-221.0 ± 108.3 kcal/d).

CONCLUSIONS

Intermittent empagliflozin supplementation is a useful therapeutic option that empowers dietary self-management, improves glycaemic control and is accompanied by body weight loss and an increase in diabetes treatment-related QoL in patients with inadequately controlled type 2 diabetes.

Overcoming Challenges of Implementing Chronic Care Model in Diabetes Management: An Action Research Approach

Background:

Reforming the health care system to improve suitable health care model for diabetic patients is essential. This study aimed to implement, identify, and overcome the challenges of implementing the Chronic Care Model in diabetes management in a clinic.

Methods:

This study is a qualitative technical action research with the Kemmis and McTaggart model including planning, action, reflection, observation, and revision plan which was conducted in the specialized polyclinic from 2015 to 2017 in Isfahan city – Iran. Data were gathered through qualitative and quantitative methods. Diabetes team and 17 patients with type 2 diabetes participated in semi-structured interviews that were purposively chosen. Qualitative data were analyzed using content analysis and then quantitative data collected.

Results:

The qualitative findings of this research are in five main categories: System design upgrade, self-management upgrade, decision support, health care organization, and clinical information system upgrade. Results of quantitative data showed that most metabolic indicators like HbA1c have statistical meaningful changes (P value < 0.05).

Conclusions:

Implementing the Chronic Care Model became feasible despite serious challenges and two groups of ready and active team and active patients were developed. The study showed that one important lost link of diabetes management is underestimating the nurses’ capabilities in the management of this disease. Inevitably, serious investment on maximum use of nurses’ knowledge and skills in improving diabetes management will help diabetes care upgrade significantly.

Benefits and limitations of implementing Chronic Care Model (CCM) in primary care programs: A systematic review

BACKGROUND

Chronic Care Model (CCM) has been developed to improve patients' health care by restructuring health systems in a multidimensional manner. This systematic review aims to summarize and analyse programs specifically designed and conducted for the fulfilment of multiple CCM components. We have focused on programs targeting diabetes mellitus, hypertension and cardiovascular disease.

METHOD AND RESULTS

This review was based on a comprehensive literature search of articles in the PubMed database that reported clinical outcomes. We included a total of 25 eligible articles. Evidence of improvement in medical outcomes and the compliance of patients with medical treatment were reported in 18 and 14 studies, respectively. Two studies demonstrated a reduction of the medical burden in terms of health service utilization, and another two studies reported the effectiveness of the programs in reducing the risk of heart failure and other cardiovascular diseases. However, CCMs were still restricted by limited academic robustness and social constraints when they were implemented in primary care. Higher professional recognition, tighter system collaborations and increased financial support may be necessary to overcome the limitations of, and barriers to CCM implementation.

CONCLUSION

This review has identified the benefits of implementing CCM, and recommended suggestions for the future development of CCM.

Cost-effectiveness of telemonitoring screening for diabetic foot ulcer: a mathematical model

BACKGROUND

One of the most common (and costly) complications of diabetes are diabetic foot ulcers, which often result in lower-extremity amputation. Regular foot care can reduce complications; however, roughly half of Canadians with diabetes do not participate in screening. We sought to evaluate the economic effects of using telemonitoring for diabetic foot ulcer prevention using mathematical modelling.

METHODS

We used Markov modelling to compare current screening standards (standard care) to population-wide and targeted (high-risk) telemonitoring programs in a hypothetical cohort of Canadian patients aged 60 years. We varied the effectiveness (or outcome), defined as the proportion of diabetic foot ulcers prevented, to explore cost-effectiveness using model parameters from published literature and clinical experts.

RESULTS

At 20%-40% effectiveness, population-based prevention resulted in 0.00399-0.00790 quality-adjusted life years (QALYs) gained per person over 5 years and an incremental cost of $479-$402 compared to standard care. At 15%-40% effectiveness, high-risk prevention resulted in a cost decrease per person over 5 years ($1.26-$25.55), with health benefits of 0.000207-0.00058 QALYs gained.

INTERPRETATION

The use of telemonitoring in the diabetic lower extremity can offer patients better quality of life and can be cost-effective compared to current Canadian screening practices. Future work should focus on developing and validating technologies based on objective outcome measures for remote monitoring of the diabetic foot.

Putting the pieces together: EHR communication and diabetes patient outcomes

OBJECTIVES

This study seeks to determine how changes in electronic health record (EHR) communication patterns in primary care teams relate to quality of care and costs for patients with diabetes.

STUDY DESIGN

EHR-extracted longitudinal observational study.

METHODS

A total of 83 health professionals in 19 care teams at 4 primary care clinics associated with a large Midwestern university participated in the study. Counts of messages routed between any 2 team members in the EHR in the past 18 months were extracted. Flow-betweenness, defined as the proportion of information passed indirectly within the team, was calculated. The analysis related changes in team flow-betweenness to changes in emergency department visits, hospital stays, and associated medical costs for the teams' patients with diabetes, while adjusting for team face-to-face communication, patient-level covariates, comorbidities, team size, and clinic fixed effects.

RESULTS

Patient hospital visits increased by 13% (standard error [SE] = 6%) for every increase of 1 percentage point in team EHR message forwarding (ie, higher team flow-betweenness). Medical costs increased by $223 (SE = $105) per patient with diabetes in the past 6 months for every increase of 1 percentage point in team flow-betweenness.

CONCLUSIONS

Primary care teams whose EHR communication reached more team members indirectly (ie, via message forwarding) had worse outcomes and higher medical costs for their patients with diabetes. EHR team communication flow patterns may be an important avenue to explore in raising quality of care and lowering costs for patients with diabetes in primary care.

The role of the chronic care model in promoting the management of the patient with rare liver disease

INTRODUCTION

The chronic care model (CCM) provides a holistic approach for managing chronic illnesses. Patients with rare liver diseases (RLD) have complex needs, impaired quality of life and often life-threatening complications. Most RLD meet the criteria for a long-term chronic condition and should be viewed through the prism of CCM. We aimed to ascertain whether the CCM has been considered for the frequently-encountered RLD.

METHODS

MEDLINE®/PubMed®/Cochrane/EMBASE were searched to identify publications relating to the use of the CCM for the management of six RLD. We identified 33 articles eligible for inclusion.

RESULTS

Six, eleven, one, thirteen, two and zero studies, discussed individual components of the CCM for autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), primary sclerosing cirrhosis (PSC), Wilsons disease (WD), alpha-1 antitrypsin deficiency (A1AD) and lysosomal acid lipase deficiency (LALd) respectively. We have not identified studies using the full CCM for any of the aforementioned RLD.

DISCUSSION

Unlike in common chronic conditions e.g. diabetes, there has been limited consideration of the use of CCM (or its components) for the management of RLD. This may reflect a reluctance of the clinical community to view these diseases as chronic or lack of healthcare policy investment in rare diseases in general.

Effectiveness of self-management support interventions for people with comorbid diabetes and chronic kidney disease: a systematic review and meta-analysis

BACKGROUND

Self-management support interventions may potentially delay kidney function decline and associated complications in patients with comorbid diabetes and chronic kidney disease. However, the effectiveness of these interventions remains unclear. We investigated the effectiveness of current self-management support interventions and their specific components and elements in improving patient outcomes.

METHODS

Electronic databases were systematically searched from January 1, 1994, to December 19, 2017. Eligible studies were randomized controlled trials on self-management support interventions for adults with comorbid diabetes and chronic kidney disease. Primary outcomes were systolic blood pressure, diastolic blood pressure, estimated glomerular filtration rate, and glycated hemoglobin. Secondary outcomes included self-management activity, health service utilization, health-related quality of life, medication adherence, and death.

RESULTS

Of the 48 trials identified, eight studies (835 patients) were eligible. There was moderate-quality evidence that self-management support interventions improved self-management activity (standard mean difference 0.56, 95% CI 0.15 to 0.97, p < 0.007) compared to usual care. There was low-quality evidence that self-management support interventions reduced systolic blood pressure (mean difference - 4.26 mmHg, 95% CI - 7.81 to - 0.70, p = 0.02) and glycated hemoglobin (mean difference - 0.5%, 95% CI - 0.8 to - 0.1, p = 0.01) compared to usual care.

CONCLUSIONS

Self-management support interventions may improve self-care activities, systolic blood pressure, and glycated hemoglobin in patients with comorbid diabetes and chronic kidney disease. It was not possible to determine which self-management components and elements were more effective, but interventions that utilized provider reminders, patient education, and goal setting were associated with improved outcomes. More evidence from high-quality studies is required to support future self-management programs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015017316 .

Changes in diabetes care introduced by a Chronic Care Model-based programme in Tuscany: a 4-year cohort study

Background

In 2010, Tuscany (Italy) implemented a Chronic Care Model (CCM)-based programme for the management of chronic diseases. The study’s objective was to evaluate its impact on the care of patients with type 2 diabetes.

Methods

A population-based cohort study was performed on patients with diabetes, identified by an administrative data algorithm, exposed to a CCM-based programme versus patients not exposed (8486 patients in each group). The groups were matched using a propensity score approach and observed from 2011 to 2014. The outcomes measured were: mortality rate and hazard ratio (HR), hospitalisation incidence rate (IR) (all causes and diabetes-related diseases) and incidence rate ratio (IRR), and Guideline Composite Indicator (GCI) as proxy of adherence to guidelines (IR and IRR). Stratified Cox regression analysis and conditional fixed effect Poisson regression analyses were performed to compute HR and IRR.

Results

A significant improvement was observed for GCI (IRR 1.58; 95% CI 1.53–1.62) and for cardiovascular long-term complications (IRR 1.11; 95% CI 1.04–1.18). A protective effect was observed for neurological long-term complications (IRR 0.85; 95% CI 0.76–0.95), acute cardio-cerebrovascular long-term complications—stroke and ST segment elevation myocardial infarction—(IRR 0.81; 95% CI 0.71–0.92) and mortality (HR 0.88; 95% CI 0.81–0.96).

Conclusion

The implementation of a CCM-based programme was followed by better management and benefits for the health status of patients. The increase in hospitalisations for cardiovascular long-term complications could engender cost-efficacy issues, but a better integrated care (GPs and specialists) and a more appropriate specialist outpatient services organisation could avoid a part of these, while still maintaining the benefits seen.

Conceptualization of the Chronic Care Model: Implications for Home Care Case Manager Practice

One of the greatest challenges for healthcare systems is the management and prevention of chronic diseases. Wagner's Chronic Care Model aims to transform the daily care of patients with chronic illnesses from acute and reactive to proactive, planned, and population-based. The purpose of this article is to provide a review of the available research relating to the Chronic Care Model and consider the implications for Home Care Case Management practice. A total of 18 research studies (5 qualitative and 13 quantitative) were reviewed. A thematic content analysis approach was used. The findings included three themes: Chronic Care Model and positive chronic illness health behaviors and outcomes; Chronic Care Model and delivery of quality chronic illness care; and the importance of the supportive role of the home care nurse in the role of Home Care Case Management. Gaps and limitations of the Chronic Care Model in relation to Home Care Case Management were identified and discussed in relationship to partnership building and reciprocal trust between patients, family caregivers, and the Home Care Case Manager. Finally, implications for the use of the Chronic Care Model in Home Care Case Manager practice, policy development, and future research were presented.

Considerations for developing chronic care system for traumatic brain injury based on comparisons of cancer survivorship and diabetes management care

Experts in traumatic brain injury (TBI) rehabilitation recently proposed the framing of TBI as a chronic disease rather than a discrete event. Within the framework of the Chronic Care Model (CCM), a systematic comparison of three diseases - cancer survivorship, diabetes management and TBI chronic care - was conducted regarding chronic needs and the management of those needs. In addition, comparisons of these conditions require comparative evaluations of disease management characteristics and the survivor concept. The analysis found diabetes is more established within the CCM, where care is integrated across specialists and primary care providers. No single comparison provides a full analogue for understanding the chronic care health delivery system for TBI, indicating the need for a separate model to address needs and resources for TBI survivors. The findings from this research can provide practitioners with a context to develop a robust continued care health system for TBI. Practitioner Summary: We examine development of a chronic care system for traumatic brain injury. We conducted a systematic comparison of Chronic Care Model elements of decision and information support. Development of capabilities using a benchmark of diabetes care, with additional insights from cancer care, provides insights for implementing TBI chronic care systems.

Optimizing Glycemic Control in Adults With Type 1 or Type 2 Diabetes Attending a Multidisciplinary Foot Clinic

OBJECTIVES

To determine the impact of a diabetes nurse educator (DNE) on glycemic control in a multidisciplinary diabetes foot (MDF) clinic.

METHODS

A prospective cohort trial to measure the impact of a DNE on glycemic control was conducted in an MDF clinic. Change in glycated hemoglobin (A1C) levels over time was measured against the percentage of patient visits (PPVs) accompanied by a glucose meter and/or diary.

RESULTS

Increasing PPVs were significantly associated with decline in A1C levels in females. Every 10% increase in PPVs resulted in a 0.18% decrease in A1C levels (p<0.0001). To achieve a clinically important decrease of 1% in A1C levels, a 56% increase in PPVs was required. Increased A1C levels were significantly associated with higher baseline A1C levels (p<0.001) and increased hospital days for foot complications (p<0.0052).

CONCLUSIONS

Regular, face-to-face contact with a DNE in an MDF clinic has a positive impact on glycemic control in females.

Individualising Chronic Care Management by Analysing Patients' Needs - A Mixed Method Approach

Background

Modern health systems are increasingly faced with the challenge to provide effective, affordable and accessible health care for people with chronic conditions. As evidence on the specific unmet needs and their impact on health outcomes is limited, practical research is needed to tailor chronic care to individual needs of patients with diabetes. Qualitative approaches to describe professional and informal caregiving will support understanding the complexity of chronic care. Results are intended to provide practical recommendations to be used for systematic implementation of sustainable chronic care models.

Method

A mixed method study was conducted. A standardised survey (n = 92) of experts in chronic care using mail responses to open-ended questions was conducted to analyse existing chronic care programs focusing on effective, problematic and missing components. An expert workshop (n = 22) of professionals and scientists of a European funded research project MANAGE CARE was used to define a limited number of unmet needs and priorities of elderly patients with type 2 diabetes mellitus and comorbidities. This list was validated and ranked using a multilingual online survey (n = 650). Participants of the online survey included patients, health care professionals and other stakeholders from 56 countries.

Results

The survey indicated that current care models need to be improved in terms of financial support, case management and the consideration of social care. The expert workshop identified 150 patient needs which were summarised in 13 needs dimensions. The online survey of these pre-defined dimensions revealed that financial issues, education of both patients and professionals, availability of services as well as health promotion are the most important unmet needs for both patients and professionals.

Conclusion

The study uncovered competing demands which are not limited to medical conditions. The findings emphasise that future care models need to focus stronger on individual patient needs and promote their active involvement in co-design and implementation. Future research is needed to develop new chronic care models providing evidence-based and practical implications for the regional care setting.

US Nurses’ Perceptions of Their Role in Diabetes Care

PURPOSE

The purpose of this study was to examine nurse and physician perceptions of nurse involvement and roles in diabetes care.

METHODS

The study used a cross-sectional design with face-to-face or telephone interviews of diabetes health care professionals in 13 countries from Asia, Australia, Europe, and North America. This article focuses on the data from US health care providers. The US sample included 51 generalist nurses, 50 diabetes specialist nurses, 166 generalist physicians, and 50 diabetes specialist physicians.

RESULTS

Nurses and physicians agreed that nurses should take a larger role in managing diabetes. Most common differences identified between nurses and physicians were that nurses provide better education, spend more time with patients, were better listeners, and knew their patients better than physicians. All nurses had a high perceived need for better understanding of psychosocial issues and were more likely than physicians to suggest helping patients to take responsibility for their care. Nurses more than physicians also said better communication was needed. Generalist nurses report that they act as intermediaries and facilitate patient appointment keeping. Specialist nurses talk to patients about self-management, teach medication management, have a higher level of involvement in medication prescribing, and are more willing to take on additional responsibilities than generalist nurses.

CONCLUSIONS

There is an increased need for more involvement by nurses, particularly specialist nurses, in diabetes care.

Inpatient Diabetes Management in the Twenty-First Century

In hospitalized patients, both hyperglycemia and hypoglycemia have been associated with poor outcomes. During the inpatient period, hyperglycemia has been associated with increased risk of infection, cardiovascular events, and mortality. It is also associated with longer length of hospital stay. Hypoglycemia has also been associated with an increased risk of mortality. Therefore, current evidence supports avoidance of both conditions among hospitalized patients whether they are admitted to critical care units or noncritical care units.

A Shared Decision-Making Approach to Telemedicine: Engaging Rural Patients in Glycemic Management

Telemedicine can connect specialist health care providers with patients in remote and underserved areas. It is especially relevant in diabetes care, where a proliferation of treatment options has added further complexity to the care of an already complex, highly prevalent disease. Recent developments in health reform encourage delivery systems to use team-based models and engage patients in shared decision-making (SDM), where patients and providers together make health care decisions that are tailored to the specific characteristics and values of the patient. The goal of this project was to design, integrate, and evaluate a team-based, SDM approach delivered to patients with diabetes in a rural community, building upon the previously established telemedicine for reach, education, access, and treatment (TREAT) model. Patients in this feasibility study demonstrated improvement in hemoglobin A1c values, and reported better understanding of diabetes. Providers reported the SDM aids increased cohesion among team members (including patients) and facilitated patient education and behavioral goal setting. This project demonstrated that SDM could be integrated into the workflow of a telemedicine team visit with good provider and patient satisfaction.

Primary care team communication networks, team climate, quality of care, and medical costs for patients with diabetes: A cross-sectional study

BACKGROUND

Primary care teams play an important role in providing the best quality of care to patients with diabetes. Little evidence is available on how team communication networks and team climate contribute to high quality diabetes care.

OBJECTIVE

To determine whether primary care team communication and team climate are associated with health outcomes, health care utilization, and associated costs for patients with diabetes.

METHODS

A cross-sectional survey of primary care team members collected information on frequency of communication with other care team members about patient care and on team climate. Patient outcomes (glycemic, cholesterol, and blood pressure control, urgent care visits, emergency department visits, hospital visit days, medical costs) in the past 12 months for team diabetes patient panels were extracted from the electronic health record. The data were analyzed using nested (clinic/team/patient) generalized linear mixed modeling.

PARTICIPANTS

155 health professionals at 6 U.S. primary care clinics participated from May through December 2013.

RESULTS

Primary care teams with a greater number of daily face-to-face communication ties among team members were associated with 52% (rate ratio=0.48, 95% CI: 0.22, 0.94) fewer hospital days and US$1220 (95% CI: -US$2416, -US$24) lower health-care costs per team diabetes patient in the past 12 months. In contrast, for each additional registered nurse (RN) who reported frequent daily face-to-face communication about patient care with the primary care practitioner (PCP), team diabetes patients had less-controlled HbA1c (Odds ratio=0.83, 95% CI: 0.66, 0.99), increased hospital days (RR=1.57, 95% CI: 1.10, 2.03), and higher healthcare costs (β=US$877, 95% CI: US$42, US$1713). Shared team vision, a measure of team climate, significantly mediated the relationship between team communication and patient outcomes.

CONCLUSIONS

Primary care teams which relied on frequent daily face-to-face communication among more team members, and had a single RN communicating patient care information to the PCP, had greater shared team vision, better patient outcomes, and lower medical costs for their diabetes patient panels.

Factors affecting screening for diabetic complications in the community: a multilevel analysis

OBJECTIVES:

The objective of the present study was to identify the factors that affect screening for diabetic complications by sex in the community.

METHODS:

This study used individual-level data from the 2013 Community Health Survey (CHS) for 20,806 (male, 9,958; female, 10,848) adults aged 30 years or older who were diagnosed with diabetes. Community-level data for 253 communities were derived from either CHS or national statistics. A chi-square test and multilevel logistic regression analysis was performed.

RESULTS:

There were significant differences in the rate of screening for diabetic complications according to individual-level and community-level variables. In the multilevel analysis, the community-level variance ratio of the null model was 7.4% and 9.2% for males and females, respectively. With regard to community-level variables, males were affected by the city type, number of physicians, and their living environment, while females were affected by number of physicians, natural and living environments, and public transportation.

CONCLUSIONS:

The factors that influenced individual willingness to undergo screening for diabetic complications differed slightly by sex; however, both males and females were more likely to undergo screening when they recognized their health status as poor or when they actively sought to manage their health conditions. Moreover, in terms of community-level variables, both males and females were affected by the number of physicians. It is essential to provide sufficient and ongoing opportunities for education on diabetes and its management through collaboration with local communities and primary care medical centers.

Continuity Clinic Model and Diabetic Outcomes in Internal Medicine Residencies: Findings of the Educational Innovations Project Ambulatory Collaborative

BACKGROUND

Efforts to improve diabetes care in residency programs are ongoing and in the midst of continuity clinic redesign at many institutions. While there appears to be a link between resident continuity and improvement in glycemic control for diabetic patients, it is uncertain whether clinic structure affects quality measures and patient outcomes.

METHODS

This multi-institutional, cross-sectional study included 12 internal medicine programs. Three outcomes (glycemic control, blood pressure control, and achievement of target low-density lipoprotein [LDL]) and 2 process measures (A1C and LDL measurement) were reported for diabetic patients. Traditional, block, and combination clinic models were compared using analysis of covariance (ANCOVA). Analysis was adjusted for continuity, utilization, workload, and panel size.

RESULTS

No significant differences were found in glycemic control across clinic models (P = .06). The percentage of diabetic patients with LDL < 100 mg/dL was 60% in block, compared to 54.9% and 55% in traditional and combination models (P = .006). The percentage of diabetic patients with blood pressure < 130/80 mmHg was 48.4% in block, compared to 36.7% and 36.9% in other models (P < .001). The percentage of diabetic patients with HbA1C measured was 92.1% in block compared to 75.2% and 82.1% in other models (P < .001). Also, the percentage of diabetic patients with LDL measured was significantly different across all groups, with 91.2% in traditional, 70.4% in combination, and 83.3% in block model programs (P < .001).

CONCLUSIONS

While high scores on diabetic quality measures are achievable in any clinic model, the block model design was associated with better performance.

Use of an electronic health record to identify prevalent and incident cardiovascular disease in type 2 diabetes according to treatment strategy

BACKGROUND

The increasing use of electronic health records (EHRs) in clinical practice offers the potential to investigate cardiovascular outcomes over time in patients with type 2 diabetes (T2D).

OBJECTIVE

To develop a methodology for identifying prevalent and incident cardiovascular disease (CVD) in patients with T2D who are candidates for therapeutic intensification of glucose-lowering therapy.

METHODS

Patients with glycated hemoglobin (HbA1c) ≥7% (53 mmol/mol) while receiving 1-2 oral diabetes medications (ODMs) were identified from an EHR (2005-2011) and grouped according to intensification with insulin (INS) (n=372), a different class of ODM (n=833), a glucagon-like peptide receptor 1 agonist (GLP-1RA) (n=59), or no additional therapy (NAT) (n=2017). Baseline prevalence of CVD was defined by documented International Classification of Diseases Ninth Edition (ICD-9) codes for coronary artery disease, cerebrovascular disease, or other CVD with first HbA1c ≥7% (53 mmol/mol). Incident CVD was defined as a new ICD-9 code different from existing codes over 4 years of follow-up. ICD-9 codes were validated by a chart review in a subset of patients.

RESULTS

Sensitivity of ICD-9 codes for CVD ranged from 0.83 to 0.89 and specificity from 0.90 to 0.96. Baseline prevalent (INS vs ODM vs GLP-1RA vs NAT: 65% vs 39% vs 54% vs 59%, p<0.001) and incident CVD (Kaplan-Meier estimates: 58%, 31%, 52%, and 54%, p=0.002) were greater in INS group after controlling for differences in baseline HbA1c (9.2±2.0% vs 8.3±1.2% vs 8.2±1.3% vs 7.7±1.1% (77 vs 67 vs 66 vs 61 mmol/mol), p<0.001) and creatinine (1.15±0.96 vs 1.10±0.36 vs 1.01±0.35 vs 1.07±0.45 mg/dL, p=0.001).

CONCLUSIONS

An EHR can be an effective method for identifying prevalent and incident CVD in patients with T2D.

Quality of care in rural youth with type 1 diabetes: a cross-sectional pilot assessment

BACKGROUND

Type 1 diabetes mellitus (T1DM) presents a significant health burden for patients and families. The quality of care (QOC) among those living in rural communities is thought to be subpar compared with those in urban communities; however, little data exist to reflect this, especially in pediatric diabetes.

OBJECTIVE

The purpose of this pilot study was to investigate diabetes QOC among families living in rural versus urban areas. 6 QOC markers were used to compare youth with T1DM: appointment adherence, patient-provider communication, diabetes education during clinic visit, congruency with diabetes standards of care, diabetes self-management behaviors, and diabetes-related hospitalizations.

RESEARCH DESIGN AND METHODS

Participants were rural or urban adult caregivers of youth ages 2-18 with ≥10-month history of T1DM receiving treatment at Seattle Children's Hospital, USA. Participants were from rural areas of central Washington, or urban areas of western Washington. Caregivers completed a 26-item survey pertaining to the 6 QOC markers. The 6 QOC markers were compared across 61 participants (34 rural, 27 urban), to determine how diabetes care quality and experiences differed. Data were collected over 12 months. Groups were compared using t-tests and χ² tests, as appropriate.

RESULTS

Compared with urban families, rural families reported significantly lower income and a 4-fold greater usage of public insurance. Among the QOC measures, rural participants were significantly worse off in the appointment adherence, patient-provider communication, and hospitalizations categories. Congruence with diabetes standards of care (foot care only) was also significantly poorer in rural participants.

CONCLUSIONS

The burden of travel in conjunction with the lack of resources in this rural population of families with T1DM youth is cause for concern and warrants further research.

Factors influencing the implementation of chronic care models: A systematic literature review

Background

The increasing prevalence of chronic disease faced by both developed and developing countries is of considerable concern to a number of international organisations. Many of the interventions to address this concern within primary healthcare settings are based on the chronic care model (CCM). The implementation of complex interventions such as CCMs requires careful consideration and planning. Success depends on a number of factors at the healthcare provider, team, organisation and system levels.

Methods

The aim of this systematic review was to systematically examine the scientific literature in order to understand the facilitators and barriers to implementing CCMs within a primary healthcare setting. This review focused on both quantitative and qualitative studies which included patients with chronic disease (cardiovascular disease, chronic kidney disease, chronic respiratory disease, type 2 diabetes mellitus, depression and HIV/AIDS) receiving care in primary healthcare settings, as well as primary healthcare providers such as doctors, nurses and administrators. Papers were limited to those published in English between 1998 and 2013.

Results

The search returned 3492 articles. The majority of these studies were subsequently excluded based on their title or abstract because they clearly did not meet the inclusion criteria for this review. A total of 226 full text articles were obtained and a further 188 were excluded as they did not meet the criteria. Thirty eight published peer-reviewed articles were ultimately included in this review. Five primary themes emerged. In addition to ensuring appropriate resources to support implementation and sustainability, the acceptability of the intervention for both patients and healthcare providers contributed to the success of the intervention. There was also a need to prepare healthcare providers for the implementation of a CCM, and to support patients as the way in which they receive care changes.

Conclusion

This systematic review demonstrated the importance of considering human factors including the influence that different stakeholders have on the success or otherwise of the implementing a CCM.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-015-0319-5) contains supplementary material, which is available to authorized users.

Diabetes self-management interventions for adults with type 2 diabetes living in rural areas: a systematic literature review

In rural communities, high rates of diabetes and its complications are compounded by limited access to health care and scarce community resources. We systematically reviewed the evidence for the impact of diabetes self-management education interventions designed for patients living in rural areas on glycemic control and other diabetes outcomes. Fifteen studies met inclusion criteria. Ten were randomized controlled trials. Intervention strategies included in-person diabetes (n = 9) and telehealth (n = 6) interventions. Four studies demonstrated between group differences for biologic outcomes, four studies demonstrated changes in behavior, and three studies demonstrated changes in knowledge. Intervention dose was associated with improved A1c or weight loss in two studies and session attendance in one study. Interventions that included collaborative goal-setting were associated with improved metabolic outcomes and self-efficacy. Telehealth and face-to-face diabetes interventions are both promising strategies for rural communities. Effective interventions included collaborative goal-setting. Intervention dose was linked to better outcomes and higher attendance.

Effectiveness of chronic care models: opportunities for improving healthcare practice and health outcomes: a systematic review

Background

The increasing prevalence of chronic disease and even multiple chronic diseases faced by both developed and developing countries is of considerable concern. Many of the interventions to address this within primary healthcare settings are based on a chronic care model first developed by MacColl Institute for Healthcare Innovation at Group Health Cooperative.

Methods

This systematic literature review aimed to identify and synthesise international evidence on the effectiveness of elements that have been included in a chronic care model for improving healthcare practices and health outcomes within primary healthcare settings. The review broadens the work of other similar reviews by focusing on effectiveness of healthcare practice as well as health outcomes associated with implementing a chronic care model. In addition, relevant case series and case studies were also included.

Results

Of the 77 papers which met the inclusion criteria, all but two reported improvements to healthcare practice or health outcomes for people living with chronic disease. While the most commonly used elements of a chronic care model were self-management support and delivery system design, there were considerable variations between studies regarding what combination of elements were included as well as the way in which chronic care model elements were implemented. This meant that it was impossible to clearly identify any optimal combination of chronic care model elements that led to the reported improvements.

Conclusions

While the main argument for excluding papers reporting case studies and case series in systematic literature reviews is that they are not of sufficient quality or generalizability, we found that they provided a more detailed account of how various chronic care models were developed and implemented. In particular, these papers suggested that several factors including supporting reflective healthcare practice, sending clear messages about the importance of chronic disease care and ensuring that leaders support the implementation and sustainability of interventions may have been just as important as a chronic care model’s elements in contributing to the improvements in healthcare practice or health outcomes for people living with chronic disease.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0854-8) contains supplementary material, which is available to authorized users.

Trends in guideline implementation: a scoping systematic review

BACKGROUND

There is currently no reliable way to choose strategies that are appropriate for implementing guidelines facing different barriers. This study examined trends in guideline implementation by topic over a 10-year period to explore whether and how strategies may be suitable for addressing differing barriers.

METHODS

A scoping systematic review was performed. MEDLINE and EMBASE were searched from 2004 to 2013 for studies that evaluated the implementation of guidelines on arthritis, diabetes, colorectal cancer and heart failure. Data on study characteristics, reason for implementation (new guideline or quality improvement), implementation strategy used, rationale for selecting that strategy and reported impact were extracted and summarized. Interventions were mapped against a published taxonomy of guideline implementation strategies.

RESULTS

The search resulted in 1,709 articles; 156 were retrieved and 127 were excluded largely because they did not evaluate guideline implementation, leaving 32 eligible for review (4 arthritis, 3 colorectal cancer, 21 diabetes, 4 heart failure). Six of 7 randomized trials and 8 of 25 observational studies had a low risk of bias. Most studies promoted guideline use for quality improvement (78.0%). Few studies rationalized strategy choice (18.8%). Most employed multiple approaches and strategies, most often educational meetings and print material for professionals or patients. Few studies employed organizational, financial or regulatory approaches. Strategies employed that were unique to the published taxonomy included professional (print material, tailoring guidelines, self-audit training or material) and patient strategies (education, counselling, group interaction, print material, reminders). Most studies achieved positive impact (87.5%). This did not appear to be associated with guideline topic, use of theory or barrier assessment, or number or type of implementation approaches and strategies.

CONCLUSIONS

While few studies were eligible, limiting insight on how to choose implementation strategies that address guideline-specific barriers, this review identified other important findings. Education for professionals or patients and print material were the most commonly employed strategies for translating guidelines to practice. Mapping of strategies onto the published taxonomy identified gaps in guideline implementation that represent opportunities for future research and expanded the taxonomy.

The eHealth Enhanced Chronic Care Model: a theory derivation approach

BACKGROUND

Chronic illnesses are significant to individuals and costly to society. When systematically implemented, the well-established and tested Chronic Care Model (CCM) is shown to improve health outcomes for people with chronic conditions. Since the development of the original CCM, tremendous information management, communication, and technology advancements have been established. An opportunity exists to improve the time-honored CCM with clinically efficacious eHealth tools.

OBJECTIVE

The first goal of this paper was to review research on eHealth tools that support self-management of chronic disease using the CCM. The second goal was to present a revised model, the eHealth Enhanced Chronic Care Model (eCCM), to show how eHealth tools can be used to increase efficiency of how patients manage their own chronic illnesses.

METHODS

Using Theory Derivation processes, we identified a "parent theory", the Chronic Care Model, and conducted a thorough review of the literature using CINAHL, Medline, OVID, EMBASE PsychINFO, Science Direct, as well as government reports, industry reports, legislation using search terms "CCM or Chronic Care Model" AND "eHealth" or the specific identified components of eHealth. Additionally, "Chronic Illness Self-management support" AND "Technology" AND several identified eHealth tools were also used as search terms. We then used a review of the literature and specific components of the CCM to create the eCCM.

RESULTS

We identified 260 papers at the intersection of technology, chronic disease self-management support, the CCM, and eHealth and organized a high-quality subset (n=95) using the components of CCM, self-management support, delivery system design, clinical decision support, and clinical information systems. In general, results showed that eHealth tools make important contributions to chronic care and the CCM but that the model requires modification in several key areas. Specifically, (1) eHealth education is critical for self-care, (2) eHealth support needs to be placed within the context of community and enhanced with the benefits of the eCommunity or virtual communities, and (3) a complete feedback loop is needed to assure productive technology-based interactions between the patient and provider.

CONCLUSIONS

The revised model, eCCM, offers insight into the role of eHealth tools in self-management support for people with chronic conditions. Additional research and testing of the eCCM are the logical next steps.