Diabetes control programs: new directions

A scoping review of the evaluation and effectiveness of technical assistance

Background

Although the benefits of evidence-based practices (EBPs) for advancing community outcomes are well-recognized, challenges with the uptake of EBPs are considerable. Technical assistance (TA) is a core capacity building strategy that has been widely used to support EBP implementation and other community development and improvement efforts. Yet despite growing reliance on TA, no reviews have systematically examined the evaluation of TA across varying implementation contexts and capacity building aims. This study draws on two decades of peer-reviewed publications to summarize the evidence on the evaluation and effectiveness of TA.

Methods

Guided by Arksey and O’Malley’s six-stage methodological framework, we used a scoping review methodology to map research on TA evaluation. We included peer-reviewed articles published in English between 2000 and 2020. Our search involved five databases: Business Source Complete, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Education Resources Information Center (ERIC), PsycInfo, and PubMed.

Results

A total of 125 evaluation research studies met the study criteria. Findings indicate that publications have increased over the last two decades, signaling a growth in the recognition and reporting of TA. Technical assistance is being implemented across diverse settings, often serving socially vulnerable and under-resourced populations. Most evaluation research studies involved summative evaluations, with TA outcomes mostly reported at the organizational level. Only 5% of the studies examined sustainability of TA outcomes. This review also demonstrates that there is a lack of consistent standards regarding the definition of TA and the level of reporting across relevant TA evaluation categories (e.g., cadence of contact, and directionality).

Conclusions

Advances in the science and practice of TA hinge on understanding what aspects of TA are effective and when, how, and for whom these aspects of TA are effective. Addressing these core questions requires (i) a standard definition for TA; (ii) more robust and rigorous evaluation research designs that involve comparison groups and assessment of direct, indirect, and longitudinal outcomes; (iii) increased use of reliable and objective TA measures; and (iv) development of reporting standards. We view this scoping review as a foundation for improving the state of the science and practice of evaluating TA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00314-1.

Barriers associated with the delivery of Medicare-reimbursed diabetes self-management education

PURPOSE

The purpose of this study was to explore the barriers that practitioners face in providing diabetes self-management education (DSME) to Medicare beneficiaries, with a special focus on barriers faced by rural providers.

METHODS

Using an e-mail survey, Diabetes Control Program Coordinators (DCPCs) in all US states were asked 3 open-ended questions to understand problems with obtaining American Diabetes Association (ADA) recognition for Medicare reimbursement, differences in obtaining ADA recognition by rural and urban facilities, and facility-level barriers to providing DSME to Medicare patients. Using a mail survey administered to half of ADA-recognized diabetes education centers (DECs), information was collected about perceived barriers to providing DSME in all areas and rural areas.

RESULTS

Most DCPCs believed it was more difficult for rural providers to obtain ADA recognition than for urban providers; the largest barriers were costs and reporting requirements. The top barriers for rural providers mentioned by DCPCs were the shortage of designated specialists, fewer resources, and high application fees for ADA recognition. Barriers identified by DEC respondents facing rural providers include staffing/institutional support, amount of Medicare reimbursement, lack of hours covered, and transportation. DEC respondents providing care in urban areas only were more likely to perceive barriers to providing diabetes education in rural areas than were rural providers.

CONCLUSIONS

Barriers to DSME are perceived to be higher for rural providers than urban providers. Urban providers perceived that many barriers to DSME are greater for rural providers. The ADA application process is perceived as expensive and laborious. Most respondents perceived Medicare reimbursement for DSME as inadequate.

Using the Essential Public Health Services as strategic leverage to strengthen the public health response to diabetes

If current trends continue, health systems will soon be overwhelmed by type 2 diabetes mellitus. Successful population-based diabetes prevention and control efforts require a sound and continually improving infrastructure. In states and U.S. territories, the Diabetes Prevention and Control Programs supported by the U.S. Centers for Disease Control and Prevention's Division of Diabetes Translation serve as a fulcrum for building and refining the infrastructure that links diverse and dynamic partners dedicated to increasing the years and quality of life and achieving health equity among people with and at risk for diabetes. The National Public Health Performance Standards offer a conceptual framework that articulates the requisite infrastructure and services provided by an interconnected network of intersectoral partners to strengthen the public health response to diabetes. These standards associated with the Essential Public Health Services are valuable tools to assess the status of the performance of the health system's infrastructure to guide improvement. The process of engaging system partners in a system-wide assessment informs and leverages cross-sectoral assets to improve health outcomes for citizens in communities shouldering the growing burden of diabetes.

Southeast Michigan Diabetes Outreach Network: quality improvement project for diabetes care

This article describes the development and process measures with related outcomes of the Southeast Michigan Diabetes Outreach Network (SEMDON), one of six Diabetes Outreach Networks in Michigan. SEMDON's mission is to strengthen diabetes prevention, detection, and treatment. Education in diabetes management is provided to participating agencies. The agency staff collect baseline data on patients with diabetes including demographics and physiologic measures. Education is given to the patients by the staff nurses. The collection of information on several care process measures and intermediate outcomes is repeated at 6 months. A report of matched data of these agencies from 404 individuals with diabetes is presented. The outcomes of blood glucose, hemoglobin A1c, blood pressure, and annual foot and eye exams will be analyzed. The SEMDON model may be an effective approach in improving the quality of diabetes care.

Federally funded sexually transmitted disease programs and managed care: a review of current and planned partnerships

BACKGROUND

The Centers for Disease Control and Prevention requested that sexually transmitted disease (STD) programs report their current activities and plans to collaborate with managed care organizations in their 1999 applications for federal funding.

GOAL

To review CDC STD program applications for funding to assess the number of activities between STD programs and managed care organizations.

METHODS

Narrative data on managed care topics were abstracted from 59 funding applications (50 states, 7 cites or counties, and 2 US territories), using standard qualitative methods. A coding system was applied to categorize each managed care activity into one of nine categories (interrater reliability, 93%). An expert panel ranked activities by complexity, and these scores were used to develop an overall complexity score for each program.

RESULTS

All but 9 of the 59 applicants reported managed care organization activities. Altogether, 208 activities were specifically documented, 45% of which were classified as operational in 1999. The most frequently reported activities involved gathering and giving information and promoting STD care through legislation and state Medicaid activities.

CONCLUSIONS

Considerable information transfer and policy action between STD programs and managed care organizations are taking place. Further integration of services and policies should be studied and encouraged to promote the effective treatment of STD.

Stereo nonmydriatic digital-video color retinal imaging compared with Early Treatment Diabetic Retinopathy Study seven standard field 35-mm stereo color photos for determining level of diabetic retinopathy

OBJECTIVE

To evaluate the ability to determine clinical levels of diabetic retinopathy, timing of next appropriate retinal evaluation, and necessity of referral to ophthalmology specialists using stereoscopic nonmydriatic digital-video color retinal images as compared with Early Treatment Diabetic Retinopathy Study (ETDRS) seven standard field 35-mm stereoscopic color fundus photographs.

DESIGN

Prospective, clinic-based, comparative instrument validation study.

PARTICIPANTS

Fifty-four patients (108 eyes) with type 1 or type 2 diabetes mellitus selected after chart review from a single center to include the full spectrum of diabetic retinopathy.

METHODS

Nonsimultaneous 45 degrees -field stereoscopic digital-video color images (JVN images) were obtained from three fields with the Joslin Vision Network (JVN) system before pupil dilation. Following pupil dilation, ETDRS seven standard field 35-mm stereoscopic color 30 degrees fundus photographs (ETDRS photos) were obtained. Joslin Vision Network images and ETDRS photos were graded on a lesion-by-lesion basis by two independent, masked readers to assess ETDRS clinical level of diabetic retinopathy. An independent ophthalmology retina specialist adjudicated interreader disagreements in a masked fashion.

MAIN OUTCOME MEASURES

Determination of ETDRS clinical level of diabetic retinopathy, timing of next ophthalmic evaluation of diabetic retinopathy, and need for prompt referral to ophthalmology specialist.

RESULTS

There was substantial agreement (kappa = 0.65) between the clinical level of diabetic retinopathy assessed from the undilated JVN images and the dilated ETDRS photos. Agreement was excellent (kappa = 0.87) for suggested referral to ophthalmology specialists for eye examinations. Comparison of individual lesions between the JVN images and the ETDRS photos and for interreader comparisons were comparable to the prior ETDRS study.

CONCLUSIONS

Undilated digital-video images using the JVN system were comparable photographs for the determination of diabetic retinopathy level. The results validate the agreement between nonmydriatic JVN images and dilated ETDRS photographs and suggest that this digital technique may be an effective telemedicine tool for remotely determining the level of diabetic retinopathy, suggesting timing of next retinal evaluation and identifying the need for prompt referral to ophthalmology specialists. Thus, the JVN system would be an appropriate tool for facilitating increased access of diabetic patients into recommended eye evaluations, but should not be construed as a paradigm that would replace the need for comprehensive eye examinations.

Report of the health care delivery work group: behavioral research related to the establishment of a chronic disease model for diabetes care

As one of four work groups for the November 1999 conference on Behavioral Science Research in Diabetes, sponsored by the National Institute on Diabetes and Digestive and Kidney Diseases, the health care delivery work group evaluated the status of research on quality of care, patient-provider interactions, and health care systems' innovations related to improved diabetes outcomes. In addition, we made recommendations for future research. In this article, which was developed and modified at the November conference by experts in health care delivery, diabetes and behavioral science, we summarize the literature on patient-provider interactions, diabetes care and self-management support among underserved and minority populations, and implementation of chronic care management systems for diabetes. We conclude that, although the quality of care provided to the vast majority of diabetic patients is problematic, this is principally not the fault of either individual patients or health care professionals. Rather, it is a systems issue emanating from the acute illness model of care, which still predominates. Examples of proactive population-based chronic care management programs incorporating behavioral principles are discussed. The article concludes by identifying barriers to the establishment of a chronic care model (e.g., lack of supportive policies, understanding of population-based management, and information systems) and priorities for future research in this area needed to overcome these barriers.

Michigan Diabetes Outreach Networks: a public health approach to strengthening diabetes care

This study describes a statewide public health approach to strengthen diabetes care; evaluates diabetes-related processes of care for individuals enrolled in the Michigan Diabetes Outreach Network (MDON) program; and, examines MDON in the context of priorities for diabetes care and public health policy. Organizational information was obtained through semi-structured interviews. Program outcomes are examined using data from client intake and follow-up assessment forms. We report percentages and mean values overall and across networks. Logistic regression is used to identify factors associated with clients receiving recommended diabetes care. Within two years, five of the networks recruited 125 providers and collected information on over 8,000 individuals with diabetes. The percentage of enrollees with a glycosylated hemoglobin measure, eye exam, and dietician visit is greater at follow-up than at intake and an intake "referral" is strongly associated with clients being trieated for high blood pressure at follow-up. The MDON model is a promising public health approach for improving diabetes care but it is necessary to identify program elements that are most effective.

Diabetes care practices in primary care: results from two samples and three measurement sets

PURPOSE

There has been substantial recent interest in diabetes disease management interventions, guidelines, and care practices. As the vast majority of diabetes care occurs in primary care settings, it makes sense to evaluate current levels of recommended practices in different primary care settings.

METHODS

We report on two separate studies that included a combined total of 389 patients seen by over 30 different providers. Three different sets of recommended practices were assessed: (1) the ADA provider recognition measures, (2) the proposed Diabetes Quality Improvement Project measures, and (3) the state of Oregon Population-Based Guidelines for Diabetes.

RESULTS

In general, there was only a moderate level of adherence to recommended practices, and adherence was much lower for behavioral or patient-focused practices as contrasted with laboratory tests. There was considerable variability across providers and across different guidelines activities.

CONCLUSIONS

Policy and quality improvement implications and future research issues are discussed, including the need for studying different measurement approaches for evaluating guidelines adherence.

Diabetes education infrastructure and capacity in hospitals and home health agencies in Maryland and Pennsylvania

In this study, questionnaire data were described regarding diabetes education program capacity in Maryland and Pennsylvania hospitals, health maintenance organizations (HMOs), and home health agencies (HHAs). Hospitals, HMOs, and HHAs in each state were asked to indicate whether they currently have a diabetes education program and, if not, whether they had such a program anytime within the past 10 years. Home health agencies were less likely to have had programs in the past and more likely to have recently established diabetes education programs. About half of hospitals currently without programs had a program sometime within the past 10 years. Hospitals in Maryland and Pennsylvania responded similarly; Pennsylvania HHAs were more likely to report having diabetes education programs than HHAs in Maryland. On the average, programs showed moderate levels of institutionalization. Respondents to the questionnaire believed that their programs would be sustained; these projections appeared to not be sensitive to availability of reimbursement.