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

Self-monitoring Blood Glucose (SMBG): Now and the Future

In 2002, the cost of diabetes in the United States reached $132 billion. There is a well-established relationship between blood glucose control and the risk of diabetes-related complications. Tight blood glucose control, through intensive diabetes therapy, reduces the risk and delays the onset of diabetesrelated microvascular complications. Regular and consistent self-monitoring of blood glucose (SMBG) is and should be a part of all diabetes disease state management programs. Pharmacists can truly increase the numbers of patients who use SMBG by being aware and familiar with the monitoring devices available to patients and identifying the physical and psychological issues surrounding SMBG. Results from SMBG and hemoglobin A1C are the basis formost of the medical decisions made for patients with diabetes. This review discusses the best time for patients to test their blood glucose, information regarding blood glucose monitoring devices, alternative site testing, and the newest technology available in glucose monitoring.

Patients', caregivers', and providers' perceived strategies for diabetes care

OBJECTIVES

To explore strategies to improve type 2 diabetes mellitus (T2DM) self-management among low-income and minority groups.

METHODS

Focus groups centered on T2DM self-care behaviors were conducted using convenient sample of patients with T2DM (N = 17), caregivers (N = 5) and healthcare providers (N = 15).

RESULTS

Patients and caregivers perceived strategies included improving patient-provider communication, providers' accessibility and compassion, and flexible clinic hours. Strategies identified by providers were realistic patient's expectations, family support, and community resources.

CONCLUSIONS

To our knowledge, this study is the first to elicit strategies to improve T2DM self-management through a joint meeting of patients, caregivers, and healthcare providers. Study findings could help inform future efforts to assist patients better manage their T2DM.

Resources for Health: A Social-Ecological Intervention for Supporting Self-management of Chronic Conditions

There is a pressing need for practical interventions to support self-management of chronic illness that can be integrated with primary care, and that take into account the patient's social environment. This pilot study was conducted with low-income clients of a community health center and focused on enhancing use of social-environmental resources supportive of self-management. Twenty-eight patients having at least one chronic illness, randomized to immediate versus delayed treatment conditions, met once with a health educator to develop a self-management plan, and received one follow-up phone call and two newsletters. Significant improvements in use of community resources, minutes of physical activity, and medication adherence were obtained compared to control. Integrating brief self-management counseling with social environmental support appeared effective, although much more can be done to better link counseling to primary care practice.

Knowledge of diabetes and hypertension care among health care workers in southwest Nigeria

BACKGROUND

There has been a progressive increase in diabetes among Nigerians. A major problem with diabetes care in the sub-Saharan African region is the inadequate training of health care workers, leading to insufficient knowledge of diabetes and other chronic diseases.

AIM

To assess health care workers' knowledge on various aspects of diabetes and hypertension management based on recommended guidelines.

MATERIALS AND METHODS

A questionnaire assessing knowledge of diabetes and hypertension care was administered among health care workers at the beginning of a workshop on diabetes education. The responses were analyzed using SPSS statistical software version 10.0.

RESULTS

A total of 184 subjects responded. One hundred four (56.5%) were male and 80 (43.5%) were female. Medical practitioners constituted 76 (41.8%) while nurses and other categories of health care workers constituted 46 (25.2%) and 60 (33%), respectively. Twenty-eight (26.9%) of these worked in primary health institutions, 46 (44.2%) in secondary health institutions, while 30 (28.9%) worked in tertiary health institutions. One hundred eighteen (64.1%) respondents gave a correct response of 5 to 6 mmol/L (90 - 108 mg/L) as the blood glucose target level for diabetic patients. Similarly, 118 (64.1%) respondents gave a correct response of < or = 130/85 mm Hg as the recommended target blood pressure for diabetic patients. The ideal serum cholesterol of 5.0 mmol/L and glycated hemoglobin were correctly indicated by 42 (22.8%) and 56 (30.4%) of the respondents, respectively. The majority of the subjects (89.1%) were aware of the fact that tight blood glucose control reduces the risk of diabetes-related complications. The variables that correlated with increased knowledge include treating more than 50 patients per month (X2 4.124, P = 0.042) and working in a tertiary center (X2 5.714, P = 0.047). Most of the health care facilities (61.7%) where the respondents work do not deliver protocol-driven care for diabetics.

CONCLUSION

A large number of health care workers in southwest Nigeria do not seem to be familiar with the current practice guidelines for the management of diabetes. There is a need to introduce protocol-driven diabetes care in our health care facilities and improve the knowledge base of practitioners.

Use of chronic care model elements is associated with higher-quality care for diabetes

PURPOSE

In 30 small, independent primary care practices, we examined the association between clinician-reported use of elements of the Chronic Care Model (CCM) and diabetic patients' hemoglobin A(1c) (HbA(1c)) and lipid levels and self-reported receipt of care.

METHODS

Ninety clinicians (60 physicians, 17 nurse-practitioners, and 13 physician's assistants) completed a questionnaire assessing their use of elements of the CCM on a 5-point scale (never, rarely, occasionally, usually, and always). A total of 886 diabetic patients reported their receipt of various diabetes care services. We computed a clinical care composite score that included patient-reported assessments of blood pressure, lipids, microalbumin, and HbA(1c); foot examinations; and dilated retinal examinations. We computed a behavioral care composite score from patient-reported support from their clinician in setting self-management goals, obtaining nutrition education or therapy, and receiving encouragement to self-monitor their glucose. HbA(1c) values and lipid profiles were obtained by independent laboratory assay. We used multilevel regression models for analyses to account for the hierarchical nature of the data.

RESULTS

Clinician-reported use of elements of CCM was significantly associated with lower HbA(1c) values (P = .002) and ratios of total cholesterol to high-density lipoprotein cholesterol (P = .02). For every unit increase in clinician-reported CCM use (eg, from "rarely" to "occasionally"), there was an associated 0.30% reduction in HbA(1c) value and 0.17 reduction in the lipid ratio. Clinician use of the CCM elements was also significantly associated with the behavioral composite score (P = .001) and was marginally associated with the clinical care composite score (P = .07).

CONCLUSIONS

Clinicians in small independent primary care practices are able to incorporate elements of the CCM into their practice style, often without major structural change in the practice, and this incorporation is associated with higher levels of recommended processes and better intermediate outcomes of diabetes care.

Trends in health service use for women in Australia with diabetes

OBJECTIVE

To describe the health, health service use and use of recommended guidelines for care for women in Australia with diabetes.

METHODS

Analysis of survey data 1996-99 from the Australian Longitudinal Study on Women's Health, linked with Medicare data for 1997-2001. Participants were 12,338 mid-age women aged 45-50 years in 1996 (1.9% with diabetes) and 10,421 older women aged 70-75 years at Survey 1 in 1996 (8.1% with diabetes). The outcome measures were number of general practice and specialist visits and use of glycosylated haemoglobin (HbAlc), lipids and microalbuminuria tests.

RESULTS

Women with diabetes at Survey 1, and those diagnosed by Survey 2, were more likely to have hypertension, heart disease and eyesight problems, have high rates of polypharmacy (four or more medications: mid age 32%, older 64%) and more consultations with general practitioners and specialists than women without diabetes. During 1997-2001, there was a trend for a greater percentage of women with diabetes to have an HbA1c test at least annually (mid age 44%-52%, older age 46%-58%). Rates of testing microalbuminuria and lipids also increased but were far from conforming to guidelines. Having more frequent consultations with a general practitioner was significantly associated with having all three recommended tests.

CONCLUSIONS

There is an increasing use of services by women with diabetes, in part due to an increase in compliance with guidelines for the management of diabetes.

IMPLICATIONS

Linked health and administrative data provide a means to monitor health service utilisation, adherence to principles for best practice care and issues of equity in care.

Randomized effectiveness trial of a computer-assisted intervention to improve diabetes care

OBJECTIVE

There is a well-documented gap between diabetes care guidelines and the services received by patients in most health care settings. This report presents 12-month follow-up results from a computer-assisted, patient-centered intervention to improve the level of recommended services patients received from a variety of primary care settings.

RESEARCH DESIGN AND METHODS

A total of 886 patients with type 2 diabetes under the care of 52 primary care physicians participated in the Diabetes Priority Program. Physicians were stratified and randomized to intervention or control conditions and evaluated on two primary outcomes: number of recommended laboratory screenings and recommended patient-centered care activities completed from the National Committee on Quality Assurance/American Diabetes Association Provider Recognition Program (PRP). Secondary outcomes were evaluated using the Problem Areas in Diabetes 2 quality of life scale, lipid and HbA1c levels, and the Patient Health Questionnaire-9 depression scale.

RESULTS

The program was well implemented and significantly improved both the number of laboratory assays and patient-centered aspects of diabetes care patients received compared with those in the control condition. There was overall improvement on secondary outcomes of lipids, HbA1c, quality of life, and depression scores; between-condition differences were not significant.

CONCLUSIONS

Staff in small, mixed-payer primary care offices can consistently implement a patient-centered intervention to improve PRP measures of quality of diabetes care. Alternative explanations for why these process improvements did not lead to improved outcomes, and suggested directions for future research are discussed.

A practical randomized trial to improve diabetes care

OBJECTIVE

There is a well-documented gap between diabetes care guidelines and the services received by patients in almost all health care settings. This project reports initial results from a computer-assisted, patient-centered intervention to improve the level of recommended services received by patients from a wide variety of primary care providers.

DESIGN AND SETTINGS

Eight hundred eighty-six patients with type 2 diabetes under the care of 52 primary care physicians participated in the Diabetes Priority Program. Physicians were stratified and randomized to intervention or control conditions and evaluated on 2 primary outcomes: number of recommended laboratory screenings and recommended patient-centered care activities completed. Secondary outcomes were evaluated using the Problem Areas in Diabetes scale and the Patient Health Questionnaire (PHQ)-9 depression scale, and the RE-AIM framework was used to evaluate potential for dissemination.

RESULTS

The program was well-implemented and significantly improved both number of recommended laboratory assays (3.4 vs 3.1; P <.001) and patient-centered aspects of diabetes care patients received (3.6 vs 3.2; P <.001) compared to those in randomized control practices. Activities that were increased most were foot exams (follow-up rates of 80% vs 52%; P <.003) and nutrition counseling (76% vs 52%; P <.001).

CONCLUSIONS

Patients are very willing to participate in a brief computer-assisted intervention that is effective in enhancing quality of diabetes care. Staff in primary care offices can consistently deliver an intervention of this nature, but most physicians were unwilling to participate in this translation research study.

The Diabetes Continuity of Care Scale: the development and initial evaluation of a questionnaire that measures continuity of care from the patient perspective

The purpose of the present study was to develop and pilot test a questionnaire to assess continuity of care from the perspective of patients with diabetes. Seven patient and two healthcare-provider focus groups were conducted. These focus groups generated 777 potential items. This number was reduced to 56 items after item reduction, face validity testing and readability analysis, and to 47 items after a preliminary factor analysis. Readability was assessed as requiring 7-8 years of schooling. Sixty adult patients with diabetes completed the draft Diabetes Continuity of Care Scale (DCCS) at a single point in time to assess the validity of the instrument. Patients completed the draft DCCS again 2 weeks later to assess test-retest reliability. A provisional factor analysis and grouping according to clinical sense yielded five domains: access and getting care, care by doctor, care by other healthcare professionals, communication between healthcare professionals, and self-care. The internal consistency (Cronbach's alpha) for the whole scale was 0.89. The test-retest reliability was r = 0.73. The DCCS total score was moderately correlated with some of the measures used to establish construct validity. The DCCS could differentiate between patients who did and did not achieve specific process and clinical indicators of good diabetes care (e.g. Hba1c tested within 6 months). The development of the DCCS was centred on the patient's perspective and revealed that the patient perspective regarding continuity of care extends beyond the concept of seeing one doctor. Initial testing of this instrument demonstrates that it has promise as a reliable and valid measure in this area.

When do patients and their physicians agree on diabetes treatment goals and strategies, and what difference does it make?

BACKGROUND

For patients with chronic illnesses, it is hypothesized that effective patient-provider collaboration contributes to improved patient self-care by promoting greater agreement on patient-specific treatment goals and strategies. However, this hypothesis has not been tested in actual encounters of patients with their own physicians.

OBJECTIVE

To assess the extent to which patients with type 2 diabetes agree with their primary care providers (PCPs) on diabetes treatment goals and strategies, the factors that predict agreement, and whether greater agreement is associated with better patient self-management of diabetes.

DESIGN

One hundred twenty-seven pairs of patients and their PCPs in two health systems were surveyed about their top 3 diabetes treatment goals (desired outcomes) and strategies to meet those goals. Using several measures to evaluate agreement, we explored whether patient characteristics, such as education and attitudes toward treatment, and patient-provider interaction styles, such as shared decision making, were associated with greater agreement on treatment goals and strategies. We then examined whether agreement was associated with higher patient assessments of their diabetes care self-efficacy and self-management.

RESULTS

Overall, agreement on top treatment goals and strategies was low (all kappa were less than 0.40). In multivariable analyses, however, patients with more education, greater belief in the efficacy of their diabetes treatment, and who shared in treatment decision making with their providers were more likely to agree with their providers on treatment goals or strategies. Similarly, physician reports of having discussed more content areas of diabetes self-care were associated with greater agreement on treatment strategies. In turn, greater agreement on treatment goals and strategies was associated both with higher patient diabetes care self-efficacy and assessments of their diabetes self-management.

CONCLUSION

Although patients and their PCPs in general had poor agreement on goals and strategies for managing diabetes, agreement was associated with higher patient self-efficacy and assessments of their diabetes self-management. This supports the hypothesis that enhancing patient-provider agreement on both overall treatment goals and specific strategies to meet these goals may lead to improved patient outcomes.

A Novel Approach for Mental Health Disease Management: The Air Force Medical Service's Interdisciplinary Model

Mental health disorders are one of the most substantial public health problems affecting society today, accounting for roughly 15% of the overall burden of disease from all causes in the United States. Although primary care (PC) has the potential to be the frontline for recognition and management of behavioral health conditions, this has been a challenge historically. In order to more effectively address the broad scope of behavioral health needs, the Air Force Medical Service (AFMS) established a new model of behavioral health care. Through a series of coordinated steps, the AFMS ultimately placed trained behavioral health providers into PC clinics to serve as consultants to PC providers (PCPs). Behavioral Health Consultants (BHCs) provide focused assessments, present healthcare options to patients, and deliver brief collaborative interventions in the PC setting. BHCs see patients at the request of the PCP, in 15-30-min appointments. In the pilot study, patients averaged 1.6 visits to the BHC. Over 70% of patients fell into six categories of presenting problems: situational reactions, depressive disorders, adjustment disorders, anxiety disorders, health promotion, and obesity. Patient data (n = 76) suggest 97% of patients seen were either "satisfied" or "very satisfied" with BHC services, and 100% of the PCPs (n = 23, 68% response rate) were highly satisfied and indicated they would "definitely recommend" others use BHC services for their patients. Both the implications and the limitations of this pilot study are discussed.

The D-Net diabetes self-management program: long-term implementation, outcomes, and generalization results

BACKGROUND

A prerequisite to translating research findings into practice is information on consistency of implementation, maintenance of results, and generalization of effects. This follow-up report is one of the few experimental studies to provide such information on Internet-based health education.

METHODS

We present follow-up data 10 months following randomization on the "Diabetes Network (D-Net)" Internet-based self-management project, a randomized trial evaluating the incremental effects of adding (1) tailored self-management training or (2) peer support components to a basic Internet-based, information-focused comparison intervention. Participants were 320 adult type 2 diabetes patients from participating primary care offices, mean age 59 (SD = 9.2), who were relatively novice Internet users.

RESULTS

All intervention components were consistently implemented by staff, but participant website usage decreased over time. All conditions were significantly improved from baseline on behavioral, psychosocial, and some biological outcomes; and there were few differences between conditions. Results were robust across on-line coaches, patient characteristics, and participating clinics.

CONCLUSIONS

The basic D-Net intervention was implemented well and improvements were observed across a variety of patients, interventionists, and clinics. There were, however, difficulties in maintaining usage over time and additions of tailored self-management and peer support components generally did not significantly improve results.

Pharmacist-led, primary care-based disease management improves hemoglobin A1c in high-risk patients with diabetes

We developed and evaluated a comprehensive pharmacist-led, primary care-based diabetes disease management program for patients with Type 2 diabetes and poor glucose control at our academic general internal medicine practice. The primary goal of this program was to improve glucose control, as measured by hemoglobin A1c (HbA1c). Clinic-based pharmacists offered support to patients with diabetes through direct teaching about diabetes, frequent phone follow-up, medication algorithms, and use of a database that tracked patient outcomes and actively identified opportunities to improve care. From September 1999, to May 2000, 159 subjects were enrolled, and complete follow-up data were available for 138 (87%) patients. Baseline HbA1c averaged 10.8%, and after an average of 6 months of intervention, the mean reduction in HbA1c was 1.9 percentage points (95% confidence interval, 1.5-2.3). In predictive regression modeling, baseline HbA1c and new onset diabetes were associated with significant improvements in HbA1c. Age, race, gender, educational level, and provider status were not significant predictors of improvement. In conclusion, a pharmacist-based diabetes care program integrated into primary care practice significantly reduced HbA1c among patients with diabetes and poor glucose control.

Practice guidelines and measurement: state-of-the-science

BACKGROUND

Restructuring of the health care system has exposed widespread evidence of practice variability and has highlighted the benefits associated with nurses embracing interdisciplinary, best practice solutions to health care delivery. Clinical practice guidelines have emerged as a valuable interdisciplinary evidenced-based tool.

PURPOSE

This article explores the state of the science of guideline measurement and evaluates the strengths and weaknesses of measurement approaches.

METHOD

A computerized search of Cumulative Index of Nursing and Allied Health Literature, Health and Psychosocial Instruments, Medline, and PubMed for the search term "practice guidelines" was combined with the following key words: attitudes, adherence, effect, impact, instrument, and measurement.

DISCUSSION

Measurement issues identified in this analysis are related to the manner in which guidelines are written and the lack of a standard methodology for measurement.

CONCLUSIONS

The challenge remains to establish sound measures of adherence and impact while controlling for confounding variables. Questions remain as to the format of practice guidelines to best grant autonomy while offering recommendations that are clear and measurable.

Quality improvement initiative to integrate teaching diabetes standards into home care visits

PURPOSE

This quality improvement project was initiated to determine the quality of diabetes care for clients of a home health agency and to integrate the teaching of diabetes standards of care into home care nursing visits.

METHODS

A descriptive study design was used to evaluate the effectiveness of teaching materials and the Standards of Care Teaching Program. Performance indicators and outcome measures from the American Diabetes Association Provider Recognition Program (ADA PRP) were used to determine the baseline status of diabetes care and for comparing performance measures from 50 home care clients.

RESULTS

The educational materials and care plan interventions helped nurses learn the standards and facilitated tracking interventions and performance measures. These results showed statistical significance in performance measures for eye, foot, lipid tests, and diabetes self-management education, but not for hemoglobin A1C, urine protein, and medical nutrition therapy.

CONCLUSIONS

The Standards of Care Teaching Program was a useful way to integrate the standards into a diabetes program and home care visits. Comparing clients' diabetes performance measures with national standards helped identify specific areas for quality improvement.

Perceived difficulty of diabetes treatment in primary care: does it differ by patient ethnicity?

PURPOSE

The purpose of this cross-sectional study was to determine the attitudes of internal medicine physicians toward treating diabetes in different patient ethnic groups and compared with treating common chronic medical conditions in primary care.

METHODS

The survey instrument was administered to 55 internal medicine physicians. An e-mail message was sent to each physician with a hyperlink to a site where the survey could be completed. The instrument was a modified, quantitative 10-point scale designed to measure attitudes regarding the difficulty of treating diabetes.

RESULTS

Diabetes was perceived to be more difficult to treat than hyperlipidemia and angina. African Americans with diabetes were perceived to be more difficult to treat than Caucasian patients. Difficulty in treating diabetes was comparable to that for hypertension, arthritis, and congestive heart failure. Physicians were confident about treatment efficacy for diabetes and changing diabetes outcomes, but not about the adequacy of time and resources for diabetes treatment.

CONCLUSIONS

Diabetes was perceived as a difficult disease to treat, African American patients were more difficult to treat, and time and resources were inadequate for diabetes treatment. To improve diabetes care, there is a need to address these attitudes and concerns of internal medicine physicians.

Is diabetes treated as an acute or chronic illness in community family practice?

OBJECTIVE

Poor quality of diabetes care has been ascribed to the acute care focus of primary care practice. A better understanding of how time is spent during outpatient visits for diabetes compared with visits for acute conditions and other chronic diseases may facilitate the design of programs to enhance diabetes care.

RESEARCH DESIGN AND METHODS

Research nurses directly observed consecutive outpatient visits during two separate days in 138 community family physician offices. Time use was categorized into 20 different behaviors using the Davis Observation Code (DOC). Time use was compared for visits for diabetes, other chronic conditions, and acute illnesses during 1,867 visits by patients > or =40 years of age.

RESULTS

Of 20 DOC behavioral categories, 10 exhibited differences among the three groups. Discriminant analysis identified two distinct factors that distinguished visits for chronic disease from visits for acute illness and visits for diabetes from those for other chronic diseases. Compared with visits for other chronic diseases, visits for diabetes devoted a greater proportion of time to nutrition counseling, health education, and feedback on results and less time to chatting. Compared with visits for acute illness, visits for diabetes were longer and involved a higher proportion of dietary advice, negotiation, and assessment of compliance.

CONCLUSIONS

Visits for diabetes are distinct from visits for other chronic diseases and acute illnesses in ways that may facilitate patient self-management. Novel quality-improvement interventions could support and expand existing differences between family physicians' current approaches to care of diabetes and other chronic and acute illnesses.

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.

Preventive care practices for diabetes management in two primary care samples

PURPOSE

To assess the level of physician performance on American Diabetes Association Provider Recognition Program (PRP) measures in two samples of primary care patients, as well as to identify patient, physician, and office characteristics related to performance levels.

METHODS

In the two studies, we surveyed 435 Type 2 diabetes patients, cared for by 47 different physicians, on their receipt of PRP preventive care activities.

RESULTS

Overall, patients in the two samples reported receiving 74% and 64% of recommended services. In both samples, performance of microvascular/glycemic control activities and cardiovascular lab checks (84% and 74%) was significantly higher than behavioral self-management/patient-focused activities (61% and 48%) (p<0.001). From a set of patient, physician, and practice setting characteristics, only the use of community resources for chronic illness management support was associated with service performance.

CONCLUSIONS

We found considerable variability in the levels of performance in providing PRP-recommended activities. Greater attention should be focused on self-management and patient-focused activities, given that these are delivered less frequently than medical/laboratory checks.

Outcomes of and for diabetes education research

PURPOSE

The purpose of this paper is to review outcome measures used to evaluate diabetes self-management education and make recommendations for future research.

METHODS

Three perspectives were used: (1) the frequency with which different measures were collected prior to 1990 was compared with a sample of the 1997 to 1999 literature, (2) a multilevel pyramid model of psychosocial-environmental factors was used to evaluate the level of outcomes assessed, and (3) the RE-AIM evaluation framework was used to assess the public health impact of studies reported in the literature.

RESULTS

Knowledge and HbA1c measures are often collected to the exclusion of other, possibly more appropriate outcomes. Research has focused almost exclusively on individual or family level outcomes and paid little attention to effects at systems levels, such as neighborhoods, communities, or healthcare systems. More recent studies have been evaluating the reach of interventions, but more practice-oriented research needs to be conducted with representative patients, providers, and settings.

CONCLUSIONS

Much has been learned about the efficacy of diabetes self-management and about measurement issues. Future research should now focus on effectiveness and generalization issues.